NABH Audit Checklist For Hospitals: Ensure Compliance & Quality

This NABH audit checklist for hospitals helps your quality team run internal audits against the standards of the National Accreditation Board for Hospitals and Healthcare Providers (NABH) and close gaps before NABH’s assessors arrive.

What is NABH Accreditation?

NABH accreditation means assessors have checked a hospital’s systems, processes and outcomes against NABH’s standards. What the standards require is covered in our guide to NABH standards and rules for hospitals, and the application steps in the NABH accreditation process.

Since 1 January 2025, NABH has assessed hospitals against the 6th edition of the NABH Accreditation Standards for Hospitals. It keeps NABH’s ten-chapter structure, with 100 standards and 639 objective elements. Of these, 105 are core elements that are checked at every assessment. Accreditation awarded under the current standards is valid for four years, with a surveillance assessment midway through the cycle.

Importance Of NABH Audit In Hospital

NABH’s final assessment scores the Core and Commitment objective elements, the surveillance assessment adds Achievement elements and re-accreditation adds Excellence elements. Every Core element must score at least 4 out of 5 at each assessment. Regular internal audits against the same elements show where you stand long before the assessors do, and give you time to put action plans in place for anything that falls short.

NABH Audit Checklist for Hospitals

Here is a detailed NABH audit checklist for hospitals to guide you through the accreditation process. The six areas below are a practical grouping for internal audits, not NABH’s own structure. Assessors score your hospital against the ten chapters of the NABH standards, so use the table to trace each area back to the chapters it covers.

In the 5th edition, infection control sat in a chapter called Hospital Infection Control (HIC). The 6th edition renamed it Infection Prevention and Control (IPC).

1. Hospital Governance and Leadership

Documentation of Policies and Procedures

• Ensure that all hospital policies and procedures are well-documented and easily available.
• Regularly update policies to reflect current best practices and regulatory requirements.

Leadership Involvement

• Hospital administration should actively participate in the NABH accreditation process.
• Hold regular meetings to review progress and address issues.

2. Patient Care and Safety

Patient Admission and Discharge Procedures

• Ensure clear protocols for patient admission and discharge.

Medication Management

• Implement strict medication management protocols to avoid errors.
• Regular audits of medication administration should be conducted.

Infection Control Measures

• Establish strong infection control protocols.
• Regularly train staff on infection control practices.

Patient Identification

• Use standardized methods for patient identification to avoid mix-ups.
• Regularly audit observance with identification protocols.

3. Clinical Services and Quality Management

Clinical Pathways

• Develop and implement clinical pathways for common conditions.
• Ensure pathways are based on current best practices and evidence.

Emergency Services

• Maintain a well-equipped emergency department.
• Ensure staff are trained to handle emergencies efficiently.

Continuous Quality Improvement

• Establish a continuous quality improvement program.
• Regularly review clinical developments and implement changes as needed.

Patient Feedback

• Actively collect and analyse patient feedback.
• Implement changes based on feedback to improve patient care.

4. Staff and Training

Adequate Staffing Levels

• Maintain sufficient staffing to meet patient needs.
• Regularly review and adjust staffing levels according to patient volume.

Staff Competency

• Regularly evaluate staff skills and provide needed training.
• Maintain proper records of staff training sessions and certifications.

Ongoing Training

• Implement ongoing training programs for all staff.
• Ensure training covers all aspects of patient care and safety.

5. Infrastructure and Facility Management

Facility Maintenance

• Ensure regular inspections and maintenance of hospital facilities.
• Ensure that all hospital equipment is well-maintained and operational.

Safety Measures

• Implement and regularly review fire safety and emergency preparedness protocols.
• Conduct regular emergency drills to ensure staff readiness.

Environmental Safety

• Ensure the hospital environment is safe and clean.
• Regularly monitor and address potential safety hazards.

6. Information Management Systems

Record Keeping

• Keep complete, accurate medical records, whether they are on paper or in an electronic medical record (EMR) system.
• Ensure data accuracy, confidentiality and security, including access controls for electronic records.

Data Analysis

• Regularly analyze clinical and operational data to identify improvement areas.
• Use data to drive decision-making and improve patient care.

Official sources: For the current standards and application process, see the National Accreditation Board for Hospitals & Healthcare Providers (NABH), its Hospitals Accreditation Programme and the NABH Accreditation Standards for Hospitals, 6th edition (PDF).

Conclusion

Run this NABH audit checklist for hospitals as a cycle, not a one-off: audit, fix, re-audit, and keep the evidence. That habit is also what carries a hospital through surveillance and re-accreditation.

For the patient feedback item, LazyMonkey’s patient feedback system for hospitals collects ward and discharge feedback through QR codes and keeps the trend reports assessors ask to see.

Frequently Asked Questions