A Quick Guide On How To Achieve Gold / Silver Quality Certificate
A Quick Guide On How To Achieve Gold / Silver Quality Certificate
A Quick Guide On How To Achieve Gold / Silver Quality Certificate
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Silver Quality Certificate
for AB PM-JAY
Silver Quality Certificate is the second level of Ayushman Bharat Quality
Certification which is revised terminology for already existing outcome -based
incentivization structure i.e. Entry level NABH/NQAS Certification. It indicates that
hospital has better quality of services and patient care but need to focus next on
organization centered standards in terms of responsibility of management system
among others. It is intended to motivate hospitals to keep increasing the level of
quality in their services. Bronze Quality Certified hospital can directly apply for this
certification. Silver Quality Certified hospitals will get additional financial benefits
over and above the ‘Hospital benefit plans’.
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1. Are 'scope of services' registered under AB PM-JAY
clearly defined and displayed at prominent place (e.g.
Hospital entrance, Registration area, Waiting area, etc.) ?
2. Are 'scope of services' registered under AB PMJAY
displayed bilingually (one local language and another
Hindi or English)?
3. Is the hospital staff aware of 'scope of services'
registered under AB PMJAY?
4. Is there a dedicated kiosk/ counter for AB PMJAY
at prominent place in the hospital?
5. Is the kiosk/ counter manned by Pradhan Mantri
Arogya Mitra (PMAM)/ trained staff during the
operational hours (e.g. Arogya Mitra & its Duty list) ?
Duty from 30-09-2019 to 03-11-2019
Day Date harshad tejalben akshay devendra mukesh Nisha Jayesh
Monday 30-09-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Tuesday 01-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Wednesday 02-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Thursday 03-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Friday 04-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Saturday 05-10-19 2 to 10 8 To 4 9 to 5 11 TO 7 12 to 8 9 to 5 2 to 10
Sunday 06-10-19 9 to 5 week off wk off wk off wk off wk off wk off
Monday 07-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Tuesday 08-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Wednesday 09-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Thursday 10-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Friday 11-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Saturday 12-10-19 12 to 8 2 to 10 8 To 4 9 to 5 11 TO 7 9 to 5 2 to 10
Sunday 13-10-19 wk off 9 to 5 wk off wk off wk off wk off wk off
Monday 14-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Tuesday 15-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Wednesday 16-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Thursday 17-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Friday 18-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Saturday 19-10-19 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 9 to 5 2 to 10
Sunday 20-10-19 wk off wk off 9 to 5 wk off wk off wk off wk off
Monday 21-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Tuesday 22-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Wednesday 23-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Thursday 24-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Friday 25-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Saturday 26-10-19 9 to 5 11 TO 7 12 to 8 2 to 10 8 To 4 9 to 5 2 to 10
Sunday 27-10-19 wk off wk off wk off 9 to 5 wk off wk off wk off
Monday 28-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Tuesday 29-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Wednesday 30-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Thursday 31-10-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Friday 01-11-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Saturday 02-11-19 8 To 4 9 to 5 11 TO 7 12 to 8 2 to 10 9 to 5 2 to 10
Sunday 03-11-19 wk off wk off wk off wk off 9 to 5 wk off wk off
6. Are required equipment’s provided to Arogya
Mitra for AB PMJAY beneficiary identification?
7. Does the hospital have a dedicated team for
AB PMJAY?
Yes / No
8. Does the hospital have at least one Pradhan Mantri Arogya
Mitra (PMAM)/ dedicated person per shift appointed for looking
after the work of Ayushman Bharat Scheme?
9.Does the nominated AB PMJAY team have
doctor(s) engaged?
10. Does the nominated AB PMJAY team have
a member from administration department?
11. Does the hospital have AB PMJAY specific IEC
materials near hospital entry and at prominent areas?
12. Does the AB PMJAY kiosk/ counter has IEC
materials pertaining to AB PMJAY on or near it?
13. Has hospital conducted any promotional activity
(like camping) for spreading awareness regarding the
AB PMJAY scheme?
14. Is hospital’s scope of services mapped with
hospital’s Manpower/Human Resources?
15. Do the hospitals maintain proper medical records
maintained for AB PMJAY patients?
16. Is AB PMJAY claim process documented in the
hospital's policies?
17. Does the hospital charge any extra money
from AB PMJAY beneficiaries?
Yes / No
18. Are the deployed staff members trained for HEM
portal?
19. Are the deployed staff members trained for TMS
portal?
20. Are the deployed staff members trained for BIS
portal?
21. Does the hospital maintain proper records
for AB PMJAY referred beneficiaries?
SR NO MONTH Visit No. Patient Registrati Admit NEW IPD Patient Gender Age Age ADULT/PE Birth Date Unit Marital Mother Address Village Taluka District State 123 STATEE COUNTRY
HIRALAL
IPD/2019/ UNM- MANGILA
01/04/197 Cardiology WARD NO- TARAKHE MADHYA OTHER MADHYA
1 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD L Male 49y 40Y - 60Y ADULT Married Gujarati Jaora Ratlam INDIA
0 Unit - 2 17 DI PRADESH STATE PRADESH
19 025045 PRAJAPAT
I
VANITABE
IPD/2019/ UNM- 585/3691,
FOLLOW N 24/07/197 Cardiology AHMEDAB AHMEDAB AHMEDAB
2 APRIL 04/00090 2018-07- 24-07-18 01-04-19 Female 40y 8m 40Y - 60Y ADULT Married Gujarati G.H.B.,BA GUJARAT GUJARAT GUJARAT INDIA
UP BALKISHA 8 Unit - 1 AD AD AD
26 058187 PUNAGAR
N NORA
SHAKARIB
IPD/2019/ UNM- EN
FOLLOW 18/03/194 Cardiology NR. BAL HIMATNA SABARKA
3 APRIL 04/00090 2019-03- 18-03-19 01-04-19 BHULESH Female 70y >= 60Y ADULT Widow Gujarati kankanol GUJARAT GUJARAT GUJARAT INDIA
UP 9 Unit - 2 MANDIR GAR NTHA
28 021286 WARBHAI
DARJI
B/H
RAILWAY
CROSSING
, NEW
CHAMUN
MANJULA DA SOC-
IPD/2019/ UNM-
BEN 01/04/196 Cardiology 36, NR. AHMEDAB AHMEDAB AHMEDAB
4 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD Female 52y 40Y - 60Y ADULT Married Gujarati GUJARAT GUJARAT GUJARAT INDIA
MAHESHB 7 Unit - 2 NAVRANG AD AD AD
53 025122
HAI JADAV HIGH
SCHOOL ,
JAGATPUR
ROAD,
CHANDKH
EDA
MANGILA
IPD/2019/ UNM-
FOLLOW L 16/03/196 CVTS Unit - MADHYA OTHER MADHYA
5 APRIL 04/00090 2019-03- 16-03-19 01-04-19 Male 56y 40Y - 60Y ADULT Married Hindi - SARSOD Daloda Mandsaur INDIA
UP RAMLALJI 3 1 PRADESH STATE PRADESH
63 021083
DHANGAR
GOPAL
IPD/2019/ UNM-
RODUJI 05/06/198 Cardiology RAHIMGA MADHYA OTHER MADHYA
6 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD Male 36y 9m 18Y - 40Y ADULT Married Gujarati - Sitamau Mandsaur INDIA
SURYAVA 2 Unit - 2 RH PRADESH STATE PRADESH
68 025070
NSHI
PUSHPAB
IPD/2019/ UNM- EN BIHAND
01/01/197 CVTS Unit - MANDSA MADHYA OTHER MADHYA
7 APRIL 04/00090 2019-04- 01-04-19 01-04-19 NEW IPD PRAKASH Female 42y 3m 40Y - 60Y ADULT Married Gujarati SANSAD Mandsaur Mandsaur INDIA
7 1 UR PRADESH STATE PRADESH
78 025095 BHAI BHAVAN
DHOBI
NATVARL
IPD/2019/ UNM- AL OD
FOLLOW 07/07/194 CVTS Unit -
8 APRIL 04/00090 2019-03- 01-03-19 01-04-19 MOHANL Male 69y 8m >= 60Y ADULT Married Gujarati VAS,BUKD PATAN PATAN PATAN GUJARAT GUJARAT GUJARAT INDIA
UP 9 2
85 016731 AL I ROAD
SOLANKI
RASIKBHA
I
IPD/2019/ UNM-
MOHANB 01/04/196 Cardiology BAHADUR BHAVNAG
9 APRIL 04/00091 2019-04- 01-04-19 01-04-19 NEW IPD Male 55y 40Y - 60Y ADULT Married Gujarati - PALITANA GUJARAT GUJARAT GUJARAT INDIA
HAI 4 Unit - 2 PUR AR
07 025431
MAKWAN
A
22. Number of AB PMJAY beneficiaries
referred to AB PMJAY hospitals in last 6 month
Only
Number..
23. Number of AB PMJAY In-Patient
Department (IPD) census for last 6 months
Only
Number..
24. Does the hospital collect feedback during
discharge from AB PMJAY beneficiaries?
25. AB PM-JAY quality audit checklist filled
regularly in HEM portal?
25. Guidelines for Monthly Self
Assessment Quality Audit Checklist
(Link:- https://hospitals.pmjay.gov.in )
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Quality Policy
We are committed to ensure that the beneficiary should get right
treatment in right time at right place by empanelled hospitals under
ABPM-JAY in India and also to monitor the quality of care provided to the
beneficiary by working with other stakeholders.
We shall endeavor to constantly and actively collaborate with all
healthcare providers to build confidence of beneficiary and stakeholders.
Also aim to wide spread the network of empanelled hospital which can be
easily accessible to patient/beneficiary for getting the free treatment
under ABPM-JAY.
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“What is Quality ???”
Standards Environment, Standards
Treatment as per Standard Treatment
Protocol Guideline and Satisfaction of
Both Clients as well as Providers.
AS A PATIENT WHAT QUALITY LEVELS WOULD
YOU ACCEPT FROM YOUR HEALTH SERVICES?
90%
95%
96%
98%
99%
99.9%
IF 99.9% IS ACCEPTABLE TO YOU, THEN…
CHIMPANZEE AND A
HUMAN BEING”
•IN OUR PROFESSION THERE IS NO SCOPE FOR ERROR.
FOR ANY ERROR COMMITTED THE DIFFERENCE LIES
BETWEEN LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY.
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1. All the services being provided by AB – PMJAY Empanelled
Hospitals, patient rights and responsibilities are clearly defined &
display at prominent place in understandable language.
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2. Hospital has displayed the IEC pertaining to
Ayushman Bharat at prominent place
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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3. The initial assessment by doctors for in-patients is documented
within 24 hours or earlier and the Patient record file have care and
treatment orders which is signed, named, timed and dated by the
concerned doctor.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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3. The initial assessment by doctors for in-patients is documented
within 24 hours or earlier and the Patient record file have care and
treatment orders which is signed, named, timed and dated by the
concerned doctor.
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4 . The results of the diagnostic (Laboratory, Radiology, etc.) tests
should be made available in defined time frame and intimated
about the critical results to the concerned personnel immediately.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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5. Events during cardio-pulmonary resuscitation are recorded and
mock drills conducted at regular interval; sequence of CPR in
pictorial manner should be displayed.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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6. Informed consent about the information on risks involved,
benefits, alternatives for the procedures, surgeon who will
perform the requisite procedure in an understandable language
Available evidence
Evidence Required Method of Assessment Response sheet Mark
(Photo to be uploaded)
a) SOP developed for taking the 100% compliance of all
informed consent from patient or 10
four evidences.
patient relative.
b) See minimum 5 in-patients files if any of the four evidence
of previous month and check is found to be non- 5
availability of: compliant.
i) Clearly defined information on
risks involved, benefits, Direct observation,
Informed consent form
alternatives for the procedures by Record review, Patient
and Post operative
surgeon who will perform the interview & Staff
notes in patient files.
requisite procedure in an interview
understandable language.
Non-compliance of all
ii) Informed consent is duly signed 0
four evidences.
by patient or patient relative and
countersigned by concerned
surgeon.
iii) Post operative notes by 55
concerned surgeon.
6. Informed consent about the information on risks involved,
benefits, alternatives for the procedures, surgeon who will
perform the requisite procedure in an understandable language
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7. The regular and periodic monitoring of anaesthesia components
like recording of heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation, airway security and patency and level
of anaesthesia should be done.
Method of Available evidence
Evidence Required Response sheet Mark
Assessment (Photo to be uploaded)
See minimum 5 post-operative
files of previous month and check 100% compliance of all three
for: 10
evidences. a) Complete
a) Availability of completely filled
documentation:
Pre-anaesthesia, during
Recording of heart
anaesthesia and post-
if any of the three evidence is rate, cardiac rhythm,
anaesthesia form in each patient 5
found to be non-compliant. respiratory rate, BP,
file.
Record review & oxygen saturation,
b) Pre-anaesthesia consent is
Staff interview airway security
duly signed by patient or patient
b) Pre-anaesthesia
relatives and countersigned by
consent duly signed
anaesthetists in each patient file..
by pt. or pt. relatives
c) Complete documentation (e.g. Non-compliance of all three
0 and countersigned by
Recording of heart rate, cardiac evidences.
anaesthetists
rhythm, respiratory rate, BP,
oxygen saturation, airway security 57
recorded ) in each patient file.
7. The regular and periodic monitoring of anaesthesia components
like recording of heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation, airway security and patency and level
of anaesthesia should be done.
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8. The documented procedure is defined and adhered to, for the
prevention of adverse events like wrong site, wrong patient and
wrong surgery.
Available evidence
Evidence Required Method of Assessment Response sheet Mark (Photo to be
uploaded)
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9. Documented procedure for management of medication are
defined and implemented e.g. Sound alike and look alike
medications are stored separately.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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9. Documented procedure for management of medication are
defined and implemented e.g. Sound alike and look alike
medications are stored separately.
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10. Listing and storage of High risk medications to be done &
orders should be verified before their dispensing.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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10. Listing and storage of High risk medications to be done &
orders should be verified before their dispensing.
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11. Verification of dosage, route, timing and expiry date before
administering the medication should be done.
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12. Adverse drug events are collected, analysed by the treating
doctor and practices are modified (if necessary) to reduce the
same.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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13. The hospital infection control committee is constituted and
functional with defined surveillance method for tracking and
analysing appropriate infection rates.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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13. The hospital infection control committee is constituted and
functional with defined surveillance method for tracking and
analysing appropriate infection rates.
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14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.
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14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.
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14. All the healthcare providers should have easy accessibility to
the hand washing facility in all patient care areas. Hand hygiene
steps to be displayed at each hand washing facilities.
Bench mark Total no. of hand hygiene opportunity - missed opportunities X100
1 Criteria Target Total no. of hand hygiene opportunities
2 % of Compliance 100 %
Available evidence
Evidence Required Method of Assessment Response sheet Mark (Photo to be
uploaded)
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15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis
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15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis
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15. Staff members should be provided with the adequate and
appropriate pre and post exposure prophylaxis
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16. The proper implementation and regular monitoring of Bio-Medical
waste segregation and collection in all the patient care areas of the
hospital and staff should be trained in handling the Bio-Medical waste and
provided with all personal protective measure.
Available evidence
Evidence Required Method of Assessment Response sheet Mark
(Photo to be uploaded)
a) Updated license available for Bio- 100% compliance of all
Medical Waste Management practice 10
six evidences.
as per BMW Rule 2016
b) SOP defined for the process of if any of the six evidence
BMW as per Pollution control is found to be non- 5
a) Updated license of
guidelines. compliant.
BMW.
c) Staff follows the SOP.
b) Available
d) Waste management bins available Direct observation,
biomedical waste bins
and BMW guideline chart is displayed Record review & Staff
and displayed chart in
in all patient care area interview
patient care area.
e) Personal protective measures (e.g.
Non-compliance of all six c) Biomedical waste
gloves, mask, apron, gum boots, 0
evidences. storage area
heavy duty rubber gloves, etc.) are
used by all categories of staff
handling Bio-Medical Waste.
f) Infection control committee visits
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common biomedical treatment facility.
16. The proper implementation and regular monitoring of Bio-Medical
waste segregation and collection in all the patient care areas of the
hospital and staff should be trained in handling the Bio-Medical waste and
provided with all personal protective measure.
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16. The proper implementation and regular monitoring of Bio-Medical
waste segregation and collection in all the patient care areas of the
hospital and staff should be trained in handling the Bio-Medical waste and
provided with all personal protective measure.
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17. A defined mechanism to be there for regular updating of the
licences / registration / certifications.
Available evidence
Evidence Method of
Response sheet Mark (Photo to be
Required Assessment
uploaded)
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17. A defined mechanism to be there for regular updating of the
licences / registration / certifications.
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18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
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18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.
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18. Safe exit plan for fire and non-fire emergencies should be
documented and ensure the awareness amongst the hospital staff
and Fire Mock drills should be conducted at least twice in a year.
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19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.
Available
Method of evidence
Evidence Required Response sheet Mark
Assessment (Photo to be
uploaded)
See minimum 5 personal files of staffs (e.g.
Consultant RMO & Nurses, etc.) and check for their 100% compliance of
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qualification, training and privelaging all five evidences.
a) Medical professionals are granted previlages to
admit and care of patients in consonance with their
if any of the five All files are
qualification, training, experience and registration.
evidence is found to 5 maintained by
b) Medical professionals admit and care care for
Record review & be non-compliant. HR Dept. with
patients as per their privelaging.
Staff interview all the the
c) Nursing staff is granted previlages in consonance
required
with their qualification, training, experience and
details
registration.
d) Nursing professional care for patients as per their Non-compliance of all
0
privelaging. five evidences.
e) System developed for updating the personal files
of staff. 94
19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.
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19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.
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19. The services provided by the medical professionals and nursing
staff should be in line with their qualification, training and
registration.
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20. Up to date and chronological details of the patient care should
be available in the medical record including discharge summary
Available evidence
Method of
Evidence Required Response sheet Mark (Photo to be
Assessment
uploaded)
a) SOP defined for the process of 100% compliance
a) All the files in
keeping medical record file of of all five 10
MRD section are
discharge patient, MLC and Death evidences.
arranged in
case if any of the five cronological order.
b) Staff is aware and follows the evidence is found
5 LAMA Death and
process defined in SOP to be non- MLC files are kept
c) See minimum 5 files from medical compliant.
Record review & seperately.
record (e.g. Surgery, Medicine, MLC,
Staff interview b) Checklist for
Death, LAMA, etc.) and check the
maintaining records
chronological account of patient care.
in cronological
i) Availability of checklist for Non-compliance of
0 order in patient file.
maintainaing records in chronological all five evidences. c) Summary of
order
medical record
d) Medical record audit with corrective
audit.
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and preventive action.
20. Up to date and chronological details of the patient care should
be available in the medical record including discharge summary
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20. Up to date and chronological details of the patient care should
be available in the medical record including discharge summary
100
THANKS
“Want your support for Improvement”