NABH Manual

CHAPTER 1 : Access, Assessment and Continuity of Care (AAC)
AAC.1. The organization defines and displays the services that it can provide.
Objective Element a) The services being provided are clearly defined and are in consonance with the needs of the community. The defined services are prominently displayed.
Interpretation A policy to be framed clearly stating the services the hospital can provide.
Remarks Scope of Services
b)
The services so defined should be displayed prominently in an area visible to all patients entering the organization. The display could be in the form of boards, citizen's charter, scrolling messages etc. Care should be taken to ensure that these are displayed in the language(s) the patient understands. All the staff in the Hospital mainly in the reception/registration, OPD, IPD are oriented to these facts through training programme regularly or through manuals.
Evident on Site
c)
The staff is oriented to these services.
AAC.2. The organization has a well defined registration and admission process.
Objective Element a) Standardized policies and procedures are used for registering and admitting patients.
Interpretation Health Care Organization (HCO) has prepared document (s) detailing the policies and procedures for registration and admission of patients which should also include unidentified patients. Self explanatory
Remarks Registration process Admission Process
b)
c)
The policies and procedures address outpatients, in-patients and emergency patients. Patients are accepted only if the organization can provide the required service.
Admission Process The staff handling admission and registration needs to be aware of the services that the organization can provide. It is also advisable to have a system wherein the staff is aware as to whom to contact if they need any clarification on the services provided.
Admission Process
d)
The policies and procedures also address managing patients during non availability of beds. The staff is aware of these processes.
The HCO is aware of the availability of alternate HCO's where the patients may be directed in case of non-availability of beds. All the staff handling these activities should be oriented to these policies and procedures.
Policy for non availability of beds
e)
Induction Manual
AAC.3. There is an appropriate mechanism for transfer or referral of patients who do not match the organizational resources.
Objective Element a) Policies guide the transfer of unstable patients to another facility in an appropriate manner.
Interpretation The organization shall at the outset define as to who is an unstable patient. The documented policy and procedure should address the methodology of safe transfer of the patient in a life threatening situation (like those who are on ventilator) to another HCO. There should be availability of an appropriate ambulance fitted with life support facilities and accompanied by trained personnel. Patients not in a life threatening situation (stable) should also be transported in a safe manner. The staff shall at least be a trained trauma/emergency technician/nurse. He/she shall have undergone training in BLS and/or ACLS. The HCO gives a case summary mentioning the significant findings and treatment given in case of patients who are being transferred from emergency. For admitted patients a discharge summary has to be given (refer AAC15).The same shall also be given to patients going against medical advice.
Remarks Patient Transfer Policy
b)
Policies guide the transfer of stable patients to another facility. Procedures identify staff responsible during transfer. The organization gives a summary of patients condition and the treatment given.
Patient Transfer Policy
c)
d)
Discharge Summary
AAC.4. During admission the patient and /or the family members are educated to make informed decisions.
Objective Element
Interpretation
Remarks
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. The patients and/or family members are explained about the possible complications. The patients and/or family members are explained about the expected costs.
The plan of care as decided by the doctor on duty or the patient management team (as the case may be) is to be discussed with the patient and/or family members. This should be done in a language the patient/attendant can understand. The above information is to be documented and signed by the concerned doctor. The patients and family are explained in detail by the treating physicians or his/her team about the outcomes of such treatment. Possible complications of the treatment, if any, are clearly communicated to the patient. Patients should be given an estimate of the expenses on account of the treatment preferably in a written form.
Patients Right Policy
c)
d)
AAC.5. Patients cared for by the organization undergo an established initial assessment.
Objective Element a) The organization defines the content of the assessments for the out patients, in-patients and emergency patients.
Interpretation The hospital shall have a protocol/policy by which a standardized initial assessment of patients is done in the OPD, emergency and in-patients. The initial assessment could be standardized across the hospital or it could be modified depending on the need of the department. However it shall be the same in that particular area e.g. in a paediatric OPD the weight and height may be a must whereas it may not be so for orthopaedics OPD. The organization can have different assessment criteria for the first visit and for subsequent visits. In emergency department this shall include recording the vital parameters. The initial assessment should also include the nursing assessment for in-patients. The assessment should be done by the treating doctor, junior doctor or a nurse. The organization determines who can do what assessment and it should be the same across the hospital. The HCO has defined and documented the time frame within which the initial assessment is to be completed with respect to OPD/ emergency/indoor patients.
Remarks Initial Assessment Policy
b)
The organization determines who can perform the assessments.
Initial Assessment Policy
c)
The organization defines the time frame within which the initial assessment is completed.
IInitial Assessment Policy
d)
e)
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 needs.
This should cover history, progress notes, investigation ordered and treatment ordered and all these are to be authenticated by treating doctor. The protocol for patients initial assessment should cover his/her nutritional needs. In case of Out patients this should be done where ever applicable. For example diabetics, CRF patients. This shall be documented by the treating doctor or by a member of his team in the case sheet. This plan is monitored by the treating doctor for its effectiveness, and wherever required by a clinical audit. The documented plan of care should cover preventive actions as necessary in the case and should include diet, drugs etc.
f)
The initial assessment results in a documented plan of care which is monitored. The plan of care also includes preventive aspects of the care.
g)
AAC.6. All patients cared for by the organization undergo a regular reassessment.
Objective Element a) All patients are reassessed at appropriate intervals.
Interpretation After the initial assessment, the patient is reassessed periodically and this is documented in the case sheet. The frequency maybe different for different areas based on the setting and the patient's condition e.g. patients in ICU need to reassessed more frequently compared to a patient in the ward. Actions taken under reassessment are documented. The staff could be the treating doctor or any member of the team as per their domain of responsibility of care. Self explanatory.
Remarks Initial Assessment Policy
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.
AAC.7. Laboratory services are provided as per the requirements of the patients.
Objective Element
Interpretation
Remarks
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. Policies and procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens. Laboratory results are available within a defined time frame.
c)
The HCO should ensure availability of laboratory services commensurate with the health care services offered by it either by providing the same in house or by outsourcing. However, test results required for emergency management (RBS, ABG etc) must be available within its premises. See also (f) below for outsourced lab facilities. The staff employed in the lab should be suitably qualified (appropriate degree) and trained to carry out the tests. Pathologist, microbiologist and biochemist supervise the staff. The HCO has documented procedures for collection, identification, handling, safe transportation, processing and disposal of specimens, to ensure safety of the specimen till the tests and retests (if required) are completed. The HCO shall define the turnaround time for all tests. The HCO should ensure availability of adequate staff, materials and equipment to make the laboratory results available within the defined time frame. The laboratory shall establish its biological reference intervals for different tests. The laboratory shall establish critical limits for tests which require immediate attention for patient management. The test results in the critical limits shall be communicated to the concerned after proper documentation. The HCO has documented procedure for outsourcing tests for which it has no facilities. This should include: a) list of tests for out sourcing. b) identity of personnel in the out sourced facilities to ensure safe transportation of specimens and completing of tests as per requirements of the patient concerned and receipt of results at HCO. c) manner of packaging of the specimens and their labelling for identification and this package should contain the test requisition with all details as required for testing. d) a methodology to check the performance of service rendered by the out sourced laboratory as per the requirements of the HCO.
Laboratory Manual
Laboratory Manual
Laboratory Manual
d)
Laboratory Manual
e)
Critical results are intimated immediately to the concerned personnel.
Laboratory Manual
f)
Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.
Laboratory Manual
AAC.8. There is an established laboratory quality assurance programme.
Objective Element a) The laboratory quality assurance programme is documented.
Interpretation The HCO has a documented quality assurance programme (preferably as per ISO 15189 Medical laboratories Particular requirements for quality and competence). This holds true for any laboratory developed methods. The laboratory director shall periodically assess the test results. Refer to ISO 15189.
Remarks Laboratory QA Manual
b)
c)
d)
e)
The programme addresses verification and validation of test methods. The programme addresses surveillance of test results. The programme includes periodic calibration and maintenance of all equipments. The programme includes the documentation of corrective and preventive actions.
Laboratory QA Manual
Laboratory QA Manual
Laboratory QA Manual Self explanatory. Laboratory QA Manual
AAC.9. There is an established laboratory safety programme.
Objective Element a) The laboratory programme documented. safety is
Interpretation A well documented lab safety manual is available in the lab. This takes care of the safety of the workforce as well as the equipments available in the lab.
Remarks Laboratory Safety Manual
b)
c)
d)
This programme is integrated with the organizations safety programme. Written policies and procedures guide the handling and disposal of infectious and hazardous materials. Laboratory personnel are appropriately trained in safe practices. Laboratory personnel are provided with appropriate safety equipment / devices.
Lab safety programme is incorporated in the safety programme of the hospital. The lab staff should follow standard precautions. The disposal of waste is according to Biomedical waste management and handling rules, 1998. All the lab staff undergo training regarding safe practices in the lab. Adequate safety devices are available in the lab e.g. fire extinguishers, dressing materials, standard precautions, disinfectants, etc.
Laboratory Safety Manual Laboratory Safety Manual
Laboratory Safety Manual Laboratory Safety Manual
e)
AAC.10. Imaging services are provided as per the requirements of the patients.
Objective Element a) Imaging services comply with legal and other requirements.
Interpretation The HCO is aware of the legal and other requirements of imaging services and the same are documented for information and compliance by all concerned in the HCO. The HCO maintains and updates its compliance status of legal and other requirements in a regular manner. Self explanatory.
Remarks Imaging Department
b)
c)
d)
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. Policies and procedures guide identification and safe transportation of patients to imaging services.
Imaging Department
As per AERB guidelines. Imaging Department The HCO has documented policies and procedures for informing the patients about the imaging activities, their identification and safe transportation to the imaging services. This should also address transfer of unstable patients to imaging services. The organization shall document turnaround time of imaging results. Critical results shall be intimated to the treating clinician at the earliest on phone, followed by written report. The HCO has documented procedure for outsourcing tests for which it has no facilities. This should include: a) list of tests for out sourcing, b) identity of personnel in the out sourced facilities to ensure safe transportation of specimens and completing of imaging results, c) manner of identification of patients and the test requisition with all details as required for testing and d) a methodology to check the selection and performance of service rendered by the outsourced imaging facility as per the requirements of the HCO. Imaging Department Patient Transfer Policy
e)
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.
Imaging Department
f)
Imaging Department
g)
Imaging Department
AAC.11. There is an established Quality assurance programme for imaging services.
Objective Element
Interpretation
Remarks
a)
The quality assurance programme for imaging services is documented. The programme addresses verification and validation of imaging methods. The programme addresses surveillance of imaging results. The programme includes periodic calibration and maintenance of all equipments. The programme includes the documentation of corrective and preventive actions.
Refer to AERB guidelines. Imaging QA Programme A document for verification and validation of imaging methods shall be available. HOD shall periodically imaging results. assess the Imaging QA Programme Imaging QA Programme Imaging QA Programme Imaging QA Programme
b)
c)
d)
Calibration and maintenance of all equipment shall be carried out by competent persons. Self explanatory.
e)
AAC.12. There is an established radiation safety programme.
Objective Element a) The radiation safety programme is documented. This programme is integrated with the organizations safety programme. Written policies and procedures guide the handling and disposal of radio-active and hazardous materials. Imaging personnel are provided with appropriate radiation safety devices. Radiation safety devices are periodically tested and documented. Imaging personnel are trained in radiation safety measures. Imaging signage are prominently displayed in all appropriate locations Policies and procedures guide the safe use of radioactive isotopes for imaging services.
Interpretation Refer to AERB guidelines
Remarks Imaging Safety Manual
b)
The safety programme of the imaging department has reference in the hospital safety manual. Radioactive and hazardous materials shall be disposed off as per bio-medical waste management and handling rules, 1998. Self explanatory.
Hospital Safety Manual
c)
Imaging Safety Manual
d)
Imaging Safety Manual Protective devices e.g. lead aprons should be exposed to X-ray for verification of cracks and damages. Self explanatory. Training Records Self explanatory.
e)
f)
g)
Evidence on side
h)
Document on safe use of radioactive isotopes for imaging services shall be available and implemented.
AAC.13. Patient care is continuous and multidisciplinary in nature.
Objective Element a) During all phases of care, there is a qualified individual identified as responsible for the patients care.
Interpretation The HCO to ensure that the care of patients is always given by appropriately qualified medical personnel (resident doctor, consultant and/or nurse).
Remarks In Patient Care Medical Care Related Process (Read responsibility) Emergency Room (Causality) Related Process (Read responsibility) IP Care Surgical Care Related Process (Read responsibility) In Patient Care Medical Care Related Process (Read responsibility) Emergency Room (Causality) Related Process (Read responsibility) IP Care Surgical Care Related Process (Read responsibility)
b)
Care of patients is coordinated in all care settings within the organization.
Care of patients is co-ordinated among various care providers in a given setting viz OPD, emergency, IP, ICU, etc. The organization shall ensure that there is effective communication of patient requirements amongst the care providers in all settings.
c)
d)
e)
f)
Information about the patients care and response to treatment is shared among medical, nursing and other care providers. Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/ departments. The patients record (s) is available to the authorized care providers to facilitate the exchange of information. Policies and procedures guide the referral of patients to other departments/ specialities.
The HCO ensures periodic discussions about each patient (covering parameters like patient care, response to treatment, unusual developments if any, etc) amongst medical, nursing and other care providers. Self explanatory.
Inpatient Care
Inpatient Care
Self explanatory. Medical Record Dept
The HCO has clearly defined and documented the policies and procedures to be adopted to guide the personnel dealing with referral of patients to other departments or specialties or even other health care providers out side the HCO.
AAC.14. The organization has a documented discharge process.
Objective Element a) The patients discharge process is planned in consultation with the patient and/or family. Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases). Policies and procedures are in place for patients leaving against medical advice. A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)
Interpretation The patient's treating doctor determines the readiness for discharge during regular reassessments. The same is discussed with the patient and family. The discharge policies and procedures are documented to ensure coordination amongst various departments including accounts so that the discharge papers are complete well within time. For MLC the organization shall ensure that the police are informed. The HCO has a documented policy for the LAMA cases. The treating doctor should explain the consequences of this action to the patient/attendant. The HCO hands over the discharge papers to the patient/attendant in all cases and copy retained. In LAMA cases, the declaration of the patient/attendant is to be recorded on proper format.
Remarks Discharge Process
b)
Discharge Process
c)
Discharge Process
d)
Discharge Process
AAC.15. Organization defines the content of the discharge summary.
Objective Element a) Discharge summary is provided to the patients at the time of discharge. Discharge summary contains the reasons for admission, significant findings and diagnosis and the patients condition at the time of discharge. Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given. Discharge summary contains follow up advice, medication and other instructions in an understandable manner. Discharge summary incorporates instructions about when and how to obtain urgent care.
Interpretation Self explanatory.
Remarks Discharge Summary
b)
Self explanatory. Discharge Summary
c)
d)
e)
The HCO should outline conditions regarding when to obtain urgent care. For example, a post op patient should report when having fever, bleeding/discharge from site.
Discharge Summary
10
f)
In case of death the summary of the case also includes the cause of death.
CHAPTER 2 : Care of Patients (COP)

COP.1. Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws, regulations and guidelines.
a)
Objective Element Care delivery is uniform when similar care is provided in more than one setting. Uniform care is guided by policies and procedures which reflect applicable laws and regulations. The care and treatment orders are signed, named, timed and dated by the concerned doctor. The care plan is countersigned by the clinician in-charge of the patient within 24 hours. Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible.
b)
Interpretation The organization shall ensure that patients with the same health problems and care needs, receive the same quality of healthcare throughout the organization irrespective of the category of ward. Self explanatory.
Remarks Uniform Care Policy
Care provision vide Nursing Council of India Act and Medical Council of India at. InPatient Dept
c)
Self explanatory. Treatment must be written daily.
orders
d)
The treatment of the patient could be initiated by a junior doctor but the same should be countersigned and authorized by the treating doctor within 24hrs. The organization could develop clinical protocols based on these and the same could be followed in management of patients. These could then be used as parameters for audit of patient care.
Authorisation of prescription by resident doctor
e)
Within scope of Medical audit committee.
COP.2. Emergency services are guided by policies, procedures, applicable laws and regulations.
a)
Objective Element Policies and procedure for emergency care are documented. Policies also address handling of medico-legal cases.
b)
Interpretation These could include SOPs/protocols to provide either general emergency care or management of specific conditions e.g. poisoning. The policy shall be in line with statutory requirements w.r.t. documentation and intimation to police. The organization shall also define as to what constitutes a MLC (in accordance with statutory rules).
Remarks Emergency Suite related Process
Emergency Suite Related Process
11
c)
The patients receive care in consonance with the policies. Policies and procedures guide the triage of patients for initiation of appropriate care. Staff is familiar with the policies and trained on the procedures for care of emergency patients. Admission or discharge to home or transfer to another organization is also documented.
Self explanatory.
Practice Objective
d)
Self explanatory.
Admission and discharge protocol in ICU

CPR Training Records
e)
All the staff working in the casualty should be oriented to the policies and practices through training/documents. Staff should preferably be trained/well versed in ACLS and BLS. Self explanatory.
f)
COP.3. The ambulance services are commensurate with the scope of the services provided by the organization.
a)
Objective Element There is adequate access and space for the ambulance(s).
b)
Ambulance(s) is appropriately equipped. Ambulance(s) is manned by trained personnel.
Interpretation The organization shall demarcate a proper space for ambulance(s).This shall be demarcated keeping in mind easy accessibility for receiving patients and to enable the ambulance(s) to turn around/exit quickly. This shall be done based on the organizations scope. The ambulance should be manned by a trained driver, technician/nurse and/or doctor depending on the situation. Personnel shall be trained in ACLS and/or BLS. The organization shall develop a checklist and ensure that the ambulance is equipped as per the checklist. This shall include both the ambulance and the equipments within it. Self explanatory. This also includes checking the expiry date of drugs. The ambulance shall be connected with the hospital/control room by wireless/mobile phones.
Remarks
Sufficient area available for parking of ambulances as per Policy.
Hospital Ambulance Services BLS Trained Driver
c)
d)
There is a checklist of all equipment and emergency medications. Equipments are checked on a daily basis. Emergency medications are checked daily and prior to dispatch. The ambulance(s) has a proper communication system.
Hospital Ambulance Services
e)
Hospital Ambulance Services Hospital Ambulance Services (By Physical Inspection)
f)
g)
COP.4. Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation.
12
a)
b)
Objective Element Documented policies and procedures guide the uniform use of resuscitation throughout the organization. Staff providing direct patient care is trained and periodically updated in cardio pulmonary resuscitation. The events during a cardio-pulmonary resuscitation are recorded. A post-event analysis of all cardiac arrests is one by a multi-disciplinary committee. Corrective and preventive measures are taken based on the post-event analysis.
Interpretation The organization shall document the procedure for same. This shall be in consonance with accepted practices. These aspects shall be covered by hands on training. If the organization has a CPR team (e.g. code blue team) it shall ensure that they are all trained in ALS and are present in all shifts. In the actual event of a CPR or a mock drill of the same, all the activities along with the personnel attended should be recorded. The analysis shall include the cause, steps taken to resuscitate and the outcome. Multidisciplinary committee shall include physicians, anaesthetists and nurses Self explanatory.
Remarks CPR Policy
CPR Training Record
c)
CPR Recording form
d)
Code Blue Committee Meeting Records
e)
Code Blue Committee Meeting Records
COP.5. Policies and procedures define rational use of blood and blood products.
a)
Objective Element Documented policies and procedures are used to guide rational use of blood and blood products. The transfusion services are governed by the applicable laws and regulations. Informed consent is obtained for donation and transfusion of blood and blood products.
Interpretation This shall address the conditions where blood and conditions where blood products can be used. Refer to Drugs and Cosmetics act.
Remarks
b)
Drugs And Cosmetic Act (ORIGINAL)
c)
d)
Informed consent also includes patient and family education about donation. Staff is trained to implement the policies.
Consent should be taken for every transfusion. However, with the same consent you can give multiple transfusions in the same sitting. For example, 2 pints of blood may be transfused serially using the same consent. However, if the same is given over two days or hours apart, then a separate consent is required. Self explanatory.
Consent form
Consent form This shall include doctors and be done either by training and/or by providing written instructions.
e)
Training records
13
f)
Transfusion reactions are analyzed for preventive and corrective actions.
The organization shall ensure that any transfusion reaction is reported. It is preferable that the organization capture feedback regarding every transfusion (including the ones without reaction) as this would enable it to capture all transfusion reactions. These are then analyzed (by individual/ committee as decided by the organization) and appropriate corrective/preventive action is taken. The organization shall maintain a record of transfusion reactions.
Transfusion reaction form
COP.6. Policies and procedures guide the care of patients in the Intensive care and high dependency units.
a)
b)
Objective Element The organization has documented admission and discharge criteria for its intensive care and high dependency units. Staff is trained to apply these criteria. Adequate staff and equipment are available.
Interpretation The organization should develop objective criteria and adhere to it.
Remarks Admission & Discharge in MICU/HDU
This shall be done by training and/or by displaying the criteria. The ICU should be equipped with all necessary life saving and monitoring equipments as well as suitably manned by trained staff. The exact requirements shall be decided by the organization. However the organization is expected to follow best clinical practices. As and when there are no vacant beds in the ICU and there is a requirement of such bed, a detailed policy and procedure should be in place to address the situation. These could be developed individually or it could be a part of the Hospital infection control manual. The organization shall ensure that the practices are in consonance with good clinical practices. These could be developed individually or it could be a part of the Hospital quality assurance programme. The organization shall ensure that the programme is in consonance with good clinical practices.
Training Records
c)
Equipment Evident on site.
d)
Defined procedures for situation of bed shortages are followed.
Policy for non availability of beds
e)
Infection control practices are followed.
Infection Control Manual
f)
A quality programme implemented.
assurance is
Quality Management Plan
14
COP.7. Policies and procedures guide the care of vulnerable patients (elderly, children, physically and/or mentally challenged).
a)
b)
c)
d)
e)
Objective Element Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines. Care is organized and delivered in accordance with the policies and procedures. The organization provides for a safe and secure environment for this vulnerable group. A documented procedure exists for obtaining informed consent from the appropriate legal representative. Staff is trained to care for this vulnerable group.
Remarks
HCO develops SOP's for delivery of care. The organization shall provide proper environment taking into account the requirement of the vulnerable group. The informed consent for this group of people should be obtained from their family or legal representative.
Policy for Vulnerable patients Policy for Vulnerable patients
General Consent
All Staff involved in the care of this group shall be adequately trained in identifying and meeting their needs.
Training Records
COP.8. Policies and procedures guide the care of high risk obstetrical patients.
a)
Objective Element The organization defines and displays whether high risk obstetric cases can be cared for or not. Persons caring for high risk obstetric cases are competent. High risk obstetric patients assessment also includes maternal nutrition. The organization has the facilities to take care of neonates of high risk pregnancies.
Interpretation The organization shall define as to what constitutes high risk obstetric case in consonance with best clinical practices. These shall not just be doctors but shall include nursing staff also. The competency shall be based on qualification, experience and training. Self explanatory.
Remarks Obstetric Dept
b)
Obstetric Dept
c)
Obstetric Dept The organization shall have a NICU with proper equipments and staff.
d)
Policy Of Paediatric Deptt.
COP.9. Policies and procedures guide the care of pediatric patients.
15
a) b)
Objective Element The organization defines and displays the scope of its pediatric services. The policy for care of neonatal patients is in consonance with the national/ international guidelines. Those who care for children have age specific competency.
Interpretation The scope shall also neonatal services, if any. Self explanatory.
Remarks include Policy Of Paediatric Deptt. Policy Of Paediatric Deptt.
c)
d) e)
Provisions are made for special care of children. Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment. Policies and procedures prevent child/ neonate abduction and abuse. The childrens family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record.
These shall not just be for doctors but shall include nursing staff also. The competency shall be based on qualification, experience and training. Adequate amenities for the care of infants and children to be available in the hospital. Self explanatory.

Paediatric Assessment Sheet
f)
The HCO shall ensure that there is an adequate security/surveillance to prevent such happenings. Self explanatory.
Policy Of Neonatal Child/ Abuse
g)
COP.10. Policies and procedures guide the care of patients undergoing moderate sedation.
a)
Objective Element Competent and trained persons perform sedation. The person administering and monitoring sedation is different from the person performing the procedure. Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedation.
b)
Interpretation Whenever parenteral route is used this shall be carried out by a doctor/nurse. Self explanatory.
Remarks Sedation policy
Sedation policy Self explanatory. The same should be documented.
c)
Sedation policy
16
d)
Patients are after sedation.
monitored
e)
Criteria are used to determine appropriateness of discharge from the recovery area. Equipment and manpower are available to rescue patients from a deeper level of sedation than that intended.
The patients vitals shall be monitored at regular intervals (as decided by the organization) till he/she recovers completely from the sedation. The same should be documented. These shall be developed by the organization in consonance with good clinical practices. The equipments shall include emergency resuscitation equipments. An anaesthesiologist shall be available in the hospital.
Sedation policy
Sedation policy
f)
To be verified by Physical Examination.
COP.11. Policies and procedures guide the administration of anaesthesia.
a)
Objective Element There is a documented policy and procedure for the administration of anaesthesia. All patients for anaesthesia have a preanaesthesia assessment by a qualified individual.
Interpretation HCO shall document on the indications, the type of anaesthesia and procedure for the same. This shall be done before the patient is wheeled into the OT complex. It shall be applicable for both routine and emergency cases. This assessment shall be done by an anaesthesiologist .It is preferable to do assessment in a standardized format. Self explanatory.
Remarks Pre-operative Evaluation
b)
Pre-operative Evaluation
c)
d)
The pre-anaesthesia assessment results in formulation of an anaesthesia plan which is documented. An immediate preoperative re-evaluation is documented. Informed consent for administration of anaesthesia is obtained by the anaesthetist. During anaesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency and level of anaesthesia.
Pre-operative Evaluation
e)
This shall be done by an anaesthesiologist just before the patient is wheeled in to the respective OT. Self explanatory.
Anaesthesia and Pain Management OT Manual Informed Consent
f)
Self explanatory. Anaesthesia and Pain Management OT Manual
17
g)
Each patients postanaesthesia status is monitored and documented.
h)
A qualified individual applies defined criteria to transfer the patient from the recovery area. All adverse anaesthesia events are recorded and monitored.
i)
This shall be done in the recovery area/OT and at least include monitoring of vitals till the patient recovers completely from anaesthesia and shall be done by an anaesthesiologist. If the patients condition is unstable and he/she requires ICU care the same shall be monitored there. The organization documents these criteria which should be in consonance with good clinical practices. These criteria shall be applied by a designated individual as decided by the HCO. All such events are documented and monitored for the purpose of taking corrective and preventive action.
PAC Form Evidenced on site
Signed by anaesthesist
In Practice.
COP.12. Policies and procedures guide the care of patients undergoing surgical procedures.
a)
Objective Element The policies procedures documented.
and are
b)
Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery. An informed consent is obtained by a surgeon prior to the procedure. Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery. Persons qualified by law are permitted to perform the procedures that they are entitled to perform. A brief operative note is documented prior to transfer out of patient from recovery area.
c)
Interpretation This shall include the list of surgical procedures as well as competency level for performing these procedures. All patients undergoing surgery are assessed pre operatively and a provisional diagnosis is made which is documented. This shall be applicable for both routine and emergency cases. Self explanatory.
Remarks OT Manual
IP Care Surgical Care Related Process Pre-operative Evaluation
General Consent
d)
Procedure should be available for preventing adverse events like wrong patients, wrong site by a suitable mechanism. The HCO identifies the individuals who have the required qualification (s), training and experience to perform procedures in consonance with the law. This note provides information about the procedure performed, post operative diagnosis and the status of the patient before shifting and shall be documented by the surgeon/member of the surgical team.
Wrong Patient wrong side Policy
e)
Personnel file as evidences
f)
OT Manual
18
g)
The operating surgeon documents the postoperative plan of care. A quality assurance programme is followed for the surgical services.
Self explanatory. OT Manual This shall be an integral part of the HCO's overall quality assurance programme. It shall focus on post operative complications e.g. bleeding, rational use of antibiotics, etc. Surveillance activities include monitoring the quality of air provided, rate of air exchange , cleaning and disinfection processes, etc. Self explanatory.
h)
IP Care Surgical Care Related Process
i)
j)
The quality assurance programme includes surveillance of the operation theatre environment. The plan also includes monitoring of surgical site infection rates.
To be covered by the internal audit under the scope of medical audit
COP.13. Policies and procedures guide the care of patients under restraints (physical and/ or chemical).
a)
Objective Element Documented policies and procedures guide the care of patients under restraints. These include both physical and chemical restraint measures. These include documentation of reasons for restraints. These patients are more frequently monitored.
Interpretation This shall clearly state the conditions/circumstances under which restraints shall be used. It shall also specify as to who can authorize the use of restraints. Physical restraints include boxer's bandage, use of cuffs etc. Chemical restraints include sedatives. Self explanatory.
Remarks Restraint Policy
b)
Restraint Policy
c)
Restraint Policy The organization shall specify the parameters and frequency of monitoring and accordingly implement the same. Self explanatory.
d)
Restraint Policy
e)
Staff receive training and periodic updating in control and restraint techniques.
Training records
COP.14. Policies and procedures guide appropriate pain management.
a)
Objective Element Documented policies and procedures guide the management of pain.
Interpretation The HCO shall define the group of patients for whom this is applicable. A good reference point for defining these patients could be those having pain as the predominant debilitating symptom.
Remarks Pain management
19
b)
The organization respects and supports the appropriate assessment and management of pain for all patients. Patient and family are educated on various pain management techniques.
Self explanatory. Pain management
c)
Self explanatory. Pain management
COP.15. Policies and procedures guide appropriate rehabilitative services.
a)
b)
Objective Element Documented policies and procedures guide the provision of rehabilitative services. These services are commensurate with the organizational requirements. Rehabilitative services are provided by a multidisciplinary team.
Remarks Physiotherapy Dept.
The scope of the departments is in consonance with the scope of the hospital.
Self explanatory.
c)
The team shall have treating doctor, rehabilitation therapist, rehabilitation nurses and other professional experts.
Physiotherapy Dept.
COP.16. Policies and procedures guide all research activities.
a)
Objective Element Documented policies and procedures guide all research activities in compliance with national and international guidelines. The organization has an ethics committee to oversee all research activities.
Remarks
NA
b)
c)
The committee has the powers to discontinue a research trial when risks outweigh the potential benefits.
An ethics committee should be framed in the hospital to monitor activities undertaken by various providers. Any research undertaken in the hospital falls under its ambit. This includes both funded and non-funded and also student studies. Self explanatory.
NA
NA
20
d)
e)
Patients informed consent is obtained before entering them in research protocols. Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal. Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organizations services.
Self explanatory. NA Self explanatory. NA
f)
Self explanatory. NA
COP.17. Policies and procedures guide nutritional therapy.
a)
b)
Objective Element Documented policies and procedures guide nutritional assessment and reassessment. Patients receive food according to their clinical needs. There is a written order for the diet. Nutritional therapy is planned and provided in a collaborative manner.
Remarks Dietary, Nutrition and Food Services
A dietician shall do the assessment of the patient in consultation with the clinician and advice regarding food. The dietician shall prepare this in the form of a diet sheet and patient shall receive food accordingly. The dietician shall ensure that this is planned in consultation with the treating doctor and the patient/patients relative after taking into regard the patients food habits (veg/ non-veg) and likes and dislikes. The dietician/nurse shall ensure this during planning. The dietary services to be designed in a manner that there is no criss cross of traffic. All the activities fall in a sequence. The organization shall ensure that hygienic conditions are followed all throughout.
Dietary, Nutrition and Food Services

Nutritional assement form
c)
Dietary, Nutrition and Food Services Dietary, Nutrition and Food Services
d)
e)
f)
When families provide food, they are educated about the patient's diet limitations. Food is prepared, handled, stored and distributed in a safe manner.
Dietary, Nutrition and Food Services Dietary, Nutrition and Food Services
COP.18. Policies and procedures guide the end of life care.
21
a)
Objective Element Documented policies and procedures guide the end of life care.
Interpretation The HCO has a documented policy for providing care to terminally ill admitted patients. This shall include providing appropriate pain and palliative care according to the wishes of the family and patient. Self explanatory.
Remarks End of Life Care Operational Policy
b)
c)
d)
These policies and procedures are in consonance with the legal requirements. These also address the identification of the unique needs of such patient and family. These also include sensitively addressing issues such as autopsy and organ donation. Staff is educated and trained in end of life care.
End of Life Care Operational Policy The religious and socio-cultural beliefs of patients/ family shall be addressed and respected. If the body of the deceased is subjected to an autopsy or for organ donation, it should be discussed with the family in a very courteous manner. Self explanatory. Training Records End of Life Care Operational Policy End of Life Care Operational Policy
e)
CHAPTER 3 : Management of Medication (MOM)

MOM.1. Policies and procedures guide the organization of pharmacy services and usage of medication.
a)
Objective Element There is a documented policy and procedure for pharmacy services and medication usage.
Interpretation The policies and procedures shall address the issues related to procurement, storage, formulary, prescription, dispensing, administration, monitoring and use of medications. Self explanatory.
Remarks
Material Management Pharmacy

Drugs And Cosmetics Act
b)
These comply with the applicable laws and regulations. A multidisciplinary committee guides the formulation and implementation of these policies and procedures.
c)
This shall be representative of major clinical departments, administration and shall include a pharmacist/ clinical pharmacologist.
Records Of Drugs and Therapeutics Committee
MOM.2. There is a hospital formulary.
22
a)
Objective Element A list of medication appropriate for the patients and organizations resources is developed. The list is developed collaboratively by the multidisciplinary committee. There is a defined process for acquisition of these medications.
Interpretation The hospital formulary shall be prepared and be preferably updated at regular intervals. Refer to MOM 1c.
Remarks Drug formulary
b)
Records Of Drugs and Therapeutics Committee
c)
d)
There is a process to obtain medications not listed in the formulary.
The process should address the issues of vendor selection, vendor evaluation, generation of purchase order and receipt of goods as per rules. Self explanatory.
Pharmacy
Local Purchase Policy
MOM.3. Policies and procedures guide the storage of medication.
a)
Objective Element Documented policies and procedures exist for storage of medication.
Interpretation These should address issues pertaining to temperature (refrigeration), light, ventilation, preventing entry of pests/ rodents and vermins. The organization shall also ensure that the storage requirements of the drug as specified by the manufacturer are adhered to. If the recommendations are conflicting in nature, the organization shall follow the manufacturers recommendation. This shall be applicable to all areas where medications are stored including wards. Self explanatory.
Remarks Policy on Storage Of Medication
b)
Medications are stored in a clean, well lit and ventilated environment.
Physical examination.
c)
Sound inventory control practices guide storage of the medications. Medications are protected from loss or theft.
ABC Analysis The organization shall ensure that it develops proper mechanisms to prevent pilferage. The organization could conduct audits at regular intervals (as defined by the organization) to detect such instances. Many drugs in ampoules, vials or tablets may look-alike or soundalike. They should be segregated and stored separately.
d)
Regular AUDIT
e)
Sound alike and look alike medications are stored separately.
Demonstrated in practice
23
f)
There is a method to obtain medication when the pharmacy is closed. Emergency medications are available all the time.
When pharmacy is closed, there should be a SOP to procure the drugs. Adequate amount of emergency medicines should be stocked at all times. Re-order level at definite quantity should be done. Self explanatory.
24 hours pharmacy is available.
g)
Stock maintenance register &records to be produced as evidences.
h)
Emergency medications are replenished in a timely manner when used.
Relevant register as evidence.
MOM.4. Policies and procedures guide the prescription of medications.
a)
Objective Element Documented policies and procedures exist for prescription of medications. The organization determines who can write orders. Orders are written in a uniform location in the medical records.
Remarks Policy on prescription of medication
b)
This shall be done by the treating doctor.
Policy on prescription of medication Policy on Verbal Orders for Medication
c)
d)
Medication orders are clear, legible, dated, timed, named and signed.
All the orders for medicines are recorded on a uniform location of the case sheet. Electronic orders when typed shall again follow the same principles. Self explanatory.
Medical Records
Medical Records
e)
Policy on verbal orders is documented and implemented.
The organization shall ensure that it has a policy to address this issue and it shall address as to who can give verbal orders and how these orders will be validated. High risk medications are medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes. Examples include medications with a low therapeutic window, controlled substances, psychotherapeutic medications, and look-alike and sound-alike medications. These medications shall preferably be given only after written orders
Policy on Verbal Orders for Medication
f)
The organization defines a list of high risk medication.
High Risk Medication
g)
High risk medication orders are verified prior to
High Risk Medication
24
dispensing.
and it should be verified by the staff before dispensing.
MOM.5. Policies and procedures guide the safe dispensing of medications.
a)
Objective Element Documented policies and procedures guide the safe dispensing of medications.
Interpretation Clear policies to be laid down for dispensing of medication e.g. route of administration, dosage, rate of administration, expiry date, etc. Recall may result based on letters from regulatory authorities or internal feedback (e.g. visible contaminant in IV fluid bottle). Self explanatory. At a minimum, labels must include the drug name, strength frequency of administration (in a language the patient understands) and expiry dates.
Remarks Safe Dispensing Of Medicine
b)
The policies include a procedure for medication recall. Expiry dates are checked prior to dispensing. Labelling requirements are documented and implemented by the organization.
Drug Labelling Policy
c) d)
Pharmacy
Drug Labelling Policy
MOM.6. There are defined procedures for medication administration.
a)
Objective Element Medications are administered by those who are permitted by law to do so. Prepared medications are labelled prior to preparation of a second drug. Patient is identified prior to administration.
Remarks Policy on prescription of medication
b)
Self explanatory. Drug Labelling Policy Self explanatory. Safe Dispensing Of Medicine
c)
d)
Medication is verified from the order prior to administration.
Staff administering medications should go through the treatment orders before administration of the medication and then only administer them. It is preferable that they also check the general appearance of the medication (e.g. melting, clumping etc.) before dispensing.
Safe Dispensing Of Medicine
25
e)
f)
g)
h)
Dosage is verified from the order prior to administration. Route is verified from the order prior to administration. Timing is verified from the order prior to administration. Medication administration is documented.
Self explanatory.
Safe Dispensing Of Medicine Safe Dispensing Of Medicine Safe Dispensing Of Medicine Safe Dispensing Of Medicine
Self explanatory.
Self explanatory.
The organization shall ensure that this is done in a uniform location and it shall include the name of the medication, dosage, route of administration, timing and the name and signature of the person who has administered the medication. At the outset the HCO could define if it would permit self administration of medications. In case the HCO permits then the policy shall include the medications which the patient can self administer. It is preferable that the organization also incorporates a method to ensure that the patient is reminded to take the medication (before every dose) and documentation of self administration. These shall address as to what are the pre-requisites for such a medication (e.g. Invoice; Clear label with mention of the name, dose, expiry date etc.)
i)
Policies and procedures govern patients self administration of medications.
Organization do not allow self Medication.
j)
Policies and procedures govern patients medications brought from outside the organization.
MOM.7. Patients and family members are educated about safe medication and food-drug interactions.
a)
Objective Element Patient and family are educated about safe and effective use of medication.
b)
Patient and family are educated about food-drug interactions.
Interpretation The organization shall make a list of such drugs and accordingly educate e.g. digoxin. This could also include education regarding the importance of taking a drug at a specific time e.g. sustained release medications. Patient and family should be counselled about their diet during medication e.g. no alcohol when taking metronidazale.
Remarks Safe Medication And Food Drugs Interactions
Safe Medication And Food Drugs Interactions
MOM.8. Patients are monitored after medication administration.
26
a)
Objective Element Patients are monitored after medication administration and this is documented.
Interpretation This shall be done by anyone involved in direct patient care. The organization could follow either a passive (documenting only if the patient tells) or active (enquiring with every patient) monitoring mechanism. The organization shall define as to what constitutes an adverse drug event. This shall be in consonance with best practices. Adverse drug events include adverse drug reactions as well as medication errors. Self explanatory. The organization shall define the timeframe for reporting once the adverse drug event has occurred. All the adverse drug reactions are analyzed regularly by the multidisciplinary committee (Refer to MOM 1C). Self explanatory.
Remarks In Patient Care Medical Care Related Process
b)
Adverse drug events are defined.
Adverse drug Reaction policy

ARD Form
c)
Adverse drug events are reported within a specified time frame. Adverse drug events are collected and analyzed.
Adverse drug Reaction policy Adverse drug Reaction policy
d)
e)
Policies are modified to reduce adverse drug events when unacceptable trends occur.
Adverse drug Reaction policy
MOM.9. Policies and procedures guide the use of narcotic drugs and psychotropic substances.
a)
b)
Objective Element Documented policies and procedures guide the use of narcotic drugs and psychotropic substances. These policies are in consonance with local and national regulations. A proper record is kept of the usage, administration and disposal of these drugs. These drugs are handled by appropriate personnel in accordance with policies.
Interpretation Self explanatory. Refer to MOM 1a.
Remarks Narcotics Policy
This is in the context of Narcotic Drugs and Psychotropic Substances Act. These shall be kept in accordance with statutory requirements. Self explanatory.
Narcotic Drugs and Psychotropic Substances Act. Records
c)
d)
MOM.10. Policies and procedures guide the usage of chemotherapeutic agents.
27
a)
b)
c)
d)
Objective Element Documented policies and procedures guide the usage of chemotherapeutic agents. Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy. Chemotherapy is prepared and administered by qualified personnel. Chemotherapy drugs are disposed off in accordance with legal requirements.
Remarks Chemotherapy policy
This shall preferably be a medical oncologist or a person who has been trained and has achieved competency in the same. This shall preferably be staff who have received special training in preparing and administration. These shall be disposed off according to BMW management and handling rules 1998 or manufacturer's recommendation.
Chemotherapy policy
Chemotherapy policy
Biomedical waste management rule and regulation.
MOM.11. Policies and procedures govern usage of radioactive drugs.
a)
Objective Element Documented policies and procedures govern usage of radioactive drugs. These policies and procedures are in consonance with laws and regulations. The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs. Staff, patients and visitors are educated on safety precautions.
Remarks Radioactive material policy
b)
Refer to AERB guidelines. Radioactive material policy Self explanatory. This shall however be in accordance with AERB guidelines.
c)
Radioactive material policy
d)
Self explanatory.
DEMONSTRATED IN PRACTICE. APPROPRIATE SIGNAGES USED AT ALL THE PLACES.
MOM.12. Policies and procedures guide the use of implantable prosthesis.
a)
Objective Element Documented policies and procedures govern procurement and usage of implantable prosthesis.
Remarks Implant Policy
28
b)
Selection of implantable prosthesis is based on scientific criteria and national /internationally recognized approvals.
c)
The batch and serial number of the implantable prosthesis are recorded in the patients medical record and the master logbook.
The organization shall ensure that relevant and sufficient scientific data are available before selection. It shall also look for international (e.g.US-FDA) or national notification (Drugs and Cosmetics Act notification October 2005) for approval of the particular product. Self explanatory.
Implant Policy
Implant Policy
MOM.13. Policies and procedures guide the use of medical gases.
a)
b)
Objective Element Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases. The policies and procedures address the safety issues at all levels.
Interpretation This shall be applicable to all gases used in the organization. It shall also address the issue of statutory requirements and approvals wherever applicable. It shall follow a uniform colour coding system. This shall include from the point of storage/source area, gas supply lines and the end user area. Appropriate safety measures shall be developed and implemented for all levels. This is the context of the Indian explosives act of 1884, Gas cylinder rules 1981 and Static and mobile pressure vessels (unfired) 1981.
Remarks Gas Masifold Process
Gas Manifold Process
c)
Appropriate records are maintained in accordance with the policies, procedures and legal requirements.
Gas Manifold Process
CHAPTER 4 : Patient Rights and Education (PRE)

PRE.1. The organization protects patient and family rights and informs them about their responsibilities during care.
a)
Objective Element Patient and family rights and responsibilities are documented.
Interpretation Hospital should respect patients rights and inform them of their responsibilities. All the rights of the patients should be displayed in the form of a Citizens Charter which should also give information of the charges and grievance redress mechanism.
Remarks Citizen Charter
29
b)
c)
Patients and families are informed of their rights and responsibilities in a format and language that they can understand. The organizations leaders protect patients rights. Staff is aware of their responsibility in protecting patients rights. Violation of patient rights is reviewed and corrective/preventive measures taken.
Self explanatory. Citizen Charter Protection also includes addressing patients grievances w.r.t rights. Training and sensitisation programmes shall be conducted to create awareness among the staff. Where patients' rights have been infringed upon, management must keep records of such violations, as also a record of the consequences, e.g. corrective actions to prevent recurrences.
Citizen Charter
d)
Employee Guide Book
e)
Patient Grievance Policy
PRE.2. Patient rights support individual beliefs, values and involve the patient and family in decision making processes.
a)
b)
Objective Element Patient and family rights address any special preferences, spiritual and cultural needs. Patient rights include respect for personal dignity and privacy during examination, procedures and treatment.
Interpretation This could include preferences and requirements
Remarks dietary worship Patients Right Policy
c)
Patient rights include protection from physical abuse or neglect. Patient rights include treating patient information as confidential. Patient rights include refusal of treatment.
d)
e)
During all stages of patient care, be it in examination or carrying out a procedure, hospital staff shall ensure that patients privacy and dignity is maintained. The organization shall develop the necessary guidelines for the same. During procedures the organization shall ensure that the patient is exposed just before the actual procedure is undertaken. With regards to photographs/recording procedures; the organization shall ensure that consent is taken and that the patients identity is not revealed. Self explanatory. Special precautions shall be taken especially w.r.t vulnerable patients e.g. elderly, neonates etc. Self explanatory. Statutory requirements w.r.t. privileged communication shall be followed at all times. During management the patients should be given the choice of treatment. The treating doctor shall discuss all the available options and allow the patient to make an informed choice including the option
Policy For Vulnerable Patients Patients Right Policy
30
of refusal.
f)
g)
Patient rights include informed consent before anaesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment. Patient rights include information and consent before any research protocol is initiated.
Self explanatory. Informed Consent
h)
Patient rights include information on how to voice a complaint. Patient rights include information on the expected cost of the treatment. Patient has a right to have an access to his / her clinical records.
i)
The organization shall ensure that International conference on harmonization (ICH) of Good clinical practice (GCP) and Declaration of Helsinki Somerset (1996) and ICMR requirements are followed. Grievance redressal mechanism must be accessible and transparent. Displayed information must be clearly available on how to voice a complaint. Refer AAC4d.
Informed Consent
Patients Right Policy The organization shall ensure that every patient has access to his/her record. This shall be in consonance with The code of medical ethics and statutory requirements.
j)
PRE.3. A documented process for obtaining patient and / or families consent exists for informed decision making about their care.
a)
b)
Objective Element General consent for treatment is obtained when the patient enters the organization. Patient and/or his family members are informed of the scope of such general consent. The organization has listed those procedures and treatment where informed consent is required. Informed consent includes information on risks, benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand.
Remarks General Consent
c)
The organization shall define as to what is the scope of this consent and the same shall be communicated to the patient and/or his family members. A list of procedures should be made for which informed consent should be taken. The consent shall have the name of the doctor performing the procedure. If it is a doctor under training the same shall be specified, however the name of the qualified doctor supervising the procedure shall also be mentioned. Consent form shall be in the
31
General Consent
Informed Consent
d)
Informed Consent
language that understands. e) The policy describes who can give consent when patient is incapable of independent decision making.
the
patient
The organization shall take into consideration the statutory norms. This would include next of kin/legal guardian. However in case of unconscious/ unaccompanied patients the treating doctor can take a decision in life saving circumstances.
Informed Consent
PRE.4. Patient and families have a right to information and education about their healthcare needs.
a)
b)
Objective Element When appropriate, patient and families are educated about the safe and effective use of medication and the potential side effects of the medication. Patient and families are educated about diet and nutrition. Patient and families are educated about immunizations.
Remarks Policy on Safe Medication
Self explanatory.
Dietary, Nutrition and Food Services Immunization cards are given in Hospital
c)
d)
e)
Patient and families are educated about their specific disease process, complications and prevention strategies. Patient and families are educated about preventing infections Patients are taught in a language and format that they can understand
Self explanatory. More applicable for paediatric population. In adults it could be for influenza, Streptococcus pneumoniae, typhoid, hepatitis B, Neisseria meningitides, etc. Self explanatory. This could also be done through patient education booklets/videos/leaflets etc. Self explanatory.
f)
Self explanatory.
PRE.5. Patient and families have a right to information on expected costs.
a)
b)
Objective Element There is uniform pricing policy in a given setting (out-patient and ward category). The tariff list is available to patients.
Interpretation There should be a billing policy which defines the charges to be levied for various activities. The organization shall ensure that there is an updated tariff list and that this list is available to patients
Remarks Billing Policy
Tariff List
32
c)
Patients are educated about the estimated costs of treatment. Patients are informed about the estimated costs when there is a change in the patient condition or treatment setting.
when required. The organization shall charge as per the tariff list. Any additional charge should also be enumerated in the tariff and the same communicated to the patients. The tariff rates should be uniform and transparent. Refer to AAC4d. Patients Right Policy When patients are shifted from one setting to another, typically to and from ICUs, the financial implications must be clearly conveyed to them.
d)
Estimated Cost Performa
CHAPTER 5 : Hospital Infection Control (HIC)

HIC.1. The 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. a) Objective Element The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections. The hospital has a multidisciplinary infection control committee. Interpretation Self explanatory. Remarks Infection Control Manual
b)
c)
The hospital has infection control team.
an
d)
The hospital has designated and qualified infection control nurse(s) for this activity.
This shall preferably have Hospital Administrator, Microbiologist, Physician, Surgeon, Manager Nursing (Nursing Supervisor), staff from CSSD, and other Support services and the hospital infection control nurse. It should also include invitees from various departments as deemed necessary. The team is responsible for day-today functioning of infection control programme. They shall support surveillance process and detect outbreaks. They shall also participate in audit activity and in infection prevention and control on a day-to-day basis. The qualification shall be either a graduate nurse or qualified nurse with competence gained by experience.
HIC.2. The hospital has an infection control manual, which is periodically updated.
33
a)
Objective Element The manual identifies the various high-risk areas and procedures.
b)
It outlines methods of surveillance in the identified high-risk areas.
c)
It focuses on adherence to standard precautions at all times. Equipment cleaning and sterilization practices are included.
Interpretation The manual should clearly identify the high risk areas of the hospital e.g. ICU, HDU, OT, Post-operative ward, Blood Bank, CSSD, etc. Similarly, all high risk procedures should be identified from infection control point of view. For example,cardiac catheterization, endoscopies, surgery lasting more than 2 hours, BMT etc. It shall define the frequency and mode of surveillance. The surveillance system should meet WHO criteria of simplicity, cost minimization, timeliness of feedback, flexibility, acceptability, consistency (reliability), sensitivity and specificity. Self explanatory.
Remarks Infection Control Manual
Infection Control Manual It shall address this at all levels e.g. ward, OT and CSSD. It is preferable that the organization follows a uniform policy across different departments within the organization. The Manual should include sterilization and disinfection policy, chemicals used/ methods and procedures followed in wards and critical areas. Special focus on critical equipments like ventilators, nebulizers etc. The HCO shall develop a system of monitoring drug susceptibility (based on culture sensitivity) and accordingly develop its antibiotic policy, which shall be reviewed at periodic intervals (maybe once in 3 months) for its continuing applicability. The laundry can be in-house or outsourced. If outsourced the organization shall ensure that it establishes adequate controls to ensure infection control. The linen change policy should be mentioned. Washing protocols for different categories of linen including blankets should be included. Self explanatory. The same shall be applicable even if this activity is outsourced. The organization could refer to ISO 22000:2005 (food safety) while addressing this issue.
d)
e)
An appropriate antibiotic policy is established and implemented.
Antibiotic Policy
f)
Laundry and linen management processes are also included.
Laundry Services
g)
Kitchen sanitation and food handling issues are included in the manual.
34
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.
Issues such as Air conditioning plant and equipment maintenance, cleaning of A/c ducts, AHUs, replacement of filters, seepage leading to fungal colonization, replacement/repair of plumbing, sewer lines (in shafts) should be included. Water supply sources and system of supply, testing for water quality must be included. Any renovation work in hospital patient care areas should be planned with Infection Control team with regard to architectural segregation, traffic flow, use of materials. The mortuary services in the hospital should be provided through walk-in cold rooms or mortuary cold cabinets. Mortuary procedures of preserving body, or body parts and safety measures while handing over body to relatives should be in accordance with the policy. The organization must have a documented policy on the updation of the infection control manual. It is desirable to update at least once in a year based on its trends & outcomes of the audit processes.
HIC.3. The infection control team is responsible for surveillance activities in identified areas of the hospital.
a)
Objective Element Surveillance activities are appropriately directed towards the identified highrisk areas.
b)
Collection of surveillance data is an ongoing process.
Interpretation The organization must be able to provide evidence of conducting periodic surveillance activities in its identified high risk areas. The specific objectives, case definitions, identification of potential indicators, frequency and duration of monitoring, methods of data collection, along with schedule of rounds should be defined. Confidentiality and anonymity must be ensured. The HCO should clearly mention which specific targeted surveillance (site specific, unit oriented, priority oriented) activities are being carried out. The organization shall ensure that it has a process in place to collect surveillance data and also to ensure that it is able to capture all such data.
35
c)
Verification of data is done on regular basis by the infection control team.
The data so collected shall be authenticated by the team by going through every data or by using random sampling so that the process can be validated. The team shall preferably verify every serious infection (as defined by the organization) report. The organization shall identify all notifiable diseases after taking into consideration the local laws, rules, regulations and notifications thereof. The organization shall ensure that this is sent at the specified frequency and in the format as required by statutory authorities. This shall be done at regular intervals (maybe monthly and consolidated into an annual report) and the organization shall take suitable steps based on the analysis. This would include categorization of areas/ surfaces; general cleaning procedures for surfaces, furniture/ fixtures, and items used in patient care. It should also include procedures for terminal cleaning, blood and body fluid cleanup, isolation rooms and all high risk (critical) areas. The common disinfectants used, dilution factors, method of use should be specified.
d)
In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.
Records from Medical Records department
e)
Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends. Surveillance activities include monitoring the effectiveness of housekeeping services.
f)
HIC.4. The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees.
a)
Objective Element The organization monitors urinary tract infections. The organization monitors respiratory tract infections.
b)
Interpretation This can be done either by sending urine or catheter tip for culture. The organization shall do this for all symptomatic catheterized patients. This can be done by sending sputum or ET/ tracheostomy secretions (obtained using a suction catheter) or ET/ tracheostomy tip or protected specimen brushing (PSB) or mini broncho-alveolar lavage (BAL) for culture. The organization shall do this for all patients on the ventilator having clinical features suggestive of infection.
Remarks Records
Records
36
c)
The organization monitors intra-vascular device infections.
d)
The organization monitors surgical site infections. Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.
For patients with symptoms suggestive of intra vascular device infection and having central line the same shall be done by sending the tip for culture. For all peripheral lines clinical evidence of thrombophlebitis would suffice. This shall be done by sending pus/ swab for culture. The feedback shall include the rates, trends and opportunities for improvement. It could also provide specific inputs to reduce the HAI rate.
Records
Records
e)
Records
HIC.5. Proper facilities and adequate resources are provided to support the infection control programme.
a)
b)
Objective Element Hand washing facilities in all patient care areas are accessible to health care providers. Compliance with proper hand washing is monitored regularly. Isolation/ barrier nursing facilities are available.
Interpretation The organization shall ensure that it provides necessary infrastructure to carry out the same. The organization shall preferably display the necessary instructions near every hand washing area. Compliance could be verified by random checking, observation, etc. The organization shall define the conditions where the same shall be carried out and ensure that it provides the necessary resources to carry out the activity (e.g. clothing, masks, gloves etc.). Self explanatory. They should be available at the point of use and the organization shall ensure that it maintains an adequate inventory.
Remarks Infection Control Manual Evidence on site Infection Control Manual Evidence on site
c)
d)
Adequate gloves, masks, soaps, and disinfectants are available and used correctly.
Facilities Available
HIC.6. The hospital takes appropriate action to control outbreaks of infections.
a)
Objective Element Hospital has a documented procedure for handling such outbreaks.
Interpretation This shall incorporate definitions as to what constitutes an outbreak; identification and investigation of such outbreaks and the procedure for management. This shall be in accordance with good clinical practices. Standard Case definitions shall include a unit of time and place along with specific biological and/or clinical criteria.
Remarks
37
b)
This procedure is implemented during outbreaks.
c)
After the outbreak is over appropriate corrective actions are taken to prevent recurrence.
The organization should be able to identify the outbreak, describe the outbreak by developing a case definition, designing a data collection form, collecting data from the affected, constructing an epidemic curve. The organization should be able to implement basic procedures to prevent recurrence such as source control if source identified, review of all infection control policies, loopholes and compliance gaps, strengthening infection control policies etc.
HIC.7. There are documented procedures for sterilization activities in the hospital.
a)
Objective Element There is adequate space available for sterilization activities.
b)
Regular validation tests for sterilization are carried out and documented.
c)
There is an established recall procedure when breakdown in the sterilization system is identified.
Interpretation Adequacy of space refers to the CSSD which should have an area of 0.7sqm/bed, suitable location, proper layout (unidirectional flow, zoning) and separation of clean and dirty areas. This shall be done by accepted methods e.g. bacteriologic, strips etc. Engineering validations like Bowie Dick tape test and leak rate test need to be carried out. The organization shall ensure that the sterilization procedure is regularly monitored and in the eventuality of a breakdown it has a procedure for withdrawal of such items.
Remarks CSSD Policy
CSSD Policy
CSSD Policy
HIC.8. Statutory provisions with regard to Bio-medical Waste (BMW) management are complied with.
a)
b)
Objective Element The hospital is authorized 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.
Interpretation The occupier shall apply in the prescribed form and get approval from the prescribed authority e.g. Pollution control board/committee. Wastes to be segregated and collected in different colour coded bags and containers as per statutory provisions. Monitoring shall be done by members of the infection control committee/team.
Remarks Copy of FORM I
Evident on Site
38
c)
The organization ensures that Bio-medical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner. Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorized contractor(s). Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.
d)
The waste is transported to the predefined site at definite time intervals (maximum within 48hours) through proper transport vehicles in a safe manner. If this activity is outsourced the organization shall ensure that it is done to an authorized contractor. Monitoring of this activity should be done by Infection Control team. If the hospital has waste treatment facility within its premises then they have to be in accordance with statutory provisions or they can outsource it to a central facility. The HCO shall ensure that the fees are deposited in a timely manner. In addition the annual reports have to be submitted by the 31st of January of every year and accident reporting has to be carried out in the prescribed form. Self explanatory.
Evident on Site Waste transportation trolley
MOU between the hospital and the Outsourced agency
e)
Copy of FORM II
f)
Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste.
Evident on site
HIC.9. The infection control programme is supported by hospital management and includes training of staff and employee health.
a)
Objective Element Hospital management makes available resources required for the infection control programme. The hospital regularly earmarks adequate funds from its annual budget in this regard.
b)
c)
It conducts regular preinduction 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.
d)
Interpretation The HCO shall ensure that the resources required by the personnel should be available in a sustained manner. This includes both men and materials. There shall be a separate budget demarcated for HIC activity. This shall be prepared taking into consideration the scope of the activity and previous years experience. There must be a documented evidence of pre induction training for appropriate categories of staff before joining concerned department(s). It should include the policies, procedures and practices of the infection control programme. Self explanatory.
Remarks Copy of the budget
Copy of the budget
Training Records
Training Records
39
e)
Appropriate pre and post exposure prophylaxis is provided to all concerned staff members.
Self explanatory.
CHAPTER 6 : Continuous Quality Improvement (CQI)

CQI.1. There is a structured quality improvement and continuous monitoring programme in the organization. Objective Element a) The quality improvement programme is developed, implemented and maintained by a multidisciplinary committee. The quality improvement programme is documented. Interpretation This committee shall have representation from management, various clinical and support departments of the HCO. This programme shall be developed, implemented and maintained in a structured manner. This should be documented as a manual. The manual shall incorporate the mission, vision, quality policy, quality objectives, service standards, important indicators as identified etc. The manual could be stand alone and should have cross linkages with other manuals. This should preferably be a person having a good knowledge of accreditation standards, statutory requirements, hospital quality improvement principles and evaluation methodologies, hospital functioning and operations. This shall preferably cover all aspects including documentation of the programme, monitoring it, data collection, review of policy and corrective action. Also refer to CQI 1b. Self explanatory. Traning Records Remarks
b)
c)
There is a designated individual for coordinating and implementing the quality improvement programme.
Accreditation Coordinator
d)
e)
The quality improvement programme is comprehensive and covers all the major elements related to quality improvement and risk management. The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism.
Quality Management Plan Risk Management
40
f)
The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified.
g)
The quality improvement programme is a continuous process and updated at least once in a year.
As quality improvement is a dynamic process, it needs to be reviewed at regular pre-defined intervals (as defined by the HCO in the quality improvement manual but at least once in four months) by conducting internal audits. This audit shall be done by a multidisciplinary team (preferably trained in NABH standards) including all the applicable standards and objective elements. At the end of the audit there shall be a formal meeting to summarise the findings and identify areas for improvement. During this meeting there shall be an analysis of key indicators as identified and determined by the organization including the mandatory indicators as laid down in CQI 2 and 3. The minutes of the review meetings should be recorded and maintained. Self explanatory. The inputs for updation could be based on the review carried out by the quality improvement committee.
Quality Committee
CQI.2. The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools for continual improvement. Objective Element a) Monitoring appropriate assessment. includes patient Interpretation The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Time for initial assessment of indoor and emergency patients. i. Percentage of cases wherein care plan is documented and counter-signed by the clinician. ii. Percentage of cases wherein screening for nutritional needs has been done. iii. Percentage of cases wherein the pre-defined initial nursing assessment is completed within 30 minutes. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Number of reporting errors/1000 investigations. ii. Percentage of re-dos. iii. Percentage of reports CoRemarks
b)
Monitoring includes safety and quality control programmes of the diagnostics services.
41
relating with clinical diagnosis. iv. Percentage of adherence to safety precautions by employees working in diagnostics. c) Monitoring includes invasive procedures. all The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Re-exploration rate. ii. Percentage of accidental removal of tubes and catheters. iii. Incidence of haematoma at puncture site. iv. Percentage of re-scheduling of procedures. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Percentage of medication errors. ii. Incidence of adverse drug reactions. iii. Percentage of medication charts with illegible writing over a given period. iv. Percentage of contrast related reactions. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Percentage of modification of anaesthesia plan. ii. Percentage of unplanned ventilation following anaesthesia. iii. Percentage of adverse anaesthesia events. iv. Anaesthesia related mortality rate. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Percentage of transfusion reactions. ii. Percentage of wastage of blood and blood products. iii. Percentage of blood component usage. iv. Turnaround time for issue of blood and blood components The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Percentage of medical records
d)
Monitoring includes adverse drug events.
e)
Monitoring includes use of anaesthesia.
f)
Monitoring includes use of blood and blood products.
g)
Monitoring includes availability and content of medical records.
42
h)
Monitoring includes infection control activities.
i)
Monitoring includes clinical research.
j)
Monitoring includes data collection to support further improvements.
k)
Monitoring includes data collection to support evaluation of these improvements.
not having discharge summary. Percentage of medical records not having initial assessment and the plan of care. iii. Percentage of medical records having incomplete and/or improper consent. iv. Percentage of missing records. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Urinary tract infection rate. ii. Respiratory infection rate. iii. Intra-vascular device infection rate. iv. Surgical site infection rate. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Number of research activities being carried out. ii. Percentage of patients withdrawing from the study. iii. Percentage of protocol violations/deviations reported. iv. Percentage of serious adverse events (which have occurred in the HCO) reported to the ethics committee within the defined timeframe. The data could be collected at predefined intervals e.g. monthly/quarterly. This data is analysed for improvement opportunities and the same are carried out. Also refer to CQI 1f All improvement activities carried out by the HCO shall have an evaluable outcome. The same shall be captured and analysed. ii.
Infection Control Committee
NA
Infection Control Committee
CQI.3. The organization identifies key indicators to monitor the managerial structures, processes and outcomes which are used as tools for continual improvement. Objective Element a) Monitoring includes procurement of medication essential to meet patient needs. Interpretation The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Percentage of drugs procured by local purchase. ii. Percentage of stock outs including emergency drugs. iii. Percentage of consumables rejected before preparation of Goods Receipt Note. iv. Incidence of variations from the Remarks Drugs and Therapeutic Committee Drug Formulary
43
procurement process.
b)
Monitoring includes reporting of activities as required by laws and regulations.
c)
Monitoring includes risk management.
d)
Monitoring utilisation manpower equipment.
of
includes space, and
e)
Monitoring includes patient satisfaction which also incorporates waiting time for services.
The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Number of births and deaths. ii. Number of notifiable diseases. iii. Submission of report/ data/form pertaining to bio-medcial waste, PNDT act and radiation safety within the defined timeframe. iv. Submission of tax returns and deduction of taxes at the specified time frame. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Number of variations observed in mock drills. ii. Incidence of falls. iii. Incidence of bed sores after admission. iv. Percentage of employees provided pre-exposure prophylaxis. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Bed occupancy rate and average length of stay. ii. OT and ICU utilization rate. iii. Equipment down time. iv. Nurse-patient ratio. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Out patient satisfaction index. ii. In patient satisfaction index. iii. Waiting time for services including diagnostics and out patient. iv. Time taken for discharge. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Employee satisfaction index. ii. Employee attrition rate. iii. Employee absenteeism rate. iv. Percentage of employees who are aware of employee rights, responsibilities and welfare schemes. The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. Number of sentinel events. ii. Percentage of near misses analysed.
MRD Policy
Quality Committee
Quality Committee
f)
Monitoring includes employee satisfaction.
Employee Satisfaction Survey
g)
Monitoring includes adverse events and near misses.
Sentinel Event Policy
44
h)
Monitoring includes data collection to support further study for improvements. Monitoring includes data collection to support evaluation of the improvements.
i)
iii. Number of security related incidents including thefts. iv. Incidence of needle stick injuries. The data could be collected at predefined intervals e.g. monthly/ quarterly. This data is analysed for improvement opportunities and the same are carried out. Also refer to CQI 1f Self explanatory. The inputs for updation could be based on the review carried out by the quality improvement committee.
MRD Policy
CQI.4. The quality improvement programme is supported by the management.
Objective Element a) Hospital Management makes available adequate resources required for quality improvement programme. Hospital earmarks adequate funds from its annual budget in this regard. Appropriate statistical and management tools are applied whenever required.
Interpretation This shall include the men, material, machine and method. These should be in steady supply so as to ensure that the programme functions smoothly. Appropriate fund allocation is done by the organization for the smooth functioning of the programme. Self explanatory.
Remarks
Budget Report
b)
Budget
c)
Monthly report of MRD
CQI.5. There is an established system for audit of patient care services.
Objective Element a) Medical and nursing staff participates in this system. The parameters to be audited are defined by the organization.
Interpretation The HCO shall identify such personnel. It could be a mix of clinicians, administrators and nurses. As these audits are retrospective/concurrent in nature, it is imperative that this be done using predefined parameters so that there is no bias. The parameters could be disease based, cost based, community based or based on length of stay. This means that the names of the patients and the hospital staff who may figure in the audit documents must not be disclosed nor any reference be made to them in public discussions/ conferences.
Remarks Medical Audit Committee
b)
Parameters for medical AUDIT
c)
Patient and staff anonymity is maintained.
YES
45
d) e)
All audits documented.
are
Self explanatory. Medical Audit Report All remedial measures as ascertained should be documented and implemented and improvements thereof recorded to complete the audit cycle. Action taken Report of the Medical Audit
Remedial measures are implemented
CQI.6. Sentinel events are intensively analyzed. Objective Element a) The organization has defined sentinel events. Interpretation The sentinel events relating to system or process deficiencies that are relevant and important to the organization must be clearly defined. The established processes should include reporting the occurrence of such events on standardised incident report forms. Root cause analysis of all such events should be carried out by a multi-disciplinary committee taking inputs from the concerned units/ discipline/ departments. The findings and recommendations arrived at after the analysis should be communicated to all concerned personnel to correct the systems and processes to prevent recurrences. Remarks Sentinel Event Policy
b)
c)
The organization 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.
d)
CHAPTER 7 : Responsibilities of Management (ROM)

ROM.1. The responsibilities of the management are defined.
a)
b)
c)
Objective Element Those responsible for governance lay down the organizations mission statement. Those responsible for governance lay down the strategic and operational plans commensurate to the organizations mission in consultation with the various stake holders. Those responsible for governance approve the organizations budget and allocate the resources
Interpretation It is not only the head of the HCO but the members of the board of governors (where applicable) who need to define it. The Governing board and the leaders of HCO shall define and develop the process for strategic and operation plans so as to achieve the organizational mission statement. The Governing board and the Head of HCO shall have the policy for budgeting and resource allocation for attaining its mission and
Remarks Quality Management Plan
Budget
46
d)
e)
required to meet the organizations mission. Those responsible for governance monitor and measure the performance of the organization against the stated mission. Those responsible for governance establish the organizations organogram. Those responsible for governance appoint the senior leaders in the organization. Those responsible for governance support research activities and quality improvement plans. The organization complies with the laid down and applicable legislations and regulations. Those responsible for governance address the organizations social responsibility.
periodically review it. The governing board and the Head of the HCO shall develop quarterly (at least) performance reports based on the strategic and operational plans. The HCO shall have a well defined organization structure/chart and this shall clearly document the hierarchy, line of control, along with the functions at various levels. Self explanatory. Quality Management Plan
Organization structure
f)
Organization structure
g)
Self explanatory. NA Self explanatory. The responsibility of compliance lies with the first two level of the hierarchy. The Governing board and Head of the HCO shall willfully develop social responsibility policy and accordingly address it.
h)
Licenses COPY
i)
Marketing Dept.
ROM.2. The services provided by each department are documented.
a)
Objective Element Each organizational programme, service, site or department has effective leadership. Scope of services of each department is defined.
b)
c)
Administrative policies and procedures for each department is maintained. Departmental leaders are involved in quality improvement.
Interpretation There needs to be a minimum essential qualification and relevant experience of the leader. The leader should have domain knowledge of that particular department. Each department's activity is to be predefined. This could be documented either at individual department level or the HCO could have a brochure detailing the scope of each department. This shall include administrative procedures like attendance, leave, conduct, replacement etc. Self explanatory.
Remarks HR Department have all the records of it
Scope of Services Evident on Site
HR Department
d)
Quality Committee
47
ROM.3. The organization is managed by the leaders in an ethical manner.
a)
Objective Element The leaders make public the mission statement of the organization. The leaders establish the organizations ethical management. The organization discloses its ownership. The organization honestly portrays the services which it can and cannot provide. The organization honestly portrays its affiliations and accreditation. The organization accurately bills for its services based upon a standard billing tariff.
Interpretation The HCO shall have a mission statement and the same shall be displayed prominently. The HCO shall function in an ethical manner. The ownership of the hospital e.g. trust, private, public has to be disclosed. Self explanatory.
Remarks Quality Management Plan

Mission statement as evidence.
b)
Ethics Committee
c) d)
Private Scope of Services
e)
Here portrays implies that the HCO convey its affiliations, accreditations for specific departments or whole hospital wherever applicable. Self explanatory. Tariff List
f)
ROM.4. A suitably qualified and experienced individual heads the organization.
a)
Objective Element The designated individual has requisite and appropriate administrative qualifications. The designated individual has requisite and appropriate administrative experience.
Remarks YES
b)
Self explanatory. 16 Years Exp.
ROM.5. Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management.
a)
Objective Element The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme.
Remarks Hospital Safety Committee
48
b)
The scope of the programme is defined to include adverse events ranging from no harm to sentinel events. Management ensures implementation of systems for internal and external reporting of system and process failures. Management provides resources for proactive risk assessment and risk reduction activities.
The HCO shall have a system of reporting of all the incident/accident.
c)
d)
The HCO has a system in place for internal and external reporting of system and process failures. Contingency plan shall be in place to deal with the situation of system and process failure anticipated within the organization. There shall be sufficient resources kept as contingency to address the risk reduction activities as and when the leaders proactively suggest. The end result of these shall result in preventive actions.
Hospital Safety Committee
CHAPTER 8: Facility Management and Safety (FMS)
FMS.1. The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.
Objective Element a) The management is conversant with the laws and regulations and knows their applicability to the organization.
Interpretation A designated management functionary has been given the responsibility to enlist the laws and regulation as applicable to the HCO. This functionary has identified the appropriate personnel in the HCO who are supposed to implement the respective laws and regulations. Self explanatory.
Remarks
Licenses & Act approval copy as evidence
b)
Management regularly updates any amendments in the prevailing laws of the land. The management ensures implementation of these requirements. There is a mechanism to regularly update licenses/ registrations/ certifications.
Copies available with MS (Process for Compliance and Updating of Regulatory & Statutory requirements) Self explanatory. Copies available with MS (Process for Compliance and Updating of Regulatory & Statutory requirements) Self explanatory. Copies available with MS(Process for Compliance and Updating of Regulatory & Statutory requirements)
c)
d)
FMS.2. The organizations environment and facilities operate to ensure safety of patients, their families, staff and visitors.
49
Objective Element a) There is a documented operational and maintenance (preventive and breakdown) plan. Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes. There is internal and external sign posting in the organization in a language understood by patient, families and community. 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.
Remarks
Bio-Medical Engg. A designated person maintains the drawings.
b)
Document with Engineering Department
c)
Self explanatory. Evident at Site
d)
Self explanatory.
Engineering / Facilities Dept.
e)
A person in the HCO management is designated to be in-charge of maintenance of facilities. The HCO has the required number of supervision and tradesmen to manage the facilities. Self explanatory.
Roster of Engineering department
f)
g)
Maintenance staff is contactable round the clock for emergency repairs. Response times are monitored from reporting to inspection and implementation of corrective actions.
Roster as Evidence
A complaint attendance register is to be maintained to indicate the date and time of receipt of complaint, allotment of job and completion of job.
Records of the Engineering Department
FMS.3 The organization has a programme for clinical and support service equipment management. Objective Element a) The organization plans for equipment in accordance with its services and strategic plan. Interpretation Self explanatory. This shall also take into consideration future requirements. Remarks
Material Management
50
b)
Equipment is selected by a collaborative process.
c)
d)
All equipment are inventoried and proper logs are maintained as required. Qualified and trained personnel operate and maintain the equipment Equipment are periodically inspected and calibrated for their proper functioning.
Collaborative process implies that during equipment selection there is involvement of end user, management, finance, engineering and bio-medical departments. Self explanatory.
Purchase Committee
Bio-Medical Engg. Registers of the BME Department Self explanatory. Bio Medical Engineer The HCO has weekly / monthly / annual schedules of inspection and calibration of equipment which involve measurement, in an appropriate manner. The HCO either calibrates the equipment in house or out sources; maintaining traceability to national or international or manufacturers guidelines/standards. Self explanatory.
e)
Calibration Process Calibration records of equipments
f)
There is a documented operational and maintenance (preventive and breakdown) plan.
Bio-Medical Engg.
FMS.4 The organization has provisions for safe water, electricity, medical gases and vacuum system. Objective Element a) Potable water and electricity are available round the clock. Alternate sources are provided for in case of failure. The organization regularly tests the alternate sources. There is a maintenance plan for piped medical gas, compressed air and vacuum installation. Interpretation The HCO shall make arrangements for supply of adequate potable water and electricity. Alternate electric supply could be from DG Sets, solar energy, UPS and any other suitable source. Self explanatory. Remarks
Engineering / Facilities Dept. Engineering / Facilities Dept.
b)
c)
Engineering / Facilities Dept.

Self explanatory. Gas Manifold
d)
FMS.5 The organization has plans for fire and non-fire emergencies within the facilities.
Objective Element
Interpretation
Remarks
51
a)
The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergences.
The HCO has a fire and non-fire emergency committee (FNEC) to review the HCOs preparedness. The HCO has conducted an exercise of hazard identification and risk analysis (HIRA) and accordingly taken all necessary steps to eliminate or reduce such hazards and associated risks. The HCO has: a) a fire plan covering fire arising out of burning of inflammable items, explosion, electric short circuiting or acts of negligence or due to incompetence of the staff on duty; b) deployed adequate and qualified personnel for this; c) acquired adequate fire fighting equipment for this which records are kept up-to-date; d) adequate training plans; e) schedules for conduct of mock fire drills; f) mock drill records; g) exit plans well displayed. The HCO has a dedicated emergency illumination system which comes into effect in case of a fire. The HCO takes care of non-fire emergency situations by identifying them and by deciding appropriate course of action. These may include : a) terrorist attack b) invasion of swarms of insects and pests c) earthquake d) invasion of stray animals e) hysteric fits of patients and/ or relatives f) civil disorders effecting the HCO g) anti-social behaviour by patients/ relatives h) temperamental disorders of staff causing deterioration in patient care i) spillage of hazardous (acids, mercury, etc.), infected materials (used gloves, syringes, tubing, sharps, etc.) medical wastes (blood, pus, amniotic fluid, vomits, etc.) j) building or structural collapse k) fall or slips (from height or on floor) or collision of personnel in passageway l) fall of patient from bed
Sprinklers and smoke detectors, Evident on site.
Disaster Mgt. Plan
52
m) bursting of pipe lines n) sudden flooding of areas like basements due to clogging in pipe lines o) sudden failure of supply of electricity, gas, vacuum, etc p) bursting of boilers and/ or autoclaves. The HCO has established liaison with civil and police authorities and fire brigade as required by law for enlisting their help and support in case of an emergency.
b)
The organization has a documented safe exit plan in case of fire and non-fire emergencies. Staff is trained for their role in case of such emergencies. Mock drills are held at least twice in a year.
Fire exit plan shall be displayed on each floor particularly close to the lifts. Exit doors should remain open on all the time. In case of fire designated person are assigned particular work. Self explanatory.
Fire Exit Plan Displayed on each floor
c)
Fire fighting team formed Training Records
d)
Records of Drills
FMS.6. The organization has a smoking limitation policy.
Objective Element a) The organization defines and implements its policies to reduce or eliminate smoking. The policy has provisions for granting exceptions for patients and families to smoke.
Interpretation Smoking in public places including hospitals has been banned in this country. In view of the law permission to smoke within the campus of hospital may not be granted.
Remarks Smoking Policy
b)
Smoking Policy
FMS.7. The organization plans for handling community emergencies, epidemics and other disasters. Objective Element a) The hospital identifies potential emergencies. Interpretation The HCO has a documented plan and procedure for handling the situations like sudden rush of victims of Remarks
53
a) b) c) d)
b)
The organization has a documented disaster management plan.
c)
d)
Provision is made for availability of medical supplies, equipment and materials during such emergencies. Hospital staff is trained in the hospitals disaster management plan. The plan is tested at least twice in a year.
earthquake flood train accident Civil unrest outside the HCO premises e) Major fire f) Invasion by enemy, etc. g) These plans and procedures cover ensuring adequacy of medical supplies, equipment, materials, identified trained personnel, transportation aids, communication aids and mock drill methodology. The disaster plan must incorporate essential elements of alert code, information and communication, action cards for each of the staff, availability and earmarking of resources, establishment of command nucleus, training and mock drills Resource availability should be according to threat perception.
Disaster Mgt. Plan
Disaster Mgt. Plan
Disaster Mgt. Plan
e)
Mock drills with and without patients have to be carried out. Only communication exercise may also be undertaken. Self explanatory.
Training Records Disaster Mgt. Plan
FMS.8. The organization has a plan for management of hazardous materials.
Objective Element a) Hazardous materials are identified within the organization.
Interpretation The HCO has identified and listed the hazardous materials and has a documented procedure for their sorting, storage, handling, transpirations, disposal mechanism, and method for managing spillages and adequate training of the personnel for these jobs. The HCO has conducted an exercise of hazard identification and risk analysis (HIRA) associated with handling of hazardous materials and accordingly taken all necessary steps to eliminate or reduce such hazards and associated risks. The HCO has ensured display of Material Safety Data Sheets (MSDS) for all hazardous materials and has accordingly arranged associated training of personnel
b)
The hospital implements processes for sorting, labelling, handling, storage, transporting and disposal of hazardous material.
Waste Mgt. Process MSDS available on site
54
c)
Requisite regulatory requirements are met in respect of radioactive materials.
who handle such materials. The situational hazards also need to be covered in HIRA so that any emergency situation arising out of process of storing, handling, storage, transportation and disposal of such hazardous materials are met effectively. Sharp bends in passages, protruding or dangling elements in passage ways, sudden swing of swing doors, ramps, entry and exit from lifts, are situations which need to be taken care of. See FMS 5 also. The HCO has the requisite training need identification for material handling and those trainings are included in the HCO training calendar. The appropriate personnel in the HCO are aware about the rules and regulations such as the Atomic Energy Act, the norms issued by Atomic Energy Regulatory Board (AERB) and the directives from the Health Physics Division of Bhaba Atomic Research Centre (BARC). Self explanatory.
As per biomedical waste management rule
d)
There is a plan managing spills hazardous materials.
for of
MSDS Self explanatory. Training Record of Medical & Paramedical Staffs.
e)
Staff is educated and trained for handling such materials.
FMS.9. The hospital has system in place to provide a safe and secure environment.
Objective Element a) The hospital has a safety committee to identify the potential safety and security risks. This committee coordinates development, implementation, and monitoring of the safety plan and policies. Patient safety devices are installed across the organization and inspected periodically.
Interpretation The HCO has a duly constituted safety committee which has identified the potential safety and security risks to staff, patients and visitors. The HCO ensures that the above Committee functions on a regular basis to coordinate development, implementation and monitoring of the plans and policies. Self explanatory.
Remarks HospitaL Safety Committee
b)
c)
Evident on site
55
d)
e)
f)
Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas. Inspection reports are documented and corrective and preventive measures are undertaken. There is a safety education programme for all staff.
Rounds to be carried out by safety committee. Facility round conducted by Safety Committee
Self explanatory. Inspection Rounds
Self explanatory. Training Record
CHAPTER 9 : Human Resource Management (HRM)

HRM.1. The Organization has a documented system of human resource planning.
Objective Element a) The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient. The required job specifications and job description are well defined for each category of staff. The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.
Interpretation The staff should be commensurate with the workload and the clinical requirement of the patients.
Remarks Manpower Planning
b)
c)
The content of each job should be well defined and the qualifications, skills and experience required for performing the job should be clearly laid down. The job description should be commensurate with the qualification. Self explanatory.
Job Specifications
Antecedent Verification Service Rule 74
HRM.2. The staff joining the organization is socialized and oriented to the hospital environment. Objective Element a) Each staff member, employee student and voluntary worker is appropriately oriented to the organizations mission and goals.
Interpretation The organization's staff including the outsourced staff should be aware and should correctly interpret the mission and goals of the organization.
Remarks Employee Guide Book
56
b)
Each staff member is made aware of hospital wide policies and procedures as well as relevant department/ unit/ service/ programmes policies and procedures. Each staff member is made aware of his/her rights and responsibilities. All employees are educated with regard to patients rights and responsibilities. All employees are oriented to the service standards of the organization.
c)
The organization's staff including the outsourced staff should be aware and should correctly interpret the policies and operating procedures of the organization as well as that of the department/ unit/ service in which he is performing the requisite duties. The HCO shall define the same in consonance with statutory requirements and the same shall be communicated to the employees. The employees should be able to identify and report violation of patient rights as and when the same occurs. The HCO shall develop benchmarks for different services being provided. This shall be based on the HCO's values and focus on development of soft skills: behaviour, attitude, communication skills, etc.
Employee Guide Book
Employee Guide Book
d)
Employee Guide Book
e)
Induction Manual
HRM.3. There is an ongoing programme for professional training and development of the staff.
Objective Element a) A documented training and development policy exists for the staff.
Interpretation A training manual incorporating the procedure for identification of training needs, the training methodology, documentation of training, training assessment, impact of training and the training calendar should be prepared. The training should focus on the revised job responsibilities as well as on the newly introduced equipment and technology. In case of new equipment the operating staff should receive training on operational as well as daily maintenance aspects. This shall include both internal & external training. For external training it could be done either by the HCO itself or by the external agency which imparted the training. Impact of training at user level should also be documented
Remarks Training and Development policy
b)
Training also occurs when job responsibilities change/ new equipment is introduced.
Training and Development Policy Record with HRD and respective Deptt. Record with HRD and respective Deptt.
c)
Feedback mechanisms for assessment of training and development programme exist.
HRM.4. Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety. Objective Element
Interpretation
Remarks
57
a)
All staff is trained on the risks within the hospital environment. Staff members can demonstrate and take actions to report, eliminate / minimize risks. Staff members are made aware of procedures to follow in the event of an incident. Reporting processes for common problems, failures and user errors exist.
The HCO shall define such risks which shall include patient, visitors and employee related risks. Self explanatory.
Hospital Safety manual
b)
Records of Drills Self explanatory. Training Records The HCO has a defined procedure for reporting of these events.
c)
d)
Quality Committee
HRM.5. An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process. Objective Element a) A well-documented performance appraisal system exists in the organization. The employees are made aware of the system of appraisal at the time of induction. Performance is evaluated based on the performance expectations described in job description. The appraisal system is used as a tool for further development. Performance appraisal is carried out at pre defined intervals and is documented.
Remarks Performance Appraisal System
b)
Self explanatory. Induction Training Programme Self explanatory. Performance Appraisal System Self explanatory. This can be done by identifying training requirements and accordingly providing for the same (wherever possible). Self explanatory.
c)
d)
Performance Appraisal System
e)
Performance Appraisal System
HRM.6. The organization has a well-documented disciplinary procedure.
Objective Element a) A written statement of the policy of the organization with regard to discipline is in place.
Remarks Disciplinary Procedure
58
b)
The disciplinary policy and procedure is based on the principles of natural justice. The policy and procedure is known to all categories of employees of the organization. The disciplinary procedure is in consonance with the prevailing laws. There is a provision for appeals in all disciplinary cases.
This implies that both parties (employee and employer) are given an opportunity to present their case and decision is taken accordingly. Self explanatory.
Disciplinary Procedure
c)
Induction Training Records Self explanatory. Disciplinary Procedure The HCO shall designate an appellate authority to consider appeals in disciplinary cases.
d)
e)
Disciplinary Procedure
HRM.7. A grievance handling mechanism exists in the organization. Objective Element a) The employees are aware of the procedure to be followed in case they feel aggrieved. The redress procedure addresses the grievance. Actions are taken to redress the grievance. Interpretation For definition of "grievance handling" refer to glossary. The HCO has a written procedure for handling grievances of employees. Self explanatory. Employee Grievance Policy Self explanatory. Employee Grievance Policy Remarks
Employee Grievance Policy
b)
c)
HRM.8. The organization addresses the health needs of the employees. Objective Element a) A pre-employment medical examination is conducted on all the employees. Health problems of the employees are taken care of in accordance with the organizations policy. Regular health checks of staff dealing with direct patient care are done atleast once a year and the findings/ results are documented. Interpretation Self explanatory. This shall however be in consonance with the law of the land. Self explanatory. This shall be in consonance with the law of the land and good clinical practices. Self explanatory. The results should be documented in the personal file. Remarks Evidenced on Personal File
b)
Medical Benefit
c)
Medical Benefit Records in Personal file
59
d)
Occupational health hazards are adequately addressed.
Self explanatory.
HRM.9. There is a documented personal record for each staff member.
Objective Element a) Personal files are maintained in respect of all employees. The personal files contain personal information regarding the employees qualification, disciplinary background and health status. All records of in-service training and education are contained in the personal files. Personal files contain results of all evaluations.
Remarks HR Department
b)
Self explanatory. Personal File as Evidence.
c)
Self explanatory. Training record kept separately Evaluations would include performance appraisals, training assessment and outcome of health checks. YES
d)
HRM.10. There 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 Element a) Medical professionals permitted by law, regulation and the hospital to provide patient care without supervision are 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. Interpretation The HCO identifies the individuals who have the required qualification (s), training and experience to provide patient care in consonance with the law. Self explanatory. Updation is done after acquisition of new skills and/or qualification. Credentialing Committee Remarks Credentialing Committee
b)
c)
The HCO shall do the same by verifying the credentials from the organization which has awarded the qualification/training.
Credentialing Committee
HRM.11. There is a process for authorizing all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications.
60
Objective Element a) Medical professionals admit and care for patients as per the laid down policies and authorization procedures of the organization. The services provided by the medical professionals are in consonance with their qualification, training and registration. The requisite services to be provided by the medical professionals are known to them as well as the various departments / units of the hospital.
Interpretation The HCO shall identify as to what each medical professional is authorized to do.
Remarks
b)
Self explanatory.
c)
Self explanatory.
HRM.12. There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of nursing staff. Objective Element a) The education, registration, training and experience of nursing staff is documented and updated periodically.
b)
All such information pertaining to the nursing staff is appropriately verified when possible.
Interpretation The HCO identifies the individuals who have the required qualification (s), training and experience to provide nursing care to patients in consonance with the law. Updation is done after acquisition of new skills and/or qualification. The HCO shall do the same by verifying the credentials from the organization which has awarded the qualification/training.
Remarks
Registration from Nursing Counsil
HR Department
HRM.13. There 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 Element a) The 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.
Interpretation The HCO shall identify as to what each nurse is authorized to do.
Remarks Privileging
b)
Self explanatory. Privileging
61
c)
The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the hospital.
Self explanatory. Nursing Manual
CHAPTER 10 : Information Management System (IMS)

IMS.1. Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require date and information from the organization. Objective Element a) The 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 organization. Policies and procedures to meet the information needs are documented. These policies and procedures are in compliance with the prevailing laws and regulations. All 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. Interpretation The HCO has manual and/or electronic Hospital Information System and/or Management Information System which provides relevant information to all concerned stakeholders. Remarks Medical Records Department
b)
A policy document is available where the HIS/MIS is described. Self explanatory.
HIS
c)
Evidenced at respective Deptt. The HCO shall define the needs for software and hardware solutions as per the information requirements and future necessities. The HCO shall define the system of releasing the relevant information to the authority as per statutory norms.
d)
HISPrimus%20Hospital %20Manual.doc#BACKUP
e)
Medical Records Department
IMS.2. The organization has processes in place for effective management of data. Objective Element a) Formats for collection standardized. data are Interpretation MIS/HIS data is collected standardised format from areas/services in the HCO. in all Remarks Medical Records Department Budget
b)
Necessary resources are available for analyzing data.
The HCO shall make available men, material, space and budget.
62
c)
d)
Documented procedures are laid down for timely and accurate dissemination of data. Documented procedures exist for storing and retrieving data. Appropriate clinical and managerial staff participates in selecting, integrating and using data.
Self explanatory. Medical Records Department The HCO shall define data management policy and ensure adequate safeguards for protection of data, where ever physical or electronic data is stored. There is a multi-disciplinary committee which is responsible for the appropriate selection of indicators, measurement of trends and initiating action wherever required. Medical Records Department
e)
Medical Audit committee scope.
IMS.3. The organization has a complete and accurate medical record for every patient. Objective Element a) b) Every medical record has a unique identifier. Organization policy identifies those authorized to make entries in medical record. Every medical record entry is dated and timed. The author of the entry can be identified. Interpretation This shall also apply to records on digital media. HCO has a written policy stating who all can make entries. Self explanatory. This could be by writing the full name or by mentioning the employee code number, with the help of stamp, etc. In case of electronic based records, authorised e-signature provision as per statutory requirements must be kept. The HCO identifies which documents form part of the medical records, documents and implements the same. The HCO shall decide the format for maintaining the continuity in the medical records. Remarks Medical Records Department Medical Records Department Medical Records Department Medical Records Department
c) d)
e)
The contents of medical record are identified and documented. The record provides an up-to-date and chronological account of patient care.
f)
Medical Record file as an Evidence
IMS.4. The medical record reflects continuity of care. Objective Element a) The medical record contains information regarding reasons for admission, diagnosis and plan of care. Interpretation Self explanatory. Medical Records Department Remarks
63
b)
c)
d)
e)
f)
g)
Operative and other procedures performed are incorporated in the medical record. When 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 hospital. The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel. In 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.
Self explanatory. Medical Records Department Self explanatory. It is mandatory to mention the clinical condition of the patient before transfer is effected. Patient Transfer Policy
Self explanatory. Medical Records Department
Self explanatory. The HCO provides the death certificate as per the International Certification of cause of death. Self explanatory.
Medical Records Department Death certificate evident
Not Applicable The HCO provides access to medical records to designated health care providers (those who are involved in the care of that patient).
IMS.5. Policies and procedures are in place for maintaining confidentiality, integrity and security of information. Objective Element a) Documented policies and procedures exist for maintaining confidentiality, security and integrity of information. Interpretation The HCO shall control the accessibility to the MRD department. It shall ensure the usage of tracer card for movement of the file in and out of the MRD so as to maintain confidentiality, security, safety and integrity of information. This is applicable for both manual and electronic records. This is in the context of Indian Evidence Act, Indian Penal Code and Code of medical Ethics. Remarks
HIS HIS Tracer card available.
b)
Policies and procedures are in consonance with the applicable laws.
Process for Compliance and Updating of Regulatory & Statutory Requirements
64
c)
The policies and procedures incorporate safeguarding of data / record against loss, destruction and tampering.
For physical records the HCO shall ensure that there is adequate pest and rodent control measures. For electronic data there should be protection against virus/trojans and also a proper backup procedure. To prevent tampering, for physical records access shall be limited only to the concerned health care provider. In electronic format this could be done by adequate passwords. The HCO carries out regular audits/rounds to check compliance with policies.
HIS HIS
d)
The hospital has an effective process of monitoring compliance of the laid down policy. The hospital uses developments in appropriate technology for improving confidentiality, integrity and security. Privileged health information is used for the purposes identified or as required by law and not disclosed without the patients authorization. A documented procedure exists on how to respond to patients/ physicians and other public agencies requests for access to information in the medical record in accordance with the local and national law.
Medical Records Department HIS
e)
The HCO shall review and update its technological features so as to improve confidentiality, integrity and security of information. The HCO shall procedure for communication. define the privileged
f)
g)
Self explanatory. In this context, the release of information in accordance with the Code of Medical Ethics 2002 should be kept in mind.
Report to Health Authority
IMS.6. Policies and procedures exist for retention time of records, data and information. Objective Element a) Documented policies and procedures are in place on retaining the patients clinical records, data and information. The policies and procedures are in consonance with the local and national laws and regulations. The retention process provides expected confidentiality and security. Interpretation The HCO shall define the retention period for each category of medical records: Out-patient, in-patient and MLC. Some of the related laws in this context are Code of Medical Ethics 2002, Consumer protection act 1987 and relevant state legislation, if any. This is applicable for both manual and electronic system. Remarks Medical Records Department
b)
c)
65
d)
The destruction of medical records, data and information is in accordance with the laid down policy.
Destruction can be done after the retention period is over and after taking approval of the competent authority.
IMS.7. The organization regularly carries out review of medical records. Objective Element a) The medical records are reviewed periodically. The review representative based on principles. uses a sample statistical Interpretation Self explanatory. Medical Records Department The HCO shall define the principles on which sampling is based. For example, simple random, systemic random sampling etc. Review shall be based on conditions of clinical and/or community importance, total discharges including deaths, total indoor patients, etc. Self explanatory. Medical Records Department Remarks
b)
c)
The review is conducted by identified care providers. The review focuses on the timeliness, legibility and completeness of the medical records. The review process includes records of both active and discharged patients. The review points out and documents any deficiencies in records. Appropriate corrective and preventive measures undertaken are documented.
Medical Audit Committee Medical Records Department Medical Records Department
d)
Self explanatory.
e)
Self explanatory. Medical Records Department Self explanatory. Medical Audit Report Medicall Records Department
f)
g)
Self explanatory. Action Taken Report
66

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CHAPTER 1 : Access, Assessment and Continuity of Care (AAC)

Remarks Scope of Services

The staff is oriented to these services.

Remarks Registration process Admission Process

Policy for non availability of beds

Remarks Patient Transfer Policy

Patient Transfer Policy

Patient Transfer Policy

Patients Right Policy

Patients Right Policy

Patients Right Policy

Patients Right Policy

Remarks Initial Assessment Policy

The organization determines who can perform the assessments.

Initial Assessment Policy

IInitial Assessment Policy

Initial Assessment Policy

Initial Assessment Policy

Initial Assessment Policy

Initial Assessment Policy

Objective Element a) All patients are reassessed at appropriate intervals.

Remarks Initial Assessment Policy

Staff involved in direct clinical care document reassessments.

Initial Assessment Policy

Initial Assessment Policy

Critical results are intimated immediately to the concerned personnel.

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

Objective Element a) The laboratory quality assurance programme is documented.

Remarks Laboratory QA Manual

Laboratory QA Manual Self explanatory. Laboratory QA Manual

AAC.9. There is an established laboratory safety programme.

Objective Element a) The laboratory programme documented. safety is

Remarks Laboratory Safety Manual

Laboratory Safety Manual Laboratory Safety Manual

Laboratory Safety Manual Laboratory Safety Manual

Remarks Imaging Department

AAC.11. There is an established Quality assurance programme for imaging services.

AAC.12. There is an established radiation safety programme.

Interpretation Refer to AERB guidelines

Remarks Imaging Safety Manual

Hospital Safety Manual

Imaging Safety Manual

Imaging Safety Manual

Imaging Safety Manual

AAC.13. Patient care is continuous and multidisciplinary in nature.

Care of patients is coordinated in all care settings within the organization.

Self explanatory. Medical Record Dept

Patient Transfer Policy

AAC.14. The organization has a documented discharge process.

Remarks Discharge Process

AAC.15. Organization defines the content of the discharge summary.

Interpretation Self explanatory.

Remarks Discharge Summary

Self explanatory. Discharge Summary

Self explanatory. Discharge Summary

Self explanatory. Discharge Summary

Self explanatory. Discharge Summary

CHAPTER 2 : Care of Patients (COP)

Remarks Uniform Care Policy

Self explanatory. Treatment must be written daily.