Ind Indicators Status

1 The hospital is identifiable with name, discipline and KP HCC registration / license number on sign board(s)
2 Location of the hospital is easily accessible to the people
3 Door plate(s) at clinics/offices clearly display name, qualification(s), and designation(s) of the staff on duty
4 The staff on duty uses the provided identity badge
5 The individual who heads the hospital has requisite qualifications and experience
6 Those responsible for management establish the Hospital's Organogram and appoint staff accordingly
7 The hospital management lays down the hospital’s mission statement
8 The hospital management develops the long- and short-term work plans
9 Those responsible to approve the hospital’s budget, allocate resources required to implement the work plans
10 Those responsible for management monitor and measure the performance of the hospital against the work plans
11 The hospital management addresses the hospital’s social and community responsibilities
12 Those responsible for governance appoint the senior leaders in the organization
13 Those responsible for governance support research activities and quality improvement plans
14 The organization complies with the laid down and applicable legislations and regulations
15 The hospital space is in accordance with the minimum requirement
16 Hospital has adequate facilities and civic amenities for the comfort of the patients and attendants
17 Hospital has adequate arrangements for the privacy of patients during consultation / examination / procedures etc
18 The management is conversant with the relevant laws and regulations
19 The management regularly updates any amendments in the prevailing laws of the land
20 The management ensures implementation of these requirements
21 There is a mechanism to regularly update licenses / registrations / certifications
22 The hospital/HCE plans for equipment in accordance with its services and long / short term plans
23 Equipment is selected by a collaborative process
24 Qualified and trained personnel operate and maintain the equipment

Equipment is periodically inspected, serviced and calibrated to ensure its proper functioning. There is a documented operational
and maintenance (preventive breakdown and replacement) plan.
25
26 The hospital has plans and provisions for i. Early detection, ii. Containment and iii. Abatement of fire and non-fire emergencies
27 The hospital has a documented safe exit (evacuation) plan in case of fire and non-fire emergencies
28 Simulation exercise is held at least once in a year
29 Staff members are trained for their role in case of such emergencies
30 Each staff member, employee, student and voluntary worker is appropriately oriented to the organization's mission and goals
31 Each regular/part time employee is made aware of their Job Description
32 Each regular / part time employee is made aware of his/her responsibilities, rights, patient's rights and patient's responsibilities
33 A well-documented performance appraisal system exists in the hospital
34 The employees are made aware of the system of performance appraisal at the time of induction
35 The appraisal system is used as a tool for further development
36 Performance appraisal is carried out at pre-defined intervals and is documented

The personal files are maintained and contain information regarding the employee's qualification/education, in-service training,
disciplinary background, evaluation results and health status
37

Only medical professionals permitted by law, regulation and the hospital are to provide patient care without supervision
38

The 1. Education, 2. Registration, 3.Training and 4. Experience of the identified health professionals is documented and updated periodically
39
40 Every medical record has a unique identifier
41 The staff authorized to make entries in the medical record is reflected in the hospital's policy and is identifiable
42 Every medical record entry is dated, timed and signed
43 The record provides an up-to-date and chronological account of patient care
The medical record contains information regarding reasons for admission, diagnosis, plan of care, informed consent,
care provided and details if shifted/discharged displaying continuity of care, copy of death certificate and copy of clinical autopsy report when
44 done in chronological order

45 Authorized care providers have access to current and past medical records
46 The medical records are reviewed regularly/periodically
47 The review focuses on the timeliness, legibility and completeness of both active (current) and discharged patients records
48 The review identifies, and documents any deficiencies in the record
49 Appropriate corrective and preventive measures undertaken are documented
50 The review uses a representative sample based on statistical principles
51 The review is conducted by identified care providers and health professionals
 A comprehensive programme covering ALL the major elements related to quality improvement and risk management is developed,
implemented and maintained by a notified committee
52
53 There is a designated individual for coordinating and implementing the quality improvement programme

The designated programme is communicated and coordinated amongst all the employees of the HCE through a proper training
mechanism
54
55 The quality improvement programme is a continuous process and updated at least once in a year
56 The quality improvement programme is documented
57 Monitoring includes appropriate patient assessment
58 Monitoring includes safety and quality control programmes of the diagnostic services
59 Monitoring includes all invasive procedures
60 Monitoring includes adverse drug events
61 Monitoring includes use of anaesthesia.
62 Monitoring includes use of blood and blood products
63 Monitoring includes availability and content of medical records
64 The hospital has defined sentinel events
65 Sentinel events are intensively analysed when they occur
66 Only the services being provided at the hospital are displayed
67 There is a well-established Registration and Disposal Process
68 There is a well-established Patient Assessment Process
69 Scope of the laboratory services is according to the clinical services provided by the HCE
70 Adequately qualified and trained personnel perform and/or supervise the investigations
Policies and procedures guide the: i. Collection, ii. Identification, iii. Handling, iv. Safetransportation, v. Processing and
71 Disposal of specimens
vi.
72 Laboratory results are available within a defined time frame
73 Critical results are reported immediately to the concerned personnel
74 Laboratory tests not available in the HCE are outsourced to laboratories, based on theirquality assurance system
75 Imaging services comply with legal and other Regulatory Requirements
76 Scope of the imaging services is in accordance with the clinical services provided by the Hospital
77 Adequately qualified and trained personnel perform, supervise and interpret theinvestigations
78 Policies and procedures guide identification and safe transportation of patients toimaging services
 79 Imaging results are available within a defined time frame
80 Critical results are intimated immediately to the concerned personnel
81 Quality Assurance activities are evident in the Imaging Department
Imaging tests not available in the hospital are outsourced on the basis of quality assurance system and compliance with
82 applicable laws and regulations
83 Policies and procedures for emergency care are documented
84 Policies also address handling of medico-legal case
85 Policies and procedures guide the prioritization of patients for initiation of appropriate care
86 Staff members are familiar with the policies and trained on the procedures for care of emergency patient
87 The patients receive care in consonance with the policie
88 Admission or discharge to home or transfer to another organization is documented product
89 Documented policies and procedures are used to guide rational use of blood and blood products
90 The transfusion services are governed by the applicable laws and regulations
91 Informed consent is obtained for donation and transfusion of blood and blood product
92 Staff members are trained to implement the policies
93 Transfusion reactions are analysed for preventive and corrective actions
94 The hospital defines and displays whether high-risk obstetric cases and their neonates can be cared for or not.
95 Persons caring for high-risk obstetric cases are competen
96 High-risk obstetric patient's assessment also includes maternal nutrition
The hospital caring for high risk obstetric cases has the facilities and technically competent staff to take care of neonates
97 of such cases
98 No treatment is administered until the identity of the patient is guaranteed
99 There is a documented policy and procedure for the administration of anaesthesia
100 All patients for anaesthesia have a pre-anaesthetic assessment and an anaesthetic plan formulated by a qualified individuals
101 Informed consent for administration of anaesthesia is obtained by a qualified member of the anaesthetic team
102 An immediate pre-operative (pre-induction) re-evaluation is documented
During anaesthesia, monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood
103 pressure, oxygensaturation, airway security and patency, and level of anaesthesia
104 No anaesthetic is administered unless the identity of the patient is guaranteed
105 Each patient's post-anaesthetic status is monitored and documented
106 A qualified individual applies defined criteria to transfer the patient from the recovery area.
107 All adverse anaesthesia events are recorded and monitored
108 The pre-anaesthesia assessment results in formulation of an anaesthetic plan for each patient, which is documented
109 The surgery-related policies and procedures are documented
110 Documented policies and procedures address the prevention of adverse events like wrong site, wrong patient and wrong surgery
111 Surgical patients have a pre-operative assessment and a provisional diagnosis documented prior to surgeryInd
112 An informed consent is obtained by an authorized member of the surgical team prior to the procedure
113 Persons qualified by law are permitted to perform the procedures that they are entitled to perform
A brief operative note is documented by the surgeon or a doctor in the surgical team prior to transferring the
114 patient out of the recovery area
115 The operating surgeon or the surgical assistant documents the post-operative plan of care.
116 A quality assurance program is followed for the surgical services
117 The surgical quality assurance programme includes surveillance of the operation theatre environment
118 The surveillance programme also includes monitoring of surgical site infection rate
119 Documented policies and procedures exist for the prescription of medications
120 The HCE formally determines who can write orders
121 Orders are written in a uniform location in the medical record
122 Medication orders are clear, legible, dated, timed, named / stamped and signed
123 Policy on verbal orders is documented and implemented
124 The hospital defines a list of high-risk medication
125 High-risk medication orders are verified prior to dispensing
126 Documented policies and procedures guide safe storage and dispensing of medications
127 The policies include a procedure for medication recall
128 Expiry dates are checked and documented prior to dispensing
129 Labelling requirements prior to dispensing are implemented
130 Medications are administered (dispensed) by those who are permitted by law and authorized to do so
131 Prepared medications are labelled prior to preparation of a second drug
132 Patient is identified prior to administration
133 Medication is verified from the order prior to administration
134 Dosage is verified from the order prior to administration
135 Route is verified from the order prior to administration
136 Timing is verified from the order prior to administration
137 Medication administration is documented
138 Policies and procedures govern patient’s self-administration of medications
139 Policies and procedures govern patient's medications brought from outside the hospital
140 General Consent for treatment / declaration on admission is obtained, patient and family members are informed of its scope
141 The hospital has listed those situations where Specific Informed Consent is required

Informed Consent includes Information on Risks, Benefits, and Alternatives and as to who will perform the requisite procedure in
a language that they can understand
142
The policy describes who can give consent when patient is incapable of independent decision- making
143
144 There is uniform category specific Pricing Policy in a given setting (outdoor/In door/diagnostics)
145 The Tariff List is available to patients
146 Patients and family are educated about the estimated costs of treatment

Patients and family are informed about the financial implications when there is a change in the patient condition or treatment
setting
147
148 The hospital informs the patient of his/her right to express relevant concern or complain either verbally or in writing
149 There is a documented process for collecting, prioritizing, reporting and investigating complaints, which is fair and timely
150 The hospital informs the patient of the progress of the investigation at regular intervals and informs about the outcome
151 The hospital uses the results of complaints investigations as part of the quality improvement process
152 The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections
153 The hospital has an Infection Control Committee
154 The hospital has an Infection Control Team
155 The hospital has designated qualified infection control nurse(s) for this activity
The establishment has appropriate consumables, collection and handling systems, equipment and facilities for
156 control of infection
All staff involved in the creation, handling and disposal of medical waste shall receive regular training and ongoing
157 education in safe handling of medical waste
158 There is adequate space available for sterilization activities
159 Regular validation tests for sterilization are carried out and documented
160 There is an established procedure for recall in case of breakdown in the sterilization system
ind 112. An informed consent is obtained by an authorized member of the surgical team prior to the procedure

Ind 118. The surveillance programme also includes monitoring of surgical site infection rate