Consultancy services for nabh and other accreditation


  • Demand on quality in healthcare being very recent phenomena, there is urgent need to have capacity building initiative, which can help healthcare providers to implement quality in structure, processes and in outcomes. We will need to train existing healthcare professionals on fundamentals of patient safety and quality of care, through competence based CERTIFIED training courses. For long term sustenance it will also be necessary to educate and train young graduating doctors and faculty members of medical institutions in the subject of quality, through long term and short term courses. Same would apply for graduating healthcare administrators. We will provide necessary resource to support these institutions.
  • The field of health care is complex and the standards developed by western institutes may not be suitable for our context. Though some of the standards can be adapted locally we need development of benchmarks suited to our requirements. We need institute, can develop standards, collect and analyse the data and disseminate among the stake holders.
  • Clinical governance: Study of clinical processes and outcomes is integral part of quality. Providing good quality health care which is safe and cost-effective comes by way of implementation of clinical governance through good practice or evidence based clinical guidelines. We need to conduct regular clinical audits. All these aspects will be in the scope of the AHPI Institute.
  • Support to Public Health System: Here the emphasis will be to build capacity in state health system starting from health directorate; district level hospitals and CHCs/PHCs. Institute will also provide advice to the government related to specific issues and problems on quality, safety and cost-effectiveness.



We provides assistance in:

  1. Gap assessment and analysis based on NABH and NABL:
  2. Assessment of infrastructural, human resource and biomedical equipment processes, documentation, orientation of staff and other features with respect to Accreditation norms.
  3. Assisting on developing plans towards fulfilment of the gaps with hospital staff so that the services offered support accreditation standards.
  1. Assistance in developing and reviewing the hospital plan for Accreditation at various stages of the project Orientation, training and assistance towards developing an organizational quality structure and culture that would set the pace for involving and integrating the hospital staff in the accreditation process.
  2. Assisting the organization and formulation of committees and teams guiding on the development of Quality Assurance Program
  3. Assisting in the development of Documents (SOPs, Manuals, Policies, instructions for the hospital, departments and infection control), modulating the existing system and suggesting changes to support accreditation norms. The required documents will be developed in collaboration with the hospital staff.
  4. Assistance in the development of Record Keeping Program of the healthcare facility through guidance on the organizing of records, development of formats wherever required and operationalization of Monitoring system
  5. Organization of Training program throughout the accreditation preparation process. These training program would be generated through, consultant trainers and resources, external trainers and resources, in house facility trainers and resources.
  6. Training of pre-identified Hospital staff on NABH methodology for accreditation
  7. Development of performance indicators and data collection & its analysis
  8. Facilitation on the development of a facility assessment program through training of facility staff to conduct assessments, assistance in organizing for internal assessments, facilitation in the conduction of mock drills, internal assessments and assistance in evaluating the results of internal assessment
  9. Monitoring of accreditation program activities, documentation, effectiveness of training programs and organizing refresher training program as per need identified

B.   Public Health

·       Projects on Evaluation and Research

·       Projects on Capacity Building

·       Training Modules and Materials

·       Project Planning, Design and Implementation

·       Proposal Writing


C.   Facility Planning and Design

D.  Management Consulting

Our Management Consulting Services are “Standalone Healthcare Organization Specific Services” and focus on our clients’ most critical issues and opportunities across all the Domain Specific Verticals of the Healthcare Organization.

The broad spectrum of Services offered by us under this vertical comprise, as follows:

  • Market Assessment & Feasibility Study Reports
  • Strategic Operational & Planning Services
  • Financial Management Services
  • Review/Develop Annual Budget Plan
  • Profit Planning services
  • Benchmarking Surveys & Gap Analysis
  • Resource Optimization
  • Accreditation Consultancy (JCI, NABH, NABL, ISO 9001)
  • Developing SOPS, Systems & Processes, Policies, Tariffs, Etc.
  • Hospital Management Information System



We will provide services in identifying Quality improvement programme in a systematic approach to bring Quality Culture to the organization.

  1. A trigger serving as a “wake-up call” that prompts the hospital to begin or renew an emphasis on quality improvement, marking the beginning of cultural shift and leading to . . .
  2. Organizational and structural changes such as establishment of quality-related councils and committees, empowerment of nurses and other staff, and investments in new technology and infrastructure that facilitate . . .
  3. A new problem-solving process, involving a standardized, systematic, multidisciplinary team approach to identify and study a problem areas, conduct root cause analysis, develop action plans, and hold team leaders accountable, resulting in establishment of . . .
  4. New protocols and practices, including evidence-based policies and procedures, clinical pathways and guidelines, error-reducing software, and patient flow management techniques, leading to . . .
  5. Improved outcomes in process and health-related measures (e.g., patient flow, errors, complications, and mortality), satisfaction and work environment, and “bottom line” indicators such as reduced length of stay and increased market share. Experiencing such positive outcomes provide motivation to hospital staff leading to institutionalizing of continuous quality improvements.

Hospitals audits help maintain standards of patient care and help in providing quality and safe patient care. Hospitals must ensure that audits take place regularly to maintain the specified standards/ criteria. We will provide comprehensive, independent hospital audit programs, using experienced auditors for clinical as well as for managerial process.


As and when any member organisation approaches us for knowing the various regulatory compliances to be complied with e.g. Fire Safety Certificate, BARC Radiation Safety Certificate, Lift Installation Certificate, Registration of hospital or nursing home, Drug Licence, Bio Medical Waste Management Certificate, PCNDT Certificate, Registration of Imaging Certificates and so on necessary consultancy guidance will be arranged.




WHO conceptual framework for the international classification for patient safety offers a definition of Safety & Risk Management (SRM) as follows; “Activities or measures taken by an individual or a healthcare organization to prevent, remedy or mitigate the occurrence or reoccurance of a real or potential safety event”. Institute of Medicine (IOM) describes ‘Patient Safety’ as the freedom from accidental injury due to medical care or from medical error. An error is considered as a failure to carry out a planned action as intended or application of an incorrect plan. Error may manifest by doing the wrong thing (commission) or by failing to do the right thing (omission), at either the planning or execution phase.

While the hospitals are setting is one of healing and comfort, it also includes certain dangers. Hospitals contain hazardous chemicals, drugs, radioactive material and infectious matter. In addition there are dangers from fire and smoke.

Hospital should ask following questions when we talk about risk management and assessment:-

  1. Is my organization has done the Risk Assessment?
  2. Is my organization prepared to respond to these events?
  3. Does my organization need to be prepared anyway?
  4. What are our priorities?

Risk are mainly categorized into these categories:-

  1. Naturally occurring events : Earthquake , flood , epidemic , pandemic.
  2. Technological events: Electrical failure, Transportation emergency, Water emergency, HVAC failure, Structural damage, Fire.
  3. Human related events : Mass casualty incident (trauma),Mass casualty incident (infectious), Terrorism – biological, Hostage situation, Bomb Threat, Civil disturbance.
  4. Events involving hazardous materials: Terrorism – chemical, Chemical exposure Radiological exposure.

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