NABH Readiness Checklist — Histopathology / Diagnostic Laboratory
A self-assessment mapped to the spirit of NABH accreditation chapters, adapted for a histopathology / diagnostic laboratory. Tick each item, add evidence references and act on gaps.
1. Access, Registration & Specimen Continuity
- Defined, displayed scope of histopathology / cytology services
- Test requisition captures adequate patient + clinical details
- Registration and unique-ID with two-identifier matching
- Documented specimen collection, transport and hand-over process
- Turnaround-time commitments defined and communicated
2. Care of Patients / Specimen Handling
- Standardised fixation (10% NBF, ratio, time recorded)
- Sample acceptance / rejection criteria applied and recorded
- Safe handling of high-risk / infectious specimens
- Critical / significant finding communication process
- Specimen, block and slide traceability end-to-end
3. Management of Reagents & Consumables
- Reagent inventory with lot numbers and expiry
- Defined storage conditions, monitored
- New-lot acceptance / QC checks
- Reagent change / rotation schedule with records
- Safe storage of formalin, xylene and hazardous chemicals
4. Patient Safety & Quality Improvement
- Quality policy, objectives and quality indicators defined
- Internal quality control (control slides / staining QC)
- Participation in EQA / proficiency testing
- Incident / adverse-event reporting and analysis
- Sentinel-event and near-miss review process
5. Infection Prevention & Control
- Biosafety practices and risk assessments
- Hand hygiene and PPE compliance
- Biomedical waste segregation per BMW Rules 2016
- Disinfection and spill-management procedures
- Staff immunisation / health surveillance where applicable
6. Facility Management & Safety
- Adequate, segregated, well-ventilated lab space
- Fire safety, electrical safety and emergency preparedness
- Chemical safety (SDS accessible, fume extraction)
- Equipment inventory, calibration and preventive maintenance
- Temperature-critical equipment monitored and logged
7. Human Resource Management
- Defined organisation structure and job responsibilities
- Qualification, registration and credentialing records
- Induction, training and continuing education records
- Documented competency assessment (initial + periodic)
- Authorised signatory / reporting list
8. Information Management System
- Standardised report format with required elements
- Report authorisation by a pathologist
- Confidentiality and data security of records (LIS)
- Backup, retrieval and retention of reports, blocks and slides
- Amended-report procedure with audit trail
9. Responsibilities of Management & Ethics
- Defined leadership responsibility and management review
- Ethical practice, impartiality and confidentiality policy
- Patient / user rights and grievance-redressal process
- Complaints handling with corrective action
- Risk management and continual improvement plan
Disclaimer
This checklist is a simplified educational readiness aid. It does not replace the official NABH standards, assessor guidance or the current accreditation-body documents. Always refer to the latest official NABH standards for your organisation type.
Unimeditrek Pvt. Ltd. · www.unilabequipments.com · Educational template — adapt to your laboratory.