Hospital in a box

Your Guide to NABH Entry Level Certification

Introduction to Hospital-In-A-Box

Starting a new hospital or optimising the operations of an existing one can be a complex journey, especially when aligning with NABH Standards. While the NABH Entry Level Standards serve as an essential guiding document for improving hospital processes, many small healthcare organisations find it difficult to translate these standards into actionable steps for implementation.

How to apply in Hope Portal

Objective

The Hospital-In-A-Box initiative is here to support healthcare organisations, particularly small and mid-sized hospitals, in implementing NABH Entry Level Standards with ease. This toolkit provides all the necessary tools, resources, and step-by-step guidance to streamline the certification process.

Provide tools and guidance for implementing NABH Entry Level Standards.

Help healthcare organisations identify and address gaps in practice.

Offer free resources, including checklists, policies, forms, and reference materials.

Support smaller organisations in their quality improvement efforts.

Encourage customisation of materials for your unique setup.

Hospital-In-A-Box Toolkit

The Hospital-In-A-Box toolkit is designed to help hospitals understand and implement the core requirements for NABH Entry Level Standards, ensuring they are well-prepared for assessments and can operate efficiently with a strong foundation of quality.

Sample policies and procedures for clinical and administrative processes.

Department-specific guidelines, checklists, and formats.

Forms, formats, and registers to streamline documentation and compliance.

Comprehensive guidance on applying for NABH assessments and achieving Entry Level Standards.

Resource Library

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1 HIB/GUIDE/01/V1.0

Guidelines

Preamble - Hospital-In-A-Box

Preamble document introduces the Hospital-in-a-Box toolkit, outlining its purpose to support hospitals in implementing NABH Entry-Level Standards. It provides an overview of the toolkit’s significance in enhancing quality and safety in healthcare delivery.

2 HIB/GUIDE/02/V1.0

Guidelines

Statutory Compliance List

This document specifies the statutory compliance requirements for NABH Entry Level Certification, detailing necessary licenses and registrations for healthcare organizations, with mandatory registrations highlighted.

3 HIB/GUIDE/03/V1.0

Guidelines

List of Terminologies

This document provides essential terminologies related to hospital practices, defining key concepts for clarity in infection control, patient safety and quality assurance.

4 HIB/GUIDE/04/V1.0

Guidelines

List of Policies

This document provides list of policies required for upload before Desktop Assessment under Entry Level program

5 HIB/GUIDE/05/V1.0

Guidelines

Manpower Requirements Guidelines

This document outlines manpower planning requirements, detailing nursing, RMO, and consultant staffing criteria based on IPHS standards, specifying roles and exclusivity based on employment type.

6 HIB/GUIDE/06/V1.0

Guidelines

FAQs

This section provides answers to commonly asked questions by hospitals

7 HIB/GUIDE/07/V1.0

Guidelines

Assessment Guidelines

This document outlines the Hospital Assessment Guidelines for the NABH Entry Level Certification Programme. It includes Onsite and Virtual Assessment Guidelines, General Instructions for hospitals, and Travel Arrangement Guidelines to ensure smooth preparation and execution of the assessment process.

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1 HIB/POLICY/01/V1.0

Policy

Sample Policy

This document mentions requirement in a policy, Example has been taken of sample policy on Information Management System dealing with Medical Records

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1 HIB/FORMAT/01/V1.0

Format

Terms of Reference (TOR)-Committees

Committee has its aim of conucting meetings, frequency, required members for meeting. The same is documented for reference in document known as "Terms of Reference (TOR)" . Example - Hospital Infection Prevention & Control Committee and Quality Assurance and Safety Committee

2 HIB/FORMAT/02/V1.0

Format

Critical Result Reporting Register Format

This document serves as a record template for critical test values, capturing essential details like patient information, test specifics, notification times, and responsible personnel.

3 HIB/FORMAT/03/V1.0

Format

Format of Training Record

This document is a training attendance sheet, designed to record details of training sessions, including topics, trainer information, trainee identities, and signatures for verification.

4 HIB/FORMAT/04/V1.0

Format

Format of Discharge Summary

This document outlines the format for a discharge summary, detailing essential patient information and clinical data to ensure continuity of care post-discharge.

5 HIB/FORMAT/05/V1.0

Format

Facility Round Report Format

A concise assessment of hospital readiness, safety, cleanliness, and equipment, detailing findings, responsibilities and corrective actions with timelines for improvement.

6 HIB/FORMAT/06/V1.0

Format

Template for PSQ Indicators

The document outlines key indicators for hospital performance, including patient assessment times, infection rates, staff attrition, and employee satisfaction, to ensure continuous quality improvement in care and management.

7.1 HIB/FORMAT/07/V1.0

Format

Hospital Emergency Codes

Code Blue Mock Drill Report - Code Blue refers to a medical emergency involving a patient in critical condition (Cardiac Arrest). It is a mock drill reporting format detailing key actions, participant roles, observations and improvement measures.

7.2 HIB/FORMAT/07/V1.0

Format

Hospital Emergency Codes

Code Pink Mock Drill Report - Code Pink refers to infact or child Abduction in hospital.A concise report documenting the Code Pink mock drill, highlighting key actions, participant roles, observations and necessary corrective and preventive measures.

7.3 HIB/FORMAT/07/V1.0

Format

Hospital Emergency Codes

Code Red Mock Drill Report - Code Red refers to a fire emergency requiring immediate evacuation and response procedures.A concise report documenting the Code Red mock drill, outlining key actions, participant roles, observations and required corrective and preventive actions.

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1 HIB/CHECK/01/V1.0

Checklist

List of Committees

This document outlines the list for various committees, including Quality & Safety, Pharmacy & Therapeutics, Blood Transfusion, Infection Control, and Medical Records to assess compliance.

2 HIB/CHECK/02/V1.0

Checklist

Key Staff Trainings List

This section outlines the mandatory training requirements to ensure staff are well-prepared and informed about essential safety and operational protocols.

3 HIB/CHECK/03/V1.0

Checklist

Signage Checklist

This document outlines signage and pictogram requirements, including radiation hazards, patient rights, and fire exit signage.

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1 HIB/CHECK/04.1/V1.0

Department Checklist

Emergency

This checklist ensures the Emergency Department meets essential operational, safety, and quality requirements for effective patient care and emergency response.

2 HIB/CHECK/04.2/V1.0

Department Checklist

Ambulance

This checklist verifies that the ambulance meets essential legal, safety, and operational standards, ensuring readiness for effective patient transport and emergency care.

3 HIB/CHECK/04.3/V1.0

Department Checklist

Operation Theatre & Recovery Room

This checklist ensures that the operation theatre and recovery room meet safety, procedural, and infection control standards for optimal patient care and surgical outcomes.

4 HIB/CHECK/04.4/V1.0

Department Checklist

Intensive Care and High Dependency Units

This checklist for the Intensive Care and High Dependency Unit ensures that critical care standards are maintained for patient safety, effective medication management, staff competencies, and adherence to protocols in high-risk environments.

5 HIB/CHECK/04.5/V1.0

Department Checklist

In Patient Department - IPD

This checklist outlines essential requirements and standards for the In-Patient Department, ensuring adherence to clinical protocols, patient safety, and quality care delivery.

6 HIB/CHECK/04.6/V1.0

Department Checklist

Specialized Wards: Paediatric, OBG, & Labour Room, Chemotherapy Unit

This checklist outline the critical requirements for the Pediatrics Ward, Labour Room, and Chemotherapy Unit, ensuring compliance with safety protocols, effective patient care, and specialized attention to vulnerable populations.

7 HIB/CHECK/04.7/V1.0

Department Checklist

Radiology : X Ray / USG/ CT Scan / MRI

This checklist ensures compliance with safety and licensing standards in the Imaging Department. It covers equipment licensing, safety signage, patient screening, consent for invasive procedures, turnaround time monitoring, and staff training in safety practices.

8 HIB/CHECK/04.8/V1.0

Department Checklist

Endoscopy / Bronchoscopy

This checklist ensures compliance with safety standards, including separate personnel for sedation, informed consent, medication management, crash cart availability, and documented reuse policies.

9 HIB/CHECK/04.9/V1.0

Department Checklist

Laboratory: Haematology / Biochemistry / Pathology / Microbiology / Histopathology / Cytology

This checklist verifies the adequacy of laboratory services, proper sample collection and handling, defined turn-around times for test results, safe disposal of samples, training in safety practices, and provision of necessary safety equipment for laboratory staff.

10 HIB/CHECK/04.10/V1.0

Department Checklist

OPD

This checklist Ensures proper registration, initial assessments, bilingual displays of care information, staff training, accessible handwashing areas, patient privacy, biomedical waste compliance, and complete prescription requirements. Monitors quality indicators like patient satisfaction and waiting times.

11 HIB/CHECK/04.11/V1.0

Department Checklist

Medication Management: Pharmacy and Pharmacy Store

This checklist ensures that all procedures related to medication procurement, storage, prescription, and dispensing are properly documented and adhered to, guaranteeing legal compliance and safety practices, particularly for high-risk medications.

12 HIB/CHECK/04.12/V1.0

Department Checklist

Hospital Infection Control

This checklist ensures proper infection control practices, including updated protocols, cleanliness, availability of PPE, hand hygiene compliance, and monitoring of hospital-associated infections. It also verifies vaccination protocols for staff and safe management of hazardous spills.

13 HIB/CHECK/04.13/V1.0

Department Checklist

CSSD

This checklist ensures proper sterilization space, unidirectional flow, documented cleaning and sterilization policies, adherence to shelf life, regular validation testing, a sterilization recall procedure, and a reuse policy for medical devices.

14 HIB/CHECK/04.14/V1.0

Department Checklist

Safety & Quality

This checklist ensures designated individuals for quality assurance, documented and updated quality programs, regular internal audits, management support for quality improvement, established committees, monitored key performance indicators and oversight of safety programs.

15 HIB/CHECK/04.15/V1.0

Department Checklist

Medical Record Department (MRD)

This checklist ensures unique identifiers, authorized entries, timely documentation and confidentiality. It covers essential patient information and retention policies, safeguarding data integrity through regular audits.

16 HIB/CHECK/04.16/V1.0

Department Checklist

Biomedical Equipment Management

This checklist ensures documented equipment plans, regular maintenance, operational compliance and comprehensive inventory management. It covers training for technicians, repair documentation and records for equipment uptime and downtime.

17 HIB/CHECK/04.17/V1.0

Department Checklist

Common Areas (Policies/Trainings/
Signages etc)

This checklist ensures that essential training sessions and critical signages are implemented for safety and compliance.

18 HIB/CHECK/04.18/V1.0

Department Checklist

Medical Gases, Vacuum System etc.

This checklist ensures the continuous availability and safety of potable water, electricity and medical gas and vacuum systems within the facility. It verifies compliance with maintenance protocols, staff training and safety measures to support patient care and operational efficiency.

19 HIB/CHECK/04.19/V1.0

Department Checklist

Housekeeping, Laundry, Kitchen

This checklist ensures compliance with biomedical waste management protocols, maintain hygiene in laundry practices and uphold food safety standards, focusing on safe handling, segregation, transportation and disposal of waste, as well as proper handling and employee health monitoring in the kitchen.

20 HIB/CHECK/04.20/V1.0

Department Checklist

Front office: Registration, Admission and Billing counters

This checklist ensures effective patient admission processes by verifying staff awareness of hospital policies, standard operating procedures and patient rights, while monitoring quality indicators related to admission times and pricing transparency.

21 HIB/CHECK/04.21/V1.0

Department Checklist

Management / Administration

This checklist verifies the establishment of a clear organizational structure, compliance with regulatory requirements, ethical leadership and transparency in ownership and billing practices within the healthcare organization.

22 HIB/CHECK/04.22/V1.0

Department Checklist

Human Resource Department

This checklist assesses the effectiveness of employee training, compliance with disciplinary and grievance policies and management of health and personal information, ensuring a supportive and safe work environment in the healthcare organization.

To download the complete toolkit click here

Assessment Guide - Entry Level

Onsite Assessment Guidelines
Virtual assessment Guidelines
General Instructions to the Hospital

Travel arrangement guidelines
Accommodation arrangement guidelines
Standard Templates and Annexures

Why Choose Hospital-In-A-Box?

At NABH, we understand that implementing quality standards can be a challenging task. That’s why Hospital-In-A-Box is designed to make the process as smooth as possible. Here’s how we can support you:

Easy Implementation:

Clear and practical guidance for implementing NABH standards.

Practical Tools:

Everything you need to get started, from checklists to sample policies.

Save Time:

Ready-to-use, customisable templates, signage, and forms.

Ensure Compliance:

Identify gaps and align your hospital’s practices with NABH standards, improving patient outcomes.

Support Continuous Improvement:

A strong foundation for ongoing quality improvement in your hospital.

Free of Charge:

Resources available at no cost, making it accessible to smaller hospitals with budget constraints.

Boosts Staff Awareness:

Training materials and signage to increase staff awareness of quality and safety practices.

Journey to NABH Entry Level Certification:
A Step-by-Step Guide

Let’s walk you through the journey to NABH Entry Level Certification:

Fee Structure for Application of
NABH Entry Level Certification

Certification Type

Certification Fees (2 years)

Virtual Assessment Fee

Focus Assessment

Re-issue of Certificate

Entry Level For Hospital Certification Program
(Above 50 Beds)

₹52,000

₹5,000

₹15,000

₹6,000

Entry Level For SHCO Certification Program (Below 50 Beds)

₹21,000

₹3,000

₹15,000

₹6,000

(Plus GST @18%)

Frequently Asked Questions

Is Hospital-In-A-Box a guarantee for successful certification?

No, Hospital-In-A-Box is a tool designed to help healthcare organisations align with NABH Entry Level Standards. While it provides valuable resources and guidance, successful certification depends on your organisation’s implementation and adherence to the standards.

Will NABH provide or recommend any consultants for certification?

NABH does not directly provide or recommend specific consultants.

Is Hospital-In-A-Box only for new hospitals seeking certification?

No, while it is especially beneficial for new hospitals seeking NABH Entry Level Certification, Hospital-In-A-Box can also be used by hospitals that are already certified to maintain or enhance their standards, or even prepare for higher levels of NABH accreditation.

How do I get access to Hospital-In-A-Box?

You can download the Hospital-In-A-Box toolkit for free from the NABH website. It is available for healthcare organisations committed to improving their quality and safety standards.

Can I modify the materials in Hospital-In-A-Box to fit my hospital’s needs?

Yes, the toolkit is flexible. Healthcare organisations are encouraged to adapt and modify the materials according to their unique services, operational needs, and the scope of their healthcare offerings.

Can we get a refund if we do not pass the assessment?

As per NABH’s policy, fees paid for certification and assessments are non-refundable, regardless of the outcome of the assessment.

Are there any limitations to using the Hospital-In-A-Box toolkit?

Hospital-In-A-Box is a guide and sample toolkit, and healthcare organisations are encouraged to adapt it to their specific needs. It is not the exclusive way to meet NABH standards, and organisations should ensure compliance through their own efforts.

What is the timeframe for completing the NABH Entry Level Certification process?

The timeframe for the NABH Entry Level Certification process depends on the hospital’s readiness. On average, hospitals may take 6-12 months to implement the standards and prepare for the assessment.

How can we track our progress during the certification process?

Hospitals can track their progress using the HOPE portal.

Ready to take the first step?
Start your NABH Entry Level Certification Application journey today by visiting the HOPE Portal.
Apply Now

Disclaimer

The content of Hospital-In-A-Box is intended to serve as a sample and guide for a better understanding of the NABH Entry Level Standards. It is not prescribed by NABH as the exclusive or only way to meet the standards. Healthcare organisations are encouraged to adapt and modify the materials according to their scope of services and operational needs. NABH is not liable for any misinterpretations or errors resulting from the unmodified use of this material or for any non-compliance during assessments that may arise as a result of using the toolkit.

↑

Hospital in a box

Your Guide to NABH Entry Level Certification

Introduction to Hospital-In-A-Box

Hospital In a Box

How to apply in Hope Portal

Objective

Provide tools and guidance for implementing NABH Entry Level Standards.

Help healthcare organisations identify and address gaps in practice.

Offer free resources, including checklists, policies, forms, and reference materials.

Support smaller organisations in their quality improvement efforts.

Encourage customisation of materials for your unique setup.

Hospital-In-A-Box Toolkit

The Hospital-In-A-Box toolkit is designed to help hospitals understand and implement the core requirements for NABH Entry Level Standards, ensuring they are well-prepared for assessments and can operate efficiently with a strong foundation of quality.

Hospital-In-A-Box Toolkit

Sample policies and procedures for clinical and administrative processes.

Department-specific guidelines, checklists, and formats.

Forms, formats, and registers to streamline documentation and compliance.

Comprehensive guidance on applying for NABH assessments and achieving Entry Level Standards.

Resource Library

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1

HIB/GUIDE/01/V1.0

Guidelines

Preamble - Hospital-In-A-Box

Preamble document introduces the Hospital-in-a-Box toolkit, outlining its purpose to support hospitals in implementing NABH Entry-Level Standards. It provides an overview of the toolkit’s significance in enhancing quality and safety in healthcare delivery.

2

HIB/GUIDE/02/V1.0

Guidelines

Statutory Compliance List

This document specifies the statutory compliance requirements for NABH Entry Level Certification, detailing necessary licenses and registrations for healthcare organizations, with mandatory registrations highlighted.

3

HIB/GUIDE/03/V1.0

Guidelines

List of Terminologies

This document provides essential terminologies related to hospital practices, defining key concepts for clarity in infection control, patient safety and quality assurance.

4

HIB/GUIDE/04/V1.0

Guidelines

List of Policies

This document provides list of policies required for upload before Desktop Assessment under Entry Level program

5

HIB/GUIDE/05/V1.0

Guidelines

Manpower Requirements Guidelines

This document outlines manpower planning requirements, detailing nursing, RMO, and consultant staffing criteria based on IPHS standards, specifying roles and exclusivity based on employment type.

6

HIB/GUIDE/06/V1.0

Guidelines

FAQs

This section provides answers to commonly asked questions by hospitals

7

HIB/GUIDE/07/V1.0

Guidelines

Assessment Guidelines

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1

HIB/POLICY/01/V1.0

Policy

Sample Policy

This document mentions requirement in a policy, Example has been taken of sample policy on Information Management System dealing with Medical Records

S.No.

Document Identifier

Document Category

Section

Description

Document Link

1

HIB/FORMAT/01/V1.0

Format

Terms of Reference (TOR)-Committees