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.