Eye Care Hospital Accreditation Consultants

Eye Care Accreditation

Eye care hospitals are an integral part of the healthcare system and accreditation would be the single most important approach for improving the quality and patient safety in Eye care. Adverse events including post surgical infection rate in eye surgeries are quite common which calls for focus on quality and patient safety in such hospitals. Adherence to accreditation standards in these settings improves quality of services leading to good clinical outcomes.

Currently in operation as Eye Care Organization.
Eye Care Organization should have implemented NABH standards in the Eye Care Organization for
a minimum of three months.
The organization that commits to comply with NABH standards and applicable legal/statutory/
regulatory requirements.

A Clinic/hospital (having exclusive eye care facility) willing to be accredited by Eye Care Organization must ensure the implementation of Eye Care standards in its organization. The assessment team look for the evidences of implementation of Eye care Standards in organization. The ECO shall be able to demonstrate to NABH assessment team that all Eye Care standards, as applicable, are followed.

Eligibility to apply for Eye Care Organization accreditation

Eye Care Organization that fulfils the following requirements:

Currently in operation as Eye Care Organization.
Eye Care Organization should have implemented NABH standards in the Eye Care Organization for a minimum of three months.
The organization that commits to comply with NABH standards and applicable legal/statutory/ regulatory requirements.

These standards are to be used by the whole organisation and not for a specific service within the organisation.

Outline of Eyecare accreditation standards

Patient Centered Standards

Access, Assessment and Continuity of Care
Care of Patients
Management of Medication
Patient Rights and Education
Hospital Infection Control

Management Centered Standards

Continous Quality Improvement
Responsibility of Management
Facility Management and safety
Human Resource Management
Information Management Systems

Benefits of Accreditation

Accreditation to a health care organization stimulates continuous improvement.
It enables the organization in demonstrating commitment to quality care and patient safety thereby ensures best clinical outcomes
It raises community confidence among the patients as the services are provided by credentialed staff.
It also provides opportunity to healthcare unit to benchmark with the best.
An accreditation status also provides marketing advantage in a competitive health care.
Finally, accreditation provides an objective system of empanelment by insurance and other third parties.

Pre-Assessment (Optional)

NABH has made pre-assessment optional. Those Eye Care Organizations which does not want to undergo pre-assessment shall provide in writing in the remark column of online application form. However, NABH shall conduct the pre-assessment for those Eye Care Organization which are desirous for the same. The Principal Assessor and other assessors (as applicable) are assigned the job of pre-assessment. Principal assessor shall submit the pre-assessment report online. The Eye Care Organization shall take corrective actions on the non-conformities raised by the Principal Assessor/ team. The Eye Care Organization shall in any case be required to pay the requisite Annual fee before the final assessment.

Final Assessment

After the Eye Care Organization has taken necessary corrective action to the non-conformities raised during the pre-assessment (which is optional), NABH shall propose to constitute an assessment team for the final assessment. However as mentioned earlier Eye Care Organization’s can directly go for final assessment without opting for pre assessment. The total number of assessors appointed shall depend on the size of the Eye Care Organization and scope of services provided. The date of final assessment shall be agreed upon by the Eye Care Organization management and assessors. Assessment shall be conducted on all the facilities covered under accreditation. The assessment team reviews the Eye Care Organization’s documented management system and verifies its compliance to the NABH standards. The documented quality system, policies and procedures, other manuals etc. shall be assessed for their implementation and effectiveness.Based on the assessment by the assessors, the assessment report is prepared and uploaded by the Principal assessor in the online portal. The details non-conformities observed during the assessment is visible to the Eye Care Organization team in the online portal once the Principal Assessor submits the report.

Scrutiny of assessment report & Accreditation Committee

The Eye Care Organization shall take necessary corrective action on the non-conformity (ies) and upload the requisite document as evidence for corrective action for each non-conformities. On successful submission of the corrective action by the Eye Care Organization, the same shall be reviewed by the Principal Assessor. Eye Care Organization are allowed to avail only two cycles of review of corrective action taken After satisfactory corrective action is taken by the Eye Care Organization, the accreditation committee examines the assessment report, additional information received from the Eye Care Organization and consequent verifications. The accreditation committee shall make appropriate recommendations regarding accreditation of the Eye Care Organization to NABH. In case the accreditation committee finds deficiencies in the assessment report to arrive at the decision, the Secretariat obtains clarification from the Principal assessor/assessors/ Eye Care Organization concerned.

Issue of Accreditation Certificate

NABH shall issue an accreditation certificate to the Eye Care Organization with a validity of three years. The certificate has a unique number and date of validity. The certificate is accompanied by the scope of accreditation. The applicant Eye Care Organization must make all payment due if any to NABH, before the issue of certificate.

Surveillance and Re assessment

Accreditation to the Eye Care Organization shall be valid for a period of three years. NABH shall conduct surveillance Assessment before completion of 15-18 months since the date of accreditation of the accredited Eye Care Organization. The Eye Care Organization shall pay the annual fees every year. The first annual fee is paid before the final assessment and is valid till the end of first year from the date of accreditation. Since then, the annual fees shall be due on the same date/ month every year. The Eye Care Organization need to apply online for renewal of accreditation at least six months before the expiry of validity of accreditation for which reassessment shall be conducted. NABH may call for un-announced visit, based on any concern or any serious incident reported upon by an individual or an organization or media.