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AAC.1. The organization defines and displays the services that it can provide.
Objective Element a) The services being provided are clearly defined and are in consonance with the needs of the community. The defined services are prominently displayed.
Interpretation A policy to be framed clearly stating the services the hospital can provide.
Remarks Scope of Services
The services so defined should be displayed prominently in an area visible to all patients entering the organization. The display could be in the form of boards, citizen's charter, scrolling messages etc. Care should be taken to ensure that these are displayed in the language(s) the patient understands. All the staff in the Hospital mainly in the reception/registration, OPD, IPD are oriented to these facts through training programme regularly or through manuals.
Evident on Site
The staff is oriented to these services.
AAC.2. The organization has a well defined registration and admission process.
Objective Element a) Standardized policies and procedures are used for registering and admitting patients.
Interpretation Health Care Organization (HCO) has prepared document (s) detailing the policies and procedures for registration and admission of patients which should also include unidentified patients. Self explanatory
Remarks Registration process Admission Process
The policies and procedures address outpatients, in-patients and emergency patients. Patients are accepted only if the organization can provide the required service.
Admission Process The staff handling admission and registration needs to be aware of the services that the organization can provide. It is also advisable to have a system wherein the staff is aware as to whom to contact if they need any clarification on the services provided.
The policies and procedures also address managing patients during non availability of beds. The staff is aware of these processes.
The HCO is aware of the availability of alternate HCO's where the patients may be directed in case of non-availability of beds. All the staff handling these activities should be oriented to these policies and procedures.
Policy for non availability of beds
AAC.3. There is an appropriate mechanism for transfer or referral of patients who do not match the organizational resources.
Objective Element a) Policies guide the transfer of unstable patients to another facility in an appropriate manner.
Interpretation The organization shall at the outset define as to who is an unstable patient. The documented policy and procedure should address the methodology of safe transfer of the patient in a life threatening situation (like those who are on ventilator) to another HCO. There should be availability of an appropriate ambulance fitted with life support facilities and accompanied by trained personnel. Patients not in a life threatening situation (stable) should also be transported in a safe manner. The staff shall at least be a trained trauma/emergency technician/nurse. He/she shall have undergone training in BLS and/or ACLS. The HCO gives a case summary mentioning the significant findings and treatment given in case of patients who are being transferred from emergency. For admitted patients a discharge summary has to be given (refer AAC15).The same shall also be given to patients going against medical advice.
Remarks Patient Transfer Policy
Policies guide the transfer of stable patients to another facility. Procedures identify staff responsible during transfer. The organization gives a summary of patient’s condition and the treatment given.
Patient Transfer Policy
Patient Transfer Policy
AAC.4. During admission the patient and /or the family members are educated to make informed decisions.
The patients and/or family members are explained about the proposed care.
The patients and/or family members are explained about the expected results. The patients and/or family members are explained about the possible complications. The patients and/or family members are explained about the expected costs.
The plan of care as decided by the doctor on duty or the patient management team (as the case may be) is to be discussed with the patient and/or family members. This should be done in a language the patient/attendant can understand. The above information is to be documented and signed by the concerned doctor. The patients and family are explained in detail by the treating physicians or his/her team about the outcomes of such treatment. Possible complications of the treatment, if any, are clearly communicated to the patient. Patients should be given an estimate of the expenses on account of the treatment preferably in a written form.
Patients Right Policy
Patients Right Policy
Patients Right Policy
Patients Right Policy
AAC.5. Patients cared for by the organization undergo an established initial assessment.
Objective Element a) The organization defines the content of the assessments for the out– patients, in-patients and emergency patients.
Interpretation The hospital shall have a protocol/policy by which a standardized initial assessment of patients is done in the OPD, emergency and in-patients. The initial assessment could be standardized across the hospital or it could be modified depending on the need of the department. However it shall be the same in that particular area e.g. in a paediatric OPD the weight and height may be a must whereas it may not be so for orthopaedics OPD. The organization can have different assessment criteria for the first visit and for subsequent visits. In emergency department this shall include recording the vital parameters. The initial assessment should also include the nursing assessment for in-patients. The assessment should be done by the treating doctor, junior doctor or a nurse. The organization determines who can do what assessment and it should be the same across the hospital. The HCO has defined and documented the time frame within which the initial assessment is to be completed with respect to OPD/ emergency/indoor patients.
Remarks Initial Assessment Policy
The organization determines who can perform the assessments.
Initial Assessment Policy
The organization defines the time frame within which the initial assessment is completed.
IInitial Assessment Policy
The protocol for patient’s initial assessment should cover his/her nutritional needs. Remarks Initial Assessment Policy b) Staff involved in direct clinical care document reassessments. The frequency maybe different for different areas based on the setting and the patient's condition e. Laboratory services are provided as per the requirements of the patients. This plan is monitored by the treating doctor for its effectiveness. Initial Assessment Policy g) Initial Assessment Policy AAC. progress notes.g. The documented plan of care should cover preventive actions as necessary in the case and should include diet. Objective Element Interpretation Remarks 4 . patients in ICU need to reassessed more frequently compared to a patient in the ward. Actions taken under reassessment are documented. investigation ordered and treatment ordered and all these are to be authenticated by treating doctor. Initial assessment includes screening for nutritional needs. CRF patients. Initial Assessment Policy Initial Assessment Policy f) The initial assessment results in a documented plan of care which is monitored. This shall be documented by the treating doctor or by a member of his team in the case sheet. Interpretation After the initial assessment. In case of Out patients this should be done where ever applicable.6. drugs etc.7. All patients cared for by the organization undergo a regular reassessment. The plan of care also includes preventive aspects of the care. and wherever required by a clinical audit. Self explanatory. This should cover history. For example diabetics. the patient is reassessed periodically and this is documented in the case sheet. Initial Assessment Policy AAC. Initial Assessment Policy c) Patients are reassessed to determine their response to treatment and to plan further treatment or discharge. Objective Element a) All patients are reassessed at appropriate intervals.d) e) The initial assessment for in-patients is documented within 24 hours or earlier as per the patient’s condition or hospital policy. The staff could be the treating doctor or any member of the team as per their domain of responsibility of care.
Laboratory Manual Laboratory Manual Laboratory Manual d) Laboratory Manual e) Critical results are intimated immediately to the concerned personnel. test results required for emergency management (RBS. handling. c) The HCO should ensure availability of laboratory services commensurate with the health care services offered by it either by providing the same in house or by outsourcing. Laboratory Manual f) Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system. This should include: a) list of tests for out sourcing. to ensure safety of the specimen till the tests and retests (if required) are completed. The HCO has documented procedure for outsourcing tests for which it has no facilities. processing and disposal of specimens. ABG etc) must be available within its premises.a) Scope of the laboratory services are commensurate to the services provided by the organization. identification. microbiologist and biochemist supervise the staff. identification. d) a methodology to check the performance of service rendered by the out sourced laboratory as per the requirements of the HCO. safe transportation. The test results in the critical limits shall be communicated to the concerned after proper documentation. processing and disposal of specimens. The HCO has documented procedures for collection. Laboratory results are available within a defined time frame. materials and equipment to make the laboratory results available within the defined time frame. b) Adequately qualified and trained personnel perform and/or supervise the investigations. See also (f) below for outsourced lab facilities. Pathologist. safe transportation. The HCO shall define the turnaround time for all tests. However. Laboratory Manual 5 . b) identity of personnel in the out sourced facilities to ensure safe transportation of specimens and completing of tests as per requirements of the patient concerned and receipt of results at HCO. The laboratory shall establish its biological reference intervals for different tests. The staff employed in the lab should be suitably qualified (appropriate degree) and trained to carry out the tests. Policies and procedures guide collection. handling. c) manner of packaging of the specimens and their labelling for identification and this package should contain the test requisition with all details as required for testing. The laboratory shall establish critical limits for tests which require immediate attention for patient management. The HCO should ensure availability of adequate staff.
There is an established laboratory safety programme. The programme includes periodic calibration and maintenance of all equipments. 6 . Adequate safety devices are available in the lab e. Laboratory personnel are appropriately trained in safe practices. fire extinguishers. 1998. Objective Element a) The laboratory quality assurance programme is documented. The laboratory director shall periodically assess the test results. Laboratory Safety Manual Laboratory Safety Manual Laboratory Safety Manual Laboratory Safety Manual e) AAC. Laboratory QA Manual Laboratory QA Manual Laboratory QA Manual Self explanatory. There is an established laboratory quality assurance programme. disinfectants. Lab safety programme is incorporated in the safety programme of the hospital. safety is Interpretation A well documented lab safety manual is available in the lab. The lab staff should follow standard precautions. Laboratory QA Manual AAC.9. dressing materials. Refer to ISO 15189. All the lab staff undergo training regarding safe practices in the lab. The programme includes the documentation of corrective and preventive actions. Objective Element a) The laboratory programme documented. Written policies and procedures guide the handling and disposal of infectious and hazardous materials. The disposal of waste is according to Biomedical waste management and handling rules. This holds true for any laboratory developed methods.g. Laboratory personnel are provided with appropriate safety equipment / devices. Remarks Laboratory Safety Manual b) c) d) This programme is integrated with the organization’s safety programme. The programme addresses surveillance of test results. standard precautions.AAC. Remarks Laboratory QA Manual b) c) d) e) The programme addresses verification and validation of test methods.10.8. Imaging services are provided as per the requirements of the patients. Interpretation The HCO has a documented quality assurance programme (preferably as per ISO 15189 Medical laboratories – Particular requirements for quality and competence). etc. This takes care of the safety of the workforce as well as the equipments available in the lab.
This should also address transfer of unstable patients to imaging services. their identification and safe transportation to the imaging services. followed by written report. Critical results shall be intimated to the treating clinician at the earliest on phone. Critical results are intimated immediately to the concerned personnel. Imaging Department Patient Transfer Policy e) Imaging results are available within a defined time frame. The organization shall document turnaround time of imaging results.11. Imaging Department The HCO has documented policies and procedures for informing the patients about the imaging activities. Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system.Objective Element a) Imaging services comply with legal and other requirements. Remarks Imaging Department b) c) d) Scope of the imaging services are commensurate to the services provided by the organization. The HCO has documented procedure for outsourcing tests for which it has no facilities. c) manner of identification of patients and the test requisition with all details as required for testing and d) a methodology to check the selection and performance of service rendered by the outsourced imaging facility as per the requirements of the HCO. Interpretation The HCO is aware of the legal and other requirements of imaging services and the same are documented for information and compliance by all concerned in the HCO. Imaging Department As per AERB guidelines. Objective Element Interpretation Remarks 7 . Self explanatory. There is an established Quality assurance programme for imaging services. b) identity of personnel in the out sourced facilities to ensure safe transportation of specimens and completing of imaging results. The HCO maintains and updates its compliance status of legal and other requirements in a regular manner. This should include: a) list of tests for out sourcing. Policies and procedures guide identification and safe transportation of patients to imaging services. Adequately qualified and trained personnel perform and/or supervise the investigations. Imaging Department f) Imaging Department g) Imaging Department AAC.
The programme includes the documentation of corrective and preventive actions. Training Records Self explanatory. Objective Element a) The radiation safety programme is documented. Self explanatory.13. Imaging personnel are trained in radiation safety measures. The programme addresses surveillance of imaging results. 8 .12. Self explanatory. e) Imaging Safety Manual f) g) Evidence on side h) Document on safe use of radioactive isotopes for imaging services shall be available and implemented.g. Patient care is continuous and multidisciplinary in nature. Imaging signage are prominently displayed in all appropriate locations Policies and procedures guide the safe use of radioactive isotopes for imaging services. This programme is integrated with the organization’s safety programme. Radiation safety devices are periodically tested and documented. Refer to AERB guidelines. The programme includes periodic calibration and maintenance of all equipments. Imaging personnel are provided with appropriate radiation safety devices. lead aprons should be exposed to X-ray for verification of cracks and damages. Radioactive and hazardous materials shall be disposed off as per bio-medical waste management and handling rules.a) The quality assurance programme for imaging services is documented. The programme addresses verification and validation of imaging methods. Written policies and procedures guide the handling and disposal of radio-active and hazardous materials. 1998. e) AAC. Imaging Safety Manual AAC. HOD shall periodically imaging results. There is an established radiation safety programme. assess the Imaging QA Programme Imaging QA Programme Imaging QA Programme Imaging QA Programme b) c) d) Calibration and maintenance of all equipment shall be carried out by competent persons. Imaging QA Programme A document for verification and validation of imaging methods shall be available. Interpretation Refer to AERB guidelines Remarks Imaging Safety Manual b) The safety programme of the imaging department has reference in the hospital safety manual. Self explanatory. Hospital Safety Manual c) Imaging Safety Manual d) Imaging Safety Manual Protective devices e.
The organization has a documented discharge process. Interpretation The HCO to ensure that the care of patients is always given by appropriately qualified medical personnel (resident doctor. Inpatient Care Inpatient Care Self explanatory. The HCO ensures periodic discussions about each patient (covering parameters like patient care. there is a qualified individual identified as responsible for the patient’s care. between shifts. etc) amongst medical. The organization shall ensure that there is effective communication of patient requirements amongst the care providers in all settings.Objective Element a) During all phases of care. etc. Remarks In Patient Care Medical Care Related Process (Read responsibility) Emergency Room (Causality) Related Process (Read responsibility) IP Care Surgical Care Related Process (Read responsibility) In Patient Care Medical Care Related Process (Read responsibility) Emergency Room (Causality) Related Process (Read responsibility) IP Care Surgical Care Related Process (Read responsibility) b) Care of patients is coordinated in all care settings within the organization. unusual developments if any. IP. response to treatment. c) d) e) f) Information about the patient’s care and response to treatment is shared among medical. and during transfers between units/ departments. Policies and procedures guide the referral of patients to other departments/ specialities. 9 . Information is exchanged and documented during each staffing shift. consultant and/or nurse). nursing and other care providers. Patient Transfer Policy AAC.14. The patient’s record (s) is available to the authorized care providers to facilitate the exchange of information. Medical Record Dept The HCO has clearly defined and documented the policies and procedures to be adopted to guide the personnel dealing with referral of patients to other departments or specialties or even other health care providers out side the HCO. Self explanatory. nursing and other care providers. ICU. emergency. Care of patients is co-ordinated among various care providers in a given setting viz OPD.
a post op patient should report when having fever. Interpretation Self explanatory. Organization defines the content of the discharge summary. Discharge summary contains follow up advice. Discharge summary contains information regarding investigation results. The discharge policies and procedures are documented to ensure coordination amongst various departments including accounts so that the discharge papers are complete well within time. Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases). Discharge Summary c) Self explanatory. Discharge Summary e) The HCO should outline conditions regarding ‘when’ to obtain urgent care. Discharge summary contains the reasons for admission. For MLC the organization shall ensure that the police are informed. The HCO hands over the discharge papers to the patient/attendant in all cases and copy retained. For example. any procedure performed. Remarks Discharge Process b) Discharge Process c) Discharge Process d) Discharge Process AAC. In LAMA cases.15.Objective Element a) The patient’s discharge process is planned in consultation with the patient and/or family. The treating doctor should explain the consequences of this action to the patient/attendant. Policies and procedures are in place for patients leaving against medical advice. medication and other instructions in an understandable manner. the declaration of the patient/attendant is to be recorded on proper format. Discharge Summary d) Self explanatory. significant findings and diagnosis and the patient’s condition at the time of discharge. Discharge summary incorporates instructions about when and how to obtain urgent care. Remarks Discharge Summary b) Self explanatory. medication and other treatment given. bleeding/discharge from site. A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice) Interpretation The patient's treating doctor determines the readiness for discharge during regular reassessments. Objective Element a) Discharge summary is provided to the patients at the time of discharge. Discharge Summary 10 . The same is discussed with the patient and family. The HCO has a documented policy for the LAMA cases.
b) Interpretation These could include SOPs/protocols to provide either general emergency care or management of specific conditions e. receive the same quality of healthcare throughout the organization irrespective of the category of ward. Self explanatory. regulations and guidelines. documentation and intimation to police. These could then be used as parameters for audit of patient care. The care plan is countersigned by the clinician in-charge of the patient within 24 hours. a) Objective Element Care delivery is uniform when similar care is provided in more than one setting. Authorisation of prescription by resident doctor e) Within scope of Medical audit committee. Treatment must be written daily.f) In case of death the summary of the case also includes the cause of death. Discharge Summary CHAPTER 2 : Care of Patients (COP) COP. timed and dated by the concerned doctor. named.g. poisoning. Remarks Emergency Suite related Process Emergency Suite Related Process 11 . Self explanatory.t. The organization shall also define as to what constitutes a MLC (in accordance with statutory rules). The care and treatment orders are signed. The organization could develop clinical protocols based on these and the same could be followed in management of patients. b) Interpretation The organization shall ensure that patients with the same health problems and care needs. Remarks Uniform Care Policy Care provision vide Nursing Council of India Act and Medical Council of India at. COP. procedures. applicable laws and regulations.2. Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible. InPatient Dept c) Self explanatory. Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws. Uniform care is guided by policies and procedures which reflect applicable laws and regulations.r. orders d) The treatment of the patient could be initiated by a junior doctor but the same should be countersigned and authorized by the treating doctor within 24hrs. The policy shall be in line with statutory requirements w. a) Objective Element Policies and procedure for emergency care are documented.1. Emergency services are guided by policies. Policies also address handling of medico-legal cases.
Self explanatory. Self explanatory. Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation. Personnel shall be trained in ACLS and/or BLS. f) Patient Transfer Policy COP. This shall be done based on the organization’s scope. Staff is familiar with the policies and trained on the procedures for care of emergency patients. Admission and discharge protocol in ICU CPR Training Records e) All the staff working in the casualty should be oriented to the policies and practices through training/documents. The ambulance shall be connected with the hospital/control room by wireless/mobile phones. Hospital Ambulance Services BLS Trained Driver c) d) There is a checklist of all equipment and emergency medications. technician/nurse and/or doctor depending on the situation. Policies and procedures guide the triage of patients for initiation of appropriate care. Admission or discharge to home or transfer to another organization is also documented.This shall be demarcated keeping in mind easy accessibility for receiving patients and to enable the ambulance(s) to turn around/exit quickly. The ambulance should be manned by a trained driver. Equipments are checked on a daily basis. Interpretation The organization shall demarcate a proper space for ambulance(s). The ambulance(s) has a proper communication system. Emergency medications are checked daily and prior to dispatch. Remarks Sufficient area available for parking of ambulances as per Policy. Practice Objective d) Self explanatory. Self explanatory.c) The patients receive care in consonance with the policies. Staff should preferably be trained/well versed in ACLS and BLS.3.4. Hospital Ambulance Services e) Hospital Ambulance Services Hospital Ambulance Services (By Physical Inspection) f) g) COP. Ambulance(s) is manned by trained personnel. The ambulance services are commensurate with the scope of the services provided by the organization. The organization shall develop a checklist and ensure that the ambulance is equipped as per the checklist. b) Ambulance(s) is appropriately equipped. a) Objective Element There is adequate access and space for the ambulance(s). This shall include both the ambulance and the equipments within it. This also includes checking the expiry date of drugs. 12 .
Remarks CPR Policy CPR Training Record c) CPR Recording form d) Code Blue Committee Meeting Records e) Code Blue Committee Meeting Records COP. This shall be in consonance with accepted practices. The transfusion services are governed by the applicable laws and regulations. anaesthetists and nurses Self explanatory. In the actual event of a CPR or a mock drill of the same. Multidisciplinary committee shall include physicians. Corrective and preventive measures are taken based on the post-event analysis. However. These aspects shall be covered by hands on training. The analysis shall include the cause. with the same consent you can give multiple transfusions in the same sitting. Remarks b) Drugs And Cosmetic Act (ORIGINAL) c) d) Informed consent also includes patient and family education about donation. Staff providing direct patient care is trained and periodically updated in cardio pulmonary resuscitation. a) Objective Element Documented policies and procedures are used to guide rational use of blood and blood products. then a separate consent is required. Interpretation This shall address the conditions where blood and conditions where blood products can be used. Self explanatory.a) b) Objective Element Documented policies and procedures guide the uniform use of resuscitation throughout the organization. However. Consent should be taken for every transfusion. code blue team) it shall ensure that they are all trained in ALS and are present in all shifts.5. 2 pints of blood may be transfused serially using the same consent. Staff is trained to implement the policies. Interpretation The organization shall document the procedure for same. Refer to Drugs and Cosmetics act. The events during a cardio-pulmonary resuscitation are recorded. e) Training records 13 . all the activities along with the personnel attended should be recorded. if the same is given over two days or hours apart. For example. Policies and procedures define rational use of blood and blood products. A post-event analysis of all cardiac arrests is one by a multi-disciplinary committee. steps taken to resuscitate and the outcome.g. Informed consent is obtained for donation and transfusion of blood and blood products. Consent form Consent form This shall include doctors and be done either by training and/or by providing written instructions. If the organization has a CPR team (e.
Staff is trained to apply these criteria. These could be developed individually or it could be a part of the Hospital infection control manual. The exact requirements shall be decided by the organization. These are then analyzed (by individual/ committee as decided by the organization) and appropriate corrective/preventive action is taken. The organization shall ensure that any transfusion reaction is reported.f) Transfusion reactions are analyzed for preventive and corrective actions. Interpretation The organization should develop objective criteria and adhere to it. However the organization is expected to follow best clinical practices. The organization shall ensure that the practices are in consonance with good clinical practices.6. d) Defined procedures for situation of bed shortages are followed. These could be developed individually or it could be a part of the Hospital quality assurance programme. The organization shall ensure that the programme is in consonance with good clinical practices. a detailed policy and procedure should be in place to address the situation. Policies and procedures guide the care of patients in the Intensive care and high dependency units. Transfusion reaction form COP. The organization shall maintain a record of transfusion reactions. assurance is Quality Management Plan 14 . Adequate staff and equipment are available. a) b) Objective Element The organization has documented admission and discharge criteria for its intensive care and high dependency units. The ICU should be equipped with all necessary life saving and monitoring equipments as well as suitably manned by trained staff. It is preferable that the organization capture feedback regarding every transfusion (including the ones without reaction) as this would enable it to capture all transfusion reactions. As and when there are no vacant beds in the ICU and there is a requirement of such bed. Remarks Admission & Discharge in MICU/HDU This shall be done by training and/or by displaying the criteria. Policy for non availability of beds e) Infection control practices are followed. Infection Control Manual f) A quality programme implemented. Training Records c) Equipment Evident on site.
Staff is trained to care for this vulnerable group. a) Objective Element The organization defines and displays whether high risk obstetric cases can be cared for or not. Policies and procedures guide the care of pediatric patients. Self explanatory. Policies and procedures guide the care of vulnerable patients (elderly. The organization shall provide proper environment taking into account the requirement of the vulnerable group. 15 . These shall not just be doctors but shall include nursing staff also. Policies and procedures guide the care of high risk obstetrical patients. High risk obstetric patient’s assessment also includes maternal nutrition.COP. Training Records COP.7. a) b) c) d) e) Objective Element Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines. The competency shall be based on qualification. Persons caring for high risk obstetric cases are competent. experience and training. The organization provides for a safe and secure environment for this vulnerable group. COP. A documented procedure exists for obtaining informed consent from the appropriate legal representative. The informed consent for this group of people should be obtained from their family or legal representative.9. d) Policy Of Paediatric Deptt. Interpretation The organization shall define as to what constitutes high risk obstetric case in consonance with best clinical practices. Policy for Vulnerable patients Policy for Vulnerable patients General Consent All Staff involved in the care of this group shall be adequately trained in identifying and meeting their needs.8. Remarks Obstetric Dept b) Obstetric Dept c) Obstetric Dept The organization shall have a NICU with proper equipments and staff. Remarks HCO develops SOP's for delivery of care. The organization has the facilities to take care of neonates of high risk pregnancies. Care is organized and delivered in accordance with the policies and procedures. physically and/or mentally challenged). children. Interpretation Self explanatory.
Remarks include Policy Of Paediatric Deptt. COP. Intra-procedure monitoring includes at a minimum the heart rate. Self explanatory. c) d) e) Provisions are made for special care of children. a) Objective Element Competent and trained persons perform sedation. The same should be documented. and level of sedation. Self explanatory. cardiac rhythm. respiratory rate. Policy Of Paediatric Deptt. The children’s family members are educated about nutrition. Policy Of Neonatal Child/ Abuse g) Policy Of Paediatric Deptt. growth. c) Sedation policy 16 . oxygen saturation. These shall not just be for doctors but shall include nursing staff also. experience and training. Interpretation The scope shall also neonatal services. blood pressure.a) b) Objective Element The organization defines and displays the scope of its pediatric services. Self explanatory. Patient assessment includes detailed nutritional. The person administering and monitoring sedation is different from the person performing the procedure. if any.10. Self explanatory. Paediatric Assessment Sheet f) The HCO shall ensure that there is an adequate security/surveillance to prevent such happenings. Policies and procedures prevent child/ neonate abduction and abuse. Those who care for children have age specific competency. Policies and procedures guide the care of patients undergoing moderate sedation. Policy Of Paediatric Deptt. Policy Of Paediatric Deptt. The policy for care of neonatal patients is in consonance with the national/ international guidelines. b) Interpretation Whenever parenteral route is used this shall be carried out by a doctor/nurse. Remarks Sedation policy Sedation policy Self explanatory. immunization and safe parenting and this is documented in the medical record. psychosocial and immunization assessment. Adequate amenities for the care of infants and children to be available in the hospital. The competency shall be based on qualification.
COP. Remarks Pre-operative Evaluation b) Pre-operative Evaluation c) d) The pre-anaesthesia assessment results in formulation of an anaesthesia plan which is documented. oxygen saturation. Anaesthesia and Pain Management OT Manual Informed Consent f) Self explanatory. Sedation policy Sedation policy f) To be verified by Physical Examination. Interpretation HCO shall document on the indications. Equipment and manpower are available to rescue patients from a deeper level of sedation than that intended. a) Objective Element There is a documented policy and procedure for the administration of anaesthesia. Pre-operative Evaluation e) This shall be done by an anaesthesiologist just before the patient is wheeled in to the respective OT. This shall be done before the patient is wheeled into the OT complex. All patients for anaesthesia have a preanaesthesia assessment by a qualified individual. Anaesthesia and Pain Management OT Manual 17 . The same should be documented. the type of anaesthesia and procedure for the same.It is preferable to do assessment in a standardized format.d) Patients are after sedation.11. The equipments shall include emergency resuscitation equipments. Self explanatory. This assessment shall be done by an anaesthesiologist . The patient’s vitals shall be monitored at regular intervals (as decided by the organization) till he/she recovers completely from the sedation. airway security and patency and level of anaesthesia. An anaesthesiologist shall be available in the hospital. monitored e) Criteria are used to determine appropriateness of discharge from the recovery area. These shall be developed by the organization in consonance with good clinical practices. Informed consent for administration of anaesthesia is obtained by the anaesthetist. Self explanatory. respiratory rate. It shall be applicable for both routine and emergency cases. An immediate preoperative re-evaluation is documented. blood pressure. Policies and procedures guide the administration of anaesthesia. During anaesthesia monitoring includes regular and periodic recording of heart rate. cardiac rhythm.
i) This shall be done in the recovery area/OT and at least include monitoring of vitals till the patient recovers completely from anaesthesia and shall be done by an anaesthesiologist.12. This note provides information about the procedure performed. All such events are documented and monitored for the purpose of taking corrective and preventive action. and are b) Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery. The HCO identifies the individuals who have the required qualification (s). An informed consent is obtained by a surgeon prior to the procedure. If the patient’s condition is unstable and he/she requires ICU care the same shall be monitored there. h) A qualified individual applies defined criteria to transfer the patient from the recovery area. wrong patient and wrong surgery. Wrong Patient wrong side Policy e) Personnel file as evidences f) OT Manual 18 . A brief operative note is documented prior to transfer out of patient from recovery area. This shall be applicable for both routine and emergency cases. Self explanatory. Remarks OT Manual IP Care Surgical Care Related Process Pre-operative Evaluation General Consent d) Procedure should be available for preventing adverse events like wrong patients. post operative diagnosis and the status of the patient before shifting and shall be documented by the surgeon/member of the surgical team. Policies and procedures guide the care of patients undergoing surgical procedures. The organization documents these criteria which should be in consonance with good clinical practices. All adverse anaesthesia events are recorded and monitored. Documented policies and procedures exist to prevent adverse events like wrong site. a) Objective Element The policies procedures documented. training and experience to perform procedures in consonance with the law. c) Interpretation This shall include the list of surgical procedures as well as competency level for performing these procedures. These criteria shall be applied by a designated individual as decided by the HCO. Persons qualified by law are permitted to perform the procedures that they are entitled to perform. All patients undergoing surgery are assessed pre operatively and a provisional diagnosis is made which is documented. PAC Form Evidenced on site Signed by anaesthesist In Practice.g) Each patient’s postanaesthesia status is monitored and documented. COP. wrong site by a suitable mechanism.
OT Manual This shall be an integral part of the HCO's overall quality assurance programme. The plan also includes monitoring of surgical site infection rates. Policies and procedures guide appropriate pain management. These include both physical and chemical restraint measures. a) Objective Element Documented policies and procedures guide the care of patients under restraints. Surveillance activities include monitoring the quality of air provided. Self explanatory. Remarks Pain management 19 .14. These include documentation of reasons for restraints. A quality assurance programme is followed for the surgical services. Infection Control Manual To be covered by the internal audit under the scope of medical audit COP. use of cuffs etc.g) The operating surgeon documents the postoperative plan of care. A good reference point for defining these patients could be those having pain as the predominant debilitating symptom. Self explanatory. cleaning and disinfection processes.g. Physical restraints include boxer's bandage. Self explanatory. It shall also specify as to who can authorize the use of restraints. rate of air exchange .13. etc. bleeding. Chemical restraints include sedatives. Remarks Restraint Policy b) Restraint Policy c) Restraint Policy The organization shall specify the parameters and frequency of monitoring and accordingly implement the same. rational use of antibiotics. d) Restraint Policy e) Staff receive training and periodic updating in control and restraint techniques. These patients are more frequently monitored. Interpretation The HCO shall define the group of patients for whom this is applicable. a) Objective Element Documented policies and procedures guide the management of pain. Self explanatory. Interpretation This shall clearly state the conditions/circumstances under which restraints shall be used. etc. Policies and procedures guide the care of patients under restraints (physical and/ or chemical). h) IP Care Surgical Care Related Process i) j) The quality assurance programme includes surveillance of the operation theatre environment. It shall focus on post operative complications e. Training records COP.
rehabilitation therapist. NA NA 20 . Self explanatory. Self explanatory.16. These services are commensurate with the organizational requirements. a) Objective Element Documented policies and procedures guide all research activities in compliance with national and international guidelines. Physiotherapy Dept. Policies and procedures guide appropriate rehabilitative services.b) The organization respects and supports the appropriate assessment and management of pain for all patients. rehabilitation nurses and other professional experts. Pain management COP. Pain management c) Self explanatory. COP. The organization has an ethics committee to oversee all research activities. Interpretation Self explanatory. Self explanatory. An ethics committee should be framed in the hospital to monitor activities undertaken by various providers. Any research undertaken in the hospital falls under its ambit.15. The scope of the departments is in consonance with the scope of the hospital. Policies and procedures guide all research activities. Rehabilitative services are provided by a multidisciplinary team. This includes both funded and non-funded and also student studies. a) b) Objective Element Documented policies and procedures guide the provision of rehabilitative services. Interpretation Self explanatory. c) The team shall have treating doctor. Remarks NA b) c) The committee has the powers to discontinue a research trial when risks outweigh the potential benefits. Patient and family are educated on various pain management techniques. Remarks Physiotherapy Dept.
The organization shall ensure that hygienic conditions are followed all throughout. Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal. Self explanatory.17. Policies and procedures guide nutritional therapy. There is a written order for the diet. Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization’s services. The dietician/nurse shall ensure this during planning. The dietician shall prepare this in the form of a diet sheet and patient shall receive food accordingly. Nutrition and Food Services A dietician shall do the assessment of the patient in consultation with the clinician and advice regarding food. Dietary. Nutrition and Food Services Dietary. Patients receive food according to their clinical needs. Food is prepared.d) e) Patient’s informed consent is obtained before entering them in research protocols. Dietary. Nutrition and Food Services Nutritional assement form c) Dietary. they are educated about the patient's diet limitations. The dietary services to be designed in a manner that there is no criss cross of traffic. The dietician shall ensure that this is planned in consultation with the treating doctor and the patient/patient’s relative after taking into regard the patient’s food habits (veg/ non-veg) and likes and dislikes. Remarks Dietary. 21 . stored and distributed in a safe manner. Policies and procedures guide the end of life care.18. Nutrition and Food Services COP. Nutrition and Food Services Dietary. NA f) Self explanatory. Interpretation Self explanatory. Nutritional therapy is planned and provided in a collaborative manner. All the activities fall in a sequence. NA Self explanatory. handled. NA COP. Nutrition and Food Services d) e) f) When families provide food. a) b) Objective Element Documented policies and procedures guide nutritional assessment and reassessment.
formulary. Staff is educated and trained in end of life care. Self explanatory.2. Policies and procedures guide the organization of pharmacy services and usage of medication. prescription. administration and shall include a pharmacist/ clinical pharmacologist. Interpretation The policies and procedures shall address the issues related to procurement. A multidisciplinary committee guides the formulation and implementation of these policies and procedures. Self explanatory. storage. Records Of Drugs and Therapeutics Committee MOM.1. If the body of the deceased is subjected to an autopsy or for organ donation. These also include sensitively addressing issues such as autopsy and organ donation. c) This shall be representative of major clinical departments. administration. End of Life Care Operational Policy The religious and socio-cultural beliefs of patients/ family shall be addressed and respected. Training Records End of Life Care Operational Policy End of Life Care Operational Policy e) CHAPTER 3 : Management of Medication (MOM) MOM. it should be discussed with the family in a very courteous manner. These also address the identification of the unique needs of such patient and family. There is a hospital formulary.a) Objective Element Documented policies and procedures guide the end of life care. dispensing. Self explanatory. Remarks Material Management Pharmacy Drugs And Cosmetics Act b) These comply with the applicable laws and regulations. Interpretation The HCO has a documented policy for providing care to terminally ill admitted patients. This shall include providing appropriate pain and palliative care according to the wishes of the family and patient. Remarks End of Life Care Operational Policy b) c) d) These policies and procedures are in consonance with the legal requirements. a) Objective Element There is a documented policy and procedure for pharmacy services and medication usage. monitoring and use of medications. 22 .
Physical examination. The process should address the issues of vendor selection. ABC Analysis The organization shall ensure that it develops proper mechanisms to prevent pilferage. The organization could conduct audits at regular intervals (as defined by the organization) to detect such instances. There is a defined process for acquisition of these medications. Policies and procedures guide the storage of medication. Refer to MOM 1c. Interpretation The hospital formulary shall be prepared and be preferably updated at regular intervals. ventilation. vials or tablets may look-alike or soundalike. Interpretation These should address issues pertaining to temperature (refrigeration). a) Objective Element Documented policies and procedures exist for storage of medication. generation of purchase order and receipt of goods as per rules. Pharmacy Local Purchase Policy MOM. preventing entry of pests/ rodents and vermins. They should be segregated and stored separately. Many drugs in ampoules.3. The organization shall also ensure that the storage requirements of the drug as specified by the manufacturer are adhered to. well lit and ventilated environment. This shall be applicable to all areas where medications are stored including wards. vendor evaluation. The list is developed collaboratively by the multidisciplinary committee. light. Self explanatory. Medications are protected from loss or theft.a) Objective Element A list of medication appropriate for the patients and organization’s resources is developed. the organization shall follow the manufacturer’s recommendation. d) Regular AUDIT e) Sound alike and look alike medications are stored separately. Self explanatory. Remarks Policy on Storage Of Medication b) Medications are stored in a clean. Demonstrated in practice 23 . c) Sound inventory control practices guide storage of the medications. Remarks Drug formulary b) Records Of Drugs and Therapeutics Committee c) d) There is a process to obtain medications not listed in the formulary. If the recommendations are conflicting in nature.
There is a method to obtain medication when the pharmacy is closed. Emergency medications are available all the time.
When pharmacy is closed, there should be a SOP to procure the drugs. Adequate amount of emergency medicines should be stocked at all times. Re-order level at definite quantity should be done. Self explanatory.
24 hours pharmacy is available.
Stock maintenance register &records to be produced as evidences.
Emergency medications are replenished in a timely manner when used.
Relevant register as evidence.
MOM.4. Policies and procedures guide the prescription of medications.
Objective Element Documented policies and procedures exist for prescription of medications. The organization determines who can write orders. Orders are written in a uniform location in the medical records.
Interpretation Self explanatory.
Remarks Policy on prescription of medication
This shall be done by the treating doctor.
Policy on prescription of medication Policy on Verbal Orders for Medication
Medication orders are clear, legible, dated, timed, named and signed.
All the orders for medicines are recorded on a uniform location of the case sheet. Electronic orders when typed shall again follow the same principles. Self explanatory.
Policy on verbal orders is documented and implemented.
The organization shall ensure that it has a policy to address this issue and it shall address as to who can give verbal orders and how these orders will be validated. High risk medications are medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes. Examples include medications with a low therapeutic window, controlled substances, psychotherapeutic medications, and look-alike and sound-alike medications. These medications shall preferably be given only after written orders
Policy on Verbal Orders for Medication
The organization defines a list of high risk medication.
High Risk Medication
High risk medication orders are verified prior to
High Risk Medication
and it should be verified by the staff before dispensing.
MOM.5. Policies and procedures guide the safe dispensing of medications.
Objective Element Documented policies and procedures guide the safe dispensing of medications.
Interpretation Clear policies to be laid down for dispensing of medication e.g. route of administration, dosage, rate of administration, expiry date, etc. Recall may result based on letters from regulatory authorities or internal feedback (e.g. visible contaminant in IV fluid bottle). Self explanatory. At a minimum, labels must include the drug name, strength frequency of administration (in a language the patient understands) and expiry dates.
Remarks Safe Dispensing Of Medicine
The policies include a procedure for medication recall. Expiry dates are checked prior to dispensing. Labelling requirements are documented and implemented by the organization.
Drug Labelling Policy
Drug Labelling Policy
MOM.6. There are defined procedures for medication administration.
Objective Element Medications are administered by those who are permitted by law to do so. Prepared medications are labelled prior to preparation of a second drug. Patient is identified prior to administration.
Interpretation Self explanatory.
Remarks Policy on prescription of medication
Self explanatory. Drug Labelling Policy Self explanatory. Safe Dispensing Of Medicine
Medication is verified from the order prior to administration.
Staff administering medications should go through the treatment orders before administration of the medication and then only administer them. It is preferable that they also check the general appearance of the medication (e.g. melting, clumping etc.) before dispensing.
Safe Dispensing Of Medicine
Dosage is verified from the order prior to administration. Route is verified from the order prior to administration. Timing is verified from the order prior to administration. Medication administration is documented.
Safe Dispensing Of Medicine Safe Dispensing Of Medicine Safe Dispensing Of Medicine Safe Dispensing Of Medicine
The organization shall ensure that this is done in a uniform location and it shall include the name of the medication, dosage, route of administration, timing and the name and signature of the person who has administered the medication. At the outset the HCO could define if it would permit self administration of medications. In case the HCO permits then the policy shall include the medications which the patient can self administer. It is preferable that the organization also incorporates a method to ensure that the patient is reminded to take the medication (before every dose) and documentation of self administration. These shall address as to what are the pre-requisites for such a medication (e.g. Invoice; Clear label with mention of the name, dose, expiry date etc.)
Policies and procedures govern patient’s self administration of medications.
Organization do not allow self Medication.
Policies and procedures govern patient’s medications brought from outside the organization.
MOM.7. Patients and family members are educated about safe medication and food-drug interactions.
Objective Element Patient and family are educated about safe and effective use of medication.
Patient and family are educated about food-drug interactions.
Interpretation The organization shall make a list of such drugs and accordingly educate e.g. digoxin. This could also include education regarding the importance of taking a drug at a specific time e.g. sustained release medications. Patient and family should be counselled about their diet during medication e.g. no alcohol when taking metronidazale.
Remarks Safe Medication And Food Drugs Interactions
Safe Medication And Food Drugs Interactions
MOM.8. Patients are monitored after medication administration.
Policies and procedures guide the usage of chemotherapeutic agents. Narcotic Drugs and Psychotropic Substances Act. administration and disposal of these drugs.a) Objective Element Patients are monitored after medication administration and this is documented. Adverse drug events are collected and analyzed. These drugs are handled by appropriate personnel in accordance with policies. Policies and procedures guide the use of narcotic drugs and psychotropic substances. Adverse drug Reaction policy Adverse drug Reaction policy d) e) Policies are modified to reduce adverse drug events when unacceptable trends occur. All the adverse drug reactions are analyzed regularly by the multidisciplinary committee (Refer to MOM 1C). Self explanatory. Adverse drug Reaction policy MOM. These shall be kept in accordance with statutory requirements. A proper record is kept of the usage. Adverse drug events include adverse drug reactions as well as medication errors.10. Records c) d) MOM. Interpretation This shall be done by anyone involved in direct patient care. Adverse drug Reaction policy ARD Form c) Adverse drug events are reported within a specified time frame. Refer to MOM 1a. Remarks Narcotics Policy This is in the context of Narcotic Drugs and Psychotropic Substances Act. Interpretation Self explanatory. a) b) Objective Element Documented policies and procedures guide the use of narcotic drugs and psychotropic substances. The organization shall define as to what constitutes an adverse drug event.9. The organization shall define the timeframe for reporting once the adverse drug event has occurred. 27 . This shall be in consonance with best practices. Remarks In Patient Care Medical Care Related Process b) Adverse drug events are defined. Self explanatory. These policies are in consonance with local and national regulations. Self explanatory. The organization could follow either a passive (documenting only if the patient tells) or active (enquiring with every patient) monitoring mechanism.
The policies and procedures include the safe storage.12. MOM. c) Radioactive material policy d) Self explanatory. a) Objective Element Documented policies and procedures govern usage of radioactive drugs. This shall preferably be staff who have received special training in preparing and administration. Interpretation Self explanatory. patients and visitors are educated on safety precautions. Chemotherapy is prepared and administered by qualified personnel.11. These shall be disposed off according to BMW management and handling rules 1998 or manufacturer's recommendation. Interpretation Self explanatory. Interpretation Self explanatory. Staff. This shall however be in accordance with AERB guidelines. a) Objective Element Documented policies and procedures govern procurement and usage of implantable prosthesis. These policies and procedures are in consonance with laws and regulations. Policies and procedures guide the use of implantable prosthesis.a) b) c) d) Objective Element Documented policies and procedures guide the usage of chemotherapeutic agents. MOM. Remarks Chemotherapy policy This shall preferably be a medical oncologist or a person who has been trained and has achieved competency in the same. Chemotherapy drugs are disposed off in accordance with legal requirements. distribution and disposal of radioactive drugs. handling. Remarks Implant Policy 28 . preparation. APPROPRIATE SIGNAGES USED AT ALL THE PLACES. Chemotherapy policy Chemotherapy policy Biomedical waste management rule and regulation. Remarks Radioactive material policy b) Refer to AERB guidelines. Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy. DEMONSTRATED IN PRACTICE. Policies and procedures govern usage of radioactive drugs. Radioactive material policy Self explanatory.
distribution. Interpretation This shall be applicable to all gases used in the organization. All the rights of the patients should be displayed in the form of a Citizens’ Charter which should also give information of the charges and grievance redress mechanism.13.US-FDA) or national notification (Drugs and Cosmetics Act notification October 2005) for approval of the particular product. procedures and legal requirements. The policies and procedures address the safety issues at all levels.1. It shall also look for international (e. The organization shall ensure that relevant and sufficient scientific data are available before selection. Implant Policy Implant Policy MOM. Gas Manifold Process CHAPTER 4 : Patient Rights and Education (PRE) PRE. storage. handling. It shall also address the issue of statutory requirements and approvals wherever applicable. c) The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook. This is the context of the Indian explosives act of 1884. It shall follow a uniform colour coding system. This shall include from the point of storage/source area. a) Objective Element Patient and family rights and responsibilities are documented. a) b) Objective Element Documented policies and procedures govern procurement. The organization protects patient and family rights and informs them about their responsibilities during care. Remarks Citizen Charter 29 . usage and replenishment of medical gases.g. Remarks Gas Masifold Process Gas Manifold Process c) Appropriate records are maintained in accordance with the policies. Gas cylinder rules 1981 and Static and mobile pressure vessels (unfired) 1981. Policies and procedures guide the use of medical gases.b) Selection of implantable prosthesis is based on scientific criteria and national /internationally recognized approvals. Self explanatory. Interpretation Hospital should respect patient’s rights and inform them of their responsibilities. Appropriate safety measures shall be developed and implemented for all levels. gas supply lines and the end user area.
The treating doctor shall discuss all the available options and allow the patient to make an informed choice including the option Patients Right Policy Policy For Vulnerable Patients Patients Right Policy Patients Right Policy 30 . Statutory requirements w. Patient rights support individual beliefs.2. Patient rights include respect for personal dignity and privacy during examination. a) b) Objective Element Patient and family rights address any special preferences. Violation of patient rights is reviewed and corrective/preventive measures taken. procedures and treatment. During procedures the organization shall ensure that the patient is exposed just before the actual procedure is undertaken. corrective actions to prevent recurrences. elderly. Training and sensitisation programmes shall be conducted to create awareness among the staff.r. Where patients' rights have been infringed upon. d) e) During all stages of patient care.g. Staff is aware of their responsibility in protecting patients rights. Patient rights include treating patient information as confidential. Patient rights include refusal of treatment.t vulnerable patients e. the organization shall ensure that consent is taken and that the patient’s identity is not revealed.g. privileged communication shall be followed at all times. hospital staff shall ensure that patient’s privacy and dignity is maintained. values and involve the patient and family in decision making processes. During management the patients should be given the choice of treatment. as also a record of the consequences. management must keep records of such violations. Self explanatory.t. neonates etc. Self explanatory. The organization shall develop the necessary guidelines for the same. Citizen Charter d) Employee Guide Book e) Patient Grievance Policy PRE. The organization’s leaders protect patient’s rights. e.r. Special precautions shall be taken especially w. be it in examination or carrying out a procedure.r. spiritual and cultural needs. Citizen Charter Protection also includes addressing patient’s grievances w.t rights.b) c) Patients and families are informed of their rights and responsibilities in a format and language that they can understand. Interpretation This could include preferences and requirements Remarks dietary worship Patients Right Policy c) Patient rights include protection from physical abuse or neglect. Self explanatory. With regards to photographs/recording procedures.
A list of procedures should be made for which informed consent should be taken. Patient has a right to have an access to his / her clinical records. Informed consent includes information on risks. i) The organization shall ensure that International conference on harmonization (ICH) of Good clinical practice (GCP) and Declaration of Helsinki Somerset (1996) and ICMR requirements are followed. This shall be in consonance with The code of medical ethics and statutory requirements. f) g) Patient rights include informed consent before anaesthesia. Patient and/or his family members are informed of the scope of such general consent.of refusal. Remarks General Consent c) The organization shall define as to what is the scope of this consent and the same shall be communicated to the patient and/or his family members. Patient rights include information and consent before any research protocol is initiated. If it is a “doctor under training” the same shall be specified. Interpretation Self explanatory. a) b) Objective Element General consent for treatment is obtained when the patient enters the organization.3. Consent form shall be in the 31 General Consent Informed Consent d) Informed Consent . alternatives and as to who will perform the requisite procedure in a language that they can understand. benefits. Grievance redressal mechanism must be accessible and transparent. A documented process for obtaining patient and / or families consent exists for informed decision making about their care. The organization has listed those procedures and treatment where informed consent is required. Informed Consent Patients Right Policy Patients Right Policy The organization shall ensure that every patient has access to his/her record. Self explanatory. Displayed information must be clearly available on how to voice a complaint. however the name of the qualified doctor supervising the procedure shall also be mentioned. Patient rights include information on the expected cost of the treatment. Refer AAC4d. Informed Consent h) Patient rights include information on how to voice a complaint. j) Patients Right Policy PRE. The consent shall have the name of the doctor performing the procedure. blood and blood product transfusions and any invasive / high risk procedures / treatment.
The tariff list is available to patients. Patient and families are educated about immunizations. e) The policy describes who can give consent when patient is incapable of independent decision making. However in case of unconscious/ unaccompanied patients the treating doctor can take a decision in life saving circumstances. This would include next of kin/legal guardian. complications and prevention strategies. Neisseria meningitides. This could also be done through patient education booklets/videos/leaflets etc. In adults it could be for influenza. etc. the patient The organization shall take into consideration the statutory norms. a) b) Objective Element When appropriate. More applicable for paediatric population. a) b) Objective Element There is uniform pricing policy in a given setting (out-patient and ward category).language that understands. Nutrition and Food Services Immunization cards are given in Hospital c) d) e) Patient and families are educated about their specific disease process.5. The organization shall ensure that there is an updated tariff list and that this list is available to patients Remarks Billing Policy Tariff List 32 . Patients Right Policy PRE. patient and families are educated about the safe and effective use of medication and the potential side effects of the medication. Patients Right Policy Patients Right Policy f) Self explanatory. Interpretation There should be a billing policy which defines the charges to be levied for various activities.4. Self explanatory. Informed Consent PRE. typhoid. Interpretation Self explanatory. Patient and families are educated about diet and nutrition. Patient and families have a right to information and education about their healthcare needs. Remarks Policy on Safe Medication Self explanatory. hepatitis B. Dietary. Self explanatory. Streptococcus pneumoniae. Patient and families are educated about preventing infections Patients are taught in a language and format that they can understand Self explanatory. Patient and families have a right to information on expected costs.
Interpretation Self explanatory. and other Support services and the hospital infection control nurse. when required.c) Patients are educated about the estimated costs of treatment. the financial implications must be clearly conveyed to them. This shall preferably have Hospital Administrator. Refer to AAC4d. The hospital has an infection control manual. Patients are informed about the estimated costs when there is a change in the patient condition or treatment setting. The tariff rates should be uniform and transparent. It should also include invitees from various departments as deemed necessary. staff from CSSD. The organization shall charge as per the tariff list. typically to and from ICUs. Any additional charge should also be enumerated in the tariff and the same communicated to the patients. a) Objective Element The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections. The team is responsible for day-today functioning of infection control programme. Physician. The organization has a well-designed. Surgeon.1. They shall support surveillance process and detect outbreaks.2. an d) The hospital has designated and qualified infection control nurse(s) for this activity. 33 . The qualification shall be either a graduate nurse or qualified nurse with competence gained by experience. Manager – Nursing (Nursing Supervisor). comprehensive and coordinated Hospital Infection Control (HIC) programme aimed at reducing/ eliminating risks to patients. Microbiologist. which is periodically updated. The hospital has a multidisciplinary infection control committee. Infection Control Manual Infection Control Manual Infection Control Manual HIC. Patients Right Policy When patients are shifted from one setting to another. Remarks Infection Control Manual b) c) The hospital has infection control team. d) Estimated Cost Performa CHAPTER 5 : Hospital Infection Control (HIC) HIC. They shall also participate in audit activity and in infection prevention and control on a day-to-day basis. visitors and providers of care.
Similarly.g. Post-operative ward. The surveillance system should meet WHO criteria of simplicity. Laundry Services g) Kitchen sanitation and food handling issues are included in the manual. etc. flexibility. sensitivity and specificity. d) Infection Control Manual e) An appropriate antibiotic policy is established and implemented. Infection Control Manual 34 . HDU. Antibiotic Policy f) Laundry and linen management processes are also included. The linen change policy should be mentioned. acceptability. Blood Bank. The same shall be applicable even if this activity is outsourced. b) It outlines methods of surveillance in the identified high-risk areas. nebulizers etc. chemicals used/ methods and procedures followed in wards and critical areas. all high risk procedures should be identified from infection control point of view. endoscopies. CSSD. ward. consistency (reliability). Self explanatory. Equipment cleaning and sterilization practices are included. Remarks Infection Control Manual Infection Control Manual Infection Control Manual It shall address this at all levels e. Washing protocols for different categories of linen including blankets should be included. The HCO shall develop a system of monitoring drug susceptibility (based on culture sensitivity) and accordingly develop its antibiotic policy. The Manual should include sterilization and disinfection policy. BMT etc. Self explanatory. Special focus on critical equipments like ventilators. cost minimization. OT and CSSD.g. timeliness of feedback. which shall be reviewed at periodic intervals (maybe once in 3 months) for its continuing applicability. OT. The organization could refer to ISO 22000:2005 (food safety) while addressing this issue.cardiac catheterization. It shall define the frequency and mode of surveillance. Interpretation The manual should clearly identify the high risk areas of the hospital e. ICU. It is preferable that the organization follows a uniform policy across different departments within the organization. If outsourced the organization shall ensure that it establishes adequate controls to ensure infection control. surgery lasting more than 2 hours.a) Objective Element The manual identifies the various high-risk areas and procedures. The laundry can be in-house or outsourced. c) It focuses on adherence to standard precautions at all times. For example.
h) Engineering controls to prevent infections are included. Interpretation The organization must be able to provide evidence of conducting periodic surveillance activities in its identified high risk areas. Remarks Infection Control Manual 35 . Confidentiality and anonymity must be ensured. Issues such as Air conditioning plant and equipment maintenance. Infection Control Manual Infection Control Manual HIC. methods of data collection. along with schedule of rounds should be defined. a) Objective Element Surveillance activities are appropriately directed towards the identified highrisk areas. The organization must have a documented policy on the updation of the infection control manual. case definitions. seepage leading to fungal colonization. identification of potential indicators. replacement of filters. The infection control team is responsible for surveillance activities in identified areas of the hospital. traffic flow. The HCO should clearly mention which specific targeted surveillance (site specific. The specific objectives. AHUs. frequency and duration of monitoring. or body parts and safety measures while handing over body to relatives should be in accordance with the policy. j) The organization defines the periodicity of updating the infection control manual. Any renovation work in hospital patient care areas should be planned with Infection Control team with regard to architectural segregation. The organization shall ensure that it has a process in place to collect surveillance data and also to ensure that it is able to capture all such data. use of materials. unit oriented. b) Collection of surveillance data is an ongoing process. The mortuary services in the hospital should be provided through walk-in cold rooms or mortuary cold cabinets. Water supply sources and system of supply. It is desirable to update at least once in a year based on its trends & outcomes of the audit processes. sewer lines (in shafts) should be included. replacement/repair of plumbing. priority oriented) activities are being carried out. cleaning of A/c ducts. i) Mortuary practices and procedures are included as appropriate to the organization.3. testing for water quality must be included. Mortuary procedures of preserving body.
The data so collected shall be authenticated by the team by going through every data or by using random sampling so that the process can be validated. isolation rooms and all high risk (critical) areas. information (in relevant format) is sent to appropriate authorities. Surveillance activities include monitoring the effectiveness of housekeeping services. a) Objective Element The organization monitors urinary tract infections. The organization shall do this for all patients on the ventilator having clinical features suggestive of infection. This would include categorization of areas/ surfaces. method of use should be specified. The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees. It should also include procedures for terminal cleaning. The organization shall do this for all symptomatic catheterized patients. The organization shall ensure that this is sent at the specified frequency and in the format as required by statutory authorities.c) Verification of data is done on regular basis by the infection control team. d) In cases of notifiable diseases. dilution factors. rules. The organization monitors respiratory tract infections. Records from Medical Records department e) Scope of surveillance activities incorporates tracking and analyzing of infection risks. This shall be done at regular intervals (maybe monthly and consolidated into an annual report) and the organization shall take suitable steps based on the analysis. rates and trends. and items used in patient care. This can be done by sending sputum or ET/ tracheostomy secretions (obtained using a suction catheter) or ET/ tracheostomy tip or protected specimen brushing (PSB) or mini broncho-alveolar lavage (BAL) for culture. blood and body fluid cleanup. furniture/ fixtures. general cleaning procedures for surfaces.4. The common disinfectants used. The team shall preferably verify every serious infection (as defined by the organization) report. regulations and notifications thereof. f) HIC. b) Interpretation This can be done either by sending urine or catheter tip for culture. The organization shall identify all notifiable diseases after taking into consideration the local laws. Remarks Records Records 36 .
d) The organization monitors surgical site infections. It could also provide specific inputs to reduce the HAI rate. The hospital takes appropriate action to control outbreaks of infections. Records Records e) Records HIC. The organization shall preferably display the necessary instructions near every hand washing area. Facilities Available HIC. Compliance could be verified by random checking. etc. They should be available at the point of use and the organization shall ensure that it maintains an adequate inventory. soaps.5. Isolation/ barrier nursing facilities are available. observation. a) Objective Element Hospital has a documented procedure for handling such outbreaks. clothing. The organization shall define the conditions where the same shall be carried out and ensure that it provides the necessary resources to carry out the activity (e. a) b) Objective Element Hand washing facilities in all patient care areas are accessible to health care providers. trends and opportunities for improvement. Remarks Infection Control Manual 37 . Self explanatory. Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff. Proper facilities and adequate resources are provided to support the infection control programme. This shall be in accordance with good clinical practices. For all peripheral lines clinical evidence of thrombophlebitis would suffice. identification and investigation of such outbreaks and the procedure for management.). Interpretation The organization shall ensure that it provides necessary infrastructure to carry out the same. and disinfectants are available and used correctly.6. gloves etc.g. The feedback shall include the rates. Standard Case definitions shall include a unit of time and place along with specific biological and/or clinical criteria. This shall be done by sending pus/ swab for culture. For patients with symptoms suggestive of intra vascular device infection and having central line the same shall be done by sending the tip for culture. masks. Compliance with proper hand washing is monitored regularly. masks. Remarks Infection Control Manual Evidence on site Infection Control Manual Evidence on site c) Infection Control Manual d) Adequate gloves.c) The organization monitors intra-vascular device infections. Interpretation This shall incorporate definitions as to what constitutes an outbreak.
Infection Control Manual Infection Control Manual HIC.b) This procedure is implemented during outbreaks. The organization should be able to implement basic procedures to prevent recurrence such as source control if source identified. This shall be done by accepted methods e. c) There is an established recall procedure when breakdown in the sterilization system is identified. Proper segregation and collection of Bio-medical Waste from all patient care areas of the hospital is implemented and monitored. The organization shall ensure that the sterilization procedure is regularly monitored and in the eventuality of a breakdown it has a procedure for withdrawal of such items. zoning) and separation of clean and dirty areas.8. Pollution control board/committee. designing a data collection form. b) Regular validation tests for sterilization are carried out and documented. strengthening infection control policies etc. a) Objective Element There is adequate space available for sterilization activities. c) After the outbreak is over appropriate corrective actions are taken to prevent recurrence. bacteriologic. Remarks CSSD Policy CSSD Policy CSSD Policy HIC. Interpretation Adequacy of space refers to the CSSD which should have an area of 0. a) b) Objective Element The hospital is authorized by prescribed authority for the management and handling of Bio-medical Waste. There are documented procedures for sterilization activities in the hospital. constructing an epidemic curve. describe the outbreak by developing a case definition. Interpretation The occupier shall apply in the prescribed form and get approval from the prescribed authority e. Statutory provisions with regard to Bio-medical Waste (BMW) management are complied with. loopholes and compliance gaps. proper layout (unidirectional flow. Engineering validations like Bowie Dick tape test and leak rate test need to be carried out. Remarks Copy of FORM I Evident on Site 38 .g.7sqm/bed. Monitoring shall be done by members of the infection control committee/team. collecting data from the affected. review of all infection control policies. suitable location. The organization should be able to identify the outbreak.g. Wastes to be segregated and collected in different colour coded bags and containers as per statutory provisions.7. strips etc.
Remarks Copy of the budget Copy of the budget Training Records Training Records 39 . This shall be prepared taking into consideration the scope of the activity and previous years’ experience. Requisite fees. Evident on site HIC. The HCO shall ensure that the fees are deposited in a timely manner. d) Interpretation The HCO shall ensure that the resources required by the personnel should be available in a sustained manner. Self explanatory. It should include the policies. d) The waste is transported to the predefined site at definite time intervals (maximum within 48hours) through proper transport vehicles in a safe manner. The hospital regularly earmarks adequate funds from its annual budget in this regard.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. procedures and practices of the infection control programme. It also conducts regular “in-service” training sessions for all concerned categories of staff at least once in a year. If the hospital has waste treatment facility within its premises then they have to be in accordance with statutory provisions or they can outsource it to a central facility. Evident on Site Waste transportation trolley MOU between the hospital and the Outsourced agency e) Copy of FORM II f) Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste. There must be a documented evidence of pre induction training for appropriate categories of staff before joining concerned department(s). Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorized contractor(s). a) Objective Element Hospital management makes available resources required for the infection control programme.9. Monitoring of this activity should be done by Infection Control team. If this activity is outsourced the organization shall ensure that it is done to an authorized contractor. b) c) It conducts regular preinduction training for appropriate categories of staff before joining concerned department(s). This includes both men and materials. Self explanatory. There shall be a separate budget demarcated for HIC activity. The infection control programme is supported by hospital management and includes training of staff and employee health. In addition the annual reports have to be submitted by the 31st of January of every year and accident reporting has to be carried out in the prescribed form. documents and reports are submitted to competent authorities on stipulated dates.
various clinical and support departments of the HCO. The manual shall incorporate the mission. statutory requirements. Accreditation Coordinator d) e) The quality improvement programme is comprehensive and covers all the major elements related to quality improvement and risk management. The manual could be stand alone and should have cross linkages with other manuals. hospital functioning and operations. Self explanatory. Self explanatory. This should be documented as a manual. data collection. There is a structured quality improvement and continuous monitoring programme in the organization. Also refer to CQI 1b.e) Appropriate pre and post exposure prophylaxis is provided to all concerned staff members. Objective Element a) The quality improvement programme is developed. Quality Management Plan Risk Management 40 . This should preferably be a person having a good knowledge of accreditation standards. review of policy and corrective action. The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism. Interpretation This committee shall have representation from management. vision. quality policy. important indicators as identified etc. This shall preferably cover all aspects including documentation of the programme. quality objectives. The quality improvement programme is documented. service standards. implemented and maintained in a structured manner.1. monitoring it. Traning Records Remarks b) Quality Management Plan c) There is a designated individual for coordinating and implementing the quality improvement programme. hospital quality improvement principles and evaluation methodologies. implemented and maintained by a multidisciplinary committee. CHAPTER 6 : Continuous Quality Improvement (CQI) CQI. This programme shall be developed.
The organization identifies key indicators to monitor the clinical structures. The following is however mandatory: i. ii. Percentage of cases wherein the pre-defined initial nursing assessment is completed within 30 minutes. Percentage of re-dos. The inputs for updation could be based on the review carried out by the quality improvement committee. The minutes of the review meetings should be recorded and maintained. ii. iii.f) The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified. Number of reporting errors/1000 investigations. it needs to be reviewed at regular pre-defined intervals (as defined by the HCO in the quality improvement manual but at least once in four months) by conducting internal audits. At the end of the audit there shall be a formal meeting to summarise the findings and identify areas for improvement. iii.2. Percentage of cases wherein care plan is documented and counter-signed by the clinician. Objective Element a) Monitoring appropriate assessment. The following is however mandatory: i. The HCO shall develop appropriate key performance indicators suitable to it. Self explanatory. During this meeting there shall be an analysis of key indicators as identified and determined by the organization including the mandatory indicators as laid down in CQI 2 and 3. As quality improvement is a dynamic process. This audit shall be done by a multidisciplinary team (preferably trained in NABH standards) including all the applicable standards and objective elements. 41 . g) The quality improvement programme is a continuous process and updated at least once in a year. processes and outcomes which are used as tools for continual improvement. Time for initial assessment of indoor and emergency patients. Percentage of reports CoRemarks b) Monitoring includes safety and quality control programmes of the diagnostics services. i. includes patient Interpretation The HCO shall develop appropriate key performance indicators suitable to it. Quality Committee Quality Management Plan CQI. Percentage of cases wherein screening for nutritional needs has been done.
Percentage of wastage of blood and blood products. Percentage of unplanned ventilation following anaesthesia.relating with clinical diagnosis. iii. Percentage of accidental removal of tubes and catheters. ii. iv. Percentage of adherence to safety precautions by employees working in diagnostics. f) Monitoring includes use of blood and blood products. Percentage of contrast related reactions. Percentage of transfusion reactions. e) Monitoring includes use of anaesthesia. The HCO shall develop appropriate key performance indicators suitable to it. Turnaround time for issue of blood and blood components The HCO shall develop appropriate key performance indicators suitable to it. The following is however mandatory: i. ii. Percentage of modification of anaesthesia plan. The HCO shall develop appropriate key performance indicators suitable to it. Percentage of re-scheduling of procedures. Anaesthesia related mortality rate. Re-exploration rate. The following is however mandatory: i. iv. The following is however mandatory: i. g) Monitoring includes availability and content of medical records. The HCO shall develop appropriate key performance indicators suitable to it. Percentage of medical records d) Monitoring includes adverse drug events. iii. 42 . Incidence of adverse drug reactions. iii. iii. The following is however mandatory: i. iv. ii. c) Monitoring includes invasive procedures. Percentage of adverse anaesthesia events. Incidence of haematoma at puncture site. Percentage of blood component usage. iv. ii. Percentage of medication errors. all The HCO shall develop appropriate key performance indicators suitable to it. iv. Percentage of medication charts with illegible writing over a given period. The following is however mandatory: i.
iv. Percentage of consumables rejected before preparation of Goods Receipt Note. i) Monitoring includes clinical research. Percentage of patients withdrawing from the study. Incidence of variations from the Remarks Drugs and Therapeutic Committee Drug Formulary 43 .3. Percentage of serious adverse events (which have occurred in the HCO) reported to the ethics committee within the defined timeframe.h) Monitoring includes infection control activities. The HCO shall develop appropriate key performance indicators suitable to it. This data is analysed for improvement opportunities and the same are carried out. Also refer to CQI 1f All improvement activities carried out by the HCO shall have an evaluable outcome. iii. Percentage of protocol violations/deviations reported. k) Monitoring includes data collection to support evaluation of these improvements. Infection Control Committee NA Infection Control Committee CQI. Objective Element a) Monitoring includes procurement of medication essential to meet patient needs. The organization identifies key indicators to monitor the managerial structures. The following is however mandatory: i. Respiratory infection rate.g. Surgical site infection rate. ii. Intra-vascular device infection rate. processes and outcomes which are used as tools for continual improvement. The same shall be captured and analysed. Percentage of medical records having incomplete and/or improper consent. iv. iv. Interpretation The HCO shall develop appropriate key performance indicators suitable to it. monthly/quarterly. Percentage of drugs procured by local purchase. Urinary tract infection rate. Percentage of medical records not having initial assessment and the plan of care. Percentage of missing records. ii. j) Monitoring includes data collection to support further improvements. The following is however mandatory: i. not having discharge summary. Percentage of stock outs including emergency drugs. iv. Number of research activities being carried out. The data could be collected at predefined intervals e. ii. The HCO shall develop appropriate key performance indicators suitable to it. ii. iii. The following is however mandatory: i. iii. iii.
ii. Submission of tax returns and deduction of taxes at the specified time frame. iv. iii. Percentage of employees who are aware of employee rights. iv. iv. Incidence of bed sores after admission. c) Monitoring includes risk management. Time taken for discharge. and e) Monitoring includes patient satisfaction which also incorporates waiting time for services. iv. The following is however mandatory: i. In patient satisfaction index. ii. Number of sentinel events. Sentinel Event Policy 44 . The following is however mandatory: i. Percentage of near misses analysed. Employee attrition rate. iii.procurement process. ii. Equipment down time. iv. The HCO shall develop appropriate key performance indicators suitable to it. iii. The following is however mandatory: i. The HCO shall develop appropriate key performance indicators suitable to it. iii. of includes space. Nurse-patient ratio. Employee satisfaction index. Bed occupancy rate and average length of stay. Submission of report/ data/form pertaining to bio-medcial waste. responsibilities and welfare schemes. Out patient satisfaction index. The following is however mandatory: i. Employee absenteeism rate. MRD Policy Quality Management Plan Quality Committee Quality Committee f) Monitoring includes employee satisfaction. PNDT act and radiation safety within the defined timeframe. Incidence of falls. The HCO shall develop appropriate key performance indicators suitable to it. Number of variations observed in mock drills. iii. ii. ii. The HCO shall develop appropriate key performance indicators suitable to it. ii. b) Monitoring includes reporting of activities as required by laws and regulations. OT and ICU utilization rate. Waiting time for services including diagnostics and out patient. Number of births and deaths. Percentage of employees provided pre-exposure prophylaxis. Employee Satisfaction Survey g) Monitoring includes adverse events and near misses. The HCO shall develop appropriate key performance indicators suitable to it. d) Monitoring utilisation manpower equipment. The HCO shall develop appropriate key performance indicators suitable to it. Number of notifiable diseases. The following is however mandatory: i. The following is however mandatory: i.
These should be in steady supply so as to ensure that the programme functions smoothly. Objective Element a) Hospital Management makes available adequate resources required for quality improvement programme.h) Monitoring includes data collection to support further study for improvements. Interpretation This shall include the men.5. As these audits are retrospective/concurrent in nature. There is an established system for audit of patient care services. Monitoring includes data collection to support evaluation of the improvements. Remarks Budget Report b) Budget c) Monthly report of MRD CQI. YES 45 . iv. The parameters could be disease based.g. MRD Policy CQI. Interpretation The HCO shall identify such personnel. This means that the names of the patients and the hospital staff who may figure in the audit documents must not be disclosed nor any reference be made to them in public discussions/ conferences. Appropriate fund allocation is done by the organization for the smooth functioning of the programme. The quality improvement programme is supported by the management. Appropriate statistical and management tools are applied whenever required. administrators and nurses. Remarks Medical Audit Committee b) Parameters for medical AUDIT c) Patient and staff anonymity is maintained. Self explanatory. This data is analysed for improvement opportunities and the same are carried out. community based or based on length of stay. monthly/ quarterly. it is imperative that this be done using predefined parameters so that there is no bias. Number of security related incidents including thefts. The data could be collected at predefined intervals e. i) iii. The inputs for updation could be based on the review carried out by the quality improvement committee. The parameters to be audited are defined by the organization.4. Hospital earmarks adequate funds from its annual budget in this regard. material. cost based. Objective Element a) Medical and nursing staff participates in this system. Also refer to CQI 1f Self explanatory. Incidence of needle stick injuries. machine and method. It could be a mix of clinicians.
Those responsible for governance lay down the strategic and operational plans commensurate to the organization’s mission in consultation with the various stake holders. a) b) c) Objective Element Those responsible for governance lay down the organization’s mission statement. The Governing board and the leaders of HCO shall define and develop the process for strategic and operation plans so as to achieve the organizational mission statement. The responsibilities of the management are defined. Action taken Report of the Medical Audit Remedial measures are implemented CQI. Objective Element a) The organization has defined sentinel events. Root cause analysis of all such events should be carried out by a multi-disciplinary committee taking inputs from the concerned units/ discipline/ departments. Sentinel events are intensively analyzed. Interpretation The sentinel events relating to system or process deficiencies that are relevant and important to the organization must be clearly defined. Remarks Sentinel Event Policy b) c) The organization has established processes for intense analysis of such events. Those responsible for governance approve the organization’s budget and allocate the resources Interpretation It is not only the head of the HCO but the members of the board of governors (where applicable) who need to define it.1. The Governing board and the Head of HCO shall have the policy for budgeting and resource allocation for attaining its mission and Remarks Quality Management Plan Quality Management Plan Budget 46 . The findings and recommendations arrived at after the analysis should be communicated to all concerned personnel to correct the systems and processes to prevent recurrences. are Self explanatory. Sentinel events are intensively analysed when they occur. Actions are taken upon findings of such analysis. Sentinel Event Policy Sentinel Event Policy d) Sentinel Event Policy CHAPTER 7 : Responsibilities of Management (ROM) ROM. The established processes should include reporting the occurrence of such events on standardised incident report forms.d) e) All audits documented.6. Medical Audit Report All remedial measures as ascertained should be documented and implemented and improvements thereof recorded to complete the audit cycle.
This could be documented either at individual department level or the HCO could have a brochure detailing the scope of each department. NA Self explanatory. a) Objective Element Each organizational programme. Those responsible for governance monitor and measure the performance of the organization against the stated mission. The HCO shall have a well defined organization structure/chart and this shall clearly document the hierarchy. ROM. The governing board and the Head of the HCO shall develop quarterly (at least) performance reports based on the strategic and operational plans. The responsibility of compliance lies with the first two level of the hierarchy. Those responsible for governance establish the organization’s organogram. h) Licenses COPY i) Marketing Dept. Each department's activity is to be predefined. Self explanatory. line of control. service. Scope of services of each department is defined.2. Those responsible for governance support research activities and quality improvement plans. along with the functions at various levels. The services provided by each department are documented. Those responsible for governance appoint the senior leaders in the organization. The leader should have domain knowledge of that particular department.d) e) required to meet the organization’s mission. This shall include administrative procedures like attendance. b) c) Administrative policies and procedures for each department is maintained. site or department has effective leadership. Interpretation There needs to be a minimum essential qualification and relevant experience of the leader. Those responsible for governance address the organization’s social responsibility. Self explanatory. The organization complies with the laid down and applicable legislations and regulations. The Governing board and Head of the HCO shall willfully develop social responsibility policy and accordingly address it. conduct. periodically review it. Departmental leaders are involved in quality improvement. replacement etc. Quality Management Plan Organization structure f) Organization structure g) Self explanatory. leave. Remarks HR Department have all the records of it Scope of Services Evident on Site HR Department d) Quality Committee 47 .
The organization honestly portrays the services which it can and cannot provide. Remarks YES b) Self explanatory. Remarks Hospital Safety Committee 48 . trust. public has to be disclosed.5. The organization accurately bills for its services based upon a standard billing tariff. a) Objective Element The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme. accreditations for specific departments or whole hospital wherever applicable. Self explanatory. Tariff List f) ROM. 16 Years Exp. The designated individual has requisite and appropriate administrative experience. b) Ethics Committee c) d) Private Scope of Services e) Here portrays implies that the HCO convey its affiliations.4. private. The leaders establish the organization’s ethical management. The organization discloses its ownership. Remarks Quality Management Plan Mission statement as evidence. a) Objective Element The leaders make public the mission statement of the organization. Self explanatory. The ownership of the hospital e. ROM. A suitably qualified and experienced individual heads the organization.ROM. Interpretation Self explanatory.3. Interpretation The HCO shall have a mission statement and the same shall be displayed prominently. a) Objective Element The designated individual has requisite and appropriate administrative qualifications. Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management. The organization is managed by the leaders in an ethical manner. The organization honestly portrays its affiliations and accreditation.g. The HCO shall function in an ethical manner. Interpretation Self explanatory.
There shall be sufficient resources kept as contingency to address the risk reduction activities as and when the leaders proactively suggest. their families. 49 . The organization’s environment and facilities operate to ensure safety of patients. The management ensures implementation of these requirements. The end result of these shall result in preventive actions. This functionary has identified the appropriate personnel in the HCO who are supposed to implement the respective laws and regulations. The organization is aware of and complies with the relevant rules and regulations. Sentinel Event Policy c) d) The HCO has a system in place for internal and external reporting of system and process failures.2. Interpretation A designated management functionary has been given the responsibility to enlist the laws and regulation as applicable to the HCO.b) The scope of the programme is defined to include adverse events ranging from “no harm” to “sentinel events”. Management ensures implementation of systems for internal and external reporting of system and process failures. Remarks Licenses & Act approval copy as evidence b) Management regularly updates any amendments in the prevailing laws of the land. Self explanatory. Objective Element a) The management is conversant with the laws and regulations and knows their applicability to the organization.1. Hospital Safety Committee Hospital Safety Committee CHAPTER 8: Facility Management and Safety (FMS) FMS. Management provides resources for proactive risk assessment and risk reduction activities. laws and byelaws and requisite facility inspection requirements. There is a mechanism to regularly update licenses/ registrations/ certifications. Copies available with MS (Process for Compliance and Updating of Regulatory & Statutory requirements) Self explanatory. The HCO shall have a system of reporting of all the incident/accident. Copies available with MS (Process for Compliance and Updating of Regulatory & Statutory requirements) Self explanatory. staff and visitors. Contingency plan shall be in place to deal with the situation of system and process failure anticipated within the organization. Copies available with MS(Process for Compliance and Updating of Regulatory & Statutory requirements) c) d) FMS.
floor plans and fire escape routes. Interpretation Self explanatory. A designated person maintains the drawings. allotment of job and completion of job. e) A person in the HCO management is designated to be in-charge of maintenance of facilities. Response times are monitored from reporting to inspection and implementation of corrective actions.Objective Element a) There is a documented operational and maintenance (preventive and breakdown) plan. Roster of Engineering department f) g) Maintenance staff is contactable round the clock for emergency repairs. Objective Element a) The organization plans for equipment in accordance with its services and strategic plan. This shall also take into consideration future requirements. Interpretation Self explanatory. Records of the Engineering Department FMS. Remarks Bio-Medical Engg. Up-to-date drawings are maintained which detail the site layout. families and community. The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies. Remarks Material Management 50 . There are designated individuals responsible for the maintenance of all the facilities. Engineering / Facilities Dept. b) Document with Engineering Department c) Self explanatory. Self explanatory.3 The organization has a programme for clinical and support service equipment management. The HCO has the required number of supervision and tradesmen to manage the facilities. Roster as Evidence A complaint attendance register is to be maintained to indicate the date and time of receipt of complaint. Evident at Site d) Self explanatory. There is internal and external sign posting in the organization in a language understood by patient.
The HCO either calibrates the equipment in house or out sources. UPS and any other suitable source. Interpretation The HCO shall make arrangements for supply of adequate potable water and electricity. maintaining traceability to national or international or manufacturer’s guidelines/standards. Remarks Engineering / Facilities Dept. b) c) Engineering / Facilities Dept. engineering and bio-medical departments. medical gases and vacuum system. Self explanatory. Purchase Committee Bio-Medical Engg. e) Calibration Process Calibration records of equipments f) There is a documented operational and maintenance (preventive and breakdown) plan. Alternate electric supply could be from DG Sets. Objective Element Interpretation Remarks 51 .5 The organization has plans for fire and non-fire emergencies within the facilities. management. electricity. Alternate sources are provided for in case of failure. Registers of the BME Department Self explanatory.4 The organization has provisions for safe water. Bio Medical Engineer The HCO has weekly / monthly / annual schedules of inspection and calibration of equipment which involve measurement. Qualified and trained personnel operate and maintain the equipment Equipment are periodically inspected and calibrated for their proper functioning. Gas Manifold d) FMS. The organization regularly tests the alternate sources. Objective Element a) Potable water and electricity are available round the clock. Engineering / Facilities Dept. in an appropriate manner. FMS. Self explanatory. Self explanatory. finance. c) d) All equipment are inventoried and proper logs are maintained as required. Collaborative process implies that during equipment selection there is involvement of end user.b) Equipment is selected by a collaborative process. There is a maintenance plan for piped medical gas. Self explanatory. Bio-Medical Engg. solar energy. compressed air and vacuum installation.
abatement and containment of fire and non-fire emergences. f) mock drill records. These may include : a) terrorist attack b) invasion of swarms of insects and pests c) earthquake d) invasion of stray animals e) hysteric fits of patients and/ or relatives f) civil disorders effecting the HCO g) anti-social behaviour by patients/ relatives h) temperamental disorders of staff causing deterioration in patient care i) spillage of hazardous (acids. c) acquired adequate fire fighting equipment for this which records are kept up-to-date. The HCO has: a) a fire plan covering fire arising out of burning of inflammable items. tubing. explosion.). amniotic fluid. pus.) medical wastes (blood. d) adequate training plans. mercury.a) The organization has plans and provisions for early detection. The HCO has a fire and non-fire emergency committee (FNEC) to review the HCO’s preparedness. The HCO takes care of non-fire emergency situations by identifying them and by deciding appropriate course of action. e) schedules for conduct of mock fire drills. vomits. syringes. The HCO has conducted an exercise of hazard identification and risk analysis (HIRA) and accordingly taken all necessary steps to eliminate or reduce such hazards and associated risks. etc. g) exit plans well displayed. etc.) j) building or structural collapse k) fall or slips (from height or on floor) or collision of personnel in passageway l) fall of patient from bed Sprinklers and smoke detectors. The HCO has a dedicated emergency illumination system which comes into effect in case of a fire. Plan 52 . infected materials (used gloves. electric short circuiting or acts of negligence or due to incompetence of the staff on duty. Evident on site. Disaster Mgt. sharps. etc. b) deployed adequate and qualified personnel for this.
Exit doors should remain open on all the time. Staff is trained for their role in case of such emergencies. vacuum. Fire exit plan shall be displayed on each floor particularly close to the lifts.7. In view of the law permission to smoke within the campus of hospital may not be granted. The organization has a smoking limitation policy. The policy has provisions for granting exceptions for patients and families to smoke. The organization plans for handling community emergencies. Mock drills are held at least twice in a year. epidemics and other disasters. Fire Exit Plan Displayed on each floor c) Fire fighting team formed Training Records d) Records of Drills FMS. Interpretation Smoking in public places including hospitals has been banned in this country.m) bursting of pipe lines n) sudden flooding of areas like basements due to clogging in pipe lines o) sudden failure of supply of electricity. b) The organization has a documented safe exit plan in case of fire and non-fire emergencies. etc p) bursting of boilers and/ or autoclaves. The HCO has established liaison with civil and police authorities and fire brigade as required by law for enlisting their help and support in case of an emergency. Interpretation The HCO has a documented plan and procedure for handling the situations like sudden rush of victims of Remarks 53 . Objective Element a) The organization defines and implements its policies to reduce or eliminate smoking. Self explanatory. In case of fire designated person are assigned particular work.6. gas. Remarks Smoking Policy b) Smoking Policy FMS. Objective Element a) The hospital identifies potential emergencies.
Process MSDS available on site 54 . Only communication exercise may also be undertaken. etc. identified trained personnel.a) b) c) d) b) The organization has a documented disaster management plan. Waste Mgt. Training Records Disaster Mgt. g) These plans and procedures cover ensuring adequacy of medical supplies. and method for managing spillages and adequate training of the personnel for these jobs. Objective Element a) Hazardous materials are identified within the organization. communication aids and mock drill methodology. Plan FMS. establishment of command nucleus. Interpretation The HCO has identified and listed the hazardous materials and has a documented procedure for their sorting. Plan Disaster Mgt. The disaster plan must incorporate essential elements of alert code. The HCO has ensured display of Material Safety Data Sheets (MSDS) for all hazardous materials and has accordingly arranged associated training of personnel Remarks Infection Control Manual b) The hospital implements processes for sorting. Plan e) Mock drills with and without patients have to be carried out. The plan is tested at least twice in a year. availability and earmarking of resources. disposal mechanism. The HCO has conducted an exercise of hazard identification and risk analysis (HIRA) associated with handling of hazardous materials and accordingly taken all necessary steps to eliminate or reduce such hazards and associated risks. materials. handling. Disaster Mgt. Hospital staff is trained in the hospital’s disaster management plan. action cards for each of the staff. Self explanatory. storage. information and communication. Plan Disaster Mgt. labelling. storage. transporting and disposal of hazardous material. transportation aids. equipment and materials during such emergencies. earthquake flood train accident Civil unrest outside the HCO premises e) Major fire f) Invasion by enemy. handling. c) d) Provision is made for availability of medical supplies. transpirations. The organization has a plan for management of hazardous materials.8. training and mock drills Resource availability should be according to threat perception. equipment.
The situational hazards also need to be covered in HIRA so that any emergency situation arising out of process of storing.c) Requisite regulatory requirements are met in respect of radioactive materials. implementation. and monitoring of the safety plan and policies. entry and exit from lifts. Remarks HospitaL Safety Committee b) Hospital Safety Committee c) Evident on site 55 . FMS. are situations which need to be taken care of. Self explanatory. Training Record of Medical & Paramedical Staffs.9. Objective Element a) The hospital has a safety committee to identify the potential safety and security risks. This committee coordinates development. The HCO has the requisite training need identification for material handling and those trainings are included in the HCO training calendar. Self explanatory. As per biomedical waste management rule d) There is a plan managing spills hazardous materials. the norms issued by Atomic Energy Regulatory Board (AERB) and the directives from the Health Physics Division of Bhaba Atomic Research Centre (BARC). Patient safety devices are installed across the organization and inspected periodically. e) Staff is educated and trained for handling such materials. storage. who handle such materials. for of MSDS Self explanatory. protruding or dangling elements in passage ways. The HCO ensures that the above Committee functions on a regular basis to coordinate development. Interpretation The HCO has a duly constituted safety committee which has identified the potential safety and security risks to staff. implementation and monitoring of the plans and policies. handling. The appropriate personnel in the HCO are aware about the rules and regulations such as the Atomic Energy Act. transportation and disposal of such hazardous materials are met effectively. sudden swing of swing doors. The hospital has system in place to provide a safe and secure environment. Sharp bends in passages. ramps. patients and visitors. See FMS 5 also.
Interpretation The organization's staff including the outsourced staff should be aware and should correctly interpret the mission and goals of the organization. Training Record CHAPTER 9 : Human Resource Management (HRM) HRM. Job Specifications Antecedent Verification Service Rule 74 HRM. Facility round conducted by Safety Committee Self explanatory. Self explanatory. The Organization has a documented system of human resource planning. Inspection reports are documented and corrective and preventive measures are undertaken. There is a safety education programme for all staff.d) e) f) 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. Objective Element a) The organization maintains an adequate number and mix of staff to meet the care. The job description should be commensurate with the qualification.1.2. The staff joining the organization is socialized and oriented to the hospital environment. Interpretation The staff should be commensurate with the workload and the clinical requirement of the patients. The organization verifies the antecedents of the potential employee with regards to criminal/negligence background. Rounds to be carried out by safety committee. Remarks Employee Guide Book 56 . The required job specifications and job description are well defined for each category of staff. Objective Element a) Each staff member. Remarks Manpower Planning b) c) The content of each job should be well defined and the qualifications. skills and experience required for performing the job should be clearly laid down. Inspection Rounds Self explanatory. treatment and service needs of the patient. employee student and voluntary worker is appropriately oriented to the organization’s mission and goals.
The HCO shall define the same in consonance with statutory requirements and the same shall be communicated to the employees. Impact of training at user level should also be documented Remarks Training and Development policy b) Training also occurs when job responsibilities change/ new equipment is introduced. students and volunteers are adequately trained on specific job duties or responsibilities related to safety. impact of training and the training calendar should be prepared. Employee Guide Book Employee Guide Book d) Employee Guide Book e) Induction Manual HRM.3. All employees are oriented to the service standards of the organization. c) Feedback mechanisms for assessment of training and development programme exist. For external training it could be done either by the HCO itself or by the external agency which imparted the training. Objective Element Interpretation Remarks 57 .4. This shall be based on the HCO's values and focus on development of soft skills: behaviour. Each staff member is made aware of his/her rights and responsibilities. In case of new equipment the operating staff should receive training on operational as well as daily maintenance aspects. The training should focus on the revised job responsibilities as well as on the newly introduced equipment and technology. Interpretation A training manual incorporating the procedure for identification of training needs. Staff members. documentation of training. communication skills. The HCO shall develop benchmarks for different services being provided. attitude. This shall include both internal & external training. Record with HRD and respective Deptt. All employees are educated with regard to patients’ rights and responsibilities.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. There is an ongoing programme for professional training and development of the staff. etc. training assessment. HRM. c) The organization's staff including the outsourced staff should be aware and should correctly interpret the policies and operating procedures of the organization as well as that of the department/ unit/ service in which he is performing the requisite duties. Training and Development Policy Record with HRD and respective Deptt. the training methodology. The employees should be able to identify and report violation of patient rights as and when the same occurs. Objective Element a) A documented training and development policy exists for the staff.
5. Objective Element a) A well-documented performance appraisal system exists in the organization. Interpretation Self explanatory. Hospital Safety manual b) Records of Drills Self explanatory. Staff members can demonstrate and take actions to report. The employees are made aware of the system of appraisal at the time of induction. Remarks Performance Appraisal System b) Self explanatory. Performance Appraisal System Self explanatory. Induction Training Programme Self explanatory. Self explanatory. failures and user errors exist. Objective Element a) A written statement of the policy of the organization with regard to discipline is in place. This can be done by identifying training requirements and accordingly providing for the same (wherever possible). An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process. c) d) Performance Appraisal System e) Performance Appraisal System HRM. The organization has a well-documented disciplinary procedure. c) d) Quality Committee HRM.a) All staff is trained on the risks within the hospital environment.6. Reporting processes for common problems. visitors and employee related risks. Performance is evaluated based on the performance expectations described in job description. Performance appraisal is carried out at pre defined intervals and is documented. Remarks Disciplinary Procedure 58 . Interpretation Self explanatory. Staff members are made aware of procedures to follow in the event of an incident. Training Records The HCO has a defined procedure for reporting of these events. The appraisal system is used as a tool for further development. eliminate / minimize risks. The HCO shall define such risks which shall include patient. Self explanatory.
d) e) Disciplinary Procedure HRM. The organization addresses the health needs of the employees. Health problems of the employees are taken care of in accordance with the organization’s policy. Disciplinary Procedure c) Induction Training Records Self explanatory. Self explanatory. The results should be documented in the personal file.8. Interpretation For definition of "grievance handling" refer to glossary. This shall however be in consonance with the law of the land. Regular health checks of staff dealing with direct patient care are done atleast once a year and the findings/ results are documented. The redress procedure addresses the grievance. A grievance handling mechanism exists in the organization. Remarks Evidenced on Personal File b) Medical Benefit c) Medical Benefit Records in Personal file 59 . This shall be in consonance with the law of the land and good clinical practices. Self explanatory. Objective Element a) The employees are aware of the procedure to be followed in case they feel aggrieved. Self explanatory. Employee Grievance Policy Remarks Employee Grievance Policy b) c) HRM. Employee Grievance Policy Self explanatory. Disciplinary Procedure The HCO shall designate an appellate authority to consider appeals in disciplinary cases.7.b) The disciplinary policy and procedure is based on the principles of natural justice. Interpretation Self explanatory. Self explanatory. Objective Element a) A pre-employment medical examination is conducted on all the employees. The policy and procedure is known to all categories of employees of the organization. Actions are taken to redress the grievance. This implies that both parties (employee and employer) are given an opportunity to present their case and decision is taken accordingly. The disciplinary procedure is in consonance with the prevailing laws. There is a provision for appeals in all disciplinary cases. The HCO has a written procedure for handling grievances of employees.
The personal files contain personal information regarding the employees’ qualification. There is a process for authorizing all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications. training and experience of the identified medical professionals is documented and updated periodically. training assessment and outcome of health checks. regulation and the hospital to provide patient care without supervision are identified. Personal File as Evidence. Personal files contain results of all evaluations.11. Interpretation The HCO identifies the individuals who have the required qualification (s). registration. There is a process for collecting. disciplinary background and health status. c) Self explanatory. Self explanatory. All such information pertaining to the medical professionals is appropriately verified when possible. Remarks HR Department b) Self explanatory. Credentialing Committee Remarks Credentialing Committee b) c) The HCO shall do the same by verifying the credentials from the organization which has awarded the qualification/training.10. All records of in-service training and education are contained in the personal files.d) Occupational health hazards are adequately addressed. Interpretation Self explanatory. YES d) HRM. training and experience to provide patient care in consonance with the law. HRM.9. Credentialing Committee HRM. Objective Element a) Medical professionals permitted by law. registration. Self explanatory. The education. training and experience) of medical professionals permitted to provide patient care without supervision. 60 . Updation is done after acquisition of new skills and/or qualification. There is a documented personal record for each staff member. Training record kept separately Evaluations would include performance appraisals. verifying and evaluating the credentials (education. Objective Element a) Personal files are maintained in respect of all employees.
Objective Element a) The education. training and experience) of nursing staff. Remarks Privileging b) Self explanatory. training and experience of nursing staff is documented and updated periodically. Privileging 61 .12. b) All such information pertaining to the nursing staff is appropriately verified when possible. Interpretation The HCO identifies the individuals who have the required qualification (s). The services provided by nursing staff are in accordance with the prevailing laws and regulations. There 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. verifying and evaluating the credentials (education. The HCO shall do the same by verifying the credentials from the organization which has awarded the qualification/training. The services provided by the medical professionals are in consonance with their qualification. training and registration. c) Self explanatory.Objective Element a) Medical professionals admit and care for patients as per the laid down policies and authorization procedures of the organization. Remarks Registration from Nursing Counsil HR Department HRM. training and registration. registration. registration. Interpretation The HCO shall identify as to what each medical professional is authorized to do.13. Updation is done after acquisition of new skills and/or qualification. The requisite services to be provided by the medical professionals are known to them as well as the various departments / units of the hospital. HRM. Interpretation The HCO shall identify as to what each nurse is authorized to do. training and experience to provide nursing care to patients in consonance with the law. Objective Element a) The clinical work assigned to nursing staff is in consonance with their qualification. Remarks b) Self explanatory. There is a process for collecting.
The HCO shall define the system of releasing the relevant information to the authority as per statutory norms.2.1. Objective Element a) Formats for collection standardized. material. Policies and procedures to meet the information needs are documented. The organization has processes in place for effective management of data. All information management and technology acquisitions are in accordance with the policies and procedures. d) HISPrimus%20Hospital %20Manual. The organization contributes to external databases in accordance with the law and regulations. Interpretation The HCO has manual and/or electronic Hospital Information System and/or Management Information System which provides relevant information to all concerned stakeholders. Objective Element a) 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. Remarks Medical Records Department b) A policy document is available where the HIS/MIS is described.doc#BACKUP e) Medical Records Department IMS. HIS c) Evidenced at respective Deptt. in all Remarks Medical Records Department Budget b) Necessary resources are available for analyzing data. The HCO shall define the needs for software and hardware solutions as per the information requirements and future necessities.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. Self explanatory. Policies and procedures exist to meet the information needs of the care providers. The HCO shall make available men. management of the organization as well as other agencies that require date and information from the organization. space and budget. These policies and procedures are in compliance with the prevailing laws and regulations. Nursing Manual CHAPTER 10 : Information Management System (IMS) IMS. data are Interpretation MIS/HIS data is collected standardised format from areas/services in the HCO. 62 . Self explanatory.
The HCO shall decide the format for maintaining the continuity in the medical records. Every medical record entry is dated and timed. This could be by writing the full name or by mentioning the employee code number. Objective Element a) The medical record contains information regarding reasons for admission. diagnosis and plan of care. authorised e-signature provision as per statutory requirements must be kept. etc. integrating and using data. Medical Records Department f) Medical Record file as an Evidence IMS. Documented procedures exist for storing and retrieving data. documents and implements the same. The organization has a complete and accurate medical record for every patient. Organization policy identifies those authorized to make entries in medical record. measurement of trends and initiating action wherever required. Interpretation Self explanatory. The medical record reflects continuity of care. Appropriate clinical and managerial staff participates in selecting. In case of electronic based records. IMS. with the help of stamp. Remarks Medical Records Department Medical Records Department Medical Records Department Medical Records Department c) d) e) The contents of medical record are identified and documented. The author of the entry can be identified. where ever physical or electronic data is stored. Medical Records Department Remarks 63 . Interpretation This shall also apply to records on digital media. Objective Element a) b) Every medical record has a unique identifier. Self explanatory. The HCO identifies which documents form part of the medical records. Self explanatory. HCO has a written policy stating who all can make entries.c) d) Documented procedures are laid down for timely and accurate dissemination of data. There is a multi-disciplinary committee which is responsible for the appropriate selection of indicators.3. The record provides an up-to-date and chronological account of patient care. Medical Records Department e) Medical Audit committee scope.4. Medical Records Department The HCO shall define data management policy and ensure adequate safeguards for protection of data.
Process for Compliance and Updating of Regulatory & Statutory Requirements 64 . security. Medical Records Department Self explanatory. Self explanatory. the medical record contains a copy of the report of the same. Policies and procedures are in place for maintaining confidentiality. It is mandatory to mention the clinical condition of the patient before transfer is effected. It shall ensure the usage of tracer card for movement of the file in and out of the MRD so as to maintain confidentiality. integrity and security of information. Patient Transfer Policy Self explanatory. The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel.5. Medical Records Department Death certificate evident Not Applicable The HCO provides access to medical records to designated health care providers (those who are involved in the care of that patient). Medical Records Department Self explanatory. The HCO provides the death certificate as per the International Certification of cause of death. This is applicable for both manual and electronic records. b) Policies and procedures are in consonance with the applicable laws.b) c) d) e) f) g) Operative and other procedures performed are incorporated in the medical record. Interpretation The HCO shall control the accessibility to the MRD department. Objective Element a) Documented policies and procedures exist for maintaining confidentiality. the medical record contains a copy of the death certificate indicating the cause. In case of death. Care providers have access to current and past medical record. Self explanatory. date and time of death. Indian Penal Code and Code of medical Ethics. safety and integrity of information. This is in the context of Indian Evidence Act. the reason for the transfer and the name of the receiving hospital. Medical Records Department IMS. security and integrity of information. When patient is transferred to another hospital. the medical record contains the date of transfer. Whenever a clinical autopsy is carried out. Remarks HIS HIS Tracer card available.
The hospital uses developments in appropriate technology for improving confidentiality. To prevent tampering. In this context. Consumer protection act 1987 and relevant state legislation. 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. Some of the related laws in this context are Code of Medical Ethics 2002. destruction and tampering. data and information. for physical records access shall be limited only to the concerned health care provider. Policies and procedures exist for retention time of records. data and information. Interpretation The HCO shall define the retention period for each category of medical records: Out-patient.c) The policies and procedures incorporate safeguarding of data / record against loss. For electronic data there should be protection against virus/trojans and also a proper backup procedure. The HCO shall procedure for communication. Remarks Medical Records Department b) Medical Records Department c) Medical Records Department 65 . Objective Element a) Documented policies and procedures are in place on retaining the patient’s clinical records. Report to Health Authority IMS. The HCO carries out regular audits/rounds to check compliance with policies. in-patient and MLC. Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization. The retention process provides expected confidentiality and security. HIS HIS d) The hospital has an effective process of monitoring compliance of the laid down policy. For physical records the HCO shall ensure that there is adequate pest and rodent control measures. Medical Records Department HIS e) The HCO shall review and update its technological features so as to improve confidentiality. This is applicable for both manual and electronic system. In electronic format this could be done by adequate passwords. The policies and procedures are in consonance with the local and national laws and regulations. define the privileged Medical Records Department f) Medical Records Department g) Self explanatory.6. integrity and security of information. if any. integrity and security. the release of information in accordance with the Code of Medical Ethics 2002 should be kept in mind.
7. etc. Destruction can be done after the retention period is over and after taking approval of the competent authority. simple random. Appropriate corrective and preventive measures undertaken are documented. Self explanatory. Medical Records Department The HCO shall define the principles on which sampling is based.d) The destruction of medical records. data and information is in accordance with the laid down policy. The review points out and documents any deficiencies in records. Review shall be based on conditions of clinical and/or community importance. Medical Audit Committee Medical Records Department Medical Records Department d) Self explanatory. legibility and completeness of the medical records. Medical Audit Report Medicall Records Department f) g) Self explanatory. For example. total indoor patients. Medical Records Department Self explanatory. uses a sample statistical Interpretation Self explanatory. Action Taken Report 66 . Medical Records Department IMS. e) Self explanatory. The review representative based on principles. The organization regularly carries out review of medical records. systemic random sampling etc. The review process includes records of both active and discharged patients. Objective Element a) The medical records are reviewed periodically. Medical Records Department Remarks b) c) The review is conducted by identified care providers. The review focuses on the timeliness. total discharges including deaths.
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