47 Common NABH Non-Conformities — And How to Avoid Them

How to use this list

The 47 non-conformities below are organised by NABH 5th edition chapter. Each entry describes what assessors typically find and how to prevent it. Use this as a self-audit checklist: walk through each NC, verify whether your hospital has the evidence to demonstrate compliance, and close gaps before your assessment window opens.

AAC — Access, Assessment and Continuity of Care (NCs 1-5)

1. Incomplete initial assessment documentation — missing allergy status or chief complaint

Assessors frequently find that initial nursing or medical assessments lack mandatory fields such as allergy history, chief complaint, or pain assessment. Partially filled forms signal that the assessment is treated as a formality rather than a clinical tool.

Prevention: Redesign assessment forms to include mandatory fields with validation. Train admitting staff to treat every field as non-negotiable. Periodic audits of a random sample of case files will catch omissions before the assessment.

2. No documented re-assessment for patients with extended stays

Patients admitted for more than a few days require periodic re-assessment to capture changes in clinical status. Hospitals often have a re-assessment policy but fail to execute it consistently — assessors find gaps of several days with no documented clinical review.

Prevention: Define re-assessment frequency in the policy (e.g., every 24 or 48 hours depending on acuity) and build it into the daily workflow. Automated reminders tied to admission date help ensure no patient is missed.

3. Discharge summary not provided within the defined timeframe

NABH expects hospitals to define a turnaround time for discharge summaries and then meet it consistently. Assessors check timestamps — if the policy says 24 hours but summaries are routinely delivered after 48, that is a non-conformity.

Prevention: Set a realistic turnaround time that your team can actually meet. Track discharge summary TAT as a quality indicator and escalate delays. Pre-populated templates reduce the documentation burden on consultants.

4. Transfer documentation lacking clinical handover details

When patients are transferred between departments or to another facility, assessors look for a structured handover note covering diagnosis, treatment given, pending investigations, and reason for transfer. Verbal-only handovers without documentation are a common NC.

Prevention: Implement a standardised transfer form (or adopt a structured handover tool such as ISBAR) and ensure it accompanies every inter-departmental and inter-facility transfer. Audit transfer records monthly.

5. No evidence of informed refusal documentation when patients leave against medical advice

Patients who discharge against medical advice (DAMA/LAMA) must have a documented informed refusal that includes the risks explained and the patient's acknowledgement. Assessors find cases where the DAMA register exists but the case file contains no corresponding clinical note explaining what risks were communicated.

Prevention: Create a DAMA documentation checklist that includes the treating doctor's note, risk explanation, and patient or attendant signature. Tie it to the discharge workflow so it cannot be bypassed.

COP — Care of Patients (NCs 6-10)

6. Uniform care protocols not standardised across departments

Assessors using tracer methodology follow a patient through multiple departments and compare how care is delivered. When the ICU follows one sedation protocol and the ward uses a different one without clinical justification, it raises a non-conformity for lack of standardised care.

Prevention: Develop hospital-wide clinical protocols endorsed by the medical committee. Ensure department-specific variations are documented with clinical rationale. Circulate updated protocols to all relevant units and maintain version-controlled records.

7. Procedural consent forms missing specific risk disclosure

Generic consent forms that say "I consent to the procedure and accept all risks" do not meet NABH requirements. Assessors expect procedure-specific consent that names the intervention, common risks, alternatives discussed, and the name of the doctor who explained them.

Prevention: Develop procedure-specific consent templates for all commonly performed surgeries and invasive procedures. Include a checklist of risks, benefits, and alternatives. Train doctors to complete the form in the patient's presence, not retrospectively.

8. Pain assessment not documented at defined intervals

NABH expects pain to be assessed using a validated scale at admission, at regular intervals, and after intervention. Assessors often find initial pain scores recorded but no follow-up reassessment — particularly in post-operative patients.

Prevention: Integrate pain reassessment into nursing observation charts at defined intervals (e.g., every 4 hours post-operatively). Use a numeric or visual analogue scale and document the response to pain management interventions.

9. No documented plan of care for high-risk patients

High-risk patients — including those on ventilators, patients with multi-organ dysfunction, or neonates in the NICU — require an individualised, documented plan of care. Assessors find that while treatment is being provided, the care plan is not documented in a structured format.

Prevention: Define what constitutes a high-risk patient in your hospital policy. Create care plan templates for common high-risk categories. Ensure the care plan is reviewed and updated during each clinical shift.

10. End-of-life care preferences not recorded or discussed

For terminally ill patients, NABH expects evidence that end-of-life care preferences were discussed with the patient or family and documented. Assessors find this conversation either did not happen or was not recorded in the case file.

Prevention: Develop a policy and documentation format for end-of-life discussions. Train senior clinicians and nursing staff on how to initiate these conversations. Include a prompt in the care plan for patients with a terminal prognosis.

MOM — Management of Medication (NCs 11-14)

11. High-alert medications not stored separately or labelled distinctly

NABH requires that high-alert medications (such as concentrated electrolytes, insulin, and anticoagulants) are stored separately from general stock and labelled with distinct identifiers. Assessors frequently find high-alert drugs mixed in with routine stock on ward shelves.

Prevention: Maintain a hospital-approved high-alert medication list. Store these drugs in clearly marked, separate bins or shelves with warning labels. Conduct monthly spot checks in all medication storage areas.

12. Look-alike, sound-alike (LASA) drug list not updated or not displayed

Hospitals are expected to maintain a current LASA list, display it in pharmacy and nursing stations, and take active measures (such as Tall Man lettering) to prevent mix-ups. Assessors find outdated lists or lists that exist in pharmacy but are absent from ward medication rooms.

Prevention: Review and update the LASA list at least annually or whenever the formulary changes. Display the list at every medication storage and preparation area. Use Tall Man lettering on labels and in the hospital information system.

13. Adverse drug reaction (ADR) reporting absent or incomplete

NABH expects a functional ADR monitoring and reporting system. Assessors find that while a policy exists, actual ADR reports are rare — suggesting under-reporting rather than an absence of events. No trending or analysis of ADR data is another common gap.

Prevention: Simplify the ADR reporting form and make it accessible to all clinical staff. Include ADR reporting in induction training. The pharmacy and therapeutics committee should review ADR data quarterly and document the analysis.

14. Medication errors not tracked through a defined reporting mechanism

A near-miss or actual medication error should trigger a documented report, root cause analysis, and corrective action. Assessors find hospitals where the error reporting culture is absent — staff fear punitive action, so errors go unreported.

Prevention: Implement a non-punitive medication error reporting policy. Train staff on what constitutes a reportable event. Track errors on a register, conduct root cause analysis for significant events, and present trends to the quality committee.

PRE — Patient Rights and Education (NCs 15-18)

15. Patient rights charter not displayed or not explained to patients

NABH requires that the patient rights and responsibilities document is communicated to every patient at the time of admission. Assessors find the charter displayed on a wall in the lobby but no evidence that it was explained to individual patients — admission staff cannot describe the process when asked.

Prevention: Include a patient rights acknowledgement step in the admission workflow. Provide a printed copy in the local language and document the patient's or attendant's acknowledgement in the admission record.

16. Informed consent obtained in a language the patient does not understand

Consent forms in English administered to patients who speak only a regional language do not meet the standard. Assessors verify by asking patients whether the consent was explained to them in a language they understood.

Prevention: Prepare consent forms in all major languages spoken by your patient population. Train staff to use interpreters or bilingual colleagues when a language gap exists. Document the language in which consent was explained.

17. No evidence of patient or family education on discharge care

Discharge education — covering medications, diet, warning signs, follow-up schedule, and activity restrictions — must be documented. Assessors find discharge summaries that list medications but no evidence that the patient was educated on how to take them or when to return.

Prevention: Develop a structured discharge education checklist that nursing staff complete with the patient or attendant. Include a section for the patient's or attendant's signature confirming they received and understood the instructions.

18. Grievance redressal mechanism not functional or not communicated

Hospitals must have a complaints and grievance mechanism with defined turnaround times. Assessors check the complaints register, response timelines, and whether patients know how to file a complaint. A register with no entries is treated with as much suspicion as one with unresolved complaints.

Prevention: Display the complaint process prominently in patient areas. Assign a responsible person for tracking and responding to complaints within the defined timeline. Analyse complaint trends quarterly and present findings to the quality committee.

HIC — Hospital Infection Control (NCs 19-24)

19. Hand hygiene compliance monitoring not conducted or not documented

NABH expects regular hand hygiene audits based on the WHO "5 Moments" framework. Assessors commonly find that compliance audits are either not conducted at all or are done sporadically with no trend data. The infection control nurse may describe the practice verbally but cannot produce records.

Prevention: Schedule monthly hand hygiene audits across all clinical areas. Use a standardised observation tool aligned with WHO methodology. Maintain a register of compliance rates and display unit-level results for staff feedback.

20. Biomedical waste segregation errors at the point of generation

Colour-coded segregation at source is a fundamental requirement. Assessors observe waste bins during ward rounds and frequently find general waste mixed with infectious waste, sharps containers overfilled beyond the three-quarter mark, or incorrect colour bags in use.

Prevention: Train all staff — including housekeeping, nursing aides, and technicians — on BMW segregation rules at induction and at least annually thereafter. Conduct weekly walk-through audits of waste bins in clinical areas and document findings.

21. Sterilisation records incomplete — missing biological indicator results

Autoclaves must be monitored using physical, chemical, and biological indicators. Assessors find that physical parameters (time, temperature, pressure) are logged but biological indicator test results are missing or not done at the required frequency.

Prevention: Run biological indicator (spore) tests at least weekly for each autoclave and after every maintenance event. Record results in a dedicated sterilisation log. Establish a protocol for what happens when a biological indicator fails (quarantine, re-sterilisation, investigation).

22. No surveillance data for hospital-acquired infections (HAIs)

The hospital infection control committee (HICC) is expected to track HAI rates — at minimum, ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), central line-associated bloodstream infection (CLABSI), and surgical site infection (SSI). Assessors find hospitals that have an HICC but no systematic surveillance programme or denominator data for rate calculation.

Prevention: Implement a surveillance programme using standardised definitions (e.g., CDC/NHSN criteria adapted for the Indian context). Collect numerator and denominator data monthly. Present trended HAI rates to the HICC at least quarterly.

23. Antibiotic stewardship programme absent or non-functional

NABH expects evidence of an antibiotic stewardship programme — including an antibiotic policy, restricted antibiotic list, and periodic review of prescribing patterns. Assessors find hospitals where the policy document exists but there is no evidence of implementation: no restriction mechanism, no audit of prescribing, and no antibiogram data.

Prevention: Form an antimicrobial stewardship committee. Develop a hospital antibiotic policy with a restricted list requiring approval from an infectious disease physician or designated authority. Audit antibiotic use quarterly and update the antibiogram annually based on microbiology data.

24. Cleaning and disinfection protocols not validated or not followed in operation theatres

Operation theatres require defined fumigation or terminal cleaning protocols with documented validation (such as environmental swab cultures). Assessors find that cleaning happens but there is no validation — no swab culture reports, no fumigation log, or the log is filled in retrospectively without actual validation data.

Prevention: Define OT cleaning protocols for between-case cleaning, terminal cleaning, and fumigation. Conduct environmental surveillance swab cultures at defined intervals (e.g., monthly) and record results. Act on any positive cultures with a documented CAPA.

PSQ — Patient Safety and Quality Improvement (NCs 25-29)

25. International Patient Safety Goals (IPSGs) not fully implemented

NABH mandates compliance with patient safety goals covering patient identification, effective communication, high-alert medications, correct-site surgery, infection prevention, and fall prevention. Assessors find that some goals are implemented but others are either missing or only partially in place — for example, two-identifier patient identification exists in some departments but not in the laboratory or radiology.

Prevention: Map each IPSG to every department where it applies. Conduct a gap assessment specifically for IPSGs and ensure implementation is uniform across the hospital, not limited to wards and ICUs.

26. Incident reporting system not used or significantly under-reported

Assessors expect to see a functioning incident reporting system with a reasonable volume of reports across departments. A hospital with hundreds of admissions per month but only one or two incident reports per quarter raises a red flag for under-reporting, not for safety.

Prevention: Foster a non-punitive reporting culture through leadership messaging and training. Make the reporting form simple and accessible (paper and digital). Provide feedback to reporters so staff see that reports lead to action, not blame.

27. Root cause analysis (RCA) not conducted for sentinel events

When a sentinel event occurs — such as wrong-site surgery, inpatient suicide, or a retained foreign body — NABH expects a formal RCA with documented corrective actions. Assessors find that sentinel events are acknowledged but the analysis is superficial, lacking systematic methodology.

Prevention: Train the quality team in a recognised RCA methodology (e.g., fishbone diagram, 5 Whys, or fault tree analysis). Conduct RCA within a defined timeframe after any sentinel event. Present findings and corrective actions to the quality committee and track implementation.

28. Quality indicator data collected but not analysed or acted upon

Hospitals often collect indicator data to fulfil the requirement but do not analyse trends, set benchmarks, or initiate improvement projects when indicators deteriorate. Assessors look for evidence of trending over time and documented action taken when a target is not met.

Prevention: Define targets for each quality indicator. Plot trends monthly and review them in quality committee meetings. When an indicator falls below target, initiate a PDCA cycle or CAPA and document the outcome.

29. No evidence of clinical audit activity

Clinical audits — such as medical record audits, mortality reviews, or surgical audit — are expected as part of the quality improvement programme. Assessors find that audit schedules exist on paper but actual audit reports, findings, and corrective actions are absent.

Prevention: Develop an annual clinical audit calendar with defined topics, responsible persons, and timelines. Ensure each audit results in a written report with findings, recommendations, and a follow-up plan. Present audit results to the medical committee.

ROM — Responsibilities of Management (NCs 30-33)

30. Hospital strategic plan or quality policy not communicated to staff

NABH expects the hospital's mission, vision, quality policy, and strategic objectives to be known across the organisation. Assessors interview staff at all levels — if a ward nurse or technician cannot articulate the hospital's quality policy in broad terms, it indicates a communication failure.

Prevention: Display the mission, vision, and quality policy in all departments. Include them in staff induction and annual refresher training. Periodically quiz staff during departmental meetings to reinforce awareness.

31. Budget allocation for quality and patient safety not documented

The management is expected to allocate resources — financial and human — for quality improvement and patient safety activities. Assessors find that while quality work happens, there is no evidence of a defined budget line for quality initiatives, training, or equipment upgrades related to patient safety.

Prevention: Include a specific budget allocation for quality and patient safety in the annual hospital budget. Document approval by the governing body. Track utilisation of this budget and present it in quality committee reviews.

32. Governing body or management review meetings not conducted at defined frequency

NABH expects regular management review meetings where quality performance, patient safety data, and accreditation progress are discussed. Assessors find meeting schedules that were not followed — either meetings were skipped or minutes are missing for several months.

Prevention: Fix a calendar for management review meetings (e.g., quarterly) and treat them as non-negotiable. Prepare a structured agenda covering quality indicators, incident reports, audit findings, and corrective actions. Maintain detailed minutes with action items and track follow-up.

33. Outsourced services not monitored for quality and safety compliance

Hospitals that outsource services such as housekeeping, laundry, food services, or security must demonstrate that these vendors meet quality and safety standards. Assessors find contracts in place but no evidence of performance monitoring — no audits of outsourced staff competency, no periodic reviews of service quality.

Prevention: Include quality and safety clauses in all outsourcing contracts. Define key performance indicators for each outsourced service. Conduct periodic audits and document findings. Maintain training records for outsourced staff on infection control and safety protocols.

FMS — Facility Management and Safety (NCs 34-39)

34. Fire safety equipment not tested at documented intervals

Fire extinguishers, smoke detectors, fire alarms, and sprinkler systems must be inspected and tested at defined intervals. Assessors find expired extinguishers, detectors with dead batteries, or a testing log that has not been updated in months.

Prevention: Create a fire safety equipment register listing every device, its location, and its testing schedule. Conduct and document inspections monthly. Replace expired or faulty equipment immediately and record the replacement.

35. Fire drills not conducted or not documented with staff participation records

Mock fire drills must be conducted at least twice a year with documented attendance and a post-drill analysis of response times and gaps. Assessors find hospitals that have not conducted a drill in over a year, or where drills were conducted but attendance records and debrief notes are missing.

Prevention: Schedule fire drills in the annual safety calendar — one per half-year at minimum. Document the drill scenario, participants, response time, gaps identified, and corrective actions. Rotate drills across shifts to ensure all staff are covered.

36. Medical gas pipeline system not maintained with documented safety checks

Medical gas pipelines (oxygen, nitrous oxide, compressed air, vacuum) require periodic maintenance and safety checks — including alarm testing, pressure verification, and leak checks. Assessors find that maintenance is done by the vendor but the hospital has no in-house log or evidence of alarm testing.

Prevention: Maintain a medical gas pipeline maintenance log with entries for every scheduled check and any corrective maintenance. Test area and master alarms at defined intervals. Keep vendor maintenance reports on file and verify that work was completed as contracted.

37. Electrical safety — no evidence of periodic earthing and equipment testing

NABH expects documented evidence of electrical safety measures including earthing verification, PAT testing of critical medical equipment, and backup power testing. Assessors find that earthing certificates are outdated or that generator changeover testing is not documented.

Prevention: Schedule annual earthing verification by a licensed electrical contractor and maintain the certificate on file. Test generator changeover at least monthly and record changeover time. Maintain a register of PAT testing for all critical medical equipment.

38. Hazardous materials inventory not maintained or MSDS not available

Hospitals use numerous hazardous materials — disinfectants, laboratory reagents, cytotoxic drugs, and compressed gases. NABH requires an inventory of all hazardous materials with corresponding Material Safety Data Sheets (MSDS) accessible to staff. Assessors find MSDS files that are incomplete, outdated, or locked away where staff cannot access them during an emergency.

Prevention: Compile a hazardous materials register for each department. Ensure current MSDS are available at the point of use — not only in the safety office. Train staff on spill management and emergency procedures for each category of hazardous material.

39. Building and infrastructure maintenance records not maintained

Preventive maintenance of lifts, HVAC systems, water treatment plants, and the building structure itself must be scheduled and documented. Assessors find that maintenance is reactive — repairs are done when things break, but there is no preventive maintenance schedule or log.

Prevention: Develop a preventive maintenance calendar for all critical building systems. Log every maintenance activity — whether preventive or corrective — with date, description, and responsible person. Review the maintenance programme annually and update it based on equipment age and condition.

HRM — Human Resource Management (NCs 40-43)

40. Staff credential verification records incomplete

NABH requires primary source verification of qualifications for all clinical staff — doctors, nurses, and paramedical professionals. Assessors find personnel files with photocopied certificates but no evidence that the originals were verified against the issuing authority or medical council registration was confirmed.

Prevention: Establish a credentialing and privileging process that includes primary source verification for every clinical hire. Maintain a checklist in each personnel file showing what was verified, when, and by whom. Re-verify registration status at defined intervals.

41. Training needs assessment not conducted or not linked to training plan

NABH expects a systematic training needs assessment (TNA) that informs the annual training calendar. Assessors find a generic training calendar that is the same every year with no evidence that it was derived from an actual needs assessment based on quality data, incident reports, or appraisal findings.

Prevention: Conduct a TNA annually using inputs from quality indicators, incident reports, audit findings, staff appraisals, and new regulatory requirements. Map identified needs to specific training programmes and track attendance and effectiveness.

42. Mandatory training attendance not tracked — BLS, fire safety, infection control

Certain training programmes are mandatory for all or specific categories of staff — Basic Life Support, fire safety, infection control, and patient safety goals. Assessors find that training was conducted but attendance records are incomplete, and there is no mechanism to identify and follow up with staff who missed the session.

Prevention: Maintain a training attendance register linked to the staff master list. After each mandatory training session, generate a list of non-attendees and schedule a make-up session. Track completion rates as a quality indicator and report to the quality committee.

43. Staff health programme not implemented — no pre-employment or periodic health checks

Healthcare workers are exposed to occupational hazards and NABH expects a staff health programme covering pre-employment screening, periodic health checks, immunisation (especially Hepatitis B), and post-exposure prophylaxis protocols. Assessors find that pre-employment checks are done for some staff but periodic health checks are absent.

Prevention: Define a staff health programme that includes pre-employment medical examination, annual health checks for at-risk staff, Hepatitis B vaccination and titre verification, and a documented post-exposure prophylaxis protocol. Maintain health records for all staff in a confidential file.

IMS — Information Management System (NCs 44-47)

44. Medical records not completed within defined timelines

NABH requires that medical records are completed — including discharge summary, operative notes, and final diagnosis coding — within a defined timeframe after discharge. Assessors audit a sample of closed records and find incomplete entries, missing signatures, or records that were never closed out.

Prevention: Define a medical record completion policy with specific timelines (e.g., within 48 hours of discharge). Conduct monthly audits of medical record completion rates. Send automated reminders to treating doctors for incomplete records and escalate persistent non-compliance.

45. Data security and patient confidentiality measures not documented or enforced

Hospitals must demonstrate that patient data — both paper and electronic — is protected against unauthorised access. Assessors find unlocked medical record rooms, shared login credentials for hospital information systems, and no documented access control policy.

Prevention: Implement role-based access controls for electronic health records. Ensure physical medical records are stored in a secure, access-controlled area. Develop a data security policy covering password management, access logs, and breach response. Audit access logs periodically.

46. No defined process for medical record retention and destruction

NABH expects a documented policy on how long medical records are retained and how they are destroyed at the end of the retention period. Assessors find hospitals with no retention policy, or a policy that exists but has never been implemented — records accumulate indefinitely with no systematic management.

Prevention: Define retention periods for different record categories in line with medico-legal requirements and NABH guidelines. Document the destruction process (including who authorises it and how confidentiality is maintained during destruction). Maintain a destruction register.

47. Quality and clinical data not analysed to support decision-making

The information management system should enable data-driven decision-making — assessors look for evidence that clinical and operational data is collected, analysed, and presented to the appropriate committees. Hospitals that collect data in registers but never aggregate, trend, or present it to leadership receive this NC.

Prevention: Establish a data analysis and reporting cycle — monthly data collection, quarterly analysis, and presentation to the quality committee and management. Define which indicators are tracked, set benchmarks, and use the data to drive improvement initiatives. Digital dashboards make this significantly easier to sustain.

Common patterns across these NCs

Looking across all 47 non-conformities, four patterns emerge repeatedly:

1. Documentation gaps: The single largest driver of NCs is not the absence of a process but the absence of evidence. The process exists and may even be well-executed — but if it is not documented, assessors cannot give credit for it. This applies to everything from hand hygiene audits to management review meetings.
2. Lack of training evidence: Many NCs relate not to untrained staff but to unrecorded training. Attendance registers are missing, training effectiveness is not evaluated, and make-up sessions for absentees are not tracked. The training happened; the proof did not.
3. No audit trail or trend data: NABH assessors do not want a single data point — they want to see trends over time. A hospital that can show three months of quality indicator data with analysis and corrective actions is in a far stronger position than one with a single month's snapshot.
4. Process exists but is not followed uniformly: Policies and SOPs are written during preparation but compliance drifts over time. Assessors using tracer methodology quickly spot the gap between what is written and what is practised — particularly in areas like consent, pain reassessment, and medication storage.

How to prevent non-conformities

Preventing NCs is not about last-minute preparation — it requires building systems that generate evidence as a by-product of daily work. Here are practical steps:

• Conduct a baseline self-assessment against every NABH standard and identify gaps early. A structured gap analysis in the first month of preparation shapes the entire remediation plan.
• Use digital checklist and audit tools to create automatic evidence trails. When staff complete a checklist on a tablet or phone, the timestamp, location, and user are captured automatically — eliminating the need to chase paper records. Tools like EaseOps are built specifically for this purpose in hospital settings.
• Build internal audit into the monthly rhythm. Do not wait for the assessment to discover gaps. Assign chapter-wise audit responsibility to trained internal auditors and review findings in the quality committee meeting every month.
• Track mandatory training attendance against the full staff list, not just by counting who showed up. The denominator matters — knowing that 80 of 100 nurses attended fire safety training (and the remaining 20 are scheduled for a make-up session) is the evidence assessors look for.
• Maintain a CAPA register and follow through. Every NC identified in an internal audit should trigger a corrective and preventive action with a responsible person, target date, and evidence of closure. Assessors review the CAPA register to judge the hospital's improvement culture.
• Rehearse with a mock assessment. Bring in an external assessor or experienced quality professional to conduct a mock assessment using NABH tracer methodology. The findings from a mock assessment are your most realistic preview of what the actual assessment will surface.

FAQs

What happens if you get a non-conformity in NABH assessment?

If a non-conformity is raised during a NABH assessment, the hospital must submit a corrective action plan (CAPA) addressing the root cause and the steps taken to resolve it. For minor NCs, hospitals are typically given a defined window to submit evidence of closure. Major NCs may require a follow-up visit or re-assessment. The accreditation decision depends on the number, severity, and nature of the outstanding NCs at the time of the final review by the NABH Accreditation Committee.

How many NCs are acceptable for NABH accreditation?

NABH does not publish a fixed threshold of acceptable non-conformities. The accreditation decision is based on the overall compliance picture — the number of NCs, their severity (major vs minor), which chapters they fall under, and whether the hospital has demonstrated a credible corrective action plan. Hospitals with only minor NCs and strong evidence of corrective action are more likely to receive a favourable decision.

Can you fix NCs after the assessment?

Yes. After the on-site assessment, hospitals receive a list of non-conformities and are given a window to submit corrective and preventive actions (CAPA) with supporting evidence. The NABH Accreditation Committee reviews the CAPA submissions before making a final accreditation decision. For major NCs, a follow-up visit may be required to verify that corrections have been implemented on the ground.

What is the difference between a major and minor NC?

A major non-conformity indicates a significant failure in meeting a NABH standard — typically a complete absence of a required process, a systemic breakdown that affects patient safety, or a critical gap with no evidence of implementation. A minor non-conformity indicates a partial gap — the process exists but is incomplete, inconsistently followed, or inadequately documented. Major NCs carry more weight in the accreditation decision and may require a follow-up assessment visit.

Key takeaways

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