NABH Case study, Nirmal Hospital Surat

Name of the project

NABH Accreditation – Healthcare Organization (HCO)

Name of the Hospital

Nirmal Hospital, Surat

Owner of the hospital

Dr. Nirmal Choraria, Chairman


Hospital Profile in Brief:

Nirmal Hospital is one of the biggest private hospitals in Surat having 100 bed. It is the first multispecialty hospital of South Gujarat to be NABH Accredited. Having highest number of critical beds in a private hospital in Surat, it also has Neonatal and Pediatric ICUs along with Medical & Surgical ICUs. It is the first Level III PICU in South Gujarat. Also, it the only hospital in Gujarat to be involved in academic programs like Critical Care Fellowships in Pediatric & Neonatology along with DNB pediatrics and DCH Pediatrics by CPS


Before Project Scenario, situation before the project

Nirmal Hospital has been striving towards delivering quality healthcare since its inception. The chairman of the hospital always had a vision to impart highest quality services to his patients and all the stakeholders.

However, when they approached us for availing our guidance and support for the NABH accreditation, during the Gap Analysis the following were the main challenges.
Infrastructure – mainly Central Sterile Supply Department (CSSD)
Full proof Disaster Management Plan – especially fire and other external disaster management
Staff training regarding the NABH standards


Medigence Solution to the situation

Medigence offered Nirmal Hospitals a comprehensive guidance and advisory support during the entire project duration. We suggested them a few very effective tips related to manpower planning that helped them to manage the situation with existing staff without making unnecessary recruitments. Our highly experienced and expert team of consultants provided adequate guidance and support to their key staff to execute the accreditation activities by their own. This helped them to get empowered and take necessary decisions as well. Thanks to the top management support all the time in giving us enough flexibility to make appropriate changes as and when required.

We could also guide them in making certain infrastructure changes which could not overburden them financially and in-turn saved cost.


Tasks in brief done by Medigence along with project duration:

The entire NABH Accreditation project could be accomplished within a period of 13 months during which the activities were divided in a phase-wise manner. From filling up the application form and submitting it to conducting various Internal Audits, Medigence provided them with all the back-end support during assessments including Pre-assessment and Final Assessment.

Initial Gap Assessment
Documentation System
Implementing Quality Improvement Systems & activities
Conducting smooth functioning of Committees
Imparting training to all key personnel related to their policies, procedures & standards
Implementing the standards as per the NABH Guidelines

There were very few partial Non-compliances and the hospital through its commitment and hard work, could get the accreditation and became the first multispecialty hospital in South Gujarat to get NABH.


Result and advantage to the Hospital after the project:

The accreditation helped them to gain community confidence to a very high extent. Certainly the advantage of being the first multispecialty hospital to have been accredited was a very huge factor. Patients have been benefited a lot due to improvement in quality of patient care and safety.

The staff in the hospital are highly trained and credentialed. They are aware about the Patient’s rights & responsibilities and protect them. This has helped in increasing the patient satisfaction.

Due to increase in community confidence, the Insurance companies, Third party administrators and various corporate clients have vested their interest in the hospital thus increasing the revenue generation.

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