Draft NABH Digital Health Standards 1st Edition

NATIONAL ACCREDITATION BOARD
FOR HOSPITALS AND HEALTHCARE PROVIDERS

(NABH)
NABH
DIGITAL HEALTH STANDARDS
FOR HOSPITALS
APRIL 2023
Draft
2
About NABH
National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a

constituent board of Quality Council of India (QCI), set up to establish and operate
accreditation programme for healthcare organizations. NABH has been established with
the objective of enhancing health system & promoting continuous quality improvement
and patient safety. The board while being supported by all stakeholders, including
industry, consumers, government, has full functional autonomy in its operation.
International Society for Quality in Healthcare (ISQua) has accredited NABH as an

Organization. The organizations accredited by NABH have international recognition. This
provides boost to medical tourism in country.
NABH is an Institutional Member as well as a member of the Accreditation Council of the

International Society for Quality in HealthCare (ISQua). NABH is one of the founder
members of Asian Society for Quality in Healthcare (ASQua).
There has been demand from SAARC/ASIAN countries for NABH accreditation and to
meet this requirement, NABH has launched NABH International and to begin with
Philippines is the first overseas destination for extending NABH accreditation services.
NABH provides accreditation to healthcare organisations in a non-discriminatory manner

regardless of their ownership, legal status, size and degree of independence.
The objective of NABH standards is to improve healthcare quality and patient safety.
NABH currently operates the following accreditation, certification and empanelment

programs
Accreditation programs
1. Hospitals
2. Small Healthcare Organizations
3. Blood Banks / Blood Center
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4. Blood Storage Center
5. MIS
6. Dental Healthcare Service Providers
7. Allopathic Clinics
8. AYUSH Hospitals
9. Panchakarma Clinics
10. Clinical Trial (Ethics Committee)
11. Eye Care Organization
12. OST Center
13. PHC
14. Wellness Centers
Certification programs
1. Entry Level Hospital
2. Entry Level Small Healthcare Organizations
3. Entry Level AYUSH Centre
4. Entry Level AYUSH Hospital
5. Nursing Excellence
6. Medical Laboratory Programme
7. Emergency Department
Empanelment programs:
NABH is the nodal body representing Quality Council of India for conducting assessments
of healthcare organizations for empanelment under Central Government Health Scheme
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(CGHS) and Ex-Servicemen Contributory Health Scheme (ECHS) and Medical Value
Travel Facilitator (MVTF)
Introduction
Technological Access to Healthcare is being increasingly seen as an important pillar of

providing safe and scalable care to citizens of a country. This is especially true for a
developing country like India, where besides the typical infrastructural challenges, patient
Information Asymmetry acts as a key impediment towards providing quality healthcare.
The need for technological access is further highlighted by the role digital health played
in delivery of healthcare services during COVID 19 Pandemic.
As the Indian Healthcare System matures further, and the recent initiatives of Ayushman
Bharat Digital Mission, Digital Health Start Ups etc. penetrate their reach further, a need
was felt to define clinical and operational standards, which can help inform patient about
the expected level of services being delivered in a facility and to improve the overall
clinical care and quality ecosystem in the country. Further, considering the unique
features of Indian Healthcare delivery institutions, a novel approach was sought to define
the respective standards and objective elements.
A systematic literature research was performed to identify existing digital health standards
as have been drafted by health accreditation agencies in other countries (US, Australia).
Reference was obtained from existing and past NABH standards. Deep consultations
were held with different HMIS and EMR vendors. Further, experience was sought from
users of these services, wherein professionals with experience in patient data and care
management, and in hospital management were interviewed. Opinion was also sought
from different assessors to understand the implementation considerations and from other
health informatics experts. Once drafted these standards were pilot tested in both small
and large sized hospitals, in urban and rural settings, in different parts of India.
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Inter-alia, these standards are expected to measure the adoption of digital technology by
a healthcare institution in providing patient care services. Besides, these standards are
expected to provide a quality rating for different hospitals based on their level of
technology adoption. This quality rating will help reduce the information asymmetry and
help patients make an informed choice of hospitals also.
NABH Digital Health Standards
NABH digital health standards are divided into different chapters based on different
clinical and non – clinical touchpoints. Further, these standards contain 151 objective
elements, which are in-turn divided as core, commitment, achievement, and excellence,
to assess maturity at different levels.
These objective elements are universally applicable to all kinds of hospitals and are
agnostic of their size (or bed capacity), location, ownership (Public, Private, PPP, Others)
or even the service profile of the hospital (single – specialty or multi – specialty).
The eight chapters are
1. Access, Assessment and Continuity of Care (AAC)
2. Care of Patients (COP)
3. Management of Medication (MOM)
4. Digital Infrastructure (DIS)
5. Digital Operations Management (DOM)
6. Finance and Procurement Management (FPM)
7. Human Resource Management (HRM)
8. Information Management System (IMS)
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Technical Standards and Objective Elements
The proposed standards have 151 objective elements.
Combining these objective elements, the following minimum compliance grid, is proposed
to be used to define the digital maturity of a hospital
Table 1
(At the time of

Core Commitment Achievement Excellence
initial
accreditation)
Silver Level 100% 60% NA NA

Gold Level 100% 60% 60% NA
Platinum Level 100% 60% 60% 60%
Table 2
(After 18 months
of initial
accreditation)
Silver Level 100% 80% NA NA

Gold Level 100% 80% 80% NA
Platinum Level 100% 80% 80% 80%
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Notes
 A Hospital can apply for any level of accreditation depending on its internal
consideration and self-assessment. Only those Objective Elements which are
applicable for the level applied, will be considered for evaluation.
 The scoring method for each objective element will be 0 (not met), 5 (Partially Met)
and 10 (Fully Met). Objective Elements pertaining to any service, which are not
provided by a Hospital (Ex. Blood Bank in a small hospital) will be marked as Not
Applicable and will not be considered for final scoring.
 The final scoring will be defined as (sum of score obtained across all applicable
objective elements) / (Highest Potential possible score). This scoring should meet
the compliance levels, as defined individually for core/commitment/achievement
and excellence objective elements separately, as defined in the grid
 For Initial Assessment, minimum compliance levels as defined in Table 1 are to be

considered.
 The period for accreditation will be 4 years. A mid period assessment, after 24
months, will be conducted (Surveillance assessment), in which Hospital will be
expected to have improved their initial maturity levels and meet the minimum
compliance levels as defined in Table 2.
 During both the assessments, (Final and surveillance) a period of 90 days will be
given to comply with any Non-Compliance as may be noted.
 After the period of 4 years from Initial grant of accreditation, the hospital is
expected to apply for full accreditation again. Further, while not mandatory,
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Hospital will be encouraged to apply for the next level of digital maturity as
applicable.
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CONTENTS
Chapter 1 Access, Assessment and Continuity of Care (AAC) 12
Chapter 2 Care of Patients (COP) 19
Chapter 3 Management of Medication (MOM) 26
Chapter 4 Digital Infrastructure (DIS) 29
Chapter 5 Digital Operations Management (DOM) 32
Chapter 6 Finance and Procurement Management (FPM) 37
Chapter 7 Human Resource Management (HRM) 41
Chapter 8 Information Management System (IMS) 45
Glossary 48
References 50
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Chapter 1
Access
Access, Assessment and Continuity of Care
(AAC)
1.1 Intent of the Chapter:
Patients are informed of the services provided by the hospital using digital technology providing
updated and easily accessible information about various hospital facilities (e.g., digital displays
for patients in waiting area). Hospital provides seamless services to patients by using simple
patient registration system. Patient's appointments are optimized through digital interventions;
patients are empowered to block treating medical practitioner’s calendar as per their
convenience.
The admissions process is integrated into hospital functions, and technology plays a vital role
in managing patient inflow and outflow.
The hospital ensures smooth patient admissions by leveraging the digital tools to assist them
in patient counselling. Patients are well informed about the package inclusions and exclusions.
Both OPD and IPD facilities are backed with automated billing to reduce fears and doubts about
patient care journey. All the patient referrals through emergency, OPD or directly by the
physician mode are managed digitally.
The hospital has digitized their laboratory operation to enhance the quality control, automate
workflows and process efficiency. Similarly, the technology adoption in radiology operations
enables management of digital imaging and multimedia content in a systematic, practical, and
efficient manner.
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Doctors uses digital tools to analyze patient progress, plan discharge or transfer. The entire
patient journey is well integrated and digital notifications are used as a medium to collaborate
and keep each stakeholder including patients informed.
Patient education via the digital mode ensures that all the health-related information is easily
understood and remembered. This results in improved decision-making by patient and/family
members and their perception of care at the hospital.
Summary of Standards
AAC.1. The hospital educates and disseminates information via digital systems
AAC.2. The hospital has an established digital registration and referral process
The hospital has a digital system to manage patient's appointments and

AAC.3.
treating medical practitioner's schedule
AAC.4. The hospital is using a digital system to manage patient's IPD admissions
The hospital has a digital system to manage the laboratory test orders and
AAC.5.
samples
AAC.6. The hospital has a digital system to manage the radiology tests and samples
AAC.7. The hospital handles the discharge and transfer process of patients digitally
AAC.8. The hospital has a digital system to capture the patient's feedback
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1.2 Digital Health Standards and Objective Elements
Digital Health Standard
The hospital educates and disseminates information via digital

AAC.1.
systems
Digital Health Objective Elements
Commitment a Hospital is using a digital system (e.g., hospital website or mobile

app) to display general information and share educational or
informative material
Commitment b The hospital displays its accreditations on its official digital system
(hospital website and/or mobile app)
Excellence c The Hospital sends informative notifications to its patients in a

digital manner
Achievement d Digital displays are used to assist patient inside the healthcare
facility
The hospital has an established digital registration and referral

AAC.2.
process
Commitment a The hospital is using at least one digital system for registration
Core b The hospital generates a unique id for every new patient using a digital
system (this can be done with or without ABHA)

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Achievement c The hospital has the capability to create ABHA for a patient
Commitment d Registration system is able to identify duplicate patient entry based on

some key data fields (e.g., Any unique id, name, date of birth and mobile
number)
Achievement e Any patient records created in an offline mode, are later synced up
when the digital system is up and running
Commitment f For every repeat patient visit, a different transaction number is

generated. This transaction number is linked to the unique patient
identifier to ensure continuity of care
Core g All patient medical records (generated at any patient touch point within
the hospital or during any of the visit) are linked to their unique patient
id
Excellence h All patients’ medical records created by hospital, are available to

hospital's other entities/facilities / or affiliates
The hospital has a digital system to manage patient's appointments

AAC.3.
and treating medical practitioner's schedule

Commitment a The hospital is using a digital system for patients to book an
appointment
Excellence b The hospital's digital system is integrated with external digital

systems to capture and manage online patient appointments

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Achievement c Patients and/or hospital staff are able to digitally view treating
medical practitioner's profile during appointment booking
Patient is able to book an appointment digitally for a specific or

Achievement d
chosen medical practitioner during appointment booking
Treating medical practitioner and/or healthcare professional are

Achievement e
able to view their appointment schedule.
The hospital has a provision to capture digital signatures of

Achievement f
treating medical practitioner
Patients are informed and notified about their upcoming / follow

Achievement g
up appointments digitally
The hospital is using a digital system to manage patient's IPD

AAC.4.
admissions
Achievement a The hospital is using a digitized admission form that includes all
admission related information for the patient
Commitment b The hospital is using a digital system to assign patients to ward /

bed and track their ward / bed information
Achievement c The hospital's digital system has the ability to admit patients on
pseudo/dummy/triage beds to manage admissions at the time of
non-availability of beds
Core Commitment Achievement Excellence 15

The hospital has a digital system to manage the laboratory test orders
AAC.5.
and samples
Core a The hospital is generating a digital unique id for every sample

collected / received which is linked to a patient id
The hospital is using a digital system to track the movement of

Achievement b
laboratory samples
Achievement c The Lab Analyzer is integrated with the LMIS so that results are
auto populated, and are not required to be manually entered
Achievement d Patients have digital access to their laboratory reports
The hospital has a digital record of laboratory tests sent outside

Excellence e
and results received thereof
The hospital has a digital system to manage the radiology tests and
AAC.6.
samples
Commitment a The hospital generates a digital unique id for every radiological

test or procedure, which is linked to the unique patient id
Commitment b The hospital is using a digital system for their radiology

department to create, finalize and issue reports

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Achievement c Patients have digital access to their radiology reports
The hospital handles the discharge and transfer process of patients

AAC.7.
digitally
Achievement a The primary treating medical practitioner is able to request and

update the patient's discharge information digitally
Achievement b The hospital uses a digital notification to communicate patient

details due for discharge, with other internal departments
Achievement c Billing department is able to give discharge clearance through a

digital system
Achievement d Treating medical practitioner is able to generate patient's

discharge summary digitally
Commitment e The hospital is using a digital system to manage inter

departmental patient's transfer in the hospital
AAC.8. The hospital has a digital system to capture the patient's feedback
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Commitment a The hospital uses a digital system to collect patient and/or family
member's feedback

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Chapter 2
Access
Care of Patients (COP)
The organization provides uniform care to all patients in various settings. The settings
include care provided in outpatient units, daycare facilities, in-patient units including critical
care units, procedure rooms and operation theatre. When similar care is provided in these
different settings, care delivery is uniform.
The hospital uses digital technology to manage illnesses and promotes wellness. This
digital adoption is available across hospital facilities such as in outpatient departments, day
care facilities, in-patient departments etc. Patients are provided with uniform care across
all the nursing stations where digital tools are used to speed-up the pre-patient assessment.
Digital systems are used to connect nursing stations with consultation services, where the
patient’s digital records are available for enhanced care. Doctors can fetch patient records
(on patient’s consent), raise electronic laboratory, radiology, and pharmacy orders. The
hospital uses software, tools etc. to fulfill patients' urgent medical needs such as scheduling
surgeries, ordering blood etc.
An established system to track and monitor the nutritional therapy and infection related
events which are addressed to provide comprehensive health care. The standards aim to
guide and encourage patient safety as the overarching principle for providing care to the
patients.
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The Hospital is using a digital system to manage surgeries and related
COP.1.
activities
COP.2. The hospital has a digital system to manage nursing care
COP.3. There is a digital system to manage OPD and IPD consultation services
COP.4. A digital system is being used to manage blood bank operations
COP.5. The hospital provides services to the patients in non-hospital environment
COP.6. There is a digital system for managing emergency and medico-legal cases
COP.7. All infection related and sentinel events are tracked and monitored digitally
The Hospital has a digital system to record dietary consultation and any
COP.8.
specific nutritional therapy provided to the patient
The Hospital is using a digital system to manage surgeries and

COP.1.
related activities
Achievement a The hospital is using a digital system to capture pre-operative

assessment of the patient which includes PAC clearance,
physician clearance, consent received, blood arranged etc.

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Excellence b The hospital is using a digital system to schedule, modify or
cancel interventional procedures / surgeries
Excellence c The hospital is using a digital system to record planned operation

start and end time
COP.2. The hospital has a digital system to manage nursing care
Excellence a The hospital is using a digital system for nurses to create OPD
initial assessment and record progress of the patient
Achievement b Nurses are using a digital system to create IPD nursing notes
COP.3. There is a digital system to manage OPD and IPD consultation services
Commitment a Treating medical practitioners creates OPD prescriptions digitally
Commitment b Treating medical practitioners creates computerized provider

order entry (CPOE) for laboratory tests through digital system

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Commitment c Treating medical practitioners are able to create computerized
provider order entry (CPOE) for radiology tests through digital
system
Commitment d Treating medical practitioners are able to create computerized

provider order entry (CPOE) for medicines through digital system
Achievement e Treating medical practitioners when placing a request are notified

on duplicate laboratory / radiology / pharmacy requests
Achievement f Patients are able to access their digital prescription
Commitment g The hospital has a digital system to notify the treating medical
practitioners of any critical values obtained in lab reports
Achievement h All patient medical records (e.g., past medical history, drug
history, surgical history etc.) are digitally accessible to the treating
medical practitioner within the hospital
Excellence i The hospital links patient's records to his / her ABHA account,
which can then be accessed by patient or by other healthcare
institutions
Excellence j Based on patient's consent, hospital can digitally access patients

past medical records as generated in other Healthcare
Institutions, via his/her ABHA account
COP.4. A digital system is being used to manage blood bank operations

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Commitment a The hospital is using a digital system to register and screen
prospective donors
The hospital is using a digital system to register and manage the

Core b
blood and blood components stock
Achievement c The hospital is using a digital system to capture blood transfusion

related incidents (e.g., error in blood transfusion) to prepare for
future corrective and preventive actions
The hospital provides services to the patients in non-hospital

COP.5.
environment
Achievement a The hospital offers remote/virtual clinical consultations and clinical

advice to patients when needed
Excellence b The Hospital provides at home services like consultations, lab

sample collection, ICU at home which are managed digitally etc.
There is a digital system for managing emergency and medico-legal

COP.6.
cases

Achievement a The hospital is using a digital casualty and emergency
registration system
Core b Hospital is using a digital checklist to qualify/label a case as a

medico-legal case
Excellence c Patient's vital monitoring status and/or results from tests taken on
hospital's ambulance are transmitted digitally to the receiving
hospital before arrival
Commitment d Hospital has a digital system deployed to manage emergency

codes and staff response
All infection related and sentinel events are tracked and monitored
COP.7.
digitally
Commitment a The hospital is using a digital system to track, report, and manage
different types of infection related incidents individually (e.g.
CAUTI, CLABSI, VAP, SSI, etc.)
Commitment b The hospital has an antibiotic usage policy which is available

digitally to the treating physicians
Excellence c A digital record is prepared for any medication administration

errors
Excellence d The hospital has a digital system to identify the vulnerable

patients who may be at risk of different types of injuries

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Achievement e All patient care incidents and sentinel events are captured
digitally
Excellence f The hospital maintains a digital record of the hospital staff,

exposed to any infections at workplace
Excellence g The hospital maintains a digital records for all healthcare staff
who have undergone any post exposure prophylaxis at the
hospital
The Hospital has a digital system to record dietary consultation and

COP.8.
any specific nutritional therapy provided to the patient
Achievement a The Hospital has a digital system to identify specific dietary

consultation services as provided to a patient
Excellence b The hospital uses a digital record of therapeutic diet given to

inpatients, as advised by the dietician

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Chapter 3
Access
Management of Medication (MOM)
The pharmacy should have a digital oversight of all the medications stocked out of the
pharmacy.
There should be a digital monitoring mechanism to ensure that the required medications are
always stocked up and well within the expiry dates.
Every high-risk medication order should be verified digitally by an application-based record to

ensure the accuracy of the dosage, frequency, and route of administration. Safety is paramount
when using narcotics, chemotherapeutic agents, and radioactive agents.
The hospital uses digital medication management to reduce medication errors and improve the
level of care for patients. The hospital should ensure the availability of a digital formulary which
is easily available and accessible to medical practitioners anywhere within the hospital
premises.
The digital system ensures centralized information and streamlines communications between
healthcare facilities and patients. The technology intervention reduces the number of errors
and ensures proper medicine stocking.
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Digital inventory is maintained for medicines and consumables in the
MOM.1.
pharmacy
MOM.2. Digital records are maintained for the pharmacy orders
Hospital Deploys a digital System to reduce the incidence of medication

MOM.3.
errors and maintain records of medical devices used
MOM.4. Hospital has a digital record to manage crash carts
Digital inventory is maintained for medicines and consumables in the

MOM.1.
pharmacy
Commitment a There is a digital inventory for medicines and consumables
Commitment b A digital record is kept for the usage of narcotic drugs and
psychotropic substances, chemotherapeutic agents, radioactive
agents, and high-risk medications
MOM.2. Digital records are maintained for the pharmacy orders

Commitment a Dispensing of medications (e.g., pharmacy to ward, nursing to
patient and pharmacist to patients etc.) is recorded digitally
Achievement b Identification and disposal of expired medicines is notified and

recorded digitally
Excellence c The hospital's formulary is available digitally which the treating

medical practitioners can refer to while making prescriptions
Hospital Deploys a digital System to reduce the incidence of

MOM.3.
medication errors and maintain records of medical devices used
Achievement a Hospital has a digital system deployed to verify patient at the bed
side before medicine administration
Achievement b Hospital has a digital record of all prosthesis and medical records
used in care delivery
MOM.4. Hospital has a digital record to manage crash carts

Core a The Hospital has a digital record of number of crash carts in the
hospital, medicines / drugs and devices to be kept in the crash
carts, their periodic audits etc.

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Chapter 4
Access
Digital Infrastructure (DIS)

The hospital provides a cross-browser compatible digital system to their staff members. Access
to digital systems is provided with secured electronic devices and through communication
pathways that have additional links to connect all electronic devices in case one link goes down.
The hospital has installed devices (UPS and a generator) that provides instantaneous and
uninterruptible power supply.
The hospital has controls in place to encrypt data i.e. data is encrypted at-rest (in all places,
including Cloud back-up) and in-transit, with decryption tools. End point devices are secured
through active anti-virus and firewall. Data controls such as audit trails for all the core
healthcare applications are maintained and analyzed to protect data.
DIS.1. Hardware and network capability is in place to facilitate hospital's digital operations
DIS.2. Data security controls are in place to prevent security breach
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Hardware and network capability is in place to facilitate hospital's
DIS.1.
digital operations
Achievement a The digital system supports accessibility of URL on both web-

based and mobile-based interface
Commitment b In case of a web based digital system, support for more than 1
widely used browsers is available
Achievement c Treating medical practitioners are equipped with electronic

devices to access electronic health records of patients
Excellence d Allied services staff members are equipped with electronic

devices to access hospitals administrative applications
Commitment e The hospital ensures that backup is available for internal network
Core f The hospital has a power backup for digital systems (i.e., UPS
and a generator)
DIS.2. Data security controls are in place to prevent security breach
Achievement a The hospital ensures that hospital data is encrypted
Core b The hospital is using an active/valid anti-virus to prevent, detect,

and remove malware for hospital applications

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Commitment c The hospital is using a firewall that monitors incoming and
outgoing network traffic
Achievement d The hospital ensures that audit trails are captured in the digital
system
Excellence e The digital system supports single sign on capabilities

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Chapter 5
Access
Digital Operations Management (DOM)
The hospital has an updated IT policy to guide standardized IT practices across the hospital.
IT infrastructure is implemented properly with monitoring controls and continuous support, and
hospital's digital operations don't face connectivity, productivity, and security issues.
The hospital has a systematic approach to manage all IT assets, including storing digital
inventory of IT assets, tracking and maintaining IT assets etc.
Processes are in place to restore data access and IT infrastructure after a disaster. Controls
such as - access management, multi factor authentication,
and usage of external storage devices are implemented to protect digital infrastructure.
The hospital is using digital means to create and analyze maintenance related activities for all
hospital items.
DOM.1. The hospital has guidelines for usage and operations of IT resources
DOM.2. The hospital has relevant IT support infrastructure available
DOM.3. Digital system is in place to manage IT/Digital assets of the hospital
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The hospital has a disaster recovery and business continuity plan for the
DOM.4.
digital systems
DOM.5. There is a digital system to provide access controls
Digital records are maintained to track all incidents and maintenance

DOM.6.
events of the facility
DOM.1. The hospital has guidelines for usage and operations of IT resources
Core a The hospital has an IT policy
Achievement b IT policy is reviewed at least once annually
DOM.2. The hospital has relevant IT support infrastructure available
Achievement a The hospital has an internal maintenance plan for IT systems and
services

Excellence b System based reports are generated to measure IT infrastructure
efficiency
Achievement c Measures are in place to monitor the performance of different

healthcare systems
Core d The hospital has continuous support including software updates

and upgrades for their clinical healthcare system
Commitment e The hospital has continuous support including updates and

upgrades for their non-clinical system (e.g., desktop, laptop,
mobile, database etc.)
Excellence f A formal change request process exists to manage IT related

changes
DOM.3. Digital system is in place to manage IT/Digital assets of the hospital
Achievement a The hospital has a digital inventory record of all IT infrastructure

(e.g., hardware, network devices, software etc.)
Excellence b A centralized digital data repository exists in the hospital
Achievement c A digital system is used to record and track IT security incidents,

issues, changes, and problems
Excellence d The hospital periodically conducts IT audits by an external vendor

The hospital has a disaster recovery and business continuity plan for
DOM.4.
the digital systems
Commitment The hospital has a disaster recovery plan available to manage

a
patient healthcare records in case of an emergency
The hospital has a disaster recovery plan available to manage

Commitment b
administrative applications in case of an emergency (i.e.,
applications that support health related systems)
The hospital is using a digital system to archive and retrieve the

Core c
data
DOM.5. There is a digital system to provide access controls
Core a The hospital uses a digital system to manage end user credential
and authentication
The digital system provides two factor authentication for all IT

Excellence b
systems
Core c Data transfer on external storage devices is protected and its use
restricted

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Excellence d The hospital staff is not allowed to use personal email ids for any
official communication and only official email ids works and
operates on all devices
An electronic session after a predetermined time of inactivity is

Commitment e
auto terminated
Digital records are maintained to track all incidents and maintenance

DOM.6.
events of the facility
Achievement a The hospital is maintaining a digital record of periodic calibration

and maintenance plans for all equipment
Achievement b Maintenance In charge/ Bio medical department are notified (e.g.,

system indicator, emails, message, system alerts) for scheduled
maintenance activities
Excellence c Hospital is maintaining a digital record for collection and disposal

of bio medical waste (including the details of the registered
disposer).
Excellence d The hospital is registered in the Healthcare Facility Registry
Excellence e Medical practitioners at the hospital are registered in the

Healthcare Professionals Registry

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Chapter 6
Access
Finance and Procurement Management (FPM)
6.1 Intent of Chapter

A digitized procurement process helps the hospital to control their assets effectively,
manage their processes and comply with regulations and policies. Digitized procurement
management activities ensures that the hospitals are ahead of the curve.
The hospital should automate their procurement cycle; indents should be raised digitally
and the entire procurement to pay cycle is managed through a digital tool.
Stock movement and updates are captured near real time resulting in improved cycle
time. Data is used in decision making and vendor performances are managed through a
digital tool.
The hospital uses a digital system to improve their finance related activities such as use
of digital system in financial accounting, budgeting, and financial analysis etc.
FPM.1. The hospital has a digital supply chain management system
The hospital manages vendor and customer payments through a

FPM.2.
digital system
FPM.3. The hospital is able to perform patient billing functions digitally

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FPM.1. The hospital has a digital supply chain management system
Commitment a The hospital is using a digital system to manage the inventory

based on the stock movement of all hospital items
Achievement b The hospital is using a digital system to create and manage

Indents for any hospital item
Achievement c The hospital has a digital system to digitally create purchase

order
Achievement d Receipt notes are digitally created once an order is received in

the hospital store
Excellence e The hospital uses a digital system to record any quality

concerns (expiry date, volume, SKU) of the purchased hospital
assets
The hospital manages vendor and customer payments through a

FPM.2.
digital system
Achievement a The hospital uses a digital payment channel to make vendor

payment (e.g., UPI, NEFT, cheque, credit/debit card etc.)

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Achievement b The hospital has a digital record of all payables and
receivables
Achievement c The hospital follows a periodic payment cycle, and system

reflects about payments to be made or received in the
upcoming cycles
Excellence d The hospital has a digital system to create a debit/credit note
FPM.3. The hospital is able to perform patient billing functions digitally
Core a The hospital is using a digital system for patients to pay for
availing any hospital services
Core b Charges for all the services and items are pre-defined in the
digital system
Excellence c The hospital has a digital portal for patient and/or family
member to view their bill
Commitment d The hospital updates the patient periodically on the updated

billing records using digital means - patient portal, SMS,
WhatsApp etc.
Core e The hospital is using a digital standardized billing template
Commitment f Hospital is using a digital system to manage the insurance

claims

40
Excellence g Patient and/or family member is notified for any update on the
TPA/ insurance process through at least one mode (e.g.,
message, e-mail, app alert) by the hospital

41
Chapter 7
Access
Human Resource Management (HRM)
The most important resource of the organization is its human resource. Human resources are
an asset for the effective and efficient functioning of the organization. The management plans
on identifying the right number and skill mix of staff required to render safe care to the patients.
The hospital uses a digital system to efficiently manage their activities around human
resources. Recruitment of staff is accomplished by having a uniform and standardized system.
All the recruitment and separation related activities are managed through digital tools including
job postings, candidate background verification, offer roll-out etc.
The organization must orient the staff to its environment and also orient them to specific duties
and responsibilities related to their position. The organization should have a digital system in
place to monitor the staff performance.
Employee learning management is conducted through a digital learning management system
as well. Employee performance and exit management is also handled through a digital system.
Note: The term “employee” refers to all salaried personnel working in the organization. The
term “staff” refers to all personnel working in the organization including employees, “fee for
service” medical professionals, part-time workers, contractual personnel and volunteers.
There is a digital platform to manage routine hospital's human resource’s

HRM.1.
administrative purpose
42
There is a digital platform to keep track of recruitment and separation related

HRM.2.
activities
HRM.3. There is a digital system to monitor staff performance
Learning management, training and certifications for the staff are managed
HRM.4.
digitally
There is a digital platform to manage routine hospital's human

HRM.1.
resource’s administrative purpose
Commitment a Personal files are maintained digitally with respect to all staff, and
their confidentiality is ensured
Commitment b The hospital is using a digital system to manage staff rostering
There is a digital platform to keep track of recruitment and separation

HRM.2.
related activities
Excellence a The digital system is integrated with external job posting

websites

43
Excellence b There is an online system to track and manage internal referrals
for staff
Excellence c The hospital enables resignation of an employee through digital

system and facilitates notification to various concerned
departments
HRM.3. There is a digital system to monitor staff performance
Excellence Goals and KPIs are set for hospital staff in the digital system (as
a
applicable)
Excellence b The hospital is using a digital system to evaluate staff

performance
Learning management, training and certifications for the staff are

HRM.4.
managed digitally
Excellence a The hospital is using a digital system to maintain staff training

records
Excellence b Digital means are used to provide periodic in-service trainings to

the staff

44
Excellence c The hospital has a digital access to different medical journals
Excellence d New joiners are provided online induction training at the time of
joining the hospital

Chapter 8
Access
Information Management System (IMS)

The goal of the information management in the organization is to ensure that the right
information is available to the right person at the right time.
Information management includes management of the hospital information system as well as

all modalities of information communicated to staff, patients, visitors, and community in general.
Data and information management must be directed to meet the organization’s needs and
support the delivery of quality patient care. The information needs are provided in an
authenticated, secure ad accurate manner at the right time and pace.
Information management also includes periodic review, revision, and withdrawal of obsolete
information to avoid any confusion among staff, patients and visitors. The hospital uses a digital
system to manage patient records. The hospital also uses a clinical decision support system to
create customized care plans.
The hospital has clearly laid down policies governing the patient data creation, modification,
and access.
IMS.1. The hospital follows defined data standards
The Hospital has a digital governance and data-driven decision-making

IMS.2.
process
46
IMS.1. The hospital follows defined data standards
Achievement a The hospital complies to defined clinical standards (e.g.,

SNOMED CT, WHO ICD) for clinical terminology for the
exchange of clinical health information
Commitment b The hospital complies to DICOM standards for digital imaging
Commitment c The hospital complies to the capturing of data still image in

JPEG and PDF format
Commitment d The hospital captures the mentioned datatypes in the following

formats:
a. Audio: MP3 / OGG

b. Video: MP4 / MOV
Excellence e The hospital has digital consent management system to capture

and enforce patient, hospital and jurisdictional privacy policies
for hospital, and health information (e.g., patient profile, health
records) exchanges between hospitals
Commitment f The hospital has a digital system to ensure mandatory fields in

healthcare system are identified and filled for any patient record

47
Commitment g The hospital has defined format and validation for mandatory
fields in healthcare system. The digital system should accept
values in that defined format while creating a patient record
The Hospital has a digital governance and data-driven decision-

IMS.2.
making process
Commitment a The hospital has a designated IT team for digital operations

management
Achievement b The hospital is using a clinical decision support system to create

customized care plans
Achievement c The hospital is using digital hospital dashboards to measure

quality of care delivery
Excellence d The hospital has a defined IT budget to manage existing IT

infrastructure and undertake future IT projects

48
Glossary
S.No. Term Definition

1 ABHA Ayushman Bharat Health Account
2 AP Account Payable
3 API Application Programming Interface
4 CPOE Computerized Provider Order Entry
5 CSSD Central Sterile Supply Department
Data at rest is data that is not actively moving from device to
Data-at-rest
6 device or network to network such as data stored on a hard drive,
laptop, flash drive, or archived/stored in some other way
Data in transit, or data in motion, is data actively moving from one
7 Data-in-transit location to another such as across the internet or through a private
network
8 DICOM Digital Imaging and Communications in Medicine
9 ECG Electrocardiogram
10 EEG Electroencephalogram
11 EMR Electronic Medical Records
12 ER Emergency Room
13 GRN Goods Receipt Notes
14 HFR Health Facility Registry
15 HR Human Resource
16 HSP Healthcare Service Provider
17 HTTPS Hypertext Transfer Protocol Secure
18 ICD International Classification of Diseases
19 ICU Intensive Care Unit
20 ID Identification Data
21 IPD In-patient Department
49
S.No. Term Definition
22 IT Information Technology
IT infrastructure refers to the composite hardware, software,
IT
23 network resources and services required for the existence,
infrastructure
operation and management of an enterprise IT environment.
24 KPI Key Performance Indicators
25 LOINC Logical Observation Identifiers Names and Codes
Master data is the set of identifiers that provides context about
26 Master Data
business data such as location, customer, product, asset, etc.
27 MCI Medical Council of India
28 MIS Management Information System
29 MLC Medico Legal Case
30 MoU Memorandum of Understanding
31 MOV QuickTime video format
32 MP3 MPEG Audio Layer 3
33 MP4 MPED-V Advanced Video Coding
34 MRN Material Receipt Notes
35 MSME Ministry of Micro, Small & Medium Enterprises
36 OGG Ogg Vorbis Compressed Audio File
37 OPD Out-patient Department
38 OT Operation Theatre
39 OTP One-time password
40 PHR Personal Health Records
41 SNOMED CT Systematized Nomenclature of Medicine Clinical Terms
42 SOP Standard Operating Procedure
43 TPA Third Party Administrator
44 UHID Unique Health Identification
45 UPS Uninterruptible Power Supply
46 WHO World Health Organization
50
51
References
 Australian Commission on Safety and Quality in Healthcare

[https://www.safetyandquality.gov.au/our-work/indicators-measurement-and-
reporting]
 Ayushman Bharat Digital Mission Sandbox Integration and Exit process
[https://sandbox.abdm.gov.in/docs/integration_and_exit_process]
 Healthcare Information and Management Systems Society [https://www.himss.org/]
 Hardware guidelines for states and healthcare institutions Ayushman Bharat Digital
Mission
[https://abdm.gov.in:8081/uploads/Hardware_Guidelines_ABDM_3513166774.pdf]
 Joint Commission International, 7th edition, January 2021
[https://www.jointcommissioninternational.org/]
 Joint Commission International, 7th edition, Survey Process Guide, January 2021
[https://www.jointcommissioninternational.org/]
 Medico Legal Issues: Guidelines to Medical Officers
[http://qi.nhsrcindia.org/sites/default/files/medico_legal.pdf]
 Minimum Viable Product (MVP) Guidance Document for ABDM Compliant HMIS/LMIS
Version 3.0, Ayushman Bharat Digital Mission
[https://abdm.gov.in:8081/uploads/Approved_MVP_document_Version_3_9fc83de1
48.pdf]
 Ministry Of Health and Family Welfare, Annual Report 2020 – 21
[https://main.mohfw.gov.in/sites/default/files/Part-
I%20Overview%20Report%20Health%20MDDS.pdf]
 National Accreditation Board For Hospitals And Healthcare Providers (NABH), 4th
Edition, December 2015
52
 National Accreditation Board For Hospitals And Healthcare Providers (NABH),
Annexures to Accreditation Standards for Hospitals, 4th Edition, December 2015
 National Accreditation Board For Hospitals And Healthcare Providers (NABH), 5th
Edition, April 2020
Certification Timeline, March 2021
[https://nabh.co/Images/PDF/NABH%20Accreditation_Certification%20Timeline.pdf]
Policies & Procedures for Assessment, Surveillance and Re-assessment of HCO
[https://nabh.co/Images/PDF/NABH-Pol_ProcHCO.pdf]
 National Health Services, United Kingdom [https://www.nhs.uk/]
 National Institution for Transforming India, Government Of India, Performance Of
Health Outcomes, A Reference Guidebook, December 2016
 The Joint Commission Health Care Quality Data, Joint Commission Quality Check
[healthcarequalitydata.org]
53
NATIONAL ACCREDITATION BOARD FOR HOSPITALS & HEALTHCARE PROVIDERS (NABH)
ITPI Building, 5th Floor, 4A, IP Estate, Ring Road, New Delhi-110002Email: helpdesk@nabh.co | Website: www.nabh.co
54

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NATIONAL ACCREDITATION BOARD

FOR HOSPITALS AND HEALTHCARE PROVIDERS

National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a

International Society for Quality in Healthcare (ISQua) has accredited NABH as an

NABH is an Institutional Member as well as a member of the Accreditation Council of the

NABH provides accreditation to healthcare organisations in a non-discriminatory manner

NABH currently operates the following accreditation, certification and empanelment

2. Small Healthcare Organizations

3. Blood Banks / Blood Center

6. Dental Healthcare Service Providers

10. Clinical Trial (Ethics Committee)

11. Eye Care Organization

12. OST Center

14. Wellness Centers

1. Entry Level Hospital

2. Entry Level Small Healthcare Organizations

3. Entry Level AYUSH Centre

4. Entry Level AYUSH Hospital

6. Medical Laboratory Programme

Technological Access to Healthcare is being increasingly seen as an important pillar of

NABH Digital Health Standards

The eight chapters are

1. Access, Assessment and Continuity of Care (AAC)

2. Care of Patients (COP)

3. Management of Medication (MOM)

4. Digital Infrastructure (DIS)

5. Digital Operations Management (DOM)

6. Finance and Procurement Management (FPM)

7. Human Resource Management (HRM)

8. Information Management System (IMS)

The proposed standards have 151 objective elements.

(At the time of

Silver Level 100% 60% NA NA

Silver Level 100% 80% NA NA

 For Initial Assessment, minimum compliance levels as defined in Table 1 are to be

Chapter 2 Care of Patients (COP) 19

Chapter 3 Management of Medication (MOM) 26

Chapter 4 Digital Infrastructure (DIS) 29

Chapter 5 Digital Operations Management (DOM) 32

Chapter 6 Finance and Procurement Management (FPM) 37

Chapter 7 Human Resource Management (HRM) 41

Chapter 8 Information Management System (IMS) 45

1.1 Intent of the Chapter:

The hospital has a digital system to manage patient's appointments and

Digital Health Standard

The hospital educates and disseminates information via digital

Digital Health Objective Elements

Commitment a Hospital is using a digital system (e.g., hospital website or mobile

Excellence c The Hospital sends informative notifications to its patients in a

Digital Health Standard

The hospital has an established digital registration and referral

Digital Health Objective Elements

Core Commitment Achievement Excellence

Commitment d Registration system is able to identify duplicate patient entry based on

Commitment f For every repeat patient visit, a different transaction number is

Excellence h All patients’ medical records created by hospital, are available to

Digital Health Standard

The hospital has a digital system to manage patient's appointments

Digital Health Objective Elements

Excellence b The hospital's digital system is integrated with external digital

Core Commitment Achievement Excellence

Patient is able to book an appointment digitally for a specific or

Treating medical practitioner and/or healthcare professional are