NABH Accreditation Checklist:
All Chapters Covered 2026

Chapter Overview: The NABH Chapters

The NABH 6th Edition Hospital Standards are organised into chapters. Each chapter covers a distinct domain of hospital functioning. Full Accreditation requires compliance across all Objective Elements (OEs) in all chapters. See the complete 6th Edition standards guide for a deeper breakdown.

AAC — Access, Assessment and Continuity of Care

AAC is the first chapter and one of the most OE-dense. It covers the patient's entire journey from arrival to discharge or transfer. Key areas assessors scrutinise in AAC:

• ✓Triage system — documented 5-level triage protocol, trained triage nurses, triage register with time stamps
• ✓Initial assessment — structured nursing and medical assessment forms completed within defined timeframes (ER: 30 min, OPD: 1 hr, IPD: 24 hrs)
• ✓Re-assessment frequency — documented re-assessment schedules per patient category (ICU hourly, ward 4-hourly, etc.)
• ✓Discharge summary — standardised discharge summary template completed within 24 hours, copy given to patient
• ✓Transfer protocol — SOP for inter-hospital transfer, transfer form, trained escort, equipment checklist
• ✓Continuity of care — documented handover (SBAR format), referral letters, follow-up appointment system

COP — Care of Patients

COP covers the clinical management of patients across all care settings. Assessors focus heavily on high-risk areas — surgical care, ICU, anaesthesia, and blood transfusion:

• ✓Surgical safety checklist — WHO Surgical Safety Checklist implemented and signed for every procedure: Sign-In, Time-Out, Sign-Out
• ✓Anaesthesia assessment — pre-anaesthesia check form, ASA classification documented, post-anaesthesia monitoring sheet
• ✓ICU protocols — ICU admission/discharge criteria, ventilator bundle checklist (CLABSI, VAP prevention), daily goals sheet
• ✓Blood transfusion — pre-transfusion checklist, bedside verification protocol, transfusion reaction management SOP
• ✓High-risk patients — documented protocols for paediatric, obstetric, elderly, and immunocompromised patients
• ✓Resuscitation — CPR SOP, crash cart checklist (daily check signed), mock code drill records (quarterly)

MOM — Management of Medications

MOM is a frequent source of CORE OE failures. High-alert medications and look-alike/sound-alike (LASA) drug controls are the most scrutinised areas:

• ✓Formulary — hospital formulary approved by P&T Committee, reviewed annually, accessible to prescribers
• ✓High-alert drugs — list defined, stored separately with red labelling, double-check protocol documented and practised
• ✓LASA drugs — list displayed in pharmacy, "Tall Man Lettering" used, separate storage bays
• ✓Medication error reporting — near-miss and error reporting system, monthly analysis, RCA for serious errors
• ✓Narcotic/psychotropic control — register maintained as per NDPS Act, dual-lock storage, daily reconciliation
• ✓Expiry checks — monthly expiry check records for all stock locations including ward satellite pharmacies

PRE — Patient Rights and Education

• ✓Patient rights charter — displayed in local language at all entry points, explained to patients on admission
• ✓Informed consent — procedure-specific consent forms, translated, witnessed, patient copy retained; consent for anaesthesia separate
• ✓Grievance mechanism — designated grievance officer, register maintained, resolution within 7 days, monthly report to management
• ✓Patient education — documented patient/family education for each admission: diagnosis, medications, diet, follow-up
• ✓Privacy and confidentiality — curtained examination areas, data protection SOP, no unauthorised sharing of records

IPC — Infection Prevention and Control

IPC is closely watched because it directly impacts patient outcomes. Three months of surveillance data must be available at assessment time:

• ✓Hand hygiene programme — WHO 5 Moments training, compliance audit data ≥80%, monthly department-wise reports displayed
• ✓HAI surveillance — CLABSI, CAUTI, VAP, SSI rates tracked monthly with NABH benchmark comparison
• ✓Sterilisation records — CSSD autoclave cycle logs, biological indicator results (weekly), Bowie Dick test (daily)
• ✓Biomedical waste — colour-coded segregation at source, BMW manifest records, MOU with authorised agency, SPCB authorisation
• ✓Outbreak management — SOP for outbreak identification, response, reporting to public health authorities, post-outbreak RCA
• ✓IPC committee — formation order, meeting minutes (quarterly), annual IPC plan with budget

PSQ — Patient Safety and Quality Improvement

• ✓KPI dashboard — minimum 10 mandatory NABH quality indicators tracked monthly, trended over 3+ months, shared with management
• ✓Incident reporting — no-blame reporting system, near-miss classification, monthly trend analysis, feedback to reporting staff
• ✓Sentinel event policy — defined list of sentinel events, mandatory RCA within 45 days, action plan with timeline
• ✓CAPA system — formal Corrective and Preventive Action process, tracking register, effectiveness review
• ✓Clinical audit — minimum 2 completed clinical audits per year, re-audit after improvement actions
• ✓Patient fall prevention — fall risk assessment tool (Morse/Humpty Dumpty), mitigation actions, fall rate tracked as KPI

ROM — Responsibilities of Management

• ✓Mission and vision — formally approved, displayed, communicated to all staff, reviewed annually
• ✓Hospital committees — 7 mandatory committees constituted with charter, membership, meeting minutes (QIPSC, P&TC, ICC, MC, MRC, Ethics, BMW)
• ✓Annual quality plan — documented quality goals for the year, progress reviewed quarterly at QIPSC
• ✓Ethics framework — ethics policy, documented conflict-of-interest declarations for leadership, ethics committee with external member
• ✓Clinical governance — M&M meetings (monthly), department medical audits, credentialing review by medical committee

FMS — Facility Management and Safety

• ✓Fire safety — Fire NOC current, fire evacuation drill records (twice yearly), fire extinguisher inspection tags, smoke detectors functional
• ✓Medical gases — piped gas system inspection certificate, cylinder manifest, area restricted, staff trained on oxygen safety
• ✓Electrical safety — earthing test certificate, UPS/generator maintenance log, electrical safety audit records
• ✓Equipment maintenance — Planned Preventive Maintenance (PPM) schedule, equipment log cards, biomedical calibration records
• ✓Disaster preparedness — Hospital Disaster Management Plan (HDMP), code system (Code Red, Blue, Pink, Black), drill records
• ✓HVAC and water — OT positive pressure validation, water quality test reports (Legionella, coliform), AC filter cleaning records

HRM — Human Resource Management

• ✓Credentialing and privileging — individual privilege list for each doctor, renewal every 3 years, based on training + outcomes evidence
• ✓Staff files — complete personnel file for every employee: qualification certificates, registration proof, appointment letter, job description
• ✓Orientation training — documented induction for all new staff covering NABH policies, patient safety, IPC, fire safety
• ✓Annual training calendar — department-wise training plan, attendance records, training effectiveness evaluation
• ✓Performance appraisal — annual appraisal for all staff, link to training needs identification
• ✓Nurse-patient ratio — documented ratios per unit (general ward 1:6, ICU 1:2), actual staffing records

IMS — Information Management System

• ✓Medical records policy — standardised medical record format, retention policy (minimum 7 years adults, 18 years paediatric), destruction register
• ✓Coding system — ICD-10 coding used for diagnosis, ICD-9 CM or CPT for procedures, coded by trained staff
• ✓Record completeness audit — monthly audit of medical record completeness, deficiency tracking, follow-up with treating team
• ✓Data confidentiality — access control for electronic records, physical record security, staff confidentiality agreement
• ✓Data backup — daily backup for electronic systems, offsite/cloud backup, restoration test records

Audit Preparation: Step-by-Step

1. 1

   Complete a Full Gap Assessment

   Score every OE against the current state. Tag each as Compliant / Partial / Non-Compliant. Separate CORE OEs — these need to be prioritised to full compliance before assessment day.

2. 2

   Build a Chapter-wise Action Plan

   For each gap, assign an owner, set a deadline, and define the evidence required. Track progress weekly at the Quality Committee. Don't let high-OE chapters like AAC and IPC fall behind.

3. 3

   Start KPI Data Collection Immediately

   NABH requires a minimum of 3 months of quality indicator data at assessment time. Begin collection on day one — retroactive data collection is not accepted. See the NABH KPI guide for the full indicator list.

4. 4

   Write and Approve SOPs

   Each chapter requires documented SOPs. SOPs must be reviewed by the relevant committee, approved by management, version-controlled, and accessible to staff. Print copies must be available at point of care.

5. 5

   Conduct Chapter-wise Internal Audits

   Run a structured internal audit for each chapter using the NABH scoring rubric. Document findings, raise CAPAs, and track to closure. Assessors will review CAPA records as evidence of a functional quality system. The NABH internal audit checklist has audit templates for each chapter.

6. 6

   Mock Assessment

   Run a full mock assessment 4–6 weeks before the NABH assessment date. Use an external NABH consultant or peer hospital team. Address all findings before the actual assessment.

7. 7

   Staff Briefing Before Assessment

   Conduct department-wise staff briefings 1 week before the assessment. Staff must know their role in each protocol, where documents are kept, and how to respond to assessor questions. Assessors test frontline nurses and ward boys — not just managers.

Statutory Licences and Certificates Required

Frequently Asked Questions

How many chapters are in the NABH 6th Edition standards?

The NABH 6th Edition has the following chapters: AAC, COP, MOM, PRE, IPC, PSQ, ROM, FMS, HRM, and IMS. Together they contain comprehensive standards and Objective Elements (OEs). Full Accreditation requires compliance across all OEs. The NABH 6th Edition standards guide covers each chapter in detail.

What documents are required for NABH accreditation?

Key documents include Clinical Establishment Registration, Fire NOC, Biomedical Waste Authorization, hospital organogram, SOPs for all clinical and administrative processes, committee formation orders, 3+ months of KPI data, internal audit records with CAPAs, staff training records, patient satisfaction survey results, and infection control data. See the accreditation cost and process guide for the full list.

What are the CORE OEs in NABH?

CORE OEs are Objective Elements marked as mandatory — a hospital must achieve full compliance on all CORE OEs to pass assessment. NABH 6th Edition has CORE OEs spread across all chapters. These cover critical patient safety areas: consent, medication safety, surgical timeout, infection control, and fire safety.

How long does NABH audit preparation take?

For a hospital starting from scratch, NABH Full Accreditation preparation realistically takes 18–24 months. Hospitals with existing quality systems can achieve it in 12–15 months. Entry Level Certification takes 6–12 months.

How many mandatory committees does NABH require?

NABH requires a minimum of 7 mandatory committees: Quality Improvement and Patient Safety Committee (QIPSC), Pharmacy and Therapeutics Committee (P&TC), Infection Control Committee (ICC), Transfusion Committee, Medical Records Committee, Ethics Committee, and Biomedical Waste Management Committee. Each must have a charter, defined membership, meeting frequency, and documented minutes.

What is the NABH scoring system?

Each NABH OE is scored on a 0–4 scale: 0 (Not Compliant), 1 (Partial — documented but not implemented), 2 (Substantial — implemented but inconsistent), 3 (Full Compliance — consistently implemented with evidence), 4 (Exceptional). A minimum average is required for accreditation, with no CORE OE scoring below 2.