nabh standards 2nd edition final 2009
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Components of Standards DevelopmentMultiple Information Sources
Scientific literature
JCI Standards
UK Healthcare Quality Standards
Thailand Standards
AHA Draft Standards
JCI Survey compliance data
Research Findings Individual input from field experts and key stakeholders
ISO 9001-2000
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Hospital StandardsHospital StandardsHospital StandardsHospital StandardsOrganized around important functions
Focus on patient and staff safety
Set standards that all organizations mustpass
To be revised periodically and raise the bar
Achieve International recognition
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NABH StandardsNABH StandardsNABH StandardsNABH Standards
10 Chapters
100 Standards
514 Objective Elements
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Standards and Objective ElementsStandards and Objective ElementsStandards and Objective ElementsStandards and Objective Elements
A standard is a statement that defines thestructures and processes that must be substantially
in place in an organization to enhance the quality ofcare
Objective element is a measurable component of astandard
Acceptable compliance with objective elementsdetermines the overall compliance with a standard
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Section I:Section I:Section I:Section I:
PatientPatientPatientPatient----Centered StandardsCentered StandardsCentered StandardsCentered Standards
STD OE
Access, Assessment and Continuity of Care (AAC) 15 78
Care of Patients (COP) 18 104
Management of Medications (MOM) 13 61
Patient Rights and Education (PRE) 5 30
Hospital Infection Control (HIC) 9 46
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Section II:Section II:Section II:Section II:
Organization Centered StandardsOrganization Centered StandardsOrganization Centered StandardsOrganization Centered Standards
STD OE
Continuous Quality Improvement (CQI) 6 39
Responsibilities of Management (ROM) 5 25
Facility Management & Safety (FMS) 9 43
Human Resource Management (HRM) 13 47
Information Management Systems (IMS) 7 41
100 514
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NABH STANDARDS
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Introduction
NABH standards for hospitals, 2nd Edition, November 2007 havebeen prepared by Technical Committee of NABH and containcomplete set of standards for evaluation of hospitals for grant of
accreditation. The standards provide framework for qualitya s su rance and qua l i t y improvemen t fo r hosp i t a l s
NABH hospital standards, 2nd edition, November 2007 have
been accredited by ISQua under its International AccreditationProgram (IAP) for a cycle of 4 years (April 2008 to March 2012).
NABH Standards contains 10 chapters,100 standards and 514
objective elements.
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Details of Chapters1) Access ,Assessment and continuity of care (AAC)
2) Care of Patients (COP).
3) Management of Medication (MOM).
4) Patient Right and Education (PRE).
5) Hospital Infection Control (HIC).
6) Continuous Quality Improvement (CQI).7) Responsibility of Management (ROM).
8) Facility Management and Safety (FMS).
9) Human Resource Management (HRM)10) Information Management System (IMS).
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Chapter 1.
ACCESS,ASSESSMENT AND
CONTINIUITY OF CARE (AAC)
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AAC.1
The organization defines and displays the
services that it can provide
Objective Elements
a) The services being provided are clearly defined and
are in consonance with the needs of the community.
b) The defined services are prominently displayed.
c) The staff is oriented to these services.
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AAC.2
The organization has a well definedregistration and admission process
Objective elementsa) Standardized policies and procedures are used for
registering and admitting patients.
b) The policies and procedures address out- patients,
in-patients and emergency patients.
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Cont
c) Patients are accepted only if the organization canprovide the required service.
d) The policies and procedures also address managing
patients during non availability of beds.e) The staff is aware of these processes.
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AAC.3
There is an appropriate mechanism fortransfer or referral of patients who do not
match the organizational resources
Objective elements
a) Policies guide the transfer of unstable patients toanother facility in an appropriate manner.
b) Policies guide the transfer of stable patients to
another facility.
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Cont
c) Procedures identify staff responsible during
transfer.
d) The organization gives a summary of patients
condition and the treatment given.
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AAC.4
During admission the patient and /or thefamily members are educated to make
informed decisions
Objective elements
a) The patients and/or family members areexplained about the proposed care.
b) The patients and/or family members are
explained about the expected results
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Cont
c) The patients and/or family members are explained
about the possible complications.
c) The patients and/or family members are explained
about the expected costs.
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AAC.5Patients cared for by the organization
undergo an established initial assessment
Objective elements
a) The organization defines the content of the
assessments for the outpatients, in-patients and
emergency patients.
b) The organization determines who can perform the
assessments.
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Cont
c) The organization defines the time frame within
which the initial assessment is completed.
d) The initial assessment for in-patients is documented
within 24 hours or earlier as per the patients
condition or hospital policy.
e) Initial assessment includes screening for nutritional
and psychosocial needs.
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Cont
f) The initial assessment results in a
documented plan of care which is monitored.
g) The plan of care also includes preventive
aspects of the care.
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AAC.6
All patients cared for by the organization
undergo a regular reassessment
Objective elements.
a) All patients are reassessed at appropriate intervals.
b) Staff involved in direct clinical care documentreassessments.
c) Patients are reassessed to determine their response
to treatment and to plan further treatment ordischarge.
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AAC.7
Laboratory services are provided as per the
requirements of the patients
Objective elements
a) Scope of the laboratory services are commensurate
to the services provided by the organization
b) Adequately qualified and trained personnel perform
and/or supervise the investigations.
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Cont..
c) Policies and procedures guide collection,identification, handling, safe transportation
processing and disposal of specimens.
d) Laboratory results are available within a definedtime frame.
e) Critical results are intimated immediately to theconcerned personnel.
f) Laboratory tests not available in the organization are
outsourced to organization(s) based on their qualityassurance system.
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AAC.8
There is an established laboratory qualityassurance programme
Objective elements
a) The laboratory quality assurance programme is
documented.b) The programme addresses verification and
validation of test methods.
c) The programme addresses surveillance of testresults.
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Contd) The programme includes periodic calibration and
maintenance of all equipments.e) The programme includes the documentation of
corrective and preventive actions
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AAC.9
There is an established laboratory safetyprogramme
Objective elements.
a) The laboratory safety programme is
documented.b) This programme is integrated with the
organizations safety programme.
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Contc) Written policies and procedures guide the handling
and disposal of infectious and hazardous materials.d) Laboratory personnel are appropriately trained in
safe practices.
e) Laboratory personnel are provided withappropriate safety equipment / devices.
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AAC.10
Imaging services are provided as per therequirements of the patients
Objective elements
a) Imaging services comply with legal and other
requirements.b) Scope of the imaging services are commensurate to
the services provided by the organization.
c) Adequately qualified and trained personnel perform,supervise and interpret the investigations.
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Cont
d) Policies and procedures guide identification and
safe transportation of patients to imaging services.
e) Imaging results are available within a defined timeframe.
f) Critical results are intimated immediately to the
concerned personnel.g) Imaging tests not available in the organization are
outsourced to organization(s) based on their quality
assurance system.
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AAC.11
There is an established Quality assurance
programme for imaging services
Objective elements
a) The quality assurance programme for imaging
services is documented.
b) The programme addresses verification and
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 all equipments.e) The programme includes the documentation
of corrective and preventive actions
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AAC.12
There is an established radiation safetyprogramme
Objective elementsa) The radiation safety programme is documented.
b) This programme is integrated with the
organizations safety programme.c) Written policies and procedures guide the handling
and disposal of radio-active and hazardous
materials.
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Cont
d) Imaging personnel are provided with appropriate
radiation safety devices
e) Radiation safety devices are periodically tested anddocumented.
f) Imaging personnel are trained in radiation safety
measures.
g) Imaging signage are prominently displayed in all
appropriate locations.
h) Policies and procedures guide the safe use of
radioactive isotopes for imaging services.
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AAC.13
Patient care is continuous and multidisciplinaryin nature
Objective elements
a) During all phases of care, there is a qualified
individual identified as responsible for the patients
care.
b) Care of patients is coordinated in all care settings
within the organization.
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Cont
c) Information about the patients care and response totreatment is shared among medical, nursing andother care providers.
d) Information is exchanged and documented duringeach staffing shift, between shifts, and duringtransfers between units/departments.
e) The patients record (s) is available to theauthorized care providers to facilitate the exchangeof information.
f) Policy and procedures guide the referral of patientsto other department / specialties.
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AAC.14
The organization has a documented discharge
process
Objective elementsa) The patients discharge process is planned in
consultation with the patient and/or family.
b) Policies and procedures exist for coordination of
various departments and agencies involved in the
discharge process (including medico-legal cases)
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Contc) Policies and procedures are in place for patients
leaving against medical adviced) A discharge summary is given to all the patients
leaving the organization (including patients leaving
against medical advice)
AAC 15
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AAC.15
Organisation defines the content of thedischarge summary
Objective elementsa) Discharge summary is provided to the patients at
the time of discharge
b) Discharge summary contains the reasons foradmission, significant findings and diagnosis and
the patients condition at the time of discharge.
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Contc) Discharge summary contains information regarding
investigation results, any procedure performed,medication and other treatment given.
d) Discharge summary contains follow up advice,medication and other instructions in an
understandable manner.
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Conte) Discharge summary incorporates instructions
about when and how to obtain urgent caref) In case of death the summary of the case also
includes the cause of death.
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Chapter 2.
Care of Patients (COP)
COP 1
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COP.1
Uniform care of patients is provided in all settings of
the organization guided by the applicable laws and
regulations
Objective elements
a) Care delivery is uniform when similar care is
provided in more than one setting
b) Uniform care is guided by policies and procedureswhich reflect applicable laws and regulations
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Contc) The care and treatment orders are signed, named,
timed and dated by the concerned doctor.d) The care plan is countersigned by the clinician in-charge of the patient within 24 hours.
e) Evidence based medicine and clinical practiceguidelines are adopted to guide patient carewhenever possible.
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COP.2
Emergency services are guided by policies,procedures, applicable laws and regulations
Objective elements
a) Policies and procedure for emergency care are
documentedb) Policies also address handling of medico-legal cases
c) The patients receive care in consonance with the
policies
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Contd) Policies and procedures guide the triage of patients
for initiation of appropriate caree) Staff is familiar with the policies and trained on the
procedures for care of emergency patients
f) Admission or discharge to home or transfer toanother organization is also documented
COP 3
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COP.3
The ambulance services are commensuratewith the scope of the services provided by the
organization
Objective elements
a) There is adequate access and space for theambulance(s)
a) Ambulance(s) is appropriately equipped
b) Ambulance(s) is manned by trained personnel
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Contd) There is a checklist of all equipment and emergency
medicationse) Equipment are checked on a daily basis
f) Emergency medications are checked daily and prior
to dispatchg) The ambulance(s) has a proper communication
system
COP 4
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COP.4
Policies and procedures guide the care ofpatients requiring cardio-pulmonary
resuscitation
Objective elements
a) Documented policies and procedures guide the
uniform use of resuscitation throughout theorganization
b) Staff providing direct patient care is trained and
periodically updated in cardio pulmonary resuscitation
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Contc) The events during a cardio-pulmonary
resuscitation are recordedd) A post event analysis of all cardiac arrests is
done by a multidisciplinary committee.
e) Corrective and preventive measures are taken
based on the post-event analysis.
COP 5
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COP.5
Policies and procedures define rational use ofblood and blood products
Objective elements
a) Documented policies and procedures are used to
guide rational use of blood and blood productsb) The transfusion services are governed by the
applicable laws and regulations
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Cont
c) Informed consent is obtained for donation and
transfusion of blood and blood products
d) Informed consent also includes patient and familyeducation about donation
e) Staff is trained to implement the policiesf) Transfusion reactions are analyzed for preventive and
corrective actions
COP 6
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COP.6
Policies and procedures guide the care ofpatients in the Intensive care and high
dependency units
Objective elements
a) The organization has documented admission and
discharge criteria for its intensive care and high
dependency units
b) Staff is trained to apply these criteria
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Contc) Adequate staff and equipment are available
d) Defined procedures for situation of bedshortages are followed
e) Infection control practices are followed
f) A quality assurance program is implemented
COP.7
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Policies and procedures guide the care ofvulnerable patients (elderly, children, physically
and/or mentally challenged)
Objective elements
a) Policies and procedures are documented and are inaccordance with the prevailing laws and the national
and international guidelines
Cont
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b) Care is organized and delivered in accordance withthe policies and procedures
c) The organization provides for a safe and secureenvironment for this vulnerable group
d) A documented procedure exists for obtaininginformed consent from the appropriate legalrepresentative.
e) Staff is trained to care for this vulnerable group.
COP.8
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COP.8
Policies and procedures guide the care of highrisk obstetrical patients
Objective elements.
a) The organization defines and displays whether high
risk obstetric cases can be cared for or notb) Persons caring for high risk obstetric cases are
competent
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Contc) High risk obstetric patients assessment also
includes maternal nutritiond) The organization caring for high risk
obstetric cases has the facilities to take care
of neonates of such cases.
COP.9
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Policies and procedures guide the care ofpediatric patients
Objective elements.
a) The organization defines and displays the scope of
its pediatric services
b) The policy for care of neonatal patients is inconsonance with the national/ international
guidelines
c) Those who care for children have age specificcompetency
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Contd) Provisions are made for special care of
children
e) Patient assessment includes detailed
nutritional, growth, psychosocial and
immunization assessmentf) Policies and procedures prevent child/
neonate abduction and abuse
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contg) The childrens family members are
educated about nutrition,immunization and safe parenting
and this is documented in themedical record
COP.10
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COP.10
Policies and procedures guide the care of
patients undergoing moderate sedation
Objective elements
a) Competent and trained persons perform sedation
b) The person administering and monitoring sedation isdifferent from the person performing the procedure
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Contc) Intra-procedure monitoring includes at a minimum
the heart rate, cardiac rhythm, respiratory rate,blood pressure, oxygen saturation, and level ofsedation
d) Patients are monitored after sedation
e) Criteria are used to determine appropriateness ofdischarge from the recovery area
f) Equipment and manpower are available to rescue
patients from a deeper level of sedation than thatintended
COP.11
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Policies and procedures guide the administrationof anesthesia
Objective elements
a) There is a documented policy and procedure for the
administration of anesthesia
b) All patients for anesthesia have a pre-anesthesia
assessment by a qualified individual
Cont
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c) The pre-anesthesia assessment results in formulationof an anesthesia plan which is documented
d) An immediate preoperative reevaluation isdocumented
e) Informed consent for administration of anesthesia is
obtained by the anesthetistf) During anesthesia monitoring includes regular and
periodic recording of heart rate, cardiac rhythm,respiratory rate, blood pressure, oxygen saturation,
airway security and patency and level of anesthesia
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Contg) Each patients post-anesthesia status is monitored
and documentedh) A qualified individual applies defined criteria to
transfer the patient from the recovery area
i) All adverse anesthesia events are recorded andmonitored
COP.12
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Policies and procedures guide the care ofpatients undergoing surgical procedures
Objective elements
a) The policies and procedures are documented
b) Surgical patients have a preoperative assessment anda provisional diagnosis documented prior to surgery
Cont
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Cont
c) An informed consent is obtained by a surgeon priorto the procedure
d) Documented policies and procedures exist toprevent adverse events like wrong site, wrongpatient and wrong surgery
e) Persons qualified by law are permitted to performthe procedures that they are entitled to perform
f) An operative note is documented prior to transfer
out of patient from recovery area
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Contg) The operating surgeon documents the post-
operative plan of care
h) A quality assurance program is followed for thesurgical services
i) The quality assurance program includes
surveillance of the operation theatre environment
j) The plan also includes monitoring of surgical siteinfection rates
COP.13
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Policies and procedures guide the care of patientsunder restraints (physical and / or chemical)
Objective elements.
a) Documented policies and procedures guide the care
of patients under restraintsb) These include both physical and chemical restraint
measures
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Contc) These include documentation of reasons for
restraintsd) These patients are more frequently monitored
e) Staff receive training and periodic updating
in control and restraint techniques
COP.14
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Policies and procedures guide appropriate painmanagement
Objective elementsa) Documented policies and procedures guide the
management of pain
b) The organization respects and supports the
appropriate assessment and management of pain for
all patients
c) Patient and family are educated on various pain
management techniques
COP.15
Policies and procedures guide appropriate
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Policies and procedures guide appropriate
rehabilitative services
Objective elementsa) Documented policies and procedures guide the
provision of rehabilitative services
b) These services are commensurate with theorganizational requirements
c) Rehabilitative services are provided by a
multidisciplinary team
COP.16
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Policies and procedures guide all researchactivities
Objective elements.
a) Documented policies and procedures guide all research
activities in compliance with national and international
guidelinesb) The organization has an ethics committee to oversee all
research activities
c) The committee has the powers to discontinue a research trialwhen risks outweigh the potential benefits
Cont
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d) Patients informed consent is obtained beforeentering them in research protocols
e) Patients are informed of their right to withdrawfrom the research at any stage and also of theconsequences (if any) of such withdrawal
f) Patients are assured that their refusal to participateor withdrawal from participation will notcompromise their access to the organizationsservices
COP.17
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Policies and procedures guide nutritional therapy
Objective elements
a) Documented policies and procedures guide
nutritional assessment and reassessment
b) Patients receive food according to their clinical
needs
c) There is a written order for the diet
d) Nutritional therapy is planned and provided in a
collaborative manner
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Conte) When families provide food, they are
educated about the patients diet limitationsf) Food is prepared, handled, stored and
distributed in a safe manner
COP.18
Policies and procedures guide the end of life
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p g
care
Objective elements
a) Documented policies and procedures guide the end
of life care
b) These policies and procedures are in consonancewith the legal requirements
c) These also address the identification of the unique
needs of such patient and family
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Contd) These also include sensitively addressing
issues such as autopsy and organ donatione) Staff is educated and trained in end of life
care
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Chapter 3.
MANAGEMENT OF MEDICATION(MOM)
MOM.1
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Policies and procedures guide the organizationof pharmacy services and usage of medication
Objective elements
a) There is a documented policy and procedure for
pharmacy services and medication usage
b) These comply with the applicable laws and
regulations
Cont
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c) A multidisciplinary committee guides the
formulation and implementation of thesepolicies and procedures
MOM.2
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There is a hospital formulary
Objective elements
a) A list of medication appropriate for the patients andorganizations resources is developed
b) The list is developed collaboratively by the
multidisciplinary committee
c) There is a defined process for acquisition of these
medications
d) There is a process to obtain medications not listed
in the formulary
MOM.3
Policies and procedures exist for storage of
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p g
medication
Objective elements
a) Documented policies and procedures exist for
storage of medication
b) Medications are stored in a clean, well lit and
ventilated environment
c) Sound inventory control practices guide storage ofthe medications
Cont
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d) Medications are protected from loss or theft
e) Sound alike and look alike medications are storedseparately
f) There is a method to obtain medication when the
pharmacy is closed
g) Emergency medications are available all the time
h) Emergency medications are replenished in a timely
manner when used
MOM.4
Policies and procedures guide the prescription of
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medications
Objective elementsa) Documented policies and procedures exist for
prescription of medications
b) The organization determines who can write ordersc) Orders are written in a uniform location in the
medical records
Cont
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d) Medication orders are clear, legible, dated, timed,
named and signed
e) Policy on verbal orders is documented and
implemented
f) The organization defines a list of high riskmedication
g) High risk medication orders are verified prior to
dispensing
MOM.4
Policies and procedures guide the safe dispensing
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of medications
Objective elementsa) Documented policies and procedures guide the safe
dispensing of medications
b) The policies include a procedure for medicationrecall
c) Expiry dates are checked prior to dispensing
d) Labeling requirements are documented andimplemented by the organization
MOM.5
There are defined procedures for medication
d i i i
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administration
Objective elements
a) Medications are administered by those who are
permitted by law to do so
b) Prepared medication are labeled prior to preparationof a second drug
c) Patient is identified prior to administration
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d) Medication is verified from the order prior to
administration
e) Dosage is verified from the order prior to
administration
f) Route is verified from the order prior toadministration
g) Timing is verified from the order prior to
administration
Cont
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h) Medication administration is documented
i) Polices and procedures govern patients selfadministration of medications
j) Polices and procedures govern patientsmedications brought from outside the
organization
MOM.7
Patients and family members are educated about
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safe medication and food-drug interactions
Objective elements
a) Patient and family are educated about safe and
effective use of medication
b) Patient and family are educated about food-drug
interactions
MOM.8
Patients are monitored after medication
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administration
Objective elementsa) Patients are monitored after medication
administration and this is documented
b) Adverse drug events are defined
c) Adverse drug events are reported within a specified
time frame
Cont
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d) Adverse drug events are collected and
analysede) Policies are modified to reduce adverse drug
events when unacceptable trends occur
MOM.9
Policies and procedures guide the use of
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Policies and procedures guide the use ofnarcotic drugs and psychotropic substances
Objective elements
a) Documented policies and procedures guide the use
of narcotic drugs and psychotropic substancesb) These policies are in consonance with local and
national regulations
Cont
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c) A proper record is kept of the usage, administration
and disposal of these drugs
d) These drugs are handled by appropriate personnel
in accordance with policies
MOM.10
Policies and procedures guide the usage of
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Policies and procedures guide the usage ofchemotherapeutic agents
Objective elements
a) Documented policies and procedures guide the
usage of chemotherapeutic agentsb) Chemotherapy is prescribed by those who have the
knowledge to monitor and treat the adverse effect
of chemotherapy
Cont
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c) Chemotherapy is prepared and administered
by qualified personneld) Chemotherapy drugs are disposed off in
accordance with legal requirements
MOM.11
Policies and procedures govern usage of
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Policies and procedures govern usage ofradioactive drugs
Objective elements.a) Documented policies and procedures govern usage
of radioactive drugs
b) These policies and procedures are in consonancewith laws and regulations
Cont
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c) The policies and procedures include the safe
storage, preparation, handling, distributionand disposal of radioactive drugs
d) Staff, patients and visitors are educated on
safety precautions
MOM.12
Policies and procedures guide the use of
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implantable prosthesis
Objective elements.
a) Documented policies and procedures govern
procurement and usage of implantable prosthesis
b) Selection of implantable prosthesis is based on
scientific criteria and national/internationally
recognized approvals
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c) The batch and serial number of the
implantable prosthesis are recorded inthe patients medical record and themaster logbook
MOM.13
Policies and procedures guide the use of
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Policies and procedures guide the use ofmedical gases
Objective elements
a) Documented policies and procedures govern
procurement, handling, storage, distribution, usageand replenishment of medical gases.
b) The policies and procedures address the safety
issues at all levels
Cont
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c) Appropriate records are maintained in
accordance with the policies, procedures and
legal requirements.
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Chapter. 4
PATIENT RIGHT AND EDUCATION
(PRE)
PRE.1
The organization protects patient and family rights
informs them about their responsibilities during
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p gcare
Objective element
a) Patient and family rights and responsibilities are
documented.
b) Patients and families are informed of their rights and
responsibilities in a format and language that they
can understand
Cont
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c) The organizations leaders protect patients rights
d) Staff is aware of their responsibility in protecting
patients rights
e) Violation of patient rights is recorded, reviewed and
corrective/preventive measures taken
PRE.2.
Patient rights support individual beliefs, valuesd i l th ti t d f il i d i i
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g ppand involve the patient and family in decision
making processes
Objective elements
a) Patient and family rights address any special
preferences, spiritual and cultural needs.
b) Patient rights include respect for personal dignity and
privacy during examination, procedures and treatment
Cont
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c) Patient rights include protection from physical
abuse or neglectd) Patient rights include treating patient information as
confidential
e) Patient rights include refusal of treatmentf) Patient rights include informed consent before
anesthesia, blood and blood product transfusionsand any invasive / high risk procedures / treatment
Cont
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g) Patient rights include information and consent before
any research protocol is initiated
h) Patient rights include information on how to voice a
complaint
i) Patient rights include information on the expectedcost of the treatment
j) Patient has a right to have an access to his / her
clinical records
PRE.3
A documented process for obtaining patientand / or families consent exists for informed
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p g pand / or families consent exists for informed
decision making about their care
Objective elements
a) General consent for treatment is obtained whenthe patient enters the organization
Cont
b) Patient and/or his family members are informed of
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b) Patient and/or his family members are informed ofthe scope of such general consent
c) The organization has listed those situations whereinformed consent is required
d) Informed consent includes information on risks ,benefits, alternatives and as to who will perform therequisite procedure in a language that they canunderstand
e) The policy describes who can give consent when
patient is incapable of independents decisionmaking.
PRE.4
Patient and families have a right to information
and education about their healthcare needs
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Objective elements
a) When appropriate, patient and families are educated
about the safe and effective use of medication andthe potential side effects of the medication
b) Patient and families are educated about diet and
nutrition
Cont
) P i d f ili d d b
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c) Patient and families are educated aboutimmunizations
d) Patient and families are educated about theirspecific disease process, complications andprevention strategies
e) Patient and families are educated about preventinginfections
f) Patients are taught in a language and format thatthey can understand
PRE.5.
Patient and families have a right to information
on expected costs
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Objective elementsa) There is uniform pricing policy in a given setting
(out-patient and ward category)
b) The tariff list is available to patients
c) Patients are educated about the estimated costs of
treatment
Cont
d i d f il i f d b h
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d. Patients and family are informed about the
financial implications when there is a change
in the patient condition or treatment setting
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Chapter 5HOSPITAL INFECTION CONTROL
(HIC)
HIC.1
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The organization has a well-designed,comprehensive and coordinated Hospital
Infection Control (HIC) programme aimed at
reducing/ eliminating risks to patients, visitorsand providers of care.
Objective elements
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a) The hospital infection control programme is
documented which aims at preventing and reducing
risk of nosocomial infections.
b) The hospital has a multi-disciplinary infection
control committee.
c) The hospital has an infection control team.
d) The hospital has designated and qualified infection
control nurse(s) for this activity
HIC.2
The hospital has an infection control manual,which is periodically updated
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which is periodically updated
Objective elements
a) The manual identifies the various high-risk areas
and procedures.b) It outlines methods of surveillance in the identified
high-risk areas.
Cont
c) It focuses on adherence to standard precautions at
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c) It focuses on adherence to standard precautions at
all times.
d) Equipment cleaning and sterilisation practices are
included.
e) An appropriate antibiotic policy is established and
implemented.
f) Laundry and linen management processes are also
included.
Cont
g) Kitchen sanitation and food handling issues are
included in the manual
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included in the manual
h) Engineering controls to prevent infections are
included
i) Mortuary practices and procedures are included as
appropriate to the organization.
j) The organization defines the periodicity of updating
the infection control manual.
HIC.3
The infection control team is responsible for
surveillance activities in identified areas of the
h it l
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hospital.
Objective elements
a) Surveillance activities are appropriately directed
towards the identified high-risk areas.
b) Collection of surveillance data is an ongoing
process.
Cont
c) Verification of data is done on regular basis by theinfection control team.
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d) In cases of notifiable diseases, information (in
relevant format) is sent to appropriate authorities.
e) Scope of surveillance activities incorporates
tracking and analyzing of infection risks, rates and
trends.
f) Surveillance activities include monitoring the
effectiveness of housekeeping services.
HIC.4
The hospital takes actions to prevent or
reduce the risks of Hospital Associated
I f ti (HAI) i ti t d l
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Infections (HAI) in patients and employees
Objective elements
a) The organization monitors urinary tract infections.
b) The organization monitors respiratory tract
infections.
Cont
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c) The organization monitors intra-vascular device
infections.d) The organization monitors surgical site infections.
e) Appropriate feedback regarding HAI rates are
provided on a regular basis to medical and nursingstaff.
HIC.5
Proper facilities and adequate resources are
provided to support the infection control
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programme
Objective elements
a) Hand washing facilities in all patient care areas are
accessible to health care providers.b) Compliance with proper hand washing is
monitored regularly.
Cont
c) Isolation/ barrier nursing facilities are
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c) Isolation/ barrier nursing facilities are
available.
d) Adequate gloves, masks, soaps, and
disinfectants are available and used correctly.
HIC.6
The hospital takes appropriate action to control
outbreaks of infections
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Objective elementsa) Hospital has a documented procedure for handling
such outbreaks.
b) This procedure is implemented during outbreaks.
c) After the outbreak is over appropriate corrective
actions are taken to prevent recurrence
HIC.7
There are documented procedures for sterilisation
activities in the hospital.
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Objective elementsa) There is adequate space available for sterilization
activities
b) Regular validation tests for sterilisation are carriedout and documented.
c) There is an established recall procedure when
breakdown in the sterilisation system is identified
HIC.8
Statutory provisions with regard to Bio-medical
Waste (BMW) management are complied with
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Objective elements
a) The hospital is authorised by prescribed authority
for the management and handling of Bio-medical
Waste.
b) Proper segregation and collection of Bio-medical
Waste from all patient care areas of the hospital is
implemented and monitored.
Cont
c) The organization ensures that Bio-medical Waste is stored
and transported to the site of treatment and disposal in
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and transported to the site of treatment and disposal in
proper covered vehicles within stipulated time limits in a
secure manner.
d) Bio-medical Waste treatment facility is managed as per
statutory provisions (if in-house) or outsourced to authorisedcontractor(s).
Cont
e) Requisite fees, documents and reports are submitted
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to competent authorities on stipulated dates.
f) Appropriate personal protective measures are usedby all categories of staff handling Bio-medical
Waste
HIC.9
The infection control programme is supported by
the organizations management and includestraining of staff and employee health
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Objective elements
a) Hospital management makes available resources
required for the infection control programme
b) The hospital regularly earmarks adequate funds
from its annual budget in this regard.
Cont
) It d t l i d ti t i i f
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c) It conducts regular pre-induction training for
appropriate categories of staff before joiningconcerned department(s).
d) It also conducts regular in-service trainingsessions for all concerned categories of staff at leastonce in a year.
e) Appropriate pre and post exposure prophylaxis isprovided to all concerned staff members
Chapter 6
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CONTINUOUS QUALITY
IMPROVEMENT (CQI)
CQI.1
There is a structured quality improvement and
continuous monitoring programme in theorganization
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Objective elementsa) The quality improvement programme is developed,
implemented and maintained by a multi-
disciplinary committee.b) The quality improvement programme is
documented.
Cont
c) There is a designated individual for coordinating
d i l i h li i
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and implementing the quality improvement
programmed) The quality improvement programme is
comprehensive and covers all the major elements
related to quality assurance and risk management.
Cont
e) The designated programme is communicated and
coordinated amongst all the employees of the
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g p y
organization through proper training mechanism.
f) The quality improvement programme is reviewed at
predefined intervals and opportunities for
improvement are identified.
g) The quality improvement programme is a
continuous process and updated at least once
in a year
CQI.2
The organization identifies key indicators to monitor
the clinical structures, processes and outcomes whichare used as tools for continual improvement.
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Objective elements
a) Monitoring includes appropriate patient assessment.
b) Monitoring includes safety and quality control
programme of the diagnostics services.
c) Monitoring includes all invasive procedures.
Cont
d) Monitoring includes adverse drug events.
) M it i i l d f th i
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e) Monitoring includes use of anaesthesia.
f) Monitoring includes use of blood and bloodproducts.
g) Monitoring includes availability and content of
medical records.h) Monitoring includes infection control activities.
i) Monitoring includes clinical research.
Cont.
j) Monitoring includes data collection to support furtheri t
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improvements.
k) Monitoring includes data collection to support
evaluation of these improvements.
CQI.3
The organisation identifies key indicators to monitor
the managerial structures, processes and outcomes
which are used as tools for continual improvement
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Objective elements
Monitoring includes procurement of medication
essential to meet patient needs. Monitoring includes reporting of activities as required
by laws and regulations.
Cont
Monitoring includes risk management.
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Monitoring includes utilisation of space, manpowerand equipment.
Monitoring includes patient satisfaction which alsoincorporates waiting time for services.
Monitoring includes employee satisfaction.
Monitoring includes adverse events and near misses.
Cont..
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Monitoring includes data collection to support further
study for improvements.
Monitoring includes data collection to support
evaluation of the improvements
CQI.4
The quality improvement programme is supported
by the management
Objective elements
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a) Hospital Management makes available adequateresources required for quality improvement
programme.
b) Hospital earmarks adequate funds from its annualbudget in this regard.
c) Appropriate statistical and management tools are
applied whenever required
CQI.5
There is an established system for audit of patient
care services
Objective elements
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Objective elements
a) Medical and nursing staff participates in thissystem.
b) The parameters to be audited are defined by the
organisation.
c) Patient and staffanonymity is maintained.
d) All audits are documented.
e) Remedial measures are implemented.
CQI.6
Sentinel events are intensively analysed
Objective elements
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j
a) The organisation has defined sentinel events.b) The organisation has established processes for intense
analysis of such events.
c) Sentinel events are intensively analysed when theyoccur.
d) Actions are taken upon findings of such analysis
Chapter 7
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Chapter 7
RESPONSIBILITIES OFMANAGEMENT (ROM)
ROM.1
The responsibilities of the management are
defined
Objective elements
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Objective elements
a) Those responsible for governance lay down the
organizations mission statement.
b) Those responsible for governance lay down the
strategic and operational plans commensurate to the
organization's mission in consultation with the
various stake holders.
Cont
c) Those responsible for governance approve theorganizations budget and allocate the resourcesrequired to meet the organizations mission.
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d) Those responsible for governance monitor andmeasure the performance of the organization
against stated mission.
e) Those responsible for governance establish theorganizations organogram.
f) Those responsible for governance appoint the
senior leaders in the organization.
Cont
g) Those responsible for governance support research
ti iti d lit i t l
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activities and quality improvement plans.
h) The organization complies with the laid down and
applicable legislations and regulations.
i) Those responsible for governance address theorganizations social responsibility.
ROM.2
The services provided by each department
are documented
Objective elements
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a) Each organizational program, service, site ordepartment has effective leadership
b) Scope of services of each department is defined
c) Administrative policies and procedures for eachdepartment is maintained
d) Departmental leaders are involved in qualityimprovement
ROM.3
The organization is managed by the leaders in an
ethical manner
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Objective elementsa) The leaders make public the mission statement of
the organization.
b) The leaders establish the organizations ethicalmanagement.
c) The organization discloses its ownership.
Cont
d) The organization honestly portrays the services
which it can and cannot provide.
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e) The organization honestly portrays its affiliationsand accreditations.
f) The organization accurately bills for its services.
ROM.4
A suitably qualified and experienced individual
heads the organisation
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Objective elementsa) The designated individual has requisite and
appropriate administrative qualifications.
b) The designated individual has requisite andappropriate administrative experience.
ROM.5
Leaders ensure that patient safety aspects and
risk management issues are an integral part ofpatient care and hospital management
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Objective elements
a) The organization has an interdisciplinary
group assigned to oversee the hospital widesafety programme.
Cont
b) The scope of the programme is defined to includeadverse events ranging from no harm to sentinelevents
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events .
c) Management ensures implementation of systems forinternal and external reporting of system andprocess failures.
d) Management provides resources for proactive riskassessment and risk reduction activities.
Chapter 8
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FACILITY MANAGEMENT ANDSAFETY (FMS)
FMS.1
The organization is aware of and complies with the
relevant rules and regulations, laws and byelaws andrequisite facility inspection requirements
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Objective elements
a) The management is conversant with the laws and
regulations and knows their applicability to the
organization.
Cont
b) Management regularly updates any amendments in
the prevailing laws of the land.
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c) The management ensures implementation of theserequirements.
d) There is a mechanism to regularly update licenses/
registrations/certifications
FMS.2
The organizations environment and facilities
operate to ensure safety of patients, staff and
visitors
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Objective elements
a) There is a documented operational and
maintenance (preventive and breakdown) plan.
a) Up-to-date drawings are maintained which detail
the site layout, floor plans and fire escape routes
Cont
c) There is internal and external sign posting in the
organization in a language understood by patients,
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ga a a a g ag y pa ,
families and community.
The provision of space shall be in accordance with
the available literature on good practices (Indian or
International Standards) and directives from
government agencies.
Cont
e) There are designated individuals responsible for the
maintenance of all the facilities.
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f) Maintenance staff is contactable round the clock foremergency repairs.
g) Response times are monitored from reporting to
inspection and implementation of correctiveactions.
FMS.3
The organization has a program for clinical
and support service equipment management
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Objective elementsa) The organization plans for equipment in accordance
with its services and strategic plan
b) Equipment is selected by a collaborative process.
c) All equipment is inventoried and proper logs are
maintained as required.
Cont
d) Qualified and trained personnel operate and
maintain the equipment.
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q p
e) Equipment are periodically inspected and calibrated
for their proper functioning.
f) There is a documented operational and maintenance(preventive and breakdown) plan.
FMS.4
The organization has provisions for safe water,
electricity, medical gases and vacuum systems
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Objective elements
a) Potable water and electricity are available round theclock.
b) Alternate sources are provided for in case of failure.
c) The organisation regularly tests the alternatesources.
Cont..
d) There is a maintenance plan for piped medical gas,
compressed air and vacuum installation.
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FMS.5
The organization has plans for fire and non-fire
emergencies within the facilities
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Objective elements
a) The organization has plans and provisions for early
detection, containment and abatement of fire andnon-fire emergencies.
Cont
b) The organization has a documented safe exit plan in
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case of fire and non-fire emergencies.c) Staff is trained for their role in case of such
emergencies.
d) Mock drills are held at least twice in a year
FMS.6
The organization has a smoking limitation
policy
Objective elements
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a) The organization defines and implements its polices
to reduce or eliminate smoking
b) The policy has provisions for granting exceptions
for patients and families to smoke
FMS.7
The organization plans for handling
community emergencies, epidemics and otherdisasters
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Objective elements
a) The hospital identifies potential emergencies.
b) The organization has a documented disastermanagement plan.
Cont
c) Provision is made for availability of medical
supplies, equipment and materials during such
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emergencies.d) Hospital staff is trained in the hospitals disaster
management plan
e) The plan is tested at least twice in a year.
FMS.8The organization has a plan for management
of hazardous materials
Obj ti l t
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Objective elementsa) Hazardous materials are identified within the
organization
b) The hospital implements processes for sorting,labelling, handling, storage, transporting and
disposal of hazardous material.
Cont
c) Requisite regulatory requirements are met in respect
f di ti t i l
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of radioactive materials.d) There is a plan for managing spills of hazardous
materials
e) Staff is educated and trained for handling suchmaterials.
FMS.9
The hospital has system in place to provide a
safe and secure environment
Obj ti l ts
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Objective elementsa) The hospital has a safety committee to identify the
potential safety and security risks.
b) This committee coordinates development,implementation, and monitoring of the safety plan
and policies.
Cont
c) Patient safety devices are installed across theorganization and inspected periodically.
d) Facility inspection rounds to ensure safety areconducted at least twice in a year in patient care
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conducted at least twice in a year in patient careareas and at least once in a year in non-patient careareas.
e) Inspection reports are documented and correctiveand preventive measures are undertaken.
f) There is a safety education programme for all staff.
Chapter 9
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HUMAN RESOURCE
MANAGEMENT
HRM.1
The organization has a documented system of
human resource planning
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Objective elements
a) The organization maintains an adequate number andmix of staff to meet the care, treatment and service
needs of the patient.
Cont
b) The required job specifications and job description
are well defined for each category of staff.
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c) The organization verifies the antecedents of the
potential employee with regards tocriminal/negligence background.
HRM.2
The staff joining the organization is socialized
and oriented to the hospital environment
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Objective elements
a) Each staff member, employee, student and voluntary
worker is appropriately oriented to theorganizations mission and goals.
Cont
b) Each staff member is made aware of hospital widepolicies and procedures as well as relevant
department / unit / service / programmes policies
and procedures
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and procedures.c) Each staff member is made aware of his/her rights
and responsibilities.
d) All employees are educated with regard to patientsrights and responsibilities.
e) All employees are oriented to the service standards
of the organisation
HRM.3
There is an ongoing programme for professional
training and development of the staff
Objective elements
) A d t d t i i d d l t li
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a) A documented training and development policy
exists for the staff.
b) Training also occurs when job responsibilitieschange/ new equipment is introduced.
c) Feedback mechanisms for assessment of training
and development programme exist.
HRM.4
Staff members, students and volunteers are
adequately trained on specific job duties orresponsibilities related to safety
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Objective elements
a) All staff is trained on the risks within the hospital
environment.b) Staff members can demonstrate and take actions to
report, eliminate / minimize risks.
Cont
c) Staff members are made aware of procedures to
follow in the event of an incident.
d) Reporting processes for common problems, failuresd i
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d) Reporting processes for common problems, failuresand user errors exist
HRM.5
An appraisal system for evaluating the performance
of an employee exists as an integral part of the
human resource management process
Objective elements
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Objective elements
a) A well-documented performance appraisal system
exists in the organization.
b) The employees are made aware of the system of
appraisal at the time of induction
Cont
c) Performance is evaluated based on the performance
expectations described in job description.
d) The appraisal system is used as a tool for further
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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.6
The organization has a well-documented
disciplinary procedure
Objective elements
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j
a) A written statement of the policy of the organization
with regard to discipline is in place.
b) The disciplinary policy and procedure is based on
the principles of natural justice.
Cont
c) The policy and procedure is known to all
categories of employees of the organization.
d) The disciplinary procedure is in consonance
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) p y pwith the prevailing laws.
e) There is a provision for appeals in all
disciplinary cases.
HRM.7
A grievance handling mechanism exists in the
organization
Objective elements
a) The employees are aware of the procedure to be
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a) The employees are aware of the procedure to be
followed in case they feel aggrieved.
b) The redress procedure addresses the grievance.c) Actions are taken to redress the grievance
HRM.8
The organization addresses the health needs of
the employees
Objective elements
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