A Principal Assessor and a team review documents, visit patient care areas, interview staff and tour the facility to judge how far each standard is implemented. The report reaches your portal within 7 days, with every non-compliance and a summary of strengths and weaknesses.
Who comes and what they do
NABH sets the team, a Principal Assessor with assessors sized to the scope, and fixes the dates with you. You have 48 hours to object to the team with valid reasons, and a NABH programme officer may attend as an observer.1 The team uses document review, visits to patient care areas, functional interviews, facility tours and special interviews to judge how far the standards are implemented.1
| Activity | What to have ready |
|---|---|
| Document review | Controlled policies and SOPs, and the records that show them in use |
| Patient care areas | Staff who can explain and show their daily practice |
| Functional interviews | Each head of department, ready to walk through their processes |
| Facility tours | Equipment, utilities and safety records for the building |
| Special interviews | The people who own quality, safety and infection control |
After the assessment, and surprise visits
The Principal Assessor uploads the report within 7 days, and you answer it on the portal in two cycles of corrective action, each reviewed within 10 days of submission.1 Once accredited, a hospital can be chosen at random for a surprise assessment, told at least 12 hours ahead, which focuses on regulatory compliance and continuous quality improvement and usually lasts no more than a day.2
- Confirm the team and dates. Raise any objection within 48 hours.
- Brief every department. Who will be interviewed, where documents are, and who can open records.
- Prepare a document room. Policies, SOPs and the evidence index, by chapter and code.
- Assign a guide to each assessor. Someone who can find any record or person within minutes.
- Log every finding as it is raised. So the corrective action starts the same evening.
- Answer the report on time. Two cycles of corrective action, each with evidence.
- Assessor ______ Area visited ______
- Activity ______ Staff interviewed ______
- Records sampled ______
- Finding raised ______ Objective element ______
- Action, owner and date ______
Questions
Who pays for the assessors' travel?
The hospital meets travel, boarding and lodging for onsite assessments, except surprise assessments, which NABH pays for.
Can an assessment be virtual?
Yes, NABH runs virtual, hybrid and desktop assessments, with documents and photographs uploaded to its portal.
How much notice comes before a surprise assessment?
At least 12 hours, and NABH selects hospitals at random, usually twice a month, or after a complaint or an adverse media report.
Sources
- 1NABH, 2025Policies and Procedures for Assessment, Surveillance and Re-assessment of HCO, Issue 5Read source
- 2NABH, 2025NABH Policy and Procedure for Surprise Assessment to an Accredited or Certified HCO, Issue 7Read source
Written by the wai team from National Accreditation Board for Hospitals and Healthcare Providers guidance, checked on 16 October 2026. This is guidance, not legal advice. NABH does not endorse wai or any software.