Assessment ke baad assessor portal pe NC report upload karta hai (Entry Level me DCAF 4 tab me dikhti hai). Har NC:
- 6 category me se ek: Policy (policy hi nahi/galat), Documentation (record adhoora), Practice (likha kuch, ho kuch aur raha), Regulation (license/legal gap — sabse serious), Patient Care, Facility Management.
- Risk-stratified: low / medium / high. Safety-related NCs aksar high aati hain.
- 'Document-practice mismatch' apne aap me NC hai — likhi hui policy jo staff follow nahi karta, assessor ke samne fail ho jati hai.
Closure process: corrective action + preventive action (CAPA) with evidence submit karo → NABH review karta hai → maximum DO review cycles, CAPA window 90 din. Major NCs close hue bina certificate nahi milta; 2 cycles ke baad bhi open rahi to mamla committee decide karti hai (risk high). CAPA likhne ka format: root cause (kyu hua) → correction (abhi kya theek kiya) → corrective action (dobara na ho uske liye system) → evidence (photo, register, training record) → responsible person + date.
ORALZY
adverse events aur medication errors pe CAPA register auto-banta hai — wahi format assessor ko chahiye. Mock audit me mili kamiyon ko bhi CAPA register me daal ke close karna best practice hai.