List of Standard Operating Procedures (SOP) Required for Pre-Accreditation Entry Level Standards for Hospital

Hospital Accreditation is a public acceptance by the National Accreditation Board of Hospitals and Healthcare. It is the achievement of accreditation standards by a Healthcare Organization, which is demonstrated through an independent external peer assessment of that organization’s level of performance about the standards. NABH aims to operate accreditation and associated programs in collaboration with stakeholders focusing on patient safety and quality of healthcare. It also encourages health care organizations (HCOs) to join the quality journey, which is why the NABH has developed Pre-Accreditation Entry Level certification standards, in consultation with various stakeholders as a stepping stone for enhancing the quality of patient care and safety. The goal is to introduce quality and accreditation to HCOs as a first step toward raising awareness and capability. After achieving Pre-Accreditation Entry Level Certification, the HCO can prepare to advance to the next stage – “Progressive” Level Certification, and finally “Full Accreditation” status. This methodology offers a step-by-step and staged approach that is suitable for any HCOs.

To implement the pre-accreditation Entry Level for hospitals, they must have facilities above 50 beds for patients. It enables hospitals in demonstrating a commitment to quality care. It raises community confidence in the services provided by the hospital. Implement the Pre-accreditation entry-level standards for hospitals beginning with document preparation. Also, the documents cover Manuals, Procedures, SOPs, etc. Individuals can start preparing with the Standard operating procedures. The pre-accreditation NABH documents – SOP contains Access, assessment, and continuity care (AAC), Care of patient (COP), continuous quality improvement (CQI), Management of Medicine (MOM), and patient rights and education (PRE) departments. The list of SOPs is given below:

Access, assessment, and continuity care (AAC)

  • SOP for the scope of services
  • SOP for registration
  • SOP for assessment policy
  • SOP for laboratory safe practices
  • SOP for radiology services
  • SOP for discharge procedure

Care of patient (COP)

  • SOP for uniform care of the patient
  • SOP for ambulance services
  • SOP for emergency care
  • SOP for the handling of medical-legal cases
  • SOP for rationale use of blood & blood products
  • SOP for the care of the vulnerable patient
  • SOP for the administration of anesthesia
  • SOP for the care of the patient under surgical procedure
  • SOP for quality assurance Program- surgical services
  • SOP for prevention of adverse events in the surgical patient
  • SOP for the pediatric patient

Continuous quality improvement (CQI)

  • SOP for continuous quality improvement

Management of Medicine (MOM)

  • SOP for Pharmacy services
  • SOP for Storage of Medication
  • SOP for Prescription of Medicines
  • SOP for Dispensing of medication
  • SOP for Medication Administration
  • SOP for Use of Radioactive drugs

Patient rights and education (PRE)

  • SOP for patient rights
  • SOP for informed consent
  • SOP for protection of patient rights
  • SOP for communication

Implementing a Pre-Accreditation entry-level standard for the hospital can help to improve the level of community confidence and trust, also it gets quality and patient safety into focus. It also provides an external recognition. Pre-accreditation can Improve patient satisfaction levels as well as Improve healthcare outcomes. It makes a patient-centered culture in the hospital.

Overview of a NABH Accreditation for Hospitals & Healthcare

National Accreditation Board for Hospitals and Healthcare Providers is known as NABH. Implementing and managing an accreditation program for healthcare and hospital organizations is the main objective of NABH. To create goals and benchmarks for the improvement of the health sector, the constituent board of the Quality Council of India attends to the consumers’ highly demanded criteria. Various parties, including the public, the government, and businesses, support the NABH.

How to prepare for NABH accreditation?
To become the Hospital accredited by NABH, the administration should prepare a plan of action to obtain a goal. The first stage is to choose a person to oversee all the activities that apply for accreditation and organize their coordination. 

  • The initial step is to suggest a candidate who is acquainted with the current quality assurance system. The officer can identify the gaps where the hospital needs to work and what needs to be improved in this way.
  • The applicant hospital must have a thorough understanding of the NABH assessment process.
  • The hospital should employ officers to create benchmarks and oversee the application of higher standards.
  • The hospital should conduct a self-assessment drive before presenting the quality criteria to the NABH team. They can proceed with submitting the application form if they determine that everything is correct.

What are the NABH records required?
There are several statutory and no statutory documented records that the NABH team will ask you to update on their protocol. Other than primary NABH documents like Manual, procedures, SOPs, Plans, etc. following documented records required are listed below:

  • Hospital registration certificate
  • Details of doctors and support staff
  • List of the services provided
  • Hospital photographs
  • NOC from the Fire department
  • Lift NOC
  • SOPs for the various quality actions followed at the hospital
  • Any other Empanelment’s/ Accreditations
  • Bio-medical waste certificate

What are the benefits of NABH accreditation?
All healthcare centers with Full NABH or Entry-level NABH receive several benefits. The list below provides some significant benefits of NABH:

  • Hospitals get improved duties from insurance firms and government panels.
  • Foundation of huge recognition to the hospital, and helps build customer trust.
  • Decrease the costs by improving Operational Efficiency
  • Better staff utilization through training & clearer assignment of roles and responsibilities with credentialing and privileging
  • Optimizing usage of Materials with better Inventory Management, avoiding Stock-outs
  • Makes the hospital qualified for the service of global patients
  • Often monitored results help the workers and other staff members to ensure better services and amenities for the patients.
  • Reduction in Hospital Infections, Medical Errors, and Accidents resulting in dropping unnecessary stays at the hospital

Steps for NABH Accreditation Consultancy

Amongst many certifications that are required for a hospital to function effectively in India, the accreditation from the National Accreditation Board for Hospitals and Healthcare Providers (NABH) is the most significant one. The NABH has been set up by the Quality Council of India (QCI) primarily to operate the accreditation of hospitals and clinics in India.

The accreditation is based on several parameters; their primary concern is maintaining certain albeit stringent standards for hospitals and clinics so that they can provide optimum healthcare services to the public. To ease the path to getting a NABH accreditation, hospitals and clinics often require the assistance of NABH consultants.

Following are the key steps that any organization / hospital needs to be follow for effective implementation of better system and quick NABH accreditation.

  • Micro level survey of the existing system and make gap analysis for the hospital.
  • Conduct awareness program (top + middle + bottom level).
  • Form a steering committee and task force for documentation
  • Identify and define SOP for various standards
  • Define committees and establish objectives
  • Prepare documents of Quality management system as well as patient care and hygiene control, infection control as well as handbooks.
  • Implementation & train all personnel in the use of procedures & formats.
  • Self-assessment of the system
  • Train internal auditors.
  • Assess the system through first internal audit.
  • Take corrective actions for non-conformities.
  • Apply for NABH accreditation.
  • Avail pre-certification audit of NABH.
  • Take actions on suggestions given by NABH auditors.
  • Final audit by NABH auditors.
  • Submit the corrective actions for the findings of NABH final audit of the assessors.
  • Get accredited by NABH.

Benefits of Accreditation with Experienced NABH Consultant

Following are the key benefits that organization can achieve with experienced NABH Consultant for implementing NABH accreditation system in any hospitals and healthcare units.

  • Patients are benefited with Accreditation most.
  • Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff.
  • Rights of patients are respected and protected.
  • Patient satisfaction can be evaluated.
  • The staffs are satisfied lot as it provides for continuous learning.
  • Accreditation to a health care organisation stimulates continuous improvement.
  • It enables the organisation in demonstrating commitment to quality care.
  • It also provides opportunity to healthcare unit to benchmark with the best.
  • Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.

Hospitalaccreditation.in has Introduced NABH Documents Package for Entry Level Accreditation for AYUSH Centre

Hospitalaccreditation.in, providing NABH consultancy and documentation services in India, has announced that introduced Ready-to-use NABH Documents package for Accreditation for AYUSH Centre.

NABH documentation kit by hospitalaccreditation.in contains sample documents required for NABH hospital accreditation as per accreditation Standards for Accreditation for AYUSH Centre Service Providers. All NABH documents for Accreditation for AYUSH Centre are in MS-Word/Excel files and user can edit them. User can make changes as per their organizations need and within few days their entire documents with all necessary controls will be ready. The total documents for NABH for Accreditation is introduced at just 35000 INR., which is very competitive price.

The content covered in the NABH documents for Entry Level Accreditation for AYUSH Centre is listed below:

  • Sample NABH Manual for hospitals
  • Sample NABH manual/SOP for departments
  • System Procedures for hospital
  • Health and Safety Procedures for hospital
  • Set of Standard blank forms and system formats
  • NABH entry level AYUSH centre Audit checklist
  • NABH entry level AYUSH centre document compliance matrix

Download Sample Documents to understand detailed content covered in this documentation package, which is given on website, anyone can download it and refer them.

Hospitalaccreditation.in also provides NABH Consultancy services for Entry Level Accreditation for AYUSH Centre, which covers following step by step consultancy services.

Online Course on NABH Training for Pre Accreditation Entry Level for Hospital

National Accreditation Board for Hospitals and Healthcare Providers (NABH) offers accreditation programme for Indian hospitals and healthcare providers. NABH has released a new batch of entry-level standards for accreditation of smaller hospitals.

Apart from pre accreditation entry level of healthcare organisations, NABH is entrusted with quality promotion initiatives, awareness activities, education and training for quality and patient safety and recognition of healthcare quality.

Online NABH Training Course with Certification

The online course for NABH Training for Pre Accreditation Entry Level for Hospital designed the knowledge and insights that can prove critical in achieving NABH accreditation for your healthcare organization in India. It also provide knowledge on how to plan and prepare for the required pre-accreditation entry level NABH documents and implement the system in hospitals in India. The NABH training online course offers practical guidelines and tips to overcome accreditation challenges that face hospitals.

The NABH training online course covers overview of NABH awareness, pre-accreditation entry level requirements, NABH documents as well as steps for implementation of pre-accreditation entry level standard for hospital.

Advantages of Learning NABH Accreditation with Online Course

  • All the contents of presentations, hand-outs and exams are well categorized in four sessions.
  • All topics like NABH awareness, accreditation requirements, documentation, and system implementation are covered with audio-visual presentation.
  • Pictures and graphics are drafted in presentation to understand each topic more effectively.
  • It contains session exams and final exam to evaluate your knowledge.
  • Allow to download Handouts in pdf format and Print as many copies as required.
  • It will save 60% time and cost as compare to attend classroom training.
  • It can be attend anywhere, anytime with PC, Laptop, Tablet or Mobile.

Impact of NABH Accreditation on the Quality of Healthcare Services

The ability of hospitals is defined by the aptitude, skills, experience, and wisdom not only of their doctors and nurses, but also other clinical and non-clinical staff, including management. The hospital consultant is the trainer for your hospital who assures you of obtaining NABH Accreditation certification for quality excellence in your hospital. Hospitals must adopt quality to ensure patient and staff satisfaction, and position ourselves on a path that promotes overall success.

By obtaining a quality NABH certification, your hospital will experience various positive results:

  • Your hospital will provide high quality care and safety by accredited personnel
  • Patient satisfaction and trust in your services will improve significantly and will be evaluated regularly for continuous improvement
  • Your hospital staff will receive a greater level of training in both clinical and non-clinical processes
  • Staff satisfaction levels will be optimum due to consistent learning, a great work environment, professional development, and responsibility and ownership of processes
  • Your data logistics (clinical and non-clinical) will be well defined, and there will be overall consistency in your records
  • A systematic and simplified framework will follow for the evaluation and improvement of process quality
  • Your hospital will be assessed and organized in an objective way by external administrators
  • Inform your community and others who are interested in quality, that you commit to it and that you will always maintain quality standards
  • Your hospital will meet the optimal benchmarks and will be a preferred health care service provider

Learn more about Readymade NABH Documents for quick reference while NABH accreditation for small health care centres, multispecialty hospitals, eye hospitals etc.

Importance of NABH Accreditation of Hospitals in Healthcare

In recent times, demand for quality in healthcare services has increased due to various market forces such as medical tourism, insurance, corporate growth and competition. National Accreditation Board for Hospitals and Healthcare Providers (NABH) defines Hospital Accreditation as a public acknowledgement by a national or international healthcare accreditation body, of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external evaluation of that level of performance of organizations in relation to the standards.

The NABH Accreditation for hospitals has become popular to the extent that it is now almost necessary for any hospitals to have accreditation for competing in healthcare market. The level of confidence and trust of the people in hospitals can be increased through NABH Accreditation since it ensures that the health care organization accredits and provides services and functions of continuous quality even in the best interest of all patients’. The primary goal of the NABH accreditation is to ensure that the hospitals not only perform evidence based practices but also give importance to access, affordability, efficiency, quality and effectiveness of healthcare.

The health organization can use a variety of benefits to be certified by NABH. The biggest beneficiaries are the patients, since they are serviced by the credential medical staff. It also provides opportunity to the hospital to benchmark with the best in the industry.

Benefits of NABH Accreditation to all interested parties in the organisation:

  • It gives a huge recognition
  • Hospital system operations and protocols
  • Improves the quality and level of care
  • Recognition of the hospital gives recognition to all the employees
  • Provides job satisfaction and a safe workplace
  • Ensures all the safety parameters are set
  • Results in continuous improvement and enhanced productivity
  • Keeps us on track with the latest technology
  • Set things right at the right place
  • The hospital shall service for international patients
  • Patients will be well respected and protected
  • Enhances the overall professional development of the staffs
  • The recognition contributes to increasing the patient flow that boosts the revenue.

Read more about Eye Care hospital accreditation requirements and Download Sample NABH Documents for Eye Care Hospitals

Guidance on Documentation for NABH Pre Accreditation Entry Level for Hospital

The National Accreditation Board of Hospital and Healthcare provider has launched new entry level standards for hospital accreditation. Because the name implies that the entry level standards are for hospitals that wish to start the quality certification process but cannot do because of the strict requirements for full accreditation by NABH.

There are two types of new standards: One, for hospitals with over 50 beds, and two, for small hospitals with less than 50 beds. In both types of NABH Accreditation, hospitals must provide documented information. One of the most important steps to obtain Pre Accreditation Entry Level is to determine what Pre Accreditation documents for hospitals are needed. The NABH Documentation required for Entry Level Certification is as follow.

What Pre Accreditation Entry Level Documents are the required?

Pre Accreditation Entry Level for Hospital

  1. Hospital Manual: Hospital Manual covers the details like introduction, scope of service, hospital policy, vision and mission, applicable laws and regulations, quality policy and organization structure.
  2. Department Manual: The different department system is given in department wise manual as listed below.
    • Central Sterility Supply Department (CSSD) manual
    • Emergency Preparedness
    • Infection Control
    • Medical Record
    • Human Resource Management
  3. Procedures: Procedures covers all the details like purpose, scope, responsibility, how procedure is followed, reference documents and formats. There are two types of procedures like System Procedures and Health and Safety Procedures.
  4. Standard Operating Procedures: Standard Operating Procedures document covers a guideline to establish system as per NABH pre entry level standards requirements. covering access, assessment and continuity care (AAC), care of patient (COP), continuous quality improvement (CQI), management of medicine and patient rights and education department
  5. Forms and Templates: It covers forms required to maintain records in the hospital as well as establish control and make system in the organization.
  6. Audit Checklist: NABH Audit Checklist covers audit questions to be used for hospital system auditing for objectively evaluate the adherence of system by functional heads to establish processes. It also includes audit questions as a quick reference for all related work areas of the hospital

Global Manager Group offers different NABH Documentation Kits for Hospital Accreditations. To get more information about these documentation kits, Click here

How Your Organizations Get Benefits of Hospital Accreditation with NABH Consultancy?

In the recent times, demand for healthcare services has increased due to various market forces such as medical tourism, insurance, business growth and competition. As a result, the expectations of higher quality consumers have also increased, which has indeed lead to the introduction of national and international accreditation bodies to act as a quality assurance mechanism, thus enhancing customers access to better healthcare services.

National Accreditation Board for Hospitals and Healthcare Providers (NABH) defines Hospital Accreditation as a public recognition by a national or international healthcare accreditation body, of the achievement of accreditation standards by a healthcare organization, demonstrated through an independent external peer assessment of that organizations level of performance in relation to the standards.

NABH Accreditation Consultancy assists healthcare organizations to establish, comply, monitor and sustain the quality processes and helps in preparing the hospitals for the accreditation according to the latest standards & editions. NABH Consultancy provides complete guidance through implementation, NABH documentation as well as training required for quick accreditation.

Benefits of Hospital Accreditation with NABH Consultancy

Following are the key benefits that organization can achieve with implementation of NABH accreditation system in any hospitals and healthcare units.

  • Patients are benefited with Accreditation most.
  • Accreditation results in high quality of care and patient safety. The patients get services by credential medical staff
  • Rights of patients are respected and protected
  • Patient satisfaction can be evaluated.
  • The staff are satisfied lot as it provides for continuous learning
  • Accreditation to a health care organisation stimulates continuous improvement.
  • It enables the organisation in demonstrating commitment to quality care.
  • It also provides opportunity to healthcare unit to benchmark with the best.
  • Accreditation provides access to reliable and certified information on facilities, infrastructure and level of care.

Introduced Readymade NABH Accreditation Documents for Eye Care Organization

Leading information sharing website for Hospital Accreditation and documentation consultancy services, Hospitalaccreditation.in introduced new product Documentation Kit for Eye Care Organization Accreditation.

Accreditation to Eye Care Organization (ECO) stimulates continuous improvement. It enables ECO in demonstrating commitment to quality care. It raises community confidence in the services provided by the ECO. It also provides opportunity to healthcare unit to benchmark with the best.

To accomplish this requirement, consultant form hospitalaccreditation.in with highly experienced in hospital accreditation have designed and offers Eye Care Organization NABH Documentation kit online to help Eye Care Organization. It covered all requirements of Eye Care Organization documentation. The document kit is having sample documents required for implementation of Eye Care Organization – NABH Accreditation as per latest National accreditation board of hospitals and healthcare provider standard (1st Edition September, 2016).

The complete set of eye care organization accreditation documents assists user to understand quality systems in hospitals and how to achieve fast and effective accreditation certification. Eye Care Organization Documentation kit contains documents like Manual, System Procedures, Process approach, Standard operating procedures, Eye Care Organization audit checklists, etc.

The ready to use Eye Care Organization accreditation documents covers sample templates that are written in simple English and easily editable format. The user can update total documentation templates as per organization working system and create own documents for their company in quick time. User can also download Free Demo that helps to learn each document in details.