NABH-PROC_C&A

PROCEDURE
FOR
HANDLING OF COMPLAINTS
AND APPEALS

NATIONAL ACCREDITATION BOARD FOR HOSPITALS

& HEALTHCARE PROVIDERS (NABH)
Quality Council of India
Institution of Engineers’ Building, IInd Floor, Bahadur Shah Zafar Marg
New Delhi - 110002, India.
Tel/ Fax: 91-11-2337 9321, 91-11-2337 9621
Website: www.qcin.org
EMail: nabh@qcin.org

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Procedure for Handling of Complaints and Appeals – PROC_C&A

Contents

Sl. Title Page Nos.

1.0 Objective 3

2.0 Scope 3

3.0 Responsibility 3

4.0 Procedure for Handling of Complaints 3

4.1 Receipt of Complaints 3

4.2 Investigation of Complaints 4

5.0 Procedure for Handling of Appeals 6

5.1 Receipt of Appeals 6

5.2 Deliberation of Appeals Committee and Recommendations 6

5.3 Decision on Appeals 7

6.0 Financing the Complaint and Appeal process 7

7.0 Records 7

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Procedure for Handling of Complaints and Appeals – PROC_C&A

1.0 OBJECTIVE
The document describes the procedures for dealing with:
- Complaints from various sources
- Appeals from Health Care Organization (HCO) against adverse decisions taken
by NABH.
- HCO, in general, would mean any entity providing health care services for which
an accreditation program is available with NABH and it may include hospital,
nursing home, blood bank, wellness centre, dental facility, imaging centre,
primary or secondary health centre etc.

2.0 SCOPE
The procedure described in this document is to be followed in NABH for dealing with
different types of complaints and appeals by HCO. Appeal can be made by HCO
against adverse decision taken by NABH in respect of - refusal to accept an
application; refusal to proceed with an assessment; corrective action requests;
changes in accreditation scope; denial of accreditation; putting in abeyance,
suspension, withdrawal of accreditation or any other action that impedes the
attainment of accreditation.

3.0 RESPONSIBILITY
Responsibility of handling of complaints and appeals rests on the designated officer
of the Board. However, the Director is responsible for monitoring of complaints and
appeals and final decision on closure of the complaint and appeal.

4.0 PROCEDURE FOR HANDLING OF COMPLAINTS

4.1 Receipt of Complaints

4.1.1 NABH is open to receiving complaints from any sources. The complaints can be
against applicant/ accredited HCO for the quality of service provided by them. The
complaint can be against personnel involved in accreditation process. The complaint
must be made in writing to Director with complete details of complainant (name,
address, organization etc.). If the complaint has no details of the complainant or the
description is not adequate, the Board will reserve the right of dealing with the

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Procedure for Handling of Complaints and Appeals – PROC_C&A

complaint as deemed fit. NABH can investigate the reports appearing in media, if
relevant.

4.1.2 A record is being maintained for the complaints that are received by NABH. The
important dates viz. date of receipt of complaint, date of acknowledgement and date
of final closure is being recorded in Complaint Register.

4.1.3 Once the complaint is received at NABH, an acknowledgement is sent to the

complainant with assurance of through investigation.

4.1.4 Initial scrutiny of the complaint is done by the designated officer. This is to determine
that the complaint falls within the ambit of NABH activities and whether the complaint
is valid.

4.1.5 If it is found that the complaint does not fall within the ambit of NABH, the complaint
is considered closed and the complaint is informed accordingly.

4.1.6 If the complaint falls within the ambit of NABH and the initial information provided in
the complaint is sufficient the complaint is investigated further.

4.2 Investigation of Complaints

The complaints received by NABH can be classified into three categories:
- Complaints against applicant/ accredited HCO
- Complaints against Assessors/Experts/ Committee members
- Complaints against NABH officials

4.2.1 Procedure for dealing with each category is given below:

4.2.1.1 Procedure for dealing with complaints against HCO

 On receipt of complaint against HCO, NABH would seek clarification from the
HCO giving them a time of 15 days to respond to the complaint.

 If the response is not satisfactory, NABH would depute an assessor/ expert to

investigate the matter.

 The assessor/ expert would place the findings of the investigation with his/ her
recommendation on action to be taken against the HCO to NABH.

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 If found necessary, Director may take further consultation with Accreditation

Committee before taking any action on the HCO.

 The action would be communicated to the HCO. The HCO would be required to
take corrective action in a stipulated time stated in the communication by NABH.
The HCO would be required to give necessary/ satisfactory documentary
evidence.
 In case the HCO is found to violate the Terms and Condition for Maintaining
NABH Accreditation or not cooperate with investigation process, the HCO may be
put under suspension/ withdrawal as per NABH procedures.

 The complainant shall be informed about the action taken by NABH.

 If the complaint is found invalid, the complainant as well as the HCO is informed
accordingly.

4.2.1.2 Procedure for dealing with complaints against Assessors/ Expert

 On receipt of complaint against assessor, NABH would seek clarification

regarding the complaint from:
- the HCO for which the assessment was done
- the other team member, if any
- any other person who may be aware of the matter in the complaint

 If it is necessary, NABH would send an independent assessor/ observer to the

HCO where the assessment was carried out to take first hand view.

 The feedback received earlier from the HCO/ principal assessor for this particular
assessor would be a source for taking action against the assessor.

 The findings from the above would be compiled so that the Director would take
appropriate step. Accreditation Committee may be consulted if found necessary.

 If the complaint is found valid, the assessor would be warned for his action. If the
complaint is of serious nature, the assessor may also be deleted from the
database of NABH assessors.

 The complainant shall be informed about the action taken by NABH.

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4.2.1.3 Procedure for dealing with complaints against NABH officials

 On receipt of complaints against NABH officials, Director would be informed, so

that clarification can be obtained from the official.

 The official, against whom the complaint has been received, is not involved in
investigation of complaints directly or indirectly.

 Information would be gathered from all sources regarding the complaint.

Independent person from the office would be appointed by Director to investigate
into the matter.
 If the complaint is found valid and of serious nature, Director would take
appropriate action as per rules.

 If the complaint is not of serious nature, Director can ask for corrective action
from the official.

 The complainant shall be informed about the action taken by NABH.

 If the complaint is against the Director, the matter will be brought to the notice of
the Chairman, NABH.

 If the complaint is against the Board, the matter will be brought to the notice of
Secretary General, QCI.

5.0 PROCEDURE FOR HANDLING OF APPEALS

5.1 Receipt of Appeals

5.1.1 NABH shall receive appeals from HCO against adverse decisions taken by NABH.
The appeals are generally addressed to the Chairman NABH.

5.1.2 Officer/ Director NABH shall acknowledge the receipt of appeals from the HCO.
Officer shall maintain record pertaining to all appeals including important details like
date of receipt, name and address of the HCO, details of appeals and outcome of
appeals in the ‘Appeals Register’.

5.1.3 The appeals shall be examined and if prima-facie they appear to be valid, they are
taken up for further actions, with approval of Director.

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5.2 Deliberation of Appeals Committee and Recommendations

5.2.1 Appeals Committee takes up the appeal for consideration. Representative from
Accreditation Committee involved in the decision appealed against, may provide
technical inputs. He/ she shall not be involved in the formulation of recommendations
of the Appeals Committee.

5.2.2 After examination of the appeal, the Committee shall seek clarification from all
appropriate sources. The Committee, if finds necessary, can depute NABH official/
an assessor or an expert to investigate the matter.

5.2.3 The Appeals Committee may recommend a fresh assessment. On the basis of fresh
assessment, the relevant accreditation committee shall give an independent view on
the status of HCOs’ quality management system and technical competence as well
as the subject matter of the appeal.

5.2.4 Based on the data gathered through any of the above means, the Appeals
Committee shall form its recommendations. The detailed report by the Committee
shall be submitted to the Chairman NABH within a reasonable time for his decision.

5.3 Decision on Appeals

5.3.1 Chairman NABH shall take a decision based on the recommendations submitted by
the Appeals Committee.

5.3.2 The decision of the Chairman NABH shall be final and HCO shall be informed
accordingly.

6.0 Financing the Complaint and Appeal Process

If the resolution of complaint/ appeal is done without undertaking any travel or

additional assessment, no financing will be needed for such resolutions.

If the resolution calls for undertaking travel and assessment, the cost will be borne by
the defaulting party.

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Procedure for Handling of Complaints and Appeals – PROC_C&A

7.0 RECORDS
NABH shall maintain Complaints Register and Appeals Register. The register has the
following:
- unique registration number given to each complaint/ appeal
- date of receipt of complaint/ appeal
- name & address of the complainant/ appellant
- date of acknowledging of the compliant/ appeal
- details of action/ investigation
- date of closure

The complaints & appeals file is maintained by designated officer. All

correspondence in respect to complaints/ appeals, investigation reports and
decisions by Director or Chairman are filed in order.

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