98815281 nabh 3rd edition presentation
TRANSCRIPT
![Page 1: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/1.jpg)
1
NABH Standards – Third Edition(Applicable from July 1st, 2012)
• 10 Chapters
• 102 Standards
• 636 Objective Elements
Updated by Anuj Jindal [[email protected]]iKure Knowledge Services
www.ikureknowledge.blogspot.in
![Page 2: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/2.jpg)
2
Standards and Objective Elements
• A standard is a statement that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care
• Objective element is a measurable component of a standard
• Acceptable compliance with objective elements determines the overall compliance with a standard
![Page 3: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/3.jpg)
3
Section I:Patient-Centered Standards
Chapter 1 Access, Assessment and Continuity of Care (AAC)
Chapter 2 Patients Rights and Education (PRE)
Chapter 3 Care of Patients (COP)
Chapter 4 Management of Medications (MOM)
Chapter 5 Hospital Infection Control (HIC)
![Page 4: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/4.jpg)
4
Section II: Management-Centered Standards
Chapter 6 Continuous Quality Improvement (CQI)Chapter 7 Responsibilities of Management (ROM)Chapter 8 Facility Management & Safety (FMS)Chapter 9 Human Resource Management (HRM)Chapter 10 Information Management Systems (IMS)
![Page 5: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/5.jpg)
5
NABH STANDARDS
![Page 6: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/6.jpg)
6
Chapter 1ACCESS, ASSESSMENT
AND CONTINUITY OF CARE (AAC)
![Page 7: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/7.jpg)
7
AAC.1The organization defines and displays the services that it
provides.
Objective Elements
a) The services being provided are clearly defined and are in consonance with the needs of the community.
b) The defined services are prominently displayed.
c) The staff is oriented to these services
![Page 8: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/8.jpg)
8
AAC.2The organization has a well defined registration and admission process.
Objective elements
a) Documented policies and procedures are used for registering and admitting patients.
b) The documented procedures address out-patients, in-patients and emergency patients.
![Page 9: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/9.jpg)
9
Cont…
c) A unique identification number is generated at the end of registration.
d) Patients are accepted only if the organization can provide the required service.
e) The documented policies and procedures also address managing patients during non availability of beds.
f) The staff is aware of these processes.
![Page 10: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/10.jpg)
10
AAC.3There is an appropriate mechanism for transfer or referral of patients.
Objective elements
a) Documented policies and procedures guide the transfer-in of patients to the organization.
b) Documented policies and procedures guide the transfer-out/referral of unstable patients to another facility in an appropriate manner.
![Page 11: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/11.jpg)
11
Cont…
c) Documented policies and procedures guide the transfer-out/referral of stable patients to another facility in an appropriate manner.
d) The documented procedures identify staff responsible during transfer/referral.
e) The organization gives a summary of patient’s condition and the treatment given.
![Page 12: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/12.jpg)
12
AAC.4 Patients cared for by the
organization undergo an established initial assessment.
• Objective elements
a) The organization defines and documents the content of the initial assessment for the out-patients, in-patients and emergency patients.
b) The organization determines who can perform the initial assessment.
![Page 13: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/13.jpg)
13
Cont…c) The organization defines the time frame
within which the initial assessment is completed based on patient's needs.
d) The initial assessment for in-patients is documented within 24 hours or earlier as per the patient's condition as defined in the organization's policy.
e) Initial assessment of in-patients includes nursing assessment which is done at the time of admission and documented.
![Page 14: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/14.jpg)
14
Cont…
f) Initial assessment includes screening for nutritional needs.
g) The initial assessment results in a documented plan of care.
h) The plan of care also includes preventive aspects of the care where appropriate.
![Page 15: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/15.jpg)
15
Cont…
i) The plan of care is countersigned by the clinician in-charge of the patient within 24 hours.
j) The plan of care includes goals or desired results of the treatment, care or service.
![Page 16: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/16.jpg)
16
AAC.5Patients cared for by the
organization undergo a regular reassessment.
• Objective elements
a) Patients are reassessed at appropriate intervals.
b) Out-patients are informed of their next follow-up, where appropriate.
![Page 17: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/17.jpg)
17
cont…
c) For in-patients during reassessment the plan of care is monitored and modified, where found necessary.
d) Staff involved in direct clinical care document reassessments.
e) Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.
![Page 18: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/18.jpg)
18
AAC.6 Laboratory services are provided as per the scope of services of the organization.
• Objective elements.
a) Scope of the laboratory services are commensurate to the services provided by the organization.
b) The infrastructure (physical and manpower) is adequate to provide for its defined scope of services.
![Page 19: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/19.jpg)
19
cont…
c) Adequately qualified and trained personnel perform, supervise and interpret the investigations.
d) Documented procedures guide ordering of tests, collection, identification, handling, safe transportation, processing and disposal of specimens.
e) Laboratory results are available within a defined time frame.
![Page 20: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/20.jpg)
20
cont…
f) Critical results are intimated immediately to the personnel concerned.
g) Results are reported in a standardized manner.
h) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.
![Page 21: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/21.jpg)
21
AAC.7There is an established laboratory
quality assurance programme
• Objective elements
a) The laboratory quality assurance programme is documented.
b) The programme addresses verification and/or validation of test methods.
c) The programme addresses surveillance of test results.
![Page 22: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/22.jpg)
22
cont…
d) The programme includes periodic calibration and maintenance of all equipment.
e) The programme includes the documentation of corrective and preventive actions.
![Page 23: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/23.jpg)
23
AAC.8There is an established
laboratory-safety programme.
• Objective elements.
a) The laboratory safety programme is documented.
b) This programme is aligned with the organization's safety programme.
![Page 24: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/24.jpg)
24
cont…
c) Written procedures guide the handling and disposal of infectious and hazardous materials.
d) Laboratory personnel are appropriately trained in safe practices.
e) Laboratory personnel are provided with appropriate safety equipment/ devices.
![Page 25: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/25.jpg)
25
AAC.9Imaging services are provided as per the
scope of services of the organization.
• Objective elements
a) Imaging services comply with the legal and other requirements.
b) Scope of the imaging services is commensurate to the services provided by the organization.
c) The infrastructure (physical and manpower) is adequate to provide for its defined scope of services.
![Page 26: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/26.jpg)
26
cont…d) Adequately qualified and trained
personnel perform, supervise and interpret the investigations.
e) Documented policies and procedures guide identification and safe transportation of patients to imaging services.
f) Imaging results are available within a defined time frame.
![Page 27: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/27.jpg)
27
cont…g) Critical results are intimated immediately
to the personnel concerned.h) Results are reported in a standardized
manner.i) Imaging tests not available in the
organization are outsourced to organization(s) based on their quality assurance system.
![Page 28: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/28.jpg)
28
AAC.10There is an established quality
assurance programme for imaging services.
• Objective elements
a) The quality assurance program for imaging services is documented.
b) The programme addresses verification and/or validation of imaging methods.
c) The programme addresses surveillance of imaging results.
![Page 29: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/29.jpg)
29
cont…
d) The programme includes periodic calibration and maintenance of all equipment.
e) The programme includes the documentation of corrective and preventive actions.
![Page 30: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/30.jpg)
30
AAC.11There is an established radiation
safety programme.Objective elements
a) The radiation-safety programme is documented.
b) This programme is aligned with the organization’s safety programme.
c) Handling, usage and disposal of radio-active and hazardous materials are as per statutory requirements.
![Page 31: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/31.jpg)
31
cont…
d) Imaging personnel are provided with appropriate radiation safety devices.
e) Radiation safety devices are periodically tested and results documented.
f) Imaging personnel are trained in radiation safety measures.
g) Imaging signage are prominently displayed in all appropriate locations.
![Page 32: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/32.jpg)
32
AAC.12Patient care is continuous and
multidisciplinary in nature.
Objective elements
a) During all phases of care, there is a qualified individual identified as responsible for the patient’s care.
b) Care of patients is coordinated in all care setting within the organization.
![Page 33: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/33.jpg)
33
cont…
c) Information about the patient's care and response to treatment is shared among medical, nursing and other care providers.
d) Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/ departments.
e) Transfers between departments/units are done in a safe manner.
![Page 34: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/34.jpg)
34
cont…
f) The patient’s record(s) is available to the authorized care providers to facilitate the exchange of information.
g) Documented procedures guide the referral of patients to other departments/ specialties.
![Page 35: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/35.jpg)
35
AAC.13The organization has a
documented discharge process.
Objective elementsa) The patient’s discharge process is planned in
consultation with the patient and/ or family.
b) Documented procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal and abandoned cases).
![Page 36: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/36.jpg)
36
cont…
c) Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request.
d) A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice and on request).
![Page 37: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/37.jpg)
37
AAC.14Organization defines the content
of the discharge summary.
• Objective elements
a) Discharge summary is provided to the patients at the time of discharge.
b) Discharge summary contains the patient's name, unique identification number, date of admission and date of discharge.
![Page 38: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/38.jpg)
38
cont…
c) Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.
d) Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given.
![Page 39: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/39.jpg)
39
cont…
e) Discharge summary contains follow up advice, medication and other instructions in an understandable manner.
f) Discharge summary incorporates instructions about when and how to obtain urgent care.
g) In case of death, the summary of the case also includes the cause of death.
![Page 40: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/40.jpg)
40
Chapter 2Care of Patients (COP)
![Page 41: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/41.jpg)
41
COP.1Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws,
regulations and guidelines.
• Objective elements
a) Care delivery is uniform for a given health problem when similar care is provided in more than one setting.
b) Uniform care is guided by documented policies and procedures.
![Page 42: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/42.jpg)
42
cont…
c) These reflect applicable laws, regulations and guidelines.
d) The organization adopts evidence-based medicine and clinical practice guidelines to guide uniform patient care.
![Page 43: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/43.jpg)
43
COP.2Emergency services are guided by documented policies, procedures
and applicable laws and regulations.Objective elements
a) Policies and procedure for emergency care are documented and are in consonance with statutory requirements.
b) This also addresses handling of medico-legal cases.
c) The patients receive care in consonance with the policies.
![Page 44: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/44.jpg)
44
cont…d) Documented policies and procedures guide
the triage of patients for initiation of appropriate care.
e) Staff are familiar with the policies and trained on the procedures for care of emergency patients.
f) Admission or discharge to home or transfer to another organization is also documented.
g) In case of discharge to home or transfer to another organization a discharge note shall be given to patient.
![Page 45: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/45.jpg)
45
COP.3The ambulance services are
commensurate with the scope of the services provided by the organization.
• Objective elements
a) There is adequate access and space for the ambulance(s).
b) The ambulance adheres to statutory requirements.
c) Ambulance(s) is appropriately equipped.
![Page 46: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/46.jpg)
46
cont…d) Ambulance(s) is manned by the trained
personnel.
e) Ambulance(s) is checked on a daily basis.
f) Equipment are checked on a daily basis using a checklist.
g) Emergency medications are checked daily and prior to dispatch using a checklist.
h) The ambulance(s) has a proper communication system.
![Page 47: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/47.jpg)
47
COP.4Documented policies and procedures
guide the care of patients requiring cardio-pulmonary resuscitation.
• Objective elements
a) Documented policies and procedures guide the uniform use of resuscitation throughout the organization.
b) Staff providing direct patient care are trained and periodically updated in cardio pulmonary resuscitation.
![Page 48: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/48.jpg)
48
cont…
c) The events during a cardio pulmonary resuscitation are recorded.
d) A post-event analysis of all cardio-pulmonary resuscitations is done by a multidisciplinary committee.
e) Corrective and preventive measures are taken based on the post-event analysis.
![Page 49: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/49.jpg)
49
COP.5Documented policies and
procedures guide nursing care.
• Objective elements
a) There are documented policies and procedures for all activities of the nursing services.
b) These reflect current standards of nursing services and practice, relevant regulations and purposes of the services.
![Page 50: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/50.jpg)
50
Cont…c) Assignment of patient care is done as per
current good practice guidelines.d) Nursing care is aligned and integrated with
overall patient care.e) Care provided by nurses is documented in the
patient record.f) Nurses are provided with adequate equipment
for providing safe and efficient nursing services.g) Nurses are empowered to take nursing-related
decisions to ensure timely care of patients.
![Page 51: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/51.jpg)
51
COP.6Documented procedures guide the
performance of various procedures.
• Objective elements
a) Documented procedures are used to guide the performance of various clinical procedures.
b) Only qualified personnel order, plan, perform and assist in performing procedures.
![Page 52: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/52.jpg)
52
cont…c) Documented procedures exist to prevent
adverse events like wrong site, wrong patient and wrong procedure.
d) Informed consent is taken by the personnel performing the procedure, where applicable.
e) Adherence to standard precautions and asepsis is adhered to during the conduct of the procedure.
f) Patients are appropriately monitored during and after the procedure.
g) Procedures are documented accurately in the patient record.
![Page 53: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/53.jpg)
53
COP.7Documented policies and
procedures define rational use of blood and blood products.
• Objective elements
a) Documented policies and procedures are used to guide rational use of blood and blood products.
b) Documented procedures guide transfusion of blood and blood products.
![Page 54: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/54.jpg)
54
cont…c) The transfusion services are governed by the
applicable laws and regulations.
d) Informed consent is obtained for donation and transfusion of blood and blood products.
e) Informed consent also includes patient and family education about donation.
f) The organization defines the process for availability and transfusion of blood/blood components for use in emergency.
![Page 55: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/55.jpg)
55
cont…g) Post-transfusion form is collected, reactions if
any identified and are analyzed for preventive and corrective actions.
h) Staff are trained to implement the policies.
![Page 56: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/56.jpg)
56
COP.8Documented policies and procedures
guide the care of patients in the Intensive Care and high dependency units.
• Objective elements.
a) Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units.
![Page 57: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/57.jpg)
57
cont…
b) The organization has documented admission and discharge criteria for its intensive care and high dependency units.
c) Staff are trained to apply these criteria.
d) Adequate staff and equipment are available.
e) Defined procedures for situation of bed shortages are followed.
![Page 58: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/58.jpg)
58
cont…
f) Infection control practices are documented and followed.
g) A quality assurance programme is documented and implemented.
![Page 59: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/59.jpg)
59
COP.9Documented policies and procedures guide the
care of vulnerable patients (elderly, children, physically and/ or mentally challenged).
• Objective elements.
a) Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.
b) Care is organised and delivered in accordance with the policies and procedures.
![Page 60: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/60.jpg)
60
cont…
c) The organisation provides for a safe and secure environment for this vulnerable group.
d) A documented procedure exists for obtaining informed consent from the appropriate legal representative.
e) Staff are trained to care for this vulnerable group.
![Page 61: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/61.jpg)
61
COP.10 Documented policies and
procedures guide obstetric care.
• Objective elements
a) There is a documented policy and procedure for obstetric services.
b) The organisation defines and displays whether high-risk obstetric cases be cared for or not.
![Page 62: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/62.jpg)
62
cont…
c) Persons caring for high-risk obstetric cases are competent.
d) Documented procedures guide provision for ante-natal services.
e) Obstetric patient's assessment also includes maternal nutrition.
f) Appropriate pre-natal, peri-natal and post-natal monitoring is performed and documented.
g) The organization caring for high-risk obstetric cases has the facilities to take care of neonates of such cases.
![Page 63: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/63.jpg)
63
COP.11Documented policies and procedures
guide paediatric services.
• Objective elements
a) There is a documented policy and procedure for paediatric services.
b) The organisation defines and displays the scope of its paediatric services.
c) The policy for care of neonatal patients is in consonance with the national/ international guidelines.
![Page 64: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/64.jpg)
64
cont…d) Those who care for children have age specific
competency.e) Provisions are made for special care of
children.f) Patient assessment includes detailed
nutritional, growth, psychosocial and immunization assessment.
g) Documented policies and procedures prevent child/ neonate abduction and abuse.
h) The children’s family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record.
![Page 65: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/65.jpg)
65
COP.12Documented policies and procedures guide the care of patients undergoing
moderate sedation.
• Objective elements
a) Documented procedures guide the administration of moderate sedation.
b) Informed consent for administration of moderate sedation is obtained.
c) Competent and trained persons perform sedation.
![Page 66: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/66.jpg)
66
cont…d) The person administering and monitoring
sedation is different from the person performing the procedure.
e) Intra – procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation and level of sedation.
f) Patients are monitored after sedation and the same is documented.
![Page 67: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/67.jpg)
67
cont…
g) Criteria are used to determine appropriateness of discharge from the recovery area.
h) Equipment and manpower are available to manage patients who have gone into a deeper level of sedation than that intended.
![Page 68: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/68.jpg)
68
COP.13Documented policies and
procedures guide the administration of anesthesia.
• Objective elements.
a) There is a documented policy and procedure for the administration of anesthesia.
b) Patients for anesthesia have a pre-anesthesia assessment by a qualified anaesthesiologist.
![Page 69: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/69.jpg)
69
cont…
c) The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented.
d) An immediate preoperative re-evaluation is performed and documented.
e) Informed consent for administration of anesthesia is obtained by the anesthesiologist.
![Page 70: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/70.jpg)
70
cont…f) During anesthesia monitoring includes
regular recording of temperature, heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation and end tidal carbon dioxide.
g) Patient’s post-anesthesia status is monitored and documented.
h) The anaesthesiologist applies defined criteria to transfer the patient from the recovery area.
![Page 71: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/71.jpg)
71
cont…i) The type of anaesthesia and anaesthetic
medications used is documented in the patient record.
j) Procedures shall comply with infection control guidelines to prevent cross-infection between patients.
k) Adverse anesthesia events are recorded and monitored.
![Page 72: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/72.jpg)
72
COP.14Documented policies and procedures guide the care of patients undergoing
surgical procedures.
• Objective elements
a) The policies and procedures are documented.
b) Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery.
c) An informed consent is obtained by a surgeon prior to the procedure.
![Page 73: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/73.jpg)
73
cont…d) Documented policies and procedure exist
to prevent adverse events like wrong site, wrong patients and wrong surgery.
e) Persons qualified by law are permitted to perform the procedures that they are entitled to perform.
f) A brief operative note is documented prior to transfer out of patient from recovery area.
g) The operating surgeons documents the post operative plan of care.
![Page 74: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/74.jpg)
74
cont…h) Patient, personnel and material flow
conforms to infection control practices.
i) Appropriate facilities and equipment/ appliances/ instrumentation are available in the operating theatre.
j) A quality assurance programme is followed for the surgical services.
k) The quality assurance program includes surveillance of the operation theatre environment.
![Page 75: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/75.jpg)
75
COP.15Documented policies and procedures
guide the care of patients under restraints (physical and/ or chemical).
• Objective elements
a) Documented policies and procedures guide the care of patients under restraints.
b) These include both physical and chemical restraint measures.
![Page 76: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/76.jpg)
76
cont…
c) These include documentation of reasons for restraints.
d) These patients are more frequently monitored.
e) Staff receive training and periodic updating in control and restraint techniques.
![Page 77: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/77.jpg)
77
COP.16Documented policies and
procedures guide appropriate pain management.
• Objective elements.a) Documented policies and procedures
guide the management of pain.b) All patients are screened for pain.
![Page 78: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/78.jpg)
78
cont…
c) Patients with pain undergo detailed assessment and periodic re-assessment.
d) The organization respects and supports management of pain for such patients.
e) Patient and family are educated on various pain management techniques, where appropriate.
![Page 79: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/79.jpg)
79
COP.17Documented policies and
procedures guide appropriate rehabilitative services.
• Objective elements
a) Documented policies and procedures guide the provision of rehabilitative services.
b) These services are commensurate with the organizational requirements.
![Page 80: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/80.jpg)
80
cont…c) Care is guided by functional assessment
and periodic re-assessment which is done and documented by qualified individual(s).
d) Care is provided adhering to infection control and safe practices.
e) Rehabilitative services are provided by a multidisciplinary team.
f) There is adequate space and equipment to perform these activities.
![Page 81: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/81.jpg)
81
COP.18Documented policies and procedures
guide all research activities.
• Objective elements
a) Documented policies and procedures guide all research activities in compliance with national and international guidelines.
b) The organization has an ethics committee to oversee all research activities.
c) The committee has the powers to discontinue a research trial when risks outweigh the potential benefits.
![Page 82: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/82.jpg)
82
cont…d) Patient’s informed consent is obtained
before entering them in research protocols.
e) Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal.
f) Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization’s services.
![Page 83: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/83.jpg)
83
COP.19Documented policies and procedures
guide nutritional therapy.
• Objective elements
a) Documented policies and procedures guide nutritional assessment and reassessment.
b) Patients receive food according to their clinical needs.
![Page 84: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/84.jpg)
84
cont…
c) There is a written order for the diet.
d) Nutritional therapy is planned and provided in a collaborative manner.
e) When families provide food, they are educated about the patients diet limitations.
f) Food is prepared, handled, stored and distributed in a safe manner.
![Page 85: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/85.jpg)
85
COP.20Documented policies and procedures
guide the end of life care.
• Objective elements
a) Documented policies and procedures guide the end of life care.
b) These policies and procedures are in consonance with the legal requirements.
c) These also address the identification of the unique needs of such patient and family.
![Page 86: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/86.jpg)
86
cont…
d) Symptomatic treatment is provided and where appropriate measures are taken for alleviation of pain.
e) Staff is educated and trained in end of life care.
![Page 87: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/87.jpg)
87
Chapter 3MANAGEMENT OF
MEDICATION (MOM)
![Page 88: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/88.jpg)
88
MOM.1Documented policies and procedures guide the organization of pharmacy services and usage of medication.
• Objective elements
a) There is a documented policy and procedure for pharmacy services and medication usage.
b) These comply with the applicable laws and regulations.
![Page 89: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/89.jpg)
89
cont…
c) A multidisciplinary committee guides the formulation and implementation of these policies and procedures.
d) There is a procedure to obtain medication when the pharmacy is closed.
![Page 90: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/90.jpg)
90
MOM.2There is a hospital formulary.
• Objective elements
a) A list of medications appropriate for the patients and as per the scope of the organization’s clinical services is developed.
b) The list is developed and updated collaboratively by the multidisciplinary committee.
![Page 91: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/91.jpg)
91
cont…
c) The formulary is available for clinicians to refer and adhere to.
d) There is a defined process for acquisition of these medications.
e) There is a process to obtain medications not listed in the formulary.
![Page 92: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/92.jpg)
92
MOM.3Documented policies and procedures
guide the storage of medication.
• Objective elements
a) Documented policies and procedures exist for storage of medication.
b) Medications are stored in a clean, safe and secure environment; and incorporating manufacturer's recommendation(s).
![Page 93: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/93.jpg)
93
cont…c) Sound inventory control practices guide
storage of the medications.d) Sound alike and look alike medications
are identified and stored separately.e) The list of emergency medications is
defined and is stored in a uniform manner.f) Emergency medications are available all
the time.g) Emergency medications are replenished
in a timely manner when used.
![Page 94: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/94.jpg)
94
MOM.4Documented policies and procedures
guide the safe and rational prescription of medications.
• Objective elements
a) Documented policies and procedures exist for prescription of medications.
b) These incorporate inclusion of good practices/guidelines for rational prescription of medications.
c) The organization determines the minimum requirements of a prescription.
![Page 95: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/95.jpg)
95
cont…d) Known drug allergies are ascertained before
prescribing.
e) The organization determines who can write orders.
f) Orders are written in a uniform location in the medical records.
g) Medication orders are clear, legible, dated, timed, named and signed.
h) Medication orders contain the name of the medicine, route of administration, dose to be administered and frequency/time of administration.
![Page 96: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/96.jpg)
96
cont…i) Documented policy and procedure on verbal
orders is implemented.
j) The organization defines a list of high-risk medication(s).
k) Audit of medication orders/prescription is carried out to check for the safe and rational prescription of medications.
l) Corrective and/or preventive action(s) is taken based on the analysis, where appropriate.
![Page 97: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/97.jpg)
97
MOM.5 Documented policies and procedures guide the safe
dispensing of medications.
• Objective elements
a) Documented policies and procedures guide the safe dispensing of medications.
b) The procedure addresses medication recall.
![Page 98: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/98.jpg)
98
cont…
c) Expiry dates are checked prior to dispensing.
d) There is a procedure for near expiry medications.
e) Labeling requirements are documented and implemented by the organization.
f) High-risk medication orders are verified prior to dispensing.
![Page 99: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/99.jpg)
99
MOM.6There are documented policies and procedures for medication
management.
• Objective elements
a) Medications are administered by those who are permitted by law to do so.
b) Prepared medication is labeled prior to preparation of a second drug.
c) Patient is identified prior to administration.
![Page 100: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/100.jpg)
100
cont…d) Medication is verified from the order prior to
administration.
e) Dosage is verified from the order prior to administration.
f) Route is verified from the order prior to administration.
g) Timing is verified from the order prior to administration.
h) Medication administration is documented.
![Page 101: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/101.jpg)
101
cont…
i) Documented polices and procedures govern patient’s self administration of medications.
j) Documented polices and procedures govern patient’s medications brought from outside the organization.
![Page 102: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/102.jpg)
102
MOM.7 Patients are monitored after medication administration.
• Objective elements
a) Documented policies and procedures guide the monitoring of patients after medication administration.
b) The organization defined those situation where close monitoring is required.
![Page 103: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/103.jpg)
103
cont…
c) Monitoring is done in a collaborative manner.
d) Medications are changed where appropriate based on the monitoring.
![Page 104: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/104.jpg)
104
MOM.8 Near misses, medication errors
and adverse drug events are reported and analyzed.
• Objective elements
a) Documented procedures exist to capture near miss, medication error and adverse drug event.
b) Near miss, medication error and adverse drug events are defined.
![Page 105: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/105.jpg)
105
cont…
c) These are reported within a specified time frame.
d) They are collected and analysed.
e) Corrective and/or preventive action(s) are taken based on the analysis where appropriate.
![Page 106: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/106.jpg)
106
MOM.9 Documented procedures
guide the use of narcotic drugs and psychotropic substances.
• Objective elements
a) Documented procedures guide the use of narcotic drugs and psychotropic substances which are in consonance with local and national regulations.
![Page 107: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/107.jpg)
107
cont…
b) These drugs are stored in a secure manner.
c) A proper record is kept of the usage, administration and disposal of these drugs.
d) These drugs are handled by appropriate personnel in accordance with the documented procedure.
![Page 108: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/108.jpg)
108
MOM.10 Documented policies and
procedures guide the usage of chemotherapeutic agents.
• Objective elements.
a) Documented policies and procedures guide the usage of chemotherapeutic agents.
![Page 109: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/109.jpg)
109
cont…
b) Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy.
c) Chemotherapy is prepared in a proper and safe manner and administered by qualified personnel.
d) Chemotherapy drugs are disposed off in accordance with legal requirements.
![Page 110: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/110.jpg)
110
MOM.11 Documented policies and
procedures govern usage of radioactive drugs.
• Objective elements.
a) Documented policies and procedures govern usage of radioactive drugs.
![Page 111: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/111.jpg)
111
cont…
b) These policies and procedures are in consonance with laws and regulations.
c) The policies and procedures include the safe storage, preparation, handling, distribution, and disposal of radioactive drugs.
d) Staff, patients and visitors are educated on safety precautions.
![Page 112: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/112.jpg)
112
MOM.12 Documented policies and procedures
guide the use of implantable prosthesis and medical devices.
• Objective elements
a) Usage of implantable prosthesis and medical devices is guided by scientific criteria for each individual item and national/international recognized guidelines/approvals for such specific item(s).
![Page 113: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/113.jpg)
113
Cont…b) Documented policies and procedures
govern procurement, storage/stocking, issuance and usage of implantable prosthesis and medical devices incorporating manufacturer's recommendation(s).
c) Patient and his/her family are counseled for the usage of implantable prosthesis and medical device including precautions, if any.
![Page 114: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/114.jpg)
114
Cont…d) The batch and serial number of the
implantable prosthesis and medical devices are recorded in the patient’s medical record and the master logbook.
![Page 115: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/115.jpg)
115
MOM.13Documented policies and procedures guide the use of medical supplies and
consumables.
• Objective elements
a) There is a defined process for acquisition of medical supplies and consumables.
b) Medical supplies and consumables are used in a safe manner, where appropriate.
![Page 116: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/116.jpg)
116
Cont…c) Medical supplies and consumables are
stored in a clean, safe and secure environment; and incorporating manufacturer's recommendation(s).
d) Sound inventory control practices guide storage of medical supplies and consumables.
![Page 117: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/117.jpg)
117
Chapter 4PATIENT RIGHT AND
EDUCATION (PRE)
![Page 118: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/118.jpg)
118
PRE.1The organization protects patient and family rights and informs them about
their responsibilities during care.
Objective element
a) Patient and family rights and responsibilities are documented and displayed.
b) Patients and families are informed of their rights and responsibilities in a format and language that they can understand.
![Page 119: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/119.jpg)
119
cont…
c) The organization’s leaders protect patient's and family rights.
d) Staff is aware of its responsibility in protecting patients and family rights.
e) Violation of patient and family rights is recorded, reviewed and corrective/ preventive measures taken.
![Page 120: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/120.jpg)
120
PRE.2.Patient and family rights support
individual beliefs, values and involve the patient and family in decision-making
processes.
Objective elementsa) Patient and family rights include respecting
any special preferences, spiritual and cultural needs.
b) Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
![Page 121: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/121.jpg)
121
cont…c) Patient and family rights include protection
from physical abuse and neglect.
d) Patient and family rights include treating patient information as confidential.
e) Patient and family rights include refusal of treatment.
f) Patient and family rights include informed consent before transfusion of blood and blood products, anaesthesia, surgery, initiation of any research protocol and any other invasive/ high-risk procedures/ treatment.
![Page 122: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/122.jpg)
122
cont…g) Patient and family rights include right to
complain and information on how to voice a complaint.
h) Patient and family rights include information on the expected cost of the treatment.
i) Patient and family rights include access to his/ her clinical records.
j) Patient and family rights include information on plan of care, progress and information on their health care needs.
![Page 123: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/123.jpg)
123
PRE.3The patient and/or family members
are educated to make informed decisions and are involved in the
care planning and delivery process.
Objective elements
a) The patient and/or family members are explained about the proposed care includinng the risks, alternatives and benefits.
![Page 124: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/124.jpg)
124
cont…b) The patient and/or family members are
explained about the expected results.c) The patient and/or family members are
explained about the possible complications.d) The care plan is prepared and modified in
consultation with patient and/or family members.
e) The care plan respects and where possible incorporates patient and/or family concerns and requests.
![Page 125: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/125.jpg)
125
cont…f) The patient and/or family members are
informed about the results of diagnostic tests and the diagnosis.
g) The patient and/or family members are explained about any change in the patient's condition.
![Page 126: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/126.jpg)
126
PRE.4 A documented procedure for obtaining patient
and/ or family's consent exists for informed decision making about their care.
• Objective elements
a) Documented procedure incorporates the list of situations where informed consent is required and the process for taking informed consent.
b) General consent for treatment is obtained when the patient enters the organisation.
![Page 127: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/127.jpg)
127
cont…c) Patient and / or his family members are
informed of the scope of such general consent.
d) Informed consent includes information regarding the procedure, risks, benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand.
e) The procedure describes who can give consent when patient is incapable of independent decision making.
![Page 128: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/128.jpg)
128
cont…f) Informed consent is taken by the person
performing the procedure.g) Informed consent process adheres to
statutory norms.h) Staff are aware of the informed consent
procedures.
![Page 129: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/129.jpg)
129
PRE.5 Patient and families have a right to
information and education about their health care needs.
• Objective elements
a) Patient and/or family are educated about the safe and effective use of medication and the potential side effects of the medication, when appropriate.
b) Patient and/or family are educated about food-drug interactions.
![Page 130: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/130.jpg)
130
cont…c. Patient and/or family are educated about diet
and nutrition.
d. Patient and/or family are educated about immunizations.
e. Patient and/or family are educated about organ donation, when appropriate.
f. Patient and/or family are educated about their specific disease process, complications and prevention strategies.
g. Patient and/or family are educated about preventing healthcare associated infections.
h. Patient and/or family are educated in a language and format that they can understand.
![Page 131: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/131.jpg)
131
PRE.6 Patient and families have a right to
information on expected costs.
• Objective elements
a) There is uniform pricing policy in a given setting (out-patient and ward category).
b) The tariff list is available to patients.
![Page 132: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/132.jpg)
132
cont…
c. The patient and/or family are explained about the expected costs.
d. Patient and/or family are informed about the financial implications when there is a change in the patient condition or treatment setting.
![Page 133: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/133.jpg)
133
PRE.7 Organization has a complaint
redressal procedure.
• Objective elements
a) The organization has a documented complaint redressal procured.
b) Patient and/or family members are made aware of the procedures for lodging complaints.
![Page 134: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/134.jpg)
134
cont…
c. All complaints are analysed.
d. Corrective and/or preventive action(s) are taken based on the analysis where appropriate.
![Page 135: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/135.jpg)
135
Chapter 5HOSPITAL INFECTION
CONTROL (HIC)
![Page 136: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/136.jpg)
136
HIC.1 The organization has a well-
designed, comprehensive and coordinated Hospital Infection Prevention and Control (HIC)
programme aimed at reducing/eliminating risks to
patients, visitors and providers of care.
![Page 137: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/137.jpg)
137
• Objective elements
a) The hospital infection prevention and control programme is documented which aims at preventing and reducing risk of healthcare associated infections.
b) The infection prevention and control programme is a continuous process and updated at least once in a year.
c) The hospital has a multi-disciplinary infection control committee, which coordinates all infection prevention and control activities.
![Page 138: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/138.jpg)
138
cont…
d. The hospital has an infection control team, which coordinates implementation of all infection prevention and control activities.
e. The hospital has designated infection control officer as part of the infection control team.
f. The hospital has designated infection control nurse(s) as part of the infection control team.
![Page 139: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/139.jpg)
139
HIC.2The organisation implements the
policies and procedures laid down in the Infection Control Manual.
• Objective elements
a) The organization identifies the various high-risk areas and procedures and implements policies and/or procedures to prevent infection in these areas.
b) The organization adheres to standard precautions at all times.
![Page 140: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/140.jpg)
140
Cont…
c) The organization adheres to hand-hygiene guidelines.
d) The organization adhere to safe injection and infusion practices.
e) The organization adheres to transmission-based precautions at all times.
f) The organization adheres to cleaning, disinfection and sterilization practices.
![Page 141: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/141.jpg)
141
Cont…g) An appropriate antibiotic policy is
established and implemented.
h) The organization adheres to laundry and linen management processes.
i) The organization adheres to kitchen sanitation and food handling issues.
j) The organization has appropriate engineering controls to prevent infections.
k) The organization adheres to housekeeping procedures.
![Page 142: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/142.jpg)
142
HIC.3The organization performs surveillance
activities to capture and monitor infection prevention and control data.
• Objective elements
a) Surveillance activities are appropriately directed towards the identified high-risk areas and procedures.
b) Collection of surveillance data is an on-going process.
![Page 143: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/143.jpg)
143
Cont…
c) Verification of data is done on regular basis by the infection control team.
d) Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.
e) Surveillance activities include monitoring the compliance with hand-hygiene guidelines.
![Page 144: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/144.jpg)
144
Cont…
f) Surveillance activities include monitoring the effectiveness of housekeeping services.
g) Appropriate feedback regarding HAI rates are provided on a regular basis to appropriate personnel.
h) In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.
![Page 145: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/145.jpg)
145
HIC.4 The organization takes actions to
prevent and control Healthcare Associated Infections (HAI) in patients.
• Objective elementsa) The organization takes action to prevent
urinary tract infections.
b) The organization takes action to prevent respiratory tract infections.
c) The organization takes action to prevent intra-vascular device infections.
d) The organization takes action to prevent surgical site infections.
![Page 146: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/146.jpg)
146
HIC.5 The organization provides adequate
and appropriate resources for prevention and control of Healthcare
Associated Infections (HAI).
• Objective elements
a) Adequate and appropriate personal protective equipment, soaps and disinfectants are available and used correctly.
![Page 147: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/147.jpg)
147
Cont…
b) Adequate and appropriate facilities for hand hygiene in all patient-care areas are accessible to healthcare providers.
c) Isolation/ barrier nursing facilities are available.
d) Appropriate pre- and post-exposure prophylaxis is provided to all staff members concerned.
![Page 148: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/148.jpg)
148
HIC.6 The organisation identifies and
takes appropriate action to control outbreaks of infections.
• Objective elements
a) Organization has a documented procedure for identifying an outbreak.
b) The organization has a documented procedure for handling such outbreaks.
![Page 149: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/149.jpg)
149
Cont…
c) This procedure is implemented during outbreaks.
d) After the outbreak is over appropriate corrective actions are taken to prevent recurrence.
![Page 150: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/150.jpg)
150
HIC.7 There are documented policies and
procedures for sterilization activities in the organisation.
• Objective elements
a) The organization provides adequate space and appropriate zoning for sterilization activities.
b) Documented procedure guides the cleaning, packing, disinfection and/or sterlization, storing and issue of items.
![Page 151: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/151.jpg)
151
Cont…
c) Reprocessing of instruments and equipment are covered.
d) Regular validation tests for sterilization are carried out and documented.
e) There is an established recall procedure when breakdown in the sterilization system is identified.
![Page 152: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/152.jpg)
152
HIC.8 Bio-medical Waste (BMW) is handled in
an appropriate and safe manner.
• Objective elements
a) The organization adheres to statutory provisions with regard to biomedical waste.
b) Proper segregation and collection of Bio-medical Waste from all patient care areas of the hospital is implemented and monitored.
![Page 153: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/153.jpg)
153
Cont…c) The organization ensures that Bio-
medical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner.
d) Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorised contractor(s).
e) Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste.
![Page 154: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/154.jpg)
154
HIC.9The infection control programme is supported by the management
and includes training of staff. • Objective elements
a) The management makes available resources required for the infection control programme.
b) The organization earmarks adequate funds from its annual budget in this regard.
![Page 155: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/155.jpg)
155
Cont…
c) The organization conducts induction training for all staff.
d) The organization conducts appropriate “in-service” training sessions for all staff at least once in a year.
![Page 156: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/156.jpg)
156
Chapter 6CONTINUOUS QUALITY
IMPROVEMENT (CQI)
![Page 157: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/157.jpg)
157
CQI.1There is a structured quality improvement and continuous monitoring programme in
the organization.
• Objective elements
a) The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee.
b) The quality improvement programme is documented.
![Page 158: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/158.jpg)
158
Cont…
c) There is a designated individual for coordinating and implementing the quality improvement programme.
d) The quality improvement programme is comprehensive and covers all the major elements related to quality assurance and supports innovation.
![Page 159: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/159.jpg)
159
Cont…
e) The designated programme is communicated and coordinated amongst all the staff of the organization through appropriate training mechanism.
f) The quality improvement programme identifies opportunities for improvement based on review at predefined intervals.
![Page 160: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/160.jpg)
160
Cont…
g) The quality improvement programme is a continuous process and updated at least once in a year.
h) Audits are conducted at regular intervals as a means of continuous monitoring.
i) There is an established process in the organization to monitor and improve quality of nursing and complete patient care.
![Page 161: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/161.jpg)
161
CQI.2There is a structured patient-safety
programme in the organization.
• Objective elements
a) The patient-safety programme is developed, implemented and maintained by a multi-disciplinary committee.
b) The patient-safety programme is documented.
![Page 162: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/162.jpg)
162
Cont…
c) The patient-safety programme is comprehensive and covers all the major elements related to patient safety and risk management.
d) The scope of the programme is defined to include adverse events ranging from "no harm" to "sentinel events".
e) There is a designated individual for coordinating and implementing the patient-safety programme.
![Page 163: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/163.jpg)
163
Cont…
f) The designated programme is communicated and coordinated amongst all the staff of the organization through appropriate training mechanism.
g) The patient-safety programme identifies opportunities for improvement based on review at pre-defined intervals.
h) The patient-safety programme is a continuous process and updated at least once in a year.
![Page 164: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/164.jpg)
164
Cont…
i) The organization adapts and implements national/international patient-safety goals/solutions.
j) The organization uses at least two identifiers to identify patients across the organization.
![Page 165: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/165.jpg)
165
CQI.3 The organization identifies key indicators
to monitor the clinical structures, processes and outcomes which are used as
tools for continual improvement.
• Objective elements
a)Monitoring includes appropriate patient assessment.
b)Monitoring includes safety and quality control programmes of the diagnostics services.
![Page 166: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/166.jpg)
166
Cont…
c) Monitoring includes medication management.
d) Monitoring includes use of anaesthesia.e) Monitoring includes surgical services.f) Monitoring includes use of blood and
blood products.g) Monitoring includes infection control
activities.h) Monitoring includes review of mortality
and morbidity indicators.
![Page 167: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/167.jpg)
167
Cont…
i) Monitoring includes clinical research.j) Monitoring includes data collection to
support further improvements.k) Monitoring includes data collection to
support evaluation of these improvements.
![Page 168: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/168.jpg)
168
CQI.4 The organization identifies key indicators to monitor the managerial structures, processes
and outcomes which are used as tools for continual improvement.
• Objective elements
a) Monitoring includes procurement of medication essential to meet patient needs.
b) Monitoring includes risk management.
![Page 169: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/169.jpg)
169
Cont…
c) Monitoring includes utilization of space, manpower and equipment.
d) Monitoring includes patient satisfaction which also incorporates waiting time for services.
e) Monitoring includes employee satisfaction.
f) Monitoring includes adverse events and near misses.
![Page 170: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/170.jpg)
170
Cont…
g) Monitoring includes availability and content of medical records.
h) Monitoring includes data collection to support further study for improvements.
i) Monitoring includes data collection to support evaluation of these improvements.
![Page 171: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/171.jpg)
171
CQI.5 The quality improvement programme is
supported by the management.
• Objective elements
a) The management makes available adequate resources required for quality improvement programme.
b) Organization earmarks adequate funds from its annual budget in this regard.
![Page 172: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/172.jpg)
172
Cont…
c) The management identifies organizational performance improvement targets.
d) The management supports and implements use of appropriate quality improvement, statistical and management tools in its quality improvement programme.
![Page 173: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/173.jpg)
173
CQI.6 There is an established system
for clinical audit.
• Objective elementsa) Medical and nursing staff participates in this
system.b) The parameters to be audited are defined
by the organisation.c) Patient and staff anonymity is maintained.d) All audits are documented.e) Remedial measures are implemented.
![Page 174: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/174.jpg)
174
CQI.7 Incidents, complaints and feedback are collected and analyzed to ensure
continual improvement.
• Objective elementsa) The organization has an incident reporting
system.b) The organization has a process to collect
feedback and receive complaints.
![Page 175: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/175.jpg)
175
Cont…
c) The organization has established processes for analysis of incidents, feedbacks and complaints.
d) Corrective and preventive actions are taken based on the findings of such analysis.
e) Feedback about care and service is communicated to staff.
![Page 176: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/176.jpg)
176
CQI.8 Sentinel events are intensively
analysed. • Objective elementsa) The organisation has defined sentinel
events.b) The organisation has established processes
for intense analysis of such events.c) Sentinel events are intensively analysed
when they occur.d) Corrective and preventive Actions are taken
based on the findings of such analysis.
![Page 177: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/177.jpg)
177
Chapter 7RESPONSIBILITIES OF MANAGEMENT (ROM)
![Page 178: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/178.jpg)
178
ROM.1 The responsibilities of those responsible
for governance are defined.
• Objective elements
a) Those responsible for governance lay down the organization’s vision, mission and values.
b) Those responsible for governance approve the strategic and operational plans and organization's budget.
![Page 179: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/179.jpg)
179
Cont…
c) Those responsible for governance monitor and measure the performance of the organization against the stated mission.
d) Those responsible for governance establish the organization’s organogram.
e) Those responsible for governance appoint the senior leaders in the organization.
f) Those responsible for governance support safety initiatives and quality-improvement plans.
![Page 180: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/180.jpg)
180
Cont…
g) Those responsible for governance support research activities.
h) Those responsible for governance address the organization’s social responsibility.
i) Those responsible for governance inform the public of the quality and performance of services.
![Page 181: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/181.jpg)
181
ROM.2 The organization complies with
the laid-down and applicable legislations and regulations.
• Objective elements
a) The management is conversant with the laws and regulations and knows their applicability to the organization.
b) The management ensures implementation of these requirements.
![Page 182: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/182.jpg)
182
Cont…
c) Management regularly updates any amendments in the prevailing laws of the land.
d) There is a mechanism to regularly update licenses/ registrations/certifications.
![Page 183: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/183.jpg)
183
ROM.3 The services provided by each department are documented.
• Objective elements
a) Scope of services of each department is defined.
b) Administrative policies and procedures for each department is maintained.
c) Each organizational program, service, site or department has effective leadership.
d) Departmental leaders are involved in quality improvement.
![Page 184: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/184.jpg)
184
ROM.4 The organization is managed by the leaders in an ethical manner.
• Objective elements
a) The leaders make public the vision, mission and values of the organization.
b) The leaders establish the organization’s ethical management.
c) The organization discloses its ownership.
![Page 185: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/185.jpg)
185
Cont…
d) The organization honestly portrays the services which it can and cannot provide.
e) The organization honestly portrays its affiliations and accreditations.
f) The organization accurately bills for it’s services based upon a standard billing tariff.
![Page 186: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/186.jpg)
186
ROM.5 The organisation displays professionalism
in management of affairs.
• Objective elements
a) The person heading the organization has requisite and appropriate administrative qualifications.
b) The person heading the organization has requisite and appropriate administrative experience.
![Page 187: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/187.jpg)
187
Cont…c) The organization prepares the strategic and
operational plans including long-term and short-term goals commensurate to the organization's vision, mission and values in consultation with the various stakeholders.
d) The organization coordinates the functioning with departments and external agencies and monitors the progress in achieving the defined goals and objectives.
![Page 188: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/188.jpg)
188
Cont…e) The organization plans and budgets for
its activities annually.f) The performance of the senior leaders is
reviewed for their effectiveness.g) The functioning of committees is
reviewed for their effectiveness.h) The organization documents employee
rights and responsibilities.
![Page 189: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/189.jpg)
189
Cont…i) The organization documents the service
standards.j) The organization has a formal
documented agreement for all outsourced services.
k) The organization monitors the quality of the outsourced services.
![Page 190: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/190.jpg)
190
ROM.6 Management ensures that patient-safety
aspects and risk-management issues are an integral part of patient care and hospital
management.
• Objective elements
a) Management ensures proactive risk management across the organization.
b) Management provides resources for proactive risk assessment and risk reduction activities.
![Page 191: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/191.jpg)
191
Cont…c) Management ensures implementation of
systems for internal and external reporting of system and process failures.
d) Management ensures that appropriate corrective and preventive actions are taken to address safety-related incidents.
![Page 192: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/192.jpg)
192
Chapter 8FACILITY MANAGEMENT AND
SAFETY (FMS)
![Page 193: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/193.jpg)
193
FMS.1 The organisation has a system in place to provide a safe and
secure environment.
• Objective elements
a) Safety committee coordinates development, implementation, and monitoring of the safety plan and policies.
![Page 194: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/194.jpg)
194
Cont…
b) Patient safety devices are installed across the organization and inspected periodically.
c) The organization is a non-smoking area.
d) Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas.
![Page 195: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/195.jpg)
195
Cont…
e) Inspection reports are documented and corrective and preventive measures are undertaken.
f) There is a safety education programme for all staff.
![Page 196: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/196.jpg)
196
FMS.2 The organization’s environment and facilities operate to ensure safety of
patients, their families, staff and visitors.
• Objective elements
a) Facilities are appropriate to the scope of services of the organization.
b) Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.
![Page 197: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/197.jpg)
197
Cont…c) There is internal and external sign
postings in the organisation in a language understood by patient, families and community.
d) The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies.
e) Potable water and electricity are available round the clock.
![Page 198: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/198.jpg)
198
Cont…
f) Alternate sources for electricity and water are provided as backup for any failure/shortage.
g) The organisation regularly tests the alternate sources.
h) There are designated individuals responsible for the maintenance of all the facilities.
![Page 199: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/199.jpg)
199
Cont…
i) There is a documented operational and maintenance (preventive and breakdown) plan.
j) Maintenance staff is contactable round the clock for emergency repairs.
k) Response times are monitored from reporting to inspection and implementation of corrective actions.
![Page 200: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/200.jpg)
200
FMS.3 The organization has a program for engineering support services.
• Objective elements
a) The organization plans for equipment in accordance with its services and strategic plan.
b) Equipments are selected, rented, updated or upgraded by a collaborative process.
![Page 201: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/201.jpg)
201
Cont…
c) Equipments are inventoried and proper logs are maintained as required.
d) Qualified and trained personnel operate and maintain equipment and utility systems.
e) There is a documented operational and maintenance (preventive and breakdown) plan.
![Page 202: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/202.jpg)
202
Cont…
f) There is a maintenance plan for water management.
g) There is a maintenance plan for electrical systems.
h) There is a maintenance plan for heating, ventilation and air-conditioning.
i) There is a documented procedure for equipment replacement and disposal.
![Page 203: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/203.jpg)
203
FMS.4 The organization has a
programme for bio-medical equipment management.
• Objective elementsa) The organization plans for equipment in
accordance with its services and strategic plan.
b) Equipment are selected, rented, updated or upgraded by a collaborative process.
![Page 204: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/204.jpg)
204
Cont…c) Equipment are inventoried and proper logs are
maintained as required.
d) Qualified and trained personnel operate and maintain the medical equipment.
e) Equipment are periodically inspected and calibrated for their proper functioning.
f) There is a documented operational and maintenance (preventive and breakdown) plan.
g) There is a documented procedure for equipment replacement and disposal.
![Page 205: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/205.jpg)
205
FMS.5The organization has a
programme for medical gases, vacuum and compressed air.
• Objective elements
a) Documented procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases.
b) Medical gases are handled, stored, distributed and used in a safe manner.
![Page 206: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/206.jpg)
206
Cont…c) The procedures for medical gases
address the safety issues at all levels.
d) Alternate sources for medical gases, vacuum and compressed air are provided for, in case of failure.
e) The organization regularly tests these alternate sources.
f) There is a maintenance plan for piped medical gas, compressed air and vacuum installation.
![Page 207: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/207.jpg)
207
FMS.6The organization has plans for fire and non-fire emergencies
within the facilities. • Objective elementsa) The organization has plans and provisions
for early detection, abatement and containment of fire and non-fire emergencies.
b) The organization has a documented safe exit plan in case of fire and non-fire emergencies.
![Page 208: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/208.jpg)
208
Cont…c) Staff is trained for its role in case of such
emergencies.
d) Mock drills are held at least twice in a year.
e) There is a maintenance plan for fire-related equipment.
![Page 209: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/209.jpg)
209
FMS.7The organization plans for handling community emergencies, epidemics
and other disasters.
• Objective elements
a) The organization identifies potential emergencies.
b) The organization has a documented disaster management plan.
![Page 210: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/210.jpg)
210
Cont…
c) Provision is made for availability of medical supplies, equipment and materials during such emergencies.
d) Staff are trained in the hospital’s disaster management plan.
e) The plan is tested at least twice in a year.
![Page 211: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/211.jpg)
211
FMS.8The organization has a plan for
management of hazardous materials.
• Objective elements
a) Hazardous materials are identified within the organization.
b) The hospital implements processes for sorting, labeling, handling, storage, transporting and disposal of hazardous material.
![Page 212: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/212.jpg)
212
Cont…
c) Requisite regulatory requirements are met in respect of radioactive materials.
d) There is a plan for managing spills of hazardous materials.
e) Staff are educated and trained for handling such materials.
![Page 213: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/213.jpg)
213
FMS.9The hospital has system in place to
provide a safe and secure environment
• Objective elements
a) The hospital has a safety committee to identify the potential safety and security risks.
b) This committee coordinates development, implementation, and monitoring of the safety plan and policies.
![Page 214: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/214.jpg)
214
Cont…
c) Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas.
d) Inspection reports are documented and corrective and preventive measures are undertaken.
e) There is a safety education programme for all staff.
![Page 215: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/215.jpg)
215
Chapter 9HUMAN RESOURCE
MANAGEMENT
![Page 216: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/216.jpg)
216
HRM.1The organization has a
documented system of human resource planning.
• Objective elements
a) Human resource planning supports the organization's current and future ability to meet the care, treatment and service needs of the patient.
![Page 217: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/217.jpg)
217
Cont…b) The organization maintains an adequate
number and mix of staff to meet the care, treatment and service needs of the patient.
c) The required job specifications and job description are well defined for each category of staff.
d) The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.
![Page 218: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/218.jpg)
218
HRM.2The organization has a documented
procedure for recruiting staff and orienting them to the organization's environment.
• Objective elements
a) There is a documented procedure for recruitment.
b) Recruitment is based on pre-defined criteria.
![Page 219: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/219.jpg)
219
Cont…c) Every staff member entering the
organization is provided induction training.
d) The induction training includes orientation to the organization’s vision, mission and values.
e) The induction training includes awareness on employee rights and responsibilities.
![Page 220: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/220.jpg)
220
Cont…f) The induction training includes
awareness on patients’ rights and responsibilities.
g) The induction training includes orientation to the service standards of the organisation.
h) Each staff member is made aware of organization wide policies and procedures as well as relevant department / unit / service / programme’s policies and procedures.
![Page 221: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/221.jpg)
221
HRM.3There is an ongoing programme
for professional training and development of the staff.
• Objective elementsa) A documented training and development
policy exists for the staff.b) The organization maintains the training
record.
![Page 222: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/222.jpg)
222
Cont…c) Training also occurs when job
responsibilities change/ new equipment is introduced.
d) Feedback mechanisms for assessment of training and development programme exist and the feedback is used to improve the training programme.
![Page 223: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/223.jpg)
223
HRM.4Staff are adequately trained on various safety-related aspects.
• Objective elements
a) Staff are trained on the risks within the organization's environment.
b) Staff members can demonstrate and take actions to report, eliminate / minimize risks.
![Page 224: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/224.jpg)
224
Cont…c) Staff members are made aware of
procedures to follow in the event of an incident.
d) Staff are trained on occupational safety aspects.
![Page 225: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/225.jpg)
225
HRM.5An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource
management process.
• Objective elements
a) A documented performance appraisal system exists in the organization.
![Page 226: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/226.jpg)
226
Cont…
b) The employees are made aware of the system of appraisal at the time of induction.
c) Performance is evaluated based on the pre-determined criteria.
d) The appraisal system is used as a tool for further development.
e) Performance appraisal is carried out at pre defined intervals and is documented.
![Page 227: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/227.jpg)
227
HRM.6The organization has documented
disciplinary and grievance-handling policies and procedures.
• Objective elements
a) Documented policies and procedures exist.
b) The policy and procedure are known to all categories of staff of the organization.
![Page 228: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/228.jpg)
228
Cont…c) The disciplinary policy and procedure is
based on the principles of natural justice.
d) The disciplinary procedure is in consonance with the prevailing laws.
e) There is a provision for appeals in all-disciplinary cases.
f) The redress procedure addresses the grievance.
g) Actions are taken to redress the grievance.
![Page 229: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/229.jpg)
229
HRM.7The organization addresses the health needs of the employees.
• Objective elements
a) A pre-employment medical examination is conducted on all the employees.
b) Health problems of the employees are taken care of in accordance with the organization’s policy.
![Page 230: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/230.jpg)
230
Cont…c) Regular health checks of staff dealing
with direct patient care are done at-least once a year and the findings/ results are documented.
d) Occupational health hazards are adequately addressed.
![Page 231: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/231.jpg)
231
HRM.8 There is a documented personal
record for each staff member.
• Objective elements
a) Personal files are maintained in respect of all employees.
b) The personal files contain personal information regarding the employees qualification, disciplinary background and health status.
![Page 232: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/232.jpg)
232
Cont…
c) All records of in-service training and education are contained in the personal files.
d) Personal files contain result of all evalutions.
![Page 233: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/233.jpg)
233
HRM.9 There is a process for credentialing
and privileging of medical professionals permitted to provide patient care without supervision.
• Objective elements
a) Medical professionals permitted by law, regulation and the organization to provide patient care without supervision is identified.
![Page 234: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/234.jpg)
234
Cont…
b) The education, registration, training and experience of the identified medical professionals is documented and updated periodically.
c) All such information pertaining to the medical professionals is appropriately verified when possible.
![Page 235: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/235.jpg)
235
Cont…d) Medical professionals are granted privileges
to admit and care for patients in consonance with their qualification, training, experience and registration.
e) The requisite services to be provided by the medical professionals are known to them as well as the various departments/ units of the hospital.
f) Medical professionals admit and care for patients as per their privileging.
![Page 236: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/236.jpg)
236
HRM.10 There is a process for credentializing
and privileging of nursing professionals permitted to provide patient care without supervision.
• Objective elements
a) Nursing staff permitted by law, regulation and the organization to provide patient care without supervision are identified.
![Page 237: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/237.jpg)
237
Cont…
b) The education, registration, training and experience of nursing staff is documented and updated periodically.
c) All such information pertaining to the nursing staff is appropriately verified when possible.
d) Nursing staff are granted privileges in consonance with their qualification, training, experience and registration.
![Page 238: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/238.jpg)
238
Cont…e) The requisite services to be provided by
the nursing staff are known to them as well as the various departments / units of the hospital.
f) Nursing professionals care for patients as per their privileging.
![Page 239: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/239.jpg)
239
Chapter10INFORMATION
MANAGEMENT SYSTEM (IMS)
![Page 240: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/240.jpg)
240
IMS.1Documented policies and
procedures exist to meet the information needs of the care providers, management of the organization as well as other
agencies that require data and information from the Organization.
![Page 241: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/241.jpg)
241
• Objective elements
a) The information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization.
b) Documented policies and procedures to meet the information needs are documented.
c) These policies and procedures are in compliance with the prevailing laws and regulations.
![Page 242: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/242.jpg)
242
Cont…
d) All information management and technology acquisitions are in accordance with the documented policies and procedures.
e) The organization contributes to external databases in accordance with the law and regulations.
![Page 243: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/243.jpg)
243
IMS.2 The organization has processes
in place for effective management of data.
• Objective elements
a) Formats for data collection are standardized.
b) Necessary resources are available for analyzing data.
![Page 244: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/244.jpg)
244
Cont…
c) Documented procedures are laid down for timely and accurate dissemination of data.
d) Documented procedures exist for storing and retrieving data.
e) Appropriate clinical and managerial staff participates in selecting, integrating and using data.
![Page 245: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/245.jpg)
245
IMS.3 The organization has a complete and accurate medical record for
every patient. • Objective elements
a) Every medical record has a unique identifier.
b) Organisation policy identifies those authorized to make entries in medical record.
![Page 246: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/246.jpg)
246
Cont…c) Entry in the medical record is named, signed,
dated and timed.
d) The author of the entry can be identified.
e) The contents of medical record are identified and documented.
f) The record provides a complete, up-to-date and chronological account of patient care.
g) Provision is made for 24-hour availability of the patient's record to healthcare providers to ensure continuity of care.
![Page 247: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/247.jpg)
247
IMS.4 The medical record reflects
continuity of care. • Objective elements
a) The medical record contains information regarding reasons for admission, diagnosis and plan of care.
b) The medical record contains the result of tests carried out and the care provided.
![Page 248: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/248.jpg)
248
Cont…
c) Operative and other procedures performed are incorporated in the medical record.
d) When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for the transfer and the name of the receiving hospital.
![Page 249: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/249.jpg)
249
Cont…e) The medical record contains a copy of
the discharge summary duly signed by appropriate and qualified personnel.
f) In case of death, the medical record contains a copy of the death certificate.
g) Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same.
h) Care providers have access to current and past medical record.
![Page 250: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/250.jpg)
250
IMS.5Documented policies and procedures are in place for maintaining confidentiality, integrity and security of records, data
and information.
• Objective elements
a) Documented policies and procedures exist for maintaining confidentiality, security and integrity of records, data and information.
![Page 251: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/251.jpg)
251
Cont…
b) Documented policies and procedures are in consonance with the applicable laws.
c) The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tampering.
d) The organization has an effective process of monitoring compliance of the laid down policy and procedure.
![Page 252: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/252.jpg)
252
Cont…
e) The organization uses developments in appropriate technology for improving confidentiality, integrity and security.
f) Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization.
![Page 253: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/253.jpg)
253
Cont…
g) A documented procedure exists on how to respond to patients/ physicians and other public agencies requests for access to information in the medical record in accordance with the local and national law.
![Page 254: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/254.jpg)
254
IMS.6Documented policies and
procedures exist for retention time of records, data and information.
• Objective elements
a) Documented policies and procedures are in place on retaining the patient’s clinical records, data and information.
b) The policies and procedures are in consonance with the local and national laws and regulations.
![Page 255: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/255.jpg)
255
Cont…
c) The retention process provides expected confidentiality and security.
d) The destruction of medical records, data and information is in accordance with the laid down policy.
![Page 256: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/256.jpg)
256
IMS.7The organization regularly carries
out review of medical records.
• Objective elements
a) The medical records are reviewed periodically.
b) The review uses a representative sample based on statistical principles.
c) The review is conducted by identified care providers.
![Page 257: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/257.jpg)
257
Cont…d) The review focuses on the timeliness,
legibility and completeness of the medical records.
e) The review process includes records of both active and discharged patients.
f) The review points out and documents any deficiencies in records.
g) Appropriate corrective and preventive measures are undertaken within a defined period of time and are documented.
![Page 258: 98815281 NABH 3rd Edition Presentation](https://reader031.vdocuments.mx/reader031/viewer/2022012310/557202f34979599169a4553f/html5/thumbnails/258.jpg)
258
Thank you