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Quality and Accreditation services


Quality & Accreditation Division (Q&A) has been playing a leadership role in the upliftment of quality environment in health care organizations in the country in both Private and Government sectors


  • Gap assessment and analysis based on JCI, NABH, NABL and ISO: Micro level assessment of existing infrastructural, human resource and biomedical equipment processes, documentation, orientation of staff and other features with respect to Accreditation norms. Assisting on developing plans towards fulfilment of the gaps with hospital staff so that the services offered support accreditation standards.
  • 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.
  • Assisting the organization and formulation of committees and teams guiding on the development of Quality Assurance Programme
  • Assisting in the development of Documents (SOPs, Manuals, Policies and Protocols, 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.
  • Assistance in the development of Record Keeping Programme of the healthcare facility through guidance on the organizing of records, development of formats wherever required and operationalization of Monitoring system
  • Organization of Training programmes throughout the accreditation preparation process. These training programmes would be generated through, consultant trainers and resources, external trainers and resources, in house facility trainers and resources.
  • Training of pre-identified Hospital staff on NABH methodology for accreditation
  • Development of performance indicators and data collection & its analysis
  • Facilitation on the development of a facility assessment programme 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
  • Monitoring of accreditation programme activities, documentation, effectiveness of training programmes and organizing refresher training programmes as per need identified