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NATIONAL
ACCREDITATION BOARD
FOR
HOSPITALS AND HEALTHCARE
PROVIDERS
(NABH)
Accreditation
Standards for Hospitals
Access
Assessment and Continuity of Care
(AAC)
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AAC.1.
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Defines and displays the services that can provide.
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AAC.2.
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Well-defined registration and admission process.
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AAC.3.
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Appropriate mechanism for transfer (in an out) or
referral of patients.
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AAC.4.
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Established initial assessment of the Patients.
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AAC.5.
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Regular reassessment of the Patients.
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AAC.6.
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Laboratory services of the organization.
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AAC.7.
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Established laboratory-quality assurance programme.
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AAC.8.
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Established laboratory-safety programme
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AAC.9.
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Imaging services of the organization
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AAC.10
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Established quality-assurance programme for imaging
services.
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AAC.11
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Established radiation-safety programme.
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AAC.12
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Continuous and multidisciplinary Patient care.
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AAC.13.
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Documented discharge process.
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AAC.14.
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Pre-defined discharge summary.
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Care of
patients (COP)
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COP 1:
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Uniform care to patients is guided by the applicable
laws, regulations and guidelines, provided in all settings of the
organization.
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COP.2:
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Documented policies and procedures as per laws and
regulations in Emergency services.
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COP.3:
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The ambulance services are commensurate with the scope
of the services provided by the organization.
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COP.4:
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Documented policies and procedures for the care of
patients in cardio-pulmonary resuscitation.
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COP.5:
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Documented policies and procedures for the guidance of
nursing care.
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COP.6:
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Documented procedures guide the performance of various
procedures.
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COP.7:
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Documented policies and procedures prescribe rational
use of blood and blood products.
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COP.8:
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Documented policies and procedures guide the care of
patients in the intensive care and high dependency units.
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COP.9:
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Documented policies and procedures guide the care of
vulnerable patients (elderly, physically and/or mentally-challenged and
children).
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COP.10:
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Documented policies and procedures guide obstetric care.
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COP.11:
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Documented policies and procedures guide paediatric
services.
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COP.12:
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Documented policies and procedures guide the care of
patients undergoing moderate sedation.
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COP.13.
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Documented policies and procedures guide the
administration of anaesthesia.
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COP.14:
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Documented policies and procedures guide the care of
patients undergoing surgical procedures
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COP.15:
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Documented policies and procedures guide the care of
patients under restraints.
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COP.16:
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Documented policies and procedures guide appropriate
pain management.
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COP.17:
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Documented policies and procedures guide appropriate
rehabilitative services.
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COP.18:
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Documented policies and procedures guide all research
activities.
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COP.19:
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Documented policies and procedures guide nutritional
therapy.
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COP.20:
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Documented policies and procedures guide the end of life
care.
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Management
of Medication (MOM)
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MOM 1:
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Documented policies and procedures guide the
organization of pharmacy services and usage of medications
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MOM 2:
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There is a hospital formulary.
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MOM 3:
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Documented policies and procedures exist for storage of
medication.
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MOM 4:
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Documented policies and procedures guide the safe and
rational prescription of medications.
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MOM 5:
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Documented policies and procedures guide the safe
dispensing of medications.
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MOM 6:
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There are documented policies procedures for medication
management.
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MOM 7:
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Patients are monitored after medication administration.
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MOM 8:
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Near misses, medication errors and adverse drug events
are reported and analyzed.
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MOM 9:
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Documented procedures guide the use of narcotic drugs
and psychotropic substances.
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MOM 10:
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Documented policies and procedures guide the usage of
chemotherapeutic agents.
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MOM 11:
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Documented policies and procedures govern usage of
radioactive drugs.
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MOM 12:
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Documented policies and procedures guide the use of
implantable prosthesis and medical devices.
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MOM 13:
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Documented policies and procedures guide the use of
medical supplies and consumable
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Patient
Rights and Education (PRE)
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PRE 1:
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The organization protects patient and family rights and
informs them about their responsibilities during care.
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PRE 2:
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Patient and family rights support individual beliefs,
values and involve the patient and family in decision-making processes.
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PRE 3:
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The patient and/or family members are educated to make
informed decisions and are involved in the care-planning and delivery
process.
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PRE 4:
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A documented procedure for obtaining patient and/or
family’s consent exists for informed decision making about their care.
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PRE 5:
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Patient and families have a right to information and
education about their healthcare needs.
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PRE.6.
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Patient and families have a right to information on
expected costs.
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PRE 7:
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Organization has a complaint redressal procedure.
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Hospital
Infection Control (HIC)
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HIC 1:
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The organization has a well-designed, comprehensive and
coordinated Hospital Infection Prevention and Control (HIC) programme aimed
at reducing/ eliminating risks to patients, visitors and providers of care.
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HIC 2:
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The organization implements the policies and procedures
laid down in the Infection Control Manual.
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HIC 3:
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The organization performs surveillance activities to
capture and monitor infection prevention and control data.
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HIC 4:
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The organization takes actions to prevent and control
Healthcare Associated Infections (HAI) in patients.
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HIC 5;
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The organization provides adequate and appropriate
resources for prevention and control of Healthcare Associated Infections
(HAI).
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HIC 6:
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The organization identifies and takes appropriate
actions to control outbreaks of infections.
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HIC 7:
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There are documented policies and procedures for
sterilization activities in the organization.
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HIC 8:
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Bio-medical waste (BMW) is handled in an appropriate and
safe manner.
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HIC 9:
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The infection control programme is supported by the
management and includes Training of staff and employee health.
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Continual Quality Improvement (CQI)
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CQI 1:
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There is a structured quality improvement and continuous
monitoring programme in the organization.
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CQI 2:
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There is a structured patient-safety programme in the
organization.
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CQI 3:
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The organization identifies key indicators to monitor
the clinical structures, processes and outcomes which are used as tools for
continual improvement.
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CQI 4:
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The organization identifies key indicators to monitor
the managerial structures, processes and outcomes, which are used as tools
for continual improvement.
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CQI 5:
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The quality improvement programme is supported by the
management.
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CQI 6:
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There is an established system for clinical audit.
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CQI 7:
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Incidents, complaints and feedback are collected and
analyzed to ensure continual quality improvement.
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CQI 8:
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Sentinel events are intensively analyzed.
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Responsibilities
of management (ROM)
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ROM 1:
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The responsibilities of those responsible for governance
are defined.
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ROM 2:
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The organization complies with the laid-down and
applicable legislations and regulations.
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ROM 3:
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The services provided by each department are documented.
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ROM 4:
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The organization is managed by the leaders in an ethical
manner.
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ROM 5:
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The organization displays professionalism in management
of affairs.
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ROM 6:
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Management ensures that patient-safety aspects and
risk-management issues are an integral part of patient care and hospital
management.
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Facility Management and Safety (FMS)
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FMS 1:
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The organization has a system in place to provide a safe
and secure environment.
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FMS 2:
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The organisation’s environment and facilities operate to
ensure safety of patients, their families, staff and visitors.
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FMS 3:
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The organization has a programme for engineering support
services.
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FMS 4:
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The organization has a programme for bio-medical
equipment management.
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FMS 5:
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The organization has a programme for medical gases, vacuum
and compressed air.
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FMS 6:
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The organization has plans for fire and non-fire
emergencies within the facilities.
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FMS 7:
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The organization plans for handling-community
emergencies, epidemics and other disasters.
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FMS 8:
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The organization has a plan for management of hazardous
materials.
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Human
Resource Management (HRM)
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HRM 1:
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The organization has a documented system of human
resource planning.
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HRM 2:
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The organization has a documented procedure for
recruiting staff and orienting them to the organisation’s environment.
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HRM 3:
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There is an ongoing programme for professional training
and development of the staff.
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HRM 4:
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Staff is adequately trained on various safety-related
aspects.
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HRM 5:
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An appraisal system for evaluating the performance of an
employee exists as an integral part of the human human resource management
process.
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HRM 6:
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The organization has documented disciplinary grievance
handling policies and procedures.
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HRM 7:
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The organization addresses the health needs of the employees.
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HRM 8:
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There is a documented personal record for each staff
member.
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HRM 9:
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There is a process for credentialing and privileging of
medical professionals permitted to provide patient care without
supervision.
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HRM 10:
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There is a process for credentialing and privileging of
nursing professionals, permitted to provide patient care without
supervision.
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Information
Management System (IMS)
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IMS 1:
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Documented policies and procedures exist to meet the
information needs of the care providers, management of the organization as
well as other agencies that require data and information from the
organization.
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IMS 2:
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The organization has processes in place for effective
management of data.
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IMS 3:
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The organization has a complete and accurate medical
record for every patient.
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IMS 4:
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The medical record reflects continuity of care.
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IMS 5:
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Documented policies and procedures are in place for
maintaining confidentiality, integrity and security of records, data and
information.
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IMS 6:
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Documented policies and procedures exist for retention
time of records, data and information.
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IMS 7:
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The organization regularly carries out review of medical
records.
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