NABH Pre-Entry Level Accreditation for Hospital Documentation Kit

The National Accreditation Board for Hospitals and Healthcare (NABH) has released a new batch of entry-level standards for accreditation of hospitals. As the name suggests, Entry Level Standards are meant for hospitals who want to get started on the quality certification journey.

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 (1st Edition April, 2014) for Pre Accreditation entry level 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 organizations 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 – Pre Accreditation entry level 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 – Pre Accreditation entry level 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 equipment
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. Standard operating procedures (28 SOPs):

It covers sample copy of SOPs covering Access, assessment and continuity care (AAC), Care of patient (COP), continuous quality improvement (CQI), Management of Medicine (MOM) and
patient rights and education (PRE) departments. It covers all SOPs details list given below;

List of SOPs
Access, assessment and continuity care (AAC)
1. SOP for scope of services
2. SOP for registration
3. SOP for assessment policy
4. SOP for laboratory safe practices
5. SOP for radiology services
6. SOP for discharge procedure
Care of patient (COP)
7. SOP for uniform care of patient
8. SOP for ambulance services
9. SOP for emergency care
10. SOP for handling of medical legal cases
11. SOP for rationale use of blood & blood products
12. SOP for care of vulnerable patient
13. SOP for administration of anesthesia
14. SOP for care of patient under surgical procedure
15. SOP for quality assurance Programme- surgical services
16. SOP for prevention on adverse event in surgical patient
17. SOP for pediatric patient
Continuous quality improvement (CQI)
18. SOP for continuous quality improvement
Management of Medicine (MOM)
19. SOP for Pharmacy services
20. SOP for Storage of Medication
21. SOP for Prescription of Medicines
22. SOP for Dispensing of medication
23. SOP for Medication Administration
24. SOP for Use of Radioactive drugs
Patient rights and education (PRE)
25. SOP for patient rights
26. SOP for informed consent
27. SOP for protection of patient rights
28. SOP for communication

6. Blank Formats (64 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. Fumigation report
3. Toilet Cleaning record
4. Suggestion Card
5. Inquiry Monitoring record
6. Evaluation Of OHS Hazards and Risks
7. OHSMP Progress Monitoring Report
8. Pest control report
9. Daily Equipment Cleaning record
10. Operation theatre readiness form
11. OHS Review Of Prioritization Of Significant OHS Hazards Its Risks Feasibility Analysis
12. Patient Complaint Report
13. List of chain pulley blocks, lifts ,pressure vessels etc.
14. Investigation Report
15. Work Permit Report
16. Firefighting checklist
17. Near Miss Report
18. Location List of fire extinguisher
19. Safety Inspection Check List
20. First aid box check list
21. Ambulance review checklist
22. Disposal of non-confirming work
23. DG Set monitoring report
24. Incineration plant report
25. Breakdown History card
26. Room Check list
27. Rodent Treatment
28. Purchase Order
29. PPE Preventive Maintenance check points
30. Sterilization report
31. Fire hydrant checklist
32. Earthing pit test report
33. Request for microbiological testing
34. Steam Boiler Monitoring report
35. Preventive maintenance schedule
36. Supplier Registration form
37. Daily stock statement
38. Cockroach Treatment
39. Anti-termite treatment
40. Preservation assessment Report
41. Change Note
42. Master list of records
43. Audit schedule/plan
44. Indoor file papers arrangement
45. Corrective Action report
46. Training calendar
47. Induction training report
48. Multi skill Index
49. Discharge Check list
50. Credentialing And Privileging Of Medical Professionals
51. Checklist for personal file
52. Gate pass
53. Indent cum incoming inspection report
54. Approved Vendor list
55. Master list cum distribution list of documents
56. Calibration status of instruments
57. Quality Objectives
58. Credentialing And Privileging Of nursing
59. Admission Check list
60. Job description and specification
61. Internal audit non conformity report
62. Training need cum record sheet
63. Continual Improvement Plan
64. Preventive Action report

7. 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

8. 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 700 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.

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