Entry-level Readiness Screening
Getting Started
This eligibility screening questionnaire has been designed to help hospitals understand their current level of readiness for applying under the NABH Entry Level Certification Programme. The questionnaire evaluates essential foundational requirements such as minimum occupancy, duration of operations, statutory licences and compliances, availability of qualified and credentialed manpower, basic quality and governance systems, patient care documentation, infrastructure and facility safety, patient feedback and complaint mechanisms, as well as staff training and development practices.
Each question within the questionnaire carries a weighted score, with different parameters assigned weightage based on their relative importance in the certification readiness process. Hospitals are required to mark their responses against each question to assess their level of preparedness for individual sections and to generate an overall consolidated readiness outcome across all sections combined.
The objective of this questionnaire is to assist hospitals in determining whether the minimum prerequisites for application under the NABH Entry Level Certification Programme are in place. The questionnaire is intended solely as a preliminary screening mechanism and should not be construed as an assessment, audit, gap analysis, or evaluation of compliance with NABH standards. Completion of the questionnaire does not establish a hospital’s conformity with certification requirements, nor does it constitute a determination of certification readiness.
Hospitals are advised to use the questionnaire as an indicative tool for understanding the fundamental eligibility requirements of the Programme and for identifying areas that may require attention prior to submission of an application.
Please note that successful completion of this questionnaire or fulfilment of the indicated screening criteria does not guarantee certification, empanelment, approval, or progression to any subsequent stage of the certification process. The grant of NABH Entry Level Certification shall be subject to successful completion of all applicable stages of the certification process, including scrutiny of the application, desktop assessment, onsite assessment, review of corrective actions, and certification committee decision, as applicable.
Accordingly, this questionnaire should be regarded solely as a preliminary eligibility screening tool designed to facilitate informed decision-making by hospitals considering application under the NABH Entry Level Certification Programme.
Inclusion Criteria:
• Hospitals providing Allopathic services only
• Hospitals must be functional since at least six months prior to the application
• Hospital must have NABH standards for a minimum of 3 months
• Minimum Occupancy Requirements
- Final Assessment: Minimum 20% (last 3 months)
- 1st Renewal: Minimum 25% (preceding 1 year)
- 2nd Renewal: Minimum 30% (preceding 1 year)
- Standalone Day-Care Centres For centres such as Ophthalmology, Chemotherapy, IVF, Dialysis, etc., day-care beds will be considered as census beds for calculating occupancy. The assessment for inclusion in the scope of certification for individual superspecialty shall however continue to be based on the availability of a minimum number of three cases in the concerned super specialty over a six-month period.
• Certification will be based on all-or-none principle; every service being offered should be applied for certification
• In day care beds, the hospital should ensure the availability of emergency services whenever necessary
Exclusion Criteria:
• Hospitals having less than the required bed occupancy
• Hospitals providing Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homoeopathy services with or without Allopathy services
• Standalone Dental, Physiotherapy, Diagnostics and Pathology, Psychology, Diabetology, De-addiction centers
• Hospitals established within six months of application
• Hospitals set up in multiple locations having separate statutory licenses not located within the same premises
• Hospitals having more than one building with separate statutory licenses with distinct legal identities
Entry Level for Hospital Certification Programme (1st Edition April 2014)
| upto 5 Beds | 6-20 Beds | 21-50 Beds | 51-100 Beds | 101-300 Beds | 301-500 Beds | 501 and above Beds |
| Certification fees for 2 years: 21,000/- Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
Certification fees for 2 years: 40,000/- Discounted Fee till 30th September 2026: 30,000/- Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
Certification fees for 2 years: 80,000/- Discounted Fee till 30th September 2026: 48,000/- Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
Certification fees for 2 years: 1,60,000/- Discounted Fee till 30th September 2026: 96,000/- Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
Certification fees for 2 years: 2,00,000/- Discounted Fee till 30th September 2026: 1,20,000/- Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
Certification Fees for 2 years: 2,00,000/-
Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
Certification fees for 2 years: 2,50,000/- Focus assessment: 15,000/- Re-issue of certificate: 6,000/- |
18% GST applicable extra.
Basic Eligibility & Operations
Verifying that the hospital meets the foundational operational requirements for certification.
This section helps the hospital evaluate whether the basic operational requirements for Entry Level certification are in place, including minimum operational period, patient occupancy, and availability of adequate patient care records to demonstrate consistent healthcare delivery.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Legal Licences & Registrations
Ensuring your facility meets all legal, safety, and regulatory requirements for certification.
This section assesses whether the hospital has obtained and maintained all mandatory statutory licences, approvals, and regulatory registrations applicable to its scope of services, ensuring legal and compliant operations.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Staff and Manpower
Assessing the availability of qualified and competent healthcare professionals across services.
This section evaluates the availability of qualified clinical, nursing, technical, and support staff as per the hospital’s declared scope of services, patient load, and applicable regulatory requirements.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Quality and Governance Structure
Evaluating the systems and leadership mechanisms driving quality and patient safety.
This section reviews whether the hospital has established a functional quality and patient safety framework, including committees, monitoring mechanisms, infection control activities, and designated quality personnel for continuous improvement.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Documentation & Medical Records
Ensuring essential patient records, policies, and procedures are documented and implemented.
This section examines the availability, implementation, and consistent usage of patient care documentation, medical records, policies, and standard operating procedures across all relevant departments and services.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Patient Feedback and Complaints
Reviewing the hospital’s system to capture, address, and learn from patient feedback and complaints.
This section assesses whether the hospital has a structured mechanism to capture, review, address, and resolve patient feedback and complaints, including implementation of corrective and preventive actions where required
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Infrastructure and Facility Safety
Assessing whether the hospital provides a safe, secure, and well-maintained care environment for patients and staff.
This section evaluates whether the hospital has adequate infrastructure, safety systems, disaster preparedness measures, and facility maintenance processes in place to ensure a safe environment for patients, staff, and visitors.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
Training and Staff Development
Evaluating the hospital’s commitment to continuous staff training, competency, and professional development.
This section reviews whether the hospital has established a structured and documented training programme for all categories of staff, including orientation, departmental training, and periodic competency development activities.
Resources
Programme on Implementation of NABH Standards 2nd Edition Entry Level Certification for Hospitals
Continual Quality Improvement : Tools and Techniques
NABH Certification Standards Guidebook for Entry Level Hospital
The NABH Entry Level Hospital Standards (2nd Edition) are structured across 10 comprehensive chapters covering the essential elements of patient safety, quality of care, and healthcare management. The chapters include:
- Access, Assessment and Continuity of Care (AAC)
- Care of Patients (COP)
- Management of Medication (MOM)
- Patient Rights and Education (PRE)
- Infection Prevention and Control (IPC)
- Patient Safety and Quality Improvement (PSQ)
- Responsibility of Management (ROM)
- Facility Management and Safety (FMS)
- Human Resource Management (HRM)
- Information Management System (IMS)
Together, these chapters provide a practical roadmap for hospitals to establish quality systems, strengthen patient safety practices, and deliver consistent, patient-centric healthcare services.
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