Latest Notifications Issued by NABH on Hospital Accreditation Standards
NOTIFICATION FOR SMALL HEALTH CARE ORGANIZATIONS
NABH has started implementation of 3rdedition accreditation standards for SHCOs w.e.f. 1st March 2023.
In view of multiple representations received from various stakeholders and our endeavour to continue conducting comprehensive assessments of SHCOs, NABH has decided to increase number of man-days for conducting the mid-term surveillance assessments of SHCOs under 3rd edition, from current 1*1 (1 assessor for 1 day) to 2* 2 (2 assessors for 2 days) with immediate effect.
There shall be no change in the number of man-days for final and re-assessments of SHCOs.
NOTIFICATION FOR FEEDBACK ON 5th EDITION ACCREDITATION STANDARDS FOR HOSPITALS
NABH will soon be initiating drafting of 6th edition of Hospital Accreditation Standards in accordance with ISQua EEA Guidelines. You are requested to give feedback on the current NABH Standards i.e. 5th Edition. Your feedback/ inputs will add value in developing new edition of Hospitals standards.
Quality Council of India (QCI) is an autonomous body under the Department for Promotion of Industry & Internal Trade (DPIIT), Ministry of Commerce & Industry, Government of India. QCI is the apex national body and provides accreditation and other related services through its constituent Boards viz. National Accreditation Board for Certification Bodies (NABCB), National Accreditation Board for Testing and Calibration Laboratories (NABL), National Accreditation Board for Hospitals (NABH), National Accreditation Board for Education and Training (NABET), National Board for Quality Promotion (NBQP).
Training and Capacity Building (TCB), an independent Cell under the ambit of QCI has been regularly conducting trainings for the laboratories, TIC Sector, and industries
Latest training program details of TCB are given below:
Good Clinical Laboratory Practices (GCLP)Workshop on International Standards ISO 15189:2022 from 23rd – 25th March 2023
GCLP outline the basic principles and procedures to be followed by clinical/diagnostic laboratories involved in patient care or clinical research so as to provide highly reliable, reproducible and auditable results, which contribute to good patient care and promote a positive attitude from a patient’s perspective.
This GCLP workshop is designed to offer comprehensive guidance for those who are implementing GCLP/ISO 15189:2022 in their medical laboratories and a special session on Quality System and QA/QC in Molecularbiology Laboratory Testing included in this workshop
Only those from accredited (NABL/NABH) medical laboratories or preparing for accreditation or planning to take up a career in medical laboratory accreditation with ISO 15189:2012/2022 and Clinical Research Organization (CRO)’s laboratories (human clinical trials), are encouraged to participate in this workshop
Basic principles of the GCLP and their relation to patient care services or clinical research.
Implementing GCLP essentials to establish a quality system and its maintenance.
Gaps between ISO 15189:2012 and ISO 15189:2022, and implementing new standards
Overview and essentials of ISO 15189:2012.
Overview and essentials of new standard – ISO 15189:2022.
Overview and essentials of NABL-112 guidelines document.
Overview and essentials of ICMR-GCLP 2021 guidelines.
Special reference to the following key components: o Quality System Essentials (QSEs). o Establishment, management and monitoring of quality system. o Quality indicators and continual improvement. o Issues with EQAS/PT, Issues with facility operation. o Internal Quality Audit (IQA) – common NCs and its closures. o Lab accreditation associated challenges and overcoming the challenges. o Biosafety and infection control. o Quality system and basic requirements in Molecularbiology Laboratory Testing/Assays – International standard. Workshop activities include didactic lectures, interactive sessions, group discussions/exercises and case studies. The faculties from national and international settings will facilitate the program.
Registration: The participants can register for the program by paying Rs. 3,500/- and the payment can be done by scanning via net-banking or GooglePay to the following bank account: Account No. 1248135000009037, Account Name: SDC Microbiology CME, Bank: Karur Vysya Bank, IFSC Code: KVBL0001248, Branch: PH Road, Chennai-600077
The workshop is restricted to 60 slots and the registration will be done on “first come-first served basis”. For online registration, the following link has to be used: https://forms.gle/yASYBXXqKnp7NmdN8. Out station participants need to book accommodation on their own
Venue: Decennial Hall, Saveetha Dental College and Hospitals Campus, Saveetha Institute of Medical and Technical Sciences (SIMATS), Deemed University, Chennai-600077.
Contact: Dr. Pachamuthu Balakrishnan, Department of Microbiology, Centre for Infectious Diseases, Saveetha Dental College and Hospitals, Saveetha Institute of Medical and Technical Sciences (SIMATS), Deemed University, Chennai-600077. WhatsApp/Mobile: 7667444221, Email: GCLPSAVEETHA@gmail.com
LATEST NOTIFICATION FROM NABH ON IMPLEMENTATION PLAN OF 3RD EDITION OF NABH SHCO ACCREDITATION STANDARDS
Announcement from NABH
NABH has released a notification on implementation of 3rd Edition of NABH SHCO Accreditation Standards.
Key information from the notification is shared below :
The 3rd Edition of NABH SHCO Accreditation Standards along with the Guidebook has been released on 31st August 2022.
The effective date of Implementation of the third edition standards for SHCO would be as below:
a. All accredited SHCOs must be in full compliance with third edition by 1st March 2023 and shall submit the documentary compliance for the same by this date. The onsite compliance shall be verified during next on-site assessment (which can be either surveillance or renewal assessment).
b. All the assessments (Pre, Final, Renewal, Surveillance) shall be based on Third Edition w. e. f. 1st March 2023.
c. For all the assessments before 1st March, 2023, decision shall be based on Second Edition. However, such SHCOs would require to comply with the Third edition in next six months from the date of accreditation.
d. NABH will not accept any application (New as well as Renewal) on Second Edition Standard after 31st December 2022.
The whole process of transition will be completed 1st September 2024.
6th Annual Conference of the Association of Practising Pathologists, India (PATHCON & Lab Expo 2022)
Pleasure to invite you all to “6th Annual Conference of the Association of Practising Pathologists, India (PATHCON & Lab Expo 2022), which is going to be held virtually on 17th (Saturday) December 2022 & in Hybrid mode at The Hotel Vivanta by Taj, Dwarka, New Delhi on 18th (Sunday) December 2022. This conference will bring together all of us who have put in a lifetime of effort to bring this association to this landmark event.
Date:17th (Saturday) December 2022 – VirtualMode Date:18th (Sunday) December 2022 – HybridMode
Participants will learn of the rapid development and spread of technical advancement in recent years, the people who made this possible and the necessary equipment, regulations and other requirements for setting up new centres. The scientific program will cover the latest developments in all disciplines of Lab medicine. The emphasis will be on interactive sessions and panel discussions with clinical colleagues to encourage active participation of all delegates. We hope the students and residents will benefit from the experience of their colleagues and teachers and gather encouragement from the pioneers in research. Several well renowned speakers have confirmed their active participation, and this will add to the academic benefits of this conference. Save the dates in your diary today. We look forward to greeting you in what promises to be an exciting and fruitful meeting with a high scientific standard.
Keeping in mind the interest of our young participants, we shall be inviting posters and abstracts for oral presentation from all across the country and details are available on the website.
This year the venue which we have finalised is situated in Dwarka, New Delhi which is well connected all across Delhi & NCR through Delhi metro and other modes of transportation. It is just 3.5 Kms away from the IGI Airport. Delhi has a wide choice of hotel accommodation for different budgets. Kindly make your arrangements for travel and stay well in advance. The weather in Delhi in December is cool and pleasant, though light jackets may be required in the evenings. The organising committee welcomes all delegates to avail the discounted early registration rates and actively participate in this landmark event in the history of our Association. Delhi is a historical city & always been a centre of power with many monument, multiple cuisine restaurants & it is a shoppers’ paradise and very well connected by road, rail and air to all major cities of India.
> Abstracts for Oral Presentation/Poster Presentation are to be submitted online through the conference website only. > You need to register yourself on the online portal for submission of the abstract. You can make the registration payment later, but submission of relevant information is must. > The presenting author MUST be registered for the conference. > The number of papers to be accommodated are limited. You can indicate your preference during submission (oral/poster). Some abstract requests for Oral presentations will be shifted to the poster section. Case reports, unless carrying a very novel message, will not be considered for oral presentations. > It is mandatory that the Presenting author is registered for the conference to be eligible for presentation and for awards. > The cut-off date will be 31 Oct 2022 by 1700 hrs. No abstracts will be considered after this Deadline. > Abstracts will be listed on the conference website by 10 Nov 2022. The abstract is restricted to a maximum of 300 words. It should include: Objectives, Methods, Results, Conclusions, and Keywords. > One participant may submit upto 3 abstracts, and only one abstract would be considered for Oral Presentation.
National conference on Strengthening Medical Product Safety Surveillance
IPC in association with Ruby Hall Clinic, Pune is organizing a national conference on “Strengthening Medical Product Safety Surveillance” on November 12, 2022 at Sheraton Grand Hotel, Bund Garden Road, Pune- 411001
HIV Testing and Counselling Training (HTCT) Certification program
The forthcoming session of a 2-day online HIV Testing and Counselling Training (HTCT) Certification program will be on 15th & 16th (Tuesday and Wednesday) November 2022, this virtual program is conducted between 1.00 PM to 5.00 PM on these 2 days.
This HIV test counselling training certification program (HTCT) is meant for the professionals/staff in the Hospitals, Diagnostic Laboratories and Blood Banks which are NABL (ISO 15189: 2012) / NABH accredited or under preparation for accreditation. This certification program provides training as per the NABL-112 document and NACO guidelines, occupational exposure & post-exposure prophylaxis (PEP), legal and ethical issues related to HIV testing.
Please refer to the attached brochure below for more details about the program and please register via online form using the following link: https://forms.gle/cVan7oYwvgneje8v7 (this online form needs to be filled in after making the payment)
NABH – Advisory for Minimum Essential Fire Safety Measuresfor All Healthcare Facilities
NABH (National Accreditation Board for Hospitals And Healthcare Providers) has issued an advisory recently on Minimum Essential Fire Safety Measures to be followed by healthcare organizations in the country.
This was the advisory for Minimum Essential Fire Safety Measures applicable to Healthcare Units under all schemes of Certification and Accreditation offered by NABH. These guidelines are meant to ensure patient safety and in no way absolves the organization of fulfilling its statutory obligations with regard to fire safety while implementing Certification, Accreditation Programs in the country.
The Advisory has listed out the scenarios where a Healthcare Organisation has Fire NOC, has No Fire NOC in place. The content of the advisory released by NABH is shared below for information purposes :
Advisory Content :
When the Healthcare Facility has Fire NOC in place, advisory calls for health facilities to check on the compliance to the minimum essential home Act/DHO fire safety measures are in place and or functioning.
Advisory says when the Healthcare facilities don’t have Fire NOC , following steps have to be addressed by a healthcare organisation :
Approval/Registration from local health authority Eg: Nursing home Act/DHO
If Fire NOC is not applicable, organisation has to provide valid justification for the same.
If Fire NOC is applicable, confirm that the organization has applied for fire NOC and there is regular correspondence (at least once in three months) with fire department which is acknowledged. Any correspondence received from the fire department has to be submitted.
In the absence of Fire NOC, Third Party Inspection Certificate should be made available.
The third-party audit should provide evidence to suggest that statutory norms are adhered to Any Observation by the third party should have been addressed.
The third-party inspection certificate is valid for a maximum period of one year
Head of the organization/Promoter to give an undertaking on the organization’s letter-head stating that fire safety measures are in place and adhered to at all times.
During assessment, verify that the points in the checklist are in place and are functioning
*NABH prescribes that Fire & Life Safety Inspection Certificates under NABCB accreditation issued by NABCB accredited Type ‘A’ Inspection Bodies for Fire & Life Safety Inspections of hospitals/health care providers shall be in accordance with the following: a. National Building Code of India b. Model Bill to provide for the maintenance of Fire and Emergency service for the state (2019) c. Respective State Fire Safety Rules d. NABH accreditation requirements for fire safety and applicable statutes e. Any other applicable statutes.
Such Fire & Life Safety Inspection Certificates shall be accepted in lieu of statutory Fire NOC, only for consideration for the purpose of NABH accreditation. This does not absolve the hospitals/health care providers from complying to Fire NOC requirements/any other extent applicable statutes. It shall be sole responsibility of hospitals/health care providers to obtain Fire NOC, as applicable.
NABCB accredited Inspection Bodies shall be required to issue a final Fire & Life Safety Inspection certificate under NABCB accreditation bearing NABCB Accreditation Mark after the inspection is carried out and satisfactory corrective action and resolution of non-conformities, if any.
NABH accreditation requirements for Fire & Life Safety : (in addition to above)
Firefighting equipment like wet riser, hydrants, auto sprinkler, fire alarm system, fire extinguishers of all types and sizes should be available as per table below (adapted from NBC 2016).
Operational and maintenance plan for firefighting equipment including refilling of extinguishers.
Up to date fire drawings to be available. Where applicable, the fire drawings should also specify the location of fire dampers.
Fire detection and smoke detectors exist across all floors. The detectors shall be tested for functionality at regular intervals, and records maintained.
Central fire alarm system is installed at a location which is staffed 24/7.
Fire exit plan for each floor. Exit door should be openable and free from any materials which will obstruct way.
Fire Exit signage on all floors well illuminated/ self-glowing, as per NBC guidelines.
Emergency illumination system in case power goes.
Designated place for assembly of patients and staff in case of fire.
Mock fire drill records and schedule of conduct of drills.
Minimum Requirements for Fire Fighting Installations
Advisory can be downloaded by clicking on the link below.
Above advisory says that Healthcare organisations need to obtain a Fire and Life Safety Inspection Certificates from Third Parties – Type A accredited Inspection Agencies accredited by NABCB in accordance with NBC 2016 and various other Regulations as mandated under various statutes, Rules, laws of centre , state etc
Hospitals , Healthcare Institutions have to look out for Type A Inspection Bodies (IBs) accredited by NABCB if they don’t have Fire NOC to seek Fire and Life Safety Inspections. Type A IBs have to obtain necessary accreditation scope as per various regulatory requirements, standards in the country. These IBs may have to seek accreditation as per IAF Code 34 ; NACE Code 71 which addresses the Inspection of Buildings activities
At the moment NABCB Accredited IBs with above IAF Scope are not found NABCB Registry. Few IBs may seek Accreditation under above scope to cater to the requirement specified by NABH in future. Healthcare organisations have to refer NABCB’s Registry for more updates on the accredited IBs list.
It’s a good move to encourage healthcare businesses to show compliance and adherence to Regulatory, Statutory requirements by offering Safety and Assurance to the users of healthcare facilities and Employees as well.