NABH assessor guide

NABH-AG

ASSESSOR GUIDE

Issue No. 3

Issue Date: 06/12

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Assessor Guide - NABH-AG

CONTENTS Sl.

Title

Page Nos.

Content

2

1.

Introduction

3

2.

Role of Assessment team

3.

Pre-Assessment

4.

On-site Assessment

5.

Feedback

3-5 5 6-8 8

HAF 1 to HAF 4

9 - 12

Declaration of Impartiality, Confidentiality and Integrity (NABH I&C 01)

Issue No. 3

Issue Date: 06/12

13

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Assessor Guide - NABH-AG

1

INTRODUCTION Accreditation is an incentive to improve capacity of Heath Care Organisations to provide quality of care. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) provides third-party accreditation to Health Care Organizations in India. It ensures that hospitals/ Small Health Care Providers (SHCO), whether public or private, national or expatriate, play their expected role in national heath system. Country and culture specific accreditation system safeguard the country health care system and also involve fewer cost and better accepted as compare to external international accreditation systems. The assessment is carried out by a team of NABH empanelled Assessors, lead by a Principal Assessor. The assessment is carried out systematically for comprehensive review of hospital/ SHCO services, functions and hospital’s/ SHCO’s quality management system. The objective evidence so collected forms the basis: •

for arriving at a judgment for recommendation of the team, to the Accreditation Committee

•

for formulating the advice to assist the hospital/ SHCO in its development.

The objective of the assessment, however, is not to compile non-conformances/ deficiencies as an evidence to justify denial of accreditation. This guide has been prepared based on the general practices followed by international bodies and the experience of experts of the country. This document accordingly aims to:

2

a.

Provide the guidance to the Assessors during the assessment of hospitals/ SHCOs.

b.

Ensure uniformity of assessment and reporting, and

c.

Eliminate ambiguities or doubts about the interpretation of requirements(s).

ROLE OF ASSESSMENT TEAM The role of NABH Assessment team is to conduct on-site assessment of applicant hospital/ SHCO and provide the report to NABH. The objective of the on-site assessment is to obtain evidence on compliance with respect to NABH standards and other policy documents. Since hospital/ SHCO accreditation requires compliance with NABH Hospital Standards/ SHCO Standards the assessment team should consider conformances against these standards in the assessment. Thus, the members of the assessment team would be required to exercise their scientific judgmental skill and form their opinion regarding extent of conformance with respect to accreditation criteria. Notwithstanding the strength of the NABH system, the success of the accreditation scheme depends on the assessment team who perform on-site assessment and, thus, play a vital role in determining the credibility and value of the accreditation.

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Issue Date: 06/12

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Assessor Guide - NABH-AG

The assessment team consists primarily of Principal Assessor and Assessor. However, in some cases a technical expert may join the team to support on specific area. Team members are required to maintain the confidentiality on the matters/ subjects related to health care organizations.

Role of Principal Assessor Before the start of Assessment the Principal Assessor should prepare an Assessment schedule in HAF 1 which should include the departments/ sections/ areas/ activities to be assessed and assignment to various Assessors based on their expertise. The schedule shall be presented to the hospital/ SHCO representative. The hospital/ SHCO will be requested to assign guide/ co-coordinator to accompany each assessor during the assessment. The Principal Assessor must review the hospital’s/ SHCO’s documented Management System to verify compliance with the requirements of NABH standards. He should assess that the documented Management System is indeed implemented & effective, as described and record observations in HAF 2. All Non-Conformance(s) must be identified and reported, separately on each sheet in HAF 3. Principal Assessor would finally summarise the conduct of Assessment and record the recommendations in HAF 4. If, during Surveillance or Re-assessment, a case of critical system failure and gross negligence in technical aspects is noticed, the Principal Assessor will at the earliest inform NABH and elaborately bring it out in the Assessment summary (HAF-4) of assessment report. The Principal Assessor must sign all pages of the assessment report. He must get an endorsement from the hospital/ SHCO on HAF 4 and hand over a photocopy of the forms HAF 3 & 4 to the hospital/ SHCO to enable them to take corrective actions. The Principal Assessor is also required to monitor the performance of Assessor(s) and the Observer. He shall recommend whether the Observer is capable to perform the role of an Assessor in his next visit. His comments/ rating for each Assessor shall be enclosed with the report.

Role of Assessor The Assessor should clearly understand the areas/ activities to be assessed by him. He must review the Hospital’s/ SHCO’s documented system to verify compliance with the requirements of NABH standards. He should assess to verify that the documented SOPs, records are indeed implemented & effective, as described and record observations in HAF 2. The report should be handed over to the Principal Assessor along with expenditure claim form.

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Assessor Guide - NABH-AG

Role of Technical Expert The role of Technical Expert is same as of an Assessor. He will provide technical assistance to the team and he will seek guidance of Principal Assessor in filling the relevant forms.

Role of Observer The Observer (Potential Assessor) will be assigned to accompany the Principal Assessor as per the schedule provided to him. The Principal Assessor shall guide him. He is not involved in assessment directly but supports the assessment as assigned by the Principal Assessor. He is not entitled for payment of any honorarium.

3.

PRE-ASSESSMENT NABH Secretariat on intimation from the organization about the preparedness to take up pre-assessment, appoints a Principal Assessor from the pool of empanelled Assessors from assessor database. Scope and type of the hospital/ SHCO is kept in mind while selecting the Principal Assessor. For carrying out the pre-assessment, Principal Assessor may also be accompanied with assessors. The number of assessors depends on the size of the hospital/ SHCO. The name of Principal Assessor and assessor(s) and the names of their organizations from which they belong are intimated to the organization for seeking their consent. Following documents are provided to the assessment team for carrying out the assessment: -

Copy of application form of the organization

-

Copy of self assessment toolkit submitted

-

Quality Manual (however named) and other NABH related documents (department manuals, SOPs)

-

Pre-Assessment Guidelines and Forms

-

Confidentiality form (NABH I&C 01)

-

Travel expenditure form

Pre-assessment is carried out to check the preparedness of the organization to undergo assessment and to review the scope of accreditation. The Principal Assessor’s major role is to explain the purpose of the assessment. He/ She explains to the organisation the methodology adopted by his/ her team during the assessment. Things are discussed in detail with the management of the organization during the opening meeting of the pre-assessment. The detailed guidelines for the assessors for carrying out Pre-Assessment is described in NABH document ‘Pre-Assessment Guidelines and forms’.

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Issue Date: 06/12

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Assessor Guide - NABH-AG

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ON-SITE ASSESSMENT A similar methodology as used in the Pre-Assessment is followed in comprising the team for final assessment of the organization. The number of assessors depends on the size of the hospital/ SHCO. The assessor(s) and the names of their organizations from which they belong are intimated to the organization for seeking their consent. NABH also assures that the team does not have any competitive position with the applicant organization. NABH also ensures that assessors do not have any direct/ in-direct relationship with the organization or they/ or their organization. Consent is obtained for the date(s) of the assessment of the organization from the Principal Assessor and other assessors accompanying for the assessment. A written communication is sent to all the team members with the following documents: -

Application form of the organization

-

Pre-Assessment report

-

Corrective action report

-

Self assessment submitted by the organization

-

Hospital/ SHCO manuals/ documents submitted by the organization

-

Confidentiality form (NABH I&C 01)

-

Travel expenditure form

Assessment Team shall meet and plan assessment programme. This shall include the distribution of work amongst the Assessors. The format of the assessment schedule to be finalised is given at HAF-1.

4.1

Opening Meeting (a)

Principal Assessor and the team shall have an opening meeting with hospital/ SHCO representatives where they get acquainted with the hospital/ SHCO, departments/ sections and their locations.

(b)

The Principal Assessors shall explain the objective and scope of assessment and what is expected from the hospital/ SHCO during the assessment.

(c)

The Principal Assessor shall present the assessment schedule (HAF 1) to hospital/ SHCO representatives. The hospital/ SHCO will be requested to assign guide/ co-coordinator to accompany each Assessor.

(d)

The Principal Assessor shall inform the hospital/ SHCO that the assessment team shall not be approached by the hospital/ SHCO for closure of nonconformances while the assessment is in progress. Non-conformances may be closed while the assessment report is being compiled.

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Assessor Guide - NABH-AG

4.2

Assessment The assessment activities include: -

Orientation of assessors to the organization’s services The assessment procedure will start with an opening meeting. The assessors will introduce themselves and explain the assessment process. Any changes to assessment agenda will also be discussed.

-

Document review Document review includes review of polices, evidence of compliance with policies, evidence of committees and evidence of statements.

-

Functional interview • • • •

-

Leadership interview. Infection control interview. Management of information/ patient records interview. Staff qualification and education interview.

Visit to patient care areas and selected department The surveyor will evaluate the process for patient care in different setting across the organization.

4.3

-

Facility tour

-

Special interview/ issue resolution

Compilation of assessment report The Assessment Report should consist of various documents in the order as indicated in HAF 4. Each form or checklist should be carefully filled in. The pages should be serially numbered. Principal Assessor shall compile the observations from the assessors (HAF 2) and summary on non-compliance (HAF 3) from all the assessors. The Principal Assessor shall give the summary of the assessment in his final report (HAF 4). The reports shall be signed by the authorized signatory of the hospital/ SHCO. In addition to the above, Principal Assessor in consultation with the team members shall fill up the score sheet and send it to NABH along with report. This remains a confidential document and copy should not be given to the hospital/ SHCO.

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Assessor Guide - NABH-AG

Guidelines for evaluation are as follows: Assessment is based on the scoring on a scale of 0, 5 and 10 as per the following details. Compliance to the requirement

:

10

Partial compliance to the requirement

:

5

Non-compliance to the requirement

:

0

Not Applicable

:

NA

(if any of the sample is found to be non co out of total samples selected)

Assessor has to provide details of deficiency both in the case of non-compliance as well as partial compliance. Evaluation criteria: • • • •

4.4

No individual standard should have more than one zero to qualify. However, no zero is accepted in the regulatory/legal requirements. The average score for individual standard must not be less than 5. The average score for individual chapter must not be less than 7. The overall average score for all standards must exceed 7

Closing Meeting The Principal Assessor and other assessors shall have a meeting with the hospital/ SHCO representatives. A copy of the report – summary of non-conformances (HAF 3) shall be handed over to the hospital/ SHCO. The closing meeting is to end with thanks giving for the co-operation and assistance provided by the hospital/ SHCO.

4.5

Post Assessment Principal Assessor shall send the report to NABH at the earliest. NABH secretariat reviews the assessment report and seeks clarification and documentation from the Principal Assessor and hospital/ SHCO, if required. NABH, on receipt of evidence of corrective action, if any, shall place the report before the Accreditation Committee for its consideration for accreditation. The assessment report is reviewed by the Accreditation Committee and recommendations made.

5

FEEDBACK Following feedbacks are obtained by NABH through the evaluation forms in the NABH document ‘Feedback Forms’. -

feedback on performance of the assessment team is obtained from the hospital/ SHCO.

Issue No. 3

feedback on performance of other assessors by the Principal Assessor. Issue Date: 06/12

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Assessor Guide - NABH-AG

ASSESSMENT SCHEDULE- HAF 1 Name & address of hospital/ SHCO:

Accreditation Coordinator:

Date(s) of Visit:

Type of Visit: Assessment / Surveillance / Re-Assessment / Verification Assessment Standard: NABH Standards/ SHCO Standards (strike off which is not applicable) Assessment Timings

Morning: Afternoon:

AM to PM to

Opening/Closing Meeting Date/Time PM PM

Daily Debriefing Date / Time (at the end of each day) Day 1: Day 2: Day 3:

Opening Meeting: Closing Meeting:

Assessment schedule: Principal Assessor to provide details of activities taken up by individual assessors/ technical expert in the following format and obtained their signature. (Separate sheets may be used for individual assessors)

Name and Expertise of the Assessor

Schedule of Department/ Section/ Activity to be Assessed (date wise) Day 1 Morning

Afternoon

Day 2 Morning

Day 3

Afternoon

Morning

Afternoon

Principal Assessor

Assessor 1 Assessor 2 Assessor -Observer/Expert

Signature of Principal Assessor

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Assessor Guide - NABH-AG

ASSESSOR’S OBSERVATIONS- HAF 2 Name of hospital/ SHCO: Date:

Area/ Department:

Activity Assessed:

Auditee: Sl.

OBSERVATION

REMARKS

Signature & Name of Assessor

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Assessor Guide - NABH-AG

ASSESSOR’S SUMMARY ON NON-COMPLIANCE- HAF 3 (For each non-compliance, refer observation no. from HAF 2 and NABH std. no. against which non-compliance is being raised) Hospital/ SHCO:

Date:

Type of Assessment: Assessment / Surveillance / Re-Assessment / Verification

Non-compliance observed: 1.

Signature & Name of Hospital/ SHCO Representative

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Signature & Name of Assessor

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Assessor Guide - NABH-AG

SUMMARY OF THE ASSESSMENT- HAF 4 Hospital/ SHCO name & address: Accreditation Coordinator:

Date(s) of Visit:

Type of Visit: Assessment / Surveillance / Re-Assessment / Verification Principal Assessor:

Assessor 1:

Assessor 2:

Assessor 3:

Assessor 4:

Assessor 5:

Assessor 6:

Other/TE

Observer:

Date of earlier visit and Purpose: ASSESSMENT SUMMARY:

Enclosures

HAF

1

HAF 2

HAF

3

HAF 4

Date by which deficiencies are to be discharged by the hospital/ SHCO:

Acknowledgement by Authorised Signatory of hospital/ SHCO & Date

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Signature of Principal Assessor & Date

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Assessor Guide - NABH-AG

NABH I&C-01

DECLARATION OF IMPARTIALITY, CONFIDENTIALITY & INTEGRITY (to be filled in by each Assessor and enclosed with the Assessment report)

Name

Assessor ID

:

(To be filled in by NABH Sect.)

Designation Organisation Address

Capacity

Principal Assessor / Assessor / Technical Expert / Observer

Health care organisation Assessed Date of visit(s) Type of visit

Pre-assessment/ Assessment / Surveillance / Re-Assessment / Verification

I ______________________________________________________________, hereby declare that i.

I have not offered any consultancy, guidance, supervision or other services to the hospital/ SHCO in any way.

ii.

I am/ am not* an ex-employee of the health care organization and am/ am not* related to any person of the management of the health care organization.

iii.

I will declare to the Board my and/ or my immediate family’s association with any of the organization that can affect the impartiality of the assessment process. I shall also keep the Board informed about changes in the status of my association with the organization before every assignment.

iv.

I got an opportunity to go through various documents of the above hospital/ SHCO and other related information that might have been given by NABH. I undertake to maintain strict confidentiality of the information acquired in course of discharge of my responsibility and shall not disclose to any person other than that required by NABH.

* strike out which is not applicable

Date: Place :

Issue No. 3

Signature

Issue Date: 06/12

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