The impetus on statutory compliances in NABH accreditation

NABH standard ROM-1 (Responsibilities of Management) in the 2^nd edition touched on the requirement for compliances to applicable laws and regulations as part of the objective element ROM-1h. The latest edition of NABH has gone one step ahead, with the formulation of a completely separate standard on this requirement. So now ROM-2 reads as “The organization complies with the laid-down and applicable legislations and regulations”. Indeed this is a welcome step as it leaves little scope for hospitals to non-comply as the new standard deals with management’s knowledge about the laws and regulations, implementation of the same with a proper mechanism to update the licenses, registrations and certifications from time to time.

For organizations planning to put the house in order and start the journey towards NABH accreditation, you can systematically check your compliance to this new standard. From our research, we have observed that most of the statutory and regulatory requirements can be categorized into following categories:

• Air & Water
• Bio-medical waste
• Blood Bank
• Electrical
• Fire safety related
• HR-related
• Pharmacy
• PNDT & MTP
• Radiology equipment
• Software licenses
• Various State and Central Govt. Taxes

Depending on the size of your organization and the scope of your services, each of these categories may have various requirements under them. For example, if you have X-Ray and CT in your hospital, AERB approvals for your equipment and layout become a mandatory requirement. You also should be keeping a track of safety and maintenance related activities for these radiology equipments.