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?

Doctor discussing with his patient

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.

Magnifying lens over an exclamation markSpot an error in this article? A typo maybe? Or an incorrect source? Let us know!

Akash Rajpal
Dr Akash Rajpal, 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.

100 COMMENTS

  1. 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

  2. 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 .

  3. 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.

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

  5. 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?

  6. 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

    ps***********@re********.com











  7. 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….

  8. 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

  9. 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?

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

  11. 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?

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

  13. 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

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

  15. 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

  16. 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+

  17. 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?

  18. 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

  19. 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 ?

  20. 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.

  21. 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,

  22. 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

  23. 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

  24. 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?

  25. 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

  26. 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

  27. 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?

  28. 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?

  29. 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.

  30. 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

  31. 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

  32. Hi Expert,

    Could I get the list of statutory compliance to be strictly adhered for commissioning a full fledged hospital i.e. right from the land acquisitions to the operational stages, ensuring to not get victimised/penalised by the competent authorities for the want of them?

  33. I’m interested to get nabh, what is the procedure to get nabh accreditation. most probably from pharmacy side.

  34. Dear Kriti,

    Both are international healthcare quality standards accredited by the international society of quality.
    NABH is propagated by Quality council of India and is an Indian product, while JCI (joint commission international) is the international arm of the american Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.
    Both are divided into patient and adminsitrative sections of healthcare.
    The majority of the standards for both NABH and JCI are the same. in JCI not all objective elements are mandatory, while in NABH all are mandatory, making it tougher to achieve. The domain areas of the standards for both JCI and NABH are also the same. Thus a comparative analysis shows that NABH standard is at par with JCI and other international standards accredited by ISQua.
    Both standards are voluntary in nature and there is no compulsion (except if you want to cater to CGHS patients where NABH is compulsory). There is no regulatory compulsion.
    NABH is technically better as there are standards for small hospitals also released by NABH which can be used by smaller hospitals. You can do either of the standards or both.

  35. I want to know the basic difference between the NABH and JCI. Besides the difference of being Indian and international accreditation bodies respectively I want to know whether there is any other difference either in the protocol or in the policies of both the accreditation bodies and whether hospitals can have JCI without going for NABH?

  36. Can anybody in the forum suggest me when and where is the next NBAH acessor training course scheduled for?
    i would be obliged if i can get an sms reply on 9826056033.
    regards
    dr Nilesh

  37. i know all about this manav cardiac hospital because i am a member of “SHRI KALIKAL KALPTARU MANIBHDRA VEER ASTHA MANDAL”. this is very good

  38. As Rajubhai Thakker admits, Manav General and Cardiac Hospital Project is really appreciable and will give much needed medical help in Panchmahal Dist.

  39. Hello Sir/Madam

    I am doing a project on Quality and would like to know the various laws and regulation related to the hospitals.

    I would also like to know various quality indicators for Department in the Hospitals.
    Please can you please provide me information on how is the Guardian and ward Act and Supreme court ruling is related to hospital?

  40. Dr Akash will answer Mr Thakkar’s query offsite since the answer to the query is expected to be too elaborate to answer here.

  41. Dear Sir,

    Namskar. Manav Cardiac hospital, a state-0f0art ultramodern project is coming up at village Paroli, just 18 km from Pavagadh in Panchmahals district, in Gujarat. This ambitious project has the potential of changing the socio-economic status of this entire tribal region.

    The land is acquired, fencing work is on. Drawings for building is under preparation. Sir, would you pl advise that what norms and facilities we should follow at the beginning. Since this project is managed by Mahavir Medical Foundation and Charitable Trust under the blessings and guidance of Acharya Shri Jagatchandrasurishwarji Maharaj Saheb in the tribal belt. Please provide guidelines.

    Regards,

    Raju M. Thakkar

  42. Complete Wellbeing informed Dr Akash about the comment by arunjoseph

    Here is the response from Dr Akash Rajpal
    ——–
    NABH is not the driving force to attract more patients. Actually it is the
    adherence to NABH standards, process compliance as a result, training of
    doctors, nurses and all staff of the hospital which leads to the quality
    process compliance which results in better patient satisfaction.
    When more patients are satisfied, word of mouth spreads, and more patients
    then come to the hospital.
    You need not have NABH to satisfy above mentioned quality aspects, but NABH
    give you a ready made guidline, which is at par with the best in the world.
    What you are wishing does gets achieved during the journey of NABH
    accreditation.

    Yes I agree, that quality, processes, attitude, bed side manners and good
    communication skills should be made mandatory in medical schools as part of
    compulsory curriculum.
    —————-

  43. may i know one thing about the NABH, is NABH is necessary for getting patients for Hospital, early days there is no NABH or ISO or any other accredation for Hospital, But peoples are moved towards the hospital due to “GOOD DOCTORS”, early days the doctors and Nurses attitudes towards the patients is great, now all thikng and acting for cash only, why u all not thinking to impove the quality of upcoming doctors attitudes towardss the patients, start and train the form student period then it will help to acchieve, if a hospital not having NABH or ISO the patients wil come and they are safe in GOOD doctors hand, so try to adopt good NABH standard for Upcoming Doctors(Student Period) so it more better.
    thank u
    Arunjoseph (MHA)
    kollam

  44. FOR anjna & Dr. Madhuri

    You are requested to procure a copy of the NABH standards and guidelines from qcin.org. You can write to

    qc**@ad****.org











    for the same.
    Basic understanding of the standards is must.
    In case of difficulties you may contact me.

  45. FOR mahesh m dumale

    You can join a NABL certification course from a ISO certification body or get details from NABL website.
    FOr more details contact me.

  46. FOR Dr.S.Mishra
    Sir you need to check the list of applicant hospitals on the qcin.org website.

  47. FOR Sonali

    You can contact

    ad****@qc**.org











    if you are interested in learning more about NAH accreditation program. It is a very structured standard for hospitals.
    Quality coordinator is the one who knows all. He is the single point contact for all quality compliance related aspects in the hospital. He wil ensure that all laid down quality processes are complied to in the organisation with help of all stake holders.
    The scope is good as more and more hospitals would embark on the journey of quality. CGHS has now made it mandatoy for hospitals to be NABH accredited for empanelment. You can judge the prospective outcome.

  48. FOR NAVEEN

    Sir, i think you meant Intensive care and not ‘incentive care’.

    The topic is vast and cant be expressed in a small email. You can research the internet for the same. You can also visit our hospital at powai(Dr L H Hiranandani Hospital) and personally interact briefly to have an overview.

  49. FOR b_18.

    You can cover waiting times in various bottleneck areas like OPD, admission counters to begin with. You need to find reasons and possible solutions.
    Waiting times are becoming more important as patient is becoming more demanding specially when he pays a handsome amount. The topic though very common, can give a great insight if approached well.

  50. FOR Dr.K.PRAVEEN RAJAN.
    Sir,
    You need to contact

    ad****@qc**.org











    for the same. The secretariat would definitely help you in that regards. Timely notices are also put up on qcin.org website.

  51. This goes out to Mr Sunil Kumar Kulkarni.
    Dear Sunil,
    Yes NABH requires maint of equipment. But NABH or no NABH maint of equipment is essential in hospital isnt it?

  52. Respected sir,

    i am a student of hospital management and want to do MBA in quality.which book i can prefer.please kindly help me.

    regards

  53. i am working as a Biomedical mgr (maint) for a new hospital . i want to know for getting NABH ACCREDITATION does maint of equipment plays any role

  54. Dear all,
    Please accept my apologies for replying so late.
    I had no clue that this article would get such an overwhelming response.
    Thank you for the same.
    I would reply to each question shortly.
    You may email me in the meantime on

    ak*********@gm***.com











    .

    Warm regards,
    Dr Akash S Rajpal.

  55. I have attanders training program which was conducted in chennai in 2008.I have got an attendence certificate only now I need to know the details of the next batch so i can write the exam and become an accessor.Kindly help me know this detail.

  56. HI, Sir I pursue MBA + PGPHA , plz give me research topic on quality management of hospital & accreditation of hospiatals in India.

  57. Dear Sir
    I am Dr.Prasanta Kumar Panda. I am a Molecularmicrobiologist with 12-13yrs of post MD experiance. I want to join the NABH team.Please advice me what to do and how to go about it
    Regards
    Dr.P.K.Panda MD

  58. DEAR SIR,
    I AM PERSUING MY MBA HOSPITAL MANAGEMENT .I WANT TO KNOW ABOUT THE VARIOUS PARAMETERS IN INFECTION CONTROL PATTERN IN AN INCENTIVE CARE UNIT . SO KINDLY REQUESTING YOU TO GIVE ME THE FULL JNFORMATION PLS .
    THANK U SIR

  59. Which coures are available to learn about accreditation programs for hospitals?Can you suggest some books on Quality system management.What is the role of a Quality Co-ordinator?What is the scope of career as Quality Co-ordinator?

  60. Sir
    I want to know the details where we can take the training to know more about this.If any course is there then where and how to go about

  61. Dear sir,

    I am a student and pursuing my MBA in hospital administration. I am doing a major research 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.

    Thanks & regards

  62. I am interested to do undertake a project in a hospital that is in the process of NABH/JCI accreditation,inorder to be able to understand the details of the accreditation process. how can i find out which hospitals are in the NABH accreditation process.
    thank you
    regards
    Dr.S.Mishra

  63. dear Dr,

    i am a hospital administartor and want to join NABH GROUP as accessor how and where i can apply.

  64. Dear sir,

    I am running organisation with all the service facility required for 10 bedded hospital to 100 beded hospital. (software, medical equipments, computer hardware, accounting solution,etc.).

    Now I am planning to do as per the NABL standard.

    Where do I get the training for the same.

    Also want to know the duration and other commercial details.

    Please mail me on my Email address.

    Thanking You

  65. we are looking for NABH accredition for a 40 bedded hospital. Do you have a detailed checklist for the same or can suggest how do we go about self assessment procedures.
    Thank you
    Regards
    Dr. madhuri Umeshchandra

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