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NABH Readiness Checklist

Assess how prepared your hospital is for NABH accreditation (5th edition). Rate each requirement across the 10 NABH chapters and get an instant readiness score, chapter-wise compliance and a list of critical gaps to close before assessment.

1. Access, Assessment & Continuity of Care (AAC)

Documented registration, admission and transfer/discharge process is in place

Initial assessment of every patient is documented within the defined timeframecritical

Defined process for patient referral and safe transfer to another facility

2. Care of Patients (COP)

Uniform care is guided by written policies and clinical protocols

Emergency, resuscitation (code blue) and ambulance services are defined and drilledcritical

Documented policies for high-risk procedures, surgery and anaesthesia

3. Management of Medication (MOM)

Formulary and documented policy for procurement, storage and prescribing of medication

High-alert and look-alike/sound-alike (LASA) drugs are identified and controlledcritical

Adverse drug event / medication error reporting system exists

4. Patient Rights & Education (PRE)

Patient rights and responsibilities are documented and displayed

Informed consent process is defined for procedures requiring itcritical

Process to obtain patient feedback and handle grievances

5. Hospital Infection Control (HIC)

Infection control programme, committee and manual are in place

Hand hygiene and biomedical waste management as per BMW Rules 2016critical

Surveillance of hospital-associated infections (HAI) with monthly rates

6. Patient Safety & Quality Improvement (PSQ)

Structured quality improvement programme with defined indicators

Incident reporting, sentinel-event and root-cause-analysis (RCA) systemcritical

International Patient Safety Goals (IPSG) implementedcritical

7. Responsibilities of Management (ROM)

Defined organogram, governance and roles/responsibilities

Valid statutory licences and registrations maintainedcritical

8. Facility Management & Safety (FMS)

Fire and emergency preparedness plan with mock drillscritical

Preventive maintenance programme for equipment and utilities

Medical gas, electrical and water safety systems verified

9. Human Resource Management (HRM)

Documented recruitment, credentialing and privileging processcritical

Ongoing training, BLS/ACLS and induction records maintained

Health checks and personnel files for all staff

10. Information Management System (IMS)

Complete, accurate and standardised medical records with retention policycritical

Confidentiality, integrity and security of patient data ensured

Result

NABH Chapter	Items	Compliance

Notes & assumptions: This is a simplified self-assessment covering representative requirements from the 10 NABH 5th-edition hospital chapters — not the full standard's objective elements. Each item scores Yes=1, Partial=0.5, No=0; the overall score is the average across all items. 'Critical gaps' counts critical items not fully compliant. Use it to prioritise, not to certify.

Disclaimer: This checklist is an informal readiness indicator only and does NOT constitute NABH accreditation, a gap audit, or professional quality/regulatory advice. It is not affiliated with or endorsed by NABH/QCI. Formal accreditation requires assessment against the complete official NABH standard by NABH. Varada Nexus accepts no liability for decisions made using this tool.

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FAQ

What is NABH accreditation?

NABH (National Accreditation Board for Hospitals & Healthcare Providers), a constituent board of QCI, accredits hospitals in India against defined quality and patient-safety standards. The current hospital standard is the 5th edition.

How many chapters are there in NABH?

The NABH 5th edition hospital standard is organised into 10 chapters covering patient-centred and organisation-centred standards, from Access & Assessment to Information Management.

What score means we are ready for a NABH assessment?

As a rough guide, 85%+ with no open critical gaps suggests you are close to assessment-ready; 70–84% means near ready; below 70% indicates significant preparation is still needed. A formal gap audit is recommended before applying.

Does this replace a formal NABH gap audit?

No. This is a quick self-assessment for prioritisation. A formal, standard-by-standard gap audit by qualified consultants is needed before applying for accreditation.