What the IPC Chapter Covers
The NABH IPC (Infection Prevention & Control) chapter is one of the most heavily weighted chapters in the 6th Edition assessment. It evaluates whether your hospital has a functioning, evidence-based infection prevention and control programme — not just a set of policies.
Assessors evaluate HIC across several domains:
- Governance — infection control committee, IPC officer, written programme
- Surveillance — HAI rates tracked with defined denominators and action thresholds
- Prevention bundles — hand hygiene, device-associated infection prevention, surgical site infection prevention
- Environment & waste — biomedical waste management, linen, kitchen hygiene
- Sterilization — CSSD processes, validation, monitoring
- Antibiotic stewardship — formulary, culture sensitivity, prescribing audits
- Staff safety — needle-stick protocol, occupational exposure, staff immunization
HIC is one of the chapters where assessors spend significant time on the floor — they will observe actual practices, not just review documents. Staff behaviour during the assessment visit carries as much weight as the policy folder.
Infection Control Committee
NABH requires a formally constituted Infection Control Committee (ICC) that meets regularly and drives the IPC programme across the hospital.
What Assessors Check
- ICC constitution order/notification — is the committee formally appointed?
- Meeting minutes for the last 6–12 months — are meetings happening at least quarterly?
- Action taken report — are decisions from previous meetings tracked to closure?
- Annual IPC programme document — signed off by the Medical Superintendent
- HAI surveillance data presented to the committee and acted upon
Minutes must show data reviewed (HAI rates, hand hygiene compliance) and decisions made — not just attendance. A one-page attendance register passed off as minutes will be flagged as Partially Met.
Hand Hygiene Programme
Hand hygiene is the single most scrutinized HIC element during NABH assessments. Assessors observe staff during the facility walkthrough, ask staff about the 5 Moments, and review compliance audit data.
The WHO 5 Moments for Hand Hygiene
| Moment | When |
|---|---|
| 1 | Before touching a patient |
| 2 | Before a clean/aseptic procedure |
| 3 | After body fluid exposure risk |
| 4 | After touching a patient |
| 5 | After touching patient surroundings |
Programme Requirements
- Alcohol-based hand rub (ABHR) available at every point of care — bedside, OT, ICU, emergency, procedure rooms
- Soap and water accessible at all sinks with signage
- Monthly compliance audits — observed using the WHO hand hygiene observation tool, results documented by unit
- Staff training records — all clinical staff trained on 5 Moments and 6-step technique, with attendance
- ABHR consumption tracking — litres consumed per 1000 patient days as a proxy compliance metric
- Compliance rate displayed — department-level rates posted to drive improvement
Hospitals that only audit hand hygiene in the 2 months before assessment are easily identified. Assessors look at the date of the earliest audit in the register — consistent monthly data going back 6+ months is the standard.
HAI Surveillance
Healthcare-associated infection (HAI) surveillance is mandatory under the NABH HIC chapter. You must track device-associated infections in ICUs and surgical site infections, using standardized definitions and rate calculations.
Mandatory HAI Indicators
| Indicator | Denominator | Target |
|---|---|---|
| CLABSI (Central Line-Associated Bloodstream Infection) | Per 1000 central line days | <2 |
| CAUTI (Catheter-Associated Urinary Tract Infection) | Per 1000 urinary catheter days | <3 |
| VAP (Ventilator-Associated Pneumonia) | Per 1000 ventilator days | <5 |
| SSI (Surgical Site Infection) | Per 100 operations (by procedure type) | <2% for clean surgeries |
What "Running Surveillance" Actually Means
- Use standard CDC/NHSN definitions for each infection type — not your own criteria
- Count device days (central line days, catheter days, ventilator days) every day — this is the denominator, and it must be tracked daily
- Identify infections prospectively, not retrospectively — the ICN reviews patients daily
- Plot rates monthly with at minimum 6 months of data before assessment
- Document any cluster or outbreak investigation, even if no formal outbreak was declared
If your hospital has a small ICU with few device days, your HAI rates may be volatile (one event = a very high rate). In this case, present cumulative data quarterly alongside monthly data to smooth the trend and show the true picture.
Track HAI Rates Inside AccredReady
AccredReady includes an HIC KPI dashboard — enter your monthly device days and infection counts, and the system calculates rates, plots trends, and flags months that breach target thresholds.
Start Free on AccredReady →Biomedical Waste Management
NABH HIC requires compliance with the Biomedical Waste Management Rules, 2016 (amended 2019). This is a regulatory requirement as well as an accreditation standard — violations carry legal consequences.
Colour-Coded Segregation
Documentation Assessors Will Check
- CPCB/PCB authorization — current, not expired, displayed at CSSD/biomedical waste storage area
- Manifest/logbook — daily record of waste generated (in kg by category) and handed over to authorised transporter
- Transporter receipt — signed proof from the authorised common biomedical waste treatment facility (CBWTF)
- Segregation audit records — monthly audit of correct segregation at point of generation, with scores
- Staff training records — all staff (including housekeeping) trained on segregation and PPE
- Spill management kit — available in all clinical areas, staff know how to use it
BMW non-compliance is one of the few HIC findings that can result in a mandatory corrective action before accreditation is granted. NABH assessors treat it as a critical standard. Ensure your CPCB authorization is current before applying.
Sterilization & Disinfection
The NABH HIC chapter covers the entire sterilization chain — from instrument decontamination in the clinical area to CSSD processing and distribution back to the point of use.
Key Requirements
-
Written sterilization policyDefines sterilization methods for each category of instrument/device (critical, semi-critical, non-critical), turnaround times, and distribution process. Must be approved and current.
-
Autoclave monitoring logsEvery sterilization cycle must be logged: date, time, load contents, cycle parameters (temperature, pressure, time), operator name. Logs must be retained for the full accreditation cycle.
-
Biological indicators (BI)Spore tests (Geobacillus stearothermophilus for steam autoclaves) must be run at least weekly. Results — positive and negative — must be recorded. A positive BI means the load must be recalled and re-sterilized.
-
Chemical indicatorsClass 1 (process indicators on packs) and Class 5 or 6 integrating indicators inside packs for each load. Assessors will check packs in clinical areas to confirm indicators have changed correctly.
-
Bowie-Dick test (pre-vacuum autoclaves)Run daily on the first cycle of the day for pre-vacuum autoclaves. Results logged and retained.
-
Sterile pack integrity checksStaff in clinical areas must check pack integrity, expiry date, and indicator colour before opening. Assessors will directly ask nursing staff to demonstrate this during the walkthrough.
Assessors frequently check the storage of sterile packs in clinical areas — opened packs, expired packs, or packs stored on the floor or near sinks are immediate non-conformances. Make sterile storage area inspection part of every internal audit round.
Antibiotic Stewardship
NABH 6th Edition includes antibiotic stewardship within the HIC chapter. The expectation is a functioning programme — not just a policy document.
Minimum Programme Requirements
- Antibiotic formulary — hospital-specific, approved by the pharmacy and therapeutics committee, categorized into first-line, second-line, and restricted antibiotics
- Antibiogram — updated at least annually from your own microbiology data, available to prescribers
- Prescribing audit — monthly audit of a sample of antibiotic prescriptions against the formulary; results reported to ICC
- Culture before antibiotics policy — documented expectation that cultures are sent before starting antibiotics for specific conditions (sepsis, pneumonia, UTI); compliance tracked
- Antibiotic de-escalation — policy that prescribers review antibiotics at 48–72 hrs based on culture results
- Restricted antibiotic authorization — process for prescribing carbapenem-class and other restricted agents requires senior approval
Outbreak Management
NABH requires a documented outbreak management plan — and if any outbreak (or cluster) occurred during the assessment period, assessors will ask to review how it was managed.
What the Plan Must Include
- Definition of an outbreak threshold (e.g., 2+ cases of the same organism in the same unit within 2 weeks)
- Roles and responsibilities during an outbreak investigation
- Steps for active surveillance, source identification, and containment
- Communication protocol — to management, clinical staff, and (if required) public health authorities
- Review and debrief process after outbreak resolution
If no outbreaks occurred during the review period, assessors may conduct a tabletop exercise or ask staff to walk through what they would do if an outbreak was suspected. Train your ICN and unit heads on the process.
Keep an Outbreak Investigation Report template ready and run at least one tabletop drill annually. Document the drill — it demonstrates preparedness even in the absence of an actual event.
Common HIC Non-Conformances
These are the HIC findings most frequently identified during NABH internal audits and external assessments:
| Finding | Typical Cause | Fix |
|---|---|---|
| Hand hygiene compliance below 80% | Infrequent audits, ABHR not available at point of care | Monthly unit-level audits; ensure ABHR at every bed |
| Device days not tracked daily | ICU nurses unaware of denominator requirement | Add device day tally to daily ICU nursing checklist |
| Expired sterile packs in clinical areas | No regular expiry check at ward level | Weekly sterile stock expiry check by nursing in-charge |
| BMW logbook incomplete | Housekeeping staff not trained on recording | Dedicated BMW register with daily entry; housekeeping supervisor responsible |
| No BI records for autoclave | BIs run but results not entered in log | Dedicated BI result register; CSSD in-charge signs off weekly |
| ICC meetings only on paper | Meetings not actually held; minutes backdated | Schedule quarterly ICC as a recurring calendar entry; attach HAI data to agenda |
| No antibiogram | Microbiology data not compiled or not shared | Annual antibiogram compiled by microbiologist, circulated to prescribers |
| Staff immunization records missing | No system to track HBV vaccination of clinical staff | HR to maintain vaccination record for all clinical staff; new joinees tracked at induction |
Stay on Top of HIC Compliance Year-Round
AccredReady lets your IPC team track HIC measurable elements, log monthly HAI and hand hygiene data, and get alerts when indicators breach thresholds — so you're always assessment-ready.
Try AccredReady Free →