Full NABH Accreditation: A Guide to Quality and Excellence
Medigence, India’s leading healthcare consulting firm has achieved the highest number of successful NABH accreditations / Full NABH for various small and large hospitals across Gujarat and nearby states.
It takes years of experience to understand NABH standards which are quite subjective in nature and Medigence is popular amongst its clients as NABH Consultants for making these tasks easy for hospitals and for providing the right but cost-effective solutions saving your time and resources.
Full NABH accreditation standards are available for :
Small Hospitals (SHCO)
Hospitals with up to 50 sanctioned beds.
Large Hospitals (HCO)
Hospitals having more than 50 sanctioned beds.
Why NABH ?
NABH certified / accredited hospitals undoubtedly have more benefits over the non-certified/accredited hospitals.
- NABH accreditation or NABH Entry Level Certification is mandatory for the hospitals who wish to provide cashless and reimbursement facilities to their patients
- NABH accredited hospitals are also highly benefited when they get empaneled with various government health schemes like Ayushman Bharat, PMJAY, MAA Yojana etc. as they get 10% extra revenue over and above the rates proposed by these schemes.
- Patients are going to be highly benefited as they get the best quality of care and treatment compared to any non-NABH accredited hospital. NABH ensures that qualified and trained staff are involved in the patient care and thus the patients trust the accredited hospitals more.
- Hospital staff also feel more content as they get to learn continuously and are empowered by hospital processes. Employees also feel highly confident and they get a safe and secure working environment.
The hospital infrastructure, facilities and maintenance are certified and reliable to be accessed along with the level of care and safety. - NABH accreditation being internationally recognized, it opens ample opportunities for medical tourism. The patients are now informed and understand the value of being treated in an accredited hospital.
- The most important benefit is that the hospital’s medical records keeping becomes so robust that it helps the hospital to protect themselves from any medico-legal cases.
What is NABH ?
The National Accreditation Board for Hospitals and Healthcare Providers (NABH) is an autonomous body which was established in 2005 as a constituent board of the Quality Council of India (QCI) under the Ministry of Commerce and Industry. Its primary objective is to create robust accreditation and certification programs to enhance the overall quality of healthcare and patient safety across all hospitals, regardless of their size, ownership, or legal status.
International Recognition
NABH accreditation standards are internationally recognised and approved by ISQua (International Society for Quality in Healthcare), based in Dublin, Ireland. ISQua is the global body that accredits healthcare accreditation organisations worldwide.
Hospitals approved by Full NABH Accreditation thus have international recognition, with their quality standards aligned with global benchmarks. This status provides an essential platform for enhancing medical tourism. NABH is also a key member of the ISQua Accreditation Council and a founder member of the Asian Society for Quality in Healthcare (ASQua).
For more information on NABH, kindly visit: https://nabh.co/
What are the full NABH accreditation standards?
NABH standards provide a very comprehensive criteria to evaluate the hospitals. It thus provides a detailed framework for improving quality and patient safety. The standards are revised every 4 years by NABH and currently the following standards are effective.
Small Hospitals (SHCO): Hospitals with up to 50 sanctioned beds.
3rd edition effective from 1st August, 2022
• 10 Chapters
• 71 Standards
• 408 Objective Elements (OEs)
Large Hospitals (HCO): Hospitals having more than 50 sanctioned beds
6th edition effective from 1st January, 2025
• 10 Chapters
• 100 Standards
• 639 Objective Elements (OEs)
These OEs are divided into four implementation sections:
- Core: are mandatory to be implemented for the first-time NABH application and then continued subsequently during all assessments
- Commitment: are also mandatory to be implemented for the first-time NABH application and then to be continued subsequently during all assessments
- Achievement: implemented at the surveillance NABH assessment.
- Excellence: implemented at the renewal NABH assessment.
NABH Chapters are divided into the following categories :
Patient Centric Standards
Chapter 1 – Access, Assessment & Continuity of Care (AAC)
Chapter 2 – Care of Patients (COP)
Chapter 3 – Management of Medication (MOM)
Chapter 4 – Patient Rights & Education (PRE)
Chapter 5 – Hospital Infection Control (HIC)
Organisation Centric Standards
Chapter 6 – Patient Safety & Quality Improvement (PSQ)
Chapter 7 – Responsibility of Management (ROM)
Chapter 8 – Facility Management & Safety (FMS)
Chapter 9 – Human Resource Management (HRM)
Chapter 10 – Information Management System (IMS)
A copy of the NABH standards can be availed from the NABH website: Click Here
Eligibility criteria
The accreditation is applicable to the following types of functional healthcare organizations:
- Facility Type: This includes both Government and Non-Government hospitals including Private, Partnerships or Trust hospitals
- Specialisation: The facility can provide either single-speciality or multidisciplinary care.
- Academic Institutions: Medical colleges that provide single or multidisciplinary care are eligible.
- Daycare Centres / Clinics are also eligible.
- Legal Compliance: The organisation must comply with all applicable legal, statutory, and regulatory requirements set by government and local bodies.
- Infrastructure: The organisation must comply with all applicable infrastructure requirements as specified by the standards.
- Full Functionality: The hospital must be fully functional and operational for at least 6 months at the time of applying for accreditation.
- The hospitals should have implemented the standards for more than 3 months.
- Standard Application across the organization: The accreditation standards must be applied to the entire institution—they cannot be implemented selectively to only certain departments or services.
Process for full NABH accreditation
The entire duration of Full NABH Accreditation can range from approximately 18 – 24 months depending upon the hospital’s readiness. But with the right NABH Consultants like Medigence guiding the hospitals, the accreditation can very well be achieved within 10-14 months’ time.
Self assessment by Hospital Team
Once the organization procures the NABH standards, the hospital team conducts a self-assessment either by themselves or with the help of qualified NABH Consultant who can help interpret the NABH Standards and guide them for the implementation. If the hospital complies with more than 80% of the NABH standards, they can proceed to start the NABH application process.
Start the Application Form
Start the registration process by accurately filling in the necessary details of the hospital to begin the application form. Our NABH Consultants at Medigence shall guide you during each step of filling the application form.
Submit the Application Form
Complete the application within 30 days after uploading all required documents, such as policies, licenses, indicators, MOUs, and staff details.
Submit the Self-Assessment Toolkit
The hospital then completes the Self-Assessment Toolkit and submits it on the NABH portal. Only the right NABH consulting firm can help the hospitals implement the NABH standards in the correct manner while providing practical solutions for each objective element.
Pay Application Fees
After completing the application form, the hospital will be required to pay the application fees. The fee amount varies according to the hospital's sanctioned bed capacity. For more information about the fees, please visit https://nabh.co/accreditations-certifications-and-empanelments/
Desktop Review
Once the application fees are paid, NABH will assign a Desktop Assessor. The assessor will review the completed application form and the submitted documents.
Submit Desktop Assessment Non-Compliance (NCs)
During the desktop review phase, the hospital shall have only one opportunity to close any Non-Compliances (NCs) raised. All NCs must be closed and submitted within 15 days. If any NCs remain open after this period, they will be reviewed again and must be cleared during the on-site assessment. The same remains at the discretion of NABH. As your NABH consultant, Medigence shall guide and assist the hospital in submitting the correct documents and evidence for any non-compliances received.
Pay the Annual Fees
After the successful desktop review, the hospital shall be prompted to pay the annual fees. Only after the fees are paid the on-site assessment dates will be allocated.
Select the Type of Assessment
There are two options for selecting the assessment type: Select either a Pre-Assessment or the Final Assessment. However, with the help of the right NABH Consulting firm like Medigence guiding, the hospital can directly opt for the Final assessment.
Get the Assessment Dates
The assessment dates will be allocated, and the details of the allocated assessor(s) will be provided via email.
Onsite Assessment
A team of assessors, sized according to the hospital's sanctioned bed capacity, will conduct the on-site assessment. They will audit the hospital against NABH standards, check statutory documents, and raise any non-conformities (NCs). Our team at Medigence as your NABH Consultant shall guide and prepare you fully before the onsite assessment. This will ensure that you go through the process of assessment very smoothly.
Submit the Assessment NC Cycle 1
The hospital is given 60 days to complete the first cycle of NC corrections and submit the evidence on the portal. Our NABH Consultant will assist your hospital in submitting the required evidence along with the comprehensive corrective and preventive actions report (CAPA) as required by NABH assessors.
Submit the Assessment NC Cycle 2
For further clarification if needed, the assessor may raise NCs in a second cycle. The hospital must submit the NC replies on the portal within 30 days. After the submission of the second cycle NCs, the assessor will review the responses and submit the final hospital report to the NABH Accreditation Committee.
Accreditation Committee Review
The Accreditation Committee reviews the complete documentation, including the assessor's report and all NC closure responses. If necessary, they may ask for additional documents. NABH Consultant at Medigence shall assist you to furnish and submit the required documents. After their final review, NABH shall submit their remarks on the portal.
Once all documents are reviewed and approved by the committee, NABH accreditation is officially granted. The accreditation is valid for 4 years.
Surveillance
In order to ensure that the hospital is maintaining the standards and implementing them, surveillance assessment is planned every 21-24 months after the accreditation is granted. As your preferred NABH Consulting firm, Medigence offers a Continuous Quality Assurance program (CQAS) that helps the hospitals to maintain the quality systems even after the accreditation is completed and ensures that your hospital is 24x7 ready for NABH assessment.
Renewal of accreditation
Renewal happens after 4 years of your first accreditation. The hospital has to apply 6 months before the expiry of the accreditation in order to maintain the same.
Why You Should Select the Medigence as Your NABH Consultant
Choosing the right NABH consultant is the crucial first step towards your accreditation goal as well as maintaining quality standards. We don’t just help you tick boxes; we transform your operations.
1. Unmatched experience
At Medigence, we have a collective of 40+ years of experience that help you navigate the complex accreditation standards. We have a proven track record of guiding and successfully assisting over 200+ hospitals, clinics, and healthcare facilities toward successful NABH accreditation. More importantly, every NABH consultant at Medigence who guides your hospital has appropriate experience of direct NABH implementation that ensures you are guided by seasoned experts and not just trainees.
2. End-to-End Empowerment
At Medigence our NABH Consultants offer a holistic 360 degree guidance and assistance that ensures a complete compliance loop: Starting from documenting your SOPs and policies, systematic training, proactive audits, and continuous compliance checks for a smooth, stress-free accreditation experience.
3. Customisation of Forms, Formats, checklists, registers and SOPs Templates
You must understand that your hospital is unique and thus the associated structure and implementation strategy should also be unique
- We provide policies, registers, and medical records according to the hospital’s setup, not a generalised format.
- We conduct department audits very comprehensively taking into account the minutest observations.
4. Ensuring Regulatory & Statutory compliances
5. Maximum Time & Cost Efficiency
Believing that Time is your most valuable asset, our NABH Consultant makes sure that you receive NABH accreditation faster than navigating the process alone. We have completed full NABH projects within 6-month timelines, which are rarely done by any other consultants. We also strive to guide you to avoid unnecessary delays and the financial burdens associated with repeat or failed assessments.
6. Certified Staff Training & Culture
We invest in your most valuable asset: your people.
- We conduct engaging, practical training for doctors, nurses, and all hospital staff, incorporating the latest guidelines.
- We provide Certified Training courses from time to time on NABH standards, ensuring staff confidence and competence.
- We help you embed a sustainable, patient-centric culture of quality throughout your organisation.
7. Conducting Mock Assessments
Walk into your final assessment with absolute confidence.
We conduct intensive and realistic Mock Audits that mirror the actual NABH process. Real world scenarios are presented in front of your staff so that they are confident to face the final assessment.
8. We Stay with You - Sustaining your quality journey!
As a part of our Continuous Quality Assurance System (CQAS) once you achieve NABH accreditation, our NABH Consultant can immediately transition into a CQAS partnership through a separate Memorandum of Understanding (MOU). This provides a robust, long-term framework for ongoing compliance.
- During the CQAS partnership, we ensure our NABH Consultant visits on a regular basis mutually agreed upon and guide the hospitals to prepare data like quality indicators, continuously training the staff, updating of the SOPs, and new medical record implementations.
- This ensures that the hospital is 24×7 ready for NABH assessments and also strengthens the culture of quality in the organization.
The Medigence Success Story
Dr Jivraj Mehta hospital, Ahmedabad
The success story of Dr Jivraj Mehta Hospital, a 205-bed multi-specialty facility, is a prime example of Medigence’s transformative approach. Our NABH Consultant didn’t just meet the standards; we achieved NABH Full Accreditation within a challenging six-month timeline after application. This was accomplished by tackling key operational hurdles head-on: engaging senior staff as change champions, optimizing the use of experienced personnel, and implementing digital transformation by moving excessive manual records to efficient digital Sheets for streamlined, compliant documentation. The result was not only rapid accreditation but also achieving zero non-compliances in the critical Facility Management & Safety (FMS) chapter.
KJ Multispeciality hospital, Junagadh
The story of the 100-bed hospital in Junagadh shows how Medigence fixes tough problems. Even though the hospital had many patients and excellent buildings (infrastructure), the staff needed help. Their paperwork was messy, and the employees weren’t trained enough, especially since this was going to become the first Full NABH accredited hospital in the whole area. Our NABH Consultants worked hard, giving lots of simple training to the team and fixing the paperwork. Crucially, while the building was great, we made minor to major changes in every department to meet all the stringent NABH guidelines and make the hospital ready for assessment. The hospital received NABH accreditation within a short span of time and set a new standard for quality care in Junagadh district in Gujarat!