National Accreditation Board for Hospitals


The first step in the process is conducting a thorough gap analysis, identifying areas where the hospital falls short of certification requirements. This analysis serves as a foundation for devising a strategic plan to close the identified gaps effectively and efficiently.

Ace Medinet excels in developing standardized operating procedures (SOPs) that align with industry best practices and certification standards. These SOPs cover various aspects of hospital operations, ensuring consistency, efficiency, and quality throughout the organization.

In addition to SOP development, Ace Medinet also focuses on the critical area of infection control. Their team of experts collaborates with hospitals to create an infection control manual tailored to their specific needs. This manual serves as a comprehensive guide for preventing and managing infections within the hospital, prioritizing patient safety.

Recognizing the significance of staff competence, Ace Medinet offers comprehensive training programs to hospital staff. These training sessions are designed to equip healthcare professionals with the necessary skills and knowledge to implement the developed SOPs, adhere to infection control protocols, and deliver high-quality patient care.

Ace Medinet Hospital Services is committed to assisting hospitals in achieving certification by providing a holistic range of services, including gap analysis, strategic planning, SOP development, infection control manuals, and staff training. With their expertise and dedication, they contribute to the enhancement of healthcare delivery and patient safety within certified hospitals.

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    • Points to be kept in mind while preparing documents for HOPE uploading

      Question No.1: What precautions we should take while sending you the documents.

      1. SNDT (Signed Named, Dated and timed) to be followed in all documents.

      2. All columns should be filled. If there is a blank space where you do not need to enter any data, please put a dash or cancel the section.

      3. Whenever there are medicines involved, please write the same in CAPITAL or separated alphabets.

      4. Non-MBBS doctors should not sign the treatment sheet.

      5. Make sure that all consent forms should be signed by respective doctors. At least one consent (out of 5) should be in Marathi.

      6. Scanning of all paper should be done through a computer scanner and not through the phone. All four corners should be captured while scanning the documents.

      7. UHID no. & patient name to be written on each sheet.

      8. At least for submission, please use our formats so that it becomes easier to clear documentation audits.

      9. Ensure that a copy of the discharge summary given to the patient is retained in the hospital.

      10. Try & collect one photo id from patients.

      11. Doctors should take interest in the implementation.


      Question No.2: Which are the minimum formats required for submission?

      Documents required for Medical IPD papers:

      1. Admission Form with Admission Consent.

      2. Initial Medical Assessment.

      3. Treatment sheet.

      4. TPR Chart.

      5. Nursing over / Nursing Notes.

      6. Feedback Form.

      7. Discharge Summary.

      8. Consent for Surgical procedure.

      9. MRD checklist.

      Documents required for Surgical IPD papers:

      1. Admission Form with Admission Consent

      2. Initial Medical Assessment

      3. Treatment sheet

      4. TPR Chart

      5. Nursing over / Nursing Notes

      6. Feedback Form

      7. Discharge Summary

      8. Consent for Anaesthesia

      9. Consent for Surgery

      10. Pre-Op checklist

      11. WHO Surgical checklist

      12. Pre-Anaesthesia evaluation

      13. Anaesthesia monitoring record

      14. Operation record

      15. Consent for Blood Transfusion (if applicable)

      16. Blood monitoring chart (if applicable)

      17. MRD checklist

      Documents required for Ophthalmic IPD papers:

      1. Admission Form with Admission Consent

      2. Initial Medical Assessment

      3. Selection of IOL

      4. Feedback Form

      5. Discharge Summary

      6. Consent for Anaesthesia

      7. Consent for Surgery

      8. Pre-Op checklist

      9. WHO Surgical checklist

      10. Pre-Anaesthesia evaluation

      11. Anaesthesia monitoring record

      12. Operation record

      13. MRD checklist

      Following registers need be maintained by Nursing Homes.

      1. OPD

      2. IPD

      3. OT

      4. Fumigation

      5. Autoclave

      6. Laboratory

      7. Imaging

      8. MLC

      9. Repair

      10. Incidence Complaint

      11. Implant

      12. BMW

    • Documents to be kept ready and complete before the Audit

      1. Registers - IPD, OPD (if any), OT, Fumigation,Autoclave, Lab, Imaging, Incidence Book, Repair Book (if any for equipment maintenance), Refrigerator Temperature.

      2. Pharmacy (if any) – Form20, Form 21, Narcotics (if registered), Emergency Drug List to be Displayed, LASA Drugs, Refrigerator Temperature.

      3. 5 Surgical & 5 Medical papers to be completed in all aspects

      4. AMC, CMC or On call basis contract, Service reports, Calibration Report.

      5. OT Swab reports, ICU Swab Reports

      6. All Mandatory Permissions


      Virtual Audit Tour

      1. Go out of the hospital premises.

      2. Enter the hospital as the patient enters and show the hospital name displayed outside. Show the ramp for the wheelchair & trolley.

      3. Show displays in two languages the Scope of services, Patients’ Rights & responsibilities, Mission, Vision, OPD Rates & Emergency Numbers.

      4. Now Receptionist has to answer OPD & IPD registration process, what is the process for Emergency & MLC patients? Also, what is his/her role when the Code is activated?

      5. OPD Room – Curtains should be available for examination of patients for privacy.

      6. Emergency Room (If any) – Emergency register, RMO & Nurse on duty, Transfer register, MLC Register.

      7. Wards – Curtains between cots, Medicine label

      8.  Patient Interview – are you made aware of your rights and responsibility, treatment cost being discussed, staff response to your needs, Treatment being discussed with patient/ relatives

      9.  ICU – Duty roaster of RMO & Nurse to be displayed as per the beds, Code Blue or Code Red can be activated, Medicine station should have a list of Emergency medicine, LASA medicine, Auditor might check the expiry of any medicine from the station,Equipment maintenance procedure of equipment in the ICU, BMW storage area & poster of Segregation. If any patient is available and stable then the auditor might interview.

           10. OT – OT Nurse required to answer all questions, Emergency Trolley with emergency medicine, Medicine expiry of any vile can be checked, O2, Nitrogen Cylinder, LASA Medicine, OT Register, Autoclave Register, Fumigation register, Equipment Maintenance, Autoclaved Drum with labelling, OT lights working or not, How OT cleaning is done? How is fumigation done? OT handwash area (No touch system), Code Blue or Code Red can be activated, OT instrument cleaning area, Autoclave Area and procedure of Autoclave, If you have different Implant register then that is required or else OT register for Ophthal.

           11. Housekeeping Staff – How many times Hospital is cleaned?, cleaning procedure, Spill Management (Demonstrate if he/she is not able to explain proper steps), How to clean the Infected and Non Infected patient room and the Needle Prick Injury process.

         12. Nursing Staff – Needle Prick Injury process, Spill Management & All Codes.

           13. MRD – How files are arranged? What is the destruction policy? Is, Fire Extinguisher available in MRD or nearby area, IPD papers, Death & MLC records

          14. Admin/ HR – Files of Doctors & Nursing Staff to be completed with the certificate, Immunisation status & Medical Records. Equipment maintenance records, Mandatory permissions, Swab reports and any other relevant files.

           15. All staff should know how to handle fire extinguishers.

           16. All Medical & Housekeeping staff should know BMW segregation.

    • 1. Procedure(s) guide collection, identification, handling, safe transportation, processing and disposal of specimens.

      2. Process addresses discharge of all patients including Medico-legal cases and patients leaving against medical advice.   

      3. Documented procedure (s) address care of patients arriving in the emergency including handling of medico-legal cases.  

      4. Documented policies and procedures are used to guide the rational use of blood and blood products.  

      5. Documented procedure for the administration of anaesthesia.    

      6. Documented procedure addresses the prevention of adverse events like wrong site, wrong patient and wrong surgery.   

      7. Documented procedure incorporating purchase, storage, prescription and dispensation of medications. 

      8. Documented procedures address procurement and usage of implantable prostheses.     

      9. Infection control manual, which is periodically updated and conducts surveillance activities. 

      10. Documented operational and maintenance (preventive and breakdown) plan for clinical and support service equipment.

      11. The organization has a documented safe exit plan in case of fire and non-fire emergencies.  

      12. Documented disciplinary and grievance handling procedure.      

      13. Documented policies and procedures for maintaining confidentiality, integrity and security of records, data and information.     

      14. Documented procedures exist for a  retention time of medical records, data and information.

      15. Define a process to whom the patient record can be released

      16. Procedure on the destruction of medical records

    • List of Training under HOPE


                    1. Training on scope of services

      2. Training on Safe practices in Laboratory 

      3. Training on Safe practices in Imaging

      4. Training on Child Abduction Prevention

      5. Training on Infection Control Practices 

      6. Fire mock drills

      7. Training on Spill Management 

      8. Training on Safety Education programme 

      9. Training on Needle Stick Injury 

      10. Training on Medication Error

      11. Training on Disciplinary procedures

      12. Training on Grievance Handling procedures 

    • Mock-Audit Points:  Entry Level

      Show you following registers:

      · IPD

      · OPD

      · OT

      · Autoclave

      · Fumigation

      · MLC

      · Alert value Laboratory

      · Alert value Imaging


      Show you fllowing displays:

      · Mission statement

      · Patients’ Rights & Responsibilities

      · Tariff card

      · Services offered

      · Code explanation

      · HAZMAT

      · LASA

      · Escape route

      · Emergency exit door

      · Cylinder storing

      · Fire alarm

      · Smoke detector

      · TAT 


      · Activation of codes

      · Patients’ rights & Responsibilities

      · Tariff card

      · Services offered

      · Body fluid spill management

      · Code explanation

      · HAZMAT

      · LASA

      · Buddy system

      · Post needle stick injury

      · Dealing with MLC

      · Night Shift emergency


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