nabhstandards vks aka

8/10/2019 Nabhstandards Vks Aka

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National Accreditation Board for Hospitals & Healthcare Providers1

Components of StandardsDevelopment

Multiple 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 Standards

Organized around important functions

Focus on patient and staff safety

Set standards that all organizations must pass

To be revised periodically and raise the bar

Achieve International recognition


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NABH Standards

10 Chapters

100 Standards

503 Objective Elements


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Standards and ObjectiveElements

A standard is a statement that defines thestructures and processes that must besubstantially in place in an organization toenhance the quality of care

Objective element is a measurable componentof a standard

Acceptable compliance with objectiveelements determines the overall compliance

with a standard


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Section I:Patient-Centered Standards

STD OE Access, Assessment and Continuity of Care (AAC) 15 78

Patients Rights and Education (PRE) 5 29

Care of Patients (COP) 18 105

Management of Medications (MOM) 13 61

Hospital Infection Control (HIC) 9 44


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Section II:Health Care Organization

Management StandardsSTD OE

Continuous Quality Improvement (CQI) 6 37

Responsibilities of Management (ROM) 5 20

Facility Management & Safety (FMS) 9 41

Human Resource Management (HRM) 13 47

Information Management Systems (IMS) 7 41100 503


7/218National Accreditation Board for Hospitals & Healthcare Providers7

NABH STANDARDS



Introduction

NABH standards for hospitals have beenprepared by Technical Committee of NABH andcontain complete set of standards for evaluation

of hospitals for grant of accreditation. Thestandards provide framework for qualityassurance and quality improvement for hospitals

NABH Standards contains 10 chapters,100standards and 503 objective elements.



Details of chapters.1) Access ,Assessment and continuity of care (AAC)2) Patient Right and Education (PRE).3) Care of Patients(COP).

4) Management of Medication (MOM).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).



Chapter 1. ACCESS,ASSESSMENT

AND CONTINIUITY OF CARE(AAC)



AAC.1The organization defines anddisplays the services that it canprovide Objective Elements

a) The services being provided are clearlydefined.

b) The defined services are prominentlydisplayed.

c) The staff is oriented to these services



AAC.2The organization has a well defined

registration and admission process Objective elementsa) Standardized policies and procedures

are used for registering and admittingpatients

b) The policies and procedures addressout- patients, in-patients and emergencypatients



Cont

c) Patients are accepted only if theorganization can provide the requiredservice

d) The policies and procedures alsoaddress managing patients during nonavailability of beds

e) The staff is aware of these processes



AAC.3There is an appropriate mechanism

for transfer or referral of patientswho do not match the organizationalresources

Objective elementsa) Policies guide the transfer of unstable

patients to another facility in an

appropriate mannerb) Policies guide the transfer of stable

patients to another facility



Cont

c) Procedures identify staff responsibleduring transfer

d) The organization gives a summary ofpatients condition and the treatmentgiven



AAC.4During admission the patient and /orthe family members are educated to

make informed decisions

Objective elementsa) The patients and/or family members

are explained about the proposed careb) The patients and/or family members

are explained about the expected results


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17

Cont

c) The patients and/or family membersare explained about the possiblecomplications

d) The patients and/or family members areexplained about the expected costs.



18

AAC.5Patients cared for by theorganization undergo anestablished initial assessment Objective elementsa) The organization defines the content of

the assessments for the out patients, in-patients and emergency patients.

b) The organization determines who canperform the assessments.



19

cont c) The organization defines the time frame

within which the initial assessment iscompleted.

d) The initial assessment for in-patients is

documented within 24 hours or earlier asper the patients condition or hospitalpolicy.

e) Initial assessment includes screening fornutritional and psychosocial needs.



20

Cont

f) The initial assessment results in adocumented plan of care.

g) The plan of care also includes preventiveaspects of the care



21

AAC.6All patients cared for by the

organization undergo a regularreassessment Objective elements.

a) All patients are reassessed atappropriate intervals.

b) Staff involved in direct clinical care

document reassessments.c) Patients are reassessed to determine

their response to treatment and to plan

further treatment or discharge.



22

AAC.7Laboratory services are provided

as per the requirements of thepatients Objective elementsa) Scope of the laboratory services are

commensurate to the services providedby the organization

b) Adequately qualified and trainedpersonnel perform and/or supervise theinvestigations.


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AAC 8


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AAC.8There is an established

laboratory quality assuranceprogramme Objective elements

a) The laboratory quality assuranceprogramme is documented.

b) The programme addresses verification

and validation of test methods.c) The programme addresses surveillance

of test results.


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cont

d) The programme includes periodiccalibration and maintenance of allequipments.

e) The programme includes thedocumentation of corrective andpreventive actions


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AAC.9There is an established

laboratory safety programme Objective elements.

a) The laboratory safety programme isdocumented.b) This programme is integrated with the

organizations safety programme.


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cont

c) Written policies and procedures guidethe handling and disposal of infectiousand hazardous materials.

d) Laboratory personnel are appropriatelytrained in safe practices.

e) Laboratory personnel are provided withappropriate safety equipment / devices.


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AAC.10Imaging services are provided as

per the requirements of the patients Objective elements

a) Imaging services comply with legal andother requirements.b) Scope of the imaging services are

commensurate to the services providedby the organization.c) Adequately qualified and trained

personnel perform and/or supervise theinvesti ations.


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cont d) Policies and procedures guide

identification and safe transportation ofpatients to imaging services.

e) Imaging results are available within a

defined time frame.f) Critical results are intimated immediatelyto the concerned personnel.

g) Imaging tests not available in theorganization are outsourced toorganization(s) based on their qualityassurance system.


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AAC.11There is an established Quality

assurance programme forimaging services

Objective elementsa) The quality assurance programme for

imaging services is documented.b) The programme addresses verification

and validation of imaging methodsc) The programme addresses surveillance

of imaging results


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cont

d) The programme includes periodiccalibration and maintenance of allequipments.

e) The programme includes thedocumentation of corrective andpreventive actions

AAC 12


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AAC.12There is an established radiation

safety programmeObjective elementsa) The radiation safety programme is

documented.b) This programme is integrated with the

organizations safety programme.

c) Written policies and procedures guidethe handling and disposal of radio-activeand hazardous materials.


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cont

d) Imaging personnel are provided withappropriate radiation safety devicese) Radiation safety devices are periodically

tested and documented.f) Imaging personnel are trained in radiationsafety measures.

g) Imaging signage are prominentlydisplayed in all appropriate locations.h) Policies and procedures guide the safe

use of radioactive isotopes for imaging

AAC 13


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AAC.13Patient care is continuous and

multidisciplinary in natureObjective elements

a) During all phases of care, there is aqualified individual identified asresponsible for the patients care.

b) Care of patients is coordinated in all caresettings within the organization.


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cont c) Information about the patients care and

response to treatment is shared amongmedical, nursing and other care providers.

d) Information is exchanged and documentedduring each staffing shift, between shifts,and during transfers betweenunits/departments.

e) The patients record (s) is available to the

authorized care providers to facilitate theexchange of information.f) Policy and procedures guide the referral of

patients to other department / specialty.

AAC 14


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AAC.14The organization has a

documented discharge process Objective elementsa) The patients discharge process is

planned.b) Policies and procedures exist for

coordination of various departments and

agencies involved in the dischargeprocess (including medico-legal cases


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cont

c) Policies and procedures are in place forpatients leaving against medical advice

d) A discharge summary is given to all thepatients leaving the organization(including patients leaving againstmedical advice)

AAC 15


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AAC.15Organisation defines the content

of the discharge summary Objective elementsa) Discharge summary is provided to the

patients at the time of dischargeb) Discharge summary contains the

reasons for admission, significant

findings and diagnosis and the patientscondition at the time of discharge.


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cont

c) Discharge summary contains informationregarding investigation results, anyprocedure performed, medication andother treatment given

d) Discharge summary contains follow upadvice, medication and other instructionsin an understandable manner.


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Chapter .2PATIENT RIGHT AND

EDUCATION (PRE)


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PRE.1

The organization protects patientand family rights during care

Objective elementa) Patient and family rights are

documented.

b) Patients and families are informed oftheir rights in a format and language thatthey can understand


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cont

c) The organizations leaders protectpatients rights

d) Staff is aware of their responsibility inprotecting patients rights

e) Violation of patient rights is reviewed andcorrective/preventive measures taken


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PRE.2.Patient rights support individual

beliefs, values and involve thepatient and family in decision

making processes Objective elementsa) Patient rights include respect for

personal dignity and privacy duringexamination, procedures and treatmentb) Patient rights include protection from

physical abuse or neglect


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c) Patient rights include treating patientinformation as confidential

d) Patient rights include refusal of treatmente) Patient rights include informed consent

before anesthesia, blood and bloodproduct transfusions and any invasive /high risk procedures / treatment


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PRE.3A documented process for

obtaining patient and / orfamilies consent exists for

informed decision making abouttheir care

Objective elementsa) General consent for treatment is

obtained when the patient enters theorganization


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b) Patient and/or his family members are informedof the scope of such general consent

c) The organization has listed those proceduresand treatment where informed consent isrequired

d) Informed consent includes information on risks, benefits, alternatives and as to who willperform the requisite procedure in a languagethat they can understand

e) The policy describes who can give consentwhen patient is incapable of independentsdecision making.

PRE 4


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PRE.4Patient and families have a right

to information and educationabout their healthcare needs

Objective elementsa) When appropriate, patient and families

are educated about the safe andeffective use of medication and thepotential side effects of the medication

b) Patient and families are educated aboutdiet and nutrition


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cont

c) Patient and families are educated aboutimmunizations

d) Patient and families are educated about

their specific disease process,complications and prevention strategiese) Patient and families are educated about

preventing infectionsf) Patients are taught in a language and

format that they can understand


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PRE.5.

Patient and families have a rightto information on expected costs

Objective elementsa) There is uniform pricing policy in a given

setting (out-patient and ward category)b) The tariff list is available to patientsc) Patients are educated about the

estimated costs of treatment


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cont

d. Patients are informed about theestimated costs when there is a changein the patient condition or treatmentsetting


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Chapter 3.Care of Patients (COP)

COP 1


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COP.1Uniform care of patients is

guided by the applicable lawsand regulations

Objective elementsa) Care delivery is uniform when similar

care is provided in more than one settingb) Uniform care is guided by policies and

procedures which reflect applicable lawsand regulations


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cont

c) The care and treatment orders aresigned, named, timed and dated by theconcerned doctor

d) The care plan is countersigned by theclinician in-charge of the patient within 24hours

e) Evidence based medicine and clinicalpractice guidelines are adopted to guidepatient care whenever possible

COP 2


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COP.2Emergency services are guided

by policies, procedures,applicable laws and regulations

Objective elementsa) Policies and procedure for emergency

care are documented

b) Policies also address handling ofmedico-legal casesc) The patients receive care in consonance

with the policies


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cont

d) Policies and procedures guide the triageof patients for initiation of appropriatecare

e) Staff is familiar with the policies andtrained on the procedures for care ofemergency patients

f) Admission or discharge to home ortransfer to another organization is alsodocumented

COP 3


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COP.3The ambulance services are

commensurate with the scope ofthe services provided by the

organization Objective elementsa) There is adequate access and space for

the ambulance(s)b) Ambulance(s) is appropriately equippedc) Ambulance(s) is manned by trained

personnel


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d) There is a checklist of all equipment andemergency medications

e) Equipment are checked on a daily basisf) Emergency medications are checked

daily and prior to dispatchg) The ambulance(s) has a proper

communication system

COP 4


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COP.4Policies and procedures guide

the care of patients requiringcardio-pulmonary resuscitation

Objective elementsa) Documented policies and procedures

guide the uniform use of resuscitationthroughout the organization

b) Staff providing direct patient care istrained and periodically updated in cardiopulmonary resuscitation


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cont

c) The events during a cardio-pulmonaryresuscitation are recorded

d) An analysis of all cardiac arrests is donee) A multidisciplinary committee monitors

the effectiveness of cardio-pulmonaryresuscitation

COP.5


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COP.5Policies and procedures define

rational use of blood and bloodproducts Objective elementsa) Documented policies and procedures are

used to guide rational use of blood andblood products

b) The transfusion services are governedby the applicable laws and regulations


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Cont c) Informed consent is obtained for donation

and transfusion of blood and bloodproducts

d) Informed consent also includes patientand family education 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.6Policies and procedures guide the

care of patients in the Intensivecare and high dependency units

Objective elementsa) The organization has documented

admission and discharge criteria for its

intensive care and high dependencyunitsb) Staff is trained to apply these criteria


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cont

c) Adequate staff and equipment areavailable

d) Defined procedures for situation of bed

shortages are followede) Infection control practices are followedf) The unique needs of end of life patients

are identified and cared forg) A quality assurance program isimplemented

COP.7


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Policies and procedures guide

the care of vulnerable patients(elderly, children, physicallyand/or mentally challenged)

Objective elementsa) Policies and procedures are documented

and are in accordance with the prevailinglaws and the national and internationalguidelines


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cont b) Staff is trained to care for this vulnerable groupc) Care is organized and delivered in accordance

with the policies and proceduresd) The organization provides for a safe and

secure environment for this vulnerable groupe) A documented procedure exists for obtaining

informed consent from the appropriate legalrepresentative

COP.8


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the care of high risk obstetricalpatients Objective elements.a) The organization defines and displays

whether high risk obstetric cases can becared for or not

b) Persons caring for high risk obstetriccases are competent


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cont

c) High risk obstetric patients assessmentalso includes maternal nutrition

d) The organization has the facilities to takecare of neonates of high risk pregnancies

COP.9


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COP.9Policies and procedures guide

the care of pediatric patients Objective elements .a) The organization defines and displays

the scope of its pediatric servicesb) The policy for care of neonatal patients is

in consonance with the national/international guidelines

c) Those who care for children have agespecific competency


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cont

d) Provisions are made for special careof children

e) Patient assessment includesdetailed nutritional, growth,psychosocial and immunizationassessment

f) Policies and procedures preventchild/ neonate abduction and abuse


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g) The childrens family members areeducated about nutrition,immunization and safe parentingand this is documented in themedical record

COP.10


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CO . 0Policies and procedures guide

the care of patients undergoingmoderate sedation

Objective elementsa) Competent and trained persons perform

sedationb) The person administering and monitoring

sedation is different from the personperforming the procedure

cont


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c) Intra-procedure monitoring includes at aminimum the heart rate, cardiac rhythm,respiratory rate, blood pressure, oxygensaturation, and level of sedation

d) Patients are monitored after sedatione) Criteria are used to determineappropriateness of discharge from therecovery area

f) Equipment and manpower are availableto rescue patients from a deeper level ofsedation than that intended

COP.11


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the administration of anesthesia Objective elementsa) There is a documented policy and

procedure for the administration ofanesthesia

b) All patients for anesthesia have a pre-

anesthesia assessment by a qualifiedindividual


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cont c) The pre-anesthesia assessment results in

formulation of an anesthesia plan which isdocumented

d) An immediate preoperative reevaluation isdocumented

e) Informed consent for administration ofanesthesia is obtained by the anesthetist

f) During anesthesia monitoring includesregular and periodic recording of heart rate,cardiac rhythm, respiratory rate, bloodpressure, oxygen saturation, airway securityand patency and level of anesthesia


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g) Each patients post -anesthesia status ismonitored and documented

h) A qualified individual applies definedcriteria to transfer the patient from therecovery area

i) All adverse anesthesia events arerecorded and monitored

COP.12


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the care of patients undergoingsurgical procedures Objective elements

a) The policies and procedures aredocumented

b) Surgical patients have a preoperativeassessment and a provisional diagnosisdocumented prior to surgery

cont


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cont c) An informed consent is obtained by a

surgeon prior to the procedured) Documented policies and procedures

exist to prevent adverse events like

wrong site, wrong patient and wrongsurgerye) Persons qualified by law are permitted to

perform the procedures that they areentitled to perform

f) An operative note is documented prior totransfer out of patient from recovery area


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cont

g) The operating surgeon documents thepost-operative plan of care

h) A quality assurance program is followed

for the surgical servicesi) The quality assurance program includes

surveillance of the operation theatreenvironment

j) The plan also includes monitoring ofsurgical site infection rates

COP.13


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Policies and procedures guide the

care of patients under restraints(physical and / or chemical) Objective elements.a) Documented policies and procedures

guide the care of patients underrestraints

b) These include both physical andchemical restraint measures


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cont

c) These include documentation of reasonsfor restraints

d) These patients are more frequentlymonitored

e) Staff receive training and periodicupdating in control and restrainttechniques

COP.14


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appropriate pain management Objective elementsa) Documented policies and procedures

guide the management of painb) The organization respects and supports

the appropriate assessment andmanagement of pain for all patients

c) Patient and family are educated onvarious pain management techniques

COP.15


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appropriate rehabilitative services Objective elementsa) Documented policies and procedures

guide the provision of rehabilitativeservices

b) These services are commensurate withthe organizational requirements

c) Rehabilitative services are provided by amultidisciplinary team

COP.16l d d d


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Policies and procedures guideall research activities

Objective elements.a) Documented policies and procedures

guide all research activities in compliancewith national and international guidelines

b) The organization has an ethics committeeto oversee all research activities

c) The committee has the powers todiscontinue a research trial when risksoutweigh the potential benefits


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cont

d) Patients informed consent is obtainedbefore entering them in researchprotocols

e) Patients are informed of their right towithdraw from the research at any stageand also of the consequences (if any) ofsuch withdrawal

f) Patients are assured that their refusal toparticipate or withdrawal fromparticipation will not compromise theiraccess to the organizations services

COP.17P li i d d id


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Policies and procedures guidenutritional therapy


guide nutritional assessment andreassessmentb) Patients receive food according to their

clinical needsc) There is a written order for the dietd) Nutritional therapy is planned and

provided in a collaborative manner


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cont

e) When families provide food, they areeducated about the patients dietlimitations

f) Food is prepared, handled, stored anddistributed in a safe manner

COP.18


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the end of life care Objective elementsa) Documented policies and procedures

guide the end of life careb) These policies and procedures are in

consonance with the legal requirements

c) These also address the identification ofthe unique needs of such patient andfamily


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Chapter4.

MANAGEMENT OFMEDICATION (MOM)

MOM.1


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organization of pharmacyservices and usage of medication Objective elementsa) There is a documented policy and

procedure for pharmacy services andmedication usage

b) These comply with the applicable lawsand regulations


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cont

c) A multidisciplinary committee guides theformulation and implementation of thesepolicies and procedures

MOM.2


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There is a hospital formulary Objective elementsa) A list of medication appropriate for the

patients and organizations resources is

developedb) The list is developed collaboratively bythe multidisciplinary committee

c) There is a defined process for acquisitionof these medications

d) There is a process to obtain medicationsnot listed in the formulary

MOM.3P li i d d i f


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Policies and procedures exist forstorage of medication.


exist for storage of medicationb) Medications are stored in a clean, well lit

and ventilated environment

c) Sound inventory control practices guidestorage of the medications

t


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cont d) Medications are protected from loss or

thefte) Sound alike and look alike medications

are stored separately

f) There is a method to obtain medicationwhen the pharmacy is closed

g) Emergency medications are available all

the timeh) Emergency medications are replenishedin a timely manner when used

MOM.4


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the prescription of medications Objective elementsa) Documented policies and procedures

exist for prescription of medicationsb) The organization determines who can

write orders

c) Orders are written in a uniform location inthe medical records

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cont

d) Medication orders are clear, legible,dated, named and signed

e) Policy on verbal orders is documentedand implemented

f) The organization defines a list of highrisk medication

g) High risk medication orders are verifiedprior to dispensing

MOM.4


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safe dispensing of medications Objective elementsa) Documented policies and procedures

guide the safe dispensing of medicationsb) The policies include a procedure for

medication recall

c) Expiry dates are checked prior todispensingd) Labeling requirements are documented

and implemented by the organization

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National Accreditation Board for Hospitals & Healthcare Providers

100

There are defined procedures

for medication administration Objective elementsa) Medications are administered by those

who are permitted by law to do sob) Prepared medication are labeled prior to

preparation of a second drug

c) Patient is identified prior to administration

cont


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101

cont

d) Medication is verified from the order priorto administration

e) Dosage is verified from the order prior toadministration

f) Route is verified from the order prior toadministration

g) Timing is verified from the order prior toadministration

cont


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102

cont

h) Medication administration is documentedi) Polices and procedures govern patients

self administration of medications j) Polices and procedures govern patients

medications brought from outside theorganization

MOM.7


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103

Patients and family members are

educated about safe medicationand food-drug interactions Objective elementsa) Patient and family are educated about

safe and effective use of medicationb) Patient and family are educated about

food-drug interactions

MOM.8


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104

Patients are monitored after

medication administration Objective elementsa) Patients are monitored after medication

administration and this is documentedb) Adverse drug events are defined

c) Adverse drug events are reported withina specified time frame

cont


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105

cont

d) Adverse drug events are collected andanalysed

e) Policies are modified to reduce adversedrug events when unacceptable trendsoccur

MOM.9l d d d


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the use of narcotic drugs andpsychotropic substances Objective elementsa) Documented policies and procedures

guide the use of narcotic drugs andpsychotropic substances

b) These policies are in consonance withlocal and national regulations

cont


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107

cont

c) A proper record is kept of the usage,administration and disposal of thesedrugs

d) These drugs are handled by appropriatepersonnel in accordance with policies

MOM.10


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108


the usage of chemotherapeuticagents


guide the usage of chemotherapeuticagents

b) Chemotherapy is prescribed by thosewho have the knowledge to monitor andtreat the adverse effect of chemotherapy

cont


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109

cont

c) Chemotherapy is prepared andadministered by qualified personnel

d) Chemotherapy drugs are disposed off inaccordance with legal requirements

MOM.11P li i d d g


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Policies and procedures govern

usage of radioactive orinvestigational drugs Objective elements.

a) Documented policies and proceduresgovern usage of radioactive orinvestigational drugs

b) These policies and procedures are inconsonance with laws and regulations

cont


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111

cont

c) The policies and procedures include thesafe storage, preparation, handling,distribution and disposal of radioactiveand investigational drugs

d) Staff, patients and visitors are educatedon safety precautions

MOM.12P li i d d id h


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112


use of implantable prosthesis Objective elements.

a) Documented policies and proceduresgovern procurement and usage ofimplantable prosthesis

b) Selection of implantable prosthesis isbased on scientific criteria andinternationally recognized approvals

cont


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113

cont

c) The batch and serial number of theimplantable prosthesis are recorded inthe patients medical record and the

master logbook

MOM.13Policies and procedures guide


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114


the use of medical gases Objective elementsa) Documented policies and procedures

govern procurement, handling, storage,distribution, usage and replenishment ofmedical gases.

b) The policies and procedures address thesafety issues at all levels

Cont


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115

Cont

c) Appropriate records are maintained inaccordance with the policies, proceduresand legal requirements.


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116

Chapter 5

HOSPITAL INFECTIONCONTROL (HIC)

HIC.1


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The organization has a well-designed, comprehensive andcoordinated Hospital Infection

Control (HIC) programme aimedat reducing/ eliminating risks topatients, visitors and providers

of care.

Objective elements


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118

Objective elementsa) The hospital has a multi-disciplinary

infection control committee.b) The hospital has an infection control

team.c) The hospital has designated and

qualified infection control nurse(s) for thisactivity

d) The hospital infection control programmeis documented.

HIC.2


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119

The hospital has an infection

control manual, which isperiodically updated.

Objective elementsa) The manual identifies the various high-

risk areas.

b) It outlines methods of surveillance in theidentified high-risk areas.


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Cont


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121

Cont

g) Kitchen sanitation and food handlingissues are included in the manual

h) Engineering controls to prevent

infections are includedi) Mortuary practices and procedures are

included as appropriate to the

organization

HIC.3Th i f ti t l t i


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The infection control team is

responsible for surveillanceactivities in identified areas ofthe hospital.

Objective elementsa) Surveillance activities are appropriately

directed towards the identified high-riskareas.

b) Collection of surveillance data is anongoing process.

Cont


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123

Cont

c) Verification of data is done on regularbasis by the infection control team.

d) In cases of notifiable diseases,

information (in relevant format) is sent toappropriate authorities.

e) Scope of surveillance activities

incorporates tracking and analyzing ofinfection risks, rates and trends.

HIC.4h h i l k i


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124

The hospital takes actions to

prevent or reduce the risks ofHospital Associated Infections

(HAI) in patients and employees. Objective elementsa) The organization monitors urinary tract

infections.b) The organization monitors respiratory

tract infections.

Cont


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125

Cont

c) The organization monitors intra-vasculardevice infections.

d) The organization monitors surgical site

infections.e) Appropriate feedback regarding HAI

rates are provided on a regular basis to

medical and nursing staff.

HIC.5


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126

Proper facilities and adequate

resources are provided to supportthe infection control programme

Objective elementsa) Hand washing facilities in all patient care

areas are accessible to health care

providers.b) Compliance with proper hand washing ismonitored regularly.


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HIC.6Th h i l k i i


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128

The hospital takes appropriate action

to control outbreaks of infections. 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 preventrecurrence

HIC.7There are documented procedures


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129

pfor sterilisation activities in the

hospital. Objective elementsa) There is adequate space available for

sterilization activitiesb) Regular validation tests for sterilisation

are carried out and documented.c) There is an established recall procedure

when breakdown in the sterilisationsystem is identified

HIC.8Statutory provisions with regard


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130

Statutory provisions with regardto Bio-medical Waste (BMW)

management are complied with Objective elements

a) The hospital is authorised by prescribedauthority for the management andhandling of Bio-medical Waste.

b) Proper segregation and collection of Bio-medical Waste from all patient careareas of the hospital is implemented andmonitored.

Cont


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131

c) The organization ensures that Bio-medical Waste is stored and transportedto the site of treatment and disposal inproper covered vehicles within stipulatedtime limits in a secure manner.

d) Bio-medical Waste treatment facility ismanaged as per statutory provisions (if

in-house) or outsourced to authorisedcontractor(s).

Cont


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132

e) Requisite fees, documents and reportsare submitted to competent authoritieson stipulated dates.

f) Appropriate personal protectivemeasures are used by all categories ofstaff handling Bio-medical Waste

HIC.9The infection control programme


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133

The infection control programme

is supported by hospitalmanagement and includes trainingof staff and employee health

Objective elementsa) Hospital management makes available

resources required for the infection

control programmeb) The hospital regularly earmarks

adequate funds from its annual budget in

this regard

Cont


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134

c) It conducts regular pre-induction trainingfor appropriate categories of staff before

joining concerned department(s).

d) It also conducts regular in-service training sessions for all concernedcategories of staff at least once in a year.

e) Appropriate pre and post exposureprophylaxis is provided to all concernedstaff members


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135

Chapter 6CONTINUOUS QUALITY

IMPROVEMENT (CQI)

CQI.1There is a structured quality


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136

There is a structured quality

assurance and continuousmonitoring programme in theorganization

Objective elementsa) The quality assurance programme is

developed, implemented and maintainedby a multi-disciplinary committee.

b) The quality assurance programme isdocumented.

Cont


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137

c) There is a designated individual forcoordinating and implementing thequality assurance programme

d) The quality assurance programme iscomprehensive and covers all the majorelements related to quality assurance

and risk management.


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Cont


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139

g) The quality assurance programme is acontinuous process and updated at leastonce in a year.

CQI.2The organization identifies key


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140

indicators to monitor the clinicalstructures, processes and

outcomes Objective elementsa) Monitoring includes appropriate patient

assessment.b) Monitoring includes diagnostics services

safety and quality control programmes.c) Monitoring includes all invasive

procedures.

Cont


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141

d) Monitoring includes adverse drug events.e) Monitoring includes use of anaesthesia.f) Monitoring includes use of blood and

blood products.g) Monitoring includes availability and

content of medical records.

h) Monitoring includes infection controlactivities.i) Monitoring includes clinical research.

CQI.3The organisation identifies key


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142

g yindicators to monitor the

managerial structures, processesand outcomes

Objective elements Monitoring includes procurement of

medication essential to meet patient

needs. Monitoring includes reporting of activities

as required by laws and regulations.

Cont


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143

Monitoring includes risk management. Monitoring includes utilisation of facilities. Monitoring includes patient satisfaction.

Monitoring includes employee satisfaction. Monitoring includes adverse events. Monitoring includes data collection to

support further study for improvements. Monitoring includes data collection to

support evaluation of the improvements.

.The quality improvement


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144

programme is supported by themanagement

Objective elementsa) Hospital Management makes available

adequate resources required for qualityimprovement programme.

b) Hospital earmarks adequate funds fromits annual budget in this regard.

c) Appropriate statistical and managementtools are applied whenever required

CQI.5There is an established system


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145

yfor audit of patient care services

Objective elementsa) Medical staff participates in this system.

b) The parameters to be audited aredefined by the organisation.

c) Patient and clinician anonymity is

maintained.d) All audits are documented.e) Remedial measures are implemented.

CQI.6Sentinel events are intensively


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146

analysed Objective elementsa) 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 they occur.d) Actions are taken upon findings of such

analysis


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147

Chapter 7

RESPONSIBILITIES OFMANAGEMENT (ROM)

ROM.1The responsibilities of the


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148

p

management are defined Objective elementsa) The organization has a documented

organogramb) Those responsible for governance

appoint the senior leaders in the

organizationc) Those responsible for governance

support the quality improvement plan

Cont


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149

d) The organization complies with the laiddown and applicable legislations andregulations

e) Those responsible for governanceaddress the organizations socialresponsibility

ROM.2The services provided by each


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150

department are documented Objective elementsa) Each organizational program, service, site or

department has effective leadershipb) Scope of services of each department is

definedc) Administrative policies and procedures for

each department is maintainedd) Departmental leaders are involved in quality

improvement

ROM.3The organization is managed by


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151

g g y

the leaders in an ethical manner Objective elementsa) The leaders make public the mission

statement of the organizationb) The leaders establish the organizations

ethical managementc) The organization discloses its ownership

Cont


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152

d) The organization honestly portrays theservices which it can and cannot provide

e) The organization accurately bills for its

services

ROM.4A suitably qualified and experienced individual heads


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153

A suitably qualified and experienced individual heads

the organisation Objective elementsa) The designated individual has requisite

and appropriate administrativequalifications.

b) The designated individual has requisite

and appropriate administrativeexperience.

ROM.5Leaders ensure that patient


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154

p

safety aspects and riskmanagement issues are anintegral part of patient care and

hospital management Objective elements

a) The organization has an interdisciplinarygroup assigned to oversee the hospitalwide safety programme.

Cont


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155

b) The scope of the programme is definedto include adverse events ranging fromno harm to sentinel events .

c) Management ensures implementation ofsystems for internal and externalreporting of system and process failures.

d) Management provides resources forproactive risk assessment and riskreduction activities.


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156

Chapter 8FACILITY MANAGEMENT AND

SAFETY (FMS)

FMS.1The organization is aware of and


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157

g

complies with the relevant rulesand regulations, laws andbyelaws and requisite facility

inspection requirements Objective elementsa) The management is conversant with the

laws and regulations and knows theirapplicability to the organization.

Cont


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158

b) Management regularly updates anyamendments in the prevailing laws of theland.

c) The management ensuresimplementation of these requirements.

d) There is a mechanism to regularly

update licenses/registrations/certifications

FMS.2The organizations environment


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159

The organization s environment

and facilities operate to ensuresafety of patients, staff and

visitors

Objective elementsa) There is a documented operational and

maintenance (preventive andbreakdown) plan.

Cont


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160

b) Up-to-date drawings are maintainedwhich detail the site layout, floor plansand fire escape routes.

c) The provision of space shall be in

accordance with the available literatureon good practices (Indian or InternationalStandards) and directives fromgovernment agencies.

d) There are designated individualsresponsible for the maintenance of all thefacilities.


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FMS.3The organization has a programf li i l d i


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162

for clinical and support serviceequipment management

Objective elementsa) The organization plans for equipment in

accordance with its services andstrategic plan

b) Equipment is selected by a collaborativeprocess.

c) All equipment is inventoried and properlogs are maintained as required.

Cont


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163

d) Qualified and trained personnel operateand maintain the equipment.

e) Equipment are periodically inspected and

calibrated for their proper functioning.f) There is a documented operational and

maintenance (preventive and

breakdown) plan.

FMS.4The organization has provisions

f f l i i di l


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164

for safe water, electricity, medicalgases and vacuum systems

Objective elementsa) Potable water and electricity are available

round the clock.b) Alternate sources are provided for in case of

failure.

c) The organisation regularly tests the alternatesources.d) There is a maintenance plan for piped

medical gas and vacuum installation.

FMS.5The organization has plans for


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165

fire and non-fire emergencieswithin the facilities

Objective elementsa) The organization has plans andprovisions for early detection, abatementand containment of fire and non-fireemergencies.

Cont


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166

b) Staff is trained for their role in case ofsuch emergencies.

c) The organization has a documented safe

exit plan in case of fire and non-fireemergencies.

d) Mock drills are held at least twice in a

year

FMS.6The organization has a smoking


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167

limitation policy Objective elementsa) The organization defines its polices to

reduce or eliminate smokingb) The policy has provisions for granting

exceptions for patients and families to

smoke

FMS.7The organization plans for handling

it g i id i


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168

community emergencies, epidemicsand other disasters

Objective elementsa) The hospital identifies potential

emergencies.b) The organization has a documented

disaster management plan.

Cont


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169

c) Provision is made for availability ofmedical supplies, equipment andmaterials during such emergencies.

d) Hospital staff is trained in the hospitalsdisaster management plane) The plan is tested at least twice in a

year.


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Cont


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171

c) Requisite regulatory requirements aremet in respect of radioactive materials.

d) There is a plan for managing spills ofhazardous materials

e) Staff is educated and trained for

handling such materials.

FMS.9The hospital has system in place

id f d


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172

to provide a safe and secureenvironment

Objective elements

a) The hospital has a safety committee toidentify the potential safety and securityrisks.

b) This committee coordinates development,implementation, and monitoring of thesafety plan and policies.

Cont


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173

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 andcorrective and preventive measures areundertaken.

e) There is a safety education programmefor all staff.


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174

Chapter9

HUMAN RESOURCEMANAGEMENT

HRM.1The organization has a

d t d t f h


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175

documented system of humanresource planning

Objective elementsa) The organization maintains an adequate

number and mix of staff to meet the care,treatment and service needs of thepatient.

Cont


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176

b) The required job specifications and jobdescription are well defined for eachcategory of staff.

c) The organization verifies the antecedentsof the potential employee with regards to

criminal/negligence background.

HRM.2The staff joining the organization


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177

The staff joining the organization

is socialized and oriented to thehospital environment

Objective elementsa) Each staff member, employee, student

and voluntary worker is appropriatelyoriented to the organizations missionand goals.

Cont b) E h t ff b i d f


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178

b) Each staff member is made aware ofhospital wide policies and procedures aswell as relevant department / unit /service / programmes policies andprocedures.

c) Each staff member is made aware ofhis/her rights and responsibilities.

d) All employees are educated with regardto patients rights and responsibilities.

e) All employees are oriented to the servicestandards of the organisation

HRM.3There is an ongoing programme

for professional training and


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179

for professional training anddevelopment of the staff

Objective elementsa) A documented training and development

policy exists for the staff.b) Training also occurs when job

responsibilities change/ new equipment

is introduced.c) Feedback mechanisms for assessmentof training and development programmeexist.

HRM.4Staff members, students and

volunteers are adequately


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180

volunteers are adequatelytrained on specific job duties orresponsibilities related to safety

Objective elementsa) All staff is trained on the risks within the

hospital environment.

b) Staff members can demonstrate andtake actions to report, eliminate /minimize risks.


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HRM.5 An appraisal system for evaluating

the performance of an employee


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182

the performance of an employeeexists as an integral part of the

human resource management

process Objective elementsa) A well-documented performance

appraisal system exists in theorganization.

Cont

b) Th l d f h


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183

b) The employees are made aware of thesystem of appraisal at the time ofinduction.

c) Performance is evaluated based on the

performance expectations described in job description.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 a well-


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184

documented disciplinaryprocedure

Objective elementsa) A written statement of the policy of the

organization with regard to discipline is inplace.

b) The disciplinary policy and procedure isbased on the principles of natural justice.

Cont


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185

c) The policy and procedure is known to allcategories of employees of theorganization.

d) The disciplinary procedure is inconsonance with the prevailing laws.e) There is a provision for appeals in all

disciplinary cases.

HRM.7A grievance handling mechanism


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186

exists in the organization Objective elementsa) The employees are aware of the

procedure to be followed in case theyfeel aggrieved.

b) The redress procedure addresses thegrievance.

c) Actions are taken to redress thegrievance


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Cont


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188

c) Regular physical and medical checks aredone at-least once a year and thefindings/ results are documented.

d) Occupational health hazards areadequately addressed.


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Cont


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N ti l A dit ti B d f H it l & H lth P id

190

c) All records of in-service training andeducation are contained in the personalfiles.

d) Personal files contain results of allevaluations

HRM 10


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191

HRM.10There is a process for collecting, verifyingand evaluating the credentials(education, registration, training and

experience) of medical professionalspermitted to provide patient care without

supervision

Objective elementsa) Medical professionals permitted by law,

regulation and the hospital to provide


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192

regulation and the hospital to providepatient care without supervision isidentified.

b) The education, registration, training and

experience of the identified medicalprofessionals is documented andupdated periodically.

c) All such information pertaining to themedical professionals is appropriatelyverified when possible.

HRM.11There is a process for authorising


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p g

all medical professionals to admitand treat patients and provide

other clinical servicescommensurate with their

qualifications

Objective elementsa) Medical professionals admit and care for

patients as per the laid down policies


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patients as per the laid down policiesand authorisation procedures of theorganization

b) The services provided by the medical

professionals are in consonance withtheir qualification, training andregistration.

c) The requisite services to be provided bythe medical professionals are known tothem as well as the various departments/ units of the hospital.

HRM.12There is a process for collecting,


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verifying and evaluating thecredentials (education,registration, training and

experience) of nursing staff Objective elements

a) The education, registration, training andexperience of nursing staff isdocumented and updated periodically.

Cont


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b) All such information pertaining to thenursing staff is appropriately verifiedwhen possible


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HRM.13There is a process to identify jobresponsibilities and make clinical work

assignments to all nursing staff memberscommensurate with their qualifications

and any other regulatory requirements

Objective elementsa) The clinical work assigned to nursing


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a) The clinical work assigned to nursingstaff is in consonance with theirqualification, training and registration.

b) The services provided by nursing staff

are in accordance with the prevailinglaws and regulations.c) The requisite services to be provided by

the nursing staff are known to them aswell as the various departments / units ofthe hospital


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Chapter.10INFORMATION

MANAGEMENT SYSTEM (IMS)

IMS.1


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Policies and procedures exist to meet theinformation needs of the care providers,management of the organization as wellas other agencies that require data andinformation from the organization

Objective elementsa) The information needs of the

organization are identified and are


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organization are identified and areappropriate to the scope of the servicesbeing provided by the organization andthe complexity of the organization

b) Policies and procedures to meet theinformation needs are documented.c) These policies and procedures are in

compliance with the prevailing laws andregulations.

Cont


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d) All information management andtechnology acquisitions are inaccordance with the policies andprocedures.

e) The organization contributes to externaldatabases in accordance with the lawand regulations

IMS.2The organization has processesin place for effective


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pmanagement of data

Objective elements

a) Formats for data collection arestandardized

b) Necessary resources are available for

analyzing data

Cont


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c) Documented procedures are laid downfor timely and accurate dissemination ofdata

d) Documented procedures exist for storingand retrieving datae) Appropriate clinical and managerial staff

participates in selecting, integrating andusing data.

IMS.3The organization has a complete


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and accurate medical record forevery patient

Objective elements a) Every medical record has a unique

identifier.b) Organization policy identifies those

authorized to make entries in medicalrecord.

Cont


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c) Every medical record entry is dated andtimed.d) The author of the entry can be identified

e) The contents of medical record areidentified and documented

f) The record provides an up-to-date and

chronological account of patient care

IMS.4The medical record reflects


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continuity of care Objective elementsa) The medical record contains information

regarding reasons for admission,diagnosis and plan of care.

b) Operative and other proceduresperformed are incorporated in themedical record


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Cont


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e) In case of death, the medical recordcontains a copy of the death certificateindicating the cause, date and time ofdeath.

f) Whenever a clinical autopsy is carriedout, the medical record contains a copyof the report of the same.

g) Care providers have access to currentand past medical record.

IMS.5Policies and procedures are in place formaintaining confidentiality integrity and


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maintaining confidentiality, integrity and

security of information


exist for maintaining confidentiality,

security and integrity of information

Cont


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b) Policies and procedures are inconsonance with the applicable lawsc) The policies and procedures incorporate

safeguarding of data/ record againstloss, destruction and tamperingd) The hospital has an effective process of

monitoring compliance of the laid downpolicy

Cont


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e) The hospital uses developments inappropriate technology for improving,confidentiality, integrity and security

f) Privileged health information is used forthe purposes identified or as required bylaw and not disclosed without the

patients authorization

Cont


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g) A documented procedure exists on howto respond to patients / physicians andother public agencies requests foraccess to information in the clinicalrecord in accordance with the local andnational law.

IMS.6Policies and procedures exist for

retention time of records data


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retention time of records, dataand information

Objective elements

a) Documented policies and procedures arein place on retaining the patients clinicalrecords, data and information

b) The policies and procedures are inconsonance with the local and nationallaws and regulations

Cont


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c) The retention process provides expectedconfidentiality and securityd) The destruction of medical records, data

and information is in accordance with thelaid down policy

IMS.7The organization regularly


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carries out medical audits Objective elementsa) The medical records are reviewed

periodicallyb) The review uses a representative sample

c) The review is conducted by identifiedcare providers.

Cont


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d) The review focuses on the timeliness,legibility and completeness of themedical records

e) The review process includes records ofboth active and discharged patients

f) The review points out and documentsany deficiencies in records

g) Appropriate corrective and preventivemeasures undertaken are documented.


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