PROJEct

n.a.b.h
ACCREDITION.
National Accreditation Board for Hospitals &
Healthcare Providers
5th Edition (2020)

SURAJ SAJJAN DHOBLE

PGDM- JA21/G2
ROLL NO – 4426
STRU
CTUR
 Introduction
 Vision & Mission
 Scope of NABH
 NABH Quality & Rule Of NABH
 Process of Accreditation
 NABH Chapter
 Self-Assessment and Final Assessment
Criteria
 Chapter wise details
 Benefits of Accreditation
 NABH Accredited Hospital in Mumbai

INTRODUTION
 National Accreditation Board for Hospitals &
Healthcare Providers, abbreviated as NABH, is a
constituent board of Quality Council of India, set up to
establish and operate accreditation programme for
healthcare organizations. Formed in 2005, it is the
principal accreditation for hospitals in India.

 NABH is an Institutional Member of the International

Society for Quality in Health Care (lSQua).

 NABH is a member of the Accreditation Council of

International Society for Quality in Health Care (ISQua).

 NABH is on board of Asian Society for Quality in

Healthcare (ASQua).

WHAT IS NABH ?

National Accreditation Board for Hospitals &

Healthcare Providers, NABH Under in Quality
Council of India.
It Sets Standards operates accreditation
program for health care organization

Establish in- 2006.

Founder - Dr Harish Nadkarni.
This NABH is 5th Edition April 2020.
CEO of NABH – Dr Atul kochkar.
 VISION

To be apex national healthcare accreditation and

quality improvement body, functioning at par with
global benchmarks.

The NABH vision is of a society that values and

maximizes the potential of all its citizens by helping
them to achieve overall health. To achieve healthy
communities, behavioral health will be recognized,
respected, and allocated resources with fairness and
equity as part of overall health.

MISSION

To Operate accreditation and allied programs in

collaboration with stakeholders focusing on patient
safety and quality of healthcare based upon national &
international standards, through process of self and
external evaluation
 SCOPE OF NABH & OBJECTIVES

 Accreditation of healthcare facilities

 Quality promotion: initiatives like Nursing Excellence,

Laboratory certification programs (not limited to
these)

 IEC activities: public lecture, advertisement,

workshops/ seminars

 Education and Training for Quality & Patient Safety

 Recognition: Endorsement of various healthcare

quality courses/ workshops

FOCUS OF QUALITY STANDARDS

 Patient Safety
 Staff & Employee Safety
 Environment and Community Safety
 Information Education and Communication
 What is NABH Quality ?

National Accreditation Board for Hospitals and

Healthcare Providers (NABH)
accreditations and accreditation standards have been
playing a significant role in improving the quality of
healthcare by assessing Hospital.
performance and setting benchmarks for Quality since
2005

What is the rules of NABH ?

The standards focus on patient safety and quality of

care.
The standards call for continuous monitoring of
sentinel events and comprehensive corrective action
plan leading to building of quality culture at all levels
and across all the functions.
 Quality Council India

National Accreditation Board for Hospitals &

Healthcare Providers

Appeals Accreditation Technical Assessor Research Secretariat

Committee Committee committee Mgmt. committe
Committee e

Panel of
Assessors
Experts
 Accreditation:-

It is public recognition by national/international

organization for the achievement of quality standards,
demonstrated through an independent external peer
assessment of that organization level of performance in
relation to the standards

 It is based on written and published standards

 Reviews are conducted by professional peers
 The accreditation process is administered by an
independent body
 The aim of accreditation is encourage
organizational development

Xxx Current Scenario :-

 Accreditation is the single most approach for

improving the quality of healthcare
 The accredited hospital gives confidence to the
patients about a transparent system of control
 An assurance is given by the accreditation body
that the accredited hospital constantly fulfils the
standard ethical practice
Accreditation is given to :-

 Hospitals
 Allopathic Clinic
 Ayush Hospitals
 Dental Clinic
 Medical Imagine Service
 Small healthcare organizations upto 50 beds
 Wellness centres
 Community health centres/Primary health

Centres
Pre -Accreditation Entry Level Certification

As large number of hospitals face challenges

and difficulties in implementing all the Accreditation
Standards, NABH has developed Pre Accreditation
Entry Level Certification standards, in consultation
with various stake holders in the country, as a stepping
stone for enhancing the quality of patient care and
safety.
The aim is to introduce quality and
accreditation to the HCOs as their first step towards
awareness and capacity building.
Once Pre Accreditation Entry Level
Certification is achieved, the HCO can then prepare and
move to the next stage - Progressive Level and finally to
Full Accreditation status.
The application hospital must have
conducted self-assessment against NABH Pre
Accreditation Entry Level standards after
implementing it for at least 3 month before submission
of application and must ensure that it complies with
the standards refer
http://www.nabh.co/Hoapital-Entrylevel-doc.aspx.

Process of Accreditation
 Appln.for Accreditation +Self-
Assessment

By HCO

Acknowledgement and scrutiny of

application by NABH Secretariat

Pre-assessment Visit by Assessment

Team

Feedback to
Final Assessment of the hospital by Healthcare
Assessment Team
Organization
and
Review of Assessment Report by
necessary
NABH Secretariat corrective
actions taken
by
Recommendation for accreditation by Healthcare
Accreditation Committee Organization

Approval for Accreditation by

Chairman, NABH

Issue of accreditation certificate by NABH Secretariat

NABH Chapter
Patient Centered Standards
CHAPTER STANDARDS
Access, Assessment and Continuity of 14
Care (AAC)
Care of Patients (COP) 20
Management of Medications (MOM) 11

Patients’ Rights and Education (PRE) 08

Hospital Infection Control (HIC) 08

Organization Centered Standards

CHAPTER STANDARDS
Patient Safety and Quality Improvement 07

Responsibility of Management 05
(ROM)
Facility Management and Safety (FMS). 07

Human Resource Management (HRM). 13

 Information Management System 07

(IMS).

Self-Assessment and Final Assessment Criteria

 Organisation is required to provide self-
assessment report in the format self-assessment toolkit
given below. All the entries are to be properly filled up.
Regarding scoring following criteria would be
applicable
 Compliance to the requirement :10
 Partial compliance to the requirement :05
( if any of the sample is found to be noncomplying
out of total samples selected )
 Non-compliance to the requirement :0
 Not Applicable : NA

There are 100 Standards and 651 Objective

elements as detailed in section 9.4 below in front of
each objective element we have to write as follows
 Documentation
 Implementation
 What is the evidence
 Score ( 0/5/10 )

Chapter wise details of Objective Elements

Chapter 1-Access, Assessment and continuity of Care

AAC - Std 1- The Organisation defines and displays

the healthcare services that it provides
 The healthcare services being provided are clearly
defined and are in consonance with the needs of the
community
 Each defined service should have appropriate
diagnostics and treatment facilities with suitably
qualified personnel with provide out-patient ,in
patient, and emergency cover
 The defined healthcare services are prominently
displayed
 The staff are oriented to these services

AAC-Std 2- The organisation has a well defined

registration and admission presses

Documented policies and procedure are used for

registering and admitting patients
 The documented procedures address out patient, in
patients and emergency patients
 A unique identification number is generated at the end
of registration
 Patients are accepted only if the organisation can
provide the required service
 The documented policies and procedures also address
managing patients during non availability of beds
 Access to the healthcare services in the organisation is
prioritised according t the clinical needs to the
patients
 The staff are aware of these processes

AAC- Std 3 –There is an appropriate mechanism

for transfer or referral of patient
 Documented policies and procedures guide the
transfer in of patient to the organisation
 Documented policies and procedures guide the
transfer out/referral of unstable patient to another
facility in and an appropriate manner
 The Document procedure identify staff responsible
during transfer/ referral
 The organisation gives a summary of patient
condition and the treatment
AAC-Std 4 – Patient cared for by the organisation
undergo an established initial assessment
 The organisation defined and documents the content
of the initial assessment for the out patients in
patients and emergency patient
 The organisation determines who can perform the
initial assessment
 The organisation defined the time frame within
which the initial assessment is completed based on
patient needs
 The initial assessment for in patients is documented
within 24 hours or earlier as per the patients
condition as defined in the organisation policy
 Initial assessment include screening for nutritional
needs .
 The initial assessment results in a document care
plan.
 The care plan reflects desired results of the
treatment ,care or services.
 The care plan is countersigned by the clinician in
charge of the patient within 24 hours

AAC-Std 5 – Patient cared for the organisation

undergo a regular reassessment
 Patient are reassessed at appropriate intervals.
 Out patents are informed of their next follow up
where appropriate
 For in patients during reassessment the care plan is
monitored and modified there found necessary
 Staff involved in direct clinical care documents
reassessments
 Patients are reassessed to determine their response
to treatment and to plan further treatment or
discharge
 The organisation lays down guidelines and
implements processes to identify early warning
signs of change or deterioration in clinical
conditions for initiating prompt intervention
AAC-Std 6 – Laboratory services are provided as
per the scope of services of the organisation

 Scope of the laboratory services commensurate to

the services provided by the organisation
 The Infrastructure ( physical and equipment ) is
adequate to provide the defined scope of service
 The manpower is adequate to provide the defined
scope of service
 Qualified and trained personnel perform, supervise
and interpret the investigations
 Laboratory results are available with in a define
theme frame
 Critical results are intimate immediately to the
personnel concerned
 Result are reported in a standardised manner
 There is a mechanism to address recall / amendment
of reports whenever applicable
 Laboratory tests no available in the organisation are
outsourced to organisation based on their quality
assurance system

AAC-Std 7 – There is an established laboratory

Quality assurance programme
 The laboratory quality assurance programme is
documented
 The Programme addresses verification and or
validation of test methods
 The programme addresses surveillance of test
result
 The programme includes periodic calibration and
maintenance of all equipment
 The programme includes the documentation of
corrective and preventive action

AAC-Std 8 – There is an established laboratory

safety programme
 The laboratory safety programme is documented
 This Programme is aligned with the organisation
safety programme
 Written procedures guide the handling and
disposal of infectious and hazardous material
 Laboratory personnel are appropriately trained in
safe practices
 Laboratory personnel are provided with
appropriate safety equipment and devices
AAC-Std 9 – Imaging services are provided as per
the scope of services of the organisation
 Imaging service comply with legal and other
requirements
 Scope of the imaging services is commensurate to
the services provided by the organisation
 The infrastructure and manpower is adequate to
provide for its defined scope of service
 Adequately qualified and trained personnel perform
supervise and interpret the investigations
 Imaging result are available within a defined
timeframe
 Critical results are intimated immediately to the
personnel concerned
 Results are reported in a standards manner
 There is a mechanism to address recall /
amendment of reports whenever applicable
 Imaging tests no available in the organisation are
outsource to organisation based on their quality
assurance system

AAC-Std 10 – There is an established quality

assurance programme for imaging service
 The quality assurance programme for imaging
services is documented
 The programme addresses periodic internal /
external peer review of imaging protocols and
results using appropriate sampling
 The programme addresses surveillance of imaging
result in collaboration and with referring clinicians
for follow up wherever applicable
 A system is in place to ensure the appropriateness
of the investigations and procedure for the clinical
indication
 The programme includes the documentation of
corrective and preventive actions
AAC-Std 11 – There is an established safety
programme in the imaging service
 The radiation safety programme is documented
 This programme is aligned with the organisation
safety programme
 Patient are appropriately screened for safety, risk
prior to undergoing an imaging on a particular
modality
 Handling uses and disposal of radio active and
hazardous materials are as per statutory
requirement
 Imaging personnel and patients are provided
with appropriate radiation safety and monitoring
devices where applicable
 Imaging and ancillary personnel are trained in
imaging safety practices and radiation safety
measures
 Imaging signage are prominently displayed in all
appropriate locations

AAC -Std 12 – Patient care is continuous and

multidisciplinary
 During all phase of care there is a qualified
individual identified as responsible for the
patient care
 Care of patients is coordinated in all care settings
within the organisation
 Information about the patients care and response
to treatment is shared among medical nursing
and other care providers
 Transfer between departments units are done in
a safe manner
 The patients records is available to the
authorised care providers to facilitate the
exchange of information
 Documented procedures guide the referral of
patient to other departments specialities
 The organisation endures continuity of care while
adhering to defined timelines and informs the
caregiver and or the patient family whenever
there is a change
 The organisation has mechanism I place to
monitor whether adequate clinical intervention
has taken place in response to a critical value
alert
AAC-Std 13 – The organisation has a documented
discharge proses

 The patients discharge process is planned in

consultation with the patient and family
 Documented procedures exist for coordination
of various departments and agencies involved in
the discharge process
 Documented policies and procedures are in
place for patients leaving against medical advice
and patients being discharge on request
 A discharge summary is given to all the patients
leaving the organisation the organisation
 The organisation defines the time taken for
discharge and monitors the same
AAC-Std 14 – Organisation defines the content of
the discharge

 Discharge summary provide to the patient at the

time of discharge
 Discharge summary contain the patients name
unique identification number date of admission
and date of discharge
 Discharge summary contains the reasons for
admission significant findings and diagnosis and
the patient condition at the time of discharge
 Discharge summary contain the information
regarding investigation results any procedure
performed medication administered and other
treatment given
 Discharge summary contain follow up advice ,
medication and other instruction in an
understandable manner
 Discharge summary incorporate instruction about
when and how to obtain urgent care
 In case of death the summary of the case also
includes the cause of death
 Chapter 2 – Care of Patient ( COP )

COP-Std 1 – Uniform care to patients is provided in

all settings of the organisation and is guided by
the applicable laws regulation and guidelines

 Care delivery is uniform for a given health

problem when similar care is provided in more
then one setting
 Uniform care is guided by documented policies
and procedures
 These reflected applicable laws regulations and
guideline
 The organisation adapts evidence based medicine
and clinical practice guidelines to guide uniform
patient care
COP-Std 2 – Emergency service are guided by
documented policies , procedure applicable laws
and regulations
 There shall be an identified area in the
organisation which is easily accessible to receive
and mangae emargency patiens
 Policies and procedures for emergency care are
documented and are in consonance with statutory
requirment
 This also addresses handling of medico leagal cases
 The patiets receive care in consonance with the
policies
 Staff are familiar with the policies and trained on
the procedures for care of emergency patient
 Admission or discharge to home or transfer to
anouthe oranisation is also documented
 In case of discharge to home transfer to anouther
organisation a discharge note shall be given to the
patient
 Quality assurance programmes are documented
and implemented
 The documented policies and procedures guide
management of patiets found dead on arrival to the
hospital
COP-Std 3 – The Ambulance Services are
commensurate with the scope of the service
Provided by the organisation

 There is adequate access and space for the

ambulance
 The ambulance address to statutory requirement
 The ambulance is appropriately equipped
 The ambulances is manned by trained personnel
 The ambulance is checked on a daily basis
 Equipment’s are checked on a daily basis using a
checklist
 Emergency medication are checked daily and prior
to dispatch using a checklist
 The ambulance has a proper communication
system
 The emergency department identifies
opportunities to initiate treatment at the earliest
when the patient is in transit to the organisation
COP-Std 4 – The organisation plans for handling
community emergencies epidemics and other
disasters
 The organisation identifies potential emergencies
 The organisation has a documented disasters
management plan
 Provision is made for availability of medical
supplies equipment and materials during such
emergencies
 Staff are trained in the hospital disaster
management plan
 The plan is tested at least twice a year

COP-Std 5 – Documented policies and procedures

guide the care of patients requiring CPR
 Documented policies and procedures guide the
uniform use resuscitation throughout the
organisation
 The events during a patient care are trained and
periodically update in CPR
 A post event analysis of all CPR is done by a
multidisciplinary committee
 Corrective and preventive measures are taken
based on the post event analysis
COP-Std 6 – Document policies and procedures
guide nursing care

 There are documented policies and procedures for

all activities of the nursing services
 These reflect current standards of nursing services
and practice relevant regulations and purposes of
the services
 Assignment of patient care is done as per current
good practice guidelines
 Nursing care is aligned and integrated with overall
patient care
 Care provided by nurses is documented in the
patient record
 Nurses are provided with adequate equipment for
providing safe and efficient nursing services
 Nurses are empowered to take nursing related
decisions to ensure the timely care of patient
COP-Std 7 – Documented procedure guide the
performance of various procedures

 Documented procedures are used to guide the

performance of various clinical procedures
 Only qualified personnel order plan perform and
assist in performing procedures
 Documented procedures exist to prevent adverse
events like a wrong site wrong patient and wrong
procedure
 Inform consent is taken by the personnel
performing the procedure where applicable
 Adherence to standard precaution and asepsis is
adhered to during the conduct of the procedure
 Patients are appropriately monitored during and
after the procedures
 Procedures are documented accurately in the
patient record
COP-Std 8 – Documented policies and procedures
define rational use of blood and blood component

 Documented policies and procedures are used to

guide the rational use of blood and blood
component
 Documented procedures govern transfusion of
blood and blood components
 The transfusion services are governed by the
applicable laws and regulation
 Informed consent is obtained for donation and
transfusion of blood and blood component
 Informed consent also includes patients and family
education about the donation
 The organisation defines the process for
availability and transfusion of blood/blood
component for use in emergency situations
 Post transfusion form is collected reactions if any
identify and are analysed for preventive and
corrective action
 Staff are trained to implement the polices
COP-Std 9 – Documented policies and procedures
guide the care of patients in the intensive care
and high dependency

 Documented policies and procedures are used to

guide the care of patients in the intensive care and
high dependency unit
 The organisation has documented admission and
discharge criteria for its intensive care and high
dependency unit
 Staff are trained to apply these criteria
 Adequate staff and equipment are available
 Defined procedures for the situation of bed
shortage are followed
 Infection control practices are documented and
followed
 A quality assurance programme is documented and
implemented
 Patients and families are counselled by the treating
medical professional at periodic intervals and
when there is a significant change is the condition
of the patient and same is documented
COP-Std 10 – documented police and procedures
guide the care of vulnerable patient
 Polices and procedures are documented and are in
accordance with the prevailing laws and the
national and international guidelines
 Care is organised and delivered in accordance with
the policies and procedures
 The organisation provides for a safe and secure
environment for the vulnerable group
 A documented procedure exists for obtaining
informed consent from the appropriate legal
representative
 Staff are trained to care for this vulnerable group
COP-Std 11 – documented policies and procedures
guide obstetric care
 There is a documented policy and procedure for
obstetric service
 The organisation defines and displays whether
high risk obstetric cases can be cared for or not
 Persons caring for high risk obstetric cases are
competent
 Documented procedures guide the provision of
ante natal services
 Obstruct patients assessment also includes
maternal neutrino
COP-Std 12 – Documented policies and procedures
guide paediatric service

 There is a documented policy and procedures for

paediatric service
 The organisation defines and display the scope of
its paediatric services
 The policy for care of neonatal patients is in
consonance with the national international
guidelines
 Those who care for children have age specific
competency
 Provisions are made for special care of children
 Patient assessment includes detailed nutritional
growth developmental and immunisation
assessment
 Documented policies and procedures prevent child
neonate abduction and abuse
 The children’s family member are educated about
neutrino immunisation and safe parenting and this
is documented
COP-Std 13 – Documented policies and procedures
guide the care of patients undergoing moderate
sedation

 Documented procedures guide the administration

of moderate sedation
 Informed consent for administration of moderate
sedation is obtained
 Competed and trained persons perform sedation
 The person administering and monitoring sedation
is different from the person performing the
procedures
 Patients are monitored after sedation and the same
decimated
 Criteria are used to determine appropriateness of
discharge from the observation recovery area
 Equipment and manpower are available to manage
patient who have gone into a deeper level of
sedation than initially intended
COP-Std 14 – Documented policies and procedures
guide the administration of anaesthesia
 There is a documented policy and procedure for
the administration of anaesthesia
 Patient for anaesthesia have a pre anaesthesia
assessment by a qualified anaesthesiologist
 The pre-anaesthesia assessment result in
formulation of an anaesthesia plan which is
documented
 An immediate preoperative re evaluation is
performed and documented
 Informed consent for administration off
anaesthesia is obtained by the anaesthesiologist
 Patient post anaesthesia status is monitored and
documented
 The type off anaesthesia and anaesthetic
medications used are documented in the patents
record
 Procedures shall comply with infraction control
guidelines to prevent cross induction between
patients
 Adverse anaesthesia events are recorded and
monitored
COP-Std 15 – documented policies and procedures
guide the care of patients undergoing surgical
procedures
 The policies and procedures are documented
 Surgical patients have a preoperative assessment
and a provisional diagnosis documented prior to
surgery
 An informed consent is obtained by a surgeon
prior to the procedure
 Persons qualified by law are permitted to
perform the procedures that they are entitled to
perform
 A brief operative note is documented prior to
transfer out of patient from recovery area
 The operating surgeon documents the
postoperative care plan
 Patient personnel and material flow conform to
infection control practice
 Appropriate facilities and equipment appliances
instrumentation are available in the operation
tether
 A quality assurance programme is followed for
the surgical services
 The quality assurance programme includes
surveillance of the operation theatre
environment
COP-Std 16 – Documented policies and procedures guide
organ transplant program in the organisation

 The organ transplant program shall be in

consonance with the legal requirement and shall
be conducted in an ethical manner
 Documented policies and procedures and
procedures guide the organ transplant program
 The organisation ensures education and co selling
of recipient and donor through trained / qualified
counsellors before organ Transplantation
 The organisation shall take measures to create
awareness regarding organ donation
COP-Std 17 – Documented policies and procedures guide
the care of patients under restraints

 Documented policies and procedures guide the

care of patients under restraints
 The polices and procedure include both physical
and chemical restraint measures
 The reasons for restraints are documented
 Patients on restraints are more frequently
monitored
 Staff receives training and periodic updating in
control and restraint techniques
COP-Std 19 – Documented polices and procedures
guide appropriate rehabilitative service
 Documented policies and procedures guide the
provision of rehabilitative services
 These services are commensurate with the
organization requirements
 Care is guide by functional assessment and periodic
re-assessment which is done and documented by
qualified individual
 Care is provided adhering to infection control and
safe practices
 Rehabilitative services are provided by a
multidisciplinary team
 There is adequate space and equipment to perform
these activates

COP-Std 20 – Documented policies and procedures

guide all research activities
 Documented policies and procedures guide all
research activates in compliance with regulatory
national and international guideline
 The organisation as and ethics committee to oversee
all research activates
 The committee has the power to discontinue a
research trial when risks outweigh the potential
benefits
 Patient informed consents is obtained research
Chapter 3 Management of Medication ( MOM )

MOM -Std 1- Document policies and procedures guide

the organisation of pharmacy Service and usage of
medication

 There is a documented policy and procedures for

pharmacy services and medication usage
Policy and procedures comply with the applicable laws
and regulation
A multidisciplinary committee guide the formulation
and implementation of these policies and procedures
There is a procedure to obtain medication when the
pharmacy is closed

MOM-Std 2 –There is a hospital formulary

 A list of medications appropriate for the patients and
as per the scope of the organisation clinical services is
developed collaboratively by the multidisciplinary
committee
 The list is reviewed and update collaboratively by the
multidisciplinary committee at least annually
 The formulary available for clinicians to refer and
adhere to
 There is a defined process for acquisition of these
medications
MOM- Std 3 – Documented policies and
procedures guide the storage of medication

 Documented polices and procedures exist for

storage of medication
 Medication are stored in a clean safe and
secure environment and incorporating
manufacture recommendation
 Sound inventory control practices guide
storage of the medications in all areas
throughout the organisation
 Look alike and sound alike medications are
identified and stored physically apart from
each other
 The list of emergency medications is defined
and is stored in a uniform manner
 Emergency are available all the time
 Emergency medications are replenished in a
timely manner when used
MOM -Std 4 – Documented polices and procedures
guide the safe and rational prescription of
medication
 Documented policies and procedures exist for
prescription of medication
 These incorporate inclusion of good practices
/guidelines for rational prescription of medication
 The organisation dreaminess the minimum
requirements of a prescription
 Known drug allergies are ascertained before prescribe
 The organisation determine who cab write orders
 Medication orders are cleat legible dated timed named
and signed
 Medication orders contain the name of the medicine
route of administration dose to be administered and
frequency time of administration
 Documented policy and procedure on verbal orders in
implemented
 The organisation defines a list of high-risk medication
 Audit of medication orders prescription is carried out
to check for safe and rational prescription of
medications
 Reconciliation of medication occur at transition point
of patient care
MOM-Std 5-Documented policies and procedure guide
the safe dispensing of medications
 Documented policies and procedure guide the safe
dispensing of medication
 The procedures address medication recall
 Expire date are checked prior to dispensing
 There is a procedure for near expiry medication
 Labelling requirements are documented and
implemented by the organisation
 High –risk medication orders are verified prior to
dispensing

MOM - Std 6- There are documented policies and

procedures for medication administration
 Medications are administered by those who are
permitted by law to do so
 Prepared medication is labelled prior to preparation
of a second drug
 Patient is identified prior to administration
 Medication is verified from the order and physically
inspected prior to administration
 Dosage is verified from the order prior ro
administration
 Route is verified from the order prior to
administration
 Timing is verified from the order prior to
administration
MOM-Std 7 – Patient are monitored after
medication administration

 Documented policies and procedures guide the

monitoring of patients after medication admin
 The organisation defines those situations where
close monitoring is required
 Monitoring is done in a collaborative manner
 Medication are change where appropriate based on
the monitoring

MOM-Std 8- Near misses medication errors and

adverse drug events are reported and analysed
 Documented procedure exists to capture near miss
medication error and adverse drug event
 Near miss medication error and adverse drug
event are defined
 These are reported within a specified time frame
 They are collected and analysed
 Corrective and of preventive action are taken
based on the analysis where appropriate
MOM –Std 9 – documented procedures guide the use of
narcotic drugs and psychotropic substances
 Documented procedures guide the use of narcotic drugs
and psychotropic substance which are in consonance
with local and national regulation
 These drugs are stored in a secure manner
 A proper records is kept of the usage administration
and disposal of these drugs
 These drugs are handled by appropriate personnel in
accordance with the documented procedure

MOM – Std 10-Documented policies & procedures guide

the usage of chemotherapeutic agents
 Documented policies and procedure guide the usage of
chemotherapeutic agents
 Chemotherapy is prescribed by those who have the
knowledge to monitoring and treat the adverse effect of
chemotherapy
 Chemotherapy is prepared in a proper and safe manner
and administered by qualified personal

MOM- Std 11- documented polices and procedure

govern usage of radioactive drugs
 Documented policies & prcd.govern usage of radioactive
 These policies & prcd.r in consonance with law
regulations.
The policies and prcd include the safe storage preparation
handling distribution and disposal radioactive drugs
Chapter 4-Patient right and education ( PRE )

PRE –Std 1- The organisation protest patients and

family rights and informs them about their
responsibility during care

 Patients and family right and responsibility are

documented and displayed
 Patients and families are informed of their rights
and responsibilities’ in a format and language that
they can understand
 The organisation leaders protect patient and
family rights
 Staff are aware of their responsibility in protecting
patient and family rights
 Violation of patients and family right is recorded,
reviewed and corrective measures taken
PRE-Std 2- patient and family rights support
individual beliefs. Values and involve the patient
and family in decision making processes
 Patients and family rights include respecting any
special preferences spiritual and cultural needs
 Patient and family rights include respect for
personal dignity and privacy during examination
procedures and treatment
 Patient and family rights include protection from
neglect or abuse
 Patient and family rights include trading patient
information confidential
 Patient and family rights include refusal of
treatment
 Patient and family have a right to seek an
additional opinion regarding clinical care
 Patient and family rights include right to complain
and information on how to vice a complaint
 Patient and family rights include information on
the expected cost of the treatment
 Patient and family rights include access to his her
clinical record
 Patient and family right include information on
care plan progress and information on their health
care needs
PRE-Std 3-The patient and or family members are
educated to make informed decisions and are
involved in the care, planning and delivery
process

 The patient and family members are explained

about the proposed care including the risk
alternatives and benefits
 The patient and family member are explained
about the expected results
 The patient and family members are explained
about the possible complications
 The care plan is prepared and modified in
consultation with patient and family members
 The care plan and where possible incorporates
patient and family concerns and requests
 The patient and family members are informed
about the results of diagnostic tests and the
diagnosis
 The patient and family members are explained
about any change in the patients condition in a
timely manner
PRE-Std 4- Informed consent is obtained from the
patient or family about their care

 Documented procedure incorporates the list of

satiations where informed consent is required and
the process for taking informed consent
 General consent for treatment is obtained when
the patient enters the organisation
 Patient and his family members are informed of
the scope of such general consent
 Informed consent includes information regarding
the procedure its risks benefits alternative and as
to who will perform the procedure in a language
that they can understand
 The procedure describes who can give consent
when patient is incapable of independent decision
making informed consent is taken by the person
performing the procedure
 Informed consent process adheres to statutory
norms
 Staff are aware of the informed consent procedure
 PRE-Std 5-Patient and families have a right to
information and education about their
healthcare needs.
 Patient and family are educated about the safe and
effective use of medication and potitionl side effect
of the medication appropriate
 Patient & family r educated about food drug
interaction
 Patient family r educated about diet and nutrition
 Patient family are educated about immunisations
 Patient and family are educated about prevention
healthcare associated infection
 Patient family easy language the can understand.

PRE-Std 6-Patients and families have a right to

information on expected costs
 There is a inform pricing policy in giving
 The relevant tariff list is available to patient
 The patient and family members are explained
about the expected cost
 Patient family are informed about the finical
implications when thee is a change in the patient
condition or treatment setting
PRE-Std 7- : The organization has a mechanism to
capture patients’ feedback and redressed of
complaints
 Organization has mechanism to capture feedbacks
from patients which includes patient satisfaction and
patients experience
 The organization has a document complaint
redressed procedure
 Patient n family r made aware of the procedure for
giving feedback and lodging complaints
 All feedback and complaints are reviewed analyzed
within defined time frame
 Corrective preventive action r taken based o the
analysis where appropriate

PRE-Std 8- The organization has a system for

effective communication with patients and or
families
 Documented policies n procedures guide the
effective communication with patient n family
 The organization shall identify special situations
where enhanced communication would required
 The organization lays down an approach for effective
communication these identified situation
 The organization also defines what constitutes and
unacceptable communication and sensitizes the staff
about the same
Chapter 5 – Hospital Infection Control ( HIC )

HIC-Std 1- The organization has a comprehensive

and coordinated hospital infection prevention
and control H.I.C program aimed at reducing
or eliminating risks to patients, visitors,
providers of care and community

 The hospital infection prevention and control

programmer is documented which aims at
preventing and reducing the risk of healthcare
associate infections in all areas of the hospital
 The infection prevention and control programmer
is a continuous process and updated at least once
in a year
 The hospital has a multi-disciplinary infection
control committee , which co-ordinate all infection
prevention and control activate
 The hospital has an infection control team which
coordinates implementation of all infection
prevention and control activities
 The hospital has designated infection control
officer as part of the infection control team
 The hospital has designated infection control
nurse as part of the infection control team
HIC-Std 2 – The organization implements the
policies and procedures laid down in the
infection control manual in all areas of the
hospital
 The organization identifies the various high-risk
areas and procedures and implements policies and
procedures to prevent infection in these areas
 The organization adheres to standard precautions at
all times
 The organization adheres to hand hygiene guidelines
 The organization adheres to transmission based
precautions at all times
 The organization adheres to safe injection and
infusion practices
 The organization adheres to cleaning disinfection
and sterilization practices
 An appropriate antibiotic policy is established and
documented
 The organization implements the antibiotic policy
and monitors rational use of antimicrobial agents
 The organization adheres to laundry and linen
management process
 The organization adheres to kitchen satiation and
food handling issues
 The organization adheres housekeeping procedure
HIC-Std 3-The organization takes actions to
prevent and control ( HAI ) In Patient

 The organization takes action to prevent catheter

associated urinary tract infections
 The organization takes action to prevent
ventilator associated pneumonia
 The organization takes action to prevent catheter
liked blood stream infections
 The organization takes action to prevent surgical
site infection

HIC-Std 4- Proper facilities and adequate resources

are provided to support the infection control
programmer

 Hand washing facilities in all patient care areas

are accessible to health care providers.
 Compliance with proper hand washing is
monitored regularly.
 Isolation/ barrier nursing facilities are available.
 Adequate gloves, masks, soaps, and disinfectants
are available and used correctly.
HIC-Std 5 - The hospital takes appropriate action
to control outbreaks of infections.
 Hospital has a documented procedure for
handling such outbreaks.
 This procedure is implemented during outbreaks.
 After the outbreak is over appropriate corrective
actions are taken to prevent recurrence

HIC-Std 6- The infection control team is

responsible for surveillance activities in
identified areas of the hospital.

 Surveillance activities are appropriately directed

towards the identified high-risk areas.
 Collection of surveillance data is an ongoing
process.
 Verification of data is done on regular basis by the
infection control team.
 In cases of modifiable diseases, information (in
relevant format) is sent to appropriate authorities.
 Scope of surveillance activities incorporates
tracking and analyzing of infection risks, rates and
trends.
HIC-Std 7- There are documented procedures for
sterilization activities in the hospital.
 There is adequate space available for sterilization
activities
 Regular validation tests for sterilization are carried
out and documented.
 There is an established recall procedure when
breakdown in the sterilization system is identified

HIC-Std 8 - The infection control programmer is

supported by hospital management and
includes training of staff and employee health
 Hospital management makes available resources
required for the infection control programmer
 The hospital regularly earmarks adequate funds
from its annual budget in this regard.
 It conducts regular pre-induction training for
appropriate categories of staff before joining
concerned department(s).
 It also conducts regular “in-service” training
sessions for all concerned categories of staff at
least once in a year.
 Appropriate pre and post exposure prophylaxis is
provided to all concerned staff members
Chapter – 06 Patient Safety and Quality Improvement
Standards

 The organization implements a structured patient-

safety program.
 The organization implements a structured quality-
improvement and continuous monitoring program
 The organization identifies key indicators to
monitor the structures, processes and outcomes
which are used as tools for continual improvement.
 The organization uses appropriate quality
improvement tools for its quality improvement
activities.
 There is an established system for clinical audit.
 The patient safety and quality improvement
programs are supported by the management.
 Incidents are collected and analyzed to ensure
continual quality improvement.
Chapter – 07 Responsibilities of management
Standards

 The organization identifies those responsible for

governance and their roles are defined.
 The organization is ethically managed by the
leaders.
 The organization is headed by a leader who shall
be responsible for operating the organization on
a day-to-day basis.
 The organization displays professionalism in its
functioning.
 Management ensures that patient safety aspects
and risk management issues are an integral part
of patient care and hospital management. These
are the standards of responsibilities of
management (R.O.M).
Chapter – 08 Facility management and safety
Standards

 The organization has a system in place to provide a

safe and secure environment.
 The organization's environment and facilities
operate in a planned manner to ensure safety of
patients, their families, staff and visitors and
promotes environment friendly measures.
 The organization’s environment and facilities
operate to ensure the safety of patients, their
families, staff and visitors.
 The organization has a programmer for the facility,
engineering support services and utility system.
 The organization has a programmer for medical
equipment management.
 The organization has a programmer for medical
gases, vacuum and compressed air.
 The organization has plans for fire and non-fire
emergencies within the facilities. These are the
standards of Facility Management and Safety
(F.M.S)
Chapter – 09 Human Resource Management
Standards
 The organization has a documented system of human
resource planning.
 The organization implements a defined process for staff
recruitment.
 Staff, is provided induction training at the time of joining
the organization.
 There is an ongoing program for professional training
and development of the staff.
 Staff are appropriately trained based on their specific job
description.
 Staff is trained in safety and quality related aspects.
 An appraisal system for evaluating the performance of
staff exists as an integral part of the human resource
management process.
 Process for disciplinary and grievance handling is
defined and implemented in the organization. The
organization promotes staff well-being and addresses their
health and safety needs.
 There is documented personal information for each staff
member.
 There is a process for credentialing and privileging of
medical professionals permitted to provide patient care
without supervision.
 There is a process for a credentialing and privileging of
nursing professionals permitted to provide patient care
without supervision.
 There is a process for credentialing and privileging of
Para clinical professionals permitted to provide patient
care without supervision. These are the standards of
human resource management (H.R.M).
Chapter – 10 Information Management System
Standards

 Information needs of the patients, visitors, staff,

management and external agencies are met.
 The organization has processes in place for
management and control of data and information.
The patients cared for by the organization have a
complete and accurate medical record.
 The medical record reflects the continuity of care.
 The organization maintains confidentiality,
integrity and security of records, data and
information.
 The organization ensures availability of current
and relevant documents, records, data and
information and provides for retention of the same.
 The organization carries out a review of medical
records

Benefits of Accreditation: 1
Benefits for patients
• High quality care
• Patient safety
• Service by credential medical staff
• Rights of patients are respected and protected

Benefits of Accreditation :2
Benefits for hospital staff
• Continuous learning
• Good working environment
• Leadership
• Ownership of clinical processes
• Improvement in professional development of
clinicians, Para-medical staff

Benefits of Accreditation :3
Benefits for hospital
• Improvement in quality of healthcare
• Patient safety and risk management
• Evidence based practice
• Continuous learning and improvement
• Improvement in confidence in patients’ and
public’s mind
•Demonstrating commitment to quality
healthcare
 NABH Accredited Hospitals in Mumbai

• Holy Spirit Hospital

• Fortis Hospital Mulund
• Godrej Memorial Hospital
• Saifee Hospital
• Lokmanya Tilak Municipal General Hospital
• Tata Memorial Hospital
• Holy Family Hospital and Medical Research
• Breach Candy Hospital Trust.
• Bombay Hospital & Medical Research Centre
• Kohinoor Hospital
• Seven Hills Hospital
• P. D. Hinduja Hospital & Medical Research Centre
• Hinduja Hospital Lalita Girdhar
• Kokilaben Dhirubhai Ambani Hospital and
Medical Research Institute
• Jaslok Hospital and Research Centre
• Lilavati Hospital & Research Centre
• Global Hospitals
• Induja Hospital
• Holy Spirit hospital