NABH-AG PE

ASSESSOR GUIDE FOR

PRE ACCREDITATION ENTRY
LEVEL

Issue No. 1 Issue Date: 04/15 Page 1 of 12

Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

CONTENTS

Sl. Title Page Nos.

Content 2

1. Introduction 3

2. Role of Assessment team 3-4

3. On-site Assessment 5-7

4. Feedback 7

HCF 1 to HCF 4 8 - 11

Declaration of Impartiality, Confidentiality and Integrity (NABH I&C 01) 12

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

1 INTRODUCTION
Pre Accreditation Entry Level is an incentive to improve capacity of Heath Care
Organisations to provide quality of care. The National Accreditation Board for
Hospitals and Healthcare Providers (NABH) provides third-party
accreditation/certification to Health Care Organizations in India. It ensures that
hospitals/ Small Health Care Providers (SHCO), whether public or private, national or
expatriate, play their expected role in national heath system. Country and culture
specific accreditation system safeguard the country health care system and also
involve fewer cost and better accepted as compare to external international
accreditation systems.

The assessment is carried out by the NABH empanelled Assessor(s). The

assessment is carried out systematically for comprehensive review of hospital/
SHCO services, functions and hospital’s/ SHCO’s quality management system. The
objective evidence so collected forms the basis:
 for arriving at a judgment for recommendation of the team, to the Accreditation
Committee
 for formulating the advice to assist the hospital/ SHCO in its development.

This guide has been prepared based on the general practices followed by
international bodies and the experience of experts of the country. This document
accordingly aims to:
a. Provide the guidance to the Assessor during the assessment of hospitals/
SHCOs.
b. Ensure uniformity of assessment and reporting, and
c. Eliminate ambiguities or doubts about the interpretation of requirements(s).

2 ROLE OF ASSESSMENT TEAM

The role of NABH Assessment team is to conduct on-site assessment of applicant
hospital/ SHCO and provide the report to NABH.

The objective of the on-site assessment is to obtain evidence on compliance with

respect to NABH standards and other policy documents.

Since hospital/ SHCO certification requires compliance with NABH Pre Accreditation
Entry Level Hospital Standards/ SHCO Standards the assessment team should
consider conformances against these standards in the assessment. Thus, the
members of the assessment team would be required to exercise their scientific
judgmental skill and form their opinion regarding extent of conformance with respect
to certification criteria.

Notwithstanding the strength of the NABH system, the success of the certification
scheme depends on the assessment team who perform on-site assessment and,
thus, play a vital role in determining the credibility and value of the certification.

The assessment team consists primarily of the Assessor. However, in some cases a
technical expert may join the team to support on specific area.

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

Assessor is required to maintain the confidentiality on the matters/ subjects related to

health care organizations.

Role of the Assessor

The Assessor should clearly understand the areas/ activities to be assessed by him.
He must review the Hospital’s/ SHCO’s documented system to verify compliance with
the requirements of NABH Pre Accreditation Entry Level standards. He should
assess to verify that the documented SOPs, records are indeed implemented &
effective, as described and record observations in HCF 2.

Before the start of Assessment the Assessor should prepare an Assessment

schedule in HCF 1 which should include the departments/ sections/ areas/ activities
to be assessed. The schedule shall be presented to the hospital/ SHCO
representative. The hospital/ SHCO will be requested to assign guide/ co-coordinator
to accompany the assessor during the assessment.

The Assessor must review the hospital’s/ SHCO’s documented Management System
to verify compliance with the requirements of NABH standards. He should assess
that the documented Management System is indeed implemented & effective, as
described and record observations in HCF 2.

All Non-Conformance(s) must be identified and reported, separately on each sheet in

HCF 3.

The Assessor would finally summarise the conduct of Assessment and record the
recommendations in HCF 4. If, during Re-assessment, a case of critical system
failure and gross negligence in technical aspects is noticed, the Assessor will at the
earliest inform NABH and elaborately bring it out in the Assessment summary (HCF-
4) of assessment report. The Assessor must sign all pages of the assessment report.

He must get an endorsement from the hospital/ SHCO on HCF 4 and hand over a
photocopy of the forms HCF 3 & 4 to the hospital/ SHCO to enable them to take
corrective actions.

The Assessor is also required to monitor the performance of the Trainee Assessor.
He shall recommend whether the Trainee Assessor is capable to perform the role of
an Assessor in his next visit. His comments/ rating for each Assessor shall be
enclosed with the report.

Role of Technical Expert

The role of Technical Expert is same as of an Assessor. He will provide technical

assistance to the team and he will seek guidance of Assessor in filling the relevant
forms.

Role of Trainee Assessor

The Trainee Assessor (Potential Assessor) will be assigned to accompany the

Assessor as per the schedule provided to him. The Assessor shall guide him. He is
not involved in assessment directly but supports the assessment as assigned by the
Assessor. He is not entitled for payment of any honorarium.

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

3. ON-SITE ASSESSMENT
NABH Secretariat on intimation from the organization about the preparedness to take
up on site-assessment, appoints an Assessor from the pool of empanelled Assessors
from assessor database. Scope and type of the hospital/ SHCO is kept in mind while
selecting the Assessor. The number of assessors depends on the size of the
hospital/ SHCO.

The assessor(s) and the names of their organizations from which they belong are
intimated to the organization for seeking their consent. NABH also assures that the
team does not have any competitive position with the applicant organization. NABH
also ensures that assessors do not have any direct/ in-direct relationship with the
organization or they/ or their organization.

Consent is obtained for the date(s) of the assessment of the organization from the
Assessor. A written communication is sent with the following documents:
- Application form of the organization
- Self assessment submitted by the organization
- Hospital/ SHCO manuals/ documents submitted by the organization
- Confidentiality form (NABH I&C 01)
- Travel expenditure form

The format of the assessment schedule to be finalized is given at HCF-1.

3.1 Opening Meeting

(a) Assessor shall have an opening meeting with hospital/ SHCO representatives
where he/she gets acquainted with the hospital/ SHCO, departments/
sections and their locations.

(b) The Assessor shall explain the objective and scope of assessment and what
is expected from the hospital/ SHCO during the assessment.

(c) The Assessor shall present the assessment schedule (HCF 1) to hospital/
SHCO representatives. The hospital/ SHCO will be requested to assign
guide/ co-coordinator to accompany each Assessor.

(d) The Assessor shall inform the hospital/ SHCO that the assessment team shall
not be approached by the hospital/ SHCO for closure of non-conformances
while the assessment is in progress. Non-conformances may be closed while
the assessment report is being compiled.

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

3.2 Assessment

The assessment activities include:

- Orientation of assessors to the organization’s services

The assessment procedure will start with an opening meeting. The assessor will
introduce themselves and explain the assessment process. Any changes to
assessment agenda will also be discussed.

- Document review
Document review includes review of polices, evidence of compliance with
policies, evidence of committees and evidence of statements.

- Functional interview

 Leadership interview.
 Infection control interview.
 Management of information/ patient records interview.
 Staff qualification and education interview.

- Visit to patient care areas and selected department

The surveyor will evaluate the process for patient care in different setting across
the organization.

- Facility tour

- Special interview/ issue resolution

3.3 Compilation of assessment report

The Assessment Report should consist of various documents in the order as

indicated in HCF 4. Each form or checklist should be carefully filled in. The pages
should be serially numbered.

Assessor shall compile the observations (HCF 2) and summary on non-compliance

(HCF 3) from all the assessors.
The Assessor shall give the summary of the assessment in his final report (HCF 4).
The reports shall be signed by the authorized signatory of the hospital/ SHCO.

In addition to the above, the Assessor shall fill up the score sheet and send it to
NABH along with report. This remains a confidential document and copy should not
be given to the hospital/ SHCO.

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

Guidelines for evaluation are as follows:

Assessment is based on the scoring on a scale of 0, 5 and 10 as per the following
details.
Compliance to the requirement : 10
Partial compliance to the requirement : 5 (if any of the sample is found to be non complying
out of total samples selected)
Non-compliance to the requirement : 0
Not Applicable : NA

Assessor has to provide details of deficiency both in the case of non-compliance as

well as partial compliance.

Evaluation criteria:
 Overall score of minimum 50% in all standards.
 Overall score of minimum 50% in each chapter.

3.4 Closing Meeting

The Assessor shall have a meeting with the hospital/ SHCO representatives. A copy
of the report – summary of non-conformances (HCF 3) shall be handed over to the
hospital/ SHCO.

The closing meeting is to end with thanks giving for the co-operation and assistance
provided by the hospital/ SHCO.

3.5 Post Assessment

The Assessor shall send the report to NABH at the earliest.

NABH secretariat reviews the assessment report and seeks clarification and
documentation from the Assessor and hospital/ SHCO, if required.

NABH, on receipt of evidence of corrective action, if any, shall place the report before
the Accreditation Committee for its consideration for certification.

The assessment report is reviewed by the Accreditation Committee and

recommendations made.

4 FEEDBACK
Following feedbacks are obtained by NABH through the evaluation forms in the
NABH document ‘Feedback Forms’.
- Feedback on performance of the assessment team is obtained from the
hospital/ SHCO.

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

ASSESSMENT SCHEDULE- HCF 1

Name & address of Hospital/ SHCO:

Accreditation Coordinator: Date(s) of Visit:

Type of Visit: Assessment / Re-Assessment / Verification

Assessment Standard: NABH Pre Accreditation Hospital Standards/ SHCO Standards (strike off
which is not applicable)

Assessment Timings Opening/Closing Meeting Daily Debriefing

Date/Time Date / Time
(at the end of each day)
Morning: AM to PM Opening Meeting: Day 1:
Afternoon: PM to PM Closing Meeting: Day 2:
Day 3:

Assessment schedule: Assessor to provide details of activities taken up by the assessor/

technical expert in the following format and obtained their signature.

Schedule of Department/ Section/ Activity to be Assessed

Name and Expertise Day 1
of the Assessor
Morning Afternoon
Assessor

Assessor --

Trainee
Assessor/Expert

Signature of Assessor

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

ASSESSOR’S OBSERVATIONS- HCF 2

Name of Hospital/ SHCO:

Date: Area/ Department: Activity Assessed:
Auditee:

Sl. OBSERVATION REMARKS

Signature & Name of Assessor

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

ASSESSOR’S SUMMARY ON NON-COMPLIANCE- HCF 3

(For each non-compliance, refer observation no. from HCF 2 and NABH std. no.
against which non-compliance is being raised)

Hospital/ SHCO:

Date: Type of Assessment: Assessment / Re-Assessment / Verification

Non-compliance observed:
1.

Signature & Name of Hospital/ SHCO Signature & Name of Assessor

Representative

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

SUMMARY OF THE ASSESSMENT- HCF 4

Hospital/ SHCO name & address:

Accreditation Coordinator: Date(s) of Visit:
Type of Visit: Assessment / Re-Assessment / Verification
Principal Assessor: Assessor 1: Assessor 2:
Assessor 3: Other/TE Trainee Assessor:
Date of earlier visit and
Purpose:
ASSESSMENT SUMMARY:

Enclosures HCF 1 HCF 2 HCF 3 HCF 4

Acknowledgement by Authorised Signatory of Signature of Assessor & Date

hospital/ SHCO & Date

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Assessor Guide for Pre Accreditation Entry Level - NABH-AG PE

NABH I&C 01

DECLARATION OF IMPARTIALITY, CONFIDENTIALITY & INTEGRITY

(to be filled in by each Assessor and enclosed with the Assessment report)

Name Assessor ID :
(To be filled in by NABH Sect.)
Designation

Organisation

Address

Capacity Assessor / Technical Expert / Trainee Assessor

Health care
organisation Assessed
Date of visit(s)

Type of visit Assessment / Re-Assessment / Verification

I ______________________________________________________________, hereby declare

that
i. I have not offered any consultancy, guidance, supervision or other services to the
hospital/ SHCO, in any way.

ii. I am/ am not* an ex-employee of the health care organisation and am/ am not* related
to any person of the management of the health care organisation.

iii. I got an opportunity to go through various documents of the above Hospital/ SHCO and
other related information that might have been given by NABH. I undertake to maintain
strict confidentiality of the information acquired in course of discharge of my
responsibility and shall not disclose to any person other than that required by NABH.
* strike out which is not applicable

Date:

Place : Signature

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