NABH STANDARDS-new edition

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(1) ± ± ± ± ± ± ± ± ±. 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 1. |

(2) .

(3) Organized around important functions Focus on patient and staff safety Set standards that all organizations must pass To be revised periodically and raise the ³bar´ Achieve International recognition 2. |

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(5) |

(6) . 10 Chapters 100 Standards 514/50Ö Objective Elements. Ö. |

(7) .

(8) . . A standard is a 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. 4. |

(9) .

(10) ! . " Access, Assessment and Continuity of Care #$ %&. '(. Care of Patients #$ #!%$ Management of Medications #$ Patients Rights and Education #-$ #.%$. %(%)* %+ ,% & +). Hospital Infection Control #$#./$. 0. *,. 5. |

(11) .

(12) 1 2 1 STD. OE. Continuous Quality Improvement #3$#./$. ,. +0. Responsibilities of Management #-$#.&$. &. /&. Facility Management & Safety #4$ #./$. 0. *+. Human Resource Management #-$. %+. *'. Information Management Systems #$. ' %)). *% &%* . |

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(14) | | . ý. |

(15) .

(16) 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 50Ö objective elements. . |

(17) .

(18)

(19) 1) Access ,Assessment and continuity of care (AAC) 2) Care of Patients(COP). 3) Management of Medication (MOM). 4) Patient Right and Education (PRE). 5) Hospital Infection Control (HIC). 6) Continuous Quality Improvement(CQI) 7) Responsibility of Management (ROM). 8) Facility Management and Safety (FMS). 9) Human Resource Management (HRM) 10) Information Management System (IMS). 9. |

(20) .

(21) Chapter 1. ACCESS,ASSESSMENT AND CONTINIUITY OF CARE (AAC). 10. |

(22) .

(23) AAC.1 ". 1 2 . 5 . a) The services being provided are clearly defined and are in consonance with the needs of the community. b) The defined services are prominently displayed. c) The staff is oriented to these services 11. |

(24) .

(25) 6/ " 1 2 7 . 1 . a) Standardized policies and procedures are used for registering and admitting patients b) The policies and procedures address out- patients, in-patients and emergency patients 12. |

(26) .

(27) Cont« c) Patients are accepted only if the organization can provide the required service d) The policies and procedures also address managing patients during non availability of beds e) The staff is aware of these processes 1Ö. |

(28) .

(29) 6+ ". . 7 1 2 . . a) Policies guide the transfer of unstable patients to another facility in an appropriate manner b) Policies guide the transfer of stable patients to another facility 14. |

(30) .

(31) Cont« c) Procedures identify staff responsible during transfer d) The organization gives a summary of patient¶s condition and the treatment given. 15. |

(32) .

(33) 6* 1 8 5 9 a) The patients and/or family members are explained about the proposed care b) The patients and/or family members are explained about the expected results 1. |

(34) .

(35) Cont« c) The patients and/or family members are explained about the possible complications d) The patients and/or family members are explained about the expected costs.. 1ý. |

(36) .

(37) 6& 5 . 1 2 1 . a) The organization defines the content of the assessments for the out±patients, inpatients and emergency patients. b) The organization determines who can perform the assessments. 1. |

(38) .

(39) cont« c) The organization defines the time frame within which the initial assessment is completed. d) The initial assessment for in-patients is documented within 24 hours or earlier as per the patient¶s condition or hospital policy. e) Initial assessment includes screening for nutritional and psychosocial needs.. 19. |

(40) .

(41) Cont« f) The initial assessment results in a documented plan of care which is monitored. g) The plan of care also includes preventive aspects of the care. 20. |

(42) .

(43) 6, 5 . 1 2 1. 1 . 6 a) All patients are reassessed at appropriate intervals. b) Staff involved in direct clinical care document reassessments. c) Patients are reassessed to determine their response to treatment and to plan further treatment or discharge. |

(44) . 21.

(45) 6' : 5 . ; . a) Scope of the laboratory services are commensurate to the services provided by the organization b) Adequately qualified and trained personnel perform and/or supervise the investigations. 22. |

(46) .

(47) cont.. c) Policies and procedures guide collection, identification, handling, safe transportation and disposal of specimens. d) Laboratory results are available within a defined time frame. e) Critical results are intimated immediately to the concerned personnel. f) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality 2Ö assurance system. |

(48) .

(49) 6( ". . . 5 5 1 . a) The laboratory quality assurance programme is documented. b) The programme addresses verification and validation of test methods. c) The programme addresses surveillance of test results. 24. |

(50) .

(51) cont« d) The programme includes periodic calibration and maintenance of all equipments. e) The programme includes the documentation of corrective and preventive actions. 25. |

(52) .

(53) 60 ". . . 5 5 1 . 6 a) The laboratory safety programme is documented. b) This programme is integrated with the organization¶s safety programme.. 2. |

(54) .

(55) cont« c) Written policies and procedures guide the handling and disposal of infectious and hazardous materials. d) Laboratory personnel are appropriately trained in safe practices. e) Laboratory personnel are provided with appropriate safety equipment / devices.. 2ý. |

(56) .

(57) 6%) 11 ; a) Imaging services comply with legal and other requirements. b) Scope of the imaging services are commensurate to the services provided by the organization. c) Adequately qualified and trained personnel perform and/or supervise the |

(58) investigations.. 2.

(59) cont« d) Policies and procedures guide identification and safe transportation of patients to imaging services. e) Imaging results are available within a defined time frame. f) Critical results are intimated immediately to the concerned personnel. g) Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system. 29. |

(60) .

(61) 6%% ". 3 5 1 11 a) The quality assurance programme for imaging services is documented. b) The programme addresses verification and validation of imaging methods c) The programme addresses surveillance of imaging results Ö0 |

(62) .

(63) cont« d) The programme includes periodic calibration and maintenance of all equipments. e) The programme includes the documentation of corrective and preventive actions. Ö1. |

(64) .

(65) 6%/ ". 5 1 . a) The radiation safety programme is documented. b) This programme is integrated with the organization¶s safety programme. c) Written policies and procedures guide the handling and disposal of radio-active and hazardous materials. Ö2. |

(66) .

(67) cont« d) Imaging personnel are provided with appropriate radiation safety devices e) Radiation safety devices are periodically tested and documented. f) Imaging personnel are trained in radiation safety measures. g) Imaging signage are prominently displayed in all appropriate locations. h) Policies and procedures guide the safe use of radioactive isotopes for imaging ÖÖ |

(68) services..

(69) AAC.1Ö Patient care is continuous and multidisciplinary in nature a) During all phases of care, there is a qualified individual identified as responsible for the patient¶s care. b) Care of patients is coordinated in all care settings within the organization. Ö4. |

(70) .

(71) cont« c) Information about the patient¶s care and response to treatment is shared among medical, nursing and other care providers. d) Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments. e) The patient¶s record (s) is available to the authorized care providers to facilitate the exchange of information. f) Policy and procedures guide the referral of patients to other department / specialty. Ö5. |

(72) .

(73) 6%* " 1 2 1 a) The patient¶s discharge process is planned in consultation with the patient and/or family. b) Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases Ö. |

(74) .

(75) cont« c) Policies and procedures are in place for patients leaving against medical advice d) A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice). Öý. |

(76) .

(77) 6%& 1 1 5 a) Discharge summary is provided to the patients at the time of discharge b) Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient¶s condition at the time of discharge. Ö. |

(78) .

(79) cont« c) Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given d) Discharge summary contains follow up advice, medication and other instructions in an understandable manner.. Ö9. |

(80) .

(81) cont« e) Discharge summary incorporates instructions about when and how to obtain urgent care f) 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. 40. |

(82) .

(83) Chapter 2. Care of Patients (COP). 41. |

(84) .

(85) 6% < 1 5 7 1 a) Care delivery is uniform when similar care is provided in more than one setting b) Uniform care is guided by policies and procedures which reflect applicable laws and regulations 42. |

(86) .

(87) cont« c) The care and treatment orders are signed, named, timed and dated by the concerned doctor d) The care plan is countersigned by the clinician in-charge of the patient within 24 hours e) Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible 4Ö. |

(88) .

(89) 6/ 1 5 1 5 = = 7 1 a) Policies and procedure for emergency care are documented b) Policies also address handling of medico-legal cases c) The patients receive care in consonance with the policies 44 |

(90) .

(91) cont« d) Policies and procedures guide the triage of patients for initiation of appropriate care e) Staff is familiar with the policies and trained on the procedures for care of emergency patients f) Admission or discharge to home or transfer to another organization is also documented 45. |

(92) .

(93) 6+ " 7 5 1 2 a) There is adequate access and space for the ambulance(s) b) Ambulance(s) is appropriately equipped c) Ambulance(s) is manned by trained personnel 4 |

(94) .

(95) cont« d) There is a checklist of all equipment and emergency medications e) Equipment are checked on a daily basis f) Emergency medications are checked daily and prior to dispatch g) The ambulance(s) has a proper communication system 4ý. |

(96) .

(97) 6* 1 ; 1 ! 5 a) Documented policies and procedures guide the uniform use of resuscitation throughout the organization b) Staff providing direct patient care is trained and periodically updated in cardio pulmonary resuscitation 4 |

(98) .

(99) cont« c) The events during a cardio-pulmonary resuscitation are recorded d) An analysis of all cardiac arrests is done e) A multidisciplinary committee monitors the effectiveness of cardio-pulmonary resuscitation. 49. |

(100) .

(101) 6& a) Documented policies and procedures are used to guide rational use of blood and blood products b) The transfusion services are governed by the applicable laws and regulations 50. |

(102) .

(103) Cont« c) Informed consent is obtained for donation and transfusion of blood and blood products d) Informed consent also includes patient and family education about donation e) Staff is trained to implement the policies f) Transfusion reactions are analyzed for preventive and corrective actions. 51. |

(104) .

(105) 6, 1 1 5 a) The organization has documented admission and discharge criteria for its intensive care and high dependency units b) Staff is trained to apply these criteria 52. |

(106) .

(107) cont« c) Adequate staff and equipment are available d) Defined procedures for situation of bed shortages are followed e) Infection control practices are followed f) A quality assurance program is implemented 5Ö. |

(108) .

(109) 6' 1 # 5= =5 5 8 5 1 $ a) Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines 54. |

(110) .

(111) cont« b) Staff is trained to care for this vulnerable group c) Care is organized and delivered in accordance with the policies and procedures d) The organization provides for a safe and secure environment for this vulnerable group e) A documented procedure exists for obtaining informed consent from the appropriate legal representative. 55. |

(112) .

(113) 6( 1 1 9 6 a) The organization defines and displays whether high risk obstetric cases can be cared for or not b) Persons caring for high risk obstetric cases are competent 5. |

(114) .

(115) cont« c) High risk obstetric patient¶s assessment also includes maternal nutrition d) The organization has the facilities to take care of neonates of high risk pregnancies. 5ý. |

(116) .

(117) COP.9 Policies and procedures guide the care of pediatric patients . a) The organization defines and displays the scope of its pediatric services b) The policy for care of neonatal patients is in consonance with the national/ international guidelines c) Those who care for children have age specific competency 5 |

(118) .

(119) cont« d) Provisions are made for special care of children e) Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment f) Policies and procedures prevent child/ neonate abduction and abuse 59. |

(120) .

(121) cont« g) The children¶s family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record. 0. |

(122) .

(123) 6%) 1 11 a) Competent and trained persons perform sedation b) The person administering and monitoring sedation is different from the person performing the procedure 1. |

(124) .

(125) cont« c) Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedation d) Patients are monitored after sedation e) Criteria are used to determine appropriateness of discharge from the recovery area f) Equipment and manpower are available to rescue patients from a deeper level of sedation than that intended 2. |

(126) .

(127) 6%% 1 a) There is a documented policy and procedure for the administration of anesthesia b) All patients for anesthesia have a preanesthesia assessment by a qualified individual Ö. |

(128) .

(129) cont« c) The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented d) An immediate preoperative reevaluation is documented e) Informed consent for administration of anesthesia is obtained by the anesthetist f) 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 4 |

(130) .

(131) cont« g) Each patient¶s post-anesthesia status is monitored and documented h) A qualified individual applies defined criteria to transfer the patient from the recovery area i) All adverse anesthesia events are recorded and monitored. 5. |

(132) .

(133) 6%/ 1 11 1 a) The policies and procedures are documented b) Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery . |

(134) .

(135) cont« c) An informed consent is obtained by a surgeon prior to the procedure d) Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery e) Persons qualified by law are permitted to perform the procedures that they are entitled to perform f) An operative note is documented prior to transfer out of patient from recovery area ý. |

(136) .

(137) cont« g) The operating surgeon documents the post-operative plan of care h) A quality assurance program is followed for the surgical services i) The quality assurance program includes surveillance of the operation theatre environment j) The plan also includes monitoring of surgical site infection rates . |

(138) .

(139) 6%+ 1 #5 8 $ 6 a) Documented policies and procedures guide the care of patients under restraints b) These include both physical and chemical restraint measures 9. |

(140) .

(141) cont« c) These include documentation of reasons for restraints d) These patients are more frequently monitored e) Staff receive training and periodic updating in control and restraint techniques. ý0. |

(142) .

(143) 6%* 1 1 a) Documented policies and procedures guide the management of pain b) The organization respects and supports the appropriate assessment and management of pain for all patients c) Patient and family are educated on various pain management techniques ý1 |

(144) .

(145) 6%& 1 a) Documented policies and procedures guide the provision of rehabilitative services b) These services are commensurate with the organizational requirements c) Rehabilitative services are provided by a multidisciplinary team ý2 |

(146) .

(147) 6%, 1 6 a) Documented policies and procedures guide all research activities in compliance with national and international guidelines b) The organization has an ethics committee to oversee all research activities c) The committee has the powers to discontinue a research trial when risks outweigh the potential benefits ýÖ. |

(148) .

(149) cont« d) Patient¶s informed consent is obtained before entering them in research protocols e) Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal f) Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization¶s services ý4 |

(150) .

(151) 6%' 1 5 a) Documented policies and procedures guide nutritional assessment and reassessment b) Patients receive food according to their clinical needs c) There is a written order for the diet d) Nutritional therapy is planned and provided in a collaborative manner |

(152) . ý5.

(153) cont« e) When families provide food, they are educated about the patients diet limitations f) Food is prepared, handled, stored and distributed in a safe manner. ý. |

(154) .

(155) 6%( 1 . a) Documented policies and procedures guide the end of life care b) These policies and procedures are in consonance with the legal requirements c) These also address the identification of the unique needs of such patient and family ýý. |

(156) .

(157) cont« d) These also include sensitively addressing issues such as autopsy and organ donation e) Staff is educated and trained in end of life care. ý. |

(158) .

(159) ChapterÖ. MANAGEMENT OF MEDICATION (MOM). ý9. |

(160) .

(161) 6% 1 1 2 5 1 a) There is a documented policy and procedure for pharmacy services and medication usage b) These comply with the applicable laws and regulations 0. |

(162) .

(163) cont« c) A multidisciplinary committee guides the formulation and implementation of these policies and procedures. 1. |

(164) .

(165) 6/ ". 5 . . a) A list of medication appropriate for the patients and organization¶s resources is developed b) The list is developed collaboratively by the multidisciplinary committee c) There is a defined process for acquisition of these medications d) There is a process to obtain medications not listed in the formulary 2 |

(166) .

(167) 6+ > 1 6 a) Documented policies and procedures exist for storage of medication b) Medications are stored in a clean, well lit and ventilated environment c) Sound inventory control practices guide storage of the medications Ö. |

(168) .

(169) cont« d) Medications are protected from loss or theft e) Sound alike and look alike medications are stored separately f) There is a method to obtain medication when the pharmacy is closed g) Emergency medications are available all the time h) Emergency medications are replenished in a timely manner when used 4. |

(170) .

(171) 6* 1 a) Documented policies and procedures exist for prescription of medications b) The organization determines who can write orders c) Orders are written in a uniform location in the medical records 5. |

(172) .

(173) cont« d) Medication orders are clear, legible, dated, named and signed e) Policy on verbal orders is documented and implemented f) The organization defines a list of high risk medication g) High risk medication orders are verified prior to dispensing . |

(174) .

(175) 6* 1 1 a) Documented policies and procedures guide the safe dispensing of medications b) The policies include a procedure for medication recall c) Expiry dates are checked prior to dispensing d) Labeling requirements are documented and implemented by the organization ý |

(176) .

(177) 6& ". a) Medications are administered by those who are permitted by law to do so b) Prepared medication are labeled prior to preparation of a second drug c) Patient is identified prior to administration. . |

(178) .

(179) cont« d) Medication is verified from the order prior to administration e) Dosage is verified from the order prior to administration f) Route is verified from the order prior to administration g) Timing is verified from the order prior to administration 9. |

(180) .

(181) cont« h) Medication administration is documented i) Polices and procedures govern patient¶s self administration of medications j) Polices and procedures govern patient¶s medications brought from outside the organization. 90. |

(182) .

(183) 6' 5 . ! 1 a) Patient and family are educated about safe and effective use of medication b) Patient and family are educated about food-drug interactions 91. |

(184) .

(185) 6( a) Patients are monitored after medication administration and this is documented b) Adverse drug events are defined c) Adverse drug events are reported within a specified time frame 92. |

(186) .

(187) cont« d) Adverse drug events are collected and analysed e) Policies are modified to reduce adverse drug events when unacceptable trends occur. 9Ö. |

(188) .

(189) 60 1 1 5 a) Documented policies and procedures guide the use of narcotic drugs and psychotropic substances b) These policies are in consonance with local and national regulations 94. |

(190) .

(191) cont« c) A proper record is kept of the usage, administration and disposal of these drugs d) These drugs are handled by appropriate personnel in accordance with policies. 95. |

(192) .

(193) 6%) 1 1 1 a) Documented policies and procedures guide the usage of chemotherapeutic agents b) Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy9 |

(194) .

(195) cont« c) Chemotherapy is prepared and administered by qualified personnel d) Chemotherapy drugs are disposed off in accordance with legal requirements. 9ý. |

(196) .

(197) 6%% 1 1 1 6 a) Documented policies and procedures govern usage of radioactive drugs b) These policies and procedures are in consonance with laws and regulations. 9. |

(198) .

(199) cont« c) The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs d) Staff, patients and visitors are educated on safety precautions. 99. |

(200) .

(201) 6%/ 1 6 a) Documented policies and procedures govern procurement and usage of implantable prosthesis b) Selection of implantable prosthesis is based on scientific criteria and internationally recognized approvals 100. |

(202) .

(203) cont« c) The batch and serial number of the implantable prosthesis are recorded in the patient¶s medical record and the master logbook. 101. |

(204) .

(205) 6%+ 1 1 a) Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases. b) The policies and procedures address the safety issues at all levels 102. |

(206) .

(207) Cont« c) Appropriate records are maintained in accordance with the policies, procedures and legal requirements.. 10Ö. |

(208) .

(209) Chapter .2 PATIENT RIGHT AND EDUCATION (PRE). 104. |

(210) .

(211) -6% " 1 2 5 1 1 . a) Patient and family rights are documented. ± Patients and families are informed of their rights in a format and language that they can understand 105. |

(212) .

(213) cont« c) The organization¶s leaders protect patient¶s rights d) Staff is aware of their responsibility in protecting patients rights e) Violation of patient rights is reviewed and corrective/preventive measures taken. 10. |

(214) .

(215) -6/6 1 = 5 91 a) Patient and family rights address any special preferences, spiritual and cultural needs b) Patient rights include respect for personal dignity and privacy during examination, procedures and treatment c) Patient rights include protection from physical abuse or neglect. 10ý. |

(216) .

(217) cont« c) Patient rights include treating patient information as confidential d) Patient rights include refusal of treatment e) Patient rights include informed consent before anesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment. 10. |

(218) .

(219) cont« f) Patient rights include information and consent before any research protocol is initiated g) Patient rights include information on how to voice a complaint h) Patient rights include information on the expected cost of the treatment i) Patient has a right to have an access to his / her clinical records 109. |

(220) .

(221) -6+ 1 8 > 91 . a) General consent for treatment is obtained when the patient enters the organization 110. |

(222) .

(223) cont« b) Patient and/or his family members are informed of the scope of such general consent c) The organization has listed those procedures and treatment where informed consent is required d) Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand e) The policy describes who can give consent when patient is incapable of independents decision making.. 111. |

(224) .

(225) -6* 1 . a) When appropriate, patient and families are educated about the safe and effective use of medication and the potential side effects of the medication b) Patient and families are educated about diet and nutrition 112. |

(226) .

(227) cont« c) Patient and families are educated about immunizations d) Patient and families are educated about their specific disease process, complications and prevention strategies e) Patient and families are educated about preventing infections f) Patients are taught in a language and format that they can understand 11Ö. |

(228) .

(229) -6&6 1 > a) There is uniform pricing policy in a given setting (out-patient and ward category) b) The tariff list is available to patients c) Patients are educated about the estimated costs of treatment 114. |

(230) .

(231) cont« d. Patients are informed about the estimated costs when there is a change in the patient condition or treatment setting. 115. |

(232) .

(233) Chapter 5 HOSPITAL INFECTION CONTROL (HIC). 11. |

(234) .

(235) 6% " 1 2 7 !. 1 = #$ 1 18 1 9 = 6 11ý. |

(236) .

(237) a) The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections b) The hospital has a multi-disciplinary infection control committee. c) The hospital has an infection control team. d) The hospital has designated and qualified infection control nurse(s) for this activity. 11. |

(238) .

(239) 6/ " =7 5 6 a) The manual identifies the various highrisk areas and procedures. b) It outlines methods of surveillance in the identified high-risk areas. 119. |

(240) .

(241) Cont« c) It focuses on adherence to standard precautions at all times. d) Equipment cleaning and sterilisation practices are included. e) An appropriate antibiotic policy is established and implemented. f) Laundry and linen management processes are also included. 120. |

(242) .

(243) Cont« g) Kitchen sanitation and food handling issues are included in the manual h) Engineering controls to prevent infections are included i) Mortuary practices and procedures are included as appropriate to the organization j) The organization defines the periodicity of updating the infection control manual 121. |

(244) .

(245) 6+ " . 6 a) Surveillance activities are appropriately directed towards the identified high-risk areas. b) Collection of surveillance data is an ongoing process. 122 |

(246) .

(247) Cont« c) Verification of data is done on regular basis by the infection control team. d) In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities. e) Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends. f) Surveillance activities include monitoring the effectiveness of housekeeping services. 12Ö. |

(248) .

(249) 6* " 9 9 #$ 5. 6 a) The organization monitors urinary tract infections. b) The organization monitors respiratory tract infections. 124. |

(250) .

(251) Cont« c) The organization monitors intra-vascular device infections. d) The organization monitors surgical site infections. e) Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.. 125. |

(252) .

(253) 6& ; . 1 . a) Hand washing facilities in all patient care areas are accessible to health care providers. b) Compliance with proper hand washing is monitored regularly. 12. |

(254) .

(255) Cont« c) Isolation/ barrier nursing facilities are available. d) Adequate gloves, masks, soaps, and disinfectants are available and used correctly.. 12ý. |

(256) .

(257) 6, " 9 9 6 a) Hospital has a documented procedure for handling such outbreaks. b) This procedure is implemented during outbreaks. c) After the outbreak is over appropriate corrective actions are taken to prevent recurrence 12 |

(258) .

(259) 6' ". 6 a) There is adequate space available for sterilization activities b) Regular validation tests for sterilisation are carried out and documented. c) There is an established recall procedure when breakdown in the sterilisation 129 system is identified |

(260) .

(261) 6( 5 7 1

(262) ! ? #

(263) ?$ 1 7 a) The hospital is authorised by prescribed authority for the management and handling of Bio-medical Waste. b) Proper segregation and collection of Biomedical Waste from all patient care areas of the hospital is implemented and monitored. 1Ö0 |

(264) .

(265) Cont« c) The organization ensures that Biomedical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner. d) Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorised contractor(s). 1Ö1. |

(266) .

(267) Cont« e) Requisite fees, documents and reports are submitted to competent authorities on stipulated dates. f) Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste. 1Ö2. |

(268) .

(269) 60 " 1 5 1 1 . 5. . . a) Hospital management makes available resources required for the infection control programme b) The hospital regularly earmarks adequate funds from its annual budget in this regard. 1ÖÖ. |

(270) .

(271) Cont« c) It conducts regular pre-induction training for appropriate categories of staff before joining concerned department(s). d) It also conducts regular ³in-service´ training sessions for all concerned categories of staff at least once in a year. e) Appropriate pre and post exposure prophylaxis is provided to all concerned staff members 1Ö4. |

(272) .

(273) Chapter CONTINUOUS QUALITY IMPROVEMENT (CQI). 1Ö5. |

(274) .

(275) 36% ". ; 5 1 1 1 2 a) The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee. b) The quality improvement programme is documented. 1Ö |

(276) .

(277) Cont« c) There is a designated individual for coordinating and implementing the quality improvement programme d) The quality improvement programme is comprehensive and covers all the major elements related to quality improvement and risk management.. 1Öý. |

(278) .

(279) Cont« e) The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism. f) The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified. 1Ö. |

(280) .

(281) Cont« g) The quality improvement programme is a continuous process and updated at least once in a year.. 1Ö9. |

(282) .

(283) 36/ " 1 2 9 5 = 7 . a) Monitoring includes appropriate patient assessment. b) Monitoring includes diagnostics services¶ safety and quality control programmes. c) Monitoring includes all invasive procedures. 140 |

(284) .

(285) Cont« d) e) f) g) h) i) j) k). 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. Monitoring includes data collection to support further improvements Monitoring includes data collection to support evaluation of these improvements 141. |

(286) .

(287) 36+ " 1 9 5 1 = which are used. as tools for continual improvement Monitoring includes procurement of medication essential to meet patient needs. Monitoring includes reporting of activities as required by laws and regulations. 142. |

(288) .

(289) Cont« Monitoring includes risk management. Monitoring includes utilisation of space, manpower and equipment. Monitoring includes patient satisfaction which also incorporates waiting time for services. Monitoring includes employee satisfaction. Monitoring includes adverse events and near misses. Monitoring includes data collection to support further study for improvements. Monitoring includes data collection to support evaluation of the improvements. 14Ö. |

(290) .

(291) 36* " ; 5 1 5 1 a) Hospital Management makes available adequate resources required for quality improvement programme. b) Hospital earmarks adequate funds from its annual budget in this regard. c) Appropriate statistical and management tools are applied whenever required 144 |

(292) .

(293) 36& ". 5 a) Medical staff participates in this system. b) The parameters to be audited are defined by the organisation. staff anonymity is c) Patient and maintained. d) All audits are documented. e) Remedial measures are implemented. 145 |

(294) .

(295) 36, 5 5. a) The organisation has defined sentinel events. b) The organisation has established processes for intense analysis of such events. c) Sentinel events are intensively analysed when they occur. d) Corrective and preventive actions are taken upon findings of such analysis 14. |

(296) .

(297) Chapter ý RESPONSIBILITIES OF MANAGEMENT (ROM). 14ý. |

(298) .

(299) -6% " 1 . a) b). c) d). Those responsible for governance lay down the organization¶s mission statement Those responsible for governance lay down the strategic and operational plans commensurate to the organization¶s mission in consultation with the various stakeholders Those responsible for governance approve the organization¶s budget and allocate the resources required to meet the organization¶s mission Those responsible for governance monitor and measure the performance of the organization against the stated mission 14. |

(300) .

(301) Cont« e) Those responsible for governance establish the organization¶s organogram. f) Those responsible for the governance appoint the senior leaders in the organization. g) Those responsible for the governance support research activities and quality improvement plans h) The organization complies with the laid down and applicable legislations and regulations d) Those responsible for governance address the organization¶s social responsibility 149. |

(302) .

(303) -6/ " 5 . . a) Each organizational program, service, site or department has effective leadership b) Scope of services of each department is defined c) Administrative policies and procedures for each department is maintained d) Departmental leaders are involved in quality improvement 150. |

(304) .

(305) ROM.Ö The organization is managed by the leaders in an ethical manner a) The leaders make public the mission statement of the organization b) The leaders establish the organization¶s ethical management c) The organization discloses its ownership 151. |

(306) .

(307) Cont« d) The organization honestly portrays the services which it can and cannot provide. e) The organization honestly portrays the affiliations and accreditations f) The organization accurately bills for it¶s services based upon a standard billing tariff.. 152. |

(308) .

(309) -6* 5; > 1 . a) The designated individual and appropriate qualifications. b) The designated individual and appropriate experience.. has requisite administrative has requisite administrative 15Ö. |

(310) .

(311) -6& : 5 9 1 1 1 a) The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme. 154. |

(312) .

(313) Cont« b) The scope of the programme is defined to include adverse events ranging from ³no harm´ to ³sentinel events´. c) Management ensures implementation of systems for internal and external reporting of system and process failures. d) Management provides resources for proactive risk assessment and risk reduction activities. 155. |

(314) .

(315) Chapter FACILITY MANAGEMENT AND SAFETY (FMS). 15. |

(316) .

(317) 46% " 1 2 7 7 1 = 7 5 7 ; 5 ; a) The management is conversant with the laws and regulations and knows their applicability to the organization. 15ý. |

(318) .

(319) Cont« b) Management regularly updates any amendments in the prevailing laws of the land. c) The management ensures implementation of these requirements. d) There is a mechanism to regularly update licenses/ registrations/certifications 15. |

(320) .

(321) FMS.2 The organization¶s environment and facilities operate to ensure safety of patients, staff and visitors a) There is a documented operational and maintenance (preventive and breakdown) plan. 159. |

(322) .

(323) Cont« b) Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes. c) There is internal and external sign posting in the organisation in a language understood by patients, families and community d) The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies. e) There are designated individuals responsible for the maintenance of all the facilities. 10. |

(324) .

(325) Cont« f) Maintenance staff is contactable round the clock for emergency repairs. g) Response times are monitored from reporting to inspection and implementation of corrective actions.. 11. |

(326) .

(327) 46+ " 1 2 1 . ; 1 a) The organization plans for equipment in accordance with its services and strategic plan b) Equipment is selected by a collaborative process. c) All equipment is inventoried and proper logs are maintained as required. 12 |

(328) .

(329) Cont« d) Qualified and trained personnel operate and maintain the equipment. e) Equipment are periodically inspected and calibrated for their proper functioning. f) There is a documented operational and maintenance (preventive and breakdown) plan.. 1Ö. |

(330) .

(331) 46* " 1 2 7 = 5= 1 5 a) Potable water and electricity are available round the clock. b) Alternate sources are provided for in case of failure. c) The organisation regularly tests the alternate sources. d) There is a maintenance plan for piped medical gas, compressed air and vacuum installation. 14. |

(332) .

(333) 46& " 1 2 ! 1 7 a) The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies. 15. |

(334) .

(335) Cont« b) Staff is trained for their role in case of such emergencies. c) The organization has a documented safe exit plan in case of fire and non-fire emergencies. d) Mock drills are held at least twice in a year. 1. |

(336) .

(337) 46, " 1 2 91 5 a) The organization defines and implement its polices to reduce or eliminate smoking b) The policy has provisions for granting exceptions for patients and families to smoke. 1ý. |

(338) .

(339) FMS.ý The organization plans for handling community emergencies, epidemics and other disasters a) The hospital identifies potential emergencies. b) The organization has a documented disaster management plan. 1. |

(340) .

(341) Cont« c) Provision is made for availability of medical supplies, equipment and materials during such emergencies. d) Hospital staff is trained in the hospital¶s disaster management plan e) The plan is tested at least twice in a year.. 19. |

(342) .

(343) FMS. The organization has a plan for management of hazardous materials a) Hazardous materials are identified within the organization b) The hospital implements processes for sorting, labelling, handling, storage, transporting and disposal of hazardous material. 1ý0. |

(344) .

(345) Cont« c) Requisite regulatory requirements are met in respect of radioactive materials. d) There is a plan for managing spills of hazardous materials e) Staff is educated and trained for handling such materials. 1ý1. |

(346) .

(347) 460 " 5 . . . . a) The hospital has a safety committee to identify the potential safety and security risks. b) This committee coordinates development, implementation, and monitoring of the safety plan and policies. c) Patient safety devices are installed across the organization and inspected periodically 1ý2. |

(348) .

(349) Cont« d) 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. e) Inspection reports are documented and corrective and preventive measures are undertaken. f) There is a safety education programme for all staff. 1ýÖ. |

(350) .

(351) Chapter9 HUMAN RESOURCE MANAGEMENT. 1ý4. |

(352) .

(353) HRM.1 The organization has a documented system of human resource planning a) The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient. 1ý5. |

(354) .

(355) Cont« b) The required job specifications and job description are well defined for each category of staff. c) The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.. 1ý. |

(356) .

(357) -6/ " 1 1 2 2 a) Each staff member, employee, student and voluntary worker is appropriately oriented to the organization¶s mission and goals. 1ýý. |

(358) .

(359) Cont« b) Each staff member is made aware of hospital wide policies and procedures as well as relevant department / unit / service / programme¶s policies and procedures. c) Each staff member is made aware of his/her rights and responsibilities. d) All employees are educated with regard to patients¶ rights and responsibilities. e) All employees are oriented to the service standards of the organisation 1ý |

(360) .

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