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.
NABH has issued a notification recently for Small Healthcare Organisations (SHCOs) which are Accredited, under Quality Management Systems Program.
Notification calls for Self Declaration cum Undertaking from already Accredited organisations / organisations under accreditation process, on the Bed Capacity declared to NABH for Accreditation purposes.
Content of the notification in a nutshell is shared here :
It has been brought to notice of NABH that many hospitals and nursing homes that have enrolled under the SHCO accreditation program of NABH, despite having sanctioned bed strength of more than 50. Notification has clarified that the bed strength of the organization will be considered only on the basis of the sanctioned beds mentioned in the statutory licenses obtained by the organization from the competent authorities. All the hospitals and nursing homes which are accredited by NABH or are in the process of getting accreditation are hereby informed to declare the bed strength and submit an undertaking signed by head of the organization to this effect to NABH secretariat within 45 days of issue of this notice.
The format for submission of the declaration is enclosed herewith and the same needs to be printed on the stamp paper of value of Rs 100/-.Further the signed declaration has to be uploaded on the ‘HCO document’ section on the respective portal account of SHCO. In case, the hospital fails to submit the declaration as mentioned above, NABH may be constrained to initiate adverse decision against the non-conforming hospitals as per the policy of NABH.
NABH Certifies, Accredits organisations which fall under the category of Healthcare Organisations and Small Healthcare Organisations which are defined as below :
Healthcare Organisation :
Healthcare organization (HCO) that should be above 50 beds to fall under the definition of Healthcare Organisation as per NABH
Small Healthcare Organisations : Hospitals and Nursing homes or day care centres with bed strength less or equal to 50 Sanctioned beds.
Exclusions to the above definition :
a) Polyclinic Diagnostic Centres
b) Super Speciality Centres
Certification / Accreditation Framework :
The Certification / Accreditation Framework for each segment differs as the criteria set by NABH varies accordingly.
Essence of the Recent Notification :
NABH’s definition of Beds in the case of SHCO is “Sanctioned Beds” meaning number of beds approved, sanctioned by the Regulator, State / Central Licensing Authorities.
Infact Hospitals apply for various empanelments with State Govts, Central Govt agencies, PSUs, Pvt Health Insurers, Corporates etc for business purposes. Sanctioned beds is the statutory norm and should be quoted with all agencies .
However , it was repeatedly discussed in various industry forums , market place conversations that beds shown for empanelment purposes & for accreditation purposes is most often different and not same as the sanctioned beds approved by the licensing authorities.
Hospitals were declaring less number of beds to NABH while applying for Accreditation which is technically not correct. Infact this was pointed out by various other healthcare organisations at the market place frequently.
Way forward :
NABH has announced a roadmap for such hospitals which are covered under Accreditation Program for implementation by SHCOs , as follows :
The hospitals which are not eligible to be covered under SHCO accreditation program due to sanctioned bed strength more than 50 should switch over and apply under hospital accreditation program. Considering the fact that there could be a break in accreditation while switching over to hospital program, NABH has decided to give a transition period of 18 months from the issue date of this notification.
The hospitals are encouraged to implement NABH 5th edition of hospital standards with in the given transition period and apply for accreditation under hospital program.
Further, during the transition period hospitals shall also be required to pay the shortfall of the applicable annual accreditation fee based on the sanctioned bed strength of the hospital.