NABH Hospital Accreditation Standards Checklist
This self-assessment checklist maps to NABH 5th Edition standards for hospital accreditation. Designed for hospital administrators, quality managers, and accreditation coordinators preparing for NABH Entry Level or Full Accreditation surveys in India.
- Industry: Healthcare
- Frequency: Quarterly (pre-accreditation review)
- Estimated Time: 60-90 minutes
- Role: Hospital Quality Manager / NABH Coordinator / Medical Superintendent
- Total Items: 27
- Compliance: NABH Hospital Accreditation Standards 5th Edition 2020, Clinical Establishments (Registration and Regulation) Act 2010, Bio-Medical Waste Management Rules 2016, Pre-Conception and Pre-Natal Diagnostic Techniques Act (PC-PNDT)
Patient Access and Assessment (ACC/COP)
Patient registration, assessment, and continuity of care standards.
- Admission, discharge, and transfer procedures documented?
- Initial patient assessment completed within defined timeframe?
- Individualised care plan documented in case records?
- Informed consent taken for procedures and documented?
- Discharge summary given to patient at time of discharge?
Infection Control (AAC / COP)
Hospital infection control and prevention programme.
- Infection Control Committee (ICC) constituted and meeting regularly?
- WHO 5-moments hand hygiene compliance audited?
- PPE (gloves, masks, gowns) available and correctly used by staff?
- Sterilisation and disinfection procedures documented and followed?
- HAI (hospital-acquired infection) surveillance and reporting in place?
Medication Management (MOM)
Safe medication management practices.
- Hospital formulary approved and available to prescribers?
- High-risk medications identified, labelled, and separately stored?
- Medication reconciliation done at admission, transfer, discharge?
- Crash cart available, checked, and documented daily?
Patient Rights and Education (PRE)
Patient rights, grievance mechanism, and education.
- Patient rights and responsibilities charter displayed in local language?
- Patient grievance redressal mechanism functional?
- Patient confidentiality and privacy maintained?
- Patient satisfaction survey conducted regularly?
Bio-Medical Waste Management
BMW compliance per Bio-Medical Waste Management Rules 2016.
- BMW segregated at source in colour-coded bags/containers?
- BMW authorisation from State Pollution Control Board valid?
- BMW handed over to authorised Common Bio-Medical Waste Facility?
- All healthcare workers trained in BMW management?
- Observations and deficiencies noted
Quality Improvement and Patient Safety (QPS)
Quality management and patient safety programmes.
- Quality Improvement Plan documented and being implemented?
- Clinical and managerial quality indicators monitored monthly?
- Adverse event reporting and root cause analysis system in place?
- Patient safety goals (correct patient, correct surgery, falls, etc.) implemented?
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Why Use This NABH Hospital Accreditation Standards Checklist?
This nabh hospital accreditation standards checklist helps healthcare teams maintain compliance and operational excellence. Designed for hospital quality manager / nabh coordinator / medical superintendent professionals, this checklist covers 27 critical inspection points across 6 sections. Recommended frequency: quarterly (pre-accreditation review).
Ensures compliance with NABH Hospital Accreditation Standards 5th Edition 2020, Clinical Establishments (Registration and Regulation) Act 2010, Bio-Medical Waste Management Rules 2016, Pre-Conception and Pre-Natal Diagnostic Techniques Act (PC-PNDT). Regulatory-aligned for audit readiness and inspection documentation.
Frequently Asked Questions
What does the NABH Hospital Accreditation Standards Checklist cover?
This checklist covers 27 inspection items across 6 sections: Patient Access and Assessment (ACC/COP), Infection Control (AAC / COP), Medication Management (MOM), Patient Rights and Education (PRE), Bio-Medical Waste Management, Quality Improvement and Patient Safety (QPS). It is designed for healthcare operations and compliance.
How often should this checklist be completed?
This checklist should be completed quarterly (pre-accreditation review). Each completion takes approximately 60-90 minutes.
Who should use this NABH Hospital Accreditation Standards Checklist?
This checklist is designed for Hospital Quality Manager / NABH Coordinator / Medical Superintendent 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.