NABH Audit

Introduction

In NABH standards there is a complete chapter devoted for HR management in hospitals. It is expected that the hospital follows all good HR practices which ultimately makes the hospital a better organization for delivering healthcare services. From NABH standards and various assessment observation, following are the important points with which an HR department of a hospital must be prepared.

NABH Self-Assessment Checklist for HR department

1. Having a documented HR plan for the hospital. The plan must mention the categories of employees, quantity required under each category, quantity available and future quantity requirements.

2. A well-developed organizational structure that incorporates all categories of employee and clearly identify their line of hierarchy.

3. Job specification and job description for each category of employee.

4. Conduction of background verification of all potential employee. A documentary evidence of the same should be available. Verification of qualification and experience should be done for all, but most importantly for doctors, nurses and technicians.

5. Availability of a policy and SOP of recruitment of employee, which outlines criteria for selection/rejection of an employee.

6. An induction training plan and record of provision of induction training to all new recruits. The induction training should necessarily cover following topics

         a. Vision, mission and values of the organization

         b. Employee rights and responsibilities

         c. Service standards of the organization

         d. Organization wide policies

         e. Relevant department specific policies

         f. Training Job Description & Fire Safety and Workplace Security aspects

7. Availability of a documented training and development plan, along-with records of all training provided (like attendance sheet).

8. Conduction of training need assessment.

9. Evaluation of training conducted and its record; such as trainees test result, feedback from HOD etc.

10. Availability of feedback from participants of the training and provision of these feedback to trainers.

11. Training topics must cover all safety related topics such as risks within hospital, what to do in case of disaster, procedure to follow in case of an incident, occupational safety etc. (Suggested read - Disaster handling checklist for hospitals).

12. Having a documented policy and process of conducting performance appraisal of employee. Performance appraisal system should be based on identified and defined criteria.

13. Having a documented policy and process of receiving employee grievance and redressing them.

14. Having a grievance Redressal committee as a final authority to take decisions on grievance related matters. (Refer grievance Redressal and disciplinary action committee under 'List of hospital committees and teams').

15. All employee must have their annual health check-up done, at-least.

16. There should be a policy to take care of healthcare needs of the employee.

17. There should be personnel file of each employee which must be updated and is kept confidential. It should contain information on-

         a. Staff qualification and experience

         b. Background verification

         c. Health status

         d. Record of all in-service training and education availed by the staff

         e. Results of all evaluations of the training

18. Availability of a credentialing and privileging policy for doctors.

19. A document listing credentials (qualifications, experiences, certificates etc.) of each doctor associated with the hospital.

20. For each doctor there should be a document that lists all the treatments and patient care activities that he/she has been permitted to undertake.

21. Availability of a credentialing and privileging policy for nurses.

22. A document listing credentials (qualifications, experiences, certificates etc.) of each nurse associated with the hospital.

23. For each nurse there should be a document that lists all the nursing care activities that he/she has been permitted to undertake.

Till - 2019

MOCK AUDIT - HR NABH

 Mock Self Assessment Toolkit

Organisation is required to provide self-assessment report in the format ‘Self Assessment Toolkit’ given below. All the entries are to be properly filled up. Regarding scoring following criteria would be applicable.

• Compliance to requirement:10

• Partial compliance to the requirement: 5 (if any of the sample is found to be noncompeting out of total samples selected)

• Non-Compliance to the requirement: 0

• Not Applicable: NA

Evaluation Criteria:

• Overall score of minimum 50% in all standards.

• Overall score of minimum 50% in each chapter.

2020

MOCK AUDIT - HR NABH

Self Assessment Toolkit

"  Organisation is required to provide self-assessment report in the format ‘Self Assessment Toolkit’ given below "

* Few Key Changes of 2020 - NABH 5th Edition are discussed below

• More Emphasis on Real Time Implementation

• Correlation Between System and Process to be in place

• System Documentation requirements have been added in the standards

• Surveillance & Re- Accreditation has got clear guidelines  

• Over All Objective Elements are - 651, Over all Standards are 100

• All Objective Elements related to the training have been removed from their respective chapters and incorporated in HRM 5 as a standard

• New Standards - HRM 5 - (Training)  & HRM 13 (Privilege)

** Accreditation Criteria has been linked to the scoring of individual Standards and objective elements.

NEW Scoring Criteria would be Applicable

The New Scoring has been changed and modified on a rating scale of 1 to 5

• Full Compliance to requirement: 05 Points

• Good Compliance: 04 Points

• Partial Compliance: 03 Points

• Poor Compliance: 02 Points

• No Compliance: 01 Points

** "The base for scoring shall be implementation"

Final Certification & Accreditation Criteria

• Overall score of minimum 80% in all standards. - More than 04 Points - Good Compliance

• Overall score of minimum 80% in each chapter. - More than 04 Points - Good Compliance

Important Note 

... NABH Audit Details prescribed Above are only basic aspects to create Awareness - Kindly Refer Original NABH Book Edition 5, 2020 release for more details ...