Run an incident management system that identifies sentinel events, analyses every incident, takes corrective and preventive action and tells the people affected. Redress complaints through a defined mechanism within a defined time frame, because both the incident system and complaint redress are Core objective elements.
What PSQ.7 and PRE.7 require
Standard PSQ.7 says incidents are collected and analysed for continual quality improvement. An incident management system is a Core element, and the hospital identifies sentinel events, analyses incidents, acts on the findings, feeds the risks into its risk management system and informs stakeholders after a near miss, adverse event or sentinel event.1 Standard PRE.7 makes complaint redress a Core element, with patients told how to give feedback and complaints reviewed within a defined time frame.1
| Element | Level | What it asks |
|---|---|---|
| PSQ.7.a | Core | An incident management system |
| PSQ.7.b | Commitment | A mechanism to identify sentinel events |
| PSQ.7.d | Commitment | Corrective and preventive action from the analysis |
| PSQ.7.f | Commitment | Informing stakeholders of a near miss, adverse or sentinel event |
| PRE.7.c | Core | Complaints redressed through the defined mechanism |
| PRE.7.e | Commitment | Feedback and complaints reviewed within a defined time frame |
When a complaint reaches NABH
A patient must first take a complaint to the hospital, and only if it is not resolved can they file it with NABH through QCI's Quality Setu portal, with evidence of that earlier correspondence and the hospital's reply.2 Complaints about billing, clinical negligence or an individual professional go to the state medical council or the National Medical Commission instead.2 A complaint or an adverse media report can also trigger a surprise assessment.3
- Define what counts. Near miss, adverse event and sentinel event, in your own policy.
- Make reporting easy. Every member of staff knows how and where to report.
- Analyse every incident. Rebuild the timeline from the record, then find the cause.
- Act and follow up. Corrective and preventive action, each with an owner and a date.
- Tell the people affected. Patients, families and staff, as your policy sets out.
- Close complaints on time. Review each within your defined time frame, and keep the reply.
- Incident number ______ Date and time ______
- Type, near miss, adverse or sentinel ______
- Timeline from the record ______
- Cause found ______
- Corrective and preventive action, owner and date ______
- Patient or family informed on ______
Questions
Is an incident reporting system mandatory for NABH?
Yes, PSQ.7.a, an incident management system, is a Core objective element and must score at least 4 at every assessment.
Can patients complain to NABH directly?
Only after taking the complaint to the hospital first, and then through QCI's Quality Setu portal with evidence of that contact.
Does NABH handle billing complaints?
No, NABH's policy sends billing, clinical negligence and complaints about individual professionals to the appropriate regulator.
Sources
- 1NABH, 2025NABH Accreditation Standards for Hospitals, 6th Edition, effective 1 January 2025Read source
- 2NABH, 2025Policy and Procedure for Handling of Complaints, Issue 8Read source
- 3NABH, 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.