NABH E-Mitra

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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

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.

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

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

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

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

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

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

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.

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.

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.

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.

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

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

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

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

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

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

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.

This section provides answers to commonly asked questions by hospitals

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.

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

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

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

Preamble document introduces the NABH E-Mitra 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.