The consultancy scope of service for Entry-Level certification
includes:
1. Gap Analysis
& Categorization
Infrastructure Check: Auditing the facility to ensure it meets the
minimum "mandatory" criteria for entry-level (e.g., separate
male/female wards, functional emergency area).
Capacity Assessment: Verifying bed strength and service scope to
determine if the hospital falls under the SHCO (Small Healthcare Organization)
or General Hospital category.
2. Core
Documentation (Simplified)
Consultants focus on creating a lean "Quality Manual" that
covers the essential requirements without over-complicating workflows:
Standard Operating Procedures (SOPs): Drafting 20–25 essential SOPs
covering high-risk areas like medication administration, hand hygiene, and
surgical safety.
Statutory Compliance Folder: Compiling a digital and physical dossier
of the "Must-Have" licenses for 2026:
Valid Biomedical Waste (BMW) Authorization.
Fire NOC or Fire Safety Certificate.
Pollution Control Board (PCB) Consent to Operate.
Pharmacy and Spirit Licenses.
3. Clinical Safety
Implementation
Infection Control: Setting up basic sterilization protocols
(autoclaving) and training staff on the 2026 BMW segregation rules.
Medication Management: Organizing the pharmacy to ensure
"Look-Alike Sound-Alike" (LASA) drugs are separated and high-alert
drugs are labeled.
Patient Rights: Implementing the display of "Patient Rights &
Responsibilities" in the local language at prominent locations.
4. Basic Quality
Indicators
Consultants help the hospital track the 10–12 mandatory indicators
required for Entry-Level, such as:
Incidence of medication errors.
Incidence of needle-stick injuries.
Patient satisfaction scores.
Turnaround time for lab reports.
5. HOPE Portal
Management (2026 Process)
In 2026, Entry-Level certification is managed through the HOPE (Healthcare
Quality Promotion Network) portal. The consultant's scope includes:
Registration: Setting up the hospital profile on the NABH HOPE Portal.
Self-Assessment: Uploading the self-declaration and evidentiary photos
(geotagged) of the facility.
Desktop Review Support: Managing the online response to queries raised
by the desktop assessor within the 10-day window.
6. Training &
Mock Surveys
Staff Sensitization: Conducting training for nurses and ward boys on
"Emergency Codes" (e.g., Code Blue, Code Red).
Internal Audit: Conducting one full cycle of internal audit to ensure
the hospital is ready for the "Virtual Assessment" or "Onsite
Assessment" by NABH/QCI.
7. Certification
& Renewal Support
NC Closure: Assisting in closing any Non-Conformities (NCs) found
during the assessment.
Renewal Roadmap: Setting a timeline for the hospital to move from
Entry-Level to Full Accreditation (usually recommended within 2 years of
getting the Entry-Level certificate).
Timeline & Fees (2026 Estimates)
Preparation Time: 3–4 months.
Assessment Time: 1–2 months.
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