Skip to content
Hospital Checklist · NABH SHCO

NABH SHCO Checklist:
Complete Small Hospital Guide 2026

The most complete NABH SHCO preparation checklist. Covers all SHCO OEs, mandatory committees, documents, and common failure points.

What is the NABH SHCO Programme?

The Small Healthcare Organisation (SHCO) programme is NABH's accreditation pathway for hospitals with up to 50 beds. It is not a simplified version of the main HCO programme — it is a purpose-built set of standards that recognises the operational realities of smaller hospitals while maintaining non-negotiable patient safety requirements.

The SHCO programme has its own set of Objective Elements (fewer than Full HCO Accreditation). The 4-level compliance structure (CORE, Commitment, Achievement, Excellence) still applies, and the same 4 passing rules must be satisfied. What changes is the scope of some standards — proportionate to a smaller organisation's capacity.

📌 Key fact: SHCO Full Accreditation covers a defined set of SHCO standards. SHCO Entry Level Certification = subset of SHCO standards. Both programmes use NABH 6th Edition as the base. AccredReady covers both SHCO Full and SHCO ELC with a dedicated module.

NABH SHCO Preparation Checklist

Use this checklist to assess your hospital's readiness. Items marked CORE are non-negotiable — failure on any CORE item = automatic assessment fail.

📋 Governance & Leadership

Governing body constitution document with roles defined
Hospital organogram updated and displayed
Quality policy signed by top management
Quality Manager appointed with defined responsibilities
Annual quality improvement plan documented
Governing body meeting minutes for last 12 monthsCORE

🏥 Patient Care & Access

OPD registration process documented and implemented
Triage protocol for emergency patientsCORE
Initial assessment form for all admitted patientsCORE
Discharge summary format with all required components
Referral and transfer policy with documentation
Do-Not-Resuscitate (DNR) policyCORE
High-risk patient identification protocolCORE

💊 Medication Management

Hospital formulary available and updated
High-alert medication list displayed in pharmacy and wardsCORE
Look-alike sound-alike (LASA) drug protocolCORE
Medication storage conditions documented and monitored
Adverse Drug Reaction (ADR) reporting system functional
Narcotic drug register maintained per NDPS ActCORE
Medication reconciliation process at admission and discharge

🦠 Infection Prevention & Control

Hand hygiene compliance data for last 3 monthsCORE
WHO 5 Moments of Hand Hygiene training recordsCORE
Biomedical waste authorisation from SPCBCORE
BMW colour-coded bin system implemented in all areasCORE
Sterilisation monitoring records (biological + chemical indicators)
Needle-stick injury protocol and post-exposure prophylaxis availableCORE
HAI surveillance data (at least SSI and CAUTI rates)
Linen management SOP with separate clean/dirty pathways

🔒 Patient Safety

Incident reporting system with anonymised reporting optionCORE
Patient identification protocol (2 identifiers minimum)CORE
Surgical safety checklist (WHO) in use for all proceduresCORE
Fall risk assessment tool implemented in wardsCORE
Pressure injury prevention protocol
Critical results communication protocol (panic values)CORE

🏗️ Facility & Safety

Valid Fire NOC from fire departmentCORE
Fire evacuation drill records (minimum 2 per year)CORE
Fire extinguisher maintenance records
Medical gas pipeline system maintenance records
Biomedical equipment calibration and maintenance records
Electrical safety inspection records
Disaster management plan with mass casualty protocol

👥 Human Resources

Credential files for all doctors (qualification + registration)CORE
Clinical privileges defined for each doctorCORE
Annual training plan with training records
POSH committee constituted (mandatory under law)CORE
Pre-employment health checkup records for all staff
Staff hepatitis B vaccination recordsCORE

📂 Medical Records & Information

Uniform medical record format across all departments
Medical record completion within 24 hours of discharge
Patient confidentiality policy implementedCORE
Medical records retention policy (minimum 3 years)
MRD in-charge appointed with defined responsibilities

Mandatory Committees for SHCO Accreditation

NABH requires specific committees to be functional — not just on paper. Each committee must have: constitution order, defined TORs, regular meetings, and documented minutes.

CommitteeMinimum FrequencyKey Requirement
Quality Assurance CommitteeMonthlyReviews KPIs, CAPA status, incident reports
Infection Control CommitteeQuarterlyHAI data review, IPC policy updates
Pharmacy & Therapeutics CommitteeQuarterlyFormulary review, ADR analysis
Medical Records CommitteeQuarterlyRecord completion rates, MRD audits
POSH CommitteeAs needed (annual report mandatory)POSH Act 2013 compliance
Biomedical Waste CommitteeQuarterlyBMW data review, compliance monitoring
Credentialing & Privileging CommitteeAnnual (for each doctor)Review and renewal of clinical privileges

SHCO Fee Calculator

NABH SHCO assessment fees are based on bed strength. The fee structure includes application fees, assessment fees, and annual surveillance fees. AccredReady includes a built-in SHCO fee calculator that gives you an estimate based on your bed count — available in the SHCO module after login.

Official SHCO fee structure: Application fee ₹25,000 + Annual fee ₹1,50,000 (Full Accreditation, up to 50 beds), plus 18% GST on both. Additional charges: Virtual assessment ₹3,000 + GST, Focus assessment ₹15,000 + GST, Certificate re-issue ₹6,000 + GST. For SHCO ELC (Entry Level), fees range from ₹21,000 (up to 5 beds) to ₹48,000 (21–50 beds) for a 2-year cycle. Always verify current fees on nabh.co before applying.

Track Your SHCO Checklist with AccredReady

AccredReady's SHCO module covers all SHCO OEs, all mandatory committees, the fee calculator, and gives you a real-time readiness score. Know exactly where your hospital stands today.

Start free trial →

Frequently Asked Questions

What is the bed limit for SHCO programme?

The SHCO programme is designed for hospitals with up to 50 operational beds. Hospitals exceeding 50 beds must apply under the main HCO programme. Bed count is verified during the application process.

Can a nursing home apply for SHCO accreditation?

Yes. Nursing homes, maternity homes, day-care surgical centres, and small specialty hospitals with up to 50 beds are eligible for the SHCO programme, provided they have valid Clinical Establishment Registration and other statutory requirements.

How is SHCO different from HCO accreditation?

SHCO has its own set of OEs — fewer in scope than HCO Full Accreditation. Some standards are proportionately simplified for smaller organisations. However, CORE OEs carry the same weight and the same 4-rule passing criteria apply. SHCO accreditation carries the same NABH branding and is internationally recognised through ISQua.

How often does NABH conduct SHCO assessments?

After initial accreditation (valid 4 years for SHCO Full, 2 years for ELC), NABH conducts a surveillance assessment at 14–18 months to verify continued compliance. A renewal assessment is required before expiry to maintain accreditation.