How a 100-Bedded Hospital Can Prepare for NABH Accreditation

Achieving NABH accreditation (National Accreditation Board for Hospitals & Healthcare Providers) is one of the most important milestones for any hospital aiming to deliver safe, high-quality, and patient-centric care. For a 100-bedded hospital, this journey builds strong systems, enhances trust, and ensures that every process — clinical or administrative — meets the highest standards.

1. Understand the NABH Standards

Start by familiarizing your team with the NABH guidelines. These cover two key areas:

• Patient-Centered Standards – such as admission, assessment, medication management, patient rights, and education.

• Hospital-Centered Standards – including facility management, infection control, HR practices, information management, and quality improvement.

Every department must align its daily operations with these benchmarks.

2. Form a Core NABH Team

Create a dedicated NABH committee led by senior management and the Quality Manager. Include representatives from nursing, pharmacy, housekeeping, and HR.

• Assign one coordinator for each NABH chapter.

• Conduct regular review meetings.

• Track progress using checklists and documentation templates.

3. Do a Gap Analysis

Carry out a detailed comparison between your current hospital practices and NABH requirements.

• Identify areas that need improvement.

• Create a step-by-step action plan with defined responsibilities and timelines.

4. Develop and Implement SOPs

Write Standard Operating Procedures (SOPs) for every key process — from patient registration to surgery and discharge.

• Ensure all SOPs are approved and circulated among departments.

• Display important policies such as fire safety, infection control, and patient rights in visible areas.

5. Strengthen Documentation

Accurate documentation is vital for NABH.

• Maintain clear and complete patient records.

• Keep committee meeting minutes, audit reports, and incident logs properly filed.

• Use digital systems like EMR or HMIS to ensure transparency and easy access.

6. Train and Motivate Your Team

A well-trained team is the foundation of NABH success.

• Conduct regular training sessions on fire safety, BLS/ACLS, infection control, and patient communication.

• Reinforce the importance of empathy, teamwork, and consistent documentation.

7. Focus on Safety and Infection Control

Establish an effective Infection Control Committee (ICC) and appoint an Infection Control Nurse (ICN).

• Ensure proper waste segregation and disposal.

• Conduct regular hygiene audits and fire drills.

• Maintain a safe and clean hospital environment.

8. Track Quality Indicators

Monitor important hospital performance metrics like:

• Patient satisfaction

• Infection rates

• Emergency response time

• Incident reporting trends

Use this data to continuously improve your services.

9. Involve Patients and Families

NABH emphasizes patient participation.

• Display patient rights and responsibilities.

• Take regular feedback and act on it promptly.

• Offer counseling and post-discharge guidance for better outcomes.

10. Prepare Through Internal Audits

Before the final NABH visit, conduct internal audits and mock inspections.

• Review all documentation.

• Ensure staff are confident and aware of protocols.

• Correct gaps and make a readiness report for submission.

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In Conclusion

Preparing for NABH accreditation helps a 100-bedded hospital strengthen its systems, enhance patient trust, and build a culture of quality. It is not just about meeting standards — it’s about creating a hospital where every patient feels safe and cared for, and every staff member takes pride in delivering excellence.