SHCO Second Edition - NE

nd
2EDITION
April 2014
STANDARDS FOR SMALL

HEALTH CARE ORGANIZATIONS
5th Floor, ITPI Building, 4A, Ring Road, IP Estate, New Delhi 110 002, India
Phone: +91‐11‐2332 3516/ 17/18/19/20, Fax: 2332 3415 NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND
Email: helpdesk@nabh.co; Website: www.nabh.co
HEALTHCARE PROVIDERS (NABH)
QUALITY : SAFETY : WELLNESS
PREFACE TO THE RE-PRINT
National Accreditation Board for Hospitals and Healthcare Providers (NABH), a constituent
board of Quality Council of India, established in 2005, is in its 15th year of creating an
ecosystem of quality in healthcare in India. NABH standards focus on patient safety and
quality of the delivery of services by the hospitals in the changing healthcare environment.
Without being prescriptive, the objective elements remain informative and guide the
organisation in conducting its operations with a focus on patient safety.
All NABH standards have been developed in consultation with various stakeholders in the
healthcare industry and if implemented help the healthcare organizations in stepwise
progression to mature quality systems covering the entire spectrum of patient safety and
healthcare delivery.
The NABH organization & the hospital accreditation standards are internationally recognized
and benchmarked. NABH is an Institutional as well as a Board member of the International
Society for Quality in Health Care (lSQua( and Asian Society for Quality in Health Care
(ASQua) and a member of the Accreditation Council of International Society for Quality in
Health Care (ISQua)
Over the years, successive NABH standards have brought about not only paradigm shifts in
the hospitals’ approach towards delivering the healthcare services to the patients but have
equally sensitised the healthcare workers and patients towards their rights and
responsibilities.
In celebration of our 74th Independence Day, on 15th of August, 2020, we are pleased
to announce, that starting today, in an enhanced effort to connect with people, all
NABH standards, across programmes, will be available free of charge as
downloadable documents in PDF format on the NABH website www.nabh.co. (The
Printed copies of Standards and Guidebooks will continue to remain available for
purchase at a nominal price).
NABH also announces the enriched continuation of its "NABH Quality Connect-Learning
with NABH" initiative, connecting free monthly training classes, webinars and seminars. The
various topics that will be taken up will cover all aspects of patient safety, including: Key
Performance Indicators, Hospital Infection Control, Management of Medication, Document
Control etc.
Recently introduced communication initiatives like Dynamic Website Resource Center and
NABH Newsletter Quality Connect (focusing on sharing the best quality practices, news
and views) will also be bettered.
It is sincerely hoped that all stakeholders will certainly benefit from the collective efforts of
the Board and practical suggestions of thousands of Quality Champions form India and
abroad
NABH remains committed to ensuring healthy lives and promote wellbeing for all at
all ages (SDG-3-Target 2030), creating a culture of quality in healthcare and taking
Quality, Safety and Wellness to the Last Man in the Line.
Jai Hind
(Dr. Atul Mohan Kochhar)

CEO-NABH 15th August 2020
NATIONAL ACCREDITATION BOARD FOR
HOSPITALS AND HEALTHCARE PROVIDERS
ACCREDITATION STANDARDS FOR

SMALL HEALTH CARE ORGANIZATIONS
(SHCO)
Second Edition - April 2014
@ National Accreditation Board for Hospitals and Healthcare Providers 1

@ No part of these publications may be reproduced in any form without the prior
permission in writing of Quality Council of India

Foreword
The Indian healthcare industry has been growing at an impressive pace. The sector
growth is being driven by country’s growing middle class, which is looking for quality
healthcare. If the economy continues to grow faster than the economies of the
developed world and the literacy rate keeps rising, much of India will be middle class by
2020.
Accreditation is an important tool for the growth of healthcare industry. Accreditation is

demonstration to the patients (and to all stake holders) that healthcare organization
conforms to global benchmarks on patient safety and quality of care. Hospital
Accreditation programme launched in February 2006 has been very well received in the
country. Considering that almost 90% of hospitals are with beds less than 100, there
was a demand to have specific guidelines on how to apply hospital accreditation
standards for small healthcare organization or carve out separate standard. The revised
edition of the standards will facilitate easy understanding and implementation and will
enable small healthcare organizations to come under the purview of Accreditation.
The second edition had been revised keeping in mind NABH’s focus on patient centric
approach and contributing to the cause of patient safety. Besides patients, who are
going to be biggest beneficiaries from accreditation, it is expected to provide easy and
transparent mechanism for empanelment of small healthcare organization(s) by
government, corporate and even by insurance companies.
It is hoped that with release of second edition of these standards, large number of small
healthcare units will comply with the standard and help in creating accredited quality
healthcare hub in the country for our own citizens as well as for the overseas patients.
Dr. K.K. Kalra

CEO – NABH

Table of Contents
Sr. No. Particulars Page No.
01. Scope 7
02. Normative Reference 7
03. Terms and Definitions 7
Patient Centered Standards
04. Access, Assessment and Continuity of Care (AAC) 9
05. Care of Patients (COP) 15
06. Management of Medication (MOM) 22
07. Patient Rights and Education (PRE) 27
08. Hospital Infection Control (HIC) 32
Organization Centered Standards
09. Continuous Quality Improvement (CQI) 37
10. Responsibilities of Management (ROM) 42
11. Facility Management and Safety (FMS) 46
12. Human Resource Management (HRM) 50
13. Information Management System (IMS) 56

Standards for Small Healthcare Organizations
Scope
These accreditation standards specify requirements for small healthcare organizations.
Normative reference
NABH document on ‘Standards for Hospital’ is used as base document.
Terms and Definitions
Small Health Care Organizations (SHCO)
Those healthcare organizations having bed strength between 20 to 50 beds and are in
possession of supportive and utility facilities that are appropriate and relevant to the
services being provided by organization.
Exclusions
- Polyclinics
- Diagnostic Centres
- Superspeciality* centres (single/ multiple)
Exceptions
Speciality** Day Care centres (minimum bed strength not mandatory)
* Super Speciality centres are the centres which reflect requirement of DM/ MCh or
equivalent qualified personnel.
** Speciality centres are the centres which reflect requirement of MD/ MS or equivalent
qualified personnel.

Chapter 1: Access, Assessment and Continuity of Care (AAC)
Chapter 1
Access, Assessment and Continuity of
Care (AAC)
Intent of the standards
Patients are well informed of the services that an organization provides. This will
facilitate in appropriately matching patients with the organization’s resources. Only
those patients who can be cared for by the organization are admitted to the
organization. Emergency patients receive life stabilizing treatment and are then either
admitted (if resources are available) or transferred appropriately to an organization that
has the resources to take care of such patients. Out-patients who do not match the
organization’s resources are similarly referred to organizations that have the matching
resources.
Patients that match the organizations resources are admitted using a defined process.
Patients cared for by the organization undergo an established initial assessment and
periodic and regular reassessments.
Assessments include planning for utilization of laboratory and imaging services. The
laboratory and imaging services are provided (or outsourced)by competent staff in a
safe environment for both patients and staff. These assessments result in formulation of
a definite plan of care.
Patient care is multidisciplinary in nature and encourages continuity of care through

well-defined transfer and discharge protocols. These protocols include transfer of
adequate information with the patient. After achieving the goals of the treatment plan, or
at request, patients are discharged in a planned and coordinated manner.

Summary of Standards
AAC. 1 The organization defines and displays the services that it can provide.
AAC. 2 The organization has a documented registration, admission and transfer

process.
AAC. 3 Patients cared for by the organization undergo an established initial

assessment.
AAC. 4 Patient care is continuous and all patients cared for by the organization
undergo a regular reassessment.
AAC. 5 Laboratory services are provided as per the scope of the hospital's services
and adhere to best practices.
AAC. 6 Imaging services are provided as per the scope of the hospital's services
and adhere to best practices.
AAC. 7 The organization has a defined discharge process

Standards and Objective Elements
Standard
AAC. 1 The organization defines and displays the services that it can provide
Objective Elements
a. The services being provided are clearly defined.
b. The defined services are prominently displayed.
c. The staff is oriented to these services.
Standard
AAC. 2 The organization has a documented registration, admission and

transfer process
Objective Elements
a. The process addresses registering and admitting out-patients, in-patients and

emergency patients.
b. The process addresses managing patients during non availability of beds.
c. Patients are accepted only if the organization can provide the required service.
d. The process addresses mechanism for transfer or referral of patients who do not
match the organizational resources.

Standard
AAC. 3 Patients cared for by the organization undergo an established initial

assessment
Objective Elements
a. The organization defines the content of the assessments for the out-patients, in-
patients and emergency patients.
b. The organization determines who can perform the assessments.
c. The organization defines the time frame within which the initial assessment is
completed.
d. The initial assessment for in-patients is documented within 24 hours or earlier.
Standard
AAC. 4 Patient care is continuous and all patients cared for by the
organization undergo a regular reassessment
Objective Elements
a. During all phases of care, there is a qualified individual identified as responsible for
the patient’s care who coordinates the care in all the settings within the
organization.
b. All patients are reassessed at appropriate intervals.
c. Staff involved in direct clinical care document reassessments.
d. Patients are reassessed to determine their response to treatment and to plan

further treatment or discharge.

Standard
AAC. 5 Laboratory services are provided as per the scope of the hospital’s
services and adhere to best practices
Objective Elements
a. Scope of the laboratory services are commensurate to the services provided by the
organization.
b. Adequately qualified and trained personnel perform and/ or supervise the

investigations.
c. Procedures guide collection, identification, handling, safe transportation,

processing and disposal of specimens.
d. Laboratory results are available within a defined time frame and critical results are
intimated immediately to the concerned personnel.
e. Laboratory tests not available in the organization are outsourced to organization(s)

based on their quality assurance system.
f. Laboratory personnel are trained in safe practices and are provided with
appropriate safety equipment/ devices.
g. Quality assurance for laboratory should be as per accepted practices and also
include periodic calibration and maintenance of all equipments.
Standard
AAC. 6 Imaging services are provided as per the scope of the hospital’s
services and adhere to best practices
Objective Elements
a. Imaging services comply with legal and other requirements.
b. Scope of the imaging services are commensurate to the services provided by the
organization.
c. Adequately qualified and trained personnel perform, supervise and interpret the
investigations.

d. Imaging results are available within a defined time frame and critical results are
intimated immediately to the concerned personnel.
e. Imaging tests not available in the organization are outsourced to organization(s)

based on their quality assurance system.
f. Imaging personnel are trained in safe practices and are provided with appropriate
safety equipment/ devices.
g. Quality assurance for Radiology services should be as per accepted practices and
also include periodic calibration and maintenance of all equipments.
Standard
AAC. 7 The organization has a defined discharge process
Objective Elements
a. Process addresses discharge of all patients including Medico-legal cases and

patients leaving against medical advice.
b. A discharge summary is given to all the patients leaving the organization (including
patients leaving against medical advice).
c. Discharge summary contains the reasons for admission, significant findings,

investigation results, diagnosis, procedure performed (if any), treatment given and
the patient’s condition at the time of discharge.
d. Discharge summary contains follow up advice, medication and other instructions in

an understandable manner.
e. Discharge summary incorporates instructions about when and how to obtain urgent
care.
f. In case of death the summary of the case also includes the cause of death.

Chapter 2: Care of Patients (COP)
Chapter 2
Care of Patients (COP)
The organization provides uniform care to all patients in different settings. The different
settings include care provided in outpatient units, various categories of wards, intensive
care units, procedure rooms and operation theatre. Care provided for a particular
clinical condition is the same irrespective of the ward setting or billing category. Policies,
procedures, applicable laws and regulations guide emergency and ambulance services,
cardio-pulmonary resuscitation, use of blood and blood products, care of patients in the
Intensive care and high dependency units.
Policies, procedures, applicable laws and regulations also guide care of vulnerable
patients (elderly, physically and/or mentally challenged and children), high risk
obstetrical patients, paediatric patients, patients undergoing moderate sedation,
administration of anaesthesia, patients undergoing surgical procedures. Nutritional
therapy is also addressed with a view to provide comprehensive health care.
The standards aim to guide and encourage patient safety as the overall principle for
providing care to patients.

COP. 1 Care of patients is uniform and is guided by established standards and

guidelines.
COP. 2 Emergency services including ambulance are guided by documented

procedures and applicable laws and regulations.
COP. 3 Documented procedures guide the care of patients requiring cardio-

pulmonary resuscitation.
COP. 4 Documented procedures define rational use of blood and blood products.
COP. 5 Documented procedures guide the care of patients in the Intensive care
and high dependency units.
COP. 6 Documented procedures guide the care of obstetrical patients.
COP. 7 Documented procedures guide the care of pediatric patients.
COP. 8 Documented procedures guide the care of patients undergoing parenteral

sedation.
COP. 9 Documented procedures guide the administration of anesthesia.
COP. 10 Documented procedures guide the care of patients undergoing surgical

procedures.

Standard
COP. 1 Care of patients is uniform and is guided by established standards and

guidelines
Objective Elements
a. Care delivery is uniform when similar care is provided in more than one setting.
b. Care delivery includes special needs of vulnerable patients (elderly, children,

physically and/ or mentally challenged).
c. The care and treatment orders are signed, named, timed and dated by the
concerned doctor.
d. The care plan is countersigned by the clinician in-charge of the patient within 24
hours.
e. Evidence based medicine and clinical practice guidelines are adopted to guide
patient care whenever possible.
Standard
COP. 2 Emergency services including ambulance are guided by documented

procedures and applicable laws and regulations
Objective Elements
a. Documented procedures address care of patients arriving in the emergency

including handling of medico-legal cases.
b. Documented procedures also guide the triage of patients for initiation of

appropriate care.
c. Staff is trained on the procedures for care of emergency patients.
d. Admission or discharge to home or transfer to another organization is also

documented.
e. Ambulance(s) is appropriately equipped and manned by trained personnel.

f. In the ambulance, there is a checklist of all equipment and emergency medications

which is checked on a regular basis.
Standard
COP. 3 Documented procedures guide the care of patients requiring cardio-

pulmonary resuscitation
Objective Elements
a. Documented procedures guide the uniform use of resuscitation throughout the

organization.
b. Staff providing direct patient care is trained and periodically updated in cardio-
pulmonary resuscitation.
c. The events during cardio-pulmonary resuscitation are recorded.
Standard
COP. 4 Documented procedures define rational use of blood and blood

products
Objective Elements
a. The Blood Bank service is governed by the applicable laws and regulations.
b. Informed consent is obtained for donation and transfusion of blood and blood
products.
c. Procedure addresses documenting and reporting of transfusion reactions.
Standard
COP. 5 Documented procedures guide the care of patients in the Intensive

care and high dependency units
Objective Elements
a. The organization has documented admission and discharge criteria for its intensive
care and high dependency units.

b. Care of patients is in consonance with the documented procedures.
c. Adequate staff and equipment are available.
Standard
COP. 6 Documented procedures guide the care of obstetrical patients
Objective Elements
a. The organization defines the scope of obstetric services.
b. Obstetric patient’s care includes regular ante-natal check ups, maternal nutrition
and post-natal care.
c. The organization has the facilities to take care of neonates.
Standard
COP. 7 Documented procedures guide the care of pediatric patients
Objective Elements
a. The organization defines the scope of its pediatric services.
b. Provisions are made for special care of children by competent staff.
c. Patient assessment includes detailed nutritional, growth, and immunization

assessment.
d. Procedure addresses prevention of child/ neonate abduction, neglect and abuse.
e. The children’s family members are educated about nutrition, immunization and
safe parenting.

Standard
COP. 8 Documented procedures guide the care of patients undergoing

parenteral sedation
Objective Elements
a. The person administering and monitoring sedation is different from the person
performing the procedure.
b. Patient’s vital parameters are monitored during and after sedation and are
discharged/ transferred once they are stable.
c. Equipment and manpower are available to rescue patients from a deeper level of
sedation than that intended.
Standard
COP. 9 Documented procedures guide the administration of anesthesia
Objective Elements
a. There is a documented policy and procedure for the administration of anesthesia.
b. All patients for anesthesia have a pre-anesthesia assessment by a qualified

individual.
c. The pre-anesthesia assessment results in formulation of an anesthesia plan which

is documented.
d. An immediate preoperative re-evaluation is documented.
e. Informed consent for administration of anesthesia is obtained by the anesthetist.
f. Anesthesia monitoring includes regular and periodic recording of heart rate,

cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security
and patency and level of anesthesia.
g. Each patient’s post-anesthesia status is monitored and documented.
h. A qualified individual applies defined criteria to transfer the patient from the
recovery area.
i. All adverse anesthesia events are recorded and monitored.

Standard
COP. 10 Documented procedure guide the care of patients undergoing surgical

procedures
Objective Elements
a. Surgical patients have a preoperative assessment and a provisional diagnosis

documented prior to surgery.
b. An informed consent is obtained by a surgeon prior to the procedure.
c. The documented procedure addresses the prevention of adverse events like wrong
site, wrong patient and wrong surgery.
d. Persons qualified by law are permitted to perform the procedures that they are
entitled to perform.
e. A brief operative note is documented prior to transfer out of patient from recovery
area.
f. The operating surgeon documents the post-operative plan of care.
g. The operation theatre is adequately spaced, equipped and monitored for infection
control practices.

Chapter 3: Management of Medication (MOM)
Chapter 3
Management of Medication (MOM)
The organization has a safe and organized medication process. The process includes
policies and procedures that guide the availability, safe storage, prescription, dispensing
and administration of medications.
The standards encourage integration of the pharmacy into everyday functioning of

hospitals and patient care. The pharmacy should ensure correct storage (as regards to
temperature, look-alike, sound-alike etc.), expiry dates and maintenance of
documentation.
The availability of emergency medication is stressed upon. Every high risk medication
order should be verified by an appropriate person so as to ensure accuracy of the dose,
frequency and route of administration. The “appropriate person” could be another
doctor, trained nurse or preferably, a clinical pharmacist. Such a person would also look
for drug-drug interactions, renal or hepatic dosing etc. There should be a mechanism by
which this person could verify the order with the prescriber in case of doubts or
clarifications and then make changes to the order after such clarifications. The
verification should occur before the medication is administered but preferably, prior to
dispensing of the medication. There should be a protocol by way of which, in case of
continued conflict, the person can approach higher authority to ensure patient safety.
The process also includes monitoring of patients after administration and procedures for
reporting and analysing medication errors. Medications also include the use of medical
gases.

MOM. 1 Documented procedures guide the organization of pharmacy services and

usage of medication.
MOM. 2 Documented procedures guide the prescription of medications.
MOM. 3 Policies and procedures guide the safe dispensing of medications.
MOM. 4 There are defined procedures for medication administration.
MOM. 5 Patients are monitored for adverse drug events after medication
administration.
MOM. 6 Documented procedures guide the use of medical gases.


Standard
MOM. 1 Documented procedures guide the organization of pharmacy

services and usage of medication
Objective Elements
a. Documented procedure shall incorporate purchase, storage, prescription and

dispensation of medications.
b. These comply with the applicable laws and regulations.
c. The hospital has a list of medications appropriate for the patient’s and
organization’s resources.
d. Sound alike and look alike medications are stored separately.
e. Beyond expiry date medications are not stored/ used.
f. Documented procedures address procurement and usage of implantable

prosthesis.
Standard
MOM. 2 Documented procedure guide the prescription of medications
Objective Elements
a. The organization determines who can write orders.
b. Orders are written in a uniform location in the medical records.
c. Medication orders are clear, legible, dated, named and signed.
d. Procedure addresses verbal orders and is implemented.
e. The organization defines a list of high risk medication.

Standard
MOM. 3 Policies and procedures guide the safe dispensing of medications
Objective Elements
a. This includes a procedure for medication recall.
b. Medications are checked prior to dispensing, including the expiry date to ensure
that they are fit for use.
c. High risk medication orders are verified prior to dispensing.
Standard
MOM. 4 There are defined procedures for medication administration
Objective Elements
a. Medications are administered by those who are permitted by law to do so.
b. Patient is identified prior to administration.
c. Prior to administration medication order including dosage, route and timing are
verified.
d. Prepared medication is labelled prior to preparation of a second drug.
e. Medication administration is documented.
f. A proper record is kept of the usage, administration and disposal of narcotics and
psychotropic medications.
g. The procedure addresses patient’s self administration of medications and

medications brought from outside the organization.

Standard
MOM. 5 Patients are monitored for adverse drug events after medication
administration
Objective Elements
a. Adverse drug events are defined.
b. Adverse drug events are documented and reported within a specified time frame.
c. Adverse drug events are collected, analyzed by the treating doctor and practices
are modified (if necessary) to reduce the same.
Standard
MOM. 6 Documented procedures guide the use of medical gases
Objective Elements
a. Documented procedures govern procurement, handling, storage, distribution,

usage and replenishment of medical gases.
b. Procedures address the safety issues at all levels.
c. Appropriate records are maintained in accordance with policies, procedures and

legal requirements.

Chapter 4: Patient Rights and Education (PRE)
Chapter 4
Patient Rights and Education (PRE)
The organization defines the patient and family rights and responsibilities. The staff is
aware of these and is trained to protect patient rights. Patients are informed of their
rights and educated about their responsibilities at the time of admission. The patients
are educated about the mechanisms available for addressing grievances.
A documented process for obtaining patient and / or families consent exists for informed
decision making about their care.
Patient and families have a right to information and education about their healthcare
needs in a language and manner that is understood by them.

PRE. 1 The organization protects patient and family rights during care and informs
them about their responsibilities
PRE. 2 Patient rights support individual beliefs, values and involve the patient and
family in decision making processes
PRE. 3 A documented policy for obtaining patient and/ or families consent exists for
informed decision making about their care
PRE. 4 Patient and families have a right to information and education about their
healthcare needs
PRE. 5 Patient and families have a right to information on expected costs

Standard
PRE. 1 The organization protects patient and family rights during care and
informs them about their responsibilities
Objective Elements
a. Patient and family rights and responsibilities are documented.
b. Patients and families are informed of their rights and responsibilities in a format
and language that they can understand.
c. Staff is aware of their responsibility in protecting patients and family rights.
d. Violation of patient and family rights is recorded, reviewed and corrective/

preventive measures taken by the organizational leaders.
Standard
PRE. 2 Patient rights support individual beliefs, values and involve the
patient and family in decision making processes
Objective Elements
a. Patient rights include respect for personal dignity and privacy during examination,
procedures and treatment.
b. Patient rights include protection from physical abuse or neglect.
c. Patient rights include treating patient information as confidential.
d. Patient rights include refusal of treatment.
e. Patient rights include obtaining informed consent before carrying out procedures.
f. Patient rights include information and consent before any research protocol is
initiated.
g. Patient rights include information on how to voice a complaint.

h. Patient rights include information on the expected cost of the treatment.
i. Patient has a right to have an access to his/ her clinical records.
Standard
PRE. 3 A documented policy for obtaining patient and/ or families

consent exists for informed decision making about their care
Objective Elements
a. General consent for treatment is obtained when the patient enters the organization.
b. Patient and/ or his family members are informed of the scope of such general
consent.
c. The organization has listed those situations where informed consent is required as
per national guidelines.
d. Informed consent includes information on risks, benefits, alternatives and as to

who will perform the requisite procedure in a language that they can understand.
e. The policy describes who can give consent when patient is incapable of
independent decision making.
Standard
PRE. 4 Patient and families have a right to information and education

about their healthcare needs
Objective Elements
a. Patients and families are educated to make informed decisions pertaining to plan
of care, preventive aspects, possible complications, the expected results and cost
at the time of admission.
b. When appropriate, patient and families are educated about the safe and effective
use of medication and the potential side effects of the medication.
c. Patient and families are educated about diet and nutrition.
d. Patient and families are educated about immunizations.

e. Patient and families are educated about preventing infections.
f. Patients are taught in a language and format that they can understand.
Standard
PRE. 5 Patient and families have a right to information on expected costs
Objective Elements
a. There is uniform pricing policy in a given setting (out-patient and ward category).
b. The tariff list is available to patients.
c. Patients are educated about the estimated costs of treatment.
d. Patients are informed about the financial implications when there is a change in the
patient condition or treatment setting.

Chapter 5: Hospital Infection Control (HIC)
Chapter 5
Hospital Infection Control (HIC)
The standards guide the provision of an effective infection control programme in the
organization. The programme is documented and aims at reducing/ eliminating infection
risks to patients, visitors and providers of care.
The organization measures and takes action to prevent or reduce the risk of Healthcare
Associated Infection (HAI) in patients, visitors and employees.
The organization provides proper facilities and adequate resources to support the
Infection Control Programme.
The programme includes an action plan to control outbreaks of infection,

disinfection/sterilization activities, biomedical waste (BMW) management, and training
of staff and employee health.

HIC. 1 The organization has a well-designed, comprehensive and coordinated

Hospital Infection Control (HIC) programme aimed at reducing/ eliminating
risks to patients, visitors and providers of care.
HIC. 2 The hospital has an infection control manual, which is periodically updated
and conducts surveillance activities.
HIC. 3 The hospital takes actions to prevent or reduce the risks of Hospital
Associated Infections (HAI) in patients and employees.
HIC. 4 There are documented procedures for sterilisation activities in the hospital.
HIC. 5 Statutory provisions with regard to Bio-Medical Waste (BMW)

management are complied with.
HIC. 6 The infection control programme is supported by hospital management

and includes training of staff and employee health.

Standard
HIC. 1 The organization has a well-designed, comprehensive and

coordinated Hospital Infection Control (HIC) programme aimed at
reducing/ eliminating risks to patients, visitors and providers of care
Objective Elements
a. The hospital has an infection control committee.
b. The hospital has a designated individual for infection control activities.
c. The hospital infection control programme is documented.
Standard
HIC. 2 The hospital has an infection control manual, which is periodically

updated and conducts surveillance activities
Objective Elements
a. The manual identifies the various high-risk areas.
b. It outlines methods of surveillance in the identified high-risk areas.
c. Surveillance activities are appropriately directed towards the identified high-risk

areas.
d. It focuses on adherence to standard precautions at all times.
e. Equipment cleaning and sterilisation practices are included.
f. Laundry and linen management processes are also included.
g. Kitchen sanitation and food handling issues are included in the manual.
h. Engineering controls to prevent infections are included.
i. Scope of surveillance activities incorporates tracking and analyzing appropriate

infection rates.

j. Feedbacks regarding these rates are provided on a regular basis to medical and
nursing staff.
Standard
HIC. 3 The hospital takes actions to prevent or reduce the risks of Hospital
Associated Infections (HAI) in patients and employees
Objective Elements
a. Hand washing facilities in all patient care areas are accessible to health care
providers.
b. Compliance with proper hand washing is monitored regularly.
c. Isolation/ barrier nursing facilities are available.
d. Adequate gloves, masks, soaps, and disinfectants are available and used
correctly.
e. Appropriate pre and post exposure prophylaxis is provided to all concerned staff
members.
Standard
HIC. 4 There are documented procedures for sterilisation activities in the

hospital
Objective Elements
a. There is adequate space available for sterilization activities.
b. Regular validation tests for sterilisation are carried out and documented.
c. There is an established recall procedure when breakdown in the sterilisation

system is identified.

Standard
HIC. 5 Statutory provisions with regard to Bio-Medical Waste (BMW)

management are complied with
Objective Elements
a. The hospital is authorised by prescribed authority for the management and

handling of Bio-Medical Waste.
b. Proper segregation and collection of Bio-Medical Waste from all patient care areas
of the hospital is implemented and monitored.
c. The organization ensures that Bio-Medical Waste is stored and transported to the
site of treatment and disposal in proper covered vehicles within stipulated time
limits in a secure manner.
d. Bio-Medical Waste treatment facility is managed as per statutory provisions (if in-
house) or outsourced to authorised contractor(s).
e. Requisite fees, documents and reports are submitted to competent authorities on

stipulated dates.
f. Appropriate personal protective measures are used by all categories of staff

handling Bio-Medical Waste.
Standard
HIC. 6 The infection control programme is supported by hospital

management and includes training of staff and employee health
Objective Elements
a. Hospital management makes available resources required for the infection control
programme.
b. It conducts regular pre-induction training for appropriate categories of staff before

joining concerned department(s).
c. It also conducts regular ‘in-service’ training sessions for all concerned categories of
staff at least once in a year

Chapter 6: Continuous Quality Improvement (CQI)
Chapter 6
Continuous Quality Improvement (CQI)
The standards encourage an environment of continual quality improvement. The quality

and safety programme should be documented and involve all areas of the organization
and all staff members. The organization should collect data on structures, processes
and outcomes, especially in areas of high risk situations. The collected data should be
collated, analysed and used for further improvements. The improvements should be
sustained. The quality programme of the diagnostic services should be integrated into
the organization’s quality plan. Infection control and patient safety plans should also be
integrated into the organization’s quality plan.
The organization should define its sentinel events and intensively investigate when such
events occur. The quality programme should be supported by the management.

CQI. 1 There is a structured quality improvement and continuous monitoring

programme in the organization
CQI. 2 The organization identifies key indicators to monitor the structures,

processes and outcomes which are used as tools for continual
improvement
CQI. 3 The quality improvement programme is supported by the management
CQI. 4 There is an established system for clinical audits
CQI. 5 Sentinel events are intensively analyzed

Standard
CQI. 1 There is a structured quality improvement and continuous

monitoring programme in the organization
Objective Elements
a. The organization develops, implements, maintains and document quality

improvement programme.
b. There is a designated individual for coordinating and implementing the quality

c. The quality improvement programme is comprehensive and covers all the major
elements related to quality improvement and risk management.
d. The designated programme is communicated and coordinated amongst all the

employees of the organization through proper training mechanism.
e. The quality improvement programme is reviewed at predefined intervals and

opportunities for improvement are identified.
f. The quality improvement programme is a continuous process and updated at least

once in a year.
Standard
CQI. 2 The organization identifies key indicators to monitor the structures,

processes and outcomes which are used as tools for continual
improvement
Objective Elements
a. Organization shall identify the appropriate key performance indicators in both

clinical and managerial areas.
b. Indicators shall be related to structures, processes and outcomes.
c. These indicators shall be monitored.

d. Monitoring includes performance of quality improvement activities in diagnostics,

ICUs and operation theatres.
e. Monitoring includes patient satisfaction which also incorporates waiting time for
services.
f. Monitoring includes employee satisfaction.
g. Monitoring includes safety aspects including adverse events.
h. Data collected are used as tools for further improvements.
i. Monitoring includes data collection to support evaluation of these improvements.
Standard
CQI. 3 The quality improvement programme is supported by the

management
Objective Elements
a. Hospital Management makes available adequate resources required for quality

b. Appropriate statistical and management tools are applied whenever required.
Standard
CQI. 4 There is an established system for clinical audits
Objective Elements
a. Medical staff participates in this system.
b. The parameters to be audited are defined by the organisation.
c. Patient and staff anonymity is maintained.
d. All audits are documented.
e. Remedial measures are implemented.

Standard
CQI. 5 Sentinel events are intensively analyzed
Objective Elements
a. The organization has identified the appropriate sentinel events.
b. The organisation has established processes for intense analysis of such events
when they occur.
c. Corrective and Preventive Actions are taken based on the findings of such
analysis.

Chapter 7: Responsibilities of Management (ROM)
Chapter 7
Responsibilities of Management (ROM)
The standards encourage the governance of the organization in a professional and

ethical manner. The responsibilities of the management are defined. The organization is
led by a suitably qualified and experienced individual. The responsibilities of the leaders
at all levels are defined. The services provided by each department are documented.
Leaders ensure that patient safety and risk management issues are an integral part of
patient care and hospital management.

ROM. 1 The responsibilities of the management are defined.
ROM. 2 The organization is managed by the leaders in an ethical manner.
ROM. 3 Leaders ensure that patient safety aspects and risk management issues
are an integral part of patient care and hospital management.


Standard
ROM. 1 The responsibilities of the management are defined
Objective Elements
a. The organization has a documented organogram.
b. Those responsible for management support quality improvement plans.
c. The management defines the rights and responsibilities of employees.
d. The organization is registered with appropriate authorities as applicable.
e. Those responsible for management address the organization’s social

responsibility.
Standard
ROM. 2 The organization is managed by the leaders in an ethical manner
Objective Elements
a. The management makes public the mission statement of the organization.
b. The leaders establish the organization’s ethical management.
c. The organization discloses its ownership.
d. The organization honestly portrays the services which it can provide.
e. The organization honestly portrays its affiliations and accreditations.
f. The organization accurately bills for its services based upon a billing tariff.

Standard
ROM. 3 Leaders ensure that patient safety aspects and risk management
issues are an integral part of patient care and hospital management
Objective Elements
a. The organization has a designated individual(s) to oversee the hospital wide safety
programme.
b. The scope of the programme is defined to include adverse events ranging from ‘no
harm’ to ‘sentinel events’.
c. Management ensures internal and external reporting of system and process

failures.

Chapter 8: Facility Management and Safety (FMS)
Chapter 8
Facility Management and Safety (FMS)
The standards guide the provision of a safe and secure environment for patients, their
families, staff and visitors. To ensure this, the organisation complies with the relevant
rules and regulations, laws and byelaws and requisite facility inspection requirements.
The organization conducts regular facility inspection rounds and take corrective and
preventive steps to adhere to facility and patient safety issues. The organization
provides for safe water, electricity, medical gases and vacuum systems. The
organization has a programme for clinical and support service equipment management.
The organization plans for emergencies within the facilities and the community.

FMS. 1 The organization’s environment and facilities operate to ensure safety of

patients, their families, staff and visitors.
FMS. 2 The organization has a program for clinical and support service equipment
management.
FMS. 3 The organization has provisions for safe water, electricity, medical gases
and vacuum systems.
FMS. 4 The organization has plans for fire and non-fire emergencies within the
facilities.

Standard
FMS. 1 The organization’s environment and facilities operate to ensure

safety of patients, their families, staff and visitors
Objective Elements
a. There is a documented operational and maintenance (preventive and breakdown)

plan.
b. Up-to-date drawings are maintained which detail the site layout, floor plans and fire
escape routes.
c. The provision of space shall be in accordance with the available literature on good
practices.
d. Maintenance staff is contactable round the clock for emergency repairs.
e. The hospital has a system to identify the potential safety and security risks
including hazardous materials.
f. Facility inspection rounds to ensure safety are conducted periodically.
g. There is a safety education programme for all staff.
Standard
FMS. 2 The organization has a program for clinical and support service
equipment management
Objective Elements
a. The organization plans for equipment in accordance with its services.
b. All equipment is inventoried and proper logs are maintained as required.
c. Qualified and trained personnel operate and maintain the equipment.
d. Equipments are periodically inspected and calibrated for their proper functioning.

e. There is a documented operational and maintenance (preventive and breakdown)

plan.
Standard
The organization has provisions for safe water, electricity, medical

FMS. 3 gas and vacuum systems
Objective Elements
a. Potable water and electricity are available round the clock.
b. Alternate sources are provided for in case of failure and tested regularly.
c. There is a maintenance plan for medical gas and vacuum systems.
Standard
The organization has plans for fire and non-fire emergencies within
FMS. 4 the facilities
Objective Elements
a. The organization has plans and provisions for early detection, abatement and
containment of fire and non-fire emergencies.
b. The organization has a documented safe exit plan in case of fire and non-fire
emergencies.
c. Staff is trained for their role in case of such emergencies.
d. Mock drills are held at least twice in a year.

Chapter 9: Human Resource Management (HRM)
Chapter 9
Human Resource Management (HRM)
The most important resource of a hospital and health care system is the human
resource. Human resources are an asset for effective and efficient functioning of a
hospital. Without an equally effective human resource management system, all other
inputs like technology, infrastructure and finances come to naught. Human resource
management is concerned with the “people” dimension in management.
The goal of human resource management is to acquire, provide, retain and maintain
competent people in right numbers to meet the needs of the patients and community
served by the organization. This is based on the organization’s mission, objectives,
goals and scope of services.
Effective Human Resource Management involves the following processes and activities:
(a) Acquisition of Human Resources which involves human resource planning, the
staff joining the organization is socialized and oriented to the hospital
environment.
(b) Training and development of staff, appraisal system for evaluating the
performance of employees are integral part of the HRM process.
(c) Organization also has a well documented disciplinary and grievance handling
procedure.

HRM. 1 The organization has a documented system of human resource planning.
HRM. 2 The staff joining the organization is socialized and oriented to the hospital
environment.
HRM. 3 There is an ongoing programme for professional training and development

of the staff.
HRM. 4 An appraisal system for evaluating the performance of an employee exists

as an integral part of the human resource management process.
HRM. 5 The organization has a well-documented disciplinary and grievance

handling procedure.
HRM. 6 The organization addresses the health needs of the employees.
HRM. 7 There is a documented personal record for each staff member.
HRM. 8 There is a process for authorizing all medical professionals to admit and
treat patients and provide other clinical services commensurate with their
qualifications.
HRM. 9 There is a process to identify job responsibilities and make clinical work
assignments to all nursing staff members commensurate with their
qualifications and any other regulatory requirements.

Standard
HRM. 1 The organization has a documented system of human resource

planning
Objective Elements
a. The organization plans and maintains an adequate number and mix of staff to
meet the care, treatment and service needs of the patient.
b. The organization verifies the antecedents of the potential employee.
Standard
HRM. 2 The staff joining the organization is socialized and oriented to the
hospital environment
Objective Elements
a. Each staff member is appropriately oriented to the organization’s mission, policies

and procedures.
b. Each staff member is made aware of his/her rights and responsibilities.
c. All employees are educated with regard to patients’ rights and responsibilities.
Standard
HRM. 3 There is an ongoing programme for professional training and

development of the staff
Objective Elements
a. A documented training and development policy exists for the staff.
b. All staff is trained on the risks within the hospital environment.
c. Staff members can demonstrate and take actions to report, eliminate/ minimize risks.
d. Training also occurs when job responsibilities change/ new equipment is introduced.

e. Feedback mechanisms for assessment of training and development programme exist.
Standard
HRM. 4 An appraisal system for evaluating the performance of an employee

exists as an integral part of the human resource management
process
Objective Elements
a. The appraisal system is documented.
b. All employees are aware of the system of appraisal.
c. Performance is evaluated based on pre-defined criteria which the employee is

aware of.
d. Performance appraisal is carried out at pre defined intervals and is documented.
Standard
HRM. 5 The organization has a well-documented disciplinary and grievance

handling procedure
Objective Elements
a. A documented procedure with regard to these is in place.
b. The documented procedure is known to all categories of employees in the

organization.
c. The redress procedure addresses the grievance.
d. Actions are taken to redress the grievance.

Standard
HRM. 6 The organization addresses the health needs of the employees
Objective Elements
a. Health problems of the employees are taken care of in accordance with the
organization’s policy.
b. Occupational health hazards are adequately addressed.
Standard
HRM. 7 There is documented personal record for each staff member
Objective Elements
a. Personal files are maintained in respect of all employees.
b. The personal files contain personal information regarding the employees

qualification, disciplinary background and health status.
c. All records of in-service training and education are contained in the personal files.
d. Personal files contain results of all evaluations.
Standard
HRM. 8 There is a process for authorising all medical professionals to admit

and treat patients and provide other clinical services commensurate
with their qualifications
Objective Elements
a. Medical professionals permitted by law, regulation and the hospital to provide

patient care without supervision are appointed.
b. Medical professionals admit and care for patients as per the laid down policies and
authorisation procedures of the organization.
c. The services provided by the medical professionals are in consonance with their
qualification, training and registration.

Standard
HRM. 9 There is a process to identify job responsibilities and make clinical

work assignments to all nursing staff members commensurate with
their qualifications and any other regulatory requirements
Objective Elements
a. The clinical work assigned to nursing staff is in consonance with their qualification,
training and registration.
b. The services provided by nursing staff are in accordance with the prevailing laws
and regulations.

Chapter 10: Information Management System (IMS)
Chapter 10
Information Management System (IMS)
Intent of Standards
Information is an important resource for effective and efficient delivery of health care.
Provision of health care and its continued improvement is dependent to a large extent
on the information generated, stored and utilized appropriately by the organizations.
One of the major intent of this chapter is to ensure data and information meet the
organization’s needs and support the delivery of quality care and service.
The goal of Information management in a hospital is to ensure that the right information
is made available to the right person. This is provided in an authenticated, secure and
accurate manner at the right time and place. This helps to achieve the ultimate
organizational goal of a satisfied and improved provider and recipient of any health care
setting.
An effective Information management system is based on the information needs of the

organization. The system is able to capture, transmit, store, analyse, utilize and retrieve
information as and when required for improving clinical outcomes as well as individual
and overall organizational performance.

IMS. 1 Documented procedures exist for effective information management to

meet the information needs of the care providers, management of the
organization as well as external agencies that require data and information
from the organization.
IMS. 2 The organization has a complete and accurate medical record for every
patient.
IMS. 3 The medical record reflects continuity of care.
IMS. 4 Documented procedures are in place for maintaining confidentiality,

integrity and security of information.
IMS. 5 Documented procedures exist for retention time of records, data and
information.
IMS. 6 The organization regularly carries out review of medical record.

Standard
IMS. 1 Documented procedures exist for effective information management

to meet the information needs of the care providers, management of
the organization as well as external agencies that require data and
information from the organization
Objective Elements
a. A documented procedure exists to meet the information needs.
b. Formats for data collection are standardized.
c. Necessary resources are available for analyzing data.
d. Documented procedures are laid down for timely and accurate dissemination of
data.
e. Documented procedures exist for storing and retrieving data.
f. The organization contributes to external databases in accordance with the law and
regulations.
Standard
IMS. 2 The organization has a complete and accurate medical record for
every patient
Objective Elements
a. Every medical record has a unique identifier.
b. Organization identifies those authorized to make entries in medical record.
c. Every medical record entry is dated and timed.
d. The author of the entry can be identified.
e. The contents of medical record are identified and documented.

Standard
IMS. 3 The medical record reflects continuity of care
Objective Elements
a. The record provides an up-to-date and chronological account of patient care.
b. The medical record contains information regarding reasons for admission,

diagnosis and plan of care.
c. Operative and other procedures performed are incorporated in the medical record.
d. When patient is transferred to another hospital, the medical record contains the
date of transfer, the reason for the transfer and the name of the receiving hospital.
e. The medical record contains a copy of the discharge note duly signed by
appropriate and qualified personnel.
f. In case of death, the medical record contains a copy of the death certificate
indicating the cause, date and time of death.
g. Whenever a clinical autopsy is carried out, the medical record contains a copy of
the report of the same.
h. Care providers have access to current and past medical record.
Standard
IMS. 4 Documented procedures are in place for maintaining confidentiality,

integrity and security of information
Objective Elements
a. Documented procedures exist for maintaining confidentiality, security and integrity

of information.
b. Documented procedures are in consonance with the applicable laws.
c. Documented procedures incorporate safeguarding of data/ record against loss,

destruction and tampering.
d. Privileged health information is used for the purposes identified or as required by

law and not disclosed without the patient’s authorization.

e. A documented procedure exists on how to respond to patients/ physicians and

other public agencies requests for access to information in the medical record in
accordance with the local and national law.
Standard
IMS. 5 Documented procedures exist for retention time of records, data and
information
Objective Elements
a. Documented procedures are in place on retaining the patient’s clinical records,

data and information.
b. The procedures are in consonance with the local and national laws and
regulations.
c. The retention process provides expected confidentiality and security.
d. The destruction of medical records, data and information is in accordance with the
laid down procedure.
Standard
IMS. 6 The organization regularly carries out review of medical records audit
Objective Elements
a. The medical records are reviewed periodically.
b. The review uses a representative sample based on statistical principles.
c. The review is conducted by identified care providers.
d. The review focuses on the timeliness, legibility and completeness of the medical
records.
e. The review process includes records of both active and discharged patients.
f. The review points out and documents any deficiencies in records.
g. Appropriate corrective and preventive measures undertaken are documented.

nd
2EDITION
April 2014
STANDARDS FOR SMALL

HEALTH CARE ORGANIZATIONS
5th Floor, ITPI Building, 4A, Ring Road, IP Estate, New Delhi 110 002, India
Phone: +91‐11‐42600600 NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND
Email: helpdesk@nabh.co; Website: www.nabh.co
HEALTHCARE PROVIDERS (NABH)

SHCO Second Edition - NE

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nd

STANDARDS FOR SMALL

(Dr. Atul Mohan Kochhar)

ACCREDITATION STANDARDS FOR

Second Edition - April 2014

@ National Accreditation Board for Hospitals and Healthcare Providers 1

@ National Accreditation Board for Hospitals and Healthcare Providers 2

Accreditation is an important tool for the growth of healthcare industry. Accreditation is

Dr. K.K. Kalra

@ National Accreditation Board for Hospitals and Healthcare Providers 3

Sr. No. Particulars Page No.

02. Normative Reference 7

03. Terms and Definitions 7

Patient Centered Standards

04. Access, Assessment and Continuity of Care (AAC) 9

05. Care of Patients (COP) 15

06. Management of Medication (MOM) 22

07. Patient Rights and Education (PRE) 27

08. Hospital Infection Control (HIC) 32

Organization Centered Standards

09. Continuous Quality Improvement (CQI) 37

10. Responsibilities of Management (ROM) 42

11. Facility Management and Safety (FMS) 46

12. Human Resource Management (HRM) 50

13. Information Management System (IMS) 56

@ National Accreditation Board for Hospitals and Healthcare Providers 5

These accreditation standards specify requirements for small healthcare organizations.

NABH document on ‘Standards for Hospital’ is used as base document.

Terms and Definitions

Small Health Care Organizations (SHCO)

Speciality** Day Care centres (minimum bed strength not mandatory)

@ National Accreditation Board for Hospitals and Healthcare Providers 7

Intent of the standards

Patient care is multidisciplinary in nature and encourages continuity of care through

@ National Accreditation Board for Hospitals and Healthcare Providers 9

AAC. 2 The organization has a documented registration, admission and transfer

AAC. 3 Patients cared for by the organization undergo an established initial

AAC. 7 The organization has a defined discharge process

@ National Accreditation Board for Hospitals and Healthcare Providers 10

Standards and Objective Elements

a. The services being provided are clearly defined.

b. The defined services are prominently displayed.

c. The staff is oriented to these services.

AAC. 2 The organization has a documented registration, admission and

a. The process addresses registering and admitting out-patients, in-patients and

b. The process addresses managing patients during non availability of beds.

@ National Accreditation Board for Hospitals and Healthcare Providers 11

AAC. 3 Patients cared for by the organization undergo an established initial

b. The organization determines who can perform the assessments.

d. The initial assessment for in-patients is documented within 24 hours or earlier.

b. All patients are reassessed at appropriate intervals.

c. Staff involved in direct clinical care document reassessments.

d. Patients are reassessed to determine their response to treatment and to plan

@ National Accreditation Board for Hospitals and Healthcare Providers 12

b. Adequately qualified and trained personnel perform and/ or supervise the

c. Procedures guide collection, identification, handling, safe transportation,

e. Laboratory tests not available in the organization are outsourced to organization(s)

a. Imaging services comply with legal and other requirements.

@ National Accreditation Board for Hospitals and Healthcare Providers 13

e. Imaging tests not available in the organization are outsourced to organization(s)

AAC. 7 The organization has a defined discharge process

a. Process addresses discharge of all patients including Medico-legal cases and

c. Discharge summary contains the reasons for admission, significant findings,