APPLICATION

FOR

CERTIFICATION OF EMERGENCY DEPARTMENT IN HOSPITAL

Issue No.: 01

Issue Date: June 2016

NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS

NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS

Assessment criteria and Fee structure

Size of Hospitals / Assessment Criteria / Certification Fee
Assessment / Application Fee / Annual Fee
25 - 200 beds* / One Man-days (1X1) / Rs 2000 / Rs 25,000
201 beds and above* / Two Man-days** (2x1) / Rs 2000 / Rs 50,000

*Operational Beds

** HCOs having more than one emergency department may require additional man days.

NOTE: The man days given above for assessment are indicative and may change depending on the facilities and size of the hospital.

Service Tax as applicable will be charged on all the above fees. You are requested to please include the service tax in the fees accordingly.

First year annual fee has to be paid before the assessment.

Guidance notes:

  1. All payments to be made online. Feeis non-refundable.
  2. The certification fee does not include expenses on travel, lodging/ boarding of assessors, which will be borne by the Healthcare Organisation (HCO) on actual basis.
  3. The certification, once granted will be valid for two years. The HCO may apply for renewal as per the NABH policy.
  4. NABH may call for an un-announced visit, which could be a Surprise Assessment or based on any concern or any serious incident reported upon by any individual or organisation or media.
  5. In case of hospitals, where there are more than one emergency departments, HCO will be charged extra Rs. 10,000/- per additional emergency site.
  6. HCOs which are offering recognised post graduate courses in Emergency Medicine shall also have to comply with the NBE/MCI requirements.

Eligibility Criteria

  1. HCO shall have at least minimum of 25 operational beds, in addition to emergency beds.
  2. Number of beds in the emergency department should be as per following criteria:

Total No. of hospital beds / Minimum Beds required in ED
Upto 50 beds / 02 beds
51- 100 beds / 04 beds
101-200 beds / 06 beds
201-350 beds / 08 beds
More than 350 / 10 beds

HCO shall apply at least 3 months after implementing NABH Emergency standards

Guidelines for filling the application form

(Please read this carefully before filling this form)

  1. For Sl. No. 8: Please specify e.g. Clinical Establishment Act, Shops and Establishments Registration Act etc.
  1. For Sl. No. 11: Please state the number currently in operation. For example, the hospital may have approval for 250 beds but presently if only 100 beds are operational, please mention only 100 (after exclusions mentioned against that point). However, the hospital shall inform NABH of any increase in operational beds within 15 days of making the additional operational beds.
  1. For SI. No. 17: Please attach the list of staff along with Names, qualification, department, registration number and nursing council attached.
  1. The hospital shall ensure that it shall send an updated information to NABH in case of any changes especially before assessment and surveillance assessment.

DEMOGRAPHIC AND GENERAL DETAILS:

  1. Name of the HCO: (the same shall appear on the certificate)

______

  1. Contact Details of HCO:

Street Address: ______

City/Town______

Locality/Village/Tehsil______

District______

State______

Website:______

3. Location of HCO : Urban □ Rural □

4. Does the HCO have split location(s): Yes □ No □

If yes, address of the other location(s) and distance from main location

______

______

______

5. Total Area of Hospital (sq. Metres): ……………………..

6. Area of the emergency (sq. Metres): ……………………

7. Ownership:

□Private – Corporate / □Armed Forces
□PSU / □Trust
□Government / □Charitable
□Others (Specifiy...... )

8. Year and month in which registered and under which authority (as per state and central requirements)

______

9. Year and month in which clinical functions started:

______

10. Contact person(s):

(Please indicate [] with whom correspondence to be made)

  • Head of the HCO □

Mr. /Ms. /Dr. ______

Designation: ______

Tel: ______Mobile: ______

Fax: ______E-mail: ______

  • Program Coordinator: □

Mr. /Ms. /Dr. ______

Designation: ______

Tel: ______Mobile: ______

Fax: ______E-mail: ______

11. HCO Information:

  1. Total Number of hospital Beds that have been sanctioned: …………..
  1. Total Number of Beds currently in operation: ……………(please exclude emergency, day-care, dialysis, recovery room beds, labour room beds from this number)
  1. Total number of beds in the Emergency Department
  1. Number of OTs for Emergency Surgery:

Minor/ Procedure room: ______

Major(if applicable) :______

I.No. of Ambulances:

ii. Type of Ambulance: BLS/ACLS

CLINICAL SERVICES AND RELATED DETAILS

12. Scope of Emergency department services:*(All the services as per Scope should be available round the clock) (you may tick more than one if applicable)

Medical emergencies

Paediatric emergencies

Surgical emergencies(General Surgery, Orthopaedic, trauma etc)

Obstetric emergencies

Ophthalmic emergencies

Others if any (mention):

13. Emergency data (Past 1 year):

a. Total no. of patients treated in emergency (past 1 year) *

*including patient admitted and observed

Year / Number of Patients
  1. No. Of patients admitted through Emergency :

Year / Number of Patients
  1. No. Of Medico Legal cases

Year / Number of Patients
  1. Number of deaths occurring in the Emergency Department:

Year / Number of Deaths

14. Scope of services of HCO:*(Tick Services being provided round the clock.)

Clinical Service / Service Provided
(mention YES or NO) / In house / Outsourced
Anaesthesiology
Cardiology
Clinical Haematology
Cardiology
Endocrinology
General Medicine
General Surgery
Gastroenterology
Nephrology
Neurology
Neurosurgery
Obstetrics and Gynaecology
Ophthalmology
Orthopaedic Surgery
Otorhinolaryngology
Paediatric Surgery
Paediatrics
Psychiatry
Transplantation Service
Urology
Others, please state

15. Clinical Support departments/services in the HCO (mention Yes/ No):

In House / Out sourced
Blood Bank / transfusion services
Pharmacy
Dietetics

16. Emergency Diagnostic Services being provided by the HCO (Round the clock):*

Diagnostic Service / Service Provided
(mention YES or NO) / In house / Outsourced
Diagnostic Imaging:
CT Scanning
MRI
Ultrasound
X-Ray
Laboratory Services:
Clinical Bio-chemistry
Clinical Microbiology and Serology
Other Diagnostic Services:
2D Echo
Arterial blood gas analyzer
Cardiac enzyme analyzer
Any Other Diagnostic Service (s):

*If Emergency services are available but not round the clock, list them with the timings:

  1. ______

2. ______

17. Staff Information (along with qualification)

Group / Number / In house / On Call
Clinicians
a) Head of Emergency Department
b) Specialists (Speciality wise)
c) Senior Residents
d) Medical Officer
e) Nurse
f) Security Staff

Add shift wise deployment of the emergency staff

(a)Equipment available in the Emergency Department (indicate Y or N) :

Equipments / Yes/No / Number
  1. Cardiac Monitor

  1. Defibrillators

  1. Nebulisers

  1. Infusion Pumps

  1. Pulse Oximeter

  1. Oxygen supply

  1. Suction apparatus

  1. Crash Cart

  1. Laryngoscope

  1. ABG

  1. Cervical collars

  1. Splints

  1. Glucometer

  1. Cervical Collar

  1. Ambu Bag

18. Furnish details of applicable statutory/ Regulatory requirements the organization isgoverned by*:

Name / Issuing Authority / Number and Date of issue / Valid Upto / Remarks
Bio-medical Waste Management and Handling Authorization
Registration Under Clinical Establishment Act (or similar)
Registration With Local Authorities, if applicable
Registration for Modality
License to operate(CT/IR)
Blood bank/ Storage centre
License for MTP (if applicable)
Registration for PCPNDT
Narcotics License
Any Other

19. Date of last Self-assessment: ______

20. Date of implementation of NABH Emergency Department Certification standards: ______

(HCO shall apply at least 3 months after implementing NABHEmergency Department Certification standards)

21. I have gone through the contents of the “NABH Standard Accreditation Agreement” and have fully understood the various clauses and shall abide by the same.

22. Date Application Completed: ______Day ______Month ______Year

Authorised Signatory

(Head of HCO or equivalent)

Name: ______

Designation: ______