( N AT I O N A L A C C R E D I TAT I O N B O A R D F O R H O S P I TA L S A N D

H E A LT H C A R E )

ACCREDITATION PROCESS
About NABH

National Accreditation Board for Hospitals & Healthcare Providers

(NABH)
A constituent board of the Quality Council of India (QCI) has been setup
to establish and operate accreditation programs for hospitals, health
care organizations and set benchmarks for the progress of the health
industry.
International Linkage – ISQua & ASQua
What is NABH Accreditation?

• NABH accreditation is a seal of approval that signifies that a

healthcare provider has met certain quality and safety
standards in its services, infrastructure, and management.

• This voluntary accreditation helps patients make informed

choices while selecting a healthcare provider. It also promotes
continuous improvement in healthcare services to strive for
continuous excellence.

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Accreditation Process

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• Application for Accreditation: To apply for NABH accreditation, a healthcare
organization (HCO) must submit an application form and pay an application
fee, providing accurate information about their services and other necessary
details.

• Registration of Application: After the NABH Secretariat receives the

completed application form, necessary documents, and fees from the HCO,
they will acknowledge the receipt of the application.

• Appointment of Principal Assessor: The primary assessor is responsible for

both the pre-assessment and on-site assessment of the HCO and will have
overall responsibility for conducting the evaluation.

• Pre-Assessment: The HCO must conduct a self-assessment and internal audit

to ensure its readiness before the pre-assessment. This must be completed
within three months of applying.

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• Assessment: After the HCO has addressed any deficiencies, NABH will
propose an assessment team for the final assessment, which must be
completed within six months of the pre-assessment visit.

• Scrutiny of Assessment Report: NABH will review the assessment report

and communicate the results to the HCO, ensuring that any non-
conformities raised by the assessment team are available to and understood
by the HCO.

• Accreditation Committee: Once the HCO has taken satisfactory corrective

action, the NABH officer will prepare a summary of all relevant information
gathered during the application processing, assessment report, and any
additional information provided by the HCO.

• Issue of Accreditation Certificate: If the recommendation for accreditation

is approved, the NABH officer will issue the accreditation certificate to the
organization (Valid for 4 years).

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• Surveillance assessment : Surveillance assessment shall be conducted at 24
months under Hospital accreditation program. Surveillance is aimed at
examining whether the accredited HCO is maintaining all the requirements
of NABH Standards and other applicable criteria.

• Re-Accreditation Assessment: The request for renewal must be submitted

at least 6 months before the expiry of the validity of accreditation.

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Benefits of NABH for Patients

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Benefits of NABH for Organization

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Benefits of NABH for Staff

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 Access Assessment and continuity of care

• Patients that match the organization’s resources are admitted using a

defined process.

• Patients cared for by the organization undergo an established initial

assessment and periodic reassessment.

• The Organization provides laboratory and imaging services commensurate

to its scope of services.

• Patient care is continuous and multidisciplinary

• Transfer and discharge protocols are well defined with adequate

information provided to the patient.

• The organization defines and displays the healthcare services that it

provides.

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Care of Patients
• The organization provides uniform care to all patients in various settings.

• Pain management, nutritional therapy and rehabilitative services are also

addressed to provide comprehensive health care.

• The management should have written guidelines for organ donation and
procurement.

• The standards aim to guide and encourage patient safety as the overarching
principle for providing care to patients.

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 Management of medication
• The organization has a safe and organized medication process, the availability,
safe storage, prescription, dispensing and administration of medications is
governed by written guidelines.

• The pharmacy should have oversight of all medications stocked out of

pharmacy.

• The pharmacy should ensure correct storage , expiry dates and maintenance
of documents.

• The availability of emergency medication is stressed upon.

• Every high-risk medication order should be verified by an appropriate person

to ensure accuracy of the dose, frequency and route of administration.

• Medications also include blood, implants and devices.

• Safety is paramount when using narcotics, chemotherapeutic agents and
radioactive agents.

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Patient Rights and Education

• The organization defines, protects and promotes the patient and family’s
rights and responsibilities.

• The expected costs of the treatment and care are explained clearly to the
patient and/or family.

• Informed consent is obtained from the patient or family for specified

procedures/care.

• The organization develops effective patient-centric communication.

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Hospital Infection Control

• The organization implements an effective healthcare associated infection

prevention and control program.

• The organization provides proper facilities and adequate resources to

support the infection prevention and control program.

• The organization measures and acts to prevent or reduce risk of healthcare

associated infection in patients and staff.

• The organization has an effective antimicrobial management program

through regularly updated antibiotic policy based on local data and monitors
its implementation.

• Surveillance activities are incorporated in the infection prevention and

control program.

• The program includes disinfection/sterilization activities and biomedical

waste management.

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 Patient Safety and quality improvement

• The standards encourage an environment of patient safety and continual quality

improvement.

• National/international patient-safety goals/solutions are implemented.

• The organization should collect data on structures, processes and outcomes,

especially in areas of high-risk situations.

• The organization should have a robust incident reporting system. Sentinel events
shall be defined. All incidents are investigated, and appropriate action is taken.

• The management should support the patient safety and quality program.

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Responsibilities of Management
• The management of the healthcare organization is aware of and manages all
the key components of governance.

• Leaders ensure that patient-safety and risk-management issues are an integral

part of patient care and hospital management.

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Facility management and safety
• The standards guide the provision of a safe and secure environment fro patients,
their families, staff and visitors.

• The organization attends to the facility, equipment, and internal physical

environment for improving patient safety and quality of services by consistently
addressing issues that may arise out of the same.

• The organization provides for safe water, electricity, medical gases and vacuum
systems.

• The organizations has a program for medical and utility equipment management.
• The organization plans for fire and non-fire emergencies within the facilities.

• The organization is a no-smoking area.

• The organization safely manages hazardous materials.

• The organization works towards measures on being energy efficient.

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Human Resource Management

• Human resources are an asset for the effective and efficient functioning of the
organization.

• The management plans on identifying the right number and skill mix of staff
required to render safe care to the patients.

• A systematic and structured appraisal system must be used for staff

development.

• The organization promotes the physical and mental well-being of staff.

• Credentialing and privileging of healthcare professionals are done to ensure

patient safety.

• A document containing all such personal information has to be maintained foe

all staff.

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Information Management System

• The goal of information management in the organization is to ensure that the

right information is available to the right person at the right time.

• Information management includes management of hospital information system

as well as all modalities of information communicated to staff, patients, visitors
and community in general.

• Information management also includes periodic review, revision and withdrawal

of obsolete information to avoid confusion among staff, patients and visitors.

• Confidentiality, integrity and security of records, data and information is

maintained.

• The organization maintains a complete and accurate medical record for every
patient.

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