Barriers to national accreditation board for hospitals and healthcare provider accreditation in public tertiary hospitals: A comprehensive review

Improved patient outcomes

NABH standards prioritize patient safety, clinical excellence, and evidence-based practices, all of which contribute to better health outcomes. Accredited public tertiary hospitals are required to implement standardized protocols for infection control, medication management, and emergency care, which can significantly reduce the risk of medical errors, healthcare-associated infections, and other adverse events. Studies indicate that accredited hospitals demonstrate lower mortality rates and higher levels of patient satisfaction, reflecting the effectiveness of these rigorous quality measures.^[7,8]

Enhanced operational efficiency

Accredited hospitals are encouraged to implement systematic documentation, structured workflows, and continuous monitoring of key performance indicators. In public tertiary care hospitals, where limited resources and high patient volumes are common challenges, these efficiency gains are particularly beneficial. Improved operational efficiency through accreditation can result in faster patient processing times, reduced waiting periods, and optimized resource allocation, which ultimately improves service delivery and patient throughput.^[9,10]

Increased staff satisfaction and professional development

Compliance with NABH standards involves regular training and upskilling of healthcare staff, enabling them to keep pace with evolving medical practices and safety protocols. This emphasis on training helps healthcare professionals gain confidence in their skills and improves morale by providing clear guidelines and expectations. Furthermore, accreditation supports a positive work environment by encouraging transparent communication, team collaboration, and staff involvement in quality improvement initiatives, all of which contribute to higher job satisfaction.^[11,12]

Building a culture of accountability and quality

NABH accreditation establishes a framework for regular audits, performance evaluations, and continuous monitoring, which collectively foster an environment of accountability. By embedding accountability into daily operations, NABH standards encourage healthcare professionals to adhere to best practices consistently, leading to improved trust between patients and providers.^[13]

Financial incentives through government initiatives

Examples include the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana, which offers a Silver Certification for hospitals meeting NABH Entry Level standards, rewarding them with an increased percentage of financial incentives. A 10% incentive is being provided to the hospitals with entry-level NABH certification and 15% for NABH full accreditation over and above the base rate of health benefit packages (HBP) packaged master rates.^[14]

Procurement-related issues

1. Requirement to procure medicines and consumables from Jan Aushadhi, where “look-alike” drugs increase risk to patient safety. Ref: NABH Standard management of medication (MOM).3.e - High-risk medications including look-alike, sound-alike (LASA) medications and different concentrations of the same medication are stored physically apart from each other.^[15]

   • Solution: Implement color-coding or labeling on LASA drugs to differentiate them and minimize confusion.

2. Near expiry policy: Near expiry policy cannot be maintained as Jan Aushadhi as the clause is not included in Memorandum of Understanding of many public hospitals with Jan Aushidhi. Ref: NABH Standard: MOM.6.c - Near-expiry medications are handled effectively.

3. Mandatory procurement from government e-marketplace, which can slow down purchasing processes.^[16]

   • Solution: Propose a streamlined approval process for urgent procurements and create buffer stock for essential supplies.

4. Lengthy procurement processes that delay access to essential drugs and supplies.

   • Solution: Establish a dedicated procurement team to handle and expedite processes, especially for critical items.

5. Equipment maintenance challenges, especially with Annual Maintenance Contracts or Comprehensive Maintenance Contracts that are often delayed or lack sufficient coverage.

   • Solution: Monitor maintenance schedules closely and establish local vendor partnerships for faster support on equipment maintenance.

Infrastructure and facilities issues

1. Aging infrastructure that requires frequent repairs and upgrades, which can be costly and time-consuming.

   • Solution: Schedule phased renovations and prioritize essential areas such as emergency wards and intensive care units.

2. High patient footfall, leading to overcrowding and increased strain on facilities.

   • Solution: Reorganize layout and create temporary patient waiting areas or expand outpatient areas to manage patient flow.

3. Housekeeping challenges in maintaining cleanliness and infection control in high-traffic areas.

   • Solution: Implement a rotating housekeeping schedule, increase staff for peak hours, and invest in automated cleaning devices.

4. Time-consuming tendering processes for renovations or new construction, causing delays in critical upgrades.

   • Solution: Advocate for faster tendering processes for urgent infrastructure improvements, such as a single-window tender approval system.^[17-19]

Financial constraints

1. Delayed approvals from finance departments, which slows down funding for essential upgrades and maintenance.

   • Solution: Propose a streamlined budgeting and approval process for quality-related expenses and seek periodic allocations.

2. Limited budget allocations for quality improvements and NABH compliance requirements.

   • Solution: Apply for government grants, utilize public-private partnerships, and seek donor support for specific quality improvement projects.

3. Difficulty in reallocating funds or securing additional resources for emergency purchases or immediate improvements.

   • Solution: Allocate a contingency fund for emergency purchases and advocate for financial flexibility in quality improvement initiatives.^[6,20]

Cultural and organizational resistance

1. Resistance to adopting new standards or practices, with staff often preferring established routines.

   • Solution: Conduct awareness sessions on the benefits of NABH accreditation and provide incentives for staff to adopt new practices.

2. Hierarchical organizational structures that hinder effective communication and cross-departmental collaboration.

   • Solution: Establish cross-departmental teams to improve communication and foster a collaborative culture for quality improvement.

3. Limited motivation among staff to prioritize quality improvement efforts due to perceived increased workload.

   • Solution: Include NABH compliance in performance evaluations and recognize departments that show consistent adherence to standards.

4. Reluctance to accept accountability for process changes or errors, hindering continuous improvement initiatives.

   • Solution: Foster an environment of openness and accountability through regular feedback, peer reviews, and transparent reporting mechanisms.^[21]

Policies and standard operating procedures (SOPs) implementation

1. Staff resistance to implementing new policies or SOPs, often due to lack of familiarity or perceived difficulty.

   • Solution: Conduct training on the importance of SOPs and integrate SOP compliance into routine performance reviews.

2. Challenges in enforcing compliance with new SOPs, such as infection control or documentation standards, which staff may not see as necessary.

   • Solution: Assign SOP champions in each department to ensure adherence and address any issues promptly.

3. Lack of awareness or training on the importance and benefits of SOPs, leading to inconsistent adherence.

   • Solution: Implement regular training sessions and provide accessible SOP manuals for all staff members.

4. Footfall in public hospitals is substantial, with patients often coming from lower socioeconomic backgrounds and having limited education levels. Maintaining proper sanitation, housekeeping, and adherence to SOPs related to hygiene presents a significant challenge.

   • Solution: Patient and Visitor Awareness: Display educational posters and distribute pamphlets to educate patients and visitors on the importance of hygiene and their role in maintaining it. Simple hand hygiene protocols like handwashing should be emphasized.^[22,23]

Shortage of human resources

1. Shortage of qualified healthcare professionals, leading to overworked staff and reduced quality of care.

   • Solution: Offer competitive packages, provide career development opportunities, and prioritize recruitment of qualified healthcare staff.

2. Difficulty in recruiting and retaining skilled personnel due to budget constraints or competitive job markets.

   • Solution: Partner with medical schools to create a pipeline for new hires and offer retention incentives like training and career progression.

3. Insufficient training and professional development opportunities, resulting in skill gaps and limited staff competency in quality management practices.

   • Solution: Arrange skill development workshops focused on quality management and compliance with NABH standards.

4. High turnover rates, with experienced staff often leaving for better opportunities, creating a lack of continuity in care and quality improvement efforts.

   • Solution: Develop a robust onboarding program and assign mentors to ensure that new staff are quickly brought up to NABH compliance standards.

5. Outsourced staff in public hospitals face three main issues: High turnover, low motivation, and eligibility gaps.

   1. Turnover: Frequent turnover among outsourced workers disrupts operations and leads to constant training needs, impacting service quality

   2. Motivation: Limited career growth, lower wages, and less job security reduce motivation and commitment, affecting overall performance

   3. Eligibility: Outsourced staff may lack essential certifications and training, which can lead to compliance issues with hospital standards.

• Solution: To address these, hospitals can set clear performance criteria in contracts, provide regular training, and offer motivational incentives, ensuring outsourced staff meet quality and operational standards effectively.^[24,25]