NABH ENTRY LEVEL STANDARDS FOR HOSPITALS

1. NABH
PRE ACCREDITATION
ENTRY LEVEL
CERTIFICATION FOR
HOSPITALS
B. Y. L. NAIR CH.
HOSPITAL

2. • NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND
HEALTHCARE PROVIDERS (NABH)
• NABH is a constituent Board of Quality Council of India (QCI),
which is an autonomous organization under the Department for
Promotion of Industry and Internal Trade (DPIIT), Ministry of
Commerce and Industry.
• NABH is set up to establish and operate accreditation and other
allied programs for healthcare organizations.
• NABH is an Institutional Member as well as a Board member of
the International Society for Quality in Health Care (lSQua) and on
the board of the Asian Society for Quality in Healthcare (ASQua).
INTRODUCTION
2

3. • 1st Edition of NABH Pre
Accreditation Entry Level
Standards for Hospitals was
released in April 2014 as a
stepping stone for enhancing
the quality of patient care and
safety to progressively move to
the final stage of the “Full
Accreditation” status .
NABH STANDARDS
3

4. 4
OVERALL CHANGES
• 10 CHAPTERS
• 45 STANDARDS
• 173 OBJECTIVE
ELEMENTS
FULL ACCREDITATION
STANDARDS
• 10 CHAPTERS
• 100 STANDARDS
• 651 OBJECTIVE
ELEMENTS
PRE ACCREDITATION ENTRY
LEVEL STANDARDS
Standards: A statement of expectation that defines the
structures and processes that must be substantially in
place in a health care organisation to enhance the quality
of care.
Objective Elements: It is that component of standard

5. • NABH Standards are listed in 10 Chapters.
• First 5 Chapters are patient centric chapters and the last 5 chapters are
organisation centric chapters.
• There are total 45 Standards spread over these 10 chapters.
• Each Standard consists of Objective Elements (OE).
• There are total 173 Objective Elements.
• The distribution of Standards and Objective Elements is given in the
following table.
NABH STANDARDS
5

6. PATIENT CENTRIC NABH STANDARDS
6
Sr.
No.
Chapter Number of
Standards
Number of
Objective
Elements
1 Access Assessment and Continuity
of Care (AAC)
7 29
2 Care of Patients (COP) 8 38
3 Management of Medication (MOM) 7 28
4 Patient Rights and Education (PRE) 2 9
5 Hospital Infection Control (HIC) 3 13

7. ORGANISATION CENTRIC NABH STANDARDS
7
Sr.
No.
10Chapter Number of
Standards
Number of
Objective
Elements
6 Patient Safety and Quality
Improvement (PSQ)
2 5
7 Responsibilities of Management
(ROM)
3 9
8 Facility Management and Safety
(FMS)
4 14
9 Human Resource Management
(HRM)
5 12
10 Information Management System 4 16

8. • Compliance to the requirement: 10
• Partial compliance to the requirement: 5 (if any of the sample is found to
be noncomplying out of total samples selected)
• Non-compliance to the requirement: 0
• Not Applicable: NA
• Evaluation Criteria:
• Overall score of minimum 50% in all standards
• Overall score of minimum 50% in each chapter
SELF ASSESSMENT SCORING SYSTEM
8

9. Objective
Elements
Documentation
(Yes/No)
Implementation
(Yes/No)
Evidence
(Cross
Reference To
Documents/
Manuals, Etc.)
Score
(0/5/10)
SELF ASSESSMENT TOOLKIT FORM
9

10. SELF ASSESSMENT TOOLKIT FORM
10

11. Thank
You
Dr. Surendra S.
Wadikar
Professor (Additional)
Dept. of Physiology