NABH AYUSH Hospital Accreditation Standards Compliance Audit
This checklist covers compliance requirements under NABH Hospital Accreditation Standards 5th Edition and applicable Indian regulations for healthcare operations. Non-compliance can result in suspension of NABH accreditation, Clinical Establishments Act penalties, and MoHFW de-registration.
- Industry: Healthcare
- Frequency: Quarterly
- Estimated Time: 25-35 minutes
- Role: AYUSH Hospital Director
- Total Items: 20
- Compliance: NABH Hospital Accreditation Standards 5th Edition, Clinical Establishments Act 2010, MoHFW Guidelines, WHO Standards
Statutory Registration & NABH Accreditation
Verify Clinical Establishments Act registration and NABH accreditation compliance.
- Is the hospital registered under the Clinical Establishments Act 2010 or equivalent State Act?
- Is NABH accreditation certificate current and displayed, with next surveillance audit scheduled?
- Is the hospital registered with the State Medical Council and PCPNDT if applicable?
- Attach photo of Clinical Establishment registration, NABH certificate, and Medical Council registration:
Infection Prevention & Biomedical Waste
Verify IPC programme compliance and biomedical waste management per BMW Rules 2016.
- Is the infection prevention and control programme documented with an active IPC committee?
- Are standard precautions (hand hygiene, PPE, waste segregation) observed and audited monthly?
- Is biomedical waste segregated at source into colour-coded bins and disposed via authorised BMW collector?
- Attach photo of IPC committee minutes, hand hygiene audit results, and BMW authorisation certificate:
Emergency Preparedness & Statutory Registers
Verify emergency response procedures, drill records, and statutory register maintenance.
- Are emergency response procedures documented, practiced through drills, and records maintained?
- Are all statutory registers (accidents, dangerous occurrences, medical examinations) maintained correctly?
- Overall compliance with applicable Indian regulatory requirements:
- Attach photo of emergency drill records, statutory registers, and compliance certificates:
Patient Safety & NABH Quality Indicators
Verify patient safety incident reporting, quality indicator tracking, and NABH compliance.
- Is the patient safety incident reporting system active and near-miss events analysed at monthly quality committee?
- Are clinical outcome indicators tracked and reported to NABH as per accreditation requirements?
- Days since last NABH surveillance assessment or desktop review:
- Medical Superintendent or Quality Director certification:
Corrective Actions & Inspector Sign-Off
Document all deficiencies and assign corrective actions. POPProbe auto-assigns these to team members, generates a signed PDF report instantly, and tracks compliance status across all locations. -> Start free, no credit card required
- List all deficiencies identified in this inspection:
- Overall compliance status?
- Corrective actions assigned to (name and department):
- Inspector digital signature and date:
Related Health Services Checklists
- NABH Radiotherapy Unit Accreditation Standards Compliance Audit
- NABH Diagnostic Imaging Centre Accreditation Compliance Checklist
- MoHFW Telemedicine Practice Guidelines 2020 Compliance Checklist
- NABH Clinical Laboratory Accreditation Standards Compliance Audit
- NABH Physiotherapy & Rehabilitation Centre Standards Compliance
- CGHS Hospital Empanelment Standards Compliance Audit Checklist
- ESI Corporation Dispensary & Hospital Standards Compliance Audit
- Ayushman Bharat PMJAY Hospital Empanelment Standards Compliance
Related Clinical Compliance Checklists
- Sterile Processing Checklist - FREE Download
- Patient Fall Risk Assessment - FREE Download
- Hand Hygiene Compliance Audit - FREE Download
- UK CQC Healthcare Compliance Checklist - FREE Download
- Australia ACSQHC Healthcare Safety Checklist - FREE Download
- India NABH Hospital Accreditation Checklist - FREE Download
- Joint Commission Hospital Accreditation Checklist - FREE Download
- Blood Bank & Transfusion Safety Checklist [FREE PDF] - FREE Download
- Ambulatory Surgery Center Safety Checklist [FREE PDF] - FREE Download
- Optometry Practice Safety & Compliance Checklist [FREE PDF] - FREE Download
Why Use This NABH AYUSH Hospital Accreditation Standards Compliance Audit?
This nabh ayush hospital accreditation standards compliance audit helps healthcare teams maintain compliance and operational excellence. Designed for ayush hospital director professionals, this checklist covers 20 critical inspection points across 5 sections. Recommended frequency: quarterly.
Ensures compliance with NABH Hospital Accreditation Standards 5th Edition, Clinical Establishments Act 2010, MoHFW Guidelines, WHO Standards. Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the NABH AYUSH Hospital Accreditation Standards Compliance Audit cover?
This checklist covers 20 inspection items across 5 sections: Statutory Registration & NABH Accreditation, Infection Prevention & Biomedical Waste, Emergency Preparedness & Statutory Registers, Patient Safety & NABH Quality Indicators, Corrective Actions & Inspector Sign-Off. It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed quarterly. Each completion takes approximately 25-35 minutes.
Who should use this NABH AYUSH Hospital Accreditation Standards Compliance Audit?
This checklist is designed for AYUSH Hospital Director professionals in the healthcare industry. It can be used for self-assessments, team audits, and regulatory compliance documentation.
Can I download this checklist as a PDF?
Yes, this checklist is available as a free PDF download. You can also use it digitally in the POPProbe mobile app for real-time data capture, photo documentation, and automatic reporting.