nabh 3rd edition
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NABH Standards Third Edition(Applicable from July 1st, 2012)
10 Chapters
1
102 Standards
636 Objective Elements
Updated by Anuj Jindal [anuj.jindal@ikure.in]
iKure Knowledge Serviceswww.ikureknowledge.blogspot.in
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Standards and Objective Elements
A standard is a statement that defines thestructures and processes that must besubstantially in place in an organization to
2
en ance e qua y o care Objective element is a measurable component
of a standard
Acceptable compliance with objective elementsdetermines the overall compliance with astandard
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Section I:Patient-Centered Standards
Chapter 1 Access, Assessment and Continuity of Care (AAC)
Chapter 2 Patients Rights and Education (PRE)
3
Chapter 3 Care of Patients (COP)
Chapter 4 Management of Medications (MOM)
Chapter 5 Hospital Infection Control (HIC)
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Section II:Management-Centered Standards
Chapter 6 Continuous Quality Improvement (CQI)
Chapter 7 Responsibilities of Management (ROM)
4
Chapter 8 Facility Management & Safety (FMS)
Chapter 9 Human Resource Management (HRM)
Chapter 10 Information Management Systems (IMS)
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NABH STANDARDS
5
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Chapter 1ACCESS, ASSESSMENT
6
(AAC)
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AAC.1The organization defines anddisplays the services that it
provides.
Ob ective Elements
7
a) The services being provided are clearlydefined and are in consonance with the needs
of the community.
b) The defined services are prominentlydisplayed.
c) The staff is oriented to these services
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AAC.2The organization has a well defined
registration and admission process.
Objective elements
D m nt d li i nd r d r r
8
used for registering and admittingpatients.
b) The documented procedures addressout-patients, in-patients and emergency
patients.
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Contc) A unique identification number is
generated at the end of registration.d) Patients are accepted only if the
9
service.
e) The documented policies and
procedures also address managingpatients during non availability of beds.
f) The staff is aware of these processes.
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AAC.3There is an appropriate mechanism
for transfer or referral of patients.
Objective elements
10
guide the transfer-in of patients to the
organization.
b) Documented policies and proceduresguide the transfer-out/referral of unstable
patients to another facility in an
appropriate manner.
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Contc) Documented policies and procedures
guide the transfer-out/referral of stablepatients to another facility in an
a ro riate manner.
11
d) The documented procedures identify
staff responsible during transfer/referral.
e) The organization gives a summary of patients condition and the treatment
given.
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AAC.4
Patients cared for by the
organization undergo an established
initial assessment. Objective elements
12
the content of the initial assessment for
the out-patients, in-patients and
emergency patients.b) The organization determines who can
perform the initial assessment.
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Contc) The organization defines the time frame
within which the initial assessment iscompleted based on patient's needs.
d) The initial assessment for in-patients is
13
documented within 24 hours or earlier asper the patient's condition as defined in
the organization's policy.
e) Initial assessment of in-patients includes
nursing assessment which is done at the
time of admission and documented.
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Cont
f) Initial assessment includes screening for
nutritional needs.
g) The initial assessment results in a
14
ocumen e p an o care.h) The plan of care also includes preventive
aspects of the care where appropriate.
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Cont
i) The plan of care is countersigned by the
clinician in-charge of the patient within 24hours.
15
e p an o care nc u es goa s ordesired results of the treatment, care or
service.
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AAC.5Patients cared for by the
organization undergo a regular
reassessment.
16
a) Patients are reassessed at appropriate
intervals.
b) Out-patients are informed of their nextfollow-up, where appropriate.
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contc) For in-patients during reassessment the
plan of care is monitored and modified,where found necessary.
d) Staff involved in direct clinical care
17
document reassessments.e) Patients are reassessed to determine
their response to treatment and to plan
further treatment or discharge.
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AAC.6
Laboratory services are provided asper the scope of services of the
organization. Objective elements.
18
commensurate to the services provided
by the organization.
b) The infrastructure (physical andmanpower) is adequate to provide for its
defined scope of services.
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contc) Adequately qualified and trained
personnel perform, supervise andinterpret the investigations.
d) Documented procedures guide ordering
19
of tests, collection, identification,handling, safe transportation, processingand disposal of specimens.
e) Laboratory results are available within adefined time frame.
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contf) Critical results are intimated immediately
to the personnel concerned.g) Results are reported in a standardized
manner.
20
h) Laboratory tests not available in theorganization are outsourced toorganization(s) based on their quality
assurance system.
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AAC.7There is an established laboratory
quality assurance programme
Objective elements
Th l b r t r lit r n
21
programme is documented.
b) The programme addresses verification
and/or validation of test methods.c) The programme addresses surveillance
of test results.
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cont
d) The programme includes periodic
calibration and maintenance of allequipment.
22
documentation of corrective and
preventive actions.
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AAC.8There is an established
laboratory-safety programme.
Objective elements.
23
documented.
b) This programme is aligned with the
organization's safety programme.
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AAC.9
Imaging services are provided as per thescope of services of the organization.
Objective elementsa) Imaging services comply with the legal
and other requirements.
25
b) Scope of the imaging services iscommensurate to the services provided
by the organization.
c) The infrastructure (physical and
manpower) is adequate to provide for its
defined scope of services.
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contd) Adequately qualified and trained
personnel perform, supervise andinterpret the investigations.
e) Documented policies and procedures
26
transportation of patients to imagingservices.
f) Imaging results are available within adefined time frame.
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contg) Critical results are intimated immediately
to the personnel concerned.h) Results are reported in a standardizedmanner.
27
i) Imaging tests not available in theorganization are outsourced toorganization(s) based on their quality
assurance system.
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AAC.10
There is an established qualityassurance programme for
imaging services. Objective elements
28
a e qua y assurance program or imaging services is documented.
b) The programme addresses verification
and/or validation of imaging methods.c) The programme addresses surveillance
of imaging results.
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contd) The programme includes periodic
calibration and maintenance of allequipment.
29
documentation of corrective and
preventive actions.
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AAC.11
There is an established radiationsafety programme.
Objective elementsa) The radiation-safety programme is
30
.
b) This programme is aligned with the
organizations safety programme.
c) Handling, usage and disposal of radio-active and hazardous materials are as
per statutory requirements.
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contd) Imaging personnel are provided with
appropriate radiation safety devices.e) Radiation safety devices are periodically
31
f) Imaging personnel are trained in radiation
safety measures.
g) Imaging signage are prominentlydisplayed in all appropriate locations.
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AAC.12
Patient care is continuous andmultidisciplinary in nature.
Objective elements
32
,
qualified individual identified as
responsible for the patients care.
b) Care of patients is coordinated in all caresetting within the organization.
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cont
c) Information about the patient's care andresponse to treatment is shared amongmedical, nursing and other care providers.
d) Information is exchanged and documented
33
, ,and during transfers between units/departments.
e) Transfers between departments/units are
done in a safe manner.
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cont
f) The patients record(s) is available to theauthorized care providers to facilitate theexchange of information.
g) Documented procedures guide the referral
34
specialties.
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contc) Documented policies and procedures are
in place for patients leaving againstmedical advice and patients being
36
.
d) A discharge summary is given to all the
patients leaving the organization
(including patients leaving againstmedical advice and on request).
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AAC.14
Organization defines the contentof the discharge summary.
Objective elements
a) Discharge summary is provided to the
37
patients at the time of discharge.b) Discharge summary contains the
patient's name, unique identification
number, date of admission and date ofdischarge.
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contc) Discharge summary contains the
reasons for admission, significantfindings and diagnosis and the patients
38
.
d) Discharge summary contains information
regarding investigation results, any
procedure performed, medicationadministered and other treatment given.
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conte) Discharge summary contains follow up
advice, medication and other instructionsin an understandable manner.
39
instructions about when and how to
obtain urgent care.
g) In case of death, the summary of thecase also includes the cause of death.
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Chapter 2
40
are o a en s
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COP.1Uniform care of patients is provided in all settings ofthe organization and is guided by the applicable laws,
regulations and guidelines.
Objective elements
41
a are e very s un orm or a g ven
health problem when similar care is
provided in more than one setting.
b) Uniform care is guided by documentedpolicies and procedures.
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contc) These reflect applicable laws, regulations
and guidelines.d) The organization adopts evidence-based
medicine and clinical ractice uidelines
42
to guide uniform patient care.
COP 2
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COP.2
Emergency services are guided bydocumented policies, procedures
and applicable laws and regulations.Objective elements
43
care are documented and are inconsonance with statutory requirements.
b) This also addresses handling of medico-legal cases.
c) The patients receive care in consonance
with the policies.
t
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contd) Documented policies and procedures guide
the triage of patients for initiation of
appropriate care.
e) Staff are familiar with the policies and
trained on the procedures for care of
44
emergency patients.f) Admission or discharge to home or transfer
to another organization is also documented.
g) In case of discharge to home or transfer toanother organization a discharge note shall
be given to patient.
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COP.3The ambulance services arecommensurate with the scope of the
services provided by the organization.
Ob ective elements
45
a) There is adequate access and space forthe ambulance(s).
b) The ambulance adheres to statutoryrequirements.
c) Ambulance(s) is appropriately equipped.
cont
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cont
d) Ambulance(s) is manned by the trainedpersonnel.
e) Ambulance(s) is checked on a daily
basis.
f) Equipment are checked on a daily basis
46
using a checklist.g) Emergency medications are checked
daily and prior to dispatch using a
checklist.
h) The ambulance(s) has a proper
communication system.
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COP.4Documented policies and procedures
guide the care of patients requiring
cardio-pulmonary resuscitation. Objective elements
47
a) Documented policies and proceduresguide the uniform use of resuscitation
throughout the organization.
b) Staff providing direct patient care aretrained and periodically updated in cardio
pulmonary resuscitation.
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contc) The events during a cardio pulmonary
resuscitation are recorded.d) A post-event analysis of all cardio-
48
multidisciplinary committee.
e) Corrective and preventive measures are
taken based on the post-event analysis.
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COP.5
Documented policies and
procedures guide nursing care.
Objective elements
49
a) There are documented policies andprocedures for all activities of the nursing
services.
b) These reflect current standards ofnursing services and practice, relevant
regulations and purposes of the services.
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Contc) Assignment of patient care is done as percurrent good practice guidelines.
d) Nursing care is aligned and integrated withoverall patient care.
e Care rovided b nurses is documented in
50
the patient record.f) Nurses are provided with adequate
equipment for providing safe and efficient
nursing services.g) Nurses are empowered to take nursing-
related decisions to ensure timely care of
patients.
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COP.6Documented procedures guide the
performance of various procedures.
Objective elements
51
a) Documented procedures are used toguide the performance of various clinical
procedures.
b) Only qualified personnel order, plan,perform and assist in performing
procedures.
cont
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cont
c) Documented procedures exist to preventadverse events like wrong site, wrongpatient and wrong procedure.
d) Informed consent is taken by the personnelperforming the procedure, whereapplicable.
52
e) Adherence to standard precautions andasepsis is adhered to during the conduct ofthe procedure.
f) Patients are appropriately monitored duringand after the procedure.
g) Procedures are documented accurately in
the patient record.
COP 7
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COP.7
Documented policies andprocedures define rational use of
blood and blood products.
Objective elements
53
a) Documented policies and procedures areused to guide rational use of blood and
blood products.
b) Documented procedures guide
transfusion of blood and blood products.
t
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cont
c) The transfusion services are governed by the
applicable laws and regulations.
d) Informed consent is obtained for donation andtransfusion of blood and blood products.
54
family education about donation.f) The organization defines the process for
availability and transfusion of blood/blood
components for use in emergency.
cont
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cont
g) Post-transfusion form is collected, reactions if
any identified and are analyzed for preventive
and corrective actions.h) Staff are trained to implement the policies.
55
COP 8
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COP.8
Documented policies and proceduresguide the care of patients in the Intensive
Care and high dependency units.
Objective elements.
56
a) Documented policies and procedures areused to guide the care of patients in the
intensive care and high dependency
units.
cont
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cont
b) The organization has documented
admission and discharge criteria for its
intensive care and high dependencyunits.
57
c a a e a e o a y ese c e a.
d) Adequate staff and equipment are
available.
e) Defined procedures for situation of bedshortages are followed.
cont
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cont
f) Infection control practices are
documented and followed.
g) A quality assurance programme isdocumented and implemented.
58
COP 9
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COP.9
Documented policies and procedures guide thecare of vulnerable patients (elderly, children,
physically and/ or mentally challenged).
Objective elements.
a) Policies and procedures are documented
59
and are in accordance with the prevailinglaws and the national and international
guidelines.
b) Care is organised and delivered inaccordance with the policies and
procedures.
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contc) The organisation provides for a safe
and secure environment for thisvulnerable group.
60
obtaining informed consent from theappropriate legal representative.
e) Staff are trained to care for this
vulnerable group.
COP 10
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COP.10
Documented policies and
procedures guide obstetric care.
Objective elements
61
a) There is a documented policy and
procedure for obstetric services.
b) The organisation defines and displays
whether high-risk obstetric cases becared for or not.
cont
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c) Persons caring for high-risk obstetric casesare competent.
d) Documented procedures guide provision forante-natal services.
e) Obstetric patient's assessment also includes
62
ma erna nu r on.
f) Appropriate pre-natal, peri-natal and post-natal monitoring is performed anddocumented.
g) The organization caring for high-riskobstetric cases has the facilities to take careof neonates of such cases.
COP.11
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Documented policies and proceduresguide paediatric services.
Objective elements
a) There is a documented policy and
63
b) The organisation defines and displaysthe scope of its paediatric services.
c) The policy for care of neonatal patients is
in consonance with the national/
international guidelines.
cont
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cont
d) Those who care for children have age specificcompetency.
e) Provisions are made for special care ofchildren.
f) Patient assessment includes detailed
64
, ,
immunization assessment.g) Documented policies and procedures prevent
child/ neonate abduction and abuse.
h) The childrens family members are educatedabout nutrition, immunization and safeparenting and this is documented in themedical record.
COP.12
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Documented policies and proceduresguide the care of patients undergoing
moderate sedation.
Objective elements
65
administration of moderate sedation.
b) Informed consent for administration of
moderate sedation is obtained.c) Competent and trained persons perform
sedation.
cont
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contd) The person administering and monitoring
sedation is different from the personperforming the procedure.
e) Intra procedure monitoring includes ata minimum the heart rate, cardiac
66
rhythm, respiratory rate, blood pressure,oxygen saturation and level of sedation.
f) Patients are monitored after sedation
and the same is documented.
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contg) Criteria are used to determine
appropriateness of discharge from therecovery area.
h E ui ment and man ower are available
67
to manage patients who have gone into adeeper level of sedation than thatintended.
COP.13
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Documented policies andprocedures guide the
administration of anesthesia. Objective elements.
68
a) There is a documented policy andprocedure for the administration of
anesthesia.
b) Patients for anesthesia have a pre-anesthesia assessment by a qualified
anaesthesiologist.
cont
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cont
c) The pre-anesthesia assessment results
in formulation of an anesthesia plan
which is documented.
d An immediate reo erative re-evaluation
69
is performed and documented.e) Informed consent for administration of
anesthesia is obtained by the
anesthesiologist.
cont
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cont
f) During anesthesia monitoring includes
regular recording of temperature, heart
rate, cardiac rhythm, respiratory rate,blood pressure, oxygen saturation and
70
.
g) Patients post-anesthesia status is
monitored and documented.
h) The anaesthesiologist applies definedcriteria to transfer the patient from the
recovery area.
cont
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cont
i) The type of anaesthesia and anaesthetic
medications used is documented in the
patient record.j) Procedures shall comply with infection
71
contro gu e nes to prevent cross-
infection between patients.
k) Adverse anesthesia events are recorded
and monitored.
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cont
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d) Documented policies and procedure existto prevent adverse events like wrong site,
wrong patients and wrong surgery.
e) Persons qualified by law are permitted to
perform the procedures that they are
73
entitled to perform.f) A brief operative note is documented prior
to transfer out of patient from recovery
area.g) The operating surgeons documents the
post operative plan of care.
cont
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h) Patient, personnel and material flowconforms to infection control practices.
i) Appropriate facilities and equipment/
appliances/ instrumentation are available
in the operating theatre.
74
j) A quality assurance programme isfollowed for the surgical services.
k) The quality assurance program includes
surveillance of the operation theatreenvironment.
COP.15
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Documented policies and proceduresguide the care of patients under
restraints (physical and/ or chemical). Objective elements
75
a) Documented policies and procedures
guide the care of patients under
restraints.
b) These include both physical andchemical restraint measures.
cont
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cont
c) These include documentation of reasons
for restraints.
d) These patients are more frequently
76
e) Staff receive training and periodicupdating in control and restraint
techniques.
COP.16
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Documented policies andprocedures guide appropriate
pain management.
77
.
a) Documented policies and proceduresguide the management of pain.
b) All patients are screened for pain.
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contc) Patients with pain undergo detailed
assessment and periodic re-assessment.d) The organization respects and supports
78
.
e) Patient and family are educated onvarious pain management techniques,where appropriate.
COP.17
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Documented policies andprocedures guide appropriate
rehabilitative services. Objective elements
79
a ocumen e po c es an proce ures
guide the provision of rehabilitativeservices.
b) These services are commensurate withthe organizational requirements.
cont
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c) Care is guided by functional assessment
and periodic re-assessment which is
done and documented by qualifiedindividual(s).
80
are s prov e a er ng to n ect on
control and safe practices.
e) Rehabilitative services are provided by a
multidisciplinary team.f) There is adequate space and equipment
to perform these activities.
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cont
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d) Patients informed consent is obtainedbefore entering them in research
protocols.
e) Patients are informed of their right to
withdraw from the research at an sta e
82
and also of the consequences (if any) ofsuch withdrawal.
f) Patients are assured that their refusal to
participate or withdrawal fromparticipation will not compromise their
access to the organizations services.
COP.19
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Documented policies and proceduresguide nutritional therapy.
Objective elementsa) Documented policies and procedures
83
gu e nu r ona assessmen an
reassessment.
b) Patients receive food according to their
clinical needs.
cont
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c) There is a written order for the diet.
d) Nutritional therapy is planned and
provided in a collaborative manner.
84
,
educated about the patients dietlimitations.
f) Food is prepared, handled, stored and
distributed in a safe manner.
COP.20
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Documented policies and proceduresguide the end of life care.
Objective elements
a) Documented policies and procedures
85
.
b) These policies and procedures are inconsonance with the legal requirements.
c) These also address the identification ofthe unique needs of such patient and
family.
cont
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d) Symptomatic treatment is provided and
where appropriate measures are taken
for alleviation of pain.
e) Staff is educated and trained in end of
86
life care.
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Chapter 3
87
MEDICATION (MOM)
MOM.1
D t d li i d d
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Documented policies and proceduresguide the organization of pharmacy
services and usage of medication.
Objective elements
88
a ere s a ocumen e po cy an
procedure for pharmacy services andmedication usage.
b) These comply with the applicable lawsand regulations.
cont
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c) A multidisciplinary committee guides the
formulation and implementation of thesepolicies and procedures.
89
medication when the pharmacy is closed.
MOM.2
Th i h it l f l
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There is a hospital formulary.
Objective elements
a) A list of medications appropriate for theatients and as er the sco e of the
90
organizations clinical services isdeveloped.
b) The list is developed and updated
collaboratively by the multidisciplinarycommittee.
cont
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c) The formulary is available for clinicians to
refer and adhere to.d) There is a defined process for acquisition
91
.
e) There is a process to obtain medicationsnot listed in the formulary.
MOM.3
Documented policies and procedures
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Documented policies and proceduresguide the storage of medication.
Objective elementsa) Documented policies and procedures
92
.
b) Medications are stored in a clean, safeand secure environment; and
incorporating manufacturer's
recommendation(s).
cont
c) Sound inventory control practices guide
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c) Sound inventory control practices guidestorage of the medications.
d) Sound alike and look alike medicationsare identified and stored separately.
93
defined and is stored in a uniformmanner.
f) Emergency medications are available all
the time.g) Emergency medications are replenished
in a timely manner when used.
MOM.4Documented policies and procedures
guide the safe and rational prescription
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guide the safe and rational prescription
of medications.
Objective elementsa) Documented policies and procedures
94
exist for prescription of medications.
b) These incorporate inclusion of good
practices/guidelines for rational
prescription of medications.c) The organization determines the
minimum requirements of a prescription.
cont
d) Known drug allergies are ascertained before
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d) Known drug allergies are ascertained beforeprescribing.
e) The organization determines who can write
orders.f) Orders are written in a uniform location in the
95
medical records.
g) Medication orders are clear, legible, dated,
timed, named and signed.
h) Medication orders contain the name of the
medicine, route of administration, dose to be
administered and frequency/time of
administration.
cont
i) Documented policy and procedure on verbal
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i) Documented policy and procedure on verbalorders is implemented.
j) The organization defines a list of high-risk
medication(s).
k Audit of medication orders/ rescri tion is
96
carried out to check for the safe and rational
prescription of medications.
l) Corrective and/or preventive action(s) is
taken based on the analysis, whereappropriate.
MOM.5
Documented policies and
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Documented policies andprocedures guide the safe
dispensing of medications.
Objective elements
97
a) Documented policies and procedures
guide the safe dispensing of
medications.
b) The procedure addresses medicationrecall.
cont
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c) Expiry dates are checked prior to
dispensing.d) There is a procedure for near expiry
98
.
e) Labeling requirements are documentedand implemented by the organization.
f) High-risk medication orders are verifiedprior to dispensing.
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cont
d) Medication is verified from the order prior
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d) Medication is verified from the order prior
to administration.
e) Dosage is verified from the order prior toadministration.
100
f) Route is verified from the order prior to
administration.
g) Timing is verified from the order prior to
administration.h) Medication administration is
documented.
cont
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i) Documented polices and procedures
govern patients self administration ofmedications.
101
ocumen e po ces an proce ures
govern patients medications broughtfrom outside the organization.
MOM.7
Patients are monitored after
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Patients are monitored aftermedication administration.
Objective elements
D m nt d li i nd r d r
102
guide the monitoring of patients aftermedication administration.
b) The organization defined those situation
where close monitoring is required.
cont
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c) Monitoring is done in a collaborative
manner.
d) Medications are changed where
103
.
MOM.8
Near misses medication errorsd d d t
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Near misses, medication errorsand adverse drug events are
reported and analyzed.
Objective elements
104
a) Documented procedures exist to capture
near miss, medication error and adversedrug event.
b) Near miss, medication error and adversedrug events are defined.
cont
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c) These are reported within a specified
time frame.
d) They are collected and analysed.
105
e orrec ve an or preven ve ac on s
are taken based on the analysis whereappropriate.
MOM.9
Documented proceduresid th f ti d
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Documented proceduresguide the use of narcotic drugs
and psychotropic substances.
Ob ective elements
106
a) Documented procedures guide the useof narcotic drugs and psychotropic
substances which are in consonance
with local and national regulations.
cont
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b) These drugs are stored in a secure
manner.
c) A proper record is kept of the usage,
107
drugs.d) These drugs are handled by appropriate
personnel in accordance with the
documented procedure.
MOM.10
Documented policies and
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Documented policies andprocedures guide the usage of
chemotherapeutic agents.
108
.
a) Documented policies and proceduresguide the usage of chemotherapeutic
agents.
cont
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b) Chemotherapy is prescribed by those
who have the knowledge to monitor and
treat the adverse effect of chemotherapy.
109
and safe manner and administered byqualified personnel.
d) Chemotherapy drugs are disposed off in
accordance with legal requirements.
MOM.11
Documented policies and
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pprocedures govern usage of
radioactive drugs.
110
ec ve e emen s.
a) Documented policies and proceduresgovern usage of radioactive drugs.
cont
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b) These policies and procedures are in
consonance with laws and regulations.
c) The policies and procedures include the
111
, , ,
distribution, and disposal of radioactivedrugs.
d) Staff, patients and visitors are educated
on safety precautions.
MOM.12
Documented policies and proceduresguide the use of implantable prosthesis
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guide the use of implantable prosthesis
and medical devices.
Objective elements
112
a) Usage of implantable prosthesis and
medical devices is guided by scientificcriteria for each individual item and
national/international recognized
guidelines/approvals for such specific
item(s).
Cont
b) Documented policies and procedures
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govern procurement, storage/stocking,
issuance and usage of implantable
prosthesis and medical devices
'
113
recommendation(s).c) Patient and his/her family are counseled
for the usage of implantable prosthesis
and medical device includingprecautions, if any.
Cont
d) The batch and serial number of the
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implantable prosthesis and medical
devices are recorded in the patients
medical record and the master logbook.
114
MOM.13
Documented policies and proceduresguide the use of medical supplies and
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guide the use of medical supplies and
consumables.
Objective elements
115
a) There is a defined process for acquisition
of medical supplies and consumables.
b) Medical supplies and consumables are
used in a safe manner, where
appropriate.
Cont
c) Medical supplies and consumables aret d i l f d
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stored in a clean, safe and secure
environment; and incorporating
manufacturer's recommendation(s).
116
storage of medical supplies andconsumables.
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Chapter 4
117
EDUCATION (PRE)
PRE.1The organization protects patient andfamily rights and informs them about
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family rights and informs them about
their responsibilities during care.
Objective element
118
a) Patient and family rights and
responsibilities are documented anddisplayed.
b) Patients and families are informed of theirrights and responsibilities in a format and
language that they can understand.
cont
c) The organizations leaders protect
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c) The organizations leaders protect
patient's and family rights.
d) Staff is aware of its responsibility in
119
.
e) Violation of patient and family rights isrecorded, reviewed and corrective/
preventive measures taken.
PRE.2.
Patient and family rights supportindividual beliefs values and involve the
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individual beliefs, values and involve the
patient and family in decision-making
processes.
120
Objective elements
a) Patient and family rights include respecting
any special preferences, spiritual and cultural
needs.
b) Patient and family rights include respect for
personal dignity and privacy during
examination, procedures and treatment.
cont
c) Patient and family rights include protectionfrom physical abuse and neglect.
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from physical abuse and neglect.
d) Patient and family rights include treating
patient information as confidential.
e Patient and famil ri hts include refusal of
121
treatment.
f) Patient and family rights include informed
consent before transfusion of blood and
blood products, anaesthesia, surgery,
initiation of any research protocol and any
other invasive/ high-risk procedures/
treatment.
cont
g) Patient and family rights include right tocomplain and information on how to
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pvoice a complaint.
h) Patient and family rights includeinformation on the expected cost of the
122
rea men .
i) Patient and family rights include accessto his/ her clinical records.
j) Patient and family rights include
information on plan of care, progress andinformation on their health care needs.
PRE.3The patient and/or family members
d t d t k i f d
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are educated to make informed
decisions and are involved in thecare planning and delivery process.
123
Objective elementsa) The patient and/or family members are
explained about the proposed care
includinng the risks, alternatives andbenefits.
cont
b) The patient and/or family members arel i d b t th t d lt
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explained about the expected results.
c) The patient and/or family members areexplained about the possible complications.
124
consultation with patient and/or family
members.
e) The care plan respects and where possibleincorporates patient and/or family concerns and
requests.
cont
f) The patient and/or family members arei f d b t th lt f di ti t t
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informed about the results of diagnostic testsand the diagnosis.
g) The patient and/or family members areex lained about an chan e in the atient's
125
condition.
PRE.4
A documented procedure for obtaining patientand/ or family's consent exists for informed
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decision making about their care.
Objective elements
126
list of situations where informed consentis required and the process for taking
informed consent.
b) General consent for treatment isobtained when the patient enters the
organisation.
cont
c) Patient and / or his family members areinformed of the scope of such general
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informed of the scope of such general
consent.d) Informed consent includes information
127
, , ,
alternatives and as to who will performthe requisite procedure in a languagethat they can understand.
e) The procedure describes who can giveconsent when patient is incapable of independent decision making.
cont
f) Informed consent is taken by the personperforming the procedure
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performing the procedure.
g) Informed consent process adheres tostatutory norms.
128
ta are aware o t e n orme consent
procedures.
PRE.5
Patient and families have a right toinformation and education about
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their health care needs.
Objective elements
129
a) Patient and/or family are educated about
the safe and effective use of medicationand the potential side effects of the
medication, when appropriate.
b) Patient and/or family are educated about
food-drug interactions.
contc. Patient and/or family are educated about diet
and nutrition.
d Patient and/or family are educated about
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d. Patient and/or family are educated about
immunizations.
e. Patient and/or family are educated about organ
130
, .
f. Patient and/or family are educated about their
specific disease process, complications and
prevention strategies.
g. Patient and/or family are educated about
preventing healthcare associated infections.
h. Patient and/or family are educated in a
language and format that they can understand.
PRE.6
Patient and families have a right toinformation on expected costs.
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p
Objective elements
131
a) There is uniform pricing policy in a given
setting (out-patient and ward category).b) The tariff list is available to patients.
cont
c The patient and/or family are explained
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c. The patient and/or family are explained
about the expected costs.d. Patient and/or family are informed about
132
the financial implications when there is a
change in the patient condition or treatment setting.
PRE.7Organization has a complaint
redressal procedure
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redressal procedure.
Objective elements
133
a) The organization has a documented
complaint redressal procured.b) Patient and/or family members are made
aware of the procedures for lodging
complaints.
cont
c. All complaints are analysed.
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d. Corrective and/or preventive action(s)
are taken based on the analysis where
134
.
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Chapter 5
135
CONTROL (HIC)
HIC.1
The organization has a well-designed, comprehensive and
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designed, comprehensive and
coordinated Hospital Infection
136
programme aimed atreducing/eliminating risks to
patients, visitors and providers
of care.
Objective elements
a) The hospital infection prevention andcontrol programme is documented which
aims at preventing and reducing risk of
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aims at preventing and reducing risk of
healthcare associated infections.
137
programme is a continuous process and
updated at least once in a year.
c) The hospital has a multi-disciplinary
infection control committee, whichcoordinates all infection prevention and
control activities.
cont
d. The hospital has an infection control
team, which coordinates implementation
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team, which coordinates implementation
of all infection prevention and controlactivities.
138
e. The hospital has designated infection
control officer as part of the infectioncontrol team.
f. The hospital has designated infection
control nurse(s) as part of the infection
control team.
HIC.2
The organisation implements thepolicies and procedures laid down in
th I f ti C t l M l
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the Infection Control Manual.
Objective elements
139
a) The organization identifies the various
high-risk areas and procedures andimplements policies and/or procedures to
prevent infection in these areas.
b) The organization adheres to standard
precautions at all times.
Cont
c) The organization adheres to hand-
hygiene guidelines
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hygiene guidelines.
d) The organization adhere to safe injection
140
e) The organization adheres totransmission-based precautions at all
times.
f) The organization adheres to cleaning,disinfection and sterilization practices.
Contg) An appropriate antibiotic policy is
established and implemented.
h) The organization adheres to laundry and
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h) The organization adheres to laundry and
linen management processes.i The or anization adheres to kitchen
141
sanitation and food handling issues.
j) The organization has appropriate
engineering controls to prevent
infections.k) The organization adheres to
housekeeping procedures.
HIC.3
The organization performs surveillanceactivities to capture and monitor
infection prevention and control data
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infection prevention and control data.
Objective elements
142
a) Surveillance activities are appropriately
directed towards the identified high-riskareas and procedures.
b) Collection of surveillance data is an on-going process.
Cont
c) Verification of data is done on regular
basis b the infection control team
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basis by the infection control team.
d) Scope of surveillance activities
143
infection risks, rates and trends.e) Surveillance activities include monitoring
the compliance with hand-hygiene
guidelines.
Cont
f) Surveillance activities include monitoring
the effectiveness of housekeeping
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the effectiveness of housekeeping
services.
144
rates are provided on a regular basis toappropriate personnel.
h) In cases of notifiable diseases,
information (in relevant format) is sent toappropriate authorities.
HIC.4The organization takes actions to
prevent and control HealthcareAssociated Infections (HAI) in patients.
Obj ti l t
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Objective elements
a) The organization takes action to prevent
145
.
b) The organization takes action to preventrespiratory tract infections.
c) The organization takes action to prevent intra-
vascular device infections.d) The organization takes action to prevent
surgical site infections.
HIC.5The organization provides adequate
and appropriate resources for
prevention and control of Healthcare
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p
Associated Infections (HAI).
146
ec ve e emen s
a) Adequate and appropriate personalprotective equipment, soaps and
disinfectants are available and used
correctly.
Cont
b) Adequate and appropriate facilities for
hand hygiene in all patient care areas
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hand hygiene in all patient-care areas
are accessible to healthcare providers.
147
available.d) Appropriate pre- and post-exposure
prophylaxis is provided to all staff
members concerned.
HIC.6
The organisation identifies andtakes appropriate action to
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control outbreaks of infections.
148
a) Organization has a documentedprocedure for identifying an outbreak.
b) The organization has a documented
procedure for handling such outbreaks.
Cont
c) This procedure is implemented during
outbreaks
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outbreaks.
d) After the outbreak is over appropriate
149
recurrence.
HIC.7
There are documented policies and
procedures for sterilization
activities in the organisation.
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activities in the organisation.
Objective elements
150
a) The organization provides adequate
space and appropriate zoning for sterilization activities.
b) Documented procedure guides the
cleaning, packing, disinfection and/or
sterlization, storing and issue of items.
Cont
c) Reprocessing of instruments and
equipment are covered
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equipment are covered.
d) Regular validation tests for sterilization
151
.
e) There is an established recall procedurewhen breakdown in the sterilization
system is identified.
HIC.8
Bio-medical Waste (BMW) is handled inan appropriate and safe manner.
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Objective elementsTh r niz ti n dh r t t t t r
152
provisions with regard to biomedical
waste.
b) Proper segregation and collection of Bio-
medical Waste from all patient careareas of the hospital is implemented and
monitored.
Cont
c) The organization ensures that Bio-medical Waste is stored and transportedto the site of treatment and disposal in
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proper covered vehicles within stipulatedtime limits in a secure manner.
153
d) Bio-medical Waste treatment facility is
managed as per statutory provisions (ifin-house) or outsourced to authorisedcontractor(s).
e) Appropriate personal protectivemeasures are used by all categories ofstaff handling Bio-medical Waste.
HIC.9
The infection control programmeis supported by the management
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and includes training of staff. Ob ective elements
154
a) The management makes available
resources required for the infection
control programme.
b) The organization earmarks adequatefunds from its annual budget in this
regard.
Cont
c) The organization conducts inductiontraining for all staff.
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d) The organization conducts appropriatein-service trainin sessions for all staff
155
at least once in a year.
Chapter 6
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CONTINUOUS QUALITY
156
CQI.1
There is a structured quality improvementand continuous monitoring programme in
the organization.
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Objective elements
157
a) The quality improvement programme is
developed, implemented and maintainedby a multi-disciplinary committee.
b) The quality improvement programme is
documented.
Cont
c) There is a designated individual for
coordinating and implementing the
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g p g
quality improvement programme.
158
comprehensive and covers all the majorelements related to quality assurance
and supports innovation.
Cont
e) The designated programme is
communicated and coordinated amongst
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all the staff of the organization through
159
.
f) The quality improvement programmeidentifies opportunities for improvement
based on review at predefined intervals.
Cont
g) The quality improvement programme is a
continuous process and updated at least
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once in a year.
160
as a means of continuous monitoring.
i) There is an established process in the
organization to monitor and improve
quality of nursing and complete patientcare.
CQI.2
There is a structured patient-safetyprogramme in the organization.
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Objective elements
161
a e pa en -sa e y programme s
developed, implemented and maintainedby a multi-disciplinary committee.
b) The patient-safety programme is
documented.
Cont
c) The patient-safety programme iscomprehensive and covers all the major
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elements related to patient safety andrisk management.
162
d) The scope of the programme is defined
to include adverse events ranging from"no harm" to "sentinel events".
e) There is a designated individual for
coordinating and implementing thepatient-safety programme.
Cont
f) The designated programme iscommunicated and coordinated amongst
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all the staff of the organization throughappropriate training mechanism.
163
g) The patient-safety programme identifies
opportunities for improvement based onreview at pre-defined intervals.
h) The patient-safety programme is a
continuous process and updated at leastonce in a year.
Cont
i) The organization adapts and implementsnational/international patient-safety
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goals/solutions.The or anization uses at least two
164
identifiers to identify patients across the
organization.
CQI.3
The organization identifies key indicatorsto monitor the clinical structures,
processes and outcomes which are used as
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tools for continual improvement.
165
ec ve e emen s
a) Monitoring includes appropriate patientassessment.
b) Monitoring includes safety and quality
control programmes of the diagnosticsservices.
Cont
c) Monitoring includes medicationmanagement.
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d) Monitoring includes use of anaesthesia.e) Monitoring includes surgical services.
166
f) Monitoring includes use of blood and
blood products.g) Monitoring includes infection control
activities.
h) Monitoring includes review of mortalityand morbidity indicators.
Cont
i) Monitoring includes clinical research.
j) Monitoring includes data collection to
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support further improvements.k) Monitoring includes data collection to
167
support evaluation of these
improvements.
CQI.4
The organization identifies key indicators tomonitor the managerial structures, processes
and outcomes which are used as tools for
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continual improvement.
168
a) Monitoring includes procurement of
medication essential to meet patient
needs.
b) Monitoring includes risk management.
Cont
c) Monitoring includes utilization of space,manpower and equipment.
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d) Monitoring includes patient satisfactionwhich also incorporates waiting time for
169
serv ces.
e) Monitoring includes employeesatisfaction.
f) Monitoring includes adverse events and
near misses.
Cont
g) Monitoring includes availability andcontent of medical records.
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h) Monitoring includes data collection tosupport further study for improvements.
170
i) Monitoring includes data collection to
support evaluation of theseimprovements.
CQI.5
The quality improvement programme issupported by the management.
Obj ti l t
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Objective elementsTh m n m nt m k v il bl
171
adequate resources required for quality
improvement programme.
b) Organization earmarks adequate funds
from its annual budget in this regard.
Cont
c) The management identifies organizationalperformance improvement targets.
d) Th t t d
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d) The management supports andimplements use of appropriate quality
172
mprovemen , s a s ca an managementools in its quality improvementprogramme.
CQI.6
There is an established system
for clinical audit.
Objective elements
) M di l d i t ff ti i t i thi
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a) Medical and nursing staff participates in this
173
.
b) The parameters to be audited are definedby the organisation.
c) Patient and staff anonymity is maintained.
d) All audits are documented.e) Remedial measures are implemented.
CQI.7Incidents, complaints and feedback
are collected and analyzed to ensure
continual improvement.
Obj ti l t
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Objective elements
174
a e organ za on as an nc en repor ngsystem.
b) The organization has a process to collectfeedback and receive complaints.
Cont
c) The organization has establishedprocesses for analysis of incidents,feedbacks and complaints.
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d) Corrective and preventive actions are
175
a en ase on e n ngs o sucanalysis.
e) Feedback about care and service iscommunicated to staff.
CQI.8
Sentinel events are intensively
analysed.
Objective elements
a) The organisation has defined sentinel
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a) The organisation has defined sentinel
176
.
b) The organisation has established processes
for intense analysis of such events.
c) Sentinel events are intensively analysedwhen they occur.
d) Corrective and preventive Actions are takenbased on the findings of such analysis.
Ch t 7
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Chapter 7
177
MANAGEMENT (ROM)
ROM.1The responsibilities of those responsible
for governance are defined.
Objective elements
a) Those responsible for governance lay
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a) Those responsible for governance lay
178
own e organ za on s v s on, m ss on
and values.b) Those responsible for governance
approve the strategic and operational
plans and organization's budget.
Cont
c) Those responsible for governance monitorand measure the performance of the
organization against the stated mission.
d) Those responsible for governance
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d) Those responsible for governance
179
.
e) Those responsible for governance appointthe senior leaders in the organization.
f) Those responsible for governance support
safety initiatives and quality-improvementplans.
Cont
g) Those responsible for governance supportresearch activities.
h) Those responsible for governance
address the organizations social
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address the organization s social
180
.
i) Those responsible for governance informthe public of the quality and performance
of services.
ROM.2
The organization complies with
the laid-down and applicable
legislations and regulations.
Obj ti l t
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Objective elements
181
a) The management is conversant with the
laws and regulations and knows theirapplicability to the organization.
b) The management ensures
implementation of these requirements.
Cont
c) Management regularly updates anyamendments in the prevailing laws of the
land.
d) There is a mechanism to regularly
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d) There is a mechanism to regularly
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up a e censes
registrations/certifications.
ROM.3The services provided by each
department are documented.
Objective elements
a) Scope of services of each department is
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a) Scope of services of each department is
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e ne .
b) Administrative policies and procedures for
each department is maintained.
c) Each organizational program, service, site or
department has effective leadership.
d) Departmental leaders are involved in quality
improvement.
ROM.4
The organization is managed bythe leaders in an ethical manner.
Objective elements
Th l d k bli th i i
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a The leaders make public the vision,
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mission and values of the organization.
b) The leaders establish the organizationsethical management.
c) The organization discloses its ownership.
Cont
d) The organization honestly portrays theservices which it can and cannot provide.
e) The organization honestly portrays its
affiliations and accreditations
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affiliations and accreditations.
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f) The organization accurately bills for its
services based upon a standard billingtariff.
ROM.5The organisation displays professionalism
in management of affairs.
Objective elements
a) The person heading the organization has
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a) The person heading the organization has
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requ s e an appropr a e a m n s ra ve
qualifications.
b) The person heading the organization has
requisite and appropriate administrative
experience.
Cont
c) The organization prepares the strategicand operational plans including long-termand short-term goals commensurate to
the organization's vision, mission and
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the organization s vision, mission and
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stakeholders.
d) The organization coordinates thefunctioning with departments andexternal agencies and monitors the
progress in achieving the defined goalsand objectives.
Cont
e) The organization plans and budgets forits activities annually.
f) The performance of the senior leaders isreviewed for their effectiveness.
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reviewed for their effectiveness.
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g e unct on ng o comm ttees sreviewed for their effectiveness.
h) The organization documents employeerights and responsibilities.
Cont
i) The organization documents the servicestandards.
j) The organization has a formaldocumented agreement for all
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g
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.
k) The organization monitors the quality ofthe outsourced services.
ROM.6Management ensures that patient-safety
aspects and risk-management issues are anintegral part of patient care and hospital
management.
Objective elements
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a) Management ensures proactive risk
management across the organization.b) Management provides resources for
proactive risk assessment and risk
reduction activities.
Cont
c) Management ensures implementation ofsystems for internal and externalreporting of system and process failures.
d) Management ensures that appropriate
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taken to address safety-related incidents.
Chapter 8
FACILITY MANAGEMENT AND
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FACILITY MANAGEMENT AND
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SAFETY (FMS)
FMS.1
The organisation has a systemin place to provide a safe and
secure environment.
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ec ve e emen s
a) Safety committee coordinatesdevelopment, implementation, and
monitoring of the safety plan and
policies.
Cont
b) Patient safety devices are installed
across the organization and inspected
periodically.
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- .
d) Facility inspection rounds to ensure
safety are conducted at least twice in a
year in patient care areas and at least
once in a year in non-patient care areas.
Cont
e) Inspection reports are documented and
corrective and preventive measures are
undertaken.
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for all staff.
FMS.2
The organizations environment andfacilities operate to ensure safety of
patients, their families, staff and visitors.
Objective elements
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a) Facilities are appropriate to the scope of
services of the organization.b) Up-to-date drawings are maintained
which detail the site layout, floor plans
and fire escape routes.
Cont
c) There is internal and external signpostings in the organisation in alanguage understood by patient, families
and community.d The rovision of s ace shall be in
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d The rovision of s ace shall be in
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accordance with the available literature
on good practices (Indian or InternationalStandards) and directives fromgovernment agencies.
e) Potable water and electricity areavailable round the clock.
Cont
f) Alternate sources for electricity and
water are provided as backup for any
failure/shortage.
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alternate sources.
h) There are designated individuals
responsible for the maintenance of all the
facilities.
Cont
i) There is a documented operational and
maintenance (preventive and
breakdown) plan.
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the clock for emergency repairs.
k) Response times are monitored from
reporting to inspection and
implementation of corrective actions.
FMS.3
The organization has a program
for engineering support services.
Objective elements
a) The organization plans for equipment in
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accordance with its services and
strategic plan.b) Equipments are selected, rented,
updated or upgraded by a collaborative
process.
Cont
c) Equipments are inventoried and proper
logs are maintained as required.
d) Qualified and trained personnel operate
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systems.
e) There is a documented operational and
maintenance (preventive and
breakdown) plan.
Cont
f) There is a maintenance plan for water
management.
g) There is a maintenance plan for electrical
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.
h) There is a maintenance plan for heating,
ventilation and air-conditioning.
i) There is a documented procedure for
equipment replacement and disposal.
FMS.4
The organization has a
programme for bio-medical
equipment management.
Objective elements
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a) The organization plans for equipment in
accordance with its services and strategicplan.
b) Equipment are selected, rented, updated or
upgraded by a collaborative process.
Cont
c) Equipment are inventoried and proper logsare maintained as required.
d) Qualified and trained personnel operate and
maintain the medical equipment.e qu pmen are per o ca y nspec e an
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e qu pmen are per o ca y nspec e an
calibrated for their proper functioning.
f) There is a documented operational and
maintenance (preventive and breakdown)
plan.
g) There is a documented procedure for
equipment replacement and disposal.
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Cont
c) The procedures for medical gasesaddress the safety issues at all levels.
d) Alternate sources for medical gases,
vacuum and compressed air are
id d f i f f il
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provided for, in case of failure.
e) The organization regularly tests thesealternate sources.
f) There is a maintenance plan for piped
medical gas, compressed air andvacuum installation.
FMS.6
The organization has plans for
fire and non-fire emergencies
within the facilities.
Objective elementsa) The organization has plans and provisions
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a) The organization has plans and provisions
for early detection, abatement and
containment of fire and non-fire
emergencies.
b) The organization has a documented safeexit plan in case of fire and non-fire
emergencies.
Cont
c) Staff is trained for its role in case of suchemergencies.
d) Mock drills are held at least twice in a
year.
) Th i i l f fi
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e) There is a maintenance plan for fire-
related equipment.
FMS.7The organization plans for handling
community emergencies, epidemicsand other disasters.
Objective elements
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a) The organization identifies potential
emergencies.b) The organization has a documented
disaster management plan.
Cont
c) Provision is made for availability of
medical supplies, equipment and
materials during such emergencies.
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management plan.
e) The plan is tested at least twice in a
year.
FMS.8The organization has a plan for
management of hazardous materials.
Objective elements
a Hazardous materials are identified within
th i ti
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the organization.
b) The hospital implements processes forsorting, labeling, handling, storage,
transporting and disposal of hazardous
material.
Cont
c) Requisite regulatory requirements are
met in respect of radioactive materials.
d) There is a plan for managing spills of.
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e) Staff are educated and trained for
handling such materials.
FMS.9
The hospital has system in place toprovide a safe and secure environment
Objective elementsa) The hospital has a safety committee to
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a) The hospital has a safety committee to
identify the potential safety and security
risks.
b) This committee coordinates development,
implementation, and monitoring of thesafety plan and policies.
Cont
c) Facility inspection rounds to ensuresafety are conducted at least twice in ayear in patient care areas and at leastonce in a year in non-patient care areas.
d) Inspection reports are documented and
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d) Inspection reports are documented and
corrective and preventive measures areundertaken.
e) There is a safety education programme
for all staff.
Chapter 9
MANAGEMENT
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MANAGEMENT
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Cont
b) The organization maintains an adequatenumber and mix of staff to meet the care,
treatment and service needs of the
patient.
c) The required job specifications and job
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c) The required job specifications and job
description are well defined for each
category of staff.
d) The organization verifies the antecedents
of the potential employee with regards tocriminal/negligence background.
HRM.2The organization has a documented
procedure for recruiting staff and orienting
them to the organization's environment.
Objective elements
a) There is a documented procedure for
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a) There is a documented procedure for
recruitment.b) Recruitment is based on pre-defined
criteria.
Cont
c) Every staff member entering theorganization is provided inductiontraining.
d) The induction training includes ,
mission and values
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mission and values.
e) The induction training includesawareness on employee rights andresponsibilities.
Cont
f) The induction training includesawareness on patients rights andresponsibilities.
g) The induction training includes
the organisation
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the organisation.
h) Each staff member is made aware of organization wide policies andprocedures as well as relevant
department / unit / service / programmespolicies and procedures.
HRM.3
There is an ongoing programme
for professional training anddevelopment of the staff.
Objective elements
a) A documented training and development
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) g ppolicy exists for the staff.
b) The organization maintains the trainingrecord.
Cont
c) Training also occurs when jobresponsibilities change/ new equipmentis introduced.
d) Feedback mechanisms for assessment
exist and the feedback is used to
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exist and the feedback is used to
improve the training programme.
HRM.4
Staff are adequately trained on
various safety-related aspects.
Objective elements
organization's environment
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organization s environment.
b) Staff members can demonstrate andtake actions to report, eliminate /
minimize risks.
Cont
c) Staff members are made aware of procedures to follow in the event of anincident.
d) Staff are trained on occupational safety.
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HRM.5
An appraisal system for evaluating theperformance of an employee exists as
an integral part of the human resource
management process.
Objective elements
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Objective elements
a) A documented performance appraisalsystem exists in the organization.
Cont
b) The employees are made aware of thesystem of appraisal at the time of induction.
c) Performance is evaluated based on the- .
d) The appraisal system is used as a tool
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d) The appraisal system is used as a tool
for further development.e) Performance appraisal is carried out at
pre defined intervals and is documented.
HRM.6The organization has documented
disciplinary and grievance-handling
policies and procedures.
Objective elements
a) Documented policies and procedures
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) p p
exist.b) The policy and procedure are known to
all categories of staff of the organization.
Cont
c) The disciplinary policy and procedure isbased on the principles of natural justice.
d) The disciplinary procedure is in
consonance with the prevailing laws.e) There is a provision for appeals in all-
di i li
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disciplinary cases.
f) The redress procedure addresses the
grievance.
g) Actions are taken to redress thegrievance.
HRM.7
The organization addresses the
health needs of the employees.
Objective elements
a) A pre-employment medical examinationis conducted on all the employees.
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b) Health problems of the employees aretaken care of in accordance with the
organizations policy.
Cont
c) Regular health checks of staff dealingwith direct patient care are done at-least
once a year and the findings/ results are
documented.ccupa ona ea azar s are
adequately addressed
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adequately addressed.
HRM.8
There is a documented personal
record for each staff member.
Objective elements
a Personal files are maintained in res ect
of all employees.
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b) The personal files contain personalinformation regarding the employees
qualification, disciplinary background and
health status.
Cont
c) All records of in-service training and
education are contained in the personal
files.
evalutions.
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evalutions.
HRM.9There is a process for credentialing
and privileging of medicalprofessionals permitted to provide
patient care without supervision. Objective elements
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a) Medical professionals permitted by law,regulation and the organization to
provide patient care without supervision
is identified.
Cont
b) The education, registration, training and
experience of the identified medical
professionals is documented and.
c) All such information pertaining to the
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) p g
medical professionals is appropriatelyverified when possible.
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HRM.10There is a process for credentializing
and privileging of nursing
professionals permitted to provide
patient care without supervision. Objective elements
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a) Nursing staff permitted by law, regulationand the organization to provide patient
care without supervision are identified.
Cont
b) The education, registration, training andexperience of nursing staff is
documented and updated periodically.
c All such information ertainin to the
nursing staff is appropriately verified
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when possible.d) Nursing staff are granted privileges in
consonance with their qualification,
training, experience and registration.
Cont
e) The requisite services to be provided by
the nursing staff are known to them as
well as the various departments / units of
the hospital.urs ng pro ess ona s care or pa en s
as per their privileging.
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p p g g
Chapter10
INFORMATION
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IMS.1
Documented policies andprocedures exist to meet the
information needs of the care,
organization as well as other
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g
agencies that require data andinformation from the Organization.
Objective elements
a) The information needs of the
organization are identified and are
appropriate to the scope of the services
being provided by the organization.ocumen e po c es an proce ures o
meet the information needs are
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documented.
c) These policies and procedures are in
compliance with the prevailing laws and
regulations.
Cont
d) All information management and
technology acquisitions are in
accordance with the documented policies.
e) The organization contributes to external
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databases in accordance with the lawand regulations.
IMS.2
The organization has processes
in place for effectivemanagement of data.
Ob ective elements
a) Formats for data collection are
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standardized.b) Necessary resources are available for
analyzing data.
Cont
c) Documented procedures are laid down
for timely and accurate dissemination of
data.
and retrieving data.
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e) Appropriate clinical and managerial staffparticipates in selecting, integrating and
using data.
IMS.3
The organization has a complete
and accurate medical record for
every patient.
a) Every medical record has a unique
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identifier.b) Organisation policy identifies those
authorized to make entries in medical
record.
Cont
c) Entry in the medical record is named,
signed, dated and timed.
d) The author of the entry can be identified.
e) The contents of medical record areu .
f) The record provides a complete, up-to-date
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and chronological account of patient care.g) Provision is made for 24-hour availability of
the patient's record to healthcare providers
to ensure continuity of care.
IMS.4
The medical record reflects
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