self assessment kit-yoga naturopathy

8/9/2019 Self Assessment Kit-Yoga Naturopathy

1/57

Self Assessment Toolkit -Yoga and Naturopathy Hospital

Compliance to the requirement: 10

Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total samples selected)

Non-compliance to the requirement: 0

Not pplicable: N

!"aluation Criteria during final assessment:

Special Note:

(Name # ddress of the $oga and Naturopath

&rganisation is required to pro"ide self assessment report in the format 'elf ssessment ool*it' gi"en belo+, ll the entries are to be properly filledup, egarding scoring follo+ing criteria +ould be applicable,

• No indi"idual standard should ha"e more than one .ero to qualify, %o+e"er/ no .ero is accepted in the regulatory legal requirements,

• he a"erage score for indi"idual standard must not be less than 5,

• he a"erage score for indi"idual chapter must not be less than ,

• he o"erall a"erage score for all standards must e2ceed ,

elf assessments should be done by the hospital in a stringent manner and if at the time of Pre assessment it is found thatthere is a significant difference bet+een the self assessment and the pre assessment report then organisations can apply forfinal assessment not earlier than si2 months from the date of completion of Pre assessment,


2/57

SELF ASSESSENT T!!L"#T

Elements

a, he ser"ices being pro"ided are clearly defined and are in consonance +ith the needs,

b, he defined ser"ices are prominently displayed,

c, he staff is oriented to these ser"ices,

a, tandardised policies and procedures are used for registering and admitting patients,

b, he policies and procedures address out-patients/ in-patients and emergency patients,

c, Patients are accepted only if the organi.ation can pro"ide the required ser"ice,

d, he policies and procedures also address managing patients during non a"ailability of beds,

e, he staff is a+are of these processes,

a, Policies guide the transfer of unstable patients to another facility in an appropriate manner,

$ocumentation%Yes& No'

#mplementation%Yes& No'

E(idence%cross reference to

documents&

manuals etc)'

Scores%*& +& ,*'

hapter ,: Access. Assessment and ontinuity of are%AA'

AA),) The organi/ation defines and displays the ser(ices that it canpro(ide)

AA)0) The organi/ation has a 1ell defined registration and admissionprocess)

AA)2) There is an appropriate mechanism for transfer or referral ofpatients 1ho do not match the organi/ational resources)


3/57

b, Policies guide the transfer of stable patients to another facility,

c, Procedures identify staff responsible during transfer,

a, he patients andor family members are e2plained about the proposed care,

b, he patients andor family members are e2plained about the e2pected results,

c, he patients andor family members are e2plained about the possible complications,

d, he patients andor family members are e2plained about the e2pected costs,

a, he organi.ation determines +ho can perform the assessments,

c, he plan of care also includes pre"enti"e aspects of the care,

a, ll patients are reassessed at appropriate inter"als,

AA)3) !rgani/ation defines the content of the discharge summary)

a, 3ischarge summary is pro"ided to the patients at the time of discharge,

d, he organi.ation gi"es a summary of patient4s condition/ in"estigations done and thetreatment gi"en,

AA)4) $uring admission the patient and & or the family mem5ers areeducated to make informed decisions)

AA)+) 6atients cared for 5y the organi/ation undergo an esta5lishedinitial assessment)

b, he initial assessment includes thorough physical chec*up/ in"estigations along +ithscreening for nutritional needs,

AA)7) All patients cared for 5y the organi/ation undergo a regular

reassessment)

b, Patients are reassessed to determine their response to treatment and to plan furthertreatment or discharge,


4/57

e, 3ischarge summary incorporates instructions about +hen and ho+ to obtain urgent care,

f, n case of death the summary of the case also includes the cause of death,

hapter 0: are of 6atients %!6'

!6)0 ) 6olicies and procedures guide appropriate pain management)

a, 3ocumented policies and procedures guide the management of pain,

c, Patient and family are educated on "arious pain management techniques,

!6)2 ) 6olicies and procedures guide all research acti(ities)

b, he organi.ation has an ethics committee to o"ersee all research acti"ities,

d, Patient4s informed consent is obtained before entering them in research protocols,

b, 3ischarge summary contains the reasons for admission/ significant findings and diagnosisand the patient4s condition at the time of discharge,

c, 3ischarge summary contains information regarding in"estigation results/ any procedureperformed/ medication and other treatment gi"en,

d, 3ischarge summary contains follo+ up ad"ice/ medication and other instructions in anunderstandable manner,

!6),) The am5ulance ser(ices are commensurate 1ith the scope of theser(ices pro(ided 5y the organi/ation)

a, he hospital should ha"e arrangement +ith emergency ambulance ser"ice and restrainttechniques,

b, he organi.ation respects and supports the appropriate assessment and management ofpain for all patients,

a, 3ocumented policies and procedures guide all research acti"ities in compliance +ith nationaland international guidelines,

c, he committee has the po+ers to discontinue a research trial +hen ris*s out+eigh thepotential benefits,

e, Patients are informed of their right to +ithdra+ from the research at any stage and also of the

consequences (if any) of such +ithdra+al


5/57

g, he entire research acti"ities should focus on Naturopathy # $oga,

!6)4) 6olicies and procedures guide nutritional therapy)

a, 3ocumented policies and procedures guide nutritional assessment and reassessment,

b, Patients recei"e food according to their clinical needs,

c, here is a +ritten order for the diet,

d, Nutritional therapy is planned and pro"ided in a collaborati"e manner,

e, 6hen families pro"ide food/ they are educated about the patients diet limitations,

f, 7ood is prepared/ handled/ stored and distributed in a safe manner,

hapter 2 6atient 8ights and Education %68E'

a, Patient and family rights address any special preferences/ spiritual and cultural needs,

c, Patient and family r ights include protection from physical abuse or neglect,

f, Patients are assured that their refusal to participate or +ithdra+al from participation +ill notcompromise their access to the organi.ation4s ser"ices,

3egree3iploma of minimum 8 years duration from recogni.ed 9edical College and ni"ersity,%e should also possess Class ; medical registration either from tateCentral

i, he doctors of other medical disciplines i,e, llopthyyur"eda%omoeonani # iddha etc,can under ta*e research acti"ities in Naturopathy # $oga sub


6/57

d, Patient and family rights include treating patient information as confidential,

e, Patient and family rights include refusal of treatment,

h, Patient and family rights include information on ho+ to "oice a complaint,

i, Patient and family rights include information on the e2pected cost of the treatment,


7/57

d, Patient and families are educated about pre"enting infections,

e, Patients and family are taught in a language and format that they can understand,

68E)4) 6atient and families ha(e a right to information on epected costs)

a, here is uniform pricing policy in a gi"en setting (out-patient and +ard category),

b, he tariff list is a"ailable to patients,

c, Patients and family are educated about the estimated costs of treatment,

hapter 4 Hospital #nfection ontrol %H#'

b, he hospital has a multi-disciplinary infection control committee,

c, he hospital has an infection control team,

d, he hospital has designated and qualified infection control nurse(s) for this acti"ity,

a, he manual identifies the "arious high-ris* areas and procedures,

b, t outlines methods of sur"eillance in the identified high-ris* areas,

c, t focuses on adherence to standard precautions at all times,

d, Patients and family are informed about the financial implications +hen there is a change inthe patient condition or treatment setting,

H#) ,) The organi/ation has a 1ell-designed. comprehensi(e andcoordinated infection control programme aimed at reducing& eliminatingrisks to patients. (isitors and pro(iders of care)

a, he hospital infection control programme is documented +hich aims at pre"enting andreducing ris* of nosocomial infections,

H#) 0) The organi/ation has an infection control manual. 1hich isperiodically updated)


8/57


9/57

a, %ospital has a documented procedure for handling such outbrea*s,

b, his procedure is implemented during outbrea*s,

c, fter the outbrea* is o"er appropriate correcti"e actions are ta*en to pre"ent recurrence,

a, here is adequate space a"ailable for sterili.ation acti"ities

b, egular "alidation tests for sterilisation are carried out and documented,

b, he hospital regularly earmar*s adequate funds from its annual budget in this regard,

e, ppropriate pre and post e2posure prophyla2is is pro"ided to all concerned staff members,

hapter + ontinuous


10/57

c, ppropriate statistical and management tools are applied +hene"er required,


11/57

8! 0) The ser(ices pro(ided 5y each department are documented)

a, !ach organi.ational program/ ser"ice/ site or department has effecti"e leadership,

b, cope of ser"ices of each department is defined,

c, dministrati"e policies and procedures for each department is maintained,

8! 2) The organi/ation is managed 5y the leaders in an ethical manner)

a, he leaders ma*e public the mission statement of the organi.ation,

b, he leaders establish the organi.ation4s ethical management,

c, he organi.ation discloses its o+nership,

d, he organi.ation honestly portrays the ser"ices +hich it can and cannot pro"ide,

e, he organi.ation honestly portrays its affiliations and accreditations,

f, he organi.ation accurately bills for it4s ser"ices based upon a standard billing tariff,

a, he designated indi"idual has requisite and appropriate administrati"e qualifications,

b, he designated indi"idual has requisite and appropriate administrati"e e2perience,

d, 3epartmental leaders are in"ol"ed in monitoring # sur"eillance acti"ities and qualityimpro"ement,

8! 4) A suita5ly ;ualified and eperienced indi(idual heads the

organi/ation)

8! +) Leaders ensure that patient safety aspects and risk managementissues are an integral part of patient care and hospital management)

a, he organi.ation has an interdisciplinary group assigned to o"ersee the hospital +ide safetyprogramme,


12/57

d, 9anagement pro"ides resources for proacti"e ris* assessment and ris* reduction acti"ities,

hapter 3: Facility anagement and Safety %FS'

b, 9anagement regularly updates any amendments in the pre"ailing la+s of the land,

c, he management ensures implementation of these requirements,

d, here is a mechanism to regularly update licenses registrationscertifications,

a, here is a documented operational and maintenance (pre"enti"e and brea*do+n) plan,

e, here are designated indi"iduals responsible for the maintenance of all the facilities,

f, 9aintenance staff is contactable round the cloc* for emergency repairs,

b, he scope of the programme is defined to include ad"erse e"ents ranging from @no harmA to@sentinel e"entsA,

c, 9anagement ensures implementation of systems for internal and e2ternal reporting ofsystem and process failures,

FS),) The organi/ation is a1are of and complies 1ith the rele(ant rulesand regulations. la1s and 5yela1s and re;uisite facility inspectionre;uirements)

a, he management is con"ersant +ith the la+s and regulations and *no+s their applicability tothe organi.ation,

FS)0) The organi/ation9s en(ironment and facilities operate to ensuresafety of patients. their families. staff and (isitors)

b, p-to-date dra+ings are maintained +hich detail the site layout/ floor plans and fire escape

routes,c, here is internal and e2ternal sign posting in the organisation in a language understood bypatient/ families and community,

d, he pro"ision of space shall be in accordance +ith the a"ailable literature on good practices(ndian or nternational tandards) and directi"es from go"ernment agencies,


13/57

a, Potable +ater and electricity are a"ailable round the cloc*,

b, lternate sources are pro"ided for in case of failure,

c, he organisation regularly tests the alternate sources,

FS)4) The organi/ation has a smoking elimination policy)

a, he organi.ation defines and implement its polices to eliminate smo*ing,

hapter = Human 8esource anagement %H8'

b, he required oining the organi/ation is sociali/ed and oriented to the

hospital en(ironment)a, !ach staff member/ employee/ student and "oluntary +or*er is appropriately oriented to theorgani.ation4s mission and goals,

b, !ach staff member is made a+are of hospital +ide policies and procedures as +ell asrele"ant department unit ser"ice programme4s policies and procedures,


14/57

a, documented training and de"elopment policy e2ists for the staff,

b, raining also occurs +hen


15/57

b, he disciplinary policy and procedure is based on the principles of natural


16/57

b, ll such information pertaining to the nursing staff is appropriately "erified +hen possible,

H8) ,*) There is a process for collecting. (erifying and e(aluating thecredentials %education. registration. training and eperience' of medicalprofessionals permitted to pro(ide patient care 1ithout super(ision)

a, 9edical professionals permitted by la+/ regulation and the hospital to pro"ide patient care+ithout super"ision are identified,

b, he education/ registration/ training and e2perience of the identified medical professionals isdocumented and updated periodically,

c, ll such information pertaining to the medical professionals is appropriately "erified +henpossible,

H8) ,,) There is a process for authori/ing all medical professionals toadmit and treat patients and pro(ide other clinical ser(ices commensurate1ith their ;ualifications)

a, 9edical professionals admit and care for patients as per the laid do+n policies and

authorisation procedures of the organi.ation,

b, he ser"ices pro"ided by the medical professionals are in consonance +ith their qualification/training and registration,

c, he requisite ser"ices to be pro"ided by the medical professionals are *no+n to them as +ellas the "arious departments units of the hospital,

H8) ,0) There is a process for collecting. (erifying and e(aluating thecredentials %education. registration. training and eperience' of nursingstaff)

a, he education/ registration/ training and e2perience of nursing staff is documented and

updated periodically,

H8) ,2) There is a process to identify >o5 responsi5ilities and makeclinical 1ork assignments to all nursing staff mem5ers commensurate1ith their ;ualifications and any other regulatory re;uirements)

a, he clinical +or* assigned to nursing staff is in consonance +ith their qualification/ trainingand registration,


17/57

hapter ? #nformation anagement System %#S'

b, Policies and procedures to meet the information needs are documented,

c, hese policies and procedures are in compliance +ith the pre"ailing la+s and regulations,

#S) 0) The medical record reflects continuity of care)

b, &perati"e and other procedures performed are incorporated in the medical record,

f, Care pro"iders ha"e access to current and past medical record,

b, he ser"ices pro"ided by nursing staff are in accordance +ith the pre"ailing la+s andregulations,

c, he requisite ser"ices to be pro"ided by the nursing staff are *no+n to them as +ell as the"arious departments units of the hospital,

#S) ,) 6olicies and procedures eist to meet the information needs of thecare pro(iders. management of the organi/ation as 1ell as other agenciesthat re;uire data and information from the organi/ation)

a, he information needs of the organi.ation are identified and are appropriate to the scope ofthe ser"ices being pro"ided by the organi.ation and the comple2ity of the organi.ation,

d, ll information management and technology acquisitions are in accordance +ith the policiesand procedures,

e, he organi.ation contributes to e2ternal databases in accordance +ith the la+ andregulations,

a, he medical record contains information regarding reasons for admission/ diagnosis andplan of care,

c, 6hen patient is transferred to another hospital/ the medical record contains the date oftransfer/ the reason for the transfer and the name of the recei"ing hospital,

d, he medical record contains a copy of the discharge note duly signed by appropriate andqualified personnel,

e, n case of death/ the medical record contains a copy of the death certificate indicating thecause/ date and time of death,


18/57

b, Policies and procedures are in consonance +ith the applicable la+s,

d, he hospital has an effecti"e process of monitoring compliance of the laid do+n policy,

c, he retention process pro"ides e2pected confidentiality and security,

#S)+ ) The organi/ation regularly carries out re(ie1 of medical records)

a, he medical records are re"ie+ed periodically,

b, he re"ie+ uses a representati"e sample based on statistical principles,

c, he re"ie+ is conducted by identified care pro"iders,

#S) 2) 6olicies and procedures are in place for maintainingconfidentiality. integrity and security of information)

a, 3ocumented policies and procedures e2ist for maintaining confidentiality/ security andintegrity of information,

c, he policies and procedures incorporate safeguarding of data record against loss/destruction and tampering,

e, he hospital uses de"elopments in appropriate technology for impro"ing confidentiality/integrity and security,

f, Pri"ileged health information is used for the purposes identified or as required by la+ and notdisclosed +ithout the patient4s authori.ation,

g, documented procedure e2ists on ho+ to respond to patients physicians and other publicagencies requests for access to information in the medical record in accordance +ith the localand national la+,

#S) 4) 6olicies and procedures eist for retention time of records. dataand information)

a, 3ocumented policies and procedures are in place on retaining the patient4s clinical records/data and information,

b, he policies and procedures are in consonance +ith the local and national la+s andregulations,

d, he destruction of medical records/ data and information is in accordance +ith the laid do+npolicy,


19/57

d, he re"ie+ focuses on the timeliness/ legibility and completeness of the medical records,

e, he re"ie+ process includes records of both acti"e and discharged patients,

f, he re"ie+ points out and documents any deficiencies in records,

g, ppropriate correcti"e and pre"enti"e measures underta*en are documented,


20/57

%ospital)


21/57


22/57


23/57


24/57


25/57


26/57


27/57


28/57


29/57


30/57


31/57


32/57


33/57


34/57


35/57


36/57


37/57


38/57


39/57


40/57


41/57


42/57


43/57


44/57


45/57


46/57


47/57


48/57


49/57


50/57


51/57


52/57


53/57


54/57


55/57


56/57


57/57

self assessment kit-yoga naturopathy

Documents