NABH STANDARDS-new edition
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Description
± ± ± ± ± ± ± ± ±
Scientific literature JCI Standards UK Healthcare Quality Standards Thailand Standards AHA Draft Standards JCI Survey compliance data Research Findings Individual input from field experts and key stakeholders ISO 9001-2000 1
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Organized around important functions Focus on patient and staff safety Set standards that all organizations must pass To be revised periodically and raise the ³bar´ Achieve International recognition 2
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10 Chapters 100 Standards 514/50Ö Objective Elements
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A standard is a that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care Objective element is a measurable component of a standard Acceptable compliance with objective elements determines the overall compliance with a standard
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! " Access, Assessment and Continuity of Care #$ %&
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Care of Patients # $ #!%$ Management of Medications # $ Patients Rights and Education #- $ #.%$
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Hospital Infection Control #$#./$
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1 2 1 STD
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Continuous Quality Improvement #3$#./$
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Responsibilities of Management #- $#.&$
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Facility Management & Safety #4$ #./$
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Human Resource Management #-$
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Information Management Systems #$
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Introduction NABH standards for hospitals have been prepared by Technical Committee of NABH and contain complete set of standards for evaluation of hospitals for grant of accreditation. The standards provide framework for quality assurance and quality improvement for hospitals NABH Standards contains 10 chapters,100 standards and 50Ö objective elements.
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1) Access ,Assessment and continuity of care (AAC) 2) Care of Patients(COP). 3) Management of Medication (MOM). 4) Patient Right and Education (PRE). 5) Hospital Infection Control (HIC). 6) Continuous Quality Improvement(CQI) 7) Responsibility of Management (ROM). 8) Facility Management and Safety (FMS). 9) Human Resource Management (HRM) 10) Information Management System (IMS). 9
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Chapter 1. ACCESS,ASSESSMENT AND CONTINIUITY OF CARE (AAC)
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AAC.1 "
1 2
5
a) The services being provided are clearly defined and are in consonance with the needs of the community. b) The defined services are prominently displayed. c) The staff is oriented to these services 11
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6/ " 1 2 7
1 a) Standardized policies and procedures are used for registering and admitting patients b) The policies and procedures address out- patients, in-patients and emergency patients 12
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Cont« c) Patients are accepted only if the organization can provide the required service d) The policies and procedures also address managing patients during non availability of beds e) The staff is aware of these processes 1Ö
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6+ "
7 1 2 a) Policies guide the transfer of unstable patients to another facility in an appropriate manner b) Policies guide the transfer of stable patients to another facility 14
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Cont« c) Procedures identify staff responsible during transfer d) The organization gives a summary of patient¶s condition and the treatment given
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6* 1 8 5 9 a) The patients and/or family members are explained about the proposed care b) The patients and/or family members are explained about the expected results 1
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Cont« c) The patients and/or family members are explained about the possible complications d) The patients and/or family members are explained about the expected costs.
1ý
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6& 5
1 2 1
a) The organization defines the content of the assessments for the out±patients, inpatients and emergency patients. b) The organization determines who can perform the assessments. 1
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cont« c) The organization defines the time frame within which the initial assessment is completed. d) The initial assessment for in-patients is documented within 24 hours or earlier as per the patient¶s condition or hospital policy. e) Initial assessment includes screening for nutritional and psychosocial needs.
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Cont« f) The initial assessment results in a documented plan of care which is monitored. g) The plan of care also includes preventive aspects of the care
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6, 5
1 2 1 1 6 a) All patients are reassessed at appropriate intervals. b) Staff involved in direct clinical care document reassessments. c) Patients are reassessed to determine their response to treatment and to plan further treatment or discharge. |
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6' : 5 ;
a) Scope of the laboratory services are commensurate to the services provided by the organization b) Adequately qualified and trained personnel perform and/or supervise the investigations. 22
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cont.. c) Policies and procedures guide collection, identification, handling, safe transportation and disposal of specimens. d) Laboratory results are available within a defined time frame. e) Critical results are intimated immediately to the concerned personnel. f) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality 2Ö assurance system. |
6( "
5 5 1
a) The laboratory quality assurance programme is documented. b) The programme addresses verification and validation of test methods. c) The programme addresses surveillance of test results. 24
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cont« d) The programme includes periodic calibration and maintenance of all equipments. e) The programme includes the documentation of corrective and preventive actions
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60 "
5 5 1
6 a) The laboratory safety programme is documented. b) This programme is integrated with the organization¶s safety programme.
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cont« c) Written policies and procedures guide the handling and disposal of infectious and hazardous materials. d) Laboratory personnel are appropriately trained in safe practices. e) Laboratory personnel are provided with appropriate safety equipment / devices.
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6%) 11 ; a) Imaging services comply with legal and other requirements. b) Scope of the imaging services are commensurate to the services provided by the organization. c) Adequately qualified and trained personnel perform and/or supervise the | investigations.
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cont« d) Policies and procedures guide identification and safe transportation of patients to imaging services. e) Imaging results are available within a defined time frame. f) Critical results are intimated immediately to the concerned personnel. g) Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system. 29
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6%% " 3 5 1 11 a) The quality assurance programme for imaging services is documented. b) The programme addresses verification and validation of imaging methods c) The programme addresses surveillance of imaging results Ö0 |
cont« d) The programme includes periodic calibration and maintenance of all equipments. e) The programme includes the documentation of corrective and preventive actions
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6%/ " 5 1
a) The radiation safety programme is documented. b) This programme is integrated with the organization¶s safety programme. c) Written policies and procedures guide the handling and disposal of radio-active and hazardous materials. Ö2
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cont« d) Imaging personnel are provided with appropriate radiation safety devices e) Radiation safety devices are periodically tested and documented. f) Imaging personnel are trained in radiation safety measures. g) Imaging signage are prominently displayed in all appropriate locations. h) Policies and procedures guide the safe use of radioactive isotopes for imaging ÖÖ | services.
AAC.1Ö Patient care is continuous and multidisciplinary in nature a) During all phases of care, there is a qualified individual identified as responsible for the patient¶s care. b) Care of patients is coordinated in all care settings within the organization. Ö4
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cont« c) Information about the patient¶s care and response to treatment is shared among medical, nursing and other care providers. d) Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments. e) The patient¶s record (s) is available to the authorized care providers to facilitate the exchange of information. f) Policy and procedures guide the referral of patients to other department / specialty. Ö5
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6%* " 1 2 1 a) The patient¶s discharge process is planned in consultation with the patient and/or family. b) Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases Ö
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cont« c) Policies and procedures are in place for patients leaving against medical advice d) A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)
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6%& 1
1 5 a) Discharge summary is provided to the patients at the time of discharge b) Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient¶s condition at the time of discharge. Ö
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cont« c) Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given d) Discharge summary contains follow up advice, medication and other instructions in an understandable manner.
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cont« e) Discharge summary incorporates instructions about when and how to obtain urgent care f) In case of death the summary of the case also includes the cause of death.Patient records also contain a copy of the discharge /case summary
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Chapter 2. Care of Patients (COP)
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6% 1 6 a) Documented policies and procedures exist for storage of medication b) Medications are stored in a clean, well lit and ventilated environment c) Sound inventory control practices guide storage of the medications Ö
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cont« d) Medications are protected from loss or theft e) Sound alike and look alike medications are stored separately f) There is a method to obtain medication when the pharmacy is closed g) Emergency medications are available all the time h) Emergency medications are replenished in a timely manner when used 4
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6* 1 a) Documented policies and procedures exist for prescription of medications b) The organization determines who can write orders c) Orders are written in a uniform location in the medical records 5
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cont« d) Medication orders are clear, legible, dated, named and signed e) Policy on verbal orders is documented and implemented f) The organization defines a list of high risk medication g) High risk medication orders are verified prior to dispensing
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6* 1 1 a) Documented policies and procedures guide the safe dispensing of medications b) The policies include a procedure for medication recall c) Expiry dates are checked prior to dispensing d) Labeling requirements are documented and implemented by the organization ý |
6& "
a) Medications are administered by those who are permitted by law to do so b) Prepared medication are labeled prior to preparation of a second drug c) Patient is identified prior to administration
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cont« d) Medication is verified from the order prior to administration e) Dosage is verified from the order prior to administration f) Route is verified from the order prior to administration g) Timing is verified from the order prior to administration 9
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cont« h) Medication administration is documented i) Polices and procedures govern patient¶s self administration of medications j) Polices and procedures govern patient¶s medications brought from outside the organization
90
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6' 5
! 1 a) Patient and family are educated about safe and effective use of medication b) Patient and family are educated about food-drug interactions 91
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6( a) Patients are monitored after medication administration and this is documented b) Adverse drug events are defined c) Adverse drug events are reported within a specified time frame 92
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cont« d) Adverse drug events are collected and analysed e) Policies are modified to reduce adverse drug events when unacceptable trends occur
9Ö
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60 1 1 5 a) Documented policies and procedures guide the use of narcotic drugs and psychotropic substances b) These policies are in consonance with local and national regulations 94
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cont« c) A proper record is kept of the usage, administration and disposal of these drugs d) These drugs are handled by appropriate personnel in accordance with policies
95
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6%) 1 1 1 a) Documented policies and procedures guide the usage of chemotherapeutic agents b) Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy9 |
cont« c) Chemotherapy is prepared and administered by qualified personnel d) Chemotherapy drugs are disposed off in accordance with legal requirements
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6%% 1 1 1 6 a) Documented policies and procedures govern usage of radioactive drugs b) These policies and procedures are in consonance with laws and regulations
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cont« c) The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs d) Staff, patients and visitors are educated on safety precautions
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6%/ 1 6 a) Documented policies and procedures govern procurement and usage of implantable prosthesis b) Selection of implantable prosthesis is based on scientific criteria and internationally recognized approvals 100
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cont« c) The batch and serial number of the implantable prosthesis are recorded in the patient¶s medical record and the master logbook
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6%+ 1 1 a) Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases. b) The policies and procedures address the safety issues at all levels 102
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Cont« c) Appropriate records are maintained in accordance with the policies, procedures and legal requirements.
10Ö
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Chapter .2 PATIENT RIGHT AND EDUCATION (PRE)
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- 6% " 1 2 5 1 1
a) Patient and family rights are documented. ± Patients and families are informed of their rights in a format and language that they can understand 105
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cont« c) The organization¶s leaders protect patient¶s rights d) Staff is aware of their responsibility in protecting patients rights e) Violation of patient rights is reviewed and corrective/preventive measures taken
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- 6/6 1
= 5 91 a) Patient and family rights address any special preferences, spiritual and cultural needs b) Patient rights include respect for personal dignity and privacy during examination, procedures and treatment c) Patient rights include protection from physical abuse or neglect
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cont« c) Patient rights include treating patient information as confidential d) Patient rights include refusal of treatment e) Patient rights include informed consent before anesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment
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cont« f) Patient rights include information and consent before any research protocol is initiated g) Patient rights include information on how to voice a complaint h) Patient rights include information on the expected cost of the treatment i) Patient has a right to have an access to his / her clinical records 109
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- 6+ 1 8
> 91
a) General consent for treatment is obtained when the patient enters the organization 110
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cont« b) Patient and/or his family members are informed of the scope of such general consent c) The organization has listed those procedures and treatment where informed consent is required d) Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand e) The policy describes who can give consent when patient is incapable of independents decision making.
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- 6* 1
a) When appropriate, patient and families are educated about the safe and effective use of medication and the potential side effects of the medication b) Patient and families are educated about diet and nutrition 112
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cont« c) Patient and families are educated about immunizations d) Patient and families are educated about their specific disease process, complications and prevention strategies e) Patient and families are educated about preventing infections f) Patients are taught in a language and format that they can understand 11Ö
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- 6&6 1 > a) There is uniform pricing policy in a given setting (out-patient and ward category) b) The tariff list is available to patients c) Patients are educated about the estimated costs of treatment 114
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cont« d. Patients are informed about the estimated costs when there is a change in the patient condition or treatment setting
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Chapter 5 HOSPITAL INFECTION CONTROL (HIC)
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6% " 1 2 7 ! 1 = #$ 1 18 1 9 = 6 11ý
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a) The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections b) The hospital has a multi-disciplinary infection control committee. c) The hospital has an infection control team. d) The hospital has designated and qualified infection control nurse(s) for this activity
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6/ " =7 5 6 a) The manual identifies the various highrisk areas and procedures. b) It outlines methods of surveillance in the identified high-risk areas. 119
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Cont« c) It focuses on adherence to standard precautions at all times. d) Equipment cleaning and sterilisation practices are included. e) An appropriate antibiotic policy is established and implemented. f) Laundry and linen management processes are also included. 120
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Cont« g) Kitchen sanitation and food handling issues are included in the manual h) Engineering controls to prevent infections are included i) Mortuary practices and procedures are included as appropriate to the organization j) The organization defines the periodicity of updating the infection control manual 121
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6+ " 6 a) Surveillance activities are appropriately directed towards the identified high-risk areas. b) Collection of surveillance data is an ongoing process. 122 |
Cont« c) Verification of data is done on regular basis by the infection control team. d) In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities. e) Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends. f) Surveillance activities include monitoring the effectiveness of housekeeping services. 12Ö
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6* " 9 9 #$ 5
6 a) The organization monitors urinary tract infections. b) The organization monitors respiratory tract infections. 124
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Cont« c) The organization monitors intra-vascular device infections. d) The organization monitors surgical site infections. e) Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.
125
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6& ; 1
a) Hand washing facilities in all patient care areas are accessible to health care providers. b) Compliance with proper hand washing is monitored regularly. 12
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Cont« c) Isolation/ barrier nursing facilities are available. d) Adequate gloves, masks, soaps, and disinfectants are available and used correctly.
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6, " 9 9 6 a) Hospital has a documented procedure for handling such outbreaks. b) This procedure is implemented during outbreaks. c) After the outbreak is over appropriate corrective actions are taken to prevent recurrence 12 |
6' "
6 a) There is adequate space available for sterilization activities b) Regular validation tests for sterilisation are carried out and documented. c) There is an established recall procedure when breakdown in the sterilisation 129 system is identified |
6( 5 7 1 ! ? # ?$ 1 7 a) The hospital is authorised by prescribed authority for the management and handling of Bio-medical Waste. b) Proper segregation and collection of Biomedical Waste from all patient care areas of the hospital is implemented and monitored. 1Ö0 |
Cont« c) The organization ensures that Biomedical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner. d) Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorised contractor(s). 1Ö1
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Cont« e) Requisite fees, documents and reports are submitted to competent authorities on stipulated dates. f) Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste
1Ö2
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60 " 1 5 1 1
5
a) Hospital management makes available resources required for the infection control programme b) The hospital regularly earmarks adequate funds from its annual budget in this regard. 1ÖÖ
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Cont« c) It conducts regular pre-induction training for appropriate categories of staff before joining concerned department(s). d) It also conducts regular ³in-service´ training sessions for all concerned categories of staff at least once in a year. e) Appropriate pre and post exposure prophylaxis is provided to all concerned staff members 1Ö4
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Chapter CONTINUOUS QUALITY IMPROVEMENT (CQI)
1Ö5
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36% " ; 5 1 1 1 2 a) The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee. b) The quality improvement programme is documented. 1Ö |
Cont« c) There is a designated individual for coordinating and implementing the quality improvement programme d) The quality improvement programme is comprehensive and covers all the major elements related to quality improvement and risk management.
1Öý
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Cont« e) The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism. f) The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified. 1Ö
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Cont« g) The quality improvement programme is a continuous process and updated at least once in a year.
1Ö9
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36/ " 1 2 9 5 = 7
a) Monitoring includes appropriate patient assessment. b) Monitoring includes diagnostics services¶ safety and quality control programmes. c) Monitoring includes all invasive procedures. 140 |
Cont« d) e) f) g) h) i) j) k)
Monitoring includes adverse drug events. Monitoring includes use of anaesthesia. Monitoring includes use of blood and blood products. Monitoring includes availability and content of medical records. Monitoring includes infection control activities. Monitoring includes clinical research. Monitoring includes data collection to support further improvements Monitoring includes data collection to support evaluation of these improvements 141
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36+ " 1 9 5 1 = which are used
as tools for continual improvement Monitoring includes procurement of medication essential to meet patient needs. Monitoring includes reporting of activities as required by laws and regulations. 142
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Cont« Monitoring includes risk management. Monitoring includes utilisation of space, manpower and equipment. Monitoring includes patient satisfaction which also incorporates waiting time for services. Monitoring includes employee satisfaction. Monitoring includes adverse events and near misses. Monitoring includes data collection to support further study for improvements. Monitoring includes data collection to support evaluation of the improvements. 14Ö
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36* " ; 5 1 5 1 a) Hospital Management makes available adequate resources required for quality improvement programme. b) Hospital earmarks adequate funds from its annual budget in this regard. c) Appropriate statistical and management tools are applied whenever required 144 |
36& " 5
a) Medical staff participates in this system. b) The parameters to be audited are defined by the organisation. staff anonymity is c) Patient and maintained. d) All audits are documented. e) Remedial measures are implemented. 145 |
36, 5 5 a) The organisation has defined sentinel events. b) The organisation has established processes for intense analysis of such events. c) Sentinel events are intensively analysed when they occur. d) Corrective and preventive actions are taken upon findings of such analysis 14
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Chapter ý RESPONSIBILITIES OF MANAGEMENT (ROM)
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- 6% " 1
a) b)
c) d)
Those responsible for governance lay down the organization¶s mission statement Those responsible for governance lay down the strategic and operational plans commensurate to the organization¶s mission in consultation with the various stakeholders Those responsible for governance approve the organization¶s budget and allocate the resources required to meet the organization¶s mission Those responsible for governance monitor and measure the performance of the organization against the stated mission 14
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Cont« e) Those responsible for governance establish the organization¶s organogram. f) Those responsible for the governance appoint the senior leaders in the organization. g) Those responsible for the governance support research activities and quality improvement plans h) The organization complies with the laid down and applicable legislations and regulations d) Those responsible for governance address the organization¶s social responsibility 149
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- 6/ " 5 a) Each organizational program, service, site or department has effective leadership b) Scope of services of each department is defined c) Administrative policies and procedures for each department is maintained d) Departmental leaders are involved in quality improvement 150
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ROM.Ö The organization is managed by the leaders in an ethical manner a) The leaders make public the mission statement of the organization b) The leaders establish the organization¶s ethical management c) The organization discloses its ownership 151
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Cont« d) The organization honestly portrays the services which it can and cannot provide. e) The organization honestly portrays the affiliations and accreditations f) The organization accurately bills for it¶s services based upon a standard billing tariff.
152
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- 6* 5; > 1
a) The designated individual and appropriate qualifications. b) The designated individual and appropriate experience.
has requisite administrative has requisite administrative 15Ö
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- 6& : 5 9 1 1 1 a) The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme. 154
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Cont« b) The scope of the programme is defined to include adverse events ranging from ³no harm´ to ³sentinel events´. c) Management ensures implementation of systems for internal and external reporting of system and process failures. d) Management provides resources for proactive risk assessment and risk reduction activities. 155
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Chapter FACILITY MANAGEMENT AND SAFETY (FMS)
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46% " 1 2 7 7 1 = 7 5 7 ; 5 ; a) The management is conversant with the laws and regulations and knows their applicability to the organization. 15ý
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Cont« b) Management regularly updates any amendments in the prevailing laws of the land. c) The management ensures implementation of these requirements. d) There is a mechanism to regularly update licenses/ registrations/certifications 15
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FMS.2 The organization¶s environment and facilities operate to ensure safety of patients, staff and visitors a) There is a documented operational and maintenance (preventive and breakdown) plan. 159
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Cont« b) Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes. c) There is internal and external sign posting in the organisation in a language understood by patients, families and community d) The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies. e) There are designated individuals responsible for the maintenance of all the facilities. 10
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Cont« f) Maintenance staff is contactable round the clock for emergency repairs. g) Response times are monitored from reporting to inspection and implementation of corrective actions.
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46+ " 1 2 1
; 1 a) The organization plans for equipment in accordance with its services and strategic plan b) Equipment is selected by a collaborative process. c) All equipment is inventoried and proper logs are maintained as required. 12 |
Cont« d) Qualified and trained personnel operate and maintain the equipment. e) Equipment are periodically inspected and calibrated for their proper functioning. f) There is a documented operational and maintenance (preventive and breakdown) plan.
1Ö
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46* " 1 2 7 = 5= 1 5 a) Potable water and electricity are available round the clock. b) Alternate sources are provided for in case of failure. c) The organisation regularly tests the alternate sources. d) There is a maintenance plan for piped medical gas, compressed air and vacuum installation. 14
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46& " 1 2
! 1 7 a) The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies. 15
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Cont« b) Staff is trained for their role in case of such emergencies. c) The organization has a documented safe exit plan in case of fire and non-fire emergencies. d) Mock drills are held at least twice in a year
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46, " 1 2 91 5 a) The organization defines and implement its polices to reduce or eliminate smoking b) The policy has provisions for granting exceptions for patients and families to smoke
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FMS.ý The organization plans for handling community emergencies, epidemics and other disasters a) The hospital identifies potential emergencies. b) The organization has a documented disaster management plan. 1
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Cont« c) Provision is made for availability of medical supplies, equipment and materials during such emergencies. d) Hospital staff is trained in the hospital¶s disaster management plan e) The plan is tested at least twice in a year.
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FMS. The organization has a plan for management of hazardous materials a) Hazardous materials are identified within the organization b) The hospital implements processes for sorting, labelling, handling, storage, transporting and disposal of hazardous material. 1ý0
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Cont« c) Requisite regulatory requirements are met in respect of radioactive materials. d) There is a plan for managing spills of hazardous materials e) Staff is educated and trained for handling such materials. 1ý1
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460 " 5
a) The hospital has a safety committee to identify the potential safety and security risks. b) This committee coordinates development, implementation, and monitoring of the safety plan and policies. c) Patient safety devices are installed across the organization and inspected periodically 1ý2
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Cont« d) Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas. e) Inspection reports are documented and corrective and preventive measures are undertaken. f) There is a safety education programme for all staff. 1ýÖ
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Chapter9 HUMAN RESOURCE MANAGEMENT
1ý4
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HRM.1 The organization has a documented system of human resource planning a) The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient. 1ý5
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Cont« b) The required job specifications and job description are well defined for each category of staff. c) The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.
1ý
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-6/ "
1 1 2 2 a) Each staff member, employee, student and voluntary worker is appropriately oriented to the organization¶s mission and goals. 1ýý
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Cont« b) Each staff member is made aware of hospital wide policies and procedures as well as relevant department / unit / service / programme¶s policies and procedures. c) Each staff member is made aware of his/her rights and responsibilities. d) All employees are educated with regard to patients¶ rights and responsibilities. e) All employees are oriented to the service standards of the organisation 1ý |
-6+ " 11 1
1
Objective elements a) A documented training and development policy exists for the staff. b) Training also occurs when job responsibilities change/ new equipment is introduced. c) Feedback mechanisms for assessment of training and development programme 1ý9 exist. |
-6*
=
; 5 5 a) All staff is trained on the risks within the hospital environment. b) Staff members can demonstrate and take actions to report, eliminate / minimize risks. 10 |
Cont« c) Staff members are made aware of procedures to follow in the event of an incident. d) Reporting processes for common problems, failures and user errors exist
11
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HRM.5 An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process a) A well-documented performance appraisal system exists in the organization. 12
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Cont« b) The employees are made aware of the system of appraisal at the time of induction. c) Performance is evaluated based on the performance expectations described in job description. 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. 1Ö
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-6, " 1 2 7 ! 5
a) A written statement of the policy of the organization with regard to discipline is in place. b) The disciplinary policy and procedure is based on the principles of natural justice. 14
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Cont« c) The policy and procedure is known to all categories of employees of the organization. d) The disciplinary procedure is in consonance with the prevailing laws. e) There is a provision for appeals in all disciplinary cases.
15
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-6' 1 1
> 1 2 a) The employees are aware of the procedure to be followed in case they feel aggrieved. b) The redress procedure addresses the grievance. c) Actions are taken to redress the grievance 1 |
HRM. The organization addresses the health needs of the employees 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 organization¶s policy. 1ý
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Cont« c) Regular physical and medical checks are done at-least once a year and the findings/ results are documented. d) Occupational health hazards are adequately addressed.
1
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-60 "
a) Personal files are maintained in respect of all employees. b) The personal files contain personal information regarding the employees qualification, disciplinary background and 19 health status |
Cont« c) All records of in-service training and education are contained in the personal files. d) Personal files contain results of all evaluations
190
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-6%) " 1= 51 1
# = 1 = 1
> $ 7
191
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a) Medical professionals permitted by law, regulation and the hospital to provide patient care without supervision is identified. b) The education, registration, training and experience of the identified medical professionals is documented and updated periodically. c) All such information pertaining to the medical professionals is appropriately verified when possible. 192
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HRM.11 There is a process for authorising all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications
19Ö
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a) Medical professionals admit and care for patients as per the laid down policies and authorisation procedures of the organization b) The services provided by the medical professionals are in consonance with their qualification, training and registration. c) The requisite services to be provided by the medical professionals are known to them as well as the various departments / units of the hospital. 194 |
-6%/ " 1= 51 1 # = 1 = 1
> $ 1
a) The education, registration, training and experience of nursing staff is documented and updated periodically. 195 |
Cont« b) All such information pertaining to the nursing staff is appropriately verified when possible
19
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-6%+ " 5 9 7 9 1 1
7 ; 5 1 5 ;
19ý
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a) The clinical work assigned to nursing staff is in consonance with their qualification, training and registration. b) The services provided by nursing staff are in accordance with the prevailing laws and regulations. c) The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the hospital 19
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!
199
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IMS.1 Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require data and information from the organization
200
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a) The information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organization b) Policies and procedures to meet the information needs are documented. c) These policies and procedures are in compliance with the prevailing laws and regulations. 201
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Cont« d) All information management and technology acquisitions are in accordance with the policies and procedures. e) The organization contributes to external databases in accordance with the law and regulations
202
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6/ " 1 2
1 a) Formats for data collection are standardized b) Necessary resources are available for analyzing data 20Ö
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Cont« c) Documented procedures are laid down for timely and accurate dissemination of data d) Documented procedures exist for storing and retrieving data e) Appropriate clinical and managerial staff participates in selecting, integrating and using data. 204
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6+ " 1 2
5 a) Every medical record has a unique identifier. b) Organization policy identifies those authorized to make entries in medical record. 205
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Cont« c) Every medical record entry is dated and timed. d) The author of the entry can be identified e) The contents of medical record are identified and documented f) The record provides an up-to-date and chronological account of patient care 20
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6* "
5
a) The medical record contains information regarding reasons for admission, diagnosis and plan of care. b) Operative and other procedures performed are incorporated in the medical record 20ý
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Cont« c) 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 d) The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel 20
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Cont« e) In case of death, the medical record contains a copy of the death certificate indicating the cause, date and time of death. f) Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same. g) Care providers have access to current and past medical record. 209
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6& 1 5= 1 5 5
a) Documented policies and procedures exist for maintaining confidentiality, security and integrity of information 210
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Cont« b) Policies and procedures are in consonance with the applicable laws c) The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tampering d) The hospital has an effective process of monitoring compliance of the laid down policy 211
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Cont« e) The hospital uses developments in appropriate technology for improving, confidentiality, integrity and security f) Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient¶s authorization 212
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Cont« g) A documented procedure exists on how to respond to patients / physicians and other public agencies requests for access to information in the clinical record in accordance with the local and national law.
21Ö
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6, > = 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 214 |
Cont« 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
215
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6' " 1 2 1 5 a) The medical records are reviewed periodically b) The review uses a representative sample c) The review is conducted by identified care providers. 21
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Cont« d) The review focuses on the timeliness, legibility and completeness of the medical records 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 undertaken are documented. 21ý
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Thank you
21
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Clinical indicators of NABH '
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Clinical indicators ' |
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220
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Clinical indicators Re-exploration rate. Percentage of accidental removal of tubes and catheters. Incidence of haematoma at puncture site. Percentage of re-scheduling of procedures.
221
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Clinical indicators of NABH Percentage of medication errors. Incidence of adverse drug reactions. Percentage of medication charts with illegible writing over a given period. Percentage of contrast related reactions.
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Clinical indicators Percentage of modification of anaesthesia plan. Percentage of unplanned ventilation following anaesthesia. Percentage of adverse anaesthesia events. Anaesthesia related mortality rate. 22Ö
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Clinical indicators of NABH 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
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Clinical indicators Percentage of medical records not having discharge summary. Percentage of medical records not having initial assessment and the plan of care. Percentage of medical records having incomplete and/or improper consent. Percentage of missing records. 225
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Clinical indicators of NABH Urinary tract infection rate. Respiratory infection rate. Intra-vascular device infection rate. Surgical site infection rate.
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Clinical indicators Number of research activities being carried out. Percentage of patients withdrawing from the study. Percentage of protocol violations/deviations reported. Percentage of serious adverse events (which have occurred in the HCO) reported to the ethics committee within the defined timeframe 22ý |
Managerial indicators of NABH Percentage of drugs procured by local purchase. Percentage of stock outs including emergency drugs. Percentage of consumables rejected before preparation of Goods Receipt Note. Incidence of variations from the procurement process. |
Managerial indicators Number of births and deaths. Number of notifiable diseases. Submission of report/ data/form pertaining to bio-medcial waste, PNDT act and radiation safety within the defined timeframe. Submission of tax returns and deduction of taxes at the specified time frame. 229
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Managerial indicators of NABH Number of variations observed in mock drills. Incidence of falls. Incidence of bed sores after admission. Percentage of employees provided pre-exposure prophylaxis.
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Managerial indicators Bed occupancy rate and average length of stay. OT and ICU utilization rate. Equipment down time. Nurse-patient ratio. 2Ö1
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Managerial indicators Out patient satisfaction index. In patient satisfaction index. Waiting time for services including diagnostics and out patient. Time taken for discharge. 2Ö2
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Managerial indicators NABH Employee satisfaction index. Employee attrition rate. Employee absenteeism rate. Percentage of employees who are aware of employee rights, responsibilities and welfare schemes. |
Managerial indicators Number of sentinel events. Percentage of near misses analysed. Number of security related incidents including thefts. Incidence of needle stick injuries 2Ö4
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Sentinel Event An unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of functionÕ for a recipient of health care services.
2Ö5
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1 Surgery performed on the wrong body part Surgery performed on the wrong patient Wrong surgical procedure performed on the wrong patient Retained instruments in patient discovered after surgery/procedure Patient death during or immediately post surgical procedure Anesthesia related event
2Ö
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Patient death or serious disability associated with: the use of contaminated drugs, devices, products supplied by the organization the use or function of a device in a manner other than the device¶s intended use the failure or breakdown of a device or medical equipment intravascular air embolism 2Öý
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Discharge of an infant to the wrong person
Patient death or serious disability associated with elopement from the health care facility Patient suicide, attempted suicide, or deliberate self-harm resulting in serious disability Intentional injury to a patient by a staff member, another patient, visitor, or other Any incident in which a line designated for oxygen or other came to be delivered to a patient and contains the wrong gas or is contaminated by toxic substances Nosocomial infection or disease causing patient death or serious disability 2Ö
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Patient death or serious disability while being cared for in a health care facility associated with: a burn incurred from any source a slip, trip, or fall an electric shock the use of restraints or bedrails
2Ö9
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1
Patient death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood products Maternal death or serious disability associated with labour or delivery in a low-risk pregnancy Medication error leading to the death or serious disability of patient due to incorrect administration of drugs, for example: ± ± ± ± ± ± ±
omission error dosage error dose preparation error wrong time error wrong rate of administration error wrong administrative technique error wrong patient error
Patient death or serious disability associated with an avoidable delay in treatment or response to abnormal test results
240
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Any instance of care ordered by or provided by an individual impersonating a clinical member of staff Abduction of a patient Sexual assault on a patient within or on the grounds of the health care facility Death or significant injury of a patient or staff member resulting from a physical assault or other crime that occurs within or on the grounds of the health care facility.
241
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: : 5 1 1 (a)Building Permit (From the Municipality). (b)No objection certificate from the Chief Fire officer. (c)License under Bio- medical Management and handling Rules, 199. (d)No objection certificate under Pollution Control Act. (e)Radiation Protection Certificate in respect of all X-ray and CT Scanners from BARC. (f)Excise permit to store Spirit. (g)Income tax PAN. (h)Permit to operate lifts under the Lifts and escalators Act. (i)Narcotics and Psychotropic substances Act and License. (j)Sales Tax Registration certificate. (k)Vehicle registration certificates for Ambulances. (l)Retail drug license (Pharmacy). (m)Wireless operation certificate from Indian post and telegraphs. (if applicable) (n)Air (prevention and control of pollution) Act, 191 and License (o)Arms Act, 1950. (if guards have weapons) (p)Atomic energy regulatory body approvals. (q)Biomedical waste management handling rules 199. (r)Boilers Act192Ö. (s)Cable television networks Act 1995. (t)Central sales tax Act, 195. (u)Consumer protection Act, 19. (v)Contract Act, 192. (w)Copyright Act, 192. (x)Customs Act, 192. (y)Dentist regulations, 19ý. (z)Drugs & cosmetics Act, 1940. (aa)Electricity Act, 199. (bb)Electricity rules, 195. (cc)Employees provident fund Act, 1952. (dd)ESI Act, 194. (ee)Employment exchange Act, 199. (ff)Environment protection Act, 19.
242
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(a)Equal remuneration Act, 19ý. (b)Explosives Act14. (c)Fatal accidents Act155. (d)Gift tax Act, 195. (e)Hire Purchase Act, 19ý2. (f)Income Tax Act, 191. (g)Indian Lunacy Act, 1912. (h)Indian medical council Act and code of medical ethics, 195. (i)Indian Nursing council Act194ý. (j)Indian penal code, 10. (k)Indian trade unions Act, 192. (l)Industrial disputes Act, 194ý. (m)Insecticides Act, 19. (n)Lepers Act (o)Maternity benefit Act, 191. (p)MTP Act, 19ý1. (q)Minimum wages Act, 194. (r)National building code. (s)National holidays under shops Act. (t)Negotiable instruments Act, 11. (u)Payment of bonus Act, 195. (v)Payment of gratuity Act, 19ý2. (w)Payment of wages Act, 19Ö. (x)Persons with disability Act, 1995. (y)Pharmacy Act, 194. (z)PNDT Act, 199. (aa)Prevention of food adulteration Act, 1954. (bb)Protection of human rights Act, 199Ö. (cc)PPF Act, 19. (dd)BARC, Act. (ee)Registration of births and deaths Act, 199. (ff)Sale of goods Act, 19Ö0. (gg)Tax deducted at source Act. (hh)Sales tax Act. (ii)SC and ST Act, 199
24Ö
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(a)License for the blood bank (b)Companies Act, 195 (c)Constitution of India (d)Transplantation of human organs Act 1994 and License (if applicable) (e)Insurance Act, 19Ö (f)Workers compensation Act, 192Ö (g)Urban land Act, 19ý
244
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