Shubh Hospital welcomes you to its well-equipped Multi-Services Super-Specialty hospitals and research centers committed to provide a range of international quality medical care at affordable cost.  25 bedded hospital, in Vidhyut nagar, main Ajmer road near Heera petrol pump, Jaipur (Raj.) India.
Shubh Hospital
Shubh Hospital

 >> Accreditation Standards - www.shubhhospital.com


Accreditation Standards Implemented For The Medical Facilities at SHUBH HOSPITAL
We have already implemented grading/Accreditation system in our Hospital
  • Process of Accreditation
    The accreditation program covers all aspects of a facility's operations and the standards apply to hospital.
    • Accreditation requires an in-depth review of every aspect of a hospital, management, operations and administration.
    • Establishment of hospital goals and objectives with provision for periodic updating.
    • Re-evaluation of whether hospital resources are being used in accordance with hospital goals,
      objectives and mission.
    • Re-evaluation of hospital policies and procedures especially as documented in the hospital's
      written directives system
    • Correction of deficiencies before they become public problems.


  • The accreditation standards provide norms against which hospital performance can be measured and monitored over time.


  • Goals of Accreditation
    • Increase hospital capabilities to prevent and control errors.
    • Increase departmental effectiveness and efficiency in the delivery of medical services.
    • Increase cooperation and coordination with other hospitals and with other areas within the
      medical system.
    • Increase citizen and employee confidence in the goals, objectives, policies, and practices of the medical system.


  • Benefits of Accreditation
    • Accountability / provides a yardstick to measure effectiveness of the hospitals' programs and
    • Defines services provided
    • Insures uniformity of services
    • Streamlines operations
    • Causes the hospital to be consistent
    • Provides more effective manpower deployment
    • Creates higher morale and a positive attitude among members of the hospital


  • Accreditation Standards (Patients' Rights)
    • Increase hospital capabilities to prevent and control errors.
    • Increase departmental effectiveness and efficiency in the delivery of medical services.
    • Increase cooperation and coordination with other hospitals and with other areas within the
      medical system.
    • There is an anonymous place in the facility to send written complaints and there is an assigned person/committee for reviewing and acting on these complaints.


  • Patient Care
  • A comprehensive history and physical examination is performed to all patients.
  • The necessary diagnostic tests (laboratory and radiology) are performed on time to determine
    the diagnosis.
  • All treatment plans are based on appropriate diagnostic results.
  • All changes to the treatment plan are added into the patient record with appropriate
  • The physician explains to all patients the diagnosis and treatment and any follow-up steps using clear and simple language.
  •  The facility has a well defined system for referrals.
  • The facility has a routine system to review the care provided by medical staff and assess its
  • The facility has a basic drug list that is known and used by all physicians.
  • The facility has adequate supply of drugs with valid shelf-life at all times.
  • The facility has a system to store and dispense drugs through SHUBH MEDICOSE (An IN- HOUSE 24 hours available facility) with a pharmacist is in charge of the pharmacy dispensing
  • The hospital is approved with many organizations and TPA for cash less mediclaim and the governing body is in continued effort for more and more attachments/ association on a very continuous basis so as to provide coverage of the maximum possible spectrum of patients
  • The facility dispenses drugs in appropriate packaging that includes a label with the name of the drug and written instructions about its use.
  • Upon dispensing the drugs, the provider gives simple and clear verbal instructions to patients.
  • Clinical practice guidelines used in the facility includes the proper use of antibiotics.
  • The emergency room is staffed at all times.
  • The facility have explicit norms and clinical practice guidelines to identify patients who urgently need care and to stabilize patients for referral.
  • The physician at the facility have adequate training in emergency care, especially in first aid, stabilization and referrals of patients to appropriate facilities.
  • We have access to an equipped ambulance (s) staffed with trained personnel to transport patients after stabilization to the referral facility within 20 min to final destination.
  • The facility has an emergency plan to handle many patient at once, such as in the case of a natural disasters / accident.
  • On admission the patient is examined by a physician, the inpatient record is filled in, and all the necessary examinations required for determining a primary diagnosis are performed within 24 hours after admission.
  • Written instructions are given to all inpatients upon discharge.
  • Only Consultant concerned discharges patient.
  • The facility has a simple system for admission and discharge.
  • Hospital services and tariff list is available at reception desk. The likely expenses are described in detail to all in-patients at the time of admission and during stay whenever needed.
  • The daily expenses and service charges and account is provided to all in-patients daily.
    We accept the payments in cash, through Cheque, DD and via Credit Card of ALL standard companies.
  • All patients scheduled for a surgical intervention undergo pre-aesthetic evaluation and have a specific anaesthesia plan.
  • All anaesthesia are provided by a "certified anaesthesiologist".
  • The facility has a system for scheduling surgeries, the schedule is updated 24 hours prior to the first surgery.
  • The surgical area has a separate section for washing hands (scrubbing area). The scrubbing area has running water, dispensers, soap and antiseptics as per standards.
  • The operating room within a facility strictly complies with structural and design standards for operation theatres .
  • The radiology room and Ultra sonography room are strictly complies with structural and design standards as specified.


  • Support Services
  • The facility structure/building(s) and its surrounding grounds are suitable for services provided to patient.
  • The facility has an efficient and accessible environment to all clients including the physically impaired.
  • The facility has the capacity to provide drugs, laboratory tests, sonography, Casualty / accident & Trauma care and x-ray services 24 hours a day 365 days a year in Emergency care.
  • There is a system for housekeeping to ensure that facility is clean at all times.
  • There is a standardized process for changing and cleaning of laundry.
  • The facility has a preventive and corrective maintenance plan for the building and medical equipment.
  • The facility has a system for proper disposal of waste products including contaminated materials as per norms of Pollution Control Board under supervision and control of Waste disposal committee and in house training of staff at a very regular interval for waste disposal.
  • The facility has decontaminated running water at all times. The source of water is connected to the main public pipes.
  • The facility is having six external telephone lines including services from BSNL, Relaince, Airtel and Fax services.
  • The facility has a system for sterilization that is well communicated to all staff and enforced.
  • The facility has an electric system along with Generator backup that provides an alternative system for illumination when needed.


  • Management of the Facility
  • The facility has a well-defined organizational structure.
  • The facility has a governing board of hospital.
  • The facility director maintains necessary quality control programs including Quality Improvement and Infection Control.
  • The facility director has well defined coordination and communication systems with facility staff.


  • Human Resources
  • The facility has a process for providing continuous education and training to improve staff competency.
  • Written job chart and descriptions are available for each position in the facility.
  • The facility has appropriate policies and procedures to guide key activities. The facility has a system to review policies and procedures are reviewed and updated routinely.


  • Management of Information
  • The facility has a system to maintain accurate and complete patient records.
  • The facility has an information system that collects and analyses key financial and clinical data.
  • The information will be used by the facility to monitor its performance and to assist in decision-making.


  • Quality Improvement
  • The facility has a system to evaluate and improve the quality of care.


  • Infection Control
  • The facility has a system to prevent and control nosocomial infections.


  • The ultimate goal of our institute is to achieve our motto : “ MAXIMUM SERVICES TO MANKIND WITH MAXIMUM HUMANITY”

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