A Complete Guide to NABH Chapters and Guidelines for Hospitals

The NABH sets out standards for hospitals which they use to improve patient safety, quality of care and management.
The concept is that we make large systems which support safe clinical practice, good record keeping and also continuous progress.
The NABH hospital accreditation standards are presented in 10 chapters. In each of these the issue is addressed which is related to a different aspect of what goes on in a hospital which in turn allows teams to identify what they need to put in place and what to continue to work on.

NABH Chapters at a Glance 
The chapters fall into two groups:
Five that are patient focused and five that are organization focused.

Section-A: Patient Centered NABH Chapters (1–5)

Chapter 1:  AAC (Access, Assessment and Continuity of Care)
In this chapter we follow the patient through registration, initial assessment, emergency care, referrals, admission, transfer and discharge. We aim that patients receive the appropriate care at the right time and that nothing falls through the cracks.

Chapter 2: COP (Care of Patients)
In this we look at how clinical care is provided which includes nursing care, anesthetics, surgery, intensive care and blood transfusion when relevant. Care should be in line with set procedures and what is accepted in the field of clinical practice.

Chapter 3: MOM (Management of Medication)
Drugs require a safer handling at each stage. We look at procurement, storage, prescription, dispensing and administration. Also included is the prevention of medication errors and management of the same.

Chapter 4: PRE (Patient Rights and Education)
This chapter is mainly on patient’s privacy, dignity and confidentiality. We cover informed consent and that the patient is very much aware of their health issue, the treatment and care that they require.

Chapter 5: IPC (Infection Prevention and Control)
In this chapter we discuss measures to put in place which will help prevent infections from which patients can suffer within the hospital environment. We cover hand hygiene, cleaning and disinfection procedures, sterilization processes, biomedical waste management, infection surveillance, and antimicrobial stewardship where it applies.

Section-B: Organisation focused NABH Chapters (6 -10)

Chapter 6: PSQ (Patient Safety and Quality Improvement)
In this area we see how hospitals measure and improve their performance which includes the use of quality indicators, internal audits, incident reporting, root cause analysis, and corrective and preventive actions.

Chapter 7: ROM (Responsibilities of Management)
We detail what of management is in charge of which includes governance, planning, resource allocation, and legal and regulatory compliance. The goal is to foster and sustain a culture of quality and safety.

Chapter 8: FMS (Facility Management and Safety)
This covers the elements of infrastructure, equipment, fire safety, utilities, emergency preparedness and disaster management. The aim is a safe environment for patients, visitors and staff.

Chapter 9: HRM (Human Resource Management)-
It includes manpower planning, recruitment, qualification and credential verification, induction, training, competency assessment and employee safety.

Chapter 10: IMS (Information Management System)
How we handle patient info and hospital records is covered: documentation, confidentiality, data security, information availability and digital records.
Key Guidelines of NABH for Hospitals to Pay Attention To.
Knowing that you have the chapters is a start but what really counts is that the requirements are present in day to day practice.

Out of which areas should we focus :
Patient safety
Infection prevention and control
Medication safety
Patient rights and consent
Documentation and records
Staff competency
Equipment and facility safety
Quality indicators
Internal audits
Continuous quality improvement.

What does the 6th Edition of NABH bring in ?
The 6th Edition of NABH’s hospital accreditation criteria which has been put out. Pay attention that they are the updated requirements which the hospitals must study and implement what is relevant to them. On patient safety, clinical quality, infection control, documentation, info systems and continuous improvement  that is what the focus is against which the official 6th Edition standards have been put forth.

NABH Quality Indicators-
Quality metrics which indicate if your processes are indeed producing the results you wish. As per your services they may include patient falls, medication errors, health care associated infections, patient feedback, turn around times and other clinical or operational measures. Collecting data is just the first step. Analyze it, look for trends, improve on poor results and document what actions were taken. NABH Infection Control Checklist.

Review your infection control measures often.

A good checklist includes:
Hand hygiene compliance
Cleaning and disinfection of patient-care areas
Sterilisation and disinfection processes
Appropriate use of personal protective equipment
Biomedical waste segregation and disposal
Infection surveillance and reporting
Staff training and awareness
Conduction and evaluation of infection control measures.
A checklist is a good tool to identify gaps. But compliance must be present in practical application, in what staff know, and in the records.

How Should Hospitals Prepare for NABH Accreditation ?
Begin with a structured gap analysis against the applicable NABH standards. Go through each section, determine the gaps in both documentation and implementation, assign responsibilities, train staff and conduct internal audits.

The main point I want you to remember is that accreditation is not simply a matter of having files and registries. Accreditation is
about establishing processes and procedures which will operate consistently each day to improve the quality of patient care.
At Qualityveda, we are convinced that quality should not merely exist on paper but rather manifest itself in how a hospital functions each and every day.
You can also review our comprehensive guide on the NABH accreditation process if you would like to know more about the details of how the certification works.

Frequently Asked Questions :-

Q. How many chapters are there in NABH ?
The National Accreditation Board for Hospitals (NABH) standards for hospital accreditation contain 10 sections/chapters;
these include:
AAC, COP, MOM, PRE, IPC, PSQ, ROM, FMS, HRM, and IMS.

Q. What is the difference between patient-centred and organisation-centred chapters ?

Chapters 1-5 are about looking after patients through assessment, treatment and medication, rights and infection control Chapters 6-10 are about managing the hospital including quality systems, leadership, premises, staff and information.

Q. What is a gap analysis in the preparation for the NabH ?
A gap analysis. A comparison of the documents and procedures you currently have with those required by the standards so that you know where to tighten up and what to fix before you are assessed.

Q. Is data collection enough for NABH quality indicators ?
No. You will also need to analyses the results, look at trends, explore poor results and record actions needed for improvement.