Implementation Case Study

NABH Full Accreditation Implementation

Regional Multi-Speciality Hospital

Project Background

The client is a prominent 150-bed multi-speciality healthcare facility operating in Uttar Pradesh. Seeking to solidify its reputation and optimize internal clinical workflows, the hospital administration aimed for the prestigious NABH Full Accreditation.

The Challenge

Initial assessments revealed severe documentation inconsistencies. Departments were operating in isolation with fragmented workflows. There was a general lack of staff readiness regarding mandatory patient safety protocols, and critical care areas lacked standardized infection control measures.

Scope of Support

The Sasha Group deployed a dedicated team of quality auditors and clinical trainers. We performed an exhaustive gap analysis against NABH 5th Edition standards. Our team formulated evidence-based SOPs, instituted core quality committees, and provided intense on-ground training to over 200 staff members.

Key Outcomes

  • Successfully cleared the final NABH assessment with zero major non-conformities.
  • Established a permanent, system-driven culture of clinical safety and accountability.
  • Drastically reduced medication errors through new standardized pharmacy workflows.
  • Improved inter-departmental communication during medical emergencies.

Implementation Timeline

Step 1

Assessment

Initial review of systems, documentation, infrastructure, and operational practices.

Step 2

Gap Analysis

Detailed comparison against applicable standards and regulatory requirements.

Step 3

Planning

Creation of implementation roadmap and department responsibilities.

Step 4

Implementation

Execution of documentation, workflow improvements, and compliance measures.

Step 5

Training

Department-level orientation and operational readiness support.

Step 6

Readiness Review

Mock assessments and final preparation before evaluation.

Systems Addressed

Nursing & IPD ICU & Emergency Quality Dept Pharmacy Facility Management HR & Admin

Related Expertise

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