nabhstandards-vks_aka (1)

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National Accreditation Board for Hospitals & Healthcare Providers

Components of Standards Development

Multiple Information Sources– Scientific literature– JCI Standards– UK Healthcare Quality Standards– Thailand Standards– AHA Draft Standards– JCI Survey compliance data– Research Findings– Individual input from field experts and key stakeholders– ISO 9001-2000

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Hospital Standards

Organized around important functions

• Focus on patient and staff safety

• Set standards that all organizations must pass

• To be revised periodically and raise the “bar”

• Achieve International recognition

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NABH Standards

• 10 Chapters

• 100 Standards

• 503 Objective Elements

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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

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Section I:Patient-Centered Standards

STDOE

• Access, Assessment and Continuity of Care (AAC) 15 78

• Patients Rights and Education (PRE) 5 29

• Care of Patients (COP) 18 105

• Management of Medications (MOM) 13 61

• Hospital Infection Control (HIC) 9 44

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Section II: Health Care Organization Management Standards

STD OE

• Continuous Quality Improvement (CQI) 6 37

• Responsibilities of Management (ROM) 5 20

• Facility Management & Safety (FMS) 9 41

• Human Resource Management (HRM) 13 47

• Information Management Systems (IMS) 7 41100 503

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NABH STANDARDS

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Introduction

• NABH standards for hospitals have been prepared by Technical Committee of NABH and contain complete set of standards for evaluation of hospitals for grant of accreditation. The standards provide framework for quality assurance and quality improvement for hospitals

• NABH Standards contains 10 chapters,100 standards and 503 objective elements.

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Details of chapters. 1) Access ,Assessment and continuity of care (AAC)2) Patient Right and Education (PRE).3) Care of Patients(COP).4) Management of Medication (MOM).5) Hospital Infection Control (HIC).6) Continuous Quality Improvement(CQI)7) Responsibility of Management (ROM).8) Facility Management and Safety (FMS).9) Human Resource Management (HRM)10) Information Management System (IMS).

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Chapter 1.ACCESS,ASSESSMENT

AND CONTINIUITY OF CARE (AAC)

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AAC.1The organization defines and displays the services that it can

provide Objective Elements

a) The services being provided are clearly defined.

b) The defined services are prominently displayed.

c) The staff is oriented to these services

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AAC.2The organization has a well defined

registration and admission process

Objective elements

a) Standardized policies and procedures are used for registering and admitting patients

b) The policies and procedures address out- patients, in-patients and emergency patients

13


Cont…

c) Patients are accepted only if the organization can provide the required service

d) The policies and procedures also address managing patients during non availability of beds

e) The staff is aware of these processes

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AAC.3There is an appropriate mechanism for transfer or referral of patients who do not match the organizational resources

Objective elements

a) Policies guide the transfer of unstable patients to another facility in an appropriate manner

b) Policies guide the transfer of stable patients to another facility

15


Cont…

c) Procedures identify staff responsible during transfer

d) The organization gives a summary of patient’s condition and the treatment given

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AAC.4During admission the patient and /or the family members are educated to

make informed decisions

• Objective elements

a) The patients and/or family members are explained about the proposed care

b) The patients and/or family members are explained about the expected results

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Cont…

c) The patients and/or family members are explained about the possible complications

d) The patients and/or family members are explained about the expected costs.

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AAC.5Patients cared for by the organization undergo an established initial assessment


a) The organization defines the content of the assessments for the out–patients, in-patients and emergency patients.

b) The organization determines who can perform the assessments.

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cont…

c) The organization defines the time frame within which the initial assessment is completed.

d) The initial assessment for in-patients is documented within 24 hours or earlier as per the patient’s condition or hospital policy.

e) Initial assessment includes screening for nutritional and psychosocial needs.

20


Cont…

f) The initial assessment results in a documented plan of care.

g) The plan of care also includes preventive aspects of the care

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AAC.6All patients cared for by the organization undergo a regular reassessment• Objective elements.

a) All patients are reassessed at appropriate intervals.

b) Staff involved in direct clinical care document reassessments.

c) Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

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AAC.7Laboratory services are provided as per the requirements of the patients • Objective elements

a) Scope of the laboratory services are commensurate to the services provided by the organization

b) Adequately qualified and trained personnel perform and/or supervise the investigations.

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cont..c) Policies and procedures guide collection,

identification, handling, safe transportation and disposal of specimens.

d) Laboratory results are available within a defined time frame.

e) Critical results are intimated immediately to the concerned personnel.

f) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

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AAC.8There is an established laboratory quality assurance programme• Objective elements

a) The laboratory quality assurance programme is documented.

b) The programme addresses verification and validation of test methods.

c) The programme addresses surveillance of test results.

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cont…

d) The programme includes periodic calibration and maintenance of all equipments.

e) The programme includes the documentation of corrective and preventive actions

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AAC.9There is an established laboratory safety programme

• Objective elements.

a) The laboratory safety programme is documented.

b) This programme is integrated with the organization’s safety programme.

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cont…

c) Written policies and 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.

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AAC.10Imaging services are provided as

per the requirements of the patients • Objective elements

a) Imaging services comply with legal and other requirements.

b) Scope of the imaging services are commensurate to the services provided by the organization.

c) Adequately qualified and trained personnel perform and/or supervise the investigations.

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cont…d) Policies and procedures guide

identification and safe transportation of patients to imaging services.

e) Imaging results are available within a defined time frame.

f) Critical results are intimated immediately to the concerned personnel.

g) Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

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AAC.11There is an established Quality

assurance programme for imaging services


a) The quality assurance programme for imaging services is documented.

b) The programme addresses verification and validation of imaging methods

c) The programme addresses surveillance of imaging results

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cont…

d) The programme includes periodic calibration and maintenance of all equipments.

e) The programme includes the documentation of corrective and preventive actions

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AAC.12There is an established radiation

safety programme

Objective elements

a) The radiation safety programme is documented.

b) This programme is integrated with the organization’s safety programme.

c) Written policies and procedures guide the handling and disposal of radio-active and hazardous materials.

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cont…d) Imaging personnel are provided with

appropriate radiation safety devices

e) Radiation safety devices are periodically tested and documented.

f) Imaging personnel are trained in radiation safety measures.

g) Imaging signage are prominently displayed in all appropriate locations.

h) Policies and procedures guide the safe use of radioactive isotopes for imaging services.

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AAC.13Patient 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 settings within the organization.

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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) The patient’s record (s) is available to the authorized care providers to facilitate the exchange of information.

f) Policy and procedures guide the referral of patients to other department / specialty.

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AAC.14The organization has a

documented discharge process Objective elements

a) The patient’s discharge process is planned.

b) Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases

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cont…

c) Policies and procedures are in place for patients leaving against medical advice

d) A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)

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AAC.15Organisation 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 reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.

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cont…

c) Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given

d) Discharge summary contains follow up advice, medication and other instructions in an understandable manner.

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cont…

e) Discharge summary incorporates instructions about when and how to obtain urgent care

f) In case of death the summary of the case also includes the cause of death.Patient records also contain a copy of the discharge /case summary

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Chapter .2PATIENT RIGHT AND

EDUCATION (PRE)

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PRE.1The organization protects patient

and family rights during care

Objective element

a) Patient and family rights are documented.

b) Patients and families are informed of their rights in a format and language that they can understand

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cont…

c) The organization’s leaders protect patient’s rights

d) Staff is aware of their responsibility in protecting patients rights

e) Violation of patient rights is reviewed and corrective/preventive measures taken

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PRE.2.Patient rights support individual beliefs, values and involve the patient and family in decision

making processes Objective elements

a) Patient rights include respect for personal dignity and privacy during examination, procedures and treatment

b) Patient rights include protection from physical abuse or neglect

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cont…

c) Patient rights include treating patient information as confidential

d) Patient rights include refusal of treatment

e) Patient rights include informed consent before anesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment

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cont…

f) Patient rights include information and consent before any research protocol is initiated

g) Patient rights include information on how to voice a complaint

h) Patient rights include information on the expected cost of the treatment

i) Patient has a right to have an access to his / her clinical records

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PRE.3A documented process for obtaining patient and / or

families consent exists for informed decision making about

their care

Objective elements

a) General consent for treatment is obtained when the patient enters the organization

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cont…b) Patient and/or his family members are informed

of the scope of such general consentc) The organization has listed those procedures and

treatment where informed consent is requiredd) Informed consent includes information on risks ,

benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand

e) The policy describes who can give consent when patient is incapable of independents decision making.

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PRE.4Patient and families have a right

to information and education about their healthcare needs


a) When appropriate, patient and families are educated about the safe and effective use of medication and the potential side effects of the medication

b) Patient and families are educated about diet and nutrition

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cont…

c) Patient and families are educated about immunizations

d) Patient and families are educated about their specific disease process, complications and prevention strategies

e) Patient and families are educated about preventing infections

f) Patients are taught in a language and format that they can understand

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


a) There is uniform pricing policy in a given setting (out-patient and ward category)

b) The tariff list is available to patients

c) Patients are educated about the estimated costs of treatment

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cont…

d. Patients are informed about the estimated costs when there is a change in the patient condition or treatment setting

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Chapter 3.Care of Patients (COP)

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COP.1Uniform care of patients is

guided by the applicable laws and regulations


a) Care delivery is uniform when similar care is provided in more than one setting

b) Uniform care is guided by policies and procedures which reflect applicable laws and regulations

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cont…

c) The care and treatment orders are signed, named, timed and dated by the concerned doctor

d) The care plan is countersigned by the clinician in-charge of the patient within 24 hours

e) Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible

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COP.2Emergency services are guided

by policies, procedures, applicable laws and regulations

Objective elements

a) Policies and procedure for emergency care are documented

b) Policies also address handling of medico-legal cases

c) The patients receive care in consonance with the policies

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cont…

d) Policies and procedures guide the triage of patients for initiation of appropriate care

e) Staff is 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

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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) Ambulance(s) is appropriately equipped

c) Ambulance(s) is manned by trained personnel

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cont…

d) There is a checklist of all equipment and emergency medications

e) Equipment are checked on a daily basis

f) Emergency medications are checked daily and prior to dispatch

g) The ambulance(s) has a proper communication system

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COP.4Policies 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 is trained and periodically updated in cardio pulmonary resuscitation

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cont…

c) The events during a cardio-pulmonary resuscitation are recorded

d) An analysis of all cardiac arrests is done

e) A multidisciplinary committee monitors the effectiveness of cardio-pulmonary resuscitation

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COP.5Policies 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) The transfusion services are governed by the applicable laws and regulations

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Cont…c) Informed consent is obtained for donation

and transfusion of blood and blood products

d) Informed consent also includes patient and family education about donation

e) Staff is trained to implement the policiesf) Transfusion reactions are analyzed for

preventive and corrective actions

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COP.6Policies and procedures guide the

care of patients in the Intensive care and high dependency units


a) The organization has documented admission and discharge criteria for its intensive care and high dependency units

b) Staff is trained to apply these criteria

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cont…

c) Adequate staff and equipment are available

d) Defined procedures for situation of bed shortages are followed

e) Infection control practices are followedf) The unique needs of end of life patients

are identified and cared forg) A quality assurance program is

implemented

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COP.7Policies and procedures guide the care of vulnerable patients (elderly, children, physically and/or mentally challenged)


a) Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines

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cont…b) Staff is trained to care for this vulnerable group

c) Care is organized and delivered in accordance with the policies and procedures

d) The organization provides for a safe and secure environment for this vulnerable group

e) A documented procedure exists for obtaining informed consent from the appropriate legal representative

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COP.8Policies and procedures guide the care of high risk obstetrical

patients • Objective elements.

a) The organization defines and displays whether high risk obstetric cases can be cared for or not

b) Persons caring for high risk obstetric cases are competent

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cont…

c) High risk obstetric patient’s assessment also includes maternal nutrition

d) The organization has the facilities to take care of neonates of high risk pregnancies

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COP.9Policies and procedures guide the care of pediatric patients


a) The organization defines and displays the scope of its pediatric services

b) The policy for care of neonatal patients is in consonance with the national/ international guidelines

c) Those who care for children have age specific competency

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cont…

d) Provisions are made for special care of children

e) Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment

f) Policies and procedures prevent child/ neonate abduction and abuse

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cont…

g) The children’s family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record

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COP.10 Policies and procedures guide the care of patients undergoing

moderate sedation • Objective elements

a) Competent and trained persons perform sedation

b) The person administering and monitoring sedation is different from the person performing the procedure

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cont…

c) Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, and level of sedation

d) Patients are monitored after sedatione) Criteria are used to determine appropriateness

of discharge from the recovery areaf) Equipment and manpower are available to

rescue patients from a deeper level of sedation than that intended

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COP.11Policies and procedures guide

the administration of anesthesia • Objective elements

a) There is a documented policy and procedure for the administration of anesthesia

b) All patients for anesthesia have a pre-anesthesia assessment by a qualified individual

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cont…c) The pre-anesthesia assessment results in

formulation of an anesthesia plan which is documented

d) An immediate preoperative reevaluation is documented

e) Informed consent for administration of anesthesia is obtained by the anesthetist

f) During anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency and level of anesthesia

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cont…

g) Each patient’s post-anesthesia status is monitored and documented

h) A qualified individual applies defined criteria to transfer the patient from the recovery area

i) All adverse anesthesia events are recorded and monitored

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COP.12Policies 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

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cont…c) An informed consent is obtained by a

surgeon prior to the procedured) Documented policies and procedures exist

to prevent adverse events like wrong site, wrong patient and wrong surgery

e) Persons qualified by law are permitted to perform the procedures that they are entitled to perform

f) An operative note is documented prior to transfer out of patient from recovery area

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cont…

g) The operating surgeon documents the post-operative plan of care

h) A quality assurance program is followed for the surgical services

i) The quality assurance program includes surveillance of the operation theatre environment

j) The plan also includes monitoring of surgical site infection rates

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COP.13Policies 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

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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

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COP.14Policies and procedures guide appropriate pain management


a) Documented policies and procedures guide the management of pain

b) The organization respects and supports the appropriate assessment and management of pain for all patients

c) Patient and family are educated on various pain management techniques

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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

c) Rehabilitative services are provided by a multidisciplinary team

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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

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cont…d) Patient’s informed consent is obtained

before entering them in research protocolse) 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

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nutritional therapy • Objective elements

a) Documented policies and procedures guide nutritional assessment and reassessment

b) Patients receive food according to their clinical needs

c) There is a written order for the diet

d) Nutritional therapy is planned and provided in a collaborative manner

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cont…

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

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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

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cont…

d) These also include sensitively addressing issues such as autopsy and organ donation

e) Staff is educated and trained in end of life care

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Chapter4.MANAGEMENT OF

MEDICATION (MOM)

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MOM.1Policies 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

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cont…

c) A multidisciplinary committee guides the formulation and implementation of these policies and procedures

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MOM.2There is a hospital formulary


a) A list of medication appropriate for the patients and organization’s resources is developed

b) The list is developed collaboratively by the multidisciplinary committee

c) There is a defined process for acquisition of these medications

d) There is a process to obtain medications not listed in the formulary

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MOM.3Policies and procedures exist for

storage of medication. • Objective elements

a) Documented policies and procedures exist for storage of medication

b) Medications are stored in a clean, well lit and ventilated environment

c) Sound inventory control practices guide storage of the medications

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cont…d) Medications are protected from loss or

thefte) Sound alike and look alike medications

are stored separatelyf) There is a method to obtain medication

when the pharmacy is closedg) Emergency medications are available all

the timeh) Emergency medications are replenished

in a timely manner when used

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MOM.4Policies and procedures guide

the prescription of medications • Objective elements

a) Documented policies and procedures exist for prescription of medications

b) The organization determines who can write orders

c) Orders are written in a uniform location in the medical records

98


cont…

d) Medication orders are clear, legible, dated, named and signed

e) Policy on verbal orders is documented and implemented

f) The organization defines a list of high risk medication

g) High risk medication orders are verified prior to dispensing

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MOM.4Policies and procedures guide the safe dispensing of medications

• Objective elementsa) Documented policies and procedures

guide the safe dispensing of medicationsb) The policies include a procedure for

medication recallc) Expiry dates are checked prior to

dispensingd) Labeling requirements are documented

and implemented by the organization

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MOM.5 There are defined procedures for medication administration


a) Medications are administered by those who are permitted by law to do so

b) Prepared medication are labeled prior to preparation of a second drug

c) Patient is identified prior to administration

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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

102


cont…

h) Medication administration is documented

i) Polices and procedures govern patient’s self administration of medications

j) Polices and procedures govern patient’s medications brought from outside the organization

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MOM.7Patients and family members are educated about safe medication

and food-drug interactions • Objective elements

a) Patient and family are educated about safe and effective use of medication

b) Patient and family are educated about food-drug interactions

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MOM.8Patients are monitored after medication administration


a) Patients are monitored after medication administration and this is documented

b) Adverse drug events are defined

c) Adverse drug events are reported within a specified time frame

105


cont…

d) Adverse drug events are collected and analysed

e) Policies are modified to reduce adverse drug events when unacceptable trends occur

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MOM.9Policies and procedures guide the use of narcotic drugs and

psychotropic substances • Objective elements

a) Documented policies and procedures guide the use of narcotic drugs and psychotropic substances

b) These policies are in consonance with local and national regulations

107


cont…

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 policies

108



the usage of chemotherapeutic agents


a) Documented policies and procedures guide the usage of chemotherapeutic agents

b) Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy

109


cont…

c) Chemotherapy is prepared and administered by qualified personnel

d) Chemotherapy drugs are disposed off in accordance with legal requirements

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MOM.11Policies and procedures govern

usage of radioactive or investigational drugs


a) Documented policies and procedures govern usage of radioactive or investigational drugs

b) These policies and procedures are in consonance with laws and regulations

111


cont…

c) The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugs

d) Staff, patients and visitors are educated on safety precautions

112


MOM.12Policies and procedures guide the

use of implantable prosthesis


a) Documented policies and procedures govern procurement and usage of implantable prosthesis

b) Selection of implantable prosthesis is based on scientific criteria and internationally recognized approvals

113


cont…

c) The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook

114



the use of medical gases • Objective elements

a) Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases.

b) The policies and procedures address the safety issues at all levels

115


Cont…

c) Appropriate records are maintained in accordance with the policies, procedures and legal requirements.

116


Chapter 5HOSPITAL INFECTION

CONTROL (HIC)

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HIC.1The organization has a well-

designed, comprehensive and coordinated Hospital Infection

Control (HIC) programme aimed at reducing/ eliminating risks to patients, visitors and providers

of care.

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a) The hospital has a multi-disciplinary infection control committee.

b) The hospital has an infection control team.

c) The hospital has designated and qualified infection control nurse(s) for this activity

d) The hospital infection control programme is documented.

119


HIC.2The hospital has an infection

control manual, which is periodically updated.


a) The manual identifies the various high-risk areas.

b) It outlines methods of surveillance in the identified high-risk areas.

120


Cont…

c) It focuses on adherence to standard precautions at all times.

d) Equipment cleaning and sterilisation practices are included.

e) An appropriate antibiotic policy is established and implemented.

f) Laundry and linen management processes are also included.

121


Cont…

g) Kitchen sanitation and food handling issues are included in the manual

h) Engineering controls to prevent infections are included

i) Mortuary practices and procedures are included as appropriate to the organization

122


HIC.3The infection control team is responsible for surveillance

activities in identified areas of the hospital.


a) Surveillance activities are appropriately directed towards the identified high-risk areas.

b) Collection of surveillance data is an ongoing process.

123


Cont…

c) Verification of data is done on regular basis by the infection control team.

d) In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.

e) Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.

124


HIC.4The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections

(HAI) in patients and employees. • Objective elements

a) The organization monitors urinary tract infections.

b) The organization monitors respiratory tract infections.

125


Cont…

c) The organization monitors intra-vascular device infections.

d) The organization monitors surgical site infections.

e) Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.

126


HIC.5Proper facilities and adequate

resources are provided to support the infection control programme


a) Hand washing facilities in all patient care areas are accessible to health care providers.

b) Compliance with proper hand washing is monitored regularly.

127


Cont…

c) Isolation/ barrier nursing facilities are available.

d) Adequate gloves, masks, soaps, and disinfectants are available and used correctly.

128


HIC.6The hospital takes appropriate action

to control outbreaks of infections. • Objective elements

a) Hospital has a documented procedure for handling such outbreaks.

b) This procedure is implemented during outbreaks.

c) After the outbreak is over appropriate corrective actions are taken to prevent recurrence

129


HIC.7There are documented procedures

for sterilisation activities in the hospital.


a) There is adequate space available for sterilization activities

b) Regular validation tests for sterilisation are carried out and documented.

c) There is an established recall procedure when breakdown in the sterilisation system is identified

130


HIC.8Statutory provisions with regard

to Bio-medical Waste (BMW) management are complied with


a) The hospital is authorised by prescribed authority for the management and handling of Bio-medical Waste.

b) Proper segregation and collection of Bio-medical Waste from all patient care areas of the hospital is implemented and monitored.

131


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).

132


Cont…

e) Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.

f) Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste

133


HIC.9The infection control programme

is supported by hospital management and includes training

of staff and employee health • Objective elements

a) Hospital management makes available resources required for the infection control programme

b) The hospital regularly earmarks adequate funds from its annual budget in this regard.

134


Cont…

c) It conducts regular pre-induction training for appropriate categories of staff before joining concerned department(s).

d) It also conducts regular “in-service” training sessions for all concerned categories of staff at least once in a year.

e) Appropriate pre and post exposure prophylaxis is provided to all concerned staff members

135


Chapter 6CONTINUOUS QUALITY

IMPROVEMENT (CQI)

136


CQI.1There is a structured quality assurance and continuous

monitoring programme in the organization


a) The quality assurance programme is developed, implemented and maintained by a multi-disciplinary committee.

b) The quality assurance programme is documented.

137


Cont…

c) There is a designated individual for coordinating and implementing the quality assurance programme

d) The quality assurance programme is comprehensive and covers all the major elements related to quality assurance and risk management.

138


Cont…

e) The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism.

f) The quality assurance programme is reviewed at predefined intervals and opportunities for improvement are identified.

139


Cont…

g) The quality assurance programme is a continuous process and updated at least once in a year.

140


CQI.2The organization identifies key

indicators to monitor the clinical structures, processes and

outcomes • Objective elements

a) Monitoring includes appropriate patient assessment.

b) Monitoring includes diagnostics services’ safety and quality control programmes.

c) Monitoring includes all invasive procedures.

141


Cont…

d) Monitoring includes adverse drug events.e) Monitoring includes use of anaesthesia.f) Monitoring includes use of blood and

blood products.g) Monitoring includes availability and

content of medical records.h) Monitoring includes infection control

activities.i) Monitoring includes clinical research.

142


CQI.3The organisation identifies key

indicators to monitor the managerial structures, processes

and outcomes • Objective elements

• Monitoring includes procurement of medication essential to meet patient needs.

• Monitoring includes reporting of activities as required by laws and regulations.

143


Cont…

• Monitoring includes risk management.• Monitoring includes utilisation of facilities.• Monitoring includes patient satisfaction.• Monitoring includes employee satisfaction.• Monitoring includes adverse events.• Monitoring includes data collection to

support further study for improvements.• Monitoring includes data collection to

support evaluation of the improvements.

144


CQI.4The quality improvement

programme is supported by the management


a) Hospital Management makes available adequate resources required for quality improvement programme.

b) Hospital earmarks adequate funds from its annual budget in this regard.

c) Appropriate statistical and management tools are applied whenever required

145


CQI.5There is an established system

for audit of patient care services • Objective elements

a) Medical staff participates in this system.

b) The parameters to be audited are defined by the organisation.

c) Patient and clinician anonymity is maintained.

d) All audits are documented.

e) Remedial measures are implemented.

146


CQI.6Sentinel 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) Actions are taken upon findings of such

analysis

147


Chapter 7RESPONSIBILITIES OF MANAGEMENT (ROM)

148


ROM.1The responsibilities of the management are defined


a) The organization has a documented organogram

b) Those responsible for governance appoint the senior leaders in the organization

c) Those responsible for governance support the quality improvement plan

149


Cont…

d) The organization complies with the laid down and applicable legislations and regulations

e) Those responsible for governance address the organization’s social responsibility

150


ROM.2 The services provided by each

department are documented• Objective elements

a) Each organizational program, service, site or department has effective leadership

b) Scope of services of each department is defined

c) Administrative policies and procedures for each department is maintained

d) Departmental leaders are involved in quality improvement

151


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


a) The leaders make public the mission statement of the organization

b) The leaders establish the organization’s ethical management

c) The organization discloses its ownership

152


Cont…

d) The organization honestly portrays the services which it can and cannot provide

e) The organization accurately bills for it’s services

153


ROM.4A suitably qualified and experienced individual heads

the organisation


a) The designated individual has requisite and appropriate administrative qualifications.

b) The designated individual has requisite and appropriate administrative experience.

154


ROM.5Leaders ensure that patient

safety aspects and risk management issues are an

integral part of patient care and hospital management


a) The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme.

155


Cont…

b) The scope of the programme is defined to include adverse events ranging from “no harm” to “sentinel events”.

c) Management ensures implementation of systems for internal and external reporting of system and process failures.

d) Management provides resources for proactive risk assessment and risk reduction activities.

156


Chapter 8FACILITY MANAGEMENT AND

SAFETY (FMS)

157


FMS.1The organization is aware of and complies with the relevant rules

and regulations, laws and byelaws and requisite facility

inspection requirements • Objective elements

a) The management is conversant with the laws and regulations and knows their applicability to the organization.

158


Cont…

b) Management regularly updates any amendments in the prevailing laws of the land.

c) The management ensures implementation of these requirements.

d) There is a mechanism to regularly update licenses/ registrations/certifications

159


FMS.2The organization’s environment and facilities operate to ensure

safety of patients, staff and visitors


a) There is a documented operational and maintenance (preventive and breakdown) plan.

160


Cont…b) Up-to-date drawings are maintained

which detail the site layout, floor plans and fire escape routes.

c) The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies.

d) There are designated individuals responsible for the maintenance of all the facilities.

161


Cont…

e) Maintenance staff is contactable round the clock for emergency repairs.

f) Response times are monitored from reporting to inspection and implementation of corrective actions.

162


FMS.3The organization has a program for clinical and support service

equipment management • Objective elements

a) The organization plans for equipment in accordance with its services and strategic plan

b) Equipment is selected by a collaborative process.

c) All equipment is inventoried and proper logs are maintained as required.

163


Cont…

d) Qualified and trained personnel operate and maintain the equipment.

e) Equipment are periodically inspected and calibrated for their proper functioning.

f) There is a documented operational and maintenance (preventive and breakdown) plan.

164


FMS.4The organization has provisions

for safe water, electricity, medical gases and vacuum systems

• Objective elementsa) Potable water and electricity are available

round the clock.b) Alternate sources are provided for in case of

failure.c) The organisation regularly tests the alternate

sources.d) There is a maintenance plan for piped medical

gas and vacuum installation.•

165


FMS.5The organization has plans for fire and non-fire emergencies

within the facilities


a) The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies.

166


Cont…

b) Staff is trained for their role in case of such emergencies.

c) The organization has a documented safe exit plan in case of fire and non-fire emergencies.

d) Mock drills are held at least twice in a year

167


FMS.6The organization has a smoking

limitation policy • Objective elements

a) The organization defines its polices to reduce or eliminate smoking

b) The policy has provisions for granting exceptions for patients and families to smoke

168


FMS.7The organization plans for handling community emergencies, epidemics

and other disasters


a) The hospital identifies potential emergencies.

b) The organization has a documented disaster management plan.

169


Cont…

c) Provision is made for availability of medical supplies, equipment and materials during such emergencies.

d) Hospital staff is trained in the hospital’s disaster management plan

e) The plan is tested at least twice in a year.

170


FMS.8The organization has a plan for

management of hazardous materials


a) Hazardous materials are identified within the organization

b) The hospital implements processes for sorting, handling, storage, transporting and disposal of hazardous material.

171


Cont…

d) Requisite regulatory requirements are met in respect of radioactive materials.

e) There is a plan for managing spills of hazardous materials

f) Staff is educated and trained for handling such materials.

172


FMS.9The hospital has system in place

to provide a safe and secure environment


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.

173


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.

174


Chapter9HUMAN RESOURCE

MANAGEMENT

175


HRM.1The organization has a

documented system of human resource planning


a) The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient.

176


Cont…

b) The required job specifications and job description are well defined for each category of staff.

c) The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.

177


HRM.2The staff joining the organization is socialized and oriented to the

hospital environment • Objective elements

a) Each staff member, employee, student and voluntary worker is appropriately oriented to the organization’s mission and goals.

178


Cont…b) Each staff member is made aware of

hospital wide policies and procedures as well as relevant department / unit / service / programme’s policies and procedures.

c) Each staff member is made aware of his/her rights and responsibilities.

d) All employees are educated with regard to patients’ rights and responsibilities.

e) All employees are oriented to the service standards of the organisation

179


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) Training also occurs when job

responsibilities change/ new equipment is introduced.

c) Feedback mechanisms for assessment of training and development programme exist.

180


HRM.4Staff members, students and

volunteers are adequately trained on specific job duties or responsibilities related to safety • Objective elements

a) All staff is trained on the risks within the hospital environment.

b) Staff members can demonstrate and take actions to report, eliminate / minimize risks.

181


Cont…

c) Staff members are made aware of procedures to follow in the event of an incident.

d) Reporting processes for common problems, failures and user errors exist

182


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 well-documented performance appraisal system exists in the organization.

183


Cont…

b) The employees are made aware of the system of appraisal at the time of induction.

c) Performance is evaluated based on the performance expectations described in job description.

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.

184


HRM.6The organization has a well-

documented disciplinary procedure


a) A written statement of the policy of the organization with regard to discipline is in place.

b) The disciplinary policy and procedure is based on the principles of natural justice.

185


Cont…

c) The policy and procedure is known to all categories of employees of the organization.

d) The disciplinary procedure is in consonance with the prevailing laws.

e) There is a provision for appeals in all disciplinary cases.

186


HRM.7A grievance handling mechanism

exists in the organization • Objective elements

a) The employees are aware of the procedure to be followed in case they feel aggrieved.

b) The redress procedure addresses the grievance.

c) Actions are taken to redress the grievance

187


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


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.

188


Cont…

c) Regular physical and medical checks are done at-least once a year and the findings/ results are documented.

d) Occupational health hazards are adequately addressed.

189


HRM.9There is documented

personal information for each staff member


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

190


Cont…

c) All records of in-service training and education are contained in the personal files.

d) Personal files contain results of all evaluations

191


HRM.10There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of medical professionals permitted to provide patient care without

supervision

192


• Objective elementsa) Medical professionals permitted by law,

regulation and the hospital to provide patient care without supervision is identified.

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.

193


HRM.11There is a process for authorising all medical professionals to admit

and treat patients and provide other clinical services

commensurate with their qualifications

194


• Objective elementsa) Medical professionals admit and care for

patients as per the laid down policies and authorisation procedures of the organization

b) The services provided by the medical professionals are in consonance with their qualification, training and registration.

c) The requisite services to be provided by the medical professionals are known to them as well as the various departments / units of the hospital.

195


HRM.12There is a process for collecting,

verifying and evaluating the credentials (education,

registration, training and experience) of nursing staff


a) The education, registration, training and experience of nursing staff is documented and updated periodically.

196


Cont…

b) All such information pertaining to the nursing staff is appropriately verified when possible

197


HRM.13There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members commensurate with their qualifications

and any other regulatory requirements

198


• Objective elementsa) The clinical work assigned to nursing

staff is in consonance with their qualification, training and registration.

b) The services provided by nursing staff are in accordance with the prevailing laws and regulations.

c) The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the hospital

199


Chapter.10INFORMATION

MANAGEMENT SYSTEM (IMS)

200


IMS.1Policies 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

201


• Objective elementsa) The information needs of the

organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organization

b) Policies and procedures to meet the information needs are documented.

c) These policies and procedures are in compliance with the prevailing laws and regulations.

202


Cont…

d) All information management and technology acquisitions are in accordance with the policies and procedures.

e) The organization contributes to external databases in accordance with the law and regulations

203


IMS.2The organization has processes

in place for effective management of data


a) Formats for data collection are standardized

b) Necessary resources are available for analyzing data

204


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.

205


IMS.3The organization has a complete and accurate medical record for

every patient • Objective elements

a) Every medical record has a unique identifier.

b) Organization policy identifies those authorized to make entries in medical record.

206


Cont…

c) Every medical record entry is 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 an up-to-date and chronological account of patient care

207


IMS.4The medical record reflects

continuity of care


a) The medical record contains information regarding reasons for admission, diagnosis and plan of care.

b) Operative and other procedures performed are incorporated in the medical record

208


Cont…

c) 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

d) The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel

209


Cont…

e) In case of death, the medical record contains a copy of the death certificate indicating the cause, date and time of death.

f) Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same.

g) Care providers have access to current and past medical record.

210


IMS.5Policies and procedures are in place for maintaining confidentiality, integrity and

security of information


a) Documented policies and procedures exist for maintaining confidentiality, security and integrity of information

211


Cont…

b) 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 hospital has an effective process of monitoring compliance of the laid down policy

212


Cont…

e) The hospital 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

213


Cont…

g) A documented procedure exists on how to respond to patients / physicians and other public agencies requests for access to information in the clinical record in accordance with the local and national law.

214


IMS.6Policies and procedures exist for

retention time of records, data and information


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

215


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

216


IMS.7The organization regularly carries out medical audits


a) The medical records are reviewed periodically

b) The review uses a representative sample

c) The review is conducted by identified care providers.

217


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 undertaken are documented.

218


Thank you

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