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Components of StandardsDevelopment
Multiple 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 Standards
Organized around important functions
Focus on patient and staff safety
Set standards that all organizations must pass
To be revised periodically and raise the bar
Achieve International recognition
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NABH Standards
10 Chapters
100 Standards
503 Objective Elements
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Standards and ObjectiveElements
A standard is a statement that defines thestructures and processes that must besubstantially in place in an organization toenhance the quality of care
Objective element is a measurable componentof a standard
Acceptable compliance with objectiveelements determines the overall compliance
with a standard
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Section I:Patient-Centered Standards
STD OE Access, Assessment and Continuity of Care (AAC) 15 78
Patients Rights and Education (PRE) 5 29
Care of Patients (COP) 18 105
Management of Medications (MOM) 13 61
Hospital Infection Control (HIC) 9 44
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Section II:Health Care Organization
Management StandardsSTD OE
Continuous Quality Improvement (CQI) 6 37
Responsibilities of Management (ROM) 5 20
Facility Management & Safety (FMS) 9 41
Human Resource Management (HRM) 13 47
Information Management Systems (IMS) 7 41100 503
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NABH STANDARDS
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Introduction
NABH standards for hospitals have beenprepared by Technical Committee of NABH andcontain complete set of standards for evaluation
of hospitals for grant of accreditation. Thestandards provide framework for qualityassurance and quality improvement for hospitals
NABH Standards contains 10 chapters,100standards and 503 objective elements.
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Details of chapters.1) Access ,Assessment and continuity of care (AAC)2) Patient Right and Education (PRE).3) Care of Patients(COP).
4) Management of Medication (MOM).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.1The organization defines anddisplays the services that it canprovide Objective Elements
a) The services being provided are clearlydefined.
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 elementsa) Standardized policies and procedures
are used for registering and admittingpatients
b) The policies and procedures addressout- patients, in-patients and emergencypatients
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Cont
c) Patients are accepted only if theorganization can provide the requiredservice
d) The policies and procedures alsoaddress managing patients during nonavailability of beds
e) The staff is aware of these processes
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AAC.3There is an appropriate mechanism
for transfer or referral of patientswho do not match the organizationalresources
Objective elementsa) Policies guide the transfer of unstable
patients to another facility in an
appropriate mannerb) Policies guide the transfer of stable
patients to another facility
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Cont
c) Procedures identify staff responsibleduring transfer
d) The organization gives a summary ofpatients condition and the treatmentgiven
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AAC.4During admission the patient and /orthe family members are educated to
make informed decisions
Objective elementsa) The patients and/or family members
are explained about the proposed careb) The patients and/or family members
are explained about the expected results
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Cont
c) The patients and/or family membersare explained about the possiblecomplications
d) The patients and/or family members areexplained about the expected costs.
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AAC.5Patients cared for by theorganization undergo anestablished initial assessment Objective elementsa) The organization defines the content of
the assessments for the out patients, in-patients and emergency patients.
b) The organization determines who canperform the assessments.
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cont c) The organization defines the time frame
within which the initial assessment iscompleted.
d) The initial assessment for in-patients is
documented within 24 hours or earlier asper the patients condition or hospitalpolicy.
e) Initial assessment includes screening fornutritional and psychosocial needs.
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Cont
f) The initial assessment results in adocumented plan of care.
g) The plan of care also includes preventiveaspects of the care
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AAC.6All patients cared for by the
organization undergo a regularreassessment Objective elements.
a) All patients are reassessed atappropriate intervals.
b) Staff involved in direct clinical care
document reassessments.c) Patients are reassessed to determine
their response to treatment and to plan
further treatment or discharge.
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AAC.7Laboratory services are provided
as per the requirements of thepatients Objective elementsa) Scope of the laboratory services are
commensurate to the services providedby the organization
b) Adequately qualified and trainedpersonnel perform and/or supervise theinvestigations.
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AAC 8
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AAC.8There is an established
laboratory quality assuranceprogramme Objective elements
a) The laboratory quality assuranceprogramme is documented.
b) The programme addresses verification
and validation of test methods.c) The programme addresses surveillance
of test results.
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d) The programme includes periodiccalibration and maintenance of allequipments.
e) The programme includes thedocumentation of corrective andpreventive actions
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AAC.9There is an established
laboratory safety programme Objective elements.
a) The laboratory safety programme isdocumented.b) This programme is integrated with the
organizations safety programme.
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c) Written policies and procedures guidethe handling and disposal of infectiousand hazardous materials.
d) Laboratory personnel are appropriatelytrained in safe practices.
e) Laboratory personnel are provided withappropriate safety equipment / devices.
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AAC.10Imaging services are provided as
per the requirements of the patients Objective elements
a) Imaging services comply with legal andother requirements.b) Scope of the imaging services are
commensurate to the services providedby the organization.c) Adequately qualified and trained
personnel perform and/or supervise theinvesti ations.
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cont d) Policies and procedures guide
identification and safe transportation ofpatients to imaging services.
e) Imaging results are available within a
defined time frame.f) Critical results are intimated immediatelyto the concerned personnel.
g) Imaging tests not available in theorganization are outsourced toorganization(s) based on their qualityassurance system.
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AAC.11There is an established Quality
assurance programme forimaging services
Objective elementsa) The quality assurance programme for
imaging services is documented.b) The programme addresses verification
and validation of imaging methodsc) The programme addresses surveillance
of imaging results
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d) The programme includes periodiccalibration and maintenance of allequipments.
e) The programme includes thedocumentation of corrective andpreventive actions
AAC 12
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AAC.12There is an established radiation
safety programmeObjective elementsa) The radiation safety programme is
documented.b) This programme is integrated with the
organizations safety programme.
c) Written policies and procedures guidethe handling and disposal of radio-activeand hazardous materials.
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d) Imaging personnel are provided withappropriate radiation safety devicese) Radiation safety devices are periodically
tested and documented.f) Imaging personnel are trained in radiationsafety measures.
g) Imaging signage are prominentlydisplayed in all appropriate locations.h) Policies and procedures guide the safe
use of radioactive isotopes for imaging
AAC 13
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AAC.13Patient care is continuous and
multidisciplinary in natureObjective elements
a) During all phases of care, there is aqualified individual identified asresponsible for the patients care.
b) Care of patients is coordinated in all caresettings within the organization.
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cont c) Information about the patients care and
response to treatment is shared amongmedical, nursing and other care providers.
d) Information is exchanged and documentedduring each staffing shift, between shifts,and during transfers betweenunits/departments.
e) The patients record (s) is available to the
authorized care providers to facilitate theexchange of information.f) Policy and procedures guide the referral of
patients to other department / specialty.
AAC 14
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AAC.14The organization has a
documented discharge process Objective elementsa) The patients discharge process is
planned.b) Policies and procedures exist for
coordination of various departments and
agencies involved in the dischargeprocess (including medico-legal cases
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c) Policies and procedures are in place forpatients leaving against medical advice
d) A discharge summary is given to all thepatients leaving the organization(including patients leaving againstmedical advice)
AAC 15
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AAC.15Organisation defines the content
of the discharge summary Objective elementsa) Discharge summary is provided to the
patients at the time of dischargeb) Discharge summary contains the
reasons for admission, significant
findings and diagnosis and the patientscondition at the time of discharge.
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c) Discharge summary contains informationregarding investigation results, anyprocedure performed, medication andother treatment given
d) Discharge summary contains follow upadvice, medication and other instructionsin an understandable manner.
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Chapter .2PATIENT RIGHT AND
EDUCATION (PRE)
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PRE.1
The organization protects patientand family rights during care
Objective elementa) Patient and family rights are
documented.
b) Patients and families are informed oftheir rights in a format and language thatthey can understand
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c) The organizations leaders protectpatients rights
d) Staff is aware of their responsibility inprotecting patients rights
e) Violation of patient rights is reviewed andcorrective/preventive measures taken
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PRE.2.Patient rights support individual
beliefs, values and involve thepatient and family in decision
making processes Objective elementsa) Patient rights include respect for
personal dignity and privacy duringexamination, procedures and treatmentb) Patient rights include protection from
physical abuse or neglect
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c) Patient rights include treating patientinformation as confidential
d) Patient rights include refusal of treatmente) Patient rights include informed consent
before anesthesia, blood and bloodproduct transfusions and any invasive /high risk procedures / treatment
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PRE.3A documented process for
obtaining patient and / orfamilies consent exists for
informed decision making abouttheir care
Objective elementsa) General consent for treatment is
obtained when the patient enters theorganization
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b) Patient and/or his family members are informedof the scope of such general consent
c) The organization has listed those proceduresand treatment where informed consent isrequired
d) Informed consent includes information on risks, benefits, alternatives and as to who willperform the requisite procedure in a languagethat they can understand
e) The policy describes who can give consentwhen patient is incapable of independentsdecision making.
PRE 4
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PRE.4Patient and families have a right
to information and educationabout their healthcare needs
Objective elementsa) When appropriate, patient and families
are educated about the safe andeffective use of medication and thepotential side effects of the medication
b) Patient and families are educated aboutdiet and nutrition
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cont
c) Patient and families are educated aboutimmunizations
d) Patient and families are educated about
their specific disease process,complications and prevention strategiese) Patient and families are educated about
preventing infectionsf) Patients are taught in a language and
format that they can understand
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PRE.5.
Patient and families have a rightto information on expected costs
Objective elementsa) There is uniform pricing policy in a given
setting (out-patient and ward category)b) The tariff list is available to patientsc) Patients are educated about the
estimated costs of treatment
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cont
d. Patients are informed about theestimated costs when there is a changein the patient condition or treatmentsetting
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Chapter 3.Care of Patients (COP)
COP 1
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COP.1Uniform care of patients is
guided by the applicable lawsand regulations
Objective elementsa) Care delivery is uniform when similar
care is provided in more than one settingb) Uniform care is guided by policies and
procedures which reflect applicable lawsand regulations
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c) The care and treatment orders aresigned, named, timed and dated by theconcerned doctor
d) The care plan is countersigned by theclinician in-charge of the patient within 24hours
e) Evidence based medicine and clinicalpractice guidelines are adopted to guidepatient care whenever possible
COP 2
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COP.2Emergency services are guided
by policies, procedures,applicable laws and regulations
Objective elementsa) Policies and procedure for emergency
care are documented
b) Policies also address handling ofmedico-legal casesc) The patients receive care in consonance
with the policies
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d) Policies and procedures guide the triageof patients for initiation of appropriatecare
e) Staff is familiar with the policies andtrained on the procedures for care ofemergency patients
f) Admission or discharge to home ortransfer to another organization is alsodocumented
COP 3
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COP.3The ambulance services are
commensurate with the scope ofthe services provided by the
organization Objective elementsa) There is adequate access and space for
the ambulance(s)b) Ambulance(s) is appropriately equippedc) Ambulance(s) is manned by trained
personnel
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d) There is a checklist of all equipment andemergency medications
e) Equipment are checked on a daily basisf) Emergency medications are checked
daily and prior to dispatchg) The ambulance(s) has a proper
communication system
COP 4
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COP.4Policies and procedures guide
the care of patients requiringcardio-pulmonary resuscitation
Objective elementsa) Documented policies and procedures
guide the uniform use of resuscitationthroughout the organization
b) Staff providing direct patient care istrained and periodically updated in cardiopulmonary resuscitation
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c) The events during a cardio-pulmonaryresuscitation are recorded
d) An analysis of all cardiac arrests is donee) A multidisciplinary committee monitors
the effectiveness of cardio-pulmonaryresuscitation
COP.5
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COP.5Policies and procedures define
rational use of blood and bloodproducts Objective elementsa) Documented policies and procedures are
used to guide rational use of blood andblood products
b) The transfusion services are governedby the applicable laws and regulations
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Cont c) Informed consent is obtained for donation
and transfusion of blood and bloodproducts
d) Informed consent also includes patientand family education 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.6Policies and procedures guide the
care of patients in the Intensivecare and high dependency units
Objective elementsa) The organization has documented
admission and discharge criteria for its
intensive care and high dependencyunitsb) Staff is trained to apply these criteria
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c) Adequate staff and equipment areavailable
d) Defined procedures for situation of bed
shortages are followede) Infection control practices are followedf) The unique needs of end of life patients
are identified and cared forg) A quality assurance program isimplemented
COP.7
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Policies and procedures guide
the care of vulnerable patients(elderly, children, physicallyand/or mentally challenged)
Objective elementsa) Policies and procedures are documented
and are in accordance with the prevailinglaws and the national and internationalguidelines
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cont b) Staff is trained to care for this vulnerable groupc) Care is organized and delivered in accordance
with the policies and proceduresd) The organization provides for a safe and
secure environment for this vulnerable groupe) A documented procedure exists for obtaining
informed consent from the appropriate legalrepresentative
COP.8
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Policies and procedures guide
the care of high risk obstetricalpatients Objective elements.a) The organization defines and displays
whether high risk obstetric cases can becared for or not
b) Persons caring for high risk obstetriccases are competent
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c) High risk obstetric patients assessmentalso includes maternal nutrition
d) The organization has the facilities to takecare of neonates of high risk pregnancies
COP.9
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COP.9Policies and procedures guide
the care of pediatric patients Objective elements .a) The organization defines and displays
the scope of its pediatric servicesb) The policy for care of neonatal patients is
in consonance with the national/international guidelines
c) Those who care for children have agespecific competency
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d) Provisions are made for special careof children
e) Patient assessment includesdetailed nutritional, growth,psychosocial and immunizationassessment
f) Policies and procedures preventchild/ neonate abduction and abuse
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g) The childrens family members areeducated about nutrition,immunization and safe parentingand this is documented in themedical record
COP.10
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CO . 0Policies and procedures guide
the care of patients undergoingmoderate sedation
Objective elementsa) Competent and trained persons perform
sedationb) The person administering and monitoring
sedation is different from the personperforming the procedure
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c) Intra-procedure monitoring includes at aminimum the heart rate, cardiac rhythm,respiratory rate, blood pressure, oxygensaturation, and level of sedation
d) Patients are monitored after sedatione) Criteria are used to determineappropriateness of discharge from therecovery area
f) Equipment and manpower are availableto rescue patients from a deeper level ofsedation than that intended
COP.11
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Policies and procedures guide
the administration of anesthesia Objective elementsa) There is a documented policy and
procedure for the administration ofanesthesia
b) All patients for anesthesia have a pre-
anesthesia assessment by a qualifiedindividual
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cont c) The pre-anesthesia assessment results in
formulation of an anesthesia plan which isdocumented
d) An immediate preoperative reevaluation isdocumented
e) Informed consent for administration ofanesthesia is obtained by the anesthetist
f) During anesthesia monitoring includesregular and periodic recording of heart rate,cardiac rhythm, respiratory rate, bloodpressure, oxygen saturation, airway securityand patency and level of anesthesia
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g) Each patients post -anesthesia status ismonitored and documented
h) A qualified individual applies definedcriteria to transfer the patient from therecovery area
i) All adverse anesthesia events arerecorded and monitored
COP.12
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Policies and procedures guide
the care of patients undergoingsurgical procedures Objective elements
a) The policies and procedures aredocumented
b) Surgical patients have a preoperativeassessment and a provisional diagnosisdocumented prior to surgery
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cont c) An informed consent is obtained by a
surgeon prior to the procedured) Documented policies and procedures
exist to prevent adverse events like
wrong site, wrong patient and wrongsurgerye) Persons qualified by law are permitted to
perform the procedures that they areentitled to perform
f) An operative note is documented prior totransfer out of patient from recovery area
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g) The operating surgeon documents thepost-operative plan of care
h) A quality assurance program is followed
for the surgical servicesi) The quality assurance program includes
surveillance of the operation theatreenvironment
j) The plan also includes monitoring ofsurgical site infection rates
COP.13
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Policies and procedures guide the
care of patients under restraints(physical and / or chemical) Objective elements.a) Documented policies and procedures
guide the care of patients underrestraints
b) These include both physical andchemical restraint measures
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c) These include documentation of reasonsfor restraints
d) These patients are more frequentlymonitored
e) Staff receive training and periodicupdating in control and restrainttechniques
COP.14
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Policies and procedures guide
appropriate pain management Objective elementsa) Documented policies and procedures
guide the management of painb) The organization respects and supports
the appropriate assessment andmanagement of pain for all patients
c) Patient and family are educated onvarious pain management techniques
COP.15
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Policies and procedures guide
appropriate rehabilitative services Objective elementsa) Documented policies and procedures
guide the provision of rehabilitativeservices
b) These services are commensurate withthe organizational requirements
c) Rehabilitative services are provided by amultidisciplinary team
COP.16l d d d
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Policies and procedures guideall research activities
Objective elements.a) Documented policies and procedures
guide all research activities in compliancewith national and international guidelines
b) The organization has an ethics committeeto oversee all research activities
c) The committee has the powers todiscontinue a research trial when risksoutweigh the potential benefits
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d) Patients informed consent is obtainedbefore entering them in researchprotocols
e) Patients are informed of their right towithdraw from the research at any stageand also of the consequences (if any) ofsuch withdrawal
f) Patients are assured that their refusal toparticipate or withdrawal fromparticipation will not compromise theiraccess to the organizations services
COP.17P li i d d id
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Policies and procedures guidenutritional therapy
Objective elementsa) Documented policies and procedures
guide nutritional assessment andreassessmentb) Patients receive food according to their
clinical needsc) There is a written order for the dietd) Nutritional therapy is planned and
provided in a collaborative manner
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cont
e) When families provide food, they areeducated about the patients dietlimitations
f) Food is prepared, handled, stored anddistributed in a safe manner
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Policies and procedures guide
the end of life care Objective elementsa) Documented policies and procedures
guide the end of life careb) These policies and procedures are in
consonance with the legal requirements
c) These also address the identification ofthe unique needs of such patient andfamily
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Chapter4.
MANAGEMENT OFMEDICATION (MOM)
MOM.1
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Policies and procedures guide the
organization of pharmacyservices and usage of medication Objective elementsa) There is a documented policy and
procedure for pharmacy services andmedication usage
b) These comply with the applicable lawsand regulations
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cont
c) A multidisciplinary committee guides theformulation and implementation of thesepolicies and procedures
MOM.2
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There is a hospital formulary Objective elementsa) A list of medication appropriate for the
patients and organizations resources is
developedb) The list is developed collaboratively bythe multidisciplinary committee
c) There is a defined process for acquisitionof these medications
d) There is a process to obtain medicationsnot listed in the formulary
MOM.3P li i d d i f
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Policies and procedures exist forstorage of medication.
Objective elementsa) Documented policies and procedures
exist for storage of medicationb) Medications are stored in a clean, well lit
and ventilated environment
c) Sound inventory control practices guidestorage of the medications
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cont d) Medications are protected from loss or
thefte) Sound alike and look alike medications
are stored separately
f) There is a method to obtain medicationwhen the pharmacy is closed
g) Emergency medications are available all
the timeh) Emergency medications are replenishedin a timely manner when used
MOM.4
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Policies and procedures guide
the prescription of medications Objective elementsa) Documented policies and procedures
exist for prescription of medicationsb) The organization determines who can
write orders
c) Orders are written in a uniform location inthe medical records
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d) Medication orders are clear, legible,dated, named and signed
e) Policy on verbal orders is documentedand implemented
f) The organization defines a list of highrisk medication
g) High risk medication orders are verifiedprior to dispensing
MOM.4
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Policies and procedures guide the
safe dispensing of medications Objective elementsa) Documented policies and procedures
guide the safe dispensing of medicationsb) The policies include a procedure for
medication recall
c) Expiry dates are checked prior todispensingd) Labeling requirements are documented
and implemented by the organization
MOM.5h d f d d
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There are defined procedures
for medication administration Objective elementsa) Medications are administered by those
who are permitted by law to do sob) Prepared medication are labeled prior to
preparation of a second drug
c) Patient is identified prior to administration
cont
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cont
d) Medication is verified from the order priorto administration
e) Dosage is verified from the order prior toadministration
f) Route is verified from the order prior toadministration
g) Timing is verified from the order prior toadministration
cont
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cont
h) Medication administration is documentedi) Polices and procedures govern patients
self administration of medications j) Polices and procedures govern patients
medications brought from outside theorganization
MOM.7
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Patients and family members are
educated about safe medicationand food-drug interactions Objective elementsa) Patient and family are educated about
safe and effective use of medicationb) Patient and family are educated about
food-drug interactions
MOM.8
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Patients are monitored after
medication administration Objective elementsa) Patients are monitored after medication
administration and this is documentedb) Adverse drug events are defined
c) Adverse drug events are reported withina specified time frame
cont
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cont
d) Adverse drug events are collected andanalysed
e) Policies are modified to reduce adversedrug events when unacceptable trendsoccur
MOM.9l d d d
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Policies and procedures guide
the use of narcotic drugs andpsychotropic substances Objective elementsa) Documented policies and procedures
guide the use of narcotic drugs andpsychotropic substances
b) These policies are in consonance withlocal and national regulations
cont
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cont
c) A proper record is kept of the usage,administration and disposal of thesedrugs
d) These drugs are handled by appropriatepersonnel in accordance with policies
MOM.10
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Policies and procedures guide
the usage of chemotherapeuticagents
Objective elementsa) Documented policies and procedures
guide the usage of chemotherapeuticagents
b) Chemotherapy is prescribed by thosewho have the knowledge to monitor andtreat the adverse effect of chemotherapy
cont
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cont
c) Chemotherapy is prepared andadministered by qualified personnel
d) Chemotherapy drugs are disposed off inaccordance with legal requirements
MOM.11P li i d d g
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Policies and procedures govern
usage of radioactive orinvestigational drugs Objective elements.
a) Documented policies and proceduresgovern usage of radioactive orinvestigational drugs
b) These policies and procedures are inconsonance with laws and regulations
cont
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cont
c) The policies and procedures include thesafe storage, preparation, handling,distribution and disposal of radioactiveand investigational drugs
d) Staff, patients and visitors are educatedon safety precautions
MOM.12P li i d d id h
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Policies and procedures guide the
use of implantable prosthesis Objective elements.
a) Documented policies and proceduresgovern procurement and usage ofimplantable prosthesis
b) Selection of implantable prosthesis isbased on scientific criteria andinternationally recognized approvals
cont
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cont
c) The batch and serial number of theimplantable prosthesis are recorded inthe patients medical record and the
master logbook
MOM.13Policies and procedures guide
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Policies and procedures guide
the use of medical gases Objective elementsa) Documented policies and procedures
govern procurement, handling, storage,distribution, usage and replenishment ofmedical gases.
b) The policies and procedures address thesafety issues at all levels
Cont
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Cont
c) Appropriate records are maintained inaccordance with the policies, proceduresand legal requirements.
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Chapter 5
HOSPITAL INFECTIONCONTROL (HIC)
HIC.1
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The organization has a well-designed, comprehensive andcoordinated Hospital Infection
Control (HIC) programme aimedat reducing/ eliminating risks topatients, visitors and providers
of care.
Objective elements
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Objective elementsa) The hospital has a multi-disciplinary
infection control committee.b) The hospital has an infection control
team.c) The hospital has designated and
qualified infection control nurse(s) for thisactivity
d) The hospital infection control programmeis documented.
HIC.2
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The hospital has an infection
control manual, which isperiodically updated.
Objective elementsa) The manual identifies the various high-
risk areas.
b) It outlines methods of surveillance in theidentified high-risk areas.
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Cont
g) Kitchen sanitation and food handlingissues are included in the manual
h) Engineering controls to prevent
infections are includedi) Mortuary practices and procedures are
included as appropriate to the
organization
HIC.3Th i f ti t l t i
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The infection control team is
responsible for surveillanceactivities in identified areas ofthe hospital.
Objective elementsa) Surveillance activities are appropriately
directed towards the identified high-riskareas.
b) Collection of surveillance data is anongoing process.
Cont
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Cont
c) Verification of data is done on regularbasis by the infection control team.
d) In cases of notifiable diseases,
information (in relevant format) is sent toappropriate authorities.
e) Scope of surveillance activities
incorporates tracking and analyzing ofinfection risks, rates and trends.
HIC.4h h i l k i
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The hospital takes actions to
prevent or reduce the risks ofHospital Associated Infections
(HAI) in patients and employees. Objective elementsa) The organization monitors urinary tract
infections.b) The organization monitors respiratory
tract infections.
Cont
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Cont
c) The organization monitors intra-vasculardevice infections.
d) The organization monitors surgical site
infections.e) Appropriate feedback regarding HAI
rates are provided on a regular basis to
medical and nursing staff.
HIC.5
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Proper facilities and adequate
resources are provided to supportthe infection control programme
Objective elementsa) Hand washing facilities in all patient care
areas are accessible to health care
providers.b) Compliance with proper hand washing ismonitored regularly.
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HIC.6Th h i l k i i
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The hospital takes appropriate action
to control outbreaks of infections. 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 preventrecurrence
HIC.7There are documented procedures
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pfor sterilisation activities in the
hospital. Objective elementsa) There is adequate space available for
sterilization activitiesb) Regular validation tests for sterilisation
are carried out and documented.c) There is an established recall procedure
when breakdown in the sterilisationsystem is identified
HIC.8Statutory provisions with regard
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Statutory provisions with regardto Bio-medical Waste (BMW)
management are complied with Objective elements
a) The hospital is authorised by prescribedauthority for the management andhandling of Bio-medical Waste.
b) Proper segregation and collection of Bio-medical Waste from all patient careareas of the hospital is implemented andmonitored.
Cont
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c) The organization ensures that Bio-medical Waste is stored and transportedto the site of treatment and disposal inproper covered vehicles within stipulatedtime limits in a secure manner.
d) Bio-medical Waste treatment facility ismanaged as per statutory provisions (if
in-house) or outsourced to authorisedcontractor(s).
Cont
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e) Requisite fees, documents and reportsare submitted to competent authoritieson stipulated dates.
f) Appropriate personal protectivemeasures are used by all categories ofstaff handling Bio-medical Waste
HIC.9The infection control programme
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The infection control programme
is supported by hospitalmanagement and includes trainingof staff and employee health
Objective elementsa) Hospital management makes available
resources required for the infection
control programmeb) The hospital regularly earmarks
adequate funds from its annual budget in
this regard
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c) It conducts regular pre-induction trainingfor appropriate categories of staff before
joining concerned department(s).
d) It also conducts regular in-service training sessions for all concernedcategories of staff at least once in a year.
e) Appropriate pre and post exposureprophylaxis is provided to all concernedstaff members
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Chapter 6CONTINUOUS QUALITY
IMPROVEMENT (CQI)
CQI.1There is a structured quality
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There is a structured quality
assurance and continuousmonitoring programme in theorganization
Objective elementsa) The quality assurance programme is
developed, implemented and maintainedby a multi-disciplinary committee.
b) The quality assurance programme isdocumented.
Cont
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c) There is a designated individual forcoordinating and implementing thequality assurance programme
d) The quality assurance programme iscomprehensive and covers all the majorelements related to quality assurance
and risk management.
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Cont
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g) The quality assurance programme is acontinuous process and updated at leastonce in a year.
CQI.2The organization identifies key
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indicators to monitor the clinicalstructures, processes and
outcomes Objective elementsa) Monitoring includes appropriate patient
assessment.b) Monitoring includes diagnostics services
safety and quality control programmes.c) Monitoring includes all invasive
procedures.
Cont
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d) Monitoring includes adverse drug events.e) Monitoring includes use of anaesthesia.f) Monitoring includes use of blood and
blood products.g) Monitoring includes availability and
content of medical records.
h) Monitoring includes infection controlactivities.i) Monitoring includes clinical research.
CQI.3The organisation identifies key
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g yindicators to monitor the
managerial structures, processesand outcomes
Objective elements Monitoring includes procurement of
medication essential to meet patient
needs. Monitoring includes reporting of activities
as required by laws and regulations.
Cont
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Monitoring includes risk management. Monitoring includes utilisation of facilities. Monitoring includes patient satisfaction.
Monitoring includes employee satisfaction. Monitoring includes adverse events. Monitoring includes data collection to
support further study for improvements. Monitoring includes data collection to
support evaluation of the improvements.
.The quality improvement
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programme is supported by themanagement
Objective elementsa) Hospital Management makes available
adequate resources required for qualityimprovement programme.
b) Hospital earmarks adequate funds fromits annual budget in this regard.
c) Appropriate statistical and managementtools are applied whenever required
CQI.5There is an established system
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yfor audit of patient care services
Objective elementsa) Medical staff participates in this system.
b) The parameters to be audited aredefined by the organisation.
c) Patient and clinician anonymity is
maintained.d) All audits are documented.e) Remedial measures are implemented.
CQI.6Sentinel events are intensively
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analysed Objective elementsa) The organisation has defined sentinel
events.b) The organisation has established processes
for intense analysis of such events.c) Sentinel events are intensively analysed
when they occur.d) Actions are taken upon findings of such
analysis
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Chapter 7
RESPONSIBILITIES OFMANAGEMENT (ROM)
ROM.1The responsibilities of the
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p
management are defined Objective elementsa) The organization has a documented
organogramb) Those responsible for governance
appoint the senior leaders in the
organizationc) Those responsible for governance
support the quality improvement plan
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d) The organization complies with the laiddown and applicable legislations andregulations
e) Those responsible for governanceaddress the organizations socialresponsibility
ROM.2The services provided by each
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department are documented Objective elementsa) Each organizational program, service, site or
department has effective leadershipb) Scope of services of each department is
definedc) Administrative policies and procedures for
each department is maintainedd) Departmental leaders are involved in quality
improvement
ROM.3The organization is managed by
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g g y
the leaders in an ethical manner Objective elementsa) The leaders make public the mission
statement of the organizationb) The leaders establish the organizations
ethical managementc) The organization discloses its ownership
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d) The organization honestly portrays theservices which it can and cannot provide
e) The organization accurately bills for its
services
ROM.4A suitably qualified and experienced individual heads
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A suitably qualified and experienced individual heads
the organisation Objective elementsa) The designated individual has requisite
and appropriate administrativequalifications.
b) The designated individual has requisite
and appropriate administrativeexperience.
ROM.5Leaders ensure that patient
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p
safety aspects and riskmanagement issues are anintegral part of patient care and
hospital management Objective elements
a) The organization has an interdisciplinarygroup assigned to oversee the hospitalwide safety programme.
Cont
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b) The scope of the programme is definedto include adverse events ranging fromno harm to sentinel events .
c) Management ensures implementation ofsystems for internal and externalreporting of system and process failures.
d) Management provides resources forproactive risk assessment and riskreduction activities.
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Chapter 8FACILITY MANAGEMENT AND
SAFETY (FMS)
FMS.1The organization is aware of and
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g
complies with the relevant rulesand regulations, laws andbyelaws and requisite facility
inspection requirements Objective elementsa) The management is conversant with the
laws and regulations and knows theirapplicability to the organization.
Cont
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b) Management regularly updates anyamendments in the prevailing laws of theland.
c) The management ensuresimplementation of these requirements.
d) There is a mechanism to regularly
update licenses/registrations/certifications
FMS.2The organizations environment
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The organization s environment
and facilities operate to ensuresafety of patients, staff and
visitors
Objective elementsa) There is a documented operational and
maintenance (preventive andbreakdown) plan.
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b) Up-to-date drawings are maintainedwhich detail the site layout, floor plansand fire escape routes.
c) The provision of space shall be in
accordance with the available literatureon good practices (Indian or InternationalStandards) and directives fromgovernment agencies.
d) There are designated individualsresponsible for the maintenance of all thefacilities.
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FMS.3The organization has a programf li i l d i
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for clinical and support serviceequipment management
Objective elementsa) The organization plans for equipment in
accordance with its services andstrategic plan
b) Equipment is selected by a collaborativeprocess.
c) All equipment is inventoried and properlogs are maintained as required.
Cont
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d) Qualified and trained personnel operateand maintain the equipment.
e) Equipment are periodically inspected and
calibrated for their proper functioning.f) There is a documented operational and
maintenance (preventive and
breakdown) plan.
FMS.4The organization has provisions
f f l i i di l
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for safe water, electricity, medicalgases and vacuum systems
Objective elementsa) Potable water and electricity are available
round the clock.b) Alternate sources are provided for in case of
failure.
c) The organisation regularly tests the alternatesources.d) There is a maintenance plan for piped
medical gas and vacuum installation.
FMS.5The organization has plans for
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fire and non-fire emergencieswithin the facilities
Objective elementsa) The organization has plans andprovisions for early detection, abatementand containment of fire and non-fireemergencies.
Cont
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b) Staff is trained for their role in case ofsuch emergencies.
c) The organization has a documented safe
exit plan in case of fire and non-fireemergencies.
d) Mock drills are held at least twice in a
year
FMS.6The organization has a smoking
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limitation policy Objective elementsa) The organization defines its polices to
reduce or eliminate smokingb) The policy has provisions for granting
exceptions for patients and families to
smoke
FMS.7The organization plans for handling
it g i id i
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community emergencies, epidemicsand other disasters
Objective elementsa) The hospital identifies potential
emergencies.b) The organization has a documented
disaster management plan.
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c) Provision is made for availability ofmedical supplies, equipment andmaterials during such emergencies.
d) Hospital staff is trained in the hospitalsdisaster management plane) The plan is tested at least twice in a
year.
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c) Requisite regulatory requirements aremet in respect of radioactive materials.
d) There is a plan for managing spills ofhazardous materials
e) Staff is educated and trained for
handling such materials.
FMS.9The hospital has system in place
id f d
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to provide a safe and secureenvironment
Objective elements
a) The hospital has a safety committee toidentify the potential safety and securityrisks.
b) This committee coordinates development,implementation, and monitoring of thesafety plan and policies.
Cont
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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 andcorrective and preventive measures areundertaken.
e) There is a safety education programmefor all staff.
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Chapter9
HUMAN RESOURCEMANAGEMENT
HRM.1The organization has a
d t d t f h
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documented system of humanresource planning
Objective elementsa) The organization maintains an adequate
number and mix of staff to meet the care,treatment and service needs of thepatient.
Cont
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b) The required job specifications and jobdescription are well defined for eachcategory of staff.
c) The organization verifies the antecedentsof the potential employee with regards to
criminal/negligence background.
HRM.2The staff joining the organization
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The staff joining the organization
is socialized and oriented to thehospital environment
Objective elementsa) Each staff member, employee, student
and voluntary worker is appropriatelyoriented to the organizations missionand goals.
Cont b) E h t ff b i d f
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b) Each staff member is made aware ofhospital wide policies and procedures aswell as relevant department / unit /service / programmes policies andprocedures.
c) Each staff member is made aware ofhis/her rights and responsibilities.
d) All employees are educated with regardto patients rights and responsibilities.
e) All employees are oriented to the servicestandards of the organisation
HRM.3There is an ongoing programme
for professional training and
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for professional training anddevelopment of the staff
Objective elementsa) A documented training and development
policy exists for the staff.b) Training also occurs when job
responsibilities change/ new equipment
is introduced.c) Feedback mechanisms for assessmentof training and development programmeexist.
HRM.4Staff members, students and
volunteers are adequately
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volunteers are adequatelytrained on specific job duties orresponsibilities related to safety
Objective elementsa) All staff is trained on the risks within the
hospital environment.
b) Staff members can demonstrate andtake actions to report, eliminate /minimize risks.
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HRM.5 An appraisal system for evaluating
the performance of an employee
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the performance of an employeeexists as an integral part of the
human resource management
process Objective elementsa) A well-documented performance
appraisal system exists in theorganization.
Cont
b) Th l d f h
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b) The employees are made aware of thesystem of appraisal at the time ofinduction.
c) Performance is evaluated based on the
performance expectations described in job description.d) The appraisal system is used as a tool
for further development.e) Performance appraisal is carried out at
pre defined intervals and is documented.
HRM.6The organization has a well-
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documented disciplinaryprocedure
Objective elementsa) A written statement of the policy of the
organization with regard to discipline is inplace.
b) The disciplinary policy and procedure isbased on the principles of natural justice.
Cont
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c) The policy and procedure is known to allcategories of employees of theorganization.
d) The disciplinary procedure is inconsonance with the prevailing laws.e) There is a provision for appeals in all
disciplinary cases.
HRM.7A grievance handling mechanism
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exists in the organization Objective elementsa) The employees are aware of the
procedure to be followed in case theyfeel aggrieved.
b) The redress procedure addresses thegrievance.
c) Actions are taken to redress thegrievance
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Cont
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c) Regular physical and medical checks aredone at-least once a year and thefindings/ results are documented.
d) Occupational health hazards areadequately addressed.
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c) All records of in-service training andeducation are contained in the personalfiles.
d) Personal files contain results of allevaluations
HRM 10
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HRM.10There is a process for collecting, verifyingand evaluating the credentials(education, registration, training and
experience) of medical professionalspermitted to provide patient care without
supervision
Objective elementsa) Medical professionals permitted by law,
regulation and the hospital to provide
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regulation and the hospital to providepatient care without supervision isidentified.
b) The education, registration, training and
experience of the identified medicalprofessionals is documented andupdated periodically.
c) All such information pertaining to themedical professionals is appropriatelyverified when possible.
HRM.11There is a process for authorising
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p g
all medical professionals to admitand treat patients and provide
other clinical servicescommensurate with their
qualifications
Objective elementsa) Medical professionals admit and care for
patients as per the laid down policies
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patients as per the laid down policiesand authorisation procedures of theorganization
b) The services provided by the medical
professionals are in consonance withtheir qualification, training andregistration.
c) The requisite services to be provided bythe medical professionals are known tothem as well as the various departments/ units of the hospital.
HRM.12There is a process for collecting,
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verifying and evaluating thecredentials (education,registration, training and
experience) of nursing staff Objective elements
a) The education, registration, training andexperience of nursing staff isdocumented and updated periodically.
Cont
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b) All such information pertaining to thenursing staff is appropriately verifiedwhen possible
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HRM.13There is a process to identify jobresponsibilities and make clinical work
assignments to all nursing staff memberscommensurate with their qualifications
and any other regulatory requirements
Objective elementsa) The clinical work assigned to nursing
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a) The clinical work assigned to nursingstaff is in consonance with theirqualification, training and registration.
b) The services provided by nursing staff
are in accordance with the prevailinglaws and regulations.c) The requisite services to be provided by
the nursing staff are known to them aswell as the various departments / units ofthe hospital
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Chapter.10INFORMATION
MANAGEMENT SYSTEM (IMS)
IMS.1
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Policies and procedures exist to meet theinformation needs of the care providers,management of the organization as wellas other agencies that require data andinformation from the organization
Objective elementsa) The information needs of the
organization are identified and are
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organization are identified and areappropriate to the scope of the servicesbeing provided by the organization andthe complexity of the organization
b) Policies and procedures to meet theinformation needs are documented.c) These policies and procedures are in
compliance with the prevailing laws andregulations.
Cont
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d) All information management andtechnology acquisitions are inaccordance with the policies andprocedures.
e) The organization contributes to externaldatabases in accordance with the lawand regulations
IMS.2The organization has processesin place for effective
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pmanagement of data
Objective elements
a) Formats for data collection arestandardized
b) Necessary resources are available for
analyzing data
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c) Documented procedures are laid downfor timely and accurate dissemination ofdata
d) Documented procedures exist for storingand retrieving datae) Appropriate clinical and managerial staff
participates in selecting, integrating andusing data.
IMS.3The organization has a complete
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and accurate medical record forevery patient
Objective elements a) Every medical record has a unique
identifier.b) Organization policy identifies those
authorized to make entries in medicalrecord.
Cont
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c) Every medical record entry is dated andtimed.d) The author of the entry can be identified
e) The contents of medical record areidentified and documented
f) The record provides an up-to-date and
chronological account of patient care
IMS.4The medical record reflects
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continuity of care Objective elementsa) The medical record contains information
regarding reasons for admission,diagnosis and plan of care.
b) Operative and other proceduresperformed are incorporated in themedical record
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e) In case of death, the medical recordcontains a copy of the death certificateindicating the cause, date and time ofdeath.
f) Whenever a clinical autopsy is carriedout, the medical record contains a copyof the report of the same.
g) Care providers have access to currentand past medical record.
IMS.5Policies and procedures are in place formaintaining confidentiality integrity and
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maintaining confidentiality, integrity and
security of information
Objective elementsa) Documented policies and procedures
exist for maintaining confidentiality,
security and integrity of information
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b) Policies and procedures are inconsonance with the applicable lawsc) The policies and procedures incorporate
safeguarding of data/ record againstloss, destruction and tamperingd) The hospital has an effective process of
monitoring compliance of the laid downpolicy
Cont
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e) The hospital uses developments inappropriate technology for improving,confidentiality, integrity and security
f) Privileged health information is used forthe purposes identified or as required bylaw and not disclosed without the
patients authorization
Cont
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g) A documented procedure exists on howto respond to patients / physicians andother public agencies requests foraccess to information in the clinicalrecord in accordance with the local andnational law.
IMS.6Policies and procedures exist for
retention time of records data
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retention time of records, dataand information
Objective elements
a) Documented policies and procedures arein place on retaining the patients clinicalrecords, data and information
b) The policies and procedures are inconsonance with the local and nationallaws and regulations
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c) The retention process provides expectedconfidentiality and securityd) The destruction of medical records, data
and information is in accordance with thelaid down policy
IMS.7The organization regularly
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carries out medical audits Objective elementsa) The medical records are reviewed
periodicallyb) The review uses a representative sample
c) The review is conducted by identifiedcare providers.
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d) The review focuses on the timeliness,legibility and completeness of themedical records
e) The review process includes records ofboth active and discharged patients
f) The review points out and documentsany deficiencies in records
g) Appropriate corrective and preventivemeasures undertaken are documented.
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Thank you