NABH ACCREDITATION: Choosing the right hospital

There are a number of hospitals in India that offer a multitude of medical services. In a medical emergency, the nearest hospital is chosen. However, when there is time to choose a hospital, how should one choose?

More important than the infrastructure, it is essential to know if the hospital has a documented process for its healthcare activities. Patient care not only involves the core clinical care, but also other support activities like requisition of tests, medicines, nurse doctor coordination, infection control practices, training, and so on. These need to run seamlessly in the background to provide the best experience to the patient and the relatives.

A quality-conscious hospital should define all such activities internally, document the same, and impart necessary training to the staff. These documented activities include detailed job responsibilities, work instructions, checklists and quality indicators for the staff to follow.

So how will the patient know about these processes? He is not expected to inquire with the hospital whether they have these processes laid down. And how many processes could he check even if allowed to?

Accreditation is the key

Organisations like the Quality Council of India [QCI] and its National Accreditation Board for Hospitals and Healthcare providers [NABH] have designed an exhaustive healthcare standard for hospitals and healthcare providers. This standard consists of stringent 500 plus objective elements for the hospital to achieve in order to get the NABH accreditation.

To comply with these standard elements, the hospital will need to have a process-driven approach in all aspects of hospital activities – from registration, admission, pre-surgery, peri-surgery and post-surgery protocols, discharge from the hospital to follow-up with the hospital after discharge.

NABH accreditation criteria

To give an idea what NABH standard comprises of, some of the 500-plus objective elements are listed here. The requirements have been grouped for easy understanding.

Information to patients

  1. The patients and/or family members are explained about the proposed care.
  2. The patients and/or family members are explained about the expected results.
  3. The patients and/or family members are explained about the possible complications.
  4. The patients and/or family members are explained about the expected costs.

Rights of the patient and family

  1. Respect for personal dignity and privacy during examination, procedures and treatment.
  2. Right to refusal of treatment.
  3. Informed consent before anaesthesia, blood and blood product transfusions and any invasive or high-risk procedures.
  4. Information on how to voice a complaint.
  5. Access to his / her clinical records.

Quality in investigations

  1. Adequately qualified and trained personnel perform and/or supervise the lab investigations.
  2. Policies and procedures guide collection, identification, handling, safe transportation and disposal of lab specimens.
  3. Laboratory and imaging results are available within a defined time frame.
  4. Critical results are intimated immediately to the concerned personnel.
  5. The lab and imaging quality programme addresses verification and validation of test methods.
  6. The lab and imaging quality programme includes periodic calibration and maintenance of all equipments.
  7. The lab and imaging programme includes the documentation of corrective and preventive actions.

Surgical services

  1. Surgical patients have a pre-operative assessment and a provisional diagnosis, documented prior to surgery.
  2. Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery.
  3. The operating surgeon documents the post-operative plan of care.
  4. There is a documented policy and procedure for the administration of anaesthesia.
  5. All patients for anaesthesia have a pre-anaesthesia assessment by a qualified individual.
  6. During anaesthesia, monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and level of anaesthesia.

Medication

  1. Documented policies and procedures exist for prescription of medications.
  2. The organisation defines a list of high-risk medication.
  3. High-risk medication orders are verified prior to dispensing.

Infection control

  1. The hospital has an infection control team.
  2. The hospital has designated and qualified infection control nurse[s] for this activity.
  3. Hand-washing facilities in all patient care areas are accessible to health care providers.
  4. Compliance regarding proper washing of hands is monitored regularly.
  5. Isolation/ barrier nursing facilities are available.
  6. Adequate gloves, masks, soaps, and disinfectants are available and used correctly.

Facility and infrastructure maintenance

  1. The organisation’s environment and facilities operate to ensure safety of patients, staff and visitors
  2. There is a documented operational and maintenance [preventive and breakdown] plan.
  3. Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.
  4. The provision of space shall be in accordance with the available literature on good practices [Indian or International Standards] and directives from government agencies.
  5. There are designated individuals responsible for the maintenance of all the facilities.
  6. Maintenance staff is contactable round the clock for emergency repairs.
  7. Response times are monitored from reporting to inspection and implementation of corrective actions.

Other

  1. Defined procedures for situation of bed shortages are followed.
  2. Ambulance[s] is appropriately equipped.
  3. Ambulance[s] is manned by trained personnel.
  4. There is a checklist of all equipment and emergency medications in the ambulance.

How NABH accreditation helps patients

In an NABH accredited hospital, there is a strong focus on the following:

  • Patient rights and benefits
  • Patient safety
  • Control and prevention of infections
  • Practicing good patient-care protocols e.g. special care for vulnerable groups, critically ill patients
  • Better and controlled clinical outcome.

NABH now is a member of the International Society for Quality in Health Care [ISQua] and thus NABH standard is at the threshold of being recognised globally.

So, if a hospital is NABH accredited, the patient can rest assured that the hospital follows stringent standards as laid down by the accreditation body for providing best in patient care comparable to any international hospital of repute.

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  • AKASH Rajpal

    AKASH Rajpal

    An M.B.,B.S doctor with post graduate credentials in public health, hospital administration and a Mergers & Acquisitions professional has worked in both public and private sectors for more than 13 years. He is founder of EKOHEALTH which facilitates discounts & cost comparisons to the un-insurable segment like the senior citizens and diabetics to help them save money on health expenses.

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100 Responses to NABH ACCREDITATION: Choosing the right hospital

  1. Pingback: Why Hospital Need Accreditation | My Health

  2. Pingback: Hospital Accreditation Problems | My Health

  3. Dear Sir,
    Iam an electronics diploma holder passed out in 1994, and was in diagnostic industry for service activities till 2002 in MNC, and now iam doing own business with products of Siemens, iris, osmetech,Sysmex which includes service and caliberations also.
    Can i have registration for equipments to standardise the equipments as per NABL/NABH norms so that we can do this help locally to our customers and educate them.

    regards
    parameshwaran
    09544931931
    Thrissur
    kerala

  4. Can you tell me” what would be the average quantity of Bio-Medical on per bed per day basis?

  5. krishna prasad

    upgrading hospitals under NABH norms is very good step as we r involved in hospital equipment business bcos of this norms hospitals r going by quality equipment
    it will be if NABH CAN PROVIDE A CITE SPECIALLY WERE ONLY NABH NORMS R FLOATED FOR UP COMING NEW HOSPITALS .

  6. Dr Ashish Malakar

    I would like to enquire about the minimum distance needed to be maintained between electric panel switch board and the gas pipe line in an ICU.

  7. monika sharma

    respected sir,
    i m a microbiologist in a hospital. i want to know about the various parameters and patterns in infection control in NABH.

  8. i want to know how to prepare documentation ,sops and implementation of nabh

  9. DR.NAGENDRA BIJILI KUMAR

    we are looking for NABH accredition for a 30 bedded hospital. do you have a detailed checklist for the same or can suggest how do we go about self assessment procedures?

  10. Srinivas Reddy P

    NABH Guidence is available including documentation for SHCO as well as Hospitals. I have enough experience in doing NABH accreditation. If you need only advise I can visit your hospitals and will give a report on the scope of the accreditation. please contact on 09914866677 or psreddy_admin@rediffmail.com

  11. Ms.Uzma Kotwal

    Hello sir/madam,
    I’m Ms.Uzma kotal,working as biomedical engineer, i just wanted to know the information related to biomedical in NABH. Could u help in providing information? Thanking you….

  12. Kindly let me know from where I can do MHA or MBA in Hospital Management through correspondence or distance education . I have PGDHA and experience of 5 years in hospital administration

  13. I am qualified in MHA, now i am looking for a experience in health care sector especially in NABH activities, where i will get a good exposure regarding NABH things and how we can implement NABH standards in health care sector if Doctors not support to this?

  14. pls guide us how to enroll for nabh accreditation training programme and what would be the fee structure for this?

  15. Dr.Ranjit Singh.

    nabh accreditation programme enrolment, pls send me details of the above.

  16. I work in a hospital with MRI dept; Would you suggest where could I get NABR or NABH training from if I do not have any medical academic background?

  17. i would like to do my Ph D on NABH Accrediation. May you suggest some topic for the Ph D related to NABH accreditation.

  18. Dear sir/mam,

    I am a student and pursuing my Masters in hospital & health information administration. I want to do a major internship project on Quality in Hospitals.

    Want to know about all the aspects of quality in hospitals.What all are the quality parameters in different dept to be followed.

    Please provide me with all the information regarding the
    Implementation of quality in hospitals & getting accreditation.
    Please suggest me which hospitals i can approach to..

    Thanks & regards

  19. dr rekha menghani

    how to enroll for nabh accreditation training programme? what’s the duration for the same/what research projects can be undertaken in this field

  20. hi
    1.i would like to know what is da policy & protocol for discarding used glass vial bottles(small&big)?
    2.what is the percentage of sodium hypo chloride solution to be kept in the PPC (puncture proof container)?
    3.& what is duration of changing of the PPC according to the percentage of solution?

    Thank You
    Regards
    Bindhu.V

  21. How to join in nabh training course. and when this programme started?

  22. SANGHITA DEY BASU

    I am interested to be a NABH implementer. Would you please let me know the date of commencement? It will be a self sponsored course. Got an experience of 10+

  23. how can i apply for nabh training program? the venue, time, & fees for the same. also i would like to know are there any certificate course for same?

  24. corrine christie

    thanks for giving me knowledge about NABH. i heard first time about NABH in my hospital and i wanted to know more about NABH so i studied on internet. i got good knowledge about NABH

  25. how can we implement NABH works in old (structural problem )hospital ? we provide services based on FMS chapter but not satisfactory due to the lack of fund h w can we rectify that problem ?

  26. Sir, we wish to open up a hospital with NABH norms.
    Where can I get details of norms?
    Pradeep

  27. sir/madam,
    i am a persuing my masters in hospital management.I wana do my desertation on gap analysis between “NABH STANDARD AND BIO-MEDICAL WASTE MANAGEMENT FOLLOWED BY A HOSPITAL”.So can you please help me in this aspect and told me how to proceed.

  28. drmadhusrivastava

    i want to enroll for the next training programme

  29. dinesh kapoor

    requirements of an ICU of a NABH accredited hospital in India.

  30. Dr. Nirmal Sagar

    kindly send me details on how to become an NABH assessor. I have sufficient international experience in the JCI and want to become an NABH Assessor.
    thanks,

  31. Dr.Pooja Chauhan

    We want to go for NABH accredition for our Hospital. Can please send me any procedure details and standard in soft copy?

    Regards,
    Dr. Pooja Chauhan

  32. hello . i want to know what minimum requirement for Microbiology lab to accredited with NABH.

  33. Dr Mamta Datta

    Pl let me know the details of kitchen requirements & regulations for NABH.

  34. Sudip Chowdhury

    Dear Sir

    Although we have reached more than 60 years of independence but only now NABH is coming up to assure the patients to get the standard approved quality in different hospitals yet better late than never. I request to make it mandatory for all hospitals and nursing homes if we want to climb to the next step in Health Care in this biggest sub-continent.As we percieve India will be the guiding source for the total globe.

    Sudip Chowdhury
    Manger Quality Sciences
    Apollo
    Ranchi

    09570129090

  35. while making unit binders,what is the difference between scope of services and standard operating procedure?

  36. i’m doing my internship,on NABH.can you provide me basic guideline how to make a project report.

  37. DR.BHAWNA SHARMA

    I’M DOING MY PROJECT WORK ON NABH WITH APOLLO HOSP. I’M SAID TO MAKE UNIT BINDERS SO FAR.CAN YOU GUIDE ME HOW TO PROCEED FURTHER?

  38. respected sir/madam
    i would like to know what are the standards which are to be maintained according to NABH while handling patient in ICU. basically to control nosocomial infections since i am from non-medical background i would request you to please guide me just regarding hand washing procedure, proper waste disposal technique, wen to use gloves, how to enter in icu i.e. dress-up.

    thanking you
    regards
    vinaya

  39. Dear Sir,

    Like NABL, can we have limited scope of NABH in a lab where many modalities of radiology are offering services i.e., can we have only xray & usg in NABH Scope for a lab which is offering CT & MRI in addition

    Regards,
    Sadaf

  40. How paramedical staff (radiographer/x-ray tech/diagnostic tech )can join the accreditation programme?

  41. I need to know about the nursing care documentation required for NABH accreditation.

  42. Dr. neeta modi

    i am having a 25 bed multispeciality hospital in goregaon / mumbai.how can i apply for nabh training program? the venue, time, & fees for the same. also i would like to know if, are there any certificate course for same?

  43. SIR I AM DOING A STUDY ON ICUNITS CAN WE GET GUIDELINES FOR INTENSIVE CARE UNITS ON THE WEBSITE

  44. give me details about NABH

  45. Dr.Dharmik shah

    NABH is a excellent body which is governing in quality health for India.

  46. how can i apply for nabh training program? the venue, time, & fees for the same. also i would like to know if, are there any certificate course for same?

  47. i agree to the fact that NABH accreditation is a check over quality of health care services in our country. there are places where a clinic in the rural setup will not have basic infrastructure but will be capable of delivering health care facilities. At the same time there can be a huge hospital in a big city with excellent infrastructure and still providing health care services. thus the role of NABH standards is not merely an overall improvement of quality but at the same time bringing the entire health care delivery model to a common universal, and acceptable quality standard. this ensures that wherever a patient is taken, he/she is assured that he is being treated in the most ethical and honest way without compromise in quality.

  48. nilay bakriwala

    Hospital Should use closed system I.V? to prevent nosocomial infection. In USA even injection is also using needle-less. For my knowledge i want to know

  49. I am Pharmacist in the State Govt. hospital in Gujarat. How can I perform my duties to the best satisfaction of the patient? Please guide me, or provide me the tips to help the patient and the organization under NABH.
    thank you
    RAZIA MIRZA

  50. Dear Dr ,
    we have a dedicated team of experts who provide consultancy for NABH .
    Kindly send in your details at kumaronkar8@gmail.com
    Thanks & Regards,
    Onkar kumar

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