Deepika Kanyal
Babaji Ghewade- Department of Hospital Administration, Datta Meghe Institute of Medical Sciences, Wardha, India
Background: The National Accreditation Board for Hospitals and Healthcare Providers (NABH.) accreditation process aims to elevate the quality of healthcare services through an impartial, external peer evaluation of an organization's performance. This study compares NABH. quality indicators in a tertiary care hospital before and after accreditation, assessing changes in patient care, hospital management, and staff performance.
Methods: A systematic review was conducted following PRISMA guidelines. Literature was searched across PubMed, Scopus, Google Scholar, and the Cochrane Library from August 2023 to January 2024. Keywords included “NABH. accreditation and hospital quality,” “Accreditation in Indian hospitals and patient safety,” and “Tertiary care hospital before and after accreditation.” Boolean operators, synonyms, and related terms were used to ensure comprehensive retrieval. Independent reviewers screened studies, and risk of bias assessment was performed using the Cochrane Risk of Bias Tool.
Results: The study highlights significant improvements in hospital quality indicators following NABH accreditation. Hospital-acquired infection rates decreased, with infection control compliance improving by 40%. Operational efficiency improved with a 20% reduction in discharge delays and a 15% increase in documentation accuracy. Patient satisfaction scores rose by 25%, and structured policies enhanced service quality by 30%. Additionally, 85% of hospital staff reported higher job satisfaction. Statistical analysis confirmed significant differences in compliance rates (p < 0.05) and patient care metrics (p < 0.01). Despite initial implementation challenges due to resource constraints, the study underscores the need for continuous monitoring and reinforcement of accreditation standards to sustain these improvements.
Conclusion: NABH accreditation improves patient safety, lowers infection rates, and boosts overall productivity. The structured framework encourages continuous improvement, but institutional commitment and ongoing oversight are necessary for long-term sustainability.
Introduction
Quality in healthcare defined as the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Globally, health systems have increasingly adopted quality improvement initiatives to achieve measurable enhancements in clinical care and patient satisfaction.
In order to provide high-quality healthcare services in India, hospitals must be accredited by the National Accreditation Board for Hospitals and Healthcare Providers (NABH.). The thorough and exacting process of NABH. accreditation is intended to guarantee that healthcare institutions adhere to set criteria for patient care, safety, and organizational management. NABH. aligns its standards with international best practices, particularly those of the International Society for Quality in Healthcare (ISQua), as a constituent board of the Quality Council of India (Q.C.I.) (1). A healthcare institution must undergo frequent evaluations in order to receive NABH. accreditation, which encourages advancements in the operational and structural areas of healthcare delivery (2).
To ensure that hospitals meet and continuously strive to exceed predefined benchmarks in important areas like patient safety, clinical care, infection control, and patient rights, the accreditation process entails an external evaluation by a qualified team of healthcare professionals who look at the organization's policies, procedures, and outcomes (3). The evaluation includes a self-assessment by the hospital, followed by an on-site survey where the external team reviews hospital operations and interacts with staff and patients. A report is then compiled that may include recommendations for improvement, and the hospital's status is then decided—either it is granted accreditation or further changes are necessary (4–6).
Accreditation contributes to the standardization of care delivery procedures, which lowers errors and fosters a culture of quality and safety (7).
Although NABH. accreditation has several advantages, the procedure is time-consuming and labor-intensive. Hospitals may find it challenging to achieve strict accreditation requirements, especially when it comes to infrastructure upgrades, personnel training, and budget allocation. Accreditation preparation can be a significant initial commitment that takes time and money. However, the long-term advantages—such as better patient care, more operational effectiveness, and a higher reputation in the healthcare sector—often exceed these difficulties (8).
This study compares performance metrics before and after certification in order to evaluate the effect of NABH. accreditation on quality indicators within a tertiary care hospital. Through an analysis of the process's observable advantages and difficulties, the research will provide significant additional information about how accreditation can promote quality enhancement in healthcare institutions (9).
PICOS Framework:
• Population (P): Indian tertiary care hospitals
• Intervention (I): Implementation of NABH accreditation
• Comparator (C): Hospital quality indicators before NABH accreditation
• Outcomes (O): Changes in infection control, patient and staff satisfaction, documentation, and discharge efficiency.
Methodology
Study design
This systematic review follows PRISMA guidelines to assess the impact of NABH. accreditation on hospital quality indicators in tertiary care settings.
Search strategy
We searched PubMed, Scopus, Google Scholar, and the Cochrane Library from August 2023 to January 2024 using the terms: “NABH accreditation AND hospital quality”, “accreditation in Indian hospitals AND patient safety”, and “tertiary care hospital AND before and after accreditation”. Boolean operators (AND, OR) and synonyms were applied. Only English-language peer-reviewed empirical studies were included.
Statistical measures & uncertainties
Chi-square test for categorical data, t-tests for continuous variables was conducted. 95% CI for all reported metrics where margin of error is ±5%
Inclusion criteria
• Studies on tertiary care hospitals in India
• Comparison of quality indicators pre- and post-NABH accreditation
Exclusion criteria
• Studies outside India
• Opinion pieces, editorials, and non-peer-reviewed articles
• Research lacking measurable outcome.
Data extraction and risk of bias
Data on study design, outcomes, and findings were extracted independently by two reviewers. Risk of bias was assessed using the Cochrane Risk of Bias Tool across domains (selection, performance, detection, reporting). The summary of this assessment is presented in Table 2.
Data synthesis
Due to heterogeneity in study design, populations, and outcome measures, a meta-analysis was not feasible. We conducted a narrative synthesis and grouped studies thematically by outcome domains.
Statistical analysis
For studies providing raw data, chi-square tests and t-tests were used to compare categorical and continuous outcomes pre- and post-accreditation. A 95% confidence interval was used, with a margin of error of ±5%.
The search approach and outcome are detailed in Figure 1; Table 1. Only English-language articles were considered.
Figure 1. PRISMA 2020 flow diagram illustrating the selection process of studies included in the systematic review.
Table 1. Characteristics and critical findings of the study included in the review.
Risk of Bias Summary (Table 2):
• Low risk: 7 studies
• Moderate risk: 15 studies
• High risk: 5 studies
Table 2. Risk of biased summary of included studies.
Result
The study findings reveal that NABH accreditation has significantly improved hospital quality indicators. Patient safety and infection control have notably advanced, with hospital-acquired infection rates decreasing and compliance with sterilization protocols improving by 40%. Operational efficiency has also been enhanced, as evidenced by a 20% reduction in patient discharge delays and a 15% increase in documentation accuracy. Standardized protocols have contributed to a decline in medical errors. Patient satisfaction has risen by 25%, particularly concerning staff behavior and communication, while structured policies have led to a 30% improvement in overall service quality. Hospital staff have experienced increased job satisfaction, with 85% reporting positive changes post-accreditation. Continuous training programs have resulted in better adherence to quality standards, reinforcing the long-term benefits of accreditation. Statistical analysis confirms these findings, with chi-square tests showing significant differences in compliance rates (p < 0.05) and paired t-tests indicating notable improvements in patient care metrics (p < 0.01). A comparative review of 27 studies supports these outcomes, highlighting consistent improvements in patient safety, infection control, and documentation. Despite initial implementation challenges due to resource constraints, the study underscores the need for continuous monitoring and reinforcement of accreditation standards to sustain these improvements.
Discussion
This systematic review provides evidence that NABH accreditation has improved multiple facets of hospital functioning. The included studies consistently report benefits in infection control, staff training, operational efficiency, and patient care protocols. For instance, studies by Yadav Nidhi et al., shows that 85% of participants felt that NABH. accreditation impacted their degree of job satisfaction after NABH. and 80% of participants believed that NABH. accreditation improved hospital services (1). A study conducted by Joseph S concludes that accreditation provides insights for redefining priorities while implementing certification in Kerala and forms a base for policy development in healthcare (5). A study conducted by Alkhenizan et al. concludes that to change healthcare workers’ attitudes regarding accreditation, healthcare professionals need to be educated about the possible benefits of certification (10). The Study by Kudur SB et al. concludes that the reduction in the adoption and adherence of NABH. standards may directly impact the occurrence of Hospital-acquired infections (H.A.I.S.). According to Joseph L. et al., healthcare professionals’ cynical attitude toward accreditation is resolved by educating them about the possible advantages of certification (7).
The NABH. provides evidence-based, organized, simplified, and methodical guidelines designed for various hospital levels to ensure optimal care and minimize infections. Similarly, a Study conducted by Ajay K concludes that the initial and post-accreditation case sheets’ scores varied significantly in statistical terms, with the post-phase case sheets receiving 15% greater scores than the prior-phase case sheets (8). According to Bajpai P's research, most study participants view these guidelines favourably and believe that they have enhanced their training and working environments. According to a study by Gadre DS et al., the revised edition of the Management of Medication Objective and Implementation Strategies should assist hospitals that previously received accreditation in implementing safe medicine and device usage (11).
A study concluded by Jain S et al. concludes that Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) generally satisfies every NABH. quality criteria. The NABH. standards are highly comprehensive and descriptive, presenting multiple challenges for their application, including the requirement for more documentation, competent personnel, and a skilled trainer/coordinator for training (12). Quality standards were implemented in the research of Hiremani SG et al. There is an opportunity for improvement in the standard of healthcare services and in the abilities and duties of employees to satisfy patients’ expectations (13). In addition, some authors conclude that, compared to NABH. guidelines, there is a delay at each phase of the discharge process, particularly in the billing procedure and setting up the room for a specific type of insured patient (14). According to Hittinahalli V et al.'s study, the NABH. standards present a framework for improving hospital facilities and patient care quality (15). According to Jain S. et al. conclusion, doctors and nurses should get specific instruction on the significance of comprehensive and efficient documentation and adequate documentation of surveillance mechanisms (16).
Puri S et al. The Study concludes that NABH. standards are mandates set by NABH. that enable safe, high-quality healthcare (17). According to a study by Agrawal T et al., needle stick injuries (N.S.I.s) may have an impact on health system training. Therefore, efforts to prepare healthcare personnel and lessen patient stress should be coordinated (18). Ghosh S et al., pharmaceutical and prescription errors can be significantly decreased by carrying out audits, considering the need to conduct clinical audits regularly (19). According to Singh P et al.'s study, hospitals should mandatorily record patient health record data to enhance documentation correctness and completeness (20). According to Kumari P et al., the quality assurance program aims to deliver prompt, high-quality patient care while adhering to Department of Radiology rules that follow established standards (21).
According to Mukherjee S. et al.'s conclusion, hospital initiatives pertaining to specific safety domains that require immediate improvement are essential (22). Tapas Sadasivan Nair et al. found that overall adherence to NABH. standards of care increased from 9% in the baseline assessment to 80% in the NABH. evaluation. The NABH. assessments revealed 831 performance gaps, including documentation problems accounting for most of those gaps (70%), followed by training (19%). Revision of current documentation or creation of new documentation (62%) and training facility staff on various protocols (35%) are the two most common ways to close performance gaps (23). Bandar Saeedan AI Dhafiri et al. conducted the Study. Managers supplied most of the responses from the 545 legitimate participants, or 53.29% of all participants. The research aimed to assess participant perceptions of the relationship between patient safety and hospital accreditation. A statistical study showed that for all 20 items, a substantially more significant proportion of participants had a favourable answer (24).
In an investigation conducted by Manpreet Singh Nanda et al. for both months, 400 patients and their families (for patients under the age of eighteen) completed questionnaires that were used to gather data. In both the Outpatient department and inpatient departments, patients’ opinions and experiences with all questionnaire items improved, but staff behaviour and communication abilities saw the most improvements (25). According to a study by Swathi S et al., hospitals should focus on improving service quality and aiming for customer retention by identifying the factors that significantly affect customer satisfaction. Customers’ satisfaction levels also aid in decision-making, staff behaviour training, and providing high-quality service (9, 26). Nurses’ job satisfaction scores in hospitals in Indore city accredited by NABH. and those not showed a highly significant difference, according to a study by Keshkali Singh et al. that used statistical analysis using the independent t-test. Research consistently demonstrates that accrediting programs enhance the calibre of work and job satisfaction of registered nurses (27).
Strengths of the review
• Employ longitudinal or randomized study designs
• Use standardized, quantifiable outcome measures
• Evaluate cost-effectiveness and sustainability of accreditation
• Focused on concrete quality indicators (e.g., HAIs, documentation, satisfaction)
Limitation of the review
• Absence of RCTs or longitudinal designs
• Variability in reported outcome metrics
• Use of self-reported satisfaction data
• Moderate to high risk of bias in several included studies
Conclusion
NABH accreditation has demonstrated a positive influence on patient-centered care, hospital operations, and safety practices in tertiary care hospitals in India. The structured frameworks it introduces lead to measurable improvements in infection control, documentation, staff training, and satisfaction. However, further research using more rigorous designs such as RCTs or longitudinal studies is required to isolate the effect of accreditation from confounding variables. A focus on quantifiable outcomes will enhance the robustness of future systematic reviews and support data-driven healthcare policy decisions.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Author contributions
DK: Validation, Methodology, Data curation, Supervision, Project administration, Conceptualization, Visualization, Software, Resources, Investigation, Funding acquisition, Formal analysis, Writing – original draft, Writing – review & editing. BG: Conceptualization, Investigation, Formal analysis, Supervision, Writing – review & editing, Methodology, Data curation, Software, Visualization, Project administration, Funding acquisition, Resources, Writing – original draft, Validation.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Acknowledgments
I express my sincere gratitude to my supervisor, Dr. Babaji Ghewade for supporting and guiding me in shaping my article in its final form. I am thankful to my research department for their valuable contribution in assisting me to formulate my article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declare that no Generative AI was used in the creation of this manuscript.
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Abbreviations
NABH, National Accreditation Board of Hospital & Healthcare; S.O.P, standard operating procedure; I.C.U, Intensive Care Unit; HAI, hospital-acquired infection; HCO, Healthcare Organization; M.O.M, management of medication; AB-PMJAY, Ayushman Bharat Pradhan Mantri Jan Arogya Yojana; N.A.B.L, National Accreditation Board for Testing and Calibration Laboratories; K.A.P, knowledge attitude and practices; H.C.W, Healthcare Workers; N.S.I, Needle stick injuries.
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Keywords: NABH, quality indicators, patient satisfaction, healthcare standards, hospital-acquired infections, accreditation, risk of bias
Citation: Kanyal D and Ghewade B (2025) Evaluating quality improvement in tertiary care hospital before and after NABH accreditation: a systematic review. Front. Health Serv. 5:1654514. doi: 10.3389/frhs.2025.1654514
Received: 26 June 2025; Accepted: 13 August 2025;
Published: 26 August 2025.
Edited by:
Alexandre Morais Nunes, University of Lisbon, PortugalReviewed by:
Ricardo De Moraes E Soares, Instituto Politecnico de Setubal (IPS), PortugalHanaa Ismail Sabra Saleh, South Valley University Faculty of Nursing, Egypt
Copyright: © 2025 Kanyal and Ghewade. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Deepika Kanyal, ZGVlcGlrYWthbnlhbDMwQGdtYWlsLmNvbQ==