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all categoriesFeaturedRecentPeopleAuthorsStudentsResearchersPublishersGovernment & NonprofitsBusinessesMusiciansArtists & DesignersTeachers+ all categoriesMost FollowedPopular..Sign Up Log In..1First Page Previous Page Next Page / 66Sections not available Zoom Out Zoom In Fullscreen Exit FullscreenSelect View Mode View ModeSlideshowScroll ...Readcast Add a Comment Embed & Share Reading should be social! Post a message on your social networks to let others k now what you're reading. Select the sites below and start sharing.Readcast this Document.. Login to Add a Comment.. Share & Embed.Add to Collections Download this Document for FreeAuto-hide: on CHAPTER 1 : Access, Assessment and Continuity of Care (AAC)AAC.1. The organizati on defines and displays the services that it can provide.Objective Element Inter pretation Remarksa) The services beingprovided are clearlydefined and are inconsonance with theneeds of the community.A policy to be framed clearly sta ting theservices the hospital can provide.Scope of Servicesb) The defined servic es areprominently displayed.The services so defined should bedisplayed prom inently in an area visibleto all patients entering the organization.The display could be in the form of boards, citizen's charter, scrollingmessages etc. Car e should be taken toensure that these are displayed in thelanguage(s) the patien t understands.Evident on Sitec) The staff is oriented tothese services.All t he staff in the Hospital mainly in thereception/registration, OPD, IPD areori ented to these facts through trainingprogramme regularly or throughmanuals.AA C.2. The organization has a well defined registration and admission process.Obje ctive Element Interpretation Remarksa) Standardized policies andprocedures are used for registering and admittingpatients.Health Care Organization (HCO) ha sprepared document (s) detailing thepolicies and procedures for registration and admission of patients which shouldalso include unidentified patients.Registr ation processAdmission Processb) The policies andprocedures address out-pati ents, in-patients andemergency patients.Self explanatoryAdmissionProcess c) Pa tients are accepted onlyif the organization canprovide the requiredservice. The staff handling admission andregistration needs to be aware of theservice s that the organization canprovide. It is also advisable to have asystem whe rein the staff is aware as towhom to contact if they need anyclarification on the services provided.Admission Process d) The policies andprocedures also addressmanaging patients duringnon availa bility of beds.The HCO is aware of the availability of alternate HCO's where the patients maybe directed in case of non-availability of beds.Policy for nonavail ability of bedse) The staff is aware of theseprocesses.All the staff handling th ese activitiesshould be oriented to these policies andprocedures.Induction Manua lAAC.3. There is an appropriate mechanism for transfer or referral of patients w ho do notmatch the organizational resources. Objective Element Interpretation Remarksa) Policies guide the transfer of unsta ble patients toanother facility in anappropriate manner.The organization shall at the outsetdefine as to who is an unstable patient.The documented poli cy and procedureshould address the methodology of safetransfer of the patient

in a lifethreatening situation (like those who areon ventilator) to another HCO. Thereshould be availability of an appropriateambulance fitted with life supportfacilities and accompanied by trainedpersonnel.Patient Transfer Policyb) Policies guide the transfer of stable patients toanother facility.Patients not in a life threateningsituation (stable) should also betransported in a safe manner.Patient Transfer Policyc) Procedures identify staff responsible duringtransfer.The staff shall at least be a trainedtrauma/emergency technici an/nurse.He/she shall have undergone training inBLS and/or ACLS.Patient Transfer Policyd) The organization gives asummary of patientscondition and thetreatme nt given.The HCO gives a case summarymentioning the significant findings an dtreatment given in case of patients whoare being transferred from emergency.For admitted patients a dischargesummary has to be given (refer AAC15).The same shall also be givento patients going against medicaladvice. Discharge SummaryAAC.4. During admission the patient and /or the family members are educat ed to makeinformed decisions.Objective Element Interpretation Remarks2 a) The patients and/or familymembers are explainedabout the proposed care.The plan of care as decided by thedoctor on duty or the patientmanagement team (as the case maybe) is to be discussed with the patientand/or family members. Th is should bedone in a language thepatient/attendant can understand. Theabove information is to be documentedand signed by the concerned doctor.Patients Righ t Policyb) The patients and/or familymembers are explainedabout the expected results.The patients and family are explained indetail by the treating physi cians or his/her team about the outcomes of such treatment.Patients Right Polic yc) The patients and/or familymembers are explainedabout the possiblecomplic ations.Possible complications of the treatment,if any, are clearly communicated to thepatient.Patients Right Policy d) The patients and/or familymembers are e xplainedabout the expected costs.Patients should be given an estimate of the ex penses on account of thetreatment preferably in a written form.Patients Righ t Policy AAC.5. Patients cared for by the organization undergo an established in itial assessment. Objective Element Interpretation Remarksa) The organization definesthe conten t of theassessments for the outpatients, in-patients andemergency patients.Th e hospital shall have a protocol/policyby which a standardized initialassess ment of patients is done in theOPD, emergency and in-patients. Theinitial asses sment could bestandardized across the hospital or itcould be modified dependin g on theneed of the department. However itshall be the same in that particular areae.g. in a paediatric OPD the weight andheight may be a must whereas it mayn ot be so for orthopaedics OPD. Theorganization can have differentassessment c riteria for the first visit andfor subsequent visits. In emergencydepartment this shall include recordingthe vital parameters. The initialassessment sh ould also include thenursing assessment for in-patients.Initial AssessmentPol icyb) The organizationdetermines who canperform the assessments.The assessmen t should be done by thetreating doctor, junior doctor or a nurse.The organizatio n determines who cando what assessment and it should bethe same across the hospi tal.Initial AssessmentPolicyc) The organization definesthe time frame withi nwhich the initialassessment is completed.The HCO has defined and documentedth e time frame within which the initialassessment is to be completed withrespect to OPD/ emergency/indoor patients.I Initial Assessment Policy3 d) The i nitial assessment for in-patients is documentedwithin 24 hours or earlier as pe r the patientscondition or hospitalpolicy.This should cover history, prog ressnotes, investigation ordered andtreatment ordered and all these are tobe authenticated by treating doctor.Initial AssessmentPolicye) Initial assessment i ncludesscreening for nutritionalneeds.The protocol for patients initialasse ssment should cover his/her nutritional needs. In case of Outpatients th is should be done where ever applicable. For example diabetics, CRFpatients.Init ial AssessmentPolicyf) The initial assessmentresults in a documentedplan of care which ismonitored.This shall be documented by thetreating doctor o r by a member of histeam in the case sheet. This plan ismonitored by the treatin g doctor for itseffectiveness, and wherever required bya clinical audit.Initial AssessmentPolicyg) The plan of care alsoincludes preventiveaspects of the c

are.The documented plan of care shouldcover preventive actions as necessaryin th e case and should include diet,drugs etc.Initial AssessmentPolicyAAC.6. All pati ents cared for by the organization undergo a regular reassessment. Objective El ement Interpretation Remarksa) All patients arereassessed at appropriateinterv als.After the initial assessment, the patientis reassessed periodically and this isdocumented in the case sheet. Thefrequency maybe different for differenta reas based on the setting and thepatient s condition e.g. patients in ICUneed t o reassessed more frequentlycompared to a patient in the ward.Initial Assessm entPolicyb) Staff involved in directclinical care documentreassessments.Act ions taken under reassessment aredocumented. The staff could be thetreating doc tor or any member of theteam as per their domain of responsibility of care. Initial AssessmentPolicyc) Patients are reassessed todetermine their responset o treatment and to planfurther treatment or discharge.Self explanatory.Initial AssessmentPolicyAAC.7. Laboratory services are provided as per the requirements of the patients.Objective Element Interpretation Remarks4 a) Scope of the laboratoryservices arecommensurate to theservices provid ed by theorganization.The HCO should ensure availability of laboratory services commensurate withthe health care services offered by iteither by providing the s ame in house or by outsourcing. However, test resultsrequired for emergency ma nagement(RBS, ABG etc) must be availablewithin its premises. See also (f) belowfor outsourced lab facilities.Laboratory Manualb) Adequately qualified an dtrained personnel performand/or supervise theinvestigations.The staff employe d in the lab should besuitably qualified (appropriate degree)and trained to c arry out the tests.Pathologist, microbiologist andbiochemist supervise the staff.Laboratory Manualc) Policies and proceduresguide collection,identificat ion, handling,safe transportation,processing and disposal of specimens.The HCO has documented proceduresfor collection, identification, handling,safe tran sportation, processing anddisposal of specimens, to ensure safetyof the specim en till the tests and retests(if required) are completed.Laboratory Manuald) Lab oratory results areavailable within a definedtime frame.The HCO shall define t he turnaroundtime for all tests. The HCO shouldensure availability of a dequate staff,materials and equipment to make thelaboratory results available w ithin thedefined time frame.Laboratory Manuale) Critical results areintimated immediately tothe concerned personnel.The laboratory shall establish itsbi ological reference intervals for different tests. The laboratory shallest ablish critical limits for tests whichrequire immediate attention for patientman agement. The test results in thecritical limits shall be communicated tothe con cerned after proper documentation.Laboratory Manualf) Laboratory tests notav ailable in theorganization areoutsourced toorganization(s) based ontheir quality assurancesystem.The HCO has documented procedurefor outsourcing tests f or which it has nofacilities. This should include:a) list of tests for out sour cing.b) identity of personnel in the outsourced facilities to ensure s afetransportation of specimens andcompleting of tests as per requirements of the patientconcerned and receipt of results atHCO.c) manner of packagi ng of thespecimens and their labelling for identification and this pack ageshould contain the test requisitionwith all details as required for test ing.d) a methodology to check theperformance of service rendered bythe out sourced laboratory as per the requirements of the HCO.Laboratory Manual5 AAC.8. There is an established laboratory quality assurance programme.Objectiv e Element Interpretation Remarksa) The laboratory qualityassurance programme isdocumented.The HCO has a documented qualityassurance programme (preferably asper ISO 15189 Medical laboratories Particular requirements for quality andcomp etence).LaboratoryQA Manual b) The programmeaddresses verification andvalidatio n of test methods.This holds true for any laboratorydeveloped methods.Labor atoryQA Manual c) The programmeaddresses surveillance of test results.The labo ratory director shall periodicallyassess the test results.LaboratoryQA Manual d ) The programme includesperiodic calibration andmaintenance of allequipmen ts.Refer to ISO 15189.LaboratoryQA Manual e) The programme includesthe docume ntation of corrective and preventiveactions.Self explanatory.LaboratoryQA Manua l AAC.9. There is an established laboratory safety programme.Objective Element I

nterpretation Remarksa) The laboratory safetyprogramme isdocumented.A well do cumented lab safety manual isavailable in the lab. This takes care of the safety of the workforce as well asthe equipments available in the lab.LaboratorySafety Manualb) This programme isintegrated with theorganizations safetyprogramme. Lab safety programme is incorporatedin the safety programme of the hospital.Labo ratorySafety Manualc) Written policies andprocedures guide thehandling and disposal of infectious and hazardousmaterials.The lab staff should follow standa rdprecautions. The disposal of waste isaccording to Biomedical wastemanagemen t and handling rules, 1998.LaboratorySafety Manuald) Laboratory personnel areapp ropriately trained insafe practices.All the lab staff undergo trainingreg arding safe practices in the lab.LaboratorySafety Manuale) Laboratory personnel areprovided with appropriatesafety equipment /devices.Adequate safety devices are availablein the lab e.g. fire extinguishers,dressing materials, stan dardprecautions, disinfectants, etc.LaboratorySafety ManualAAC.10. Imaging servi ces are provided as per the requirements of the patients.6 Objective Element Interpretation Remarksa) Imaging services complywith lega l and other requirements.The HCO is aware of the legal andother requirements o f imaging servicesand the same are documented for information and complia nce by allconcerned in the HCO. The HCOmaintains and updates its complian cestatus of legal and other requirementsin a regular manner.Imaging Departmentb) Scope of the imagingservices arecommensurate to theservices provided by t heorganization.Self explanatory.Imaging Departmentc) Adequately qualified andt rained personnel performand/or supervise theinvestigations.As per AERB guideli nes.Imaging Departmentd) Policies and proceduresguide identification andsafe transportation of patients to imagingservices.The HCO has documented polici es andprocedures for informing the patientsabout the imaging activities, the ir identification and safe transportation tothe imaging services. This should al soaddress transfer of unstable patients toimaging services.Imaging DepartmentPat ient Transfer Policye) Imaging results areavailable within a definedtime frame .The organization shall documentturnaround time of imaging results.Imaging De partmentf) Critical results areintimated immediately tothe concerned personn el.Critical results shall be intimated to thetreating clinician at the earli est onphone, followed by written report.Imaging Departmentg) Imaging tests not availablein the organization areoutsourced toorganization(s) based ontheir quality assurancesystem.The HCO has documented procedurefor outsourcing tests for which it has nofacilities. This should include:a) list of tests for out sou rcing,b) identity of personnel in the outsourced facilities to ensure safetransportation of specimens andcompleting of imaging results,c) manner of identification of patientsand the test requisition with all detailsas required for testing andd) a methodology to check the selectionand performance of service rendered bythe outsourced imaging facility as per the requirements of the HCO.I maging DepartmentAAC.11. There is an established Quality assurance programme for imaging services.Objective Element Interpretation Remarks7 a) The quality assuranceprogramme for imagingservices is documented.Refer to AERB guidelines.ImagingQA Programmeb) The programmeaddresses verification an dvalidation of imagingmethods.A document for verification andvalidation of imaging methods shall beavailable.ImagingQA Programmec) The programmeaddresses surveillance of imaging results.HOD shall periodically assess theimaging re sults.ImagingQA Programmed) The programme includesperiodic calibration andm aintenance of allequipments.Calibration and maintenance of allequipment s hall be carried out bycompetent persons.ImagingQA Programmee) The programme includesthe documentation of corrective and preventiveactions.Self explanato ry.ImagingQA ProgrammeAAC.12. There is an established radiation safety programme . Objective Element Interpretation Remarksa) The radiation safetyprogramme i sdocumented.Refer to AERB guidelinesImaging Safety Manualb) This programme isi ntegrated with theorganizations safetyprogramme.The safety programme of the im agingdepartment has reference in thehospital safety manual.Hospital Safety M anualc) Written policies andprocedures guide thehandling and disposal of rad io-active andhazardous materials.Radioactive and hazardous materialsshall be disposed off as per bio-medicalwaste management and handling rules,1998.Imaging

Safety Manuald) Imaging personnel areprovided with appropriateradiation safety devices.Self explanatory.Imaging Safety Manuale) Radiation safety devicesare periodically tested anddocumented.Protective devices e.g. lead apronsshould be exposed to X-ray for verification of cracks and damages.Imaging Safety M anualf) Imaging personnel aretrained in radiation safetymeasures.Self explanat ory.Training Recordsg) Imaging signage areprominently displayed inall appro priate locationsSelf explanatory.Evidence on sideh) Policies and proceduresgui de the safe use of radioactive isotopes for imaging services.Document on s afe use of radioactiveisotopes for imaging services shall beavailable and implem ented.Imaging Safety ManualAAC.13. Patient care is continuous and multidisciplin ary in nature.8 Objective Element Interpretation Remarksa) During all phases of care,there is a qualifiedindividual identified asresponsible for thepatients care.The HC O to ensure that the care of patients is always given byappropriately quali fied medicalpersonnel (resident doctor, consultantand/or nurse).In Patient Care Medical Care RelatedProcess(Read responsibility) Emergency Room(Causality) Re latedProcess(Read responsibility)IP Care SurgicalCareRelated Process(Read res ponsibility)b) Care of patients iscoordinated in all caresettings within theorganization.Care of patients is co-ordinated amongvarious care providers in a given settingviz OPD, emergency, IP, ICU, etc. Theorganization shall ensure t hat there iseffective communication of patientrequirements amongst the car eproviders in all settings.In Patient CareMedical Care RelatedProcess(Read re sponsibility) Emergency Room(Causality) RelatedProcess(Read responsibility)IP Care Surgical CareRelated Process(Read responsibility)c) Information about th epatients care andresponse to treatment isshared among medical,nursing and other careproviders.The HCO ensures periodic discussionsabout each patient ( coveringparameters like patient care, responseto treatment, unusual developments if any, etc) amongst medical, nursing andother care providers.Inpatient Cared) Information is exchangedand documented duringeach staffing shift,between shi fts, and duringtransfers between units/departments.Self explanatory.Inpatient Caree) The patients record (s) isavailable to the authorizedcare providers to fac ilitatethe exchange of information.Self explanatory.Medical Record Deptf) Poli cies and proceduresguide the referral of patients to other departments/ s pecialities.The HCO has clearly defined anddocumented the policies andpr ocedures to be adopted to guide thepersonnel dealing with referral of patien ts to other departments or specialties or even other health careproviders ou t side the HCO.Patient Transfer PolicyAAC.14. The organization has a documented discharge process.9 Objective Element Interpretation Remarksa) The patients dischargeprocess is planned inconsultation with thepatient and/or family.The patient s treating doctor determinesthe readiness for discharge duringregular reassessments. Th e same isdiscussed with the patient and family.Discharge Processb) Policies and proceduresexist for coordination of various departments andagencies invol ved in thedischarge process(including medico-legalcases).The discharge policie s and proceduresare documented to ensure coordinationamongst various departments includingaccounts so that the discharge papersare complete well within time. Fo r MLCthe organization shall ensure that thepolice are informed.Discharge Process c) Policies and proceduresare in place for patientsleaving against medicalad vice.The HCO has a documented policy for the LAMA cases. The treating doctor sho uld explain the consequences of thisaction to the patient/attendant.Discharge Pr ocessd) A discharge summary isgiven to all the patientsleaving the organizat ion(including patients leavingagainst medical advice)The HCO hands over the disc hargepapers to the patient/attendant in allcases and copy retained. In LAMA cases, the declaration of thepatient/attendant is to be recorded onproper fo rmat.Discharge ProcessAAC.15. Organization defines the content of the discharge summary.Objective Element Interpretation Remarksa) Discharge summary isprovide d to the patients atthe time of discharge.Self explanatory.Discharge Summary b) Discharge summarycontains the reasons for admission, significantfindings and d iagnosis andthe patients condition atthe time of discharge.Self explanatory.Disch arge Summaryc) Discharge summarycontains informationregarding investigationre

sults, any procedureperformed, medication andother treatment given.Self explan atory.Discharge Summaryd) Discharge summarycontains follow up advice,medication and other instructions in anunderstandable manner.Self explanatory.Discharg e Summarye) Discharge summaryincorporates instructionsabout when and how toobt ain urgent care.The HCO should outline conditionsregarding when to obtain urge nt care.For example, a post op patient shouldreport when having fever,bleedin g/discharge from site.Discharge Summary10 f) In case of death thesummary of the case alsoincludes the cause of de ath.Self explanatory.Discharge SummaryCHAPTER 2 : Care of Patients (COP)COP.1. U niform care of patients is provided in all settings of the organization and is g uidedby the applicable laws, regulations and guidelines.Objective Element Interp retation Remarksa) Care delivery is uniformwhen similar care isprovided in more than onesetting.The organization shall ensure thatpatients with the sa me health problemsand care needs, receive the samequality of healthcare throughout theorganization irrespective of the categoryof ward.Uniform Care Pol icyb) Uniform care is guided bypolicies and procedureswhich reflect applicab lelaws and regulations.Self explanatory. Care provision videNursing Council of India Act and MedicalCouncil of India at.c) The care and treatmentorders are signed, named,timed and dated by theconcerned doctor.Self explanatory. Tr eatment ordersmust be written daily.InPatient Deptd) The care plan iscounter signed by theclinician in-charge of thepatient within 24 hours.The treatment o f the patient could beinitiated by a junior doctor but the sameshould be counter signed and authorizedby the treating doctor within 24hrs.Authorisation of prescr iption by resident doctor e) Evidence based medicineand clinical practiceguide lines are adopted toguide patient carewhenever possible.The organization could develop clinicalprotocols based on these and the samecould be followed in manag ement of patients. These could then be used asparameters for audit of patient c are.Within scope of Medical auditcommittee.COP.2. Emergency services are guided by policies, procedures, applicable laws andregulations.Objective E lement Interpretation Remarksa) Policies and procedure for emergency care ared ocumented.These could include SOPs/protocols toprovide either general emergency careor management of specific conditionse.g. poisoning.EmergencySuite related Process b) Policies also addresshandling of medico-legalcases.The policy sha ll be in line with statutoryrequirements w.r.t. documentation andintimation to p olice. The organizationshall also define as to what constitutesa MLC (in accorda nce with statutoryrules).Emergency Suite Related Process11 c) The patients receive carein consonance with thepolicies.Self explanatory .Practice Objectived) Policies and proceduresguide the triage of patientsfor i nitiation of appropriatecare.Self explanatory.Admission anddischarge protocol in ICUe) Staff is familiar with thepolicies and trained on theprocedures for care of emergency patients.All the staff working in the casualtyshould be oriented to the policies andpractices through training/documents.Staff should preferabl y be trained/wellversed in ACLS and BLS.CPR Training Recordsf) Admission or disc harge tohome or transfer toanother organization isalso documented.Self expl anatory.Patient Transfer PolicyCOP.3. The ambulance services are commensurate wi th the scope of the services providedby the organization. Objective Element Int erpretation Remarksa) There is adequate accessand space for theambulance(s).T he organization shall demarcate aproper space for ambulance(s).Thisshall be demarcated keeping in mindeasy accessibility for receiving patientsand to ena ble the ambulance(s) to turnaround/exit quickly.Sufficient area availablefor par king of ambulances as per Policy.b) Ambulance(s) isappropriately equipped.This shall be done based on theorganizations scope.Hospital AmbulanceServicesc) Ambulance(s) is mannedby trained personnel.The ambulance should be manned by a trained driver, technician/nurse and/or doctor depending on the situation.Pe rsonnel shall be trained in ACLSand/or BLS.BLSTrained Driver d) There is a checklist of allequipment and emergencymedications.The organization shall dev elop achecklist and ensure that theambulance is equipped as per theche cklist.Hospital AmbulanceServicese) Equipments are checkedon a daily basis.Thi s shall include both the ambulanceand the equipments within it.Hospital Ambulanc eServicesf) Emergency medicationsare checked daily andprior to dispatch.Self

explanatory. This also includeschecking the expiry date of drugs.Hospital A mbulanceServicesg) The ambulance(s) has aproper communicationsystem.The ambulan ce shall be connected withthe hospital/control room bywireless/mobile phones. (By PhysicalInspection)COP.4. Policies and procedures guide the care of patients requiring cardio-pulmonaryresuscitation.12 Objective Element Interpretation Remarksa) Documented policies andprocedures guide theuniform use of resuscitation throughoutthe organization.The organi zation shall documentthe procedure for same. This shallbe in consonance with a cceptedpractices.CPR Policyb) Staff providing directpatient care is trained an dperiodically updated incardio pulmonaryresuscitation.These aspects shall be covered byhands on training. If theorganization has a CPR team (e.g.code blu e team) it shall ensure thatthey are all trained in ALS and arepresent in all sh ifts.CPR Training Recordc) The events during acardio-pulmonaryresuscitation a re recorded.In the actual event of a CPR or amock drill of the same, all t heactivities along with the personnelattended should be recorded.CPR Recording f ormd) A post-event analysis of allcardiac arrests is one by amulti-disciplinaryc ommittee.The analysis shall include thecause, steps taken to resuscitateand the outcome. Multidisciplinarycommittee shall include physicians,anaesthetists a nd nursesCode Blue CommitteeMeeting Recordse) Corrective and preventivemeasures are taken basedon the post-event analysis.Self explanatory.Code Blue CommitteeMe eting RecordsCOP.5. Policies and procedures define rational use of blood and blo od products.Objective Element Interpretation Remarksa) Documented policies andpr ocedures are used toguide rational use of bloodand blood products.This shall address the conditionswhere blood and conditions whereblood products can be used .b) The transfusion servicesare governed by theapplicable laws andregulat ions.Refer to Drugs and Cosmetics act.Drugs And Cosmetic Act(ORIGINAL)c) Informe d consent isobtained for donation andtransfusion of blood andblood products.C onsent should be taken for everytransfusion. However, with thesame consent yo u can give multipletransfusions in the same sitting. For example, 2 pints of blo od may betransfused serially using the sameconsent. However, if the same isgiven over two days or hours apart,then a separate consent is required.Consent formd) Informed consent alsoincludes patient and familyeducation about donation.Self explanatory.Consent forme) Staff is trained toimplement the policies.This sh all include doctors and bedone either by training and/or byproviding written ins tructions.Training records13 f) Transfusion reactions areanalyzed for preventiveand corrective actions.Th e organization shall ensure thatany transfusion reaction is reported.It is prefe rable that the organizationcapture feedback regarding everytransfusion (includi ng the oneswithout reaction) as this wouldenable it to capture all transfu sionreactions. These are then analyzed(by individual/ committee asdecided by the organization) andappropriate corrective/preventiveaction is taken. The orga nizationshall maintain a record of transfusion reactions.Transfusion reactio n formCOP.6. Policies and procedures guide the care of patients in the Intensive care and highdependency units.Objective Element Interpretation Remarksa) The o rganization hasdocumented admissionand discharge criteria for its intensive ca re and highdependency units.The organization should developobjective criteria and adhere to it.Admission & Discharge in MICU/HDUb) Staff is trained to appl ythese criteria.This shall be done by trainingand/or by displaying the crit eria.Training Recordsc) Adequate staff andequipment are available.The ICU shou ld be equipped withall necessary life saving andmonitoring equipments as wel l assuitably manned by trained staff.The exact requirements shall bedecided by the organization.However the organization isexpected to follow best cli nicalpractices.Equipment Evident on site.d) Defined procedures for situation of bed shortagesare followed.As and when there are no vacantbeds in the ICU and there is arequirement of such bed, a detailedpolicy and procedure should be inpl ace to address the situation.Policy for non availability of bedse) Infection c ontrol practicesare followed.These could be developedindividually or it could be a part of the Hospital infection controlmanual. The organization shall ensure that the practices are inconsonance with good clinicalpractices.In fection Control Manualf) A quality assuranceprogramme isimplemented.These co

uld be developedindividually or it could be a part of the Hospital quality assuranceprogramme. The organization shallensure that the programme is inconsona nce with good clinicalpractices.Quality Management Plan14 COP.7. Policies and procedures guide the care of vulnerable patients (elderly, children,physically and/or mentally challenged).Objective Element Interpretatio n Remarksa) Policies and proceduresare documented and are inaccordance with theprevailing laws and thenational and internationalguidelines.Self explanato ry.b) Care is organized anddelivered in accordancewith the policies andp rocedures.HCO develops SOP s for delivery of care.Policy for Vulner ablepatients c) The organization providesfor a safe and secureenvironment for thisvulne rable group.The organization shall provideproper environment taking intoac count the requirement of thevulnerable group.Policy for Vulner ablepatientsd ) A documented procedureexists for obtaininginformed consent from theappropria te legalrepresentative.The informed consent for this groupof people should be o btained fromtheir family or legal representative.General Consente) Staff is trai ned to care for this vulnerable group.All Staff involved in the care of thisgrou p shall be adequately trained inidentifying and meeting their needs.Training Rec ordsCOP.8. Policies and procedures guide the care of high risk obstetrical patie nts.Objective Element Interpretation Remarksa) The organization definesand dis plays whether highrisk obstetric cases can becared for or not.The organization s hall define as towhat constitutes high risk obstetriccase in consonance with bestclinical practices.Obstetric Deptb) Persons caring for highrisk obstetr ic cases arecompetent.These shall not just be doctors butshall include nursing staff also. Thecompetency shall be based onqualification, experience andt raining.Obstetric Deptc) High risk obstetric patientsassessment also includesmate rnal nutrition.Self explanatory.Obstetric Deptd) The organization has thefacilit ies to take care of neonates of high riskpregnancies.The organization shal l have a NICUwith proper equipments and staff.Policy Of Paediatric Deptt . COP. 9. Policies and procedures guide the care of pediatric patients.15 Objective Element Interpretation Remarksa) The organization definesand displ ays the scope of its pediatric services.The scope shall also includeneonatal services, if any.Policy Of Paediatric Deptt . b) The policy for care of ne onatal patients is inconsonance with thenational/ internationalguidelines. Self explanatory.Policy Of Paediatric Deptt . c) Those who care for children have age specificcompetency.These shall not just be for doctorsbut shall includ e nursing staff also.The competency shall be based onqualification, experience andtraining.Policy Of Paediatric Deptt . d) Provisions are made for special care of children.Adequate amenities for the care of infants and children to be availablein the hospital.Policy Of Paediatric Deptt . e) Patient assessmentinc ludes detailednutritional, growth,psychosocial andimmunization assessment.Sel f explanatory.Paediatric Assessment Sheetf) Policies and proceduresprevent ch ild/ neonateabduction and abuse.The HCO shall ensure that there isan adequate s ecurity/surveillance toprevent such happenings.Policy Of Neonatal Child/Abuseg) The childrens familymembers are educatedabout nutrition,immunization and s afeparenting and this isdocumented in the medicalrecord.Self explanatory.Poli cy Of Paediatric Deptt . COP.10. Policies and procedures guide the care of pati ents undergoing moderate sedation.Objective Element Interpretation Remarksa) Com petent and trainedpersons perform sedation.Whenever parenteral route is usedth is shall be carried out by adoctor/nurse.Sedation policyb) The person admi nisteringand monitoring sedation isdifferent from the personperforming the proce dure.Self explanatory.Sedation policyc) Intra-procedure monitoringincludes at a minimum theheart rate, cardiac rhythm,respiratory rate, bloodpressure, oxygen saturation, and level of sedation.Self explanatory. The same shouldbe documen ted.Sedation policy16 d) Patients informed consentis obtained before enteringthem in researchprotoc ols.Self explanatory.NAe) Patients are informed of their right to withdraw fr omthe research at any stageand also of theconsequences (if any) of such withd rawal.Self explanatory.NAf) Patients are assured thattheir refusal to participat eor withdrawal fromparticipation will notcompromise their accessto the o rganizationsservices.Self explanatory.NACOP.17. Policies and procedures guide nut

ritional therapy.Objective Element Interpretation Remarksa) Documented policies andprocedures guidenutritional assessment andreassessment.Self explanatory.Diet ary, Nutritionand Food Servicesb) Patients receive foodaccording to their cli nicalneeds.A dietician shall do the assessmentof the patient in consultation wit hthe clinician and advice regardingfood.Dietary, Nutritionand Food ServicesNutr itional assement formc) There is a written order for the diet.The dietician shal l prepare this inthe form of a diet sheet and patientshall receive food accordin gly.Dietary, Nutritionand Food Servicesd) Nutritional therapy isplanned and p rovided in acollaborative manner.The dietician shall ensure that thisis planned in consultation with thetreating doctor and thepatient/patients relative after takinginto regard the patients food habits(veg/ non-veg) and likes anddislik es.Dietary, Nutritionand Food Servicese) When families providefood, they ar e educatedabout the patient s dietlimitations.The dietician/nurse shall ensu re thisduring planning.Dietary, Nutritionand Food Servicesf) Food is prepared, handled,stored and distributed in asafe manner.The dietary services to be design edin a manner that there is no crisscross of traffic. All the activities fallin a sequence. The organizationshall ensure that hygienicconditions are foll owed allthroughout.Dietary, Nutritionand Food ServicesCOP.18. Policies and pro cedures guide the end of life care.21 Objective Element Interpretation Remarksa) Documented policies andprocedures g uide the endof life care.The HCO has a documented policyfor providing care to te rminally illadmitted patients. This shall includeproviding appropriate pain a ndpalliative care according to thewishes of the family and patient.End of Li fe CareOperational Policyb) These policies andprocedures are inconsonance wi th the legalrequirements.Self explanatory.End of Life CareOperational Policyc) T hese also address theidentification of the uniqueneeds of such patient andfam ily.The religious and socio-culturalbeliefs of patients/ family shall beaddre ssed and respected.End of Life CareOperational Policyd) These also includesens itively addressingissues such as autopsyand organ donation.If the body of the deceased issubjected to an autopsy or for organ donation, it sho uld bediscussed with the family in a verycourteous manner.End of Life CareOpera tional Policye) Staff is educated andtrained in end of life care.Self explana tory. Training RecordsCHAPTER 3 : Management of Medication (MOM)MOM.1. Policies and procedures guide the organization of pharmacy services and usage of medicati on.Objective Element Interpretation Remarksa) There is a documentedpolicy and procedure for pharmacy services andmedication usage.The policies and procedur es shalladdress the issues related toprocurement, storage, formulary,presc ription, dispensing,administration, monitoring and useof medications.Material M anagementPharmacyb) These comply with theapplicable laws andregulations.Sel f explanatory.Drugs And Cosmetics Actc) A multidisciplinarycommittee guides t heformulation andimplementation of thesepolicies and procedures.This shall be representative of major clinical departments,administration and shall inc lude apharmacist/ clinical pharmacologist.Records Of Drugs andTherapeutics Co mmitteeMOM.2. There is a hospital formulary.22 Objective Element Interpretation Remarksa) A list of medicationappropriate for the patientsand organizationsresources is developed.The hospital formulary shall beprepared and be preferably updatedat regular intervals.Drug formulary b) The list is developedcollaboratively by themultidisciplinarycommittee.Re fer to MOM 1c.Records Of Drugs andTherapeutics Committeec) There is a defined pr ocessfor acquisition of thesemedications.The process should address theissues of vendor selection, vendor evaluation, generation of purchaseorder and receipt of goods as per rules.Pharmacyd) There is a process toobtain medications notlis ted in the formulary.Self explanatory.Local Purchase PolicyMOM.3. Policies and p rocedures guide the storage of medication.Objective Element Interpretation Remar ksa) Documented policies andprocedures exist for storage of medication.These should address issuespertaining to temperature(refrigeration), light, vent ilation,preventing entry of pests/ rodentsand vermins.Policy on Storage Of Medic ationb) Medications are stored ina clean, well lit andventilated environment .The organization shall also ensurethat the storage requirements of thedrug as specified by themanufacturer are adhered to. If therecommendations are confli

cting innature, the organization shall followthe manufacturersrecommendation. T his shall beapplicable to all areas wheremedications are stored includi ngwards.Physical examination.c) Sound inventory controlpractices guide storage of the medications.Self explanatory.ABC Analysisd) Medications are protectedfro m loss or theft.The organization shall ensure that itdevelops proper mechanism s toprevent pilferage. The organizationcould conduct audits at regular inte rvals (as defined by theorganization) to detect suchinstances.Regular AU DITe) Sound alike and look alikemedications are storedseparately.Many drugs in ampoules, vials or tablets may look-alike or sound-alike. They should be s egregatedand stored separately.Demonstrated in practice23 f) There is a method toobtain medication whenthe pharmacy is closed.When pharmacy is closed, thereshould be a SOP to procure thedrugs.24 hours pharmacy isavailable.g) Emergency medicationsare available all the time.Adequate amount of emergencymedicines should be stocked at alltimes. Re-order level at defin itequantity should be done.Stock maintenance register &records to be produced as evidences.h) Emergency medicationsare replenished in a timelymanner when used.S elf explanatory.Relevant register as evidence.MOM.4. Policies and procedures gui de the prescription of medications.Objective Element Interpretation Remarksa) Do cumented policies andprocedures exist for prescription of medications.Self ex planatory.Policy on prescriptionof medicationb) The organizationdetermines who can writeorders.This shall be done by the treatingdoctor.Policy on prescriptiono f medicationPolicy on Verbal Orders for Medicationc) Orders are written in auniform location in themedical records.All the orders for medicines arereco rded on a uniform location of the case sheet. Electronic orderswhen typed shall again follow thesame principles.Medical Recordsd) Medication orders areclear, legible, dated, timed,named and signed.Self explanatory.Medical Recordse) Policy on verbal orders isdocumented andimplemented.The organization shall ensure tha t ithas a policy to address this issueand it shall address as to who cangive ver bal orders and how theseorders will be validated.Policy on Verbal Orders for M edicationf) The organization defines alist of high risk medication.High risk m edications aremedications involved in a highpercentage of medication errors or sentinel events and medicationsthat carry a high risk for abuse,error, or other adverse outcomes.Examples include medications witha low therapeutic wi ndow,controlled substances,psychotherapeutic medications, andlook-alike and s ound-alikemedications.High Risk Medicationg) High risk medicationorders are ve rified prior toThese medications shall preferablybe given only after written ord ersHigh Risk Medication24 dispensing. and it should be verified by the staff before dispensing. MOM.5. P olicies and procedures guide the safe dispensing of medications.Objective Elemen t Interpretation Remarksa) Documented policies andprocedures guide the safedispe nsing of medications.Clear policies to be laid down for dispensing of medication e.g. routeof administration, dosage, rate of administration, expiry date, etc.S afe Dispensing Of Medicineb) The policies include aprocedure for medication recall.Recall may result based on lettersfrom regulatory authorities or inter nal feedback (e.g. visiblecontaminant in IV fluid bottle).Drug LabellingPolic yc) Expiry dates are checkedprior to dispensing.Self explanatory.Pharmacyd) Labe lling requirements aredocumented andimplemented by theorganization.At a minim um, labels must includethe drug name, strength frequencyof administration (in a language thepatient understands) and expirydates.Drug Labelling Policy MOM.6. There are defined procedures for medication administration. Objective Element I nterpretation Remarksa) Medications areadministered by those whoare permitted b y law to doso.Self explanatory.Policy on prescriptionof medicationb) Prepared me dications arelabelled prior topreparation of a seconddrug.Self explanatory. Drug Labelling Policyc) Patient is identified prior toadministration.Self explan atory.Safe Dispensing Of Medicined) Medication is verified fromthe order prior toadministration.Staff administering medicationsshould go through the tr eatmentorders before administration of themedication and then onlyadminister them. It is preferable thatthey also check the generalappearance of the medi cation (e.g.melting, clumping etc.) beforedispensing.Safe Dispensing Of Medic ine25

e) Dosage is verified from theorder prior toadministration.Self explanatory. Safe Dispensing Of Medicinef) Route is verified from theorder prior toadmini stration.Self explanatory.Safe Dispensing Of Medicineg) Timing is verified fro m theorder prior toadministration.Self explanatory.Safe Dispensing Of Medici neh) Medication administrationis documented.The organization shall ensure thatt his is done in a uniform locationand it shall include the name of themedication, dosage, route of administration, timing and the nameand signature of the per son whohas administered the medication.Safe Dispensing Of Medicinei) Policies and proceduresgovern patients self administration of medications.At the outse t the HCO could defineif it would permit self administrationof medications. In c ase the HCOpermits then the policy shall includethe medications which the patien tcan self administer. It is preferablethat the organization alsoincorporates a method to ensurethat the patient is reminded to takethe medication (before eve ry dose)and documentation of self administration.Organization do not allowsel f Medication.j) Policies and proceduresgovern patientsmedications brought from outside the organization.These shall address as to what arethe pre-requisites for such amedication (e.g. Invoice; Clear labelwith mention of the name, dose, expiry date etc.)MOM.7. Patients and family members are educated about safe medi cation and food-druginteractions. Objective Element Interpretation Remarksa) Pa tient and family areeducated about safe andeffective use of medication.The organization shall make a list of such drugs and accordinglyeducate e.g. di goxin. This couldalso include education regardingthe importance of taking a drug at aspecific time e.g. sustained releasemedications.Safe Medication And Fo odDrugs Interactionsb) Patient and family areeducated about food-druginteract ions.Patient and family should becounselled about their diet duringmedicatio n e.g. no alcohol whentaking metronidazale.Safe Medication And FoodDrugs Interac tionsMOM.8. Patients are monitored after medication administration.26 when required. The organizationshall charge as per the tariff list.Any addi tional charge should alsobe enumerated in the tariff and thesame communicated to thepatients. The tariff rates should beuniform and transparent.c) Patients are educatedabout the estimated costsof treatment.Refer to AAC4d.Patients Right Policyd) Patients are informedabout the estimated costswhen there is a change inthe patient condition or treatment setting.When patients are shifted from onesetting to another, typically to andfrom ICUs, the financial implicationsmust be clearly conveyed to them.Estimated Cost PerformaCHAPTER 5 : Hospital Infecti on Control (HIC)HIC.1. The organization has a well-designed, comprehensive and coordinated HospitalInfection Control (HIC) programme aimed at reducing / eliminating risks to patients, visitorsand providers of care. Objective Eleme nt Interpretation Remarksa) The hospital infectioncontrol programme isdocume nted which aims atpreventing and reducingrisk of nosocomialinfections.Self e xplanatory.Infection Control Manualb) The hospital has a multi-disciplinary inf ectioncontrol committee.This shall preferably have HospitalAdministrator, Micro biologist,Physician, Surgeon, Manager Nursing (Nursing Supervisor), staff from CSSD, and other Supportservices and the hospital infectioncontrol nurse. It should also includeinvitees from various departmentsas deemed necessary.Infecti on Control Manualc) The hospital has aninfection control team.The team is res ponsible for day-to-day functioning of infection controlprogramme. They shall supportsurveillance process and detectoutbreaks. They shall alsoparticipa te in audit activity and ininfection prevention and control ona day-to-day basis .Infection Control Manuald) The hospital hasdesignated and qualifiedinfectio n control nurse(s)for this activity.The qualification shall be either agraduat e nurse or qualified nursewith competence gained byexperience.Infection Contr ol ManualHIC.2. The hospital has an infection control manual, which is periodica lly updated.33 Objective Element Interpretation Remarksa) The manual identifies thevarious h igh-risk areasand procedures.The manual should clearly identifythe high risk ar eas of the hospitale.g. ICU, HDU, OT, Post-operativeward, Blood Bank, CSSD, etc. Similarly, all high risk proceduresshould be identified from infectioncontrol p oint of view. For example,cardiac catheterization,endoscopies, surgery lasti ng morethan 2 hours, BMT etc.Infection Control Manualb) It outlines methods o

f surveillance in theidentified high-risk areas.It shall define the frequency andmode of surveillance.The surveillance system shouldmeet WHO criteria of simplicity,cost minimization, timeliness of feedback, flexibility, accept ability,consistency (reliability), sensitivityand specificity.Infection Contro l Manualc) It focuses on adherence tostandard precautions at alltimes.Self expla natory.Infection Control Manuald) Equipment cleaning andsterilization practic es areincluded.It shall address this at all levels e.g.ward, OT and CSSD. I t ispreferable that the organizationfollows a uniform policy acrossdiffe rent departments within theorganization.The Manual should includesteriliza tion and disinfection policy,chemicals used/ methods andprocedures followed i n wards andcritical areas. Special focus oncritical equipments like ventilat ors,nebulizers etc.Infection Control Manuale) An appropriate antibioticpolicy is established andimplemented.The HCO shall develop a system of monitoring drug susceptibility(based on culture sensitivity) andaccordingly develop its ant ibioticpolicy, which shall be reviewed atperiodic intervals (maybe once in 3mont hs) for its continuingapplicability.Antibiotic Policyf) Laundry and linenma nagement processesare also included.The laundry can be in-house or outsourced. If outsourced theorganization shall ensure that itestablishes adequate controls toensure infection control. The linenchange policy should be mentioned .Washing protocols for differentcategories of linen includingblankets shou ld be included.Laundry Servicesg) Kitchen sanitation andfood handling issues a reincluded in the manual.Self explanatory. The same shall beapplicable even if t his activity isoutsourced. The organization couldrefer to ISO 22000:2005 (fo odsafety) while addressing this issue.Infection Control Manual34 h) Engineering controls toprevent infections areincluded.Issues such as Air conditioningplant and equipment maintenance,cleaning of A/c ducts, AHU s,replacement of filters, seepageleading to fungal colonization,replacemen t/repair of plumbing,sewer lines (in shafts) should beincluded. Water supply s ources andsystem of supply, testing for water quality must be included. Anyr enovation work in hospital patientcare areas should be planned withInfection Con trol team with regardto architectural segregation, trafficflow, use of materials .Infection Control Manuali) Mortuary practices andprocedures are includedas appropriate to theorganization.The mortuary services in thehospital shoul d be provided throughwalk-in cold rooms or mortuary coldcabinets. Mortuary pro cedures of preserving body, or body parts andsafety measures while handing over body to relatives should be inaccordance with the policy.j) The organizati on definesthe periodicity of updatingthe infection controlmanual.The organiz ation must have adocumented policy on the updationof the infection control ma nual. It isdesirable to update at least once ina year based on its trends &outcomes of the audit processes.Infection Control ManualHIC.3. The infection co ntrol team is responsible for surveillance activities in identified areas of the hospital.Objective Element Interpretation Remarksa) Surveillance activities are appropriately directedtowards the identified high-risk areas.The organization m ust be able toprovide evidence of conductingperiodic surveillance activities in itsidentified high risk areas.The specific objectives, casedefinitions, id entification of potentialindicators, frequency and durationof monitoring, meth ods of datacollection, along with schedule of rounds should be defined.Conf identiality and anonymity mustbe ensured. The HCO shouldclearly mention wh ich specifictargeted surveillance (site specific,unit oriented, priority ori ented)activities are being carried out.Infection Control Manualb) Collection of surveillancedata is an ongoingprocess.The organization shall ensure that ith as a process in place to collectsurveillance data and also toensure that it is able to capture allsuch data.35 c) Verification of data is doneon regular basis by theinfection control te am.The data so collected shall beauthenticated by the team by goingthrough every data or by usingrandom sampling so that theprocess can be validat ed. The teamshall preferably verify every seriousinfection (as defined by th eorganization) report.d) In cases of notifiablediseases, information (inrel evant format) is sent toappropriate authorities.The organization shall identify allnotifiable diseases after taking intoconsideration the local laws, rules,regu

lations and notificationsthereof. The organization shallensure that this is sent at thespecified frequency and in theformat as required by st atutoryauthorities.Records from MedicalRecords departmente) Scope of surveilla nceactivities incorporatestracking and analyzing of infection risks, rates andt rends.This shall be done at regular intervals (maybe monthly andconsolid ated into an annual report)and the organization shall takesuitable steps b ased on theanalysis.f) Surveillance activitiesinclude monitoring theeffecti veness of housekeeping services.This would include categorization of areas/ sur faces; general cleaningprocedures for surfaces, furniture/fixtures, and items us ed in patientcare. It should also includeprocedures for terminal cleaning ,blood and body fluid cleanup,isolation rooms and all high risk(critical) a reas. The commondisinfectants used, dilution factors,method of use should be s pecified.HIC.4. The hospital takes actions to prevent or reduce the risks of Hos pital AssociatedInfections (HAI) in patients and employees.Objective Element Int erpretation Remarksa) The organization monitorsurinary tract infections.This can be done either by sendingurine or catheter tip for culture. Theorganization sh all do this for allsymptomatic catheterized patients.Recordsb) The organizati on monitorsrespiratory tract infections.This can be done by sendingsputum or ET/ tracheostomysecretions (obtained using a suctioncatheter) or ET/ trache ostomy tip or protected specimen brushing (PSB)or mini broncho-alveolar lavag e(BAL) for culture. The organizationshall do this for all patients on theventila tor having clinical featuressuggestive of infection.Records36 c) The organization monitorsintra-vascular deviceinfections.For patients wi th symptomssuggestive of intra vascular deviceinfection and having central line thesame shall be done by sending thetip for culture. For all peripherallines c linical evidence of thrombophlebitis would suffice.Recordsd) The organization monitorssurgical site infections.This shall be done by sending pus/swab for cult ure. Recordse) Appropriate feedbackregarding HAI rates areprovided on a r egular basis to medical andnursing staff.The feedback shall include thera tes, trends and opportunities for improvement. It could also providespecific inp uts to reduce the HAIrate.RecordsHIC.5. Proper facilities and adequate resources are provided to support the infection controlprogramme.Objective Element Interp retation Remarksa) Hand washing facilities inall patient care areas areaccessibl e to health careproviders.The organization shall ensure that itprovides necessar y infrastructure tocarry out the same.Infection Control ManualEvidence on siteb) Compliance with proper hand washing is monitoredregularly.The organization shall preferablydisplay the necessary instructionsnear every hand washing a rea.Compliance could be verified byrandom checking, observation, etc.Infecti on Control ManualEvidence on sitec) Isolation/ barrier nursingfacilities are a vailable.The organization shall define theconditions where the same shall becarr ied out and ensure that itprovides the necessary resourcesto carry out t he activity (e.g.clothing, masks, gloves etc.).Infection Control Manuald) Adeq uate gloves, masks,soaps, and disinfectantsare available and usedcorrectly. Self explanatory. They should beavailable at the point of use and theorganizatio n shall ensure that itmaintains an adequate inventory.Facilities AvailableHI C.6. The hospital takes appropriate action to control outbreaks of infections.Ob jective Element Interpretation Remarksa) Hospital has adocumented procedure fo r handling such outbreaks.This shall incorporate definitions asto what constit utes an outbreak;identification and investigation of such outbreaks and the procedurefor management. This shall be inaccordance with good clinicalpracti ces.Standard Case definitions shallinclude a unit of time and placealong with specific biological and/or clinical criteria.Infection Control Manual37 c) The organization ensuresthat Bio-medical Waste isstored and transported tot he site of treatment anddisposal in proper coveredvehicles within stipulatedti me limits in a securemanner.The waste is transported to the pre-defined site at definite time intervals(maximum within 48hours) throughproper transport vehi cles in a safemanner. If this activity is outsourcedthe organization shall ensur e that itis done to an authorized contractor.Monitoring of this activity should bedone by Infection Control team.Evident on SiteWaste transportation trolleyd) B io-medical Wastetreatment facility ismanaged as per statutoryprovisions (if i

n-house) or outsourced to authorizedcontractor(s).If the hospital has waste tr eatmentfacility within its premises then theyhave to be in accordance withs tatutory provisions or they canoutsource it to a central facility.MOU betwee n the hospitaland the Outsourcedagencye) Requisite fees, documentsand report s are submittedto competent authoritieson stipulated dates.The HCO shall ensur e that the feesare deposited in a timely manner. Inaddition the annual reports h ave tobe submitted by the 31st of Januaryof every year and accident reportinghas to be carried out in theprescribed form.Copy of FORM IIf) Appropriate pe rsonalprotective measures areused by all categories of staff handling Bio-medi calWaste.Self explanatory.Evident on siteHIC.9. The infection control programme is supported by hospital management and includestraining of staff and employee h ealth.Objective Element Interpretation Remarksa) Hospital managementmakes avail able resourcesrequired for the infectioncontrol programme.The HCO shall ensur e that theresources required by thepersonnel should be available in asustai ned manner. This includesboth men and materials.Copy of the budgetb) The hos pital regularlyearmarks adequate fundsfrom its annual budget inthis regard.Ther e shall be a separate budgetdemarcated for HIC activity. Thisshall be prepared taking intoconsideration the scope of theactivity and previous yearsexp erience.Copy of the budgetc) It conducts regular pre-induction training for appropriate categories of staff before joiningconcerned department(s).There must be a documentedevidence of pre induction trainingfor appropriate categ ories of staff before joining concerneddepartment(s). It should include thepol icies, procedures and practicesof the infection control programme.Training Recor dsd) It also conducts regular in-service trainingsessions for all concernedcategor ies of staff at leastonce in a year.Self explanatory.Training Records39 e) Appropriate pre and postexposure prophylaxis isprovided to all concerneds taff members.Self explanatory.CHAPTER 6 : Continuous Quality Improvement (CQI)CQ I.1. There is a structured quality improvement and continuous monitoring program me in theorganization.Objective Element Interpretation Remarksa) The quality i mprovementprogramme is developed,implemented andmaintained by a multi-discip linary committee.This committee shall haverepresentation from management,va rious clinical and supportdepartments of the HCO. Thisprogramme shall b e developed,implemented and maintained in astructured manner.b) The quality i mprovementprogramme isdocumented.This should be documented as amanual. The ma nual shallincorporate the mission, vision,quality policy, quality objecti ves,service standards, importantindicators as identified etc. Themanual co uld be stand alone andshould have cross linkages withother manuals.Quality M anagement Planc) There is a designatedindividual for coordinatingand impleme nting thequality improvementprogramme.This should preferably be a personhaving a good knowledge of accreditation standards, statutoryrequirements, hosp ital qualityimprovement principles andevaluation methodologies, hospitalfunct ioning and operations.Accreditation Coordinator d) The quality improvementprog ramme iscomprehensive and coversall the major elementsrelated to qualityim provement and riskmanagement.This shall preferably cover allaspects includ ing documentation of the programme, monitoring it, datacollection, review of policy andcorrective action. Also refer to CQI1b.Quality Management PlanRisk Ma nagemente) The designatedprogramme iscommunicated andcoordinated amongst al lthe employees of theorganization throughproper trainingmechanism.Self expl anatory.Traning Records40 f) The quality improvementprogramme is reviewed atpredefined intervals and opportunities for improvement areidentified.As quality improvement is adyn amic process, it needs to bereviewed at regular pre-definedintervals (as defi ned by the HCO inthe quality improvement manual butat least once in four months) byconducting internal audits. Thisaudit shall be done by a multi-discipli nary team (preferably trainedin NABH standards) including allthe applicable st andards andobjective elements. At the end of the audit there shall be a formalm eeting to summarise the findingsand identify areas for improvement.During this m eeting there shall bean analysis of key indicators asidentified and determined by theorganization including themandatory indicators as laid downin CQI 2 and 3. The minutes of thereview meetings should berecorded and maintained.Quality

Committeeg) The quality improvementprogramme is acontinuous process andup dated at least once in ayear.Self explanatory. The inputs for updation could be based on thereview carried out by the qualityimprovement committee.Quality M anagement PlanCQI.2. The organization identifies key indicators to monitor the c linical structures, processesand outcomes which are used as tools for continual improvement. Objective Element Interpretation Remarksa) Monitoring includesapp ropriate patientassessment.The HCO shall develop appropriatekey performance ind icators suitableto it. The following is however mandatory:i. Time for initi al assessmentof indoor and emergencypatients.i. Percentage of cases whereincare plan is documented andcounter-signed by the clinician.ii. Percentage of cases wh ereinscreening for nutritional needshas been done.iii. Percentage of cases where inthe pre-defined initial nursingassessment is completed within30 minutes.b) M onitoring includes safetyand quality controlprogrammes of thediagnostics ser vices.The HCO shall develop appropriatekey performance indicators suitableto it . The following is however mandatory:i. Number of reportingerrors/1000 inv estigations.ii. Percentage of re-dos.iii. Percentage of reports Co-41 relating with clinical diagnosis.iv. Percentage of adherence tosafety prec autions byemployees working indiagnostics.c) Monitoring includes allinvasiv e procedures.The HCO shall develop appropriatekey performance indicators suitabl eto it. The following is however mandatory:i. Re-exploration rate.ii. Perce ntage of accidentalremoval of tubes and catheters.iii. Incidence of haematom a atpuncture site.iv. Percentage of re-scheduling of procedures.d) Monitoring includesadverse drug events.The HCO shall develop appropriatekey performance ind icators suitableto it. The following is however mandatory:i. Percentage of medicationerrors.ii. Incidence of adverse drugreactions.iii. Percentage of medicationcharts with illegible writing over a given period.iv. Percentage of contrast relatedreactions.e) Monitoring includes use of anaesthesia.The HCO shal l develop appropriatekey performance indicators suitableto it. The following is however mandatory:i. Percentage of modification of anaesthesia plan.ii. Per centage of unplannedventilation followinganaesthesia.iii. Percentage of adv erseanaesthesia events.iv. Anaesthesia related mortalityrate.f) Monitoring inc ludes use of blood and blood products.The HCO shall develop appropriatekey perfo rmance indicators suitableto it. The following is however mandatory:i. Perc entage of transfusionreactions.ii. Percentage of wastage of bloodand blood pro ducts.iii. Percentage of bloodcomponent usage.iv. Turnaround time for issue of blood and blood componentsg) Monitoring includesavailability and content of me dical records.The HCO shall develop appropriatekey performance indicators suitab leto it. The following is however mandatory:i. Percentage of medical record s42 not having discharge summary.ii. Percentage of medical recordsnot having ini tial assessmentand the plan of care.iii. Percentage of medical recordshaving i ncomplete and/or improper consent.iv. Percentage of missing records.h) Monitori ng includesinfection control activities.The HCO shall develop appropriatekey pe rformance indicators suitableto it. The following is however mandatory:i. U rinary tract infection rate.ii. Respiratory infection rate.iii. Intra-vascular device infectionrate.iv. Surgical site infection rate.Infection Control Committ eei) Monitoring includesclinical research.The HCO shall develop appropriatekey performance indicators suitableto it. The following is however mandatory:i. Number of research activitiesbeing carried out.ii. Percentage of patientswith drawing from the study.iii. Percentage of protocolviolations/deviations report ed.iv. Percentage of serious adverseevents (which have occurred inthe HCO) repor ted to the ethicscommittee within the definedtimeframe.NAj) Monitoring includ es datacollection to supportfurther improvements.The data could be collected a t pre-defined intervals e.g.monthly/quarterly. This data isanalysed for i mprovementopportunities and the same arecarried out. Also refer to CQI 1f In fection Control Committeek) Monitoring includes datacollection to supportevalu ation of theseimprovements.All improvement activities carriedout by the HCO shall have anevaluable outcome. The same shallbe captured and analysed.CQ I.3. The organization identifies key indicators to monitor the manageria l structures,processes and outcomes which are used as tools for continual impro

vement.Objective Element Interpretation Remarksa) Monitoring includesprocuremen t of medication essential tomeet patient needs.The HCO shall develop appropri atekey performance indicators suitable toit. The following is however mandatory: i. Percentage of drugs procured bylocal purchase.ii. Percentage of stock outs in cludingemergency drugs.iii. Percentage of consumablesrejected before prepara tion of Goods Receipt Note.iv. Incidence of variations from theDrugs and Therap euticCommitteeDrug Formulary43 procurement process.b) Monitoring includesreporting of activities asrequired by laws andregulations.The HCO shall develop appropriatekey performance indic ators suitable toit. The following is however mandatory:i. Number of births and deaths.ii. Number of notifiable diseases.iii. Submission of report/ data/form pertaining to bio-medcial waste,PNDT act and radiation safetywithin the d efined timeframe.iv. Submission of tax returns anddeduction of taxes at the specifiedtime frame.MRD Policyc) Monitoring includes riskmanagement.The HCO sh all develop appropriatekey performance indicators suitable toit. The following i s however mandatory:i. Number of variations observed inmock drills.ii. Incidence of falls.iii. Incidence of bed sores after admission.iv. Percentage of empl oyees providedpre-exposure prophylaxis.Quality Management Pland) Monitoring inc ludesutilisation of space,manpower andequipment.The HCO shall develop appropr iatekey performance indicators suitable toit. The following is however mandatory :i. Bed occupancy rate and averagelength of stay.ii. OT and ICU utilization rate .iii. Equipment down time.iv. Nurse-patient ratio.Quality Committeee) Monitoring includespatient satisfaction whichalso incorporates waitingtime for services.T he HCO shall develop appropriatekey performance indicators suitable toit. The fo llowing is however mandatory:i. Out patient satisfaction index.ii. In patient sa tisfaction index.iii. Waiting time for services includingdiagnostics and out pat ient.iv. Time taken for discharge.Quality Committeef) Monitoring includesemploy ee satisfaction.The HCO shall develop appropriatekey performance indicators suit able toit. The following is however mandatory:i. Employee satisfaction index.ii. Employee attrition rate.iii. Employee absenteeism rate.iv. Percentage of employ ees who areaware of employee rights,responsibilities and welfareschemes.Emp loyee SatisfactionSurveyg) Monitoring includesadverse events and near misses.Th e HCO shall develop appropriatekey performance indicators suitable toit. The fol lowing is however mandatory:i. Number of sentinel events.ii. Percentage of nea r missesanalysed.Sentinel Event Policy44 iii. Number of security relatedincidents including thefts.iv. Incidence of needle stickinjuries.h) Monitoring includes datacollection to supportfurthe r study for improvements.The data could be collected at pre-defined intervals e.g. monthly/quarterly. This data is analysed for improvement opportunities and thesame are carried out. Also refer to CQI1f MRD Policyi) Monitoring inclu des datacollection to supportevaluation of theimprovements.Self explanatory. The inputs for updation could be based on the reviewcarried out by the quality impr ovementcommittee.CQI.4. The quality improvement programme is supported by the ma nagement. Objective Element Interpretation Remarksa) Hospital Managementmakes available adequateresources required for quality improvementprogramme.This sh all include the men, material,machine and method. These shouldbe in steady suppl y so as to ensurethat the programme functionssmoothly.Budget Reportb) Hospita l earmarksadequate funds from itsannual budget in thisregard.Appropriate fun d allocation is doneby the organization for the smoothfunctioning of the program me.Budgetc) Appropriate statistical andmanagement tools areapplied whenever r equired.Self explanatory.Monthly report of MRDCQI.5. There is an established sys tem for audit of patient care services.Objective Element Interpretation Remarksa ) Medical and nursing staff participates in thissystem.The HCO shall identi fy suchpersonnel. It could be a mix of clinicians, administrators andnurse s.Medical Audit Committeeb) The parameters to beaudited are defined by theorg anization.As these audits areretrospective/concurrent in nature, itis imperat ive that this be done usingpredefined parameters so that thereis no bias. The pa rameters could bedisease based, cost based,community based or based onlen gth of stay.Parameters for medicalAUDITc) Patient and staff anonymity is maint ained.This means that the names of thepatients and the hospital staff whomay fig

ure in the audit documentsmust not be disclosed nor anyreference be made to them in publicdiscussions/ conferences. YES45 d) All audits aredocumented.Self explanatory.Medical Audit Reporte) Remedia l measures areimplementedAll remedial measures asascertained should be docu mentedand implemented andimprovements thereof recorded tocomplete the audit cy cle.Action taken Report of theMedical AuditCQI.6. Sentinel events are intensiv ely analyzed.Objective Element Interpretation Remarksa) The organization hasde fined sentinel events.The sentinel events relating tosystem or process defic iencies thatare relevant and important to theorganization must be clearlydefi ned.Sentinel Event Policyb) The organization hasestablished processes for inte nse analysis of suchevents.The established processes shouldinclude reporting the occurrence of such events on standardisedincident report forms.Sentinel Even t Policyc) Sentinel events areintensively analysed whenthey occur.Root cause analysis of all suchevents should be carried out by amulti-disciplinary commit tee takinginputs from the concerned units/discipline/ departments.Sentinel Event Policyd) Actions are taken uponfindings of such analysis.The findings and re commendationsarrived at after the analysis shouldbe communicated to all concerne dpersonnel to correct the systemsand processes to preventrecurrences.Sentinel Event PolicyCHAPTER 7 : Responsibilities of Management (ROM)ROM.1. The responsi bilities of the management are defined.Objective Element Interpretation Remarksa ) Those responsible for governance lay down theorganizations missionstatement. It is not only the head of the HCObut the members of the board of governors (whe re applicable) whoneed to define it.Quality Management Planb) Those responsible for governance lay down thestrategic and operationalplans commensurate tothe organizations missionin consultation with thevarious stake holders.The Gover ning board and theleaders of HCO shall define anddevelop the process for stra tegicand operation plans so as toachieve the organizational missionstatemen t.Quality Management Planc) Those responsible for governance approve theorgan izations budget andallocate the resourcesThe Governing board and the Headof HCO shall have the policy for budgeting and resource allocationfor attaining its mission andBudget46 NABH Manual Download this Document for FreePrintMobileCollectionsReport DocumentReport this document?Please tell us reason(s) for reporting this document Spam or junk Porn adult content Hateful or offensive If you are the copyright owner of this document and want to report it, please fo llow these directions to submit a copyright infringement notice. Report Cancel . .This is a private document. Info and Rating Reads:2,426Uploaded:01/27/2011Category:Uncategorized.Rated:Copyright:Attribution Non-commercial . FollowPuneet K Jain..Share & Embed Related Documents PreviousNext p. p. p. p. p. p. p. p. p. p. p.

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