Before Applying for NABH Accreditation

Before Applying for NABH Accreditation

10 Essential Checks a Hospital Should Make Before Applying for NABH Accreditation

In the rapidly evolving healthcare ecosystem, quality and patient safety have emerged as key differentiators. One of the most prestigious benchmarks of quality in Indian healthcare is the NABH (National Accreditation Board for Hospitals & Healthcare Providers) accreditation.

Earning NABH accreditation not only enhances a hospital’s credibility but also ensures that patients receive care that is safe, effective, and consistent. However, before initiating the accreditation process, hospitals must perform a comprehensive self-assessment to ensure readiness.

Here are 10 essential checks every hospital should make before applying for NABH accreditation:

✅ 1. Legal and Statutory Compliance

Before anything else, ensure all statutory licenses and registrations are in place:

Clinical Establishment license
Fire NOC and Pollution Control Board clearance
Bio-medical waste authorization
AERB compliance for radiology services

All documentation should be current, accessible, and properly filed.

✅ 2. Defined Scope of Services

Your hospital’s declared scope should accurately reflect the services provided:

Clearly define clinical, diagnostic, and support services
Ensure no mismatch between on-paper documentation and actual services

✅ 3. Effective Leadership and Governance

A hospital must demonstrate strong leadership and accountability through:

A clear organizational chart
Functional committees for Quality, Infection Control, Safety, and Ethics
Proper documentation of meetings and decisions

✅ 4. Policies and SOPs in Place

Documented procedures are crucial:

Prepare department-wise NABH-aligned policies
Draft SOPs for critical functions like admission, discharge, infection control, and consent
Ensure staff is trained and follows these procedures

✅ 5. Human Resource Preparedness

Ensure your team is qualified and well-documented:

Staff files with licenses, certifications, and training records
Regular training programs and appraisals
Adequate staff-patient ratios in all departments

 

✅ 6. Infrastructure and Facility Management

Your infrastructure must support safety and cleanliness:

Functional fire extinguishers, safety signage, and evacuation plans
Preventive maintenance schedules
Well-documented housekeeping and waste management protocols

✅ 7. Patient-Centric Processes

Patient care should reflect NABH’s core values:

Systems for informed consent, patient rights, and grievance redressal
Regular collection of patient feedback
Counseling and education for patients and families

✅ 8. Clinical Quality and Safety Indicators

Monitor and improve clinical outcomes:

Track hospital-acquired infections, medication errors, falls, surgical site infections
Regularly analyze mortality and morbidity data
Use data for quality improvement initiatives

✅ 9. Standardized Medical Records

Consistency in documentation is critical:

Standard formats for OPD, IPD, OT, ICU records
Maintain accurate clinical notes, consent forms, and nursing care plans
Conduct regular medical record audits

✅ 10. Internal Assessments and Mock Audits

Lastly, validate your hospital’s readiness:

Perform NABH self-assessments
Organize mock audits with internal or external auditors
Use results to plug gaps and prepare staff