*Components of Standards DevelopmentMultiple Information SourcesScientific literatureJCI StandardsUK Healthcare Quality StandardsThailand StandardsAHA Draft StandardsJCI Survey compliance dataResearch FindingsIndividual input from field experts and key stakeholdersISO 9001-2000

*Hospital StandardsOrganized 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

*NABH Standards10 Chapters

100 Standards

503 Objective Elements

*Standards and Objective ElementsA 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

*Section I:Patient-Centered StandardsSTDOEAccess, Assessment and Continuity of Care (AAC)1578

Patients Rights and Education (PRE)529

Care of Patients (COP)18 105

Management of Medications (MOM)1361

Hospital Infection Control (HIC)944

*Section II: Health Care Organization Management StandardsSTDOE

Continuous Quality Improvement (CQI)637

Responsibilities of Management (ROM)520

Facility Management & Safety (FMS)941

Human Resource Management (HRM)1347

Information Management Systems (IMS)741100503

*NABH STANDARDS

*Introduction 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.

*Details 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).

*Chapter 1.ACCESS,ASSESSMENT AND CONTINIUITY OF CARE (AAC)

*

AAC.1The organization defines and displays the services that it can provide Objective ElementsThe services being provided are clearly defined.The defined services are prominently displayed.The staff is oriented to these services

*AAC.2The organization has a well defined registration and admission process Objective elementsStandardized policies and procedures are used for registering and admitting patientsThe policies and procedures address out- patients, in-patients and emergency patients

*Cont

Patients are accepted only if the organization can provide the required serviceThe policies and procedures also address managing patients during non availability of bedsThe staff is aware of these processes

*AAC.3There is an appropriate mechanism for transfer or referral of patients who do not match the organizational resources

Objective elementsPolicies guide the transfer of unstable patients to another facility in an appropriate mannerPolicies guide the transfer of stable patients to another facility

*ContProcedures identify staff responsible during transferThe organization gives a summary of patients condition and the treatment given

*AAC.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 careThe patients and/or family members are explained about the expected results

*ContThe patients and/or family members are explained about the possible complications The patients and/or family members are explained about the expected costs.

*AAC.5Patients cared for by the organization undergo an established initial assessment Objective elementsThe organization defines the content of the assessments for the outpatients, in-patients and emergency patients. The organization determines who can perform the assessments.

*contThe 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.

*ContThe initial assessment results in a documented plan of care.The plan of care also includes preventive aspects of the care

*AAC.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.

*AAC.7Laboratory services are provided as per the requirements of the patients Objective elementsScope of the laboratory services are commensurate to the services provided by the organization Adequately qualified and trained personnel perform and/or supervise the investigations.

*cont..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.

*AAC.8There is an established laboratory quality assurance programme

Objective elementsThe laboratory quality assurance programme is documented. The programme addresses verification and validation of test methods. The programme addresses surveillance of test results.

*contThe programme includes periodic calibration and maintenance of all equipments.The programme includes the documentation of corrective and preventive actions

*AAC.9There is an established laboratory safety programme Objective elements.The laboratory safety programme is documented. This programme is integrated with the organizations safety programme.

*contWritten 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.

*AAC.10Imaging services are provided as per the requirements of the patients Objective elementsImaging 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.

*contPolicies 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.

*AAC.11There is an established Quality assurance programme for imaging services Objective elementsThe quality assurance programme for imaging services is documented. The programme addresses verification and validation of imaging methods The programme addresses surveillance of imaging results

*contThe programme includes periodic calibration and maintenance of all equipments.The programme includes the documentation of corrective and preventive actions

*AAC.12There is an established radiation safety programme

Objective elementsThe 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.

*contImaging personnel are provided with appropriate radiation safety devicesRadiation 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.

*AAC.13Patient care is continuous and multidisciplinary in nature Objective elementsDuring 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.

*contInformation 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.

*AAC.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

*contPolicies 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)

*AAC.15Organisation defines the content of the discharge summary Objective elements Discharge summary is provided to the patients at the time of dischargeDischarge summary contains the reasons for admission, significant findings and diagnosis and the patients condition at the time of discharge.

*contDischarge summary contains information regarding investigation results, any procedure performed, medication and other treatment givenDischarge summary contains follow up advice, medication and other instructions in an understandable manner.

*contDischarge summary incorporates instructions about when and how to obtain urgent careIn 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

*Chapter .2PATIENT RIGHT AND EDUCATION (PRE)

*PRE.1The organization protects patient and family rights during care

Objective elementPatient and family rights are documented. Patients and families are informed of their rights in a format and language that they can understand

*contThe organizations leaders protect patients rightsStaff is aware of their responsibility in protecting patients rightsViolation of patient rights is reviewed and corrective/preventive measures taken

*PRE.2.Patient rights support individual beliefs, values and involve the patient and family in decision making processes Objective elementsPatient rights include respect for personal dignity and privacy during examination, procedures and treatmentPatient rights include protection from physical abuse or neglect

*contPatient rights include treating patient information as confidentialPatient rights include refusal of treatmentPatient rights include informed consent before anesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment

*contPatient rights include information and consent before any research protocol is initiatedPatient rights include information on how to voice a complaintPatient rights include information on the expected cost of the treatmentPatient has a right to have an access to his / her clinical records

*PRE.3A documented process for obtaining patient and / or families consent exists for informed decision making about their care

Objective elementsGeneral consent for treatment is obtained when the patient enters the organization

*contPatient and/or his family members are informed of the scope of such general consentThe organization has listed those procedures and treatment where informed consent is requiredInformed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understandThe policy describes who can give consent when patient is incapable of independents decision making.

*PRE.4Patient and families have a right to information and education about their healthcare needs

Objective elementsWhen appropriate, patient and families are educated about the safe and effective use of medication and the potential side effects of the medicationPatient and families are educated about diet and nutrition

*contPatient and families are educated about immunizationsPatient and families are educated about their specific disease process, complications and prevention strategiesPatient and families are educated about preventing infectionsPatients are taught in a language and format that they can understand

*PRE.5. Patient and families have a right to information on expected costs

Objective elementsThere is uniform pricing policy in a given setting (out-patient and ward category)The tariff list is available to patientsPatients are educated about the estimated costs of treatment

*contPatients are informed about the estimated costs when there is a change in the patient condition or treatment setting

*Chapter 3.Care of Patients (COP)

*COP.1Uniform care of patients is guided by the applicable laws and regulations

Objective elementsCare delivery is uniform when similar care is provided in more than one settingUniform care is guided by policies and procedures which reflect applicable laws and regulations

*contThe care and treatment orders are signed, named, timed and dated by the concerned doctorThe care plan is countersigned by the clinician in-charge of the patient within 24 hoursEvidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible

*COP.2Emergency services are guided by policies, procedures, applicable laws and regulations Objective elementsPolicies and procedure for emergency care are documentedPolicies also address handling of medico-legal casesThe patients receive care in consonance with the policies

*contPolicies and procedures guide the triage of patients for initiation of appropriate careStaff is familiar with the policies and trained on the procedures for care of emergency patientsAdmission or discharge to home or transfer to another organization is also documented

*COP.3The ambulance services are commensurate with the scope of the services provided by the organization Objective elementsThere is adequate access and space for the ambulance(s)Ambulance(s) is appropriately equippedAmbulance(s) is manned by trained personnel

*contThere is a checklist of all equipment and emergency medicationsEquipment are checked on a daily basisEmergency medications are checked daily and prior to dispatchThe ambulance(s) has a proper communication system

*COP.4Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation Objective elementsDocumented policies and procedures guide the uniform use of resuscitation throughout the organizationStaff providing direct patient care is trained and periodically updated in cardio pulmonary resuscitation

*contThe events during a cardio-pulmonary resuscitation are recordedAn analysis of all cardiac arrests is doneA multidisciplinary committee monitors the effectiveness of cardio-pulmonary resuscitation

*COP.5Policies and procedures define rational use of blood and blood products Objective elementsDocumented policies and procedures are used to guide rational use of blood and blood productsThe transfusion services are governed by the applicable laws and regulations

*ContInformed consent is obtained for donation and transfusion of blood and blood productsInformed consent also includes patient and family education about donationStaff is trained to implement the policiesTransfusion reactions are analyzed for preventive and corrective actions

*COP.6Policies and procedures guide the care of patients in the Intensive care and high dependency units Objective elementsThe organization has documented admission and discharge criteria for its intensive care and high dependency unitsStaff is trained to apply these criteria

*contAdequate staff and equipment are availableDefined procedures for situation of bed shortages are followedInfection control practices are followedThe unique needs of end of life patients are identified and cared forA quality assurance program is implemented

*COP.7Policies and procedures guide the care of vulnerable patients (elderly, children, physically and/or mentally challenged) Objective elementsPolicies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines

*contStaff is trained to care for this vulnerable groupCare is organized and delivered in accordance with the policies and proceduresThe organization provides for a safe and secure environment for this vulnerable groupA documented procedure exists for obtaining informed consent from the appropriate legal representative

*COP.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 notPersons caring for high risk obstetric cases are competent

*contHigh risk obstetric patients assessment also includes maternal nutritionThe organization has the facilities to take care of neonates of high risk pregnancies

*COP.9Policies and procedures guide the care of pediatric patients Objective elements.The organization defines and displays the scope of its pediatric servicesThe policy for care of neonatal patients is in consonance with the national/ international guidelinesThose who care for children have age specific competency

*contProvisions are made for special care of childrenPatient assessment includes detailed nutritional, growth, psychosocial and immunization assessmentPolicies and procedures prevent child/ neonate abduction and abuse

*contThe childrens family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record

*COP.10 Policies and procedures guide the care of patients undergoing moderate sedation Objective elementsCompetent and trained persons perform sedationThe person administering and monitoring sedation is different from the person performing the procedure

*contIntra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedationPatients are monitored after sedationCriteria are used to determine appropriateness of discharge from the recovery areaEquipment and manpower are available to rescue patients from a deeper level of sedation than that intended

*COP.11Policies and procedures guide the administration of anesthesia Objective elementsThere is a documented policy and procedure for the administration of anesthesiaAll patients for anesthesia have a pre-anesthesia assessment by a qualified individual

*contThe 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 anesthetistDuring 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

*contEach patients post-anesthesia status is monitored and documentedA qualified individual applies defined criteria to transfer the patient from the recovery areaAll adverse anesthesia events are recorded and monitored

*COP.12Policies and procedures guide the care of patients undergoing surgical procedures Objective elementsThe policies and procedures are documentedSurgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery

*contAn informed consent is obtained by a surgeon prior to the procedureDocumented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgeryPersons qualified by law are permitted to perform the procedures that they are entitled to performAn operative note is documented prior to transfer out of patient from recovery area

*contThe operating surgeon documents the post-operative plan of careA quality assurance program is followed for the surgical servicesThe quality assurance program includes surveillance of the operation theatre environmentThe plan also includes monitoring of surgical site infection rates

*COP.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 restraintsThese include both physical and chemical restraint measures

*contThese include documentation of reasons for restraintsThese patients are more frequently monitoredStaff receive training and periodic updating in control and restraint techniques

*COP.14Policies and procedures guide appropriate pain management Objective elementsDocumented policies and procedures guide the management of painThe organization respects and supports the appropriate assessment and management of pain for all patientsPatient and family are educated on various pain management techniques

*COP.15Policies and procedures guide appropriate rehabilitative services Objective elementsDocumented policies and procedures guide the provision of rehabilitative servicesThese services are commensurate with the organizational requirementsRehabilitative services are provided by a multidisciplinary team

*COP.16Policies and procedures guide all research activities Objective elements.Documented policies and procedures guide all research activities in compliance with national and international guidelinesThe organization has an ethics committee to oversee all research activitiesThe committee has the powers to discontinue a research trial when risks outweigh the potential benefits

*contPatients informed consent is obtained before entering them in research protocolsPatients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawalPatients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organizations services

*COP.17Policies and procedures guide nutritional therapy Objective elementsDocumented policies and procedures guide nutritional assessment and reassessmentPatients receive food according to their clinical needsThere is a written order for the dietNutritional therapy is planned and provided in a collaborative manner

*contWhen families provide food, they are educated about the patients diet limitationsFood is prepared, handled, stored and distributed in a safe manner

*COP.18Policies and procedures guide the end of life care Objective elementsDocumented policies and procedures guide the end of life careThese policies and procedures are in consonance with the legal requirementsThese also address the identification of the unique needs of such patient and family

*contThese also include sensitively addressing issues such as autopsy and organ donationStaff is educated and trained in end of life care

*Chapter4.MANAGEMENT OF MEDICATION (MOM)

*MOM.1Policies and procedures guide the organization of pharmacy services and usage of medication Objective elementsThere is a documented policy and procedure for pharmacy services and medication usageThese comply with the applicable laws and regulations

*contA multidisciplinary committee guides the formulation and implementation of these policies and procedures

*MOM.2There is a hospital formulary Objective elementsA list of medication appropriate for the patients and organizations resources is developedThe list is developed collaboratively by the multidisciplinary committeeThere is a defined process for acquisition of these medicationsThere is a process to obtain medications not listed in the formulary

*MOM.3Policies and procedures exist for storage of medication.

Objective elementsDocumented policies and procedures exist for storage of medicationMedications are stored in a clean, well lit and ventilated environmentSound inventory control practices guide storage of the medications

*contMedications are protected from loss or theftSound alike and look alike medications are stored separatelyThere is a method to obtain medication when the pharmacy is closedEmergency medications are available all the timeEmergency medications are replenished in a timely manner when used

* MOM.4Policies and procedures guide the prescription of medications Objective elementsDocumented policies and procedures exist for prescription of medications The organization determines who can write ordersOrders are written in a uniform location in the medical records

*contMedication orders are clear, legible, dated, named and signedPolicy on verbal orders is documented and implementedThe organization defines a list of high risk medicationHigh risk medication orders are verified prior to dispensing

*MOM.4Policies and procedures guide the safe dispensing of medications Objective elementsDocumented policies and procedures guide the safe dispensing of medicationsThe policies include a procedure for medication recallExpiry dates are checked prior to dispensingLabeling requirements are documented and implemented by the organization

*MOM.5 There are defined procedures for medication administration

Objective elementsMedications are administered by those who are permitted by law to do soPrepared medication are labeled prior to preparation of a second drugPatient is identified prior to administration

*contMedication is verified from the order prior to administrationDosage is verified from the order prior to administrationRoute is verified from the order prior to administrationTiming is verified from the order prior to administration

*contMedication administration is documentedPolices and procedures govern patients self administration of medicationsPolices and procedures govern patients medications brought from outside the organization

*MOM.7Patients and family members are educated about safe medication and food-drug interactions Objective elementsPatient and family are educated about safe and effective use of medicationPatient and family are educated about food-drug interactions

*MOM.8Patients are monitored after medication administration Objective elementsPatients are monitored after medication administration and this is documentedAdverse drug events are definedAdverse drug events are reported within a specified time frame

*contAdverse drug events are collected and analysedPolicies are modified to reduce adverse drug events when unacceptable trends occur

*MOM.9Policies and procedures guide the use of narcotic drugs and psychotropic substances Objective elementsDocumented policies and procedures guide the use of narcotic drugs and psychotropic substancesThese policies are in consonance with local and national regulations

*contA proper record is kept of the usage, administration and disposal of these drugsThese drugs are handled by appropriate personnel in accordance with policies

*MOM.10Policies and procedures guide the usage of chemotherapeutic agents Objective elementsDocumented policies and procedures guide the usage of chemotherapeutic agentsChemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy

*contChemotherapy is prepared and administered by qualified personnelChemotherapy drugs are disposed off in accordance with legal requirements

*MOM.11Policies and procedures govern usage of radioactive or investigational drugs Objective elements.Documented policies and procedures govern usage of radioactive or investigational drugsThese policies and procedures are in consonance with laws and regulations

*contThe policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugsStaff, patients and visitors are educated on safety precautions

*MOM.12Policies and procedures guide the use of implantable prosthesis Objective elements.Documented policies and procedures govern procurement and usage of implantable prosthesisSelection of implantable prosthesis is based on scientific criteria and internationally recognized approvals

*contThe batch and serial number of the implantable prosthesis are recorded in the patients medical record and the master logbook

*MOM.13Policies and procedures guide the use of medical gases Objective elementsDocumented 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

*ContAppropriate records are maintained in accordance with the policies, procedures and legal requirements.

*Chapter 5HOSPITAL INFECTION CONTROL (HIC)

*HIC.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.

*Objective elementsThe 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 activityThe hospital infection control programme is documented.

*HIC.2The hospital has an infection control manual, which is periodically updated. Objective elementsThe manual identifies the various high-risk areas.It outlines methods of surveillance in the identified high-risk areas.

*ContIt 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.

*ContKitchen sanitation and food handling issues are included in the manualEngineering controls to prevent infections are included Mortuary practices and procedures are included as appropriate to the organization

*HIC.3The infection control team is responsible for surveillance activities in identified areas of the hospital. Objective elementsSurveillance activities are appropriately directed towards the identified high-risk areas.Collection of surveillance data is an ongoing process.

*ContVerification 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.

*HIC.4The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees. Objective elementsThe organization monitors urinary tract infections.The organization monitors respiratory tract infections.

*ContThe 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.

*HIC.5Proper facilities and adequate resources are provided to support the infection control programme Objective elementsHand washing facilities in all patient care areas are accessible to health care providers. Compliance with proper hand washing is monitored regularly.

*ContIsolation/ barrier nursing facilities are available.Adequate gloves, masks, soaps, and disinfectants are available and used correctly.

*HIC.6The hospital takes appropriate action to control outbreaks of infections. Objective elementsHospital 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

*HIC.7There are documented procedures for sterilisation activities in the hospital. Objective elementsThere is adequate space available for sterilization activitiesRegular validation tests for sterilisation are carried out and documented.There is an established recall procedure when breakdown in the sterilisation system is identified

*HIC.8Statutory provisions with regard to Bio-medical Waste (BMW) management are complied with Objective elementsThe 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.

*ContThe 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).

*ContRequisite 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

*HIC.9The infection control programme is supported by hospital management and includes training of staff and employee health Objective elementsHospital management makes available resources required for the infection control programmeThe hospital regularly earmarks adequate funds from its annual budget in this regard.

*ContIt 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

*Chapter 6CONTINUOUS QUALITY IMPROVEMENT (CQI)

*CQI.1There is a structured quality assurance and continuous monitoring programme in the organization Objective elementsThe quality assurance programme is developed, implemented and maintained by a multi-disciplinary committee. The quality assurance programme is documented.

*ContThere 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.

*ContThe 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.

*ContThe quality assurance programme is a continuous process and updated at least once in a year.

*CQI.2The organization identifies key indicators to monitor the clinical structures, processes and outcomes Objective elementsMonitoring includes appropriate patient assessment.Monitoring includes diagnostics services safety and quality control programmes.Monitoring includes all invasive procedures.

*ContMonitoring 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.

*CQI.3The organisation identifies key indicators to monitor the managerial structures, processes and outcomes

Objective elementsMonitoring includes procurement of medication essential to meet patient needs.Monitoring includes reporting of activities as required by laws and regulations.

*ContMonitoring 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.

*CQI.4The quality improvement programme is supported by the management Objective elementsHospital 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

*CQI.5There is an established system for audit of patient care services Objective elementsMedical 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.

*CQI.6Sentinel events are intensively analysed Objective elementsThe 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

*Chapter 7RESPONSIBILITIES OF MANAGEMENT (ROM)

*ROM.1The responsibilities of the management are defined Objective elementsThe organization has a documented organogram Those responsible for governance appoint the senior leaders in the organizationThose responsible for governance support the quality improvement plan

*ContThe organization complies with the laid down and applicable legislations and regulationsThose responsible for governance address the organizations social responsibility

*ROM.2 The services provided by each department are documented

Objective elementsEach organizational program, service, site or department has effective leadership Scope of services of each department is definedAdministrative policies and procedures for each department is maintainedDepartmental leaders are involved in quality improvement

*ROM.3The organization is managed by the leaders in an ethical manner Objective elementsThe leaders make public the mission statement of the organizationThe leaders establish the organizations ethical managementThe organization discloses its ownership

*ContThe organization honestly portrays the services which it can and cannot provideThe organization accurately bills for its services

*ROM.4A suitably qualified and experienced individual heads the organisation

Objective elementsThe designated individual has requisite and appropriate administrative qualifications.The designated individual has requisite and appropriate administrative experience.

*ROM.5Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management

Objective elementsThe organization has an interdisciplinary group assigned to oversee the hospital wide safety programme.

*ContThe 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.

*Chapter 8FACILITY MANAGEMENT AND SAFETY (FMS)

*FMS.1The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements Objective elementsThe management is conversant with the laws and regulations and knows their applicability to the organization.

*ContManagement 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

*FMS.2The organizations environment and facilities operate to ensure safety of patients, staff and visitors Objective elementsThere is a documented operational and maintenance (preventive and breakdown) plan.

*ContUp-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.

*ContMaintenance staff is contactable round the clock for emergency repairs. Response times are monitored from reporting to inspection and implementation of corrective actions.

*FMS.3The organization has a program for clinical and support service equipment management Objective elementsThe organization plans for equipment in accordance with its services and strategic planEquipment is selected by a collaborative process.All equipment is inventoried and proper logs are maintained as required.

*ContQualified 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.

*FMS.4The organization has provisions for safe water, electricity, medical gases and vacuum systems Objective elementsPotable 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.

*FMS.5The organization has plans for fire and non-fire emergencies within the facilities Objective elementsThe organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies.

*ContStaff 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

*FMS.6The organization has a smoking limitation policy

Objective elementsThe organization defines its polices to reduce or eliminate smokingThe policy has provisions for granting exceptions for patients and families to smoke

*FMS.7The organization plans for handling community emergencies, epidemics and other disasters Objective elementsThe hospital identifies potential emergencies. The organization has a documented disaster management plan.

*ContProvision is made for availability of medical supplies, equipment and materials during such emergencies. Hospital staff is trained in the hospitals disaster management planThe plan is tested at least twice in a year.

*FMS.8The organization has a plan for management of hazardous materials

Objective elementsHazardous materials are identified within the organizationThe hospital implements processes for sorting, handling, storage, transporting and disposal of hazardous material.

*Cont

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.

*FMS.9The hospital has system in place to provide a safe and secure environment Objective elementsThe 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.

*ContFacility 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.

*Chapter9HUMAN RESOURCE MANAGEMENT

*HRM.1The organization has a documented system of human resource planning Objective elementsThe organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient.

*ContThe 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.

*HRM.2The staff joining the organization is socialized and oriented to the hospital environment Objective elementsEach staff member, employee, student and voluntary worker is appropriately oriented to the organizations mission and goals.

*ContEach 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

*HRM.3There is an ongoing programme for professional training and development of the staff Objective elementsA 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.

*HRM.4Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety Objective elementsAll staff is trained on the risks within the hospital environment. Staff members can demonstrate and take actions to report, eliminate / minimize risks.

*ContStaff members are made aware of procedures to follow in the event of an incident. Reporting processes for common problems, failures and user errors exist

*HRM.5An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process Objective elementsA well-documented performance appraisal system exists in the organization.

*ContThe 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.

*HRM.6The organization has a well-documented disciplinary procedure Objective elementsA 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.

*ContThe 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.

*HRM.7A grievance handling mechanism exists in the organization Objective elementsThe 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

*HRM.8The organization addresses the health needs of the employees Objective elementsA 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.

*ContRegular physical and medical checks are done at-least once a year and the findings/ results are documented.Occupational health hazards are adequately addressed.

*HRM.9There is documented personal information for each staff member Objective elementsPersonal files are maintained in respect of all employees.The personal files contain personal information regarding the employees qualification, disciplinary background and health status

*ContAll records of in-service training and education are contained in the personal files.Personal files contain results of all evaluations

* 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

*Objective elementsMedical 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.

*HRM.11There is a process for authorising all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications

*Objective elementsMedical professionals admit and care for patients as per the laid down policies and authorisation procedures of the organizationThe 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.

*HRM.12There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of nursing staff Objective elementsThe education, registration, training and experience of nursing staff is documented and updated periodically.

*ContAll such information pertaining to the nursing staff is appropriately verified when possible

* 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

*Objective elementsThe clinical work assigned to nursing staff is in consonance with their qualification, training and registration.The services provided by nursing staff are in accordance with the prevailing laws and regulations.The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the hospital

*Chapter.10INFORMATION MANAGEMENT SYSTEM (IMS)

* IMS.1Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require data and information from the organization

*Objective elementsThe information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organizationPolicies and procedures to meet the information needs are documented.These policies and procedures are in compliance with the prevailing laws and regulations.

*ContAll information management and technology acquisitions are in accordance with the policies and procedures.The organization contributes to external databases in accordance with the law and regulations

*IMS.2The organization has processes in place for effective management of data

Objective elementsFormats for data collection are standardized Necessary resources are available for analyzing data

*ContDocumented procedures are laid down for timely and accurate dissemination of data Documented procedures exist for storing and retrieving dataAppropriate clinical and managerial staff participates in selecting, integrating and using data.

*IMS.3The organization has a complete and accurate medical record for every patient Objective elements Every medical record has a unique identifier.Organization policy identifies those authorized to make entries in medical record.

*ContEvery medical record entry is dated and timed.The author of the entry can be identifiedThe contents of medical record are identified and documentedThe record provides an up-to-date and chronological account of patient care

*IMS.4The medical record reflects continuity of care Objective elementsThe medical record contains information regarding reasons for admission, diagnosis and plan of care.Operative and other procedures performed are incorporated in the medical record

*ContWhen patient is transferred to another hospital, the medical record contains the date of transfer, the reason for the transfer and the name of the receiving hospitalThe medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel

*ContIn case of death, the medical record contains a copy of the death certificate indicating the cause, date and time of death.Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same.Care providers have access to current and past medical record.

* IMS.5Policies and procedures are in place for maintaining confidentiality, integrity and security of information Objective elementsDocumented policies and procedures exist for maintaining confidentiality, security and integrity of information

*ContPolicies and procedures are in consonance with the applicable laws The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tamperingThe hospital has an effective process of monitoring compliance of the laid down policy

*ContThe hospital uses developments in appropriate technology for improving, confidentiality, integrity and securityPrivileged health information is used for the purposes identified or as required by law and not disclosed without the patients authorization

*ContA documented procedure exists on how to respond to patients / physicians and other public agencies requests for access to information in the clinical record in accordance with the local and national law.

*IMS.6Policies and procedures exist for retention time of records, data and information Objective elementsDocumented policies and procedures are in place on retaining the patients clinical records, data and informationThe policies and procedures are in consonance with the local and national laws and regulations

*ContThe retention process provides expected confidentiality and securityThe destruction of medical records, data and information is in accordance with the laid down policy

*IMS.7The organization regularly carries out medical audits Objective elementsThe medical records are reviewed periodicallyThe review uses a representative sampleThe review is conducted by identified care providers.

*ContThe review focuses on the timeliness, legibility and completeness of the medical recordsThe review process includes records of both active and discharged patientsThe review points out and documents any deficiencies in recordsAppropriate corrective and preventive measures undertaken are documented.

*Thank you

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