Scribd
Upload
230 views10 pages

Pre-Assessment Guidelines and Forms: Nabh-Ayush-Pa

This document provides guidelines and forms for conducting a pre-assessment of an AYUSH hospital seeking accreditation from NABH. The guidelines describe the purpose of pre-assessment as determining the hospital's readiness for final assessment and estimating resource needs. The forms include a checklist to verify compliance with standards, identify any deficiencies, and make recommendations regarding the assessment timeline and resources required. The principal assessor is responsible for conducting the pre-assessment and compiling the completed forms and checklist into a report.

Uploaded by

ankit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
230 views10 pages

Pre-Assessment Guidelines and Forms: Nabh-Ayush-Pa

This document provides guidelines and forms for conducting a pre-assessment of an AYUSH hospital seeking accreditation from NABH. The guidelines describe the purpose of pre-assessment as determining the hospital's readiness for final assessment and estimating resource needs. The forms include a checklist to verify compliance with standards, identify any deficiencies, and make recommendations regarding the assessment timeline and resources required. The principal assessor is responsible for conducting the pre-assessment and compiling the completed forms and checklist into a report.

Uploaded by

ankit
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 10

NABH-AYUSH-PA

PRE-ASSESSMENT
GUIDELINES AND FORMS

Issue No. 1

Issue Date: 01/ 10

Page 1 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

CONTENTS
Sl.

Title
Content

Page Nos.
2

1.

Guide to use Pre-Assessment Forms & Checklist

35

2.

Checklist For Review And Verification AYUSH-PAF 1

67

3.

Non Conformity observed during Pre-Assessment AYUSH -PAF


2

4.

Pre Assessment Report AYUSH -PAF 3

Issue No. 1

Issue Date: 01/ 10

Page 2 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

GUIDE TO USE PRE-ASSESSMENT FORMS & CHECKLIST


1.

Introduction
It is presumed that the Principal Assessor/Principal Assessor, who has been
nominated by NABH Secretariat, is fully aware of the NABH Accreditation process, its
objectives and the on-site Assessment procedure. The Principal Assessor shall have
the overall responsibility of conducting the pre-assessment and for conducting the onsite final assessment of the concerned AYUSH hospital. Towards the task of on-site
assessment, he shall be assisted by a team of assessors commensurate with the
scope of accreditation.
This document contains Pre-assessment form and Checklist, which will form a part of
the Pre-assessment Report. The document shall guide the Principal Assessor in
completing various forms & checklists and compiling the report.

2.

Pre-Assessment
After the AYUSH hospital has taken the corrective action on the concerns expressed
in the content of the application and has submitted a report to the satisfaction of the
NABH, NABH Secretariat shall fix up a date for Pre-assessment in consultation with
the AYUSH hospital and the Principal Assessor.
While the assessment team proceeds to the AYUSH hospital for Pre-assessment, it
should be in possession of the AYUSH hospitals Applications Form, NABH Standards
for AYUSH Hospitals, fee structure and any other information supplied by NABH
Secretariat.

Issue No. 1

Issue Date: 01/ 10

Page 3 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

The Principal Assessor, during Pre-assessment shall:


i.

Check the implementation of NABH Standards for AYUSH Hospitals,


whichever is applicable.

ii.

Study the scope of accreditation so that the time frame, number of assessors
required in various fields and visits to various departments and services, if
applicable, for the assessment can be determined. The Principal Assessor
shall also assess whether the Assessment is required to be split, based on the
location of the AYUSH hospital or the number of fields/ departments.

iii.

Check whether the AYUSH hospital has conducted a comprehensive Internal


Audit in accordance with NABH Standards, whichever is applicable.

iv.

Assess the degree of preparedness of the AYUSH hospital for the Assessment
in terms of compliance to AYUSH -PAF 1.

v.

Obtain signatures on NABH document Terms and Conditions for Maintaining


Accreditation, from the AYUSH hospital, if not submitted by AYUSH hospital
earlier

vi.

Explain to the AYUSH Hospital regarding the methodology to be adopted for


Assessment and the obligations of the AYUSH Hospital.

vii.

3.

Submit a report to NABH Secretariat.

Compilation of Pre-Assessment Forms & Checklist


The Principal Assessor must review the AYUSH Hospitals documented Quality
System to verify compliance with the requirements of NABH. He should complete the
Checklist AYUSH - PAF 1 by recording his observation Yes or No (by marking a
in the appropriate box), related to the requirements of respective clause number of the
checklist and offering brief comments. If the Principal Assessor has a doubt in other
area(s), not listed in the checklist, he is free to assess or go into details where he feels
and annex his findings, to the report.

Issue No. 1

Issue Date: 01/ 10

Page 4 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

All deficiencies must be identified and reported, separately in AYUSH -PAF 2.


Additional sheets may be added, if required. The Principal Assessor should finally
summarise the conduct of Pre-Assessment and record the recommendations in
AYUSH -PAF 3. The Principal Assessor must carefully fill the forms and check list and
sign all pages of the Pre-Assessment Report. He should also obtain signature of the
authorised person of the AYUSH hospital on AYUSH -PAF 2 & 3. The report should
be compiled in the order AYUSH -PAF 3, 2 & 1 and any other additional pages or
annexure thereafter.
The Principal Assessor shall submit the Pre-Assessment Report to NABH Secretariat
within 10 days of completion of Pre-Assessment.

Issue No. 1

Issue Date: 01/ 10

Page 5 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

AYUSH -PAF 1
1 of 2

CHECKLIST FOR REVIEW AND VERIFICATION


AYUSH Hospital:

Sl.

Date(s) of Visit:

Requirement

Observation*
Yes

No

Assessment Standard: NABH Standards for AYUSH/Unani/Homeopathy/Siddha/Yoga and


Naturopathy (strike which is applicable)
1.

Review of Application Form

for correctness of contents.

for licenses/ registration/other legal requirements

Organogram

Comments on Application Form:


2.

Documentation of Quality Assurance Program

Adequacy of Quality Assurance program

Availability of all required cross-referenced Procedures


(list enclosed)

Availability of other documents like Safety Manual, Infection


Control Manual, Standards, Codes, Policy and procedures etc.
(list enclosed)

Availability of NABH documents (list enclosed)

Comments:
3.

Implementation of Quality Assurance Program/ Documentation (sample audit)

Availability of relevant documents at place of work

Are policy & procedures being followed

Awareness of NABH requirements

Comments on Implementation and effectiveness of Quality System:


* Mark in the appropriate box

Issue No. 1

Issue Date: 01/ 10

Page 6 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

NPF 1
2 of 2

Sl.

Requirement

Observation*
Yes

4.

No

Medical Audit

Availability of Medical audit committee and procedures

All requirements of NABH Standards for AYUSH Hospitals (which


ever is applicable), covering all activities of AYUSH hospital
audited at least once in the last one year

Timely corrective action on deficiencies

Audit conducted by Independent and competent personnel

Comments on effectiveness of Internal Audit:


5.

Personnel

Training programme organised for its personnel

Plan/ Schedule for imparting training to its personnel for the


current year

Suitability of persons authorised for specific tasks with reference


to the field(s) applied

Comments on Personnel and Training:


6.

House keeping and Environmental conditions

Does the AYUSH hospital demonstrate adequate house keeping

Maintenance of necessary environmental conditions (sample audit)

Comments on General House keeping:


7.

Discussions with the AYUSH Hospital on Final Assessment

Overview of the methodology to be adopted

Task/ role of Principal Assessor, Technical Assessor(s) and


Observers

Obligations of the AYUSH hospital

Record any special discussion:


* Mark in the appropriate box

Issue No. 1

Issue Date: 01/ 10

Page 7 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

AYUSH -PAF 2
DEFICIENCIES OBSERVED DURING PRE-ASSESSMENT
AYUSH Hospital

Date(s) of Visit:

Assessment Standard: NABH Standards for AYUSH/Unani/Homeopathy/Siddha/Yoga and


Naturopathy (strike which is applicable)

Sl.

Deficiency

Signature/ Name of Authorised Personnel of AYUSH


hospital & Date

Remarks

Signature/ Name of Principal Assessor &


Date

Note: Use additional sheets of this form, if required

Issue No. 1

Issue Date: 01/ 10

Page 8 of 9

Pre-Assessment Guidelines & Forms NABH- AYUSH -PA

AYUSH-PAF 3

PRE-ASSESSMENT REPORT
AYUSH Hospital name & address:

Accreditation Coordinator:

Date(s) of Visit:

Persons Contacted:

Pre-Assessment Team:

Summary of Pre-Assessment:

Recommendations of Time Estimation and Readiness of AYUSH hospital:

Number of Assessors required, as per Scope of


Accreditation

Number of audit days required

Whether the Assessment is required to be split


based on locations of AYUSH hospital or
number of fields/ departments. If yes, elaborate

Yes / No

Is the AYUSH hospital ready for Assessment. If


no, specify estimated time for taking corrective
actions

Yes / No

Any specific recommendations:

Signature/ Name of Authorised Personnel of AYUSH


hospital & Date

Issue No. 1

Issue Date: 01/ 10

Signature/ Name of Principal Assessor &


Date

Page 9 of 9

NATIONAL ACCREDITATION BOARD FOR HOSPITALS


& HEALTHCARE PROVIDERS (NABH)
Quality Council of India
Institution of Engineers Building, IInd Floor, Bahadur Shah Zafar Marg
New Delhi - 110002, India.
Tel/ Fax: 91-11-2337 9321, 91-11-2337 9621
Website: www.qcin.org
E-Mail: [email protected]

You might also like