Abstract of Dissertation

Keyword : Entry Level Pre- Accreditation; NABH Standards; SCHO; Gap Assessment; Self- Assessment tool kit

Objective : • To identify gaps as per the NABH pre-accreditation entry-level hospital standards for SCHOs. • To compare the compliance of SCHOs for entry-level pre-accreditation NABH standards, before and after obtaining entry-level pre-accreditation NABH certification. • To give suggestions and recommendations for filling the gaps in SCHOs, in accordance to pre-accreditation NABH entry-level standards

Background : The quality of care and patient safety are the central principles in healthcare. To maintain the quality of healthcare organization in India, NABH was established in 2006 as a constituent board of Quality Council of India. There is a total of 105 standards and 686 objective elements in NABH, fourth edition 2015. Healthcare organizations in India that are below 50 beds, also known as Small Healthcare organizations (SHCOs), between 50-100 beds and above 100 beds large multispecialty hospitals. As around 90% of healthcare organizations are SCHOs and as they cater to a huge population because of its easy reach, their accreditation was necessary as an important step for quality patient care. The standards and objectives elements of full NABH accreditation is quite difficult for these SHCOs to implement at first, so entry level Pre-accreditation NABH standards were developed to help small healthcare organizations to easily achieve this objective element of NABH which is just 25% of full NABH accreditation, having only 41 standards and 149 objective elements. The previous studies show that the journey of quality began long back in the US, ASQua, etc. were all established to set standards for healthcare organization for continuous quality improvement. Also, previous studies indicate how accreditation improves the hospital’s clinical as well as financial outcomes. In India, since a majority of Hospitals are SCHOs, no much literature is found on the level of compliance of these SCHOs to the standards set by NABH for entry-level pre-accreditation. Keeping this research gap in mind, this study was done.

Methodology : The study was a descriptive cross-sectional study, conducted in Delhi and nearby regions for a duration of three months. For this purpose, 12 SCHOs were selected by convenience sampling technique, out of a total of approximately 60 projects. The data was collected using SCHO entry level self-assessment toolkit, to do the gap assessment in SHCOs. The 12 SCHOs was grouped into four stages for ease of study on the basis of the time period between the filling of application form for entry level to the actual assessment. The result shows that those SCHOs which have just filled an application form for entry-level NABH, are least compliant, while those SCHOs who have just 4-5 months to undergo actual pre-accreditation entry level NABH for entry level, was less compliant as compared to those SCHOs which have just 4-5 months for the actual assessment. The reason for low compliance and increased partial compliance is that these SCHOs which obtained NABH certification did not implement the standards they have documented. The study gives a conclusion that the SCHOs are not having a serious approach towards quality and accreditation. Those who received pre-accreditation NABH certification become complacent and ignore the need to continuously improve the quality. The recommendations and suggestions for the same were given to study.