A comprehensive mapping of NABH Non-Compliances in hospitals undergoing entry level and full accreditation: insights from selected hospitals in Ahmedabad

Accreditation is an incentive to improve the capacity of Health Care Organisations to provide quality of care. The National Accreditation Board for Hospitals and Health care Providers (NABH) provide third-party accreditation to health care Organisations in India. Quality health care is a fundamental patient right, yet disparities persist due to inconsistent service delivery and weak regulatory oversight. This study comprehensively maps the Non-Compliances (NCs) reported during NABH assessments of hospitals in Ahmedabad, Gujarat, undergoing entry level and full accreditation.

A retrospective record review study of NABH accreditation assessment reports was conducted for hospitals, two seeking full accreditation and four entry-level accreditations, between June and July 2024. NCs were categorized into Policy, Documentation, Practice, Regulation, Patient Care, and Facility Management, and further stratified by risk severity (low, medium, high). Descriptive statistics and qualitative analyses were used to assess NC patterns.

Entry-level hospitals reported 15 NCs, primarily related to documentation and safety, with most categorized as medium-risk. Full-accredited hospitals had 94 NCs, with documentation (27.6%), process (25.5%), and policy (23.4%) being the most affected domains. Safety-related NCs, although fewer, were frequently high-risk, including lapses in infection control and patient monitoring.

The findings underscore systemic gaps in documentation, process standardization, and safety practices. Entry-level hospitals struggle with foundational systems, while full-accreditation hospitals face challenges in implementing complex quality processes. Addressing these NCs requires proactive leadership, staff engagement, and integration of accreditation standards into daily operations. Accreditation should be viewed not as a one-time compliance effort but as a pathway to sustained quality and patient safety.