Title: Components of Standards Development
1Components of Standards Development
- 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
2Hospital 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
3NABH Standards
- 10 Chapters
- 100 Standards
- 503 Objective Elements
4Standards and Objective Elements
- A standard is a statement that defines the
structures and processes that must be
substantially in place in an organization to
enhance the quality of care - Objective element is a measurable component of a
standard - Acceptable compliance with objective elements
determines the overall compliance with a standard
5Section IPatient-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
6Section II Health Care Organization Management
Standards
- STD 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 41
- 100 503
7NABH STANDARDS
8Introduction
- NABH standards for hospitals have been prepared
by Technical Committee of NABH and contain
complete set of standards for evaluation of
hospitals for grant of accreditation. The
standards provide framework for quality assurance
and quality improvement for hospitals - NABH Standards contains 10 chapters,100 standards
and 503 objective elements.
9Details of chapters.
- Access ,Assessment and continuity of care (AAC)
- Patient Right and Education (PRE).
- Care of Patients(COP).
- Management of Medication (MOM).
- Hospital Infection Control (HIC).
- Continuous Quality Improvement(CQI)
- Responsibility of Management (ROM).
- Facility Management and Safety (FMS).
- Human Resource Management (HRM)
- Information Management System (IMS).
10Chapter 1.ACCESS,ASSESSMENT AND CONTINIUITY OF
CARE (AAC)
11AAC.1The organization defines and displays the
services that it can provide
- Objective Elements
- The services being provided are clearly defined.
- The defined services are prominently displayed.
- The staff is oriented to these services
12AAC.2The organization has a well defined
registration and admission process
- Objective elements
- Standardized policies and procedures are used
for registering and admitting patients - The policies and procedures address out-
patients, in-patients and emergency patients
13Cont
- Patients are accepted only if the organization
can provide the required service - The policies and procedures also address managing
patients during non availability of beds - The staff is aware of these processes
14AAC.3There is an appropriate mechanism for
transfer or referral of patients who do not match
the organizational resources
- Objective elements
- Policies guide the transfer of unstable
patients to another facility in an appropriate
manner - Policies guide the transfer of stable patients
to another facility
15Cont
- Procedures identify staff responsible during
transfer - The organization gives a summary of patients
condition and the treatment given
16AAC.4During admission the patient and /or the
family members are educated to make informed
decisions
- Objective elements
- The patients and/or family members are
explained about the proposed care - The patients and/or family members are
explained about the expected results
17Cont
- The patients and/or family members are
explained about the possible complications - The patients and/or family members are explained
about the expected costs.
18AAC.5Patients cared for by the organization
undergo an established initial assessment
- Objective elements
- The organization defines the content of the
assessments for the outpatients, in-patients and
emergency patients. - The organization determines who can perform the
assessments.
19cont
- The organization defines the time frame within
which the initial assessment is completed. - The initial assessment for in-patients is
documented within 24 hours or earlier as per the
patients condition or hospital policy. - Initial assessment includes screening for
nutritional and psychosocial needs.
20Cont
- The initial assessment results in a documented
plan of care. - The plan of care also includes preventive aspects
of the care
21AAC.6All patients cared for by the organization
undergo a regular reassessment
- Objective elements.
- All patients are reassessed at appropriate
intervals. - Staff involved in direct clinical care document
reassessments. - Patients are reassessed to determine their
response to treatment and to plan further
treatment or discharge.
22AAC.7Laboratory services are provided as per the
requirements of the patients
- Objective elements
- Scope of the laboratory services are commensurate
to the services provided by the organization - Adequately qualified and trained personnel
perform and/or supervise the investigations.
23cont..
- Policies and procedures guide collection,
identification, handling, safe transportation and
disposal of specimens. - Laboratory results are available within a defined
time frame. - Critical results are intimated immediately to the
concerned personnel. - Laboratory tests not available in the
organization are outsourced to organization(s)
based on their quality assurance system.
24AAC.8There is an established laboratory quality
assurance programme
- Objective elements
- The laboratory quality assurance programme is
documented. - The programme addresses verification and
validation of test methods. - The programme addresses surveillance of test
results.
25cont
- The programme includes periodic calibration and
maintenance of all equipments. - The programme includes the documentation of
corrective and preventive actions
26AAC.9There is an established laboratory safety
programme
- Objective elements.
- The laboratory safety programme is documented.
- This programme is integrated with the
organizations safety programme.
27cont
- Written policies and procedures guide the
handling and disposal of infectious and hazardous
materials. - Laboratory personnel are appropriately trained in
safe practices. - Laboratory personnel are provided with
appropriate safety equipment / devices.
28AAC.10Imaging services are provided as per the
requirements of the patients
- Objective elements
- Imaging services comply with legal and other
requirements. - Scope of the imaging services are commensurate to
the services provided by the organization. - Adequately qualified and trained personnel
perform and/or supervise the investigations.
29cont
- Policies and procedures guide identification and
safe transportation of patients to imaging
services. - Imaging results are available within a defined
time frame. - Critical results are intimated immediately to the
concerned personnel. - Imaging tests not available in the organization
are outsourced to organization(s) based on their
quality assurance system.
30AAC.11There is an established Quality assurance
programme for imaging services
- Objective elements
- The quality assurance programme for imaging
services is documented. - The programme addresses verification and
validation of imaging methods - The programme addresses surveillance of imaging
results
31cont
- The programme includes periodic calibration and
maintenance of all equipments. - The programme includes the documentation of
corrective and preventive actions
32AAC.12There is an established radiation safety
programme
- Objective elements
- The radiation safety programme is documented.
- This programme is integrated with the
organizations safety programme. - Written policies and procedures guide the
handling and disposal of radio-active and
hazardous materials.
33cont
- Imaging personnel are provided with appropriate
radiation safety devices - Radiation safety devices are periodically tested
and documented. - Imaging personnel are trained in radiation safety
measures. - Imaging signage are prominently displayed in all
appropriate locations. - Policies and procedures guide the safe use of
radioactive isotopes for imaging services.
34AAC.13Patient care is continuous and
multidisciplinary in nature
- Objective elements
- During all phases of care, there is a qualified
individual identified as responsible for the
patients care. - Care of patients is coordinated in all care
settings within the organization.
35cont
- Information about the patients care and response
to treatment is shared among medical, nursing and
other care providers. - Information is exchanged and documented during
each staffing shift, between shifts, and during
transfers between units/departments. - The patients record (s) is available to the
authorized care providers to facilitate the
exchange of information. - Policy and procedures guide the referral of
patients to other department / specialty.
36AAC.14The organization has a documented
discharge process
- Objective elements
- The patients discharge process is planned.
- Policies and procedures exist for coordination of
various departments and agencies involved in the
discharge process (including medico-legal cases
37cont
- Policies and procedures are in place for patients
leaving against medical advice - A discharge summary is given to all the patients
leaving the organization (including patients
leaving against medical advice)
38AAC.15Organisation defines the content of the
discharge summary
- Objective elements
- Discharge summary is provided to the patients at
the time of discharge - Discharge summary contains the reasons for
admission, significant findings and diagnosis and
the patients condition at the time of discharge.
39cont
- Discharge summary contains information regarding
investigation results, any procedure performed,
medication and other treatment given - Discharge summary contains follow up advice,
medication and other instructions in an
understandable manner.
40cont
- Discharge summary incorporates instructions about
when and how to obtain urgent care - In case of death the summary of the case also
includes the cause of death.Patient records also
contain a copy of the discharge /case summary
41Chapter .2PATIENT RIGHT AND EDUCATION (PRE)
42 PRE.1The organization protects patient and
family rights during care
- Objective element
- Patient and family rights are documented.
- Patients and families are informed of their
rights in a format and language that they can
understand
43cont
- The organizations leaders protect patients
rights - Staff is aware of their responsibility in
protecting patients rights - Violation of patient rights is reviewed and
corrective/preventive measures taken
44PRE.2.Patient rights support individual beliefs,
values and involve the patient and family in
decision making processes
- Objective elements
- Patient rights include respect for personal
dignity and privacy during examination,
procedures and treatment - Patient rights include protection from physical
abuse or neglect
45cont
- Patient rights include treating patient
information as confidential - Patient rights include refusal of treatment
- Patient rights include informed consent before
anesthesia, blood and blood product transfusions
and any invasive / high risk procedures /
treatment
46cont
- Patient rights include information and consent
before any research protocol is initiated - Patient rights include information on how to
voice a complaint - Patient rights include information on the
expected cost of the treatment - Patient has a right to have an access to his /
her clinical records
47PRE.3A documented process for obtaining patient
and / or families consent exists for informed
decision making about their care
- Objective elements
- General consent for treatment is obtained when
the patient enters the organization
48cont
- Patient and/or his family members are informed of
the scope of such general consent - The organization has listed those procedures and
treatment where informed consent is required - Informed consent includes information on risks ,
benefits, alternatives and as to who will perform
the requisite procedure in a language that they
can understand - The policy describes who can give consent when
patient is incapable of independents decision
making.
49PRE.4Patient and families have a right to
information and education about their healthcare
needs
- Objective elements
- When appropriate, patient and families are
educated about the safe and effective use of
medication and the potential side effects of the
medication - Patient and families are educated about diet and
nutrition
50cont
- Patient and families are educated about
immunizations - Patient and families are educated about their
specific disease process, complications and
prevention strategies - Patient and families are educated about
preventing infections - Patients are taught in a language and format that
they can understand
51PRE.5. Patient and families have a right to
information on expected costs
- Objective elements
- There is uniform pricing policy in a given
setting (out-patient and ward category) - The tariff list is available to patients
- Patients are educated about the estimated costs
of treatment
52cont
- Patients are informed about the estimated costs
when there is a change in the patient condition
or treatment setting
53Chapter 3.Care of Patients (COP)
54COP.1Uniform care of patients is guided by the
applicable laws and regulations
- Objective elements
- Care delivery is uniform when similar care is
provided in more than one setting - Uniform care is guided by policies and procedures
which reflect applicable laws and regulations
55cont
- The care and treatment orders are signed, named,
timed and dated by the concerned doctor - The care plan is countersigned by the clinician
in-charge of the patient within 24 hours - Evidence based medicine and clinical practice
guidelines are adopted to guide patient care
whenever possible
56COP.2Emergency services are guided by policies,
procedures, applicable laws and regulations
- Objective elements
- Policies and procedure for emergency care are
documented - Policies also address handling of medico-legal
cases - The patients receive care in consonance with the
policies
57cont
- Policies and procedures guide the triage of
patients for initiation of appropriate care - Staff is familiar with the policies and trained
on the procedures for care of emergency patients - Admission or discharge to home or transfer to
another organization is also documented
58COP.3The ambulance services are commensurate
with the scope of the services provided by the
organization
- Objective elements
- There is adequate access and space for the
ambulance(s) - Ambulance(s) is appropriately equipped
- Ambulance(s) is manned by trained personnel
59cont
- There is a checklist of all equipment and
emergency medications - Equipment are checked on a daily basis
- Emergency medications are checked daily and prior
to dispatch - The ambulance(s) has a proper communication
system
60COP.4Policies and procedures guide the care of
patients requiring cardio-pulmonary resuscitation
- Objective elements
- Documented policies and procedures guide the
uniform use of resuscitation throughout the
organization - Staff providing direct patient care is trained
and periodically updated in cardio pulmonary
resuscitation
61cont
- The events during a cardio-pulmonary
resuscitation are recorded - An analysis of all cardiac arrests is done
- A multidisciplinary committee monitors the
effectiveness of cardio-pulmonary resuscitation
62COP.5Policies and procedures define rational use
of blood and blood products
- Objective elements
- Documented policies and procedures are used to
guide rational use of blood and blood products - The transfusion services are governed by the
applicable laws and regulations
63Cont
- Informed consent is obtained for donation and
transfusion of blood and blood products - Informed consent also includes patient and family
education about donation - Staff is trained to implement the policies
- Transfusion reactions are analyzed for preventive
and corrective actions
64COP.6Policies and procedures guide the care of
patients in the Intensive care and high
dependency units
- Objective elements
- The organization has documented admission and
discharge criteria for its intensive care and
high dependency units - Staff is trained to apply these criteria
65cont
- Adequate staff and equipment are available
- Defined procedures for situation of bed shortages
are followed - Infection control practices are followed
- The unique needs of end of life patients are
identified and cared for - A quality assurance program is implemented
66COP.7Policies and procedures guide the care of
vulnerable patients (elderly, children,
physically and/or mentally challenged)
- Objective elements
- Policies and procedures are documented and are in
accordance with the prevailing laws and the
national and international guidelines
67cont
- Staff is trained to care for this vulnerable
group - Care is organized and delivered in accordance
with the policies and procedures - The organization provides for a safe and secure
environment for this vulnerable group - A documented procedure exists for obtaining
informed consent from the appropriate legal
representative
68COP.8Policies and procedures guide the care of
high risk obstetrical patients
- Objective elements.
- The organization defines and displays whether
high risk obstetric cases can be cared for or not - Persons caring for high risk obstetric cases are
competent
69cont
- High risk obstetric patients assessment also
includes maternal nutrition - The organization has the facilities to take care
of neonates of high risk pregnancies
70COP.9Policies and procedures guide the care of
pediatric patients
- Objective elements.
- The organization defines and displays the scope
of its pediatric services - The policy for care of neonatal patients is in
consonance with the national/ international
guidelines - Those who care for children have age specific
competency
71cont
- Provisions are made for special care of children
- Patient assessment includes detailed nutritional,
growth, psychosocial and immunization assessment - Policies and procedures prevent child/ neonate
abduction and abuse
72cont
- The childrens family members are educated about
nutrition, immunization and safe parenting and
this is documented in the medical record
73COP.10 Policies and procedures guide the care
of patients undergoing moderate sedation
- Objective elements
- Competent and trained persons perform sedation
- The person administering and monitoring sedation
is different from the person performing the
procedure
74cont
- Intra-procedure monitoring includes at a minimum
the heart rate, cardiac rhythm, respiratory rate,
blood pressure, oxygen saturation, and level of
sedation - Patients are monitored after sedation
- Criteria are used to determine appropriateness of
discharge from the recovery area - Equipment and manpower are available to rescue
patients from a deeper level of sedation than
that intended
75COP.11Policies and procedures guide the
administration of anesthesia
- Objective elements
- There is a documented policy and procedure for
the administration of anesthesia - All patients for anesthesia have a pre-anesthesia
assessment by a qualified individual
76cont
- The pre-anesthesia assessment results in
formulation of an anesthesia plan which is
documented - An immediate preoperative reevaluation is
documented - Informed consent for administration of anesthesia
is obtained by the anesthetist - 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
77cont
- Each patients post-anesthesia status is
monitored and documented - A qualified individual applies defined criteria
to transfer the patient from the recovery area - All adverse anesthesia events are recorded and
monitored
78COP.12Policies and procedures guide the care of
patients undergoing surgical procedures
- Objective elements
- The policies and procedures are documented
- Surgical patients have a preoperative assessment
and a provisional diagnosis documented prior to
surgery
79cont
- An informed consent is obtained by a surgeon
prior to the procedure - Documented policies and procedures exist to
prevent adverse events like wrong site, wrong
patient and wrong surgery - Persons qualified by law are permitted to perform
the procedures that they are entitled to perform - An operative note is documented prior to transfer
out of patient from recovery area
80cont
- The operating surgeon documents the
post-operative plan of care - A quality assurance program is followed for the
surgical services - The quality assurance program includes
surveillance of the operation theatre environment - The plan also includes monitoring of surgical
site infection rates
81COP.13Policies and procedures guide the care of
patients under restraints (physical and / or
chemical)
- Objective elements.
- Documented policies and procedures guide the care
of patients under restraints - These include both physical and chemical
restraint measures
82cont
- These include documentation of reasons for
restraints - These patients are more frequently monitored
- Staff receive training and periodic updating in
control and restraint techniques
83COP.14Policies and procedures guide appropriate
pain management
- Objective elements
- Documented policies and procedures guide the
management of pain - The organization respects and supports the
appropriate assessment and management of pain for
all patients - Patient and family are educated on various pain
management techniques
84COP.15Policies and procedures guide appropriate
rehabilitative services
- Objective elements
- Documented policies and procedures guide the
provision of rehabilitative services - These services are commensurate with the
organizational requirements - Rehabilitative services are provided by a
multidisciplinary team
85COP.16Policies and procedures guide all research
activities
- Objective elements.
- Documented policies and procedures guide all
research activities in compliance with national
and international guidelines - The organization has an ethics committee to
oversee all research activities - The committee has the powers to discontinue a
research trial when risks outweigh the potential
benefits
86cont
- Patients informed consent is obtained before
entering them in research protocols - Patients are informed of their right to withdraw
from the research at any stage and also of the
consequences (if any) of such withdrawal - Patients are assured that their refusal to
participate or withdrawal from participation
will not compromise their access to the
organizations services
87COP.17Policies and procedures guide nutritional
therapy
- Objective elements
- Documented policies and procedures guide
nutritional assessment and reassessment - Patients receive food according to their clinical
needs - There is a written order for the diet
- Nutritional therapy is planned and provided in a
collaborative manner
88cont
- When families provide food, they are educated
about the patients diet limitations - Food is prepared, handled, stored and distributed
in a safe manner
89COP.18Policies and procedures guide the end of
life care
- Objective elements
- Documented policies and procedures guide the end
of life care - These policies and procedures are in consonance
with the legal requirements - These also address the identification of the
unique needs of such patient and family
90cont
- These also include sensitively addressing issues
such as autopsy and organ donation - Staff is educated and trained in end of life care
91Chapter4.MANAGEMENT OF MEDICATION (MOM)
92MOM.1Policies and procedures guide the
organization of pharmacy services and usage of
medication
- Objective elements
- There is a documented policy and procedure for
pharmacy services and medication usage - These comply with the applicable laws and
regulations
93cont
- A multidisciplinary committee guides the
formulation and implementation of these policies
and procedures
94MOM.2There is a hospital formulary
- Objective elements
- A list of medication appropriate for the patients
and organizations resources is developed - The list is developed collaboratively by the
multidisciplinary committee - There is a defined process for acquisition of
these medications - There is a process to obtain medications not
listed in the formulary
95MOM.3Policies and procedures exist for storage
of medication.
- Objective elements
- Documented policies and procedures exist for
storage of medication - Medications are stored in a clean, well lit and
ventilated environment - Sound inventory control practices guide storage
of the medications
96cont
- Medications are protected from loss or theft
- Sound alike and look alike medications are stored
separately - There is a method to obtain medication when the
pharmacy is closed - Emergency medications are available all the time
- Emergency medications are replenished in a timely
manner when used
97 MOM.4Policies and procedures guide the
prescription of medications
- Objective elements
- Documented policies and procedures exist for
prescription of medications - The organization determines who can write orders
- Orders are written in a uniform location in the
medical records
98cont
- Medication orders are clear, legible, dated,
named and signed - Policy on verbal orders is documented and
implemented - The organization defines a list of high risk
medication - High risk medication orders are verified prior to
dispensing
99MOM.4Policies and procedures guide the safe
dispensing of medications
- Objective elements
- Documented policies and procedures guide the safe
dispensing of medications - The policies include a procedure for medication
recall - Expiry dates are checked prior to dispensing
- Labeling requirements are documented and
implemented by the organization
100MOM.5 There are defined procedures for
medication administration
- Objective elements
- Medications are administered by those who are
permitted by law to do so - Prepared medication are labeled prior to
preparation of a second drug - Patient is identified prior to administration
101cont
- Medication is verified from the order prior to
administration - Dosage is verified from the order prior to
administration - Route is verified from the order prior to
administration - Timing is verified from the order prior to
administration
102cont
- Medication administration is documented
- Polices and procedures govern patients self
administration of medications - Polices and procedures govern patients
medications brought from outside the organization
103MOM.7Patients and family members are educated
about safe medication and food-drug interactions
- Objective elements
- Patient and family are educated about safe and
effective use of medication - Patient and family are educated about food-drug
interactions
104MOM.8Patients are monitored after medication
administration
- Objective elements
- Patients are monitored after medication
administration and this is documented - Adverse drug events are defined
- Adverse drug events are reported within a
specified time frame
105cont
- Adverse drug events are collected and analysed
- Policies are modified to reduce adverse drug
events when unacceptable trends occur
106MOM.9Policies and procedures guide the use of
narcotic drugs and psychotropic substances
- Objective elements
- Documented policies and procedures guide the use
of narcotic drugs and psychotropic substances - These policies are in consonance with local and
national regulations
107cont
- A proper record is kept of the usage,
administration and disposal of these drugs - These drugs are handled by appropriate personnel
in accordance with policies
108MOM.10 Policies and procedures guide the usage
of chemotherapeutic agents
- Objective elements
- Documented policies and procedures guide the
usage of chemotherapeutic agents - Chemotherapy is prescribed by those who have the
knowledge to monitor and treat the adverse effect
of chemotherapy
109cont
- Chemotherapy is prepared and administered by
qualified personnel - Chemotherapy drugs are disposed off in accordance
with legal requirements
110MOM.11Policies and procedures govern usage of
radioactive or investigational drugs
- Objective elements.
- Documented policies and procedures govern usage
of radioactive or investigational drugs - These policies and procedures are in consonance
with laws and regulations
111cont
- The policies and procedures include the safe
storage, preparation, handling, distribution and
disposal of radioactive and investigational drugs - Staff, patients and visitors are educated on
safety precautions
112MOM.12Policies and procedures guide the use of
implantable prosthesis
- Objective elements.
- Documented policies and procedures govern
procurement and usage of implantable prosthesis - Selection of implantable prosthesis is based on
scientific criteria and internationally
recognized approvals
113cont
- The batch and serial number of the implantable
prosthesis are recorded in the patients medical
record and the master logbook
114MOM.13Policies and procedures guide the use of
medical gases
- Objective elements
- Documented policies and procedures govern
procurement, handling, storage, distribution,
usage and replenishment of medical gases. - The policies and procedures address the safety
issues at all levels
115Cont
- Appropriate records are maintained in accordance
with the policies, procedures and legal
requirements.
116Chapter 5HOSPITAL INFECTION CONTROL (HIC)
117HIC.1The organization has a well-designed,
comprehensive and coordinated Hospital Infection
Control (HIC) programme aimed at reducing/
eliminating risks to patients, visitors and
providers of care.
118- Objective elements
- The hospital has a multi-disciplinary infection
control committee. - The hospital has an infection control team.
- The hospital has designated and qualified
infection control nurse(s) for this activity - The hospital infection control programme is
documented.
119HIC.2The hospital has an infection control
manual, which is periodically updated.
- Objective elements
- The manual identifies the various high-risk
areas. - It outlines methods of surveillance in the
identified high-risk areas.
120Cont
- It focuses on adherence to standard precautions
at all times. - Equipment cleaning and sterilisation practices
are included. - An appropriate antibiotic policy is established
and implemented. - Laundry and linen management processes are also
included.
121Cont
- Kitchen sanitation and food handling issues are
included in the manual - Engineering controls to prevent infections are
included - Mortuary practices and procedures are included
as appropriate to the organization
122HIC.3The infection control team is responsible
for surveillance activities in identified areas
of the hospital.
- Objective elements
- Surveillance activities are appropriately
directed towards the identified high-risk areas. - Collection of surveillance data is an ongoing
process.
123Cont
- Verification of data is done on regular basis by
the infection control team. - In cases of notifiable diseases, information (in
relevant format) is sent to appropriate
authorities. - Scope of surveillance activities incorporates
tracking and analyzing of infection risks, rates
and trends.
124HIC.4The hospital takes actions to prevent or
reduce the risks of Hospital Associated
Infections (HAI) in patients and employees.
- Objective elements
- The organization monitors urinary tract
infections. - The organization monitors respiratory tract
infections.
125Cont
- The organization monitors intra-vascular device
infections. - The organization monitors surgical site
infections. - Appropriate feedback regarding HAI rates are
provided on a regular basis to medical and
nursing staff.
126HIC.5Proper facilities and adequate resources
are provided to support the infection control
programme
- Objective elements
- Hand washing facilities in all patient care areas
are accessible to health care providers. - Compliance with proper hand washing is monitored
regularly.
127Cont
- Isolation/ barrier nursing facilities are
available. - Adequate gloves, masks, soaps, and disinfectants
are available and used correctly.
128HIC.6The hospital takes appropriate action to
control outbreaks of infections.
- Objective elements
- Hospital has a documented procedure for handling
such outbreaks. - This procedure is implemented during outbreaks.
- After the outbreak is over appropriate corrective
actions are taken to prevent recurrence
129HIC.7There are documented procedures for
sterilisation activities in the hospital.
- Objective elements
- There is adequate space available for
sterilization activities - Regular validation tests for sterilisation are
carried out and documented. - There is an established recall procedure when
breakdown in the sterilisation system is
identified
130HIC.8Statutory provisions with regard to
Bio-medical Waste (BMW) management are complied
with
- Objective elements
- The hospital is authorised by prescribed
authority for the management and handling of
Bio-medical Waste. - Proper segregation and collection of Bio-medical
Waste from all patient care areas of the hospital
is implemented and monitored.
131Cont
- The organization ensures that Bio-medical Waste
is stored and transported to the site of
treatment and disposal in proper covered vehicles
within stipulated time limits in a secure manner. - Bio-medical Waste treatment facility is managed
as per statutory provisions (if in-house) or
outsourced to authorised contractor(s).
132Cont
- Requisite fees, documents and reports are
submitted to competent authorities on stipulated
dates. - Appropriate personal protective measures are used
by all categories of staff handling Bio-medical
Waste
133HIC.9The infection control programme is
supported by hospital management and includes
training of staff and employee health
- Objective elements
- Hospital management makes available resources
required for the infection control programme - The hospital regularly earmarks adequate funds
from its annual budget in this regard.
134Cont
- It conducts regular pre-induction training for
appropriate categories of staff before joining
concerned department(s). - It also conducts regular in-service training
sessions for all concerned categories of staff at
least once in a year. - Appropriate pre and post exposure prophylaxis is
provided to all concerned staff members
135Chapter 6CONTINUOUS QUALITY IMPROVEMENT (CQI)
136CQI.1There is a structured quality assurance and
continuous monitoring programme in the
organization
- Objective elements
- The quality assurance programme is developed,
implemented and maintained by a
multi-disciplinary committee. - The quality assurance programme is documented.
137Cont
- There is a designated individual for coordinating
and implementing the quality assurance programme
- The quality assurance programme is comprehensive
and covers all the major elements related to
quality assurance and risk management.
138Cont
- The designated programme is communicated and
coordinated amongst all the employees of the
organization through proper training mechanism. - The quality assurance programme is reviewed at
predefined intervals and opportunities for
improvement are identified.
139Cont
- The quality assurance programme is a continuous
process and updated at least once in a year.
140CQI.2The organization identifies key indicators
to monitor the clinical structures, processes and
outcomes
- Objective elements
- Monitoring includes appropriate patient
assessment. - Monitoring includes diagnostics services safety
and quality control programmes. - Monitoring includes all invasive procedures.
141Cont
- Monitoring includes adverse drug events.
- Monitoring includes use of anaesthesia.
- Monitoring includes use of blood and blood
products. - Monitoring includes availability and content of
medical records. - Monitoring includes infection control activities.
- Monitoring includes clinical research.
142CQI.3The organisation identifies key indicators
to monitor the managerial structures, processes
and outcomes
- Objective elements
- Monitoring includes procurement of medication
essential to meet patient needs. - Monitoring includes reporting of activities as
required by laws and regulations.
143Cont
- 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.
144CQI.4The quality improvement programme is
supported by the management
- Objective elements
- Hospital Management makes available adequate
resources required for quality improvement
programme. - Hospital earmarks adequate funds from its annual
budget in this regard. - Appropriate statistical and management tools are
applied whenever required
145CQI.5There is an established system for audit of
patient care services
- Objective elements
- Medical staff participates in this system.
- The parameters to be audited are defined by the
organisation. - Patient and clinician anonymity is maintained.
- All audits are documented.
- Remedial measures are implemented.
146CQI.6Sentinel events are intensively analysed
- Objective elements
- The organisation has defined sentinel events.
- The organisation has established processes for
intense analysis of such events. - Sentinel events are intensively analysed when
they occur. - Actions are taken upon findings of such analysis
147Chapter 7RESPONSIBILITIES OF MANAGEMENT (ROM)
148ROM.1The responsibilities of the management are
defined
- Objective elements
- The organization has a documented organogram
- Those responsible for governance appoint the
senior leaders in the organization - Those responsible for governance support the
quality improvement plan
149Cont
- The organization complies with the laid down and
applicable legislations and regulations - Those responsible for governance address the
organizations social responsibility
150ROM.2 The services provided by each department
are documented
- Objective elements
- Each organizational program, service, site or
department has effective leadership - Scope of services of each department is defined
- Administrative policies and procedures for each
department is maintained - Departmental leaders are involved in quality
improvement
151ROM.3The organization is managed by the leaders
in an ethical manner
- Objective elements
- The leaders make public the mission statement of
the organization - The leaders establish the organizations ethical
management - The organization discloses its ownership
152Cont
- The organization honestly portrays the services
which it can and cannot provide - The organization accurately bills for its
services
153ROM.4A suitably qualified and experienced
individual heads the organisation
- Objective elements
- The designated individual has requisite and
appropriate administrative qualifications. - The designated individual has requisite and
appropriate administrative experience.
154ROM.5Leaders ensure that patient safety aspects
and risk management issues are an integral part
of patient care and hospital management
- Objective elements
- The organization has an interdisciplinary group
assigned to oversee the hospital wide safety
programme.
155Cont
- The scope of the programme is defined to include
adverse events ranging from no harm to
sentinel events. - Management ensures implementation of systems for
internal and external reporting of system and
process failures. - Management provides resources for proactive risk
assessment and risk reduction activities.
156Chapter 8FACILITY MANAGEMENT AND SAFETY (FMS)
157FMS.1The organization is aware of and complies
with the relevant rules and regulations, laws and
byelaws and requisite facility inspection
requirements
- Objective elements
- The management is conversant with the laws and
regulations and knows their applicability to the
organization.
158Cont
- Management regularly updates any amendments in
the prevailing laws of the land. - The management ensures implementation of these
requirements. - There is a mechanism to regularly update
licenses/ registrations/certifications
159FMS.2The organizations environment and
facilities operate to ensure safety of patients,
staff and visitors
- Objective elements
- There is a documented operational and maintenance
(preventive and breakdown) plan.
160Cont
- Up-to-date drawings are maintained which detail
the site layout, floor plans and fire escape
routes. - The provision of space shall be in accordance
with the available literature on good practices
(Indian or International Standards) and
directives from government agencies. - There are designated individuals responsible for
the maintenance of all the facilities.
161Cont
- Maintenance staff is contactable round the clock
for emergency repairs. - Response times are monitored from reporting to
inspection and implementation of corrective
actions.
162FMS.3The organization has a program for clinical
and support service equipment management
- Objective elements
- The organization plans for equipment in
accordance with its services and strategic plan - Equipment is selected by a collaborative process.
- All equipment is inventoried and proper logs are
maintained as required.
163Cont
- Qualified and trained personnel operate and
maintain the equipment. - Equipment are periodically inspected and
calibrated for their proper functioning. - There is a documented operational and maintenance
(preventive and breakdown) plan.
164FMS.4The organization has provisions for safe
water, electricity, medical gases and vacuum
systems
- Objective elements
- Potable water and electricity are available round
the clock. - Alternate sources are provided for in case of
failure. - The organisation regularly tests the alternate
sources. - There is a maintenance plan for piped medical gas
and vacuum installation. -
165FMS.5The organization has plans for fire and
non-fire emergencies within the facilities
- Objective elements
- The organization has plans and provisions for
early detection, abatement and containment of
fire and non-fire emergencies.
166Cont
- Staff is trained for their role in case of such
emergencies. - The organization has a documented safe exit plan
in case of fire and non-fire emergencies. - Mock drills are held at least twice in a year
167FMS.6The organization has a smoking limitation
policy
- Objective elements
- The organization defines its polices to reduce or
eliminate smoking - The policy has provisions for granting exceptions
for patients and families to smoke
168FMS.7The organization plans for handling
community emergencies, epidemics and other
disasters
- Objective elements
- The hospital identifies potential emergencies.
- The organization has a documented disaster
management plan.
169Cont
- Provision is made for availability of medical
supplies, equipment and materials during such
emergencies. - Hospital staff is trained in the hospitals
disaster management plan - The plan is tested at least twice in a year.
170FMS.8The organization has a plan for management
of hazardous materials
- Objective elements
- Hazardous materials are identified within the
organization - The hospital implements processes for sorting,
handling, storage, transporting and disposal of
hazardous material.
171Cont
- Requisite regulatory requirements are met in
respect of radioactive materials. - There is a plan for managing spills of hazardous
materials - Staff is educated and trained for handling such
materials.
172FMS.9The hospital has system in place to provide
a safe and secure environment
- Objective elements
- The hospital has a safety committee to identify
the potential safety and security risks. - This committee coordinates development,
implementation, and monitoring of the safety plan
and policies.
173Cont
- Facility inspection rounds to ensure safety are
conducted at least twice in a year in patient
care areas and at least once in a year in
non-patient care areas. - Inspection reports are documented and corrective
and preventive measures are undertaken. - There is a safety education programme for all
staff.
174Chapter9HUMAN RESOURCE MANAGEMENT
175HRM.1The organization has a documented system of
human resource planning
- Objective elements
- The organization maintains an adequate number and
mix of staff to meet the care, treatment and
service needs of the patient.
176Cont
- The required job specifications and job
description are well defined for each category of
staff. - The organization verifies the antecedents of the
potential employee with regards to
criminal/negligence background.
177HRM.2The staff joining the organization is
socialized and oriented to the hospital
environment
- Objective elements
- Each staff member, employee, student and
voluntary worker is appropriately oriented to the
organizations mission and goals.
178Cont
- Each staff member is made aware of hospital wide
policies and procedures as well as relevant
department / unit / service / programmes
policies and procedures. - Each staff member is made aware of his/her rights
and responsibilities. - All employees are educated with regard to
patients rights and responsibilities. - All employees are oriented to the service
standards of the organisation
179HRM.3There is an ongoing programme for
professional training and development of the
staff
- Objective elements
- A documented training and development policy
exists for the staff. - Training also occurs when job responsibilities
change/ new equipment is introduced. - Feedback mechanisms for assessment of training
and development programme exist.
180HRM.4Staff members, students and volunteers are
adequately trained on specific job duties or
responsibilities related to safety
- Objective elements
- All staff is trained on the risks within the
hospital environment. - Staff members can demonstrate and take actions to
report, eliminate / minimize risks.
181Cont
- Staff members are made aware of procedures to
follow in the event of an incident. - Reporting processes for common problems, failures
and user errors exist
182HRM.5An appraisal system for evaluating the
performance of an employee exists as an integral
part of the human resource management process
- Objective elements
- A well-documented performance appraisal system
exists in the organization.
183Cont
- The employees are made aware of the system of
appraisal at the time of induction. - Performance is evaluated based on the performance
expectations described in job description. - The appraisal system is used as a tool for
further development. - Performance appraisal is carried out at pre
defined intervals and is documented.
184HRM.6The organization has a well-documented
disciplinary procedure
- Objective elements
- A written statement of the policy of the
organization with regard to discipline is in
place. - The disciplinary policy and procedure is based on
the principles of natural justice.
185Cont
- The policy and procedure is known to all
categories of employees of the organization. - The disciplinary procedure is in consonance with
the prevailing laws. - There is a provision for appeals in all
disciplinary cases.
186HRM.7A grievance handling mechanism exists in
the organization
- Objective elements
- The employees are aware of the procedure to be
followed in case they feel aggrieved. - The redress procedure addresses the grievance.
- Actions are taken to redress the grievance
187HRM.8The organization addresses the health needs
of the employees
- Objective elements
- A pre-employment medical examination is conducted
on all the employees. - Health problems of the employees are taken care
of in accordance with the organizations policy.
188Cont
- Regular physical and medical checks are done
at-least once a year and the findings/ results
are documented. - Occupational health hazards are adequately
addressed.
189HRM.9There is documented personal information
for each staff member
- Objective elements
- Personal files are maintained in respect of all
employees. - The personal files contain personal information
regarding the employees qualification,
disciplinary background and health status
190Cont
- All records of in-service training and education
are contained in the personal files. - Personal files contain results of all evaluations
191 HRM.10There is a
process for collecting, verifying and evaluating
the credentials (education, registration,
training and experience) of medical
professionals permitted to provide patient care
without supervision
192- Objective elements
- Medical professionals permitted by law,
regulation and the hospital to provide patient
care without supervision is identified. - The education, registration, training and
experience of the identified medical
professionals is documented and updated
periodically. - All such information pertaining to the medical
professionals is appropriately verified when
possible.
193HRM.11There is a process for authorising all
medical professionals to admit and treat
patients and provide other clinical services
commensurate with their qualifications
194- Objective elements
- Medical professionals admit and care for patients
as per the laid down policies and authorisation
procedures of the organization - The services provided by the medical
professionals are in consonance with their
qualification, training and registration. - The requisite services to be provided by the
medical professionals are known to them as well
as the various departments / units of the
hospital.
195HRM.12There is a process for collecting,
verifying and evaluating the credentials
(education, registration, training and
experience) of nursing staff
- Objective elements
- The education, registration, training and
experience of nursing staff is documented and
updated periodically.
196Cont
- All such information pertaining to the nursing
staff is appropriately verified when possible
197 HRM.13There is a process to
identify job responsibilities and make clinical
work assignments to all nursing staff members
commensurate with their qualifications and any
other regulatory requirements
198- Objective elements
- The clinical work assigned to nursing staff is in
consonance with their qualification, training and
registration. - The services provided by nursing staf