NABH-PROC_ COMPLAINTS

POLICY & PROCEDURE FOR

HANDLING OF COMPLAINTS

Issue No. 5 Issue Date: 02/2020 Page 1 of 7

Policy & Procedure for Handling of Complaints – PROC_COMPLAINTS

Contents
Sl. Title Page Nos.

Objective 3

1.0. Definitions 3

2.0. Scope 3

3.0 Responsibility 4

4.0 Procedure 4

4.1 Receipt of Complaints 4

4.2 Investigation of Complaints 5

4.3 Reporting on Complaints and other Related Actions 7

5.0 Records 7

Issue No. 5 Issue Date: 02/2020 Page 2 of 7

Policy & Procedure for Handling of Complaints – PROC_COMPLAINTS

Objective

The document describes the policy and procedure for dealing with complaints received from
various sources

1.0. Definitions

1.1. Complaint: Expression of dissatisfaction, other than an appeal, by any person or

organization, to NABH, about a NABH accredited/certified or applicant Health Care
Organization(HCO), where a response is expected. Any adverse media report shall
also be taken as complaint.

1.2. Complainant: any individual / organization / body that is making a complaint.

1.3. Feedback are the positive and negative expressions by any person or organization
against the services rendered. Feedback are not treated as complaints.

1.3 Health Care Organization (HCO): Any entity providing health care services for which
an accreditation or certification program is available with NABH.

2.0 Scope

The procedure includes, complaints against applicant or accredited/certified Health

Care Organizations (HCO) for the quality of the services provided by them. This may
also include complaints regarding misuse of the accreditation/certification status either
in scope or in use of the NABH mark

The procedure deals with all complaints received by NABH from any source including
information from regulators/ government department. It covers complaints received
vide any of the means like letters, e-mails, even relevant references appearing in print
media.

All complaints are treated as confidential unless desired otherwise by the Government
or by law.

Issue No. 5 Issue Date: 02/2020 Page 3 of 7

Policy & Procedure for Handling of Complaints – PROC_COMPLAINTS

Complaints related to NABH assessors shall be dealt by NABH Assessors

Management Committee. Complaints against NABH staff shall be dealt by CEO,
NABH. In such cases, QCI Conduct Rules shall be followed for imposing the
disciplinary action.

3.0 Responsibility

3.1 The responsibility for handling of complaints against HCOs shall rest with the
Complaints Committee, NABH. The Complaints Committee shall evaluate and
investigate the complaint and if necessary, adverse decision as per NABH procedures
shall be recommended to CEO-NABH. If these recommendations are accepted by
CEO then the concerned program officer will carry out the recommendations as per
NABH Policy on Adverse Decision.

3.2 CEO, NABH is responsible for monitoring of complaints.

3.3 Any ethics related complaint / ethical issues shall be referred to Ethics Committee of
Quality Council of India (QCI).

4.0 Procedure

4.1 Receipt of Complaints

The complaint must be made in writing to the CEO-NABH in any of the following
manner a) letter addressed to the NABH Complaints Committee b) NABH website on
the link https://www.nabh.co/Complaint.aspx c) on email id
complaints.redressal@nabh.co with complete details of the complainant (name,
address, email id & phone number etc.), description of the issue and supporting
documentary evidences.

NABH shall not accept those complaints which are incomplete w.r.t. above mentioned
details. Complaints not related to NABH Accreditation/ Certification Standards, e.g.
financial, billing, clinical negligence, complaints against individual health worker,
generalized statement shall not be accepted.

Issue No. 5 Issue Date: 02/2020 Page 4 of 7

Policy & Procedure for Handling of Complaints – PROC_COMPLAINTS

Anonymous complaints shall be registered, only if prima-facie they appear to be valid

and having some substance with supporting evidence.

All complaints received in NABH shall be channeled to the Complaints Committee

which maintains record pertaining to all complaints including important dates like date
of receipt, date of closure or final disposal in Complaints register.

4.2 Investigation of Complaints

4.2.1 All complaints shall undergo initial scrutiny by the Complaints Screening Committee to
determine whether they fall within the ambit of NABH activities and whether they are
valid, based on which any of the following action shall be taken.

a) If a complaint is outside the ambit of NABH activities, the complaint shall be

treated as closed and the complainant shall be informed accordingly.

b) If information provided in the complaint is inadequate for any meaningful follow-

up and the complainant is not able to provide minimum required information such
complaints shall also be treated as closed and the complainant shall be informed
accordingly.

c) If the complaint clearly falls within the ambit of NABH activities and appears to be
valid, the initial information provided is sufficient for initial investigation the same
shall be taken up for further action.

d) In case any more information is needed, the complainant shall be asked for the
same. NABH shall ensure that proper and timely communications are being sent
to client organization and other stake holders where necessary.

4.2.2 The Complaints Committee where appropriate shall give opportunity to the HCO to
address the complaint. When this is not appropriate, the officer may seek clarifications
from the HCO and if required may depute NABH representative or an assessor or an
expert with the approval of CEO, NABH to the HCO to investigate the matter. All
expenses related to investigation shall be borne by NABH.

Issue No. 5 Issue Date: 02/2020 Page 5 of 7

Policy & Procedure for Handling of Complaints – PROC_COMPLAINTS

4.2.3 The Complaints Committee shall analyse the findings of the investigation. If the
investigations reveal serious concerns with respect to the compliance to laid down
NABH accreditation/certification standards, wrong representation of scope of
accreditation/certification, wilful and/ or repeated misuse of NABH symbol etc. or in
case of non-cooperation with the investigation process, the adverse decision shall be
taken as per NABH procedures. Complaints Committee shall proceed further for
implementation of the adverse decision as per NABH procedures through the
Accreditation Committee.

If found necessary, NABH shall request to accredited/ certified/applicant HCOs for their
records of the complaints and the follow-up.

In case there is a media report regarding sentinel event in an applicant/

accredited/certified HCO, NABH may seek report on the above.

If found necessary, surprise assessment shall be scheduled for finding factual

accuracy of complaint against applicant/ accredited/certified HCO. The report shall be
placed before the Accreditation Committee

If there is any assessment already scheduled for HCO under question, the complaint
shall be forwarded to Principal assessor for evaluation. His / Her comments are
received along with the assessment report shall be placed before Accreditation
Committee for further action.

If the complaint is found invalid, the complainant as well as the HCO shall be informed
accordingly. The Committee shall exercise the right to dispose it off at this stage.

The concerned program officer of the HCO shall be informed about the decision /
action taken.

Complaints against the applicant or accredited/certified HCOs shall be disposed of

within 90 days of the receipt.

Complainant shall be informed within 15 days of the receipt if they are not falling within
the purview of NABH.

Issue No. 5 Issue Date: 02/2020 Page 6 of 7

Policy & Procedure for Handling of Complaints – PROC_COMPLAINTS

4.3 Reporting on Complaints and other Related Actions

4.3.1 As an outcome of investigation of complaint and corrective action if felt necessary; the
Complaints Committee shall inform the Quality Team and corrective action shall be
initiated by Quality Team in line with the requirements of Procedure for Control of Non-
Conformities and Corrective Action

4.3.2 All records pertaining to complaints shall be maintained by the Complaints Committee.
The status of complaints shall be reported to the CEO, NABH, who is responsible for
monitoring of complaints.

4.3.3 The Complaints Committee shall analyse all the complaints and their outcome. If this
analysis reflects certain trends, the trend and remedial measures will be reported to NABH
Board. The findings from the complaints become the basis of continuous quality
improvement for NABH, wherever appropriate.

5.0 Records

5.1 Complaints record shall be maintained in Complaints register.

5.2 Complaints file is maintained by Complaints Committee, where all correspondence in

respect of complaints received, decisions, and any other relevant documents are filed
date-wise. NABH ensures that complaints are resolved within a defined time frame. No
records shall be maintained for unregistered complaints.

Issue No. 5 Issue Date: 02/2020 Page 7 of 7

NATIONAL ACCREDITATION BOARD FOR HOSPITALS
& HEALTHCARE PROVIDERS (NABH)
Quality Council of India
5th Floor, ITPI Building
4 A, Ring Road, IP Estate
New Delhi - 110 002, India
Telefax: +91-11-42600600
Email: helpdesk@nabh.co
Web-site: www.nabh.co