APPLICATION

For
ACCREDITATION OF SHCO

Issue No.: 04
Issue Date: July 2014

NATIONAL ACCREDITATION BOARD FOR

HOSPITALS & HEALTHCARE PROVIDERS
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 NATIONAL ACCREDITATION BOARD FOR
HOSPITALS & HEALTHCARE PROVIDERS
Assessment criteria and Fee structure

Small Health Care Organisation

Pre-assessment Assessment Surveillance Application Fee Annual Fee
Two man-days Four man days One man day Rs. 25,000/- Rs. 1,00,000/-
(2x1) (2x2)

NOTE: The man days given above for assessment and surveillance are indicative and may change depending on the facilities and size of the
SHCO.

Service Tax: w.e.f. 15.11.2015 a service tax of 14.50% will be charged on all the above fees. You
are requested to include the service tax in the fees accordingly while sending to NABH.

Guidance notes:

1. The SHCO can fill the application form online (www.nabh.co) through the website & submit the
documents and fees online. Fees are non-refundable.
2. In case of any difficulty in accessing online system, application form can be download from the
web-site. Three hard copies of this application form duly filled in are to be submitted along with self-
assessment toolkit, necessary documents and fees. Fees to be paid through Demand Draft in favour
of Quality Council of India payable at New Delhi.
3. The accreditation fee does not include expenses on travel, lodging/ boarding of assessors, which
will be born by the SHCO on actual basis.
4. The application fee includes pre-assessment charges.
5. The accreditation, once granted will be valid for three years, after which SHCO may apply for
renewal as per NABH policy.
6. The first annual fee is payable after pre-assessment visit and before final assessment visit.
7. 10% discount will be admissible in case SHCOs pay the accreditation fee for three years in one
instalment.
8. The surveillance visit will be planned during 2nd year of accreditation which is usually between
15-18 months.
9. NABH may call for un-announced visit, based on any concern or any serious incident reported
upon by any individual or organisation or media.

Definition:

Small Health Care Organisations (SHCO)

Those healthcare organizations having bed strength upto 50 beds and are in possession of supportive
and utility facilities that are appropriate and relevant to the services being provided by organization.
Day Care centres (upto 50 beds) are included.

Exclusions
- Polyclinics
- Diagnostic Centres
- Super speciality* centres (single/ multiple)

Exceptions
Speciality** Day Care centres (minimum bed strength not mandatory)

* Super Speciality centres are the centres which reflect requirement of DM/ MCh or equivalent qualified
personnel.
** Speciality centres are the centres which reflect requirement of MD/ MS or equivalent qualified personnel.

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 Guidelines for filling the application form
(Please read this carefully before filling this form)

1. For offline applications/hard copy, kindly fill the application form in BLACK INK only. You
should submit a typed version of the filled application form.
2. For Sl. No. 6: Please specify e.g. Clinical Establishment Act, Shops and Establishments
Registration Act, State Health Authority etc.
3. For Sl. No. 8.e: Provide the information using the example below.

Address Building /Block Level Area /Activity

Basement CSSD, Parking
Ground floor OPD , Billing,
Reception,
Laboratory
First floor OT ,ICU

4. For Sl. No. 10 and 11: Please specify Ten most frequent clinical diagnosis & surgical
procedures done generally for the various specialities in the SHCO for in patients e.g. of
surgical procedures is Hernia Repair, Caesarean Section, Cholecystectomy,
Appendisectomy etc. (Minor procedures like Lumbar Puncture, Pleural tap, Intra-Coastal
Drainage should be excluded from the above list).
5. For Sl. No. 12, 13, 14 and 15:
a. In Sl No.12, please indicate “Yes” only if there are qualified consultants managing the
speciality. Under the column number of consultants, please mention full time or part time
consultants.
b. While filling the row “others” in Sl No. 12, mention only the name of any recognised
speciality. Please do not mention services.
c. In point 13, 14 & 15, under last column, kindly indicate if the Outsourced services are
located in the same premises or different location.
d. Please note that this list of specialities is based on the recognised medical courses by the
Medical Council of India/ National Board of Examination.
e. PLEASE NOTE THAT THE SCOPE OF ACCREDITATION SHALL BE TRANSCRIBED
FROM THESE HEADINGS ONLY. For the sake of uniformity the scope shall mention the
specialities using the same terminology.
6. For Sl. No. 16: Name of unit/ward: E.g. Emergency, semi- private, ICU etc
Type of care pertains to nature of service e.g. adult/paediatric; male/female. Use codes like
AM (adult male), AF (adult female), SM (surgical male), SF (surgical female). If there is no
categorization please mention as open to all. In case of split locations please specify the
location
7. For Sl. No. 17: Under the category of Consultants: Others, kindly mention the On call
staff, Part time/ visiting staff. Also mention the frequency of visits for the visiting/part time
staff.
8. For Sl. No. 18: If a particular license is not required in your region or is not applicable for
your set up kindly mention the same in “Remarks” column. Please mention if any licenses
are pending and mention details as to how it is being addressed.
9. The SHCO shall ensure that it shall send an updated application form to NABH in case of
any changes especially before pre-assessment and final assessment.

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Kindly tick the appropriate box (Please refer definition on page 2):

You can apply under SHCO, if your answer to ‘a’ & ‘b’ is Yes OR if your answer to ‘c’
is Yes.

a. Is your bed strength up to 50 beds Yes No

b. Are you in possession of supportive and utility facilities that are appropriate and
relevant to the organization Yes No

OR

c. Speciality Day Care centres Yes No

DEMOGRAPHIC AND GENERAL DETAILS:

1. Applying for (please tick the relevant)

a. Accreditation* □
* (SHCO shall at least be functioning for 6 months before applying)
b. Re-accreditation □
Reaccreditation cycle number ……………

2. Name of the SHCO: (the same shall appear on the accreditation certificate)

3. Contact Details of SHCO:

Street Address
City/Town
Locality/Village/Tehsil
District
State
Website

Location of SHCO: Urban □ □

Rural

Does the SHCO have split location(s): Yes □ No □

If yes, address of the other location(s) and distance from main location

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4. Ownership/ Legal Identity: (Please indicate [√] against relevant option)

Private – corporate Armed Forces

PSU Trust
Government Charitable
Others (Specify ……………………………………………………)

5. Year in which Clinical Function started:

6. Year and month in which registered and under which authority (as per state and
central requirements)

7. Contact person(s):
(Please indicate [√] with whom correspondence to be made)

Top Management in the SHCO)

Mr./Ms./Dr.
Designation:
Tel: Mobile:
Fax:
E-mail:

Accreditation Coordinator:
Mr./Ms./Dr.
Designation:
Tel: Mobile:
Fax:
E-mail:

8. SHCO Information:

a. Total Number of Beds that have been sanctioned:

b. Total Number of Beds currently in Operation: (please exclude emergency, day-care,
recovery room beds labour room beds from this numbers

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 Bed Type Number of Beds
Inpatient beds (non ICU)
Inpatient beds ( ICU)
Total

Others :
 Emergency Beds
 Day – care beds
 Recovery room beds
 Labour room beds
 Dialysis
 (Specify)
 (Specify)

c. Number of OTs:
d. Procedure rooms
e. SHCO Layout:
i) Number of buildings
ii) List the areas / departments /units floor wise for each building in a tabular
format as mentioned in guidelines and provide it as an attachment.
iii) In case of split location the layout for each of the addresses must be given.

CLINICAL SERVICES AND RELATED DETAILS

9. OPD & IPD data:

a. OPD DATA (Past two years)

Year Number of Patients

b. IPD DATA ( Past two years) OR average occupancy rate

Year Number of Patients Admitted

10. Ten most frequent clinical diagnosis for in patients:

i) ii)
iii) iv)
v) vi)
vii) viii)
ix) x)
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11. Ten most frequent surgical procedures done for in patients:

i) ii)
iii) iv)
v) vi)
vii) viii)
ix) x)

12. Scope of Accreditation (Clinical services being provided by the SHCO)

Speciality Service Average Average Number of

Provided Daily Out Daily in Consultants
(mention Patients Patients
Yes or No) during the during the
Previous Previous
Calendar Calendar
year year
Anaesthesiology
Burns unit
Critical care unit NA
combined NA
General speciality NA
-
-
Dermatology &
Venereology
Dentistry
Emergency Medicine
Family Medicine
General Medicine
Geriatrics
General Surgery
Obstetrics &
Gynaecology
Ophthalmology
Orthopaedic surgery*
Otorhinolaryngology
Paediatrics
Psychiatry
Respiratory medicine
Sports medicine
Day care services


Others , please state Yes / No

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Among the above please list the services which are outsourced if any:

*Please mention if joint replacement or arthroscopic procedures are being done. If yes,
Operation Theatre should follow the super speciality OT guidelines:

13. Scope of Accreditation – Clinical Support departments/services in the SHCO

(mention Yes/ No):

Services In House Out Sourced

Ambulance
Blood Bank / transfusion services
Dietetics
Psychology
Rehabilitation
 Occupation Therapy
 Physiotherapy
 Speech & Language Therapy

14. Scope of Accreditation (Diagnostic Services being provided by the SHCO)

Diagnostic Service In House Out Sourced

Diagnostic imaging
Bone densitometry
CT Scanning
DSA lab
Gamma Camera
MRI
PET
Ultrasound
X - ray
Mammography
Fluoroscopy / IITV
Laboratory services:
Clinical Bio-chemistry
Clinical Microbiology & Serology
Clinical Pathology
Cytopathology
Genetics
Haematology
Histopathology
Molecular Biology
Toxicology
Other Diagnostic services:
2 D Echo
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Audiometry
EEG
EMG/EP
Holter Monitoring
Spirometery
Tread Mill Testing
Urodynamic Studies
Any other Diagnostic Services

15. Details of Non Clinical and Administrative departments

Support Service In House Out Sourced

Bio – medical Engineering
Catering & Kitchen services
CSSD
General Administration
Housekeeping
Human Resources
Information Technology
Laundry
Maintenance / Facility Management
Management of Bio – Medical Waste
Medical Gases
Mortuary Services
Pharmacy
Security
Community service
Supply Chain Management / Material
management
Other ,please specify

16. List Ambulatory unit /inpatient care Units/Wards, the Number and The type
of care given in each Unit/Ward: Refer guidelines on pg 3 point no. 6

Name or Unit / Ward Number of Beds Type of Care

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17. A. Staff Information *

Group Total Number Remarks if any

Managerial
Doctors
 Resident(non PG)/
Medical Officer
 Consultants
a) Full time
b) Others

Allied Medical Speciality

staff*
Nurses
Technicians
Housekeeping staff
Others

17. B. Student information

Student Group: UG Total Number Remarks if any

/Intern / PG (Medical,
Nursing, Others-Specify)

18. STATUTORY COMPLIANCES: Furnish details of applicable Statutory /

Regulatory requirements the organisation is governed by:

License/ Certificate Number and Date Valid up to Remarks

of Issue (Please mention if
any licenses are
pending and how it
is being addressed)

General:
Bio – medical Waste
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management and
Handling Authorization
Registration Under
Clinical Establishment
Act (or Similar)
Registration With Local
Authorities
NOC from Pollution
control Board for water,
noise, air pollution
Facility Management
Fire (NOC)
License for Diesel
Storage
License to Store
compressed Gas
Registration for Boiler
Sanction / License for
Lifts
Radiology
Registration for Modality
License to operate
(CT/Interventional
Radiology (IR)
RSO
Registration for PNDT
Clinical Departments:
Blood Bank
License for MTP

Pharmacy
Drugs – Bulk license
Drugs – Retail license
Narcotic License
Miscellaneous:
Canteen / F & B License
License for Possession
and Use of Methylated
Spirit, Denatured spirit
and Methyl alcohol
License for Possession
of Rectified Spirit & ENA
Any Other

*Please submit scanned soft copies of all the statutory requirements while submitting the documents .
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19. Litigation, if any:

20. Date of last Self – assessment:

21. Date of implementation of NABH standards:

(SHCO shall apply at least 3 months after implementing NABH standards)

22. I have gone through the contents of the “NABH Standard Accreditation
Agreement” and have fully understood the various clauses and shall
abide by the same.

23. Date Application Completed: Day Month Year

Authorised Signatory (CEO or equivalent)

Name:

Designation:

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