Contact Information:

Website: www.hope.qcin.org
Email: [email protected]
Phone: 1800-102-3814
 Table of Content

Content Page No
1. About the Organization 3
1.1 About Quality Council of India (QCI) 3
1.2 Accreditation Boards of QCI 3
1.3 About National Accreditation Board of Hospitals
and healthcare providers (NABH) 3
1.4 NABH Program and Activities 4
2. Accreditation Overview 5
2.1 About Accreditation 5
2.2 About Healthcare Accreditation 5
2.3 Need of Accreditation Bodies 5
2.4 Why NABH? 5
2.5 Benefits of NABH Certification 6
3. Process of Entry Level Certification Program 7
3.1 Difference between NABH Full Accreditation and
Entry Level Certification 7
3.2 About HOPE 7
3.3 Procedure of Entry Level Certification 8
3.4 Steps for Entry Level Certification 9
3.4.1. Registration 9
3.4.2 Sections to be covered under Desktop Assessment 9
3.4.3 Fee Submission 12
3.4.4 On Site Assessment 12
3.4.5 Certification 12
4. Outline of questionnaire 13
4.1 Outline of NABH Standards 13
4.2 Revised Questionnaire for Entry Level Certification 15
5. HOPE- Healthcare Organizations’ Platform for Entry Level Certification 16
5.1 Registration Steps on Web Portal 16
5.2 Key Points to Remember 22
5.3 Documentation steps on Mobile App 23

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5.4 Key Points to Remember 26
5.5 Steps to reply DA NC 26
6. Post Entry Level Certification –
Full Certification and Maintenance of Accreditation 30
6.1 Levels of Hospital Accreditation 30
6.2 Ongoing Process of Accreditation 30
7. Abbreviations 31
8. Documents Required 32

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1. About the Organization

1.1 Quality Council of India

Established in 1997 through a Cabinet decision of the Government of India (GoI) – QCI
is an autonomous organization under the Department of Industrial Policy and
Promotion (DIPP), Ministry of Commerce and Industry. It was established as the
national body for accreditation and quality promotion in the country. The Council was
established to provide a credible, reliable mechanism for third party assessment of
products, services and processes which is accepted and recognized globally.

1.2 Accreditation Boards of QCI

1. National Accreditation Board for Hospitals and Healthcare Providers (NABH)
2. National Accreditation Board for Certification Bodies (NABCB)
3. National Accreditation Board for Testing and Calibration Laboratories (NABL)
4. National Accreditation Board for Education and Training (NABET)
5. National Board for Quality Promotion (NBQP)

1.3 National Accreditation Board for Hospitals & Healthcare Providers

NABH is a constituent board of Quality Council of India, set up to establish and operate
accreditation and other allied programmes for healthcare organizations. The mission
of NABH is to operate accreditation and allied programs in collaboration with
stakeholders focusing on patient safety and quality of healthcare by adopting various
national/international best practices.

Global Recognition:
 NABH is an Institutional Member as well as a Board member of the International
Society for Quality in Health Care (lSQua) and on board of Asian Society for Quality
in Healthcare (ASQua).

3
1.4 NABH Program and Activities
 Accreditation- NABH accreditation is aimed at establishing common framework for
healthcare organizations to demonstrate and practice compliance to patient safety
protocols. NABH is operating various accreditation programs for Hospitals, Small
healthcare organization, Blood Bank, Blood Storage Centre, Medical Imaging
Services, Dental Facilities/Dental Clinics, Oral Substitution Therapy Centre,
Allopathic Clinic, AYUSH Hospitals, Community Health Care, Primary Health Care,
Wellness Centre, Clinical Trial (Ethics Committees), Panchkarma Clinic, Eye Care
Organization and Integrated Rehabilitation Centres For Addicts.
 Certification- NABH is operating various certification programs such as Entry-Level
Hospitals, Entry-Level SHCO, Nursing Excellence, Medical Laboratory Program and
Standards for Emergency Department in Hospitals.
 Empanelment- A network of ECHS And CGHS empaneled hospitals can also apply
for NABH accreditation to provide quality medicare to beneficiaries and their
dependents. As per the empanelment protocols, the accreditation helps the
hospitals to ensure cashless transactions, as far as possible, for the patients.
 Training & Education- NABH conducts various awareness and educational
workshops such as Programme on Implementation of NABH Standards for
Hospitals, Programme on Implementation of NABH Standards for Blood Bank,
Programme on Implementation of NABH Standards for Nursing Excellence
Certification, Programme on Implementation of NABH Standards for Entry-Level
Hospital etc.

4
2. Accreditation Overview

2.1 What is Accreditation?

It is a process to measure the performance of an organization against a set of
nationally recognized, practice-focused and evidence-based standards. The process of
validation is a series of steps carried out to measure the quality of the organization’s
functions and services and is valid only for a specified time period. The goal is
continuous development, quality improvement and overall performance of the
organization.

2.2 About Healthcare Accreditation

National Accreditation System for hospitals ensure that hospitals and healthcare
organisations, whether public or private, play their expected roles in the National
Healthcare Ecosystem by complying with the highest standards of the Accreditation
Body. It is a mechanism to enhance and maintain the quality of healthcare services
across all departments of a healthcare organisation. In India, Healthcare System
operates in an environment of rapid social, economical and technical developments
and raise concerns on the quality of healthcare. Therefore, an assurance by the
Accreditation Body helps in creating accountability of healthcare organisation among
its stakeholders and making it more receptive with the trust of improved services.

2.3 Role of Accreditation Bodies

Accreditation bodies, such as NABH, provide quality assurance in patient and
organization centric activities of healthcare institutions. As a result, there has been an
interest and willingness to opt for accreditation due to multiple benefits and
recognition of quality service in healthcare sector. In addition, various market forces
such as medical tourism, insurance services, growing pool of private healthcare
institutions and rising competition have pushed healthcare organizations to obtain
highest industrial standards. Thus, it ensures that the investment is put to best use
possible, by creating a differentiating factor in the industry.

2.4 Why NABH?

It is a national accreditation body aimed to ensure that healthcare organizations are
providing quality care and high quality of services to the patients. An accreditation
status through NABH provides marketing advantage in the competitive healthcare

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sector by simultaneously strengthening the hospital’s functioning. It provides an
opportunity for the hospital to benchmark its services with the global standards and
increase patient footfall and have a share of growing medical tourism market in India.

NABH Accreditation and Certification Program sets the highest benchmarks of hospital
operations at all levels and across functions as per the globally accepted norms. The
standards provide framework for quality care of patients and necessary
improvements in hospitals by systemizing the hospital operations and protocols. It
evaluates all the aspects of the hospital with a comprehensive approach before
accreditation resulting in continuous improvement and enhanced productivity.

2.5 Benefits of NABH Certification-

Patients - Patients are the biggest beneficiaries among all the stakeholders as
certification results in high quality of care and patient safety and ensures the whole
system is patient centric.

Healthcare Organization- Certification to a health care organization stimulates

continuous improvement. It enables the organization in demonstrating commitment
to quality care. It raises community confidence in the services provided by the health
care organization. It provides an opportunity to healthcare unit to benchmark with
the best and benefit from financial incentives given under various government
schemes to such accredited hospitals.

Healthcare Staff- It improves overall professional development of the hospital staff

and provides leadership for quality improvement in various techniques. It also creates
a good working environment where the staff can continuously learn and take
ownership of their roles and responsibilities.

Regulatory Bodies- Certification provides access to reliable and certified information

on facilities, infrastructure and level of care, which can be used by insurance
organizations and other third parties, thus, reducing uncertainties while making a
public decision and getting assurance about the capabilities of the healthcare
organization.

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3. Process of Entry Level Certification Program

3.1 Difference between NABH Full Accreditation and Entry Level Certification

 Full Accreditation
NABH has designed an exhaustive list of healthcare standards for hospitals and
healthcare providers. The standard consists of more than 600 stringent objective
elements for the hospital to achieve in order to get the NABH Accreditation.

 Entry Level Certification

As numerous hospitals were facing challenges and difficulties in implementing the
complete Accreditation Standards, therefore, NABH has developed Entry Level
Certification program with simplified objective elements, in consultation with
various stake holders in the country, as a stepping stone for enhancing the quality
of patient care and safety. It is also the first step towards NABH Accreditation.

3.2 About HOPE – Healthcare Organizations’ Platform for Entry-Level Certification

QCI has launched a new platform, Healthcare Organizations’ Platform for Entry-Level
Certification (HOPE) for the Entry Level Certification program. The complete
certification process that includes registration, documentation and fee submission will
be carried out on HOPE. It is a multifarious platform for certification process of
Healthcare organizations which provides complete information about the simplified
certification process, requirements and compliances. HOPE incorporate guidebook,
presentations, documents, videos in knowledge bank and additionally supported with
a toll free helpline.

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3.3 Procedure for Entry Level Certification

Temporary
Registration on Web Portal Application
Number

Information, document submission (on web

portal and mobile application)

Permanent
Fee Submission Application
Number

NC closure by
NC on No NC on
uploading Desktop
Desktop Desktop
evidence by Assessment (DA)
Assessment Assessment
HCO/SHCO

Closure NC closure by NC closure

evidence uploading acceptance
not evidence by
accepted HCO/SHCO

Application Rejected

NC closure
acceptance Date allotment for on-site assessment

NC closure by No NC on
uploading On-site assessment by on-site
NC Raised
evidence by assessor assessment
HCO/SHCO

Closure NC closure by NC closure

evidence uploading acceptance
not evidence by
accepted HCO/SHCO

Application Rejected

NC closure Certification recommendation

acceptance decision by Committee

Certification
Not Granted Certification
Granted

Printable Digital
Certification

8
3.4 Steps for Entry Level Certification

3.4.1 Registration
HCOs/SHCOs can register online on www.hope.qcin.org. An account will be created
after filling the user registration form. User can login with the username and password
received on their registered mail id and has to submit all the required details through
web portal and mobile application followed by the fee payment. The details entered
by applicant for registration on the HOPE website cannot be edited once the details
are submitted. Please make sure that the details are filled accurately.

Please ensure that you change your password as per your convenience once you login
to your account. (It has been explained in detailed in Chapter 5).

3.4.2 Sections to be filled on HOPE Portal

a) General Information
This section covers basic information of the hospital and is divided into the following
categories:
 Contact Details- Covers details such as the Name of the Hospital, Address, the
person responsible for coordinating and implementing the quality improvement
programme. It also includes the City and State in which the hospital is located.
 Hospital Information- Covers details related to hospital establishment like
Registration Number, Registration Date, Type of Ownership.

b) Statutory Compliances
This section covers the following things –
 Statutory Compliances – This section states the types of statutory compliances the
organization must provide. It includes acquired licenses such as, the AERB license
for X-Ray, Mobile X-Ray, OPG, CT scan, radiotherapy, IMRT, Cobalt, Linear
Accelerator, Brachytherapy etc. In addition, license number, status, issuing
authority etc. are also evaluated.
 Details of MoU of various outsourced services related to the hospital – This part
of the statutory compliance validates the various outsourced services and details
of the same.

c) Hospital Staffing

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This section covers details pertaining to the Hospital Staff such as name, designation,
qualification, type of degree, registration number, working department etc. It is
divided into the following categories:
• General duty medical officers
• Nurses
• Paramedical staff
• Administrative and support staff

d) Clinical Services Details

This section covers the type of clinical service details in the hospital such as OPD / IPD
data, Average Occupancy Rate, ICU Data, Scope of Services, etc. The Scope of Service
include the name of the service offered, details of full time / part time / visiting
consultants, doctors name, graduation, post- graduation, etc. Additional information
required from the HCOs/SHCOs is as follows:
 Ten most frequent clinical services where admissions take place
 Ten most frequent diagnoses for in-patients
 Ten most frequent surgical procedures at your hospital
 Choose the type of sterilization modes used in the hospital

e) Physical Infrastructure
This section focuses on the physical infrastructure of the hospital. It gives a clear
indication of the kind of medical facilities available at the hospital. It covers the
following details:
 Bed Strength-Seeks information about the number of operational bed for
categories like Emergency ward, ICU, HDU, General, private and semi-private ward.
 Service Offered- Seeks location details of the services offered like Anesthesia,
blood bank, cardiac OY, cath lab, CCU, ICU, labour room, medical ward, NICU,
nuclear medicine, OT, ortho ward etc.
 Laboratory Services- Requires information of laboratory services which includes
Clinical Bio-chemistry, Clinical Microbiology and Serology, Clinical Pathology,
Cytopathology, Genetics, Haematology, Histopathology, Toxicology and Molecular
Biologylabs.
 Diagnostic Imaging- Validates details of service offered like Bone Densitometry,
CT Scanning, DSA Lab, Gamma Camera, Mammography, MRI, Nuclear medicine,
PET, ultrasound, Urodynamic Studies and X-Ray.

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 Others- Covers the remaining services offered by the hospital like 2D Echo,
Audiometry, EEG, EMG/EP, holter monitoring, Spirometry-PFT and Tread Mill
Testing.
Apart from these clinical services this section includes questions like Availability of
electrical supplies, water supplier, elevators, Type of trolleys present at the
hospital, Ambulance Accessibility, Uniform signage system in the Facility etc.

f) Quality Improvement Process

This section covers all the vital areas related to patient care, the details are as follows
 Committee/Coordinator- Answers questions, whether the hospital has a
committee /coordinator for activities such as quality safety, infection control,
pharmacy and therapeutic, blood transfusion and medical record.
 Registration, Admission and Billing process- Focuses on parameter for patient
identification, patients rights and responsibilities and documentation of
registration and admission of patients.
 Patient and Family Education-Consists of consent records required from patient
and family end - Blood and Blood Products Transfusion Consent, Blood Donation
Consent, Anesthesia Consent, Surgery Consent.
 Patient Related Process- Information pertaining to UHID of patient and his/her
corresponding document forms for OPD, IPD, emergency, MLC etc. are checked.
 Nursing Care Process- Includes nursing documentation like medication
administration record, nursing monitoring charts and nurses notes.
 Medication Management- Includes documentation like storage of medication,
emergency medication, prescription, medication order etc.
 Human Resource Training- Verifies trainings conducted by HCOs on scope of
services, Safe practices in Laboratory, Safe practices in Imaging, care of Emergency
patients in consonance with the scope of the services of hospital, Child Abduction
Prevention, Disciplinary procedures etc.
 Infection Control- Focuses on Hand Hygiene, General Cleanliness, Standard
Precaution & Personal Protective Equipment, Occupational Health, Bio Medical
Waste, Water Testing etc.
 Management Process- Seeks information regarding Medication Error and Adverse
Drug Reaction, Laboratory, Blood Bank etc.

11
 Safety Management- Requires photographs to be uploaded for the safety
management devices/procedures like Adequate safety devices that are available in
the lab, Aprons and shields usage for shielding of body parts of staff and patients,
Department where radioactive drugs are used, Filled WHO Surgical Safety checklist
used for every surgery.
 Record Management- Documents pertaining to Medical Records and Fire
Extinguishers in the Medical Record Department (MRD) are required.

g) Documentation
This section covers all the important documents related to General Information,
Statutory Compliances, Hospital Staffing, Clinical Services Details, Physical
Infrastructure and Quality Improvement Process. Documentation will be done by
using web portal.

3.4.3 Fee Submission

The fee to be submitted by HCO (Hospitals with More than 50 Sanctioned beds) and
SHCO (Hospitals up to 50 Sanctioned beds) is as follows:
 HCO – Entry Level Certification Fee: Rs 52,000 + GST
 SHCO – Entry Level Certification Fee: Rs 21,000 + GST

3.4.4. Desktop Assessment

Desktop Assessment of HCOs will be done online through web portal and mobile
application by DA team. DA team will raise NCs and HCOs/SHCOs will have a specified
timeline to close all the non-compliances. The DA team will have to verify all the
replies within a specific period of time.

3.4.5 On Site Assessment

After closing all non-compliance(s) generated at DA stage, HCOs will be moved to next
stage of on-site assessment followed by the assessment planning. On-Site Assessment
will be done by the assessor. Final quality check of the assessment will be done by the
experts and NCs (if any) will be raised for any clarifications or missing pieces. HCOs will
be having a defined time to close all the NCs.

3.4.6 Certification
Application will be sent to certification committee after closure of all the NCs from
HCOs and quality check team. Final decision taken by the committee will be notified

12
to the HCOs. If the application gets rejected at committee stage, HCOs will be having
an appeal facility after paying the appeal fees. Digital Certificate will be provided to all
the hospitals that the accreditation committee approves.

4. Outline of The Questionnaire

Entry Level Certification Process is based on the NABH standards that comprises of 10
chapters. As part of the HOPE program the Entry Level Certification Questionnaire has
been revised to make it simpler and has been drafted based on the objective element
given in the aforementioned NABH standards. The standards are detailed below-

4.1 Outline of NABH Standards

Patient Centered Standards

Chapter Description
Access, Assessment Lays down key safety and process elements that the
and Information organization should meet, in the continuum of the patient
(AAI) care within the hospital and till discharge.

Care Of Patient Patients in the Emergency Department are provided urgent

(COP) care including ambulance services in consonance with their
clinical requirements and in accordance to the statutes of
the land.

Hospital Infection The standards guide the provision of an effective infection

Control (HIC) control programme in the organization. Their programme
should be documented and aimed at reducing/eliminating
infection risks to patients, visitors and providers of care
while proactively monitoring its adherence.

Management of The organization should have a mechanism to ensure that

Medication (MOM) the emergency medications are standardized, readily
available and replenished in a timely manner. The process

13
 also includes monitoring of patients after administration
and procedures for reporting and analyzing adverse drug
events.

Patient Right and The HCO should define the patient and family rights and
Education (PRE) responsibilities. In addition, the staff should be trained to
protect patient rights and patients are informed of their
rights and educated about their responsibilities at the time
of admission.

Organization Centered Standards

Chapter Description
Continuous Quality The standards introduce the subject of continual quality
Improvement (CQI) improvement and patient safety by documenting HCOs
quality and safety programme and involve all areas of the
organization and staff members in it.

Responsibilities of The standards encourage the governance of the

Management organization in a professional and ethical manner. The
(ROM) responsibilities of the management are defined.

Facility The standards guide the provision of a safe and secure

Management and environment for patients, their families, staff and visitors.
Safety (FMS) To ensure this, the organization conducts regular facility
inspection rounds and takes the appropriate action to
ensure safety.

Human Resource The goal of human resource management is to acquire,

Management provide, retain and maintain competent people in right
(HRM) numbers to meet the needs of the patients and community
served by the organization.

14
 Information The chapter emphasizes the requirements of a medical
Management record in the hospital as it is an important aspect of
System (IMS) continuity of care and communication between the various
care providers.

4.2 Revised Questionnaire for Entry-Level Certification- The Questionnaire is

divided into seven parts, which has been elaborated in Section 3.4.

The categorization into seven parts is as follows-

Part I – General Information
Part II – Physical Infrastructure
Part III – Statutory Compliances
Part IV- Clinical Services Details
Part V – Hospital Staffing
Part VI –Quality Improved Process
Part VII- Documentation Requirements

15
5. HOPE- Healthcare Organizations’ Platform for Entry Level Certification

5.1 Registration steps on web portal

Step 1:

STEPS TO APPLY ONLINE

Go to www.hope.qcin.org to open the web page and click on ‘register’ tab

Quality Council of India Creating an Ecosystem for Quality 77

Step 2:

STEPS TO APPLY ONLINE

Fill in all the details

Then Click on Create Account

Quality Council of India Creating an Ecosystem for Quality 88

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Step 3:

STEPS TO APPLY ONLINE

On-Screen Pop-Up Appears that confirms successful registration of the HCO

Screenshot of the application

Quality Council of India Creating an Ecosystem for Quality 99

Step 4:

STEPS TO APPLY ONLINE

User receives email

with Username and
Password
Screenshot of the application

Quality Council of India Creating an Ecosystem for Quality 1100

17
Step 5:

STEPS TO APPLY ONLINE

Screenshot of the application

Login with the registered Username

and Password as received on mail

Quality Council of India Creating an Ecosystem for Quality 1100

Step 6:

STEPS TO APPLY ONLINE

SPOC Name Displayed on the top right
Home Page as appears after logging in

Screenshot of the application

Quality Council of India Creating an Ecosystem for Quality 1122

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Step 7:

STEPS TO APPLY ONLINE

Home Page after clicking on Registration will
show the registration details

General Information Tab

Screenshot of the application

Fill in all the details of the Healthcare Organization by

expanding the sub categories. Do so by clicking on the (+)
sign.

Quality Council of India Creating an Ecosystem for Quality 1133

Step 8:

Difference between web portal and mobile application

documentation uploads

Documents that require to be uploaded through the web portal online will have an “Upload any file” icon next to them as highlighted.

Documents that require to be uploaded through the mobile application online will have a “View Uploaded File” icon next to them as
highlighted.

Quality Council of India Creating an Ecosystem for Quality 1133

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Step 9:

STEPS TO APPLY ONLINE

Statutory Compliances Tab

Screenshot of the application

Attach relevant documents and fill complete
details of the HCO.

Attach relevant documents and fill complete

details of the HCO.
Quality Council of India Creating an Ecosystem for Quality 1155

Step 10:

STEPS TO APPLY ONLINE

Fill up all the details in the below seven sections
highlighted as under

Screenshot of the application

Quality Council of India Creating an Ecosystem for Quality 1166

20
Step 11:

STEPS TO APPLY ONLINE Applicant can save their progress any time during the
process of filling up the application form

Quality Council of India Creating an Ecosystem for Quality 1177

Step 12:

After filling up all the necessary details and attaching

all the required documents, Click on the “Final
STEPS TO APPLY ONLINE Submit” button

* Note: The applicant will not be able to make any

changes to the form after clicking this button

Quality Council of India Creating an Ecosystem for Quality 1188

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Step 13:

STEPS TO APPLY ONLINE

Click on the SPOC name (top right) and then log out
successfully.
Remember to save your progress before logging out of the
portal.

Quality Council of India Creating an Ecosystem for Quality 1199

5.2 Key Points to Remember-

 It is compulsory to save the information on the Desktop Portal first before
using the Mobile Application for further documentation uploads.
 The applicant can only login on either the Desktop Portal or the Mobile
Application and cannot use both the online tools simultaneously.
 The Mobile Application can only be downloaded on Android Operating
Systems.
 It is necessary to make sure that user is connected to an active internet
connection while uploading documents on Mobile App.
 The details entered by applicant for registration on the HOPE website cannot
be edited once the details are submitted. Please make sure that the details
are filled accurately.

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5.3 Documentation Steps- Mobile App

Step 1:

USING THE MOBILE APPLICATION

Login to the mobile application with the

username and password created through the web
portal

Quality Council of India Creating an Ecosystem for Quality 2200

Step 2:

STEPS TO UPLOAD DOCUMENTATIONS

After Clicking on the “arrow” button

to the right of the section

“Hospital Information”

This is the first page after logging in to the mobile

application. User can select the category and start
uploading the documents.

Quality Council of India Creating an Ecosystem for Quality 2211

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Step 3:

STEPS TO UPLOAD DOCUMENTATIONS

1. A blue “camera”
icon shows that 3. The “camera”
NO photographic icon now turns
evidence has been orange, after the
added to the photographic
corresponding evidence has been
parameter yet added

2. Upload the
documents 4. Tap on the
according to the “SYNC” button to
parameter by upload the
clicking on the photographic
adjacent “Camera” evidence to the
shaped icon web portal online

Quality Council of India Creating an Ecosystem for Quality 2222

Step 4:

VERIFICATION OF UPLOADED DOCUMENTATIONS ON WEB PORTAL

Click on the “View the uploaded file” button

Quality Council of India Creating an Ecosystem for Quality 2244

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Step 5:

VERIFICATION OF UPLOADED DOCUMENTATIONS ON WEB PORTAL

On-Screen Pop-up appears showing the serial number of the file uploaded and “Action”
that can be taken to either “Download” the document or “Delete” it as deemed fit.

Document Serial Number “Download” Button “Delete” Button

“Action” Buttons

Quality Council of India Creating an Ecosystem for Quality 2244

Step 6:

STEPS TO UPLOAD DOCUMENTATIONS

Do not forget to click on the SYNC button to update the

uploaded documents online and save your progress

Quality Council of India Creating an Ecosystem for Quality 2255

25
5.4 Keys points to remember-
 Once the payment has been made by the applicant, the application will go to the
desktop assessment team for verification.
 Upon verification by the team, applicant will receive a mail for any non-conformity
raised in the application.
 Applicants have to use the same ID and Password, they used while registering, to reply
the NC raised.
 After logging in the web portal, applicant will have to check each tab in which NC is
raised.
 Applicant has to submit reply to all the NCs before the application can move to the
onsite assessment stage.

5.5 Steps to reply to DA NC

Step 1:

26
 Step 2:

Step 3:

27
 Step 4:

Step 5:

28
 Step 6:

Step 7:

29
Step 8:

6. Post Entry Level Certification – Full Certification & Maintenance of Accreditation

6.1 Levels of Hospital Accreditation

The validity period for Entry Level Certification is for two years. Once it is achieved,
the HCO can then consider to prepare and move to the next stage that is to Full
Accreditation status. The validity period for NABH full accreditation is for 3 years
subject to terms and conditions.

6.2 Ongoing Process of Accreditation

NABH accreditation is not a one-time event, and the accreditation is not permanent.
The onus of continuously maintaining standards and continuously monitoring policies
and practices falls on the hospital. Once a hospital gets accredited, the accreditation
is valid for a defined period and is subject to change based on subsequent surveillance.
NABH conducts a regular surveillance of the accredited organization (the first such is
usually planned during the 2nd year).

30
7. Abbreviations

1. DA- Desktop Assessment

2. NC- Non Compliance
3. HCO- Healthcare Organizations
4. SHCO- Small Healthcare Organisations
5. ECHS- Ex-Servicemen Contributory Health Scheme
6. CGHS – Central Government Health Scheme
7. AERB – Atomic Energy Regulatory Body
8. OPG - Orthopantomogram
9. CT - Computed Tomography
10. IMRT- Intensity Modulated Radiation Therapy
11. OPD- Out Patient Department
12. IPD - Inpatient Department
13. ICU- Intensive Care Unit
14. HDU- High Dependency Unit
15. CCU- Critical Care Unit
16. NICU- Neonatal Intensive Care Unit
17. OT- Operation Theater
18. DSA- Digital Subtraction Angiography
19. PET- Polyethylene Terephthalate
20. EEG- Electroencephalography
21. EMG- Electromyography
22. UHID- Unique Health Identification Number
23. MLC- Medico Legal Cases
24. WHO- World Health Organization

31
8. Documentations Required

1 - General Information
 Certificate which validates the registered name of the Hospital to be uploaded
through portal
Note - The same name will appear on the digital certificate provided at the end of
pre-entry level accreditation certification process.

Hospital Information
 Registration Certificate of hospital under one of the following body / act to be
uploaded through portal
o State / Local Statutory Hospital Registering Body
o Clinical Establishment Act
o Shop and Establishment Act
 Registration Certificate of hospital for type of ownership/partnership like private-
corporate, proprietary, cooperative society etc. to be uploaded through portal
 Certificate of the hospital under any government empanelment schemes (as
applicable) such as ECHS, CGHS, etc. to be uploaded through mobile application

2 - Physical Infrastructure
 Documentation pertinent to Land / Rent Agreement or occupancy certificate to
be uploaded through portal.
Laboratory Services (as applicable) – If any of the services is located outside the
hospital premises

MoU with the other Hospital to be uploaded through portal for:

 Clinical Biochemistry Lab
 Clinical Microbiology & Serology Lab
 Clinical Pathology Lab
 Cytopathology Lab
 Genetics Lab
 Hematology Lab
 Histopathology Lab
 Toxicology Lab

32
 Molecular Biology Lab
Diagnostic Imaging (as applicable)- If any of the services is located outside the
hospital premises

MoU with the other Hospital to be uploaded through portal for:

 Bone Densitometry service vendor
 CT Scanning service vendor
 DSA Lab
 Gamma Camera service vendor
 Mammography service vendor
 MRI service vendor
 Nuclear Medicine service vendor
 PET service vendor
 Ultrasound service vendor
 Urodynamic Studies service vendor
 X-Ray service vendor
Others Services (as applicable) – If any of the services is located outside the
hospital premises

MoU with the other Hospital to be uploaded through portal for

 2D Echo service vendor
 Audiometry service vendor
 EEG service vendor
 EMG/EP service vendor
 Holter Monitoring service vendor
 Spirometry - PFT service vendor
 Tread Mill Testing service vendor
Other Diagnostic Services
 MoU with the other Hospital to be uploaded through portal for any other
diagnostic service offered. 
Water Supplier
 Certificate of portability of alternate as well as drinking water source as per IS
10500: 2012 to be uploaded through mobile application
Elevators
 Certificate of Lift License / Safety for all elevators to be uploaded through portal

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Ambulance – All Documents uploaded through Mobile Application
 List of dugs present in the ambulance
 Training records and driving license of the drivers deputed in ambulances
 Training records of the doctors deputed in ambulances
 Training records of the nurses deputed in ambulances 
 Training records of the technicians deputed in ambulances 
3 Statutory Compliances (as applicable) – All Documents to be uploaded through
Mobile Application
 Legal status for conducting business under Shops and Commercial
Establishments Act (Registration and place of business of the hospital) certificate
 State Pollution Control Board (SPCB) Consent to generate Bio-Medical Waste
(BMW)
 MoU with BMW collecting Agency
 Pollution Control Board License for water and Air Pollution (above 50 beds)
 Registration under PC-PNDT Act certificate
 Registration under MTP Act certificate
 AERB License for X-Ray
 AERB license for Mobile X-Ray(s)
 AERB License for Dental X-Rays
 AERB License for OPG
 AERB License for CT scan machine
 AERB License for Mammography services 
 AERB License for BMD services
 AERB License for C-Arm services
 AERB License for Cath Lab
 RSO Level I,II,III License
 Nuclear Medicine Compliance License
 PET Scan Compliance License
 SPET / CT Compliance License
 Radiotherapy Compliance License
 IMRT Compliance License
 Cobalt Compliance License
 Linear Accelerator Compliance License
 Brachytherapy Compliance License
 Narcotics License

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 Retail Pharmacy License
* In case license is expired, document of renewal application will also be required
which will be uploaded through portal.
MoU of Outsourced Services related to the hospital
 MoU with the other Hospital to be uploaded through portal for all the
outsourced services.
4 - Clinical Service Details OPD and IPD Data
 UHID OF 5 patients treated in past 6 months under each clinical services offered
to be uploaded through mobile application
5 - Hospital Staffing
*No Documents Required

6 - Quality Improvement Process Committee/Coordinator – All the documents to

be uploaded through app
 Documents for any two changes made in the hospital which are related to quality
& patient safety along with the expenses incurred certified by Top Management.
 Documents for any five indicators data signed by top management.
Registration Admission & Billing process (as applicable) -
 Upload scanned copies of documents through portal for registration and
admission of patients in the following
o OPD
o IPD
o Emergency
 Upload a copy of basic tariff List which includes bed charges, OT, charges, ICU
charges, packages, etc. through mobile application

Patient and Family Education (Understandable Language by patient) (as applicable)

 Blood and blood product consent of 3 patients to be uploaded through mobile
application.
 Blood donation consent of 3 patients to be uploaded through mobile application.
 Anesthesia Consent of 3 patients to be uploaded through mobile application.
 Surgery consent of 3 patients to be uploaded through mobile application.
 Training material on education on safe parenting, nutrition and immunization to
be uploaded through portal.
Patient Related Processes (as applicable) – All the documents to be uploaded
through app

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 Upload UHID of any one patient and corresponding filled Initial Assessment form
for OPD by doctor, IPD by doctor, IPD by nurse and Emergency.
 Upload any 1 MLC or Police intimation form or MLC register scanned copy.
 Copy of scope of Obstetric Services being offered and UHID of Patient with
corresponding copies of Ante natal check-ups, maternal nutrition, and post-natal
care.
 Copy of UHID of any 1 patient and the corresponding filled copy of assessment
sheet including nutritional, growth and immunization.
 Upload a copy of Pediatrics service
 Upload register (or any other documentary evidence) of patients who were
referred/transferred from Inpatient area.
 Upload a filled patient case sheet of any 1 patient from the ICU.
 Upload a filled patient case sheet of any 1 patient from any 1 ward.
 Upload a copy of any 1 patient case sheet having Pre anesthesia assessment
format.
 Upload a copy of any 1 patient case sheet having anesthesia monitoring format.
 Upload a copy of any 1 patient case sheet having post anesthesia status
monitoring format.
 Upload a copy of adverse anesthesia events records in past 3 months (if
applicable)
 Upload a copy of any 1 patient case sheet having Preoperative assessment and
provisional diagnosis.
 Upload a copy of any 1 patient case sheet having Operative notes and Post-
operative plan of care.
 Upload filled ward discharge summary (all pages) of any one patient.
 Upload filled discharge summary (all pages) of any one LAMA patient.
Nursing Care Processes (as applicable) – All the documents to be uploaded through
app
 Upload 1 copy of nursing documentation (Medication Administration Record).
 Upload a copy of nursing monitoring charts.
 Upload a copy of nurses’ notes.
Medication Management (as applicable) – All the documents to be uploaded
through app
 Upload copies of fridge temperature records of last three months.
 Scanned list of emergency and high risk medications.
 Upload photo of stock of emergency medications.

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 Upload copies of prescriptions of any 3 patients.
 Upload copy of medication order from ICU, Wards, Emergency, Obs & Gyn and
Pediatric. 
Human Resource Training (as applicable) – All the documents to be uploaded
through app
 Upload training record for scope of services 
 Upload training record for care of emergency patients
 Upload training record for Infection Control Practices
 Upload training record for Safety Education programme
 Upload training record for Medication Error
 Upload training record for Grievance Handling procedures
 Upload training record for Safe Practices in Laboratory
 Upload training record for Safe Practices in Imaging
 Upload training record for Child Abduction Prevention
 Upload training record video on fire mock drills 
 Upload training record for Spill Management
 Upload training record for needle stick injury
 Upload training record for Disciplinary Procedures 
 Upload training record of staff on Preparation and Administration of
Chemotherapeutic Dugs
Infection Control (as applicable) – All the documents to be uploaded through app
 Upload copy of housekeeping checklist for any 3 locations.
 Upload photo of autoclaving records indicators.
 Upload Microbiological surveillance culture report of OT, Labor Room, ICU, and
NICU (All for the past 3 months).
 Upload records of pre and post exposure prophylaxis provided to staff
 Upload Bio medical waste (BMW) authorization from Pollution control board
(through portal)
 Upload MoU with outsourced bio medical waste agency (through portal)
 Upload photo of display of work instructions for segregation and handling of
biomedical waste.
 Upload Record of fee, documents & report submitted to competent authorities
on stipulated dates for BMW.
Management Process
 Upload a scanned copy of the documented hospital mission through portal. 
 Upload the organization’s organogram through portal.

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 Upload the handling record of patient grievances/complaints through mobile
app.
 Upload the documents of composition of all committee (Quality and Safety,
Infection Control, Pharmacy and Therapeutics, Blood Transfusion, and Medical
Records etc.) through portal.
 Upload copy of terms of reference of all the committees through portal
 Upload a copy of minutes of meeting of all the committees for last 3 months
through mobile app
 Upload scanned data of Medication Error and Adverse drug reaction of last 3
months through mobile app
 Upload scanned Root Cause Analysis (RCA) and Corrective & Preventive Action
(CAPA) of Medication Error and Adverse drug reaction of last 3 months through
mobile app
 Upload scope of services through mobile app. (Laboratory and Imaging)
 Upload the Defined turnaround time for tests through mobile app. (Laboratory
and Imaging)
 Upload a copy of Critical result reporting register wherein there is
documentation pertaining to the – time at which the test result was ready / -
time at which the test result had been communicated, name of the individual to
whom the test result has been conveyed and name and signature of the person
who has conveyed the result through mobile app. (Laboratory and Imaging)
 Upload copies of blood transfusion record which has the orders for transfusion,
pre-transfusion medications (if any), record of verification of cross matching,
label of the transfused blood product, monitoring of patient during the
transfusion (at least 3) through Mobile app.
 Upload scanned filled Blood transfusion reaction form in past 3 months through
mobile app.
 Upload scanned copy of the Blood transfusion committee's minutes, discussed
reaction and CAPA through portal. 
Safety Management – All the documents uploaded through app
 Upload filled WHO Surgical Safety checklist used for every surgery (any 3).
 Upload scanned copy of facility inspection rounds.
 Copy of document of maintenance plan of medical gases and vacuum systems.
 Copy of floor plans with exit routes.
Record Management – All the documents to be uploaded through app
 Upload checklist for completeness for medical records.

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 Filled case sheet of patients having doctors name, signature, date & time (1 from
each ICU, Operative Patient, Ward, Emergency and Obs & Gyn).

7 - Documentation Requirements – All the documents to be uploaded through Portal

 Scanned copy of procedure(s) guide collection, identification, handling, safe
transportation, processing and disposal of specimens.
 Scanned copy of process addresses discharge of all patients including Medico-
legal cases and patients leaving against medical advice.
 Scanned copy of documented procedure (s) address care of patients arriving in
the emergency including handling of medico-legal cases.
 Scanned copies of documented policies and procedures that are used to guide
the rational use of blood and blood products.
 Scanned copies of documented procedures that govern transfusion of blood and
blood product.
 Scanned copies of documented procedure for the administration of anesthesia.
 Copy of a defined criterion to transfer the patient from the recovery area.
 Scanned copies of documented procedure that addresses the prevention of
adverse events like wrong site, wrong patient and wrong surgery.
 Scanned copies of documented procedure incorporating purchase, storage,
prescription and dispensation of medications.
 Scanned copies of documented procedures that address procurement and usage
of implantable prostheses.
 Scanned copies of documented policies and procedure that exist for storage of
medications. 
 Scanned copies of documented policies and procedures that govern usage of
radioactive drugs.
 Policies and procedures that include the safe storage, preparation, handling,
distribution and disposal of radioactive drugs.
 Scanned copies of infection control manual, which is periodically updated and
conducts surveillance activities.
 Scanned copies of documented operational and maintenance (preventive and
breakdown) plan for clinical and support service equipment. 
 Scanned copies of documented safe exit plan in case of fire and non-fire
emergencies.
 Copy of well-defined staff recruitment process.
 Scanned copies of documented disciplinary and grievance handling procedure.

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 Scanned copies of documented policies and procedures for maintaining
confidentiality, integrity and security of records, data and information. 
 Scanned copies of documented procedures that exist for retention time of
medical records, data and information. 
 Copy of a defined process to whom the patient record can be released.
 Scanned copies of procedure on destruction of medical records.

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 

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