NABH accreditation can be revoked under certain circumstances if a healthcare organization fails to maintain the required standards or violates the terms of accreditation. Below are the key reasons and processes through which NABH accreditation can be revoked:
Reasons for Revocation of NABH Accreditation
1. Non-Compliance with Standards:
- NABH-accredited hospitals are expected to consistently meet the standards outlined in the accreditation. If a hospital is found to be significantly non-compliant during surveillance audits or surprise inspections, its accreditation may be revoked.
- Examples of non-compliance include:
- Failure to maintain patient safety standards.
- Inadequate infection control measures.
- Incomplete or poor documentation of medical records.
- Lack of proper infrastructure or equipment maintenance.
2. Failure to Implement Corrective Actions:
- If NABH identifies deficiencies during an audit, it typically provides the healthcare organization with a timeline to implement corrective actions.
- If the hospital fails to address these deficiencies within the stipulated time, NABH may revoke the accreditation.
3. Misrepresentation or Falsification of Information:
- If an organization is found to have provided false information or misrepresented its practices and facilities during the accreditation process or in subsequent audits, NABH has the right to revoke its accreditation.
4. Significant Patient Safety Violations:
- In cases where serious patient safety incidents occur due to negligence or failure to follow established protocols, NABH may revoke accreditation immediately.
- Examples include medical malpractice, improper handling of medications, or unsafe surgical practices.
5. Failure to Pay Accreditation Fees:
- Healthcare organizations are required to pay accreditation and renewal fees to NABH. Failure to comply with these financial obligations may also result in revocation.
6. Inability to Maintain Required Records:
- Inadequate or incomplete record-keeping, particularly related to patient care, staff training, and facility management, may lead to revocation if not addressed after warnings.
Process of Revocation
1. Identification of Non-Compliance:
- During routine audits, surveillance visits, or complaint investigations, NABH auditors may identify non-compliances or serious violations of standards.
2. Issuance of Warning and Corrective Action Request:
- In most cases, NABH will issue a formal warning and request the organization to submit a corrective action plan.
- The healthcare organization is given a specific timeframe (e.g., 30-90 days) to address the deficiencies and implement the necessary changes.
3. Follow-Up Assessment:
- NABH may conduct a follow-up audit to verify whether the organization has implemented the corrective actions and now complies with the standards.
- If the deficiencies are adequately addressed, the hospital can retain its accreditation.
4. Revocation:
- If the healthcare organization fails to implement corrective actions or if the violations are severe enough, NABH may decide to revoke the accreditation.
- The revocation process involves a formal notification to the hospital, stating the reasons for the decision.
5. Appeal Process:
- Organizations whose accreditation has been revoked have the option to appeal the decision.
- They can submit supporting documentation and evidence to NABH explaining their side of the situation.
- NABH will review the appeal and decide whether to reinstate accreditation or uphold the revocation.
Implications of Revocation
- Reputation Damage: Losing NABH accreditation can significantly affect a hospital’s reputation, leading to a loss of patient trust and a decline in patient numbers.
- Loss of Insurance Partnerships: Many insurance companies and government schemes prefer to work with accredited hospitals. Losing NABH accreditation could result in the termination of partnerships with insurance providers.
- Ineligibility for Government Programs: Accredited hospitals may be eligible for various government healthcare programs and subsidies. Revocation can make hospitals ineligible for such programs.
Can Accreditation be Reinstated?
- Yes, once accreditation is revoked, the hospital can reapply for NABH accreditation after correcting the identified issues.
- The reapplication process will involve submitting a new application, paying the required fees, and undergoing the complete accreditation process, including audits and assessments, just like a new applicant.
NABH accreditation is a voluntary but rigorous process that requires healthcare organizations to maintain high standards of quality and safety. While revocation is relatively rare, it can happen when serious non-compliances or violations occur. Maintaining consistent compliance with NABH standards is crucial for retaining accreditation and the associated benefits such as improved patient trust, better operational efficiency, and partnerships with insurance providers.