Checklist of Radiology and Imaging department and its quality indicators for NABH accreditation preparation

Imaging department is one of the pivotal department for diagnosis of diseases. It includes both radiation based and non-radiation based imaging modalities. The key result areas (KRAs) for imaging departments are availability of required tests, accuracy of diagnosis, safety of patients and staff, maintenance of turn-around time and optimal utilization of equipment. NABH standards for imaging revolves around these KRAs. 

Below is the compilation of all requirements that is applicable to an imaging department for NABH accreditation fulfillment

Checklist for Pharmacy and its quality indicators

A significant number of standards and objective elements of NABH are applicable to Pharmacy of a hospital. Most of these requirements are given under the chapter of ‘Management of Medication’, but there are objective elements under other chapters also, which are applicable to pharmacy. The checklist below has been prepared after taking in consideration all such requirements. Objective of this checklist is that the hospital should be able to prepare and quickly evaluate everything that is applicable to pharmacy under NABH accreditation preparation.

A. Legal requirements
1. The person dispensing the medicine in pharmacy is a qualified pharmacist (B. Pharm or D. Pharm). The qualification certificate should preferably be displayed in pharmacy.

Checklist of facility safety inspection for NABH accreditation preparation

NABH puts high importance to safety in hospitals and ask the preparing hospitals to ensure that the facility is safe for patients, staff and visitors. As per one of the objective elements (FMS.1 e. of NABH 4^th edition), the preparing hospital is required to conduct facility inspection rounds to ensure safety. Further, it also states that the round should be conducted at-least twice in patient care areas and once in non-patient care areas. In-order for these rounds to be effective, it is important that a comprehensive checklist be used so that common safety hazards and potential risks could be checked and necessary remedial measures be taken. Below, I have prepared a checklist of points that could be used for such rounds. The checklist also addresses various other safety parameters that has been asked in different standards and objective elements of NABH standards book.

This checklist would be of much more value if used along-with the Infrastructure checklist for NABH accreditation preparation.

Checklist of Hospital’s Human Resources Department for NABH accreditation preparation

In NABH standards there is a complete chapter devoted for HR management in hospitals. It is expected that the hospital follows all good HR practices which ultimately makes the hospital a better organization for delivering healthcare services. From NABH standards and various assessment observation, following are the important points with which an HR department of a hospital must be prepared.

Other checklists available for NABH accreditation preparation: 

Infrastructure, IPD-Wards, ICU, Medical Records, Operation Theatre, Ambulance,

All checklists

Checklist for HR department
1. Having a documented HR plan for the hospital. The plan must mention the categories of employees, quantity required under each category, quantity available and future quantity requirements.

Checklist of Ambulance for NABH accreditation preparation

Ambulance plays a vital role in emergency medical care. In-order to be able to provide best ambulance services to emergency cases, NABH has specified certain requirements to be met. As functionally ambulance is related to emergency care, it is suggested that this checklist be used in combination with checklist of emergency department.

Specific points that needs to be taken care of for ambulance are

Emergency department checklist and quality indicators for NABH accreditation preparation

Emergency is an integral part of any hospital. Quality of emergency care depends upon several factors related to its infrastructure, design and processes. In NABH standards, there are several requirements that relates to the functioning of emergency and it must be taken care of by a hospital while preparing for accreditation. Below is the list of all such requirements which has been picked from NABH standards and observations made during assessments.

Operation Theater checklist and quality indicators for NABH accreditation preparation

One of the most difficult area to prepare for accreditation is operation theater. It’s a complex department where multiple critical function happens and many categories of staff are involved. Besides, infrastructure of OT is also very important for accreditation preparation. Based upon commonly observed things during NABH assessments and standards & objective elements under different chapters, here is a checklist that can be used for preparing OT for accreditation.

Medical Records checklist and quality indicators for NABH accreditation preparation

Medical Records of patient is the most important record that a hospital maintains. Contents in medical records serves as an important evidence of compliance to many NABH standards and objective elements. For a hospital that is preparing for NABH accreditation, concentrating on medical records is very important. Here is the list of things that must be ensured to comply with accreditation requirements.

(Please note that this checklist is meant for documentation and organizing of medical records and not meant for treatment audit or medical audit)

1.   Medical record of each patient should have a unique identification number. 

2. Unique identification number of the medical record should be printed/written on every sheet inside the medical record to prevent misplacement of sheets

ICU checklist and quality indicators for NABH accreditation preparation

ICU is a type of specialized wards for providing intensive care to patient in critical condition. It plays an important role in providing quality healthcare and there are several standards applicable to it under NABH. Since it is a ward, all requirements mentioned in the post on ‘In-patient wards checklist and Quality Indicators for NABH accreditation’ is also applicable to it. In addition, following points should be taken care of while preparing ICU for NABH accreditation.

1. Restricted entry to ICU. There should be an demarcation from where entry should be restricted to ICU staff only.
2. Hand washing (or hand rub) at the entry of ICU. Staff must wash their hands or use hand rub before entering ICU and after coming out of it
3. Nurse : Patient ratio to be maintained at 1:1 in all shift. 

In-patient wards checklist and Quality Indicators for NABH accreditation

In-patient wards are the place where most of the patient care activities happens. While preparing for NABH, wards requires high amount of attention as a large number of NABH standards applies to it. This post identifies such requirements and can be used as a checklist by hospitals preparing for NABH accreditation. The checklist, being general in nature, must be reviewed for its suitability to individual hospital, before use.

The checklist is relevant for an inter-mediate care ward. There are additional requirements for specialized wards such as ICU, emergency etc. which will be listed under separate heading in upcoming posts. Readers are requested to subscribe to the blog through email for getting regular updates on posts.

Before going through this checklist please also go through ‘Infrastructure checklist for NABH accreditation’

Infrastructure checklist for NABH accreditation

My earlier post on ‘Preparing for NABH accreditation’, mentions broad approach towards accreditation and the post on ‘How not to prepare for accreditation’ lists out the prevention that you must take. Although NABH standards is largely based on processes, hospital’s infrastructure also plays a pivotal role in determining accreditation status for a hospital. The problem here is that it has not been separately or clearly identified in NABH standards book as standards related to infrastructure. Many infrastructural requirements are actually interpreted from standards and are usually checked during assessments. As fulfilling infrastructure requirements may take more effort and longer time to complete, many hospitals may feel the need of having a checklist of infrastructural requirements that they can fulfill while they start to work upon process related requirements.  

After gleaning through NABH standards and observation of various NABH external assessment, I have listed down following infrastructure related requirement, with an objective that hospitals can use it as a checklist for addressing them. Please note that all of these requirements may not be mandatory, but are usually expected in assessments out of interpretation of NABH standards.

PREPARING FOR NABH ACCREDITATION

NABH accreditation for hospitals has become popular to the extent that it is now almost a necessity for any hospitals to have accreditation for competing in healthcare market. Hundreds of hospitals have applied and are making effort to bring themselves up to the level expected by NABH. There are different ways in which hospitals prepare themselves for accreditation. Some put up their own team to understand and implement standards while others hire a consultant to help them towards this. Chain hospitals replicate their accreditation work of one of their other hospitals in other units. Irrespective of the method adopted, preparation for accreditation requires, substantial resources, proper planning and dedicated efforts on part of the organization. Preparing for accreditation is like a journey with milestones to achieve and unless the path and approach chosen is correct, reaching the milestones can become very difficult.

With my experience of over 10 years with NABH accreditation, I have published a book ‘Accreditation of HealthcareOrganizations’ (Jaypee Publishers), which could be very helpful for those hospitals preparing for accreditation. Till date, it is the only book on this subject in the country.

For those who would like to have a quick read, instead of reading the entire book, below I have written a brief on ‘Preparing for Accreditation’, which I have taken mostly from one of the chapters of my book.

How not to prepare for accreditation

With a sizable number of accredited and a long list of applicant hospitals, NABH accreditation is on its way to soon become a norm for hospital industry in India. Almost all for profit hospitals and a large number of charitable hospitals in India aspires for accreditation and most of them have either revamped or in process of revamping their organization in accordance to accreditation standards.


I have written a long post on 'How to prepare for accreditation', but equally important is also to know, how not to prepare for it. Below, I have covered this topic explaining what could happen if wrong approach is followed for accreditation preparation.