Hospital Quality Manager checklist for NABH

1. Governance and Leadership

Ensure the establishment of a Quality Management Committee.

Review the quality policy and objectives.

Conduct regular meetings to discuss quality initiatives.

Ensure leadership commitment to quality improvement.

2. Quality Management System

Develop and implement a Quality Management System (QMS).

Document quality processes and protocols.

Regularly review and update quality manuals.

Ensure compliance with NABH standards.

3. Patient Safety and Risk Management

Implement a patient safety policy.

Conduct regular risk assessments.

Develop incident reporting and management systems.

Review and analyze adverse events and near misses.

4. Clinical Governance

Monitor clinical outcomes and indicators.

Ensure adherence to clinical protocols and guidelines.

Conduct regular clinical audits.

Facilitate multidisciplinary case reviews.

5. Training and Education

Develop a training program for staff on quality and safety.

Conduct regular workshops and refreshers on NABH standards.

Monitor and evaluate the effectiveness of training programs.

Ensure documentation of staff training records.

6. Patient Rights and Education

Ensure awareness of patient rights among staff and patients.

Provide educational materials to patients regarding their rights.

Implement feedback mechanisms for patient grievances.

Regularly review patient satisfaction surveys.

7. Continuous Improvement

Establish a framework for continuous quality improvement (CQI).

Encourage staff involvement in quality improvement initiatives.

Monitor the outcomes of CQI projects.

Celebrate successes and learn from failures.

8. Documentation and Record Keeping

Ensure all quality-related documents are up-to-date and accessible.

Maintain records of quality audits, training, and incident reports.

Conduct regular reviews of documentation practices.

Ensure compliance with legal and regulatory requirements.

9. Performance Measurement

Develop key performance indicators (KPIs) for quality.

Regularly monitor and report on KPIs.

Benchmark performance against national standards.

Implement corrective actions based on performance data.

10. External Accreditation and Compliance

Prepare for NABH accreditation assessments.

Ensure all required documentation is in place for audits.

Conduct mock assessments to identify areas for improvement.

Stay updated with changes in NABH standards and requirements.