Accreditation & Certification

Accreditation & Certification

1. Accreditation Readiness & Gap Assessments

Comprehensive gap assessment (NABH, JCI, NQAS, Kayakalp, ISO)
Department-wise compliance review
Risk-based prioritization of gaps
Readiness scoring & milestone planning
Leadership briefing reports

2. Policy, SOP & Documentation Development

NABH/JCI-aligned policies & SOPs
Department manuals (nursing, HR, pharmacy, IC, safety)
Clinical pathways & evidence-based protocols
Documentation templates, checklists & forms
Master Index creation & version control

3. Quality & Patient Safety Compliance Systems

Incident reporting system setup
Quality indicator program
RCA, ACA, FMEA training
Infection control program strengthening
Medication safety framework

4. Departmental Accreditation Support

OT, ICU, ER, NICU, Dialysis, CSSD readiness
Sterilization validation & CSSD audits
Radiology compliance (AERB & radiation safety)
Lab quality program, QC & EQAS setup

5. Mock Surveys & Continuous Readiness

Full mock surveys with scoring
Tracer methodology & facility tracers
Daily readiness checklists
Environment of Care rounds
Interview preparation for staff & leaders

6. Certification Programs Support

ISO 9001 (QMS)
ISO 15189 (Medical Labs)
ISO 27001 (Information Security)
ISO 14001 (Environmental)
Green Hospital certifications
GHA accreditation readiness

7. Training & Workforce Development

Accreditation awareness & onboarding
Departmental compliance training
Quality & patient safety workshops
IC, medication safety, documentation training
Teamwork & safety culture orientation

8. Digital & Data Support for Accreditation

Quality & safety KPI dashboards
HIS documentation mapping
Digital records readiness (EHR/EMR)
Data validation & integrity audits
Compliance tracking dashboards

9. Licensing & Regulatory Compliance

Hospital establishment licensing
Pharmacy, blood bank & lab licensing
Fire & safety compliance review
BMW & pollution board requirements
Regulatory audit preparedness

10. Post-Accreditation Sustainability

Monthly audits & assessments
Quarterly performance dashboards
Annual accreditation maintenance plan
Corrective action tracking
Competency & refresher training calendar

11. Trusted Partner & Shared Purpose Framework

Long-term partnership with hospitals
Joint governance & co-design with leaders
Shared purpose: safer care & reliability
Transparent milestone-driven reporting
Capability building for independent sustainability