how to acheive nabh standards in phc & chc part 2-4
TRANSCRIPT
How to achieve NABH “Process” Standards in PHCs
Dr J L MeenaState Quality Assurance Officer
Department of Health & Family welfare
Government of Gujarat
Email:- [email protected]
Web:- www.gujhealth.gov.in/quality-assurance-program.htm149
8. Access to the Facility
Objective Elements• The facility should be easily assessable by
approachable all weather roads.• There should be transport facility from main
road to the facility campus in case it is at significant distance.
• Adequate sign posting to be available at various strategic location so as to guide patients to the facility.
There should be transport facility from main road to the facility campus in case it is at significant
distance.
Adequate sign posting to be available at various strategic location so as to guide patients to the
facility.
Objective Elements• At least 1 medical officer and 1 nurse shall be
available at all times in the facility.• 3 medical officers and 3 staff nurses shall be
available on-call on 24X7 basis.• Staff shall attend to any emergency at all times
beyond the normal OPD or working hours.• At least 1 staff member should be available at
all times to provide guidance or basic information to the patients and their families.
9. Availability of Staff
Exchange a few words with the clients
At least 1 staff member should be available at all times to provide guidance or basic information to the patients and
their families.
• Facility should have Assistant Professor from Medical College designated as its Radiological Surveillance Officer.
• Facility should be guarded by Security personnel 24X7.
• Available staff should be immunized and insured for health / hospitalization.
9. Availability of Staff Cont…
Facility should have Assistant Professor from Medical College designated as its
Radiological Surveillance Officer.
Objective Elements• All patients to under go a unified assessment
with privacy and dignity.• The nurse / ANM should carry out assessment
in terms of noting the vitals, height and weight of the patient in a pre designated area of the OPD card.
• Medical officer to documented the findings of the patient in a definite area in the OPD card.
• Advise for medication and investigation to be documented in predefined areas of the card.
10. Evaluation of the Patients
The nurse / ANM should carry out assessment in terms of noting the vitals, height and weight of the patient in a
pre designated area of the OPD card.
• The documentation to be legible, timed, dated, named and signed by the medical officers.
• The instructions to be communicated to the patient in an understandable (variable and written) manner.
• The assessment of the patient is uniform in all settings i.e. casualty, OPD, Wards etc.
• Records of all such assessments to be maintained (for time limits as per regulations) in the facility.
10. Evaluation of the Patients Cont…
The instructions to be communicated to the patient in an understandable (variable and written)
manner.
Records of all such assessments to be maintained (for time limits as per regulations) in the facility.
Records of all such assessments to be maintained (for time limits as per regulations) in the facility.
Records of all such assessments to be maintained (for time limits as per regulations) in the facility.
Objective Elements• The staff should be courteous, humane and
empathetic.• Care shall commensurate with the amenities
available.• Care should be provided in manner in which
dignity and privacy of patient is maintained.• Organization should have Care, Admission,
Referral and Discharge Policies.• Organization should have written SOPs on care.
11. Care of Patients
Organization should have written SOPs on care.
Quality Manual
Infection Control Manual
Policies and SPOs
Job charts of employees
Disaster Management Manual
Forms and Formats
• Organization should have written Consent Policy.• Care shall be comprehensive in nature i.e.
preventive, promotive, curative and rehabilitative in nature.
• Documentation for all procedures carried out in the facility to be mentioned in the case records.
• All the instruction by the medical officer to be legible, dated, timed, named and signed.
• Patient admitted in the hospital to be evaluated for their progress at least twice a day.
11. Care of Patients Cont…
Care shall be comprehensive in nature i.e. preventive, promotive, curative and rehabilitative
in nature.
• Patient's condition to be communicated to the family members.
• A discharge summary to be given to the patients on their separation from hospital i.e. discharge, LAMA, Referral.
• In case of death a death summary to be given to the patients family.
• A general consent to be obtained for all patients accepted in the facility.
11. Care of Patients Cont…
A discharge summary to be given to the patients on their separation from hospital i.e. discharge, LAMA, Referral.
• An informed consent to be obtained for patients undergoing any procedures.
• A list of procedures for which informed consent to be obtained shall be available in the facility.
• The consent for shall be in vernacular / local language.
• Consent shall be obtained either by the medical officer or the nurse.
11. Care of Patients Cont…
Objective Elements• Organization should have written infection Control
Policy.• Organization should have identified / ear marked
resources for infection control.• Organization should have written protocols on cleaning
of the infection prone areas (OT, Wards and Labour room) and equipments used in patient care.
• The center shall take all precautions to control infection.
• Adherence to standard precautions to be maintained by all staff.
12. Control of Infection
Organization should have written infection Control Policy.
INDEX
S.
No
.
Contents Pa
ges
1. Responsibility for
implementation
4
2. Quality Core Group-IV
3. Amendment Sheets 5
4. Executive Summary
5. Part-I; General Information 7
6. Part-II; Infection control 9
7. Part-III; Bio-medical waste
handling and management
32
8. Part-IV; Sanitation, Hygiene
and potable water
39
9. Annexure 42
Organization should have written protocols on cleaning of the infection prone areas (OT, Wards and Labour room)
and equipments used in patient care.
• Mopping (by disinfectants) of all areas of the center to be carried out at least twice a day.
• Carbolisation of the OT, Labour Room, Laboratory to be carried out at least twice a day.
• Availability of running tap water for hand washing of staff to be maintained 24 hours a day.
• The hospital environment to be kept clean from litters, pest and stray animals.
• Adequate lighting arrangement and cross ventilation to be present in all areas.
12. Control of Infection Cont…
• Sanitation of the toilets and hygiene of the staff to be maintained.
• Adequate amount of bleaching lotion to be available for disinfection purposes.
• The labour room, OT and ward areas to be washed with soap and water regularly and a documentation there of to be maintained.
• Autoclaving of all the instruments and linen uses in the labour room, OT, dressing room to be done.
• Quality checks of the autoclave to be maintained by using quick strips.
12. Control of Infection Cont…
The labour room, OT and ward areas to be washed with soap and water regularly and a
documentation there of to be maintained
Objective Elements• Hospital waste generated shall be managed in
accordance with the Biomedical waste management and handling rules 1998.
• General waste to be collected in Green bags.• The yellow bags to be subjected to deep burial and a
pit for the same to be created with in the hospital premise according to the dimensions specified by the biomedical rules 1998.
• Facilities for syringe and needle distruction to be available and practiced.
• Chemical treatment of plastics to be carried out by using freshly prepared bleaching lotion.
13. Hospital Waste Management
S.no. Type of Waste Quantity(Kg / day)
%
1 Infectious Waste
A Pathological & Anatomical 1.5 6
B Sharp including syringe 1 4
C Non Sharp waste 7.5 30
Total 10 40
2 General WasteTotal 15 60
Grand Total 25 100
Type of Biomedical Waste Generate 30 beds Hospitals
Hospital waste generated shall be managed in accordance with the Biomedical waste management and handling rules 1998
The yellow bags to be subjected to deep burial and a pit for the same to be created with in the hospital premise according to the dimensions specified by
the biomedical rules 1998
The yellow bags to be subjected to deep burial and a pit for the same to be created with in the hospital premise according to the dimensions specified by
the biomedical rules 1998
• A site for composting of biodagradable waste to be available with in the hospital premises.
• Annual report to be submitted to the competent authority by 31st January every year.
• Accident spillage of waste shall be reported and handled as per the BMW Guidelines.
• Segregation of wastes to be done in maximum of 3 bags (Black, Yellow & Blue).
• Organization should have resources to train all health personnel on handling BMW as per regulations.
13. Hospital Waste Management Cont…
Annual report to be submitted to the competent authority by 31st January every year
ANNUALREPORT (FORM II)
(To be submitted to the prescribed authority by 31 January every year).PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
1 . Particulars of the applicant:
(i) Name of the authorized person( MO):-
(ii) Name of the institution:
Address
Tel. No
Fax No.
2. Categories of waste generated and quantity on a monthly average basis:
3. Brief details of the treatment facility:
In case of off-site facility:
Name & address of the operator
4. Category-wise quantity of waste treated:
5. Mode of treatment with details:
6. Any other information:
7. Certified that the above report is for the period from Date .............TO..................
Place............... Signature
Date................ Designation
Accident spillage of waste shall be reported and handled as per the BMW Guidelines
BIOMEDICALWASTE ACCIDENT REPORTING (FORM III)
PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP
1. Date and time of accident:-
2. Sequence of events leading to accident:-
3. The waste involved in accident :
4. Assessment of the effects of the accidents on human health
and the
environment:-
5. Emergency measures taken:-
6. Steps taken to alleviate the effects of accidents :-
7. Steps taken to prevent the recurrence of such an accident:-Place............... Signature
Date................ Designation
Organization should have resources to train all health personnel on handling BMW as per
regulations.
Objective Elements• The facility should have Reverse Osmosis (RO)
Plant.• The center shall promote sanitation hygiene and
availability of potable water in the community by involving the Panchayati Raj Institute (PRI).
• The center shall distribute chlorine tablets to the community and educate them about their usage.
• The perils of open defecation to be informed to the community.
14. Sanitation, Hygiene and Potable Water
The center shall promote sanitation hygiene and availability of potable water in the community by
involving the Panchayati Raj Institute (PRI).
• Creation of soak pit and trench lavatories to be carried out by involving the PRI.
• Health education and maintenance of hygiene to be done by adopting the principles of school health and involving public opinion makers.
• A plan to combat disasters, epidemics in the community shall be ready in the facility, communicated to all concerned and rehearsed at least twice a year.
14. Sanitation, Hygiene and Potable Water Cont…
Health education and maintenance of hygiene to be done by adopting the principles of school health
and involving public opinion makers.
A plan to combat disasters, epidemics in the community shall be ready in the facility,
communicated to all concerned and rehearsed at least twice a year.
Objective Elements• The health workers and related staff to be
involved in counseling the community regarding population stabilization, safe sex, hygiene, breast feeding, anemia, nutrition, spacing of children, Vitamin-A deficiency etc.
• Appropriate IEC tools to be available so as to create awareness amongst the community for availing the services of the center.
• Trust to be given for reproductive and child health services.
15. Counseling and IEC
The health workers and related staff to be involved in counseling the community regarding population stabilization, safe sex, hygiene, breast feeding, anemia, nutrition, spacing of children, Vitamin-A
deficiency etc.
Appropriate IEC tools to be available so as to create awareness amongst the community for availing
the services of the center.
Appropriate IEC tools to be available so as to create awareness amongst the community for availing
the services of the center.
Appropriate IEC tools to be available so as to create awareness amongst the community for availing
the services of the center.
• Staff of the center to disseminate the plans and programs (specific to the area) of the Government by using all IEC tools available e.g. posters, pamphlets, wall hangings, paintings, audiovisual tools etc.
• Counseling shall also include knowledge about HIV / AIDS and other communicable diseases.
• Organization should have policy of printing "name & contact number of doctor" on the cards (OPD & Discharge), IEC tools used.
15. Counseling and IEC Cont…
Staff of the center to disseminate the plans and programs (specific to the area) of the Government by using all IEC tools available e.g.
posters, pamphlets, wall hangings, paintings, audiovisual tools etc.
Organization should have policy of printing "name & contact number of doctor" on the cards (OPD &
Discharge), IEC tools used
Objective Elements• The organization shall give impetus to the
preventive aspect of health care.• The staff (Doctors, Nurses, ANMs, LHVS,
Pharmacist, Health Educator, Health Assistants) shall maintain open channels of communication with the patients and their families.
• Immunization shall commensurate with the universal immunization program.
• Expecting mothers to be given two doses of tetanus immunization in their antenatal checkups.
16. Preventive Health
The staff (Doctors, Nurses, ANMs, LHVS, Pharmacist, Health Educator, Health Assistants) shall maintain
open channels of communication with the patients and their families.
• New borns to be immunized according to the schedule and a card stating their immunization status and growth pattern along with the mile stones to be available with all parents.
• Field health workers shall educate about adolescent health and life style management.
Organization should be involved in : Management of disease outbreaks-
identification, classification (water-borne, vector-borne, vaccine ref-entable), incidence reporting, investigation, data collation, analysis and reporting.
16. Preventive Health Cont…
New borns to be immunized according to the schedule and a card stating their immunization status and growth pattern along with the mile
stones to be available with all parents
New borns to be immunized according to the schedule and a card stating their immunization status and growth pattern along with
the mile stones to be available with all parents
Management of disease outbreaks-identification, classification (water-borne, vector-borne, vaccine ref-entable), incidence reporting,
investigation, data collation, analysis and reporting“District Authority”.
Water quality surveillance. Disaster mapping-identification,
preparedness (equipments, antidotes, emergency care, referral services) and networking.
• Organization should have identified resources (equipments & drugs) for handling such preventive programmes / actions.
16. Preventive Health Cont…
Disaster mapping-identification, preparedness (equipments, antidotes, emergency care,
referral services) and networking.
Organization should have identified resources (equipments & drugs) for handling such
preventive programmes / actions.
Objective Elements• The center shall participate in all the National
Health programs as stated in IPHS.• Community mobilization and their
participation to make the program successful is responsibility of the center.
• Report of such program shall be submitted to the authorities periodically by the MOIC.
17. Participation in National Health Programs
Community mobilization and their participation to make the program successful is responsibility of
the center
18. Referral Services
Objective Elements• The center shall practice a bi-directional or
standardized referral system as per the policy.• The referral cards (with contact numbers) according to
the colour coding to be available and a document there of to be maintained.
• Patient shall be referred from the FRU / Sub-center or referral to CHC or District Hospital.
• All such patient to be followed up for their profress by the MOIC.
• Entries of the transferring in or out to be maintained in register or the computer.
The referral cards (with contact numbers) according to the colour coding to be available and a
document there of to be maintained
19. Community Mobilization with PRI
Objective Elements• The organization shall have a continuous interaction
with the PRI.• All meeting should be planned and that the agenda of
meeting should be area specific and / or as per the requirements of the community.
• All meeting to be documented.• Diseases profile along with seasonal variation to be
discussed and appropriate proactive intervention to be planed.
• Gatekeeper approach in in mobilizing the community shall be follow.
All meeting should be planned and that the agenda of meeting should be area specific and / or as per
the requirements of the community
Diseases profile along with seasonal variation to be discussed and appropriate proactive intervention
to be planed
20. Social Responsibility
Objective Elements• The center shall understand that it is an
integral part of the society.• The center shall carry out camps, melas, and
healthy competitions etc. periodically.• Respect to the senior citizens and active
participation in school health shall be documented.
• Training to the community on household remedies and first aid shall to be carried out and documented.
• A sense of ownership of the facility by the community to be created.
• Centre shall participate in all cultural activities in the community.
20. Social Responsibility Cont…
Training to the community on household remedies and first aid shall to be carried out and
documented