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

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.

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?

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