Professional Documents
Culture Documents
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PROGRASSIVE LEVEL
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ENTRY LEVEL
Accreditation
Pre-Accreditation
(Progressive- Level)
Pre-Accreditation
(Entry-Level)
GUIDEBOOK FOR
CONTENTS
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 01
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04
List of Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 06
AAC1
The SHCO defines and displays the services that it can provide.. . . . . . . . . . . . . . 09
AAC1a
AAC2
AAC2a
AAC2b
AAC3
AAC3a
The SHCO defines the content of the assessments for inpatients and
emergency patients.
AAC5
Laboratory services are provided as per the scope of the SHCO's services . . . . . . 21
and laboratory safety requirements.
AAC5b
AAC7
AAC7a
AAC7c
COP2
COP2a
10
11
12
COP3
COP3c
COP4
COP4a
COP5
COP5a
COP6
COP6a
COP6d
COP7
COP7a
COP8
COP8c
14
MOM1
MOM1a
MOM1e
MOM2
MOM2d
The SHCO defines a list of high-risk medication and the process to prescribe them.
HIC1
CQI2
CQI2a
18
ROM1
ROM1a
ROM2
ROM2a
20
21
22
FMS1
FMS1c
The SHCO has a system to identify the potential safety and security
risks including hazardous materials.
FMS2
The SHCO has a program for clinical and support service equipment . . . . . . . . . 92
management.
FMS2b
FMS3
The SHCO has provisions for safe water, electricity, medical gas, . . . . . . . . . . . . . 97
and vacuum systems.
FMS3c
FMS4
The SHCO has plans for fire and nonfire emergencies within the facilities. . . . . . 102
FMS4a
FMS4b
The SHCO has a documented safe exit plan in case of fire and nonfire emergencies.
24
HRM2
HRM2a
HRM2b
HRM3
HRM3a
26
IMS1
The SHCO has a complete and accurate medical record for every patient. . . . . . 123
IMS1e
IMS3
IMS3a
27
IMS4
IMS4a
IMS4c
APPENDIXES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
1. Formation of Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
2. Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
3. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
FOREWORD
Since January 2011, the Forum of Government Sponsored Health Insurance Schemes in India,
organized by World Bank in close partnership with central and state governments, has been a
platform for facilitating knowledge-sharing between key policymakers heading central and state
government health insurance schemes. This practitioner-to-practitioner knowledge exchange
created a subgroup, a Quality and Accreditation Collaborative, which includes Government of India
(GOI) and state government-financed health insurance and health financing programs, commercial
insurers, hospitals, National Accreditation Board for Hospitals and Healthcare Providers (NABH),
industry chambers such as the Federation of Indian Chambers of Commerce and Industry (FICCI),
and other health sector stakeholders. By contributing to overall improvement in the quality of
service delivery, the potential impact of this initiative extends far beyond the 15 or so participating
health programs, to the healthcare system as a whole.
The Collaborative has embarked on several initiatives aimed at contributing to healthcare quality,
particularly where payers could play a catalytic role. It has been supporting the development of
standard treatment guidelines, promoting the use of systematic priority setting and health
technology assessments, and also the promotion of linkages to provider accreditation. As a
landmark initiative that could go a long way to strengthen the quality of healthcare delivery in the
country, particularly among the network hospitals participating in Government Sponsored Health
Insurance Schemes, it developed Pre-Accreditation Entry-level Standards for Small Healthcare
Organizations (SCHOs). These pre-accreditation entry-level standards are in accordance with the
standards of the National Accreditation Board for Hospitals and Healthcare Organizations (NABH).
The Collaborative considered several potential subsets of NABH standards and objective elements,
and identified a subset suited for the creation of pre-accreditation entry-level certification by
NABH, which could be feasibly undertaken by resource restrained hospitals, could be
independently assessed, and which could be used as standardized empanelment criteria for health
insurance programs, meeting their common needs for quality and patient safety. Two sets of preaccreditation entry-level standards, one based on NABH SHCO standards for hospitals under 50
beds, and the other using NABH standards for hospitals with 50 beds or more, were suggested by
the Collaborative which were finalized and published by the NABH in 2014. This has created a
quality benchmark which is not only within the reach of the vast majority of hospitals, but also sets
the stage for steady progress to higher levels of NABH standards.
The NABH Pre-Accreditation Entry-Level Standards for SHCOs consist of 41 standards1 and 149
objective elements2 .
However, the task of the Collaborative did not end when the pre-accreditation entry-level standards
were published. To facilitate the attainment of pre-accreditation entry-level standards by small
1
A standard is a statement of expectation that defines the structures and process that must be substantially in place in an
organization to enhance the quality of care.
2
An objective element is that component of a standard which can be measured objectively on a rating scale. The acceptable
compliance with the measureable elements will determine the overall compliance with the standard.
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National Accreditation Board for Hospitals and Healthcare Providers
hospitals which may not be able to access or afford consultants to help them on this journey, the
Collaborative embarked on developing a Guidebook that could be useful for small hospitals to
understand the standards better, and also demystified the process of achieving them. Thus,
regardless of their size, hospitals that aspire to improve the quality of their care but lack the internal
capacity to achieve this on their own, will benefit from this document. A team of renowned experts
in healthcare quality, with considerable experience and exposure to accreditation and quality
assessments, joined hands to undertake the development of this Guidebook, which consists of
supporting tools and templates for selected pre-accreditation entry-level standards and objective
elements published by NABH, as prioritized by the Collaborative based on their complexity and
need for further detailing.
This Guidebook for Pre-Accreditation Entry-Level Standards for SHCOs contains comprehensive
information on the prioritized 27 standards and 34 objective elements (including the Hospital
Infection Control [HIC] Manual included as an Annexure in the soft copy version of this guide). The
Guidebook includes an overview of each objective element, suggestions on how to fulfil the
objective element, tasks and responsibilities of various team members in the hospital to fulfil the
objective element, and various other tools such as audit checklists, training material, sample
Standard Operating Procedures (SOPs), and other sample templates to assist in the implementation
of the standards by SHCOs. The Guidebook also provides guidance on the organizational structure
required in SCHOs to achieve compliance with the pre-accreditation entry-level standards. The soft
copy version of this Guidebook also includes several additional reference documents, including
specimens graciously contributed by several hospitals to improve an understanding of what final
documents have been used by real-life hospitals.
NABH's pre-accreditation entry-level standards will soon be followed by pre-accreditation
progressive-level standards as an intermediate stage to full accreditation, and all these sets of
standards will aim to serve as important milestones in a hospital's journey towards greater quality
and patient safety, contributing to the overall shared objective of safer, accessible, and affordable
healthcare.
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National Accreditation Board for Hospitals and Healthcare Providers
PREFACE
Despite the rapid growth of the health industry in India, patient safety and quality care remains a
great concern.
NABH has been operating an accreditation and allied program since 2006. Only 295 hospitals and 49
small healthcare organizations (SHCOs) have achieved accreditation till date. Furthermore, the
myth that achieving accreditation is a mammoth task and is very costly has been a deterrent for the
majority of hospitals. In order to be more inclusive, Pre-Accreditation Entry-level Standards have
been developed through the collaborative efforts of various stakeholders, so that more hospitals
can join the quality journey. A step-wise approach to enhance quality was considered more suitable
given the existing challenges.
This Guidebook has been prepared with the objective of enabling SHCOs to prepare for the
accreditation process on their own, without an external agency, thus making the entire
accreditation process more cost-effective and sustainable. The Guidebook is expected to help
SHCOs achieve a proper understanding of the standards and the objective elements and how they
can be implemented. It will also promote uniformity in the interpretation and implementation of
the standards across hospitals.
This excellent work is the outcome of the Forum of Government Sponsored Health Insurance
Schemes, supported by World Bank, which created a Quality and Accreditation Collaborative for
this purpose. The Guidebook has been approved by the Technical Committee of NABH and shall be
made available online.
Dr. K. K. Kalra,
CEO, NABH
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National Accreditation Board for Hospitals and Healthcare Providers
ACKNOWLEDGEMENTS
The conceptualization, compilation and production of this document has been possible due to the
elaborate and collective effort of various stakeholders, including the members of the Quality and
Accreditation Collaborative, World Bank, officials from NABH, technical experts on healthcare
quality, and a team of reviewers and resource persons. We would like to express our great
appreciation to all the stakeholders involved in developing this Guidebook and the funding support
provided by the World Bank-DFID Trust Fund.
List of Contributors and Co-Authors
Convener
Dr. Alexander Thomas, President, Consortium of Accredited Healthcare Organizations (CAHO);
Chairman, Advisory Committee, NABH Accreditation of Government Hospitals, Govt. of Karnataka.
Co-Authors
Dr. Antony Lazar Basile, Medical Director, STAR Hospitals, Hyderabad.
Dr. Manju Chacko, Team Leader, Quality, Bangalore Baptist Hospital, Bangalore.
Dr. Badari Datta H.C., Head of Quality and Consultant ENT Surgeon, Bangalore Baptist Hospital,
Bangalore.
Ms. Lallu Joseph, Quality Manager, Christian Medical College, Vellore.
Dr. K. Kalra, CEO, National Accreditation Board for Hospitals and Healthcare Providers (NABH).
Ms. Beenamma Kurien, Quality Assurance Coordinator, Karnataka Health System Development and
Reform Project (KHSDRP), Government of Karnataka.
Dr. A. Malathi, Head of Medical Services, Compliance and Education, Manipal Health Enterprises
Pvt. Ltd.
Dr. Suneel C. Mundkur, Additional Professor, Department of Pediatrics, Kasturba Medical College,
Manipal.
Dr. Nitin Shantilal Raithatha, Professor of Obstetrics and Gynecology, Pramukh Swami Medical
College, Shree Krishna Hospital, Karamsad.
Dr. Arati Verma, Senior Vice President, Medical Quality, Max Healthcare; Chair, NABH Appeals
Committee; Chair, NABH Assessor Management Committee.
World Bank facilitation team
Dr. Somil Nagpal, Senior Health Specialist, World Bank.
Dr. Abha Mehndiratta, Consultant, World Bank.
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National Accreditation Board for Hospitals and Healthcare Providers
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National Accreditation Board for Hospitals and Healthcare Providers
LIST OF ABBREVIATIONS
ACLS
AHPI
BP
Blood Pressure
BPL
BT
Bleeding Time
CCTV
Closed-Circuit Television
CDC
CEO
CMO
CSSD
CT
Computed Tomography
CTVS
DAMA
EMO
ENT
Ear-Nose-Throat
ER
Emergency Room
ESI
FICCI
FOGSI
HDU
HOD
Head of Department
HCO
Healthcare Organization
HR
Human Resources
HSG
Hysterosalpingogram
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National Accreditation Board for Hospitals and Healthcare Providers
ICC
ICN
ICU
ID
Identification
IG
Immunoglobulin
IMC
INC
IPD
Inpatient Department
ISMP
KMC
KPI
Lab
Laboratory
LAMA
LASA
LMO
LPG
MCI
MO
Medical Officer
MRD
MRSA
MS
Medical Superintendent
MTP
NABH
NABL
NACO
NALS
NBM
Nil by Mouth
NBC
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National Accreditation Board for Hospitals and Healthcare Providers
NICU
OBD
OPD
Outpatient Department
OT
Operating Theatre
PA
Public Announcement
PAC
Preanesthesia Consent
PALS
PEP
Pre-exposure Prophylaxis
PICU
PNDT
PPE
PPTCT
RCOG
RMO
SHCO
SOP
TAT
TPA
UHID
USG
Ultrasonography
WHO
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National Accreditation Board for Hospitals and Healthcare Providers
Chapter 1
ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)
STANDARD AAC1. THE SHCO DEFINES AND DISPLAYS THE SERVICES THAT IT CAN PROVIDE.
Objective Elements
AAC1a. The services being provided are clearly defined.
AAC1b. The defined services are prominently displayed.*
AAC1c. The relevant staff are oriented to these services.*
I. OVERVIEW
Scope: To guide the SHCO on how to define the scope of services and ensure that these services are
displayed for the convenience and information of patients.
SHCOs may differ in the kind of services they provide, in terms of the number of beds, or specialties.
For example, one SHCO may have maternity services as its main offering, with 30 beds, while
another may have all secondary care services such as general surgery and ICU. This objective
element guides the SHCO on how to prepare a list of services that it is providing to its patients. These
may be further divided into overall services provided by the SHCO, and services provided by each
department. It is recommended that the services listed match the actual facilities that the SHCO is
capable of providing, and permitted to provide, and also comply with statutory and regulatory
requirements. For example, the Medical Termination of Pregnancy (MTP) service can be provided
only if the SHCO has a licence for the same.
*Objective Elements AAC1b and AAC1c are self-explanatory and therefore not included in this Guidebook.
AAC1b. The defined services are prominently displayed.
Of the list of services that have been defined in the scope, the SHCO can identify those that are relevant to the patients,
and display these bilingually, so that patients are fully informed and can avail of these services. As the method of display
has not been specified by NABH, SHCOs may customize the same. They may use boards placed at the entrance and in
reception areas, and additionally, put these on their website, or have pamphlets for distribution if needed.
AAC1c. The relevant staff are oriented to these services.
The SHCO should ensure that clinical and nonclinical staff are familiar with the services on offer, so that they can guide the
patients accordingly. This may be done through training of staff.
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National Accreditation Board for Hospitals and Healthcare Providers
It is recommended that:
i.
The Head of the SHCO take input from other team members and departmental staff to
compile the list of services.
ii. The responsibility for ensuring that the services are listed correctly lies with the Head of the
SHCO who approves the same by signing off the policy document that lists the scope.
iv. Whenever a new service is introduced, the scope of services policy document is amended
accordingly.
v. The scope of service may be divided as follows (NABH has not specified a template or
minimum structure for listing the scope of services):
l
Clinical services
l
Support services
l
Additional services
l
Service exclusion, if any
Clinical Services
Support Services
General Medicine
Dietary
General Surgery
Pediatrics
Hospital Laundry
Medico-social department
Anesthesiology
Emergency Department
Ambulance
Diagnostic Services
l
Laboratory
l
Radiology-
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National Accreditation Board for Hospitals and Healthcare Providers
ii. A valid licence related to the scope of services such as MTP licence, Prenatal Diagnostic
Techniques (PNDT), if applicable.
III. TASKS AND RESPONSIBILITIES
No.
Task
Responsibility
i.
Head of SHCO
ii.
iii.
Assigned staff
iv.
Administrative department
v.
Administrative department/
Engineering department
vi.
vii.
Checkpoint
Yes
i.
ii.
iii.
No
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National Accreditation Board for Hospitals and Healthcare Providers
Remarks
AAC2a. Process addresses registering and admitting outpatients, inpatients, and emergency
patients.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on preparing a process for registering and admitting outpatients,
inpatients, and emergency patients.
It is recommended that:
Once the patient is brought to the SHCO, the patient is registered and admitted, if required.
Only patients that can be cared for by the SHCO are admitted.
Patients that match the SHCO's resources are registered and admitted using a defined process.
The defined process covers all patients OPD, new and follow-up patients, and emergency patients.
The defined process:
i.
ii. Has a uniform registration system for patients and maintains the records of patients coming
to the hospital.
iii. Provides registration for IPD if it matches the scope of services provided.
iv. Provides a mechanism for admission such that the patient can avail of healthcare services.
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National Accreditation Board for Hospitals and Healthcare Providers
i. Policy on registration
Each patient being assessed at the hospital should be registered and provided with a unique
identification number.
SOP on OPD registration
No.
Process
Responsibility
Supporting Document
Register
Registration form
Referral slip
Registration clerk
Register/OPD slip
Registration clerk
Consultant
Registration
clerk/Emergency
registration counter
Register
Registration clerk
Register
Register
Registration clerk
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National Accreditation Board for Hospitals and Healthcare Providers
Process
Responsibility
Supporting Document
Admission Clerk
Admission Register
Treating Doctor
Admission slip/order
Treating Doctor
Treating Doctor
Admission note
Admission Clerk
Admission note
Admission Clerk
Staff nurse
Medical record
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National Accreditation Board for Hospitals and Healthcare Providers
Task
Responsibility
i.
Top management
ii.
iii.
Preparation of policy
Quality team
iv.
Checkpoint
Yes
i.
ii.
iii.
iv.
Staff awareness
No
Remarks
AAC2b. Process addresses mechanism for transfer or referral of patients who do not match the
SHCO's resources.
Note: Sections II and III are provided as samples to guide the SHCO in developing its own customized
documents.
I. OVERVIEW
Scope: To guide the SHCO on transfer or referral of patients who do not match the SHCO's resources.
It is recommended that the following standardized approach be used for referring a patient in case
the service required does not match with the service available in the HCO:
i.
Patients who do not match the SHCO's resources are referred to organizations that have
matching resources.
ii. All patients reaching the emergency department in critical conditions are provided with
first-aid and all available life-saving measures.
iii. In case of non-availability of beds in the inpatient care wards, patients are placed in the
emergency ward until beds are available.
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National Accreditation Board for Hospitals and Healthcare Providers
iv. In case of absolute non-availability of beds, or if the patient's medical needs are not within
the scope of the hospital, the doctor on duty makes enquiries about the availability of beds
in the nearest Government facility or at a hospital of the patient's preference, and transfers
the patient in the hospital's ambulance or 108 ambulance. The patient is accompanied by
the appropriate doctor or nurse if required.
v. Emergency patients receive life-stabilizing treatment and if resources are not available,
transferred to an organization that has the required resources.
The medical problem is not within the scope of the services defined by the hospital
Special investigations are required that are not available in the hospital
However, the patient shall be shifted only after first-aid is provided and the patient is stabilized.
SOP for referral-out or transfer-out
No.
Process Flow
Responsibility
Supporting Document
Admission Clerk
Register
Treating Doctor
Medical record
Treating Doctor
Consent
Treating Doctor
Transfer-out register
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
iii.
Consent form
iv.
Staff awareness
v.
Transfer-out register/record
No
Remarks
STANDARD AAC3. PATIENTS CARED FOR BY THE SHCO UNDERGO AN ESTABLISHED INITIAL
ASSESSMENT.
Objective Elements
AAC3a. The SHCO defines the content of the assessments for inpatients and emergency patients.
AAC3b. The SHCO determines who can perform the assessments.*
AAC3c. The initial assessment for inpatients is documented within 24 hours or earlier.*
*Objective Elements AAC3b and AAC3c are self-explanatory and therefore not included in this
Guidebook.
AAC3a. The SHCO defines the content of the assessments for inpatients and emergency patients.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO to (i) follow a uniform protocol for the initial clinical assessments of
inpatients/emergency patients requiring healthcare services; and (ii) ensure that the care provided
to each patient is based on an assessment of the patient's relevant medical needs.
It is recommended that:
i.
The SHCO have a standardized format for initial assessment for emergency and inpatient
departments.
ii. The initial assessment is standardized across the hospital or it may be modified depending
on the needs of the department.
iii. The format is designed so as to ensure that the laid-down parameters are captured.
iv. Every initial assessment contains the presenting complaint, vital signs, and salient
examination findings.
v. Time frame for initial assessment: Every patient of the hospital (IPD and Emergency
services) be appropriately assessed for her/his clinical condition based on standard norms
of medical practice. The initial assessment should be done within a specified time frame to
facilitate the early plan of care. Initial assessments and timelines should be followed for
every patient admitted.
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National Accreditation Board for Hospitals and Healthcare Providers
Assessment by
Unstable Patient
Stable Patient
Documentation
Doctor
Immediately
Immediately
Nurse
Immediately
Immediately
Basic Qualification
Registration
Medical
Nursing
Diploma/Degree/Postgraduate in
Nursing
No. Process
Responsibility
Supporting Document
All patients who come to the emergency EMO/Treating Doctor Medical record
department shall be assessed.
/Staff nurse
complaints
l
History
of illness
l
Allergies
l
Temperature,
l
Physical examination
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National Accreditation Board for Hospitals and Healthcare Providers
The patient shall be assessed and the records shall be documented. Then a documented plan of care
is drawn up, based on the initial assessment.
No. Process
Responsibility
Supporting Document
Treating Doctor/
Doctor on Duty
Medical record
Treating Doctor
Medical record
Staff Nurse
Medical record
Medical record
Medical record
l
Temperature,
l
Physical examination.
l
Weight,
height
l
BP
l
Routine
lab investigations
l
Hb, blood
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National Accreditation Board for Hospitals and Healthcare Providers
No. Process
Responsibility
Supporting Document
Treating Doctor/Staff
nurse
Medical record
Treating Doctor/Staff
nurse
Medical record
l
BT, CT
l
NST (Non-stress
l
Foetal
test)
monitoring
l
Months
l
Tetanus
injections
l
2-3 ultrasounds
in whole period
(immediately after confirmation of
pregnancy, 20 week anomaly and
32 week growth scan)
l
PPTCT
counseling
l
Multidisciplinary
approach for
patients with medical disorders in
pregnancy
or provisional diagnosis
as applicable
l
Plan of
Task
Responsibility
i.
ii.
iii.
Quality team
iv.
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
Availability of policy
ii.
iii.
iv.
Staff awareness
v.
No
Remarks
STANDARD AAC5. LABORATORY SERVICES ARE PROVIDED AS PER THE SCOPE OF THE
SHCO'S SERVICES AND LABORATORY SAFETY REQUIREMENTS.
Objective Elements
AAC5a. Scope of the laboratory services are commensurate with the services provided by the
SHCO.*
AAC5b. Procedures guide collection, identification, handling, safe transportation, processing and
disposal of specimens.
AAC5c. Laboratory results are available within a defined time frame and critical results are
intimated immediately to the concerned personnel.*
AAC5d. Laboratory personnel are trained in safe practices and are provided with appropriate safety
equipment or devices.*
* Objective Elements AAC5a, AAC5c and AAC5d are self explanatory and therefore not included in
this Guidebook
AAC5b. Procedures guide collection, identification, handling, safe transportation, processing and
disposal of specimens.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO to prepare a department Lab Manual that incorporates all the
documented procedures for collection.
Lab Manual
It is recommended that:
i.
The SHCO has a department Lab Manual that incorporates all the documented procedures
for collection, identification, handling, safe transportation, processing and disposal of
specimens.
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National Accreditation Board for Hospitals and Healthcare Providers
ii. The SHCO has a Lab Safety Manual that incorporates all safety aspects including the use of
PPE, disposal and discarding of specimens, biomedical waste management rules, and staff
training.
iii. The SHCO ensures the safety of the specimen till the test (and retest, if required).
iv. The SHCO ensures that a unique hospital identification number (UHID) is used for the
identification of the patient.
v. In addition, it may use another number to identify the sample.
vi. The disposal of waste is as per the statutory requirements (Bio-medical Waste
Management and Handling Rules).
vii. Reporting of critical results: critical results are those result values which require immediate
attention by the doctor/nurse failing which there is a danger of harm to the patient. The
policy for reporting such result values are as follows:
viii. All laboratory test results, which are so far from the reference range that they indicate a
potentially dangerous condition requiring immediate attention, are intimated to the
concerned Consultant immediately.
ix If the consultant is not reachable, the result is brought to the notice of the Medical Officer
on duty.
x. The concerned Ward nurse is also informed of the result if the patient has been admitted.
xi. The list of values considered as critical may be displayed at prominent locations in the lab.
Name (Register/Format)
Responsible Person
Lab Manual
Lab Technicians
Lab Technicians
Lab Technicians
Lab Technicians
Lab Technicians
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National Accreditation Board for Hospitals and Healthcare Providers
Procedure
Sample Collection, Identification, Handling, and Transportation of Samples, Processing of
Samples, Disposal of Specimens
No.
Process Flow
Responsibility
Supporting Document
1.
Sample Collection
Technician
Sample Identification
Technician
Sample Handling
Technician
l
All samples
l
Universal
precautions are to be
observed while handling samples.
4.
Technician
l
All measures
l
Necessary
5.
Processing of Samples
Technician
l
The processing of samples should be
carried out as per the requirements
of individual tests.
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National Accreditation Board for Hospitals and Healthcare Providers
Procedure or Lab
Manual
No. Process
Responsibility
Supporting Document
l
The procedure
l
Samples
should be processed
without delay, and on a priority
basis for emergency cases.
6.
Disposal of Specimens
Technician
l
Disposal
is to be carried out in
accordance with Biomedical
Waste-Handling Rules.
l
Precautions
should be observed in
accordance with the Hospital
Infection Control Manual.
Task
Responsibility
i.
ii.
iii.
Quality team
iv.
Checkpoint
Yes
i.
Availability of policy
ii.
iii.
iv.
Availability of PPE
v.
vi.
No
24
National Accreditation Board for Hospitals and Healthcare Providers
Remarks
AAC7a. Process addresses discharge of all patients including medico-legal cases and patients
leaving against medical advice.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO to develop a documented discharge process, to observe that patient care
is multidisciplinary in nature, and to encourage continuity of care through a well-defined discharge
process.
It is recommended that the discharge procedures are documented as below to ensure coordination
among various departments, including Accounts, so that the discharge papers are ready on time:
i.
ii. Discharge planning be initiated by the Consultant on the basis of the patient's condition.
iii. The patient be assessed as 'medically stable' and fit for discharge. This may include
assessment of functional, medical, medication, and nutritional needs.
iv. The discharge summary be provided to every patient at the time of discharge.
v. A copy of the discharge summary be kept in the medical record.
vi. At the time of discharge, there should be coordination with the Billing Department.
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National Accreditation Board for Hospitals and Healthcare Providers
vii. For MLCs, the treating Consultant should document the discharge in the case sheet, which
is then intimated to the RMO. The RMO endorses it and intimates the nearest police station
through the EMO by filling up the police intimation form.
viii. In case of death of non MLCs, the death summary should also contain the cause of death.
The body should be handed over to the relatives or shifted to the mortuary.
ix. In case of death of MLCs, the body should be shifted to the mortuary immediately. The EMO
informs the nearest police station of the death. The body is later handed over to the police
for further necessary action.
x. LEFT AGAINST MEDICAL ADVICE (LAMA)
l
Under
the scope of patient rights, no patients may be kept in hospital against their will
except in some conditions such as major psychiatric illness, intoxication, or when the
patient is in police custody.
l
The nursing staff and the doctor concerned should try to persuade the patient to stay and
at the same time try to find out why the patient wishes to leave. If possible, the problem
should be addressed.
l
The responsibility of the treating consultant is to explain the consequences of this action
to the patient or attendant, and also that if the patient leaves the hospital against
medical advice, the hospital ceases to be responsible for her/his care.
l
Despite this, if the patient still wishes to be discharged, all possible steps should be taken
to ensure the patient or authorized attendant signs a form to this effect before leaving
the hospital.
l
In the event that the patient refuses to sign the form, this should be documented clearly
xi. The discharge summary should be prepared and handed over to the patient and a copy of
the discharge summary should be attached to the patient case sheet.
xii. At the time of discharge, the investigation results should also be handed over to the patient
and a copy should be kept by the hospital.
The discharge process should be coordinated with other departments in case the patient had
consultations with other departments.
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National Accreditation Board for Hospitals and Healthcare Providers
Discharge Process
Treating Consultant informs Ward nurse about discharging the patient
(evening before the scheduled day of discharge)
Patient's relative informed about discharge by the Ward nurse
Final decision on discharge taken by the treating consultant
(on the scheduled day of discharge)
Is the patient
a paying
case?
Yes
Patient send-off
Patient send-off
I. REQUIRED DOCUMENTS
i.
Policy on Discharge
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National Accreditation Board for Hospitals and Healthcare Providers
Policy
The SHCO shall have a Discharge Plan which is a multidisciplinary, collaborative process involving
the patient, patient's family, and concerned team members during a specific episode of illness.
Process of discharge
No. Process
Responsibility
Supporting Document
Head of the
Department/ Quality
team
Discharge summary
Treating Doctor
Treating Doctor
Staff Nurse/CHD
Treating Doctor
Staff Nurse/Billing
section
Treating Doctor/Staff
Nurse
Discharge summary
Staff Nurse
Discharge summary
10
Ward attendant
Task
Responsibility
i.
Top Management
ii.
iii.
Administrative department
iv.
28
National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
Availability of policy
ii.
iii.
iv.
v.
No
Remarks
AAC7c. Discharge summary contains the reasons for admission, significant findings, investigation
results, diagnosis, procedure performed (if any), treatment given, and the patient's condition at
the time of discharge.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. GUIDANCE NOTE
To guide the SHCO to prepare a discharge summary which includes adequate information that is
required when the patient leaves the SHCO.
After the final decision to discharge the patient is taken, the treating Consultant prepares the
discharge summary of the patient which contains the following information:
i.
ii.
Departments shall prepare discharge summary forms based on the content specific to
their department
xi. In case of a death, the death summary shall also contain the cause of death
xii. Periodic medical record audits shall be conducted to ensure that the discharge summary
complies with the content requirement.
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National Accreditation Board for Hospitals and Healthcare Providers
Task
Responsibility
i.
ii.
Preparation of policy
Quality team
iii.
Treating doctor
iv.
Quality team
Checkpoint
Yes
i.
Availability of policy
ii.
iii.
iv.
v.
No
V. REFERENCES
Accreditation Standards for Hospitals, NABH, 3rd Edition, November 2011.
30
National Accreditation Board for Hospitals and Healthcare Providers
Remarks
Chapter 2
CARE OF PATIENTS (COP)
STANDARD COP2. EMERGENCY SERVICES INCLUDING AMBULANCE ARE GUIDED BY
DOCUMENTED PROCEDURES AND APPLICABLE LAWS AND REGULATIONS.
Objective Elements
COP2a. Documented procedures address care of patients arriving in the emergency including
handling of medico-legal cases.
COP2b. Staff should be well versed in the care of Emergency patients in consonance with the scope
of the services of hospital.*
COP2c. Admission or discharge to home or transfer to another organization is also documented.*
*Objective Elements COP2b and COP2c are self-explanatory and therefore not included in this
Guidebook.
COP2a. Documented procedures address care of patients arriving in the emergency including
handling of medico-legal cases.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on the provision of uniform and appropriate care to all patients based on
acuity and patient need; and at the same time to follow all legal and patient safety requirements.
It is recommended that each SHCO be able to provide a defined standard of care to patients
presenting there, within the scope of available staff and resources. These could include SOPs or
protocols to provide either general emergency care or management of specific conditions such as
poisoning, acute abdominal pain (see http://clinicalestablishments.nic.in/En/1068downloads.aspx).
i.
The procedure for medico-legal cases (MLCs) should be in line with statutory requirements
with respect to documentation and intimation to police. The SHCO should also define what
constitutes an MLC (in accordance with statutory rules).
ii. A list of common emergencies that the SHCO has received in the last five years be prepared.
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National Accreditation Board for Hospitals and Healthcare Providers
iii. Based on this list, the sequence of steps or procedures to be followed in each case should be
defined and documented. Staff should be trained for the same.
iv. Process to ensure safe transfer of the patient within the hospital and outside the hospital
including good referral practices should be in place
v. Staff should be aware of their roles and responsibilities in different emergency scenarios
(roles of the attendant, nurse, doctor).
vi. Some resources that may be helpful to develop such mechanisms in the hospital are
available in the References.
Policy for providing services for emergency patient and in medico-legal cases.
ii. SOP for handling different emergency situations common to SHCO including initial
screening, admission, first aid, referral, DAMA/LAMA, transfer within or outside hospital,
ambulance, code blue/CPR.
iii. SOP for handling MLCs.
iv. Required registers for MLC.s
Responsibility
Quality Team
MLC Certificates
EMO
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National Accreditation Board for Hospitals and Healthcare Providers
Yes
NO
Comments
Responsibility
Supporting Document
Doctor on duty
Casualty register
{Casualty register format}
Consultant on duty
(full time or visiting)
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National Accreditation Board for Hospitals and Healthcare Providers
Process Flow
Responsibility
Supporting Document
Doctor on duty
MLC register
Nurse on duty in
emergency
Transfer record
Triage record/Casualty
Register
Doctor on duty
Nurse on duty
Doctor on duty
Transfer/DAMA register
Refer to AAC
Transfer register
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National Accreditation Board for Hospitals and Healthcare Providers
Process Flow
Responsibility
Supporting Document
Transfer register
Doctor on duty
Nurse on duty
Transfer register
Doctor on duty
Transfer register
Nurse on duty
Doctor on duty
Ambulance register
Nurse on duty
Ambulance driver/
staff of the
ambulance if the
ambulance is from
the receiving hospital.
Doctor on duty
Nurse on duty
List of cases that should be considered as MLC (cases may include and not be limited to):
i.
ALL suspected accidental, suicidal and homicidal cases that may include
- poisoning
- road traffic accidents
- falls from a height
- sharp-edged injuries
- near drowning
- blunt injuries
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National Accreditation Board for Hospitals and Healthcare Providers
- fire-arm injuries
- burn injuries
ii. Sexual assault /rape
iii. Brought-dead patients
iv. When clinical findings do not correspond with history (suspected foul play)
v. Any accidental or domestic injury to any female within seven years of marriage.
SOP for handling MLC
No. Procedural steps
Responsibility
Supporting Document
EMO/Nursing
Patient record/MLC
register
EMO
Patient record/MLC
register
Patient record/MLC
register
EMO/Nursing
Patient record/MLC
register
EMO/Nursing
MLC book
l
Examine
36
National Accreditation Board for Hospitals and Healthcare Providers
Responsibility
l
For all
l
While
l
Record
l
All alleged
l
In assault
l
Obtain
l
In all poisoning
37
National Accreditation Board for Hospitals and Healthcare Providers
Supporting Document
Responsibility
Supporting Document
l
No lavage sample
should be attempted
in any acid or kerosene oil poisoning or
burn case.
l
In all MLCs,
medico-legal
evidence like patient's clothes with
blood stains, stab injury, cut mark and
bullet hole marks shall be encircled,
signed by the examining doctor, and
preserved. Any foreign body recovered
from the patient after an operation, such
as a bullet, shall be sealed and handed
over to the police under receipt.
l
Clothes/weapon/gastric
lavage samples
of all MLCs should be properly
preserved, labeled and handed over to
the medical records department (MRD)
to be handed over to the police when
demanded.
l
Picture
l
No information
Patient record/MLC
register
Patient record/MLC
register
Patient record/MLC
register
Nursing
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National Accreditation Board for Hospitals and Healthcare Providers
Patient record/MLC
register
Responsibility
Supporting Document
10
Patient record/MLC
register
11
Patient record/MLC
register
12
13
EMO
Patient record/MLC
register
14
Patient record/MLC
register
15
EMO/Nursing
Patient record/MLC
register
16
Patient record/MLC
register
17
Patient record/MLC
register
18
Patient record/MLC
register
19
Patient record/MLC
register
20
MRD
Pt record /MLC
register
21
MRD
Patient record/MLC
register
39
National Accreditation Board for Hospitals and Healthcare Providers
Responsibility
Supporting Document
22
MRD
Patient record/MLC
register
23
MRD
Patient record/MLC
register
24
MO/MRD
Patient record/MLC
register
Exhibit 1
Format of Intimation
To
The Police Sub-Inspector,
M.L.C. NOTIFICATION
(This form should be filled by the Doctor while admitting/discharging the patient)
Patient Name :---------------------------------------------------------------------------------------------Address:----------------------------------------------------------------------------------------------------Age:-------------------- Sex:-------------------- M/F:---------------------- UHID : --------------------Admitted on : ------------ ---at : --------------------------- IP No: ---------- MLC No.: -------------Date
Time
Patient Brought: -------------------------------------------------------------------------------------------Treating Doctors: ------------------------------------------------------------------------------------------Admitted by M. O.: ----------------------------------------------------------------------------------------Observation of injuries/History while admitted:
X- RAY/CT Scan/MRI
Date/ Time of Admission/ Discharge/Death : ------------------------------------------------
Doctor
40
National Accreditation Board for Hospitals and Healthcare Providers
I. OVERVIEW
Scope: To sensitize SHCOs on the legal requirements and regulations as well as preparing all staff on
patient safety, especially the importance of informed consent, recognizing transfusion reactions,
and the importance of reporting it for further improvement.
It is recommended that:
i.
The SHCO have an SOP for blood or blood component transfusion, monitoring and
reporting any untoward reaction in the patient ranging from mild (itching, skin rash, chills,
rigor or fever) to severe (hemolysis, hemoglobinuria, acute renal failure, or death).
41
National Accreditation Board for Hospitals and Healthcare Providers
iv. Standards for blood bank and blood transfusion may be found in :
l
National
l
http://www.naco.gov.in/NACO/Quick_Links/Publication/Blood_Safety__Lab_Services/
Operational__Technical_guidelines_and_policies/standards_for_blood_bank/
l
NACO,
ii. SOPs for handling blood and blood components including acquisition, storage, transport,
blood component transfusion, and monitoring during transfusion.
iii. SOP for detecting and reporting blood transfusion reactions for improving patient safety.
iv. Legal papers and licenses and applicable MOUs, whichever is applicable as per regulation.
Responsibility
i.
ii.
iii.
iv.
v.
Superintendent / responsible
person or consultant
42
National Accreditation Board for Hospitals and Healthcare Providers
Yes
NO
Comments
UHID
Blood Group
Name:
Designation:
Signature:
Name:
Designation:
Signature:
Pulse
BP
Respiration Rate
O Hr
15 min
30 min
1 hr
1hr 30 min
2 hr
2 hr 30 min
Blood transfusion completion time
Post transfusion vitals
At 30 min
At 1 hr
43
National Accreditation Board for Hospitals and Healthcare Providers
Remarks
Signature
UHID
Blood Group
Blood Group
Type of blood/component:
Time of issue:
Time of starting transfusion :
Time of completion:
Nature of transfusion reaction:
Sign and symptoms to BTR:
Pain:Site of pain
Hemoglobinuria
Date:
Time:
Signature
STANDARD COP4. DOCUMENTED PROCEDURES GUIDE THE CARE OF PATIENTS AS PER THE
SCOPE OF SERVICES PROVIDED BY THE SHCO IN INTENSIVE CARE AND HIGH DEPENDENCY
UNITS.
Objective Elements
COP4a. Care of patients is in consonance with the documented procedures.
COP4b. Adequate staff and equipment are available.*
* Objective Element COP4b is self-explanatory and therefore not included in this Guidebook.
44
National Accreditation Board for Hospitals and Healthcare Providers
I. OVERVIEW
Scope: To instil confidence in the SHCO regarding NABH standards which can be helpful for better
patient management and satisfaction.
It is recommended that SHCOs prepare written SOPs for all possible common procedures in order to
care for High Dependency Unit (HDU) and ICU patients safely and consistently.
It is recommended that SHCOs prepare a manual for ICU and HDU which contains a list of all the dayto-day general procedures as well as special procedures within the scope of the hospital services
(cardiac/neuro/obstetric/surgical ICU):
i.
General procedures include Ryles tube insertion, IV line care, catheter care, ventilator care,
bundle care, bed sore and fall prevention, blood component therapy, total parenteral
nutrition.
ii. The structure of the SOP should be simple, easy to understand, and contain step-by-step
algorithms to illustrate care pathways. Big procedures may be split into small multiple
procedures to simplify them. For example, ventilator care may be split into preparation
before patient arrives, putting patient on ventilator (initiation), continuous monitoring,
weaning, extubation and post-extubation care.
iii. SOPs should be based on standard national or international guidelines (CDC Guidelines for
Infection Control, Critical Care Society Guidelines, 2010; AHPI, FOGSI, NACO, WHO
Guidelines) that adopt customized changes to suit local requirements of infrastructure and
feasibility.
For details, see:
l
Ministry
l
CDC Guidelines for Infection Control, 2003. Available at
www.cdc.gov/ncidod/hip/enviro/guide.htm
l
Critical Care Society Guidelines, 2010. Available at
www.isccm.org/pub-icuguidelines.aspx
45
National Accreditation Board for Hospitals and Healthcare Providers
l
Royal College of Obstetricians and Gynaecologists Guidelines, 2014. Available at
https://www.rcog.org.uk/en/guidelines-research-services/guidelines/?p=5
l
FOGSI Guidelines. Available at
http://www.fogsi.org/index.php?option=com_content&view=article&id=84&Itemid=131
l
Ministry of Health, Government of India, NACO Guidelines. Available at
http://www.naco.gov.in/NACO/About_NACO/Policy__Guidelines/Policies__Guidelines1/
Policy for providing critical care services for medical, surgical, pediatric, obstetrics or
neonatal patients.
ii. SOPs for holistic care of critically ill patients and their management in ICUs or HDUs.
iii. Forms and formats for informed consent, Procedure checklists, Lab or Imaging
investigations, Monitoring sheets for doctors and and nurses, Blood and blood component
transfusion.
Key personnel meet and finalize the scope of critical care for different category of patients,
such as surgical, medical, neonate and pediatrics within ICU / HDU.
ii. Policy and SOPs for admission, discharge, transfer and management of patients in ICU and
HDU.
iii. SOPs for different procedures to be done within ICU / HDU.
iv. Process to ensure regular update of these SOPs as per current evidence-based practices
should be established
v. Training of all doctors, nurses and support staff regarding SOPs, clinical and administrative
processes including infection control practices.
vi. Ensuring good inventory practices for essential medications, biomedical equipment and
consumables, throughout the day, every day and throughout the year.
vii. Provision for acquiring them in case they are out of stock in an emergency.
46
National Accreditation Board for Hospitals and Healthcare Providers
Yes
NO
Comments
Responsibility
Supporting Document
Doctor on duty
Nurse on duty
Doctor on duty
HIC manual
Nurse on duty
47
National Accreditation Board for Hospitals and Healthcare Providers
Process Flow
Responsibility
Supporting Document
Doctor on duty
Patient record
Nurse on duty
ICU register
Doctor on duty
Nurse on duty
Patient record
ICU register
Doctor on duty
Patient record
Nurse on duty
ICU register
Doctor on duty
Patient record
Nurse on duty
ICU register
Doctor on duty
Patient record
Nurse on duty
ICU register
Doctor on duty
Patient record
Nurse on duty
ICU register
Patient record
ICU register
Doctor on duty
Patient record
Nurse on duty
ICU register
48
National Accreditation Board for Hospitals and Healthcare Providers
I. OVERVIEW
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
Scope: To guide the SHCO on how to clearly communicate the different obstetrical services that the
SHCO can or cannot provide for pregnant women during the antenatal, intranatal and postnatal
period.
It is recommended that the SHCO:
i.
Clearly define and display the services that it can provide such as antenatal services,
intranatal and postnatal services.
ii. List the different diagnostic facilities available for this category of patients.
iii. Define and display whether it can cater to high-risk pregnancies such as eclampsia , or
medical disorder with pregnancy.
iv. Provide details on provision for termination of pregnancy and family planning services, if
applicable.
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National Accreditation Board for Hospitals and Healthcare Providers
Responsibility
ii
iii.
iv.
Management
i.
Checkpoint
Yes
i.
ii.
iii.
NO
Comments
STANDARD COP6. DOCUMENTED PROCEDURES GUIDE THE CARE OF PEDIATRIC PATIENTS AS PER
THE SCOPE OF SERVICES PROVIDED BY THE SHCO.
Objective Elements
COP6a. The SHCO defines the scope of its pediatric services.
COP6b. Provisions are made for special care of children by competent staff.*
COP6c. Patient assessment includes detailed nutritional growth and immunization assessment.*
COP6d. Procedure addresses identification and security measures to prevent child or neonate
abduction and abuse.
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National Accreditation Board for Hospitals and Healthcare Providers
COP6e. The children's family members are educated about nutrition, immunization and safe
parenting.*
*Objective Elements COP6b, COP6c, COP6e, are self-explanatory and therefore not included in this
Guidebook.
I. OVERVIEW
Scope: To guide the SHCO on how to decide and communicate clearly to the community the
different pediatric services that can or cannot be provided for neonates, infants and children.
The scope of pediatric services is defined by the hospital and may include:
Pediatric/neonatal services
Immunization services
Emergency services
Developmental clinic
Responsibility
i.
HOD Pediatrics
ii.
MS
iii.
MS
51
National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
NO
Comments
COP6d. Procedure addresses Identification and Security Measures to Prevent Child or Neonate
Abduction and Abuse.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on the prevention of neonate/child abductions and abuse and to ensure
proper safety for newborns and children.
It is recommended that:
i.
Hospital staff are trained and parents educated about the policy and procedures for
preventing infant and child abduction, and safety measures and precautions are taken to
prevent infant abduction and abuse. Parents are advised to supervise their children at all
times in waiting rooms and outpatient clinics.
ii. Proper security measures are taken to avoid any abduction or abuse of children in the
hospital premises by posting security guards outside each department in the hospital.
iii. Electronic surveillance in the form of CCTVs may be installed in closed areas for monitoring.
The HCO may also have a code pink protocol or SOP for the prevention of child /neonatal
abduction or abuse.
II. REQUIRED DOCUMENTS
i.
Task
Responsibility
i.
Formulate SOP/policies
Quality officer
ii.
Medical superintendent
iii.
Patient education
Nurses/Medical officers
iv.
Security personnel
v.
Audit team
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
iii.
iv.
v.
NO
Comments
Note : Samples may be used as templates to guide the SHCO to develop customized SOPs.
No. Process Flow
Responsibility
Supporting Document
1.
Nurses
SOP/identification
band
2.
Security personnel/
Nurse
3.
4.
Nurses
5.
Nurses
6.
Nurses
7.
Security staff
8.
Movement of unrelated/unidentified
attendants is restricted.
Security staff
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National Accreditation Board for Hospitals and Healthcare Providers
Medical records
Responsibility
Supporting Document
Quality team
COP7a. There is a documented policy and procedure for the administration of anesthesia.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on how to develop and implement policies and SOPs related to the
administration of anesthesia with emphasis for patient safety and smooth day- to-day functioning
of OT.
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National Accreditation Board for Hospitals and Healthcare Providers
Compliance with COP7 a is starting point and acts as guiding document in the SHCO. This element
helps to increase the capacity of the SHCO for patient safety while administering anesthesia. It also
helps the SHCO minimize adverse events and medico-legal issues.
It is recommended that:
i.
The SHCO develop policies for anesthesia services, including who can perform them (fulltime staff or visiting consultants who are qualified or trained) and when (elective or
emergency services) along with a back-up mechanism in case of non-availability of
designated individual.
ii. The SHCO develops processes for all anesthesia procedures relevant to the scope of
services of the hospital, including the preanesthetic check-up and review, immediate
preoperative assessment, different anesthesia procedures such as spinal, epidural,
regional blocks, short GA, full general anesthesia, IV deep sedation with local anesthesia,
intra-operative monitoring and documentation in a standardized format, immediate
postoperative monitoring, transferring patient to ward or ICU based on defined criteria
(that is, Aldrette criteria).
iii. There is a defined process for taking informed consent from the patient and relatives.
iv. The SHCO trains all doctors and surgical staff according to the WHO surgical safety checklist.
(WHO Surgical Safety Checklist and Implementation Manual. Available at
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/)
I. REQUIRED DOCUMENTS
i.
ii. SOPs for handling day-to-day functioning and providing anesthesia services.
iii. SOPs for elective and emergency surgeries.
iv. SOPs to handle a potential situation where the patient needs to be referred for further
management.
v. SOPs for postanesthesia status monitoring.
vi. Informed consent formats.
vii. Formats for preanesthesia assessment, immediate preoperative re-evaluation, monitoring
during and after anesthesia.
viii. WHO surgical safety checklist (anesthesia related component)
55
National Accreditation Board for Hospitals and Healthcare Providers
Task
Responsibility
i.
Management
ii.
HR / Superintendent/
Head of SHCO
iii.
Anesthetist, OT nurse,
Quality team/ designated
person
iv.
HR/Quality team
/Consultant in-charge
v.
Anesthetist/OT nurse
vi.
Quality team/
designated person /
Consultant in-charge
Checkpoint
Yes
i.
ii.
PAC documented
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
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National Accreditation Board for Hospitals and Healthcare Providers
NO
Comments
COP8c. Documented procedure addresses the prevention of adverse events like wrong site,
wrong patient and wrong surgery.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO to develop and implement policies and SOPs for conducting safe surgical
procedures and preventing potential adverse events.
It is recommended that:
i.
Personnel involved in care of surgical patients take all necessary measures to reduce the risk
of occurrence of adverse events in surgical patients. Refer to:
WHO, Surgical Safety Checklist and Implementation Manual. Available at
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
WHO, Safe Surgery. Available at
http://www.who.int/patientsafety/safesurgery/en/
WHO, Tools and Resources on Patient Safety. Available at
http://www.who.int/patientsafety/safesurgery/tools_resources/en/
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National Accreditation Board for Hospitals and Healthcare Providers
ii. The SHCO has SOPs to implement and demonstrate methods to prevent adverse surgical
events such as identification tags, badges, and cross-checks.
iii. All personnel follow site- and side-marking procedures uniformly, and regularly check the
same.
iv. All stakeholders follow the checklist at preoperative ward level, checklist for receiving the
patient in the immediate preoperative area, and the checklist before the patient is taken
onto the table, along with the surgical safety checklists before induction of anesthesia,
before incision, and at the end of the surgery.
v. Proper coordination takes place between ward/ICU staff, OT staff, medical officers,
anesthesiologist and consultant surgeon.
vi. Patient participation during the checklist process could help reduce adverse events and
near-misses.
vii. Any adverse event with a surgical patient be reported to hospital management and to the
concerned people. These committees do a root-cause analysis and take appropriate
preventive measures to prevent the occurrence of a similar event in the future.
ii. SOPs for surgical services including informed consent process, wheel-in, execution of
surgery, infection control practices, and safe hand over of the patient.
iii. WHO surgical safety checklist format.
iv. Incident report form in case of any event.
Task
Responsibility
i.
Surgical head/
Anesthetist/ Nurse incharge
ii.
HR/Quality team /
designated Consultant/
person
iii.
iv.
Quality team /
designated Consultant/
person
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
iii.
iv.
v.
vi.
NO
Comments
Supporting Document
OT list, Consent form
l
Inpatient
l
Consent
2.
Responsibility
number
Preprocedure/preoperative verification
Physician and
Surgical safety
Anesthetist
checklist
l
Patient's
band
l
Procedure
or surgery to be performed
59
National Accreditation Board for Hospitals and Healthcare Providers
Responsibility
3.
Physician and
Surgical safety
Anesthetist,
checklist
Primary Nurse,
OR Nurse/Registrar
Supporting Document
l
Multiple
l
Multiple
5.
6.
7.
Time-out procedure:
Infection Control
Nurse, OR Nurse/
Doctor
OR Nurse
8.
l
Correct
patient
l
Correct
side or site
l
Correct
procedure
l
Correct
patient position
l
Correct
radiographs
l
Correct
Surgical safety
checklist
OR Nurse/Doctor
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National Accreditation Board for Hospitals and Healthcare Providers
Surgical safety
checklist
Responsibility
Supporting Document
Surgical safety
checklist
l
Verification
of correct patient
l
Verification
l
Agreement
on the procedure/verification
of radiographs
l
Verification
l
Available
12. Discrepancies
Physician and
Attending
Consultant
(Physician and
Anesthetist)
V. REFERENCES
Resources for SOPs and formats taken from H. M. Patel Center for Medical Care and Education;
and NABH Standards for Hospitals (3rd Edition), November 2011.
CDC Guidelines for Infection Control. Available at
http://www.cdc.gov/HAI/prevent/prevent_pubs.html.
FOGSI Guidelines. Available at
http://www.fogsi.org/index.php?option=com_content&view=article&id=84&Itemid=131
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National Accreditation Board for Hospitals and Healthcare Providers
Gautam Biswas, Recent Advances in Forensic Medicine and Toxicology, Jaypee Brothers, 2015.
Jagdish Singh, Medical Negligence and Compensation, Bharat Law Publishers, 2014.
Medico-legal Forms and Formats, Kerala Medico-Legal Society. Available at
https://sites.google.com/site/keralamedicolegalsociety/medico-legal-certificates
Ministry of Health and Family Welfare Acts, Government of India. Available at
http://www.mohfw.nic.in/index1.php?page=1&ipp=50&lang=1&level=2&sublinkid=2526&lid=18
10
Ministry of Health and Family Welfare, Government of India, Guidelines and Protocols: Medicolegal Care for Survivors/Victims of Sexual Violence. Available at
http://www.mohfw.nic.in/WriteReadData/l892s/9535223249GuidelinesandProtocolsorsexualvio
lence_MOHFWf.pdf
Ministry of Health and Family Welfare, Government of India, Standard Treatment Guidelines, the
Clinical Establishments Act 2010. Available at
http://clinicalestablishments.nic.in/En/1068-downloads.aspx
Ministry of Health, Government of India, NACO Guidelines. Available at
http://www.naco.gov.in/NACO/About_NACO/Policy__Guidelines/Policies__Guidelines1/
NACO, Ministry of Health and Family Welfare, Government of India, Operational and Technical
Guidelines and Policies for Blood Safety and Lab Services. Available at
http://www.naco.gov.in/NACO/Quick_Links/Publication/Blood_Safety__Lab_Services/
NACO, Ministry of Health and Family Welfare, Government of India. Standards for Blood Banks
and Blood Transfusion Services. Available at
http://www.naco.gov.in/upload/Final%20Publications/Blood%20Safety/Standards%20for%20Blo
od%20Banks%20and%20Blood%20Transfusion%20Services.pdf
Royal College of Obstetricians and Gynaecologists Guidelines. Available at
https://www.rcog.org.uk/guidelines
Satish Tiwari, Textbook on Medico-legal Issues, Jaypee Brothers, 2012.
Society of Critical Care Medicine Guidelines. Available at
http://www.learnicu.org/pages/guidelines.aspx
WHO, Surgical Safety Checklist and Implementation Manual. Available at
http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
WHO, Safe Surgery. Available at
http://www.who.int/patientsafety/safesurgery/en/
WHO, Tools and Resources on Patient Safety. Available at
http://www.who.int/patientsafety/safesurgery/tools_resources/en/
WHO, Safe and Rational Clinical Use of Blood. Available at
http://www.who.int/bloodsafety/clinical_use/en/
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National Accreditation Board for Hospitals and Healthcare Providers
Chapter 3
MANAGEMENT OF MEDICATION (MOM)
STANDARD MOM1. DOCUMENTED PROCEDURES GUIDE THE ORGANIZATION OF
PHARMACY SERVICES AND USAGE OF MEDICATION.
Objective Elements
MOM1a. Documented procedures incorporate purchase, storage, prescription, and dispensation
of medications.
MOM1b. These comply with the applicable laws and regulations.*
MOM1c. Sound alike and look alike medications are stored separately.*
MOM1d. Medications beyond the expiry date are not stored or used.*
MOM1e. Documented procedures address procurement and usage of implantable prosthesis.
*Objective Elements MOM1b, MOM1c, and MOM1d are self-exlanatory and therefore not
included in this Guidebook.
MOM1a. Documented procedure shall incorporate purchase, storage, prescription and
dispensation of medications.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on procedures to be followed for purchase, storage, prescription and
dispensation of drugs in a safe manner and to avoid medication errors.
It is recommended that:
i. There is a defined process for the acquisition of medications as per the defined list of the
SHCO. A list of vendors is selected by the SHCO depending on their reputation.
ii. Medications are ordered according to the defined reorder level proposed by the SHCO.
iii. Medications are stored in a clean and safe environment as recommended by the
manufacturer.
iv. There are some medicines which"look alike", for example, Adrenaline and Atropine. There
are some medicines which"sound alike", for example, Levoflox and Levocet, Depomedrol
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National Accreditation Board for Hospitals and Healthcare Providers
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National Accreditation Board for Hospitals and Healthcare Providers
Procedure
Responsibility
1.
Pharmacy in-charge
2.
Pharmacy staff
3.
Pharmacy staff
4.
HOD/staff
i.
Pharmacy/Purchase in-charge
6.
Pharmacy/Purchase in-charge
7.
Pharmacy/Purchase in-charge
8.
Pharmacy/Purchase staff
9.
Pharmacy/Purchase staff
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National Accreditation Board for Hospitals and Healthcare Providers
No.
Procedure
Responsibility
10.
Pharmacy/Purchase staff
11.
Accounts department
Procedure
Responsibility
1.
2.
Pharmacy staff,
Nursing staff in patient care
areas
3.
4.
5.
6.
Pharmacy in-charge
7.
8.
9.
Pharmacy in-charge
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National Accreditation Board for Hospitals and Healthcare Providers
No.
Procedure
Responsibility
1.
Medical Professionals
(Consultants/ Residents/Medical
Officers)
2.
Medical Professionals
(Consultants/ Residents/Medical
Officers)
3.
Medical Professionals
(Consultants/ Residents/Medical
Officers)
4.
Medical Professionals
(Consultants/ Residents/Medical
Officers)
5.
Procedure
Responsibility
1.
Pharmacist
2.
Pharmacist
3.
Pharmacist
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National Accreditation Board for Hospitals and Healthcare Providers
Tasks
Responsibility
i.
Pharmacist/Doctors
ii.
Purchase/Pharmacist
iii.
Management/Quality
team/Pharmacist
iv.
Prescription Format
Quality
team/Pharmacist/Doctors
v.
Quality team/
Pharmacists/Doctors/ Nurse
Checkpoint
Yes
i.
ii.
iii.
No
Remarks
Medical implants are devices or tissues that are placed inside or on the surface of the
body. Many implants are prosthetics, intended to replace missing body parts. Other
implants deliver medication, monitor body functions, or provide support to organs and
tissues.
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National Accreditation Board for Hospitals and Healthcare Providers
ii.
Some implants are made from skin, bone or other body tissues. Others are made from
metal, plastic, ceramic or other materials.
iii.
Implants can be placed permanently or they can be removed once they are no longer
needed. For example, stents or hip implants are intended to be permanent. But
chemotherapy ports or screws to repair broken bones can be removed when they are no
longer needed. The risks of medical implants include surgical risks during placement or
removal, infection, and implant failure. Some people also have reactions to the materials
used in implants.
iv.
The selection of implants is based on scientific criteria that are recognized nationally and
internationally. The primary selection of implants is done by the consultants.
v.
vi.
Once the implants are procured, they are stored in the General Stores/OT Stores/Trauma
OT Store/Pharmacy; whenever the stock level reaches the reorder level, a purchase
order is placed and stock procured. Stocks are stored as per the manufacturer's
recommendations.
vii. Ophthalmological implants such as IOLs are stored in the pharmacy and should be
procured against a written prescription order.
viii. The patient and/or family members are counseled before the usage of a particular
implant and urged to report any adverse situation that may arise following implantation.
II
ix.
The batch and serial numbers of the implants used are recorded in the master file and
patient record.
x.
REQUIRED DOCUMENTS
Note: The following is a sample list of documents which may be modified by the hospital according
to its function.
No.
Procedure
Responsibility
1.
Purchase/Pharmacy in-charge
2.
3.
Purchase/Pharmacy in-charge
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National Accreditation Board for Hospitals and Healthcare Providers
No.
Procedure
Responsibility
4.
HOD/staff
5.
Purchase/Pharmacy in-charge
6.
Purchase/Pharmacy in-charge
7.
Purchase/Pharmacy in-charge
8.
Pharmacy/Purchase staff
9.
Pharmacy/Purchase staff
10.
Pharmacy/Purchase staff
11.
Accounts Department
12.
Pharmacy/ Store
13.
OT staff
Pharmacy staff
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National Accreditation Board for Hospitals and Healthcare Providers
Task
Responsibility
i.
Select Implant
Treating Doctor
ii.
Pharmacy/ Stores
iii.
Stores
iv.
Stores
v.
OT Staff
Checkpoint
Yes
i.
List of implants
ii.
Usage of implants
iii.
No
Remarks
MOM2d. The SHCO defines a list of high-risk medication and process to prescribe them.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
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National Accreditation Board for Hospitals and Healthcare Providers
I. OVERVIEW
Scope: To guide the SHCO on how to define the list of high-risk medications and the process to
prescribe them in order to ensure patient safety.
There are many medicines which have low therapeutic index. An error in prescribing these
medicines may result in catastrophy. These medicines are called 'high-risk medicines'. Examples of
high-risk medicines are muscle relaxants, sedatives, electrolyte solutions. The SHCO should make a
list of high-risk medicines and educate its staff regarding their usage. As added caution, the SHCO
may consider labelling the high-risk medicines, keeping them seperately, and avoiding verbal orders
for the medicines.
It is recommended that:
i.
The SCHO prepare a list of high-risk medications used in the SHCO. This list should be made
known to all staff (nursing/pharmacists/doctors). The medications should be doubly
checked before dispensing as well as during administration. (The list of high-risk
medicines may be prepared as per the Annexure in the Institute for Safe Medication
Practices (ISMP) list.)
No.
Tasks
Responsibility
i.
Pharmacist/Doctors
ii.
Management/Pharmacists/
Doctors
iii.
Management/Pharmacist
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
No
Remarks
V. REFERENCES
Accreditation Standards for Hospitals, NABH, 3rd Edition, November 2011.
de Vries, T.P.G.M., R. H. Henning, H. V. Hogerzeil and D. A. Fresle, A Guide to Good Prescription,
World Health Organization Action Programme on Essential Drugs, Geneva, 1994.
General Medical Council (GMC), 2013. Good Practice in Prescribing and Managing Medicines and
Devices. Available at
http://www.gmc-uk.org/Good_practice_in_prescribing.pdf_58834768.pdf
Institute for Safe Medication Practices, 4th April 2013. ISMP's List of High-Alert Medications. ISMP
Medication Safety Alert.
WHO, 2003.Guidelines for the Storage of Essential Medicines and Other Health Commodities.
Available at
http://apps.who.int/medicinedocs/en/d/Js4885e/
ANNEXURES
1.
2.
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National Accreditation Board for Hospitals and Healthcare Providers
Chapter 4
HOSPITAL INFECTION CONTROL (HIC)
STANDARD HIC1. THE SHCO HAS AN INFECTION CONTROL MANUAL WHICH IT
PERIODICALLY UPDATES; THE SHCO CONDUCTS SURVEILLANCE ACTIVITIES*.
Objective Elements
HIC1a. It focuses on adherence to standard precautions at all times.
HIC1b. Cleanliness and general hygiene of facilities will be maintained and monitored.
HIC1c. Cleaning and disinfection practices are defined and monitored as appropriate.
HIC1d. Equipment cleaning, disinfection and sterilization practices are included.
HIC1e. Laundry and linen management processes are also included.
*A sample Hospital Infection Control (HIC) manual has been included as an annexure in the soft
copy of this document. It addresses all the objective elements listed above. Hence, limited details
on the HIC manual are provided in this chapter.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide both staff and patients in the SHCO on the standard precautions to be followed in
order to:
i.
Reduce and prevent the incidence of hospital acquired infections in the SHCO.
ii. Identify high-risk areas where active surveillance should be practiced in an SHCO so as to
reduce the rate of infections.
iii. Develop policies and procedures for standards of cleanliness, sanitation, and asepsis in the
SHCO.
Hospital Infection Control (HIC) Manual
It is recommended that the SHCO have an HIC Manual on standard precautions that staff should
follow to prevent patients from acquiring infections within the SHCO.
It is recommended that the HIC Manual:
i.
Explains to staff the standard precautions and the universal precautions that should be
ideally practiced in the SHCO.
ii. Focuses on the importance of hand hygiene as this is one of the root causes for all hospital
acquired infections.
iii. Provides guidelines for the care to be taken in high-risk areas like OT (Operation
Theatre), CSSD (Central Sterile Supply Department), and ICU (Intensive Care Unit).
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National Accreditation Board for Hospitals and Healthcare Providers
iv. Defines the protocol to be followed in case of a needle-stick injury to any staff.
v. Defines the colour coding for biomedical waste segregation which should be as per the
State regulations or as per statutory regulations.
vi. Enlists the conditions to be followed by the SHCO for isolation practices.
vii. Lists the standard cleaning, disinfection and sterilization practices to be followed in the
HCO to prevent infections.
viii. Outlines the precautions and the methodology to be followed in case of spills.
ix. Lists the standard housekeeping practices to be practiced by the SHCO.
x
xi. Lists the hygiene practices to be followed in the kitchen of the SHCO.
xii. Defines conditions that will help SHCOs to identify an outbreak and the measures that need
to be followed in case of an outbreak.
II. REQUIRED DOCUMENTS
No.
Name (Register/Format)
Responsible Person
i.
HIC Manual
Task
Responsibility
i.
Define the content of the HIC Manual Clinical Department Heads along with
designated HIC staff
ii.
Checkpoint
Yes
i.
ii.
iii.
iv.
No
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National Accreditation Board for Hospitals and Healthcare Providers
Remarks
Chapter 5
CONTINUOUS QUALITY IMPROVEMENT (CQI)
STANDARD CQI2. THE SHCO IDENTIFIES KEY INDICATORS TO MONITOR THE STRUCTURES,
PROCESSES, AND OUTCOMES WHICH ARE USED AS TOOLS FOR CONTINUOUS
IMPROVEMENT.
Objective Elements
CQI2a. The SHCO identifies the appropriate key performance indicators in both clinical and
managerial areas.
CQI2b. These indicators shall be monitored.*
*Objective Element CQI2b is self-explanatory and therefore not included in this Guidebook.
CQI2a. The SHCO identifies the appropriate key performance indicators in both clinical and
managerial areas.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on how to measure the performance of an SHCO by indicators that
represent the functioning of various services, personnel, and departments.
There are three dimensions of quality, namely, Structures, Processes and Outcomes. Examples of
Structures are infrastructure, number of nurses available, number of doctors available, availability
of biomedical equipment. Examples of Processes include hand washing, administration of
medications, reporting of X-Ray. Examples of Outcomes include Surgical Site Infection Rate,
Patient Satisfaction Index, number of falls in the hospital.
If Structures and Processes are good, the Outcomes will consequently also be good. For example, to
ensure quality care in the ER, the Structures necessary are availability of doctors and nurses,
availability of equipment and medicines. For Processes, the doctors and nurses should provide the
correct treatment using standard treatment guidelines and protocols. The presence of Structures
alone does not ensure quality. If both Structures and Processes are appropriate, they will lead to
good Outcomes.
When we want to measure quality, we may measure either the structure, process or outcome. If we
measure outcome, indirectly we are measuring both structure and process. But if we are measuring
either structure or process, it is uncertain whether good outcomes will be achieved. For example, if
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National Accreditation Board for Hospitals and Healthcare Providers
we measure percentage of beds with hand sanitizer available by the bedside, it does not give us any
idea of how often it is used. If we are measuring a process, for example, compliance with hand
washing, we know that is an important component to control hospital-acquired infection, but we
are still uncertain whether the hospital-acquired infection rate is low. If we measure surgical site
infection rate, which is an outcome of several structures and processes, we are indirectly measuring
structures and processes. Therefore, if the surgical site infection rate has gone up, we need to look
into individual structures and processes that contribute to the outcome. For example, we may look
into factors such as whether antibiotic prophylaxis was given half an hour before surgery (process),
presence of hand wash facilities in the surgical ward (structure), proper OT air conditioning
(structure), and availability of sterile equipment (structure).
To summarize, we may measure quality by measuring structure, process or outcome by using Key
Performance Indicators (KPI). KPIs are indicators that help to objectively discern the functioning of a
particular process or a system. As the health system is very complex with multiple stakeholders
playing a key role in any process, it is very difficult to determine the performance of a process unless
an indicator which is measurable is developed. For example, if a doctor is asked about the
medication errors in his workplace, he may accept that medication errors do happen, but he will not
be able to identify the nature of medication errors and the measures to be taken to decrease them.
If the number of medication errors are captured as an indicator, they may be classified and a rootcause analysis conducted to decrease the number of medication errors. Some indicators such as the
time taken for the initial assessment, surgical site infection rate, catheter-associated urinary tract
infection rate, are clinical indicators which are directly related to clinicians, which include doctors
and nurses. There are other indicators that are directly related to hospital administration, such as
the number of emergency medicines which are out of stock.
l
Nonclinical:
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National Accreditation Board for Hospitals and Healthcare Providers
Responsibility
Administration
1.
Identification of KPI
Quality team/Administration
2.
Quality team
3.
Quality team
4.
5.
Quality team/personnel
6.
Quality team
7.
Analysis of data
stakeholders
8.
Quality team
9.
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National Accreditation Board for Hospitals and Healthcare Providers
No.
Tasks
Responsibility
i.
Top management
ii.
Identify KPI
Departmental heads,
Quality team, Top management
iii.
Quality team
iv.
Collect data
v.
Validate data
Quality team
vi.
Quality team/Administration
vii.
Quality team
viii.
ix.
x.
xi.
IV.AUDIT CHECKLIST
No.
Checkpoint
Yes
i.
ii.
iii.
iv.
No
V. REFERENCES
Accreditation Standards for Hospitals, NABH, 3rd Edition, November 2011.
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National Accreditation Board for Hospitals and Healthcare Providers
Remarks
Chapter 6
RESPONSIBILITIES OF MANAGEMENT (ROM)
STANDARD ROM1. THE RESPONSIBILITIES OF THE MANAGEMENT ARE DEFINED.
Objective Elements
ROM1a. The SHCO has a documented organogram.
ROM1b. The SHCO is registered with appropriate authorities as applicable.*
ROM1c. The SHCO has a designated individual(s) to oversee the hospital-wide safety program.*
*Objective Elements ROM1b and ROM1c are self-explanatory and therefore not included in this
Guidebook.
I. OVERVIEW
Scope: To guide the SHCO on prepaing a picture of the structure of the SHCO, namely, its leadership,
its functional levels - departments, units, subunits - and the jobs at different levels, as well as the
relationship between personnel and between levels of jobs.
An effective organogram may be prepared with the help of the following steps and principles:
i.
The different functionaries (designations) and functional units (departments) are listed.
ii. A clear chain of command or hierarchy exists in the functioning of the SCHO which provides:
a. A pathway for the flow of information from top to bottom and vice versa.
b. An indication of whom to report to regarding day-to-day functioning.
c. An indication of whom to approach for escalation in problem resolution.
d. An indication of cross-related functional departments and individuals.
iii. This is represented in the form of a flow chart.
iv. Under each functional unit or department, it is possible to similarly list out the different
categories of staff in the unit, number of staff in each category, and the hierarchy within the
unit starting from the department head, and section in-charges. This is optional.
v. The organogram forms the framework based on which an adequate mix of staff is made
available to cater to the services rendered in the SHCO.
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National Accreditation Board for Hospitals and Healthcare Providers
No. Procedure
Responsibility
Supporting
Documents
i.
Top management
Organogram
ii.
HR staff or Quality
department staff or
Heads of respective
departments
Induction training
material
l
Regular
Training material
on SHCO-wide
policies and
procedures
Task
Responsibility
i.
HR in-charge
ii.
o
iii.
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
iii.
iv.
v.
vi.
No
Remarks
ANNEXURE
Organogram (This is a representative organogram. The hospital may replace the prompts with
actual designations and suitably modify it.)
Department
Sub-unit
Sub-unit
Department
Department
Department
Department
Department
Department
Department
Department
Sub-unit
Sub-unit
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National Accreditation Board for Hospitals and Healthcare Providers
Departmental structure (This is optional. The hospital may replace the prompts with actual
designations and names of unit or subunits)
Department Head
Sub-unit
Sub-unit
Section In-charge
Staff category
Section In-charge
Staff category
Staff category
Section In-charge
Staff category
Staff category
Section In-charge
Staff category
Staff category
Staff category
ROM2a. The management makes public the mission statement of the SHCO.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To orient the management of the SHCO, and in turn the staff, to the rationale of the SHCO
that is encapsulated in the mission statement.
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National Accreditation Board for Hospitals and Healthcare Providers
The mission statement refers to the overall purpose of an organization. The mission answers the
question, "What does the organization aim to accomplish?"
Mission statements are designed to fulfil three basic purposes:
a. To inspire and motivate organizational members to higher levels of performance.
b. To guide resource allocation in a consistent manner.
c.
To create a balance among the competing, and often conflicting interests of various
organizational stakeholders.
The content of the mission statement usually includes the following components:
a. Purpose - defines the patients, stakeholders, markets, and geographical areas served, and
services provided.
b. Strategy - refers to the tools used such as distinctive or core competencies, technologies,
elements of growth and profitability, and the self-image of the organization.
c.
Values - the compass which guides the philosophy in the SHCO, such as social or civic
responsibility, commitment, dedication, accountability, stewardship, employee well-being,
learning, training and development.
d. Behavioral Standards - How employees are expected to behave - ethically, morally, honestly,
with integrity, professionally - as well as to be improvement-oriented, achievement-oriented,
empowering, innovative, adaptive, and creative.
No. Procedure
Responsibility
Supporting
Documents
1.
Top management
Mission statement
2.
Operations Head
and Maintenance
/Facility in-charge
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National Accreditation Board for Hospitals and Healthcare Providers
No. Procedure
Responsibility
Supporting
Documents
3.
HR staff , or Quality
department staff, or
Heads of respective
departments
Induction training
material.
Training material on
SHCO-wide policies
and procedures.
4.
HR department,
All manuals.
Quality department Hospital brochure.
No.
Task
Responsibility
i.
ii.
iii.
iv
Top management
vi
Quality Department or HR
department
vii
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National Accreditation Board for Hospitals and Healthcare Providers
V. REFERENCES
Forehand, A., "Mission and Organizational Performance in the Healthcare Industry". Journal of
Health Management, July-August 2000, Vol. 45, No. 4, pp. 267-77.
Pearce, John A. and Fred David, Corporate Mission Statements: The Bottom Line, The Academy of
Management Executives, May 1987, Vol. 1, No. 2, pp.109-115.
Smith, Mark, Ronald B. Heady et al. Do Missions Accomplish their Missions? An Exploratory Analysis
of Mission Statement Content and Organizational Longevity. Available at
http://www.huizenga.nova.edu/Jame/articles/mission-statement-content.cfm
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National Accreditation Board for Hospitals and Healthcare Providers
Chapter 7
FACILITY MANAGEMENT AND SAFETY (FMS)
STANDARD FMS1. THE SHCO's ENVIRONMENT AND FACILITIES OPERATE TO ENSURE SAFETY OF
PATIENTS, THEIR FAMILIES, STAFF AND VISITORS.
Objective Elements
FMS1a. Internal and external signages shall be displayed in a language understood by the patients
or families and communities.*
FMS1b. Maintenance staff is contactable round the clock for emergency repairs.*
FMS1c. The SHCO has a system to identify the potential safety and security risks including
hazardous materials.
FMS1d. Facility inspection rounds to ensure safety are conducted periodically.*
FMS1e. There is a safety education programme for relevant staff.*
*Objective Elements FMS1a, FMS1b, FMS1d, and FMS1e are self-explanatory and therefore not
included in this Guidebook.
FMS1c. The SHCO has a system to identify the potential safety and security risks including
hazardous materials.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To ensure the safety of patients, families, staff and visitors to the SHCO by identifying all the
potential risks, and having adequate safety measures in place to prevent accidents and harm.
Risk is a potential threat that affects the ability to achieve the desired outcome. A SHCO setting is an
environment of risk and potential danger. There are potential hazards in every area of the SHCO
such as radiation leaks, chemical exposure, infections, and security issues. Risk management is
achieved through detecting, managing, reporting, and correcting potential deficiencies. It is
recommended that
l
Staff
be educated about the various risks in the hospital environment, identify potential
risks, manage and report them immediately.
l
Appropriate mechanisms be implemented for the staff and visitors to report any identified
potential risk.
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National Accreditation Board for Hospitals and Healthcare Providers
l
The reported
Responsibility
Supporting
Documents
HR/Training
department
Training records
Reporting forms/
Register
Reporting forms/
Register
Reporting forms/
Register
Designated person/
Concerned
departments
Reporting forms/
Register
Reporting forms/
Register
Procedure
Designated person
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National Accreditation Board for Hospitals and Healthcare Providers
Inspection
report
the mercury with a dropper or scoop up beads with a piece of heavy paper like
playing cards.
l
Place the mercury-contaminated instruments (dropper/heavy paper) and any broken glass
l
Do not use a broom or paint brush. It will spread them around by breaking them into smaller
beads.
l
Do not use vacuum as it will disperse mercury vapour into the air and increase the likelihood
of human exposure.
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b) Security Risks
SHCOs face a wide range of security issues from handling thefts, workplace violence, abduction,
aggrieved patients or mobs to bomb threats. Adequate mechanisms must be in place to prevent
their occurrence and to address them, in case they happen.
Theft in hospital
l
All staff should wear hospital ID at all times.
l
Staff must report any unidentified individuals or suspicious activity.
l
Visitors without guest passes will not be permitted inside the SHCO.
l
CCTV monitoring of the corridors and common areas is necessary.
l
Patients to be instructed to keep their belongings safe and locked.
l
Theft must be immediately reported to the security department.
l
Security department must take control of the scene and scrutinize all CCTV recordings and
movements.
l
All staff in the area should be interrogated about any suspicious movement.
l
Every effort must be made to solve the case. Security department must include the senior
equipment.
l
Risk
assessment and control in the purchase of articles and substances to avoid the
introduction of fire hazards whenever and wherever possible.
l
Strict preventive maintenance programs for electrical wiring and appliances, like non use of
Training of the employees on fire prevention and fire management is most essential for ensuring
safety in the structure. The SHCO should train all employees on how to avoid fire incidents specific
to their workplace as well as basic techniques on the use of fire extinguishers.
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National Accreditation Board for Hospitals and Healthcare Providers
good standard wiring and do not permit substandard wiring that does not follow
electrical safety requirements.
l
Staff operating the equipment must be trained and have adequate knowledge on the use of
equipment.
l
Conduct periodic safety inspections in order to detect potential problems.
e) Risk of Fall
The risk of a fall applies not just for patients but for all staff of an SHCO, visitors and patient
attendants. Fall prevention strategies and also the incidence of fall should be audited to check if
they are serving the purpose for which they were constituted and also to review if any new
interventions are required to prevent falls.
To prevent falls, the following may be observed:
l
All wheelchairs and stretchers used for transferring patients should have restraint belts.
l
All roads
and corridors must be level and any broken or chipped floor tiles should be
immediately replaced.
l
While cleaning, the area should be cordoned off with appropriate signage like "wet floor".
colour.
l
Grab bars must be provided in all toilets.
l
Adequate lighting must be present in all areas.
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National Accreditation Board for Hospitals and Healthcare Providers
Task
Responsibility
ii
All staff
iii
iv
Checkpoint
Yes
ii
iii
Documentation of reported
potential risks
iv
vi
vii
No
Remarks
Available/Not available
STANDARD FMS2. THE SHCO HAS A PROGRAM FOR CLINICAL AND SUPPORT SERVICE EQUIPMENT
MANAGEMENT
Objective Elements
FMS2a. The SHCO plans for equipment in accordance with its services.*
FMS2b. There is a documented operational and maintenance (preventive and breakdown) plan.
*Objective Element FMS2a is self-explanatory and therefore not included in this Mnaual.
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National Accreditation Board for Hospitals and Healthcare Providers
FMS2b. There is a documented operational and maintenance (preventive and breakdown) plan.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To ensure that equipment is used or operated in the right manner, equipment is checked
periodically to avert repairs, and also to address repairs immediately, if they occur.
SHCO equipment includes biomedical equipment like monitors or infusions, used for direct patient
care and engineering equipment such as generators and motors for the functioning of the hospital.
It is recommended that they be operated and maintained appropriately, otherwise it could
compromise patient care.
Operational plan
Operational plan is to ensure that the equipment is used or operated by the technician as per the
instructions of the manufacturer. In order to do so, it is recommended that the operator or
technician be trained in safe operation by the equipment company.
Maintenance plan
l
Maintenance plan addresses preventive and breakdown maintenance.
l
The primary aim of preventive maintenance is to avoid or mitigate failure of equipment. It is
Inventory of equipment.
ii. Checklists and operational instructions for all equipment based on operator's manual.
iii. Planned preventive maintenance schedule for all equipment.
iv. Handling breakdown repairs of equipment.
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National Accreditation Board for Hospitals and Healthcare Providers
SAMPLE DOCUMENTS
Sample inventory of equipment
l
As good
l
Example for inventory number: Simple running numbers like 001, 002 or BBH/ BM/ DEFIB/
003.
n
BBH- Bangalore Baptist Hospital
n
BM- Biomedical Equipment
n
DEFIB- Defibrillator
n
003- Running number
l
Inventory
number and serial number (assigned by manufacturer) are the two IDs of the
equipment.
l
A database
l
Inventory should be managed and updated by the engineering team when new equipment
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National Accreditation Board for Hospitals and Healthcare Providers
Supporting
Documents
Engineering
Operational plan
for each
equipment
Engineering / Staff
handling the
equipment
Training records/
checklist and
records
Operational plan
for the
equipment
Operational plan
for the
equipment
Procedure
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National Accreditation Board for Hospitals and Healthcare Providers
Responsibility
Supporting
Documents
Engineering
Engineering
Operators
Manual
Engineering
Records of
preventive
maintenance
Engineering
Intimation to the
users
Engineering
Records of
preventive
maintenance
Preventive
maintenance
schedule
The repair may include spare part replacement and Engineer/ Outsourced
small component replacement.
engineer
Complaint
register
Receipts
Engineer
Complaint
Register
Engineer
Complaint
register
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National Accreditation Board for Hospitals and Healthcare Providers
Tasks
Responsibility
i.
Engineer
ii.
Engineer
iii.
iv.
Engineer
v.
Engineer
vi.
Engineer
Checkpoint
Yes
i.
ii.
iii.
iv.
v.
vi.
vii.
No
Remarks
STANDARD FMS3. THE SHCO HAS PROVISIONS FOR SAFE WATER, ELECTRICITY, MEDICAL
GAS, AND VACUUM SYSTEMS.
Objective Elements
FMS3a.Potable water and electricity are available round the clock.*
FMS3b. Alternate sources are provided for in case of failure and tested regularly.*
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FMS3c. There is a maintenance plan for medical gas and vacuum systems.
*Objective Elements FMS3a and FMS3b are self-explanatory and therefore not included in this
Guidebook.
FMS3c. There is a maintenance plan for medical gas and vacuum systems.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To ensure that there is safe and continuous supply of medical gases and vacuum for the
patients in the wards, ICUs, OTs.
Medical gases form the very backbone of an SHCO. Without them it would be impossible to run a
healthcare organization, as they play an essential role in the functioning of critical care units and key
operational areas.
It is recommended that:
Medical gas installations are constructed as per norms and licenses obtained for Liquid Medical
Oxygen (LMO) as per requirements.
Strict safety requirements as per the norms are followed.
Trained medical gas operators or technicians be available in the case of central supply and
continuous supply.
Maintenance should be done regularly as per requirements.
Protocol for operating medical gas and vacuum installations shall be managed as per policy.
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Procedure
Responsibility
Supporting
Documents
HR/Engineering
Engineering
Records of
backup cylinders
Engineering
Actual
availability/
Inspections at
random
Engineering
Personal Files
Daily, weekly,
monthly and
annual
maintenance
schedule,
records of
maintenance.
Daily Check
Parameters to be checked
1.
2.
Vacuum pump
3.
Air compressor
4.
Weekly Maintenance
All medical gas outlets of the clinical area to be checked for pressure range and leaks. If the
pressure drops, the outlet needs to be scanned.
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National Accreditation Board for Hospitals and Healthcare Providers
Monthly Maintenance
No
Daily Check
Parameters to be checked
1.
Vacuum Pump
Cleaning, oil level and quality, belt tension check for fasteners, auto
drain and check for silencer cleaning, loading and unloading
pressure range.
2.
Manifolds
3.
Air compressors
Cleaning, oil level and quality, belt tension check for fasteners, auto
drain and check for silencer cleaning, water pressure, temperature
sensor, cooling tower, loading and unloading pressure range,
servicing suction and discharge valves, and servicing of NonReturn
Valve.
Annual Maintenance
As per the equipment requirements and manual, thorough overhaul should be performed.
Colour coding of medical gas pipelines:
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Task
Responsibility
i.
Engineer
ii.
Engineer
iii.
iv.
Engineer
v.
Engineer
Checkpoint
Yes
i.
ii.
iii.
iv.
v.
Chained cylinders
vi.
vii.
viii.
ix.
Annual overhaul
x.
xi.
xii.
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No
Remarks
STANDARD FMS4. THE SHCO HAS PLANS FOR FIRE AND NONFIRE EMERGENCIES WITHIN
THE FACILITIES.
Objective Elements
FMS4a. The SHCO has plans and provisions for early detection, abatement, and
containment of fire and nonfire emergencies.
FMS4b. The SHCO has a documented safe exit plan in case of fire and nonfire
emergencies.
FMS4c. Staff is trained for their role in case of such emergencies.*
FMS4d. Mock drills are held at least twice in a year.*
*Objective Elements FMS4c and FMS4d are self-explanatory and therefore not included in
this Guidebook.
FMS4a. The SHCO has plans and provisions for detection, abatement and containment of
fire and nonfire emergencies.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing
their own customized documents.
I. OVERVIEW
Scope: To ensure that adequate systems are available for the early detection, abatement
and containment of fire and nonfire emergencies to ensure the safety of the occupants
(patients, relatives, staff) and infrastructure of the SHCO.
In an SHCO set-up, potential emergency situations include fire emergencies and nonfire
emergencies such as terrorist attacks, stray animals, earthquakes, antisocial behaviour of
relatives, chemical spillage, structural collapse, patient fall, flooding, and bursting of
pipelines.
It is recommended that:
i. Smoke detectors, leak detectors, and systems like alarms, hooters, and Public
Address (PA) systems be available for use in case of emergencies.
ii. These systems be maintained and tested to ensure their functionality at all times.
iii. A trained multidisciplinary team handle such emergencies wherein a common
telephone number (help line) or other mechanisms be used to alert and activate
this team.
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SAMPLE DOCUMENTS
Sample protocol for the management fire and nonfire emergencies.
Procedure
Responsibility
Supporting
Documents
Engineering
Maintenance
records and
checklists
Engineering
Maintenance
records and
checklists
HR/Training
department
Training records
All staff
Staff
Designated team
Designated team
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National Accreditation Board for Hospitals and Healthcare Providers
Task
Responsibility
i.
Head of SHCO
ii.
Head of SHCO
iii.
Leak detection system of LPG bank, medical gas bank as per norms
Engineer
iv.
Designated
team
v.
HR/ Training
department
vi.
HR/ Training
department
Checkpoint
Yes
i.
ii.
iii.
iv.
v.
vi.
vii.
Staff training
viii.
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National Accreditation Board for Hospitals and Healthcare Providers
No
Remarks
FMS4b. The SHCO has a documented safe exit plan in case of fire and nonfire
emergencies.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing
their own customized documents.
I. OVERVIEW
Scope: To ensure that the occupants of the SHCO building are evacuated to safety in case of
an emergency situation. In order to do so, it is recommended that the SHCO should have
safe exit plans for its occupants.
It is recommended that:
i.
In case of an emergency situation, the occupants of the SHCO are evacuated to a safe
area as quickly as possible. The National Building Code (NBC) has prescribed structural
specifications for buildings which conduct evacutions in an emergency.
ii. Irrespective of the infrastructure, the staff in the SHCO should be trained to evacuate
patients to safety in any emergency according to the plan that is prepared for the
purpose.
iii. Appropriate evacuation plans should be documented and tested out frequently by
conducting mock drills.
SAMPLE DOCUMENTS
Sample of Emergency Floor Plan
Emergency Floor Plans: An emergency floor plan shows the possible evacuation routes in
the floor of the building. It is usually color-coded and uses broad arrows to indicate the
designated exit. This should be available in all conspicuous places, especially in all clinical
areas. Marking of the location of the display should also be available in the floor plan to
orient the person looking at the floor plan, which is usually marked as "You are here".
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in the SHCO should be trained in basic firefighting techniques, like handling fire
extinguishers.
l
All staff in the SHCO should be aware of their role in any emergency.
l
Signages such as emergency floor plans and fire exits, should be available in all areas.
l
Emergency lights should be available for facilitating evacuation in an emergency, as power
l
In case of fire, it could be the security in-charge along with the engineering or
maintenance
team.
l
The fire fighting team should immediately proceed to the scene with additional firefighting
equipment, try to extinguish the fire, or escalate to the city fire department.
l
The engineering
team should ensure that the fire pumps are kept running and that the
correct pressure is maintained, ensure that the firewater tank is kept topped up, ensure
that the sub-station is staffed and that electric supply to the fire-affected area is cut off .
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National Accreditation Board for Hospitals and Healthcare Providers
The housekeeping staff and other staff may form a ring around the scene of fire and ensure
l
that the functioning and movement of the fire fighting team or Fire Brigade personnel are
not hampered. They can also assist the team if required.
l
The evacuation
team may consist of the doctors and nursing staff who can move the
patients in the immediate fire area to the designated assembly areas or to other beds
totally away from the scene of fire. Walking patients can be conducted in a group to a safe
area through fire exits or other exit staircases. Patients on life-support systems should be
evacuated along with the equipment.
l
One
staff member should be designated by the Senior Nurse to check toilets and other
rooms to make sure that there are no patients hiding or trapped in those areas.
Task
Responsibility
i.
Head of SHCO
ii.
Designated person
iii.
Designated person
iv.
Engineer
v.
Designated team
vi.
Designated team
Checkpoint
Yes
i.
ii.
Emergency lighting.
iii.
iv.
v.
vi.
vii.
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No
Remarks
V. REFERENCES
Accreditation Standards for Hospitals, NABH, 3rd Edition, November 2011.
Bureau of Indian Standards, National Building Code of India 2005, Group 1, New Delhi.
G. B. Menon, Fire Advisor, Government of India, Handbook on Building Fire Codes, Fire Fighting
and Fire Safety Requirements. Available at
www.urbanindia.nic.in/publicinfo/byelaws/chap-7.pdf
Fire Fighting and Fire Safety Requirements, Chapter 7. Available at
www.urbanindia.nic.in/publicinfo/byelaws/chap-7.pdf
IITK-GSDMA, Fire 05-V3.0. Available at
http://www.iitk.ac.in/nicee/IITK-GSDMA/F05.pdf
Indian Standards, Basic Requirements for Hospital Planning, Part 1 upto 30 bedded hospital, IS
12433 (Part 1): 1988.
Indian Standards, Basic Requirements for Hospital Planning, Part 2 upto 100 bedded hospital, IS
12433 (Part 2): 2001.
Indian Standards, Recommendations for Basic Requirements of General Hospital Buildings,
Part 3, Engineering services department, IS: I0905 (Part 3)-1984.
Medical Equipment Maintenance Program Overview. Available at
http://whqlibdoc.who.int/publications/2011/9789241501538_eng.pdf
NABH & Fire Safety. Available at
http://nabh.co/Images/PDF/Fire_Safety_NABH.pdf
OSHA (Occupational Safety & Health Administration) Technical Manual. Available at
www.osha.gov
R. Craig Schroll, Fire Detection and Alarm Systems: A Brief Guide, Dec. 01, 2007. Available at
http://ohsonline.com/Articles/2007/12/Fire-Detection-and-Alarm-Systems-A-Brief-Guide.aspx
www.bis.org.in
R. R. Nair, Fire Safety Expert and Consultant, Maintenance Schedule, adapted from lecture notes
of 2014.
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Chapter 8
HUMAN RESOURCE MANAGEMENT (HRM)
STANDARD HRM2. THE SHCO HAS A WELL-DOCUMENTED DISCIPLINARY AND GRIEVANCE
HANDLING PROCEDURE
Objective Elements
HRM2a. A documented procedure regarding disciplinary and grievance handling is in place.
HRM2b. The documented procedure is known to all categories of employees in the SHCO.
HRM2c. Actions are taken to redress the grievance.*
*Objective HRM2c is self-explanatory and therefore not included in this Guidebook.
I. OVERVIEW
Scope: To guide the SHCO on taking prompt action for disciplinary action and grievance redressal by
designated individuals which helps to avoid bias or prejudice. It is recommended that the
management of the SHCO predefines the mechanism for addressing disciplinary action and
grievance redressal.
i.
Disciplinary action: This is the recommended sequence of activities carried out when staff
do not comply with laid-down norms, service standards, rules and regulations of the SHCO.
Staff should be made aware of the consequences of not abiding with the applicable policies
of the SHCO. A member of staff who is aware of disciplinary action is less likely to commit an
offence. The mechanism identifies situations that warrant a review of the event by a
committee. The quantum of the disciplinary action may be predefined for certain situations
or the committee may give its suggestions to the SHCO management. There is scope for an
appeal if the member of staff wishes to do so. There is a separate mechanism to address
breach of conduct with regard to sexual harassment at the workplace in accordance with
the law.
ii. Grievance redressal: This is the recommended sequence of activities carried out to address
the grievances of patients, visitors, relatives and staff. The staff in the SHCO should be aware
that there is a grievance redressal procedure if they do not get what is due to them, thereby
safeguarding their rights. The mechanism describes which person the staff can contact and
the process of review of the case by a grievance redressal officer or committee. The
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National Accreditation Board for Hospitals and Healthcare Providers
committee rules whether the grievance is genuine or not and gives its recommendations
accordingly. There is scope to appeal to a higher authority.
Preliminary assessment
of complaint by the HOD
Major offence
Repeat offender
Minor offence
Counseling or
Warning
Hearing in disciplinary
committee
Staff allowed to
present his/her
explanation
Complainant
presents the details
of the offence
Decision of disciplinary
committee
No Offence
Gross misconduct
Offence
Termination
Disciplinary action
Decision up held
Appeal
Decision reversed
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National Accreditation Board for Hospitals and Healthcare Providers
No offence
No action
Staff discusses
grievance with HOD
Resolution of grievance
No
Yes
Discussion with HR
Resolution
No resolution
No action
Hearing in grievance
handling committee
Respondent is allowed
to present his/her
explanation
Complainant
presents the details
of the grievance
Decision of grievance
handling committee
No cause for
concern
Grievance upheld
Action taken
Grievance resolved
Decision upheld
Appeal by any
involved party
Decision reversed
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No
Task
Disciplinary procedure
Responsibility
i.
HR department
ii.
Authorized by Top
management
iii.
Authorized by Top
management
iv.
Disciplinary committee
or designated individual
v.
Disciplinary committee
or designated individual
vi.
Authorized by Top
management
vii.
HR department
viii.
Authorized by Top
management
ix.
x.
Member Secretary
of ICC
xi.
xii.
Proceedings of ICC
Member Secretary
of ICC
xiii.
Member Secretary
of ICC
HR department
Top management
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National Accreditation Board for Hospitals and Healthcare Providers
HR department
ii.
iii.
HR department
iv.
HR department
Quality department
Checkpoint
Yes
i.
ii.
iii.
v.
vi.
vii.
viii.
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National Accreditation Board for Hospitals and Healthcare Providers
No
Remarks
HRM2b. The documented procedure is known to all categories of employees in the SHCO.
Note: Sections II and III below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To make staff aware of the disciplinary procedure so that they are less likely to err since they
know the consequences. Staff also become aware that the disciplinary proceedings are free of bias
or prejudice as well as how to access the grievance handling mechanism in a timely manner.
It is important for the staff to know the procedures that will be followed both for disciplinary action
and grievance redressal. It is recommended that the management should take the time and make
the effort to conduct training for the staff right from the time they join the SHCO, and also to
periodically retrain them on the same.
Task
Responsibility
i.
HR department
Quality
department
l
The
l
The
ii.
HR department
HOD of
respective
departments
Quality
department
l
Retraining
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National Accreditation Board for Hospitals and Healthcare Providers
Checkpoint
Yes
i.
ii.
iii.
iv.
No
Remarks
HRM3a. Health problems of the employees are taken care of in accordance with the SHCO's
policy.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To ensure a healthy workforce. It also aims to avoid occupational health-related issues
among the staff and to address them when they do occur. Proper attention to the health and
occupational safety of the staff boosts morale, reduces absenteeism, and increases the quality of
services rendered.
The extent to which the hospital management supports the healthcare needs of the staff is partly
mandatory and partly discretionary as per the following principles:
i.
Employee health benefit is a statutory requirement if the SHCO falls within the gamut of the
Employee State Insurance Norms (more than 10 or more staff employed on the rolls). Staff
who earn less than Rs.15,000 gross salary are eligible as per the act and are provided free
treatment at the Employee's State Insurance (ESI) or ESI-empanelled hospitals. There is a
financial contribution from the hospital and the staff towards enlisting the eligible staff
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National Accreditation Board for Hospitals and Healthcare Providers
under the ESI: employees contribute 1.75 percent and employers contribute 4.75 percent.
Remittance into the ESI account is made within 21 days from the end of the due month. The
SHCO should refer to the latest norms issued under the ESI Act.
ii. Occupational hazards resulting in health problems also should be covered by the SHCO.
These include:
a. Preventive measures such as pre-exposure prophylaxis when possible - for example,
Hepatitis B vaccine or Influenza vaccine for staff who are at risk.
b. Post-exposure prophylaxis such as immunoglobulin treatment post-Hepatitis B
exposure and Antiviral medication for staff involved in the treatment of patients with
H1N1.
c. Provision of safety measures such as the provision of masks and gloves to protect the
staff from acquiring diseases in the SHCO.
d. Staff benefits may also include discounts for investigations or treatment for general
illness at the hospital. This may be in the form of a health insurance cover. The amount of
discount or insurance premium that is contributed by the hospital is left to the discretion
of the SHCO management.
Procedure
Responsibility
Supporting
Documents
1.
HR staff
List of staff
under ESI
2.
HR staff
ESI
correspondence
files
3.
HR/Accounts
department
Accounts
statement
ESI statement
4.
Accounts
department
Accounts
statement
ESI statement
5.
HR staff
HR training
material
6.
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National Accreditation Board for Hospitals and Healthcare Providers
Medical records
Billing details
Eligibility
Benefit
General health
insurance
OPD
investigations
All staff
Percentage of discount
Staff dependents
Percentage of discount
All staff
Percentage of discount
Staff dependents
Percentage of discount
All staff
Staff dependents
OPD
consultations
Inpatient stay
Procedure
No.
Procedure
Responsibility
Supporting
Documents
1.
HR staff
List of health
benefits
2.
HR staff
HR training
material
3.
HOD of Front
office, Billing,
Admission
Internal
communication
4.
HR In-charge
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Control officer).
- Date and time of exposure.
- Procedure details: what, where, how, with what device.
- Exposure details: route, body substance involved, volume or duration of contact.
- Information about source person and exposed person.
l
Post-exposure management: Assessment of infection risk.
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National Accreditation Board for Hospitals and Healthcare Providers
l
Vaccinated person: Test exposed person for antibody to HBsAg. If adequate, no treatment
required. If not adequate, administer HBIG and one Hepatitis B vaccine booster dose.
Percutaneous (needle-stick) or mucosal exposure to HBsAg-negative blood or body fluids:
l
Unvaccinated person: Administer Hepatitis B vaccine regimen .
l
Vaccinated person: No treatment required.
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needle used in patient's artery or vein. HIV positive source. Recommend expanded 3 drug
PEP.
l
HIV negative source: No specific treatment
l
HIV unknown
source: Presence of high risk factors for exposure to HIV in the source.
Recommend 2 drug PEP.
Task
Responsibility
a. i.
HR Staff
b.
HR staff
c.
HR staff
d.
HR staff
e.
f.
Accounts department
g.
HR staff
h.
Pre-exposure prophylaxis
Hospital management
extends free/concession/partpaymentfor vaccines..
Pre- employment check-up
identifies staff for pre-exposure
prophylaxis (HR staff and
Physician/Infection control nurse).
HR creates the process flow for
staff member to be administered
the vaccine.
HR maintains records.
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i.
Postexposure prophylaxis
j.
k.
Checkpoint
Yes
No
Remarks
i.
Applicable/Not
Applicable
ii.
Available - Yes/No
Updated every month
- Yes/No
iii.
iv.
v.
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National Accreditation Board for Hospitals and Healthcare Providers
vi.
vii.
viii.
V. REFERENCES
Accreditation Standards for Hospitals, NABH, 3rd Edition, November 2011.
CDC, Updated U.S. Public Health ServiceGuidelines for the Management of Occupational
Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR,
2001, 50(No. RR-11). Available at
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm
The Gazette of India, Registered no - DL (N) 04/0007/2003---13. Part II, Section I, No 18, New
Delhi, Tuesday, April 23, 2003 / Visakha 3, 1935 (SAKA).
WHO, Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and
Recommendations for Postexposure Prophylaxis. Available at
http://www.who.int/occupational_health/activities/5pepguid.pdf
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Chapter 9
INFORMATION MANAGEMENT SYSTEM (IMS)
STANDARD IMS1. THE SHCO HAS A COMPLETE AND ACCURATE MEDICAL RECORD FOR
EVERY PATIENT.
Objective Elements
IMS1a. Every medical record has a unique identifier.*
IMS1b. The SHCO identifies those authorized to make entries in medical record.*
IMS1c. Every medical record entry is dated and timed.*
IMS1d. The author of the entry can be identified.*
IMS1e. The contents of medical records are identified and documented.
*Objective Elements IMS1a, IMS1b, IMS1c, and IMS1d are self-explanatory and therefore not
included in this Guidebook.
The medical report contain demographic information including the patient's name, age
or date of birth, gender, address, telephone number, details of any legally-authorized
representative.
ii.
The SHCO decide the sequence in which these records can be stored (details in the next
section).
iii.
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iv.
The same are audited at the time of placement of these records within the Medical
Records Department. Any deficiency and incompleteness may be documented and
corrected.
v.
All the formats contain the UHID number and assembled chronologically.
vi.
All the documentation is made by the identified careproviders with date and time.
l
Where applicable, the record may include: consent forms, hemodialysis, chemotherapy,
diabetic charts, diet, pain assessment sheets, PAC/Anesthesia consent monitoring forms,
recovery charts, pre-op checklist, OT records, post-op records, surgical safety checklist,
intake-output chart, fluid chart, ICU monitoring chart, trauma/emergency sheet.
SOP on providing a complete and accurate medical record for every patient
No.
Process flow
Responsibility
Supporting Document
1.
Registration counter/
MRD
Medical record
2.
Doctors/nurses/
dietitians/
physiotherapists, as
applicable
Medical record
3.
Doctors/nurses/
dietitians/
physiotherapists, as
applicable
Medical record
4.
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Hospital formats
No.
Process flow
Responsibility
Supporting Document
5.
Medical record
6.
Medical record
7.
Deficiency checklist
ii.
Where applicable, the document may also include consent forms, hemodialysis,
chemotherapy, diabetic charts, diet, pain assessment sheets, PAC, anaesthesia consent
monitoring, recovery charts, pre-op checklist, OT record, post-op record, surgical safety
checklist, intake-output chart, fluid chart, ICU monitoring chart, trauma/emergency
sheet.
The SHCO may decide the sequence in which these records are to be stored:
1.
2.
Consent forms
3.
4.
Trauma/Emergency sheet
5.
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6.
Consultation sheets
7.
8.
Progress sheet
9.
Doctors' orders
No.
Points to check
D/C*
1.
2.
Final outcome
3.
4.
Discharge summary
5.
6.
Consent forms
7.
OT/post-operative notes
8.
Responsibility
Target Time
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UHID
Comments
No.
Tasks
Responsibility
i.
ii.
iii.
iv.
v.
Medical officer
vi.
Checkpoint
Yes
i.
ii.
iii.
iv.
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No
Remarks
IMS3a. Documented procedures exist for maintaining confidentiality, security and integrity of
information.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on the safe management of confidentiality, integrity and security of
information stored in medical records such that loss, theft, and tampering are prevented.
It is recommended that:
i.
The patient is the owner of his or her medical record and no form of it should be made
available to any third party without written authorization from the patient. Access to the
Medical Records Department (MRD) is limited to authorized department staff.
ii.
The patient's relatives require written authorization from the patient to obtain
information from the medical records. The administrator or members of the Quality team
(for audit reasons), or court-of-law or police (for legal reasons) may have access to
information within medical records with an approved written request form. For patients
and the TPAs (for financial reasons), such information should not be given in its original
form; a photocopy of the same may be handed over to the patient after obtaining the
approved authorization.
iii.
Once the patient is discharged from the SHCO, the medical records can reach the MRD in a
stipulated time frame (defined by the SHCO).
iv.
The MRD is responsible for proper storage, retrieval, and maintenance of confidentiality
and security of the record.
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v.
The Medical Records Officer (MRO) is the overall supervisor of the medical records from
when they are generated, through storing, until destruction. However, it is the
responsibility of every doctor/nurse/administrator to take care of the medical records at
their level -- in the wards or in the billing section -- to maintain the confidentiality and
privacy of information.
vi.
This is also applicable to all electronic information such as discharge summaries, cath lab
reports, lab reports, digitized X-Rays, electronic medical records, and any other electronic
information.
The MRD is responsible for the proper storage and retrieval of the record as well as the
maintenance of confidentiality and security. During normal working hours, the SHCO
shall have at least one member of staff available in the department.
ii.
iii.
Regarding control on retrieval or accessibility of the medical record, the SHCO shall
l
Maintain records in a proper and accessible manner.
l
Hand
over the records as and when required by the chief administrator for
administrative purposes by getting a written requisition form duly signed.
l
Provide records required for MLCs in a court of law by the Consultant or MOs.
l
Provide inpatient records for the follow-up of inpatients by the Consultant as well as
by the patients.
l
Provide a discharge summary, investigation reports,
iv.
In case the patient's medical record data is lost or tampered with, the MRO shall
immediately inform the chief administrator, who is responsible for taking appropriate
action.
v.
At the end of the workday, the MRO is responsible for locking up the department. The key
should be handed over to the security post. Thereafter, the security department is
responsible for the protection of the medical record room.
vi.
If a medical record is requested by a doctor outside working hours, an MRO or a frontoffice executive or a medical officer with a security guard may retrieve it from the MRD
after proper documentation in a register including the patient's hospital number, name,
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The records which the hospital must preserve for the long term (such as medico-legal and
death files) may preferably be segregated, identified and stored in a separate area. The
same shall be retrieved and transported to a safer place in case of an emergency.
No.
Process Flow
Responsibility
Document/Record
1.
MRO
MRD receiving
register
2.
MRO/security staff
3.
MRO
Tracer card
4.
MRO
Tracer card/
medical record
5.
MRO
Medical records
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No.
Process Flow
Responsibility
Document/Record
6.
MRO
Pest control
records/fire safety
plan
7.
Top management/
MRO
Privileged
communication
record
Tasks
Responsibility
i.
MRO
ii.
MRO
iii.
MRO
iv.
Pest/rodent control
Administration in-charge/MRO
v.
Security staff
Checkpoint
Yes
i.
ii.
iii.
The audited sample of case sheets are wellprotected from loss, theft and tampering.
iv.
v.
vi.
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No
Remarks
IMS4a. Documented procedures exist for retention time of the patient's clinical records, data and
information.
IMS4c. The destruction of medical records, data and information is in accordance with the laid
down procedure.
Note: Sections II, III, and IV below are provided as samples to guide SHCOs in developing their own
customized documents.
I. OVERVIEW
Scope: To guide the SHCO on the retention of medical records as per legal and regulatory
requirements and on the destruction of records when they are not required.
It is recommended that:
i.
The records are stored in the MRD for the following retention period as per the
requirements.
Inpatient Record: Minimum of three years (as per MCI requirements)
Outpatient Record: As per the state law and hospital policy
Medico-Legal Record: Lifetime
Birth and Death Record: Lifetime
ii.
After the retention period, the medical record may be destroyed unless a competent
authority approves its further retention.
iii.
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iv.
If the process of destruction is outsourced, the hospital should take adequate measures
to safeguard against the leaking of information from these records.
ii.
Policy: The SHCO retains its medical records (both outpatient and inpatient) as per the applicable
legal and regulatory requirements
Inpatient Record: Minimum of three years (as per MCI requirements)
Outpatient Record: As per the state law and hospital policy
Medico-Legal Record: Life time
Birth and Death Record: Life time
No.
Process Flow
Responsibility
Supporting Documents
1.
Quality team
SOP
2.
MRO
Medical records
3.
MRO
Verification list
Policy: The SHCO defines the process of the destruction of medical records in a safe and secure
manner after the completion of the retention period without compromising on the confidentiality
and privacy of the information.
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No.
Process Flow
Responsibility
Supporting Documents
1.
Quality team
SOP
2.
MRO
3.
MRO
Notification
4.
MRO
Verification list
5.
MRO
Permission letter
6.
MRO
7.
MRO
Process Flow
Responsibility
i.
Quality team
ii.
MRO
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Checkpoint
Yes
i.
ii.
iii.
The audited sample of case sheets are wellpreserved for the duration of the retention period.
iv.
v.
No
Remarks
V. REFERENCES
Accreditation Standards for Hospitals, NABH, 3rd edition, November 2011.
Code Pink, 2006. Available at
http://www.the-hospitalist.org/article/code-pink/
Edna K. Huffman, Medical Record Management, Physicians' Record Company, 1st edition,1990.
Francis, C.M., C. Mario de Souza, Hospital Administration, Jaypee Brothers, 2004.
Indian Public Health Standards, Guidelines for MRD in Hospitals: Guidelines for District Hospitals,
Revision 2012, DGHS, Ministry of Health and Family Welfare, Government of India.
Preservation of Records, Code of Ethics Regulations, 2002, amended in 2009.
WHO, Medical Records Manual, A Guide for Developing Countries, Revised edition, 2006.
http://www.wpro.who.int/publications/docs/MedicalRecordsManual.pdf
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APPENDIXES
Appendix 1
FORMATION OF HOSPITAL COMMITTEES
Hospital committees (or hospital teams, in case of limited human resources) can provide a platform
for multidisciplinary stakeholders to work together in implementing high-quality care across
SHCOs, and to conduct periodic evaluations for continuous improvement. The appointment and/or
re-appointment of members to these committees or teams will be made by the Medical Director.
Unless otherwise stated, the committees or teams will include a broad representation of
stakeholders and shall consist of an appropriate number of individuals to be of an effective, yet
manageable, size.
The membership to a committee or team is determined by a nomination process for a term of one
year. The committee/team chairperson may co-opt additional members on a temporary basis
according to need, and will inform the Medical Director of any additional members. The
committees/teams are required to meet as per calendars planned, monthly or quarterly (or earlier
if there are issues that require attention). If a member does not attend three consecutive meetings,
he or she will automatically lose membership and be replaced. Each committee/team will record
the minutes of each meeting, including the list of attendees. Actions will be closed in a timely
manner. The list of the various medical committees/teams is given below, along with a detailed note
on their purpose, responsibilities and composition.
1.
2.
3.
CPR Committee
4.
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l
To ensure the protection of patient rights and ethical practices across the organization.
l
To hold
leaders, work groups, departmental heads and managers accountable for the
application of performance improvement principles and the aggressive pursuit of
improved performance.
l
To define the accreditation roadmap of the organization and ensure compliance to NABH
accreditation standards.
l
To review
l
To ensure
priorities.
l
To oversee
risk management activities for the hospital, such as training programs in fire
safety and biomedical waste management.
l
To oversee and review the effectiveness of other medical committees.
l
To review or delegate to other appropriate committees or departments, the examination
of patient complaints, incident reports, or other matters involving quality of care and
clinical performance, and ensuring that appropriate action is taken for the problems that
have been identified. This includes but is not limited to:
v
Appropriateness of care
v
Medical assessment and treatment of patients
v
Critical Incident Review
v
Effectiveness of care
v
Use of clinical guidelines
v
Clinical audits against established standards and clinical indicators
v
Morbidity and mortality reviews
l
To evaluate patient satisfaction and the quality of patient care through an objective and
systematic monitoring of services, complaints and MLCs, and to recommend and oversee
corrective and preventive actions.
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Sample Composition
No.
Composition
Designation
1.
Chairperson
2.
Medical Quality
Coordinator
3.
Member
4.
Emergency Head
Member
5.
Nursing Head
Member
6.
MRD Head
Member
the infection control program of the SHCO, so as to ensure that the best
standards are in place and that risks of infection are minimized.
l
To ensure that infection control policies and procedures are being consistently followed
l
To monitor surveillance data and identify opportunities for improvement.
l
To advise
l
To ensure
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Sample Composition
No.
Composition
Designation
1.
Chairperson
2.
Quality Manager
Coordinator
3.
Member
4.
Member
5.
Nursing Head
Member
6.
Member
7.
Member
8.
Member
9.
Head of Engineering
Member
10.
Member
11.
Head of Housekeeping
Member
ensure that policies and procedures related to CPR are consistently followed
throughout the organization.
l
To ensure
CPR training for all staff in CPR, training for selected staff, and to ensure that
they understand their roles and responsibilities for code blue.
l
To use
simulation in the form of mock drills in order to assess the responsiveness and
competence of the CPR Team.
l
To advise
on the design and implementation of the audit process that monitors the
incidence and outcomes of cardiac arrest/medical emergency calls.
l
To ensure the availability and maintenance of the equipment and drugs required.
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l
To advise on the appropriate choice of equipment and medicines for use in resuscitation
procedures.
l
To offer
l
To review all cardiac arrest case files to assess the adequacy of response and to evaluate
Composition
Designation
1.
HOD Emergency
Chairperson
2.
Coordinator
3.
Medical Quality
Member
4.
Nursing Head
Member
5.
Emergency Doctor
Member
6.
Anesthesia Representative
Member
7.
ICU Representative
Member
8.
HOD Security
Member
l
To manage the drug formulary system by evaluating the usage of medications periodically
the SHCO towards a generic drug regime and away from the branded drug
system.
l
To monitor
adverse drug events and ensure that corrective and preventive actions are
taken.
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Sample Composition
No.
Composition
Designation
1.
Clinical HOD
Chairperson
2.
Pharmacy Head
Coordinator
3.
Member
4.
Member
5.
Quality Manager
Member
6.
Nursing Head
Member
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Appendix 2
FREQUENTLY ASKED QUESTIONS (FAQs)
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attending doctor, after eliciting history and examining the patient, believes that some investigation
by law enforcement agencies is essential.
How should an MLC certificate be given?
The following link provides examples and formats for different types of MLC:
http://dhs.kerala.gov.in/docs/orders/code.pdf
How does one seal samples in MLC situations?
This link provides details on sealing samples: https://www.youtube.com/watch?v=J4N4h9IBYqc
What is triage?
During a medical triage, patients' injuries or ailments are evaluated and sorted according to the
urgency of the treatment required. This is an effective strategy in situations where there are many
patients and only limited resources available in a short time-period, such as after a natural disaster
or terrorist attack. Triage should take place as soon as possible after victims are located or rescued.
During medical triage, the victims' conditions are evaluated and prioritized into four categories:
-
Immediate (I): The victim has life-threatening injuries (airway, bleeding, or shock) that
demands immediate attention to save his or her life; rapid, lifesaving treatment is urgent.
Delayed (D): Injuries do not jeopardize the victim's life. The victim may require professional
care, but treatment can be delayed.
Dead (DEAD): No respiration after two attempts to open the airway. Because CPR is
one-on-one care and is labour-intensive, CPR is not performed when there are many more
victims than rescuers.
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takes over. Empty ampules should be returned to the pharmacy against which narcotics will be
issued. There will be a separate entry register for broken ampules.
What are verbal medication orders and who can carry out verbal orders?
Verbal orders are carried out only during medical emergencies where the ordering doctor is not
available to write the order and any delay will result in compromised patient care. Verbal orders
shall only be accepted by a registered nurse. The verbal order shall be documented by the nurse
who accepts the order, including the name of the doctor issuing the order. The nurse accepting the
order shall record and then read back the order to the doctor and document the same. The verbal
order must be signed by the doctor as soon as possible.
HOSPITAL INFECTION CONTROL (HIC)
What are nosocomial infections? How are they transmitted?
Nosocomial infections or healthcare associated infections are defined as infections acquired
during, or as a result of, hospitalization. Generally, a patient who develops an infection after 48
hours of hospitalization is considered to have healthcare associated infections (HAIs). Such
infections can be transmitted through contact, droplets, and air.
What is MRSA? What is the single most important factor in containing MRSA?
MRSA is Methicillin-Resistant Staphylococcus Aureus. The single most important factor in
containing (prevention of) MRSA is maintaining good hand hygiene.
What forms of protection are necessary to prevent the spread of respiratory infections?
Heavy-duty N95 or N97 masks should be used for open pulmonary tuberculosis or suspected
pulmonary tuberculosis, and surgical masks for other common droplet infections, for example,
respiratory viral illness. Surgical masks can also be used to contain transmission of invasive
meningococcal disease (Meningococcal Meningitis and meningococcemia). Nonimmune or
pregnant staff should not enter the room of patients known or suspected to have rubella, varicella,
and measles.
What are the common modes of sterilization used in hospitals?
Common modes of sterilization are steam sterilization (autoclave), gas sterilization (ethylene
oxide), and hot air oven.
What is CSSD and what is its purpose? List the zones of CSSD.
CSSD stands for Central Sterile Supply Department. The purpose of CSSD is to provide all the
required sterile items required in a hospital in order to meet the needs of all patient care areas.
CSSD is divided into 3 zones: soiled (decontamination), clean zone (packaging), and sterile zone
(sterilization and storage).
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What is a "trend"?
When data over a period of months is depicted in the form of a graph, it is easier to see whether
quality is improving or deteriorating. This is known as a trend. However, in the initial phases of the
quality journey, the trend appears to be downward because of improved data collection.
Are there any special precautions to be taken while measuring KPIs?
Indicators should be carefully chosen so that they really measure the important performance.
There should be no bias in data collection. The formula used should be correct and the data has to
be validated by an authorized person. The proper root cause has to be identified, and corrective and
preventive action implemented. There should be a constant collection of data to see the
effectiveness of implementation of actions. If these points are not taken care of, KPIs may give
incorrect information regarding performance, which may turn out to be detrimental.
RESPONSIBILITIES OF MANAGEMENT (ROM)
What is an organogram? How frequently does it have to be updated?
An organogram is the graphic representation of a reporting relationship in an organization. It has to
be updated at least once a year, or as and when there are changes made in the organizational
structure.
What should the mission statement be comprised of?
The mission should define the following:
1. Purpose of the organization
2. Strategy of the organization
3. Values of the organization
FACILITIES MANAGEMENT AND SAFETY (FMS)
What is MSDS and why is it required?
A Material Safety Data Sheet (MSDS) is a document that contains information on the potential
hazards of a chemical and how to work safely with it. It is an essential starting point for the
development of a complete health and safety program. An MSDS is prepared by the manufacturer
of the material. It should explain the hazards of the product, how to use the product safely, what to
expect if the recommendations are not followed, what to do if accidents occur, how to recognize
symptoms of overexposure, and what to do if such incidents occur.
Why should medical gas pipelines have standardized colour coding? What standard should SHCOs
follow for colour coding?
Since health risks can result from using the wrong medical gas, medical gas pipelines should be
colour coded. This will also help in identifying problems in different lines and isolating them if
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required. The color coding may follow standards such as IS/ISO 9170-1 : 2008, NFPA 99. HTM, ANSI
and CGA C-9 standards.
What building norms should be followed while constructing an SHCO? Where are the fire
protection and detection requirements for buildings to be found?
The National Building Code of India (NBC), a comprehensive building code, provides guidelines for
regulating the building construction activities across the country. The Code contains administrative
regulations, development control rules and general building requirements; fire safety
requirements; stipulations regarding materials, structural design and construction (including
safety); and building and plumbing services.
Considering a series of developments in the field of building construction including the lessons
learnt in the aftermath of a number of natural calamities like devastating earthquakes and super
cyclones, the NBC was revised and has now been published as the National Building Code of India
2005 (NBC 2005). The comprehensive NBC 2005 contains 11 Parts some of which are further divided
into Sections, totalling 26 chapters.
Part 4 of the National Building Code covers the requirements for fire prevention, life safety in
relation to fire and fire protection of buildings. The Code specifies construction, occupancy and
protection features that are necessary to minimize danger to life and property from fire.
HUMAN RESOURCES MANAGEMENT (HRM)
What is a grievance-handling mechanism?
The sequence of activities carried out to address the grievances of patients, visitors, relatives and
staff is known as the grievance-handling mechanism. The mechanism describes whom the staff,
patient and patient attenders may contact to review the facts of the case by a grievance redressal
officer or committee.
INFORMATION MANAGEMENT SYSTEM (IMS)
Is it mandatory to have a medical records officer?
No, it is not mandatory. However, in view of the many processes involved and the large amount of
information to be preserved and managed, it is preferable for an SHCO to appoint a medical records
officer (MRO) to take care of the same.
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Appendix 3
GLOSSARY
l
Assessment - All activities including history-taking, physical examination, and laboratory
investigations that contribute towards determining the prevailing clinical status of the
patient.
l
Biomedical
l
Confidentiality
l
Hazardous material - Substances dangerous to human and other living organisms which
special precautions for disposal. They include biologic waste that can transmit disease
(for example, blood and tissues), radioactive materials, and toxic chemicals. Other
examples are infectious waste such as used needles, used bandages and fluid-soaked
items.
l
Information: Processed data which lends meaning to the raw data .
l
Inventory
control: The method of supervising the intake, use and disposal of various
goods in hands. It relates to supervision of the supply, storage and accessibility of items in
order to ensure adequate supply without stock-outs/excessive storage. It is also the
process of balancing ordering costs against carrying costs of the inventory so as to
minimize total costs.
l
Maintenance:
l
Patient record/Medical record: A document which contains the chronological sequence
2000) or a series of activities for carrying out work, which when observed by all, helps to
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ensure the maximum use of resources and efforts to achieve the desired output.
l
Process: A set of interrelated or interacting activities which transform inputs into outputs
l
Referral-out
of patient: Safe transfer of a patient to another organization due to nonavailability of required resources including expert /equipment / facility.
l
Risk
l
Risk management: Clinical and administrative activities to identify, evaluate, and reduce
e.g. clinical activities: General medicine, General surgery, Paediatrics, OBG, etc.; support
services: Ambulance, Pharmacy, etc.
l
Security: Protection from loss, destruction, tampering, and unauthorized access or use.
l
Unstable
patient: A patient whose vital parameters need external assistance for their
maintenance.
Note: The complete glossary is available in the NABH Manual on Accreditation Standards for
Hospitals, 3rd Edition, November 2011.
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Website: www.nabh.co