NABH-PA

PRE-ASSESSMENT
GUIDELINES AND FORMS

Issue No. 4 Issue Date: 08/ 08 Page 1 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

CONTENTS

Sl. Title Page Nos.

Content 2

1. Guide to use Pre-Assessment Forms & Checklist 3–5

2. Checklist For Review And Verification – PAF 1 6–7

3. Non Conformity observed during Pre-Assessment – PAF 2 8

4. Pre Assessment Report – PAF 3 9

Issue No. 4 Issue Date: 08/ 08 Page 2 of 9

Pre-Assessment Guidelines & Forms – NABH-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 on-
site final assessment of the concerned hospital/ Small Health Care Organisation
(SHCO). 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 hospital/ SHCO 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 hospital/ SHCO and the Principal Assessor.

While the assessment team proceeds to the hospital/ SHCO for Pre-assessment, it
should be in possession of the hospital’s/ SHCO’s Applications Form, NABH
Standards, fee structure and any other information supplied by NABH Secretariat.

Issue No. 4 Issue Date: 08/ 08 Page 3 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

The Principal Assessor, during Pre-assessment shall:

i. Check the implementation of Hospital NABH Standards/ SHCO Standards,

which ever 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 hospital/ SHCO or the number of fields/ departments.

iii. Check whether the hospital/ SHCO has conducted a comprehensive Internal
Audit in accordance with NABH Standards/ SHCO Standards, which ever is
applicable.

iv. Assess the degree of preparedness of the hospital/ SHCO for the Assessment
in terms of compliance to PAF 1.

v. Obtain signatures on NABH document – Terms and Conditions for Maintaining

Accreditation, from the hospital/ SHCO, if not submitted by hospital/ SHCO
earlier
vi. Explain to the Hospital/ SHCO regarding the methodology to be adopted for
Assessment and the obligations of the Hospital/ SHCO.

vii. Submit a report to NABH Secretariat.

3. Compilation of Pre-Assessment Forms & Checklist

The Principal Assessor must review the Hospital’s/ SHCO’s documented Quality
System to verify compliance with the requirements of NABH. He should complete the
Checklist 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. 4 Issue Date: 08/ 08 Page 4 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

All deficiencies must be identified and reported, separately in 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 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
hospital/ SHCO on PAF 2 & 3. The report should be compiled in the order 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. 4 Issue Date: 08/ 08 Page 5 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

PAF 1
1 of 2
CHECKLIST FOR REVIEW AND VERIFICATION

Hospital/ SHCO: Date(s) of Visit:

Sl. Requirement Observation*

Yes No

1. Review of Application Form

ƒ for correctness of contents.
ƒ for licenses/ registration/other legal requirements
ƒ Organogram
Comments on Application Form:

2. Documentation of Quality Assurance Program

ƒ Adequacy of Quality Assurance program
ƒ Availability of all required cross-referenced Procedures
(list enclosed)
ƒ Availability of other documents like Safety Manual, Infection
Control Manual, Standards, Codes, Policy and procedures etc.
(list enclosed)
ƒ Availability of NABH documents (list enclosed)
Comments:

3. Implementation of Quality Assurance Program/ Documentation (sample audit)

ƒ Availability of relevant documents at place of work
ƒ Are policy & procedures being followed
ƒ Awareness of NABH requirements
Comments on Implementation and effectiveness of Quality System:

* Mark √ in the appropriate box

Issue No. 4 Issue Date: 08/ 08 Page 6 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

NPF 1
2 of 2

Sl. Requirement Observation*

Yes No

4. Medical Audit
ƒ Availability of Medical audit committee and procedures
ƒ All requirements of NABH Standards/ SHCO Standards (which
ever is applicable), covering all activities of hospital/ SHCO
audited at least once in the last one year
ƒ Timely corrective action on deficiencies
ƒ Audit conducted by Independent and competent personnel
Comments on effectiveness of Internal Audit:

5. Personnel
ƒ Training programme organised for its personnel
ƒ Plan/ Schedule for imparting training to its personnel for the
current year
ƒ 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

ƒ Does the hospital/ SHCO demonstrate adequate house keeping
ƒ Maintenance of necessary environmental conditions (sample audit)
Comments on General House keeping:

7. Discussions with the Hospital/ SHCO on Final Assessment

ƒ Overview of the methodology to be adopted
ƒ Task/ role of Principal Assessor, Technical Assessor(s) and
Observers
ƒ Obligations of the hospital/ SHCO
Record any special discussion:

* Mark √ in the appropriate box

Issue No. 4 Issue Date: 08/ 08 Page 7 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

PAF 2

DEFICIENCIES OBSERVED DURING PRE-ASSESSMENT

Hospital/ SHCO: Date(s) of Visit:

Sl. Deficiency Remarks

Signature/ Name of Authorised Personnel of hospital/ Signature/ Name of Principal Assessor &
SHCO & Date Date
Note: Use additional sheets of this form, if required

Issue No. 4 Issue Date: 08/ 08 Page 8 of 9

Pre-Assessment Guidelines & Forms – NABH-PA

PAF 3

PRE-ASSESSMENT REPORT
Hospital/ SHCO name & address:

Accreditation Coordinator: Date(s) of Visit:

Persons Contacted:

Pre-Assessment Team:

Summary of Pre-Assessment:

Recommendations of Time Estimation and Readiness of hospital/ SHCO:

ƒ Number of Assessors required, as per Scope of
Accreditation

ƒ Number of audit days required

ƒ Whether the Assessment is required to be split Yes / No
based on locations of hospital/ SHCO or
number of fields/ departments. If yes, elaborate
ƒ Is the hospital/ SHCO ready for Assessment. If Yes / No
no, specify estimated time for taking corrective
actions
ƒ Any specific recommendations:

Signature/ Name of Authorised Personnel of hospital/ Signature/ Name of Principal Assessor &
SHCO & Date Date

Issue No. 4 Issue Date: 08/ 08 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: nabh@qcin.org