National Accreditation Board for Hospitals & Healthcare Providers

APPLICATION

FOR

NURSING EXCELLENCE PROGRAM

Issue No.: 01

Issue Date: November2014

NATIONAL ACCREDITATION BOARD FOR HOSPITALS and HEALTHCARE PROVIDERS

NATIONAL ACCREDITATION BOARD FOR HOSPITALS and HEALTHCARE PROVIDERS

Assessment criteria and Fee structure

NOTE: The man days given above for assessment are indicative and may change depending on the facilities and size of the hospital.

Service Tax: w.e.f. 01.06.2015 a service tax of 14% will be charged on all the above fees. You are requested to please include the service tax in the fees accordingly while sending to NABH.

Guidance notes:

1. Fees to be paid through Demand Draft/ local cheque in favour of Quality Council of India payable at New Delhi. Fees will be calculated on the operational beds. Fees are non-refundable.
2. Three copies of this application form duly filled in are to be submitted along with necessary documents and fees.
3. Self Assessment Toolkit (soft copy) duly filled in is to be submitted by the HCO along with the application form.
4. The certification fee does not include expenses on travel, lodging/ boarding of assessors, which will be borne by the HCO on actual basis.
5. The certification, once granted will be valid for two years. The HCO may apply for renewal as per the NABH policy.
6. NABH may call for an un-announced visit, which could be a Surprise Assessment or based on any concern or any serious incident reported upon by any individual or organisation or media.

Eligibility Criteria

1. Health Care Organization (HCO)shall have atleast 10 operational beds.

2. HCO shall at least be functioning for 6 months before applying.

3. HCO shall apply at least 3 months after implementing NABH Nursing Excellence standards

Guidelines for filling the application form

(Please read this carefully before filling this form)

1. Kindly fill the application form in BLACK INK only. You can also submit a printed version of the filled application form.
2. For Sl. No. 2: Split locations - This pertains to all units which are a part of the hospital. e.g. outreach clinics, satellite clinics, laundry, etc.
3. For Sl. No. 4: Please specify e.g. Clinical Establishment Act, Shops and Establishments Registration Act etc.
4. For Sl. No. 7: Please state the number currently in operation. For example, the hospital may have approval for 250 beds but presently if only 100 beds are operational, please mention only 100 (after exclusions mentioned against that point). However, the hospital shall inform NABH of any increase in operational beds within 15 days of making the additional operational beds.
5. For Sl. No. 7.d: Provide the information using the example below.

1. For Sl. No. 12,13 and 14:
2. Please note that this list of specialities is based on the recognised medical courses by the Medical Council of India/ National Board of Examination.
3. For Sl. No. 15: Type of care pertains to nature of service e.g. adult/paediatric; male/female. Use codes like AM (adult male), AF (adult female), AMF (adult male and female), PM (paediatric male), PF (paediatric female), PMF (paediatric male and female). If there is no categorization please mention as open to all. In case of split locations please specify the location
4. For SI.No. 16: Pleaseattach the list of staff along with Names, qualification, department, registration number and nursing council attached.
5. The hospital shall ensure that it shall send an updated application form to NABH in case of any changes especially before assessment and surveillance assessment.

DEMOGRAPHIC AND GENERAL DETAILS:

1. Name of the HCO: (the same shall appear on the certificate)

______

1. Contact Details of HCO:

Street Address

City/Town______

Locality/Village/Tehsil______

District______

State

Website:______

Location of HCO : Urban □ Rural □

Does the HCO have split location(s): Yes □No□

If yes, address of the other location(s) and distance from main location

______

______

______

1. Ownership:

1. Year and month in which registered and under which authority (as per state and central requirements)

______

1. Year and month in which clinical functions started:

______

1. Contact person(s):

(Please indicate [] with whom correspondence to be made)

• Headof the HCO □

Mr. /Ms. /Dr. ______

Designation: ______

Tel: ______Mobile: ______

Fax: ______E-mail: ______

• Program Coordinator*: □

Mr./Ms./Dr. ______

Designation: ______

Tel: ______Mobile: ______

Fax: ______E-mail: ______

*Shall necessarily be a nursing professional

1. HCO Information:

1. Total Number of Beds that have been sanctioned: …………..
2. Total Number of Beds currently in operation: ……………(please exclude emergency, day-care, dialysis, recovery room beds, labour room beds from this number)

• Emergency beds

• Day-care beds

• Recovery room beds

• Labour room beds

• Dialysis

• (Specify)

• (Specify)

1. Number of OTs:

General: ______Super-speciality:______

1. HCO layout:
2. Number of buildings ______
3. List the areas / departments / units floor wise for each building in a tabular format as mentioned at point 5 of the “guidelines for filling the application form” on page 3 and provide it as an attachment.
4. In case of split location the layout for each of the addresses must be given

1. Which shift duration is followed in HCO: 6 hours □ 8 hours □ 12 hours □

(Please indicate []as applicable)

1. Is there any Nursing School attached with HCO: Yes □ No□

1. Is any Nursing hostel / residence facility available in HCO premises or nearby for

Nurses: Yes □ No □

CLINICAL SERVICES AND RELATED DETAILS

11. OPD and IPD data:

1. OPD DATA (Past 2 years)

1. IPD DATA (Past 2 years) OR AVERAGE OCCUPANCY RATE

1. NURSING ATTRITION RATE (Past 2 years)

12. Clinical departments /services available in the HCO:

• Combined

• Speciality ICU (please specify)

1. Clinical Support departments/services in the HCO (mention Yes/ No):

1. Diagnostic Services being provided by the HCO (mention Yes/ No):

1. List Ambulatory unit / Inpatient Care Units/ Wards, the Number and The type of care given in each Unit/ Ward: Refer paragraph 7 page 3

1. A. Staff Information:

B. Details of Staff:

(Attach a separate sheet, if required)

C. Student Information:

1. Litigation, if any:

______

1. Date of last Self-assessment:______

1. Date of implementation of NABH NURSING EXCELLENCE standards: ______

(HCO shall apply at least 3 months after implementing NABH Nursing Excellence standards)

1. I have gone through the contents of the “NABH Standard Accreditation Agreement” and have fully understood the various clauses and shall abide by the same.

1. Date Application Completed: ______Day ______Month ______Year

Authorised Signatory

(Head of HCO or equivalent)

Name: ______

Designation: ______

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