Our scope of service for NABH
consultancy is centered on the 6th Edition Hospital Standards for
HCO and 3rd Edition Hospital Standards for SHCO, which emphasize
digital healthcare, patient-reported outcomes, and cybersecurity. A
comprehensive consultancy typically provides the following end-to-end services:
1. Preliminary Assessment &
Roadmap
·
Gap Analysis: Conducting
a 360-degree audit of existing clinical and administrative processes against
639 objective elements of the 6th Edition.
·
Infrastructure Guidance: Advisory
on meeting stringent facility requirements, such as fire safety, OT HVAC
systems, and patient-centered design.
·
Project Planning: Defining
timelines, assigning departmental responsibilities, and establishing a core
"NABH Committee".
·
Statutory
Evidence: Organizing and uploading all current
legal compliances, licenses, and MOUs required for the desktop review
2. Documentation & System
Design
·
Self-Assessment
Toolkit: Consultants assist in completing the mandatory self-assessment,
ensuring every objective element of the NABH 6th Edition is accurately
addressed.
·
Manual Development: Creating
a hierarchy of documents including Quality Manuals, Safety Manuals, and
Departmental SOPs.
·
Policy Formulation: Developing
custom policies for the 10 NABH chapters, covering clinical care, medication
management, and hospital infection control.
·
Format
Compliance: Ensuring all uploads meet strict
technical requirements (e.g., PDF for documents, Excel for manpower, JPG for
photos, with each file under 3MB).
·
Statutory Evidence: Organizing and uploading all current legal compliances, licenses, and
MOUs required for the desktop review
·
Digital Integration: Assisting
in the setup of digital dashboards for tracking quality indicators and
patient-reported outcome measures as required by the 2025/2026 standards.
3. Training & Capacity
Building
·
Awareness Programs: Educating
all staff—from doctors to housekeeping—on general NABH requirements.
·
Technical Training: specialized
workshops on Infection Prevention & Control (IPC), medication safety, and
emergency code management.
·
Internal Auditor Training: Certifying
internal staff to perform ongoing self-assessments to maintain compliance.
4. Implementation Support
·
Process Rollout: Hands-on
assistance in implementing newly designed workflows across nursing, pharmacy,
and diagnostic departments.
·
Quality Indicator Framework: Helping
the hospital select and track at least 15-25 mandatory quality indicators.
·
Committe Organization: Activating
and monitoring regular meetings for Hospital Infection Control,
Pharmaco-therapeutic, and Safety Committees.
5. Assessment Readiness &
Liaison
·
Application Management: Facilitating
the online application process through the NABH Portal and managing
follow-ups.
·
Mock Surveys: Conducting
final practice audits using tracer methodology to ensure staff can answer
assessor questions confidently.
·
NC Closure: Assisting
in the rapid resolution of "Non-Conformities" (NCs) raised during the
official NABH assessment to ensure final certificate issuance.
6. Specialized Advisory (2026
Focus)
·
Cybersecurity & IT: Guidance
on meeting the new 6th Edition requirements for data privacy and digital
medical record security.
·
Regulatory Compliance: Ensuring
all legal licenses (Fire NOC, AERB, BMW, etc.) are valid and documented for the
assessment.
7. Surveillance
& Surveillance Monitoring
·
Evidence of Continuity: Uploading
minutes of recent committee meetings (Quality, Infection Control) and evidence
of mock drills (Fire, CPR).
·
Internal Audit Reports: Preparing
and uploading internal audit and facility inspection round reports in the exact
annexure formats (e.g., DS-2026-Annexure) required by NABH.
8. Post-Assessment Support
·
NC Resolution: Reviewing
the Desktop Review Report issued by the Principal Assessor and
assisting the hospital in closing any identified "Non-Conformities"
(NCs) within the typically strict 7-to-15-day window.
·
Assessor Liaison: Managing
communication with the NABH Secretariat regarding clarifications on uploaded
documents.
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