NATIONAL ACCREDITATION BOARD FOR HOSPITALS &

HEALTHCARE PROVIDERS (NABH)

Information Brochure for Empanelment

of Medical Value Travel Facilitator

May 2016

1st Edition
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

1. Medical Value Travel Facilitator Empanelment Program

Empanelment is the provision by an independent body of written assurance (a

certificate) that the services being provided by the facilitator meets specific
requirements.

Medical Tourism in India is playing a vital role in improving the economic and social
status of the society. A large and growing population, a booming economy, rapid
urbanization which has expanded the middle class, and awareness on emerging new
diseases, lifestyle diseases & their burden has enabled the medical tourism industry
to grow at much higher rate.

The objective of NABH is to initiate programs focusing on patient safety through

process of self and external evaluation in order to test the accountability and reliability
of the facilitators.

The empanelment criteria’s are not expected to be prescriptive. They only lay down
the requirements and it is up to organization to come out with the systems, processes
and modes of measuring performance indicators which can demonstrate compliance
to the requirements as specified in the empanelment criteria.

The certificate issued shall be valid for two years. The organization should apply for
renewal six months before the expiry of validity.

Scope of the Program:

This document explains the process of evaluation under the scheme for voluntary
empanelment of Medical Value Travel Facilitator (MVTF). It describes the requirement
that should be followed in order to obtain and maintain the certificate of empanelment.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

2. Benefits of Empanelment

Benefits for Clients/ Patients

Clients/ patients are the biggest beneficiary among all the stakeholders. The
empanelment criteria’s are crucial for ensuring patients safety and the quality of
services being offered. Any unethical practices carried out by facilitator might have
deep consequences in the outcome of the treatment. Empanelment results in the
promotion of safe, effective, competent and ethical procedure for medical value travel
facilitator. They all are serviced by credential staff and their rights are respected and
protected.

Benefits for Organization

Empanelment to Facilitator stimulates continuous improvement. It enable
organizations in demonstrating commitment to quality. It raises community confidence
in the services provided by them. The other advantages of empanelment are as
follows:

 Improve Safety, Accountability of services offered and patient Care

 Earn a Credible Mark of Compliance with empanelment Criteria
 Achieve Greater Efficiency, Profitability, and More Productive Operations
 Become More Competitive, Gain Public Recognition, and Grow Revenue
 Improves patients and Employee Satisfaction
 SIES benefits under IEC and RCMC scheme
 Standardised vision, mission and policy statement formed

Benefits for Staff

The staff in an empaneled organization is satisfied a lot as it provides for continuous
learning, good working environment and leadership. It improves overall professional
development of all the staffs irrespective of their professional background.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

3. About NABH

National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a

constituent board of Quality Council of India, set up to establish and operate
accreditation programme for healthcare organizations. The board is structured to cater
to much desired needs of the consumers and to set benchmarks for progress of health
industry. The board while being supported by all stakeholders including industry,
consumers, government, have full functional autonomy in its operation.

NABH is an institutional member of the International Society for Quality in Health Care
(ISQUA). ISQUA is an international body which grants approval to Accreditation
Bodies and their standards in the area of healthcare.

Currently, NABH offers accreditation to Hospitals, Small Healthcare Organizations,

Blood Banks, Blood Storage Centre, PHC/CHC, Wellness Centre, AYUSH Hospitals,
Medical Imaging Services, Allopathic Clinics and Dental Facilities.

In addition to the above accreditation programs, NABH also offers following

Certification programs:

A) NABH-Safe I certification program

B) Medical Laboratory certification program
C) Nursing Excellence certification program
D) Entry Level Hospitals & Small Healthcare Organisations

NABH has launched a new program called ‘Empanelment of Medical Value Travel
Facilitator (MVTF)’.

This information brochure is specifically prepared to give information about Medical

Value Travel Facilitator Empanelment program.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

3. About NABH Continued

International Society for Quality in Healthcare (ISQua) has accredited “Standards for
Hospitals”, 4th Edition, December 2015 developed by National Accreditation Board for
Hospitals & Healthcare Providers (NABH, India) under its International Accreditation
Program for a cycle of 4 years (April 2016 to March 2020). The approval of ISQua
authenticates that NABH standards are in consonance with the global benchmarks set
by ISQua. The hospitals accredited by NABH have international recognition. This will
provide boost to medical tourism.

ISQua is an international body which grants approval to Accreditation Bodies in the

area of healthcare as mark of equivalence of accreditation program of member
countries.

NABH is an Institutional Member as well as a member of the Accreditation Council of

the International Society for Quality in HealthCare (ISQua). NABH is the founder
member of Asian Society for Quality in Healthcare (ASQua)
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

4. About Medical Tourism & Facilitator

Medical tourism is the attempt on the part of a tourist facility or destination to attract
tourists by deliberately promoting its healthcare services and facilities, in addition to
its regular tourist amenities. International medical tourism refers to cross-border travel
made by people for medical facilities either to leverage costs back home or to avail
quality treatment from medically advanced Nations.

A Medical Tourism Facilitators is an agency involved in managing and

coordinating all the activities related to care of the patients and their treatments
while travelling abroad. Medical tourism agencies and facilitators are an important
part of the medical tourism industry, helping patients to engage in medical tourism.

Why Medical Tourism

• Medical treatment that was unavailable in their own communities.

• High cost of health care.
• Some treatments may not be legal in the home country, such as some fertility
procedures.
• Improvements in both technology and standards of care in many countries.
• The avoidance of waiting times.

Factors for choosing Medical Tourism Destination

• Rich cultural heritage & tourism potential.

• Availability of advanced equipment & medical experts.
• Reputation for age-old medicines and therapies such as ayurveda,
homoeopathy, Unani, naturopathy and yoga.
• Wellness tourism: large number of tourist places for tourist attractions.
• Cost-effective and qualitative advanced healthcare.
• Availability of the procedures.
• Religious and cultural affinity.
• Political climate.
• Credentials of health care providers.
• The vacation package offered along with clinical care.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

4. About Medical Tourism & Facilitator Continued

Why India as a Favorite destination?

• High savings
• No wait-lists
• High quality treatment
• World class facilities
• Access to latest technology
• Best surgeons
• Customer care
• Travel opportunities
• Rich Cultural Heritage

Advantages of Medical Tourism

Inarguably medical tourism is an economic tool for nations striving to boost

their economies through direct benefits such as:

 Increase in revenue, employment opportunities, investment in tourism

avenues etc.

 Indirect benefits that include spillover effects leading to growth in other

industries.

 Rise in living standards of people associated with tourism.

 Need for education, demand for related educational courses, growth of

ancillary industries, and so on.

Role of Healthcare Accreditation in Medical Tourism

• Hospital accreditation and standardization is a vital component in any well-

ordered society. It has been defined by the academic community as an
external assessment and self-assessment process, in relation to established
standards, to accurately assess the level of performance and the implement
action plans to improve.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

4. About Medical Tourism & Facilitator Continued

Need of Healthcare Accreditation in Medical Tourism

• Medical tourism requires a strong presence of accreditation of healthcare

due to a certain amount of unethical situations. There has been an increase
in the demand for low-cost insurance products in this rapidly developing
market as well as for medical travel websites, associations and agencies that
help patients to find hospitals abroad.

• So it is necessary for the patient to research and observe that the lack of
accreditation might have deep consequences, not only in the outcome of the
treatment itself but also in the quality of the service.
 NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

5. Organizational Structure

Quality Council of India

National Accreditation Board for Hospitals and

Healthcare Providers (NABH)

Appeals Committee

Accreditation Technical Assessor Research Secretariat

Committee Committee Management Committee
Committee

Panel of Assessors/
Experts

NATIONAL
ACCREDITATION
BOARD FOR
HOSPITALS
& HEALTHCARE
PROVIDERS (NABH)
Page 6
Organizational
Structure
Accreditation
Committee
The main functions of
Accreditation
Committee are as
follows:
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

5. Organizational Structure Continued

Empanelment Committee

The main functions of Empanelment Committee are as follows:

 Recommending to board about grant of empanelment or otherwise based on

evaluation of assessment reports & other relevant information.

 Approval of the major changes in the scope of empanelment including

enhancement and reduction, in respect of empaneled Medical Value Travel
Facilitator.

 Recommending to the board on launching of new initiatives

Technical Committee

The main functions of Technical Committee are as follows:

 Drafting of empanelment criteria and other documents

 Periodic review of Empanelment Criteria

Appeals Committee

The Appeal Committee addresses appeals made by the medical value travel facilitator
against any adverse decision regarding evaluation taken by the NABH. The adverse
decisions may relate to the following:

 Refusal to accept an application.

 Refusal to proceed with an assessment.

 Corrective action requests.

 Changes in scope of empanelment.

 Decisions to deny, suspend or withdraw empanelment, and

 Any other action that impedes the attainment of empanelment.

NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

5. Organizational Structure Continued

NABH Secretariat

The Secretariat coordinates the entire activities related to NABH empanelment for
Medical Value Travel Facilitator.

Panel of Assessors and Experts

NABH has a panel of trained and qualified assessors for assessment of Medical Value
Travel Facilitator.

Assessors

NABH has empaneled experts for assessment of Medical Value Travel Facilitator.
They are trained by NABH on medical value travel facilitator empanelment criteria and
various assessment techniques. The assessors are responsible for evaluating the
medical value travel facilitator compliance with NABH empanelment criteria.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

6. NABH Empanelment Criteria

NABH Empanelment criteria for Medical Value Travel Facilitator prepared by technical
committee contains complete set of criteria for evaluation of Medical Value Travel
Facilitator for grant of Empanelment.

The empanelment criteria provide framework for quality of care for patients and quality
improvement for medical value travel facilitator. The empanelment criteria help to build
a quality culture at all level and across all the functions of Medical Value Travel
Facilitator.

Outline of Empanelment Criteria for Medical Value Travel Facilitator (MVTF):

NABH for empanelment of Medical Travel Facilitator has 7 sections.

Summary of Empanelment criteria for Medical Value Travel Facilitator

 Technical and infrastructure specifications of the Organization

 Statuary Compliance Information

 Organization Information

 Facilities Provided by the Organization

 Privacy Policy & Procedures

 General Policy & Procedures

 Organization Responsibilities
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

7. Assessment criteria & Methodology

Medical Value Travel Facilitator willing to be empaneled by NABH must ensure the
implementation of NABH empanelment Criteria.

The assessment team will check the implementation of NABH empanelment criteria
by the Medical Value Travel Facilitator. Medical Value Travel Facilitator shall be able
to demonstrate to NABH assessment team that all NABH empanelment criteria, as
applicable, are followed.

NABH Secretariat on intimation from the Medical Value Travel Facilitator about the
preparedness to take up assessment, appoints an assessor from the pool of
empaneled assessors.

Following documents are provided to the assessment team for carrying out the
assessment:

- Copy of application form.

- Applicable documents (SOPs, Protocol, and Policy & Procedures) of the
Organization.
- Empanelment criteria
- Confidentiality form

In order to obtain evidence on compliance with respect to NABH empanelment criteria

and applicable rules & regulations, different methodology for onsite assessment is
practiced which includes facility inspection, documents and records review & interview
of staffs.

During assessment, assessment objectives are discussed with the Medical Value
Travel Facilitator and a copy of detailed report is handed over to the management of
the organization at the end of the assessment.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

8. Preparing for NABH Accreditation

Medical Value Travel Facilitator shall first decide about getting empanelment from
NABH. It is important for a facilitator to make a definite plan of action for obtaining
empanelment and nominate a responsible person to co-ordinate all activities related
to seeking empanelment. An official nominated should be familiar with existing quality
assurance system.

Medical Value Travel Facilitator shall procure a copy of empanelment criteria from the
NABH official website by downloading it. Further clarification regarding empanelment
criteria can be got from NABH Secretariat in person, by post, by e-mail or on
telephone.

Medical Value Travel Facilitator for empanelment shall understand the NABH
assessment procedure and ensure that the empanelment criteria required are
implemented in the organization.

Medical Value Travel Facilitator can download the application form for NABH
empanelment from the web-site and must be ready for maintaining compliance before
submission of application and must ensure that it complies with NABH requirement for
empanelment.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

9. NABH Empanelment Procedure

Application Form + Internal Audit Report +

Minutes of Management Review Meeting
(By Medical Value Travel Facilitator)

Acknowledgment and Scrutiny of

application
(By NABH Secretariat) Feedback
To
Medical Travel
On-site Assessment of the Medical Value Facilitator
Travel Facilitator (MTF) And
Necessary
(By Assessor)
Corrective
Action
Taken
By
Review of Assessment Report
Them
(By NABH Secretariat)

Recommendation for Empanelment

(By Empanelment Committee)

Approval for Empanelment (Two years)

(By Chairman, NABH)

Issue of Certificate
(By NABH Secretariat)
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

9. NABH Empanelment Procedure continued

Application for Certification:

Medical Value Travel Facilitator shall apply to NABH for empanelment by practicing
following steps:
 Filling online application form
 Pay application fee as detailed in the application form
 Attach copy of last internal audit report
 Attach copy of minutes of last management review meeting

Scrutiny of application:
Application form is scrutinized at NABH Secretariat and if it is found to be complete in
all respects, a unique reference number is issued to the Centre. The Medical Value
Travel Facilitator shall be required to quote this reference number in all future
correspondence with NABH.

Appointment of Assessor:
NABH shall appoint Assessor who shall have the overall responsibility of conducting
the assessment for the Medical Value Travel Facilitator. He/ She will conduct the on-
site assessment of the Organization.

On-site Assessment:
The date of on-site assessment shall be agreed upon by the organization management
and assessor. Assessment shall be conducted on all the facilities/services of the
Facilitators. The assessor reviews the documented management system and verifies
its compliance to the NABH empanelment criteria. The documented quality system,
SOPs, work procedures etc. shall be assessed for their implementation and
effectiveness. The technical competence of the organization shall also be evaluated.

Based on the assessment by the assessment team, the assessment report is prepared
in a prescribed format. The details of nonconformity observed any during the
assessment are handed over to the organization by the assessment team and detailed
assessment report is sent to NABH.
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

9. NABH Empanelment Procedure continued

Issue of Accreditation Certificate

NABH shall issue an empanelment certificate to the Medical Value Travel Facilitators
with a validity of two years. The certificate has a unique number and date of validity.
The certificate is accompanied by scope of services.

The applicant must make all payment due to NABH, before the issue of the
assessment visit.

All decision taken by NABH regarding grant of empanelment shall be open to appeal
by the organization, to chairman NABH.

Follow up

Medical Value Travel Facilitator shall have a maximum of 30 days to close all the non-
conformities and submit corrective actions to NABH. A copy of such corrective actions
shall be forwarded to Assessor for their comments, whether to accept or otherwise
NATIONAL ACCREDITATION BOARD FOR HOSPITALS &
HEALTHCARE PROVIDERS (NABH)

10. Assessment criteria, Fees structure & Payment details

Assessment criteria and Fee structure

Assessment Site visit Application Fees Certification Fees

Medical Value Travel 1x1 man-days 5,000/- 20,000/-

Facilitator

Service Tax: A service tax as applicable from time to time 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. Application shall be considered only when complete details of the facilitator is

provided. Assessment shall be done comprehensively. There shall be one person
coordinating all the activities of the Organization.

2. Application form duly filled shall be submitted online along with relevant documents
and application fees.

3. Fees shall be paid only through online mode (Credit card or Debit card), Bank transfer
and is non-refundable.

4. The accreditation fee does not include expenses on travel, lodging/ boarding of
assessors, which will be borne by the applicant on actual basis.

5. The first year annual fees shall be payable before the assessment visit.

6. The second year annual fee shall be paid at the start of second year of accreditation.

7. The certification, once granted shall be valid for two years.

8. The organization shall apply for renewal six months before the expiry of validity in the
prescribed form with application fee for consecutive cycle.

9. NABH may call for an un-announced visit, which could be a Surprise Assessment or
based on any concern/ feedback/ complaint reported by any individual or organization
or media and expenses on such visit shall be borne by NABH.