Why Hospitals and Healthcare Providers Should Obtain NABH Accreditation?

Every healthcare facility has internal operational rules and regulations. However, accreditation ensures that the organization complies with the norms and criteria established by a recognized, external organization. Accreditation provides an external validation mark for your company, demonstrating that they comply with industry standards and best practices. However, certification in healthcare is more than just a matter of reputation. Going through the certification process helps to streamline processes, enhance treatment quality, and foster confidence among patients and the community.

NABH offers a wonderful opportunity for healthcare businesses to create standards and processes while also improving the dependability of service operations. Accreditation is beneficial to all stakeholders in a hospital, but it is especially beneficial to patients. It encourages continual improvement in governance, operations, and activities for a hospital (clinical and administrative). Staff is imbued with a feeling of ownership and clinical competence. Accreditation is entirely optional, and in today’s competitive market, hospitals are more interested in establishing their quality-of-service delivery.

Accreditation is described as the public acknowledgment of a health organization’s achievement of accreditation requirements established by a National Health Accreditation agency. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a component of the Quality Council of India (QCI), which was established in 2006 to oversee and certify healthcare providers and hospital programs. IRDA, on the other hand, is the primary independent top statutory board that governs the Indian insurance business.

Hospital accreditation is NABH’s flagship program, with the primary goal of encouraging patient safety and quality improvement in public and commercial hospitals. It creates a uniform framework for hospitals and other healthcare institutions to adopt compliance patient safety measures. NABH’s quality standards have been approved by the International Society for Quality in Healthcare. Not only this, but it may also be essential for a variety of other reasons. For example, did you know that having accreditation can make the process simple and safe? It can be almost just as important as what we believe it to be for you to have access to NABH awareness training and other opportunities. The followings are the significance and benefits of NABH accreditation:

  • The most beneficiaries are the patients: With NABH accreditation and the adoption of its requirements at the hospital, patients benefit the most from efficient services and excellent treatment. NABH supports improved patient happiness, which leads to improved clinical results. When the hospital obtains greater patient satisfaction numbers, it results in profit for all stakeholders and staff. It naturally motivates them to put in more effort and obtain cutting-edge technologies to raise the bar for better patient care.
  • Establishes a sense of social trust: NABH Accreditation contributes to improved community confidence in the services offered by the hospital’s certified medical team by enhancing the patient experience and staff productivity.
  • For insurance and third-party services, the IRDA requires NABH Accreditation: The Insurance Regulatory and Development Authority of India (IRDA) has now required all hospitals impaneled with it to enroll in NABH to provide treatment under Cashless Insurance Schemes (CIS). As it cuts down on inflated invoices and inconsistencies, NABH accreditation assures a fair billing procedure and quality care in hospitals.
  • Improved workplaces for employees: The training, updates, and skill development, proper NABH Documents that the personnel of NABH Accredited hospitals receives is comparable to those of their equivalents in worldwide hospitals. A positive work atmosphere and increased clinical process expertise are advantageous to the workforce of hospitals with NABH accreditation.
  • Hospitals benefit from an edge in marketing: The hospital that receives NABH accreditation benefits from increased medical care since it improves its reputation and sets it apart from other hospitals. NABH accreditation can increase patient confidence in the quality of services and healthcare facilities provided by the hospital, which supports in the growth of healthcare services at the hospital.

What is the NABH Accreditation Process for Hospitals in India?

The Government of India established the National Accreditation Board for Hospitals and Healthcare Providers (NABH) in 2005 to improve the country’s healthcare quality. The Quality Council of India (QCI) governs this autonomous agency, which is in charge of developing policies and maintaining QCI standards. Some international healthcare standards, such as the Japan Council for Quality in Health Care, the Australian Council on Healthcare Criteria, and the United States National Committee for Quality Assurance, are identical to the NABH accreditation standards.

To minimize medical errors, NABH requires hospitals to follow standardized SOPs (standard operating procedures). Additionally, SOPs enhance healthcare quality, efficiency, waste reduction, and employee happiness. NABH accreditation is only granted to hospitals that follow the SOPs. Let’s take a closer look at NABH and the stages involved in the NABH accreditation process for hospitals.

To get NABH certification, hospital administration must establish an action plan and choose an individual or organization to handle all accreditation-related activities. The steps for qualifying for NABH accreditation are as follows:

  1. The hospital seeking accreditation must hire a quality assurance officer who is familiar with the existing system. This assists the officer in identifying flaws and areas for improvement.
  2. The officer must have a comprehensive understanding of the NABH accreditation process. 
  3. The selected officer must confirm the implementation of higher standards in the hospital. 
  4. Before completing the application form, the hospital shall conduct a self-assessment against NABH criteria.

As a result, some of the processes that enable NABH accreditation for hospitals, which is a seven-step processes. The steps for obtaining NABH accreditation in India are as follows:

Step 1: Application Submission to NABH: After following the NABH standards for at least three months, the hospital should apply to NABH using the required application form. The following information is contained in the application form:

  1. Self-declaration of terms and conditions described by NABH
  2. Self-assessment, as suggested by NABH 
  3. Hospital manual/ quality standards as per prescribed NABH standards 
  4. Relevant documents to be uploaded with the application

Step 2: Review of Application by NABH: Following the submission of the NABH application, the NABH officers will review the forms as well as any documents. Before issuing accreditation, the department will ask the applicant to explain or correct any anomalies it finds in the form. If the application is appropriate and complete, the department will issue a letter of acknowledgment and a special reference number to the hospital.

Step 3: Pre-Assessment: The NABH department assigns a principal inspector or assessment team to pre-assess the hospital within three months of fee deposition as the next step in the accreditation process. Pre-assessments can be completed on-site, remotely, on a desktop, or in a hybrid format. The following are the same’s objectives: –

  1. Evaluate the hospital’s preparation for the final assessment
  2. Determine the number of assessors required and the duration of the accreditation process
  3. Review the authenticity of NABH documents / SOPs of the hospital
  4. Explain the practice to be adopted for the evaluation of the hospital

Step 4: Final Assessment: Within six months of the fee being deposited, the final assessment is completed in an onsite, remote, desktop, or hybrid format. It contains a thorough analysis of all the duties and products the hospital provides. To address any discrepancies or questions identified during the pre-assessment, the prospective hospital must take the appropriate corrective action.

Step 5: Review of Assessment Report: The chief assessor examines the assessment report after the last assessment. The following grading on a scale of 0, 5, and 10 is used to evaluate the assessment report and acknowledged some Conditions for qualifying for NABH accreditation:

  1. Compliance with the requirement
  2. Partial compliance with the requirement
  3. Non-compliance with the requirement

To be eligible for NABH accreditation, an organization must completely comply with all applicable regulatory and legal criteria. No individual standard may include more than one zero, and the average score for each standard cannot be less than five. The ultimate average score for all criteria must be greater than seven and the average score for each chapter cannot be less than seven.

Step 6: Approval and Issue of certification by Accreditation Committee: Within three months after the final evaluation, the accreditation committee approves and issues a certification of accreditation to the hospital if it meets the requirements for NABH accreditation. Also, the NABH accreditation certificate is effective for three years.

Step 7: Reassessment and Surveillance: Upon the announcement of the certificate of accreditation, the NABH team will perform annual surveillance and reassessments for the following three years. At least six months before the NABH accreditation’s validity expires, the hospital must apply for renewal of accreditation.

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