NABH SHCO Accreditation Documents

NABH SHCO Accreditation Documents

In healthcare, NABH SHCO (Small Healthcare Organizations) Accreditation plays a critical role as it defines quality and patient safety standards that help small hospitals, clinics, and healthcare centers deliver services that are safe, reliable, and patient-centered.

Types of NABH Accreditation Documents:

NABH Pre-Accreditation requires multiple documents for assessment.

Short guidance documents that introduce NABH standards, Chapter, and OE to hospitals.

Helps organizations understand requirements, Internal audit, identify gaps, and plan for full accreditation.

Covers areas like patient rights, infection control, documentation, staff responsibilities, Committee, Quality indicatro, and facility management.

NABH Entry-Level Accreditation:

Provides a simplified set of standards suitable for small or new healthcare organizations.

Ensures hospitals implement essential patient safety and quality practices and quality improvement processes.

Prepares organizations for full NABH accreditation in the future.

Benefits:

Provides a basic roadmap to implement NABH standards in Healthcare & Hospital.

Promotes patient safety, quality care, and standardized processes.

Builds trust and credibility among patients and regulatory authorities.

Example: A small clinic following NABH Entry-Level standards ensures informed consent, infection control, and staff training are properly implemented before applying for full accreditation.

NABH Entry Level

Total Chapter: 10

Standard: 41

Objective Elements: 149

Chapter Name List

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

2. COP (Care of Patients)

3. MOM (Management of Medication)

4. PRE (Patient Rights and Responsibility)

5. HIC ( Hospital Infection Control)

6. CQI (Continuous Quality Improvement)

7. ROM (Responsibility of Management)

8. FMS (Facility of Management and Safety)

9. HRM (Human Resource Management)

10. IMS (Information Management System)

Chapter 1. AAC

1. Scope of Services, Display, Training, and SOPs.
2. Admission registration for IPD, OPD, and emergency patients.
3.  Written instructions and forms for patient transfer and referral to other agencies.
4.  Patient assessment and reassessment for inpatient and emergency patients, as well as SOP, TAT, and form, are necessary.
5. Scope of Services ( Pathology, Radiology)
6. Written guidelines for Sample Collection, Identification, Handling, safe transportation, and Disposal of specimens.
7. Register of TAT and Critical Value, and equipment training
8. Patient Discharge Process, IPD Patient, MLC Patients, and LAMA (Leaving Against Medical Advice) Patients.
9. Discharge summary contains reason for admission, significant findings, investigation result, diagnosis (if any), Procedure performed, treatment given, patient condition, follow-up advice, medication, instruction, and obtained urgent care number.
10. If Death summary, include the case of Death.

Chapter 2. Care of Patient

1. Emergency Service Scope of Services
2. Ambulance guideline, Medicine, and equipment.
3. Blood and blood product, Requisition form, Informed Consent, Monitoring form, and SOP.
4. Scope of Services of HDU & ICU
5. Scope of Services of Obstetric patients (include antenatal, check-ups, maternal nutrition and postnatal care)
6. SOP for administration of anaesthesia.
7. SOP for patient care under Surgical Procedure
8. Care and treatment order signed and dated by the doctor
9. Emergency Admission Register and discharge, transfer, and MLC register.
10. Reporting Transfusion Reaction, Form and SOP.
11. Scope of Services: Paediatric patients,
12. Patient assessment, nutritional growth, and immunisation assessment.
13. Mock Drill for child/neonate abduction and abuse.
14. Family education form, nutrition, immunisation, and safe parenting.
15. Pre-anaesthesia assessment form, filled by a doctor, includes an anaesthesia plan, preoperative evaluation documents.
16. Informed Consent for the administration of anaesthesia 
17. Anaesthesia monitoring form, records, heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security, and level of anaesthesia.
18.  Post-Anaesthesia monitoring and documents.
19. Surgical notes
20. Surgery Consent
21. SSI Checklist
22. Adverse events like wrong patient, wrong surgery, and wrong site.
23. Operation Notes and Postoperative plan of care.
24. OT Infection Control Guideline.

Chapter 3. Management of Medication

1. Guidelines for Purchases, Storage, Prescription, and Dispensation of Medication.
2. LASA medicine is stored separately.
3. Expired medicine should be removed from the storage area.
4. SOP for procurement and implantable prosthesis.
5. SOP for Prescription
6. List of High Risk Medicine and the prescribing process.
7. Medication, Clear, legible, date, and signed.
8. Medication Administration check- Patient name, dose, route, timing, and verification.
9. Records for administration and dispensing Narcotic and Psychotropic medicine.
10. Adverse Drug reaction guideline display and monitoring
11. Policy for use of radioactive drugs.
12. Radiactive drug, safe Storage, preparation, handling, distribution, and disposal of radioactive drugs.

Chapter 4: Patient Rights and Education

1. Patients' Rights and Responsibilities displayed
2. Cost Estimation Form

Chapter 5: Hospital Infection Control

1. Cleaning Schedule
2. Equipment Cleaning, disinfection, and sterilization Process.
3. Linen and Laundry Management Process.
4. Hand hygiene display patient washroom
5. Staff vaccination
6. Biomedical Waste Management Guideline.
7. Display BMW signage.

Chapter 6: Continuous Quality Improvement

1. Quality Improvement and Patient Safety Programme
2. Key performance indicators, clinical and managerial.

Chapter 7: Responsibility of Management

1. Organogram
2. Quality and Safety Programme.
3. Mission, Vision and Core Values
4. Billing Process Manual.
5. Quality Core Committee
6. Safety Committee
7. Infection Control Committee
8. PTC Committee
9. Blood Transfusion Committee
10. Medical Records Committee

Chapter 8: Facility & Safety Management

1. Facility Inspection Round
2. Internal and External Signage
3. Maintenance staff rounds daily
4. MSDS
5. Safety Mock Drill
6. Equipment Plan
7. Operation and maintenance (Prevention and Brackdown)
8. Maintenance plan for medical gas vacuum system.
9. Fire Exit Plan
10. Fire mock drill at least 2 in a year

Chapter 9: Human Resource Management

1. HR Manual
2. Risk Management Training
3. Training Job responsibility change & New equipment introduction.