[Clinic name]
Controlled document
[Address]
[Registration or licence number]
NABH assessment checklist
1Eligibility and application
- Operating for at least six months, with average bed occupancy of 30% over the last six months.
- The right programme chosen, HCO for more than 50 sanctioned beds, SHCO for 50 or fewer.
- The standards implemented for at least three months before applying.
- Every service at the location included, because NABH accredits all or none.
2Self-assessment
- Every objective element scored on NABH's 5 point scale, from samples.
- Not applicable elements listed and sent to the NABH secretariat before the assessment.
- Core elements at 4 or higher before the final assessment.
- A named coordinator who owns the plan.
3Documentation
- Every objective element marked with an asterisk backed by a controlled document.
- Each document named, dated for issue and review, and signed for approval.
- SOPs reviewed at least once a year.
- Records complete and never altered after the fact.
4Medical records
- Ten files a reviewer could read cold, complete and chronological.
- Every entry signed, dated and timed, with an identifiable author.
- Consent, costs explained and education recorded where they happened.
- Access to records logged and limited by role.
5What an NABH inspector may ask
- Show me the medical record for this patient. What to show, a complete, chronological record, every entry signed, dated and timed.
- How do you tell patients what their care will cost? What to show, the expected cost, explained before care, and what was charged.
- How do patients give feedback or complain, and how fast do you respond? What to show, the mechanism, a defined time frame and the actions taken.
- Walk me through your last serious incident. What to show, the report, the analysis and the corrective and preventive action.
- How do you keep records confidential and secure? What to show, role-based access, an access log and where records are hosted.
- How do you communicate with patients who speak another language? What to show, how the hospital identifies the need and meets it.
AAppendix, Assessment day log
- A.1Assessor ______ Area visited ______
- A.2Activity ______ Staff interviewed ______
- A.3Records sampled ______
- A.4Finding raised ______ Objective element ______
- A.5Action, owner and date ______