NationalAccreditationBoardforHospitalsandHealthcareProviders (NABH)

DREAMDIGITALIZATION
TORforPortal developmentof NABH LastdateforSubmission:30thofMarch2011

AbbreviationsUsed AYUSH:Ayurveda,YogaandNaturopathy,Unani,Siddha,Homoeopathy DD:DemandDraft FA:FinalAssessment FAQs:FrequentlyAskedQuestions HAF:HospitalAssessmentForm HCO:HealthCareOrganizations ID:IdentificationNumber ISQua:InternationalSocietyforQualityinHealthCare NABH:NationalAccreditationBoardforHospitalsandHealthcareProviders PA:PreAssessment PACA:PreAssessmentCorrectiveAction PAF:PreAssessmentForm PPT:PowerPointPresentation QCI:QualityCouncilofIndia SHCO:SmallHealthCareOrganisation SMS:ShortMessagingService

ScopeforDreamDigitalizationProjectForNABH NABH has a large volume of applications and needs to move on to an efficient online method of tracking applicants, managing the accreditation process and providingamoreefficientmethodforassessorsandfinallyprovideaccountability datatoNABHsecretariatandcommitteemembers. ObjectiveistodesignanddevelopaPortalhavingcompleteworkflowautomation andknowledgebaseforallitsinternal&externalstakeholderslike GeneralPublic Applicants HealthcareOrganization NABHAssessors NABHSecretariat GovtAgencies Consultants National Accreditation Board for Hospitals & Healthcare Providers (NABH) standards.NABHcurrentlyprovidesaccreditationtothefollowing: Hospitals SmallHealthCareOrganizations(SHCOs) BloodBanks WellnessCenters AYUSH(5subprogramsAyurveda,YogaAndUnani,Siddha,Naturopathy, Homoeopathy MedicalImagingServices DentalCenters PrimaryHealthCenter/CommunityHealthCenter Clinics

Navigationflow **

A1GeneralInformation
FAQs EducationMaterial ListofAccreditedHospitals Accreditationstatus/scope Feedback/enquiry Updates/events News/pressrelease Services/products/trainingcalendar Usefullinks

A2PotentialApplicants
FAQs Registration(formdetailing) Aboutus/IntroductiontoNABH

A3ApplicantHCO
Downloadsforms/Terms&conditionsetc UploadingorOnlinesubmission Acceptance Scheduling Preassessment Assessment Verification Surveillance ReAccreditation

ATR&Feedback

A4AccreditedHCOAllA3pointsand:
QualityIndicators/trends/Projectsetc

A5Assessors:
Application UploadingandOnlinesubmission Training/Certification Observership Credentialing Appraisal Renewal/AdditionalCredentials Form16A ChangeofStatus Feedback Reporting

**MorecontentscanbecollectedandaddedduringSRSphase

Userroleswithdifferentprivileges
Stakeholders are divided into 4 groups and exclusive login ids and passwords will be assigned to the members of each group. The access to information will be group specific.Variousgroupsare: 1. 2. 3. 4. 5. 6. 7. HCOs Assessors Committeemembers Boardmembers NABHsecretariat Limitedaccesstoconsultants(eg.Todashboard) LimitedaccesstoGovt.agenciesforGovt.projects

Methodology
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. SoftwareRequirementsSpecification(SRS) Designing&development UserBetaEvaluation Finetuningandinstallation Training UAT(UserAcceptancetesting) Finetuning&issueresolution Golive Dataentryforoldrecords Softwaremaintenanceandupgradation Databackupandsecurity

12. Sourcecodeofprogramme

1. SoftwareRequirementsSpecification
1.1 To digitalize the documentation of NABH (to start with hospital accreditation programme) for effective documentation and management withtheaimofmaintainingminimalmanualrecords. Tohavethebasicsoftwarekeepinginmindfuturerequirements(scalable). Toaddressrequirementsfromassessors,committeesandsecretariatpoint ofview. To effectively disseminate information among all concerned in NABH secretariatandassessors. Toaddressandtrackclinicalindicators. Tomaintainandtrackassessorsdatabase,performanceandfeedback. For knowledge sharing among assessors, committees and HCOs (applicant andaccredited).

1.2 1.3 1.4 1.5 1.6 1.7

2. DesiredFeaturesForSystemArchitecture 2.1 Systemarchitecture

Theproposedsystemistobeawebbasedsystembuilttoservetheusers spread over the internet and intranet. The serverside will host the web enabled database for serving data. Typically, the users may request information from an Internet server holding the data repository and uploaddocuments.Thentheserverwillprocesstherequestandsendthe informationbacktotheusers.Theservercomponents,i.e.thewebserver orapplicationserverandthedataservershouldformapartoftheserver architecture.

Only authorized NABH staff should have access to the server application or database. This architecture may have to be developed specifically for internet applications for publishing secure data. It may be designed to handle intranet sites and should scale to meet server capacity needs as websitedemandincreases.

We may need following servers, but this should not be considered as completelist i. Webserver/applicationserver ii. Databaseserver iii. Backupservers iv. Firewallandloadbalancer

2.2 Desiredfeaturesfordocumentsandcontentmanagementsystem
i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. xiv. xv. xvi. xvii. xviii. Robusthighlyavailablewebportal Document/contentmanagementsystem General information on common site for all, and specific information resourcepagesformembers,HCOsandassessors. Provisionforsuggestionanddiscussionongeneralpage Onlineregistrationandaccessforcommitteemembersandsecretariat,HCOs andassessors Onlineforms(convertfromphysicalforms) Onlineapplication,selfassessmenttoolkit,documentssubmission Onlinepaymentsystem Searchabledatabaseofusers,hospitals,assessorsetc. Mailmergesystemtoautomaticallysendemailstonotifyonactionspending. DataofclinicalindicatorsofHCOs. Documentation(trainingmanuals,onlinehelp,videos,FAQsetc.) AudittrailforeachHCOaspertheiruniqueIDnumberbyNABHsecretariat. Onlinetrackerforapplications(applicationformstatus) Automatedupdationoflistsofnewregistrations,paymentsreceivedetc Provision to compare ratings of present and past assessments/self and pre assessments. Mail/SMSandonlineAlerts(whenloggingin,therecanbeapagewithalert andalerthistoryfortheuser). Onlineentrybyassessorsforassessment(pre,final,surveillance,verification, reassessment)checklistonline Second and Third year Fee Reminders: Mail alert to HCO for submission of therequiredannualaccreditationfee Maintainandtrackassessordatabase,performanceandfeedback.

xix.

xx. ResourcePagesforassessors,HCOsrefertopageno.14 xxi. Dashboardfordetailsrefertopageno.13. xxii. DocumentandworkflowManagement a) Multipleusersshouldbeabletoviewthedocuments. b) During the assessment process the documents can be viewed by multiplepeoplebasedonrole.Similarly,editingprivilegewillbebased onrole. xxiii. Complaints record/documentationkind of complaint, resolution, time withinwhichcomplaintresolved xxx.Followup Surveillance visit: NABH and HCO gets an alert 2 month before the surveillance visit. Hospitals upload the updated documents, if any. NABH getsanalertforthesame.

Reassessment:SystemwouldprovidevariousalertstoNABHandHCOforre assessmentsevenmonthsbeforetheexpiryofaccreditation

Feedbackforms.FlagRepeatnoncompliances.Analytics

3.

TrainingtoNABHstaff
3.1 Regardingsoftwareusage 3.2 Smalltechnicalerrorstomanage

4. HelpDeskforNABH
A telephone number/e mail for Helpdesk to be made available to NABH at all times. Problems associated with the Software and related documentation. All issuesareprioritizedandassignedaccordingtotheseverityoftheissue.

Issueclassification
NABHs request for services will fall under one of the following categories. All issues reported to Customer Support are classified and directed to the appropriate team for response and resolution. This classification is used to set expectationsregardingtheresponsetime.

10

Impact Fatal

Description

Definition

ResponseTime

Application (Severity1) Unavailable Critical Severelossof (Severity2) functionality Important Individual (Severity3) functionalitynot working Minor Designor (Severity4) documentation problem

Operationshalted,usersarenotable Within4hours tocompletetheircriticaloperations andnoworkaroundisavailable Keyoperationalfunctionscannotbe performedonthelivesystemasa result. Individualfunctionalitynotworking resultinginminordegraded operations. Within8hours

Within24hours

Basedonmutual Issueisdocumentationrelatedor hasminimalimpactonoperations.or agreement hasaworkaround,i.e.anotherway ofcompletingtherequiredtask.

AccreditationProgrammeProcessFlow
NABH standards and guidelines can be purchased and downloaded online by making necessarypayment.

Submissionofapplicationanddocumentation
1. Theapplicationformshouldbeavailableonlineandcanbefilledonline.However theoptionofsendingapplicationbypostwillremain.Forthepaymentdetails(itis also proposed to have online payment option). Scanned signature of HCO representativemaybeallowed. Auniqueid/registrationno.andpasswordisautogeneratedwhentheapplication formisacceptedonline.Thisisusedbythehospitaltologintoitsaccountforany future correspondence. The hospital is in a pending state until the secretariat acceptsthepayment.Statusoftheapplicationisdisplayedonthesiteandalerts senttoHCOandNABH.

2.

11

3. 4.

If the payment is made online an auto generated payment received alert will be sendtoNABH. Ifpaymentisnotmadeonline,theHCOtakesaprintoutoftermsandconditions and writes the application no., sign it and send a hard copy to NABH secretariat alongwiththecheque/DD.NABHtoconfirmpaymenthasbeenreceivedemail notificationofpaymentreceivedconfirmation. The hospital is in a pending state until the secretariat accepts the payment. StatusoftheapplicationisdisplayedonthesiteandalertssenttoHCOandNABH. All mandatory columns to be filled before uploading application form (esp. paymentdetails.Thetermsandconditionsdocumentistobemodifiedtoincludea columnforapplicationno.andstatethatapplicationno.hasbeenelectronically submitted. TheHCOisthenaskedtosubmit/uploadtheselfassessmenttoolkitthroughtheir ID. Documentssubmission a) Against each standard HCO should provide supporting documentation to confirm to the standards. Documents may be uploaded (Supporting documentscanbeheavyfilesinvariousformatspdf,word,excel,ppt,etc.) or sent by post. Scrutiny of documents sent by the HCO is done at NABH office, and the status of documents is displayed online (Complete/Incomplete). A list of documents is displayed online, with the documentsreceivedshowingatickmarkagainstthenameofthedocument.

5. 6.

7.

8.

b)

AnalertisalsosenttoHCO.Oncedocumentationiscomplete,alertissentto NABH. Thedocumentsareuploadedchapterwiseandthesamearemadeavailable to the designated assessors. The designated assessor should be able to review the documents for its adequacy and enter the comments if any and the HCO and the secretariat will be alerted of the same. The HCO also uploadsthelistofstatutoryrequirements,thestatusandexpiryifapplicable. HCO has the responsibility to notify NABH that they are ready for pre assessment.

c)

12

Preassessment

Selection of assessors based on geographical location and qualification from assessors list. Software should provide assessors details like number of assessments done, category (Principal Assessor, Assessor, Trainee Assessor) grades, present assignments/assessments to be undertaken by date etc. are displayed.AlertsaresenttoAssessorsandHCOs. The assessors for PA are chosen and they are given access to the required documentsbytheNABHsecretariat(theycanaccessthroughtheiruniqueidsand password). 2. Finalized dates for PA are uploaded by NABH secretariat, and alerts are sent to assessorsandHCO. 3. Softwareensuresrolebasedaccess,privileges 4. BeforetheonsitepreassessmentanofficialemailandsmsalerttobothHCOand assessorsontheupcomingvisit. 5. The PA form for assessors use is available for downloads and uploads on their resourcepage. 6. Oncetheonsiteassessmentisdone,theonsiteassessorswillsubmitaPAreport which the HCO will have to respond to. The PA report outlines any deficiency, corrective action, objective evidence, and Principal assessors comments. The assessmentteamwilluploadthereport,andanalerttoHCOandsecretariatwillbe sentindicatingthatthePAreportisreadyforviewing. 7. HCO will need to submit a PACA report. The due date of this report is discussed duringthesitevisitandtheprincipalassessorwillenterthedateintothesoftware. TwoweeksbeforetheduedateanalertissenttotheHCOandNABHsecretariat. At this point if the HCO wishes the secretariat can change the due date of the report. An email to confirm the change in date will be sent automatically to the HCO. 8. The principal assessor also uploads the team feedback form on the assessors resource page. Similarly the HCO submits the feedback forms about the team to NABHsecretariat. 9. TheHCOuploadsthepreassessmentcorrectiveactionreport(PACA). 10. Mail and sms alerts to assessment team for review. Automatic alerts are sent to theteamaftersevendaysiftheassessmentteamfailstouploadtheircomments. 11. The assessors review the report and upload their individual comments and principalassessor,theconsolidatedcomments. 12. MailalerttoNABHsecretariatandinturnmailalerttoHCOtoviewthecomments online.

1.

13

FinalAssessment
1. Theassessorsforfinalassessmentarechoseninthesamemannerastheyarefor PA,andtheyaregivenaccesstotherequireddocumentsbyNABHsecretariat(they can access through their unique ids and password). At least one of the member (preferably the Principal Assessor) from the preassessment team will be part of theassessmentteam.Alertsaresenttothechosenassessors. The assessor downloads the required forms and format from the assessors resource page and uploads them back after filling them. Also HAF 3 & 4 which needstohaveahardcopydulysignedalongwithscopeofservicesdocumentand undertakingbythehospitalforcomplyingwithallapplicablerulesandregulations. The following reports must be available for each assessment: score sheet, travel form. Score sheet will be entered by all team, each report should calculate the average(autocalculation). The principal assessor also uploads the team feedback form. Similarly the HCO submitsthefeedbackformsabouttheteam. MailalerttoNABHforFAreportandfeedbackforms.MailalerttoHCOforviewing theFAreport. TheHCOuploadsthefinalassessmentcorrectiveactionreport. Mailalerttoassessmentteamforreview. The assessors review the report and upload their individual comments and principalassessor,theconsolidatedcomments. MailalerttoNABHsecretariatforthesame. Whenever there is any update (by any stakeholder) the system administrator at secretariatwillgetanautomatedmailalertwiththedetailsofpersonuploading. HCOateachstageshouldknowstatusandalsoreceiveanalertbyemailandinthe system,secretariatwillchangethestagesforinformationpurposes

2.

3. 4. 5. 6. 7. 8. 9.

ReviewbyAccreditationCommittee
1. Theaccreditationcommitteeaccessesthefinalassessmentreportsandcorrective action reports with the help of the unique ids and passwords provided, once the noticefromNABHsecretariatissent. Based on FACA report Accreditation committee decides the Accreditation level (Accredited or Preaccreditation Entry or Preaccreditation Progressive levels) on compliance to standards and scoring. Chairperson will authorise release of final recommendations.

2.

14

3. 4. 5.

AlertissenttoNABHSecretariat NABHupdatestheresultsonHCOsresourcepageandsimultaneouslyemailalertis senttotheHCO. HCOs name is displayed online in the list of hospitals (Accredited or Pre accreditationEntryorPreaccreditationProgressivelevels).

Entryandprogressivelevelaccreditation
1. 2. 3. 4. 5. Three monthly alerts to those HCOs who are in Entry and progressive level for furthercorrectiveactionandtimeperiod. Entry and progressive level HCOs upload Corrective actions along with the evidences. AlertsaresenttotheAccreditationcommitteeandNABHsecretariat. If accreditation committee wants verification then alert is sent to the NABH secretariat. NABHsecretariatfinalizesthedatewithassessors. EmailalertissenttoHCOs,assessorandaccreditationcommittee

6.

Verificationassessment
1. 2. Verificationreportisuploadedbyassessors. EmailalertissenttoHCOs,NABHsecretariatandaccreditationcommitteetoview.

SurveillanceVisit
Surveillancevisitiswithin18monthsfromtheaccreditationdate 1. NABHsecretariatgetsareminderalert2monthbeforethesurveillancevisit. 2. Hospitalsuploadtheupdateddocuments,ifany.NABHgetsanalertforthesame. Surveillance onsite visit check what improvement, HCO will need to upload variousindicatorsandreports. 3. TheHCOshouldsubmitdetailspertainingtoinputsregardingadditionoffacilities, infrastructureaddition/modificationandalsotocapturethevariousimprovement activitiescarriedout.

15

Theassessorsforsurveillanceassessmentareassignedandtheyaregivenaccessto therequireddocumentsbyNABHsecretariat(theycanaccessthroughtheirunique idsandpassword). 5. The assessor downloads the required forms and format from the website and uploadsthembackafterfillingthemexceptHAF3&4whichalsoneedstohavea hardcopydulysignedalongwithscopeofservicesdocumentandundertakingby thehospitalforcomplyingwithallapplicablerulesandregulations. 6. The principal assessor also uploads the team feedback form. Similarly the HCO submitsthefeedbackformsabouttheteam. 7. Mail alert to NABH for surveillance assessment report and feedback forms. Mail alerttoHCOforviewingthesurveillancereport. 8. TheHCOuploadsthesurveillanceassessmentcorrectiveactionreport. 9. Mailalerttoassessmentteamforreview. 10. The assessors review the report and uploads their individual comments and principalassessortheconsolidatedcomments. 11. MailalerttoNABHsecretariatforthesame.

4.

ReAssessment
NABHgetsanalertforreassessmentsevenmonthsbeforetheexpiryofaccreditation. HCO also gets an alert for reassessment seven months before the expiry of accreditation mentioning that it is required to submit the application form along with theapplicationfeesandallNABHrelateddocuments,sixmonthsbeforetheexpiry.

DashBoard

Thedashboardwillhavethefollowing:

16

1.

Committees
Nameandcontactdetailsofthemembers,committeeToR,minutesof meetingsandmeetingscheduleofthefollowingbodies: i. NABHgoverningbody ii. Accreditationcommittee iii. Technicalcommittee iv. Appealscommittee

2. Eventscalendar
Datesoftheupcomingassessments,conclaves,eventsetc.Colourcodingforall theseeventsmaybeused.

3.

Trainingprogrammes
Detail information about the programme specification of the trainings and workshops.

4. KnowledgeCentre
A knowledge centre can be created as part of the web portal for research and buildingawarenesstotheinternationalcommunity.Additionalinformationmaybe maintainedthatisofbenefittoNABHmembersandsometothegeneralpublicor topotentialNABHmembers. It may include ISQua international standard, National or International guidelines best practices, international Audit reports, international conferences technical reports/presentations, journals, accreditation procedures and system of other countries, clinical journal of relevant programmes, and rules and regulations like NBC,AERBetc

5. Quality/ClinicalindicatorsofaccreditedHCOs
The system will support NABH approved clinical indicator data for all the accreditedhospitals. HCOs will upload their clinical data on a prescheduled frequency and simultaneously auto calculation will be done by software (formulae for the indicatorsshouldbeinthesoftware).

17

Quality Indicators to be monitored by HCOs: (at present but with a provision of additionalindicators) 1. Percentageofmedicationerrors 2. Percentageoftransfusionreactions 3. Urinarytractinfectionrate 4. Respiratoryinfectionrate 5. Intravasculardeviceinfectionrate 6. Surgicalsiteinfectionrate 7. Incidenceoffalls 8. Incidenceofbedsoresafteradmission 9. Bedoccupancyrateandaveragelengthofstay 10. Incidenceofneedlestickinjuries

6. RequirementsfromISQuaandotheraccreditationbodiestobeincorporated 7. Resourcepagesfortheassessors,HCOs
7.1 Assessorresourcepage i. Listofactiveassessorsareawiseandcontactdetails,qualification,number ofassessmenttobedone,performancelevel ii. Formsanddocuments iii. Uploadingnews iv. Sharinggoodpractices v. Variousguidelines vi. Provisionfortheassessorstosendqueriestothesecretariat vii.OnlineDiscussionpanelsforknowledgesharing 7.2 HCOresourcepage i. ProvisionfortheHCOtosendqueriestothesecretariat ii. ProfilesofHCOscontainingtheirdetailsrelatedtoaccreditationprocess

18

Accreditationtimeline:
(Oncethesoftwareisimplemented)

Recommended prior steps are (1) Obtain a copy of NABH standards & guide book (2) Attend NABHawarenessprogramsconductedbyQCI Duration (Days) Day Zero Requirements on Requirements on the part of Requirements on the Total thepartofHCOs NABH partofAssessors line Submission of application (along with fee amount) + self assessment toolkit + documents Within (1) Receive and write a letter of 7 7Days acknowledgement to HCO along withuniquerefno. (2)Reflectsameonwebsite Within Reviewofapplication 17 10Days And documents for completeness and appropriateness. Askformoreinformationfrom HCO,ifrequired 7Days Ask for suitable dates for PA 24 fromHCO Approvalofassessmentteams. Information to accounts dept about approved team of assessors Within Preassessmentscheduling 30Days 7Days Sendapplicationand 30 documents/Accessgivenby NASBHofficetoassessorsfor Preassessment 10 (1)Sendcommentson 40 documentstoNABH andHCO. (2)Informifanyextra requirement time

19

12

Pre assessment

Preassessment The assessment team will compile and submit / upload the report and an alert to HCOandNABHwill be sent indicating that PA report is readyforviewing.

45

Within 60

Receive pre assessment reportatHCO Take corrective action and send report to NABH secretariat

Receive pre assessment report atNABHsecretariat

50

110

AlertcomestoNABHand assessorforcomment Reportsenttoassessor

5 10

10 7 3to5 5

Final assessment

Ask for suitable dates from HCOforFA Finalassessmentscheduling Assessmentteamwillcompile andsubmit/uploadthereport offinalassessmentandan alerttoHCOandNABHwillbe sentindicatingthatFAreportis readyforviewing.

Alert comes to NABHandassessor forcomment Feedback on corrective action taken report to NABH by Assessor and Principal Assessor Finalassessment

115 125

135 140 145 150

Within 90 Takecorrective days actionandsend

240

20

reportonFA, asdiscussedand decidedbyHCO andassessor duringFA

Alert comes to NABH and assessorforcomment Receivecorrectiveactiontaken reportonFAfromHCO Forward corrective action takenreportonFAtoassessors

Feedback on corrective action taken report to NABH by Assessor andpriAssessor Review on FA CA and send commentstoNABH

245

250

15

Alert to AC members with uniqueidnotoviewthereport online / Submit the compiled report to accreditation committee Review by accreditation committee The accreditation committee accesses the final assessment reports and corrective action reports with the help of the unique ids and passwords provided Award of accreditation by committee

255

270

Verification visit (if needed)

AsandifdecidedbyAC

Within 7 days from AC meeting

Surveillance visit within 18 monthsofaccreditation

Surveillancevisit

21