finalization of hospital accreditation standards

Finalization of Hospital Accreditation Standards

Workshop on

Directorate General of Health Services (DGHS)Government of the People’s Republic of Bangladesh

September 08, 2012

Draft | Hospital Standards

• The hospital standards are first divided into two major sections:

1. Patient-Focused Standards [5 chapters]

2. Hospital-Focused Standards [5 chapters]


Draft | Patient Focus Standards | 5 Chapters

• Patient-focused standards section is extended into 5 chapters:

1. Patient Safety Goals [PSG]

2. Total Patient Management [TPM]

3. Critical Care Management [CCM]

4. Total Medication Management [TMM]

5. Patient and Family, Rights and Education [PFRE]


Draft | Hospital-Focused Standards | 5 Chapters

• Hospital-focused standards section is further extended into another 5 chapters:

1. Quality and Risk Management [QRM]

2. Infections Control and Prevention [ICP]

3. Facility Safety and Equipment Management [FSEM]

4. Governance and HR Management [GHM]

5. Information and Communication [IAC]


Patient Focus Standards| Chapter 1

PSG.1 Identify Patients CorrectlyPSG.2 Improve Effective CommunicationPSG.3 Improve the Safety of High-Alert MedicationsPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-

Patient SurgeryPSG.5 Reduce the Risk of Hospital–Associated InfectionsPSG.6 Reduce the Risk of Patient’s Falls


6 (six) Patient Safety [PSG] Goals



Total Patient Management [TPM]

• Admission to the Hospital• Continuity of Care• Assessment of patient• Laboratory Services• Radiology and Diagnostic Imaging Services• Uniform Care Delivery• Care of High-Risk Patients and Provision of High-Risk Services• Food and Nutrition Therapy• End-of-Life Care• Discharge, Referral, and Follow-Up• Transfer of Patients | Transportation



Critical Care Management [CCM]

• Management Responsibility• Sedation Care• Anesthesia Care• Surgical Care



Total Medication Management [TMM]

• Management Responsibility• Selection and Procurement• Storage• Ordering and Transcribing• Preparing and Dispensing• Administration• Monitoring



Patient & Family, Rights & Education [PFRE]

• Patient and Family Rights• Informed Consent• Research• Organ Donation• Patient and Family Education

Hospital-Focused Standards| Section 2 | Chapter 1


Quality and Risk Management [QRM]

• Leadership and planning• Design of Clinical and Managerial Processes• Data Collection for Quality Measurement• Analysis of Measurement Data• Gaining and Sustaining Improvement



Infection Control and Prevention [ICP]

• Leadership and Coordination• Focus of the Program• Isolation Procedures• Barrier Techniques and Hand Hygiene• Integration of the Program with Quality Improvement and Patient

Safety• Education of Staff about the Program



Facility Safety and Equipment Management [FSME]

• Leadership and Coordination• Safety and Security• Hazardous Materials• Disaster Readiness• Fire Safety• Medical Equipment• Utility Systems• Staff Education



Governance & HR Management [GHM]

• Governance of the Organization• Leadership of the Organization• Direction of Departments and Services• Organizational Ethics• HR Planning• Orientation and Education• Medical Staff Credentials | Clinical Privileging • Ongoing Monitoring and Evaluation of Medical Staff • Nursing Staff Credentials• Other Health Care Practitioners Credentials



Information and Communication [IAC]

• Communication with the Community• Communication with Patients and Families• Communication between Practitioners within and outside of the

Organization• Leadership and Planning• Patient Clinical Record• Aggregate Data and Information

For any queries or for more information : Road 35 House 5, Gulshan 2| Dhaka 1212, Bangladesh | Tel: 880 9887561/9887925/8811888| Fax: 880 9887563

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finalization of hospital accreditation standards

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