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