HOSPITAL ACCREDITATION

Bishwajit Mazumder
Nursing Instructor
Dhaka Nursing College, Dhaka
E. mail: mbishwa@rocketmail.com
Hospital accreditation
Introduction:
Health systems currently operate within an environment of rapid social,
economic and technological change. Such changes are expected to continue for the
foreseeable future as a result of restructured economic and social policies, globalization
of markets and enhanced worldwide communication. New insurance mechanisms,
restructuring and health reform initiatives, privatization within the health sector,
redistribution of human and other resources, reduced public funding, new technology, and
many other factors may raise concern for the quality of healthcare. As a result of these
health sector reforms, national health systems are coming under increasing scrutiny with
a view to cost containment and quality improvement.
Hospital accreditation has been defined as A self-assessment and external peer
assessment process used by health care organizations to accurately assess their level of
performance in relation to established standards and to implement ways to continuously
improve Critically, accreditation is not just about standard-setting: there are analytical,
counseling and self-improvement dimensions to the process. Accreditation is a formal
process by which a recognized body usually an independent body assesses and recognizes
that a health care organization meets applicable predetermined and published standards. .
A health care establishment is said to be accredited when the disposition and
organization of its resources and activities make up a process which results in medical
care of satisfactory quality. Accreditation implies confidence in a hospital by the
population. In almost all cases this can be achieved without major investments in
infrastructure.

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Accreditation can be the single most important approach for improving the
quality of healthcare structures. In an accreditation system, institutional resources are
evaluated periodically to ensure quality of services. Standards may be minimal, defining
the bottom level or base, or more detailed and demanding. Accreditation standards are
usually regarded as optimal and achievable, and are designed to encourage continuous
improvement efforts within accredited organizations.
Hospitals are an integral part of health systems; by harmonizing standards in
hospitals in line with other institutions and levels of care, continuity of care is improved
and the healthcare network strengthened. Hospital accreditation is gaining prominence
due to globalization efforts and especially trading in health services. Hospital
accreditation is a system of ongoing consensus, rationalization and hospital organization.
National ownership is crucial, both to lay the foundation and to maintain, from the
beginning, a high degree of integrity and accountability of the national accreditation
system.
Background of Hospital accreditation:
The most important objectives include enhancing health systems, promoting
continuous quality improvement, informing decision-making and ensuring accountability
to national health policies. Country and culture-specific accreditation systems not only
safeguard the countrys primary healthcare, but they also involve fewer costs and are
better accepted as compared to external international accreditation systems. Hospitals
and healthcare services are vital components of any well-ordered and humane society,
and will indisputably be the recipients of societal resources. Those hospitals should be
places of safety, not only for patients but also for the staff and for the general public, is of
the greatest importance. Quality of hospitals and healthcare services is also of great
interest to many other bodies, including governments, NGOs targeting healthcare and
social welfare, professional organizations representing doctors, patient organizations,
shareholders of companies providing healthcare services, etc. However, accreditation
schemes are not the same thing as government-controlled initiatives set up to assess
healthcare providers with only governmental objectives in mind - ideally, the functioning

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and finance of hospital accreditation schemes should be independent of governmental

control.
In 1917, the American College of Surgeons established a set of minimum
standards for hospitals.
In 1951, the American College of Surgeons, American College of Physicians,
American Hospital Association, and the American Medical Association cooperated to
form the Joint Commission on Accreditation of Hospitals to address the need to improve
the quality of care in the United States of America. Today it is the primary instrument
used by the United States Health Care Financing Administration to approve the transfer
of medicine funds to hospitals. Only hospitals that have passed an accreditation process
can receive payments. Countries in WHO regions have also employed this method, such
as Egypt and Lebanon (EMR); Brazil and Argentina (AMR); Thailand, Taiwan and
Indonesia (SEAR); England, France and Spain (EUR); South Africa (AFR); and Korea
(WPR).
Key terms:
Quality: According to ISO 9000:- Quality is defined as the degree to which a set of
inherent characteristics fulfills requirements.
According to WHO:- Quality of care is the level of attainment of health systems
intrinsic goals for health improvement and responsiveness to legitimate expectations of
the population.
Accreditation: Public recognition by a national healthcare accreditation body of the
achievement of accreditation standards by a healthcare organization, demonstrated
through an independent external peer assessment of that organizations level of
performance in relation to the standards.
Certification: Formal recognition of compliance with set standards (e.g. ISO 9000
series for quality systems) validated by external evaluation by an authorized auditor.
Licensure: Process by which a government authority grants permission, usually
following inspection against minimal statutory standards, to an individual practitioner or
healthcare organization to operate or to engage in an occupation or profession.
Standard:

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The Joint Commission defines standards as statements that define performance

expectations and/or structures and processes that must be in place for a hospital to
provide safe, quality care, treatment, and services (Hospital Accreditation Standards,
2010, p GL20).
The Foundation: Structure, Process, and Outcomes:
In 1966, when the Medicare CoPs were first drafted, 3 aspects of patient care
that could be measured to assess the quality of care were identified: structure, process,
and outcome. Donabedian16 theorized that these factors were related; ideally, a good
structure (eg, safe and sanitary building, necessary equipment, qualified personnel, and
properly organized staff) for patient care would increase the likelihood of a good process
of patient care (eg, the right diagnosis and best treatment available), and a good process
increased the likelihood of a good outcomes.
Donabedian Structure, Process, Outcomes Traid:

Structure

Process

Outcome

Regulatory

Procedure

Quality and safe

-CMS

Process

care

-State
Instructions
Patient
Hospital
Accreditation:
Vision:-Other policy
satisfaction
The following vision will be formulated: A quality conscious and accountable health care

Staff satisfaction

system within which all stakeholders have a say and that enables rational, effective, safe
and cost-effective provision of care.
Mission:

This accreditation organization is committed to and exists to provide leadership

in enhancing health care quality and to promote accountability and rationality in health
care. This mission will be achieved through
a) Accreditation
b) Partnership and Collaboration - promoting networking, partnership and collaboration
between disciplines and organizations at regional, national and international level

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c) Research and Dissemination - promoting research which is of a quality and scale to

achieve a national reputation in all fields and an international reputation in quality areas
encouraging and facilitating the development of multi disciplinary research groups
which are of sufficient size and quality.
d) Training
e) Quality culture - Promoting innovative and flexible policies in the employment and
development of staff
Goals:
The main purpose of our policy is to help planners to promote, implement,
monitor and evaluate robust practice in order to ensure that occupies a central place in the
development of the healthcare system In doing so it recognizes the roles to be played by a
multiplicity of stakeholders from the govt. , non-governmental and private and economic
sectors. Quality should be an integral part of the overall national health policy. It is
believed that accreditation if sensibly designed can have a significant impact on
improving quality and safety in health care; improving health outcomes; ensuring more
equitable health service provision; enhancing management practices; and improving
decision making.
Purposes:
Quality improvement: using the accreditation process to bring about changes in
practice
that will improve the quality of care for patients;
Informing decision-making: providing data on the quality of health care that various
stakeholders, policymakers, managers, clinicians and the public, can use to guide their
decisions;
Accountability and regulation: making health care organizations accountable to
statutory or other agencies, such as professional bodies, government, patient groups and
society at large, and regulating their behavior to protect the interests of patients and other
stakeholders.
Standards are statements of expectation that define the structures, processes, and results
that must be firmly established in an organization so that it may provide quality care.

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Objectives:
Conduct comprehensive assessments of health care organizations in consonance with
the national framework, for the promotion and maintenance of quality and standards.
To engage and train conscientious surveyors and to develop training systems generally
for accreditation surveyors.
To promote accreditation, including its values, purpose and results to health care
organizations, medical profession, patients and the community.
To collaborate with relevant organizations.
To regularly monitor and evaluate all aspects of the accreditation system and
accreditation decisions and provide feedback on the standards.
What is Hospital Accreditation?
"The Hospital Accreditation" approach is a concept and practice that yields
beneficial results to patients, customers, hospital personnel, the hospital, the Faculty of
Medicine, the society and the country as a whole.
Or,
Hospital accreditation has been defined as A self-assessment and external
peer assessment process used by health care organizations to accurately assess their level
of performance in relation to established standards and to implement ways to
continuously improve.
(http://en.wikipedia.org/wiki/Hospital_accreditation)
Objectives of hospital accreditation:
1. Enhanced health systems- integrating and involving hospitals as an active component
of the health care network.
2. Continuous quality improvement- using the accreditation process to bring about
changes in practice that will improve the quality of care for patients.
3. Informed decision-making- providing data on the quality of health care that various
stakeholders, policy-makers, managers, clinicians and the public can use to guide their
decisions.
4. Improved accountability and regulation- making health care organizations
accountable to statutory or other agencies, such as professional bodies, government,
patient groups and society at large, and regulating their behaviors to protect the interests
of patients and other stakeholders.

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BENEFITS TO ACCREDITATION:
BENEFITS OF PATIENTS:1. Continuity of care & Safe transport
2. Pain management & Focus on patient safety
3. Patient satisfaction is evaluated
4. Rights are respected and protected
5. Access to a quality focused organization
6. Credentialed and privileged medical staff
7. High quality of care
8. Understandable education and communication
BENEFITS FOR THE STAFFS:1. Improves professional staff development.
2. Provides education on consensus standards.
3. Provides leadership for quality improvement within medicine and nursing.
4. Increases satisfaction with continuous learning, good working environment, leadership
and ownership.
BENEFITS FOR THE HOSPITAL:1. Improves care.
2. Stimulates continuous improvement.
3. Demonstrates commitment to quality care.
4. Raises community confidence.
9. Opportunity to benchmark with the best.
BENEFITS TO THE COMMUNITY:1. Quality revolution
2. Disaster preparedness
3. Epidemics
4. Access to comparative database
STRATEGIES FOR DEVELOPING HOSPITAL ACCREDITATION:
Strategies should aim at fostering national accreditation initiatives and
providing guidance for national accreditation efforts to ensure that accreditation systems
are developed in a way that upholds the principles of health for all. The following
strategies may be implemented by Member States in collaboration with WHO.
1. Raising awareness at national level and encouraging debate by interested stakeholders
to develop consensus on launching hospital accreditation.
2. Strengthening hospital inspection units and improving administrative procedures in
ministries of health in preparation for launching accreditation.
3. Establishing national hospital registers with detailed profiles of individual hospitals.

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4. Studying efforts and experiences in hospital accreditation in the Region and

exchanging experiences through a network of interested institutions and experts.
5. Collaborating with regional and international bodies (e.g. Gulf Cooperation Council)
for advocacy of hospital accreditation.
6. Participating in annual international forums (e.g. meetings of the International Society
for Quality in Health Care) to update knowledge on hospital accreditation and share
experiences with others.
7. Designating an expert advisory group on hospital accreditation in the Region to
provide objective guidance to national authorities in addressing accreditation issues.
8. Reviewing periodically and documenting progress in implementing hospital
accreditation in the Region.
9. Applying, after adaptation, the suggested steps for implementing hospital accreditation
at national and local
NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE
PROVIDERS (NABH)
ISQua is an international body which grants approval to Accreditation Bodies
in the area of healthcare as mark of equivalence of accreditation program of member
countries. NABH is a member of ISQua Accreditation Council. NABH is an Institutional
Member as well as a member of the Accreditation Council of the International Society for
Quality in HealthCare (ISQua). NABH is the founder member of proposed Asian Society
for Quality in Healthcare (ASQua) being registered in Malaysia. NABH is a member of
International Steering Committee of WHO Collaborating Centre for Patient Safety as a
nominee of ISQua Accreditation Council
Objectives of NABH:1. Enhancing health system & promoting continuous quality improvement and patient
safety.
2. It provides accreditation to hospitals in a non-discriminatory manner regardless of their
ownership, legal status, size and degree of independence.
Organizational Structure:

National Accreditation Board for Hospitals and

Healthcare Providers (NABH)

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Appeals Committee

Accreditation

Technical

Committee

Committee

Organizational Structure:

Secretariat

Panel of
Assessors &

Accreditation CommitteeExperts
The main functions of Accreditation Committee are as follows:
- Recommending to board about grant of accreditation or otherwise based on evaluation
of assessment reports & other relevant information.
- Approval of the major changes in the Scope of Accreditation including enhancement
and reduction, in respect of accredited hospitals.
- Recommending to the board on launching of new initiatives
Technical CommitteeThe main functions of Technical Committee are as follows:
- Drafting of accreditation standards and guidance documents
- Periodic review of standards
Appeals CommitteeThe Appeal Committee addresses appeals made by the hospitals against any
adverse decision regarding accreditation taken by the NABH. The adverse decisions may
relate to the following:
- Refusal to accept an application,
- Refusal to proceed with an assessment,
- Corrective action requests,
- Changes in accreditation scope,
- Decisions to deny, suspend or withdraw accreditation, and
- Any other action that impedes the attainment of accreditation.
NABH SecretariatThe Secretariat coordinates the entire activities related to NABH Accreditation
to hospitals and healthcare organizations.
Panel of Assessors and ExpertsNABH has a panel of trained and qualified assessors for assessment of hospitals.

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1. Principal Assessor
The Principal Assessor is overall responsible for conducting the pre-assessments
and final assessments of the hospitals.
2. Assessors
NABH has empanelled experts for assessment of hospitals. They are trained by
NABH on hospital accreditation and various assessment techniques. The assessors are
responsible for evaluating the hospitals compliance with NABH Standards.
NABH Standards
NABH Standards for hospitals prepared by technical committee contains
complete set of standards for evaluation of hospitals for grant of accreditation. The
standards provide framework for quality of care for patients and quality improvement for
hospitals. The standards help to build a quality culture at all level and across all the
function of hospital. NABH Standards has10 chapters incorporating 10 standards and 636
objective elements.
Outline of NABH Standards
Patient Centered Standards 1. Access, Assessment and Continuity of Care (AAC)
2. Care of Patient (COP)
3. Management of Medication (MOM)
4. Patient Right and Education (PRE)
5. Hospital Infection Control (HIC)
Organization Centered Standards
1. Continuous Quality Improvement (CQI)
2. Responsibility of Management (ROM)
3. Facility Management and Safety (FMS)
4. Human Resource Management (HRM)
5. Information Management System (IMS)
Assessment Criteria
A hospital willing to be accredited by NABH must ensure the implementation
of NABH standards in its organization.
The assessment team will check the implementation of NABH Standards in organization.
The Hospital shall be able to demonstrate to NABH assessment team that all NABH
standards, as applicable, are followed.
Preparing for NABH Accreditation

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Hospital management shall first decide about getting accreditation for its
hospital from NABH. It is important for a hospital to make a definite plan of action for
obtaining accreditation and nominate a responsible person to co-ordinate all activities
related to seeking accreditation. An official nominated should be familiar with existing
hospital quality assurance system. Hospital shall procure a copy of standards from the
NABH Secretariat against payment. Further clarification regarding standards can be got
form NABH Secretariat in person, by post, by e-mail or on telephone.
The hospital looking for accreditation shall understand the NABH assessment procedure.
The hospitals shall ensure that the standards are implemented in the organization. The
hospitals can download the application form for NABH Accreditation from the web-site.
The applicant hospital must have conducted self-assessment against NABH standards at
least 3 months before submission of application and must ensure that it complies with
NABH Standards.

Preparing for NABH Accreditation:

Obtain a copy of NABH
Standards
(From
NABH office)
Get accustomed
to the
standard & implement them
(By health care organization)
Obtain a copy of Application
Form
Fill
andNABH
submit
thesite)
(From
web
Application
(to
Secretariat) fee
PayNABH
the Accreditation

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NABH Accreditation Procedure:

Application for accreditation +

Self-Assessment by
HCO (By health care organizations)
Acknowledgment and Scrutiny of
application

Feedback

(by NABH
Secretariat)
Pre
- Assessment
visit

To

(By Assessment Team)

Health

Final Assessment of hospital

care

(By Assessment team)

Organizati

Review of Assessment Report

on

(by NABH Secretariat)

Recommendation for Accreditation
(by Accreditation Committee)

And
Necessary

Approval for Accreditation

Corrective

(by Chairman, NABH)

Action

Issue of Accreditation certificate

Taken

(by NABH Secretariat)

By

NABH Accreditation Procedure:

Application for accreditation:

Health
care
Organizati
on

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The hospital shall apply to NABH in the prescribed application form. The
application shall be accompanied with the following:
- Prescribed application fee as detailed in the application form
- Signed copy of Terms and Conditions for Maintaining NABH Accreditation,
available free on the web-site
- Filled in Self Assessment Toolkit, available free on the web-site.
- Quality/ hospital Manual (as per NABH standards) and other NABH relevant
documents i.e. different policies and procedures of the hospital
Self-Assessment toolkit is for self-assessing itself against NABH Standards.
The self assessment shall be done by the hospital in a stringent manner and if at the time
of pre-assessment it is found that there is a significant difference between the self
assessment and the pre-assessment report then the organization shall apply for final
assessment not earlier than six months from the date of completion of pre-assessment.
The applicant hospital must apply for all its facilities and services being rendered from
the specific location. NABH accreditation is only considered for hospitals entire
activities and not for a part of it.
Scrutiny of application:
NABH Secretariat receives the application form and after scrutiny of
application for its completeness in all respect, acknowledgement letter for the application
shall be issued to the hospital with a unique reference number. The hospital shall be
required to quote this reference number in all future correspondence with NABH.
Pre-Assessment:
NABH appoints a Principal Assessor/ Assessment Team who is responsible for
pre assessment of healthcare organization. NABH forwards the application form,
documents, procedures, Self assessment toolkit to the Principal Assessor/ Assessment
Team.
Objective of Pre-assessment:
1. Check the preparedness of the hospital for final assessment
2. Review the scope of accreditation and ascertain the requirement of the number of
assessors and the duration of the accreditation
3. Review of the documentation system of the hospital
4. Explain the methodology to be adopted for assessment.
The Principal assessor shall submit a pre-assessment report in the format specified in the
document Pre-Assessment Guidelines & Forms. Copy of the report is handed over to

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the organization after the assessment and original sent to NABH Secretariat. The hospital
shall be required to pay the requisite Annual fee before the final assessment.
Final Assessment:
The hospital is required to take necessary corrective action to the nonconformities pointed out during the pre-assessment. The final assessment involves
comprehensive review of hospital functions and services. NABH shall appoint an
assessment team. The team shall include Principal assessor (already appointed) and the
assessors. The total number of assessors appointed shall depend on the number of beds
and services provided. The date of final assessment shall be agreed upon by the hospital
management and assessors. Assessment shall be conducted on hospitals department and
services.
Based on the assessment by the assessors, the assessment report is prepared by
the Principal assessor in a format prescribed by NABH.
The details of non-conformity (ies) observed during the assessment are handed over to
the hospital by the Principal assessor and detailed assessment report is sent to NABH.

Scrutiny of assessment reportNABH shall examine the assessment report. The report is taken to the
accreditation committee. Depending on the score and compliance to standard would
decided the award of accreditation
Issue of Accreditation Certificate:
NABH shall issue an accreditation certificate to the hospital with a validity of
three years. The certificate has a unique number and date of validity. The certificate is
accompanied by scope of accreditation.
The applicant hospital must make all payment due to NABH, before the issue of
certificate.
All decision taken by NABH regarding grant of accreditation shall be open to appeal by
the hospitals, to chairman NABH.
Surveillance and Re assessment:
Accreditation to a hospital shall be valid for a period of three years. NABH
conducts one surveillance of the accredited hospitals in one accreditation cycle of three

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years. The surveillance visit will be planned during the 2nd year i.e. after 18 months of
accreditation.
The hospitals may apply for renewal of accreditation at least six months before
the expiry of validity of accreditation for which reassessment shall be conducted. NABH
may call for un-announced visit, based on any concern or any serious incident reported
upon by an individual or organization or media.
Conclusions:
Sound quality management improves business performance, often resulting in a
positive effect on market share, efficiency, and customer satisfaction. The Joint
Commission, the nations largest and oldest accrediting body, is associated with many
positive changes in healthcare delivery and, for many years, has been the first choice of
hospitals seeking accreditation.
Reference:
Oakland, John S. (2000). Total Quality Management: text with cases, 2nd edition. British
library cataloguing in publication data, Great Britain.
National Accreditation Board for Hospitals & Healthcare Providers (NABH), General
information brochure, 2012.
Vallejo, B. C, Flies, L. A, Fine, & D. d J.(2011). A Comparison of Hospital Accreditation
Programs.
Developing Hospital Accreditation System in Bangladesh, (2008)Strategic Paper for
Developing Hospital Accreditation in Bangladesh.
Technical discussions Accreditation of hospitals and medical education institutionschallenges and future directions, WHO. (2003).
http://www.qualitydigest.com/inside/twitter-ed/guideline-quality-accreditationhospitals.html
http://www.qualitydigest.com/inside/twitter-ed/guideline-quality-accreditationhospitals.html
http://en.wikipedia.org/wiki/Accreditation