1. NABH Pre- Assessment: Closing Meeting 16 &17 March 2012 Gracy Mathai Dr. Deepak Singla

2. Thank you to my team

3. Thank you to each and everyone of you

4. SORRY

5. Standard : NABH 2 nd edition 2007, all applicable clauses out of 100 standards. Scope of Accreditation: Management of a Tertiary Care Hospital. Sampling: All assessments are sampling exercises. If we have not recorded a deficiency in a certain area, this is not to be construed as none exist there. Confidentiality assured.

6. Excellent!!! Top management commitment – Everyone’s commitment!!! Patient satisfaction Quality Facility ICU OT Radiology

7. You need to improve on... Statutory & Legal requirements Documentation – Name, Sign, Date, Time and the consent forms Inventory of all the assets Kitchen

8. Way ahead You will have to close the deficiencies and send the reports to NABH. Start doing it from today. Once the deficiencies are effectively closed this will be presented before the Accreditation Committee of the NABH who will take further actions. They have the right to contact the Principal Assessor, any other team member, or staff of the Hospital to gather further information.

9. Suggested format for closure DeficiencyRoot causeCorrection/ Corrective action/ Preventive action Objective evidence Proper identification is a prerequisite Must address the root cause Give hyperlinks

10. Thank you very much