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