APPLICATION
FOR
NURSING EXCELLENCE PROGRAM
Issue No.: 01
Issue Date: November 2014
NATIONAL ACCREDITATION BOARD FOR
HOSPITALS and HEALTHCARE PROVIDERS
NATIONAL ACCREDITATION BOARD FOR
HOSPITALS and HEALTHCARE PROVIDERS
Assessment criteria and Fee structure
Size of Hospitals
Assessment Criteria
Assessment
10-30
Certification Fee
Application
cum First year
Certification
Fee
Second Year
Certification Fee
One man-days (1X1)
Rs. 25,000/-
Rs. 25,000/-
Two man-days (1X2)
Rs. 45,000/-
Rs. 45,000/-
Four man-days (2X2)
Rs. 55,000/-
Rs. 55,000/-
Six man-days(2X3)
Rs. 65,000/-
Rs. 65,000/-
beds
31- 100
Beds
101- 350
Beds
351 beds
and above
NOTE: The man days given above for assessment are indicative and may change depending on the
facilities and size of the hospital.
Service Tax: w.e.f. 01.06.2015 a service tax of 14% will be charged on all the above fees. You are requested
to please include the service tax in the fees accordingly while sending to NABH.
Guidance notes:
1.
2.
3.
4.
5.
6.
Fees to be paid through Demand Draft/ local cheque in favour of Quality Council of India payable
at New Delhi. Fees will be calculated on the operational beds. Fees are non-refundable.
Three copies of this application form duly filled in are to be submitted along with necessary
documents and fees.
Self Assessment Toolkit (soft copy) duly filled in is to be submitted by the HCO along with the
application form.
The certification fee does not include expenses on travel, lodging/ boarding of assessors, which
will be borne by the HCO on actual basis.
The certification, once granted will be valid for two years. The HCO may apply for renewal as per
the NABH policy.
NABH may call for an un-announced visit, which could be a Surprise Assessment or based on any
concern or any serious incident reported upon by any individual or organisation or media.
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Eligibility Criteria
1. Health Care Organization (HCO) shall have at least 10 operational beds.
2. HCO shall at least be functioning for 6 months before applying.
3. HCO shall apply at least 3 months after implementing NABH Nursing Excellence standards
Guidelines for filling the application form
(Please read this carefully before filling this form)
1. Kindly fill the application form in BLACK INK only. You can also submit a printed version of the filled
application form.
2. For Sl. No. 2: Split locations - This pertains to all units which are a part of the hospital. e.g. outreach
clinics, satellite clinics, laundry, etc.
3. For Sl. No. 4: Please specify e.g. Clinical Establishment Act, Shops and Establishments Registration
Act etc.
4. For Sl. No. 7: Please state the number currently in operation. For example, the hospital may have
approval for 250 beds but presently if only 100 beds are operational, please mention only 100 (after
exclusions mentioned against that point). However, the hospital shall inform NABH of any increase in
operational beds within 15 days of making the additional operational beds.
5. For Sl. No. 7.d: Provide the information using the example below.
Address
(Location)
Building
Block
/ Level
Ground
floor
First floor
Area/Activity
OPD, Billing, Reception, Laboratory
OT, ICU
6. For Sl. No. 12,13 and 14:
a. Please note that this list of specialities is based on the recognised medical courses by the
Medical Council of India/ National Board of Examination.
7. For Sl. No. 15: Type of care pertains to nature of service e.g. adult/paediatric; male/female. Use
codes like AM (adult male), AF (adult female), AMF (adult male and female), PM (paediatric male),
PF (paediatric female), PMF (paediatric male and female). If there is no categorization please
mention as open to all. In case of split locations please specify the location
8. For SI. No. 16: Please attach the list of staff along with Names, qualification, department, registration
number and nursing council attached.
9. The hospital shall ensure that it shall send an updated application form to NABH in case of any
changes especially before assessment and surveillance assessment.
3
DEMOGRAPHIC AND GENERAL DETAILS:
1.
Name of the HCO: (the same shall appear on the certificate)
_______________________________________________________________________
2.
Contact Details of HCO:
Street Address
City/Town_______________________________________________________________
Locality/Village/Tehsil_____________________________________________________
District__________________________________________________________________
State
Website:____________________________________________________________________
□
Does the HCO have split location(s): Yes □
Location of HCO
:
Urban
Rural
No
□
□
If yes, address of the other location(s) and distance from main location
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
3.
Ownership:
□Private – Corporate
□Armed Forces
□PSU
□Trust
□Government
□Charitable
□Others (Specifiy.........................................................................................)
4.
Year and month in which registered and under which authority (as per state and
central requirements)
_______________________________________________________________________
5.
Year and month in which clinical functions started:
_______________________________________________________________________
4
6. Contact person(s):
(Please indicate [] with whom correspondence to be made)

Head of the HCO
□
Mr. /Ms. /Dr. ___________________________________________________________
Designation: __________________________________________________________
Tel: ___________________________ Mobile: _______________________________
Fax: __________________________ E-mail: _______________________________

Program Coordinator*:
□
Mr./Ms./Dr. ___________________________________________________________
Designation: __________________________________________________________
Tel: ___________________________ Mobile: _______________________________
Fax: __________________________ E-mail: _______________________________
*Shall necessarily be a nursing professional
7. HCO Information:
a. Total Number of Beds that have been sanctioned: …………..
b. Total Number of Beds currently in operation: ……………(please exclude
emergency, day-care, dialysis, recovery room beds, labour room beds from
this number)
Bed Type
In patient beds ( non ICU)
Number of Beds
In patient beds ( ICU )
Total
Others:


Emergency beds
Day-care beds



Recovery room beds
Labour room beds
Dialysis

(Specify)

(Specify)
c. Number of OTs:
General: ___________
Super-speciality:______________
d. HCO layout:
i. Number of buildings _________________
ii. List the areas / departments / units floor wise for each building in a tabular format as
mentioned at point 5 of the “guidelines for filling the application form” on page 3 and provide it
as an attachment.
iii. In case of split location the layout for each of the addresses must be given
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8.
Which shift duration is followed in HCO:
6 hours
□
8 hours
□
12 hours
□
(Please indicate [] as applicable)
□
Is there any Nursing School attached with HCO: Yes
10.
Is any Nursing hostel / residence facility available in HCO premises or nearby for
Nurses: Yes
□
No
No
□
9.
□
CLINICAL SERVICES AND RELATED DETAILS
11.
OPD and IPD data:
a. OPD DATA (Past 2 years)
Year
Number of Patients
b. IPD DATA (Past 2 years) OR AVERAGE OCCUPANCY RATE
Year
Number of Patients Admitted
c. NURSING ATTRITION RATE (Past 2 years)
Year
Attrition Rate
12. Clinical departments /services available in the HCO:
Clinical Service
Service Provided
(mention YES or NO)
Number of
Beds
Allocated
(if any)
Number of
Nursing
staff
posted
Anaesthesiology
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Cardiac Anaesthesia
Cardiology
Cardiothoracic Surgery
Clinical Haematology
Critical Care

Combined

Speciality ICU
(please specify)








Day Care Services




Dermatology and Venereology
Emergency Medicine
Endocrinology
Family Medicine
General Medicine
General Surgery
Geriatrics
Hepatology
Hepato-Pancreato-Biliary
Surgery
Immunology
Medical Gastroenterology
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Neonatology
Nephrology
Neurology
Neuro-Radiology
Neurosurgery
Nuclear Medicine
Obstetrics and Gynaecology
Oncology

Medical Oncology

Radiation Oncology

Surgical Oncology
Obstetrics and Gynaecology
Ophthalmology
Orthopaedic Surgery*
Otorhinolaryngology
Paediatric Cardiology
Paediatric Gastroenterology
Paediatric Surgery
Paediatrics
Plastic and Reconstructive
Surgery
Psychiatry
Respiratory Medicine
Rheumatology
Sports Medicine
Surgical Gastroenterology
Transplantation Service



Urology
Vascular Surgery
8
Others, please state
Among the above please list the services which are outsourced if any but are available
in house:
*Please mention if joint replacement or arthroscopic procedures are being done:
13. Clinical Support departments/services in the HCO (mention Yes/ No):
In House
Out sourced
Ambulance
Blood Bank / transfusion services
14. Diagnostic Services being provided by the HCO (mention Yes/ No):
Diagnostic Service
In House
Out sourced
Diagnostic Imaging:
Bone Densitometry
CT Scanning
DSA Lab
Gamma Camera
Mammography
MRI
PET
Ultrasound
X-Ray
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Laboratory Services:
Clinical Bio-chemistry
Clinical Microbiology and Serology
Clinical Pathology
Cytopathology
Genetics
Haematology
Histopathology
Molecular Biology
Toxicology
Other Diagnostic Services:
2D Echo
Audiometry
EEG
EMG/EP
Holter Monitoring
Spirometry
Tread Mill Testing
Urodynamic Studies
Any Other Diagnostic Service (s):
15. List Ambulatory unit / Inpatient Care Units/ Wards, the Number and The type of care
given in each Unit/ Ward: Refer paragraph 7 page 3
Name of Unit/ Ward
Number of Beds
Type of Care
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16. A. Staff Information:
Group
Number
Remarks if any
Nurses
a) B.Sc
b) GNM
c) ANM
Any Speciality Nurse available
(e.g. Infection Control, Paediatric,
Oncology, Cardiac, etc )
a)
b)
c)
d)
Others
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B. Details of Staff:
(Attach a separate sheet, if required)
S.No Name of Nursing Staff
Department Posted Registration Name of Nursing
Number
Council
C. Student Information:
Student Group: UG / Intern / PG
(Nursing )
17.
Number
Remarks if any
Litigation, if any:
________________________________________________________________________
18. Date of last Self-assessment: _____________________________________________
19. Date of implementation of NABH NURSING EXCELLENCE standards:
________________________________
(HCO shall apply at least 3 months after implementing NABH Nursing Excellence standards)
20. 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.
21. Date Application Completed: _________ Day _______ Month ________Year
Authorised Signatory
(Head of HCO or equivalent)
Name: ___________________________
Designation: ______________________
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