APPLICATION For ACCREDITATION OF SHCO

Issue No.: 02 Issue Date: April 2009

NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS

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NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS

Assessment criteria and Fee structure
Small Health Care Organisation
Pre-assessment Two man-days (2x1) Assessment Four man days (2x2) Surveillance One man day Application Fee Rs. 25,000/Annual Fee Rs. 1,00,000/-

NOTE: The man days given above for assessment and surveillance are indicative and may change depending on the facilities and size of the hospital.

Guidance notes:
1. 2. 3. 4. 5. 6. 7. 8. 9. Fees to be paid through Demand Draft/ local cheque in favour of Quality Council of India payable at New Delhi. Three copies of this application form duly filled in are to be submitted along with necessary documents and fees. Self Assessment Toolkit dully filled in is to be submitted by the SHCO along with the application form. The accreditation fee does not include expenses on travel, lodging/ boarding of assessors, which will be born by the hospital on actual basis. The application fee includes pre-assessment charges. The accreditation, once granted will be valid for three years, after which hospital may apply for renewal as per NABH policy. The first annual fee is payable after pre-assessment visit and before assessment visit. The surveillance visit will be planned during 2nd year of accreditation which is usually after 18 months. NABH may call for un-announced visit, based on any concern or any serious incident reported upon by any individual or organisation or media.

Definition:
Small Health Care Organisations (SHCO)
Those healthcare organizations having bed strength between 20 to 50 beds and are in possession of supportive and utility facilities that are appropriate and relevant to the services being provided by organization. Exclusions - Polyclinics - Diagnostic Centres - Superspeciality* centres (single/ multiple) Exceptions Speciality** Day Care centres (minimum bed strength not mandatory) * ** Super Speciality centres are the centres which reflect requirement of DM/ MCh or equivalent qualified personnel. Speciality centres are the centres which reflect requirement of MD/ MS or equivalent qualified personnel. 2

Kindly tick the appropriate box (Please refer definition on page 2):

You can apply under SHCO, if your answer to a & b is Yes OR if your answer to c is Yes.
a. b. Is your bed strength between 20-50 beds Yes No

Are you in possession of supportive and utility facilities that are appropriate and relevant to the organization. Yes No

OR c. Speciality Day Care centres Yes No

1.

Name of the Hospital: _______________________________________________________________________ Address: _______________________________________________________________________ _______________________________________________________________________

2.

3.

Ownership/ Legal Identity:

Is the organisation a public/ government establishment or an independent/ private sector provider?

_______________________________________________________________________ 4. Year in which established: _______________________________________________________________________ Contact person(s):

(Please indicate [] with whom correspondence to be made)

5.

Chief Executive Officer: (or equivalent) Mr./Ms./Dr. ___________________________________________________________ Designation: __________________________________________________________ Tel: ___________________________ Mobile: _______________________________ Fax: _________________________________________________________________ E-mail: _______________________________________________________________ Accreditation Coordinator: Mr./Ms./Dr. ___________________________________________________________ Designation: __________________________________________________________ Tel: ___________________________ Mobile: _______________________________ Fax: _________________________________________________________________ E-mail: _______________________________________________________________
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6.

Is the Hospital registered with Local Authorities:

(Where applicable as per the State Norms)

_______________________________________________________________________ 7. Number of Inpatient Beds: (number currently in operation) (please exclude emergency, day-care, recovery
room beds etc.)

_______________________________________________________________________ 8. OPD & IPD data: OPD DATA (Past two years) Period Number of Patients

IPD DATA (Past two years) Period Number of Patients Admitted

9.

Scope of Accreditation (Clinical services being provided by the hospital) Clinical Service Anaesthesia Burn Unit Cardiology Cardiothoracic Surgery Care of the Elderly Coronary Care Unit Day Care Treatment Endoscopy Day Care Treatment Bronchoscopy Dentistry Dermatology Service Provided? YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
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Number of Beds Available

Dialysis Emergency Medicine Ear Nose and Throat Fertility Gastroenterology GI Surgery General Medicine General Surgery Gynaecology Hyperbaric Medicine Intensive Care Unit adult Intensive Care Unit pediatric Intensive Care Unit neonatal Laser treatment Nephrology Neurology Neurosurgery Nuclear Medicine Obstetrics Oncology Medical Oncology Radiation Oncology Surgical Oncology Ophthalmology Oral Surgery Orthodontics Orthopaedic Surgery Plastic Surgery Paediatrics & Neonatology Paediatric Surgery Palliative Care Preventive Health Screening Clinics Rehabilitation

YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO
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Respiratory Medicine Surgical ICU Tissue Bank Transplantation Services Urology Others, please state

YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

10. Scope of Accreditation (Diagnostic Services being provided by the hospital)

Diagnostic Service In House Serves other organisation Out sourced

Diagnostic Imaging: CT Scanning DSA Lab MRI PET Gamma Camera Ultrasound X-Ray Laboratory Services: Clinical Bio-chemistry Clinical Pathology Haematology Clinical Microbiology & Serology Histopathology Cytopathology Genetics Molecular Biology Blood Bank Blood Transfusion services YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

Pharmacy: Dispensary Manufacturing Total Parentral Nutrition Professions allied to medicine: Dietetics Physiotherapy Occupational Therapy Speech and Language Therapy Ambulance Service Social Work YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO YES/NO

11. List Impatient Care Units/ Wards, the Number and The type of care given on each Unit/ Ward. Name of Unit/ Ward Number of Beds Type of Care Given Floor/ Location

Name of Unit/ Ward

Number of Beds

Type of Care Given

Floor/ Location

12. List Ambulatory/ Out Patients Units, the number of visits and the Type of Service Name of Ambulatory/ Out Patient Unit of Clinic Average Visits per month Type of Service

13. Non clinical and Administrative Departments Support service Catering Cleaning services General Administration Laundry Management of clinical waste Management of nonclinical waste Mortuary Services Occupational Health Patient Advisory Service Security Technical Department/ Equipment Management Other, please specify In House Serves other Organisations Out sourced

14. Staff Information (append the list for all ) Group Managerial Doctors Resident Doctors Consultants a) Full Time b) Part Time Nurses Technicians Paramedical Others Number Remarks if any

15. Furnish the list of applicable Statutory/ Regulatory requirements the organisation is governed by: ________________________________________________________________________ ________________________________________________________________________

16. Litigation, if any: ________________________________________________________________________

17. Date of last Self-assessment: ______________________________________________

18. Date of Implementation of NABH standards:

(Hospital shall apply at least 3 months after implementing NABH standards)

19. Terms and Conditions for maintaining NABH accreditation submitted: Yes

No

20. Declaration by SHCO:

We hereby declare that: we are familiar with the terms and conditions of maintaining NABH accreditation (NABH-T&C) we agree to comply fully with NABH Standards for Small Health Care Organisations we agree to comply with accreditation procedures, pay all costs for pre-assessment, assessment, verification visit (if any), surveillance and reassessment irrespective of the result we agree to co-operate with the assessment team appointed by NABH for examination of all relevant documents by them and their visits to those parts of the SHCO that are part of the scope of accreditation the information given in the application form is correct.

21. Date Application Completed: _______ Day _____ Month ______Year

Authorised Signatory Name: ___________________________ Designation: ______________________

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