HOPE is a new NABH web portal for Healthcare Organizations to achieve Entry Level Certification, this portal will revamp entry level certification process for HCO/SHCO. It is a multifarious platform for certification process of healthcare organizations with complete information about the simplified certification process, requirements and compliances. It is easiest way to achieve your initial level quality improvement task by this portal.
Here We provide easiest way to make the certification process swift smooth and support for clarification and easy understanding.
What is importance of Hope Certification?
It is Mandatory for all HCO/SHCOs to get insurance tie-up, state and central government empanelment schemes.
Quality Council of India will allow HCOs and SHCOs to be eligible for NABH accreditation after successful completion HOPE certification
HOPE’s web portal has been designed to pave way for hassle free and convenient online documentation, and evidences by the HCOs/SHCOs.
Sl No
|
Process
|
Time line
|
1
|
System Implementation
|
3month
|
2
|
Gap Assessment
|
1 day
|
3
|
Registration on the web portal
|
1 day
|
4
|
Application submission along with the required documents with Fee Submission
|
20 days
|
5
|
Desktop Assessment (DA) and NCs raised by HOPE
|
7 days
|
6
|
Desktop Assessment NC CA Report Submission
|
7 days
|
7
|
Onsite Assessment (OSA) and NCs raised by Assessor
|
3 Months
|
8
|
Onsite Assessment NC CA Report Submission
|
1 Month
|
9
|
Certificate issued by HOPE
|
1 Month
|
Step to achieve HOPE certification by easiest way with smart work
A.To get NABH Entry level Standard guide book and also HOPE guide book :
Click below the link:
Note: The above link for SHCO Pre -Accreditation Entry level standards only. This can also be used for healthcare organisations(HCO) preparing for Pre accreditation Entry level. Guidance is provided for those objective elements only which are found difficult to understand and implement. Healthcare organisations shall have to prepare against all objective elements given in the respective category for assessment. This document (s) is just a guidance note to enable HCOs to prepare for certification process. HCOs are advised to refer to other re levent resource material on the subject available. Guidance for hospital infection prevention & control is annexed in a separate file along with this guidebook.
Link here.
B.To Conduct Orientation Programme
It must be covered up from top management to bottom line employees. You can get source of material from HOPE web portal.
Click below link:
C. To Fix or appoint Quality Service Coordinator
D. To Frame HOPE Implementation Core Team
Members:
· Head of the Hospital
· Medical Director/CMO/MO
· CEO /AO/Admin Manager
· HR Manager
· Nursing I/c
· Infection control nurse
· Maintenance I/c
· Quality Coordinator
E. To implement Entry level standard with required documents
The Implement process will take at least 3 months routed through the following committees
1.Quality Improvement committee
2.Infection Control committee
3.Blood Transfusion committee
4.CPR committee
5.Safety committee
6.Medical Records committee
7.Employees Grievance & Disciplinary action committee
8.Sexual harassment committee and others if any
F. Submit on line application: see HOPE application guidelines
1.Documents required :
· Clinical Establishment Act
· Pollution control board:BMW authorisation/Air/Water
· BMWM MOU
· FORM-D
· Conducting legal business certificate like private ltd, partnership firm etc.,,
· Narcotic drug license/Pharmacy license
· Scan Registration
· AERB for Radiation exposure equipments
· MTP
· Out sourced service MOU
· Government empanelment MOU
· OT/ICU/Dialysis/and other higher dependancy unit culture report for last 3 months
· Water analysis report
· Endotoxine report for RO water
· Facility safety inspection rounds report
· Building lease agreement
2.Staffing Pattern :Nurse Patient ratio
ICU: for ventilator case
|
1:1
|
ICU :non ventilator case
|
1:2
|
Higher Dependancy Unit
|
1:3
|
OT
|
2:1
|
Ward
|
1:6
|
OP
|
1:100
|
3.Medical Officer
To ensure round the clock service in all areas
4.Paramedical staff :
To ensure qualified or experienced staff
5.Scope of service
To ensure full time/part time or visiting consultant visit for scope applying service with registration certificates/last 6 months consultant seen OP/emergency/IP patients case sheets first page with UHID number and also must provide relevant equipment details for the same
6.Quality Improvement Service
Documents Required:
· Five Quality Indicators for last 3 month
· OP/Emergency Initial assessment
· DMO Initial assessment form
· Nurses initial assessment form
· Re-assessment form for ICU/ward
· Blood Transfusion consent/reaction monitoring/reporting form
· Blood transfusion register
· Blood transfusion committee minutes record
· Blood donation consent form
· Safe parenting Nutrition and Immunization chart
· Anaesthesia Consent/pre-assessment, immediate pre-assessment/monitoring post aneasthesia chart
· Surgery consent,pre-operative evaluation, operative notes and post operative plan documents
· MLC register/form
· OG scope of service signage and Ante natal check-ups, maternal nutrition, and post-natal care documents
· Paediatric scope of service signage and initial assessment sheet including nutritional, growth and immunization.
· Referral & Transfer form or register
· Discharge Summary including LAMA patients with urgent care notes
· Nursing notes/monitoring chart/drug chart
· LASA drugs storage photos
· OP prescription for 3 patients
· IP Medication order for 3 patients
· Photo evidence of medication labelling with date and time of preparation, name of the drugs and its dilution
· HR training (see application form)
The training records must be standard format
Training Topic
Date (DD/MM/YYYY)
Time (HH:MM) From: To:
Trainer's Name with sign
Trainer's Designation
Trainee's Name
Trainee's Designation
Trainee's Department
Trainee's Signature
· Fire Mock Drill Video
· Organisation chart
· patient grievances/complaints record
· Adverse drug reaction reporting form/register
· Lab TAT display /critical alert value register
· X-ray TAT display/ critical alert value register
· House keeping check list
· Doctors order for ICU/Ward/Emergency/OG/OT
· Documents and Procedure :
click the below link for Model documents
G.Signages
· Biomedical Waste segregation
· Fire/Emergency Exit
· Facility direction
· OG scope of service
· Paediatric scope of service
· Patients rights and responsibility
· Hang hygiene IEC
· AERB
· PNDT Declaration
· Lift
· Fire Evacuation
· Patient compliant address
· Hospitals scope and non scope of service
· Other Safety signages
H. Important points to ensure while application submission
· Authorised entry person must be signed with name , date, time in all medical records
· All medical records should have been patient name, UHID,date,time,ward, room number
· Records should not be overwrite
· Consent form(bilingual) must be treating or procedure performing doctors name with sign and procedure name its also be entered
· Appreviation should not be used like BD
· Medication order must be in capital letters
· Quality indicators should be in graphical presentation
· All SOP/manual should have been entered authorized signatory
I. Steps during HOPE Certification accreditation –
• Monthly once to conduct internal audit followed by management review meeting
• Prepare action plan to bridge the gaps
• Monitoring steering team function and its task force for documentation and implementation
• Periodic to conduct awareness program and define accreditation policy and establish
• Create awareness about NABH objectives to top + middle + bottom level staff.
• Regular Update documents of Quality management system as well as SOP and other
policies.
• Implementation & train all personnel in the use of procedures & formats.
• Self assessment of the system
• Periodic knowledge update by internal Coordinator.
• Take corrective actions for non-conformities.
• Carry out management review meeting
• Apply for NABH accreditation.
• Avail pre-assessment audit of NABH.
• Take actions on suggestions given by NABH auditors.
• Final audit by NABH auditors.
• Submit the corrective actions for the findings of NABH final audit of the assessors.
For any assistance will be provided to HCOs ,kindly mail to medpointhcg@gmail.com
Courtesy:NABH,MedpointHealthcare
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