The National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), setup to establish & operate accreditation programme for healthcare organization. The board is structured to cater too much desired needs of the consumers and to set benchmarks for progress of health industry.

HOPE stands for Healthcare Organisation Platform for Entry Level certification. NABH has partnered with IRDA to carry out entry level certification of hospitals which has been made mandatory for providing cashless insurance facility to the citizens at their premises. Healthcare Organization Platform for Entry Level Certification (HOPE) is an online portal for HCOs to apply under NABH Entry Level Certification Programme.

Please visit the link to access the HOPE Portal:- hope.qcin.org.

Certification Standards for Entry Level Certification.

A copy of the Entry Level Certification Standards can be downloaded from NABH website at the following link https://portal.nabh.co/NABHStandards.aspx#gsc.tab=0

The fee structure is available on NABH website at the following link https://nabh.co/13050-2/

The general policies are available on NABH website at the following link https://nabh.co/general-policies/

No, NABH does not provide any consultancy to the Healthcare Organizations (HCOs)

No, NABH does not empanel or associate itself with any consultant organization or agency to provide Entry Level Certification.

The hospitals up to 50 sanctioned beds come under Small HealthCare Organisation (SHCO) category and the hospitals with more than 50 sanctioned beds come under the HCO category

To apply under Entry Level Programme, an HCO must be functioning for at least a period of six months and must have implemented the Entry Level Standards for a minimum period of three months at the time of application.

The HCO should have a occupancy of at least 30% for last three months.

Only Health Care Organizations (HCOs) providing Allopathic services can apply for Entry Level Certification.

Health Care Organizations (HCOs) under AYUSH system of medicines, Physiotherapy centres, exclusive diagnostic centres or any other type of healthcare establishment where a MBBS doctor is not involved are excluded to apply under the programme.

The application will be scrutinized in Desktop assessment and it will be rejected. The fees paid will be non-refundable.

Entry Level Certification is valid for a period of 2 years.

Currently only Health Care Organizations (HCOs) registered and functioning in India can apply under the programme.

The hospital can refer to the below-mentioned link: Please go to Education and Training Tab. https://www.nabh.co/EducationTraining.aspx#gsc.tab=0

A standard is a statement that defines the structures and processes that must be substantially in place in the organisation to enhance the quality of care. The standards are numbered serially, and a uniform system followed for numbering. The first three letters reflect the name of the chapter and the number following this reflects the order of the standard in the chapter.

The standard focuses on the key points required for providing patient-centred, safe, high-quality care. The interests of various stakeholders have been incorporated into the standard. They provide a framework for quality assurance and quality improvement.

The focus is on patient safety and quality of patient care. It sets forth the basic standards that organisations must achieve to improve the quality of care.

Ten Chapters of NABH are:

• Access, Assessment and Continuity of Care (AAC)
• Care of Patients (COP)
• Management of Medication (MOM)
• Patient Rights and Education (PRE)
• Hospital Infection Control (HIC)
• Continuous Quality Improvement (CQI)
• Responsibilities of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)

There are 5 patient centric chapters, they are as follows

• Access, Assessment and Continuity of Care (AAC)
• Care of Patients (COP)
• Management of Medication (MOM)
• Patient Rights and Education (PRE)
• Hospital Infection Control (HIC)

There are organisation centric chapters, they are as follows

• . Continuous Quality Improvement (CQI)
• Responsibilities of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)

Objective element is the measurable component of a standard. Acceptable compliance with objective elements determines the overall compliance with a standard. The objective element is scored during assessments to arrive at the compliance. Objective element is numbered alphabetically in a serial order. For example, AAC.1. e. would mean that it is the fifth objective element of the first standard of the chapter titled Access, Assessment and Continuity of Care’.

An organization planning to go for NABH certification may obtain a copy of NABH Entry Level Certification standards and assess their compliance with the standards to ensure that the standards are implemented and integrated with the hospital functioning.

All aspiring healthcare organizations desirous to achieve certification can apply online by registering on HOPE portal.

When does the applicant hospital gets a permanent application number? The applicant hospital gets a permanent application number after paying the application fee.

Hospitals are required to inform the NABH secretariat well in advance about any split locations, services provided at each location, and the distance between them before planning an assessment. The NABH secretariat will then make a decision on whether to conduct one or separate assessments after careful consideration.

The Hospital can send a request on its letter head signed by the hospital authority registered with NABH. The scanned copy of letter can be mailed to concerned program officer.

The Hospital are advised to fill up the application form very carefully as the information in application form cannot be changed once the application form is submitted.

• Statutory compliance – Registration with local authority, Biomedical Waste Authorization from State Pollution Control Board
• Hospital staffing- which includes consultant details, medical officer details, consultant details, nurse details, paramedical staff details and administrative staff details.
• Standard wise policies, manuals, checklist, MOU’s, training documents etc.

It is important for the hospital to have all their statutory licenses, policies and manuals ready for review during assessments. Additionally, the assessment team will also be looking over the checklists, forms, and formats used by the hospital for documentation purposes. It is also recommended that the hospital keeps a hospital orientation PowerPoint presentation on hand which gives a brief overview of the hospital.

It is imperative for hospitals to comply with ethical standards and refrain from submitting false or forged documents. NABH has a zero-tolerance policy towards forgery. Any hospital found guilty of submitting false documents will be subjected to strict action as per NABH guidelines. This policy is a crucial step towards fostering transparency and maintaining honesty in the certification process.

As the hospital will finish filling the application form, the payment option will pop and the hospital will be at Fee submission stage.

No, Other online payment options are available in the portal.

No, fees once paid will not be refunded.

Debit card, Credit card, UPI and NEFT

No, fees will not be refunded. HCO will have to register again and pay the fees again to apply for empanelment

The fee structure for various programs is available on NABH website. The same can be accessed by clicking on the below link: https://nabh.co/wp-content/uploads/2023/10/RevisedFeeStructure_NABH.pdf

Fee to be paid Online at NABH Portal or Bank Transfer. In case fee is paid by bank transfer hospital must upload transaction details on the NABH Portal and update in the remark’s column.

No, the fees once paid is non-refundable.

After filling in all the required details, click the ‘Pay’ button. Applicant will be redirected to the Payment Gateway Pages select the type of payment to be used and pay the applicable certification fee.

Applicants cannot edit information. Notify NABH secretariat for changes.

To complete all sections of the application, it is necessary to fill in the details accurately. In order to prevent any loss of data, applicants are advised to save their progress frequently by clicking on the “save” button.

We recommend saving your work periodically to prevent data loss.

The following formats are recommended:

• Image – JPG, JPEG, PNG
• Document – PDF

The documents that are uploaded by the organisation as evidence must be clear and readable.

The applicant can either download the templates to fill in the details and upload the same file on the respective question or they can add details on the portal itself, the same will be displayed in the Table.

Successful or error message will appear, if there are some errors then reupload the file after correcting such error Click on ‘Upload Excel’ Button.

Click on the ‘Add’ button to fill in the details manually. Use this option to add less data only

• Pop-up will appear, fill in all the required fields and click on the ‘Save’ button.
• Once details are filled it will be visible under table, use edit or delete icon for editing the data.

Once submitted, the information in registration form cannot be changed or replaced.

The HCO should go through the application to check if there’s any missing information. Secondly if the HCO has filled Aadhar/pan details, they can check if the numbers are correct or not.

The HCO needs to review all the entered data and ensure that no fields are left empty which will be reflected as “*” in red color. If after rechecking the HCO is facing the issue again, they need to logout and login again, Clear cache history or inform to program officer.

Using of multiple devices to fill the data of one hospital may lead to data loss.

The HCO is required to have all the necessary and applicable document available at the time of registration to avoid unnecessary delays. HCO will not be able to submit the registration form until all the mandatory documents and information is not filled.

Submission of the form beyond the stipulated time will lead to inactivation of the application and the HCO will have to register themselves again.

Any HCO applying for the certification hasto follow the following process:

• Submission of registration form
• Completion of application form
• Payment of application fee
• Desktop Assessment
• Submission of CAPA for NCs raised in Desktop Assessment
• On-site / virtual assessment
• Submission of CAPA raised in On-site / virtual assessment
• Certification committee review
• Approval from certification committee.

For all the documents written in language other than English, a translated copy in English version is required during submission.

It is imperative that HCO possesses all the necessary and relevant documents prior to submitting the application form. Failure to provide the mandatory documents and information will lead to the inability to submit the application form. It is essential that HCO takes all necessary measures to ensure the availability of the required documents at the time of submission.

If any of the documents mentioned are not applicable to a healthcare organization (HCO), they should upload a page with the words “Not Applicable” written on it. Please note that the registration form cannot be submitted until all the sections containing documents and information are filled.

No, NABH will not accept any application in hard copy. All the applicants are required to submit the application on the HOPE portal.

Applicants can save and edit the application form before final submission.

It is crucial that HCO marks all the required options and uploads all the relevant documents before submitting the application form. This will ensure a smooth and successful submission process

All mandatory requirements are marked with red asterisks in the application form. Additionally, any missing information will be highlighted during the final submission.

After submitting the application form, it is not possible to modify or replace the entered information. However, if the HCO (Healthcare Organization) needs to make any changes, they can send the details of the required change along with all supporting information to NABH. Please note that NABH reserves the right to decide whether the requested changes can be made or not.

No, a new application number will be allotted to the HCO on new registration.

After submitting all the required information and completing the payment process, the HCO will be reviewed for desktop assessment.

The assessor reviews the application to ensure that it is complete and that all the required documents have been provided. If any requirements are missing, non-conformities (NCs) are raised after a review by the assessor. The HCO is notified of these NCs and given the opportunity to address and resolve them.

There are 2 cycles for the submission of corrective actions against the deficiencies as raised by the assessor.

HCO will not be able to know the assessor conducting DA.

HCO willreceive an e-mailregarding the updated status on the registered e-mail ID. The status will also be updated on the HOPE portal. The HCO can check the status directly on the HOPE portal as well.

All the raised NCs by the assessor will be available for response to the HCO on the HOPE portal.

After log in account on portal, the HCO should open DA Tab and then needs to look at every segment of the application for NC’s raised. The NC’s will be reflected as on count besides every segment/NABH Chapter.

Please note that the Red Text indicates the number of non-conformities (NCs) that have been raised under a specific section. When the NC Button appears in Red, it means that there is an NC that requires a response. To reply to the NC that has been raised, you can simply click on the NC Button.

When responding to a raised Non-Conformity (NC), it is important to provide a detailed remark or justification in the ‘NC Reply’ text box. Additionally, it is recommended to upload any relevant evidence or documentation by clicking on the ‘Choose File’ button. This will facilitate a better understanding of the NC and expedite the resolution process. Please be advised that a thorough and comprehensive response will enable to address the matter in a timely and efficient manner.

When all the required documents are uploaded and the required justified reasons are provided, click on the ‘Submit’ button to successfully submit the response for the respective NC

The NC Button will change to a ‘Yellow’ color upon successful response upload.

No, the organization will not be able to know assessor name and details who is reviewing the application.

If the application has been rejected at the DA level, the HCO should go through the DA remark uploaded by the assessor regarding the discrepancy in the form submitted by the HCO, The HCO should rectify the same and apply afresh under the program.

HCO can e-mail the program officer for any technical issue or concern.

It is not necessary that desktop and onsite assessor will be same

There must be some discrepancy in the documents submitted by the HCO, The HCO can go through the DA remark uploaded by the assessor regarding the discrepancy.

No matter how many NCs the assessor has raised, The HCO will have to reply to all the NCs, failing which the application will get inactivated. Also, the request for assessor change will not be entertained.

The date is decided as per the assessor’s availability and schedule of assessment team. The date of final assessmentshall be agreed upon by the HCO management and assessors.

HCO will bear the travel and stay arrangements of the assessor

Assessor is to be provided with local hospitality of lodging and boarding in a clean hotel with good reputation within reasonable proximity of HCO. The location must also consider the route and time that assessor will have to travel on his way back to the port of exit after the assessment.

No, HCO do not have to pay anything to the assessor. In fact, any payment will be looked upon adversely by NABH. If assessor demands anything, please report to the NABH immediately. The feedback shall remain confidential and will not affect the assessment process at any stage.

The HCO should not book extra stay for the assessor after the assessment has been completed.

Yes. An email will be sent to the registered email address of HCO with the details of assessment team.

Once the assessment team is assigned, the HCO may contact assessment team on the contact details which are shared on registered email address.

The assessment team reviews the HCOs documented management system and verifies its compliance to the NABH standards. The documented quality system, policies and procedures, other manuals etc. shall be assessed for their implementation and effectiveness.

The assessment report is visible to the HCO on the HOPE portal.

The assessment report is discussed by the assessor with the assesses during closing meeting. The HCO may clarify any doubts during closing meeting.

No gifts to be given to assessors at any point. NABH will look adversely upon this practice.

The assessment team checks the compliance of NABH standards by reviewing the records and documents of healthcare organisation, taking facility rounds, interviewing the staff, patients and management.

The on-site assessment will be conducted by the team of assessor/s. He/she will take round of facilities of the hospital, check the documents and records, take photos, interview staff, upload evidences, etc. It is a finding process to check whether the on- site evidence matches the requirements of the standard.

3 – 4 weeks, it may be subjected to change due to different reasons like delay in the responses from the hospital, inadvertent reasons etc

No, it will be only assigned by the NABH secretariat. However, HCO will have an option to accept/reject the assigned on-site assessment date.

No, the assessments cannot be conducted on National Holidays i.e. Republic Day – 26th January, Independence Day 15th August and Gandhi Jayanti 2nd October.

HCO are eligible only after the successful completion of desktop assessment stage.

All statuary compliances, consultant list, other manpower details (nurses, RMO’s. paramedical staff etc.), NC closure of desktop assessment and all other documents submitted during desktop assessment should be available.

Inspection can take place any day between Monday to Saturday

A new assessor will be allocated for the same date or nearest possible date. The same will be updated to HCO via e-mail and remarks on portal.

In such case, HCO must report the issues to NABH secretariat.

Assessor will have the option of raising an NC (Non-Compliance) for the information which they find to be incorrect. HCO has to clear all the NCs to be eligible for certification. HCO will have a maximum of 2 chances to clear all the NCs.

When an assessor identifies evidences during assessment that the care and the services provided in HCO do not meet the Entry level standards, it will consider that as a Non-Compliance.

The NCs can be viewed on the HOPE portal.

The HCO must submit Corrective and Preventive Action (CAPA) against raised each NC’s. The HCO must also submit the evidence of CAPA as implemented across organisation as the closure of NC’S.

CAPA stands for corrective and preventive action

Corrective action: Action taken to eliminate the cause of Non-Compliance so as to prevent reoccurrence.

Preventive action: Action taken to prevent the occurrence of Noncompliance as a result of risk analysis.

The HCO must inform about the change to the Program officer through email with a request letter on the hospital letter head signed by competent authority of the hospital.

Two Opportunities, Cycle-1 and Cycle-2

The HCO is given only 2 opportunities for CAPA Submission. If there are still open NC’S after cycle 2 the case will be placed in the certification committee with the available document for the final decision.

If all NC’s are accepted in cycle-1 the case will be taken to the certification committee for final decision.

CAPA report is to be uploaded on portal only.

Once the assessor completesthe CAPA review cycle-2, the case istaken to Certification committee for review and decision.

File can be uploaded in file type of .doc, .docx, .pdf, .xls, .xlsx, .jpg, .jpeg.

Yes, Assessment report is shared by assessor. Once reports are uploaded in the portal, HCO can also view the reports.

Non-Compliances are raised for the information which assessor may find to be incorrect. Effective replies to all the NCs raised during and after assessment during CAPA cycles make HCO eligible to undergo for further process.

There is no limit for the number of evidences to be submitted for a non- compliance.

No, once submitted, the corrective actions will be non-editable.

If there are any non-conformities, they can be replied by uploading the requisite evidence to close the same.

No, first the NABH team will review all the information submitted against any non- compliance. After the successful verification of information case presented to the certification committee, review committee will check the assessment report on the basis of which final decision will be made.

If the reasons for rejection are fulfilled and closed, then HCO can apply afresh on portal

Hospital can contact the designated program officer or send an email to hope@qcin.org

After satisfactory corrective action is taken by the HCO, the committee examines the assessment report, additional information received from the HCO and consequent verifications. The committee shall make appropriate recommendations regarding certification of the HCO to NABH.

In case the committee finds deficiencies in the assessment report to arrive at the decision, additional documents or clarifications may be asked for by the committee from the HCO/ Assessor

You are requested to e-mail your documents and queries.

Yes, it is mandatory to submit assessor feedback as the stage will not proceed further without feedback submission.

The assessor does not have rights to view feedback given by hospital. The confidentiality is maintained.

The HCO will receive a communication through the portal once case has been recommended for Entry level certification by the committee.

No, there is no provision for HCO to be present in the meeting of certification committee.

NABH shall issue a certificate along with Scope of services certificate to the HCO with a validity of 2 years. The applicant HCO must make all payment due if any to NABH, before the issue of certificate.

The ongoing commitments of certified HCOs towards NABH will be:

• Diligently follow the NABH standards as an ongoing commitment towards patient safety and quality of healthcare.
• Correct use of NABH logo.
• Conduct the processes of HCO in a manner that addresses patient safety and quality in healthcare.

The rules for the usage of NABH logo are displayed on the NABH website.

On noticing the deviations with respect to the requirements of continuing the certification, NABH secretariat will be taking decision as per the adverse decision policy and procedures of NABH.

HCO can contact the NABH secretariat through mail or through call mentioned in the link- https://www.nabh.co/ContactUS.aspx. Please click to the contact tab

Application fees once paid is not refundable.

It can apply forfocus assessment. Please refer to “NABH Policy and Procedures on Focus Assessment”

The HCO is required to update for the purpose of focus assessment which needs to be conducted as focus assessment is done in case of addition in scope of services

The HCO must refer to policy for focus assessment. https://nabh.co/Images/PDF/Policy_for_Focus_Assessment.pdf

YES, the HCO will have NC’S after focus assessment for which the HCO has to submit CAPA to the assessor through email

Yes,theHealthcare Organisation isrequired to pay Rs15000/+taxesforfocus assessment.

It is onsite assessment which includes 1 assessor for 1 day.

The HCO shallsubmit the signed copy of NABH Standard Agreement at the time of grant of certification. The agreement is required to be submitted on a stamp paper. A certified HCO shall abide by the conditions as mentioned in the agreement at all times during the duration of certification. Any deviation or noncompliance of the conditions of the agreement of grant of certification shall invite the action from NABH as mentioned in the document “NABH policies and procedures for dealing with Adverse and Other Decisions”.

• Go to NABH website
• Click on What we do tab
• Select your program under
• Go to certified HCO’s tab
• Click on the name of your hospital and download the soft copies of NABH Scope certificates.

The hard copies are dispatched from NABH secretariat. This may take up to 30 working days after the grant of certification.

The certification certificate is accompanied by “Scope of Certification” which shall define services being offered by HCO.

The Hard copy of certificate and scope certificate will be dispatched at the hospitals address as filled in the application form.

The scopes will be provided as per the scope applied in the application form.

No, HCO must fill the form correctly and any changed required in scope should be intimated to NABH Secretariat before the inspection.

The HCO can firstly check the scope of services tab of the application i.e., if the scope is not applied by the HCO, it will not be deliberated by the certification committee and reason for denial of the scope will be mentioned in the portal. If the hospital has any further concern regarding the scope please drop an email to hope@qcin.org

Yes, it is possible to apply for a name change in the certificate, subject to compliance with NABH Policy and Procedure for Change of Name of an Accredited Certified Healthcare Organisation

HCO needsto inform concerned NABH program officer about the addition of scope of service. For more information HCO can visit the NABH portal for NABH Policy & Procedure for Focus Assessment of an Accredited / Certified Healthcare Organisation

The HCO may refer to the NABH website for the Policies and procedures for handling of appeals for the reconsideration of decision of certification Committee.

Appeal should be submitted about the decision in writing within 30 days to NABH in a prescribed format obtained from NABH website.

No, there is no fee for submitting appeal

Once the appeal has been rejected, the hospital is required to comply with the decision that has been made.

Yes, Complainant can write their concern against certified or applicant health care organization through Quality Setu portal available at NABH website

helpdesk@nabh.co

The HCO is required to register their complaint at Quality setu: https://qualitysetu.qcin.org/

011-42-600-600