Which edition applies now
NABH's Hospital Accreditation Standards, 6th edition, took effect on 1 January 2025. NABH stopped accepting 5th-edition applications at the end of 2024 and stopped 5th-edition surveillance assessments after March 2025, so any hospital preparing today is preparing against the 6th edition. Accreditation runs on a four-year cycle.
Where indicators sit in the standard
Quality indicators live in the chapter on Patient Safety and Quality Improvement (PSQ). The standard asks a hospital to identify key indicators for its structures, processes and outcomes, to monitor them across four groups — clinical, infection control, managerial and patient safety — and then to do four things with the numbers: have the quality team validate the data, analyse it for improvement opportunities, make and evaluate the improvements, and feed the results back to staff.
NABH describes the set as 32 mandatory organisation-wide indicators, plus 18 department-specific clinical indicators, and runs training on them. The full list is in the standard; the groups look like this.
Clinical
For example: time taken for the initial assessment of in-patients, medication errors, adverse drug reactions, unplanned return to the operating theatre, return to emergency within 72 hours with a similar complaint, and pressure ulcers.
Infection control
For example: catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), central-line bloodstream infection (CLABSI), surgical site infection (SSI), hand-hygiene compliance, and prophylactic antibiotics given on time.
Managerial
For example: rescheduled surgeries, turnaround time for issuing blood, nurse-to-patient ratio, outpatient and diagnostic waiting times, time taken for discharge, records with incomplete consent, and stock-outs of emergency drugs.
Patient safety
For example: patient falls, near misses, needle-stick injuries, proper handovers, and variations found in mock drills.
The formulas
NABH publishes a template for its indicators. Every indicator in it is collected monthly, and the formulas below are taken from it. Notice that almost all of them are rates, not counts.
| Indicator | How it is calculated |
|---|---|
| Patient falls | Falls ÷ inpatient-days × 1,000 (assisted falls count) |
| Medication errors | Errors ÷ patient-days × 1,000, for in-patients, found through incident reports plus chart review or direct observation |
| CAUTI | Catheter-associated UTIs ÷ urinary catheter-days × 1,000 |
| Surgical site infection | SSIs ÷ surgeries × 100, revised as each 30- or 90-day follow-up window closes |
| Mortality rate | Deaths ÷ (discharges + deaths) × 100 |
| Average length of stay | Inpatient-days ÷ (discharges + deaths), where inpatient-days is the sum of the daily census, a same-day stay counts as one day, and emergency, rehabilitation and day-care beds are excluded |
| Time for initial assessment | Minutes from the patient reaching the ward bed to the doctor documenting the assessment, averaged across admissions |
What an assessor looks at
The template lays each indicator out as a twelve-month table running April to March, a trend chart, and then three short sections: the analysis, the corrective actions taken, and the preventive actions taken. That is the evidence. A number on its own proves little; a number that moved, an explanation of why, and a record of what was changed is what accreditation is looking for. Hospitals can add their own indicators on top of the mandatory ones.
Five mistakes that make a year of data unusable
- Counting instead of rating. "Six falls this month" means nothing until it is divided by inpatient-days. Capture the denominator — the daily census, catheter-days, the number of surgeries — from day one, because it cannot be rebuilt afterwards.
- Definitions that drift. If one month counts assisted falls and the next does not, the trend line is fiction. Write each definition down once and keep it.
- Treating a low number as good news. Zero medication errors in a busy hospital usually means nobody is reporting them. A healthy reporting culture often makes the numbers look worse before they get better.
- Skipping validation. The standard asks the quality team to validate the data before it is analysed. Spot-checking a sample of charts against the incident register each month is the cheapest way to do it.
- Analysis without action. An assessor reads the corrective and preventive action sections first. A trend chart with nothing written underneath it is a missed point.
Where software helps, and what to check
Most of the work above is capture: incidents reported when they happen, infections recorded against the patient and the device, and a daily census you can trust. Medixar records incidents on the A–I harm scale, keeps infection-surveillance registers for CAUTI, CLABSI, VAP and SSI with outbreak alerts, maintains the statutory registers, and shows mortality, length of stay, bed occupancy and readmissions on a quality dashboard.
Whichever system you use, ask the vendor one question before you rely on it for accreditation: does it calculate each indicator with NABH's denominator — patient-days, catheter-days, surgeries — or does it only count events? The answer decides whether the software produces your evidence or just your raw material.
Preparing for NABH?
We'll show you how incident reporting, infection surveillance and the registers work in Medixar, on a tenant of your own.
Book a demoSources
- NABH, Implementation plan of the 6th edition standards (notification NABH/Gen/2024/6413, September 2024).
- NABH, Key performance indicators training, 6th edition hospital standards.
- NABH, Template for PSQ indicators (EM/FORMAT/06, 2026).
This article is about running a hospital and preparing for accreditation. It is not medical advice, it has not been reviewed by a clinician, and it does not replace the NABH standard or NABH's own training.