NABH Documents For Hospital Accreditation As Per 5th Edition – Complete Documentation Kit

We had prepared the documentation for hospitals based on the NABH standard for hospital accreditation as per the 5th edition revised in April 2020. The NABH accreditation documents for hospital consists of the following:

• Hospital Manual: A sample Hospital Manual which meets the NABH requirements for hospital accreditation. This includes vision and mission and hospital quality policy, organization structure, and macro-level system for compliance of hospital accreditation standards.
• Department wise manual: The different department system is given in 5 departments wise manual as listed below.

1. Infection control
2. Emergency preparedness
3. Medical record
4. Human resources
5. Central sterility supply department
6. Bio Medical Manual.

• System Procedures: We had prepared 8 system procedures to standardize the working in the hospitals and establish a systematic approach
• Health and safety procedures: Total 9 health and safety procedures
• Process approach for hospitals: More than 15 process approach
• Standard operating procedures: Work instructions and SOPs for establishing a good hospital management system. We had prepared more than 75 standard operating procedures.
• Forms and templates: Set of 64 standard forms and sample blank templates.
• Hospital committee book: For 8 committee roles and responsibilities
• NABH audit checklists: We are providing a set of over 700 audit questions, which can be customized to make your own NABH checklist for internal auditing of your hospital.

Documentation:-

Our document kit is having sample documents required for implementation of NABH hospital accreditation as per latest National accreditation board of hospitals and healthcare provider standard (5th Edition April, 2020) for Accreditation standards for Hospital. The documents are prepared by the highly experienced team of people with rich experience of hospitals system establishment and process improvement and many hospitals are appraised successfully. You need to study it do necessary changes as per your company need and within 4 days your entire editable documents with all necessary details are ready as well as your team will got many ideas for system establishment to reduce the cost and effort with all necessary controls and your total documents are ready. We had given all type of templates and organization use it as per their need and many organization are certified globally in 1st trial with the help of our documents from any kind of stringent lead appraisal audit.
Under this directory further files are made in word document as per the details listed below. All the documents are related to NABH – Accreditation standards for Hospital for and user can edit it in line with their own processes.

1. Hospital Manual:

It covers sample copy of hospital manual details for NABH – Accreditation standards for Hospital is implemented. It covers Introduction, scope of service, hospital policy, vision and mission,
applicable laws and regulations, Quality policy and organization structure and covers 1st tier of NABH documents

Details of hospital manual

1. Cover page
2. Introduction
3. Scope of services
4. Hospital policies (Applicability of NABH Standards)
5. Vision and Mission
6. Applicable laws and regulation
7. Quality Policy
8. Organization structure

2. Department Manual:

It covers sample copy of department manual for NABH is implemented. It covers 5 department manual of NABH documents details given below

Details of department manual

1. Central sterility supply department (CSSD) manual
2. Emergency Preparedness Manual
3. Infection control
4. Medical Record
5. Human Resource management (HR Manual )

3. System Procedures (08 Procedures):

It covers sample copy of system procedures covering all the specific practice areas of 08 processes. Our procedures help the organization to make the best system and quick process improvements. All procedures are divided in 08 system procedures as listed below.

List of system procedure

1. Procedure for control of non–conforming services
2. Procedure for management review
3. Procedure for document and data control
4. Procedure for corrective and preventive action
5. Procedure for control of quality records
6. Procedure for internal audit
7. Procedure for control of monitoring and measuring equipments
8. Procedure for Training

4. Health and Safety Procedures (09 Procedures):

It covers sample copy of health and safety procedures covering all the specific practice areas of 09 processes. Our procedures help the organization to make the best system and quick
process improvements. All procedures are divided in 09 system procedures as listed below.

List of health and safety procedure

1. Procedure for hazards identification and risk assessment
2. Procedure for identification of legal and other requirements
3. Procedure for objectives and targets
4. Procedure for OHSMP
5. Procedure for consultation and communication
6. Procedure for operational control
7. Procedure for emergency preparedness and response
8. Procedure for performance monitoring and measurement
9. Procedure for incident investigation, non–conformity, corrective action and preventive action

5. Process Approach (16 System Process Approaches):

It covers sample copy of process approaches covering all the specific practice areas of 16 process approach. Our process approach helps the organization to make the best system and
quick process improvements. All process approach are divided in 16 system process as listed below

List of process Approach

1. Billing Section
2. Medical shop
3. CATH Laboratory
4. Client Service
5. ECG Laboratory
6. Engineering
7. Human Resource Department
8. Linen Activity
9. Marketing
10. X-Ray and Sonography Laboratory
11. Utility
12. Stores
13. Purchase
14. Pathology Laboratory
15. Nursing Station
16. Microbiology Laboratory

6. Standard operating procedures (89 SOPs):

It covers sample copy of SOPs covering Access, assessment and continuity care (AAC), Care of patient (COP), Facility Management and Safety (FMS), Human resource management (HRM),
Management of Medicine (MOM), Patient rights and education (PRE) and Patient safety and Quality improvement departments (PSQ). It covers all SOPs details list given below;

List of SOPs
Access, Assessment and Continuity of Care (AAC)

1. Scope of services
2. Registration
3. Policy for Admission
4. Filling the admission form
5. Procedure during non availability of beds
6. Laboratory safe practices
7. Radiology services
8. Admission of patient in ICU
9. Assessment Policy
10. Handling and disposal of radioactive wastes
11. Discharge Procedure
12. Patient Education on expected cost
13. Transfer Policy

Care of Patient (COP) 

1. Uniform care of patient
2. Administration of Anesthesia
3. Admission Criteria for ICU
4. Ambulance services
5. Bed Management in ICU
6. Care of patient under Surgical Procedure
7. Care of Vulnerable Patient
8. Cardiac Pulmonary Resuscitation
9. Criteria for Discharge of Patient
10. Emergency care
11. Handling of Medical Legal Cases
12. End of Life Care
13. Nutritional Assessment of Patient
14. Pain Management
15. Prevention on Adverse Event in Surgical Patient
16. Quality Assurance Programme- Surgical Services
17. Rationale use of Blood & Blood Products
18. Rehabilitative Services
19. Sedation
20. Care of obstetrics Patient
21. Organ Transplant Policy

Facility Management and Safety (FMS)

1. Maintenance Activity
2. Code Blue
3. Code Pink
4. Code Red
5. Bio Medical Manual

General 

1. Casualty
2. CCU Patient
3. CTOT
4. Dialysis
5. Dressing and plaster
6. EEG
7. Endoscopy
8. Enquiry
9. Paediatric
10. Gynac
11. Physiotherapy
12. ENT
13. Kitchen
14. Dental
15. Ortho and Neuro OT
16. Library
17. Nursing Station
18. Landry
19. SICU
20. Eye OT
21. Security
22. GOT
23. Urology and Lithotripsy
24. Plastic OT
25. General Health Check Up

Human Resource Management (HRM)

1. Performance Review and Appraisal Policy
2. Employee Grievance policy

Management of Medication (MOM)

1. Pharmacy Services
2. Use of Radioactive and Investigational Drugs
3. Disposal of Chemotherapeutic drugs
4. Hospital Formulary
5. Acquisition of medicines
6. Prescription of medicines
7. Dispensing of medication
8. Medication administration
9. Storage of medication
10. Verbal order of medication
11. Use of medical gases
12. List of high risk medication
13. Usage of Chemotherapeutic Agents
14. Use of Implantable Prosthesis

Patient Rights and Education (PRE)

1. Patient Rights
2. Informed Consent
3. Protection of patient rights
4. List of condition required informed consent
5. Communication

Safety and Quality Improvement (PSQ)

1. Safety Programme
2. Indicator Monitoring System
3. Sentinel events and incident reporting
4. Clinical Audit

7. Blank Formats (91 Formats):

It covers sample copy of forms required to maintain records in the hospital as well as establish control and make system in the organization. The samples given are as a guide and not compulsory to follow and hospitals are free to change the same to suit own requirements. The formats list given below;

List of Formats

1. Sanitation audit report
2. Breakdown History card
3. Operative notes
4. Pest control report
5. Request for microbiological testing
6. Purchase Order
7. Fumigation report
8. Room Check list
9. Indent cum incoming inspection report
10. Operation theatre readiness form
11. Anti termite treatment
12. Supplier Registration form
13. Toilet Cleaning record
14. Rodent Treatment
15. Approved Vendor list
16. Daily Equipment Cleaning record
17. Cockroach Treatment
18. Daily stock statement
19. House keeping records
20. R.O. Plant Log Sheet
21. Gate pass
22. Suggestion Card
23. Operation theatre readiness report
24. Preservation assessment Report
25. Patient Complaint Report
26. Emergency register
27. Master list cum distribution list of documents
28. Inquiry Monitoring record
29. Patient Transfer Register
30. Change Note
31. List of chain pulley blocks, lifts ,pressure vessels etc
32. Patient Registration form
33. Calibration status of instruments
34. Evaluation Of OHS Hazards and Risks
35. Blood Transfusion and Adverse Effects Form
36. Master list of records
37. OHS Review Of Prioritization Of Significant OHS Hazards Its Risks Feasibility Analysis
38. Blood Transfusion Patient Information and Consent
39. Indoor file papers arrangement
40. OHSMP Progress Monitoring Report
41. High risk consent
42. Audit schedule/plan
43. Near Miss Report
44. Anaesthesia Records
45. Internal audit non conformity report
46. Investigation Report
47. Post Operative Monitoring
48. Corrective Action report
49. Safety Inspection Check List
50. Pre Operative Checklist
51. Preventive Action report
52. Work Permit Report
53. Surgical safety checklist
54. Training calendar
55. First aid box check list
56. Nursing Notes
57. Training need cum record sheet
58. Fire fighting checklist
59. Estimate Form
60. Induction training report
61. PPE Preventive Maintenance check points
62. SURGERY CONSENT FORM
63. Job description and specification
64. Location List of fire extinguisher
65. Anaesthesia Consent Form
66. Multi skill Index
67. Fire hydrant checklist
68. Discharge Summary
69. Admission Check list
70. Ambulance review checklist
71. Crash Cart / Emergency Medicine Check List
72. Discharge Check list
73. Earthing pit test report
74. Autoclave Register
75. Checklist for personal file
76. Disposal of non confirming work
77. ADVERSE DRUG REACTION FORM
78. Employee Training sheet
79. Sterilization report
80. Patient assessment & Plan of Care
81. Credentialing and privileging of medical professional
82. DG Set monitoring report
83. MLC form
84. Steam Boiler Monitoring report
85. Vaccination records
86. Incineration plant report
87. MRD Register
88. Narcotics Drug Register
89. Preventive maintenance schedule
90. Credentialing and privileging of Nursing and allied staff
91. Medication Administration Report

8. Hospital committee:

This gives the list of all 8 committees and formation of committee and functions and guidelines for the committee.

List of committees

1. Quality Improvement Committee
2. Infection Control Committee
3. Pharmaco- Therapeutic Committee
4. Medical Audit Committee
5. Safety Committee
6. Grievance Re-dressal Committee
7. Disaster Preparedness Committee
8. Ethics Committee

9. Audit checklist (more than 700 questions)

There covers audit questions to be used for hospital system auditing for objectively evaluate the adherence of system by functional heads to establish processes. It also includes audit questions
as a quick reference for all related work areas of the hospital. Total more than 250 audit questions gives better understanding to the process owners as well as to the auditors to establish good
system and process discipline in hospital as well as for each department. It will be very good tool for the auditors to make audit questionnaire while auditing and make effectiveness in auditing in the hospital.

10. Compliance matrix

This compliance matrix contains NABH – Accreditation standards for hospital and healthcare providers clause wise list of documented information for easy reference of users and to
understand how this system is made.