nabh standards 2nd edition final 2009

7/23/2019 Nabh Standards 2nd Edition Final 2009

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1

National Accreditation Board for Hospitals & Healthcare Providers

Components of Standards DevelopmentMultiple Information Sources

Scientific literature

JCI Standards

UK Healthcare Quality Standards

Thailand Standards

AHA Draft Standards

JCI Survey compliance data

Research Findings Individual input from field experts and key stakeholders

ISO 9001-2000


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Hospital StandardsHospital StandardsHospital StandardsHospital StandardsOrganized around important functions

Focus on patient and staff safety

Set standards that all organizations mustpass

To be revised periodically and raise the bar

Achieve International recognition


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NABH StandardsNABH StandardsNABH StandardsNABH Standards

10 Chapters

100 Standards

514 Objective Elements


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Standards and Objective ElementsStandards and Objective ElementsStandards and Objective ElementsStandards and Objective Elements

A standard is a statement that defines thestructures and processes that must be substantially

in place in an organization to enhance the quality ofcare

Objective element is a measurable component of astandard

Acceptable compliance with objective elementsdetermines the overall compliance with a standard


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Section I:Section I:Section I:Section I:

PatientPatientPatientPatient----Centered StandardsCentered StandardsCentered StandardsCentered Standards

STD OE

Access, Assessment and Continuity of Care (AAC) 15 78

Care of Patients (COP) 18 104

Management of Medications (MOM) 13 61

Patient Rights and Education (PRE) 5 30

Hospital Infection Control (HIC) 9 46


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Section II:Section II:Section II:Section II:

Organization Centered StandardsOrganization Centered StandardsOrganization Centered StandardsOrganization Centered Standards

STD OE

Continuous Quality Improvement (CQI) 6 39

Responsibilities of Management (ROM) 5 25

Facility Management & Safety (FMS) 9 43

Human Resource Management (HRM) 13 47

Information Management Systems (IMS) 7 41

100 514


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NABH STANDARDS


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Introduction

NABH standards for hospitals, 2nd Edition, November 2007 havebeen prepared by Technical Committee of NABH and containcomplete set of standards for evaluation of hospitals for grant of

accreditation. The standards provide framework for qualitya s su rance and qua l i t y improvemen t fo r hosp i t a l s

NABH hospital standards, 2nd edition, November 2007 have

been accredited by ISQua under its International AccreditationProgram (IAP) for a cycle of 4 years (April 2008 to March 2012).

NABH Standards contains 10 chapters,100 standards and 514

objective elements.


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Details of Chapters1) Access ,Assessment and continuity of care (AAC)

2) Care of Patients (COP).

3) Management of Medication (MOM).

4) Patient Right and Education (PRE).

5) Hospital Infection Control (HIC).

6) Continuous Quality Improvement (CQI).7) Responsibility of Management (ROM).

8) Facility Management and Safety (FMS).

9) Human Resource Management (HRM)10) Information Management System (IMS).


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Chapter 1.

ACCESS,ASSESSMENT AND

CONTINIUITY OF CARE (AAC)


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AAC.1

The organization defines and displays the

services that it can provide

Objective Elements

a) The services being provided are clearly defined and

are in consonance with the needs of the community.

b) The defined services are prominently displayed.

c) The staff is oriented to these services.


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AAC.2

The organization has a well definedregistration and admission process

Objective elementsa) Standardized policies and procedures are used for

registering and admitting patients.

b) The policies and procedures address outpatients,

in-patients and emergency patients.


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Cont

c) Patients are accepted only if the organization canprovide the required service.

d) The policies and procedures also address managing

patients during non availability of beds.e) The staff is aware of these processes.


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AAC.3

There is an appropriate mechanism fortransfer or referral of patients who do not

match the organizational resources

Objective elements

a) Policies guide the transfer of unstable patients toanother facility in an appropriate manner.

b) Policies guide the transfer of stable patients to

another facility.


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Cont

c) Procedures identify staff responsible during

transfer.

d) The organization gives a summary of patients

condition and the treatment given.


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AAC.4

During admission the patient and /or thefamily members are educated to make

informed decisions

Objective elements

a) The patients and/or family members areexplained about the proposed care.

b) The patients and/or family members are

explained about the expected results


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Cont

c) The patients and/or family members are explained

about the possible complications.

c) The patients and/or family members are explained

about the expected costs.


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18National Accreditation Board for Hospitals & Healthcare Providers

AAC.5Patients cared for by the organization

undergo an established initial assessment

Objective elements

a) The organization defines the content of the

assessments for the outpatients, in-patients and

emergency patients.

b) The organization determines who can perform the

assessments.


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Cont

c) The organization defines the time frame within

which the initial assessment is completed.

d) The initial assessment for in-patients is documented

within 24 hours or earlier as per the patients

condition or hospital policy.

e) Initial assessment includes screening for nutritional

and psychosocial needs.


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Cont

f) The initial assessment results in a

documented plan of care which is monitored.

g) The plan of care also includes preventive

aspects of the care.


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AAC.6

All patients cared for by the organization

undergo a regular reassessment

Objective elements.

a) All patients are reassessed at appropriate intervals.

b) Staff involved in direct clinical care documentreassessments.

c) Patients are reassessed to determine their response

to treatment and to plan further treatment ordischarge.


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AAC.7

Laboratory services are provided as per the

requirements of the patients

Objective elements

a) Scope of the laboratory services are commensurate

to the services provided by the organization

b) Adequately qualified and trained personnel perform

and/or supervise the investigations.


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Cont..

c) Policies and procedures guide collection,identification, handling, safe transportation

processing and disposal of specimens.

d) Laboratory results are available within a definedtime frame.

e) Critical results are intimated immediately to theconcerned personnel.

f) Laboratory tests not available in the organization are

outsourced to organization(s) based on their qualityassurance system.


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AAC.8

There is an established laboratory qualityassurance programme

Objective elements

a) The laboratory quality assurance programme is

documented.b) The programme addresses verification and

validation of test methods.

c) The programme addresses surveillance of testresults.


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Contd) The programme includes periodic calibration and

maintenance of all equipments.e) The programme includes the documentation of

corrective and preventive actions


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AAC.9

There is an established laboratory safetyprogramme

Objective elements.

a) The laboratory safety programme is

documented.b) This programme is integrated with the

organizations safety programme.


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Contc) Written policies and procedures guide the handling

and disposal of infectious and hazardous materials.d) Laboratory personnel are appropriately trained in

safe practices.

e) Laboratory personnel are provided withappropriate safety equipment / devices.


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AAC.10

Imaging services are provided as per therequirements of the patients

Objective elements

a) Imaging services comply with legal and other

requirements.b) Scope of the imaging services are commensurate to

the services provided by the organization.

c) Adequately qualified and trained personnel perform,supervise and interpret the investigations.


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Cont

d) Policies and procedures guide identification and

safe transportation of patients to imaging services.

e) Imaging results are available within a defined timeframe.

f) Critical results are intimated immediately to the

concerned personnel.g) Imaging tests not available in the organization are

outsourced to organization(s) based on their quality

assurance system.


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AAC.11

There is an established Quality assurance

programme for imaging services

Objective elements

a) The quality assurance programme for imaging

services is documented.

b) The programme addresses verification and

validation of imaging methods

c) The programme addresses surveillance of imaging

results.


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contd) The programme includes periodic calibration

and maintenance of all equipments.e) The programme includes the documentation

of corrective and preventive actions


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AAC.12

There is an established radiation safetyprogramme

Objective elementsa) The radiation safety programme is documented.

b) This programme is integrated with the

organizations safety programme.c) Written policies and procedures guide the handling

and disposal of radio-active and hazardous

materials.


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Cont

d) Imaging personnel are provided with appropriate

radiation safety devices

e) Radiation safety devices are periodically tested anddocumented.

f) Imaging personnel are trained in radiation safety

measures.

g) Imaging signage are prominently displayed in all

appropriate locations.

h) Policies and procedures guide the safe use of

radioactive isotopes for imaging services.


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AAC.13

Patient care is continuous and multidisciplinaryin nature

Objective elements

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

individual identified as responsible for the patients

care.

b) Care of patients is coordinated in all care settings

within the organization.


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Cont

c) Information about the patients care and response totreatment is shared among medical, nursing andother care providers.

d) Information is exchanged and documented duringeach staffing shift, between shifts, and duringtransfers between units/departments.

e) The patients record (s) is available to theauthorized care providers to facilitate the exchangeof information.

f) Policy and procedures guide the referral of patientsto other department / specialties.


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AAC.14

The organization has a documented discharge

process

Objective elementsa) The patients discharge process is planned in

consultation with the patient and/or family.

b) Policies and procedures exist for coordination of

various departments and agencies involved in the

discharge process (including medico-legal cases)


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Contc) Policies and procedures are in place for patients

leaving against medical adviced) A discharge summary is given to all the patients

leaving the organization (including patients leaving

against medical advice)

AAC 15


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AAC.15

Organisation defines the content of thedischarge summary

Objective elementsa) Discharge summary is provided to the patients at

the time of discharge

b) Discharge summary contains the reasons foradmission, significant findings and diagnosis and

the patients condition at the time of discharge.


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Contc) Discharge summary contains information regarding

investigation results, any procedure performed,medication and other treatment given.

d) Discharge summary contains follow up advice,medication and other instructions in an

understandable manner.


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Conte) Discharge summary incorporates instructions

about when and how to obtain urgent caref) In case of death the summary of the case also

includes the cause of death.


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Chapter 2.

Care of Patients (COP)

COP 1


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COP.1

Uniform care of patients is provided in all settings of

the organization guided by the applicable laws and

regulations

Objective elements

a) Care delivery is uniform when similar care is

provided in more than one setting

b) Uniform care is guided by policies and procedureswhich reflect applicable laws and regulations


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Contc) The care and treatment orders are signed, named,

timed and dated by the concerned doctor.d) The care plan is countersigned by the clinician in-charge of the patient within 24 hours.

e) Evidence based medicine and clinical practiceguidelines are adopted to guide patient carewhenever possible.


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COP.2

Emergency services are guided by policies,procedures, applicable laws and regulations

Objective elements

a) Policies and procedure for emergency care are

documentedb) Policies also address handling of medico-legal cases

c) The patients receive care in consonance with the

policies


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Contd) Policies and procedures guide the triage of patients

for initiation of appropriate caree) Staff is familiar with the policies and trained on the

procedures for care of emergency patients

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

COP 3


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COP.3

The ambulance services are commensuratewith the scope of the services provided by the

organization

Objective elements

a) There is adequate access and space for theambulance(s)

a) Ambulance(s) is appropriately equipped

b) Ambulance(s) is manned by trained personnel


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Contd) There is a checklist of all equipment and emergency

medicationse) Equipment are checked on a daily basis

f) Emergency medications are checked daily and prior

to dispatchg) The ambulance(s) has a proper communication

system

COP 4


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COP.4

Policies and procedures guide the care ofpatients requiring cardio-pulmonary

resuscitation

Objective elements

a) Documented policies and procedures guide the

uniform use of resuscitation throughout theorganization

b) Staff providing direct patient care is trained and

periodically updated in cardio pulmonary resuscitation


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Contc) The events during a cardio-pulmonary

resuscitation are recordedd) A post event analysis of all cardiac arrests is

done by a multidisciplinary committee.

e) Corrective and preventive measures are taken

based on the post-event analysis.

COP 5


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COP.5

Policies and procedures define rational use ofblood and blood products

Objective elements

a) Documented policies and procedures are used to

guide rational use of blood and blood productsb) The transfusion services are governed by the

applicable laws and regulations


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Cont

c) Informed consent is obtained for donation and

transfusion of blood and blood products

d) Informed consent also includes patient and familyeducation about donation

e) Staff is trained to implement the policiesf) Transfusion reactions are analyzed for preventive and

corrective actions

COP 6


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COP.6

Policies and procedures guide the care ofpatients in the Intensive care and high

dependency units

Objective elements

a) The organization has documented admission and

discharge criteria for its intensive care and high

dependency units

b) Staff is trained to apply these criteria


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Contc) Adequate staff and equipment are available

d) Defined procedures for situation of bedshortages are followed

e) Infection control practices are followed

f) A quality assurance program is implemented

COP.7


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Policies and procedures guide the care ofvulnerable patients (elderly, children, physically

and/or mentally challenged)

Objective elements

a) Policies and procedures are documented and are inaccordance with the prevailing laws and the national

and international guidelines

Cont


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Cont

b) Care is organized and delivered in accordance withthe policies and procedures

c) The organization provides for a safe and secureenvironment for this vulnerable group

d) A documented procedure exists for obtaininginformed consent from the appropriate legalrepresentative.

e) Staff is trained to care for this vulnerable group.

COP.8


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COP.8

Policies and procedures guide the care of highrisk obstetrical patients

Objective elements.

a) The organization defines and displays whether high

risk obstetric cases can be cared for or notb) Persons caring for high risk obstetric cases are

competent


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Contc) High risk obstetric patients assessment also

includes maternal nutritiond) The organization caring for high risk

obstetric cases has the facilities to take care

of neonates of such cases.

COP.9


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Policies and procedures guide the care ofpediatric patients

Objective elements.

a) The organization defines and displays the scope of

its pediatric services

b) The policy for care of neonatal patients is inconsonance with the national/ international

guidelines

c) Those who care for children have age specificcompetency


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Contd) Provisions are made for special care of

children

e) Patient assessment includes detailed

nutritional, growth, psychosocial and

immunization assessmentf) Policies and procedures prevent child/

neonate abduction and abuse


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contg) The childrens family members are

educated about nutrition,immunization and safe parenting

and this is documented in themedical record

COP.10


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COP.10

Policies and procedures guide the care of

patients undergoing moderate sedation

Objective elements

a) Competent and trained persons perform sedation

b) The person administering and monitoring sedation isdifferent from the person performing the procedure


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Contc) Intra-procedure monitoring includes at a minimum

the heart rate, cardiac rhythm, respiratory rate,blood pressure, oxygen saturation, and level ofsedation

d) Patients are monitored after sedation

e) Criteria are used to determine appropriateness ofdischarge from the recovery area

f) Equipment and manpower are available to rescue

patients from a deeper level of sedation than thatintended

COP.11


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Policies and procedures guide the administrationof anesthesia

Objective elements

a) There is a documented policy and procedure for the

administration of anesthesia

b) All patients for anesthesia have a pre-anesthesia

assessment by a qualified individual

Cont


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c) The pre-anesthesia assessment results in formulationof an anesthesia plan which is documented

d) An immediate preoperative reevaluation isdocumented

e) Informed consent for administration of anesthesia is

obtained by the anesthetistf) During anesthesia monitoring includes regular and

periodic recording of heart rate, cardiac rhythm,respiratory rate, blood pressure, oxygen saturation,

airway security and patency and level of anesthesia


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Contg) Each patients post-anesthesia status is monitored

and documentedh) A qualified individual applies defined criteria to

transfer the patient from the recovery area

i) All adverse anesthesia events are recorded andmonitored

COP.12


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Policies and procedures guide the care ofpatients undergoing surgical procedures

Objective elements

a) The policies and procedures are documented

b) Surgical patients have a preoperative assessment anda provisional diagnosis documented prior to surgery

Cont


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Cont

c) An informed consent is obtained by a surgeon priorto the procedure

d) Documented policies and procedures exist toprevent adverse events like wrong site, wrongpatient and wrong surgery

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

f) An operative note is documented prior to transfer

out of patient from recovery area


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Contg) The operating surgeon documents the post-

operative plan of care

h) A quality assurance program is followed for thesurgical services

i) The quality assurance program includes

surveillance of the operation theatre environment

j) The plan also includes monitoring of surgical siteinfection rates

COP.13


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Policies and procedures guide the care of patientsunder restraints (physical and / or chemical)

Objective elements.

a) Documented policies and procedures guide the care

of patients under restraintsb) These include both physical and chemical restraint

measures


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Contc) These include documentation of reasons for

restraintsd) These patients are more frequently monitored

e) Staff receive training and periodic updating

in control and restraint techniques

COP.14


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Policies and procedures guide appropriate painmanagement

Objective elementsa) Documented policies and procedures guide the

management of pain

b) The organization respects and supports the

appropriate assessment and management of pain for

all patients

c) Patient and family are educated on various pain

management techniques

COP.15

Policies and procedures guide appropriate


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Policies and procedures guide appropriate

rehabilitative services

Objective elementsa) Documented policies and procedures guide the

provision of rehabilitative services

b) These services are commensurate with theorganizational requirements

c) Rehabilitative services are provided by a

multidisciplinary team

COP.16


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Policies and procedures guide all researchactivities

Objective elements.

a) Documented policies and procedures guide all research

activities in compliance with national and international

guidelinesb) The organization has an ethics committee to oversee all

research activities

c) The committee has the powers to discontinue a research trialwhen risks outweigh the potential benefits

Cont


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d) Patients informed consent is obtained beforeentering them in research protocols

e) Patients are informed of their right to withdrawfrom the research at any stage and also of theconsequences (if any) of such withdrawal

f) Patients are assured that their refusal to participateor withdrawal from participation will notcompromise their access to the organizationsservices

COP.17


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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

c) There is a written order for the diet

d) Nutritional therapy is planned and provided in a

collaborative manner


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Conte) When families provide food, they are

educated about the patients diet limitationsf) Food is prepared, handled, stored and

distributed in a safe manner

COP.18

Policies and procedures guide the end of life


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p g

care

Objective elements

a) Documented policies and procedures guide the end

of life care

b) These policies and procedures are in consonancewith the legal requirements

c) These also address the identification of the unique

needs of such patient and family


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Contd) These also include sensitively addressing

issues such as autopsy and organ donatione) Staff is educated and trained in end of life

care


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Chapter 3.

MANAGEMENT OF MEDICATION(MOM)

MOM.1


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Policies and procedures guide the organizationof 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

Cont


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c) A multidisciplinary committee guides the

formulation and implementation of thesepolicies and procedures

MOM.2


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There is a hospital formulary

Objective elements

a) A list of medication appropriate for the patients andorganizations resources is developed

b) The list is developed collaboratively by the

multidisciplinary committee

c) There is a defined process for acquisition of these

medications

d) There is a process to obtain medications not listed

in the formulary

MOM.3

Policies and procedures exist for storage of


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p g

medication

Objective elements

a) Documented policies and procedures exist for

storage of medication

b) Medications are stored in a clean, well lit and

ventilated environment

c) Sound inventory control practices guide storage ofthe medications

Cont


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d) Medications are protected from loss or theft

e) Sound alike and look alike medications are storedseparately

f) There is a method to obtain medication when the

pharmacy is closed

g) Emergency medications are available all the time

h) Emergency medications are replenished in a timely

manner when used

MOM.4

Policies and procedures guide the prescription of


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medications

Objective elementsa) Documented policies and procedures exist for

prescription of medications

b) The organization determines who can write ordersc) Orders are written in a uniform location in the

medical records

Cont


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d) Medication orders are clear, legible, dated, timed,

named and signed

e) Policy on verbal orders is documented and

implemented

f) The organization defines a list of high riskmedication

g) High risk medication orders are verified prior to

dispensing

MOM.4

Policies and procedures guide the safe dispensing


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of medications

Objective elementsa) Documented policies and procedures guide the safe

dispensing of medications

b) The policies include a procedure for medicationrecall

c) Expiry dates are checked prior to dispensing

d) Labeling requirements are documented andimplemented by the organization

MOM.5

There are defined procedures for medication

d i i i


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administration

Objective elements

a) Medications are administered by those who are

permitted by law to do so

b) Prepared medication are labeled prior to preparationof a second drug

c) Patient is identified prior to administration

Cont


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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 toadministration

g) Timing is verified from the order prior to

administration

Cont


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h) Medication administration is documented

i) Polices and procedures govern patients selfadministration of medications

j) Polices and procedures govern patientsmedications brought from outside the

organization

MOM.7

Patients and family members are educated about


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safe medication and food-drug interactions

Objective elements

a) Patient and family are educated about safe and

effective use of medication

b) Patient and family are educated about food-drug

interactions

MOM.8

Patients are monitored after medication


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administration

Objective elementsa) Patients are monitored after medication

administration and this is documented

b) Adverse drug events are defined

c) Adverse drug events are reported within a specified

time frame

Cont


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d) Adverse drug events are collected and

analysede) Policies are modified to reduce adverse drug

events when unacceptable trends occur

MOM.9

Policies and procedures guide the use of


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Policies and procedures guide the use ofnarcotic drugs and psychotropic substances

Objective elements

a) Documented policies and procedures guide the use

of narcotic drugs and psychotropic substancesb) These policies are in consonance with local and

national regulations

Cont


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

and disposal of these drugs

d) These drugs are handled by appropriate personnel

in accordance with policies

MOM.10

Policies and procedures guide the usage of


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Policies and procedures guide the usage ofchemotherapeutic agents

Objective elements

a) Documented policies and procedures guide the

usage of chemotherapeutic agentsb) Chemotherapy is prescribed by those who have the

knowledge to monitor and treat the adverse effect

of chemotherapy

Cont


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c) Chemotherapy is prepared and administered

by qualified personneld) Chemotherapy drugs are disposed off in

accordance with legal requirements

MOM.11

Policies and procedures govern usage of


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Policies and procedures govern usage ofradioactive drugs

Objective elements.a) Documented policies and procedures govern usage

of radioactive drugs

b) These policies and procedures are in consonancewith laws and regulations

Cont


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c) The policies and procedures include the safe

storage, preparation, handling, distributionand disposal of radioactive drugs

d) Staff, patients and visitors are educated on

safety precautions

MOM.12


i l t bl th i


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implantable prosthesis

Objective elements.

a) Documented policies and procedures govern

procurement and usage of implantable prosthesis

b) Selection of implantable prosthesis is based on

scientific criteria and national/internationally

recognized approvals

cont


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c) The batch and serial number of the

implantable prosthesis are recorded inthe patients medical record and themaster logbook

MOM.13



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Policies and procedures guide the use ofmedical gases

Objective elements

a) Documented policies and procedures govern

procurement, handling, storage, distribution, usageand replenishment of medical gases.

b) The policies and procedures address the safety

issues at all levels

Cont


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c) Appropriate records are maintained in

accordance with the policies, procedures and

legal requirements.


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Chapter. 4

PATIENT RIGHT AND EDUCATION

(PRE)

PRE.1

The organization protects patient and family rights

informs them about their responsibilities during


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p gcare

Objective element

a) Patient and family rights and responsibilities are

documented.

b) Patients and families are informed of their rights and

responsibilities in a format and language that they

can understand

Cont


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c) The organizations leaders protect patients rights

d) Staff is aware of their responsibility in protecting

patients rights

e) Violation of patient rights is recorded, reviewed and

corrective/preventive measures taken

PRE.2.

Patient rights support individual beliefs, valuesd i l th ti t d f il i d i i


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g ppand involve the patient and family in decision

making processes

Objective elements

a) Patient and family rights address any special

preferences, spiritual and cultural needs.

b) Patient rights include respect for personal dignity and

privacy during examination, procedures and treatment

Cont


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c) Patient rights include protection from physical

abuse or neglectd) Patient rights include treating patient information as

confidential

e) Patient rights include refusal of treatmentf) Patient rights include informed consent before

anesthesia, blood and blood product transfusionsand any invasive / high risk procedures / treatment

Cont


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g) Patient rights include information and consent before

any research protocol is initiated

h) Patient rights include information on how to voice a

complaint

i) Patient rights include information on the expectedcost of the treatment

j) Patient has a right to have an access to his / her

clinical records

PRE.3

A documented process for obtaining patientand / or families consent exists for informed


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p g pand / or families consent exists for informed

decision making about their care

Objective elements

a) General consent for treatment is obtained whenthe patient enters the organization

Cont

b) Patient and/or his family members are informed of


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b) Patient and/or his family members are informed ofthe scope of such general consent

c) The organization has listed those situations whereinformed consent is required

d) Informed consent includes information on risks ,benefits, alternatives and as to who will perform therequisite procedure in a language that they canunderstand

e) The policy describes who can give consent when

patient is incapable of independents decisionmaking.

PRE.4

Patient and families have a right to information

and education about their healthcare needs


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Objective elements

a) When appropriate, patient and families are educated

about the safe and effective use of medication andthe potential side effects of the medication

b) Patient and families are educated about diet and

nutrition

Cont

) P i d f ili d d b


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c) Patient and families are educated aboutimmunizations

d) Patient and families are educated about theirspecific disease process, complications andprevention strategies

e) Patient and families are educated about preventinginfections

f) Patients are taught in a language and format thatthey can understand

PRE.5.

Patient and families have a right to information

on expected costs


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Objective elementsa) There is uniform pricing policy in a given setting

(out-patient and ward category)

b) The tariff list is available to patients

c) Patients are educated about the estimated costs of

treatment

Cont

d i d f il i f d b h


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d. Patients and family are informed about the

financial implications when there is a change

in the patient condition or treatment setting


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Chapter 5HOSPITAL INFECTION CONTROL

(HIC)

HIC.1


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The organization has a well-designed,comprehensive and coordinated Hospital

Infection Control (HIC) programme aimed at

reducing/ eliminating risks to patients, visitorsand providers of care.

Objective elements


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a) The hospital infection control programme is

documented which aims at preventing and reducing

risk of nosocomial infections.

b) The hospital has a multi-disciplinary infection

control committee.

c) The hospital has an infection control team.

d) The hospital has designated and qualified infection

control nurse(s) for this activity

HIC.2

The hospital has an infection control manual,which is periodically updated


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which is periodically updated

Objective elements

a) The manual identifies the various high-risk areas

and procedures.b) It outlines methods of surveillance in the identified

high-risk areas.

Cont

c) It focuses on adherence to standard precautions at


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c) It focuses on adherence to standard precautions at

all times.

d) Equipment cleaning and sterilisation practices are

included.

e) An appropriate antibiotic policy is established and

implemented.

f) Laundry and linen management processes are also

included.

Cont

g) Kitchen sanitation and food handling issues are

included in the manual


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included in the manual

h) Engineering controls to prevent infections are

included

i) Mortuary practices and procedures are included as

appropriate to the organization.

j) The organization defines the periodicity of updating

the infection control manual.

HIC.3

The infection control team is responsible for

surveillance activities in identified areas of the

h it l


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hospital.

Objective elements

a) Surveillance activities are appropriately directed

towards the identified high-risk areas.

b) Collection of surveillance data is an ongoing

process.

Cont

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


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d) In cases of notifiable diseases, information (in

relevant format) is sent to appropriate authorities.

e) Scope of surveillance activities incorporates

tracking and analyzing of infection risks, rates and

trends.

f) Surveillance activities include monitoring the

effectiveness of housekeeping services.

HIC.4

The hospital takes actions to prevent or

reduce the risks of Hospital Associated

I f ti (HAI) i ti t d l


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Infections (HAI) in patients and employees

Objective elements

a) The organization monitors urinary tract infections.

b) The organization monitors respiratory tract

infections.

Cont


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c) The organization monitors intra-vascular device

infections.d) The organization monitors surgical site infections.

e) Appropriate feedback regarding HAI rates are

provided on a regular basis to medical and nursingstaff.

HIC.5

Proper facilities and adequate resources are

provided to support the infection control


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programme

Objective elements

a) Hand washing facilities in all patient care areas are

accessible to health care providers.b) Compliance with proper hand washing is

monitored regularly.

Cont

c) Isolation/ barrier nursing facilities are


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c) Isolation/ barrier nursing facilities are

available.

d) Adequate gloves, masks, soaps, and

disinfectants are available and used correctly.

HIC.6

The hospital takes appropriate action to control

outbreaks of infections


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Objective elementsa) Hospital has a documented procedure for handling

such outbreaks.

b) This procedure is implemented during outbreaks.

c) After the outbreak is over appropriate corrective

actions are taken to prevent recurrence

HIC.7

There are documented procedures for sterilisation

activities in the hospital.


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Objective elementsa) There is adequate space available for sterilization

activities

b) Regular validation tests for sterilisation are carriedout and documented.

c) There is an established recall procedure when

breakdown in the sterilisation system is identified

HIC.8

Statutory provisions with regard to Bio-medical

Waste (BMW) management are complied with


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Objective elements

a) The hospital is authorised by prescribed authority

for the management and handling of Bio-medical

Waste.

b) Proper segregation and collection of Bio-medical

Waste from all patient care areas of the hospital is

implemented and monitored.

Cont

c) The organization ensures that Bio-medical Waste is stored

and transported to the site of treatment and disposal in


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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 authorisedcontractor(s).

Cont

e) Requisite fees, documents and reports are submitted


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to competent authorities on stipulated dates.

f) Appropriate personal protective measures are usedby all categories of staff handling Bio-medical

Waste

HIC.9

The infection control programme is supported by

the organizations management and includestraining of staff and employee health


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Objective elements

a) Hospital management makes available resources

required for the infection control programme

b) The hospital regularly earmarks adequate funds

from its annual budget in this regard.

Cont

) It d t l i d ti t i i f


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c) It conducts regular pre-induction training for

appropriate categories of staff before joiningconcerned department(s).

d) It also conducts regular in-service trainingsessions for all concerned categories of staff at leastonce in a year.

e) Appropriate pre and post exposure prophylaxis isprovided to all concerned staff members

Chapter 6


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CONTINUOUS QUALITY

IMPROVEMENT (CQI)

CQI.1

There is a structured quality improvement and

continuous monitoring programme in theorganization


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Objective elementsa) The quality improvement programme is developed,

implemented and maintained by a multi-

disciplinary committee.b) The quality improvement programme is

documented.

Cont

c) There is a designated individual for coordinating

d i l i h li i


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and implementing the quality improvement

programmed) The quality improvement programme is

comprehensive and covers all the major elements

related to quality assurance and risk management.

Cont

e) The designated programme is communicated and

coordinated amongst all the employees of the


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g p y

organization through proper training mechanism.

f) The quality improvement programme is reviewed at

predefined intervals and opportunities for

improvement are identified.

g) The quality improvement programme is a

continuous process and updated at least once

in a year

CQI.2

The organization identifies key indicators to monitor

the clinical structures, processes and outcomes whichare used as tools for continual improvement.


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Objective elements

a) Monitoring includes appropriate patient assessment.

b) Monitoring includes safety and quality control

programme of the diagnostics services.

c) Monitoring includes all invasive procedures.

Cont

d) Monitoring includes adverse drug events.

) M it i i l d f th i


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e) Monitoring includes use of anaesthesia.

f) Monitoring includes use of blood and bloodproducts.

g) Monitoring includes availability and content of

medical records.h) Monitoring includes infection control activities.

i) Monitoring includes clinical research.

Cont.

j) Monitoring includes data collection to support furtheri t


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improvements.

k) Monitoring includes data collection to support

evaluation of these improvements.

CQI.3

The organisation identifies key indicators to monitor

the managerial structures, processes and outcomes

which are used as tools for continual improvement


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Objective elements

Monitoring includes procurement of medication

essential to meet patient needs. Monitoring includes reporting of activities as required

by laws and regulations.

Cont

Monitoring includes risk management.


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Monitoring includes utilisation of space, manpowerand equipment.

Monitoring includes patient satisfaction which alsoincorporates waiting time for services.

Monitoring includes employee satisfaction.

Monitoring includes adverse events and near misses.

Cont..


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Monitoring includes data collection to support further

study for improvements.

Monitoring includes data collection to support

evaluation of the improvements

CQI.4

The quality improvement programme is supported

by the management

Objective elements


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a) Hospital Management makes available adequateresources required for quality improvement

programme.

b) Hospital earmarks adequate funds from its annualbudget in this regard.

c) Appropriate statistical and management tools are

applied whenever required

CQI.5

There is an established system for audit of patient

care services

Objective elements


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Objective elements

a) Medical and nursing staff participates in thissystem.

b) The parameters to be audited are defined by the

organisation.

c) Patient and staffanonymity is maintained.

d) All audits are documented.

e) Remedial measures are implemented.

CQI.6

Sentinel events are intensively analysed

Objective elements


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j

a) The organisation has defined sentinel events.b) The organisation has established processes for intense

analysis of such events.

c) Sentinel events are intensively analysed when theyoccur.

d) Actions are taken upon findings of such analysis

Chapter 7


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Chapter 7

RESPONSIBILITIES OFMANAGEMENT (ROM)

ROM.1

The responsibilities of the management are

defined

Objective elements


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Objective elements

a) Those responsible for governance lay down the

organizations mission statement.

b) Those responsible for governance lay down the

strategic and operational plans commensurate to the

organization's mission in consultation with the

various stake holders.

Cont

c) Those responsible for governance approve theorganizations budget and allocate the resourcesrequired to meet the organizations mission.


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d) Those responsible for governance monitor andmeasure the performance of the organization

against stated mission.

e) Those responsible for governance establish theorganizations organogram.

f) Those responsible for governance appoint the

senior leaders in the organization.

Cont

g) Those responsible for governance support research

ti iti d lit i t l


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activities and quality improvement plans.

h) The organization complies with the laid down and

applicable legislations and regulations.

i) Those responsible for governance address theorganizations social responsibility.

ROM.2

The services provided by each department

are documented

Objective elements


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a) Each organizational program, service, site ordepartment has effective leadership

b) Scope of services of each department is defined

c) Administrative policies and procedures for eachdepartment is maintained

d) Departmental leaders are involved in qualityimprovement

ROM.3

The organization is managed by the leaders in an

ethical manner


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Objective elementsa) The leaders make public the mission statement of

the organization.

b) The leaders establish the organizations ethicalmanagement.

c) The organization discloses its ownership.

Cont

d) The organization honestly portrays the services

which it can and cannot provide.


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e) The organization honestly portrays its affiliationsand accreditations.

f) The organization accurately bills for its services.

ROM.4

A suitably qualified and experienced individual

heads the organisation


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Objective elementsa) The designated individual has requisite and

appropriate administrative qualifications.

b) The designated individual has requisite andappropriate administrative experience.

ROM.5

Leaders ensure that patient safety aspects and

risk management issues are an integral part ofpatient care and hospital management


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Objective elements

a) The organization has an interdisciplinary

group assigned to oversee the hospital widesafety programme.

Cont

b) The scope of the programme is defined to includeadverse events ranging from no harm to sentinelevents


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events .

c) Management ensures implementation of systems forinternal and external reporting of system andprocess failures.

d) Management provides resources for proactive riskassessment and risk reduction activities.

Chapter 8


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FACILITY MANAGEMENT ANDSAFETY (FMS)

FMS.1

The organization is aware of and complies with the

relevant rules and regulations, laws and byelaws andrequisite facility inspection requirements


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Objective elements

a) The management is conversant with the laws and

regulations and knows their applicability to the

organization.

Cont

b) Management regularly updates any amendments in

the prevailing laws of the land.


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c) The management ensures implementation of theserequirements.

d) There is a mechanism to regularly update licenses/

registrations/certifications

FMS.2

The organizations environment and facilities

operate to ensure safety of patients, staff and

visitors


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Objective elements

a) There is a documented operational and

maintenance (preventive and breakdown) plan.

a) Up-to-date drawings are maintained which detail

the site layout, floor plans and fire escape routes

Cont

c) There is internal and external sign posting in the

organization in a language understood by patients,


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ga a a a g ag y pa ,

families and community.

The provision of space shall be in accordance with

the available literature on good practices (Indian or

International Standards) and directives from

government agencies.

Cont

e) There are designated individuals responsible for the

maintenance of all the facilities.


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f) Maintenance staff is contactable round the clock foremergency repairs.

g) Response times are monitored from reporting to

inspection and implementation of correctiveactions.

FMS.3

The organization has a program for clinical

and support service equipment management


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Objective elementsa) The organization plans for equipment in accordance

with its services and strategic plan

b) Equipment is selected by a collaborative process.

c) All equipment is inventoried and proper logs are

maintained as required.

Cont

d) Qualified and trained personnel operate and

maintain the equipment.


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q p

e) Equipment are periodically inspected and calibrated

for their proper functioning.

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

FMS.4

The organization has provisions for safe water,

electricity, medical gases and vacuum systems


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Objective elements

a) Potable water and electricity are available round theclock.

b) Alternate sources are provided for in case of failure.

c) The organisation regularly tests the alternatesources.

Cont..

d) There is a maintenance plan for piped medical gas,

compressed air and vacuum installation.


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FMS.5

The organization has plans for fire and non-fire

emergencies within the facilities


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Objective elements

a) The organization has plans and provisions for early

detection, containment and abatement of fire andnon-fire emergencies.

Cont

b) The organization has a documented safe exit plan in


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case of fire and non-fire emergencies.c) Staff is trained for their role in case of such

emergencies.

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

FMS.6

The organization has a smoking limitation

policy

Objective elements


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a) The organization defines and implements its polices

to reduce or eliminate smoking

b) The policy has provisions for granting exceptions

for patients and families to smoke

FMS.7

The organization plans for handling

community emergencies, epidemics and otherdisasters


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Objective elements

a) The hospital identifies potential emergencies.

b) The organization has a documented disastermanagement plan.

Cont

c) Provision is made for availability of medical

supplies, equipment and materials during such

i


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emergencies.d) Hospital staff is trained in the hospitals disaster

management plan

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

FMS.8The organization has a plan for management

of hazardous materials

Obj ti l t


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Objective elementsa) Hazardous materials are identified within the

organization

b) The hospital implements processes for sorting,labelling, handling, storage, transporting and

disposal of hazardous material.

Cont

c) Requisite regulatory requirements are met in respect

f di ti t i l


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of radioactive materials.d) There is a plan for managing spills of hazardous

materials

e) Staff is educated and trained for handling suchmaterials.

FMS.9

The hospital has system in place to provide a

safe and secure environment

Obj ti l ts


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Objective elementsa) 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.

Cont

c) Patient safety devices are installed across theorganization and inspected periodically.

d) Facility inspection rounds to ensure safety areconducted at least twice in a year in patient care


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conducted at least twice in a year in patient careareas and at least once in a year in non-patient careareas.

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

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

Chapter 9


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HUMAN RESOURCE

MANAGEMENT

HRM.1

The organization has a documented system of

human resource planning


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Objective elements

a) The organization maintains an adequate number andmix of staff to meet the care, treatment and service

needs of the patient.

Cont

b) The required job specifications and job description

are well defined for each category of staff.


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c) The organization verifies the antecedents of the

potential employee with regards tocriminal/negligence background.

HRM.2

The staff joining the organization is socialized

and oriented to the hospital environment


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Objective elements

a) Each staff member, employee, student and voluntary

worker is appropriately oriented to theorganizations mission and goals.

Cont

b) Each staff member is made aware of hospital widepolicies and procedures as well as relevant

department / unit / service / programmes policies

and procedures


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and procedures.c) Each staff member is made aware of his/her rights

and responsibilities.

d) All employees are educated with regard to patientsrights and responsibilities.

e) All employees are oriented to the service standards

of the organisation

HRM.3

There is an ongoing programme for professional

training and development of the staff

Objective elements

) A d t d t i i d d l t li


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a) A documented training and development policy

exists for the staff.

b) Training also occurs when job responsibilitieschange/ new equipment is introduced.

c) Feedback mechanisms for assessment of training

and development programme exist.

HRM.4

Staff members, students and volunteers are

adequately trained on specific job duties orresponsibilities related to safety


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Objective elements

a) All staff is trained on the risks within the hospital

environment.b) Staff members can demonstrate and take actions to

report, eliminate / minimize risks.

Cont

c) Staff members are made aware of procedures to

follow in the event of an incident.

d) Reporting processes for common problems, failuresd i


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d) Reporting processes for common problems, failuresand user errors exist

HRM.5

An appraisal system for evaluating the performance

of an employee exists as an integral part of the

human resource management process

Objective elements


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Objective elements

a) A well-documented performance appraisal system

exists in the organization.

b) The employees are made aware of the system of

appraisal at the time of induction

Cont

c) Performance is evaluated based on the performance

expectations described in job description.

d) The appraisal system is used as a tool for further


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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.6

The organization has a well-documented

disciplinary procedure

Objective elements


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j

a) A written statement of the policy of the organization

with regard to discipline is in place.

b) The disciplinary policy and procedure is based on

the principles of natural justice.

Cont

c) The policy and procedure is known to all

categories of employees of the organization.

d) The disciplinary procedure is in consonance


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) p y pwith the prevailing laws.

e) There is a provision for appeals in all

disciplinary cases.

HRM.7

A grievance handling mechanism exists in the

organization

Objective elements

a) The employees are aware of the procedure to be


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a) The employees are aware of the procedure to be

followed in case they feel aggrieved.

b) The redress procedure addresses the grievance.c) Actions are taken to redress the grievance

HRM.8

The organization addresses the health needs of

the employees

Objective elements


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National Accreditation Board for Hospitals & Healthcare Provide

nabh standards 2nd edition final 2009

Documents