Self Assessm

applicable.

Compliance to the requirement: 10

Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total s
Non-compliance to the requirement: 0
Not Applicable: NA

Evaluation Criteria during final assessment:

No individual standard should have more than one zero to qualify. However, no zero is accepted in th
The average score for individual standard must not be less than 5.
The average score for individual chapter must not be less than 7.
The overall average score for all standards must exceed 7.

Special Note:

Self assessments should be done by the hospital in a stringent manner and if at the time
assessment and the pre assessment report then organisations can apply for final assess

SELF ASSESSM

Objective Elements

Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)

AAC.1: The organisation defines and displays the services that it can provide.
a The services being provided are clea
needs of the community.
 b The defined services are prominently

c The staff is oriented to these services

AAC.2: The organisation has a well defined registration and admission process.
a. Standardized policies and procedure
patients.
b. The policies and procedures address
patients.
c. Patients are accepted only if the orga

d. The policies and procedures also add

availability of beds.
e. The staff is aware of these processes

AAC.3 There is an appropriate mechanism for transfer or referral of patients who do not match t
a. Policies guide the transfer of unstab
manner.
b. Policies guide the transfer of stable p

c. Procedures identify staff responsible

d. The organization gives a summary o

AAC.4 During admission the patient and/ or family members are educated to make informed dec
a. The patients and/ or family members

b. The patients and/ or family members

c. The patients and/ or family members

complications.
d. The patients and/ or family members

AAC.5 Patients cared for by the organisation undergo an established initial assessment.
a. The organisation defines the content
patients and emergency patients.
b. The organisation determines who can
 c. The organisation defines the time fra
completed.
d. The initial assessment for in-patients
per the patient's condition or hospital
e. Initial assessment includes screening

f. The initial assessment results in a do

g. The plan of care also includes preven

AAC.6 All patients cared for by the organisation undergo a regular reassessment.
a. All patients are reassessed at approp

b. Staff involved in direct clinical care do

c. Patients are reassessed to determine

further treatment or discharge.

AAC.7 Laboratory services are provided as per the requirements of the patients.
a. Scope of the laboratory services are
organisation.
b. Adequately qualified and trained pers
investigations.
c. Policies and procedures guide collect
transportation, processing and dispos
d. Laboratory results are available within

e. Critical results are intimated immedia

f. Laboratory tests not available in the o

based on their quality assurance syst

AAC.8 There is an established laboratory quality assurance programme.

a. The laboratory quality assurance prog

b. The programme addresses verificatio

c. The programme addresses surveillan

d. The programme includes periodic cal

e. The programme includes the docume

AAC.9 There is an established laboratory safety programme.

a. The laboratory safety programme is d

b. This programme is integrated with the

c. Written policies and procedures guide

hazardous materials.
d. Laboratory personnel are appropriate
 e. Laboratory personnel are provided w

AAC.10 Imaging services are provided as per the requirement of the patients.
a. Imaging services comply with the leg

b. Scope of the imaging services are co

organisation.
c. Adequately qualified and trained pers
investigations.
d. Policies and procedures guide identif
imaging services.
e. Imaging results are available within a

f. Critical results are intimated immedia

g. Imaging tests not available in the org

based on their quality assurance syst

AAC.11 There is an established quality assurance programme for imaging services.

a. The quality assurance program for im

b. The programme addresses verificatio

c. The programme addresses surveillan

d. The programme includes periodic cal

e. The programme includes the docume

AAC.12 There is an established radiation safety programme.

a. The radiation safety programme is do

b. This programme is integrated with the

c. Written policies and procedures guide

and hazardous materials.
d. Imaging personnel are provided with

e. Radiation safety devices are periodic

f. Imaging personnel are trained in radi

g. Imaging signage are prominently dis

h. Policies and procedures guide the sa

services.

AAC.13 Patient care is continuous and multidisciplinary in nature.

a. During all phases of care, there is a q
the patients care.
b. Care of patients is coordinated in all c

c. Information about the patient's care a

medical, nursing and other care provi
 d. Information is exchanged and docum
shifts, and during transfers between u
e. The patients record(s) is available to
exchange of information.
f. Policies and procedures guide the re
specialities.

AAC.14 The organisation has a documented discharge process.

a. The patients discharge process is pla
family.
b. Policies and procedures exist for coo
agencies involved in the discharge pr
c. Policies and procedures are in place

d. A discharge summary is given to all th

patients leaving against medical advi

AAC.15 Organisation define the content of the discharge summary.

a. Discharge summary is provided to the

b. Discharge summary contains the rea

diagnosis and the patients condition

c. Discharge summary contains informa

procedure performed, medication and

d. Discharge summary contains follow u

an understandable manner.

e. Discharge summary incorporates inst

care.

f. In case of death the summary of the

Chapter 2: CARE OF PATIENTS (COP)

COP.1: Uniform care of patients is provided in all settings of the organization and is guided by th
guidelines.
a Care delivery is uniform when similar
 b Uniform care is guided by policies an
and regulations.

c The care and treatment orders are si

concerned doctor.

d The care plan is countersigned by the

hours.
e Evidence based medicine and clinica
patient care whenever possible.

COP.2: Emergency services are guided by policies, procedures and applicable laws and regulati
a Policies and procedure for emergenc

b Policies also address handling of me

c The patient receives care in consona

d Policies and procedures guide the tria

care.
e Staff is familiar with the policies and t
emergency patients.
f Admission or discharge to home or tr
documented.

COP.3: The ambulance services are commensurate with the scope of the services provided by th
a There is adequate access and space

b Ambulance(s) is appropriately equipp

c Ambulance(s) is manned by the train

d There is a checklist of all equipment a

e Equipment are checked on a daily ba

f Emergency medications are checked

g The ambulance(s) has a proper comm

COP.4: Policies and procedures guide the care of patients requiring cardio-pulmonary resuscita
a Documented policies and procedures
throughout the organisation.
b Staff providing direct patient care is tr
pulmonary resuscitation.
c The events during a cardio pulmonar

d A post-event analysis of all cardiac as

committee.
 e Corrective and preventive measures

COP.5: Policies and procedures define rational use of blood and blood products.
a Documented policies and procedures
blood products.
b The transfusion services are governe

c Informed consent is obtained for don

products.
d Informed consent also includes patie

e Staff is trained to implement the polic

f Transfusion reactions are analysed fo

COP.6: Policies and procedures guide the care of patients in the intensive Care and High Depend
a The organisation has documented ad
care and high dependency units.
b Staff is trained to apply these criteria.

c Adequate staff and equipment are av

d Defined procedures for situation of be

e Infection control practices are followe

f A quality assurance programme is im

COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically and/ or
a Policies and procedures are docume
laws and the national and internation
b Care is organised and delivered in ac

c The organisation provides for a safe

group.
d A documented procedure exists for o
appropriate legal representative.
e Staff is trained to care for this vulnera

COP.8: Policies and procedures guide the care of high-risk obstetrical patients.
a The organisation defines and display
for or not.
b Persons caring for high-risk obstetric

c High-risk obstetric patients assessme

 d The organization caring for high risk o
of neonates of such cases.

COP.9: Policies and procedures guide the care of paediatric patients.

a The organisation defines and display

b The policy for care of neonatal patien

international guidelines.
c Those who care for children have age

d Provisions are made for special care

e Patient assessment includes detailed

immunization assessment.
f Policies and procedures prevent child

g The childrens family members are ed

safe parenting and this is documente

COP.10: Policies and procedures guide the care of patients undergoing moderate sedation.
a Competent and trained persons perfo

b The person administering and monito

performing the procedure.
c Intra procedure monitoring includes
respiratory rate, blood pressure, and
d Patients are monitored after sedation

e Criteria are used to determine approp

area.
f Equipment and manpower are availa
sedation than that intended.

COP.11: Policies and procedures guide the administration of anesthesia.

a There is a documented policy and pro

b All patients for anesthesia have a pre

individual.
c The pre-anesthesia assessment resu
is documented.
d An immediate preoperative re-evalua

e Informed consent for administration o

f During anesthesia monitoring include

cardiac rhythm, respiratory rate, bloo
and patency and level of anesthesia.
 g Each patients post-anesthesia status

h A qualified individual applies defined

recovery area.
i All adverse anesthesia events are rec

COP.12: Policies and procedures guide the care of patients undergoing surgical procedures.
a The policies and procedures are docu

b Surgical patients have preoperative a

documented prior to surgery.
c An informed consent is obtained by th

d Documented policies and procedure

site, wrong patients and wrong surge
e Persons qualified by law are permitte
entitled to perform.
f A brief operative note is documented
area.
g The operating surgeons documents t

h A quality assurance programme is fol

i The quality assurance program includ

environment.
j The plan also includes monitoring of

COP.13: Policies and procedures guide the care of patients under restraints (physical and/ or ch
a Documented policies and procedures

b These include both physical and chem

c These include documentation of reas

d These patients are more frequently m

e Staff receive training and periodic upd

COP.14: Policies and procedures guide appropriate pain management.

a Documented policies and procedures

b The organization respects and suppo

management of pain for all patients.
 c Patient and family are educated on v

COP.15: Policies and procedures guide appropriate rehabilitative services.

a Documented policies and procedures

b These services are commensurate w

c Rehabilitative services are provided b

COP.16: Policies and procedures guide all research activities.

a Documented policies and procedures
with national and international guideli
b The organization has an ethics committee

c The committee has the powers to discont

potential benefits.

d Patients informed consent is obtained be

e Patients are informed of their right to

also of the consequences (if any) of
f Patients are assured that their refusa
participation will not compromise the

COP.17: Policies and procedures guide nutritional therapy.

a Documented policies and procedures
reassessment.
b Patients receive food according to the

c There is a written order for the diet.

d Nutritional therapy is planned and pr

e When families provide food, they are

f Food is prepared, handled, stored an

COP.18: Policies and procedures guide the end of life care.

a Documented policies and procedures

b These policies and procedures are in

c These also address the identification

family.
 d These also include sensitively addres
donation.
e Staff is educated and trained in end o

Chapter 3: MANAGEMENT OF MEDICATION (MOM)

MOM.1: Policies and procedures guide the organization of pharmacy services and usage of med
a There is a documented policy and pro
medication usage.
b These comply with the applicable law

c A multidisciplinary committee guides

policies and procedures.

MOM.2: There is a hospital formulary.

a A list of medication appropriate for th
developed.
b The list is developed collaboratively b

c There is a defined process for acquis

d There is a process to obtain medicati

MOM.3: Policies and procedures exist for storage of medication.

a Documented policies and procedures

b Medications are stored in a clean, we

c Sound inventory control practices gui

d Medications are protected from loss o

e Sound alike and look alike medication

f There is a method to obtain medicatio

g Emergency medications are available

h Emergency medications are replenish

MOM.4: Policies and procedures exist for prescription of medications.

a Documented policies and procedures
 b The organization determines who can

c Orders are written in a uniform locatio

d Medication orders are clear, legible, d

e Policy on verbal orders is documente

f The organization defines a list of high

g High risk medication orders are verifie

MOM.5: Policies and procedures guide the safe dispensing of medications.

a Documented policies and procedures

b The policies include a procedure for m

c Expiry dates are checked prior to disp

d Labeling requirements are document

MOM.6: There are defined procedures for medication administration.

a Medications are administered by thos

b Prepared medication are labeled prio

c Patient is identified prior to administra

d Medication is verified from the order p

e Dosage is verified from the order prio

f Route is verified from the order prior

g Timing is verified from the order prior

h Medication administration is documen

i Polices and procedures govern patien

j Polices and procedures govern patien

organization.

MOM.7: Patients and family members are educated about safe medication and food-drug interac
 a Patient and family are educated abou

b Patient and family are educated abou

MOM.8: Patients are monitored after medication administration.

a Patients are monitored after medicati

b Adverse drug events are defined.

c Adverse drug events are reported wit

d Adverse drug events are collected an

e Policies are modified to reduce adver

occur.

MOM.9: Policies and procedures guide the use of narcotic drugs and psychotropic substances.
a Documented policies and procedures
psychotropic substances.
b These policies are in consonance wit

c A proper record is kept of the usage,

d These drugs are handled by appropri

MOM.10: Policies and procedures guide the usage of chemotherapeutic agents.

a Documented policies and procedures
agents.
b Chemotherapy is prescribed by those
the adverse effect of chemotherapy.
c Chemotherapy is prepared and admi

d Chemotherapy drugs are disposed of

MOM.11: Policies and procedures govern usage of radioactive drugs.

a Documented policies and procedures

b These policies and procedures are in

c The policies and procedures include

distribution, and disposal of radioactiv
d Staff, patients and visitors are educat
MOM.12: Policies and procedures guide the use of implantable prosthesis.
a Documented policies and procedures
implantable prosthesis.
b Selection of implantable prosthesis is
internationally recognized approvals.
c The batch and serial number of the im
patients medical record and the mas

MOM.13: Policies and procedures guide the use of medical gases.

a Documented policies and procedures
distribution, usage and replenishmen
b The policies and procedures address

c Appropriate records are maintained in

and legal requirements.

Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)

PRE.1: The organization protects patient and family rights informs them about their responsibili
a Patient and family rights and respons

b Patients and families are informed of

and language that they can understa
c The organizations leaders protect pa

d Staff is aware of their responsibility in

e Violation of patient and family rights i

preventive measures taken.

PRE.2: Patient and family rights support individual beliefs, values and involve the patient and fam
a Patient and family rights address any
needs.
b Patient and family rights include resp
examination, procedures and treatme
c Patient and family rights include prote

d Patient and family rights include treat

e Patient and family rights include refus

f Patient and family rights include infor

blood product transfusions and any in

g Patient and family right include inform

protocol is initiated.
h Patient and family rights include infor
 i Patient and family rights include infor

j Patient and family have a right to hav

PRE.3: A documented process for obtaining patient and/ or family's consent exists for informed
a General consent for treatment is obta

b Patient and / or his family members a

consent.
c The organisation has listed those situ

d Informed consent includes informatio

who will perform the requisite proced

e The policy describes who can give co

independent decision-making.

PRE.4: Patient and families have a right to information and education about their health care nee
a When appropriate, patient and familie
effective use of medication and the p

b Patient and families are educated ab

c Patient and families are educated ab

d Patient and families are educated ab

complications and prevention strateg
e Patient and families are educated ab

f Patients and family are taught in a lan

PRE.5: Patient and families have a right to information on expected costs.

a There is uniform pricing policy in a giv

b The tariff list is available to patients.

c Patients and family are educated abo

d Patients and family are informed abo

change in the patient condition or trea

Chapter 5: HOSPITAL INFECTION CONTROL (HIC)

HIC.1: The organization has a well-designed, comprehensive and coordinated infection control p
eliminating risks to patients, visitors and providers of care.
a The hospital infection control program
and reducing risk of nosocomial infec
b The hospital has a multi-disciplinary i

c The hospital has an infection control

 d The hospital has designated and qua

HIC.2: The organisation has an infection control manual, which is periodically updated.
a The manual identifies the various hig

b It outlines methods of surveillance in

c It focuses on adherence to standard

d Equipment cleaning and sterilisation

e An appropriate antibiotic policy is esta

f Laundry and linen management proc

g Kitchen sanitation and food handling

h Engineering controls to prevent infect

i Mortuary practices and procedures a

j The organization defines the periodic

HIC.3: The infection control team is responsible for surveillance activities in identified areas of t
a Surveillance activities are appropriate
areas
b Collection of surveillance data is an ongo

c Verification of data is done on regular bas

d In cases of notifiable diseases, informatio

authorities.
e Scope of surveillance activities incorp
risks, rates and trends.
f Surveillance activities include monito

HIC.4: The organization takes actions to prevent or reduce the risk of Hospital Associated Infect
employees.
a The organization monitors urinary tra

b The organization monitors respiratory

c The organization monitors intra-vascu

d The organization monitors surgical si

e Appropriate feedback regarding HAI

medical and nursing staff.
HIC.5: Proper facilities and adequate resources are provided to support the infection control pro
a Hand washing facilities in all patient c
providers.
b Compliance with proper hand washin

c Isolation/ barrier nursing facilities are

d Adequate gloves, masks, soaps, and

HIC.6: The organisation takes appropriate actions to control outbreaks of infections.

a Hospital has a documented procedur

b This procedure is implemented during

c After the outbreak is over appropriate

recurrence.

HIC.7: There are documented procedures for sterilisation activities in the organisation.
a There is adequate space available fo

b Regular validation tests for sterilisatio

c There is an established recall proced

system is identified.

HIC.8: Statutory provisions with regard to Bio-medical Waste (BMW) management are complied
a The hospital is authorised by prescrib
handling of Bio-medical Waste.
b Proper segregation and collection of
of the hospital is implemented and m
c The organization ensures that Bio-me
site of treatment and disposal in prop
limits in a secure manner.
d Bio-medical Waste treatment facility i
house) or outsourced to authorised c
e Requisite fees, documents and repor
stipulated dates.
f Appropriate personal protective meas
handling Bio-medical Waste.

HIC.9: The infection control programme is supported by the organisations management and inc
employee health.
a Hospital management makes availab
programme.
b The hospital regularly earmarks adeq
regard.
c It conducts regular pre-induction train
joining concerned department(s).
d It also conducts regular in-service tr
of staff at least once in a year.
 e Appropriate pre and post exposure p
members

Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)

CQI.1: There is a structured quality improvement and continuous monitoring programme in the o
a The quality improvement programme
by a multi-disciplinary committee.
b The quality improvement programme

c There is a designated individual for c

improvement programme

d The quality improvement programme

elements related to quality improvem

e The designated programme is comm

employees of the organization throug
 f The quality improvement programme
opportunities for improvement are ide

g The quality improvement programme

once in a year.

CQI.2: The organization identifies key indicators to monitor the clinical structures, processes an
tools for continual improvement.
a Monitoring includes appropriate patie
b Monitoring includes safety and quality
services.

c Monitoring includes all invasive proce

d Monitoring includes adverse drug eve

e Monitoring includes use of anaesthes

f Monitoring includes use of blood and

g Monitoring includes availability and co

 h Monitoring includes infection control a

i Monitoring includes clinical research.

j Monitoring includes data collection to

k Monitoring includes data collection to

CQI.3: The organization identifies key indicators to monitor the managerial structures, processe
tools for continual improvement.

a Monitoring includes procurement of m

b Monitoring includes reporting of activ

c Monitoring includes risk managemen

d Monitoring includes utilisation of spac

e Monitoring includes patient satisfactio

services.
f Monitoring includes employee satisfa

g Monitoring includes adverse events a

h Monitoring includes data collection to

i Monitoring includes data collection to

CQI.4: The quality improvement programme is supported by the management.

 a Hospital Management makes availab
improvement programme.
b Hospital earmarks adequate funds fro

c Appropriate statistical and managem

CQI.5: There is an established system for audit of patient care services.

a Medical and nursing staff participates

b The parameters to be audited are de

c Patient and staff anonymity is mainta

d All audits are documented.

e Remedial measures are implemented

CQI.6: Sentinel events are intensively analysed.

a The organisation has defined sentine
b The organisation has established pro

c Sentinel events are intensively analys

d Corrective and preventive Actions are

Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)

ROM.1: The responsibilities of the management are defined.
a Those responsible for governance lay

b Those responsible for governance lay

commensurate to the organizations m
holders.

c Those responsible for governance ap

the resources required to meet the or

d Those responsible for governance m

organization against the stated missio
e Those responsible for governance es

f Those responsible for governance ap

g Those responsible for governance su

h The organization complies with the la

i Those responsible for governance ad

ROM.2: The services provided by each department are documented.

 a Each organizational program, service

b Scope of services of each departmen

c Administrative policies and procedure

d Departmental leaders are involved in

ROM.3: The organization is managed by the leaders in an ethical manner.

a The leaders make public the mission

b The leaders establish the organizatio

c The organization discloses its owners

d The organization honestly portrays th

e The organization honestly portrays its

f The organization accurately bills for it

tariff.

ROM.4: A suitably qualified and experienced individual heads the organisation.

a The designated individual has requisi
qualifications.
b The designated individual has requisi

ROM.5: Leaders ensure that patient safety aspects and risk management issues are an integral p
management.
a The organization has an interdisciplin
wide safety programme.
b The scope of the programme is defin
harm to sentinel events.
c Management ensures implementation
reporting of system and process failu
d Management provides resources for
activities.

Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)

FMS.1: The organization is aware of and complies with the relevant rules and regulations, laws a
inspection requirements.
a The management is conversant with
applicability to the organization.
b Management regularly updates any a

c The management ensures implemen

 d There is a mechanism to regularly up

FMS.2: The organizations environment and facilities operate to ensure safety of patients, their f
a There is a documented operational a
plan.
b Up-to-date drawings are maintained w
escape routes.
c There is internal and external sign po
understood by patient, families and c
d The provision of space shall be in acc
practices (Indian or International Stan
agencies.
e There are designated individuals resp
facilities.
f Maintenance staff is contactable roun

g Response times are monitored from r

corrective actions.

FMS.3: The organization has a program for clinical and support service equipment management
a The organization plans for equipmen
plan.
b Equipment is selected by a collabora

c All equipment is inventoried and prop

d Qualified and trained personnel opera

e Equipment are periodically inspected

f There is a documented operational a

plan.

FMS.4: The organization has provisions for safe water, electricity, medical gases and vacuum sy
a Potable water and electricity are avai

b Alternate sources are provided for in

c The organisation regularly tests the a

d There is a maintenance plan for pipe

installation.

FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.
a The organization has plans and provi
abatement of fire and non-fire emerg
b The organization has a documented
emergencies.
c Staff is trained for their role in case o

d Mock drills are held at least twice in a

FMS.6: The organization has a smoking limitation policy.

 a The organization defines and implem

b The policy has provisions for granting

smoke.

FMS.7: The organization plans for handling community emergencies, epidemics and other disas
a The hospital identifies potential emer

b The organization has a documented

c Provision is made for availability of m

during such emergencies.
d Hospital staff is trained in the hospita

e The plan is tested at least twice in a y

FMS.8: The organization has a plan for management of hazardous materials.

a Hazardous materials are identified wi

b The hospital implements processes f

transporting and disposal of hazardou
c Requisite regulatory requirements are

d There is a plan for managing spills of

e Staff is educated and trained for hand

FMS.9: The organisation has systems in place to provide a safe and secure environment.
a The hospital has a safety committee
risks.
b This committee coordinates developm
safety plan and policies.
c Patient safety devices are installed a
periodically.
d Facility inspection rounds to ensure s
patient care areas and at least once i
e Inspection reports are documented a
undertaken.
f There is a safety education programm

Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)

HRM.1: The organization has a documented system of human resource planning.

a The organization maintains an adequ
treatment and service needs of the p
b The required job specifications and jo
category of staff.
 c The organization verifies the anteced
criminal/negligence background.

HRM.2: The staff joining the organization is socialized and oriented to the hospital environment.
a Each staff member, employee, stude
oriented to the organizations mission
b Each staff member is made aware of
as relevant department / unit / service

c Each staff member is made aware of

d All employees are educated with rega

e All employees are oriented to the ser

HRM.3: There is an ongoing programme for professional training and development of the staff.
a A documented training and developm

b Training also occurs when job respon

introduced.
c Feedback mechanisms for assessme
exist.

HRM.4: Staff members, students and volunteers are adequately trained on specific job duties or
a All staff is trained on the risks within t

b Staff members can demonstrate and

risks.
c Staff members are made aware of pr

d Reporting processes for common pro

HRM.5: An appraisal system for evaluating the performance of an employee exists as an integra
management process.
a A well-documented performance app

b The employees are made aware of th

c Performance is evaluated based on t

description.
d The appraisal system is used as a to

e Performance appraisal is carried out

HRM.6: The organization has a well-documented disciplinary procedure.

a A written statement of the policy of th
place.
 b The disciplinary policy and procedure

c The policy and procedure is known to

organization.
d The disciplinary procedure is in conso

e There is a provision for appeals in all

HRM.7: A grievance handling mechanism exists in the organization.

a The employees are aware of the proc
aggrieved.
b The redress procedure addresses the

c Actions are taken to redress the griev

HRM.8: The organization addresses the health needs of the employees.

a A pre-employment medical examinati

b Health problems of the employees ar

organizations policy.
c Regular health checks of staff dealing
once a year and the findings/ results

d Occupational health hazards are ade

HRM.9: There is a documented personal record for each staff member.

a Personal files are maintained in respe

b The personal files contain personal in

qualification, disciplinary background

c All records of in-service training and e

d Personal files contain result of all eva

HRM.10: There is a process for collecting, verifying and evaluating the credentials (education, re
of medical professionals permitted to provide patient care without supervision.

a Medical professionals permitted by la

patient care without supervision is ide

b The education, registration, training a

professionals is documented and upd
c All such information pertaining to the
when possible.

HRM.11: There is a process for authorising all medical professionals to admit and treat patients
commensurate with their qualifications.
 a Medical professionals admit and care
authorisation procedures of the organ

b The services provided by the medica

qualification, training and registration

c The requisite services to be provided

them as well as the various departme

HRM.12: There is a process for collecting, verifying and evaluating the credentials (education, re
of nursing staff.
a The education, registration, training a
and updated periodically.
b All such information pertaining to the
possible.

HRM.13: There is a process to identify job responsibilities and make clinical work assignments t
commensurate with their qualifications and any other regulatory requirements.

a The clinical work assigned to nursing

training and registration.
b The services provided by nursing sta
and regulations.
c The requisite services to be provided
well as the various departments / unit

Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)

IMS.1: Policies and procedures exist to meet the information needs of the care providers, manag
as other agencies that require data and information from the Organization.

a The information needs of the organiz

scope of the services being provided
organization.
b Policies and procedures to meet the

c These policies and procedures are in

regulations.
d All information management and tech
the policies and procedures.
e The organization contributes to extern
regulations.

IMS.2: The organization has processes in place for effective management of data.
a Formats for data collection are stand

b Necessary resources are available fo

c Documented procedures are laid dow

data.
d Documented procedures exist for sto
 e Appropriate clinical and managerial s
using data.

IMS.3: The organization has a complete and accurate medical record for every patient.
a Every medical record has a unique id

b Organisation policy identifies those a

c Every medical record entry is dated a

d The author of the entry can be identif

e The contents of medical record are id

f The record provides an up-to-date an

IMS.4: The medical record reflects continuity of care.

a The medical record contains informat
diagnosis and plan of care.
b Operative and other procedures perfo

c When patient is transferred to anothe

date of transfer, the reason for the tra

d The medical record contains a copy o

appropriate and qualified personnel.
e In case of death, the medical record c
indicating the cause, date and time o
f Whenever a clinical autopsy is carrie
the report of the same.
g Care providers have access to curren

IMS.5: Policies and procedures are in place for maintaining confidentiality, integrity and security
a Documented policies and procedures
and integrity of information.
b Policies and procedures are in conso

c The policies and procedures incorpor

destruction and tampering.
d The hospital has an effective process
policy.
e The hospital uses developments in a
confidentiality, integrity and security.
f Privileged health information is used
law and not disclosed without the pat
g A documented procedure exists on h
other public agencies requests for ac
accordance with the local and nationa

IMS.6: Policies and procedures exist for retention time of records, data and information.
 a Documented policies and procedures
records, data and information.
b The policies and procedures are in co
and regulations.
c The retention process provides expec

d The destruction of medical records, d

laid down policy.

IMS.7: The organization regularly carries out review of medical records.

a The medical records are reviewed pe

b The review uses a representative sam

c The review is conducted by identified

d The review focuses on the timeliness

records.
e The review process includes records

f The review points out and documents

g Appropriate corrective and preventive

 lf Assessment Toolkit

omplying out of total samples selected)

zero is accepted in the regulatory/ legal requirements.

er and if at the time of Pre assessment it is found that there is a significant difference between the
ply for final assessment not earlier than six months from the date of completion of Pre assessme

F ASSESSMENT TOOLKIT

Interpretation

RE (AAC)

e.
s being provided are clearly defined and are in consonance with the A policy to be framed clearly
e community. stating the services the hospital
can provide.
d services are prominently display. The services so defined should be
visible prominently in an area
visible to all patients entering the
organization. The display could be
in the form of boards, citizen's
charter, scrolling messages etc.
care should be taken to ensure
that these are displayed in the
language (s) the patient
understands.

oriented to these services. All the staff in the Hospital mainly

in the reception/registration, OPD,
IPD are oriented to these facts
ess. through training programme
conducted regularly or through
ed policies and procedures are used for registering and admitting Health
manuals. Care Organization (HCO)
has prepared document (s)
detailing the policies and
s and procedures address out-patients, in-patients and emergency The policies and procedures
procedures for registration and
address out-patients, in-patients
admission of patients which
and emergency
e accepted only if the organization can provide the required service. should
The staffalso includeadmission
handling unidentified
and
patients. needs to be aware of
registration
the services that the organization
s and procedures also address managing patients during non The HCO is aware
can provide. of the
It is also advisable to
of beds. availability
have a system whereinHCOs
of alternate the staff is
where
aware the
as topatients
whom to may be if
contact
aware of these processes. All the
directed staff handling
in any these
caseclarification
of non-availability
they need
activities should be orientedonofthe
of beds. provided.
services
these policies and procedures.

who do not match the organisation resources.

ide the transfer of unstable patients to another facility in an appropriate The organization shall at the
outset define as to who is an
unstable patient. The documented
ide the transfer of stable patients to another facility. Patients
policy and not in a life threatening
procedure should
situation (stable)
address the methodology should also be
of safe
identify staff responsible during transfer. transported
The staffofshall
transfer in a safe
at leastin
the patient manner.
bea alife
trained trauma/emergency
threatening situation (like those
zation gives a summary of patients condition and the treatment given. technician/nurse/.
who HCO
The are ongivesventilator) He/She
a case shall
tosummary
another
have undergone
HCO. Therethe
mentioning should training in BLS
be availability
significant findings
and/or
of an ACLS.
appropriate ambulance
and treatment given in case of
fitted withwho
patients life are
support
beingfacilities
transferredand
make informed decision.
accompanied
from emergency. by trained
For admitted
s and/ or family members are explained about the proposed care. personnel.
patients
The plaina of discharge summaryby
care as decided
has
the management teamAAC
to be given (refer 15).
(as the
The same shall also
case may be) is to be discussed be given to
s and/ or family members are explained about the expected results. The patients
patients goingand family are
against
with the patient and/or medical
family
explained
advice. in detail by the training
members. This should be done in
s and/ or family members are explained about the possible physicians
Possible or his/her team
complications about
of the
a language the patient/attendant
ns. the outcomes
treatment, if of such
any, are treatment.
clearly
can understand. The above
s and/ or family members are explained about the expected costs. communicated
information
Patients shouldis toto be
be the patient.
documented
given as
and signed
estimate of bythethe concerned
expenses on
doctor. of the treatment
account
assessment. preferably in a written form

sation defines the content of the assessments for the out patients, in The hospital shall have a
d emergency patients. protocol/policy by which a
standardized initial assessment of
sation determines who can perform the assessments. The assessment should be done
patients is done in the OPD.
by the treating doctor, junior
Emergency and in-patients. The
doctor or a nurse. The
initial assessment could be
organization determines who can
standardized across the hospital
do what assessment and it should
or it could be modified depending
be the same across the hospital.
on the need of the department.
However it shall be the same in
that particular area e.g. in a
sation defines the time frame within which the initial assessment is The HCO has defined and
documented the time frame within
ssessment for in-patients is documented within 24 hours or earlier as which the initial
The should cover assessment
history, is to
ent's condition or hospital policy. be completed with
progress notes, investigation respect to
OPD/
ordered emergency/
and treatment indoor patients.
ordered
ssment includes screening for nutritional needs. The protocol
and all these for arepatients
to be initial
assessment
authenticated should
by treatingcoverdoctor.
his/her
ssessment results in a documented plan of care which is monitored. This shall be
nutritional needs,documented
in case ofbyOut the
treating
patients this should be done of
doctor or by a member
care also includes preventive aspects of the care. his
The
whereteam in the
documented
ever case plan
applicable. sheet.
of
For careThis
plan
should
exampleis monitored
cover byCRF
preventive
diabetics, the actions
training
patients.
doctor
as for its effectiveness
necessary in the case and and
ment. whenever
should required
include diet,by a clinical
drugs etc.
audit.
are reassessed at appropriate intervals. After the initial assessment, the
patient is reassessed periodically
ed in direct clinical care document reassessments. Actions
and this taken under
is documented in the
reassessment
case sheet. The are documented.
frequency may
e reassessed to determine their response to treatment and to plan the
be staff
Selfdifferent could
explanatory. be the
areas based treating
on the
tment or discharge. doctor
setting or and any themember
patient'sofcondition
the learn
as
e.g.per their domain
patients in ICU need of to
ents. responsibility
reassessed of
more care.
frequently
compared to a patient in the ward.
e laboratory services are commensurate to the services provided by the The HCO should ensure
n. availability of laboratory services
commensurate with the health
qualified and trained personnel perform and/or supervise the The staff employed in the lab
care services offered by it either
ns. should be suitably qualified
by providing the same in house or
d procedures guide collection, identification, handling, safe (appropriate
The HCO hasdegree) documented and trained
by outstanding. However, test
on, processing and disposal of specimens. to carry
procedures out the tests,
for collection, Pathologist,
results required for emergency
Microbiologist
identification, and
handling,Biochemistsafe
results are available within a defined time frame. management
The HCO shall (RBS,
define ABGthe etc.)
supervise
transportation, the staff.
processing
must be available
turnaround time for all tests. within itsandThe
disposal
premises. of specimens,
See also (f) to
below ensure
forof
ults are intimated immediately to the concerned personnel. HCOlaboratory
The should ensure
shall availability
establish
safety of thelab
outsourced specimen
facilities. till the its
adequate reference
biological staff, materials intervalsandfor
tests and retests (if required) are
tests not available in the organization are outsourced to organization(s) equipment
The HCO
different
completed.
to make
has
tests. a the laboratory
documented
The laboratory
heir quality assurance system. results
procedure available
shall establish withinlimits
for outstanding
critical the tests
for
defined
for which
tests time
which it hasframe.
no facilities.
require immediate This
should
attention include.
for patienta) List of tests for
management.
out
Thesourcing.
tests results b) Identity of
in the critical
ory quality assurance programme is documented. personnel
limit HCO
The shall be in the
has out sourcedto the
communicated
a documented
facilities
concerned
quality to ensure
assuranceafter proper safe
programme
transportation
documentation.
(preferably of specimens
as per ISO 15189and
mme addresses verification and validation of test methods. This holds true
completing for any
of tests laboratory
as- Particular
per
Medical laboratories
developed
requirements methods.
of the patient
for quality and
mme addresses surveillance of test results. The laboratory
concerned
competence). and director
receipt of (orresults
in-
charge)
at HCO. shall c) Mannerperiodically
of packagingassess
thethe
testspecimens
results. and their
mme includes periodic calibration and maintenance of all equipments. of Refer to ISO 15189.
lavbelling for identification and
this package should contain the
mme includes the documentation of corrective and preventive actions. Self explanatory.
test rquisition with all details as
required for testing. d) a
methodology to check the
perforance of service rendered by
ory safety programme is documented. the
A outdocumented
well sourced laboratory lab safelty as per
the requirements
manual is available of inthethe HCO.lab.
This takes care of the safety of
mme is integrated with the organisation's safety programme. Lab safety programme is
the workforce as well as the
incorporated in the safety
equipments available in the lab.
cies and procedures guide the handling and disposal of infectious and The programme
lasb staff of should
the hospital. follow
materials. standard precautions. The
disposal of waste is according to
personnel are appropriately trained in safe practices. All the lab staff undergo training
Biomedical waste management
regarding safe practices in the
and handling rules, 1998.
lab.
personnel are provided with appropriate safety equipment/ devices. Adequate safety devices are
available in the lab e.g. fire
extinguishers, dressing materials
s. disinfectants, etc.

rvices comply with the legal and other requirement. The HCO is aware of the legal
and other requirements of
e imaging services are commensurate to the services provided by the imaging services and the same
Self explanatory
n. are documented for information
qualified and trained personnel perform, supervise and interpret the and
As percompliance by all concerned
AERB guidelines.
ns. in the HCO. The HCO maintains
and updates its compliance status
d procedures guide identification and safe transportation of patients to The HCO
of legal and has documented
other requirements in
vices. policies
a regularand procedures for
manner.
sults are available within a defined time frame. informing the patients
The organization shall about the
document
imaging activities,
turnaround time of imagingtheir
ults are intimated immediately to the concerned personnel. identification
Critical resultsand
results. safe
shall be intimated
transportation to the
to the treating clinician imaging
at the
services.onThis
earliest should
phone, also by
followed
ts not available in the organization are outsourced to organization(s) The HCO has documented
address
written transfer of unstable
report.
heir quality assurance system procedure
patients to for outsourcing tests
imaging services.
for which it has no facilities. This
ervices. should include: a) List of tests for
out sourcing. b) Identity of
assurance program for imaging services is documented. Refer to AERB
personnel in theguidelines
out sourced
facilities to ensure safe
mme addresses verification and validation of imaging methods. transportation
A document forofverification
specimensand and
completingofofimaging
validation imagingmethods
results. c)
mme addresses surveillance of imaging results. Manner
shall
HOD (orof
be identification
available.
in-charge) shallof
patients andassess
periodically the testthe requisition
imaging
with all
results. details as required for
mme includes periodic calibration and maintenance of all equipments. Calibration
testing and and . d) Amaintenance
methodologyoftoall
equipment shall be carried
check the selection and out by
mme includes the documentation of corrective and preventive actions. competent
perforance
Self explanatory.persons.
of service rendered by
the outsourced imaging facility as
per the requirements of the HCO.

on safety programme is documented. Refer to AERB guidelines

mme is integrated with the organizations safety programme. The safety programme of the
imaging department has
cies and procedures guide the handling and disposal of radio-active reference
Radioactivein and
the hospital
hazardoussafety
ous materials. manual.
materials shall be disposed off as
per bio-medical waste
rsonnel are provided with appropriate radiation safety devices. Self explanatory
management and handling rules,
1998.
afety devices are periodically tested and documented. Protective devices e.g. lead
aprons should be exposed to X-
rsonnel are trained in radiation safety measures. ray
Sel for verification of cracks and
explanatory.
damages.
gnage are prominently displayed in all appropriate locations. Self explanatory

d procedures guide the safe use of radioactive isotopes for imaging Document on safe use of
radioactive isotopes for imaging
services shall be available and
implemented.
hases of care, there is a qualified individual identified as responsible for The HCO to ensure that the care
s care. of patients is always given by
appropriately qualified medical
ients is coordinated in all care setting within the organisation. Care of patients
personnel is co-ordinated
(resident doctor,
among various care
consultant and/or nurse). providers in a
about the patient's care and response to treatment is shared among given setting viz OPD,
The HCO ensures periodic emergency,
rsing and other care providers. IP, ICU etc. The organization
discussions about each patient shall
ensure that
(covering there is effective
parameters like patient
communication
care, response to of treatment,
patient
requirements amongst thecare
unusual developments if any. etc)
providers in all settings.
amongst medical, nursing and
other care providers.
 is exchanged and documented during each staffing shift, between Self explanatory
during transfers between units/ departments.
s record(s) is available to authorized care providers to facilitate the Self explanatory
f information.
d procedures guide the referral of patients to other departments/ The HCO has clearly defined and
documented the policies and
procedures to be adopted to
guide the personnel dealing with
s discharge process is planned in consultation with the patient and/ or referral of patients
The patient's treatingto other
doctor
departments or specialities
determines the readiness for or
even otherduring
discharge healthregular
care provider
d procedures exist for coordination of various departments and The
out discharge
side policies and
the HCO.
reassessments. The same is
volved in the discharge process (including medico-legal cases) procedures are documented to
discussed with the patient and
ensure coordination amongst
d procedures are in place for patients leaving against medical advice. family.
The HCO has a documented
various departments including
policy for the LAMA
accounts so that thecases. The
discharge
e summary is given to all the patients leaving the organization (including The HCO
treating hands
doctor over
should the
explain
papers are complete well within the
ving against medical advice). discharge
consequencespapers to the
time. For MLC the organization the
of this action to
patient/attendent
patient/attendent.
shall ensure that thein all cases
police and
are
a copy is
informed. retained. In LAMA
cases, the declaration of the
patient/attendent is to be recorded
summary is provided to the patients at the time of discharge. on
Selfproper format.
explanatory

summary contains the reasons for admission, significant findings and Self explanatory
nd the patients condition at the time of discharge.

summary contains information regarding investigation results, any Self explanatory

performed, medication and other treatment given.

summary contains follow up advice, medication and other instructions in Self explanatory
andable manner.

summary incorporates instructions about when and how to obtain urgent The HCO should outline
conditions regarding "when" to
obtain urgent care, For example,
a post op patient should report
death the summary of the case also includes the cause of death. Self explanatory
when having fever,
bleeding/discharge from site.

n and is guided by the applicable laws, regulations and

ry is uniform when similar care is provided in more than one setting. The organisation shall ensure that
patients with the same health
problems and care needs, receive
the same quality of healthcare
throughout the organization
irrespective of the category of
ward.
re is guided by policies and procedures which reflect applicable laws Self explanatory
ions.

nd treatment orders are signed, named, timed and dated by the Self explanatory, Treatment
doctor. orders must be written daily.

an is countersigned by the clinician in-charge of the patient within 24 The treatment of the patient could
be initiated by a junior doctor but
the same should be
ased medicine and clinical practise guidelines are adopted to guide The organization
countersigned could
and developby
authorized
e whenever possible. clinical
the treating doctor withinon
protocols based 24these
hrs.
and the same could be followed in
management of patients. These
ble laws and regulations. could then be used as parameters
d procedure for emergency care are documented. for audit
These of patient
could icludecare.
SOPs/protocols to provide either
o address handling of medico-legal cases. general emergency
The policy care
shall be in lineorwith
management
statutary of specificw.r.t.
requirements
receives care in consonance with the policies. conditions e.g. poisoning.
documentation
Self explanatory and intimation to
police. The organization shall also
define as to what constitutes a
d procedures guide the triage of patients for initiation of appropriate Self explanatory
MLC (in accordance with statutory
rules).
iliar with the policies and trained on the procedures for care of All the staff working in the
patients. casualty should be oriented to the
policies and practices through
or discharge to home or transfer to another organisation is also Self explanatory
training/documents. Staff should
d. preferably be trained/well versed
in ACLS and BLS.
rvices provided by the organisation.
equate access and space for the ambulance(s). The organization shall demarcute
a proper space for ambulance (s).
(s) is appropriately equipped. This shall
This shall be
be done
demarcated
based onkeeping
the
in mind easy accessibility
organization's scope. for
(s) is manned by the trained personnel receiving patients
The ambulance and tobeenable
should
the ambulance (s)
manned by a trained to driver,
turn
around/exit quickly.
technician/nurse
checklist of all equipment and emergency medications. The organization and/or doctor a
shall develop
depending
checklist onensure
and the situation.
that the
are checked on a daily basis. Personnel
ambulance shall beboth
trained
is equipped
This shall include as in
the per the
ACLS and/or
checklist. BLS.
ambulance the equipments within
medications are checked daily and prior to dispatch. it.
Self explanatory. This also
includes checking the expiry date
ance(s) has a proper communication system. of
The drugs.
ambulance shall be
connected with the
hospital/control room by
pulmonary resuscitation. wireless/mobile phones.

d policies and procedures guide the uniform use of resuscitation The organisation shall document
the organisation. the procedure for same. This shall
be in consonance with accepted
ing direct patient care is trained and periodically update in cardio These aspects shall be covered
practices.
resuscitation. by hands on training. If the
organization has a CPR team
during a cardio pulmonary resuscitation are recorded. In thecode
(e.g. actual event
blue of ait CPR
team) shall or a
mock dril of the same, all
ensure that they are all trained the in
nt analysis of all cardiac asserts is done by a multidisciplinary activities
The
ALS analysis along with the
shall include
and are present personnel
in all the
shifts.
attended
cause, should
steps takenbe to
recorded.
resuscitate
and the outcome. Multidisciplinary
committee shall include
physicians, anaesthetists and
nurses.
and preventive measures are taken based on the post-event analysis. Self explanatory

ucts.
d policies and procedures are used to guide rational use of blood and This shall address the conditions
ucts. where blood and conditions where
blood products can be used.
sion services are governed by the applicable laws and regulations. Refer to Drugs and Cosmatics
act.
onsent is obtained for donation and transfusion of blood and blood Consent should be taken for
every transfusion. However, with
the same consent you can give
onsent also includes patient and family education about donation. self explanatory
multiple transfusions in the same
sitting. For example, 2 pints of
ned to implement the policies. This
bloodshall
mayinclude doctorsserially
be transfused and be
done
using either
the same by training
consent. and/or by
n reactions are analysed for preventive and corrective actions. providing
However, written
if the same
The organization instruction.
shallisensure
given over
that
two
any transfusion reaction then
days or hours apart is a
separate consent
reported. is required.
It is preferable that the
are and High Dependency Units. organization capture feedback
regarding every transfusion
sation has documented admission and discharge criteria for its intensive The organization
(including the ones should
withoutdevelop
gh dependency units. objective
reaction) as criteria and adhere
this would enabletoitit.to
cature all transfusion analyzed (by
ned to apply these criteria. This shall be done by training
individual/organization) and by
deplaying the criteria.
appropriate corrective/preventive
taff and equipment are available. The
actionICU shouldThe
is taken. be equipped
organizationwith
all necessary life
shall maintain a record ofsaving and
ocedures for situation of bed shortages are followed. monitoring
transfusion
As and when equipmebnts
reactions.
there are no asvacant
well
as suitably manned
beds in the ICU and there is aby trained
staff. The
requirement exact
of requirements
ntrol practices are followed. These could besuch bed, a
developed
shall be
detailed decided
policy andbyprocedure
thebe a part of
individually or it could
organization.
should However
be ininfection
place the
to control
address the
surance programme is implemented. the hospital
These could beexpected
developed
organization
situation. is to follow
manual. Theororganization
individually it could be ashall part of
best
ensure clinical practices.
that the practices are in
the Hospital quality assurance
y, physically and/ or mentally challenged and children). consonance programme. The with organization
good clinical
practices.
shall ensure that the programme
d procedures are documented and are in accordance with the prevailing is in explanatory
Self consonance with good
e national and international guidelines. clinical practices.
anised and delivered in accordance with the policies and procedures. HCO develops SOP's for delivery
of care
sation provides for a safe and secure environment for this vulnerable The organization shall provide
proper envirnment taking into
account the requirement of the
ted procedure exists for obtaining informed consent from the The informed
vulnerable consent for this
group.
legal representative. group of people should be
obtained from their family or legal
ned to care for this vulnerable group. All staff involved in the care of this
representative.
group shall be adequately trained
in identifying and meeting their
needs.
nts.
sation defines and displays whether high-risk obstetric cases be cared The organization shall define as
to what constitutes high risk
obstetric case in consonance with
ring for high-risk obstetric cases are competent. These shall not
best clinical just be doctors
practices.
but shall include nursing staff
also. The competency shall be
bstetric patients assessment also includes maternal nutrition. Self
basedexplanatory
on qualification, experience
and training.
zation caring for high risk obstetric cases has the facilities to take care The organization shall have a
s of such cases. NICU with proper equipments and
staff.

sation defines and displays the scope of its dediatric services. The scope shall also include
neonatal services, if any.
or care of neonatal patients is in consonance with the national/ Self explanatory
al guidelines.
care for children have age specific competency. These shall not just be for doctors
but shall include nursing staff
also. The competency shall be
are made for special care of children. Adequate amentities forexperience
based on qualification, the care
of infants and
and training. children to be
available in the hospital.
essment includes detailed nutritional, growth, psychosocial and Sel explanatory
on assessment.
d procedures prevent child/ neonates abduction and abuse. The HCO shall ensure that there
is an adquate
security/surveillance to prevent
ns family members are educated about nutrition, immunization and self
suchexplanatory.
happenings.
ing and this is documented in the medical record.

derate sedation.
and trained persons perform sedation. Whenever parenteral route is
used this shall be carried out by a
administering and monitoring sedation is different from the person doctor/nurse.
self explanatory
the procedure.
edure monitoring includes at a minimum the heart rate, cardiac rhythm, Self explanatory, The same
rate, blood pressure, and oxygen saturation, and level of sedation. should be documented
e monitored after sedation. The patient's vitals shall be
monitored at regular intervals (as
decided by the organization) till
used to determine appropriateness of discharge from the recovery These
he/she shall be developed
recovers completelybyfrom
the
organization in consonance with
the sedation. The same should be
good critical practices.
documented.
and manpower are available to rescue patients from a deeper level of The equipments shall include
an that intended. emergency resuscitation
equipments. An anaesthesiologist
shall be available in the hospital.

documented policy and procedure for the administration of anesthesia. HCO shall document on the
indications, the type of
anaesthesia and procedure for
for anesthesia have a pre-anesthesia assessment by a qualified This shall be done before the
the same.
patient is wheeled into the OT
complex. It shall be applicable for
esthesia assessment results in formulation of an anesthesia plan which Self
both explanatory
routine and emergency
ted. cases. This assessment shall be
ate preoperative re-evaluation is documented. done by an
this shall beanaesthesiologist.
done by an It is
preferable
anaesthesiologist just before thea
to do assessment in
standardized format
patient is wheeled in to the
onsent for administration of anesthesia is obtained by the anesthetist. Self explanatory
respective OT

sthesia monitoring includes regular and periodic recording of heart rate, Self explanatory
hm, respiratory rate, blood pressure, oxygen saturation, airway security
y and level of anesthesia.
nts post-anesthesia status is monitored and documented. This shall be done in the recovery
area/OT and at least include
monitoring of vitals till the patient
ndividual applies defined criteria to transfer the patient from the The organization
recovers completelydocuments
from
ea. these criteria which
anaesthesia and shall should
be donebe inby
consonance
an with good
anaesthesiologist. clinical
if the
anesthesia events are recorded and monitored. All such
practices.events
Theseare documented
criteria shall be
patient's
and condition
monitored is unstable
for the purpose and
of
applied
he/she by a designated
requires ICU care individual
the
taking
as corrective
decided by theand
HCO.preventive
same
action.shall be monitored there.
gical procedures.
s and procedures are documented. This shall include the list of
surgical procedures as well as
competency level for performing
tients have preoperative assessment and a provisional diagnosis All patients
these undergoing surgery
procedures.
d prior to surgery. are assessed pre operatively and
a provisional diagnosis is made
d consent is obtained by the surgeon prior to the procedure. Self explanatory
which is documented. This shall
be applicable for both routine and
d policies and procedure exist to prevent adverse events like wrong emergency cases.be available for
Procedure should
patients and wrong surgery. preventing adverse events like
wrong patients, wrong site by a
alified by law are permitted to perform the procedures that they are The HCOmechanism.
suitable identifies the individuals
perform. who have the required
qualification (s0, training and
ative note is documented prior to transfer out of patient from recovery This note provides
experience information
to perform procedures
about the procedure
in cosonance with theperformed,
law.
post operative diagnosis and the
ng surgeons documents the post operative plan of care. Self explanatory.
status and shall be documented
by the surgeon/member of the
surance programme is followed for the surgical survices. surgical team.
This be an integral part of the
HCO's overall quality assurance
programme. It shall focus on post
assurance program includes surveillance of the operation theatre Surveillance activities include
operative complications e.g.
nt. monitoring the quality
bleeding rational use ofof air
provided , rate
antibiotics, etc. of air
so includes monitoring of surgical site infection rates. Self explanatory.
exchange,cleaning and
disinfection processes , etc.

(physical and/ or chemical).

d policies and procedures guide the care of patients under restraints. This shall clearly state the
conditions/Circumstances under
which restraints shall be used .It
de both physical and chemical restraint measures. Physical
shall alsorestraints
specify asinclude
to whoboxer's
can
bandage, use of cuffs ec.
authorize the use of restrains.
Chemical restraints include
de documentation of reasons for restraints. Self explanatory.
sedatives.

ents are more frequently monitored. The organization shall specify the
parameters and frequency of
monitoring and accordingly
e training and periodic updating in control and restraint techniques. Self explanatory.
implement the same.

d policies and procedures guide the management of pain. The HCO shall define the group of
patients for whom this is
applicable. A good reference point
zation respects and supports the appropriate assessment and Selfdefining
for explanatory.
these patients could
nt of pain for all patients. be those having pain as the
predominant debilitating
symptom.
 family are educated on various pain management techniques. Self explanatory.

d policies and procedures guide the provision of rehabilitative services. Self explanatory.

ces are commensurate with the organizational requirements. The scope of the departments is
in consonance with the scope of
the hospital.
ve services are provided by a multidisciplinary team. The team shall have treating
doctor, rehabilitation therapist,
rehabilitation nurss and other
professional experts.

d policies and procedures guide all research activities in compliance Self explanatory.
al and international guidelines.
ation has an ethics committee to oversee all research activities. An ethics committee should be
framed in the hospital to monitor
activities undertaken by various
ee has the powers to discontinue a research trial when risks outweigh the Self explanatory.
providers. Any research
efits.
undertaken in the hospital
rmed consent is obtained before entering them in research protocols. fallsunder its ambit. This includes
Self explanatory.
both funded and non-fundes and
also student studies.
e informed of their right to withdraw from the research at any stage and Self explanatory.
consequences (if any) of such withdrawal.
e assured that their refusal to participate or withdrawal from Self explanatory.
n will not compromise their access to the organizations services.

d policies and procedures guide nutritional assessment and Self explanatory.

ent.
ceive food according to their clinical needs. A dietician shall do the
assessment of the patient in
consulation with the clinician and
written order for the diet. The
advicedietician shallfood.
regarding prepare this in
the form of a diet sheet and
patient shall receive food
herapy is planned and provided in a collaborative manner. The dietician shall ensure that this
accordingly.
is planned in consultation with the
treating doctor and the
ies provide food, they are educated about the patients diet limitations. The dietician / nurse
patient/patient's shall
relative ensure
after
this planning.
taking into regard the patient's
pared, handled, stored and distributed in a safe manner. food habitts services
The dietary (veg/ non-veg)
to be and
likes and dislikes.
designed in a manner that there is
no criss cross of traffic. All the
activities fall in a squence. The
organization shall ensure that
d policies and procedures guide the end of life care. hygienic
The HCOconditions are follwed all
has a documented
throughout.
policy for providing care to
terminallly ill admitted
ies and procedures are in consonance with the legal requirements. Self explanatory.
patients.This shall include
providing appropriate pain and
address the identification of the unique needs of such patient and palliative careand
The religious according to the
socio-cultural
wishes of the family and patient.
beliefs of patients/ family shall be
addresed and respected.
 include sensitively addressing issues such as autopsy and organ If the body of the deceased is
subjected to an autopsy or for
argan donation, it should be
cated and trained in end of life care. Self explanatory.
discussed with the family in a very
courteous manner.

es and usage of medication.

documented policy and procedure for pharmacy services and The polices and procedures shall
usage. address the issues related to
procurement, storage, formulary,
ply with the applicable laws and regulations. Self explanatory.
prescription, dispensing,
administration, monitoing and use
plinary committee guides the formulation and implementation of these of medications.
This shall be representative of
d procedures. major clinical departments
administration and shall include a
pharmacist/ clinical
pharmacologist.
dication appropriate for the patients and organizations resources is The hospital formulary shall be
prepared and be preferably
updated at regular intervals.
eveloped collaboratively by the multidisciplinary committee. Refer to MOM 1c.

defined process for acquisition of these medications. The process should address the
issues of vendor selection,vendor
evalation,generation of vendor
process to obtain medications not listed in the formulary. Self explanatory
evaluation,generation of purchase
order and receipt of goods and
receipt of goods as per rules.

d policies and procedures exist for storage of medication. These should address issues
pertaining to temperature
(refrigeraion),light, ventilation
s are stored in a clean, well lit and ventilated environment. The organization
preventing entry of shall also
pests/rodents
ensure that
and vermins. the storage
requirements of he drug as
ntory control practices guide storage of the medications. Self explanatory
specified by the manufacturer are
adhered to.If the
s are protected from loss or theft. recommendations
The oranization shall areensure
confilicting
that
recommendations in nature,
it develops proper mechanisums the
organization shall follow
to prevent pilferage. The the
e and look alike medications are stored separately. manufacturer's
Many drugs in recommendation.
organization could conductvials
ampoules, or
audits
This
tabletsshall
maybe applicable
look-alike orto all
sound
at regular intervals (as defined by
areas
alike.
the whereshould
They
organiztion)medications
to are
be segregated
detect such
method to obtain medication when the pharmacy is closed. when
stored
and pharmacy
including is closed
wards.
stored seperately. , there
instances
should be SOP to procure the
drugs.
medications are available all the time. Adequate amount of emergency
medicines should be stocked at
all times. Re-order level at definite
medications are replenished in a timely manner when used. self explanatory
quantity should be done.

d policies and procedures exist for prescription of medications. self explanatory

zation determines who can write orders. this shall be done by the treating
doctor.
written in a uniform location in the medical records. all the orders for medicines are
recorded on a uniform location of
the case sheet. Electronic orders
orders are clear, legible, dated, timed, named and signed. Self
whenexplanatory
typed shall again follow the
same principles.
erbal orders is documented and implemented. The organization shall ensure that
it has a policy to address as to
who can give verbal orders and
zation defines a list of high risk medication. High risk medications
how these orders will be arevalidated
medications involved in a high
percentage of medication errors
edication orders are verified prior to dispensing. These medications
or sentinel events and shalll
preferably be given
medications that carry onlya arter
high risk
written orders
for abuse, and
error, or itother
should be
adverse
verified by the staff before
outcomes.Examples include
dispensing.
medications with a low therapeutic
d policies and procedures guide the safe dispensing of medications. window,
Clear controlled
policies to besubstances,
laid down for
psychotherapeutic
dispensing of medication e.g.
medications,and
route look-alike
of administration, and
dosage,
s include a procedure for medication recall. Recall
rate of may
sound-alike result based
medications.
administration, on letters
expiry
from
date ,regulatory
etc. authoroties or
internal feedback( e.g. visible
s are checked prior to dispensing. Self explanatory
contaminant in IV fliud bottle)

quirements are documented and implemented by the organization. At a minimum, labels must include
the drug name,
strenght,ffrequency of
administration ( in a language the
patient understands ) and expry
s are administered by those who are permitted by law to do so. dates.
Self explanatory

medication are labeled prior to preparation of a second drug. Self explanatory

entified prior to administration. Self explanatory

is verified from the order prior to administration. Staff administering medications

should go through the treatent
orders before administration of
verified from the order prior to administration. Self explanatoryand then only
the medication
administer them. It is preferable
rified from the order prior to administration. that
Self they also check the general
explanatory
appearance of the medication)
eg .melting, clumping etc.)
erified from the order prior to administration. Self explanatory

administration is documented. The organization shall ensure that

this is done in a uniform location
and it shall include the name of
procedures govern patients self administration of medications. At the outsetdosage,
medication, the HCO could
route of
define if it would permit
administration, timing and selfthe
administration
name and of medications.
signature of the In
procedures govern patients medications brought from outside the These
case shall
the HCO address
permits ass toperson
then what
the
n. who
are has
theshalladministered
pre-requisites the
policy
medication include thefor such a
medication ( which
medications eg. invoice, clear can
the patient
label with mention
self administer. If isofpreferable
the name
nd food-drug interactions. ,dose,
that theexpiry date etc)also
organization
incorporates a method to ensure
that the patient is reminded to
take the medication ( before every
dose) and documentation of self
administration
 family are educated about safe and effective use of medication. The organization shall make a list
of such drugs and accordingly
educate eg. digoxin. This could
family are educated about food-drug interactions. Patient and family
also include should
education be
regarding
counselled
the immportance of taking aduring
about their diet drug
medication
at a specificeg. noeg.
time alcohol when
sustained
taking
releasemetronidazle.
medications.

e monitored after medication administration and this is documented. This shall be done by anyone
involced in direct patient care. The
organization could follow either a
ug events are defined. The organization
pasiive shall only
( documenting define as
if the
to what constitutes an adverse
patient tellls ) or active ( enquiring
drug
with event.patient
every This shall be in
) monitoring
ug events are reported within a specified time frame. Self explanatory
consonance with best
mechanism.
The organization shall
practices.Adverse drugdefine
eventsthe
timeframe
include for reporting
adverse drug once theas
reactions
ug events are collected and analysed. All the adverse
adverse drughas
drug event reaction are
occured.
well as medication
analysed errors.
regularly by the multi-
disciplinary committee
modified to reduce adverse drug events when unacceptable trends Self explanatory

otropic substances.
d policies and procedures guide the use of narcotic drugs and Self explanatory
c substances.
ies are in consonance with local and national regulations. This is in context of narcotic drugs
and psychotropic substances act.
cord is kept of the usage, administration and disposal of these drugs. These shall be kept in accordance
with statutory requirements.
s are handled by appropriate personnel in accordance with policies. Self explanatory

nts.
d policies and procedures guide the usage of chemotherapeutic Self explanatory

apy is prescribed by those who have the knowledge to monitor and treat This shall preferably be a medical
e effect of chemotherapy. oncologist or a person who has
been trained and had achieved
apy is prepared and administered by qualified personnel. This shall preferable
competency be staff who
in the same.
have received special trainig in
preparing and administration.
apy drugs are disposed off in accordance with legal requirements. These shall be disposed off
according to Bio-medical waste
management and handling rules
1998 or manufacturer's
recommendation.
d policies and procedures govern usage of radioactive drugs. Self explanatory

ies and procedures are in consonance with laws and regulations. Refer to AERB guidelines.

s and procedures include the safe storage, preparation, handling, Self explanatory. This shall
and disposal of radioactive drugs. however be in accordance with
AERB guidelines.
nts and visitors are educated on safety precautions. Self explanatory
 d policies and procedures govern procurement and usage of Self explanatory
prosthesis.
f implantable prosthesis is based on scientific criteria and national/ The organisation shall ensure that
ally recognized approvals. relevant and sufficient scientic
data are available before
and serial number of the implantable prosthesis are recorded in the Self explanatory
selection. It shall also look for
edical record and the master logbook. international (e.g. US-FDA) of
national notification (Drugs and
Cosmetics Act notification october
2005) for approval of the
d policies and procedures govern procurement, handling, storage, particular
This shall product.
be applicable to all
usage and replenishment of medical gases. gases used in the organization . It
shall also address the issue of
s and procedures address the safety issues at all levels. This shallrequirements
statutory include from andthe point of
storage/source
approvals wherever area,applicable
gas supplyIt
lines
shall and the
follow a end usercolour
uniform
records are maintained in accordance with the policies, procedures This is the context
area.Appropriate of themeasures
safety Indian
equirements. coding system.
explosives act of 1884, Gas
shall be developed and
cylinder
implementedrules for
1981all and static and
levels.
mobile pressure vessels (unfired)
1981.

out their responsibilities during care.

family rights and responsibilities are documented. Hospital should respect

patient'srights and inform them of
d families are informed of their rights and responsibilities in a format their responsibilites.
self explanatory.
ge that they can understand. All the rights of the patient should
be displye in theincludes
form of a
zations leaders protect patient's and family rights. Protection also
citizens' charter which should also
addressing patient"s grievances
give information of the charges
re of their responsibility in protecting patients and family rights. w.r.t rights.
Traning and sensitisation
and grievance redressal
programmes
mechanism. shall be conducted
patient and family rights is recorded, reviewed and corrective/ to create
Where aeareness
patient"s among
rights have the
been
measures taken. staff.
infringed upon,management must
keep records of such violations,as
also a record of the
ve the patient and family in decision-making processes.
consequences,e.g. corrective
family rights address any special preferences, spiritual and cultural actions
This could to prevent
include recurrences.
dietary
preferences and worship
family rights include respect for personal dignity and privacy during requirements.
During all stages of patient
n, procedures and treatment. care,be it in examination or
family rights include protection from physical abuse and neglect. carrying out a procedure,hospital
Self explanotry. Special
staff shall
precautions ensure thattaken
shall be patient's
privacy and dignity is
especially w.r.t. vulnerable maintained .
family rights include treating patient information as confidential. Self
The explanatory.
organization statutory
shall develop
patients .eg. elderly, neonates etc.
requirement
the necessaryw.r.t. privilged
guidelines for the
communication
same. During shall be followed
procedures the
family rights include refusal of treatment. During management the patients
at all times. shall ensure that the
organization
should be given the choice of
patient
treatment is exposed just before
.The treating doctor the
family rights include informed consent before anaesthesia, blood and self explanatory
actualsprocedure is undertaken.
shall discuss all the available
uct transfusions and any invasive/ high-risk procedures/ treatment.
With
optionsregards to photographs
and allow the aptient to
/recording procedures,the
make an informed choice
family right include information and consent before any research organization the shall
The organization
including ensure
shall
option that
ensure
of refusal.
nitiated. consent
that is taken and
international that the on
conference
patient's identity
harmonization is not
(ICH) of revealed.
good
family rights include information on how to voice a complaint. Grievance redressal mechanism
clinical practice (GCP) and
must be accesssible and
Declaration of Helsinki Somerset
transparent. Information must be
(1996) and ICMR requirements
clearly available on how to voice a
are followed.
complaint.
 family rights include information on the expected cost of the treatment. Refer AAC4d.

family have a right to have an access to his/ her clinical records. The organization shall ensur that
every patient has access to
his/her record. This shall be in
exists for informed decision making about their care. consonance with the code of
medical ethics and statutory
nsent for treatment is obtained when the patient enters the organisation. requirements.
Self explanatory

/ or his family members are informed of the scope of such general The organization shall difine as to
what is the scope of this consent
and the same shall be
sation has listed those situations where informed consent is required. A list of procedures should be
communicated to the patient
made for which informed consent
and /or his family members.
onsent includes information on risks, benefits, alternatives and as to should be taken.
The consent shall have the name
rform the requisite procedure in a language that they can understand. of the doctor performing the
procedure. If it is a "doctor under
describes who can give consent when patient is incapable of training" the sameshall
The organisation shalltake
be into
nt decision-making. specified,
considerationhowever the name
the statutory of
norms.
the qualified doctor supervising
This would include next of
the procedure
kin/legal shallHowever
guardian. also be in
their health care needs. mentioned consent
case of unconscious/ form shall be
in the language
unaccompanied that the patient
opriate, patient and families and are educated about the safe and Self explanatory.patients the
understands.
e of medication and the potential side effects of the medication. treating in life saving
circumstances.
families are educated about diet and nutrition Self explanatory.

families are educated about immunisations. Self explanatory. More applicable

for paediatric population. In adults
families are educated about their specific disease process, itSelf
could be for influenza,
explanatory. This could also
ns and prevention strategies. streptococcus
be done through pneumonia,
patient education
typhoid, hepatitis B, Neisseria
booklets/videos/leaflets etc.
families are educated about preventing infections. Self explanatory.
meningitides, etc,
d family are taught in a language and format that they can understand. Self explanatory.

iform pricing policy in a given setting (out-patient and ward category). There should be a billing policy
which defines the charges to be
levied for various activities.
st is available to patients. The organization shall ensure that
there is an updated tariff list and
d family are educated about the estimated cost of treatment. Refer to list
that this AAC4d.
is available to patients
when required. The organization
d family are informed about the financial implications when there is a When patients
shall charge asare
pershifted from
the tariff list.
he patient condition or treatment setting. one
Any setting
additionalto another, typically
charge should to
also
and form ICUs, the
be enumerated financial
in the tariff and
implication must be clearly
the same communicated to the
conveyed
patients. Theto them.
tariff rates should be
uniform and transparent.
ed infection control programme aimed at reducing/

al infection control programme is documented which aims at preventing Self explanatory.

ng risk of nosocomial infections.

al has a multi-disciplinary infection control committee. This shall preferably have

Hospital Administrator, Surgeon,
al has an infection control team. Manager
The teamisNursing (Nursing
responsible for day-
Supervisor(, staff form CSSD, and
to-day functioning of infection
the hospital
control infectionThey
programme. control
shall
nurse.
supportItsurveillance
could also include
process and
invitees form various
detect outbreaks. Theydepartments
shall also
as deemed necessary.
participate in infection prevention
and control on a day-today basis.
al has designated and qualified infection control nurse(s) for this activity. The qualification shall be either a
graduate nurse or qualified nurse
with competence gained by
ly updated. experience.

l identifies the various high-risk areas and procedures. The manual should clearly identify
the high risk areas of the hospital
methods of surveillance in the identified high-risk areas. e.g. ICU,
It shall HDU,the
define OT, Post-operative
frequency and
ward,
mode Blood Bank, CSSD,
of surveillance. The etc.
similarly,
surveillance all highsystem riskshould
procedures meet
n adherence to standard precautions at all times. Self
should explanatory.
be identified from
WHO criteria of simplicity, cost
infection
minimization control point ofof
timeliness view. For
cleaning and sterilisation practices are included. It shall address
example, cardiac this at all levels e.
catheterization,
feedback flexibility, acceptability,
g. ward, OT and
endoscopies, CSSD.
surgery It is more
lasting
consistency, (reliability), sensitivity
preferable
than 2 hours, thatBMT the organization
etc.
iate antibiotic policy is established and implemented. The HCO shall develop a system
and specificity.
follows a uniform policy across
of monitoring drug susceptibility
different departments within the
d linen management processes are also included. (based
The on culture
laundry can be sensitivity)
in-house and
organization. The or
accordingly
outsourced. develop
If outsourced its antibiotic
the
manual should include
policy, which shall
organization shall ensure
be reviewed the it at
nitation and food handling issues are included in the manual. sterilization
Self explanatory. and disinfection
The same shall
periodic
establishes intervals
adequate (maybe controlsonce toin
policy,
be chemicals
applicable even used/methods
if this activity
3 months)
ensure for its
infection followed continuing
control. The linen
g controls to prevent infections are included. and
is
Issues procedures
outsourced.
such asThe organization
air conditioning in wards
applicability.
change policy should be
and
plantcritical
could areas.
referequipment
and to ISO Special
22000:2005 focus
mentioned.
on
(food critical
safety) Washing
equipments
while protocols
like
addressing for
this
actices and procedures are included as appropriate to the organization. The maintenance;
mortuary cleaning
services of AC
in the
different
ventilators, categories
nebulizers
issue. AHUS replacement of of linen
etc.
ducts,
hospital
includingshould blankets be should
provided be
filters;
through seepage
walk-in leading
cold rooms to fungal
or
included.
zation defines the periodicity of updating the infection control manual. colonization;
The
mortuary coldreplacement/repair
organization must have
cabinets. Mortuarya
of plumbing,
documented sewer
policy
procedures of preserving body, or lines
on the (in
shafts)
updation
body parts should
ofand thebe included.
infection
safety Water
control
measures
supply,
manual.
while sources
It is desirable
handling andbody
over system
to update
to of
identified areas of the hospital. supply
at least sources
once in and
a yearwater based quality
on
relatives should be in accordance
must
its
with be
trends included.
and outcomes
the policy. must be able to Any renovation
of the
e activities are appropriately directed towards the identified high-risk The organization
work in
audit hospital patient with
processes.
provide evidence of conducting
Infection Control team with regard
surveillance data is an ongoing process periodic
The surveillance
organization shallactivities
ensure in
that
to architectural segregation, traffic
its identified
it hasuse a process high risk
in place areas. The
flow, of materials etc.to collect
specific
surveillance objectives,
data case
f data is done on regular basis by the infection control team The collected also
data soidentification
definitions,
and shall to
of be all
ensure
authenticatedthat it is able to
by thefrequency capture
team by
potential
such data. indicators,
otifiable diseases, information (in relevant format) is sent to appropriate going
The throughofevery
organization
and duration shall data
monitoring, or byall
identity
using
notifiable
methods random diseases
of data sampling after so
collection, that
taking along
the
into
with process
consideration
schedule can of be validated.
the local
rounds shouldlaws,The be
urveillance activities incorporates tracking and analyzing of infection This
team shall
shall be done at regular
preferably verify every
rules,
defined. regulations
Confidentiality and and
and trends. intervals
serious (maybe (as
infection monthly defined and
notifications
anonymity must thereof.
be The by
ensured. The
consolidated
the organization into an
report. annual
e activities include monitoring the effectiveness of housekeeping servicesThis
HCO would
organization
should include
shall
clearly categorization
ensure
mention that this
report) and the organization shall
of
is areas/surfaces;
sent
which at the specified
specific targeted general frequency
take suitable steps based on the
cleaning
and in theprocedures
surveillance format
(site for surfaces,
as required
specific, unitby
analysis.
tal Associated Infections (HAI) in patients and furniture/
statutory
oriented, fixtures,
authorities.
priority and
oriented) items used
in patient care. It
activities are being carried out. should also
include procedures for terminal
cleaning, blood and body fluid
zation monitors urinary tract infections. This
cleanup, can isolation
be done either roomsby and all
sending urine or
high risk (critical) areas. The catheter tip for
zation monitors respiratory tract infections. culture.
common
This canThe be organization
disinfectants
done used,
by sending shall do
this
sputum for all
dilution or symptomatic
factors, method of use
ET/ tracheostomy
catheterized
should
secretions be patients.using a
specified.
(obtained
zation monitors intra-vascular device infections. For patients with symptoms
suction
suggestive catheter)
of intraofvascularET/
tracheostomy
device infection tip or protected
andbyhaving
zation monitors surgical site infections. This shall be done sending
specimen
central linefor brushing
the same (PSB)
shall or bemini
pus/swab culture.
broncho-alveolar
doneby sending the lavagetip for (BAL)
culture. for
feedback regarding HAI rates are provided on a regular basis to The
culture.feedback
The shall
organization
For all peripheral lines clinical include the
shall do
d nursing staff. rates.
this forTrends
evidence allofpatientsand opportunities
on the
thrombophlebitis
for improvement.
ventilator
would suffice. having It couldfeatures
clinical also
provide
suggestive specific inputs to reduce
of infection.
the HAI rate.
infection control programme.
ing facilities in all patient care areas are accessible to health care The organization shall ensure that
it provides necessary
e with proper hand washing is monitored regularly. infrastructure to carry
The organization shallout the
preferably
same.
display the necessary instruction
arrier nursing facilities are available. near every had washing
The organization area.the
shall define
Compliance
conditions where couldthe be same
verified by
shall
random checking, observation,
loves, masks, soaps, and disinfectants are available and used correctly. be
Selfcarried out andThe
explanatory. ensure
should thatbeit
etc.
provides the necessary resources
available at the point of use and
to carry
the out the activity
organization (e.g. that
shall ensure
clothing,
it maintainsmasks,
an gloves etc.).
adequate
fections.
inventory.
s a documented procedure for handling such outbreaks. This shall incorporate definitions
as to what constitutes an
dure is implemented during outbreaks. outbreak, identification
The organization shouldand be able
investigation of such
to identify the outbreak, outbreaks
describe
and
the the procedure
outbreak for
by developing
utbreak is over appropriate corrective actions are taken to prevent The organization
management. This should
shall bebe a able
case
to definition,
implementwith designing
basic proceduresa in
datato
accordance
collection good
from, collection clinical
data
prevent
practices. recurrence
Standard such as
Case an
ganisation. from
source thecontrol
affected, constructing
if include
source identified,
definitions
epidemic shall
curve. a unit of
review of all infection control
time and place along with specific
equate space available for sterilization activities. Adequacy
polices, of space
biologicalloopholes
and/or refers
and
clinical to the
criteria.
CSSD whichgaps,
compliance should have an area
strengthening
idation tests for sterilisation are carried out and documented. of 0.7sq.
infection
This m/bed,
shallcontrol
be done suitable
polices location,
etc.
by accepted
proper layout (unidirectional
method e.g. bacteriologic, strips flow,
zoning)
etc. and
Engineering separation of
validations clean
like
established recall procedure when breakdown in the sterilisation The
and organization
dirty areas. shall ensure that
dentified. Bowie
the sterilization procedure is rate
Dick tape test and leak
test needmonitored
regularly to be carried andoutin the
ement are complied with. eventuality of a breakdown it has
a procedure for withdrawal of
al is authorised by prescribed authority for the management and such items. shall apply in the
The occupier
Bio-medical Waste. prescribed form and get approval
regation and collection of Bio-medical Waste from all patient care areas form
Wastes thetoprescribed
be segregated authorityande.g.
ital is implemented and monitored. Pollution control board/committee.
collected in different colour coded
bags and containers as per
zation ensures that Bio-medical Waste is stored and transported to the The waste
statutory is transported
provisions. to the
Monitoring
ment and disposal in proper covered vehicles within stipulated time pre-defined site at definite
shall be done by member of time
the
ecure manner. intervals (Maximum within
infection control committee/team. 48
hours) through proper transport
l Waste treatment facility is managed as per statutory provisions (if in- If the hospital
activity has waste
is outsourced the
utsourced to authorised contractor(s). treatment
organization.facility within itsof this
Monitoring
premises the they
activity should be have
done to bybe in
ees, documents and reports are submitted to competent authorities on The HCO
accordance shall
withensure that
statutory
infection Control team. the
ates. fees are deposited in a timely
provisions or they can outsource it
manner.
to In addition
a central facility. the annual
personal protective measures are used by all categories of staff Self explanatory.
reports have to be submitted by
o-medical Waste.
the 31st of January of every year
and accident reporting has to be
management and includes training of staff and carried out in the prescribed form.

anagement makes available resources required for the infection control The HCO shall ensure that the
. resources required by the
al regularly earmarks adequate funds from its annual budget in this personnel
There shallshould be available
be a separate in a
budget
sustained manner. This includes
demarcated for HIC activity. This
both
shall men and materials.
be prepared taking into
regular pre-induction training for appropriate categories of staff before There must
consideration bethe
a documented
scope of the
cerned department(s). evidence of previous
activity and pre-induction
years,training
for appropriate
experience.
ucts regular in-service training sessions for all concerned categories Self explanatory. categories of staff
east once in a year. before joining concerned
department(s). it should include
the policies, procedures and
practices of the infection control
programme.
 pre and post exposure prophylaxis is provided to all concerned staff Self explanatory.

g programme in the organization.

improvement programme is developed, implemented and maintained This committee shall have
isciplinary committee. representation from management,
improvement programme is documented. various clinical
This should be and support as a
documented
departments
manual. The manual shallThis
of the HCO.
programme shall be develop,
incorporate the
implemented and maintained
mission,vision,quality in a
objectives,
structured manner.
service standards,important
indicators as identified etc. The
manual could be stand alone and
should have cross linkages with
other manuals.

designated individual for coordinating and implementing the quality

nt programme
This should preferably be a
person having a good knowledge
of accreditation standards,
statutory
Requirements, hospital quality
improvement principles and
evaluation methodologies,hospital
functioning and operations

improvement programme is comprehensive and covers all the major The shall preferably cover all
elated to quality improvement and risk management. aspects including documentation
of the programme, monitoring it
data collection, review of policy
and corrective action.Also refer to
CQI 1b.

ated programme is communicated and coordinated amongst all the Self explanatory
of the organization through proper training mechanism.
 improvement programme is reviewed at predefined intervals and As quality improvement is a
es for improvement are identified. dynamic process, it needs to be
reviewed at regular pre-defined
intervals (as defined by the HCO
in the quality improvement
manual but at least once in four
months) by conducting internal
audits. This audits shall be done
by a multi-disciplinary team
(preferable trained in NABH
standards) and objective
elements.At the end of the audit
there shall be a formal meeting to
summarise the findings and
identity areas for improvement.
During this meeting there shall be
an analysis of key indicators as
identified and determined by the
organization including the
mandatory indicators as laid down
in CQI 2 and 3. The minutes of
the review meetings should be
recorded and maintained.

improvement programme is a continuous process and updated at least Self explanatory. The inputs for
ear. updation could be based on the
review carried out by the quality
improvement committee.

ctures, processes and outcomes which are used as

ncludes appropriate patient assessment. The HCO shall develop

appropriate key performance
indicators suitable to it. The
following is however mandatory:i.
Time for initial assessment of
indoor and emergency patients.ii.
Percentage of cases wherein
care plan is documented and
counter-signed by the clinician.iii.
Percentage of cases wherein
screening for nutritional needs
has been done.iv. Percentage of
cases wherein the pre-defined
intial nursing assessment is
completed within 30 monutes.
ncludes safety and quality control programmes of the diagnostics The HCO shall develop
appropriate key performance
indicators suitable to it . The
following is however mansatory : i.
Number of reporting
errors/1000 investigationa ii.
Percentage of re-dos. iii.
Percentage of reports co-relating
with clinical diagnosis. iv.
Percentage of adherence to
safety precautions by employees
working in diagnostics.

ncludes all invasive procedures. The HCO shall develop

appropriate key performance
indicators suitable to it . The
following is however mansatory :i.
Re-exploration rate ii.
Percentage of accidental
remeoval of tubes and catheters
iii. Incidence of haematoma at
puncture site iv. Percentage of
re-scheduling of procedures.

ncludes adverse drug events. The HCO shall develop

appropriate key performance
indicators suitable to it. The
following is however mndatroy:
i. Percentage of medication
errors.ii. Incidence of adverse
drug reactions iii. Percentage of
medication charts with illegible
writing over a given period. iv.
ncludes use of anaesthesia. Percentage
The HCO shall of contrast
developrelated
reactions.
appropriate key performance
Indicators suitable to it . The
following is however mandatory :

i. Percentage of modification of
anaesthesia plan.
ncludes use of blood and blood products. ii. Percentage
The HCO of unplanned
shall develop
ventilation following anaesthesia.
appropriate key performance
iii. Percentage of adverse
indicators suitable to it. The
anaesthesia events. mansatory :i.
following is however
iv. Anaesthesia
Percentage ofrelated mortality
transfusion
rate.
reactions.
ii. Percentage of wstage of
ncludes availability and content of medical records. blood
The HCOand shall
blooddevelop
products.
iii. Percentage of blood
appropriate key performance
component usage. to it. The
indicators suitable
iv. Turnaround
following timemandatory
is however for issue ofi.
bloodPercentage
and blood components.
of medical
records not having discharge
summary.
ii. Percentage of medical
records not having initial
assessment and the plan of care.
iii. Percentage of medical
records having incomplete and/or
improper consent.
iv. Percentage of missing
records.
ncludes infection control activities. The HCO shall develop
appropriate key performance
ncludes clinical research. indicators suitable
The HCO shall to it. The
develop
following is however mandatory: i.
appropriate key performance
indicators suitable to it. Therate.
Urinary tract infection
ii. Respiratory
following infection
is however rate.
mandatory:i.
iii. Intra-vascular device
Number of research activities
infection rate. out.
being carried
iv. Surgical
ii. Percentage siteofinfection
patientsrate
withdrawing from the study.
ncludes data collection to support further improvements. The data could be collected at
iii. Percentage of protocol
pre-defined intervals e.g.
violations/deiations reported.
monthly/quaterly. This data is
iv. Percentage of serious
analysed for improvement
adverse events (which have
opportunities and the same are
occurred in the HCO) reported to
carried out.Also refer to CQI 1f
the ethics committee within the
ncludes data collection to support evaluation of these improvements. defined
All timeframe
improvement activities carried
out by the HCO shall have an
evaluable outcome. The same be
captured and analysed.
structures, processes and outcomes which are used as

ncludes procurement of medication essential to meet patient needs. The HCO shall develop
appropriate key performace
ncludes reporting of activities as required by laws and regulations. indicators suitable
The HCO shall to it. The
develop
following is however mandatory: i.
appropriate key performace
Percentage of drugs
indicators suitable to it. The
procured byhowever
following is local purchase.
mandatory:
ii.
i. Percentage of stock
Number of birthes outs
and
including
deaths. emergency drugs.
iii.
ii. Percentage of consumables
Numberof notifiable
rejected
diseases. before preparation of
Goods Receipt
iii. Submission ofNote.
iv. Incidence ofpertaining
report/data/form variations tofrom
bio-
the procurement
medical waste,PNDT act and
radiation safety within the defined
timeframe.
iv. Submission of tax returns
and deduction of taxes at the
specified time frame.

ncludes risk management. The HCO shall develop

appropriate key performace
ncludes utilisation of space, manpower and equipment. indicators
The HCO shall suitable to it. The
develop
following is however
appropriate key performace mandatory:i.
Number of variations
indicators suitable to it. The
ncludes patient satisfaction which also incorporates waiting time for The
observedHCO in shall
mockdevelop
drills.
following is however mandatory:
appropriate key ofperformace
i.ii. Bed
Incidence
occupancy falls.
rate and
indicators
iii. suitable
Incidence of to it. The
ncludes employee satisfaction. average
The HCO length ofbed
stay.sores after
following
admission. isshall develop
however mandatory: i.
ii. OT andkey
appropriate ICUperformace
utilization rate.
iv. Out patient satisfaction index.
iii. Percentage
Equipment
indicators suitable ofto
down employees
time.
it. The
ncludes adverse events and near misses. ii.
The In patient satisfaction index.
iv. HCO
provided shall develop
pre-exposure
Nurse-patient
following is however ratio
iii. Waiting
appropriate
prophylaxis. key for mandatory:i.
timeperformace
services
Employee
including diagnostics
indicators satisfaction
suitable to and
it. The index.
out
ncludes data collection to support further study for improvements. The data could be collected
.following at
patient. is however mandatory: i.
pre-defined
ii. Time
Employee intervals e.g.
iv. Number
monthly/quarterly. of attrition
taken sentinel rate
for discharge.
events.
Thisinputs
data is
ncludes data collection to support evaluation of these improvements. iii.
Self
ii. Employee
explanatory.
Percentage absenteeism
The
of near misses rate
for
analysed
iv.
updations for
Percentage improvement
could of
be employees
based on the
analysed.
opportunities and the same are
who
review
iii. arecarried
aware
Number of of
out employees
by the
security quality
related
carried out.Also
rights,responsibilitiesrefer andalso refer to
nt. improvement
incidents
CQI 1f. including thefts. welfare
committee.17
schemes.
iv. Incidence of needle stick
.injuries.
anagement makes available adequate resources required for quality This shall include the men,
nt programme. material,machine and
rmarks adequate funds from its annual budget in this regard. method.These
Appropriate fund should so as is
allocation to
ensure that the programme
done by the organization for the
functions
smooth smoothly. of the
functioning
statistical and management tools are applied whenever required. Self Explanatory
programme.

d nursing staff participates in this system. The HCO shall identify such
personnel. It could be a mix of
eters to be audited are defined by the organisation. clinicians, administrators
As these audits are ans
nurse.
retrospective/concurrent in nature,
staff anonymity is maintained. itThis
is imperative
means thatthat thethis be done
names of the
using
patients and the hospital staffso
predefined parameters who
that there
may isinno
thebias. The
re documented. Self figure
explanantory audit documents
parameters
must not be could be disease
disclosed or any
based, cost based,community
reference be made to them in
measures are implemented. All
basedremedial
public or basedmeasures as of stay
on length
discussions/conferences.
ascertained should be
documented and implements
thersof recorded to complete the
sation has defined sentinel events. The
auditsentinel
cycle. events relating to
system or process deficiencies
sation has established processes for intense analysis of such events. The established
that are relevant processes should
and important to
include reporting the occurrence
the organization must be clearly
ents are intensively analysed when they occur. of
Rootsuch
defined. events
cause on standardized
analysis of all such
incident report forms.
events should be carried out by a
and preventive Actions are taken based on the findings of such analysis. The findings and committee taking
multi-disciplinary
recommendations
inputs from the concerned arrived at after
the analyses should be
units/discipline/departments
communicated to all concerned
personnel to correct the systems
and processes to prevent
recurrences.
onsible for governance lay down the organizations mission statement. It is not only the head of the HCO
but te members of the board of
onsible for governance lay down the strategic and operational plans governors (where
The Governing applicable)
boars and the who
rate to the organizations mission in consultation with the various stake need to define it.
leaders of HCO shall define and
develop the processs for strategic
and operation plans so as to
onsible for governance approve the organizations budget and allocate The Governing
achieve boars and the
the organizational
es required to meet the organizations mission. leaders
mission of HCO shall have the
statement.
policy for budgeting and resource
onsible for governance monitor and measure the performance of the The Governing
allocation boars and
for attaining the
its mission
n against the stated mission. leaders of HCO shall
and periodically reviewdevelop
it.
quarterly (at least) performance
onsible for governance establish the organizations organogram. The HCO shall have a well
reports based on the strategic and
defined organization
operational plans.
structure/chart and this shall
onsible for governance appoint the senior leaders in the organization. Self explanatory
clearly document the hierarchy,
line of control,along with the
onsible for governance support research activities and quality improvemefunctions
Self explanatory
at various levels.

zation complies with the laid down and applicable legislations and regulatSelf explanatory The
responsibility of compliance lies
with the first two level of the
onsible for governance address the organizations social responsibility. hierarchy
The Governing board and Head of
the HCO shall willfully develop
social responsibility policy and
accordingly address it.
 izational program, service, site or department has effective leadership. There needs to be a minimum
essential qualification and
ervices of each department is defined. relevant experienceactivity
Each departments of the leader.
is to be
The leader shoul have
predefined. This could be domain
knowledge
documented ofeither
that particular
at individual
ive policies and procedures for each department is maintained. This shall include
department administrative
department level or the HCO
procedures like attendance,
could have a brochure
leave,conduct detailing
replacement etc
tal leaders are involved in quality improvement. Self explanatory
the scope of each department.

s make public the mission statement of the organization. The HCO shall have a mission
statement and the same shall be
s establish the organizations ethical management. displayed
The HCO prominently.
shall function in an
ethical manner.
zation discloses its ownership. The ownership of the hospital
e.g.trust , private ,pulic has to be
zation honestly portrays the services which it can and cannot provide. disclosed.
Self explanatory

zation honestly portrays its affiliations and accreditations. Here portrays implies that the
HCO conveys its
affilations,accreditations for
zation accurately bills for its services based upon a standard billing Self explanatory
specific departments or whole
hospital wherever applicable.
on.
ated individual has requisite and appropriate administrative Self explanatory
ns.
ated individual has requisite and appropriate administrative experience. Self explanatory

sues are an integral part of patient care and hospital

zation has an interdisciplinary group assigned to oversee the hospital Self explanatory
programme.
of the programme is defined to include adverse events ranging from no The HCO shall have a system of
entinel events. reporting of all the
incidents/accidents.
nt ensures implementation of systems for internal and external The HCO has a system in place
system and process failures. for internal and external reporting
of system and process failures.
nt provides resources for proactive risk assessment and risk reduction There shall be
Contingrncy sufficient
plan shall be in place
resources
to deal with the as
kept contingency
situation of to
address
system and the process
risk reduction
failure
activities
anticipated aswithin
and when
the the leaders
proactively
arganization. suggest. The end
result of these shall result of thses
shall result of these shall result in
d regulations, laws and byelaws and requisite facility preventive actions.

ement is conversant with the laws and regulations and knows their A designated management
to the organization. functionary has been given the
nt regularly updates any amendments in the prevailing laws of the land. responsibility to enlist the laws
Self explanatory
and regulation as applicable to
the HCO. This functionary has
ement ensures implementation of these requirements. Self explanatory
identified the appropriate
personnel in the HCO who are
supposed to implement the
respective laws and regulations.
mechanism to regularly update licenses/ registrations/certifications. Self explanatory

ty of patients, their families, staff and visitors.

documented operational and maintenance (preventive and breakdown) Self explanatory

drawings are maintained which detail the site layout, floor plans and fire A designated person maintains
tes. the drawings.
ernal and external sign posting in the organisation in a language Self explanatory
by patient, families and community.
on of space shall be in accordance with the available literature on good Self explanatory
ndian or International Standards) and directives from government

designated individuals responsible for the maintenance of all the A Person in the HCO
management is designated to be
in-charge of maintenance of
ce staff is contactable round the clock for emergency repairs. Self explanatory
facilities.The HCO has the
required number of supervisors
imes are monitored from reporting to inspection and implementation of A andComplaint attendance
tradesmen to mnageregister
the
ctions. is to be maintained
facilities. to indicate the
date and time of receipt of
pment management. complaint,allotment of job and
completion of job.
zation plans for equipment in accordance with its services and strategic Self explanatory. This shall also
take into consideration future
is selected by a collaborative process. requirements.
Collaborative process implies that
during equipment selection there
ent is inventoried and proper logs are maintained as required. is involvement
Self of end user,
explanatory
management , finance ,
engineering and bio-medical
nd trained personnel operate and maintain the equipment. Self explanatory
departments.

are periodically inspected and calibrated for their proper functioning.

The HCO has
weekly/monthly/annual schedules
documented operational and maintenance (preventive and breakdown) of inspection
Self and calibration of
explanatory
equipment which involve
measurement in an appropriate
manner. The equipment in house
ases and vacuum systems. or out sources , Mintaining
ter and electricity are available round the clock. traceability
The HCO shallto national
make or
intenational or manufacturer's
arrangements for supply of
ources are provided for in case of failure. guidelines/standards.
adequate electric
Alternate potablesupply
water and
could be
electricity.
form DG Sets. Solar energy. UPS
sation regularly tests the alternate sources. Self any
and explanatory.
other suitable source.

maintenance plan for piped medical gas, compressed air and vacuum Self explanatory.

he facilities.
zation has plans and provisions for early detection, containment and The HCO has a fire and non-fire
of fire and non-fire emergencies. emergency committee (FNEC) to
zation has a documented safe exit plan in case of fire and non-fire review
Fire exitthe HCOs
plan shallpreparedness.
be displayed
es. The HCO has conducted close
on each floor particularly an to
exercise
the of
lifts. of
Exit hazard
doors identification
should remain
ned for their role in case of such emergencies. In
andcase
risk fire,
analysis designated
(HIRA) and person
open
are on all the
assignedtaken time.
particular work.
accordingly all necessary
are held at least twice in a year Self
stepsexplanatory.
to eliminate or reduce such
hazards and associated risks. The
HCO has:
a) a fire plan covering fore
arising out of burning of
inflammable items, explosion,
electric short circuiting or acts of
negligence of due to
incompetence of the staff on duty;
zation defines and implement its polices to reduce or eliminate smoking. Smoking in public places including
hospitals has been banned in this
has provisions for granting exceptions for patients and families to country.
In view of the law, permission to
smoke within the campus of
hospital may not be granted.
mics and other disasters.
al identifies potential emergencies. The HCO has a documented plan
and procedure for handling the
zation has a documented disaster management plan. situations
The disaster likeplan
sudden
mustrush of
victims
incorporate essential elements ofa)
of
earthquake;
alert code,availability
informationshould
and be
made for availability of medical supplies, equipment and materials Resource b)cards
flood;
emergencies. communication,
according to threat perception.for
action
each of the staff, availability and
aff is trained in the hospitals disaster management plan. Mock drills with
earmarking c)resources,
of train
and accident;
without
patients have to
establishment of we carried out.
command
Only d)civil
nucleus, unrestand
communication
training outside the
exercise
mock HCO
may
drills.
tested at least twice in a year. Self explanatory.
remises;
also be undertaken.
e) major
fire;
. f) invasion by enemy, etc.
Tese plans
materials are identified within the organization. The HCO has identified
and procedures and listed
cover ensuring
the hazardous materials
adequacy of medical supplies, and has
al implements processes for sorting, labelling, handling, storage, a
Thedocumented
HCO has
equipment, procedure
conducted
materials, antheir
identifying
g and disposal of hazardous material. sorting,
exercise storage, handling,
of hazard transportation
trained personnel, identification
transpirations,
and
aids,risk analysis
communication disposal
(HIRA)
aids and
egulatory requirements are met in respect of radioactive materials. The appropriate
mechanism, personnel
andhandling
method of forin the
associated with
mock drill methodology.
HCO
managing are aware about
spillages and the rules
adequate
hazardous materials and
and regulations
training of the such as the
personnel for these
plan for managing spills of hazardous materials. Self explanatory.
according taken all necessary
Atomic
jobs. Energy Act, the norms
steps to eliminate or reduce such
issued by Atomic Energy
cated and trained for handling such materials. hazards and associated risks. The
Self explanatory.
Regulatory Board (AERB) and the
HCO has ensured display of
directives form the Health Physics
Material Safety Data Sheets
Division of Bhabha Atomic
(MSDS) for all hazardous
environment. Research Center (BARC).
materials and has according
arranged associated training of
al has a safety committee to identify the potential safety and security The HCO has a duly constituted
personnel who handle such
safety committee which has
materials. The situational hazards
identified the potential safety and
ttee coordinates development, implementation, and monitoring of the The also HCO
need ensures that the
to be covered in above
HIRA
security risks to staff, patients and
and policies. committee
so that anyfunctions
emergency on situation
a regular
visitors.
basis
arisingtoout coordinate
of process development,
of storing,
ety devices are installed across the organization and inspected Self explanatory
implementation
handling, storage, and monitoring of
transportation
.
the
andplans
disposalandofpolicies.
such hazardous
materialstoare
pection rounds to ensure safety are conducted at least twice in a year in Rounds be met effectively.
carried out by
e areas and at least once in a year in non-patient care areas. Sharp committee.
safety bends in passages,
protruding or dangling elements in
reports are documented and corrective and preventive measures are Self
passageexplanatory.
ways, sudden swing of
. swing doors, ramps, entry and exit
safety education programme for all staff. fromexplanatory.
Self lifts, are situations which
need to be taken care of. See
FMS 5 also. The HCO has the
requisite training need handling
and those trainings are included
in the HCO training calendar.
ning.
zation maintains an adequate number and mix of staff to meet the care, The staff should be
nd service needs of the patient. commensurate with the workload
and the clinical requirement of the
d job specifications and job description are well defined for each The content of each job should be
patients.
staff. well defined and the
qualifications, skills and
experience required for
performing the job should be
clearly laid down. The job
description should be
commensurate with the
qualification.
zation verifies the antecedents of the potential employee with regards to Self explanatory
gligence background.

ospital environment.
member, employee, student and voluntary worker is appropriately The organizations staff including
the organizations mission and goals. the outsourced staff should be
aware and should correctly
member is made aware of hospital wide policies and procedures as well The organizations.
interpret the missionstaffandincluding
goals of
department / unit / service / programmes policies and procedures. the outsourced
the organization. staff should be
aware and should correctly
interpret the policies and
member is made aware of his/her rights and responsibilities. The HCO procedures
operating shall define ofthethe
same in
consonance with statutory
organization as well as that of the
es are educated with regard to patients rights and responsibilities. requirements
The employees
department/ and the same
should
unit/ service shall
beinable to
which
be communicated
identify and report to the
violation
he is performing the requisite of
employees.
patient
duties. rights as and when the
es are oriented to the service standards of the organisation. The HCO shall develop
same occurs.
benchmarks for different services
being provided. This shall be
opment of the staff. based on the HCOs

ted training and development policy exists for the staff. A training manual incorporating
the procedure for identification of
o occurs when job responsibilities change/ new equipment is training needs,
The training the training
should focus on the
methodology,
revised job responsibilities as of
documentation well
training,
as on thetraining assessment,
newly introduced
mechanisms for assessment of training and development programme This
impactshall
equipment include
of training boththe
and include
and technology. training
In
both
case of new equipment thetraining.
internal
calendar and
should external
be prepared.
For external
operating byshould
staff the HCO itself or
receive
pecific job duties or responsibilities related to safety. by the external agency which
training on operational as well as
imparted the training.
daily maintenance Impact of
aspects.
ained on the risks within the hospital environment. training
The HCO at shall
user define
level should also
such risks
be documented.
which shall include patient,
ers can demonstrate and take actions to report, eliminate / minimize visitors and employee related
Self explanatory.
risks.

ers are made aware of procedures to follow in the event of an incident. Self explanatory.

rocesses for common problems, failures and user errors exist. The HCO has a defined
procedure for reporting of these
events.
exists as an integral part of the human resource

mented performance appraisal system exists in the organization. Self explanatory.

yees are made aware of the system of appraisal at the time of induction. Self explanatory.

ce is evaluated based on the performance expectations described in job Self explanatory.

sal system is used as a tool for further development. Self explanatory. This can be
done by identifying training
requirements and accordingly
ce appraisal is carried out at pre defined intervals and is documented. Self explanatory.
providing for the same (wherever
possible)

atement of the policy of the organization with regard to discipline is in Self explanatory.
nary policy and procedure is based on the principles of natural justice. This implies that both parties
(employee and employer) are give
an opportunity to present their
and procedure is known to all categories of employees of the Self
caseexplanatory.
and decision is taken
n. accordingly.
nary procedure is in consonance with the prevailing laws. Self explanatory.

provision for appeals in all-disciplinary cases. The HCO shall designate an

appellate authority to consider
appeals in disciplinary cases.

yees are aware of the procedure to be followed in case they feel For definition of grievance
handling refer to glossary. The
s procedure addresses the grievance. HCO has a written procedure for
Self explanatory
handing grievance of employees.

taken to redress the grievance. Self explanatory

oyment medical examination is conducted on all the employees. Self explanatory. This shall
however be in consonance with
lems of the employees are taken care of in accordance with the the
Selflow of the land.
explanatory. The shall be in
ns policy. consonance with the low of the
land and good clinical practices.
alth checks of staff dealing with direct patient care are done at-least Self explanatory. The result
r and the findings/ results are documented. should be documented in the
personal file.
al health hazards are adequately addressed. Self explanatory.

es are maintained in respect of all employees. Self explanatory.

al files contain personal information regarding the employees Self explanatory.

n, disciplinary background and health status.

of in-service training and education are contained in the personal files Self explanatory.

es contain result of all evalutions. Evaluations would include

performance appraisals, training
assessment and outcome of
health checks.
entials (education, registration, training and experience)
on.

fessionals permitted by law, regulation and the hospital to provide The HCO identifies the individuals
e without supervision is identified. who have the required
qualification (s), training and
ion, registration, training and experience of the identified medical Self explanatory.
experience Updation
to provide is done
patient care
als is documented and updated periodically. after acquisitionwith
in consonance of new skills
the law.
and/or qualification.
ormation pertaining to the medical professionals is appropriately verified The HCO shall do the same by
ble. verifying the credentials from the
organization which has awarded
the qualification/training.
it and treat patients and provide other clinical services
 fessionals admit and care for patients as per the laid down policies and The HCO shall identify as to what
n procedures of the organization. each medical professional is
authorized to do.
s provided by the medical professionals are in consonance with their Self explanatory.
n, training and registration.

te services to be provided by the medical professionals are known to Self explanatory.

ll as the various departments/ units of the hospital.

entials (education, registration, training and experience)

ion, registration, training and experience of nursing staff is documented The HCO identifies the individuals
d periodically. who have the required
qualification (s), training and
ormation pertaining to the nursing staff is appropriately verified when The HCO shall do the same by
experience to provide nursing
verifying the credentials from the
care to patients in consonance
organization which has awarded
with the law. Updation is done
the qualification/training6t
after acquisition of new skills
work assignments to all nursing staff members and/or qualification
nts.

work assigned to nursing staff is in consonance with their qualification, The HCO shall identify as to what
d registration. each nurse is authorized to do.
s provided by nursing staff are in accordance with the prevailing laws Self explanatory
ions.
te services to be provided by the nursing staff are known to them as Self explanatory
various departments / units of the hospital.

are providers, management of the organization as well

ation needs of the organization are identified and are appropriate to the The HCO has manual and/or
e services being provided by the organization and the complexity of the electronic Hospital Information
n. System and/or Management
Information System information
d procedures to meet the information needs are documented. A
to policy document
all concerned is available
stakeholders.
where the HIS/MIS is described.
ies and procedures are in compliance with the prevailing laws and Self explanatory.

ion management and technology acquisitions are in accordance with The HCO shall define the needs
and procedures. for software and hardware
solutions as per the information
zation contributes to external databases in accordance with the law and The HCO shall define the system
requirement and future
of releasing the relevant
necessities.
information to the authority as per
data. statutory norms.

data collection are standardized MIS/HIS data are collected in

standardized format from all
resources are available for analyzing data. The HCO shall in
areas/services make available
the HCO.
men, material, space and budget.
d procedures are laid down for timely and accurate dissemination of Self explanatory.

d procedures exist for storing and retrieving data. The HCO shall define data
management policy and ensure
adequate safeguards for
protection of data, wherever
physical of electronic data in
stored.
 clinical and managerial staff participates in selecting, integrating and There is a multi-disciplinary
committee which is responsible
for the appropriate selection of
ry patient. indicators, measurement of trends
and initiating action wherever
cal record has a unique identifier. required.
This shall also apply to records on
digital media.
n policy identifies those authorized to make entries in medical record. HCO has a written policy stating
who all con make entries.
cal record entry is dated and timed. Self explanatory.

of the entry can be identified. This could be by writing the full

name or by mentioning the
ts of medical record are identified and documented. employee code number,
The HCO identifies whichwith the
help of stamp, etc.
documents form part ofIn case
theof
electronic
medical based records,
provides an up-to-date and chronological account of patient care. The HCOrecords,
authorized shall documents
decide
e-signature the and
format
provision
implements
for the the
same.
as per statutory requirementsin
maintaining continuity
the
mustmedical records.
be dept.

al record contains information regarding reasons for admission, Self explanatory.

nd plan of care.
nd other procedures performed are incorporated in the medical record. Self explanatory

nt is transferred to another hospital, the medical record contains the Self explanatory. It is mandatory
sfer, the reason for the transfer and the name of the receiving hospital. to mention the clinical condition of
the patient before transfer is
effected.
al record contains a copy of the discharge note duly signed by Self explanatory
and qualified personnel.
death, the medical record contains a copy of the death certificate Self explanatory. The HCO
he cause, date and time of death. provides the death certificate as
per the international Certification
a clinical autopsy is carried out, the medical record contains a copy of Self explanatory.
of Cause of Death.
f the same.
ers have access to current and past medical record. The HCO provides access to
medical records to designated
health care providers (those who
ntegrity and security of information. are involved in the care of that
patient).
d policies and procedures exist for maintaining confidentiality, securityThe HCO shall control the
y of information. accessibility to the MRD
d procedures are in consonance with the applicable laws. department. It shallofensure
This is the context Indianthe
usage of tracer card for
Evidence Act, Indian Penal Code
movement
and physical
Code of ofMedical
the file IEthics.
and out of
s and procedures incorporate safeguarding of data/ record against loss, For records the HCO
the MRD so as to maintain
and tampering. shall ensure that there is
confidentiality, security, safety and
adequate pest and rodent control
al has an effective process of monitoring compliance of the laid down The HCOofcarries
integrity out regular
information.
measures. For electronic data
audits/rounds
The is applicable to check
for both manual
there should be protection against
al uses developments in appropriate technology for improving, compliance
and electronic
The HCO shall with policies.
records.
virus/trojans andreview
also aand update
proper
ity, integrity and security. its technological
backup procedure. features
To preventso as to
improve
tampering, confidentiality, integrity
for physical records
health information is used for the purposes identified or as required by The
and HCO shall
security define the
access shall ofbeinformation.
limited only to the
disclosed without the patients authorization. procedure for privileged
concerned health care provider. In
communication.
ted procedure exists on how to respond to patients/ physicians and Self explanatory.
electronic format In thisthis context,
could be
c agencies requests for access to information in the medical record in the
done release of information
by adequate passwords. in
e with the local and national law. accordance with the Code of
Medical Ethics 2002 should be
kept in mind.
information.
 d policies and procedures are in place on retaining the patients clinical The HCO shall define the
ta and information. retention period for each category
s and procedures are in consonance with the local and national laws of medical
Some records:
of the relatedOut-patient,
laws in this
ions. in-patient and
context are CodeMLC.
of Medical
Ethics 2002, Consumer Protection
on process provides expected confidentiality and security. This is applicable
Act 1987 for both
and relevant manual
state
and electronic system.
legislation, if any.
ction of medical records, data and information is in accordance with the Destruction can be done after the
olicy. retention period is over and after
taking approval of the competent
authority.

al records are reviewed periodically. Self explanatory.

uses a representative sample based on statistical principles. The HCO shall define the
principles on which sampling is
based. For example, simple
is conducted by identified care providers. Self explanatory
random, systemic random
sampling etc. Review shall be
focuses on the timeliness, legibility and completeness of the medical based on conditions of clinical
Self explanatory
and/or community importance,
total discharges including deaths.
process includes records of both active and discharged patients. Self explanatory
Total indoor patients, etc.

points out and documents any deficiencies in records. Self explanatory

corrective and preventive measures undertaken are documented. Self explanatory

icant difference between the self
completion of Pre assessment.

Remark

The needs of the community should

be considered especially when
planning a new HCO or adding new
services
Claims of services and expertise
being available should actually be
available. Display in the form of
brochures only is NOT acceptable.
Display should be at least bi-lingual.

Admission must be authorized by a

doctor.
GS1 standards in barcoding can be
used to identify and track the
patient within and outside the
hospital.

Also refer to AAC 3.

Orientation can be provided by

documentation/ training.

These patients include those who

have come to the emergency but
need to be transferred to another
Also refer to COP
organization 3. already
or those
admitted but who now require care
A
in doctor
anothershould accompany
organization it alsoan
unstable patient. being shifted for
includes patients
diagnostic
This tests. patients being
shall include
Also refer toboth
transferred COPfor3.diagnostic
and/or therapeutic purpose.

With regards to expected costs, an

estimate could be prepared and the
same given to the patient. This
estimate shall be prepared the basis
of the treatment plan. It could be
prepared by the OPD/Registration /
Admission staff in consultation with
the treating doctor.
Also
In refer
case of to HRM 10a.
packages it should clearly
state the terms and conditions and
also the exceptions if any.
This could be done by the treating
doctor and/or dietician.
For definition of plan of care and
clinical audit refer to glossary.
This could also be done through
booklets/ patient information leaflets
etc. e.g. diabetes, hypertension.

Every patient shall be reassessed at

least once every day by the treating
The nursing staff can document
doctor.
patient's vitals.

For example a cardiac care HCO

must necessarily have facilities for
cardiac enzyme testing.
For adequancy of qualification refer
to NABL. 112.
The policy should be in line with
standard precautions. The disposal
of waste shall be as per the
The turnaround time could be
statutory requirements (Bio-medical
different tests and could be decided
waste management and handling
based
If on practical
it is not the natureto of test andthe
establish
rules, 1998.)
critically ofreference
biological test. interval for a
The authority
particular for control
analyte, and the
the laboratory
methods for control,
should carefully of such
evaluate the
outsourcing
published data shall
forbe
itsdefined and
own reference
documented.
intervals.

This could be as per Occupational

Health and safety Management
System - OHSAS 18001:2007.
All the statutory requirements are
met with, like BARC clearance,
dosimeters,
For example,lead sheets, lead
a neuro-science
aprons,shall
centre signages, display
have CT as per
and MRI.
PNDT act, reports to competent
authority, etc.

The defined timeframe could be

different for different type of tests.
The HCO shall define the critical
results which require immediate
attention
MOU should of clinician e.g. ectopic
be available for all
pregnancy.
outsourced activities. See AAC 7 f
also.

This could be done on the basis of

entries either on case sheet or
lectronic patient records (EPR).
For example 1) Nurses handling
taking over notes. 2) Transfer
summary.

Referral could be for opinion, co-

management, take over. It could be
graded into immediate, urgent
priority or routine categories.

This policy could address the

reasons of LAMA for any possible
corrective and/or preventive action
by the HCO.

The instruction shall be in a manner

that the patient can easiliy
understand and avoid use of
medical terms e.g. BID, TID etc.
This could be in the form of whiat
medicines to take, when to consult
a doctor or bow to seek medical
help and contact number of the
hospital/doctor.
For example, consent before,
surgery, providing first aid to
emergency patients and police
intimation in cases of medicolegal
cases.

For electronic records the

organization shall ensure that the
same in captured in the system.

The clinician in charge implies the

treating doctor.
For definitions of evidence based
medicine and clinical practise
guidelines, refer to glossary.

Also refer to AAC5a.

Poisoning cases, road traffic

accidents, patients with coronary
disease,
This shouldetc,be
shall be deaft
based as per
on good
hospital policies and procedures.
clinical practices. For triage refer to
glossary.

Also refer to AAC 14 and 15. The

discharge note shall incorporate
salient features of investigations
done and treatment.

In case a rapid turn around of the

ambulance in required (where
checking may not be possible prior
to dispatch), only the medications
used could be topped up or the
HCO could keep an additional set of
drugs as stand by.
The document could be displayed
prominently in critical areas such as
emergency. ICU, OT etc.

This could be done using the pre-

defined procedural checklist and by
monitoring if the prescribed activity
has been performed properly and in
the right sequence.
During subsequent resuscitations it
is preferable that implementation of
these actions is noted and training
be modified if necessary.

A good reference guide is the NABH

standards for blood banks.

Also refer to PRE3 d and e.

Consent for blood transfusion
during surgery shall be taken
This could be
separately. in the form
It should of clubbed
not be
booklet/leaflet.
with the surgery consent form.
Records of the same should be
available.
For transfusion reactions refer to
glossary.

A good starting point could be

various national and international
critical care society guidelines.

Good clinical practices include

monitoring infection rates, re-
admission rates, re-intubation rates
etc.

Refer to disability act, mental act.

For example, play room for children,

anti-skid tiles for elderly, ramps with
railings for disabled, etc.
Refer to PRE 3e.

Records of the same should be

available.

The display should be in a

prominent location. Refer to AAC 1b
also.

It is preferable that this is done by a

dietician.
The display should be in a
prominent location. Refer to AAC 1b
also.
There are national and international
guidelines available for the cases of
neonates by WHO, etc. The
hospital should take them into
account.
For example, playroom and breast
feeding room.
The same needs to be documented.

Examples could include

identification tag, unsupervised
phototherapy leading to nurns, etc.
For example, growth chart,
immunisation chart, etc. This
(origional/copy) should be a part of
the medical record. The education
should preferably be in the
language
Technicianthat thenot
shall family
administer
understands.
sedation

In addition, certain other parameters

may be monitored on a case to
case basis.

For addition of anaesthesia refer to

glossary. The standard is not
applicable for local anaesthesia.

The plan should mention the type of

anaesthesia, the drug(s0 to be used
for induction and the drug to be
used for maintenance ..

Also refer to PRE 3d.

The same should be documented.

This shall be done by the operating
surgeon.
Also refer to PRE 3d.

The HCO should be able to

demonstrable methods to prevent
these events e.g. identification tags
Also
badgets,refercross
to HRM 11b. etc. Refer to
checks,
WHO "Safe surgery saves lives"
initiative.
If it is documented by a person
other than the chief operating
surgeon the same shall be
The plan shall include
countersigned advice
by the chief on IV
surgeon
fluids, medications,
within 24 hours. care of wound,
nursing care, observing for any
complication, etc.

For air conditioning of OT OT refer

to the glossary
All the post operative patients shall
be screened for the same.

Records of the same should be

available.

For example cancer pain,neuralgias

and arthralgia.
Pain assesssment and mangement
could be carried out using a pain
rating scale.
For example,provision of ante natal
and post natal exercises could form
a part of obstetric rehabilitaton
programme.

For example, International

conference on harmonization (ICH)
of Good clinical practice (GCP) and
Refer to schedule
declaration Y of somerset
of Helsinki Drugs and
cosmetics act and ICMR guidelines.
(1996) and Ethical Guidelines for
Biomedical Researchon Human
Subjects (ICMR-2000).

For example, diabetic diet high

protein diet,total parenteral nutrition,
etc.
Records of the same should be
available.

Relevant legislations include Drugs

and cosmetics Act food and Drugs
and Psychotropic substances
Acts,Drugs and gagical Remedies
(Objectionable Advertisement) Act,
etc.
For example, pharmaco-
therapeutic committee.

For example, local purchase.

Vaccines should preferable be kept

in vaccine refrigerators (Ice Lined
Refrigerator).
The organization shall follow
inventory control practics like first in
and first out , ABC, etc.

the organization can folllow a

method of storing drugs by generic
name in an alphabetical order to
itaddress
is preferable that .the HCO has a
this issue
24 hours pharmacy.

refer to MOM 1a
The organization can explore the
possibility of writing orders in block
letters so that the issue of legibility
is adderessed.

This shall be done at alll levels e.g.

pharmacy, ward, etc
This is applicable to all dispensing
areas wherein medicines are
dispensed either as cut strips or
from bulk containers.

Refer to statutory requiremenys. in

addition to doctors, nursing staff
may also administer.
applicable for parenteral drugs

Identification shall be done by

unique identification number( eg.
hospital number/IP number,
etc)with/without name

the records shall reflect the actual

administration.For example, if brand
Y was given in place of brand
for example,
X(same slf administration of
gnerically)the
insulin.
documentation shall be of brand Y.
Similarly if the order was for a tablet
of 250mg but the administsation
was1/2 a tablet of 500mg the latter
shall be documented.
Refer to glossary for "adverse drug
event"

This refers to the layout/location of

radiaton waste pipes,delay waste
pipes, delay tanks, etc.
For an example of "patient
responsibility refer to glossary.

Examples of this include falling from

the bed/trolley due to
negligence,assaultt,repeated
Example of this include
internal examinations,manhandling
MTP,patients
etc. of tubeculosis or any
other infections disease
In case of refusal the treating doctor
shall explain the consequences of
refusal of consent
Informed treatmentof and document
the patient is
the same for doing HIV test.
mandatory
This cannot include conset for
invasive procedures for invasive
procedures or other procedures for
The policy for HIV testing should
which consent is required as per
follow the national policy on HIV
this standard.
testing (NACO).

For example, hand washing and

avoiding overcrowding near the
patient.

Reference documents could include

Prevention of hospital acquired
infections- a practical guide (2nd
edition, 2002) by WHO, CDC
Guidelines and Manual for control
of
ForHospital for controlofofthe
the composition Hospital
team
Associated Infections,
refer to WHO, APIC and CDCStandard
Operative Procedures by NACO,
guidelines.
Ministry of Health and family
Welfare, Govt. of India.
It is preferable for them to have
undergone a short term training
programme on infection control
nursing by a recognized institute.

Refer to glossary for standard

precautions.

The HCO could also refer to

international guidelines while
framing the policy. Use of WHO
reference document Global strategy
for containment resistance,
2001[WHO/CDC/CSR/DRS2001.2]c
an be a good starting point.
Refer to glossary for air conditioning
in OT.
Standard precautions must be
adhered to.

The HCO should use a judicious

mix of active and passive
surveillance.

Refer to glossary for notifiable

diseases.
A simple calculation of infected
patients (numerator) provides only
limited information which would be
This is applicable even if the
difficult to interpret. Risk factor
housekeeping services are
analysis would require infected and
outsourced.
non infected patients, in order to
calculate infection and risk adjusted
rates.

The HCO may extend this activity to

asymptomatic catheterised patients
also. It is preferable
It is preferable to usetoCDC
also. It is
preferable
definitions. to use CDC definitions.
It is preferable to use CDC
definitions.
It is preferable to use CDC
definitions.
This could be in the form of a
bulletin/newsletter.
Optimal hand hygiene requirements
includes large washbasins, hands
free control, soap and facility for
drying hands without contamination.
The hand hygiene the hand hygiene
Refer to glossary
guidelines shall beofr
based on WHO
isolation/barrier
2007 guidelines nursing.
on patient safety
(website: www.who.int/patientsafety)

To define as to what constitutes an

outbreak the HCO should have
baseline rates.

The HCO shall provide for the same

in all areas where sterilization
activities are carriedeach
WHO recommends out. Itload
is to
preferable to have separate
have a number, content description, areas
for
tempreceiving,
and timewashing, cleaning,
The HCO
packing, couldrecord achart,
have sterile
sterilization, batchstorage
physical/chemical
processing system tests
with daily,
date andweekly
and issue.test, steam processing,
biological
machine number for effective recall.
and ETO processing.

For example, gloves and masks,

protective glasses, gowns, etc.

Doctors also need to be trained.

For example, hepatitis B vaccination
and PEP for needle stick injury.

For examples, core committee,

quality improvement committee,
Etc.
Refer to AAC 8, AAC 11, COP 6,
COP 12 and HIC 2 also.
Refer to guidelines for
documentation.

For example accreditation co-

ordinator, quality management
representative, quality manager.

Refer to glossary for definition of

Risk management and Quality
improvement.

This could be bone throught regular

training programme or printed
materials
The assessors shall be either
trained internally or externall in
NABH standards. They shall assess
areas independent of their area of
work
Reporting errors need to be
captured. It is better if the
organization caputers these errors
as errors picked up before
dispatching the reports and errors
picked after the dispatch of reports.
This includes transcription errors
also.
Re-dos include tests which needed
to be repeated in view of poor
sample or improper positioning and
in case of radiology also includes
radiology also include films
wastage.To capture co-relation it
becomes mandatory that all
investigation forms have a
provisional diagnosis/relevant
clinical details written on them .The
HCO could decide as to which tests
will be monitered.To capture
adherence to safety precautions
the organization needs to do a
random check of all employees per
month (working in these areas and
including all categories of staff) and
capture data.

Adverse anaesthesia events include

events which happen during the
procedure like hypoxia, arrhythmias,
cardiac arrest etc.

Wastage includes blood products

found unfit for use

Missing records include records

within the retention
Refer to HIC 4

Refer to ICMR guidelines and GCP

for reporting time of serious adverse
events.

For example data can be collected

to study the reasons for Re Dos in
surgical patients
Data could be represented
graphically e.g. bar chart,pie chart,
etc.
For example , once the reasons for
Re Dos have been analysed and
preventive and corrective measures
undertaken then data can be
collected to confirm that reductions
have occurred in the incidence of
Re Dos.
Local purchase implies drugs
purchased outside the formulary.
For example, tax , EPF, notifiable
diseases,births and deaths,PNDT
act, AERB guidelines etc.

Mock drills include fire,nono-fire and

disaster management.
Refer to glossary for definition of
risk management
Waiting time implies the time taken
from the time that the patient
registers to the time taken for
assessment to be done by the
doctor/ diagnostic procedure to be
performed. Time taken for
discharge implies the time from
which the doctor writes for
discharge to the time for final
clearance
The bedget could be earmarked
based on previous years spending.
If
Fornoexample
data is available the HCO
,Root cause analysis,
could
FMEA, project evalution by
make a beginning and review
earmarking(PERT),
technique a budget but reviewing
Critical path it
at the end
method of 6 months
(CPM), Controlto makeetc.
charts any
necessary modifications.
These could be members of the
core committee/quality assurance
committee, etc.
The auit shall encompass all
aspects of care including clinical
and nursing.

The HCO could use a checklist with

the predefined parameters and the
audit findings could be recorded on
This should preferably be done
this sheet.
based on root cause analysis.

Refer to Glossary for definition of

sentinel events.

For definition of mission refer to

glossary.
Refer to glossary for strategic and
operational plans.Stakeholders
include the community the
organization serves.

Senior leaders include the first two

rungs of the organogram
It is not only the Head of the HCO
but the members of the Board of
governors (where applicable) who
This shall include central
need to support this.
legislations (e.g. Drugs and
Cosmetics act, MTP act,PNDT
For example,free
Act,1996), camps
Bio medical outreach
waste act,
programmes,adoption of villages,
Air (Prevention and control of
PHCs etc.Act, 1981, Atomic Energy
pollution)
Requlatory Body Approvals, License
under Bio-medical Manaement and
Handling Rules, 1998, respective
state legislations (Maharashtra
Maintenance of clinical Records act,
clinical establishment of west
Bengal) and local regulations (e.g..
building byelaws).
For example,nephrology
department could do all activities
like
It could be common for the entire
biopsy,shunts,listulas,dialysis(haem
HCO.
o, CAPD),etc.
To effectively implement this each
department could have its
department objectives/ key
performance indicators and the
responsibility of achieving them
could be that of
For definition of the leader.
mission refer to
glossary.
A good reference guide is code of
medical ethics 2002 published by
MCI.
The disclosure could be in the
registration certificate/ quality
manual , etc. implies that the that
Here portrays
HCO conveys to the patients clearly
what it can and cannot provide. The
services that it cannot provide could
also be conveyed verbally. Refer to
Also
AAC refer
1 alsoto PRE 5. The tariff could
be devised by a tariff committee.

This implies to the individual looking

after the day to day Board of
Governors.
AppropriateAppropriate implies
implies administrative
qualification in hospital
experience in a HCO.
management/ administration.

The group could have a mix of

administratorsgineers, doctors and
nurses, Refer to glossary for
Refer to glossary
definition of safetyfor definition of
programme.
adverse events and sentinel events.
Reporting incident/accident should
for example, MRI machine, of the
not just be based on severity of the
HCO breaks down. In this case
incident. In fact, all incidents must
internal reporting is to be done to
be reported.
Refer to glossary for definition
reporting is to be done to CEO ofand
risk definition of risk assessement
external reporting to be done o the
and risk reduction.
patients.

For example, the protection

guidelines given in national building
code of India,relevant state and
local body regulations (Kerala state
building rules).
Refer glossary for definition of
preventive and breakdown
maintenance.

These signages shall guide patients

and visitors. It is preferable that
signages are bilingual. Statutory
For example Indian standards (IS
requirements shall be met.
12433) formulated by Bureau of
Indian standards (for 30 and 100
bedded hospitals and other
standards), IS 10905 for basic
requirements for general hospital
buildings.

For water quality, refer to IS 10500.

The National Building Code is a

good reference guide.
Refer to National Disaster
Management Authority guidelines.
Quantity of resources i.e. medical
stores etc. should match with the
expected workload.

This is only the minimum frequency

and this may be increased.

The hazardous materials could be

identified as per part II of
manufacture, Storage and Import of
Hazardous Chemical (Amendment)
Rules, 2000.
In addition Biological materials like
blood, body fluids and
microbiological cultures, mercury,
nuclear isotopes, medical gases,
LPG gas, steam, ETO etc are some
of the other common hazardous
materials.

The safety committee must include

representatives form facility
management, clinicians,
administrator, nursing and
paramedical staff.
It is example,
For preferablegrabthat bars,
the HCO
bed rails,
conducts
sing an exercise
posting, of Hazard
safety belts in
Identification
stretchers andand Riskchairs,
wheel Analysis
alarms
During these rounds potential safety
(HIRA)
both and and
visual accordingly
auditorytakes
whereall
risks are identified.
necessary steps
applicable, warningto eliminate
signs likeof
reduce
radiation such
or hazards
biohazard,
Before and after evidence and
call may
bells,befire
associated
safety risks.
devices
maintained. etc.

A good reference could be the MCI

and INC guidelines.
Refer to glossary for definition of job
description and job specification.
This report could be got firm the
district magistrate (s) of the district
(s) where the employee has served
earlier and/or from the previous
employer.
It could
This alsobebedone
could obtained fromofthe
as a part the
regulatory bodies
induction training . like MCI (Good
Conduct Certificate).
This could be done as a part of the
induction training and the same
could be provided in the form of a
booklet. In also reinforce the correct
This could be of
interpretation done as a and
policies part of the
induction
procedures.training and the same
could
For be provided
patient in the
right refer to form
PRE of2. a
booklet.
The employees should be trained to
implement the service standards of
the organization.

The training shall be for all

categories of staff including doctors
and outsourced staff (wherever
applicable).

For example, fire and non fire

emergency, needle stick injury, etc.
Staff should be able to practically
demonstrate actions like taking care
of blood spills, medication errors
The staff should
and other adversebeevent
able to intimate
reporting
the sequence
systems. of events the they will
undertake in the eventuality of
Reporting processes could be
occurrence of any adverse event.
checked form time to time by the
management to ensure their
implementation.

For definition of performance

appraisal refer to glossary.
To be incorporated in the service
booklet and included in the
induction training.
For definition of job description refer
to glossary.

This shall be done at least once a

year.

For definition of disciplinary

procedure refer to glossary.
This could be in the form of service
rules.
Refer to relevant labour laws and
CCS (CCA) rules.
Appellate authority should be higher
than the disciplinary authority.

The HCO could address all points in

HRM2, HRM4, HRM5, HRM6

For example, performing pre-

employment HIV testing is illegal.
For example, employee health and
safety policy.
The HCO could define the
parameters and it could be different
for different categories of personnel.
For
The definition
HCO could of also
occupational
identify health
hazard
competentreferindividuals
to glossaryto perform
the same.

For definition of credentialing refer

to glossary.

A good reference could be MCIs

website.
For example, radiotherapy can only
be give by a radiation oncologist.

Where authorization is provided on

the basis of training the HCO shall
maintain a copy of the training
The HCO
record andcould
verifyincorporate
it. this in
the brochure itself.

Refer to Indian Nursing Council Act,

1947

For example. An infection Control

Nurse should have had requisite in-
house / external training and
experience and the aptitude and
knowledge to perform the tasks
required of her.

For example, daily census report,

utilization rates, etc. Also refer to
CQI 2 and CQI 3.

Some of these include:-IT Act 2000

for computer based records, PNDT
Act for relevant details of all patients
undergoing ultrasound, Code of
Medical Ethics, 2002, RTI Act 2005,
For
etc. example, sending
Relevant sate birth and
legislation e.g.
death statistics,
Maintenance notifiable
of Clinical diseases
Records Act
(refer
(MOCRA)to glossary) and pulse polio
in Maharashtra.
programme.

This is in the context of frequency of

capturing data namely daily, weekly,
monthly quarterly, yearly etc.
(Statistical bulletin).
The organization could decide on
which data needs to be shared with
whom and also the modalities (e.g.
Storage could be physical of
memos, circulars etc.) for
electronic. Wherever electronic
dissemination of such data.The
storage is done the HCO shall
organization could decide on which
ensure that there ate adequate
data needs to be shared with whom
safeguards for protection of data.
and also the modalities (e.g.
memos, circulars etc.) for
dissemination of such data.
For example, CR number, hospital
number, etc. GS1 standards and
numbering
This could besystem can category
different be used to of
identify andfortrack
personnel the patient
different entries,record
but it
within and
shall be outside
uniform the hospital.
across the HCO.
For records on electronic
For example. Progress record media byit is
preferable
doctor and that the date and time is
medication
automatically
administrationgenerated by the
chat by nurse.
system.
For example, admission order, face
sheet, IP sheet, discharge
summary, doctors order consent
form etc.

For definition of plan of care refer to

glossary. After the initial visit it shall
at
Alsoleast have
refer a provision
to COP 12f. diagnosis.
The final diagnosis (IP) must be is
as per ICD 10.
If the patient has been transferred
at his/her request a note may be
added to that effect. In such
instances the name of the receiving
Discharge note is the same as
hospital could be the name the
discharge summary. Also refer to
patient15.desires to go to. However, if
AAC
Alsopatient
refer tohas
AAC 15 g.
the been transferred by
the HCO it shall have an
acknowledgement form the
For definition of autopsy refer to
receiving hospital.
glossary.

For example, privileged

communication.
It is preferable that softwares when
used shall be validated and duly
authenticated.
Refer to IMS 7.

For example, moving form physical

to electronic format, remote backup
of data, etc.
Special care should be taken in
medico-legal cases.
The HCO could define the
periodicity.

The HCO shall identify and

authorize such individuals.

An adequate mix of both active and

discharged patients should be used.
For example, missing final
diagnosis, absence of OT motes in
an operated patient, etc.