Statutory compliances as required under NABH

In an earlier blog titled 'The impetus on statutory compliances in NABH accreditation', I had discussed briefly about the categories of regulatory and statutory compliances required under NABH accreditation for a hospital. If you refer to the page 12 and 13 of the NABH Application Form for hospitals (item 19), you would find a list of applicable statutory / regulatory requirements for a hospital. The same list is regenerated here as:

You can download the source file by clicking here.

Building a new hospital? First refer to NABH standards..

NABH accreditation has become a buzz word in the social circles of hospital administrators and quality professionals but hardly anyone pays attention to the actual NABH standards. Having visited some hospitals, old and new, which are planning for the accreditation, one of the clearly observable deficiencies I came across was the infrastructure. Old hospitals were built in the times when building laws were not as stringent as they are now. One can empathize with their administrators when they say that their hospitals can’t stand NABH’s scrutiny. But what I am shocked at is the lack of attention even new hospitals have paid to the building guidelines.

There is a larger consensus that slowly, but steadily, all healthcare facilities in our country will have to comply with some or the other quality accreditation systems, be it NABH or anything else. Today NABH is voluntary in nature. But who knows, tomorrow government might require certain category of hospitals to mandatorily go for accreditation. While old hospitals may be able to give some reasonable excuses, new hospitals will have no excuse to give. And imagine if medical insurance companies start demanding that all empanelled hospitals should have NABH accreditation. Can the new hospitals and those to come in future miss this opportunity? I am sure revenue and profitability are on top of their minds and they can’t miss the cashless pie of the business.

Therefore, my humble request to such hospitals would be that when they conceptualize their hospitals and sit with their architects and engineers, they should first of all put the basic NABH-related structural compliances in place. The fancy-stuff can wait. Yes, it has its business benefits, but it can’t match the benefits that the accreditation can bring.

Go through the latest standards (whichever are applicable to your facility) of NABH and decide for yourself how you are going to design your hospital around these requirements. I am sure there are sufficient intelligent engineering and architectural consulting firms who can help you meet both quality and aesthetic requirements in the same structure. Make NABH standards as the foundation of your building design.

For the hospitals which were built recently or even as long as 5-10 years back should consider giving NABH standards a try. If you find your hospital is non-compliant to some of the requirements of NABH, it’s still a very cost-effective proposition to make suitable changes (if possible) in your buildings. It is any day easy to change processes and manpower behaviour to suit the accreditation requirements, but building of an operational hospital is one thing which cannot be modified easily.

The impetus on statutory compliances in NABH accreditation

NABH standard ROM-1 (Responsibilities of Management) in the 2^nd edition touched on the requirement for compliances to applicable laws and regulations as part of the objective element ROM-1h. The latest edition of NABH has gone one step ahead, with the formulation of a completely separate standard on this requirement. So now ROM-2 reads as “The organization complies with the laid-down and applicable legislations and regulations”. Indeed this is a welcome step as it leaves little scope for hospitals to non-comply as the new standard deals with management’s knowledge about the laws and regulations, implementation of the same with a proper mechanism to update the licenses, registrations and certifications from time to time.

For organizations planning to put the house in order and start the journey towards NABH accreditation, you can systematically check your compliance to this new standard. From our research, we have observed that most of the statutory and regulatory requirements can be categorized into following categories:

• Air & Water
• Bio-medical waste
• Blood Bank
• Electrical
• Fire safety related
• HR-related
• Pharmacy
• PNDT & MTP
• Radiology equipment
• Software licenses
• Various State and Central Govt. Taxes

Depending on the size of your organization and the scope of your services, each of these categories may have various requirements under them. For example, if you have X-Ray and CT in your hospital, AERB approvals for your equipment and layout become a mandatory requirement. You also should be keeping a track of safety and maintenance related activities for these radiology equipments.