Download APPLICATION For ACCREDITATION OF MEDICAL IMAGING

APPLICATION
For
ACCREDITATION OF MEDICAL
IMAGING SERVICES
Issue No.: 03
Issue Date: April 2012
NATIONAL ACCREDITATION BOARD FOR
HOSPITALS & HEALTHCARE PROVIDERS
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NATIONAL ACCREDITATION BOARD FOR
HOSPITALS & HEALTHCARE PROVIDERS
Assessment criteria and Fee structure for Medical
Imaging Services
Practice
Category
Assessment Criteria
Preassessment
(based on no.
of modalities
present)
Assessment
Accreditation Fee
Surveillance
Application
Fee
Annual Fee
Small Practice,
1 modality
One man day
Two man days
(2x1)
One man day
Rs. 10,000/-
Rs. 30,000/-
Medium
Practice, 2
modalities
One man day
Two man days
(2x1)
One man day
Rs. 15,000/-
Rs. 40,000/-
Large
Practice, 3 or
more than 3
modalities
Two man days
(2x1)
Four (2x2) man
days
Two man days
(2x1)
Rs. 20,000/-
Rs. 60,000/-
NOTE: The man days given above for assessment and surveillance are indicative and may change depending on the facilities and size
and type of services.
Service Tax: w.e.f. 15.11.2015 a service tax of 14.50% will be charged on all the above fees. You are
requested to please include the service tax in the fees accordingly while sending to NABH.
Guidance notes:
1.
Five copies of Application Forms to be submitted along with fees as per NABH Standards for
Medical Imaging Services.Fees are non-refundable.
2.
Fees to be paid through Demand Draft/ local cheque in favour of ‘Quality Council of India’ payable
at New Delhi.
3.
Self Assessment Toolkit dully filled in is to be submitted by the MIS along with the application form
4.
Other relevant documents be submitted by the MIS are detailed in Annexure I
5.
The accreditation fee does not include expenses on travel, lodging/ boarding of assessors, which
will be borne by the Medical Imaging Services on actual basis.
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6.
The application fee includes pre-assessment charges.
7.
The accreditation, once granted will be valid for three years, after which Medical Imaging Services
may apply for renewal as per NABH policy.
8.
The first annual fee is payable after pre-assessment visit and before assessment visit.
9.
10% discount will be admissible in case MIS pays the accreditation fee for three year in one
installment
10. The surveillance visit will be planned during 2nd year of accreditation which is usually after 18
months.
11. NABH may call for un-announced visit, based on any concern or any serious incident reported
upon by any individual or organization or media.
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Guidelines for filling the application form
(Please read this carefully before filling this form)
1. For Sl. No. 3- Kindly mention if the organization is a public/ government establishment or an
independent/ private sector provider.
2. For Sl. No. 7- Please specify e.g. clinical establishment, shop, etc.
3. For Sl. No. 8 & 9 – Please provide all the detail in the prescribed format, separately for each
equipment. Please submit scanned copies of all the statutory requirements while submitting the
documents.
4. For Sl. No. 10- If a particular license is not required in your region or is not applicable for your set up
kindly mention the same in “Remarks” column. You can also use this column to state “applied for” ;
“pending approval”; “applied for renewal on….” etc.
5. For Sl. No. 11 – The services listed under A if existing are mandatory to apply for. However
application for services listed under B and C are optional.
6. For Sl. No. 14 a. Please indicate if there are individuals holding recognized degrees managing the department.
Please mention full time and part time consultants separately as X + Y=Z
b. Please include list of Doctors, Nursing and technical staff with credentials and
privileges.
7. Documents to be submitted to NABH shall be inclusive of but not limited to as per list mentioned in
Annexure1.
The MIS shall ensure that it shall send an updated application form to NABH in case of any changes especially before preassessment and final assessment
Definition:
Medical Imaging Services (MIS)
Medical Specialty that uses X-rays, gamma rays, high frequency sound waves , magnetic fields or
isotopes to produce images of organs and other internal structure of the body. The specialty aims to
detect & diagnose disease as well as to carry out interventional procedures to confirm the diagnosis and
treat certain diseases and abnormalities.
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Application Form for Accreditation of Medical Imaging Services
First Accreditation
Renewal of Accreditation
1. Name of the Centre/HCO:
_______________________________________________________________________
2. Address: _______________________________________________________________
______________________________________________________________________
______________________________________________________________________
3. Ownership: _____________________________________________________________
4. Name of Parent Organization: _____________________________________________
(if part of any other organization)
Telephone No. _____________________ Fax No. __________________ e-mail ______________________
5. Name to appear on Certificate if Accreditation is granted:
_______________________________________________________________________
6. Contact person(s):
(Please indicate [] with whom correspondence be made)

Chief Executive Officer/ Head of Department/ equivalent
Mr./Ms./Dr. ___________________________________________________________
Designation: __________________________________________________________
Tel: ___________________________ Mobile: _______________________________
Fax: _________________________________________________________________
E-mail: _______________________________________________________________

Accreditation Coordinator:
Mr./Ms./Dr. ___________________________________________________________
Designation: __________________________________________________________
Tel: ___________________________ Mobile: _______________________________
Fax: _________________________________________________________________
E-mail: _______________________________________________________________
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7.
Whether the Medical Imaging Service is registered with Local Authorities:(Where
applicable as per the State or Central Norms)
______________________________________________________________________
8.
Details regarding Ultrasound Equipment registration with PC-PNDT:
Equipment
9.
Registration number and
date
Valid Upto
Remarks (if any)
Details regarding AERB approval of equipment, facility design and installation,
Operation certificate and Personnel:
Name of
Equipment
License/Certificate
Number and
Date
Valid Upto
Remarks (if
any)
NOC/Type-approval
certificate of Equipment
Site Layout approval
Installation/Operation
Certificate
Personnel(RSO)
10. List of other relevant legal documents applicable to MIS with date, number & validity
of registrations/license *.
License/Certificate
Number and Date
Valid Upto
Remarks (if any)
General:
Bio-medical Waste
Management and Handling
Authorization
Employee Provident Fund
Employee State Insurance
NOC for Import of Equipment
PAN/TAN
Registration of Company
(ROC)
Registration Under Clinical
Establishment Act (or similar)
Registration With Local
Authorities
Facility management:
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Building Occupancy /
Completion Certificate
Fire (NOC)
License for Diesel Storage
License for Electrical
Installations
License to Store Compressed
Gas
Sanction for Lifts
Prevention and Control of
Pollution Act (For generator)
Pharmacy (if over multiple locations license for each of them separately)
Drugs-Bulk license
Drugs-Retail license
License for Possession and
Use of Methylated Spirit,
Denatured spirit, Methyl
alcohol and Ethyl Alcohol
Narcotic license
Nuclear Medicine and Radiation therapy:
Authorization to Use
Radiopharmaceuticals in
Humans
Authorization for
Radionuclide Imaging
NOC for procurement of
Radiopharmaceuticals
Any other:
Canteen/ F & B license
*Please submit scanned copies of all the statutory requirements while submitting the documents
11. Modalities:
(Please indicate [] on modalities existing at your Diagnostic Centre/HCO/SHCO)
1. Category A: Following Imaging Services if provided at the centre/HCO, they are
mandatory to be applied for :Radiography
Fluoroscopy based Radiographic Procedures
Interventional Procedures
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Ultrasound
Mammography
Magnetic Resonance Imaging (MRI)
Computed Tomography (CT) scan
Nuclear Medicine
Others
2. Category B: Following Imaging Services may be excluded from the scope of
Accreditation if desired :Bone Mineral Densitometry
OPG
Dental X-ray
3. Category C: Non- Imaging Services which may be included in the scope of Accreditation
if desired
Electrocardiogram. (ECG).
Holter Monitoring
Echocardiogram (ECHO)
Tread Mill Testing (TMT)
Electroencephalography (EEG)
Electromyography (EMG)/Evoke Potential (EP).
Nerve Conduction Velocity (NCV)
Spirometry
Audiometry
Uroflowmetry (UF)
Any other, please specify …………………………………………..
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12. Scope of Accreditation (in detail)
For Category A:
Scope of service
Inclusive of
Radiography
General Radiography
Dental Radiography
Fluoroscopy based Radiographic
Procedures
Fluoroscopy based Investigative Procedures
Interventional Procedures
Fluoroscopy Guided Vascular Procedures
Fluoroscopy Guided Non-Vascular Procedures
Angiography/Cardiovascular Labs setups for vascular imaging
and interventional procedures
Mammography
Mammography
Interventional Procedures
Ultrasound
General Ultrasound
Colour Doppler flow imaging
Interventional procedures
USG guided HIFU
MR imaging
MR guided procedures
MR guided HIFU
CT Imaging
Cone Beam Computed Tomography
CT guided procedures
Magnetic Resonance Imaging
(MRI)
Computed Tomography
(CT) scan
Nuclear Medicine
Others
Plainer Gamma Camera
SPECT/SPECT CT
Positron Emission Tomography(PET)/PET-CT
Radionuclide therapy
Radio frequency ablation(RFA) and Laser / Cryoablation /
Thermoablation
Tele radiology
Any other imaging service
For Category B:
Scope of service
Bone mineral Densitometry
OPG
Dental X-ray
Inclusive of
Dual Energy X Ray Absorptiometry (DEXA)
Quantitative Computed Tomography (QCT)
Quantitative Ultrasound(QUS)
OPG
Dental X-ray
For Category C
Refer to point 11
13. Organization Chart: Provide Organogram
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14. Staff Information: Details with educational qualification and experience of all Imaging
Personnel(Radiologist and technicians)
Sl.
No.
Name
Designation
Qualification
Experience in Medical
Imaging Services (yrs)
*Note: Separate list of personnel working in X-radiation environment should also be
included with TLD batch numbers.
15. Equipment: Details of all equipments in the Medical Imaging Services
Sl.No
Name of Equipment
Make/ Model
Date
Installation
of
AMC/CMC
status
Average patient
load
*Note: Each equipment should be listed separately.
16. Details of Self-assessment :
Date of Self-assessment __________________________________________________
Done by __________________________________________________
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17. Date of completion of application: __________ Day __________ Month ________Year
18. Litigation, if any:
______________________________________________________________________________
Medical Director/ Authorized Signatory
Name: ___________________________
Designation: ______________________
NATIONAL ACCREDITATION BOARD FOR HOSPITALS
& HEALTHCARE PROVIDERS (NABH)
Quality Council of India
Institution of Engineers’ Building, IInd Floor, Bahadur Shah Zafar Marg
New Delhi - 110002, India.
Tel/ Fax: 91-11-2337 9321, 91-11-2337 9621
Website: www.qcin.org; www.nabh.co
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Annexure I
Reference list of Documents for MIS Accreditation Programme
1. Statutory and legal obligation as applicable with date, number & validity of registrations/license
(attach the Photocopies of all legal documents)
2. Manuals:
(Apex Manual to be submitted to NABH and all other to be prepared and kept ready for review during
assessment):
 Apex Manual
 Safety Manual
 Infection Control Manual
For Guidance Purpose the content of manual may include(but not limited to) following:
Content of Apex/Quality Manual
a. Introduction to organization
b. Vision, Mission, AIM, Quality Policy
c. Quality Objectives
d. List of Committees
e. Organogram
f. Status of Statutory requirements
g. NABH MIS chapter wise documentation (CS, CPP, CE,CP, CDR, RCS)
h. Continuous Quality Improvement Programmes (verification processes, validation
processes, adverse event reporting, and quality indicators monitored
i. Performance/Quality indicators(at least on quality indicator related to patient service and
one for each modality)
Content of Safety Manual
a. Introduction to centre
b. Medical codes (code blue, code red etc)
c. Safety committee
d. Fire Safety (fire preventive and extinguishing methods, fire & safety trainings, Emergency
Evacuation procedures etc.)
e. Electrical safety
f. Radiation safety
g. Equipment safety
h. Medical gas safety
i. Water safety
j. Building safety
k. Patient safety
l. Vulnerable patient safety
m. Geriatrics patients safety
n. Anesthesia safety
o. Falls and falls reduction programme
p. Employee safety
q. Personal protective equipments
r. Risk management
s. Sentinel events
Content of Infection Control Manual
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a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
Introduction of MIS
Introduction to MIS Infection Control Programme (MIS-ICP)
MIS Infection Control Committee (MIS-ICC)
Infection Control Team
Goals and Objectives of MIS ICP
Responsibilities of MIS- ICP
Hand Hygiene
Procedures related Protocols (E.g. Personal hygiene, injection, oxygen administration etc)
Equipment related Protocols
Environment related Protocols (high risk areas, water quality, pest control etc)
Employee related Protocols (employee Health Programme, post exposure prophylaxis etc)
Surveillance and reporting of Infection
Bio medical waste (law & rule, BMW management at MIS)
5. List of Committees with frequency of meeting and date of last meeting held
6. List of trainings held
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