Salient changes in the Draft copy of NABH 6th

edition standards for Hospitals - 2024

• Inclusion of preventive health care and continuity of care at home.

• Inclusion of current standard clinical practices (OBG & Paediatrics)
• More emphasis on addressing social, economic and environmental factors
• Removing duplication on safety/legal aspects
• Removing duplication on budget, resource allocation etc
• More emphasis on top leadership responsibility on patient safety aspects and risk
management issues

• Patient engagement in the care process

• Many excellence and achievement level objective elements (OE) were moved to
the commitment/core level and reducing the number of OE with achievement and

excellence level

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AAC
New Removed Combined
Standard on preventive and OE on Alignment of patient Lab quality and safety program
promotive health services are safety program with lab and standards are combined as a
provided in a safe, Imaging safety program single standard
collaborative and consistent
manner which include

- Age appropriate screening

for NCD, Mental health &
Immunisation

- Health education on life

style modifications.

OE on providing care by OE on Patients are transported OEs of lab test quality,

expanding access to health in a safe and timely manner to equipment calibration and
practices through domiciliary fro form the imaging services. CAPA are combined into
visits, wherever applicable. participation in proficiency
testing / external quality
assurance scheme.
OE on Alignment of patient Imaging quality and safety
safety program with Imaging program standards are
safety program combined as a single standard
OEs on QA program for the OE on periodic calibration and
imaging equipment and maintenance of imaging
protocol equipment
3 OEs on contents of the
discharge summary is
combined

Others

Achievement level to Commitment - OE on documentation of care plan and when and how to
obtain urgent care documentation in the discharge summary

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COP
Duplication on the safety, legal and Infection control are removed. Obstetrics standard is included
with new OEs on current practices in the speciality.

New Removed Combined

OE on encouraging the OE on care provided in OEs on Emergency care in
presence of birth companion consonance with applicable consonance with statuary
during labour laws and regulation requirement and MLC cases

OE on treating pregnant OE on uniform care delivery

woman and her companion when care is provided in more
respectfully ensuring privacy than one setting.
and confidentiality
OE on the treating doctor OE on daily check of OEs on daily check on
explains the danger sign and ambulance ambulance equipment,
important care activities to the medication and consumables
pregnant women and her
companion
OE on adherence to the legal OEs on Nursing clinical OE on alignment and
and defined Assisted practice guidelines integration of nursing care with
Reproductive Technology overall patient care and nursing
(ART) practices documentation in the patient
record
OE on provisions of adolescent OE on adhering to standard
friendly health care service precautions during clinical
procedure
OE on including patient/family
education on blood donation in
the informed consent for blood
transfusion
OE on upgrading ICU
infrastructure as per the
guidelines
OE on providing safe and
secure environment for the
vulnerable patient

Others

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MOM - No major changes

Others

Excellence level to Achievement - OE on clinician adherence to current formulary

PRE
New Removed Combined
OE on promotion of patient OE on Patent and/or family
engagement to promote clinical member education on proposed
outcome, quality and safety care, expected result and
(Excellence) possible complications.

Others

Core level to Achievement - OE on patient rights determining what information regarding their
care would be provided to self and family.

IPC - HIC chapter is renamed as IPC (Infection

Prevention and Control)
New Removed Combined
OE on resource availability and
allocation of adequate funds
for infection prevention and
control

Others

Achievement level to Commitment - OE on Isolation/barrier nursing facility

Excellence level to Core - OE on antibiotic stewardship program

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PSQ
New Removed Combined
OE on quality improvement OE on Clinical safety officer
programme focusses on
appropriateness of clinical care
(Excellence)
OE on including OE on Patient safety
improvements in patient care programme identifying
delivery and hospital opportunities for improvement
operations which will have an based on the review at pre-
impact on cost and efficiency defined intervals.
in quality improvement process

OEs on usage of statistical and

managerial tools for quality
improvement activities
OE on resource availability for
patient safety and quality
improvement programme

Others

Excellence level to Achievement- OE on PROM

Excellence level to Commitment - OE on the process of informing various stakeholders in case of

a near miss/ADR/Sentinel event

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ROM
New Removed Combined
OE on developing clinical OE on display of vision, OE on administrative
governance framework by mission and values of the qualification and experience of
those responsible for organisation and making them the person heading the
governance public. organisation.
New standard on Ensuring OE on staff rights and
sustainability in hospital by responsibilities
addressing environmental,
social and economic factors
from long term well-being of
healthcare system and
community including

- Energy efficient and

environment friendly
hospital (transferred to her
form FMS chapter)

- Organisation’s social
responsibility

- Promotion of of Staff well-

being (transferred to her
form HRM chapter)

- Sustainable procurement
practices (Excellence)

- Financial Sustainability of
the hospital

- Encouraging employee to
use common/public
transportation,
OE on resource availability for
patient safety and quality
improvement programme

Others - Management word is replaced with Top leadership in the standard/OEs on patient safety
and risk management issues.

Excellence level to Core - OE on ethical implications, dilemmas and concerns

Achievement level to Commitment - OE on monitoring the performance of the organisation and

review of the organisation’s leader performance
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FMS
New Removed Combined
OE on developing clinical OE on initiatives towards
governance framework by energy-efficient environmental
those responsible for friendly hospital (as it is
governance included in ROM- new
standard)
OEs on plan and provision for OE on the procedure for
fire and non-fire emergencies medical gases addresses the
are splitter as two different safety at all levels.
OEs
OE on service continuity plan
in case of fire and non-fire
emergencies

Others

Excellence level to Core - OE on risk assessment before construction, renovation and expansion

Achievement level to Commitment - OE on Electrical safety audit

HRM
New Removed Combined
OE on inclusion of information OE on promotion of staff
system, information security, wellbeing (as it is included in
information use and ROM- new standard)
management in induction
training

Others

Excellence level to Achievement - OE on Evaluation of training effectiveness

Excellence level to Core - OE on human resource planning

Achievement level to Commitment - OE on using appraisal system as a tool for further

development

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IMS

New Removed Combined

OE on effort to use digital OE on promotion of staff
health technology to improve wellbeing (as it is included in
operational efficiency, patient ROM- new standard)
safety and patient experience
(Excellence)

Others

Excellence level to Core - OE on ensuring accurate information meets stakeholder requirements.

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