IMPLEMENTING NABH

WELCOME PARTICIPANTS!
SECTION I:
PATIENT-CENTERED STANDARDS
SECTION II:
MANAGEMENT CENTERED STANDARDS
 Access, Assessment & Continuity of Care (AAC)
AAC.1. : THE ORGANIZATION DEFINES
AND DISPLAYS THE SERVICES THAT IT
CAN PROVIDE.
OBJECTIVE ELEMENTS
a) The services being provided are clearly defined and are in
consonance with the needs of the community.
b) The defined services are prominently displayed.
c) The staff is oriented to these services.
AAC.2. : THE ORGANISATION HAS A WELL
DEFINED REGISTRATION AND ADMISSION
PROCESS.
OBJECTIVE ELEMENTS
a) Documented policies and procedures are used for registering
and admitting patients.
b) The documented procedures address out- patients, in-patients
and emergency patients.
c) A unique identification number is generated at the end of
registration.
d) Patients are accepted only if the organisation can provide the
required service.
e) The documented policies and procedures also address
managing patients during non availability of beds.
f) The staff is aware of these processes.
AAC.3. : THERE IS AN APPROPRIATE
MECHANISM FOR TRANSFER (IN AND OUT)
OR REFERRAL OF PATIENTS.
OBJECTIVE ELEMENTS
a) Documented policies and procedures guide the transfer-in of
patients to the organisation.
b) Documented policies and procedures guide the
transfer-out/referral of unstable patients to another facility in
an appropriate manner.
c) Documented policies and procedures guide the transfer-in of
patients to the organisation.
d) Documented policies and procedures guide the
transfer-out/referral of unstable patients to another facility in
an appropriate manner.
e) Documented policies and procedures guide the transfer-
out/referral of stable patients to another facility in an
appropriate manner.
f) The documented procedures identify staff responsible during
transfer/referral.
g) The organisation gives a summary of patient’s condition and
the treatment given.
AAC.4. : PATIENTS CARED FOR BY THE
ORGANISATION UNDERGO AN
ESTABLISHED INITIAL ASSESSMENT.
OBJECTIVE ELEMENTS
a) The organisation defines and documents the content of the
initial assessment for the out–patients, in-patients and
emergency patients.
b) The organisation determines who can perform the initial
assessment.
c) The organisation defines the time frame within which the
initial assessment is completed based on patient’s needs.
d) The initial assessment for in-patients is documented within 24
hours or earlier as per the patient’s condition as defined in the
organisation’s policy.
f) Initial assessment of in-patients includes nursing assessment
which is done at the time of admission and documented.
g) Initial assessment includes screening for nutritional needs.
h) The initial assessment results in a documented plan of care.
i) The plan of care also includes preventive aspects of the care
where appropriate.
i) The plan of care is countersigned by the clinician in-charge
of the patient within 24 hours.
j) The plan of care includes goals or desired results of the
treatment, care or service.
AAC.5. : PATIENTS CARED FOR BY THE
ORGANISATION UNDERGO A REGULAR
REASSESSMENT.
OBJECTIVE ELEMENTS
a) Patients are reassessed at appropriate intervals.
b) Out-patients are informed of their next follow up where
appropriate.
c) For in-patients during reassessment the plan of care is
monitored and modified where found necessary.
d) Staff involved in direct clinical care document reassessments.
e) Patients are reassessed to determine their response to treatment
and to plan further treatment or discharge.
AAC.6. : LABORATORY SERVICES ARE
PROVIDED AS PER THE SCOPE OF SERVICES
OF THE
OBJECTIVE ELEMENTS ORGANISATION.
a) Scope of the laboratory services are commensurate to the
services provided by the organisation.
b) The infrastructure (physical and manpower) is adequate to
provide for its defined scope of services.
c) Adequately qualified and trained personnel perform, supervise
and interpret the investigations.
d) Documented procedures guide ordering of tests, collection,
identification, handling, safe transportation, processing and
disposal of specimens.
e) Laboratory results are available within a defined time frame.
f) Critical results are intimated immediately to the personnel
concerned.
g) Results are reported in a standardised manner.
h) Laboratory tests not available in the organisation are
outsourced to organisation (s) based on their quality
assurance system.
AAC.7. STANDARD

There is an established laboratory

quality assurance programme.
AAC.7. OBJECTIVE ELEMENTS…
a) The laboratory quality assurance programme is
documented.

b) The programme addresses verification and/or

validation of test methods.

c) The programme addresses surveillance of test results.

AAC.7. OBJECTIVE ELEMENTS

d) The programme includes periodic calibration and

maintenance of all equipment.

e) The programme includes the documentation of corrective

and preventive actions.
AAC.8. STANDARD

There is an established laboratory

safety programme.
AAC.8. OBJECTIVE ELEMENTS…

a) The laboratory safety programme is documented.

b) This programme is aligned with the organisation’s

safety programme.
AAC.8. OBJECTIVE ELEMENTS

c) Written procedures guide the handling and disposal of

infectious and hazardous materials.
d) Laboratory personnel are appropriately trained in safe
practices.
e) Laboratory personnel are provided with appropriate safety
equipment / devices.
AAC.9. STANDARD

Imaging services are provided as per

the scope of services of the
organisation.
AAC.9. OBJECTIVE ELEMENTS…

a) Imaging services comply with legal and other

requirements.
b) Scope of the imaging services is
commensurate to the services provided by the
organisation.
c) The infrastructure (physical and manpower) is
adequate to provide for its defined scope of
services.
AAC.9. OBJECTIVE ELEMENTS…
d) Adequately qualified and trained personnel perform,
supervise and interpret the investigations.
e) Documented policies and procedures guide
identification and safe transportation of patients to
imaging services.
f) Imaging results are available within a defined time
frame.
AAC.9. OBJECTIVE ELEMENTS
g) Critical results are intimated immediately to the
personnel concerned.
h) Results are reported in a standardised manner.
i) Imaging tests not available in the organisation are
outsourced to organisation (s) based on their quality
assurance system.
AAC.10. STANDARD

There is an established quality

assurance programme for imaging
services.
AAC.10. OBJECTIVE ELEMENTS…
a) The quality assurance programme for imaging
services is documented.
b) The programme addresses verification and/or
validation of imaging methods.
c) The programme addresses surveillance of imaging
results.
AAC.10. OBJECTIVE ELEMENTS

d) The programme includes periodic calibration and

maintenance of all equipment.

e) The programme includes the documentation of corrective

and preventive actions.
AAC.11. STANDARD

There is an established radiation

safety programme.
AAC.11. OBJECTIVE ELEMENTS…
a) The radiation safety programme is documented.
b) This programme is aligned with the organisation’s
safety programme.
c) Handling, usage and disposal of radio-active and
hazardous materials are as per statutory requirements.
AAC.11. OBJECTIVE ELEMENTS
d) Imaging personnel are provided with appropriate radiation
safety devices.
e) Radiation safety devices are periodically tested and results
documented.
f) Imaging personnel are trained in radiation safety measures.
g) Imaging signage are prominently displayed in all appropriate
locations.
AAC.12. STANDARD

Patient care is continuous and

multidisciplinary in nature.
AAC.12. OBJECTIVE ELEMENTS…

a) During all phases of care, there is a qualified individual

identified as responsible for the patient’s care.

b) Care of patients is coordinated in all care settings within the

organisation.
AAC.12. OBJECTIVE ELEMENTS…
c) Information about the patient’s care and response to
treatment is shared among medical, nursing and other
care providers.

d) Information is exchanged and documented during

each staffing shift, between shifts, and during
transfers between units/departments.
AAC.12. OBJECTIVE ELEMENTS
e) Transfers between departments/units are done in a
safe manner.
f) The patient’s record (s) is available to the authorised
care providers to facilitate the exchange of
information.
g) Documented procedures guide the referral of patients
to other departments / specialities.
AAC.13. STANDARD

The organisation has a documented

discharge process.
AAC.13. OBJECTIVE ELEMENTS…
a) The patient’s discharge process is planned in
consultation with the patient and/or family.
b) Documented procedures exist for coordination of
various departments and agencies involved in the
discharge process (including medico-legal and
absconded cases).
AAC.13. OBJECTIVE ELEMENTS
c) Documented policies and procedures are in place for
patients leaving against medical advice and patients
being discharged on request.
d) A discharge summary is given to all the patients
leaving the organisation (including patients leaving
against medical advice and on request).
AAC.14. STANDARD

Organisation defines the content of

the discharge summary.
AAC.14. OBJECTIVE ELEMENTS…

a) Discharge summary is provided to the patients at the

time of discharge.

b) Discharge summary contains the patient’s name,

unique identification number, date of admission and
date of discharge.
AAC.14. OBJECTIVE ELEMENTS…
c) Discharge summary contains the reasons for
admission, significant findings and diagnosis and the
patient’s condition at the time of discharge.
d) Discharge summary contains information regarding
investigation results, any procedure performed,
medication administered and other treatment given.
AAC.14. OBJECTIVE ELEMENTS
e) Discharge summary contains follow up advice,
medication and other instructions in an
understandable manner.
f) Discharge summary incorporates instructions about
when and how to obtain urgent care.
g) In case of death, the summary of the case also
includes the cause of death.
CARE OF PATIENTS (COP)
CHAPTER 2: CARE OF PATIENT
There are Standards broadly applicable to:
• 13 Standards
• 136 Objective elements
 Emergency & Day care services
 Ambulance services
 Nursing Department
 Blood Bank
 All Intensive Care Areas & HDUs
 OBG Department
 Pediatric Department
 All Surgical departments
 Anesthesia Department
 Outpatient Department
 Physiotherapy & Rehabilitation department
 Research Department
 Dietetics Department

47
COP.1. STANDARD

Uniform care to patients is provided

in all settings of the organisation and
is guided by the applicable laws,
regulations and guidelines.
COP.1. OBJECTIVE ELEMENTS…

a) Care delivery is uniform for a given health problem when

similar care is provided in more than one setting.

b) Uniform care is guided by documented policies and

procedures.
COP.1. OBJECTIVE ELEMENTS

c) These reflect applicable laws, regulations and

guidelines.

d) The organisation adopts evidence based medicine and

clinical practice guidelines to guide uniform patient
care.
COP.2. STANDARD

Emergency services are guided by

documented policies, procedures,
applicable laws and regulations.
COP.2. OBJECTIVE ELEMENTS…
a) Policies and procedure for emergency care are
documented and are in consonance with statutory
requirements.
b) This also address handling of medico-legal cases.
c) The patients receive care in consonance with the
policies.
COP.2. OBJECTIVE ELEMENTS…
d) Documented policies and procedures guide the triage
of patients for initiation of appropriate care.

e) Staff is familiar with the policies and trained on the

procedures for care of emergency patients.
COP.2. OBJECTIVE ELEMENTS

f) Admission or discharge to home or transfer to another

organisation is also documented.

g) In case of discharge to home or transfer to another

organisation a discharge note shall be given to the patient.
COP.3. STANDARD

The ambulance services are

commensurate with the scope of the
services provided by the
organization.
COP.3. OBJECTIVE ELEMENTS…
a) There is adequate access and space for the ambulance
(s).
b) The ambulance adheres to statutory requirements.
c) Ambulance(s) are appropriately equipped.
d) Ambulance(s) are manned by trained personnel.
e) Ambulance (s) is checked on a daily basis.
COP.3. OBJECTIVE ELEMENTS
f) Equipment are checked on a daily basis using a
checklist.
g) Emergency medications are checked daily and prior to
dispatch using a checklist.
h) The ambulance(s) have a proper communication
system.
COP.4. STANDARD

Documented policies and procedures

guide the care of patients requiring
cardio-pulmonary resuscitation.
COP.4. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide the
uniform use of resuscitation throughout the
organisation.

b) Staff providing direct patient care is trained and

periodically updated in cardio pulmonary
resuscitation.
COP.4. OBJECTIVE ELEMENTS

c) The events during a cardio-pulmonary resuscitation are

recorded.
d) A post-event analysis of all cardiac arrests is done by a
multidisciplinary committee.
e) Corrective and preventive measures are taken based on the
post-event analysis.
COP.5. STANDARD

Documented policies and procedures

guide nursing care.
COP.5. OBJECTIVE ELEMENTS…
a) There are documented policies and procedures for all
activities of the nursing services.

b) These reflect current standards of nursing services and

practice, relevant regulations and purposes of the
services.
COP.5. OBJECTIVE ELEMENTS…

c) Assignment of patient care is done as per current good

practice guidelines.
d) Nursing care is aligned and integrated with overall
patient care.
e) Care provided by nurses is documented in the patient
record.
COP.5. OBJECTIVE
ELEMENTS
f) Nurses are provided with adequate equipment for
providing safe and efficient nursing services.

g) Nurses are empowered to take nursing- related

decisions to ensure timely care of patients.
COP.6. STANDARD

Documented procedures guide the

performance of various procedures.
COP.6. OBJECTIVE ELEMENTS…
a) Documented procedures are used to guide the
performance of various clinical procedures.
b) Only qualified personnel order, plan, perform and
assist in performing procedures.
c) Documented procedures exist to prevent adverse
events like wrong site, wrong patient and wrong
procedure.
COP.6. OBJECTIVE ELEMENTS
d) Informed consent is taken by the personnel performing
the procedure, where applicable.
e) Adherence to standard precautions and asepsis is
adhered to during the conduct of the procedure.
f) Patients are appropriately monitored during and after
the procedure.
g) Procedures are documented accurately in the patient
record.
COP.7. STANDARD

Policies and procedures define

rational use of blood and blood
products.
COP.7. OBJECTIVE ELEMENTS…
a) Documented policies and procedures are used to guide
rational use of blood and blood products.
b) Documented procedures govern transfusion of blood
and blood products.
c) The transfusion services are governed by the
applicable laws and regulations.
COP.7. OBJECTIVE ELEMENTS…
d) Informed consent is obtained for donation and
transfusion of blood and blood products.
e) Informed consent also includes patient and family
education about donation.
f) The organisation defines the process for availability
and transfusion of blood/blood components for use in
emergency.
COP.7. OBJECTIVE ELEMENTS

g) Post-transfusion form is collected, reactions if any

identified and are analysed for preventive and
corrective actions.

h) Staff are trained to implement the policies.

COP.8. STANDARD

Documented policies and procedures

guide the care of patients in the
intensive care and high dependency
units.
COP.8. OBJECTIVE ELEMENTS…
a) Documented policies and procedures are used to guide
the care of patients in the intensive care and high
dependency units.
b) The organisation has documented admission and
discharge criteria for its intensive care and high
dependency units.
c) Staff is trained to apply these criteria.
COP.8. OBJECTIVE ELEMENTS
d) Adequate staff and equipment are available.
e) Defined procedures for situation of bed shortages are
followed.
f) Infection control practices are documented and
followed.
g) A quality-assurance programme is documented and
implemented.
COP.9. STANDARD

Documented policies and procedures

guide the care of vulnerable patients
(elderly, children, physically and/or
mentally challenged).
COP.9. OBJECTIVE ELEMENTS…
a) Policies and procedures are documented and are in
accordance with the prevailing laws and the national
and international guidelines.

b) Care is organised and delivered in accordance with the

policies and procedures.
COP.9. OBJECTIVE ELEMENTS
c) The organisation provides for a safe and secure
environment for this vulnerable group.
d) A documented procedure exists for obtaining
informed consent from the appropriate legal
representative.
e) Staff are trained to care for this vulnerable group.
COP.10. STANDARD

Documented policies and procedures

guide obstetric care.
COP.10. OBJECTIVE ELEMENTS…
a) There is a documented policy and procedure for
obstetric services.
b) The organisation defines and displays whether high-
risk obstetric cases can be cared for or not.
c) Persons caring for high-risk obstetric cases are
competent.
d) Documented procedures guide provision of ante-natal
services.
COP.10. OBJECTIVE ELEMENTS
e) Obstetric patient’s assessment also includes maternal
nutrition.
f) Appropriate pre-natal, peri-natal and post-natal
monitoring is performed and documented.
g) The organisation caring for high risk obstetric cases
has the facilities to take care of neonates of such
cases.
COP.11. STANDARD

Documented policies and procedures

guide paediatric services.
COP.11. OBJECTIVE ELEMENTS…
a) There is a documented policy and procedure for
paediatric services.
b) The organisation defines and displays the scope of its
pediatric services.
c) The policy for care of neonatal patients is in
consonance with the national/ international guidelines.
COP.11. OBJECTIVE ELEMENTS…
d) Those who care for children have age- specific
competency.
e) Provisions are made for special care of children.
f) Patient assessment includes detailed nutritional,
growth, psychosocial and immunisation assessment.
COP.11. OBJECTIVE ELEMENTS

g) Documented policies and procedures prevent child/ neonate

abduction and abuse.

h) The children’s family members are educated about nutrition,

immunisation and safe parenting and this is documented in
the medical record.
COP.12. STANDARD

Documented Policies and procedures

guide the care of patients undergoing
moderate sedation.
COP.12. OBJECTIVE ELEMENTS…
a) Documented procedures guide the administration of
moderate sedation.
b) Informed consent for administration of moderate
sedation is obtained.
c) Competent and trained persons perform sedation.
COP.12. OBJECTIVE ELEMENTS…
d) The person administering and monitoring sedation is
different from the person performing the procedure.
e) Intra-procedure monitoring includes at a minimum the
heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation, and level of sedation.
COP.12. OBJECTIVE ELEMENTS
f) Patients are monitored after sedation and the same
documented.
g) Criteria are used to determine appropriateness of
discharge from the recovery area.
h) Equipment and manpower are available to manage
patients who have gone into a deeper level of sedation
than initially intended.
COP.13. STANDARD

Documented policies and procedures

guide the administration of
anaesthesia.
COP.13. OBJECTIVE ELEMENTS…
a) There is a documented policy and procedure for the
administration of anaesthesia.
b) Patients for anaesthesia have a pre-anaesthesia
assessment by a qualified anaesthesiologist.
c) The pre-anaesthesia assessment results in formulation
of an anesthesia plan which is documented.
COP.13. OBJECTIVE ELEMENTS…
d) An immediate pre-operative re-evaluation
is performed and documented.
e) Informed consent for administration of
anaesthesia is obtained by the
anaesthesiologist.
f) During anaesthesia monitoring includes
regular recording of temperature, heart rate,
cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation and end tidal
carbon dioxide.
COP.13. OBJECTIVE ELEMENTS…
g) Patient’s post-anaesthesia status is monitored and
documented.
h) The anaesthesiologist applies defined criteria to
transfer the patient from the recovery area.
i) The type of anaesthesia and anaesthetic medications
used are documented in the patient record.
COP.13. OBJECTIVE ELEMENTS

j) Procedures shall comply with infection control

guidelines to prevent cross-infection between patients.

k) Adverse anesthesia events are recorded and

monitored.
COP.14. STANDARD

Documented policies and procedures

guide the care of patients undergoing
surgical procedures.
COP.14. OBJECTIVE ELEMENTS…
a) The policies and procedures are documented.
b) Surgical patients have a preoperative assessment and a
provisional diagnosis documented prior to surgery.
c) An informed consent is obtained by a surgeon prior to
the procedure.
COP.14. OBJECTIVE ELEMENTS…
d) Documented policies and procedures exist to prevent
adverse events like wrong site, wrong patient and
wrong surgery.

e) Persons qualified by law are permitted to perform the

procedures that they are entitled to perform.
COP.14. OBJECTIVE ELEMENTS…

f) A brief operative note is documented prior to transfer

out of patient from recovery area.
g) The operating surgeon documents the post-operative
plan of care.
h) Patient, personnel and material flow conforms to
infection control practices.
COP.14. OBJECTIVE ELEMENTS…
i) Appropriate facilities and equipment/
appliances/instrumentation are available in the
operating theatre.
j) A quality assurance program is followed for the
surgical services.
k) The quality assurance program includes surveillance
of the operation theatre environment.
COP.15. STANDARD

Documented policies and procedures

guide the care of patients under
restraints (physical and/or chemical).
COP.15. OBJECTIVE ELEMENTS

a) Documented policies and procedures guide the care of

patients under restraints.
b) These include both physical and chemical restraint
measures.
c) These include documentation of reasons for restraints.
d) These patients are more frequently monitored.
e) Staff receives training and periodic updating in control and
restraint techniques.
COP.16. STANDARD

Documented policies and procedures

guide appropriate pain management.
COP.16. OBJECTIVE ELEMENTS

a) Documented policies and procedures guide the management

of pain.
b) All patients are screened for pain.
c) Patients with pain undergo detailed assessment and periodic
re-assessment.
d) The organisation respects and supports management of pain
for such patients.
e) Patient and family are educated on various pain
management techniques where appropriate.
COP.17. STANDARD

Documented policies and procedures

guide appropriate rehabilitative
services.
COP.17. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide the provision of
rehabilitative services.
b) These services are commensurate with the organisational
requirements.
c) Care is guided by functional assessment and periodic re-
assessment which is done and documented by qualified
individual (s).
d) Care is provided adhering to infection control and safe
practices.
e) Rehabilitative services are provided by a multidisciplinary
team.
f) There is adequate space and equipment to perform these
activities.
COP.18. STANDARD

Documented policies and procedures

guide all research activities.
COP.18. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide all
research activities in compliance with national
and international guidelines.
b) The organisation has an ethics committee to
oversee all research activities.
c) The committee has the powers to discontinue
a research trial when risks outweigh the
potential benefits.
COP.18. OBJECTIVE ELEMENTS

d) Patients’ informed consent is obtained before entering them

in research protocols.
e) Patients are informed of their right to withdraw from the
research at any stage and also of the consequences (if any)
of such withdrawal.
f) Patients are assured that their refusal to participate or
withdrawal from participation will not compromise their
access to the organisation’s services.
COP.19. STANDARD

Documented policies and procedures

guide nutritional therapy.
COP.19. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide nutritional
assessment and reassessment.
b) Patients receive food according to their clinical needs.
c) There is a written order for the diet.
d) Nutritional therapy is planned and provided in a
collaborative manner.
e) When families provide food, they are educated about
the patient’s diet limitations.
f) Food is prepared, handled, stored and distributed in a
safe manner.
COP.20. STANDARD

Documented policies and procedures

guide the end of life care.
COP.20. OBJECTIVE ELEMENTS…

a) Documented policies and procedures guide the end of

life care.
b) These policies and procedures are in consonance with
the legal requirements.
c) These also address the identification of the unique
needs of such patient and family.
d) Symptomatic treatment is provided and where
appropriate measures are taken for alleviation of pain.
e) Staff is educated and trained in end of life care.
SECTION I:
PATIENT-CENTERED STANDARDS
Management of Medication(MOM)

132
MOM.1. STANDARD

Documented policies and procedures

guide the organisation of pharmacy
services and usage of medication.
MOM.1. OBJECTIVE ELEMENTS
a) There is a documented policy and procedure for
pharmacy services and medication usage.
b) These comply with the applicable laws and
regulations.
c) A multidisciplinary committee guides the formulation
and implementation of these policies and procedures.
d) There is a procedure to obtain medication when the
pharmacy is closed.
MOM.2. STANDARD

There is a hospital formulary.

MOM.2. OBJECTIVE ELEMENTS…
a) A list of medication appropriate for the patients and
as per the scope of the organisation’s clinical services
is developed.

b) The list is developed and updated collaboratively by

the multidisciplinary committee.
MOM.2. OBJECTIVE ELEMENTS

c) The formulary is available for clinicians to refer and

adhere to.
d) There is a defined process for acquisition of these
medications.
e) There is a process to obtain medications not listed in
the formulary.
MOM.3. STANDARD

Documented policies and procedures

guide the storage of medication.
MOM.3. OBJECTIVE ELEMENTS…
a) Documented policies and procedures exist for storage
of medication.
b) Medications are stored in a clean, safe and secure
environment; and incorporating manufacturer’s
recommendation(s).
c) Sound inventory control practices guide storage of
the medications.
MOM.3. OBJECTIVE ELEMENTS
d) Sound-alike and look-alike medications are identified
and stored separately.
e) The list of emergency medications is defined and is
stored in a uniform manner.
f) Emergency medications are available all the time.
g) Emergency medications are replenished in a timely
manner when used.
MOM.4. STANDARD

Documented policies and procedures

guide the safe and rational
prescription of medications.
 MOM.4. OBJECTIVE ELEMENTS…
a) Documented policies and procedures exist for
prescription of medications.
b) These incorporate inclusion of good
practices/guidelines for rational prescription of
medications.
c) The organisation determines the minimum
requirements of a prescription.
MOM.4. OBJECTIVE ELEMENTS…
d) Known drug allergies are ascertained before
prescribing.
e) The organisation determines who can write orders.
f) Orders are written in a uniform location in the
medical records.
g) Medication orders are clear, legible, dated, timed,
named and signed.
MOM.4. OBJECTIVE ELEMENTS…
h) Medication orders contain the name of the medicine,
route of administration, dose to be administered and
frequency/time of administration.
i) Documented policy and procedure on verbal orders is
implemented.
j) The organisation defines a list of high risk
medication(s).
MOM.4. OBJECTIVE ELEMENTS
k) Audit of medication orders/prescription is carried out
to check for safe and rational prescription of
medications.

l) Corrective and/or preventive action(s) is taken based

on the analysis, where appropriate.
MOM.5. STANDARD

Documented policies and procedures

guide the safe dispensing of
medications.
MOM.5. OBJECTIVE ELEMENTS…

a) Documented policies and procedures guide the safe

dispensing of medications.
b) The procedure addresses medication recall.
c) Expiry dates are checked prior to dispensing.
d) There is a procedure for near expiry medications.
MOM.5. OBJECTIVE ELEMENTS

e) Labelling requirements are documented and

implemented by the organisation.

f) High-risk medication orders are verified prior to

dispensing.
MOM.6. STANDARD

There are documented policies and

procedures for medication
management.
MOM.6. OBJECTIVE ELEMENTS…

a) Medications are administered by those who are

permitted by law to do so.
b) Prepared medication is labelled prior to preparation
of a second drug.
c) Patient is identified prior to administration.
MOM.6. OBJECTIVE ELEMENTS…
d) Medication is verified from the order prior to
administration.
e) Dosage is verified from the order prior to
administration.
f) Route is verified from the order prior to
administration.
g) Timing is verified from the order prior to
administration.
MOM.6. OBJECTIVE ELEMENTS

h) Medication administration is documented.

i) Documented policies and procedures govern patient’s
self-administration of medications.
j) Documented policies and procedures govern patient’s
medications brought from outside the organisation.
MOM.7. STANDARD

Patients are monitored after

medication administration.
MOM.7. OBJECTIVE ELEMENTS
a) Documented policies and procedures guide the
monitoring of patients after medication
administration.
b) The organisation defines those situations where close
monitoring is required.
c) Monitoring is done in a collaborative manner.
d) Medications are changed where appropriate based
on the monitoring.
MOM.8. STANDARD

Near misses, medication errors and

adverse drug events are reported and
analysed.
MOM.8. OBJECTIVE ELEMENTS…

a) Documented procedure exists to capture near miss,

medication error and adverse drug event.

b) Near miss, medication error and adverse drug event

are defined.
MOM.8. OBJECTIVE ELEMENTS

c) These are reported within a specified time frame.

d) They are collected and analysed.
e) Corrective and/or preventive action(s) are taken
based on the analysis where appropriate.
MOM.9. STANDARD

Documented procedures guide the

use of narcotic drugs and psychotropic
substances.
MOM.9. OBJECTIVE ELEMENTS…

a) Documented procedures guide the use of narcotic

drugs and psychotropic substances which are in
consonance with local and national regulations.

b) These drugs are stored in a secure manner.

MOM.9. OBJECTIVE ELEMENTS

c) A proper record is kept of the usage, administration

and disposal of these drugs.

d) These drugs are handled by appropriate personnel in

accordance with the documented procedure.
MOM.10. STANDARD

Documented policies and procedures

guide the usage of chemotherapeutic
agents.
MOM.10. OBJECTIVE ELEMENTS…

a) Documented policies and procedures guide the usage

of chemotherapeutic agents.

b) Chemotherapy is prescribed by those who have the

knowledge to monitor and treat the adverse effect of
chemotherapy.
MOM.10. OBJECTIVE ELEMENTS

c) Chemotherapy is prepared in a proper and safe

manner and administered by qualified personnel.

d) Chemotherapy drugs are disposed off in accordance

with legal requirements.
MOM.11. STANDARD

Documented policies and procedures

govern usage of radioactive drugs.
MOM.11. OBJECTIVE ELEMENTS…

a) Documented policies and procedures govern usage of

radioactive drugs.

b) These policies and procedures are in consonance with

laws and regulations.
MOM.11. OBJECTIVE ELEMENTS

c) The policies and procedures include the safe storage,

preparation, handling, distribution and disposal of
radioactive drugs.

d) Staff, patients and visitors are educated on safety

precautions.
MOM.12. STANDARD

Documented policies and procedures

guide the use of implantable
prosthesis and medical devices.
MOM.12. OBJECTIVE ELEMENTS…

a) Usage of implantable prosthesis and medical devices

is guided by scientific criteria for each individual item
and national / international recognized guidelines /
approvals for such specific item(s).
MOM.12. OBJECTIVE ELEMENTS…
b) Documented policies and procedures govern
procurement, storage / stocking, issuance and usage
of implantable prosthesis and medical devices
incorporating manufacturer’s recommendation(s).
c) Patient and his / her family are counselled for the
usage of implantable prosthesis and medical device
including precautions, if any.
MOM.12. OBJECTIVE ELEMENTS

d) The batch and serial number of the implantable

prosthesis and medical devices are recorded in the
patient’s medical record and the master logbook.
MOM.13. STANDARD

Documented policies and procedures

guide the use of medical supplies and
consumables.
 NABH - Chapter 4
Patients Rights and Educations (PRE)

176
PRE.1. STANDARD

The organization protects patient and

family rights and informs them about
their responsibilities during care.
PRE.1. OBJECTIVE ELEMENTS…

a) Patient and family rights and responsibilities are

documented and displayed.

b) Patients and families are informed of their rights and

responsibilities in a format and language that they
can understand.
PRE.1. OBJECTIVE ELEMENTS
c) The organization's leaders protect patient and family
rights.
d) Staff is aware of its responsibility in protecting patient
and family rights.
e) Violation of patient and family rights is recorded,
reviewed and corrective/ preventive measures taken.
PRE.2. STANDARD

Patient and family rights support

individual beliefs, values and involve
the patient and family in decision
making processes.
PRE.2. OBJECTIVE ELEMENTS…
a) Patient and family rights include respecting any
special preferences, spiritual and cultural needs.
b) Patient and family rights include respect for personal
dignity and privacy during examination, procedures
and treatment.
c) Patient and family rights include protection from
physical abuse or neglect.
PRE.2. OBJECTIVE ELEMENTS…

d) Patient and family rights include treating patient

information as confidential.
e) Patient and family rights include refusal of treatment.
f) Patient and family rights include informed consent before
transfusion of blood and blood products, anesthesia,
surgery, initiation of any research protocol and any other
invasive / high risk procedures / treatment.
PRE.2. OBJECTIVE ELEMENTS

g) Patient and family rights include right to complain and

information on how to voice a complaint.
h) Patient and family rights include information on the
expected cost of the treatment.
i) Patient and family rights include access to his / her
clinical records.
j) Patient and family rights include information on plan of
care, progress and information on their health care
needs.
PRE.3. STANDARD

The patient and/ or family members

are educated to make informed
decisions and are involved in the care
planning and delivery process
PRE.3. OBJECTIVE ELEMENTS…
a) The patient and/or family members are explained
about the proposed care including the risks,
alternatives and benefits.
b) The patient and/or family members are explained
about the expected results.
c) The patient and/or family members are explained
about the possible complications.
PRE.3. OBJECTIVE ELEMENTS…
d) The care plan is prepared and modified in consultation
with patient and/or family members.

e) The care plan respects and where possible

incorporates patient and/or family concerns and
requests.
PRE.3. OBJECTIVE ELEMENTS
f) The patient and/or family members are informed
about the results of diagnostic tests and the diagnosis.

g) The patient and/or family members are explained

about any change in the patient’s condition.
PRE.4. STANDARD

A documented process for obtaining

patient and / or family’s consent
exists for informed decision making
about their care.
PRE.4. OBJECTIVE ELEMENTS…
a) Documented procedure incorporates the list of
situations where informed consent is required and
the process for taking informed consent.
b) General consent for treatment is obtained when the
patient enters the organization.
PRE.4. OBJECTIVE ELEMENTS…
c) Patient and/or his family members are informed of the
scope of such general consent.
d) Informed consent includes information regarding the
procedure, risks , benefits, alternatives and as to who
will perform the requisite procedure in a language that
they can understand.
PRE.4. OBJECTIVE ELEMENTS

e) The procedure describes who can give consent when patient

is incapable of independent decision making.
f) Informed consent is taken by the person performing the
procedure.
g) Informed consent process adheres to statutory norms.
h) Staff is aware of the informed consent procedure.
PRE.5. STANDARD

Patient and families have a right to

information and education about
their healthcare needs.
PRE.5. OBJECTIVE ELEMENTS…
a) Patient and/or family are educated about the safe
and effective use of medication and the potential side
effects of the medication, when appropriate.
b) Patient and/or family are educated about food-drug
interactions.
c) Patient and/or family are educated about diet and
nutrition.
PRE.5. OBJECTIVE ELEMENTS…
d) Patient and/or family are educated about
immunizations.
e) Patient and/or family are educated about organ
donation, when appropriate.
f) Patient and/or family are educated about their
specific disease process, complications and
prevention strategies.
PRE.5. OBJECTIVE ELEMENTS
g) Patient and/or family are educated about preventing
healthcare associated infections.

h) Patient and/or family are educated in a language and

format that they can understand.
PRE.6. STANDARD

Patient and families have a right to

information on expected costs.
PRE.6. OBJECTIVE ELEMENTS

a) There is uniform pricing policy in a given setting (out-patient

and ward category).
b) The tariff list is available to patients.
c) The patient and/or family members are explained about the
expected costs.
d) Patient and/or family are informed about the financial
implications when there is a change in the patient condition
or treatment setting.
PRE.7. STANDARD

Organisation has a complaint redressal

procedure.
PRE.7. OBJECTIVE ELEMENTS

a) The organisation has a documented complaint redressal

procedure.
b) Patient and/or family members are made aware of the
procedure for lodging complaints.
c) All complaints are analysed.
d) Corrective and/or preventive action (s) are taken based on
the analysis where appropriate.
SECTION I:
PATIENT-CENTERED STANDARDS
Hospital Infection Control (HIC)

203
HIC.1. STANDARD

The organisation has a well-designed,

comprehensive and coordinated
Hospital Infection Prevention and
Control (HIC) programme aimed at
reducing/ eliminating risks to
patients, visitors and providers of
care.
HIC.1. OBJECTIVE ELEMENTS…
a) The hospital infection prevention and control
programme is documented which aims at preventing
and reducing risk of healthcare associated infections.

b) The infection prevention and control programme is a

continuous process and updated at least once in a
year.
HIC.1. OBJECTIVE ELEMENTS…
c) The hospital has a multi-disciplinary infection control
committee, which co-ordinates all infection
prevention and control activities.
d) The hospital has an infection control team, which co-
ordinates implementation of all infection prevention
and control activities.
HIC.1. OBJECTIVE ELEMENTS

e) The hospital has designated infection control officer

as part of the infection control team.

f) The hospital has designated infection control nurse(s)

as part of the infection control team.
HIC.2. STANDARD

The organisation implements the

policies and procedures laid down in
the Infection Control Manual.
HIC.2. OBJECTIVE ELEMENTS…
a) The organisation identifies the various high-risk areas
and procedures and implements policies and/or
procedures to prevent infection in these areas.
b) The organization adheres to standard precautions at
all times.
c) The organization adheres to hand-hygiene guidelines.
HIC.2. OBJECTIVE ELEMENTS…
d) The organisation adheres to safe injection and
infusion practices.
e) The organisation adheres to transmission- based
precautions at all times.
f) The organisation adheres to cleaning, disinfection and
sterilization practices.
g) An appropriate antibiotic policy is established and
implemented.
HIC.2. OBJECTIVE ELEMENTS
h) The organisation adheres to laundry and linen
management processes.
i) The organisation adheres to kitchen sanitation and
food-handling issues.
j) The organization has appropriate engineering controls
to prevent infections.
k) The organization adheres to housekeeping procedures.
HIC.3. STANDARD

The organisation performs

surveillance activities to capture and
monitor infection prevention and
control data.
HIC.3. OBJECTIVE ELEMENTS…
a) Surveillance activities are appropriately directed
towards the identified high-risk areas and
procedures.
b) Collection of surveillance data is an on-going process.
c) Verification of data is done on a regular basis by the
infection control team.
HIC.3. OBJECTIVE ELEMENTS…
d) Scope of surveillance activities incorporates tracking
and analysing of infection risks, rates and trends.
e) Surveillance activities include monitoring the
compliance with hand-hygiene guidelines.
f) Surveillance activities include monitoring the
effectiveness of housekeeping services.
HIC.3. OBJECTIVE ELEMENTS
g) Appropriate feedback regarding HAI rates are
provided on a regular basis to appropriate personnel.

h) In cases of notifiable diseases, information (in

relevant format) is sent to appropriate authorities.
HIC.4. STANDARD

The organisation takes actions to

prevent and control Healthcare
Associated Infections (HAI) in
patients.
HIC.4. OBJECTIVE ELEMENTS
a) The organisation takes action to prevent urinary tract
infections.
b) The organisation takes action to prevent respiratory
tract infections.
c) The organisation takes action to prevent intra-
vascular device infections.
d) The organisation takes action to prevent surgical site
infections.
HIC.5. STANDARD

The organisation provides adequate

and appropriate resources for
prevention and control of Healthcare
Associated Infections (HAI).
HIC.5. OBJECTIVE ELEMENTS…
a) Adequate and appropriate personal protective
equipment, soaps, and disinfectants are available and
used correctly.

b) Adequate and appropriate facilities for hand hygiene

in all patient-care areas are accessible to health care
providers.
HIC.5. OBJECTIVE ELEMENTS
c) Isolation / barrier nursing facilities are available.

d) Appropriate pre and post-exposure prophylaxis is

provided to all staff members concerned.
HIC.6. STANDARD

The organisation identifies and takes

appropriate action to control
outbreaks of infections.
HIC.6. OBJECTIVE ELEMENTS

a) Organisation has a documented procedure for identifying

an outbreak.
b) Organisation has a documented procedure for handling
such outbreaks.
c) This procedure is implemented during outbreaks.
d) After the outbreak is over appropriate corrective actions are
taken to prevent recurrence.
HIC.7. STANDARD

There are documented policies and

procedures for sterilisation activities
in the organisation.
HIC.7. OBJECTIVE ELEMENTS…
a) The organisation provides adequate space and
appropriate zoning for sterilisation activities.
b) Documented procedure guides the cleaning, packing,
disinfection and/or sterilization, storing and issue of
items.
c) Reprocessing of instruments and equipment is
covered.
HIC.7. OBJECTIVE ELEMENTS

d) Regular validation tests for sterilisation are carried

out and documented.

e) There is an established recall procedure when

breakdown in the sterilisation system is identified.
HIC.8. STANDARD

Biomedical waste (BMW) is handled

in an appropriate and safe manner.
HIC.8. OBJECTIVE ELEMENTS…

a) The organisation adheres to statutory provisions

with regard to biomedical waste.
b) Proper segregation and collection of biomedical
waste from all patient-care areas of the hospital is
implemented and monitored.
c) The organisation ensures that biomedical waste is
stored and transported to the site of treatment and
disposal in proper covered vehicles within
stipulated time limits in a secure manner.
HIC.8. OBJECTIVE ELEMENTS
d) Biomedical waste treatment facility is managed as per
statutory provisions (if in-house) or outsourced to
authorised contractor(s).
e) Appropriate personal protective measures are used
by all categories of staff handling biomedical waste.
HIC.9. STANDARD

The infection control programme is

supported by the management and
includes training of staff.
HIC.9. OBJECTIVE ELEMENTS

a) The management makes available resources required for

the infection control programme.
b) The organisation earmarks adequate funds from its annual
budget in this regard.
c) The organisation conducts induction training for all staff.
d) The organisation conducts appropriate “in-service”
training sessions for all staff at least once in a year.
HAND HYGIENE
Use Alcohol Rub or Soap and Water
HAND HYGIENE TECHNIQUE WITH SOAP
AND WATER
HAND HYGIENE TECHNIQUE WITH ALCOHOL
RUB
 COLOR CODING FOR BMW
Yellow Bag Red Bag Blue Bag Black Bag White

Anatomical Waste Soiled Waste Plastic Waste  Unbroken Glass bottle Puncture proof , tamper resistant
Tissues Solid Waste I/V sets & tubings. 100 ml or more than 100 container
Organs Blood & body fluid stained catheters ml (in a separate bag for Needles
Body Parts dressings, swabs, cotton etc. syringes easy disposal) Scalpels
Soiled Plaster casts Vacutainers (without  Cytotoxic drugs (To be Lancets
Lab Cultures needles) discarded in separate bin. Blades
Urine Bags The bin needs to be labeled Broken ampoules
Blood bags and tubings with the cytotoxic sticker). Glass pieces and small vials <100 ml in
which are highly  Discarded Medicines the puncture proof container)
contaminated Syringes with needles coming in contact
with body fluids
Needle Stick Injury (NSI)
After Exposure What Should do ?

FIRST AID •Wash off with soap and water

•Let blood flow
•Apply alcohol solution

REPORTING Triage Doctor on Duty ,ICN

Nursing Supervisor
Needle Stick Reporting Form
TESTING TITERS Of the victim

RESULT If positive – take treatment and

prophylaxis as per doctors order If
negative inform the patient
SECTION II:
MANAGEMENT CENTERED STANDARDS
CONTINUOUS QUALITY IMPROVEMENT
CQI.1. STANDARD

There is a structured quality improvement

and continuous monitoring programme in
the organisation.
CQI.1. OBJECTIVE ELEMENTS…
a) The quality improvement programme is
developed, implemented and maintained by a
multi-disciplinary committee.
b) The quality improvement programme is
documented.
c) There is a designated individual for
coordinating and implementing the quality-
improvement programme.
CQI.1. OBJECTIVE ELEMENTS…
d) The quality improvement programme is
comprehensive and covers all the major
elements related to quality assurance and
supports innovation.

e) The designated programme is communicated

and coordinated amongst all the staff of the
organisation through appropriate training
mechanism.
CQI.1. OBJECTIVE ELEMENTS…
f) The quality improvement programme
identifies opportunities for improvement
based on review at pre-defined intervals.

g) The quality improvement programme is a

continuous process and updated at least once
in a year.
CQI.1. OBJECTIVE ELEMENTS

h) Audits are conducted at regular intervals as a

means of continuous monitoring.

i) There is an established process in the

organisation to monitor and improve quality
of nursing and complete patient care.
CQI.2. STANDARD

There is a structured patient-safety

programme in the organisation.
CQI.2. OBJECTIVE ELEMENTS…

a) The patient-safety programme is developed,

implemented and maintained by a multi-
disciplinary committee.

b) The patient-safety programme is documented.

CQI.2. OBJECTIVE ELEMENTS…
c) The patient-safety programme is
comprehensive and covers all the major
elements related to patient safety and risk
management.

d) The scope of the programme is defined to

include adverse events ranging from “no
harm” to “sentinel events”.
CQI.2. OBJECTIVE ELEMENTS…
e) There is a designated individual for
coordinating and implementing the patient-
safety programme.

f) The designated programme is communicated

and coordinated amongst all the staff of the
organisation through appropriate training
mechanism.
CQI.2. OBJECTIVE ELEMENTS…
g) The patient-safety programme identifies
opportunities for improvement based on
review at pre-defined intervals.

h) The patient-safety programme is a continuous

process and updated at least once in a year.
CQI.2. OBJECTIVE ELEMENTS
i) The organisation adapts and implements
national/international patient safety
goals/solutions.

j) The organisation uses at least two identifiers

to identify patients across the organisation.
CQI.3. STANDARD

The organisation identifies key indicators

to monitor the clinical structures,
processes and outcomes, which are used
as tools for continual improvement.
CQI.3. OBJECTIVE ELEMENTS…
a) Monitoring includes appropriate patient assessment.
 Time for initial assessment of indoor and emergency

patients.
 Percentage of cases (in-patients) wherein care plan with

desired outcomes is documented and counter-signed by the

clinician.
 Percentage of cases (in-patients) wherein screening for

nutritional needs has been done.

 Percentage of cases (in-patients) wherein the nursing care

plan is documented.
CQI.3. OBJECTIVE ELEMENTS…
b) Monitoring includes safety and quality- control
programmes of all the diagnostic services.
 Number of reporting errors/1000 investigations.
 Percentage of re-dos.
 Percentage of reports co-relating with clinical
diagnosis.
 Percentage of adherence to safety precautions by
employees working in diagnostics.
CQI.3. OBJECTIVE ELEMENTS…
c) Monitoring includes medication management.
 Incidence of medication errors.
 Percentage of admissions with adverse drug reaction
(s).
 Percentage of medication charts with error prone
abbreviations.
 Percentage of patients receiving high-risk
medications developing adverse drug event.
CQI.3. OBJECTIVE ELEMENTS…

e) Monitoring includes use of anaesthesia.

Percentage of modification of anaesthesia
plan.
Percentage of unplanned ventilation following
anaesthesia.
Percentage of adverse anaesthesia events.
Anaesthesia related mortality rate.
CQI.3. OBJECTIVE ELEMENTS…
e) Monitoring includes surgical services.
 Percentage of unplanned return to OT.

 Percentage of re-scheduling of surgeries.

 Percentage of cases where the organization's

procedure to prevent adverse events like wrong site,

wrong patient and wrong surgery have been adhered
to.
 Percentage of cases who received appropriate

prophylactic antibiotics within the specified time

frame.
CQI.3. OBJECTIVE ELEMENTS…
f) Monitoring includes use of blood and blood
products.
 Percentage of transfusion reactions.
 Percentage of wastage of blood and blood
products.
 Percentage of blood component usage.
 Turnaround time for issue of blood and
blood components.
CQI.3. OBJECTIVE ELEMENTS…
g) Monitoring includes infection control
activities.
Urinary tract infection rate.
Pneumonia rate.
Bloodstream infection rate.
Surgical site infection rate.
CQI.3. OBJECTIVE ELEMENTS…
h) Monitoring includes review of mortality and
morbidity indicators.
Mortality rate.
Return to ICU within 48 hours.
Return to the emergency department within
72 hours with similar presenting complaints.
Re-intubation rate.
CQI.3. OBJECTIVE ELEMENTS…
i) Monitoring includes clinical research.
 Percentage of research activities approved by Ethics
Committee.
 Percentage of patients withdrawing from the study.
 Percentage of protocol violations/deviations
reported.
 Percentage of serious adverse events (which have
occurred in the organisation) reported to the ethics
committee within the defined timeframe.
CQI.3. OBJECTIVE ELEMENTS

j) Monitoring includes data collection to support

further improvements.

k) Monitoring includes data collection to support

evaluation of these improvements.
CQI.4. STANDARD

The organisation identifies key indicators to

monitor the managerial structures, processes
and outcomes which are used as tools for
continual improvement
CQI.4. OBJECTIVE ELEMENTS…
a) Monitoring includes procurement of medication
essential to meet patient needs.
 Percentage of drugs and consumables procured by
local purchase.
 Percentage of stock outs including emergency drugs.
 Percentage of consumables rejected before
preparation of Goods Receipt Note.
 Percentage of variations from the procurement
process.
CQI.4. OBJECTIVE ELEMENTS…
b) Monitoring includes risk management.
Number of variations observed in mock drills.
Incidence of falls.
Incidence of bed sores after admission.
Percentage of employees provided pre-
exposure prophylaxis.
CQI.4. OBJECTIVE ELEMENTS…
c) Monitoring includes utilisation of space,
manpower and equipment.
Bed occupancy rate and average length of
stay.
OT and ICU utilization rate.
Critical equipment down time.
Nurse-patient ratio for ICUs and wards.
CQI.4. OBJECTIVE ELEMENTS…
d) Monitoring includes patient satisfaction which
also incorporates waiting time for services.
Out patient satisfaction index.
In patient satisfaction index.
Waiting time for services including
diagnostics and out-patient consultation.
Time taken for discharge.
CQI.4. OBJECTIVE ELEMENTS…
e) Monitoring includes employee satisfaction.
Employee satisfaction index.
Employee attrition rate.
Employee absenteeism rate.
Percentage of employees who are aware of
employee rights, responsibilities and welfare
schemes.
CQI.4. OBJECTIVE ELEMENTS…
f) Monitoring includes adverse events and near
misses.
Number of sentinel events reported,
collected and analysed within the defined
timeframe.
Percentage of near misses.
Incidence of blood body fluid exposures.
Incidence of needle stick injuries.
CQI.4. OBJECTIVE ELEMENTS…
g) Monitoring includes availability and content
of medical records.
Percentage of medical records not having
discharge summary.
Percentage of medical records not having
codification as per International Classification
of Diseases (ICD).
Percentage of medical records having
incomplete and/or improper consent.
Percentage of missing records.
CQI.4. OBJECTIVE ELEMENTS

h) Monitoring includes data collection to support

further improvements.

i) Monitoring includes data collection to support

evaluation of these improvements.
CQI.5. STANDARD

The quality improvement programme

is supported by the management.
CQI.5. OBJECTIVE ELEMENTS…
a) The management makes available adequate
resources required for quality improvement
programme.
b) Organisation earmarks adequate funds from
its annual budget in this regard.
c) The management identifies organisational
performance improvement targets.
CQI.5. OBJECTIVE ELEMENTS…

d) The management supports and implements

use of appropriate quality improvement,
statistical and management tools in its quality
improvement programme.
CQI.6. STANDARD

There is an established system for clinical

audit.
CQI.6. OBJECTIVE ELEMENTS…
a) Medical and nursing staff participates in this
system.
b) The parameters to be audited are defined by
the organisation.
c) Patient and staff anonymity is maintained.
d) All audits are documented.
e) Remedial measures are implemented.
CQI.7. STANDARD

Incidents, complaints and feedback are

collected and analysed to ensure
continual quality improvement.
CQI.7. OBJECTIVE ELEMENTS…
a) The organisation has an incident reporting
system.
b) The organisation has a process to collect
feedback and receive complaints.
c) The organisation has established processes for
analysis of incidents, feedbacks and
complaints.
 CQI.7. OBJECTIVE ELEMENTS

d) Corrective and preventive actions are taken

based on the findings of such analysis.

e) Feedback about care and service is

communicated to staff.
CQI.8. STANDARD

Sentinel events are intensively analysed.

CQI.8. OBJECTIVE ELEMENTS
a) The organisation has defined sentinel events.
b) The organisation has established processes for
intense analysis of such events.
c) Sentinel events are intensively analysed when they
occur.
d) Corrective and preventive actions are taken based
on the findings of such analysis.
RESPONSIBILITIES OF MANAGEMENT
(ROM)
Chapter 7: Responsibility of
Management
About the chapter
6 Standards
38 Objective Elements
Key Departments involved Key Personnel Involved

•Administration • Head of the hospital

•All clinical departments • All administrative staff

•All non clinical departments •All HODs - Clinical Departments

•All HODs - Non Clinical departments.

280
ROM.1. STANDARD

The responsibilities of those responsible for

governance are defined.
ROM.1. OBJECTIVE ELEMENTS…
a) Those responsible for governance lay down
the organisation’s vision, mission and values.
b) Those responsible for governance approve the
strategic and operational plans and
organisation’s budget.
c) Those responsible for governance monitor and
measure the performance of the organisation
against the stated mission.
ROM.1. OBJECTIVE ELEMENTS…
d) Those responsible for governance establish the
organisation’s organogram.
e) Those responsible for governance appoint the
senior leaders in the organisation.
f) Those responsible for governance support
safety initiatives and quality-improvement
plans.
ROM.1. OBJECTIVE ELEMENTS
g) Those responsible for governance support
research activities.
h) Those responsible for governance address the
organisation’s social responsibility.
i) Those responsible for governance inform the
public of the quality and performance of
services.
ROM.2. STANDARD

The organisation complies with the laid-

down and applicable legislations and
regulations.
ROM.2. OBJECTIVE ELEMENTS…

a) The management is conversant with the laws

and regulations and knows their applicability
to the organisation.

b) The management ensures implementation of

these requirements.
ROM.2. OBJECTIVE ELEMENTS

d) Management regularly updates any

amendments in the prevailing laws of the
land.

e) There is a mechanism to regularly update

licenses/ registrations/certifications.
ROM.3. STANDARD

The services provided by each department are

documented.
ROM.3. OBJECTIVE ELEMENTS
a) Scope of services of each department is
defined.
b) Administrative policies and procedures for
each department are maintained.
c) Each organisational programme, service, site
or department has effective leadership.
d) Departmental leaders are involved in quality
improvement.
ROM.4. STANDARD

The organisation is managed by the

leaders in an ethical manner.
ROM.4. OBJECTIVE ELEMENTS…
a) The leaders make public the vision, mission
and values of the organisation.

b) The leaders establish the organisation’s

ethical management.

c) The organisation discloses its ownership.

ROM.4. OBJECTIVE ELEMENTS
d) The organisation honestly portrays the
services which it can and cannot provide.
e) The organisation honestly portrays its
affiliations and accreditations.
f) The organisation accurately bills for its
services based upon a standard billing tariff.
ROM.5. STANDARD

The organisation displays professionalism in

management of affairs.
ROM.5. OBJECTIVE ELEMENTS…
a) The person heading the organisation has
requisite and appropriate administrative
qualifications.

b) The person heading the organisation has

requisite and appropriate administrative
experience.
ROM.5. OBJECTIVE ELEMENTS…

c) The organization prepares the strategic and

operational plans including long term and
short term goals commensurate to the
organization's vision, mission and values in
consultation with the various stake holders.
ROM.5. OBJECTIVE ELEMENTS…
d) The organisation coordinates the functioning
with departments and external agencies, and
monitors the progress in achieving the
defined goals and objectives.

e) The organisation plans and budgets for its

activities annually.
ROM.5. OBJECTIVE ELEMENTS…
f) The performance of the senior leaders is
reviewed for their effectiveness.

g) The functioning of committees is reviewed for

their effectiveness.

h) The organisation documents employee rights

and responsibilities.
ROM.5. OBJECTIVE ELEMENTS…

i) The organisation documents the service

standards.
j) The organisation has a formal documented
agreement for all outsourced services.
k) The organisation monitors the quality of the
outsourced services.
ROM.6. STANDARD

Management ensures that patient-safety aspects

and risk-management issues are an integral part
of patient care and hospital management.
ROM.6. OBJECTIVE ELEMENTS…

a) Management ensures proactive risk

management across the organisation.

b) Management provides resources for proactive

risk assessment and risk reduction activities.
ROM.6. OBJECTIVE ELEMENTS
c) Management ensures implementation of
systems for internal and external reporting of
system and process failures.

d) Management ensures that appropriate

corrective and preventive action is taken to
address safety-related incidents.
NABH – CHAPTER 8
FACILITY MANAGEMENT & SAFETY
(FMS)
FMS.1. STANDARD

The organisation has a system in place

to provide a safe and secure
environment.
FMS.1. OBJECTIVE ELEMENTS…
a) Safety committee coordinates development,
implementation, and monitoring of the safety
plan and policies.
b) Patient safety devices are installed across the
organisation and inspected periodically.
c) The organisation is a non-smoking area.
FMS.1. OBJECTIVE ELEMENTS
d) Facility inspection rounds to ensure safety are
conducted at least twice in a year in patient-
care areas and at least once in a year in non-
patient care areas.
e) Inspection reports are documented and
corrective and preventive measures are
undertaken.
f) There is a safety education programme for
staff.
FMS.2. STANDARD

The organization's environment and facilities

operate to ensure safety of patients, their
families, staff and visitors.
FMS.2. OBJECTIVE ELEMENTS…

a) Facilities are appropriate to the scope of

services of the organisation.

b) Up-to-date drawings are maintained which

detail the site layout, floor plans and fire
escape-routes.
FMS.2. OBJECTIVE ELEMENTS…
c) There is internal and external sign postings in
the organisation in a language understood by
patient, families and community.
d) The provision of space shall be in accordance
with the available literature on good practices
(Indian or International Standards) and
directives from government agencies.
FMS.2. OBJECTIVE ELEMENTS…

e) Potable water and electricity are available

round the clock.

f) Alternate sources for electricity and water are

provided as backup for any failure / shortage.
FMS.2. OBJECTIVE ELEMENTS…
g) The organisation regularly tests these
alternate sources.
h) There are designated individuals responsible
for the maintenance of all the facilities.
i) There is a documented operational and
maintenance (preventive and breakdown)
plan.
FMS.2. OBJECTIVE ELEMENTS

j) Maintenance staff is contactable round the

clock for emergency repairs.

k) Response times are monitored from reporting

to inspection and implementation of
corrective actions.
FMS.3. STANDARD

The organisation has a programme for

engineering support services.
FMS.3. OBJECTIVE ELEMENTS…
a) The organisation plans for equipment in
accordance with its services and strategic
plan.
b) Equipment are selected, rented, updated or
upgraded by a collaborative process.
c) Equipment are inventoried and proper logs
are maintained as required.
FMS.3. OBJECTIVE ELEMENTS…
d) Qualified and trained personnel operate and
maintain equipment and utility systems.
e) There is a documented operational and
maintenance (preventive and breakdown)
plan.
f) There is a maintenance plan for water
management.
g) There is a maintenance plan for electrical
systems.
FMS.3. OBJECTIVE ELEMENTS

h) There is a maintenance plan for heating, ventilation

and air-conditioning.

i) There is a documented procedure for equipment

replacement and disposal.
FMS.4. STANDARD

The organisation has a programme for bio-

medical equipment management.
FMS.4. OBJECTIVE ELEMENTS…
a) The organisation plans for equipment in
accordance with its services and strategic
plan.
b) Equipment are selected, rented, updated or
upgraded by a collaborative process.
c) Equipment are inventoried and proper logs
are maintained as required.
FMS.4. OBJECTIVE ELEMENTS
d) Qualified and trained personnel operate and
maintain the medical equipment.
e) Equipment are periodically inspected and
calibrated for their proper functioning.
f) There is a documented operational and
maintenance (preventive and breakdown)
plan.
g) There is a documented procedure for
equipment replacement and disposal.
FMS.5. STANDARD

The organisation has a programme for medical

gases, vacuum and compressed air.
FMS.5. OBJECTIVE ELEMENTS…
a) Documented procedures govern
procurement, handling, storage, distribution,
usage and replenishment of medical gases.
b) Medical gases are handled, stored, distributed
and used in a safe manner.
c) The procedures for medical gases address the
safety issues at all levels.
FMS.5. OBJECTIVE ELEMENTS
d) Alternate sources for medical gases, vacuum
and compressed air are provided for, in case of
failure.
e) The organisation regularly tests these
alternate sources.
f) There is an operational and maintenance plan
for piped medical gas, compressed air and
vacuum installation.
FMS.6. STANDARD

The organisation has plans for fire and non-fire

emergencies within the facilities.
FMS.6. OBJECTIVE ELEMENTS...
a) The organisation has plans and provisions for
early detection, abatement and containment
of fire and non-fire emergencies.
b) The organisation has a documented safe exit
plan in case of fire and non-fire emergencies.
c) Staff is trained for its role in case of such
emergencies.
FMS.6. OBJECTIVE ELEMENTS

d) Mock drills are held at least twice a year.

e) There is a maintenance plan for fire-related

equipment
FMS.7. STANDARD

The organisation plans for handling community

emergencies, epidemics and other disasters.
FMS.7. OBJECTIVE ELEMENTS…
a) The organisation identifies potential
emergencies.
b) The organisation has a documented disaster
management plan.
c) Provision is made for availability of medical
supplies, equipment and materials during
such emergencies.
FMS.7. OBJECTIVE ELEMENTS

d) Staff is trained in the hospital’s disaster

management plan.

e) The plan is tested at least twice a year.

FMS.8. STANDARD

The organisation has a plan for

management of hazardous materials.
FMS.8. OBJECTIVE ELEMENTS…
a) Hazardous materials are identified within the
organisation.

b) The organisation implements processes for

sorting, labelling, handling, storage,
transporting and disposal of hazardous
material.
FMS.8. OBJECTIVE ELEMENTS
c) Requisite regulatory requirements are met in
respect of radioactive materials.

d) There is a plan for managing spills of

hazardous materials.

e) Staff is educated and trained for handling such

materials.
HUMAN RESOURCE MANAGEMENT
(HRM)
HRM.1. STANDARD

The organization has a documented system

of human resource planning.
HRM.1. OBJECTIVE ELEMENTS…
a) Human resource planning supports the
organisation’s current and future ability to
meet the care, treatment and service needs
of the patient.
b) The organization maintains an adequate
number and mix of staff to meet the care,
treatment and service needs of the patient.
HRM.1. OBJECTIVE ELEMENTS
c) The required job specifications and job
description are well defined for each category
of staff.

d) The organization verifies the antecedents of

the potential employee with regards to
criminal/negligence background.
HRM.2. STANDARD

The organisation has a documented

procedure for recruiting staff and orienting
them to the organisation’s environment.
HRM.2. OBJECTIVE ELEMENTS…
a) There is a documented procedure for
recruitment.
b) Recruitment is based on pre-defined criteria.
c) Every staff member entering the organisation
is provided induction training.
d) The induction training includes orientation to
the organisation’s vision, mission and values.
HRM.2. OBJECTIVE ELEMENTS…
e) The induction training includes awareness on
employee rights and responsibilities.
f) The induction training includes awareness on
patient’s rights and responsibilities.
g) The induction training includes orientation to the
service standards of the organisation.
HRM.2. OBJECTIVE ELEMENTS

h) Every staff member is made aware of organisation

wide policies and procedures as well as relevant
department / unit / service / programme’s policies
and procedures.
HRM.3. STANDARD

There is an ongoing programme for

professional training and development of
the staff.
HRM.3. OBJECTIVE ELEMENTS…

a) A documented training and development

policy exists for the staff.
b) The organisation maintains the training record
c) Training also occurs when job responsibilities
change/ new equipment is introduced.
HRM.3. OBJECTIVE ELEMENTS

d) Feedback mechanisms for assessment of

training and development programme exist
and the feedback is used to improve the
training programme.
HRM.4. STANDARD

Staff is adequately trained on various safety

related aspects.
HRM.4. OBJECTIVE ELEMENTS
a) Staff is trained on the risks within the
organisation’s environment.
b) Staff members can demonstrate and take
actions to report, eliminate / minimise risks.
c) Staff members are made aware of procedures
to follow in the event of an incident.
d) Staff is trained on occupational safety aspects.
HRM.5. STANDARD

An appraisal system for evaluating the

performance of an employee exists as an integral
part of the human resource management
process.
HRM.5. OBJECTIVE ELEMENTS…

a) A documented performance appraisal system

exists in the organization.

b) The employees are made aware of the system

of appraisal at the time of induction.
HRM.5. OBJECTIVE ELEMENTS

c) Performance is evaluated based on the pre-

determined criteria.
d) The appraisal system is used as a tool for further
development.
e) Performance appraisal is carried out at pre- defined
intervals and is documented.
HRM.6. STANDARD

The organization has documented disciplinary

and grievance-handling policies and procedures.
HRM.6. OBJECTIVE ELEMENTS…
a) Documented policies and procedures exist.

b) The policies and procedures are known to all

categories of staff of the organisation.

c) The disciplinary policy and procedure is based on

the principles of natural justice.
HRM.6. OBJECTIVE ELEMENTS
d) The disciplinary procedure is in consonance
with the prevailing laws.
e) There is a provision for appeals in all
disciplinary cases.
f) The redress procedure addresses the
grievance.
g) Actions are taken to redress the grievance.
HRM.7. STANDARD

The organization addresses the health needs of

the employees.
HRM.7. OBJECTIVE ELEMENTS…

a) A pre-employment medical examination is

conducted on all the employees.

b) Health problems of the employees are taken care

of in accordance with the organisation’s policy.
HRM.7. OBJECTIVE ELEMENTS

c) Regular health checks of staff dealing with direct

patient care are done at-least once a year and the
findings/results are documented.

d) Occupational health hazards are adequately

addressed.
HRM.8. STANDARD

There is documented personal information for

each staff member.
HRM.8. OBJECTIVE ELEMENTS…
a) Personal files are maintained in respect of all staff.
b) The personal files contain personal information
regarding the staff’s qualification, disciplinary
background and health status.
HRM.8. OBJECTIVE ELEMENTS

c) All records of in-service training and

education are contained in the personal files.

d) Personal files contain results of all

evaluations.
HRM.9. STANDARD

There is a process for credentialing and

privileging of medical professionals,
permitted to provide patient care without
supervision.
HRM.9. OBJECTIVE ELEMENTS…
a) Medical professionals permitted by law, regulation
and the organisation to provide patient care
without supervision are identified.

b) The education, registration, training and experience

of the identified medical professionals is
documented and updated periodically.
HRM.9. OBJECTIVE ELEMENTS…
c) All such information pertaining to the medical
professionals is appropriately verified when
possible.

d) Medical professionals are granted privileges to

admit and care for patients in consonance with
their qualification, training, experience and
registration.
HRM.9. OBJECTIVE ELEMENTS
e) The requisite services to be provided by the
medical professionals are known to them as well as
the various departments / units of the
organisation.

f) Medical professionals admit and care for patients

as per their privileging.
HRM.10. STANDARD

There is a process for credentialing and

privileging of nursing professionals, permitted to
provide patient care without supervision.
HRM.10. OBJECTIVE ELEMENTS…
a) Nursing staff permitted by law, regulation and the
organisation to provide patient care without
supervision are identified.

b) The education, registration, training and experience

of nursing staff is documented and updated
periodically.
HRM.10. OBJECTIVE ELEMENTS…
c) All such information pertaining to the nursing
staff is appropriately verified when possible.

d) Nursing staff are granted privileges in

consonance with their qualification, training,
experience and registration.
NABH – CHAPTER 10
INFORMATION MANAGEMENT SYSTEM
(IMS)
IMS.1. STANDARD
Documented policies and procedures exist to
meet the information needs of the care
providers, management of the organization as
well as other agencies that require data and
information from the organization.
IMS.1. OBJECTIVE ELEMENTS…
a) The information needs of the organization are
identified and are appropriate to the scope of the
services being provided by the organization.
b) Documented policies and procedures to meet the
information needs exist.
c) These policies and procedures are in compliance with
the prevailing laws and regulations.
IMS.1. OBJECTIVE ELEMENTS
d) All information management and technology
acquisitions are in accordance with the
documented policies and procedures.

e) The organization contributes to external

databases in accordance with the law and
regulations.
IMS.2. STANDARD

The organization has processes in place for

effective management of data.
IMS.2. OBJECTIVE ELEMENTS…

a) Formats for data collection are standardized.

b) Necessary resources are available for
analyzing data.
c) Documented procedures are laid down for
timely and accurate dissemination of data.
IMS.2. OBJECTIVE ELEMENTS

d) Documented procedures exist for storing and

retrieving data.

e) Appropriate clinical and managerial staff

participates in selecting, integrating and using data.
IMS.3. STANDARD

The organization has a complete and accurate

medical record for every patient.
IMS.3. OBJECTIVE ELEMENTS…
a) Every medical record has a unique identifier.
b) Organization policy identifies those authorized
to make entries in medical record.
c) Entry in the medical record is named, signed,
dated and timed.
IMS.3. OBJECTIVE ELEMENTS
d) The author of the entry can be identified.
e) The contents of medical record are identified
and documented.
f) The record provides a complete, up-to-date
and chronological account of patient care.
g) Provision is made for 24-hour availability of
the patient’s record to healthcare providers to
ensure continuity of care.
IMS.4. STANDARD

The medical record reflects continuity of care.

IMS.4. OBJECTIVE ELEMENTS…
a) The medical record contains information
regarding reasons for admission, diagnosis
and plan of care.
b) The medical record contains the results of
tests carried out and the care provided.
c) Operative and other procedures performed
are incorporated in the medical record.
IMS.4. OBJECTIVE ELEMENTS…
d) 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.

e) The medical record contains a copy of the

discharge summary duly signed by
appropriate and qualified personnel.
IMS.4. OBJECTIVE ELEMENTS
f) In case of death, the medical record contains
a copy of the cause of death certificate.
g) Whenever a clinical autopsy is carried out, the
medical record contains a copy of the report
of the same.
h) Care providers have access to current and
past medical record.
IMS.5. STANDARD

Documented policies and procedures are in place

for maintaining confidentiality, integrity and
security of records, data and information.
IMS.5. OBJECTIVE ELEMENTS…
a) Documented policies and procedures exist for
maintaining confidentiality, security and
integrity of records, data and information.
b) Documented policies and procedures are in
consonance with the applicable laws.
c) The policies and procedure(s) incorporate
safeguarding of data/record against loss,
destruction and tampering.
IMS.5. OBJECTIVE ELEMENTS…
d) The organization has an effective process of
monitoring compliance of the laid down policy and
procedure.

e) The organisation uses developments in appropriate

technology for improving confidentiality, integrity and
security.
IMS.5. OBJECTIVE ELEMENTS
f) Privileged health information is used for the
purposes identified or as required by law and
not disclosed without the patient’s
authorization.
g) 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.
IMS.6. STANDARD

Documented policies and procedures exist for

retention time of records, data and information.
IMS.6. OBJECTIVE ELEMENTS…
a) Documented policies and procedures are in
place on retaining the patient’s clinical
records, data and information.

b) The policies and procedures are in

consonance with the local and national laws
and regulations.
IMS.6. OBJECTIVE ELEMENTS
c) The retention process provides expected
confidentiality and security.

d) The destruction of medical records, data and

information is in accordance with the laid- down
policy.
IMS.7. STANDARD

The organization regularly carries out review of

medical records.
IMS.7. OBJECTIVE ELEMENTS…

a) The medical records are reviewed periodically.

b) The review uses a representative sample based on
statistical principles.
c) The review is conducted by identified care
providers.
d) The review focuses on the timeliness, legibility and
completeness of the medical records.
IMS.7. OBJECTIVE ELEMENTS

e) The review process includes records of both

active and discharged patients.
f) The review points out and documents any
deficiencies in records.
g) Appropriate corrective and preventive
measures are undertaken within a defined
period of time and are documented.