nabh 3rd edition

7/31/2019 NABH 3rd Edition

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

10 Chapters

1

102 Standards

636 Objective Elements

Updated by Anuj Jindal [[email protected]]

iKure Knowledge Serviceswww.ikureknowledge.blogspot.in


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Standards and Objective Elements

A standard is a statement that defines thestructures and processes that must besubstantially in place in an organization to

2

en ance e qua y o care Objective element is a measurable component

of a standard

Acceptable compliance with objective elementsdetermines the overall compliance with astandard


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Section I:Patient-Centered Standards

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

Chapter 2 Patients Rights and Education (PRE)

3

Chapter 3 Care of Patients (COP)

Chapter 4 Management of Medications (MOM)

Chapter 5 Hospital Infection Control (HIC)


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Section II:Management-Centered Standards

Chapter 6 Continuous Quality Improvement (CQI)

Chapter 7 Responsibilities of Management (ROM)

4

Chapter 8 Facility Management & Safety (FMS)

Chapter 9 Human Resource Management (HRM)

Chapter 10 Information Management Systems (IMS)


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NABH STANDARDS

5


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Chapter 1ACCESS, ASSESSMENT

6

(AAC)


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AAC.1The organization defines anddisplays the services that it

provides.

Ob ective Elements

7

a) The services being provided are clearlydefined and are in consonance with the needs

of the community.

b) The defined services are prominentlydisplayed.

c) The staff is oriented to these services


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AAC.2The organization has a well defined

registration and admission process.

Objective elements

D m nt d li i nd r d r r

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used for registering and admittingpatients.

b) The documented procedures addressout-patients, in-patients and emergency

patients.


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Contc) A unique identification number is

generated at the end of registration.d) Patients are accepted only if the

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service.

e) The documented policies and

procedures also address managingpatients during non availability of beds.

f) The staff is aware of these processes.


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AAC.3There is an appropriate mechanism

for transfer or referral of patients.

Objective elements

10

guide the transfer-in of patients to the

organization.

b) Documented policies and proceduresguide the transfer-out/referral of unstable

patients to another facility in an

appropriate manner.


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Contc) Documented policies and procedures

guide the transfer-out/referral of stablepatients to another facility in an

a ro riate manner.

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d) The documented procedures identify

staff responsible during transfer/referral.

e) The organization gives a summary of patients condition and the treatment

given.


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AAC.4

Patients cared for by the

organization undergo an established

initial assessment. Objective elements

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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.


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Contc) The organization defines the time frame

within which the initial assessment iscompleted based on patient's needs.

d) The initial assessment for in-patients is

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documented within 24 hours or earlier asper 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.


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Cont

f) Initial assessment includes screening for

nutritional needs.

g) The initial assessment results in a

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ocumen e p an o care.h) The plan of care also includes preventive

aspects of the care where appropriate.


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Cont

i) The plan of care is countersigned by the

clinician in-charge of the patient within 24hours.

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e p an o care nc u es goa s ordesired results of the treatment, care or

service.


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AAC.5Patients cared for by the

organization undergo a regular

reassessment.

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a) Patients are reassessed at appropriate

intervals.

b) Out-patients are informed of their nextfollow-up, where appropriate.


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contc) For in-patients during reassessment the

plan of care is monitored and modified,where found necessary.

d) Staff involved in direct clinical care

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document reassessments.e) Patients are reassessed to determine

their response to treatment and to plan

further treatment or discharge.


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AAC.6

Laboratory services are provided asper the scope of services of the

organization. Objective elements.

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commensurate to the services provided

by the organization.

b) The infrastructure (physical andmanpower) is adequate to provide for its

defined scope of services.


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contc) Adequately qualified and trained

personnel perform, supervise andinterpret the investigations.

d) Documented procedures guide ordering

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of tests, collection, identification,handling, safe transportation, processingand disposal of specimens.

e) Laboratory results are available within adefined time frame.


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contf) Critical results are intimated immediately

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

manner.

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h) Laboratory tests not available in theorganization are outsourced toorganization(s) based on their quality

assurance system.


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AAC.7There is an established laboratory

quality assurance programme

Objective elements

Th l b r t r lit r n

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programme is documented.

b) The programme addresses verification

and/or validation of test methods.c) The programme addresses surveillance

of test results.


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cont

d) The programme includes periodic

calibration and maintenance of allequipment.

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documentation of corrective and

preventive actions.


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AAC.8There is an established

laboratory-safety programme.

Objective elements.

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documented.

b) This programme is aligned with the

organization's safety programme.


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AAC.9

Imaging services are provided as per thescope of services of the organization.

Objective elementsa) Imaging services comply with the legal

and other requirements.

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b) Scope of the imaging services iscommensurate to the services provided

by the organization.

c) The infrastructure (physical and

manpower) is adequate to provide for its

defined scope of services.


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contd) Adequately qualified and trained

personnel perform, supervise andinterpret the investigations.

e) Documented policies and procedures

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transportation of patients to imagingservices.

f) Imaging results are available within adefined time frame.


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contg) Critical results are intimated immediately

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

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i) Imaging tests not available in theorganization are outsourced toorganization(s) based on their quality

assurance system.


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AAC.10

There is an established qualityassurance programme for

imaging services. Objective elements

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a e qua y assurance program or imaging services is documented.

b) The programme addresses verification

and/or validation of imaging methods.c) The programme addresses surveillance

of imaging results.


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contd) The programme includes periodic

calibration and maintenance of allequipment.

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documentation of corrective and

preventive actions.


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AAC.11

There is an established radiationsafety programme.

Objective elementsa) The radiation-safety programme is

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.

b) This programme is aligned with the

organizations safety programme.

c) Handling, usage and disposal of radio-active and hazardous materials are as

per statutory requirements.


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contd) Imaging personnel are provided with

appropriate radiation safety devices.e) Radiation safety devices are periodically

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f) Imaging personnel are trained in radiation

safety measures.

g) Imaging signage are prominentlydisplayed in all appropriate locations.


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AAC.12

Patient care is continuous andmultidisciplinary in nature.

Objective elements

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,

qualified individual identified as

responsible for the patients care.

b) Care of patients is coordinated in all caresetting within the organization.


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cont

c) Information about the patient's care andresponse to treatment is shared amongmedical, nursing and other care providers.

d) Information is exchanged and documented

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, ,and during transfers between units/departments.

e) Transfers between departments/units are

done in a safe manner.


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cont

f) The patients record(s) is available to theauthorized care providers to facilitate theexchange of information.

g) Documented procedures guide the referral

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specialties.


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contc) Documented policies and procedures are

in place for patients leaving againstmedical advice and patients being

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.

d) A discharge summary is given to all the

patients leaving the organization

(including patients leaving againstmedical advice and on request).


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AAC.14

Organization defines the contentof the discharge summary.

Objective elements

a) Discharge summary is provided to the

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patients at the time of discharge.b) Discharge summary contains the

patient's name, unique identification

number, date of admission and date ofdischarge.


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contc) Discharge summary contains the

reasons for admission, significantfindings and diagnosis and the patients

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.

d) Discharge summary contains information

regarding investigation results, any

procedure performed, medicationadministered and other treatment given.


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conte) Discharge summary contains follow up

advice, medication and other instructionsin an understandable manner.

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instructions about when and how to

obtain urgent care.

g) In case of death, the summary of thecase also includes the cause of death.


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Chapter 2

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are o a en s


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

regulations and guidelines.

Objective elements

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a are e very s un orm or a g ven

health problem when similar care is

provided in more than one setting.

b) Uniform care is guided by documentedpolicies and procedures.


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contc) These reflect applicable laws, regulations

and guidelines.d) The organization adopts evidence-based

medicine and clinical ractice uidelines

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to guide uniform patient care.

COP 2


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COP.2

Emergency services are guided bydocumented policies, procedures

and applicable laws and regulations.Objective elements

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care are documented and are inconsonance with statutory requirements.

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

c) The patients receive care in consonance

with the policies.

t


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contd) 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

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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 toanother organization a discharge note shall

be given to patient.


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COP.3The ambulance services arecommensurate with the scope of the

services provided by the organization.

Ob ective elements

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

b) The ambulance adheres to statutoryrequirements.

c) Ambulance(s) is appropriately equipped.

cont


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cont

d) Ambulance(s) is manned by the trainedpersonnel.

e) Ambulance(s) is checked on a daily

basis.

f) Equipment are checked on a daily basis

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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.


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COP.4Documented policies and procedures

guide the care of patients requiring

cardio-pulmonary resuscitation. Objective elements

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a) Documented policies and proceduresguide the uniform use of resuscitation

throughout the organization.

b) Staff providing direct patient care aretrained and periodically updated in cardio

pulmonary resuscitation.


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contc) The events during a cardio pulmonary

resuscitation are recorded.d) A post-event analysis of all cardio-

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multidisciplinary committee.

e) Corrective and preventive measures are

taken based on the post-event analysis.


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COP.5

Documented policies and

procedures guide nursing care.

Objective elements

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a) There are documented policies andprocedures for all activities of the nursing

services.

b) These reflect current standards ofnursing services and practice, relevant

regulations and purposes of the services.


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Contc) Assignment of patient care is done as percurrent good practice guidelines.

d) Nursing care is aligned and integrated withoverall patient care.

e Care rovided b nurses is documented in

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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.


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COP.6Documented procedures guide the

performance of various procedures.

Objective elements

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a) Documented procedures are used toguide the performance of various clinical

procedures.

b) Only qualified personnel order, plan,perform and assist in performing

procedures.

cont


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cont

c) Documented procedures exist to preventadverse events like wrong site, wrongpatient and wrong procedure.

d) Informed consent is taken by the personnelperforming the procedure, whereapplicable.

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e) Adherence to standard precautions andasepsis is adhered to during the conduct ofthe procedure.

f) Patients are appropriately monitored duringand after the procedure.

g) Procedures are documented accurately in

the patient record.

COP 7


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COP.7

Documented policies andprocedures define rational use of

blood and blood products.

Objective elements

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a) Documented policies and procedures areused to guide rational use of blood and

blood products.

b) Documented procedures guide

transfusion of blood and blood products.

t


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cont

c) The transfusion services are governed by the

applicable laws and regulations.

d) Informed consent is obtained for donation andtransfusion of blood and blood products.

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family education about donation.f) The organization defines the process for

availability and transfusion of blood/blood

components for use in emergency.

cont


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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.

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COP 8


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COP.8

Documented policies and proceduresguide the care of patients in the Intensive

Care and high dependency units.

Objective elements.

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a) Documented policies and procedures areused to guide the care of patients in the

intensive care and high dependency

units.

cont


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cont

b) The organization has documented

admission and discharge criteria for its

intensive care and high dependencyunits.

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c a a e a e o a y ese c e a.

d) Adequate staff and equipment are

available.

e) Defined procedures for situation of bedshortages are followed.

cont


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cont

f) Infection control practices are

documented and followed.

g) A quality assurance programme isdocumented and implemented.

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COP 9


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COP.9

Documented policies and procedures guide thecare of vulnerable patients (elderly, children,

physically and/ or mentally challenged).

Objective elements.

a) Policies and procedures are documented

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and are in accordance with the prevailinglaws and the national and international

guidelines.

b) Care is organised and delivered inaccordance with the policies and

procedures.


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contc) The organisation provides for a safe

and secure environment for thisvulnerable group.

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obtaining informed consent from theappropriate legal representative.

e) Staff are trained to care for this

vulnerable group.

COP 10


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COP.10


procedures guide obstetric care.

Objective elements

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a) There is a documented policy and

procedure for obstetric services.

b) The organisation defines and displays

whether high-risk obstetric cases becared for or not.

cont


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c) Persons caring for high-risk obstetric casesare competent.

d) Documented procedures guide provision forante-natal services.

e) Obstetric patient's assessment also includes

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ma erna nu r on.

f) Appropriate pre-natal, peri-natal and post-natal monitoring is performed anddocumented.

g) The organization caring for high-riskobstetric cases has the facilities to take careof neonates of such cases.

COP.11


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Documented policies and proceduresguide paediatric services.

Objective elements

a) There is a documented policy and

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

c) The policy for care of neonatal patients is

in consonance with the national/

international guidelines.

cont


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cont

d) Those who care for children have age specificcompetency.

e) Provisions are made for special care ofchildren.

f) Patient assessment includes detailed

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, ,

immunization assessment.g) Documented policies and procedures prevent

child/ neonate abduction and abuse.

h) The childrens family members are educatedabout nutrition, immunization and safeparenting and this is documented in themedical record.

COP.12


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Documented policies and proceduresguide the care of patients undergoing

moderate sedation.

Objective elements

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administration of moderate sedation.

b) Informed consent for administration of

moderate sedation is obtained.c) Competent and trained persons perform

sedation.

cont


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contd) The person administering and monitoring

sedation is different from the personperforming the procedure.

e) Intra procedure monitoring includes ata minimum the heart rate, cardiac

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rhythm, respiratory rate, blood pressure,oxygen saturation and level of sedation.

f) Patients are monitored after sedation

and the same is documented.


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contg) Criteria are used to determine

appropriateness of discharge from therecovery area.

h E ui ment and man ower are available

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to manage patients who have gone into adeeper level of sedation than thatintended.

COP.13


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Documented policies andprocedures guide the

administration of anesthesia. Objective elements.

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a) There is a documented policy andprocedure for the administration of

anesthesia.

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

anaesthesiologist.

cont


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cont

c) The pre-anesthesia assessment results

in formulation of an anesthesia plan

which is documented.

d An immediate reo erative re-evaluation

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is performed and documented.e) Informed consent for administration of

anesthesia is obtained by the

anesthesiologist.

cont


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cont

f) During anesthesia monitoring includes

regular recording of temperature, heart

rate, cardiac rhythm, respiratory rate,blood pressure, oxygen saturation and

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.

g) Patients post-anesthesia status is

monitored and documented.

h) The anaesthesiologist applies definedcriteria to transfer the patient from the

recovery area.

cont


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cont

i) The type of anaesthesia and anaesthetic

medications used is documented in the

patient record.j) Procedures shall comply with infection

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contro gu e nes to prevent cross-

infection between patients.

k) Adverse anesthesia events are recorded

and monitored.


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cont


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d) Documented policies and procedure existto 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

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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.

cont


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h) Patient, personnel and material flowconforms to infection control practices.

i) Appropriate facilities and equipment/

appliances/ instrumentation are available

in the operating theatre.

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j) A quality assurance programme isfollowed for the surgical services.

k) The quality assurance program includes

surveillance of the operation theatreenvironment.

COP.15


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Documented policies and proceduresguide the care of patients under

restraints (physical and/ or chemical). Objective elements

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a) Documented policies and procedures

guide the care of patients under

restraints.

b) These include both physical andchemical restraint measures.

cont


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cont

c) These include documentation of reasons

for restraints.

d) These patients are more frequently

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e) Staff receive training and periodicupdating in control and restraint

techniques.

COP.16


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Documented policies andprocedures guide appropriate

pain management.

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.

a) Documented policies and proceduresguide the management of pain.

b) All patients are screened for pain.


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contc) Patients with pain undergo detailed

assessment and periodic re-assessment.d) The organization respects and supports

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.

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

COP.17


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Documented policies andprocedures guide appropriate

rehabilitative services. Objective elements

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a ocumen e po c es an proce ures

guide the provision of rehabilitativeservices.

b) These services are commensurate withthe organizational requirements.

cont


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c) Care is guided by functional assessment

and periodic re-assessment which is

done and documented by qualifiedindividual(s).

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are s prov e a er ng to n ect on

control and safe practices.

e) Rehabilitative services are provided by a

multidisciplinary team.f) There is adequate space and equipment

to perform these activities.


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cont


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d) Patients informed consent is obtainedbefore entering them in research

protocols.

e) Patients are informed of their right to

withdraw from the research at an sta e

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and also of the consequences (if any) ofsuch withdrawal.

f) Patients are assured that their refusal to

participate or withdrawal fromparticipation will not compromise their

access to the organizations services.

COP.19


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Documented policies and proceduresguide nutritional therapy.

Objective elementsa) Documented policies and procedures

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gu e nu r ona assessmen an

reassessment.

b) Patients receive food according to their

clinical needs.

cont


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c) There is a written order for the diet.

d) Nutritional therapy is planned and

provided in a collaborative manner.

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,

educated about the patients dietlimitations.

f) Food is prepared, handled, stored and

distributed in a safe manner.

COP.20


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Documented policies and proceduresguide the end of life care.

Objective elements


85

.

b) These policies and procedures are inconsonance with the legal requirements.

c) These also address the identification ofthe unique needs of such patient and

family.

cont


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d) Symptomatic treatment is provided and

where appropriate measures are taken

for alleviation of pain.

e) Staff is educated and trained in end of

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life care.


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Chapter 3

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MEDICATION (MOM)

MOM.1

D t d li i d d


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Documented policies and proceduresguide the organization of pharmacy

services and usage of medication.

Objective elements

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a ere s a ocumen e po cy an

procedure for pharmacy services andmedication usage.

b) These comply with the applicable lawsand regulations.

cont


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c) A multidisciplinary committee guides the

formulation and implementation of thesepolicies and procedures.

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medication when the pharmacy is closed.

MOM.2

Th i h it l f l


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There is a hospital formulary.

Objective elements

a) A list of medications appropriate for theatients and as er the sco e of the

90

organizations clinical services isdeveloped.

b) The list is developed and updated

collaboratively by the multidisciplinarycommittee.

cont


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c) The formulary is available for clinicians to

refer and adhere to.d) There is a defined process for acquisition

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.

e) There is a process to obtain medicationsnot listed in the formulary.

MOM.3

Documented policies and procedures


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Documented policies and proceduresguide the storage of medication.


92

.

b) Medications are stored in a clean, safeand secure environment; and

incorporating manufacturer's

recommendation(s).

cont

c) Sound inventory control practices guide


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c) Sound inventory control practices guidestorage of the medications.

d) Sound alike and look alike medicationsare identified and stored separately.

93

defined and is stored in a uniformmanner.

f) Emergency medications are available all

the time.g) Emergency medications are replenished

in a timely manner when used.

MOM.4Documented policies and procedures

guide the safe and rational prescription


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guide the safe and rational prescription

of medications.


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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.

cont

d) Known drug allergies are ascertained before


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d) Known drug allergies are ascertained beforeprescribing.

e) The organization determines who can write

orders.f) Orders are written in a uniform location in the

95

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.

cont

i) Documented policy and procedure on verbal


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i) Documented policy and procedure on verbalorders is implemented.

j) The organization defines a list of high-risk

medication(s).

k Audit of medication orders/ rescri tion is

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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, whereappropriate.

MOM.5



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Documented policies andprocedures guide the safe

dispensing of medications.

Objective elements

97


guide the safe dispensing of

medications.

b) The procedure addresses medicationrecall.

cont


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c) Expiry dates are checked prior to

dispensing.d) There is a procedure for near expiry

98

.

e) Labeling requirements are documentedand implemented by the organization.

f) High-risk medication orders are verifiedprior to dispensing.


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cont

d) Medication is verified from the order prior


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d) Medication is verified from the order prior

to administration.

e) Dosage is verified from the order prior toadministration.

100

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.

cont


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i) Documented polices and procedures

govern patients self administration ofmedications.

101

ocumen e po ces an proce ures

govern patients medications broughtfrom outside the organization.

MOM.7

Patients are monitored after


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Patients are monitored aftermedication administration.

Objective elements

D m nt d li i nd r d r

102

guide the monitoring of patients aftermedication administration.

b) The organization defined those situation

where close monitoring is required.

cont


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c) Monitoring is done in a collaborative

manner.

d) Medications are changed where

103

.

MOM.8

Near misses medication errorsd d d t


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Near misses, medication errorsand adverse drug events are

reported and analyzed.

Objective elements

104

a) Documented procedures exist to capture

near miss, medication error and adversedrug event.

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

cont


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c) These are reported within a specified

time frame.

d) They are collected and analysed.

105

e orrec ve an or preven ve ac on s

are taken based on the analysis whereappropriate.

MOM.9

Documented proceduresid th f ti d


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Documented proceduresguide the use of narcotic drugs

and psychotropic substances.

Ob ective elements

106

a) Documented procedures guide the useof narcotic drugs and psychotropic

substances which are in consonance

with local and national regulations.

cont


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b) These drugs are stored in a secure

manner.

c) A proper record is kept of the usage,

107

drugs.d) These drugs are handled by appropriate

personnel in accordance with the

documented procedure.

MOM.10



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Documented policies andprocedures guide the usage of

chemotherapeutic agents.

108

.

a) Documented policies and proceduresguide the usage of chemotherapeutic

agents.

cont


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b) Chemotherapy is prescribed by those

who have the knowledge to monitor and

treat the adverse effect of chemotherapy.

109

and safe manner and administered byqualified personnel.

d) Chemotherapy drugs are disposed off in

accordance with legal requirements.

MOM.11



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pprocedures govern usage of

radioactive drugs.

110

ec ve e emen s.

a) Documented policies and proceduresgovern usage of radioactive drugs.

cont


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b) These policies and procedures are in

consonance with laws and regulations.

c) The policies and procedures include the

111

, , ,

distribution, and disposal of radioactivedrugs.

d) Staff, patients and visitors are educated

on safety precautions.

MOM.12

Documented policies and proceduresguide the use of implantable prosthesis


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guide the use of implantable prosthesis

and medical devices.

Objective elements

112

a) Usage of implantable prosthesis and

medical devices is guided by scientificcriteria for each individual item and

national/international recognized

guidelines/approvals for such specific

item(s).

Cont

b) Documented policies and procedures


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govern procurement, storage/stocking,

issuance and usage of implantable

prosthesis and medical devices

'

113

recommendation(s).c) Patient and his/her family are counseled

for the usage of implantable prosthesis

and medical device includingprecautions, if any.

Cont

d) The batch and serial number of the


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implantable prosthesis and medical

devices are recorded in the patients

medical record and the master logbook.

114

MOM.13

Documented policies and proceduresguide the use of medical supplies and


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guide the use of medical supplies and

consumables.

Objective elements

115

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.

Cont

c) Medical supplies and consumables aret d i l f d


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stored in a clean, safe and secure

environment; and incorporating

manufacturer's recommendation(s).

116

storage of medical supplies andconsumables.


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Chapter 4

117

EDUCATION (PRE)

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


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family rights and informs them about

their responsibilities during care.

Objective element

118

a) Patient and family rights and

responsibilities are documented anddisplayed.

b) Patients and families are informed of theirrights and responsibilities in a format and

language that they can understand.

cont

c) The organizations leaders protect


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c) The organizations leaders protect

patient's and family rights.

d) Staff is aware of its responsibility in

119

.

e) Violation of patient and family rights isrecorded, reviewed and corrective/

preventive measures taken.

PRE.2.

Patient and family rights supportindividual beliefs values and involve the


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individual beliefs, values and involve the

patient and family in decision-making

processes.

120

Objective elements

a) Patient and family rights include respecting

any special preferences, spiritual and cultural

needs.

b) Patient and family rights include respect for

personal dignity and privacy during

examination, procedures and treatment.

cont

c) Patient and family rights include protectionfrom physical abuse and neglect.


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from physical abuse and neglect.

d) Patient and family rights include treating

patient information as confidential.

e Patient and famil ri hts include refusal of

121

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.

cont

g) Patient and family rights include right tocomplain and information on how to


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pvoice a complaint.

h) Patient and family rights includeinformation on the expected cost of the

122

rea men .

i) Patient and family rights include accessto his/ her clinical records.

j) Patient and family rights include

information on plan of care, progress andinformation on their health care needs.

PRE.3The patient and/or family members

d t d t k i f d


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are educated to make informed

decisions and are involved in thecare planning and delivery process.

123

Objective elementsa) The patient and/or family members are

explained about the proposed care

includinng the risks, alternatives andbenefits.

cont

b) The patient and/or family members arel i d b t th t d lt


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explained about the expected results.

c) The patient and/or family members areexplained about the possible complications.

124

consultation with patient and/or family

members.

e) The care plan respects and where possibleincorporates patient and/or family concerns and

requests.

cont

f) The patient and/or family members arei f d b t th lt f di ti t t


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informed about the results of diagnostic testsand the diagnosis.

g) The patient and/or family members areex lained about an chan e in the atient's

125

condition.

PRE.4

A documented procedure for obtaining patientand/ or family's consent exists for informed


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decision making about their care.

Objective elements

126

list of situations where informed consentis required and the process for taking

informed consent.

b) General consent for treatment isobtained when the patient enters the

organisation.

cont

c) Patient and / or his family members areinformed of the scope of such general


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informed of the scope of such general

consent.d) Informed consent includes information

127

, , ,

alternatives and as to who will performthe requisite procedure in a languagethat they can understand.

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

cont

f) Informed consent is taken by the personperforming the procedure


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performing the procedure.

g) Informed consent process adheres tostatutory norms.

128

ta are aware o t e n orme consent

procedures.

PRE.5

Patient and families have a right toinformation and education about


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their health care needs.

Objective elements

129

a) Patient and/or family are educated about

the safe and effective use of medicationand the potential side effects of the

medication, when appropriate.

b) Patient and/or family are educated about

food-drug interactions.

contc. Patient and/or family are educated about diet

and nutrition.

d Patient and/or family are educated about


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d. Patient and/or family are educated about

immunizations.

e. Patient and/or family are educated about organ

130

, .

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.

PRE.6

Patient and families have a right toinformation on expected costs.


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p

Objective elements

131

a) There is uniform pricing policy in a given

setting (out-patient and ward category).b) The tariff list is available to patients.

cont

c The patient and/or family are explained


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c. The patient and/or family are explained

about the expected costs.d. Patient and/or family are informed about

132

the financial implications when there is a

change in the patient condition or treatment setting.

PRE.7Organization has a complaint

redressal procedure


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redressal procedure.

Objective elements

133

a) The organization has a documented

complaint redressal procured.b) Patient and/or family members are made

aware of the procedures for lodging

complaints.

cont

c. All complaints are analysed.


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d. Corrective and/or preventive action(s)

are taken based on the analysis where

134

.


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Chapter 5

135

CONTROL (HIC)

HIC.1

The organization has a well-designed, comprehensive and


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designed, comprehensive and

coordinated Hospital Infection

136

programme aimed atreducing/eliminating risks to

patients, visitors and providers

of care.

Objective elements

a) The hospital infection prevention andcontrol programme is documented which

aims at preventing and reducing risk of


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aims at preventing and reducing risk of

healthcare associated infections.

137

programme is a continuous process and

updated at least once in a year.

c) The hospital has a multi-disciplinary

infection control committee, whichcoordinates all infection prevention and

control activities.

cont

d. The hospital has an infection control

team, which coordinates implementation


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team, which coordinates implementation

of all infection prevention and controlactivities.

138

e. The hospital has designated infection

control officer as part of the infectioncontrol team.

f. The hospital has designated infection

control nurse(s) as part of the infection

control team.

HIC.2

The organisation implements thepolicies and procedures laid down in

th I f ti C t l M l


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the Infection Control Manual.

Objective elements

139

a) The organization identifies the various

high-risk areas and procedures andimplements policies and/or procedures to

prevent infection in these areas.

b) The organization adheres to standard

precautions at all times.

Cont

c) The organization adheres to hand-

hygiene guidelines


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hygiene guidelines.

d) The organization adhere to safe injection

140

e) The organization adheres totransmission-based precautions at all

times.

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

Contg) An appropriate antibiotic policy is

established and implemented.

h) The organization adheres to laundry and


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h) The organization adheres to laundry and

linen management processes.i The or anization adheres to kitchen

141

sanitation and food handling issues.

j) The organization has appropriate

engineering controls to prevent

infections.k) The organization adheres to

housekeeping procedures.

HIC.3

The organization performs surveillanceactivities to capture and monitor

infection prevention and control data


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infection prevention and control data.

Objective elements

142

a) Surveillance activities are appropriately

directed towards the identified high-riskareas and procedures.

b) Collection of surveillance data is an on-going process.

Cont

c) Verification of data is done on regular

basis b the infection control team


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basis by the infection control team.

d) Scope of surveillance activities

143

infection risks, rates and trends.e) Surveillance activities include monitoring

the compliance with hand-hygiene

guidelines.

Cont

f) Surveillance activities include monitoring

the effectiveness of housekeeping


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the effectiveness of housekeeping

services.

144

rates are provided on a regular basis toappropriate personnel.

h) In cases of notifiable diseases,

information (in relevant format) is sent toappropriate authorities.

HIC.4The organization takes actions to

prevent and control HealthcareAssociated Infections (HAI) in patients.

Obj ti l t


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Objective elements

a) The organization takes action to prevent

145

.

b) The organization takes action to preventrespiratory tract infections.

c) The organization takes action to prevent intra-

vascular device infections.d) The organization takes action to prevent

surgical site infections.

HIC.5The organization provides adequate

and appropriate resources for

prevention and control of Healthcare


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p

Associated Infections (HAI).

146

ec ve e emen s

a) Adequate and appropriate personalprotective equipment, soaps and

disinfectants are available and used

correctly.

Cont

b) Adequate and appropriate facilities for

hand hygiene in all patient care areas


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hand hygiene in all patient-care areas

are accessible to healthcare providers.

147

available.d) Appropriate pre- and post-exposure

prophylaxis is provided to all staff

members concerned.

HIC.6

The organisation identifies andtakes appropriate action to


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control outbreaks of infections.

148

a) Organization has a documentedprocedure for identifying an outbreak.

b) The organization has a documented

procedure for handling such outbreaks.

Cont

c) This procedure is implemented during

outbreaks


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outbreaks.

d) After the outbreak is over appropriate

149

recurrence.

HIC.7

There are documented policies and

procedures for sterilization

activities in the organisation.


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activities in the organisation.

Objective elements

150

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.

Cont

c) Reprocessing of instruments and

equipment are covered


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equipment are covered.

d) Regular validation tests for sterilization

151

.

e) There is an established recall procedurewhen breakdown in the sterilization

system is identified.

HIC.8

Bio-medical Waste (BMW) is handled inan appropriate and safe manner.


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Objective elementsTh r niz ti n dh r t t t t r

152

provisions with regard to biomedical

waste.

b) Proper segregation and collection of Bio-

medical Waste from all patient careareas of the hospital is implemented and

monitored.

Cont

c) The organization ensures that Bio-medical Waste is stored and transportedto the site of treatment and disposal in


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proper covered vehicles within stipulatedtime limits in a secure manner.

153

d) Bio-medical Waste treatment facility is

managed as per statutory provisions (ifin-house) or outsourced to authorisedcontractor(s).

e) Appropriate personal protectivemeasures are used by all categories ofstaff handling Bio-medical Waste.

HIC.9

The infection control programmeis supported by the management


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and includes training of staff. Ob ective elements

154

a) The management makes available

resources required for the infection

control programme.

b) The organization earmarks adequatefunds from its annual budget in this

regard.

Cont

c) The organization conducts inductiontraining for all staff.


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d) The organization conducts appropriatein-service trainin sessions for all staff

155

at least once in a year.

Chapter 6


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CONTINUOUS QUALITY

156

CQI.1

There is a structured quality improvementand continuous monitoring programme in

the organization.


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Objective elements

157

a) The quality improvement programme is

developed, implemented and maintainedby a multi-disciplinary committee.

b) The quality improvement programme is

documented.

Cont

c) There is a designated individual for

coordinating and implementing the


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g p g

quality improvement programme.

158

comprehensive and covers all the majorelements related to quality assurance

and supports innovation.

Cont

e) The designated programme is

communicated and coordinated amongst


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all the staff of the organization through

159

.

f) The quality improvement programmeidentifies opportunities for improvement

based on review at predefined intervals.

Cont

g) The quality improvement programme is a

continuous process and updated at least


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once in a year.

160

as a means of continuous monitoring.

i) There is an established process in the

organization to monitor and improve

quality of nursing and complete patientcare.

CQI.2

There is a structured patient-safetyprogramme in the organization.


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Objective elements

161

a e pa en -sa e y programme s

developed, implemented and maintainedby a multi-disciplinary committee.

b) The patient-safety programme is

documented.

Cont

c) The patient-safety programme iscomprehensive and covers all the major


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elements related to patient safety andrisk management.

162

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 thepatient-safety programme.

Cont

f) The designated programme iscommunicated and coordinated amongst


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all the staff of the organization throughappropriate training mechanism.

163

g) The patient-safety programme identifies

opportunities for improvement based onreview at pre-defined intervals.

h) The patient-safety programme is a

continuous process and updated at leastonce in a year.

Cont

i) The organization adapts and implementsnational/international patient-safety


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goals/solutions.The or anization uses at least two

164

identifiers to identify patients across the

organization.

CQI.3

The organization identifies key indicatorsto monitor the clinical structures,

processes and outcomes which are used as


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tools for continual improvement.

165

ec ve e emen s

a) Monitoring includes appropriate patientassessment.

b) Monitoring includes safety and quality

control programmes of the diagnosticsservices.

Cont

c) Monitoring includes medicationmanagement.


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d) Monitoring includes use of anaesthesia.e) Monitoring includes surgical services.

166

f) Monitoring includes use of blood and

blood products.g) Monitoring includes infection control

activities.

h) Monitoring includes review of mortalityand morbidity indicators.

Cont

i) Monitoring includes clinical research.

j) Monitoring includes data collection to


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support further improvements.k) Monitoring includes data collection to

167

support evaluation of these

improvements.

CQI.4

The organization identifies key indicators tomonitor the managerial structures, processes

and outcomes which are used as tools for


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continual improvement.

168

a) Monitoring includes procurement of

medication essential to meet patient

needs.

b) Monitoring includes risk management.

Cont

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


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d) Monitoring includes patient satisfactionwhich also incorporates waiting time for

169

serv ces.

e) Monitoring includes employeesatisfaction.

f) Monitoring includes adverse events and

near misses.

Cont

g) Monitoring includes availability andcontent of medical records.


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h) Monitoring includes data collection tosupport further study for improvements.

170

i) Monitoring includes data collection to

support evaluation of theseimprovements.

CQI.5

The quality improvement programme issupported by the management.

Obj ti l t


171/258

Objective elementsTh m n m nt m k v il bl

171

adequate resources required for quality

improvement programme.

b) Organization earmarks adequate funds

from its annual budget in this regard.

Cont

c) The management identifies organizationalperformance improvement targets.

d) Th t t d


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d) The management supports andimplements use of appropriate quality

172

mprovemen , s a s ca an managementools in its quality improvementprogramme.

CQI.6

There is an established system

for clinical audit.

Objective elements

) M di l d i t ff ti i t i thi


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a) Medical and nursing staff participates in this

173

.

b) The parameters to be audited are definedby the organisation.

c) Patient and staff anonymity is maintained.

d) All audits are documented.e) Remedial measures are implemented.

CQI.7Incidents, complaints and feedback

are collected and analyzed to ensure

continual improvement.

Obj ti l t


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Objective elements

174

a e organ za on as an nc en repor ngsystem.

b) The organization has a process to collectfeedback and receive complaints.

Cont

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


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d) Corrective and preventive actions are

175

a en ase on e n ngs o sucanalysis.

e) Feedback about care and service iscommunicated to staff.

CQI.8

Sentinel events are intensively

analysed.

Objective elements

a) The organisation has defined sentinel


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a) The organisation has defined sentinel

176

.

b) The organisation has established processes

for intense analysis of such events.

c) Sentinel events are intensively analysedwhen they occur.

d) Corrective and preventive Actions are takenbased on the findings of such analysis.

Ch t 7


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Chapter 7

177

MANAGEMENT (ROM)

ROM.1The responsibilities of those responsible

for governance are defined.

Objective elements

a) Those responsible for governance lay


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a) Those responsible for governance lay

178

own e organ za on s v s on, m ss on

and values.b) Those responsible for governance

approve the strategic and operational

plans and organization's budget.

Cont

c) Those responsible for governance monitorand measure the performance of the

organization against the stated mission.

d) Those responsible for governance


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d) Those responsible for governance

179

.

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

f) Those responsible for governance support

safety initiatives and quality-improvementplans.

Cont

g) Those responsible for governance supportresearch activities.

h) Those responsible for governance

address the organizations social


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address the organization s social

180

.

i) Those responsible for governance informthe public of the quality and performance

of services.

ROM.2

The organization complies with

the laid-down and applicable

legislations and regulations.

Obj ti l t


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Objective elements

181

a) The management is conversant with the

laws and regulations and knows theirapplicability to the organization.

b) The management ensures

implementation of these requirements.

Cont

c) Management regularly updates anyamendments in the prevailing laws of the

land.

d) There is a mechanism to regularly


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d) There is a mechanism to regularly

182

up a e censes

registrations/certifications.

ROM.3The services provided by each

department are documented.

Objective elements

a) Scope of services of each department is


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a) Scope of services of each department is

183

e ne .

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.

ROM.4

The organization is managed bythe leaders in an ethical manner.

Objective elements

Th l d k bli th i i


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a The leaders make public the vision,

184

mission and values of the organization.

b) The leaders establish the organizationsethical management.

c) The organization discloses its ownership.

Cont

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

e) The organization honestly portrays its

affiliations and accreditations


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affiliations and accreditations.

185

f) The organization accurately bills for its

services based upon a standard billingtariff.

ROM.5The organisation displays professionalism

in management of affairs.

Objective elements

a) The person heading the organization has


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a) The person heading the organization has

186

requ s e an appropr a e a m n s ra ve

qualifications.

b) The person heading the organization has

requisite and appropriate administrative

experience.

Cont

c) The organization prepares the strategicand operational plans including long-termand short-term goals commensurate to

the organization's vision, mission and


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the organization s vision, mission and

187

stakeholders.

d) The organization coordinates thefunctioning with departments andexternal agencies and monitors the

progress in achieving the defined goalsand objectives.

Cont

e) The organization plans and budgets forits activities annually.

f) The performance of the senior leaders isreviewed for their effectiveness.


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reviewed for their effectiveness.

188

g e unct on ng o comm ttees sreviewed for their effectiveness.

h) The organization documents employeerights and responsibilities.

Cont

i) The organization documents the servicestandards.

j) The organization has a formaldocumented agreement for all


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g

189

.

k) The organization monitors the quality ofthe outsourced services.

ROM.6Management ensures that patient-safety

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

management.

Objective elements


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j

190

a) Management ensures proactive risk

management across the organization.b) Management provides resources for

proactive risk assessment and risk

reduction activities.

Cont

c) Management ensures implementation ofsystems for internal and externalreporting of system and process failures.

d) Management ensures that appropriate


191/258

) g pp p

191

taken to address safety-related incidents.

Chapter 8

FACILITY MANAGEMENT AND


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FACILITY MANAGEMENT AND

192

SAFETY (FMS)

FMS.1

The organisation has a systemin place to provide a safe and

secure environment.


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193

ec ve e emen s

a) Safety committee coordinatesdevelopment, implementation, and

monitoring of the safety plan and

policies.

Cont

b) Patient safety devices are installed

across the organization and inspected

periodically.


194/258

194

- .

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.

Cont

e) Inspection reports are documented and

corrective and preventive measures are

undertaken.


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195

for all staff.

FMS.2

The organizations environment andfacilities operate to ensure safety of

patients, their families, staff and visitors.

Objective elements


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j

196

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.

Cont

c) There is internal and external signpostings in the organisation in alanguage understood by patient, families

and community.d The rovision of s ace shall be in


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d The rovision of s ace shall be in

197

accordance with the available literature

on good practices (Indian or InternationalStandards) and directives fromgovernment agencies.

e) Potable water and electricity areavailable round the clock.

Cont

f) Alternate sources for electricity and

water are provided as backup for any

failure/shortage.


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198

alternate sources.

h) There are designated individuals

responsible for the maintenance of all the

facilities.

Cont

i) There is a documented operational and

maintenance (preventive and

breakdown) plan.


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199

the clock for emergency repairs.

k) Response times are monitored from

reporting to inspection and

implementation of corrective actions.

FMS.3

The organization has a program

for engineering support services.

Objective elements

a) The organization plans for equipment in


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200

accordance with its services and

strategic plan.b) Equipments are selected, rented,

updated or upgraded by a collaborative

process.

Cont

c) Equipments are inventoried and proper

logs are maintained as required.

d) Qualified and trained personnel operate


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201

systems.

e) There is a documented operational and

maintenance (preventive and

breakdown) plan.

Cont

f) There is a maintenance plan for water

management.

g) There is a maintenance plan for electrical


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202

.

h) There is a maintenance plan for heating,

ventilation and air-conditioning.

i) There is a documented procedure for

equipment replacement and disposal.

FMS.4

The organization has a

programme for bio-medical

equipment management.

Objective elements


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203

a) The organization plans for equipment in

accordance with its services and strategicplan.

b) Equipment are selected, rented, updated or

upgraded by a collaborative process.

Cont

c) Equipment are inventoried and proper logsare maintained as required.

d) Qualified and trained personnel operate and

maintain the medical equipment.e qu pmen are per o ca y nspec e an


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204

e qu pmen are per o ca y nspec e an

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.


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Cont

c) The procedures for medical gasesaddress the safety issues at all levels.

d) Alternate sources for medical gases,

vacuum and compressed air are

id d f i f f il


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206

provided for, in case of failure.

e) The organization regularly tests thesealternate sources.

f) There is a maintenance plan for piped

medical gas, compressed air andvacuum installation.

FMS.6

The organization has plans for

fire and non-fire emergencies

within the facilities.

Objective elementsa) The organization has plans and provisions


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207

a) The organization has plans and provisions

for early detection, abatement and

containment of fire and non-fire

emergencies.

b) The organization has a documented safeexit plan in case of fire and non-fire

emergencies.

Cont

c) Staff is trained for its role in case of suchemergencies.

d) Mock drills are held at least twice in a

year.

) Th i i l f fi


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208

e) There is a maintenance plan for fire-

related equipment.

FMS.7The organization plans for handling

community emergencies, epidemicsand other disasters.

Objective elements


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209

a) The organization identifies potential

emergencies.b) The organization has a documented

disaster management plan.

Cont

c) Provision is made for availability of

medical supplies, equipment and

materials during such emergencies.


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210

management plan.

e) The plan is tested at least twice in a

year.

FMS.8The organization has a plan for

management of hazardous materials.

Objective elements

a Hazardous materials are identified within

th i ti


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211

the organization.

b) The hospital implements processes forsorting, labeling, handling, storage,

transporting and disposal of hazardous

material.

Cont

c) Requisite regulatory requirements are

met in respect of radioactive materials.

d) There is a plan for managing spills of.


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212

e) Staff are educated and trained for

handling such materials.

FMS.9

The hospital has system in place toprovide a safe and secure environment

Objective elementsa) The hospital has a safety committee to


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213

a) The hospital has a safety committee to

identify the potential safety and security

risks.

b) This committee coordinates development,

implementation, and monitoring of thesafety plan and policies.

Cont

c) Facility inspection rounds to ensuresafety are conducted at least twice in ayear in patient care areas and at leastonce in a year in non-patient care areas.

d) Inspection reports are documented and


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214

d) Inspection reports are documented and

corrective and preventive measures areundertaken.

e) There is a safety education programme

for all staff.

Chapter 9

MANAGEMENT


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215

MANAGEMENT


216/258

Cont

b) The organization maintains an adequatenumber and mix of staff to meet the care,

treatment and service needs of the

patient.

c) The required job specifications and job


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217

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 tocriminal/negligence background.

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


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218

a) There is a documented procedure for

recruitment.b) Recruitment is based on pre-defined

criteria.

Cont

c) Every staff member entering theorganization is provided inductiontraining.

d) The induction training includes ,

mission and values


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219

mission and values.

e) The induction training includesawareness on employee rights andresponsibilities.

Cont

f) The induction training includesawareness on patients rights andresponsibilities.

g) The induction training includes

the organisation


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220

the organisation.

h) Each staff member is made aware of organization wide policies andprocedures as well as relevant

department / unit / service / programmespolicies and procedures.

HRM.3

There is an ongoing programme

for professional training anddevelopment of the staff.

Objective elements

a) A documented training and development


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221

) g ppolicy exists for the staff.

b) The organization maintains the trainingrecord.

Cont

c) Training also occurs when jobresponsibilities change/ new equipmentis introduced.

d) Feedback mechanisms for assessment

exist and the feedback is used to


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exist and the feedback is used to

improve the training programme.

HRM.4

Staff are adequately trained on

various safety-related aspects.

Objective elements

organization's environment


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organization s environment.

b) Staff members can demonstrate andtake actions to report, eliminate /

minimize risks.

Cont

c) Staff members are made aware of procedures to follow in the event of anincident.

d) Staff are trained on occupational safety.


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HRM.5

An appraisal system for evaluating theperformance of an employee exists as

an integral part of the human resource

management process.

Objective elements


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Objective elements

a) A documented performance appraisalsystem exists in the organization.

Cont

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

c) Performance is evaluated based on the- .

d) The appraisal system is used as a tool


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d) The appraisal system is used as a tool

for further development.e) Performance appraisal is carried out at

pre defined intervals and is documented.

HRM.6The organization has documented

disciplinary and grievance-handling

policies and procedures.

Objective elements



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) p p

exist.b) The policy and procedure are known to

all categories of staff of the organization.

Cont

c) The disciplinary policy and procedure isbased 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-

di i li


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disciplinary cases.

f) The redress procedure addresses the

grievance.

g) Actions are taken to redress thegrievance.

HRM.7

The organization addresses the

health needs of the employees.

Objective elements

a) A pre-employment medical examinationis conducted on all the employees.


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b) Health problems of the employees aretaken care of in accordance with the

organizations policy.

Cont

c) Regular health checks of staff dealingwith direct patient care are done at-least

once a year and the findings/ results are

documented.ccupa ona ea azar s are

adequately addressed


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adequately addressed.

HRM.8

There is a documented personal

record for each staff member.

Objective elements

a Personal files are maintained in res ect

of all employees.


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b) The personal files contain personalinformation regarding the employees

qualification, disciplinary background and

health status.

Cont

c) All records of in-service training and

education are contained in the personal

files.

evalutions.


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evalutions.

HRM.9There is a process for credentialing

and privileging of medicalprofessionals permitted to provide

patient care without supervision. Objective elements


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a) Medical professionals permitted by law,regulation and the organization to

provide patient care without supervision

is identified.

Cont

b) The education, registration, training and

experience of the identified medical

professionals is documented and.

c) All such information pertaining to the


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) p g

medical professionals is appropriatelyverified when possible.


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HRM.10There is a process for credentializing

and privileging of nursing

professionals permitted to provide

patient care without supervision. Objective elements


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a) Nursing staff permitted by law, regulationand the organization to provide patient

care without supervision are identified.

Cont

b) The education, registration, training andexperience of nursing staff is

documented and updated periodically.

c All such information ertainin to the

nursing staff is appropriately verified


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when possible.d) Nursing staff are granted privileges in

consonance with their qualification,

training, experience and registration.

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.urs ng pro ess ona s care or pa en s

as per their privileging.


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p p g g

Chapter10

INFORMATION


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IMS.1

Documented policies andprocedures exist to meet the

information needs of the care,

organization as well as other


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g

agencies that require data andinformation from the Organization.

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.ocumen e po c es an proce ures o

meet the information needs are


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documented.

c) These policies and procedures are in

compliance with the prevailing laws and

regulations.

Cont

d) All information management and

technology acquisitions are in

accordance with the documented policies.

e) The organization contributes to external


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databases in accordance with the lawand regulations.

IMS.2

The organization has processes

in place for effectivemanagement of data.

Ob ective elements

a) Formats for data collection are


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standardized.b) Necessary resources are available for

analyzing data.

Cont

c) Documented procedures are laid down

for timely and accurate dissemination of

data.

and retrieving data.


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e) Appropriate clinical and managerial staffparticipates in selecting, integrating and

using data.

IMS.3

The organization has a complete

and accurate medical record for

every patient.

a) Every medical record has a unique


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identifier.b) Organisation policy identifies those

authorized to make entries in medical

record.

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 areu .

f) The record provides a complete, up-to-date


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and chronological account of patient care.g) Provision is made for 24-hour availability of

the patient's record to healthcare providers

to ensure continuity of care.

IMS.4

The medical record reflects

nabh 3rd edition

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