nabh 3rd edition presentation

258
1 NABH Standards – Third Edition (Applicable from July 1 st , 2012) 10 Chapters 102 Standards 636 Objective Elements Updated by Anuj Jindal [[email protected]] iKure Knowledge Services www.ikureknowledge.blogspot.in

Upload: anuj-jindal

Post on 26-Oct-2014

14.158 views

Category:

Documents


19 download

DESCRIPTION

NABH Standards 3rd Edition

TRANSCRIPT

Page 1: NABH 3rd Edition Presentation

1

NABH Standards – Third Edition(Applicable from July 1st, 2012)

• 10 Chapters

• 102 Standards

• 636 Objective Elements

Updated by Anuj Jindal [[email protected]]iKure Knowledge Services

www.ikureknowledge.blogspot.in

Page 2: NABH 3rd Edition Presentation

2

Standards and Objective Elements

• A standard is a statement 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

Page 3: NABH 3rd Edition Presentation

3

Section I:Patient-Centered Standards

Chapter 1 Access, Assessment and Continuity of Care (AAC)

Chapter 2 Patients Rights and Education (PRE)

Chapter 3 Care of Patients (COP)

Chapter 4 Management of Medications (MOM)

Chapter 5 Hospital Infection Control (HIC)

Page 4: NABH 3rd Edition Presentation

4

Section II: Management-Centered Standards

Chapter 6 Continuous Quality Improvement (CQI)Chapter 7 Responsibilities of Management (ROM)Chapter 8 Facility Management & Safety (FMS)Chapter 9 Human Resource Management (HRM)Chapter 10 Information Management Systems (IMS)

Page 5: NABH 3rd Edition Presentation

5

NABH STANDARDS

Page 6: NABH 3rd Edition Presentation

6

Chapter 1ACCESS, ASSESSMENT

AND CONTINUITY OF CARE (AAC)

Page 7: NABH 3rd Edition Presentation

7

AAC.1The organization defines and displays the services that it

provides.

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

Page 8: NABH 3rd Edition Presentation

8

AAC.2The organization 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.

Page 9: NABH 3rd Edition Presentation

9

Cont…

c) A unique identification number is generated at the end of registration.

d) Patients are accepted only if the organization 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.

Page 10: NABH 3rd Edition Presentation

10

AAC.3There is an appropriate mechanism for transfer or referral of patients.

Objective elements

a) Documented policies and procedures guide the transfer-in of patients to the organization.

b) Documented policies and procedures guide the transfer-out/referral of unstable patients to another facility in an appropriate manner.

Page 11: NABH 3rd Edition Presentation

11

Cont…

c) Documented policies and procedures guide the transfer-out/referral of stable patients to another facility in an appropriate manner.

d) The documented procedures identify staff responsible during transfer/referral.

e) The organization gives a summary of patient’s condition and the treatment given.

Page 12: NABH 3rd Edition Presentation

12

AAC.4 Patients cared for by the

organization undergo an established initial assessment.

• Objective elements

a) The organization defines and documents the content of the initial assessment for the out-patients, in-patients and emergency patients.

b) The organization determines who can perform the initial assessment.

Page 13: NABH 3rd Edition Presentation

13

Cont…c) The organization 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 organization's policy.

e) Initial assessment of in-patients includes nursing assessment which is done at the time of admission and documented.

Page 14: NABH 3rd Edition Presentation

14

Cont…

f) Initial assessment includes screening for nutritional needs.

g) The initial assessment results in a documented plan of care.

h) The plan of care also includes preventive aspects of the care where appropriate.

Page 15: NABH 3rd Edition Presentation

15

Cont…

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.

Page 16: NABH 3rd Edition Presentation

16

AAC.5Patients cared for by the

organization 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.

Page 17: NABH 3rd Edition Presentation

17

cont…

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.

Page 18: NABH 3rd Edition Presentation

18

AAC.6 Laboratory services are provided as per the scope of services of the organization.

• Objective elements.

a) Scope of the laboratory services are commensurate to the services provided by the organization.

b) The infrastructure (physical and manpower) is adequate to provide for its defined scope of services.

Page 19: NABH 3rd Edition Presentation

19

cont…

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.

Page 20: NABH 3rd Edition Presentation

20

cont…

f) Critical results are intimated immediately to the personnel concerned.

g) Results are reported in a standardized manner.

h) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

Page 21: NABH 3rd Edition Presentation

21

AAC.7There is an established laboratory

quality assurance programme

• 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.

Page 22: NABH 3rd Edition Presentation

22

cont…

d) The programme includes periodic calibration and maintenance of all equipment.

e) The programme includes the documentation of corrective and preventive actions.

Page 23: NABH 3rd Edition Presentation

23

AAC.8There is an established

laboratory-safety programme.

• Objective elements.

a) The laboratory safety programme is documented.

b) This programme is aligned with the organization's safety programme.

Page 24: NABH 3rd Edition Presentation

24

cont…

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.

Page 25: NABH 3rd Edition Presentation

25

AAC.9Imaging services are provided as per the

scope of services of the organization.

• Objective elements

a) Imaging services comply with the legal and other requirements.

b) Scope of the imaging services is commensurate to the services provided by the organization.

c) The infrastructure (physical and manpower) is adequate to provide for its defined scope of services.

Page 26: NABH 3rd Edition Presentation

26

cont…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.

Page 27: NABH 3rd Edition Presentation

27

cont…g) Critical results are intimated immediately

to the personnel concerned.h) Results are reported in a standardized

manner.i) Imaging tests not available in the

organization are outsourced to organization(s) based on their quality assurance system.

Page 28: NABH 3rd Edition Presentation

28

AAC.10There is an established quality

assurance programme for imaging services.

• Objective elements

a) The quality assurance program for imaging services is documented.

b) The programme addresses verification and/or validation of imaging methods.

c) The programme addresses surveillance of imaging results.

Page 29: NABH 3rd Edition Presentation

29

cont…

d) The programme includes periodic calibration and maintenance of all equipment.

e) The programme includes the documentation of corrective and preventive actions.

Page 30: NABH 3rd Edition Presentation

30

AAC.11There is an established radiation

safety programme.Objective elements

a) The radiation-safety programme is documented.

b) This programme is aligned with the organization’s safety programme.

c) Handling, usage and disposal of radio-active and hazardous materials are as per statutory requirements.

Page 31: NABH 3rd Edition Presentation

31

cont…

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.

Page 32: NABH 3rd Edition Presentation

32

AAC.12Patient care is continuous and

multidisciplinary in nature.

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 setting within the organization.

Page 33: NABH 3rd Edition Presentation

33

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) Transfers between departments/units are done in a safe manner.

Page 34: NABH 3rd Edition Presentation

34

cont…

f) The patient’s record(s) is available to the authorized care providers to facilitate the exchange of information.

g) Documented procedures guide the referral of patients to other departments/ specialties.

Page 35: NABH 3rd Edition Presentation

35

AAC.13The organization has a

documented discharge process.

Objective elementsa) 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 abandoned cases).

Page 36: NABH 3rd Edition Presentation

36

cont…

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 organization (including patients leaving against medical advice and on request).

Page 37: NABH 3rd Edition Presentation

37

AAC.14Organization defines the content

of the discharge summary.

• 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.

Page 38: NABH 3rd Edition Presentation

38

cont…

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.

Page 39: NABH 3rd Edition Presentation

39

cont…

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.

Page 40: NABH 3rd Edition Presentation

40

Chapter 2Care of Patients (COP)

Page 41: NABH 3rd Edition Presentation

41

COP.1Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws,

regulations and guidelines.

• 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.

Page 42: NABH 3rd Edition Presentation

42

cont…

c) These reflect applicable laws, regulations and guidelines.

d) The organization adopts evidence-based medicine and clinical practice guidelines to guide uniform patient care.

Page 43: NABH 3rd Edition Presentation

43

COP.2Emergency services are guided by documented policies, procedures

and applicable laws and regulations.Objective elements

a) Policies and procedure for emergency care are documented and are in consonance with statutory requirements.

b) This also addresses handling of medico-legal cases.

c) The patients receive care in consonance with the policies.

Page 44: NABH 3rd Edition Presentation

44

cont…d) Documented policies and procedures guide

the triage of patients for initiation of appropriate care.

e) Staff are familiar with the policies and trained on the procedures for care of emergency patients.

f) Admission or discharge to home or transfer to another organization is also documented.

g) In case of discharge to home or transfer to another organization a discharge note shall be given to patient.

Page 45: NABH 3rd Edition Presentation

45

COP.3The ambulance services are

commensurate with the scope of the services provided by the organization.

• Objective elements

a) There is adequate access and space for the ambulance(s).

b) The ambulance adheres to statutory requirements.

c) Ambulance(s) is appropriately equipped.

Page 46: NABH 3rd Edition Presentation

46

cont…d) Ambulance(s) is manned by the trained

personnel.

e) Ambulance(s) is checked on a daily basis.

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) has a proper communication system.

Page 47: NABH 3rd Edition Presentation

47

COP.4Documented policies and procedures

guide the care of patients requiring cardio-pulmonary resuscitation.

• Objective elements

a) Documented policies and procedures guide the uniform use of resuscitation throughout the organization.

b) Staff providing direct patient care are trained and periodically updated in cardio pulmonary resuscitation.

Page 48: NABH 3rd Edition Presentation

48

cont…

c) The events during a cardio pulmonary resuscitation are recorded.

d) A post-event analysis of all cardio-pulmonary resuscitations is done by a multidisciplinary committee.

e) Corrective and preventive measures are taken based on the post-event analysis.

Page 49: NABH 3rd Edition Presentation

49

COP.5Documented policies and

procedures guide nursing care.

• 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.

Page 50: NABH 3rd Edition Presentation

50

Cont…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.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.

Page 51: NABH 3rd Edition Presentation

51

COP.6Documented procedures guide the

performance of various procedures.

• 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.

Page 52: NABH 3rd Edition Presentation

52

cont…c) Documented procedures exist to prevent

adverse events like wrong site, wrong patient and wrong procedure.

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.

Page 53: NABH 3rd Edition Presentation

53

COP.7Documented policies and

procedures define rational use of blood and blood products.

• Objective elements

a) Documented policies and procedures are used to guide rational use of blood and blood products.

b) Documented procedures guide transfusion of blood and blood products.

Page 54: NABH 3rd Edition Presentation

54

cont…c) The transfusion services are governed by the

applicable laws and regulations.

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 organization defines the process for availability and transfusion of blood/blood components for use in emergency.

Page 55: NABH 3rd Edition Presentation

55

cont…g) Post-transfusion form is collected, reactions if

any identified and are analyzed for preventive and corrective actions.

h) Staff are trained to implement the policies.

Page 56: NABH 3rd Edition Presentation

56

COP.8Documented policies and procedures

guide the care of patients in the Intensive Care and high dependency units.

• Objective elements.

a) Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units.

Page 57: NABH 3rd Edition Presentation

57

cont…

b) The organization has documented admission and discharge criteria for its intensive care and high dependency units.

c) Staff are trained to apply these criteria.

d) Adequate staff and equipment are available.

e) Defined procedures for situation of bed shortages are followed.

Page 58: NABH 3rd Edition Presentation

58

cont…

f) Infection control practices are documented and followed.

g) A quality assurance programme is documented and implemented.

Page 59: NABH 3rd Edition Presentation

59

COP.9Documented policies and procedures guide the

care of vulnerable patients (elderly, children, physically and/ or mentally challenged).

• 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.

Page 60: NABH 3rd Edition Presentation

60

cont…

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.

Page 61: NABH 3rd Edition Presentation

61

COP.10  Documented policies and

procedures guide obstetric care.

• Objective elements

a) There is a documented policy and procedure for obstetric services.

b) The organisation defines and displays whether high-risk obstetric cases be cared for or not.

Page 62: NABH 3rd Edition Presentation

62

cont…

c) Persons caring for high-risk obstetric cases are competent.

d) Documented procedures guide provision for ante-natal services.

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 organization caring for high-risk obstetric cases has the facilities to take care of neonates of such cases.

Page 63: NABH 3rd Edition Presentation

63

COP.11Documented policies and procedures

guide paediatric services.

• Objective elements

a) There is a documented policy and procedure for paediatric services.

b) The organisation defines and displays the scope of its paediatric services.

c) The policy for care of neonatal patients is in consonance with the national/ international guidelines.

Page 64: NABH 3rd Edition Presentation

64

cont…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 immunization assessment.

g) Documented policies and procedures prevent child/ neonate abduction and abuse.

h) The children’s family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record.

Page 65: NABH 3rd Edition Presentation

65

COP.12Documented policies and procedures guide the care of patients undergoing

moderate sedation.

• 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.

Page 66: NABH 3rd Edition Presentation

66

cont…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.

f) Patients are monitored after sedation and the same is documented.

Page 67: NABH 3rd Edition Presentation

67

cont…

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 that intended.

Page 68: NABH 3rd Edition Presentation

68

COP.13Documented policies and

procedures guide the administration of anesthesia.

• Objective elements.

a) There is a documented policy and procedure for the administration of anesthesia.

b) Patients for anesthesia have a pre-anesthesia assessment by a qualified anaesthesiologist.

Page 69: NABH 3rd Edition Presentation

69

cont…

c) The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented.

d) An immediate preoperative re-evaluation is performed and documented.

e) Informed consent for administration of anesthesia is obtained by the anesthesiologist.

Page 70: NABH 3rd Edition Presentation

70

cont…f) During anesthesia monitoring includes

regular recording of temperature, heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation and end tidal carbon dioxide.

g) Patient’s post-anesthesia status is monitored and documented.

h) The anaesthesiologist applies defined criteria to transfer the patient from the recovery area.

Page 71: NABH 3rd Edition Presentation

71

cont…i) The type of anaesthesia and anaesthetic

medications used is documented in the patient record.

j) Procedures shall comply with infection control guidelines to prevent cross-infection between patients.

k) Adverse anesthesia events are recorded and monitored.

Page 72: NABH 3rd Edition Presentation

72

COP.14Documented policies and procedures guide the care of patients undergoing

surgical procedures.

• 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.

Page 73: NABH 3rd Edition Presentation

73

cont…d) Documented policies and procedure exist

to prevent adverse events like wrong site, wrong patients and wrong surgery.

e) Persons qualified by law are permitted to perform the procedures that they are entitled to perform.

f) A brief operative note is documented prior to transfer out of patient from recovery area.

g) The operating surgeons documents the post operative plan of care.

Page 74: NABH 3rd Edition Presentation

74

cont…h) Patient, personnel and material flow

conforms to infection control practices.

i) Appropriate facilities and equipment/ appliances/ instrumentation are available in the operating theatre.

j) A quality assurance programme is followed for the surgical services.

k) The quality assurance program includes surveillance of the operation theatre environment.

Page 75: NABH 3rd Edition Presentation

75

COP.15Documented policies and procedures

guide the care of patients under restraints (physical and/ or chemical).

• Objective elements

a) Documented policies and procedures guide the care of patients under restraints.

b) These include both physical and chemical restraint measures.

Page 76: NABH 3rd Edition Presentation

76

cont…

c) These include documentation of reasons for restraints.

d) These patients are more frequently monitored.

e) Staff receive training and periodic updating in control and restraint techniques.

Page 77: NABH 3rd Edition Presentation

77

COP.16Documented policies and

procedures guide appropriate pain management.

• Objective elements.a) Documented policies and procedures

guide the management of pain.b) All patients are screened for pain.

Page 78: NABH 3rd Edition Presentation

78

cont…

c) Patients with pain undergo detailed assessment and periodic re-assessment.

d) The organization respects and supports management of pain for such patients.

e) Patient and family are educated on various pain management techniques, where appropriate.

Page 79: NABH 3rd Edition Presentation

79

COP.17Documented policies and

procedures guide appropriate rehabilitative services.

• Objective elements

a) Documented policies and procedures guide the provision of rehabilitative services.

b) These services are commensurate with the organizational requirements.

Page 80: NABH 3rd Edition Presentation

80

cont…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.

Page 81: NABH 3rd Edition Presentation

81

COP.18Documented policies and procedures

guide all research activities.

• Objective elements

a) Documented policies and procedures guide all research activities in compliance with national and international guidelines.

b) The organization 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.

Page 82: NABH 3rd Edition Presentation

82

cont…d) Patient’s 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 organization’s services.

Page 83: NABH 3rd Edition Presentation

83

COP.19Documented policies and procedures

guide nutritional therapy.

• Objective elements

a) Documented policies and procedures guide nutritional assessment and reassessment.

b) Patients receive food according to their clinical needs.

Page 84: NABH 3rd Edition Presentation

84

cont…

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 patients diet limitations.

f) Food is prepared, handled, stored and distributed in a safe manner.

Page 85: NABH 3rd Edition Presentation

85

COP.20Documented policies and procedures

guide the end of life care.

• 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.

Page 86: NABH 3rd Edition Presentation

86

cont…

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.

Page 87: NABH 3rd Edition Presentation

87

Chapter 3MANAGEMENT OF

MEDICATION (MOM)

Page 88: NABH 3rd Edition Presentation

88

MOM.1Documented policies and procedures guide the organization of pharmacy services and usage of medication.

• 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.

Page 89: NABH 3rd Edition Presentation

89

cont…

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.

Page 90: NABH 3rd Edition Presentation

90

MOM.2There is a hospital formulary.

• Objective elements

a) A list of medications appropriate for the patients and as per the scope of the organization’s clinical services is developed.

b) The list is developed and updated collaboratively by the multidisciplinary committee.

Page 91: NABH 3rd Edition Presentation

91

cont…

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.

Page 92: NABH 3rd Edition Presentation

92

MOM.3Documented policies and procedures

guide the storage of medication.

• 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).

Page 93: NABH 3rd Edition Presentation

93

cont…c) Sound inventory control practices guide

storage of the medications.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.

Page 94: NABH 3rd Edition Presentation

94

MOM.4Documented policies and procedures

guide the safe and rational prescription of medications.

• 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 organization determines the minimum requirements of a prescription.

Page 95: NABH 3rd Edition Presentation

95

cont…d) Known drug allergies are ascertained before

prescribing.

e) The organization 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.

h) Medication orders contain the name of the medicine, route of administration, dose to be administered and frequency/time of administration.

Page 96: NABH 3rd Edition Presentation

96

cont…i) Documented policy and procedure on verbal

orders is implemented.

j) The organization defines a list of high-risk medication(s).

k) Audit of medication orders/prescription is carried out to check for the safe and rational prescription of medications.

l) Corrective and/or preventive action(s) is taken based on the analysis, where appropriate.

Page 97: NABH 3rd Edition Presentation

97

MOM.5 Documented policies and procedures guide the safe

dispensing of medications.

• Objective elements

a) Documented policies and procedures guide the safe dispensing of medications.

b) The procedure addresses medication recall.

Page 98: NABH 3rd Edition Presentation

98

cont…

c) Expiry dates are checked prior to dispensing.

d) There is a procedure for near expiry medications.

e) Labeling requirements are documented and implemented by the organization.

f) High-risk medication orders are verified prior to dispensing.

Page 99: NABH 3rd Edition Presentation

99

MOM.6There are documented policies and procedures for medication

management.

• Objective elements

a) Medications are administered by those who are permitted by law to do so.

b) Prepared medication is labeled prior to preparation of a second drug.

c) Patient is identified prior to administration.

Page 100: NABH 3rd Edition Presentation

100

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.

h) Medication administration is documented.

Page 101: NABH 3rd Edition Presentation

101

cont…

i) Documented polices and procedures govern patient’s self administration of medications.

j) Documented polices and procedures govern patient’s medications brought from outside the organization.

Page 102: NABH 3rd Edition Presentation

102

MOM.7 Patients are monitored after medication administration.

• Objective elements

a) Documented policies and procedures guide the monitoring of patients after medication administration.

b) The organization defined those situation where close monitoring is required.

Page 103: NABH 3rd Edition Presentation

103

cont…

c) Monitoring is done in a collaborative manner.

d) Medications are changed where appropriate based on the monitoring.

Page 104: NABH 3rd Edition Presentation

104

MOM.8 Near misses, medication errors

and adverse drug events are reported and analyzed.

• Objective elements

a) Documented procedures exist to capture near miss, medication error and adverse drug event.

b) Near miss, medication error and adverse drug events are defined.

Page 105: NABH 3rd Edition Presentation

105

cont…

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.

Page 106: NABH 3rd Edition Presentation

106

MOM.9 Documented procedures

guide the use of narcotic drugs and psychotropic substances.

• Objective elements

a) Documented procedures guide the use of narcotic drugs and psychotropic substances which are in consonance with local and national regulations.

Page 107: NABH 3rd Edition Presentation

107

cont…

b) These drugs are stored in a secure manner.

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.

Page 108: NABH 3rd Edition Presentation

108

MOM.10 Documented policies and

procedures guide the usage of chemotherapeutic agents.

• Objective elements.

a) Documented policies and procedures guide the usage of chemotherapeutic agents.

Page 109: NABH 3rd Edition Presentation

109

cont…

b) Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy.

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.

Page 110: NABH 3rd Edition Presentation

110

MOM.11 Documented policies and

procedures govern usage of radioactive drugs.

• Objective elements.

a) Documented policies and procedures govern usage of radioactive drugs.

Page 111: NABH 3rd Edition Presentation

111

cont…

b) These policies and procedures are in consonance with laws and regulations.

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.

Page 112: NABH 3rd Edition Presentation

112

MOM.12 Documented policies and procedures

guide the use of implantable prosthesis and medical devices.

• 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).

Page 113: NABH 3rd Edition Presentation

113

Cont…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 counseled for the usage of implantable prosthesis and medical device including precautions, if any.

Page 114: NABH 3rd Edition Presentation

114

Cont…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.

Page 115: NABH 3rd Edition Presentation

115

MOM.13Documented policies and procedures guide the use of medical supplies and

consumables.

• Objective elements

a) There is a defined process for acquisition of medical supplies and consumables.

b) Medical supplies and consumables are used in a safe manner, where appropriate.

Page 116: NABH 3rd Edition Presentation

116

Cont…c) Medical supplies and consumables are

stored in a clean, safe and secure environment; and incorporating manufacturer's recommendation(s).

d) Sound inventory control practices guide storage of medical supplies and consumables.

Page 117: NABH 3rd Edition Presentation

117

Chapter 4PATIENT RIGHT AND

EDUCATION (PRE)

Page 118: NABH 3rd Edition Presentation

118

PRE.1The organization protects patient and family rights and informs them about

their responsibilities during care.

Objective element

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.

Page 119: NABH 3rd Edition Presentation

119

cont…

c) The organization’s leaders protect patient's and family rights.

d) Staff is aware of its responsibility in protecting patients and family rights.

e) Violation of patient and family rights is recorded, reviewed and corrective/ preventive measures taken.

Page 120: NABH 3rd Edition Presentation

120

PRE.2.Patient and family rights support

individual beliefs, values and involve the patient and family in decision-making

processes.

Objective elementsa) 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.

Page 121: NABH 3rd Edition Presentation

121

cont…c) Patient and family rights include protection

from physical abuse and neglect.

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, anaesthesia, surgery, initiation of any research protocol and any other invasive/ high-risk procedures/ treatment.

Page 122: NABH 3rd Edition Presentation

122

cont…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.

Page 123: NABH 3rd Edition Presentation

123

PRE.3The patient and/or family members

are educated to make informed decisions and are involved in the

care planning and delivery process.

Objective elements

a) The patient and/or family members are explained about the proposed care includinng the risks, alternatives and benefits.

Page 124: NABH 3rd Edition Presentation

124

cont…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.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.

Page 125: NABH 3rd Edition Presentation

125

cont…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.

Page 126: NABH 3rd Edition Presentation

126

PRE.4 A documented procedure for obtaining patient

and/ or family's consent exists for informed decision making about their care.

• 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 organisation.

Page 127: NABH 3rd Edition Presentation

127

cont…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.

e) The procedure describes who can give consent when patient is incapable of independent decision making.

Page 128: NABH 3rd Edition Presentation

128

cont…f) Informed consent is taken by the person

performing the procedure.g) Informed consent process adheres to

statutory norms.h) Staff are aware of the informed consent

procedures.

Page 129: NABH 3rd Edition Presentation

129

PRE.5 Patient and families have a right to

information and education about their health care needs.

• 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.

Page 130: NABH 3rd Edition Presentation

130

cont…c. Patient and/or family are educated about diet

and nutrition.

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.

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.

Page 131: NABH 3rd Edition Presentation

131

PRE.6 Patient and families have a right to

information on expected costs.

• 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.

Page 132: NABH 3rd Edition Presentation

132

cont…

c. The patient and/or family 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.

Page 133: NABH 3rd Edition Presentation

133

PRE.7 Organization has a complaint

redressal procedure.

• Objective elements

a) The organization has a documented complaint redressal procured.

b) Patient and/or family members are made aware of the procedures for lodging complaints.

Page 134: NABH 3rd Edition Presentation

134

cont…

c. All complaints are analysed.

d. Corrective and/or preventive action(s) are taken based on the analysis where appropriate.

Page 135: NABH 3rd Edition Presentation

135

Chapter 5HOSPITAL INFECTION

CONTROL (HIC)

Page 136: NABH 3rd Edition Presentation

136

HIC.1 The organization 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.

Page 137: NABH 3rd Edition Presentation

137

• 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.

c) The hospital has a multi-disciplinary infection control committee, which coordinates all infection prevention and control activities.

Page 138: NABH 3rd Edition Presentation

138

cont…

d. The hospital has an infection control team, which coordinates implementation of all infection prevention and control activities.

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.

Page 139: NABH 3rd Edition Presentation

139

HIC.2The organisation implements the

policies and procedures laid down in the Infection Control Manual.

• Objective elements

a) The organization 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.

Page 140: NABH 3rd Edition Presentation

140

Cont…

c) The organization adheres to hand-hygiene guidelines.

d) The organization adhere to safe injection and infusion practices.

e) The organization adheres to transmission-based precautions at all times.

f) The organization adheres to cleaning, disinfection and sterilization practices.

Page 141: NABH 3rd Edition Presentation

141

Cont…g) An appropriate antibiotic policy is

established and implemented.

h) The organization adheres to laundry and linen management processes.

i) The organization 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.

Page 142: NABH 3rd Edition Presentation

142

HIC.3The organization performs surveillance

activities to capture and monitor infection prevention and control data.

• 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.

Page 143: NABH 3rd Edition Presentation

143

Cont…

c) Verification of data is done on regular basis by the infection control team.

d) Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.

e) Surveillance activities include monitoring the compliance with hand-hygiene guidelines.

Page 144: NABH 3rd Edition Presentation

144

Cont…

f) Surveillance activities include monitoring the effectiveness of housekeeping services.

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.

Page 145: NABH 3rd Edition Presentation

145

HIC.4 The organization takes actions to

prevent and control Healthcare Associated Infections (HAI) in patients.

• Objective elementsa) The organization takes action to prevent

urinary tract infections.

b) The organization takes action to prevent respiratory tract infections.

c) The organization takes action to prevent intra-vascular device infections.

d) The organization takes action to prevent surgical site infections.

Page 146: NABH 3rd Edition Presentation

146

HIC.5 The organization provides adequate

and appropriate resources for prevention and control of Healthcare

Associated Infections (HAI).

• Objective elements

a) Adequate and appropriate personal protective equipment, soaps and disinfectants are available and used correctly.

Page 147: NABH 3rd Edition Presentation

147

Cont…

b) Adequate and appropriate facilities for hand hygiene in all patient-care areas are accessible to healthcare providers.

c) Isolation/ barrier nursing facilities are available.

d) Appropriate pre- and post-exposure prophylaxis is provided to all staff members concerned.

Page 148: NABH 3rd Edition Presentation

148

HIC.6 The organisation identifies and

takes appropriate action to control outbreaks of infections.

• Objective elements

a) Organization has a documented procedure for identifying an outbreak.

b) The organization has a documented procedure for handling such outbreaks.

Page 149: NABH 3rd Edition Presentation

149

Cont…

c) This procedure is implemented during outbreaks.

d) After the outbreak is over appropriate corrective actions are taken to prevent recurrence.

Page 150: NABH 3rd Edition Presentation

150

HIC.7 There are documented policies and

procedures for sterilization activities in the organisation.

• Objective elements

a) The organization provides adequate space and appropriate zoning for sterilization activities.

b) Documented procedure guides the cleaning, packing, disinfection and/or sterlization, storing and issue of items.

Page 151: NABH 3rd Edition Presentation

151

Cont…

c) Reprocessing of instruments and equipment are covered.

d) Regular validation tests for sterilization are carried out and documented.

e) There is an established recall procedure when breakdown in the sterilization system is identified.

Page 152: NABH 3rd Edition Presentation

152

HIC.8 Bio-medical Waste (BMW) is handled in

an appropriate and safe manner.

• Objective elements

a) The organization adheres to statutory provisions with regard to biomedical waste.

b) Proper segregation and collection of Bio-medical Waste from all patient care areas of the hospital is implemented and monitored.

Page 153: NABH 3rd Edition Presentation

153

Cont…c) The organization ensures that Bio-

medical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner.

d) Bio-medical 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 Bio-medical Waste.

Page 154: NABH 3rd Edition Presentation

154

HIC.9The infection control programme is supported by the management

and includes training of staff. • Objective elements

a) The management makes available resources required for the infection control programme.

b) The organization earmarks adequate funds from its annual budget in this regard.

Page 155: NABH 3rd Edition Presentation

155

Cont…

c) The organization conducts induction training for all staff.

d) The organization conducts appropriate “in-service” training sessions for all staff at least once in a year.

Page 156: NABH 3rd Edition Presentation

156

Chapter 6CONTINUOUS QUALITY

IMPROVEMENT (CQI)

Page 157: NABH 3rd Edition Presentation

157

CQI.1There is a structured quality improvement and continuous monitoring programme in

the organization.

• Objective elements

a) The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee.

b) The quality improvement programme is documented.

Page 158: NABH 3rd Edition Presentation

158

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 assurance and supports innovation.

Page 159: NABH 3rd Edition Presentation

159

Cont…

e) The designated programme is communicated and coordinated amongst all the staff of the organization through appropriate training mechanism.

f) The quality improvement programme identifies opportunities for improvement based on review at predefined intervals.

Page 160: NABH 3rd Edition Presentation

160

Cont…

g) The quality improvement programme is a continuous process and updated at least once in a year.

h) Audits are conducted at regular intervals as a means of continuous monitoring.

i) There is an established process in the organization to monitor and improve quality of nursing and complete patient care.

Page 161: NABH 3rd Edition Presentation

161

CQI.2There is a structured patient-safety

programme in the organization.

• Objective elements

a) The patient-safety programme is developed, implemented and maintained by a multi-disciplinary committee.

b) The patient-safety programme is documented.

Page 162: NABH 3rd Edition Presentation

162

Cont…

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".

e) There is a designated individual for coordinating and implementing the patient-safety programme.

Page 163: NABH 3rd Edition Presentation

163

Cont…

f) The designated programme is communicated and coordinated amongst all the staff of the organization through appropriate training mechanism.

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.

Page 164: NABH 3rd Edition Presentation

164

Cont…

i) The organization adapts and implements national/international patient-safety goals/solutions.

j) The organization uses at least two identifiers to identify patients across the organization.

Page 165: NABH 3rd Edition Presentation

165

CQI.3 The organization identifies key indicators

to monitor the clinical structures, processes and outcomes which are used as

tools for continual improvement.

• Objective elements

a)Monitoring includes appropriate patient assessment.

b)Monitoring includes safety and quality control programmes of the diagnostics services.

Page 166: NABH 3rd Edition Presentation

166

Cont…

c) Monitoring includes medication management.

d) Monitoring includes use of anaesthesia.e) Monitoring includes surgical services.f) Monitoring includes use of blood and

blood products.g) Monitoring includes infection control

activities.h) Monitoring includes review of mortality

and morbidity indicators.

Page 167: NABH 3rd Edition Presentation

167

Cont…

i) Monitoring includes clinical research.j) Monitoring includes data collection to

support further improvements.k) Monitoring includes data collection to

support evaluation of these improvements.

Page 168: NABH 3rd Edition Presentation

168

CQI.4 The organization identifies key indicators to monitor the managerial structures, processes

and outcomes which are used as tools for continual improvement.

• Objective elements

a) Monitoring includes procurement of medication essential to meet patient needs.

b) Monitoring includes risk management.

Page 169: NABH 3rd Edition Presentation

169

Cont…

c) Monitoring includes utilization of space, manpower and equipment.

d) Monitoring includes patient satisfaction which also incorporates waiting time for services.

e) Monitoring includes employee satisfaction.

f) Monitoring includes adverse events and near misses.

Page 170: NABH 3rd Edition Presentation

170

Cont…

g) Monitoring includes availability and content of medical records.

h) Monitoring includes data collection to support further study for improvements.

i) Monitoring includes data collection to support evaluation of these improvements.

Page 171: NABH 3rd Edition Presentation

171

CQI.5 The quality improvement programme is

supported by the management.

• Objective elements

a) The management makes available adequate resources required for quality improvement programme.

b) Organization earmarks adequate funds from its annual budget in this regard.

Page 172: NABH 3rd Edition Presentation

172

Cont…

c) The management identifies organizational performance improvement targets.

d) The management supports and implements use of appropriate quality improvement, statistical and management tools in its quality improvement programme.

Page 173: NABH 3rd Edition Presentation

173

CQI.6 There is an established system

for clinical audit.

• Objective elementsa) 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.

Page 174: NABH 3rd Edition Presentation

174

CQI.7 Incidents, complaints and feedback are collected and analyzed to ensure

continual improvement.

• Objective elementsa) The organization has an incident reporting

system.b) The organization has a process to collect

feedback and receive complaints.

Page 175: NABH 3rd Edition Presentation

175

Cont…

c) The organization has established processes for analysis of incidents, feedbacks and complaints.

d) Corrective and preventive actions are taken based on the findings of such analysis.

e) Feedback about care and service is communicated to staff.

Page 176: NABH 3rd Edition Presentation

176

CQI.8 Sentinel events are intensively

analysed. • Objective elementsa) 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.

Page 177: NABH 3rd Edition Presentation

177

Chapter 7RESPONSIBILITIES OF MANAGEMENT (ROM)

Page 178: NABH 3rd Edition Presentation

178

ROM.1 The responsibilities of those responsible

for governance are defined.

• Objective elements

a) Those responsible for governance lay down the organization’s vision, mission and values.

b) Those responsible for governance approve the strategic and operational plans and organization's budget.

Page 179: NABH 3rd Edition Presentation

179

Cont…

c) Those responsible for governance monitor and measure the performance of the organization against the stated mission.

d) Those responsible for governance establish the organization’s organogram.

e) Those responsible for governance appoint the senior leaders in the organization.

f) Those responsible for governance support safety initiatives and quality-improvement plans.

Page 180: NABH 3rd Edition Presentation

180

Cont…

g) Those responsible for governance support research activities.

h) Those responsible for governance address the organization’s social responsibility.

i) Those responsible for governance inform the public of the quality and performance of services.

Page 181: NABH 3rd Edition Presentation

181

ROM.2 The organization complies with

the laid-down and applicable legislations and regulations.

• Objective elements

a) The management is conversant with the laws and regulations and knows their applicability to the organization.

b) The management ensures implementation of these requirements.

Page 182: NABH 3rd Edition Presentation

182

Cont…

c) Management regularly updates any amendments in the prevailing laws of the land.

d) There is a mechanism to regularly update licenses/ registrations/certifications.

Page 183: NABH 3rd Edition Presentation

183

ROM.3 The services provided by each department are documented.

• Objective elements

a) Scope of services of each department is defined.

b) Administrative policies and procedures for each department is maintained.

c) Each organizational program, service, site or department has effective leadership.

d) Departmental leaders are involved in quality improvement.

Page 184: NABH 3rd Edition Presentation

184

ROM.4 The organization is managed by the leaders in an ethical manner.

• Objective elements

a) The leaders make public the vision, mission and values of the organization.

b) The leaders establish the organization’s ethical management.

c) The organization discloses its ownership.

Page 185: NABH 3rd Edition Presentation

185

Cont…

d) The organization honestly portrays the services which it can and cannot provide.

e) The organization honestly portrays its affiliations and accreditations.

f) The organization accurately bills for it’s services based upon a standard billing tariff.

Page 186: NABH 3rd Edition Presentation

186

ROM.5 The organisation displays professionalism

in management of affairs.

• Objective elements

a) The person heading the organization has requisite and appropriate administrative qualifications.

b) The person heading the organization has requisite and appropriate administrative experience.

Page 187: NABH 3rd Edition Presentation

187

Cont…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 stakeholders.

d) The organization coordinates the functioning with departments and external agencies and monitors the progress in achieving the defined goals and objectives.

Page 188: NABH 3rd Edition Presentation

188

Cont…e) The organization plans and budgets for

its activities annually.f) The performance of the senior leaders is

reviewed for their effectiveness.g) The functioning of committees is

reviewed for their effectiveness.h) The organization documents employee

rights and responsibilities.

Page 189: NABH 3rd Edition Presentation

189

Cont…i) The organization documents the service

standards.j) The organization has a formal

documented agreement for all outsourced services.

k) The organization monitors the quality of the outsourced services.

Page 190: NABH 3rd Edition Presentation

190

ROM.6 Management ensures that patient-safety

aspects and risk-management issues are an integral part of patient care and hospital

management.

• Objective elements

a) Management ensures proactive risk management across the organization.

b) Management provides resources for proactive risk assessment and risk reduction activities.

Page 191: NABH 3rd Edition Presentation

191

Cont…c) Management ensures implementation of

systems for internal and external reporting of system and process failures.

d) Management ensures that appropriate corrective and preventive actions are taken to address safety-related incidents.

Page 192: NABH 3rd Edition Presentation

192

Chapter 8FACILITY MANAGEMENT AND

SAFETY (FMS)

Page 193: NABH 3rd Edition Presentation

193

FMS.1 The organisation has a system in place to provide a safe and

secure environment.

• Objective elements

a) Safety committee coordinates development, implementation, and monitoring of the safety plan and policies.

Page 194: NABH 3rd Edition Presentation

194

Cont…

b) Patient safety devices are installed across the organization and inspected periodically.

c) The organization is a non-smoking area.

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.

Page 195: NABH 3rd Edition Presentation

195

Cont…

e) Inspection reports are documented and corrective and preventive measures are undertaken.

f) There is a safety education programme for all staff.

Page 196: NABH 3rd Edition Presentation

196

FMS.2 The organization’s environment and facilities operate to ensure safety of

patients, their families, staff and visitors.

• Objective elements

a) Facilities are appropriate to the scope of services of the organization.

b) Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.

Page 197: NABH 3rd Edition Presentation

197

Cont…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.

e) Potable water and electricity are available round the clock.

Page 198: NABH 3rd Edition Presentation

198

Cont…

f) Alternate sources for electricity and water are provided as backup for any failure/shortage.

g) The organisation regularly tests the alternate sources.

h) There are designated individuals responsible for the maintenance of all the facilities.

Page 199: NABH 3rd Edition Presentation

199

Cont…

i) There is a documented operational and maintenance (preventive and breakdown) plan.

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.

Page 200: NABH 3rd Edition Presentation

200

FMS.3 The organization has a program for engineering support services.

• Objective elements

a) The organization plans for equipment in accordance with its services and strategic plan.

b) Equipments are selected, rented, updated or upgraded by a collaborative process.

Page 201: NABH 3rd Edition Presentation

201

Cont…

c) Equipments are inventoried and proper logs are maintained as required.

d) Qualified and trained personnel operate and maintain equipment and utility systems.

e) There is a documented operational and maintenance (preventive and breakdown) plan.

Page 202: NABH 3rd Edition Presentation

202

Cont…

f) There is a maintenance plan for water management.

g) There is a maintenance plan for electrical systems.

h) There is a maintenance plan for heating, ventilation and air-conditioning.

i) There is a documented procedure for equipment replacement and disposal.

Page 203: NABH 3rd Edition Presentation

203

FMS.4 The organization has a

programme for bio-medical equipment management.

• Objective elementsa) The organization plans for equipment in

accordance with its services and strategic plan.

b) Equipment are selected, rented, updated or upgraded by a collaborative process.

Page 204: NABH 3rd Edition Presentation

204

Cont…c) Equipment are inventoried and proper logs are

maintained as required.

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.

Page 205: NABH 3rd Edition Presentation

205

FMS.5The organization has a

programme for medical gases, vacuum and compressed air.

• 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.

Page 206: NABH 3rd Edition Presentation

206

Cont…c) The procedures for medical gases

address the safety issues at all levels.

d) Alternate sources for medical gases, vacuum and compressed air are provided for, in case of failure.

e) The organization regularly tests these alternate sources.

f) There is a maintenance plan for piped medical gas, compressed air and vacuum installation.

Page 207: NABH 3rd Edition Presentation

207

FMS.6The organization has plans for fire and non-fire emergencies

within the facilities. • Objective elementsa) The organization has plans and provisions

for early detection, abatement and containment of fire and non-fire emergencies.

b) The organization has a documented safe exit plan in case of fire and non-fire emergencies.

Page 208: NABH 3rd Edition Presentation

208

Cont…c) Staff is trained for its role in case of such

emergencies.

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

e) There is a maintenance plan for fire-related equipment.

Page 209: NABH 3rd Edition Presentation

209

FMS.7The organization plans for handling community emergencies, epidemics

and other disasters.

• Objective elements

a) The organization identifies potential emergencies.

b) The organization has a documented disaster management plan.

Page 210: NABH 3rd Edition Presentation

210

Cont…

c) Provision is made for availability of medical supplies, equipment and materials during such emergencies.

d) Staff are trained in the hospital’s disaster management plan.

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

Page 211: NABH 3rd Edition Presentation

211

FMS.8The organization has a plan for

management of hazardous materials.

• Objective elements

a) Hazardous materials are identified within the organization.

b) The hospital implements processes for sorting, labeling, handling, storage, transporting and disposal of hazardous material.

Page 212: NABH 3rd Edition Presentation

212

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 are educated and trained for handling such materials.

Page 213: NABH 3rd Edition Presentation

213

FMS.9The hospital has system in place to

provide a safe and secure environment

• Objective elements

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.

Page 214: NABH 3rd Edition Presentation

214

Cont…

c) 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.

d) Inspection reports are documented and corrective and preventive measures are undertaken.

e) There is a safety education programme for all staff.

Page 215: NABH 3rd Edition Presentation

215

Chapter 9HUMAN RESOURCE

MANAGEMENT

Page 216: NABH 3rd Edition Presentation

216

HRM.1The organization has a

documented system of human resource planning.

• Objective elements

a) Human resource planning supports the organization's current and future ability to meet the care, treatment and service needs of the patient.

Page 217: NABH 3rd Edition Presentation

217

Cont…b) The organization maintains an adequate

number and mix of staff to meet the care, treatment and service needs of the patient.

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.

Page 218: NABH 3rd Edition Presentation

218

HRM.2The organization has a documented

procedure for recruiting staff and orienting them to the organization's environment.

• Objective elements

a) There is a documented procedure for recruitment.

b) Recruitment is based on pre-defined criteria.

Page 219: NABH 3rd Edition Presentation

219

Cont…c) Every staff member entering the

organization is provided induction training.

d) The induction training includes orientation to the organization’s vision, mission and values.

e) The induction training includes awareness on employee rights and responsibilities.

Page 220: NABH 3rd Edition Presentation

220

Cont…f) The induction training includes

awareness on patients’ rights and responsibilities.

g) The induction training includes orientation to the service standards of the organisation.

h) Each staff member is made aware of organization wide policies and procedures as well as relevant department / unit / service / programme’s policies and procedures.

Page 221: NABH 3rd Edition Presentation

221

HRM.3There is an ongoing programme

for professional training and development of the staff.

• Objective elementsa) A documented training and development

policy exists for the staff.b) The organization maintains the training

record.

Page 222: NABH 3rd Edition Presentation

222

Cont…c) Training also occurs when job

responsibilities change/ new equipment is introduced.

d) Feedback mechanisms for assessment of training and development programme exist and the feedback is used to improve the training programme.

Page 223: NABH 3rd Edition Presentation

223

HRM.4Staff are adequately trained on various safety-related aspects.

• Objective elements

a) Staff are trained on the risks within the organization's environment.

b) Staff members can demonstrate and take actions to report, eliminate / minimize risks.

Page 224: NABH 3rd Edition Presentation

224

Cont…c) Staff members are made aware of

procedures to follow in the event of an incident.

d) Staff are trained on occupational safety aspects.

Page 225: NABH 3rd Edition Presentation

225

HRM.5An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource

management process.

• Objective elements

a) A documented performance appraisal system exists in the organization.

Page 226: NABH 3rd Edition Presentation

226

Cont…

b) The employees are made aware of the system of appraisal at the time of induction.

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.

Page 227: NABH 3rd Edition Presentation

227

HRM.6The organization has documented

disciplinary and grievance-handling policies and procedures.

• Objective elements

a) Documented policies and procedures exist.

b) The policy and procedure are known to all categories of staff of the organization.

Page 228: NABH 3rd Edition Presentation

228

Cont…c) The disciplinary policy and procedure is

based on the principles of natural justice.

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.

Page 229: NABH 3rd Edition Presentation

229

HRM.7The organization addresses the health needs of the employees.

• 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 organization’s policy.

Page 230: NABH 3rd Edition Presentation

230

Cont…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.

Page 231: NABH 3rd Edition Presentation

231

HRM.8 There is a documented personal

record for each staff member.

• Objective elements

a) Personal files are maintained in respect of all employees.

b) The personal files contain personal information regarding the employees qualification, disciplinary background and health status.

Page 232: NABH 3rd Edition Presentation

232

Cont…

c) All records of in-service training and education are contained in the personal files.

d) Personal files contain result of all evalutions.

Page 233: NABH 3rd Edition Presentation

233

HRM.9 There is a process for credentialing

and privileging of medical professionals permitted to provide patient care without supervision.

• Objective elements

a) Medical professionals permitted by law, regulation and the organization to provide patient care without supervision is identified.

Page 234: NABH 3rd Edition Presentation

234

Cont…

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.

Page 235: NABH 3rd Edition Presentation

235

Cont…d) Medical professionals are granted privileges

to admit and care for patients in consonance with their qualification, training, experience and registration.

e) The requisite services to be provided by the medical professionals are known to them as well as the various departments/ units of the hospital.

f) Medical professionals admit and care for patients as per their privileging.

Page 236: NABH 3rd Edition Presentation

236

HRM.10 There is a process for credentializing

and privileging of nursing professionals permitted to provide patient care without supervision.

• Objective elements

a) Nursing staff permitted by law, regulation and the organization to provide patient care without supervision are identified.

Page 237: NABH 3rd Edition Presentation

237

Cont…

b) The education, registration, training and experience of nursing staff is documented and updated periodically.

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.

Page 238: NABH 3rd Edition Presentation

238

Cont…e) The requisite services to be provided by

the nursing staff are known to them as well as the various departments / units of the hospital.

f) Nursing professionals care for patients as per their privileging.

Page 239: NABH 3rd Edition Presentation

239

Chapter10INFORMATION

MANAGEMENT SYSTEM (IMS)

Page 240: NABH 3rd Edition Presentation

240

IMS.1Documented 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.

Page 241: NABH 3rd Edition Presentation

241

• 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 are documented.

c) These policies and procedures are in compliance with the prevailing laws and regulations.

Page 242: NABH 3rd Edition Presentation

242

Cont…

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.

Page 243: NABH 3rd Edition Presentation

243

IMS.2 The organization has processes

in place for effective management of data.

• Objective elements

a) Formats for data collection are standardized.

b) Necessary resources are available for analyzing data.

Page 244: NABH 3rd Edition Presentation

244

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.

Page 245: NABH 3rd Edition Presentation

245

IMS.3 The organization has a complete and accurate medical record for

every patient. • Objective elements

a) Every medical record has a unique identifier.

b) Organisation policy identifies those authorized to make entries in medical record.

Page 246: NABH 3rd Edition Presentation

246

Cont…c) Entry in the medical record is named, signed,

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 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.

Page 247: NABH 3rd Edition Presentation

247

IMS.4 The medical record reflects

continuity of care. • Objective elements

a) The medical record contains information regarding reasons for admission, diagnosis and plan of care.

b) The medical record contains the result of tests carried out and the care provided.

Page 248: NABH 3rd Edition Presentation

248

Cont…

c) Operative and other procedures performed are incorporated in the medical record.

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.

Page 249: NABH 3rd Edition Presentation

249

Cont…e) The medical record contains a copy of

the discharge summary duly signed by appropriate and qualified personnel.

f) In case of death, the medical record contains a copy of the 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.

Page 250: NABH 3rd Edition Presentation

250

IMS.5Documented policies and procedures are in place for maintaining confidentiality, integrity and security of records, data

and information.

• Objective elements

a) Documented policies and procedures exist for maintaining confidentiality, security and integrity of records, data and information.

Page 251: NABH 3rd Edition Presentation

251

Cont…

b) Documented 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 organization has an effective process of monitoring compliance of the laid down policy and procedure.

Page 252: NABH 3rd Edition Presentation

252

Cont…

e) The organization 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.

Page 253: NABH 3rd Edition Presentation

253

Cont…

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.

Page 254: NABH 3rd Edition Presentation

254

IMS.6Documented policies and

procedures exist for retention time of records, data and information.

• 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.

Page 255: NABH 3rd Edition Presentation

255

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.

Page 256: NABH 3rd Edition Presentation

256

IMS.7The organization regularly carries

out review of medical records.

• 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.

Page 257: NABH 3rd Edition Presentation

257

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 are undertaken within a defined period of time and are documented.

Page 258: NABH 3rd Edition Presentation

258

Thank you