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NABH Accreditation



     IMA constituted the Hospital Board India – (IMA-HBI) with the objective of helping the hospitals in preparing for the medical standards, providing uniform treatment, addressing Human capital related issues pertaining to the Healthcare Industry and improvement of public Health and Medical Education in India.

     Accreditation of healthcare is an important tool for improving and regulating the quality of care.

     "Cluster Based Technical Assistance for NABH Pre-Accreditation Entry Level Certification Programme" by IMA Maharashtra State & State Chapter of IMA Hospital Board of India is efforts by IMA-HBI to facilitate accreditation for small & medium size hospitals.

     This initiative is by IMA , IMA-Hospital Board of India. IMA Life Membership & HBI membership is compulsory.

     This initiative is a part of the leadership role that IMA played in championing the cause for a more liberal accreditation programme that suits the realities of the tens of thousands of small and medium medical professionals owned hospitals which are the true back bone of the health care delivery across our country.

     The IMA has an exclusive agreement with NABH to promote this programme across the country and a successful pilot programme has been working in South India over last 2 years with considerable participation.

     The key reason for IMA to develop this cluster based technical support programme enabling the hospitals to achieve the entry level NABH accreditation was the prevalent scenario where several private agencies are offering so called consultancy support at inflated prices and without sufficient technical knowhow.

     There have been several instances over the last few years of our hospitals being swindled by such fly by night operators and agencies.

     The technical assistance programme designed and offered by IMA HBI is implemented Nationally and has been pilot tested and modified to the needs of small and mid-sized hospitals.

     This works on the principle of collaboration between the participants hospital under the IMA umbrella and offers trustworthy and sound technical assistance validated and constantly monitored by the IMA team.

     Any short comings in the support programme shall be immediately addressed through a monitoring committee of IMA and corrective actions ensured on receiving any grievances from our participant hospitals.

     IMA-HBI-NABH initiative is transparent on the cost sharing to be borne by each category of hospitals ( classified according to bed strength) and the services that will be provided by the technical assistance team.

What is NABH?

     National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations. The board while being supported by all stakeholders including industry, consumers, government, have full functional autonomy in its operation.

What is Accreditation?

     A public recognition of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organization's level of performance in relation to the standards.

What NABH accreditation means?

     Commitment to create a culture of quality, patient safety, efficiency and accountability towards patient care.

     Establishment of protocols and policies as per National/International Standards for patient care, medication management, consent process, patient safety, clinical outcomes, medical records, infection control and staffing. Patients are treated with respect, dignity and courtesy at all times. Patients are involved in care planning and decision making. Patients are treated by qualified and trained staff. Feedback from patients is sought and complaints (if any) are addressed. Transparency in billing and availability of tariff list.

     Continuous monitoring of its services for improvement. Commitment to prevent adverse events that may occur.

What are the benefits of Accreditation?

     Accreditation benefits everyone. Patients are the biggest beneficiaries. Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff. Rights of patients are respected and protected. Patient satisfaction is regularly evaluated.

     Accreditation to a Hospital stimulates continuous improvement. It enables hospital in demonstrating commitment to quality care. It raises community confidence in the services provided by the hospital. It also provides opportunity to healthcare unit to benchmark with the best.

     The Staff in an accredited hospital are satisfied lot as it provides for continuous learning, good working environment, leadership and above all ownership of clinical processes. It improves overall professional development of Clinicians and Paramedical staff and provides leadership for quality improvement within medicine and nursing.

     Accreditation provides an objective system of empanelment by insurance and other Third Parties. Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.

General outline of IMA-HBI-NABH accreditation drive :

Baseline assessment:

     Knowledgeable and credible evaluators objectively assess each area and conduct a detailed baseline assessment of the organization's current scenario and each measurable element.

     Score gives specific findings and recommendations.

     Baseline quality data as required by the quality monitoring standards is also analysed. This defines gap analysis from the defined standards.

Action planning :

     Using the findings of the baseline assessment & gap analysis, a detailed project plan is developed, starting first with priority areas of the core standards. Responsibilities, deliverables and time frames are assigned (e.g., revise informed consent policy, develop a new informed consent statement, educate staff in the next immediate period.)

Training :

     Good people skills, time-management skills, and consensus-building skills, and to explain each chapter of standards to the hospital nodal people, doctors from throughout the hospital and carry out the process.

SOPs & Documentation :

     In addition to an overall project plan, it is helpful to compile a list of all required policies and procedures, SOPs & documentation that will need development and revision.

     Continuous monitoring the progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals.

Mock Survey :

     "Mock Survey " is done before the actual accreditation survey. Evaluators will look at the organization with a fresh and objective eye. Final revisions and corrections will be advised based on the findings of the final mock survey.

NABH ENTRY LEVEL ACCREDITATION for hospitals in Maharashtra State for IMA-HBI members -

     On requests from small hospitals an Introductory Offer till 7th MAY 2017 the first slab of 1-25 beds has been introduced.
1-25 beds - Rs 30,000/- [Only till 07.05.2017]
26- 50 beds - Rs.50,000/-
51-100 beds - Rs.1,00,000/
101-200 beds - Rs 1,50,000/-
201-300 beds - Rs 2,00,000/'
300 beds + - Rs 2,50,000/-
[IMA-HBI membership is compulsory]

     We are sure that our professional community would recognize the importance of this key initiative and value the credibility factor embedded in this joint endeavor; as in case of many other programmes and causes IMA has championed on behalf of our fraternity.

     We look forward to your overwhelming supporting in enrolling your hospitals in this programme.

     For any assistance/information/enrolling for accreditation please contact 'Team IMA-HBI'
Dr Jayesh Lele 9821220519
Dr Mangesh Pate 9820064054
Dr Dinesh Thakare 8888129007

Hospital Board of India : Affiliation Application Form Download Hospital Board of India NABH Enrolment Form Download
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   It is an honor to get elected as the President of the most prestigious, vibrant, active and one of the largest branches of IMA. It gives me immense pleasure to communicate with you through our monthly bulletin IMA Plus. I am thankful to managing committee of IMA Pune and Life members of IMA Pune for giving me this opportunity to work as the President of IMA Pune. I assure you that I will try to put my best efforts to justify your belief and faith in me. This organisation has a rich leagacy of 91 years.
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   We, at IMA Pune, are fortunate to have great legacy of getting very dynamic, energetic, principled and helping leaders successively, to lead from the front. After a very eventful and successful tenure of Dr. Padma Iyer, we have at the helm of IMAs affairs Dr. Sanjay Patil, a non-assuming but towering personality and risen to this level from the level of grass root, hard core worker.
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