Methodology of Safe-ITSM- NABH

  • Safe-I secretariat coordinates this program.
  • The following steps would be carried out for hospitals to achieve Safe-I
    • purchase the application form for Safe-I
    • hospital applies for Safe-I thereby showing the intent to go down the journey of  ensuring “quality”
    • The existing certificates of the hospital would be evaluated by the  Safe-I secretariat
    • If the hospital does not meet the mandatory certifications as required by the government, the application would be rejected
    • Only hospital that meets the mandatory requirements would be eligible to be a part of this program.
  • The hospital who applies would be provided a complete package of a doctor who would –
    • carry out the baseline assessment,
    • help form the HICC,
    • develop protocols and policies on Infection Control.
    • training the trainers of the hospital
    • conduct  handholding sessions
    • end line assessment would also be carried out
  • Hospital invites the independent Safe-I assessor.
  • The hospital has the right to deny such handholding by the faculty. Modules which have been uploaded into the NABH website can be used by the hospital. A unique password would be provided to each hospital that applies, through which the contents can be viewed. However the cost of the program remains unchanged even if a hospital prefers to get the Safe-I certificate on their own.
  • Independent assessors would be sent by NABH Safe-I secretariat to evaluate the processes and adherence to policies on Infection Control by the hospital. This would be done within 5 months of application.
  • If the hospital passes the assessment, the final installment would have to be paid to the Safe-I secretariat. Upon payment, the Safe-I certification would be provided by NABH. If the hospital does not pass this assessment, they need not pay the final installment. Such hospitals may reapply again.
  •  The Safe-I certificate would have a validity of 2 years. During the second year the Safe-I secretariat would randomly send assessors to assess whether the hospital that had achieved Safe-I has been actually carrying out the processes as per the laid down guidelines.
  • If the hospital fails this random assessment, the certification would be withdrawn. If the hospital passes, the certification continues till the end of the second year.
  • At the end of 2 years, the hospital can reapply for the Safe-I certification.
  • Safe-I secretariat would maintain complete records of each hospital that has applied, has passed or failed the assessment. The list of assessors would also be maintained. Safe-I secretariat would also provide the hospitals that have failed the reasons thereof, so that improvements could be made subsequently.