NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS (NABH) Neer Partie iit iemrlas less sl (e ey and Healthcare Providers (NABH)(eg An Breck, ‘ Dep Z LPS Apt, National Accreditation Board for Hospitals and Healthcare Providers (NABH) Accreditation Standards for Hospitals 4" Edition December 2015 © Nations Accreditation Board for Hospitals and Hesithcare ProvidersThe and stan hos} inter sou info del and cert end The req pro con = has Th the sta cor © All Rights Reserved 3 No part ofthis book may be reproduced or transmitted in any form without permission in writing from the author. Ao 4 Edition December 2015 q De rel do ‘© National Accreditation Board for Hospitals and Healthcare Providers iW erINTRODUCTION The third edition of NABH standard has been in practice for four years now (2012-15) and is revised and up-graded to 4" edition. The guiding principles for revision of the standards have mainly been the experience of stake holders including assessors, hospitals, members of accreditation and technical committees and review of other international healthcare standards. Before finalization of these, public opinion was also sought. Secretariat of NABH did bulk of job by collating and assimilating the feedback information, linking with relevant chapters and presenting to the technical committee for deliberations. It was finally the Technical Committee which went in to thought process and came out with the edition, which is now in your hands. During this process views of certain societies i.e Critical Society & Palliative Care Society of India were also taken on end of life care issues in our country. The accreditation standards are not expected to be prescriptive. They only lay down the requirements and it is up to the healthcare organizations to come out with the systems, processes and modes of measuring performance indicators, which can demonstrate ‘compliance to the requirements as specified in the standard. The Technical Committee has tried its best to be as objective and pragmatic as possible. There can be more than one way, by which a healthcare organisation can comply with the requirements of the standards. Three books are being made available for use of stakeholders ie 4th edition Standards book, a guidebook containing glossary and a compilation of various practices in the form of annexures, including matrix for calculating quality indicators and other relevant material. Accreditation as we know is basically a framework which helps healthcare organizations to establish objective systems aimed at patient safety and quality of care. Documentation plays an important role in defining such systems. Wherever there are references to documented requirements, it needs to be clearly understood that such documentation needs to be established and understood at all levels, reviewed at regular © National Accreditation Board for Hospitals and Healthcare Providers iEEE intervals, and controlled and evidenced for their effective implementation by way of 3. records. ‘The fourth edition of these standards has put more focus on certain aspects which were 4. hitherto not adequately brought out in the previous edition. For example. the present edition tries to bring focus to the promotional, preventive and educational aspects of care giving; new standard on communication, inclusion of national programs in the hospital ecosystem, use of generic medicines in prescription writing: inclusion of 5. pharmacovigilance and hemovigilance programs in training and awareness initiatives, organ transplant standard, innovations for CQ! etc. These standards give stress on | setting patient safety goals appropriate to the Indian context and focus more on outcome based indicators. The requirements of the standards shall have to be identified: evidenced by data | gathered, analysed and interpreted with the aim of improving the quality system of a Ti hospital. Wherever the word shall/should is used, it is imperative that the organisation fu implement the same. Where the phrase carvcould/preferable is used the organisation a would use its discretion and implement it according to the practicability of the proposed st guidance. si a on In general, the organisation will need to establish clear evidence backed by robust , systems and data collection to prove that they are complying with the intent ‘of the ‘ standards. These systems are as we say, defined, implemented, owned by the staff and 3 finally provide objective evidence of compliance. Some of the key issues are as follows; s 1 1. Patient related: monitoring safety, treatment standards and quality of care. This ~ would mean effectively meeting the expectation of patients and their families and ; associates. 1 2. Employee related: monitoring competence, on-going training, awareness of ; patient requirements and monitoring employee satisfaction. , ‘© National Accreditation Board for Hospitals and Healthcare Providers w j3. Regulatory related: identifying, complying with and monitoring the effective implementation of legal, statutory and regulatory requirements which affect patient safety 4 Organisation policies related: defining, promoting awareness of and ensuring implementation of, the policies and procedures laid down by the organisation, amongst staffs, patients and interested parties including visiting medical consultants. 5. _ NABH Standards related: identification of how the organization meets the NABH standards and the objective elements. Where a part of an element, an element or a standard cannot be applied in a particular organization, adequate explanation and justification must be provided to NABH and its team of assessors to enable ‘exclusion of applicability. In particular, it must be ensured that the intent of each chapter of standards is understood and applied The 4" edition of accreditation standard is divided into 10 chapters, which have been further divided into 105 standards (as compared to 102 in 3" edition). Put together there are 683 objective elements (as compared to 636 in 3° edition) incorporated within these standards. The increase in objective elements is to put increased emphasis on patient safety and also to encourage healthcare organizations to pursue continuous quality improvements. Objective element are required to be complied with in order to meet the requiroment of a particular Standard. Similarly, standards are required to be complied with, in order to meet the requirement of a particular Chapter. Finally, compliance with ‘all chapters is equally important to establish compliance with the Accreditation Standard. The Standards shall facilitate health care organizations to deliver safe high quality care. fn the beginning of each chapter, intent is given to highlight the summary of the chapter. The intent statement provides a brief explanation of a chapter's rationale, meaning, and ‘Significance. Intent statements may contain detailed expectations of the chapter that are evaluated in the on-site assessment process. For most of the objective elements, {© National Accreditation Board for Hospitals and Healthcare Providers yES interpretation is provided in a separate book just to further elaborate on how that objective element can be met. We are thankful to chairman & members of Technical Committee who have put great efforts to accomplish this task. These standards are equally applicable to government and private hospitals, and are applicable to whole organisation. Standards are dynamic ‘and would be under constant review process. Comments and suggestions for improvement are appreciated. We seek your support in keeping these standards adequate to the need of the industry. Dr. K.K. Kalra CEO NABH ® Z Natonal Accreditation Board for Hospitals and Healthcare Providers “iTable of Contents “Sr. No. | Particulars Page No. ‘01. | Access, Assessment and Continuity of Care (aac) 01-13, 02. = Care of Patients (COP) 14-33, @3._| Management of Medication (MOM) 3a-44 04. Patient Rights and Education (PRE) 45-53 Hospital Infection Control (HIC) 54-62 Continuous Quality Improvement (CQl) 63-71 Responsibilities of Management (ROM) 72-78 08. Facility Management and Safety (FMS) 79-86 Human Resource Management (HRM) 87-94 40, _| Information Management System (IMS) | 95-102 ss | © Natona’ Accretion Boar or Hosptals and Healthcare Providers vi{© National Accreditation Board for Hospitals and Healthcare Providers viiAscoss Assessment end Continully of Gare (AAC) Chapter 1 Access Assessment and Continuity of Care (AAC) Intent of the chapter: Patients are well informed of the services that an organisation provides. This will facilitate in appropriately matching patients with the organisation’s resources. Only those patients who can be cared for by the organisation are admitted to the organisation. Emergency patients receive life-stabilising treatment and are then either admitted (if resources are available) or transferred appropriately to an organisation that has the resources to take care of such patients. Out-patients who do not match the organisation's resources are similarly referred to organisations that have the matching resources. Patients that match the organisations resources are admitted using a defined process Patients cared for by the organisation undergo an established initial assessment and periodic and regular reassessments. Assessments include planning for utilisation of laboratory and imaging services. The laboratory and imaging services are provided by competent staff in a safe environment for both patients and staff. These assessments result in formulation of a definite care plan. Patient care is multidisciplinary in nature and encourages continuity of care through well-defined transfer and discharge protocols. These protocols include transfer of adequate information with the patient. © National Accreditation Board for Hospitals and Healthcare Providers 1Access Assessment and Continuity of Care (AAC) Summary of Standards AAC.1. The organisation defines and displays the healthcare services that it provides. AAC.2. ‘The organisation has @ well-defined registration and admission process. AAC.3. There is an appropriate mechanism for transfer (in and out) or referral of patients. AACA, Patients cared for by the organisation undergo an established initial assessment. AACS. Patients cared for by the organisation undergo a regular reassessment. AACE. Laboratory services are provided as per the scope of services of the ‘organisation. AAG. There is an established laboratory quality assurance programme. AAC. There is an established laboratory safety programme. AAC. Imaging services are provided as per the scope of services of the organisation. AAC.10. ‘There is an established quality assurance programme for imaging services. AAC.11, There is an established safety programme in the imaging services. AAC.12, Patient care is continuous and multidisciplinary in nature. AAC.13, ‘The organisation has a documented discharge process, AAG.14. Organisation defines the content of the discharge summary. * This implies that this objective element reqi 's documentation. ‘© National Acoreditation Board for Hospitals and Healthcare ProvidersAccess Assessment and Continuity of Care (AAC) Standards and Objective Elements Standard ‘AaC.1, |The organisation defines and displays the healthcare services that it provides. Objective Elements a. The healthcare services being provided are clearly defined and are in consonance with the needs of the community. b. Each defined service should have appropriate diagnostics and treatment facilities with suitably qualified personnel who provide out-patient, in-patient and emergency cover. c. The defined healthcare services are prominently displayed d. The staff are oriented to these services. Standard ‘AAC.2. _| The organisation has_a well-defined registration and admission process. Objective Elements a. Documented policies and procedures are used for registering and admitting patients. * b. The documented procedures address out-patients, in-patients and emergency patients. * C. A unique identification number is generated at the end of registration. d. Patients are accepted only if the organisation can provide the required service. {© National Accreditation Board for Hospitals and Heaithcare Providers aAccess Assessment and Continuity af Care (AAC) e. The documented policies and procedures also address managing patients during non-availability of beds, * Access to the healthcare services in the organisation is prioritised according to the clinical needs of the patient. The staff are aware of these processes. Standard ‘AAC.3, | There is an appropriate mechanism for transfer (in and out) or referral of patie Objective Elements a. Documented policies and procedures guide the transfer-in of patients to the organisation. * Documented policies and procedures guide the transfer-out/referral of unstable Patients to another facility in an appropriate manner. * Documented policies and procedures guide the transfer- out/referral of stable patients to another facility in an appropriate manner. * The documented procedures identify staff responsible during transfer/referral.* The organisation gives a summary of patient's condition and the treatment given © National Accreditation Board tor Hospitals and Healthcare Providers 4Access Assessment and Continuity of Care (AAC) Standard AAC. Patients cared for by the organisation undergo an established initial assessment Objective Elements a. The organisation defines and documents the content of the initial assessment for the out-patients, in-patients and emergency patients, * b. The organisation determines who can perform the initial assessment. * c The organisation defines the time frame within which the initial assessment is completed based on patient's needs, * d. The initial assessment for in-patients is documented within 24. hours or earlier as per the patient's condition, as defined in the organisation's policy. * & Inia! assessment of in-patients includes nursing assessment which is done at the time of admission and documented. * f. Initial assessment includes screening for nutritional needs 9. The initial assessment results in a documented care plan. * h. The Care plan reflects desired results of the treatment, care or service. The Care plan is countersigned by the clinician in-charge of the patient within 24 hours. ‘© National Accreditation Board for Hospitals and Healthcare Providers 5Access Ascessmentand Continuity of Care (ARC) Standard | ‘AAC.S. | Patients cared for by the organisation undergo a regular reassessment. Objective Elements a. Patients are reassessed at appropriate intervals. b. Out-patients are informed of their next follow-up, where appropriate. ¢. _ For in-patients during reassessment the Care plan is monitored and modified, where found necessary. d. Staff involved in direct clinical care document reassessment. * e. Patients are reassessed to determine their response to treatment and to plan further treatment or discharge. f. The organization lays down guidelines and implements processes to identify early warning signs of change or deterioration in clinical conditions for initiating prompt intervention. ‘Standard AAC.6. | Laboratory services are provided as per the scope of services of the organisation. Objective Elements ‘a. Scope of the laboratory services commensurate to the services provided by the organization. b. The infrastructure (physical and equipment) is adequate to provide the defined scope of services. ‘© National Accreditation Board for Hospitals and Healthcare Providers 6Access Assessment and Continuly of Care (AAC) c. The manpower is adequate to provide the defined scope of services. 4. Qualified and trained personnel perform, supervise and interpret the investigations. fe. Documented procedures guide ordering of tests, collection, identification, handling, safe transportation, processing and disposal of specimens. * {. Laboratory results are available within a defined time frame. * 9. Critical results are intimated immediately to the personnel concerned. * h. Results are reported in a standardised manner. i. There is a mechanism to address recall / amendment of reports whenever applicable. ji. Laboratory tests not available in the organisation are outsourced to organisation(s) based on their quality assurance system. * Standard = AAC.7. _| There is an established laboratory quality assurance programme. Objective Elements a. The laboratory quality assurance programme is documented. * b. The programme addresses verification and / or validation of test methods. * c. The programme addresses surveillance of test results. * d. The programme includes periodic calibration and maintenance of all equipment. * ‘© National Accreditation Board for Hospitals and Healthcare Providers 7Access Assessment and Continuity of Care (AAC) e The programme includes the documentation of corrective and preventive actions.* Standard | AACS. ‘There is an established laboratory safety programme. Objective Elements a. The laboratory safety programme is documented. * b. This programme is aligned with the organisation's safety programme. c. Written procedures guide the handling and disposal of infectious and hazardous materials. * d. Laboratory personnel are appropriately trained in safe practices. . Laboratory personnel are provided with appropriate safety equipment / devices. Standard AAC.9. | Imaging servic8s are provided as per the scope of services of the organisation. Objective Elements a. __ Imaging services comply with legal and other requirements, b. Scope of the imaging services is commensurate to the services provided by the organisation. c. The infrastructure (physical and equipment) and manpower is adequate to provide for its defined scope of services. ‘© National Accreditation Board for Hospitals and Healthcare Providers @Access Assessment and Continuity of Care (AAC) d. ‘Adequately qualified and trained personnel perform, supervise and interpret the investigations. Documented policies and procedures exist to ensure correct identification and safe and timely transportation of patients to and from the imaging services. * Imaging results are available within a defined timeframe. * Critical results are intimated immediately to the personnel concerned.” Results are reported in a standardised manner. There is a mechanism to address recall / amendment of reports whenever applicable. Imaging tests not available in the organisation are outsourced to organisation(s) based on their quality assurance system. * Standard Objective Elements a. b, The quality assurance programme for imaging services is documented. * The programme addresses periodic intemal / external peer review of imaging protocols and results using appropriate sampling. The programme addresses surveillance of imaging results in collaboration with referring clinicians for follow up wherever applicable * © National Accreditation Board for Hospitals and Healthcare Providers 8‘Access Assessment and Continuity of Care (AAC) d. A system is in place to ensure the appropriateness of the investigations and procedures for the clinical indication. e. The programme includes periodic calibration and maintenance of all equipment. * 1. The programme includes the documentation of corrective and preventive actions.* ‘Standard Objective Elements a. The radiation-safety programme is documented. * b. This programme is aligned with the organisation’s safety programme. c. Patients are appropriately screened for safety / risk prior to undergoing an imaging on a particular modality. d. Handling, usage anédisposal of radio-active and hazardous materials are as per statutory requirements. fe. Imaging personnel and patients are provided with appropriate radiation safety and monitoring devices where applicable. f. Radiation-safety and monitoring devices are periodically tested and results are documented. * g. Imaging and ancillary personnel are trained in imaging safety practices and radiation-safety measures. B National Accreditation Board for Hospitals and Heaitheare Providers 70Access Assessment and Continuity of Care (AAC) h Imaging signage are prominently displayed in all appropriate locations. ‘Standard Aac.12. | Pati it care is continuous and multidisciplinary in nature. Objective Elements a. During all phases of care, there is a qualified individual identified as responsible for the patient's care. Care of patients is coordinated in all care settings within the organisation. Information about the patient's care and response to treatment is shared among medical, nursing and other care-providers. Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments. Transfers between departments/units are done in a safe manner. The patient's record(s) is available to the authorised care-providers to facilitate the exchange of information. Documented procedures guide the referral of patients to other departments/ specialities. * The organisation ensures continuity of care while adhering to defined timelines and informs the caregiver and/or the patient/family whenever there is a change in schedule. The organisation has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to a critical value alert. National Accreditation Board for Hospitals and Healthcare Providers 1"‘Access Assessment and Gontinulty of Care (AAC) ‘Standard AAG.13. | The organisation has a documented discharge process. Objective Elements a. The patient's discharge process is planned in consultation with the patient and/or family b. Documented procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal and absconded cases). * c. Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request. * d. A discharge summary is given to all the patients leaving the organisation (including patients leaving against medical advice and on request). e. The organisation defines the time taken for discharge and monitors the same. Standard | AAC.14, | Organisation defines the content of the discharge summary. Objective Elements a. Discharge summary is provided to the patients at the time of discharge. Discharge summary contains the patient's name, unique identification number, date of admission and date of discharge. Discharge summary contains the reasons for admission, significant findings an¢ diagnosis and the patient's condition at the time of discharge. © National Accreditation Board for Hospitals and Healthcare Providers 12Access Assessment ans Cofitinuity of Care (AAC) 4. Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given, e. Discharge summary contains follow-up advice, medication and other instructions in an understandable manner. # Discharge summary incorporates instructions about when and how to obtain urgent care. g. In case of death, the summary of the case also includes the cause of death. National Accreditation Board for Hospitals and Healthcare Providers 19Care of Patlenis (COP) Intent of the chapter: The organisation provides uniform care to all patients in different settings. The different Settings include care provided in outpatient units, various categories of wards, intensive Care units, procedure rooms and operation theatre. When similar care is provided in these different settings, care delivery is uniform. Policies, procedures, applicable laws and regulations guide emergency and ambulance services, cardio-pulmonary resuscitation, use of blood and blood components, care of patients in the intensive care and high dependency units. Policies, procedures, applicable laws and regulations also guide care of vulnerable Patients (elderly, physically and/or mentally-challenged and children), high-risk obstetrical patients, paediatric patients, patients undergoing moderate sedation, administration of anaesthesia, patients undergoing surgical procedures, patients under restraints, research activities and end of life care Pain management, nutritional therapy and rehabilitative services are also addressed with a view to providing comprehensive health care. The standards aim to guide and encourage patient safety as the overall principle for providing care to patients. © National Accreditation Board for Hospitals and Healthcare Providers 14Care of Patients (COP) Summary of Standards COP 1: | Uniform care to patients is provided in all settings of the organisation and is guided by the applicable laws, regulations and guidelines. COP2: | Emergency services are guided by documented policies, procedures, applicable laws and regulations. COP 3: The ambulance services are commensurate with the scope of the services provided by the organisation. cop.4. _| The organisation plans for handling community emergencies, epidemics and other disasters. COP 5: Documented policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation. cop 6: | Documented policies and procedures guide nursing care. | | COP 7: | Documented procedures guide the performance of various procedures. | _| COP 8: Documented policies “tnd procedures define rational use of blood and | blood components. Documented policies and procedures guide the care of patients in = intensive care and high dependency units. COP 10: | Documented policies and procedures guide the care of vulnerable patients. COP 11: | Dooumented policies and procedures guide obstetric care. National Accreditation Board for Hospitals and Healthcare Providers 15