NABH standards Objective Elements Key functions Benefits

1. NATIONALACCREDITATION BOARD FOR
HOSPITALS

2. NABH stands for National Accreditation Board for Hospitals
and Healthcare Providers. It's an autonomous organization that
establishes and runs accreditation programs for healthcare
facilities in India

3. NABH's purpose
❏ To improve patient safety and quality
❏ To set benchmarks for the health industry
❏ To streamline hospital operations
❏ To demonstrate a commitment to quality and patient safety

4. NABH accreditation process
❏ Assesses hospitals based on parameters like operating protocols,
price transparency, and patient care
❏ Grades hospitals based on their performance
❏ Helps healthcare providers optimize their processes

5. Benefits of NABH accreditation
❏ Sets healthcare facilities apart from their competitors
❏ Enhances the reputation of healthcare providers
❏ Attracts more patients and collaborations with other healthcare
stakeholders
❏ Leads to increased productivity and cost savings

6. What is NABH and its aim and objective?
NABH is a constituent board of QCI- Quality Council of India. It sets standards
and operates accreditation programmes for health care organizations.
❏ Medical Excellence.
❏ Ensure a ‘Quality Assurance’ system.
❏ Risk Management System and patient care and treatment.
❏ Patient/Organization need.
❏ Helps Standardization.

7. The NABH standards touch all those areas where we face difficulties in day to
day issues, risk to us or our patients, and there is a strong focus on patient
requirements i.e. Care satisfaction, Education and information safety.

8. What is QCI?
(QCI) Quality Council of India is an autonomous body set up
jointly by Govt. of India and industry to establish and operate
accreditation structure for assessment conformity bodies offering
certification, inspection, testing and registration services etc. in the
field of health, environment, food safety, information security,
occupational health and safety and quality management.

9. Structure of NABH Standards
10 chapters
105 Standards
683 Objective elements

10. What are the 10 chapters of NABH?
Patient centered standards:-
❏ Chapter-1 (AAC) Access, Assessment and continuity of care
❏ Chapter-2 (COP) Care of Patient
❏ Chapter-3 (MOM) Management of Medication
❏ Chapter-4 (PRE) Patient Right and Education
❏ Chapter-5 (HIC) Hospital Infection Control

11. Organization centered Standards:-
❏ Chapter-6 (CQI) Continuous Quality Improvement
❏ Chapter-7 (ROM) Responsibility of Management
❏ Chapter-8 (FMS) Facility Management and Safety
❏ Chapter-9 (HRM) Human Resource Management
❏ Chapter-10 (IMS) Information Management System

12. How does NABH score over various ISO standards?
❏ ISO is a certification and not an accreditation.
❏ ISO is generic and not specific to the healthcare industry.
❏ ISO does not call for clinical audits, it centers only on systems.
❏ Accreditation on the other hand, focuses on competency in
terms of its staff, equipment, premises, facilities etc with respect
to the scope of services being rendered by the healthcare
organization.

13. Ten steps to Accreditation
❏ Step 1 Obtain copy of NABH standards
❏ Step 2 Carry out self-assessment on status of compliance with
the NABH standards.
❏ Step 3 Identify gap areas and prepare an action plan to bridge
the gaps.
❏ Step 4 Ensure that NABH standards are implemented and
integrated with hospital functioning
❏ Step 5 Obtain copy and submit application form for assessment

14. ❏ Step 6 Pay the accreditation fee
❏ Step 7 Receive from NABH the assessment program including
dates and names of assessors
❏ Step 8 Facilitate the assessment
❏ Step 9 Receive recommendation on accreditation
❏ Step 10 Maintain a quality improvement program based on
continuous monitoring of patient care services.

15. Access, Assessment, and Continuity of Care
❏ The organization defines and displays the services it can provide.
❏ The organization has a well-defined registration and admission
process.
❏ There is an appropriate mechanism for transfer or referral of patients
who do not match the organization resources.
❏ During admission the patients and/ or the family members are
educated to make informed decisions.

16. ❏ Patients care for by the organization undergo an established initial
assessment
❏ All patients care for by the organization undergo a regular assessment
❏ Laboratory services are provided as per the requirement of the
patients.
❏ There is an established laboratory quality assurance program.

17. ❏ There is an established laboratory safety program.
❏ Imaging services are provided as per the requirement of the
patients.
❏ There is an established quality assurance program for imaging
services.
❏ There is an established radiation safety program.
❏ Patient care is continuous and multi-disciplinary in nature.
❏ The organization has a documented discharge process.
❏ Organization defines the content of the discharge summary.

18. Patients’ Rights and Education
❏ The organization protects patients and family rights during care.
❏ Patients and family rights support individual beliefs, values and
involve the patient and the family in the decision making
process.
❏ A documented process for obtaining patient and/ or families
consent exists for informed decision making about their care.
❏ Patients and families have a right to information and education
about their health care needs.
❏ Patients and families have a right to information on expected
costs.

19. Care of patients
❏ Uniform care of patients is guided by the applicable laws and
regulations.
❏ Emergency services are guided by the policies, procedure and
applicable laws and regulations.
❏ The ambulance services are commensurate with the scope of the
services provided by the organization.
❏ Policies and procedures guide the care of patients requiring
cardiopulmonary resuscitation.

20. ❏ Policies and procedures define rational use of blood and blood
products.
❏ Policies and procedures guide the care of vulnerable patients in
the Intensive care and high dependency units.
❏ Policies and procedures guide the care of vulnerable patients
(elderly, physically and / or mentally challenged and children).
❏ Policies and procedures guide the care of high risk obstetrical
patients.
❏ Policies and procedures guide the care of pediatric patients.
❏ Policies and procedures guide the administration of anesthesia

21. ❏ Policies and procedures guide the care of patients undergoing
surgical procedures.
❏ Policies and procedures guide the care of patients under
restraints.
❏ Policies and procedures guide appropriate pain management.
❏ Policies and procedures guide appropriate rehabilitative
services.
❏ Policies and procedures guide all research activities.
❏ Policies and procedures guide Nutritional therapy.
❏ Policies and procedures guide the end of life care.
❏ Policies and procedures guide the care of patients undergoing
moderate sedation.

22. MANAGEMENT OF MEDICATION
❏ Policies and procedures guide the organization of pharmacy
services and usage of medication.
❏ There is a hospital formulary.
❏ Policies and procedures exist for storage of medication.
❏ Policies and procedures exist for prescription of medications.
❏ Policies and procedures guide the safe dispensing of
medications.
❏ Patients are monitored after medication administration.

23. ❏ There are defined procedures for medication administration.
❏ Patients and family members are educated about safe
medication and food drug interactions.
❏ Policies and procedures guide the use of narcotic drugs and
psychotropic substances.
❏ Policies and procedures guide the usage of chemotherapeutic
agents.
❏ Policies and procedures over usage of radioactive or
investigational drugs.
❏ Policies and procedures guide the use of implantable prosthesis.
❏ Policies and procedures guide the use of medical gases

24. HOSPITAL INFECTION CONTROL
❏ The organization has a well-designed, comprehensive and
coordinated infection control program aimed at reduction /
eliminating risk to patients, visitors and providers of care.
❏ The organization has an infection control manual, which is
periodically updated.
❏ The infection control team is responsible for surveillance
activities in the identified areas of the organization.
❏ The organization takes actions to prevent or reduce the risk of
Hospital Associated infections (HIA) in patients and employees.

25. ❏ Proper facilities and adequate resources are provided to support
the infection control program.
❏ The organization takes appropriate actions to control outbreak
of infections.
❏ There are documented procedures for sterilization activities in
the organization.
❏ Statutory provisions with regard to biomedical Waste (BMW)
management are complied with.
❏ The infection control program is supported by the organization’s
management and includes training of staff and employee health.

26. CONTINUOUS QUALITY IMPROVEMENT
❏ There is structured quality assurance and continuous monitoring
program in the organization
❏ The organization identifies key indicators to monitor the clinical
structures, processes and outcomes.
❏ The quality improvement program is supported by the
management.
❏ There is an established system for audit of patient care services.
❏ Sentinel events are intensively analyzed.

27. RESPONSIBILITY OF MANAGEMENT
❏ The responsibilities of the management are defined.
❏ The services provided by each department are documented.
❏ The organization is managed by the leaders in an ethical
manner.
❏ A suitably qualified and experienced individual heads the
organization.
❏ Leaders ensure that patient safety aspects and risk management
issues are an integral part of patient care and hospital
management.

28. FACILITY MANAGEMENT AND SAFETY
❏ The organization is aware of and complies with the relevant
rules and regulations, laws and bylaws and requisite facility
inspection requirement.
❏ The organization’s environment and facilities operate to ensure
safety of patients, their families,staff and visitors.
❏ The organization has a program for clinical and support service
equipment management.
❏ The organization has provisions for safe water, electricity,
medical gases and vacuum systems.

29. ❏ The organization has plans for fire and non-fire emergencies
within the facilities.
❏ The organization has a smoking policy.
❏ The organization plans for handling community emergencies,
epidemics and other disasters.
❏ The organization has a plan for management of hazardous
materials.
❏ The organization has systems in place to provide a safe and
secure environment.

30. HUMAN RESOURCE MANAGEMENT
❏ The organization has a documented system of human resource
planning.
❏ The staff joining the organization is socialized and oriented to
the hospital environment.
❏ There is an ongoing program for professional training and
development of the staff.
❏ Staff members, students and volunteers are adequately trained
on specific job duties or responsibilities related to safety.

31. ❏ A grievance handling mechanism exists in the organization.
❏ The organization addresses the health needs of the employees.
❏ There is a documented personal record for each staff member.
❏ There is a process for collecting, verifying and evaluating the
credentials (education, registration,training and experience) of
medical professionals permitted to provide patient care without
supervision.
❏ There is a process for authorization for all medical professionals
to admit and treat patients and provide other clinical services
commensurate with their qualifications.

32. ❏ There is a process for collecting, verifying and evaluating the
credentials (education, registration,training and experience) of nursing
staff.
❏ There is a process to identify job responsibilities and make clinical
work assignments to all nursing staff members commensurate with
their qualifications and other regulatory requirements.
❏ An appraisal system for evaluating the performance of an employee
exists as an integral part of the human resource management process.
❏ The organization has a well-documented disciplinary procedure.

33. INFORMATION MANAGEMENT SYSTEM
❏ Policies and procedures exist to meet the information needs of
the care providers, management of the organization as well as
other agencies that require data and information from the
organization.
❏ The organization has processes in place for effective
management of data.
❏ The organization has a complete and accurate medical record for
every patient.

34. ❏ The medical record reflects continuity of care.
❏ Policies and procedures are in place for maintaining
confidentiality, integrity and security of information.
❏ Policies and procedures exist for retention time of records, data
and information.
❏ The organization regularly carries out medical audits.