CONTENTS Clinical Areas 1, | Emergency 4 2. | Ambulance 7 3, | Out Patient Department 7 4. | Wards 10 %. | Specialized Wards: Paediatric, OBG, & Labour Room, 4 Chemotherapy Unit 6 | Palliative Care 16 7. | Daycare 7 @. | Dialysis Unit 18 9. | Intensive Care, Neonatal 7 Paediatric ICU and High 20 Dependency Units 70. | Operation Theatre 25 11, | Recovery Room 28 72, | Endoscopy / Bronchoscopy 29 73, | Rehabiltation 3 14, | Radiology B 16. | Nuclear Medicine 34 16. | Cardiac Catheterization lab 36 17, | _ Collection centre (lab) 38 48, | Laboratory: Haematology 7 Biochemistry 7 Pathology 7 39 Microbiology / Histopathology / Cytology 79, | Blood Bank and Transfusion Services a 20. | _ Radiation therapy / Radioactive drugs a2 21, | Nutrition Therapy 44 22, | Hospital Infection Control a5 23, | _ Organ transplant a 2a, | Dental 28 25. | Nursing 50Non Clinical Areas 1 Document Review 54 2. Quality Management 55 3 Management / Administration 58 a Committees 60 5 Human Resource Department 6 6 Medical Record Department (MRD) Ca 7 Hospital information System (HIS) 66 8 Front office: Registration, Admission and Biling counters 7 9 Biomedical Equipment Management: Equipment, 68 Medical Gases, Vacuum System etc. 10. Pharmacy 6 1 Purchase, Store and Materials Management 70 12 Facility Management: Engineering and Maintenance 7 73, Safety Program 72 14, Housekeeping 73 15. Laundry and Linen 74 76 Kitchen / Canteen 75 17 Mortuary 76 18, CSSD 77 Interviews 2. Staff interview - Care of patients 80 3. Siaff interview — HR. 80 4 Staff interview — Safety 80CLINICAL AREAS1. Emergency Room Quick list: * Policies and procedures on *__ Identified area for emergency “dead on arrival’, transfer / care, defined beds discharge process, «© Triage availability of beds + Mic «Access to emergency «Disaster management-Disaster Pian, tested twice a year © Quality assurance * BMW ‘+ Ambulance communication * Infection control ‘+ Medication management + Case records ~documentation + CPR: Assigned Roles and Fire safety Responsibilities + Equipment / furniture maint’nce «Medical gas * Crowd management + Reassessment © Clinical Pathways + Discharge! transfer note- DTH + Dead on arrival Patients or transfer to another organisation AAC Te * Defined services are displayed prominently FMS2c,d | Signposting and directional signages (bilingual) from approach road ‘* Adequacy of access to Emergency (easy and unobstructed). Flow of patients, unobstructed ‘AAC Ze ‘Managing non-availability of beds COP 9e COP 9b '* Admission criteria and priorities for ICU AAC Swe [© Patient transfer (in and out) / In case of transfer of patients: check stability/unstableftransfer notes/treatment summary. Discharge summary / transfer note copy retained. ‘+ Documented policies and procedures on transfer-in/transfer-out of unstable patients /transfer-out of stable patients ‘+ Referral of patients ‘*__Check identified staff responsible during transfer ‘AAC4a,b.c, | © Predefined initial assessment 8 ‘* Time frame for doing and documenting initial assessment ‘¢__ Staff awareness on above policies AAC 12d | Structured clinical handover by doctors & nurses; wansfer summary AAC 13d | ¢ Discharge summary for LAMA COP Te ‘* Clinical care pathways are developed, consistently followed across all settings of care, and reviewed periodicallyCOP 2g dentified area for emergency care; defined no. of beds, adequate manpower Prevention of patient over-crowding is planned, and crowd management ‘measures are implemented, Policies/procedures/protocols for emergency care Procedure for handling MLC cases (including capturing identification marks and police intimation) ‘Triage, contents of triage policy: categories, ask for demonstration Staff awareness on the policies and procedures for care of emergency patients Emergency care/ admission/ discharge documentation Patients waiting in the emergency are reassessed as appropriate for change in status. COP 2h AAC 3 Discharge note given — home, another hospital COP2i CQ13 afi. hai) Quality assurance programme Capture of quality indicators CoP 2] Policy on “dead on arrival” COP 3a, hy The organisation has access to ambulance services commensurate with the scope of the services provided by it. Communication with ambulance — evidence Identifies opportunities for to initiate treatment for in transit patients Copa Disaster management plan Mock drills of disaster management (at least twice a year) Staff awareness on Disaster management plan COPS ae ‘Documented policies and procedures on uniform use of resuscitation Display of CPR protocols The events during a CPR are recorded During cardio-pulmonary resuscitation, assigned roles and responsibilities are complied with. ‘Training in CPR - BLS / ALS COP 6a, be, fe Documented policies and procedures for all activities of the Nursing Services in Emergency Current standards of nursing services and practice Nursing Plan of Care Nurses are provided with appropriate and adequate equipment for providing safe and efficient nursing care. Nursing Care documentation, Nursing empowerment COP Tg Procedures are performed based on the clinical needs of the patient. Documented procedures on various clinical procedures Qualified personnel are performing procedures Procedures on prevention wrong site, patient and procedure Informed consent taken by the doctor performing the procedure Adherence to standard precautions and asepsis Monitoring of patients done during and after the procedure Procedures are documented accurately in the patient record Care is taken to prevent adverse events like a wrong patient, wrong procedure and wrong site. * COP ah ‘Moderate (conscious) sedation, monitoring, consent MOM 3b-g Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medicationsMOM4ah Prescription of medicines. Medication orders, High risk medications defined MOM ‘Medication administration. Staff interview on administration Medication administration documentation MOM 7 ad Patient monitoring after medication administration Check where close monitoring is required Change of medications based on monitori; PRES b.c.f ‘Communication with patients & relatives HIC2 ‘Adequate & appropriate PPE. Hand hygiene facilities Barrier nursing HICSag ‘Adhering hand hygiene guidelines, Use of PPE Safe injection practice Rational use of antimicrobial HiC4at “Testing of water quality Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management + Food distributed safely HIC 8b, € ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS Sef HAZMAT Spill management HRM 11,12 (Credentialing and privileging for doctor and nurse Patient interview Staff interview Data collection for quality indicators to be verified: © PSQ3.a(1): Time for initial assessment PSQ3.a(11): return to Emergency with 72 hrs with similar presenting complaints PSQ 3: hand hygiene compliance, compliance to medication prescription in capitals PSQ 3a (4): Medication error rates PSQ 4 d (i): No of variations in mock drills (disaster management)2. Ambulance ‘© The organisation has access to ambulance services commensurate with the COP 3a scope of the services provided by it. COP 3b ‘Adequacy of parking for Ambulances COP3e National ambulance code AIS - Adherence to Statutory requirements © Type of ambulance: ALS/BLS/PTA © RC book and Fitness cert © License of driver (s) © Insurance © Emission check (PUC) © Checking of siren/horn © Checking of wheel © Ambulance: adequate equipment in working order COPad Ambulance: manned by trained personnel COP3e.fe [© Check list of Ambulance, drugs and equipment ‘* Checking of emergency drugs prior to dispatch ‘¢ Cleaning of ambulance — every day and after each transport COPah ‘Communication system of Ambulance COP 3i ‘+ Identifies opportunities for to initiate treatment for in transit patients ROM Sef [* Formal documented agreement (MOU) for outsourced ambulance services, if any + Monitoring of the quality of the outsourced ambulance services Patient interview Staff interview 3. Out Patient Department Quick list: ‘+ Initial assessment- outpatients, ‘+ Display of scope in Obs/Paed daycare, + Priority access in clinical needs ‘+ Admission process + Follow-up date * Drug reconciliation in ‘+ Patients’ rights displayed- right admissions to respect for values and belief + Case records ~documentation ‘+ Medication management ‘* Complaint redressal, feedback * CAPITAL letters — prescription + Medical gas ‘© Physician's sample drugs ‘+ Vulnerable patients «Fire safety «Infection control * BMW ‘+ Equipment / furniture maint'nce AAC Dae Patient admission from OPD. Managing non availability of beds Patient transfer AAC2T ‘Access prioritised according to elinical needs AAC 3b Referral of patients‘AAC 4a, b,c, ‘Predefined initial assessment- outpatients, daycare, fg hi ‘© Time frame for doing and documenting initial assessment ‘© Initial assessment to include screening for nutritional needs. © Documented plan of care including preventive aspects of the care AACSB + Out-patients are informed of their next follow up where appropriate COP 106, d,€| Care of high risk obstetrical patients — display the scope ‘© _Ante- natal card; frequency of visits. Maternal nutvtion assessment COPTIB.e, | Care of paediatric patients: display the scope . provisions for special care oF fh children, detailed nutritional, growth, psychosocial and immunization assessment, parent education on nutrition, immunization and safe parenting and documentation of the same COPTSB..d | * Care of vulnerable patients - Policy and procedure, safe and secure environment, informed consent from the appropriate legal representative MOM3e [Mechanism for physician's sample MOM 4ach|° Prescription of medicines. Medication orders ‘© Prescriptions in CAPITAL letters ‘© High risk medications defined © Drugaallergy and previous drug reactions PRET a,d [+ Patients’ rights displayed, staff awareness PRE2 ‘+ Respect value and beliefs PRE3 ‘+ Patient and family members provided multidiseiplinary counselling PRE4b.6 | General consent for treatment ‘¢ Patient and/or his family members interview for the scope of general consent PREST ~ Patient and family are educated on various pain management techniques, when appropriate. PREGa,b | Uniform pricing policy. Availabilty of tri lis to patients PRETa< | Documented complaint redressal procedure ‘© Patient and/or family members interview for awareness of the procedure for Jodging complaints, PRESB. 6.1 | Communication with patients & relatives HICZe-f | Adequate & appropriate PPE ‘= Hand hygiene facilities © Barrier nursing ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice Tica at Risk sialification malix for frequency of Cleaning © BMW handled appropriately & safely HICSB.e | © Occupational safety ‘© Immunization policy ‘© Implement work restrictions for staf with transmissible infections ‘© Measures for blood and body fluid * _ Post exposure prophylaxis TMS3ef |» HAZMAT ‘© Spill managementFMS 8 '* Documented plan for handling fire and non-fire emergencies ‘© Safe exit plan. Signage pertaining to fire exits ‘+ Open and easily accessible fire exits without any obstruction ‘* Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire extinguishers, no smoking signs etc. '* Staff awareness on above policies and procedures ‘© Patient interview ‘© Staff Interview — Care of Patients ‘© Staff interview — HR + Staff Interview — Safer Data collection for quality indicators to be verifies © PSQ 3d(32) : Compliance rate to Medication prescription in capitals * PSQ 3c (22): Waiting time for out-patient consultation10 4. Wards Quick list: + Initial assessment &reassess'nt «Admission process Planned discharges Care plan «Discharge &disch. Summary Nursing care according to © Early warning signs current standard of Practice * CPR- Assigned Roles and * Case records — documentation Responsibilities + Documentation of hand-over + Referrals «Safe transfer of patients «Physician's sample drugs = Pain management ‘* Medication orders + Nutritional assessment «Medication management + Blood transfusion + Narcotics + Vulnerable patients + Restraint policy ‘+ Patients’ rights displayed- right «| Hazmat to respect for values and belief «Patient feedback + Fire safety «Medical gas * BMW * Equipment / furniture maintnce ——* infection control ‘* Medication reconciliations «Hand hygiene ‘+ Monitoring of patients after * DVT medication admn + Pressure ulcers + Appropriate and adequate = Patient Experience equipment AAC4ai [© Predefined inital assessment ‘+ Time frame for doing and documenting initial assessment ‘* Initial assessment to include screening for nutritional needs ‘© Initial Nursing Assessment ‘* Plan of care includes desired outcomes ‘¢__ Plan of care countersigned by clinician in charge within 24 hours AAC Sa,¢,d, [* Reassessment — frequency of reassessment, documentation, response to e treatment, plan for further treatment or discharge ‘+ Monitoring of plan of care, modification where found necessary AAC ST ‘* Wentifies early warning signs. Staff taining ‘RAC 12 ‘Qualified individual identified as responsible for the patient's care ‘+ Multidisciplinary care & co-ordination among various depts. / staff / shifts ‘© Structured handing / taking over by doctors & nurses, and documentation ‘+ Transfer of patients between departments/units. Referrals ‘¢ Adequate clinical intervention in response to a critical alert ‘AAC 13a-e | Discharge planning (atleast 24 hrs in advance) in consultation with patient, family, coordinating with various depts... including MLCs ‘+ Summary given to all including LAMA and discharge on request ‘2 Defines time taken for discharge; monitors delay AAC dag _[* Content of discharge summary. Receipt acknowledged COP Tad [* Uniform care: evidence based medicine & clinical practice guidelinesCOP Sa, be CPR — Policy and procedure, staff trained in CPR, Documentation of events, during CPR, Communication of CAPA measures, assigned roles and responsibilities are complied with. COP Gag | * Documented policies and procedures for Nursing Services ‘* Assignment of patient care as per current standard of practice ‘+ Nursing care is aligned and integrated with overall patient care ‘+ Nursing Plan of Care documented in the patient record ‘+ Provision of adequate equipment ‘+ Empowerment for nursing related decisions COP7ag | Documented procedures of various clinical procedures '* Qualifications of the personnel, who are performing procedures ‘+ Prevention of adverse events - wrong site, patient and procedure ‘+ Informed consent taken by the doctor performing the procedure ‘© Adherence to standard precautions and asepsis ‘* Monitoring of patients during and after the procedure ‘¢ Documentation of the procedures accurately in the patient record COPS, 4.8, | * Scope of transfusion services h ‘+ Rational use of blood and blood products; transfusion ‘© Informed consent ‘+ Monitoring transfusion reactions; post transfusion forms '* Staff awareness on above policies © Quality Assurance Programme COPT4ad [+ Care of patients undergoing surgeries — policies & procedures, preop assessment, provisional diagnosis prior to surgery, informed consent, procedures to prevent adverse events, post op care plan documented, Surgical Safety Checklist COP 16 ‘> Care of vulnerable patients © Pressure ulcer . s & procedures on the care of patients under restraints ‘* Documentation of reasons for restraints; monitoring and frequency ‘¢ Staff awareness on control and restraint techniques: monitorins COP I7a2 [© Policies & procedures on pain management ‘+ Pain screening; pain assessment and periodic re-assessment ‘+ Pain alleviation methods initiated and monitored for response ‘+ Education of patient and/or family on pain management techniques COP 19a-f [Nutritional assessment and reassessment ‘+ Written Order for diet; food as per patient's clinical needs ‘+ Planning of nutritional therapy ‘* Patient and/or family’s education on the patient's diet limitations + Food is stored and distributed safel ‘* Mechanism for physician’s sample MOM 3¢,b-g | © Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications MOM4ai—[* Prescription of medicines (CAPITAL letters) ‘+ Medication orders ‘© High risk medications defined ¢ Verbal orders MOM4C&h| «Previous ADRs # Drug reconciliation12 MOM 6aj “Medication management Staff interview on the methodology of administration Medication administration documentation Patient's self-administration of medicines Management of medications got from outside the HCO Retum of medication to pharmacy MOM Tad Patient monitoring after medication administration Definer situations where close monitoring is required Change of medications based on monitoring Measures to avoid Tubing mis-connection MOM 8 ae ‘Near miss, medication error and adverse drug event are defined Reporting within a specified time frame MOM9 ad Narcotic drugs procedure Storage: handling: documentation PRE La, b,d PRE2ak Patients’ rights: displayed. Staff awareness Respect for value and beliefs PRE2b Patient's right to privacy during examination / procedures PRES Patient/family explained : care plan, risks, complications, tests, change in condition Multidisciplinary counselling PRE4ah Informed consent PRES ah Patient and family education about their health care needs (medications, food drug interaction, diet and nutrition, immunisations) Patient and family educated on Pain management technique PRE 76 “Mechanism to capture patient experience PRESb.ce ‘Communication with patients & relatives Monitor and review the implementation of effective communication HiC2et Tnstructions for hand washing displayed near every hand washing area Adherence to safe injection and infusion practices Cleaning, disinfection and sterilisation practices Segregation of bio-medical waste. Use of PPE HIC3eh, fe Hand hygiene surveillance MDRO surveillance Housekeeping Feedback on HAL Antimicrobial usage policy HIC 4a ‘Segregation of bio-medical waste HICS ad ‘Hand hygiene facilities, instructions for proper hand hygiene Check Isolation / Barrier nursing facility available Negative pressure rooms. Appropriate signages Check adequate soap, masks, gloves and disinfectants are available Pre & post exposure prophylaxis HIC76, c.f Storage of sterilised items, Re-use of instruments and equipments Recall procedure HICS To prevent HAL in the staff FMS Tab Grab bars Provision for differently abled13 FMS2b-d [Floor plans; Fire Escape routes; Layout of beds, spacing, visual privacy; Signages FMS = CCTV coverage ¢ HAZMAT & spill management FMS ‘* All equipment are inventoried and log maintained / calibrated ‘¢ PM labels on Equipment/calibration records/Refrigerator FMS 6ad [© Colour coding of gas pipelines ‘* Medical gases handling, storage and usage safely ‘© Storage of oxygen cylinders/Condition of Humidifiers + Alarm units installed FMS7 ‘+ Documented plan for handling fire and non-fire emergencies * Table top ‘+ Safe exit plan. Signage pertaining to fire exits '* Open and easily accessible fire exits without any obstruction ‘© Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire extinguishers, no smoking signs etc. IMS3acd | ication no, / Named, signed, dated and timed entry / author are clear, up-to-date and chronological IMS45 ‘* Medical record contain the details of assessment, re-assessments and consultation (Operative and other procedures are documented in case records Patient interview Staff interview Data collection for quality indicators to be verified: PSQ3.a(1): Time for initial assessment PSQ 3a (4) : Medication Error rates PSQ 3a (4) : Percentage of medication charts with error prone abbreviations PSQ 3a (6): Percentage of patients developing ADRs PSQ 3a (8): Percentage of cases — prevent adverse events like wrong site, patient, surgery PSQ 3a (9): Percentage of transfusion reactions PSQ 3a (9): Incidence of hospital associated pressure ulcers after admission PSQ 3b (13): CAUTI PSQ 3b (16): SSI PSQ 3b (17): Hand Hygiene compliance rate PSQ 3c (21): Nurse patient ratio PSQ 3d(30) : Incidence of needle stick injury PSQ 3d(31) : Appropriate handover during shift change PSQ 3d(32) : Compliance rate to Medication prescription in capitals PSQ 4d(28) : Patient fall rate PSQ 4l(29) : Percentage of near-misses PSQ 4c(24) : Time taken for discharge14 5. Special Care Wards a) Paediatric Quick list: (in addition to wards) * Provision for special care of children + Prevention of child abduction * Credentialing & privileging COP i ah Policy for Care of neonatal patients Documented policy and procedure for paediatric services, Display of scope ‘Age specific competency, provisions for special care of children, Detailed nutritional, growth, developmental and immunization assessment Protocols for preventing child/neonate abduction and abuse Parent education on nutrition, immunization and safe parentin ARM lat HRM 12 0-f ‘Credentialing and privileging of doctors and nurses b) Obstetrics & Gynaecology and Labour Room Quick list: (in addition to wards) © High risk obs MTP. «Pre, peri &post natal monitoring * Credentialing & privileging COP Te ‘+ MIP: register, consents, confiedntiality ROM 2b PRE 2d COP 10ag | Obstetric services - policy and procedure ‘* Care of high risk obstetrical patients: Display of scope- whether high risk obstetric cases cared for or not '* Obstetrical patient's Assessment including maternal nutrition ‘+ Competence of staff handling high risk obstetrical cases ‘* Pre-natal, perinatal and post-natal monitoring and documentation ‘+ Documented procedures on provision of ante-natal services ¢ Facilities to take care of neonates of high risk pregnancies, MOM '* Procedure for handling narcotics/ Ticense/ documentation of usage/ disposal handled by competent staff HRM TT af [Credentialing and privileging of doctors and nurses, HRM 12 af15 c) Chemotherapy Unit Quick list: (in addition to wards) © Chemotherapy management Narcotics Disposal of chemo drugs Credentialing & privileging MOM6 ‘Check labelling prior to preparation of a second drug Check patient is identified before administering medication, verified from the order/ dosage /route/ timing prior to administration MOMS Procedure for handling narcotics’ license/ documentation of usage/ disposal/ handled by competent staff. MOM 9a ‘Chemotherapeutic drug usage procedure Chemotherapy prescription Preparation, administration and disposal of chemotherapy drugs Biosafety cabinet class Il (preferably class II A) Check knowledge of monitoring and treatment of adverse effects Disposal Patient & family education Staff training ARM Il at HRM 12 a-f ‘Credentialing and privileging of doctors and nurses16 6. Palliative Care Quick list: * Pain management © End of life care + Narcotics © Multi-professional Approach ‘COP 16a ‘* Define the group of patients for whom palliative care is applicable COP T7e.d [© Appropriate assessment and management of pain Pain alleviation methods or medication are initiated for the patient. Subsequently the patient is monitored for response to pain alleviation ‘methods. Based on the response, measures and medication are fully titrated Patient and family education on various pain management techniques COP 2082 End of life care ~ Documented policies and procedures In consonance with legal requirements Treatment and measures for alleviation of pain Multiprofessional approach to provide end of life care. Staff awareness on end of life care (© Respecting the patients values, religion, and cultural preferences © Involving patients family in all aspects of care © Responding to the psychological, emotional, spiritual and cultural ‘concerns of the family. MOMS, 6&7 | Check labelling prior to preparation of a second drug ‘© Check patient is identified before administering medication, verified from the order/ dosage /route/ timing prior to administration MOMS © Procedure for handling narcotics/ license/ documentation of usage/ disposal/ handled by competent staff, ‘© Patient interview ‘* Staff interview17 7. Day care Quick list: + Initial assessment + Consents + Nursing ‘+ Medication management «Narcotics ‘© Monitoring after procedure AAC Sa ‘Documentation of initial assessment COPTa.d [© Pre, during and post procedural instructions, assessment and monitoring cop7f ‘* Informed consent for procedures coP7g ‘© Monitoring at least for 2 hours after the procedure ¢ Procedures documented in the patient record COP 126 [Consent for procedural sedation COP 13d [Informed consent for anaesthesia’ Cop13h | Type of anaesthesia and medications documented COP 14 cdf [© Informed consent for surgery ‘* Documented policies to prevent wrong site, wrong patient, wrong surgery ‘* Surgery notes and post-op care plan documented MOM6 ‘* Check labelling prior to preparation of a second drug ‘* Check patient is identified before administering medication, verified from the order/ dosage /route/_ timing prior to administration MOMS ‘* Procedure for handling narcoticy/Ticense/ documentation of usage/ disposal/ handled by competent staff Patient interview ¢__ Staff interview Data collection for quality indicators to be verified: ‘* PSQ 34(30) : Incidence of needle stick injury18 8. Dialysis Unit Quick list: + Dialyzer re-use ‘+ Infection control + Medication management + Hand hygiene «Medication orders ‘* RO water, monthly endotoxin «Narcotics levels «Medical gas * Informed consent + Nursing care + Blood transfusion © Documentation of hand-over * Case records —documentation + Vulnerable patients * Organ transplant awareness + Restraint policy + BMW * Hazmat + Fire safety «Equipment / furniture maint'ance Patients’ rights right to respect * HIV Testing for values and belief COPSD ‘= Training in CPR COPI5¢ [+ Counselling before organ transplantation MOM Seg [6 High risk drug & Emergency drug management MOM 4a ‘Prescription of medicines. Medication orders * Verbal order MOMT aI [© Medication administration. Staff interview on administration ‘* Medication administration documentation ‘* Patient monitoring after medication administration ‘© Check where close monitoring is required ‘+ Change of medications based on monitoring PRE4ad-h | © Informed consent (includes risk, benefits and alternatives) ‘* Who can give consent when patient is incapable and next of kin is not available ‘+ Validity of the consent for six months and endorsement each time HIC2et |e Adequate & appropriate PPE ‘+ Hand hygiene facilities © Barrier nursing ICS ag ‘+ Adhering hand hygiene guidelines © Use of PPE © Safe injection practice HC dat Testing of water quality ‘© Risk statification matrix for frequency of cleaning © BMW handled appropriately & safely © Laundry and linen management Food distributed safely HICSad__[ Prevention of HAls TIC Tab Catheter washing area ‘+ Cleaning/packing/disinfection or sterilization ¢ Reprocessing of single use instrument19 HICSb.e | Occupational safety ‘+ Immunization policy ‘+ Implement work restrictions for staff with transmissible infections ‘+ Measures for blood and body fluid + Post exposure prophylaxis ‘© Quality of RO water. = .CCTy coverage ‘+ Wdentification of hazmat. Sorting, labelling, handling, storage, transporting and disposal of hazardous materials © Spills management plan of hazardous materials. Staff awareness Spill management FMS46,d,__[* All equipment are inventoried and log maintained / calibrated ‘+ Preventive maintenance/service labels on Equipment/calibration records FMS Sabe | Appropriate Medical equipment * PMs © Calibration of equipment FMS 6ad |» Colour coding of gas pipelines ‘+ Medical gases handling, storage and usage safely '* Storage of oxygen cylinders/Condition of Humidifiers + Alarm units FMS7 '* Documented plan for handling fire and non-fire emergencies + Table top ‘* Safe exit plan. Signage pertaining to fire exits '* Open and easily accessible fire exits without any obstruction ‘* Smoke detectors, fire alarms, fire alarm control panel ete. Fire exit, fire extinguishers, no smoking signs etc ‘© Patient interview ‘2 _ Staff interview Data collection for quality indicators to be verified: PSQ 3a (4) : Medication Error rates PSQ 3a (4) : Percentage of medication charts with error prone abbreviations PSQ 3a (6): Percentage of patients developing ADRs PSQ 3a (9): Percentage of transfusion reactions PSQ 3b (13): CAUTI PSQ 3b (16): CLABSI PSQ 3b (17): Hand Hygiene compliance rate PSQ 34(30) : Incidence of needle stick injury PSQ 3d(31) : Appropriate handover during shift change PSQ 3d(32) : Compliance rate to Medication prescription in capitals PSQ 4d(28) : Patient fall rate PSQ 4d(29) : Percentage of near-misses20 9. ICU, PICU, NICU, HDU + Initial assessment &reassess'nt —« —Admission &disch criteria + Care plan + Discharge &disch. Summary + Nursing care + Early warning signs * CPR + Case records - documentation + Hand hygiene ‘+ Documentation of hand-over ‘+ Infection control ‘© Physician's sample drugs «Safe transfer of patients ‘* Medication orders «Pain management * Medication management + Nutritional assessment + Narcotics Blood transfusion + Restraint policy * Vulnerable patients + Hazmat * Patient feedback «Fire safety + Medical gas + BMW + Endo life care ‘+ Engineering controls «Credentialing & privileging © Compressed air purity + Equipment / furniture maintince © Referrals + Quality assurance ‘+ Patients’ rights displayed: right «Adapt care bundles to respect for values and belief * APACHE/SOFA scoring- ‘© Policy for bed shortage Standard mortality Rate * Counselling by doctor Quick list: AAC4ai [© Predefined initial assessment ‘+ Time frame for doing and documenting initial assessment ‘+ Initial assessment to include screening for nutritional needs ‘© Initial Nursing Assessment ‘* Plan of care includes desired outcomes ‘¢ Plan of care countersigned by clinician in charge within 24 hours AACS acd, [© Reassessment — frequency of reassessment, documentation, response (0 e treatment, plan for further treatment or discharge ‘+ Monitoring of plan of care, modification where found necessary ‘AC 12h | © Qualified individual identified as responsible for the patient's care ‘* Multidisciplinary nature of patient care and co-ordination among various departments / units / staff shifts ‘+ Structured handing / taking over by doctors & nurses, and documentation ‘© Transfer of patients between departments/units ‘* Referral of patients to other departments/specialties ‘¢__ Adequate clinical intervention in response to a critical alert AAC T3at [© Discharge planning in consultation with patient, family, coordinating with various depis.., including MLCs ‘+ Summary given to all including LAMA and di ‘+ Defines time taken for discharge; monitors dela AAC dag | + Content of discharge summary COP Ie,d |» Care pathways ‘* Evidence based medicine and clinical practice guidelines ‘¢_Multidisciplinary and multispecialty care21 COP Sa, be CPR — Policy and procedure, staff trained in CPR, Documentation of events & assigned during CPR, Communication of CAPA measures Display of CPR protocols COP6ah ‘Documented policies and procedures for Nursing Services Assignment of patient care as per current guidelines, Nursing care is aligned and integrated with overall patient care Nursing Plan of Care documented in the patient record Provision of appropriate & adequate equipment Empowerment for nursing related decisions COPT ah Documented procedures of various clinical procedures (Qualifications of the personnel, who are performing procedures Prevention of adverse events - wrong site, patient and procedure Informed consent taken by the doctor performing the procedure Adherence to standard precautions and asepsis Monitoring of patients during and after the procedure Documentation of the procedures accurately in the patient record COP Sb cd, ah “Transfusion done safely Rational use of blood and blood products; transfusion Informed consent Monitoring transfusion reactions; post transfusion forms Staff awareness on above policies Quality Assurance Programme COP Sah Documented policies and procedures on the care of patients Appropriate Bundle care ‘Adinission and discharge criteria Adherence to infection control practices Adequacy of staff and equipment. ICU Manual Procedures when there is a bed shortage Counselling of patients & family Quality assurance program Staff awareness COP Tah Documented policy and procedure for paediatric services Care of paediatric patients - display the scope, ‘Age specific competency, provisions for special care of children, Detailed nutritional, growth, psychosocial and immunization provision for preventing child/neonate abduction and abuse Parent education on nutrition, immunization and safe parentin sessment, COP 2 ah “Moderate sedation. Consent. Monitoring (during & post procedure) COP Had Care of patients undergoing surgeries — policies & procedures, preop assessment, provisional diagnosis prior to surgery, informed consent, procedures to prevent adverse events, post op care plan documented, Surgical Safety Checklist COP I6adet Identifies and manage vulnerable patients Pressure ulcers Dvr Policies & procedures on the care of patients under restraints Informing patients” family Documentation of reasons for restraints; monitoring and frequency Staff awareness on control and restraint techniques: monitoring22 COP 7ae Policies & procedures on pain management ain screening; pain assessment and periodic re-assessment Education of patient and/or family on pain management techniques COP 19a ‘Nutritional assessment and reassessment Written Order for diet: food as per patient's clinical needs, Planning of nutritional therapy Patient and/or family’s education on the patient's diet limitations Food is stored and distributed safel COP 20a End of life care ~ Documented policies and procedures Multiprofessional approach In consonance with legal requirements Treatment and measures for alleviation of pain Staff awareness on end of life care MOM 3a-g ‘Mechanism for physician's sample Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications MOM4ai Prescription of medicines (CAPITAL letters) Medication orders High risk medications defined Verbal orders MOM4t Prescription audit MOM 4h. Drug reconciliation MOM 6ay Medication management Staff interview on the methodology of administration Safe dispensing medication Recall medication Medication administration documentation Patient's self-administration of medicines Management of medications got from outside the HCO MOM7 ad Patient monitoring after medication administration Check where close monitoring is required Change of medications based on monitorin; MOM 8 ae “Monitored afte rmedication administration Near miss, medication error and adverse drug event are defined Reporting within a specified time frame MOM9 ad Narcotic drugs procedure Storage: handling: documentation PRET a,b,d PRE2ak Patients’ rights. displayed. Staff awareness Respect value and beliefs PRES Patients & family explained = care plan, risks, complications, tests, change in condition Multidisciplinary counseling PREGa de Informed consent PRES ai Patient and family education about their health care needs (medications, food drug interaction, diet and nutrition, immunizations, pain management techniques) PRESb.cT ‘Communication with patients & relatives HIC2 “Adequate & appropriate PPE, Hand hygiene facilities Barrier nursing23 HIC3ag ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice Rational use of antimicrobial HIC 4at Testing of water quality Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management Food distributed satel HICSad Prevention of HAIs HIC 7a,b.¢ Catheter washing area Cleaning/packing/disinfection or sterilization Reprocessing of single use instrument HIC8D.e ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS 2det Quality of RO water. Altemate source for electricity and water FMS abet CCT coverage Identification of hazmat. Sorting, labelling, handling, storage, transporting and disposal of hazardous materials Spills management plan of hazardous materials. Staff awareness Spill management FMS 46, d, ‘All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records FMS Sabe ‘Appropriate Medical equipment PMS Calibration of equipment FMS 60d Colour coding of gas pipelines Medical gases handling, storage and usage safely Storage of oxygen cylinders/Condition of Humidifiers Alarm units FMS7 Documented plan for handling fire and non-fire emergencies Table top Safe exit plan. Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction ‘Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire extinguishers, no smoking signs etc. ARM Ii at HRM 12 af Credentialing and privileging of doctors and nurses IMS 3.a,¢, d Medical record unique identification no. 7 Named, signed, dated and timed entry / author are clear. up-to-date and chronological IMS45 Test results are there in case sheet IMS 4 (Operative and other procedures are documented in case records Patient interview Staff interview24 Data collection for quality indicators to be verifies PSQ 3. (1): Time for initial assessment PSQ 3a (4) : Medication Error rates PSQ 3a (4) : Percentage of medication charts with error prone abbreviations PSQ 3a (6): Percentage of patients developing ADRs PSQ 3a (8): Percentage of cases — prevent adverse events like wrong site, patient, surgery PSQ 3a (9): Percentage of transfusion reactions PSQ 3a (9): Incidence of hospital associated pressure ulcers after admission PSQ 36 (13): CAUTL PSQ 3b (14): VAP PSQ 3b (15): CLABSI PSQ 3b (16): SSI PSQ 3b (17): Hand Hygiene compliance rate PSQ 3c (21): Nurse patient ratio PSQ 3d(30) : Incidence of needle stick injury PSQ 3d(31) : Appropriate handover during shift change PSQ 3d(32) : Compliance rate to Medication prescription in capitals PSQ 4d(28) : Patient fall rate PSQ 4d(29) : Percentage of near-mi PSQ 4c(24) : Time taken for discharge PSQ 3a (11): Standard mortality Rate s25 10. Operation Theatre Quick list: Preop assessment & provisional diagnosis documented Informed consent for surgery obtained by a surgeon Documented policies and procedures to prevent adverse events Qualified surgeon to perform. Operating notes & post-operative plan of care Infection control practices Availability of appropriate facilities & equipment in OT Quality assurance programme. Engineering controls = Anaesth assessment and plan + Consents + Adverse anaesth events * Vulnerable patients ‘Prevention of wrong site, ete + Medication management Blood transfusion * Medication orders + Medical gas * Labelling of medicines + Compressed air purity * Safe injection practice «Engineering controis + Narcotics ‘+ Infection control * Adequate equipment + Hand hygiene * Equipment / furniture maint’ance + Steriisation + BMW «Re-use policy «Hazmat * Fire safety * Patients’ rights displayed- right to respect for values and belief «Credentialing & privileging * Case records ~documentation ‘+ Post-operative care plan document COPGah [Documented policies and procedures Tor Nursing Services in OT ‘© Assignment of patient care. Nursing Plan of Care documented © Provision of adequate equipment ‘¢ Empowerment for nursing related decisions COPSb.GF [© Rational use of blood and blood products; gh © Transfused safely ‘* Informed consent ‘* Monitoring transfusion reactions: post transfusion forms ‘* Staff awareness on above policies ‘¢ Blood and blood component transfused in defined time frame. COP Sak [© Administration of anaesthesia — Policy and procedure ‘© Pre-anaesth assessment. Anaesthesia plan. Immediate pre-op assessment ‘© Pre-induction assessment ‘* Informed consent for anaesthesia obtained by the anaesthesiologist ‘* Monitoring during & post anaesthesia ‘© Criteria for transfer / discharge from recovery area ‘* Adherence to infection control guidelines ‘+ Monitoring and recording of adverse anaesthesia events COP T4a-g [Surgical procedures - Policy and procedure Surveillance of OT environment. Monitoring of SSI26 MOM 3a, b-g ‘Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications MOMS ad Narcotic drugs procedure Storage; handling: documentation MOM 100d Procedure for procuring, storage / stocking, usage of implants Counselling of patient and/or family for the usage of implants Entry of batch & serial no in patient's case file and master log book Recall of prostehsis PRET a,b,d PRE2a-k Patients’ rights: displayed. Staff awareness Respect value and beliefs PRES Patients & family explained : care plan, risks, complications, tests, change in condition Multidisciplinary counseling PRE4a, de Informed consent PRES ai Patient and family education about their health care needs (medications, food drug interaction, diet and nutrition, immunizations, pain management techniques) PREGad Information about expected cost PRES b,c ‘Communication with patients & relatives HIC2 ef ‘Adequate & appropriate PPE Hand hygiene facilities Barrier nursing HICSag ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice HIC4 at “Testing of water quality Engineering control in OT — air quality, AHU cleaning, Filters and its cleaning & replacements Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management ¢ Rational use of antimicrobial HICSad Prevention of HAIs HIC 7b Cleaning/packing/disinfection or sterilization Reprocessing of single use instrument HICED. «| ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS 26-2 Floor plans; Fire Escape routes; Signages Layout of OT (no mix of sterile and unsterile) Availability of potable water and electricity round the clock Altemate sources for electricity & water as backup for any failure Access control for outsiders FMS 2 def Quality of RO water. Alternate source for electricity and water27 FMS3bef [~ (CCT Veoverage Identification of hazmat, Sorting, labelling, handling, storage, transporting and disposal of hazardous materials Spills management plan of hazardous materials. Staff awareness Spill management FMS46,d, [All equipment are inventoried and log maintained / calibrated ‘+ Preventive maintenance/service labels on Equipmentcalibration records FMS Sabe | Appropriate Medical equipment + PMS © Calibration of equipment FMS 6a-d___| © Colour coding of gas pipelines ‘+ Medical gases handling, storage and usage safely ‘* Storage of oxygen cylinders/Condition of Humidifiers + Alarm units FMS7 ‘* Documented plan for handling fire and non-fire emergencies + Table top ‘+ Safe exit plan. Signage pertaining (o fire exits ‘© Open and easily accessible fire exits without any obstruction ‘+ Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire HRMIlat |« HRM 12 af extinguishers, no smoking signs etc. Credentialing and privileging of doctors and murses IMS3acd |e Medical record unique identification no, 7 Named, signed, dated and timed entry / author are clear. up-to-date and chronological IMSa4d Operation notes documented in case records Patient interview Staff interview Data collection for quality indicators to be ver + PSQ3a(4) PSQ 3a (4) PSQ 3a (6) PSQ 3a (7) PSQ 3a (8): PSQ 3a (9): Medication Error rat Percentage of medication charts with error prone abbreviations Percentage of patients developing ADRs. Percentage of unplanned return to OT Percentage of cases — prevent adverse events like wrong site, patient, surgery Percentage of transfusion reactions PSQ 3b (16): SSI PSQ 3b (17): Hand Hygiene compliance rate PSQ 3b(18): Percentage of cases who received appropriate prophylactic antibiotic within the specified time frame PSQ 3b(19): Percentage of re-scheduling of surgeries PSQ 3c (21): Nurse patient ratio PSQ 34(30) PSQ 3d(31) : Appropriate handover during shift change PSQ 3d(32) : Compliance rate to Medication prescription in capitals PSQ 40(25): Percentage of medical record having i PSQ 4d(28) : Patient fall rate PSQ 4d(29) : Percentage of near-misses Incidence of needle stick injury complete and/or improper consent28 11. Recovery Room Quick list: Nursing care = CPR Pain management ‘+ Documentation of hand-over Blood transfusion «Vulnerable patients Discharge criteria «Fire safety Infection control « BMW Medication management + Narcotics Restraint policy © Medication orders Hazmat Patients’ rights-Right for value and belief + Case records ~documentation COPSa,be CPR — Policy and procedure, staff trained in CPR, Documentation of events & responsibilities during CPR, Communication of CAPA measures COP 12g,f “Monitoring post anaesthesia. Criteria for transfer / discharge from recovery area COPTaRe Operating notes and post-operative plan of care MOM 3a, b-g Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications MOM4 ai Prescription of medicines (CAPITAL letters) Medication orders. High risk medications defined Verbal orders MOM 6aj Medication management Staff interview on the methodology of administration Safe dispensing medication Recall medication Medication administration documentation Patient's self-administration of medicines Management of medications got from outside the HCO MOM Tad Patient monitoring after medication administration Check where close monitoring is required Change of medications based on monitoring MOMS ae ‘Near miss, medication error and adverse drug event are defined Reporting within a specified time frame MOM9 ad Narcotic drugs procedure Storage: handling: documentation ‘Staff interview Patient interview29 12. Endoscopy / Bronchoscopy Quick list: Safe transfer of patients + CPR Documentation of handing over * Vulnerable patients Case records ~documentation ‘Infection control BMW * Hand hygiene Medication management © Narcotics Medication orders + Fire safety Medical gas + Equipment / furniture maint’nce Consents + Steriisation / disinfection Patients’ rights + Hazmat © Procedure checklist ‘© Procedural sedation record COPSa, be ‘+ CPR-— Policy and procedure, staff trained in CPR, Documentation of events & assigned during CPR, Communication of CAPA measures Display of CPR protocols COPTah ‘Documented procedures of various clinical procedures Qualifications of the personnel, who are performing procedures Prevention of adverse events - wrong site, patient and procedure Informed consent taken by the doctor performing the procedure Adherence to standard precautions and asepsis Monitoring of patients during and after the procedure Documentation of the procedures accurately in the patient record COP ah Procedures on the administration of moderate sedation. Informed consent. Competency of persons performing sedation. Check who gives sedation and ‘who monitors patient ‘+ Intra-procedure monitoring parameters & documentation ‘* Discharge/transfer criteria from the recovery area ‘* Availability of equipment and manpower to manage patients who have gone into a deeper level of sedation MOM 3a, bg '* Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications MOM4 ai Prescription of medicines (CAPITAL letters) Medication orders. High risk medications defined Verbal orders MOM 6 ah Medication management. Staff interview on the methodology of administration. Documentation MOM Tad Patient monitoring after medication administration Close monitoring requirement situations MOM 9 ad Narcotic drugs procedure Storage: handling; documentation PRES Gy Tnformed consent HIC 2e-4 ‘Adequate & appropriate PPE Hand hygiene facilities Barrier nursing HICSag ‘© Adhering hand hygiene guidelines © Use of PPE Safe injection practice30 HiC4at ‘Testing of water quality Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management HICS ad Prevention of HAIs HIC 7a) Look for scope disinfection and the usage of cidex. If cidex is used look for exhaust as it is carcinogenic. Bronchoscopy room also should be a negative pressure room Cleaning/packing/disinfection or sterilization Reprocessing of single use instrument ICSE. «| ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS 26-2 Floor plans; Fire Escape routes, Signages Layout of OT (no mix of sterile and unsterile) Availability of potable water and electricity round the clock Alternate sources for electricity & water as backup for any failure Access control for outsiders FMS 2 def Quality of RO water. Alternate source for electricity and water FMS 3 bef -CCTVeoverage Identification of hazmat. Sorting, labelling, handling, storage, transporting and disposal of hazardous materials Spills management plan of hazardous materials. Staff awareness Spill management FMS 45, d, ‘All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records FMS Sabo ‘Appropriate Medical equipment PMS Calibration of equipment FMS Gad Colour coding of gas pipelines Medical gases handling, storage and usage safely Storage of oxygen eylinders/Condition of Humidifiers Alarm units FMS7 ‘Documented plan for handling fire and non-fire emergencies Table top Safe exit plan. Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire extinguishers, no smoking signs etc. HRM 11 at HRM 12 af (Credentialing and privileging of doctors and nurses IMS 3a,c,d Medical record unique identification no, 7 Named, signed, dated and timed entry / author are clear, up-to-date and chronological Patient interview Staff interview31 13.Rehabilitation / Physiotherapy Quick list: Vulnerable patients Functional assessment Infection control Hazmat Equipment / furniture maint’ance Scope of dept Biomedical waste management Patients’ rights Case records —documentation Fire safety Clinical Pathway COP Bag Policies and procedures on rehabilitative services Scope of the department ‘Adequate space and equipments Multidisciplinary team approach Registration if applicable Assessment and Reassessment Check for the cleaning of the equipment after used by each patient Functional assessment scales Adherence to infection control and safe practices Care pathways COP Tad Pain management COP 16ae Care of vulnerable patients Safe and secure environment Safety of patients, FMS Sef HAZMAT Spill management- Chemical spill FMS 3 €1 FMS 4 cf ‘All equipment are inventoried and log maintained / calibrated PM labels on Equipment/calibration records/Refrigerator Patient interview Staff interview32 14. Radiology Quick list: + Statutory requirements + Radiation signages «TAT, critical alert-not more than * Recall / amendment of reports one hour ‘+ Patient screening for safety + Safe transfer of patients «PPE «© Vulnerable patients + Patients’ rights * Infection control «Medication management «MOU for outsourced investigations + Hazmat . * BMW ‘© Equipment / furniture maint’ance Quality assurance + Fire safety Safety precautions while + Clinico-radiological meeting transporting patients to and from * Appropriateness of investigation imaging centre AACTb.c [© Suitable qualified personnel 12 _ Service in scope should be defined RAC 9a ‘> Comply with BARCIAERB legal requirements ROM2b ‘AAC 9b-j | * Scope. Adequate infrastructure (physical and manpower) ‘* Technician qualified as per AERB ‘* Identification and safe transportation of patients to the imaging services ‘© Tumaround time. Critical results intimation (of outsourced results also) not more than | hour ‘© Standardized reporting of results '* Mechanism to address recall / amendment of reports '* Monitoring of waiting time, time for tests, time for reports ‘* Documented procedures for outsourcing tests # Adequate number of manpower and infrastructure ‘AAC 10at [Quality assurance programme documented. Peer review of reports and protocols. Appropriateness of investigation ‘+ Feedback to stakeholders ‘© Calibration and maintenance of all equipment = CAPA ¢ Glinico-radiological meeting AAC Tiag | © Safety programme documented including usage of safely equipment and TLD badges Safety devices provided and periodically checked ‘+ “ALARA”, Patients sereened for safety ‘© Usage and disposal of radioactive and hazmat as per statutory requirements ‘© Staff training. ‘+ Imaging signages: - Radiation hazard, PC-PNDT act COP 12a [© Informed consent for procedural sedation ‘+ Competent and trained person administer procedural sedation ‘+ Person administering and doing the procedure need to be two different individual ‘© Intraprocedure monitoring + _Disogharge criteria MOMSa,b¢ [+ dates, storage, emergency crash carts,33 PRE4d '* Informed consent HIC3a ‘+ _ Safe injection and infusion practices FMS3ef |» HAZMAT ¢ _ Spill management- Chemical spill FMS3cf, [All equipment are inventoried and log maintained / calibrated FMS4ef | ¢ PM labels on Equipment/calibration records Refrigerator Pationt & staff interview Data collection for quality indicators to be verifies © PSQ 3a (2): Number of reporting error © PSQ 3a (3): Percentage of adherence to safety precautions by staff working in diagnostics © PSQ4e (23) : Waiting me for diagnostic34 15. Nuclear Medicine Quick list: Statutory requirements + Radiation signages ‘+ Patient screening for safety * Recall / amendment of reports «PPE «Safe transfer of patients ‘+ Patients’ rights displayed- right © Vulnerable patients to respect for values and belief ‘+ Medication management * Infection control + Hazmat © Equipment / furniture maint’ance + BMW + Fire safety ‘* critical alert-not more than one hour AAC Ibe | * Suitable qualified personnel ‘+ _ Service in scope should be defined AAC 9a ‘+ Comply with BARC/AERB legal requirements ROM2b ‘AAC 9bj | Scope. Adequate infrastructure (physical and manpower) ‘* Technician qualified as per AERB ‘+ Identification and safe transportation of patients to the imaging services ‘+ Tumaround time. Critical results intimation (of outsourced results also) not ‘more than | hour ‘+ Standardized reporting of results ‘* Mechanism to address recall / amendment of reports ‘* Monitoring of waiting time, time for tests time for reports ‘* Documented procedures for outsourcing tests ‘+ Adequate number of manpower and infrastructure ‘AAC 10a-f [Quality assurance programme documented. Peer review of reports and protocols. Appropriateness of investigation ‘* Feedback to stakeholders ‘* Calibration and maintenance of all equipment + CAPA + Clinico-radiological meeting AAC Tiag [© Safety programme documented including usage of safety equipment and TLD badges Safety devices provided and periodically checked “ALARA, Patients sereened for safety. '* Usage and disposal of radioactive and hazmat as per statutory requirements ‘© Staff training. ‘+ Imaging signages: - Radiation hazard, PC-PNDT act COP T2ah [Informed consent for procedural sedation ‘* Competent and trained person administer procedural sedation ‘* Person administering and doing the procedure need to be two different individual ‘* Intra procedure monitoring 2 Discharge criteria MOM 3. b-g [+ Medication storage. inventory. expiry dates, storage, emergency crash carts,35 ation records/Refrigerator ‘© Use of radioactive during safely | ‘* Storage securely MOM 9a-¢ | . Administered qualified personne! + Proper record of usage, administration and disposal PREGA ‘+ Informed consent HIC 3a ‘* Safe injection and infusion practices FMS Sef |» HAZMAT ‘+ _ Spill management- Chemical spill FMS3ef, [All equipment are inventoried and log maintained / calibrated FMS 4 ¢_PM labels on Equipmentica Patient & staff interview Data collection for quality indicators to be verifie © PSQ 3a (2): Number of reporting error © PSQ 3a (3): Percentage of adherence to safety precautions by staff working in diagnostics © PSQ 4c (23) : Waiting time for diagnostic36 16. Cardiac Catheterisation Lab Quick list: + Statutory requirements + Radiation signages + Patient screening for safety * Recall / amendment of reports * CPR «Safe transfer of patients * Moderate sedation Vulnerable patients ‘+ Medication management «Infection control © Narcotics + Equipment / furniture maint ance + Reuse policy + Fire safety * Case records documentation + BMW ‘Patients’ rights dispiayed- right + Hazmat to respect for values and belief * Procedural sedation record BAC I« ‘* Comply with BARC/AERB legal requirements ROM 2, ‘AAC bch | © Scope. Adequate infrastructure (physical and manpower) ‘* Technician qualified as per AERB ‘* Identification and safe transportation of patients to the imaging services + Standardized reporting of results ‘AAC Tae | Quality assurance programme documented. Peer review of reports and protocols. Appropriateness of investigation. ‘© Calibration and maintenance of all equipment ‘+ Documentation of corrective and preventive actions AAC Tiag | Radiation Safety programme documented including usage of safety equipment and TLD badges Safety devices provided and. periodically checked ‘* Patients screened for safety. © Staff training. 2 Imaging signage prominently displayed COPSa.be [© CPR — Policy and procedure, siaff trained in CPR, Documentation of events during CPR, Communication of CAPA measures COPTa-g | © Documented procedures of various clinical procedures ‘* Qualifications of the personnel, who are performing procedures '* Informed consent taken by the doctor performing the procedure ‘© Adherence to standard precautions and asepsis ‘+ Monitoring of patients during and after the procedure ‘+ Documentation of the procedures accurately in the patient record COP 2ah [© Procedures on the administration of moderate sedation. Informed consent ‘* Competency of persons performing sedation. Check who gives sedation and who monitors patient ‘* Intra-procedure monitoring parameters & documentation ‘* Discharge/transfer criteria from the recovery area ‘© Availabilty of equipment and manpower to manage patients who have gone into a deeper level of sedation MOM 3a,b-g |° Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA. high risk medications37 MOM4ai Prescription of medicines (CAPITAL letters) Medication orders. High risk medications defined Verbal orders MOM Gach Medication management. Staff interview on the methodology of administration. Documentation MOM 7a-d Patient monitoring after medication administration Close monitoring requirement situations MOM 9 a-d Narcotic drugs procedure Storage: handling: documentation MOM 10 ad Procedure for procuring, storage / stocking, usage of implants Counselling of patient and/or family for the usage of implants Entry of batch & serial no in patient's case file and master log book Recall of prostehsis PRE4d Informed consent HIC 2ef ‘Adequate & appropriate PPE. Hand hygiene facilities Barrier nursing HICSag ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice Rational use of antimicrobial HIC4at ‘Testing of water quality Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management Food distributed safel HIC Sad Prevention of HAIs HIC Tab Catheter washing area Cleaning/packing/disinfection or sterilization Reprocessing of single use instrument HICSb.€ ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS 3ef HAZMAT Spill management Chemical spill FMS 3c, FMS 4 cf ‘All equipment are inventoried and log maintained / calibrated PM labels on Equipment/calibration records/Refrigerator Patient interview Staff interview Data collection for quality indicators to be verified: © PSQ 3a (2): Number of reporting error © PSQ 3a (3): Percentage of adherence to safety precautions by staff working in diagnosti © PSQ 4c (23) : Waiting time for diagnost38 17. Collection centre (lab) Quick list: Specimen transport + Patient privacy PPE * Infection contro! Spill management * Needle stick injuries Hand hygiene AAC be ‘+ Procedures for collection, safe handling, safe transportation AACSd.e [© Staff trained in safe practices + Provided with PPE. Lab staff immunised PRE2D ‘+ Patient's right to privacy during specimen collection HIC2e ‘+ Safe injection HICSa,b | Adequate PPE, soaps, disinfectants ‘© Adequate hand hygiene facility HICSé + PEP for needle stick injuries FMSSef |e HAZMAT Spill management- Chemical spill39 18. Laboratories Quick list: + TAT, critical alert- not more than * Test reports one hour * Quality assurance ‘+ Recall / amendment of reports + MOU for outsourced + Lab safety investigations © PPE © Spill management * BMW «Equipment / furniture maint'ance + Spill management ‘+ Immunisation of staff = Hazmat ‘Patients’ rights- respect for + Fire safety value and belief «Ensures quailty of test results Clinicopathological meeting AAC Ibe Suitable qualified personnel Service in scope should be defined ‘AAC 6a} ‘Scope commensurate with services. Adequate infrastructure and manpower. Qualified personnel Documented procedures for collection, processing, etc TAT. Critical results (of outsourced investigations also) not more than one hour Reported in a standardised manner. Signatures Outsourced investigations report Mechanism for recall / amendment of reports Quality assurance of outsourced investigations AAC T at ‘Quality assurance programme documented - ILQA - ELQA Feedback from various stakeholders Traceability of calibration records to national / international standards Verification’ validation and LJ graphs / software validation/ surveillance / calibration/ maintenance / Corrective and Preventive actions Calibration of POC equipment also CAPA Clinico-pathological meeting AAC Bad Documented lab safety programme Documented policies & procedures for disposal of infectious & hazmat Awareness of safety among employees - Staff trained in safe practice Staff have safety equipment / fire extinguisher / dressing materials / ete. Immunisation Reagent storage. PRE44.g) HIV consent HIC2e4 “Adequate & appropriate PPE Hand hygiene facilities Barrier nursingHIC3ag ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice HIC 4at Testing of water quality Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management HICED, ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS Ser HAZMAT Spill management- Chemical spill FMS 3 FMS 4 cf ‘All equipment are inventoried and log maintained / calibrated PM labels on Equipment/calibration records/Retrigerator FMS7 ‘Documented plan for handling fire and non-fire emergencies Safe exit plan. Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire extinguishers, no smoking signs etc. IMS 4 Test results are there in case sheets ‘Staff interview Data collection for quality indicators to be verifies © PSQ 3a (2): Number of reporting error © PSQ 3a (3): Percentage of adherence to safety precautions by staff working in diagnostics, © PSQ 4c (23) : Waiting time for diagnostic41 19. Blood Bank Quick list: + Statutory ‘= Turn around time «Transfusion committee * Biomedical waste management «Infection control «Hazmat «Medication management Equipment / furniture maint'nce = Documentation + Fire safety + Scope of transfusion service- + Rational use of Blood and Blood MoU component + Quality Assurance Programme COP Sa ‘* Blood bank licence ROM 2b COP 8 b-h Policies for rational use, transfusion Informed consent for donation and transfusion ‘Tum around time of availability of blood Process for availability and transfusion in emergency ‘Transfusion reactions analysis Staff awareness on above PRESG Informed consent HIC2¢F ‘Adequate & appropriate PPE. Hand hygiene facilities Barrier nursing HIC Sag ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice HICad ‘> BMW handled appropriately & safely HIC8b.€ ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis HAZMAT Spill management- Chemical spill ‘All equipment are inventoried and log maintained / calibrated PM labels on Equipment/calibration records/Refrigerator ‘Documented plan for handling fire and non-fire emergencies Safe exit plan. Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Smoke detectors, fire alarms, fire alarm control panel ete. Fire exit, fire extinguishers, no smoking signs etc. ‘+ Patient & staff interview Data collection for quality indicators to be verified: © PSQ3.(9): Transfusion reactions © PSQ3c (20); Turnaround time for issue of blood and blood components.42 20. Radiotherapy Quick list: Statutory requirements + Radiation signages ‘+ Patient screening for safety * Recall / amendment of reports «PPE «Safe transfer of patients ‘+ Patients’ rights- Respect for © Vulnerable patients patient and safety ‘+ Medication management * Infection control + Hazmat + MOU for outsourced + BMW investigations * Quality assurance © Equipment / furniture maint’ance * Case records ~documentation «Fire safety AACTbe [© Suitable qualified personnel 1* Service in scope should be defined AAC 9a ‘+ Comply with BARC/AERB legal requirements ROM2b ‘AAC 9b-j | Scope, Adequate infrastructure (physical and manpower) ‘© Technician qualified as per AERB ‘* Identification and safe transportation of patients to the imaging services © Turnaround time. Critical results intimation (of outsourced results also) not more than | hour ‘* Standardized reporting of results ‘* Mechanism to address recall / amendment of reports ‘* Monitoring of waiting time, time for tests, time for reports ‘+ Documented procedures for outsourcing tests + Adequate number of manpower and infrastructure ‘AAC 10a [* Quality assurance programme documented. Peer review of reports and protocols. Appropriateness of investigation ‘+ Feedback to stakeholders ‘* Calibration and maintenance of all equipment + CAPA ‘* Clinico-radiological meeting ‘AAC Tia-g [* Safety programme documented including usage of safety equipment and TLD badges Safety devices provided and periodically checked ‘* “ALARA®, Patients screened for safety ‘© Usage and disposal of radioactive and hazmat as per statutory requirements ‘© Staff training. + _Imaging signages: - Radiation hazard COP 12h [© Informed consent for procedural sedation ‘* Competent and trained person administer procedural sedation ‘+ Person administering and doing the procedure need to be two different individual ‘*Intraprocedure monitoring + _Disogharge criteria MOMS. b-g | Medication storage, inventory, expiry dates, storage, emergency erash carts, PRE 4d ‘¢ Informed consent HIC 3d ‘+ _ Safe injection and infusion practices43 FMSef [~* HAZMAT + _ Spill management- Chemical spill FMS 3 ¢1 ‘> All equipment are inventoried and log maintained / calibrated FMS4cf | PM labels on Equipment/calibration recordy/Refrigerator Patient & staff interview21. Nutrition Therapy Quick list: Nutritional assessment & + Maternal & paed nutritional reassessment assessment Safe storage and distribution of ~*~ Documentation food Capturing of CO! 3 & 4 data + Patient interviews Patient family education AACS Thitial assessment includes nutritional assessment for all the patients( OPD, IPD and daycare) and all the therapeutic diet patients are re-assessed daily COP 19 af Procedure (s) for nutritional assessment and reassessment Food according to the patient's clinical needs Written order for the diet Planning of nutritional therapy in a collaborative manner Food is stored and distributed safely Families are educated about the patients diet limitations Patient and their attendant to be educated about diet limitation ‘Screening for nutritional risk COP 10e COP Ig “Maternal nutrition assessment Paediatric nutritional assessment All the patients require therapeutic diets are as the screening is done by nurses/doctors. ssed by the dietician though PRES ed Patient and/or family interview on education on food-drug interactions, Patient and/or family interview on education on diet and nutrition45 23. Hospital Infection Control Quick list: © Documented HIC + ICO,ICN + High risk areas & surveillance + HAls + Antibiotic policy + BMW «Hand hygiene «Pre / post exposure prophylaxis «Isolation policy © Outbreaks + HIC Budget + Training «Immunisation policy «Post exposure prophylaxis «Work restriction policy for staff with transmissible HICT aj [* Documented Infection Control Programme & updated at least annually * Risk reduction goals * Updation of Infection Prevention and Control Programme * IC committee ~ Composition, functions, frequency of meetings, minutes # Inf control team, ICO, ICN(s) #Privileging of ICO & ICNs HICZa-c| © Themenagement mokes avalable resources required for the Infection control programme. ‘+ The organisation earmarks adequate funds from its annual budget in this regard. ‘+ Adequate and appropriate personal protective equipment, soaps, and disinfectan} are available and used correctly. ‘© Adequate and appropriate facilities for hand hygiene in all patient-care areas are accessible to healthcare providers. ‘+ _Isolation/barrier nursing facilities are available. HIC3ag | The organisation adheres to standard precautions at all times. ‘© The organisation to hand-hygiene guidelines. ‘© The organisation adheres to transmission-based precautions, ‘* The organisation adheres to safe injection and infusion practices. ‘© Appropriate antimicrobial usage policy is established and documented. ‘© The organisation implements the antimicrobial usage policy and monitors the rath use of antimicrobial agents The organisation implements an antibiotic stewardship programme. HIC4at [+ The organisation has appropriate engineering controls to prevent infections, The organisation designs and implements a plan to reduce the risk of infection du} construction anf renovation. ‘The organisation adheres to housekeeping procedures. Biomedical waste (BMW) is handled appropriately and safely. The organisation adheres to laundry and linen management processess. The organisation adheres to kitchen sanitation and food-handling issues. nal ng46 HIC Sad ‘+ The organisation takes action to prevent catheter-associated urinary tract infecti ‘+ The organisation takes action to prevent infection-related ventilator associated complication/ventilator-associated pnemonia. ‘+ The organisation takes action to prevent catheter linked blood stream infections. ‘2 _The organisation takes action to prevent surgical site i factions. ns. HIC 6a The scope of surveillance incorporates tracking and analyzing of infection risks, rates trends. ‘* Verification of data is done regularly by the infection control team. ‘+ Surveillance is directed towards the identified high-risk activities. ‘+ Surveillance includes monitoring compliance with hand-hygiene guidelines. ‘+ Surveillance includes mechanisms to compare the occurrence of mul resistant organisms and highly virulent infections. ‘= Surveillance includes monitoring the effectiveness of housekeeping services. ‘+ Feedback regarding surveillance data is provided regularly to the appropriate health care provider. ‘© The organisation identifies and takes appropriate action to control outbreaks of infections. ‘© Surveillance data is analyzed and appropriate corrective and preventive actions are taken. drug nd HIC Tae * The organisation provides adequate space and aprropriate zoning for sterilization activities. * Cleaning, packing, disinfection and/or sterilization, storing and the issue of items is done as per the written guidance. * Reprocessing of single-use instruments, equipment and devices are done as per written guidance, * Regular validation tests for sterilization are carried out and documented. * The established recall procedure is implemented when a breakdown in the Sterilization system is identified. HIC See '* The organisation implements occupational health and safety practices to reduce the risk of transmitting microorganisms among healthcare providers. ‘* The organisation implements an immunisation policy for its staff. ‘¢ The organisation implements work restrictions for healthcare providers with transmissible infections. ‘* The organisation implements measures for blood and body fluids exposure prevention. ‘© Appropriate post-exposure prophylaxis is provided to all staff members concerned. © Staff interview + Patient interview Data collection for quality indicators to be verified: PSQ 3b (13): CAUTL PSQ 3b (14): VAP PSQ 3b (15): CLABSI PSQ 3b (16): SSI47 ‘* SQ 3b (17): Hand Hygiene compliance rate # PSQ 3c (21): Nurse patient ratio ‘+ PSQ 34(30) : Incidence of needle stick injury 24. Organ transplant Quick list: «Legal requirements «Policies & procedures ‘* Informed consents ‘© Creating awareness © Qualified counsellors * Privileging Transplant ICU COP Ian ‘Admission discharge criteria to transplant ICU Adequate staff & equipment Infection control practices Quality assurance programme Patients and family counselled COP Isa ROM 2b Legal requirements Submission of reports COP 16b ‘Documented policies and procedures on indications, donor & recipient fitness, education & consents, care paths Special consents from donor and receipients COP 16 (Qualified counsellors Evidence of counselling documented in required statutory formats & case sheets Donor and recipients are explained about the benefit and possible risks Recipients are also educated about immune-suppression and the required monitoring and follow-up COP 16d Creating awareness — standees, posters, hand-outs, te HRM 11 af HRM 12 af, Privileging of doctors Privileging of nurses Staff interview Patient interview25. Dental Quick list: Initial assessment & reass'ment Pain management Vulnerable patients Medication orders Medication management Hazmat Equipment / furniture maint'ance 48 Safe transfer of patients Infection control CPR Case records —documentation Patients’ rights Fire safety BMW AAC Ia ROM2b ‘Comply with BARC/AERB legal requirements ‘AAC Hag Radiation Safety programme documented including usage of safety equipment and TLD badges Safety devices provided and periodically checked Patients screened for safety. Staff training. Imaging signage prominently displayed COPSabe CPR — Policy and procedure, staff trained in CPR, Documentation of events during CPR, Communication of CAPA measures, COPT ah ‘Documented procedures of various clinical procedures Qualifications of the personnel, who are performing procedures Informed consent taken by the doctor performing the procedure Adherence to standard precautions and asepsis Monitoring of patients during and after the procedure Documentation of the procedures accurately in the patient record COP I2ah Procedures on the administration of moderate sedation, Informed consent. Competency of persons performing sedation. Check who gives sedation and ‘who monitors patient Intra-procedure monitoring parameters & documentation Discharge/transfer criteria from the recovery area Availability of equipment and manpower to manage patients who have gone into a deeper level of sedation COP sae Policies & procedures on pain management ain screening; pain assessment and periodic re-assessment Education of patient and/or family on pain management techniques MOM 3a, b-g “Medication storage, inventory, expiry dates, storage conditions, emergency crash carts, LASA, high risk medications MOM 10 ad Procedure for procuring, storage / stocking, usage of implants Counselling of patient and/or family for the usage of implants Entry of batch & serial no in patient's case file and master log book Recall of prostehsis PRET a,b,d PRE2ak Patients’ rights: displayed. Staff awareness Respect value and beliefs PRES Patients & family explained : care plan, risks, complications, tests, change in condition Multidisciplinary counseling PRE4a de Informed consent49 PRES ai Patient and family education about their health care needs (medications, food drug interaction, diet and nutrition, immunizations, pain management techniques) PREG ad Information about expected cost PRESb.GT ‘Communication with patients & relatives HIC 2 ‘Adequate & appropriate PPE. Hand hygiene facilities Barrier nursing HICa ag ‘Adhering hand hygiene guidelines Use of PPE Safe injection practice Rational use of antimicrobial HIC Fat Testing of water quality Risk stratification matrix for frequency of cleaning BMW handled appropriately & safely Laundry and linen management HICSad Prevention of HATs HIC Tab Cleaning/packing/disinfection or sterilization Reprocessing of single use instrument HICSS ‘Occupational safety Immunization policy Implement work restrictions for staff with transmissible infections Measures for blood and body fluid Post exposure prophylaxis FMS 2b-g Floor plans; Fire Escape routes, Signages Layout of OT (no mix of sterile and unsterile) Availability of potable water and electricity round the clock Alternate sources for electricity & water as backup for any failure Access control for outsiders FMS 2 def Quality of RO water. Alternate source for electricity and water FMS 3 bef CCT Veoverage Tdentification of hazmat, Sorting, labelling, handling, storage, transporting and disposal of hazardous mater Spills management plan of hazardous materials. Staff awareness Spill management FMS 46, d, ‘All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipmenv/calibration records FMS Sabo ‘Appropriate Medical equipment PMS Calibration of equipment FMS 6a-d Colour coding of gas pipelines Medical gases handling, storage and usage safely Storage of oxygen cylinders/Condition of Humidifiers Alarm units50 FMS7 ‘Documented plan for handling fire and non-fire emergencies Table top Safe exit plan. Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Smoke detectors, fire alarms, fire alarm control panel etc. Fire exit, fire extinguishers, no smoking signs etc RMI af HRM 12 af ‘+ Credentialing and privileging of doctors and nurses IMS 3a, c,d ‘+ Medical record unique identification no. / Named, signed, dated and timed entry / author are clear, up-to-date and chronological IMS 4d Operation notes documented in case records Patient interview Staff interview 26. Nursing Quick list: Nursing manual-clinical pathway Nursing initial assessment Adequacy of nursing staff + Reassessment Manpower planning + Aligned care plan Privileging + Structured handover Credentialing © Clinical audits Contingency plan for shortfall in «Nursing empowerment nurses © Training in CPR - ICU Competent nurses in high risk + Provided with adequate obs & paediatric services equipment Monitoring of nursing services & © Patient feedback to include KPis nursing care Nurses part of CPR, safety and * Documentation of monitoring HIC committee and all nursing activities Appropriate. & adequate equipment AACIb [+ Suitably qualified nurses are available for each service AAC4a, [© Defines and documents initial assessment. Time frame defined a AACSd_ [+ Documented reassessmentsl ‘AAC 12 [~ During all phases of care there is a nurse For continuity of care ‘AAC I2d |« Structured clinical handover between shifis & transfers between units / departments COP Sab [All nurses in ICU should have CPR training COPSd [+ One nursing staff to be a member of CPR committee COP Gach | + Nursing care is provided to patients in accordance with written guidance. * «The organisation develops and implements nursing clinical practice guidelines reflecting current standards of practice. * ‘© Assignment of patient care is done as per current good clinical/ nursing practice guidelines. © The organisation implements acuity-based staffing to improve patient outcomes} ‘Nursing care is aligned and integrated with overall patient care * Care provided by nurses is documented in the pati * Nurses are provided with appropriate and adequate equipment for providing safe and efficient nursing care. «Nurses are empowered to make patient care decisions within their scope of practice. t record. COP Te [+ Nurse patient ratio in ICU adequate and as per guidelines COP 10g [+ Competent nurses caring high risk obstetric cases COP If | + Nurses in paediatric services have age specific competencies PRET [© Feedback from patients includes aspects related to nursing care FIC 1a | HIC shall be multidisciplinary and shall include nursing staff PSQ1 | + Patient safety programme PSQ2 [+ Quality Assurance Programme PSQ3___|~ KPI PSQS + Clinical audits HRM1 [© Man power planning © Numbers as per guidelines «Contingency plans for shortfall TIRM 12° Credentialing + Privileging © Staff interview Y Patient care v OER Safety Data collection for quality indicators to be veri PSQ3.a(1): Time for initial assessment PSQ3.a(1): Time for initial assessment PSQ 3a (4) : Medication Error rates PSQ 3a (8): Percentage of cases — prevent adverse events like wrong site, patient, surgery PSQ 3a (9): Percentage of transfusion reactions PSQ 3a (9): Incidence of hospital associated pressure ulcers after admission PSQ 3b (13): CAUTI PSQ 3b (14): VAP PSQ 3b (15): CLABSI PSQ 3b (16): SSI PSQ 3b (17): Hand Hygiene compliance rate PSQ 3c (21): Nurse patient ratioPSQ 3d(30) : Incidence of needle stick injury PSQ 3d(31) : Appropriate handover during shift change PSQ 4d(28) : Patient fall rate PSQ 4d(29) : Percentage of near-misses 52NON CLINICAL AREAS54 1. Document Review Quick list: Vision, Mission, Values HIC manual Updation of manuals Licenses ‘Apex manual Safety manual Organogram Document control NABH Application Form contents Self-assessment checklist Internal assessment report Scope of services of the onganization HICe ‘Documented Infection control programmee PSQIT&2 Patient safety programme and Quality assurance PSQ7 Incident ROM 1 Organization structure (Organogram) Vision and mission, strategic plans Ethical framework Annual budget QIP and safety initiative Strategic and operational plan ROM4 Effectiveness of committee Staff rights and responsibilities Service standards FMS7 ‘Mock drill and table top IMS 6a, ‘Control of documents, forms and formats55 2. Quality Management Quick list: + QIP committee + Safety programme © Quality assurance (emergency, * Internal audits lab, ICU, OT) © Capturing of CQI3 & 4 data * Validation of data © Quality improvement targets & «Staff & patient interviews Tools «Incidents and sentinel events © Clinical audits * Clinical & Patient safety officer © Analysis of patient safety risks * PROM ‘Feedbacks to implement patient «Table top safety & QIP MOMk [+ Prescription audit, at least once a month PSQ Tad ‘+ The patient -safety programme is developed , implemented and maintained by multi-disciplinary safety committee + The patient: safety programme is comphrehensive and covers all the major elements related to patient safety ‘©The program covers incidents ranging from " no harm’ to ‘sentinel events’. ‘+ Designated patient safety officer(s) co-ordinates implementation of patient - saf programme * Designated patient safety officer(s) co-ordinates implementation of the clinical of the patient safety programme ‘© The patient safety programe identifies opportunities for improvement based of review at pre-defined intervals ‘+ The organisation perform proactive analysis of patient safety risks and makes improvements accordingly * The patient- safety programme is reviewed and update at least once a year The organisation adapts and implements national/international patient safety goals/solutions he ety spects the56 PSQ2ah | © The quality improvement programme is devloped, implemented and maintained by a multidisciplinary committee ‘©The quality improvement programme is comprehensive and covers all the majors elements related to quality assurance © The quality improvement prgramme improves process efficency and effectivne: There isa designated individual for co-ordinating and implementing the quality| improvement programme * The quality improvement programme identifies opportunities for improvement] based on the review at pre-defined intervals The quality improvement programme is reviewed and updated at least once ayear * Audits are conducted at regular intervals as a means of continuous monitoring ‘+ There is an established processes in the organisation to monitor and improve the quality of nursing care PSQ3ai |e The organisation identifies and monitor key indicators to oversee the clinical stuctures, processes and outcomes © The organisation identifies and monitors the key indicators to oversee infection] control activities ‘© The organisation identifies and monitors key indicators to oversee the managerial stuctures , processes and outcomes © The organisations identifies and monitor key indicators to oversee patient safet activities © The organisation has a mechanissm to capture patient reported outcome measure * Verification of data is done regularly by the quality team © There isa mechanism for analysis of data which results in identifying pportunitles for improvement ‘© The improvement are implemented and evaluated Feedback about care and services is communicated to staff PSQ4ad |e The organisation undertakes quality improvements activities ‘© The organisation uses appropriate analytical tools for its quality improvement activities ©The organisation uses appropriate managerial tools for its quality improvement] activities ‘© The organizations uses appropriate managerial tools for its quality improvement activities PSQSaf | + Clinical Audits are performed to improve the quality of patient care The parameters to be audited are defined by the organisation Medical and nursing staff participant in clinical audit Patient and staff anonymity are maintained Clinical Audits are documented Remedial measure are implemented37 PSQ6ag | + The management creates a culture of safety. ‘©The leaders at all levels in the organisation are aware of the intent of the patient safety and quality improvement programme and the approach to its implementation, * Departmental leaders are involved in patient safety and quality improvement. ‘+The management makes available adequate resources required for patient safety and quality improvement programme. Organisation earmarks adequate funds from its annual budget in this regard. ‘+ The management identifies organisational performance improvement targets. * The management uses the feedback obtained from the workforce to improve patient safety and quality improvement programme. PSQ7 ‘© The organisation implements an incident management system.* ‘©The organisation has a mechanism to identify sentinel events." ‘+ The organisation has established processes for analysis of incidents. © Corrective and preventive actions are taken based on the findings of such analysis. ‘© The organisation incorporates risks identified in the analysis of incidents into the risk management system. ©The organisation shall have a process for informing various stakeholders in case of a near miss/adverse event/sentinel event. IMS2e | Clinical and managerial staff participate in integrating data (selection of indicators, trends, initiating action)3. Top Management / ROM inter 58 Quick list: + Operational & strategic planning + Ethical management Actions on recommendations of | « +—Mechanism to update statutory committees requirements: «Risk management * Support for quality, infection control PRE 1c, | Protection of patient rights by addressing grievance HIC1 | Hospital prevention and control programme HIC2b | Budget - HIC PSQ2 | Availability of resources required for QIP cdef __| Identification organizational performance improvement targets Those responsibilities for governance are identified, and their roles and responsibilities are ROM.LA defined and documented. ROM.1.8. | Those responsible for governance lay down the organisation's vision, mission and values. rom.i.c | Tose responsible for governance approve the startegic and operational plans and the PEG | organisation's annual budget. roM..p | Tse responsible for governance monitor and measure the performance of the 0 | organisation against the stated mission. ROM.1.€ | Those responsible for governance appoint the senior leaders in the organisation. rome | Tose responsible for governance support safety initiatives and quality improvement plans. rom.1.¢ | These responsible for governance support the ethical management framework of the 2-6 | organisation. rom.n | These responsible for governance inform the public of the quality and performance of PMH | services, ROM.2.A_| The leaders make public the vision, mission and values of the organisation ROM.2.8_| The leaders establish the organisation's ethical management framework, rom.c_| Te ethical management framework includes processes for managing issues with ethical implications, dilemmas and concerns. ROM.2.0_| The organisation discloses its ownership, ROM.2.€ | The organisation honestly portrays its affiliations and accreditations Roma.a_ | The person heading the organisation has requisite and appropriate administrative 34 | qualifications, roma. | The Person heading the organisation has requisite and appropriate administrative ‘3-5 | experiences. poma.c_| The leaders responsible for and complies with the laid-down and applicable legislations, regulations and notifications.59 ‘The leader appoints/participates in the recruitment of senior leadership of the ROM:3.0 | organisation who will assist in the day-to-day functioning of the organisation. The leader ensures that each organisational programme, service, site or department has ROM3.E effective leadership. ROM.3.F_| The performance of the organisation's leader is reviewd for effectiveness, The organisation has strategic and operational plans, including long-term and short-term ROM..A | goals commensurate to the organisation's vision, mission and values in consultation with the various stakeholders. Roma. | Te organisation coordinates the functioning with departments and external agencies and monitors the progress in achieving the defined goals and objectives. ROMA.C_| The organisation plans and budgets for its activities annually. ROM.A.D_| The functioning of committees is reviewed for their effectiveness ROM.A.E | The organisation documents staff rights and responsibilities roma. | Te organisation documents the service standards that are measurable and monitors them ROM..G_| Systems and processes are in place for change management ROMS.A_| Management ensures proactive risk management across the organisation. noms.e | Management provides resources fr proactive risk assessment and rsk-reduction activities. Rom.s.c_ | Management ensures integration between quality improvement, risk management and ‘© | strategic planning within the organisation. noms | Management ensures implementation of systems for internal and external reporting of system and process failures. ‘Management ensures that it has a documented agreement for all outsourced services that ROMS. include service parameters. Roms | Management monitors the quality ofthe outsourced servies and improvements are made 15 | as required. RM 36 [© Training and Development program RMS |» Grievance handling TRM9 |» Staff health programme4. Committees Quick list: + Scope * Composition of committee + Frequency of meetings as per * Action taken on soP recommendations + Minutes of meetings COP Sede [* Composition and functioning of Resuscitation committee ‘* Analysis of all eardiac arrests '* Corrective and preventive measures taken based on analysis MOMT¢ [Drugs & therapeutic committee or anything similar MOM2a,b | Development of formulary and updation MOM & ‘+ Analysis of adverse drug events HIC Te '* Infection control committee composition and functioning PSO2 ‘© Safety committee composition and functioning FMS tab | Scope, development, implementation & monitoring of safety programme cQ7 ‘© Clinical audit committee CQ Tab Quality improvement committee - Composition and functioning, ‘+ Quality Improvement plan ROM I? ‘© Management support for QIP and safety ROM Sd ‘+ _Anti-sexual harassment committee FIRM 8d = Disciplinary & grievance committee IMS 2a ‘© Document control IMS3f ‘Abbreviation policy in manuals IMS 7-2 Medical records committee6 5. Human Resource Department Quick list: + HR planning + Recruitment procedure + Training & development * Training on safety © Appraisal * Disciplinary & grievance «Health needs * Personal fle * Credentialing & privileging «Job description HRM..a_ | Human resource planning supports the organisation's current and future ability to meet the care, treatment and service needs the patient, ‘The organisation maintains an adequate number and mix of staff to meet the care, HEM18 | treatment and service needs of the patient The organisation has contingency plans to manage long: and short-term workforce HRM.I.C shortages, including unplanned shortages. HRMLA.D_| The job specification and job description are defined for each category of staf. HRM.1.E | The organisation performs a background check of new staff. HRM.A.F | Reporting relationships are defined for each categpry of staff. HRM.I.G__| Exit interviews are conducted and used as a tool to improve human resource practices. HRM.2.A__| Written guidance governs the process of recruitment HRM.2.B_| A pre-employment medical examination is conducted on the staff. HRM.2.C _| The organisation defines and implements a code of conduct for its staf. HRM.2.D_| Administrative procedures for human resource management are documented HRM.3.A | Staff are provided with induction training. vurnaa.e._| The induction training includes orientation to the organisation's vision, mission and 8 | values The induction training includes awareness on staff rights and responsiblties and patient HRM.3.C rights and responsibilities. HRML3.D_| The induction training includes training on safety. vuawaa.e_| The induction training includes training on cardio-pulmonary resuscitation for staff providing direct patient care. HRM.3.F_| The induction training includes training in hospital Infection prevention and contro HRM.3.6_| The induction training includes orientation to the service standards ofthe organisation. HRM3.H_| The induction training includes an orientation on administrative procedures The induction training includes an orientation on relevant HRM. : : department/unit/service/programme's policies and procedures. HRMA.A_| Written guidance governs training and development policy forthe staf HRM.A.B _| The organisation maintains the training record HRM.4.C_| Training also occurs when job responsibilities change/new equipment is introduced sr.a.p | Feedback mechanisms are in place for improvement of taining and development programme. HAMA _| Evaluation of training effectiveness s done by the organisation, HRM.A.F _| The organisation supports continuing professional development and learning.62 Staff involved in blood transfusion services are trained in the handling of blood and blood HEMSA | products. HRM.5.6_| Staff are trained in handling vulnerable patients. HRM5.C_| Staff are trained in control and restraint techniques. HRM.5.D_| Staff are trained in healthcare communication techniques. HAMs.£ | St2ffinvolved in direct patient care are provided training on cardiopulmonary resuscitation periodically HRMS. _| Staff are provided training on infection prevention and control HRM.6.A_| Staff are trained in the organisation's safety pogramme Ham.e.s | Staffare provided training in the detection, handling, minimisation and eliminated of identified risks within the organisation's environment, HRM.6.C_| Staff members are made aware of procedures to follow in the event of an incident. HRM.6._| Staff are trained in occupational safety aspects, HRM.6.E_| Staff are trained in the organisation's disaster management plan HRM.6.F_| Staff are trained in handling fire and non-fire emergencies. HRM.6.G_| Staff are trained in the organisation's quality improvement programme. HRM.7.A_| Performance appraisal is done for staff within the organisation. HRM.7.B_| The staff are made aware of the system of appraisal at the time of induction. HRM.7.C_| Performance is evaluated based on the pre-determined criteria, HRM.7.D_| The appraisal system is used as a tool for further development. HRM.7.£_| Performance appraisal is carried out at defined intervals and is documented. HRM.8&.A_| Written guidance governs disciplinary end grievances handling mechanisms amas | Te disciplinary and grievances handling mechanism is known to all categories of staff of the organisation. HRM.8.C_| The disciplinary policy and procedure are based on the principles of natural justice. HRM.8.0_| The disciplinary and grievance procedure is in consonance wih the prevailing laws. HRM8.E_| There is a provision for appeals in all disciplinary cases. HRM.8.F _| Actions are taken to redress the grievance. HRMS.A_| Staff well-being is promoted. urm.o.p | Health problems of the staff, including occupational health hazards, are taken care of in accordance wih the organisation's policy. Health checks of staff dealing with direct patient care are done at least once a year and HRMS.C | the findings/results are documented, HRMS. _| Organisation provides treatment to staff who sustain workplace-related injuries. HRMS. | The organisation has meaures in place for prevention and handling workplace violence. HRM.10.4 | Personal files are maintained with respect to all staff, and their confidentiality is ensured. RM.i0.8 | The Personal files contain personal information regarding the staff's qualification, job description, verification of credentials and health status. HRM.10.C | Records of in-service training and education are contained in the personal files HRM.10.0 | Personal files contain results of all evaluations and remarks HrM.iz.a | Medical professionals permitted by law, regulation and the organisation to provide patient care without supervision are identified.63 ‘The education, registration, training and experience of the identified medical HRM.11.8 | professionals are documented and updated periodically HRM.11.¢ | The information about medical professionals is appropriately verified when possible, amar. | Medical professionals are granted privileges to admit and care for patients in consonance 'P | with their qualification, training, experience and registration. The requisite services to be provided by the medical professionals are known to them a5, HRM.ALE well as the various departments/units of the organisation. HRM.11.F | Medical professionals admit and care for patients as per their privileging, ‘Nursing staff permitted by law, regulation and the organisation to provide patient care HRM.12-4 | ithout supervision are identified. The education, registration, training and experience of nursing staff are documented and HRM.12.8 updated periodically HRM.12.C | The information about the nursing staff is appropriately verified when possible. vaw.az.p | Nutsing staff are granted privileges in consonance with their qualification, training, experience and registration umvaze | The requisite services tobe provided by the nursing staff are Known to them as well as the various departments/units of the organisation. HRM.12.F | Nursing professionals care for patients as per their privileging. avaa.a | °2"@linical professionals permitted by Iaw, regulation and the organisation to provide -A | patient care without supervision are identified Rn.ia.e | The education, registration, training and experience of para-clinical professionals are © | appropriately verified, documented and updated periodically. urm.tacc | P2t@clinical professionals are granted privileges in consonance with their ~* | qualification trainingexperience and registration. The requisite services to be provided by the para-clinical professionals are known to them HRM.13.0 as well as the various departments/units of the organisation HRM.13.€ | Para-clinical professionals care for patients as per their privileging. Data collection for quality indicators to be verifies CQL4 e (i); Employee satisfaction index CQ14 e Gi): Employee atrition rate CQ14e Gi): Absenteeism rate CQ14 e (iv): Percentage of employees aware of employee rights & responsibilities6. Medical Records Department Quick list: Security & confidentiality Destruction of case records Medical record auit Transter notes Birth and death report Retention policy System for access to records Case records sampling Statutory documents Fire safety FMS7 Plans for fire IMS3e-g “Medical record unique number Policy on authorized person to make entry Every entry is named, signed, dated and timed Author is clear Contents of medical record are identified and documented Abbreviation policy Records are up to date and chronologically arranged 24-hour availability of the patient's record to healthcare providers to ensure continuity of care IMS4 ah Medical record has reason for admission / diagnosis/ plan of care/ Operative and other Procedure sheet Contains detail of assessment,re-assessment and consultations Medical record contains the results of tests carried out and the care provided Transferring patients: medical records have date of transfer/reasons/name of receiving hospital Signed Discharge note/copy of death certificate with cause, date and time of death Copy of clinical autopsy report (where applicable) Access to current and past medical record IMS Saf ‘Security, integrity and confidentiality of data and information Safeguarding data/ record against loss, destruction and tampering ‘Technology used for improving confidentiality, security and integrity Usage of privileged health information. Documented policies on how to handle MR information requirement IMS 6ad Process for document control Retention policy of patient's clinical records, data and information Maintenance of confidentiality and security at all stages Method for destruction of medical records, data and information IMS Tae Medical record audit: Frequency, Sample size, Person (s) authorized. Timeliness, legibility and completeness, Active and discharged patients records, Deficiencies identified and documentation of same_CAPA ‘Case records sampling ‘AAC bg Discharge summary : Patient's name, UHID number, date of admission and date of discharge. Reason for admission, findings, diagnosis, condition at the time of discharge. Investigation results, procedure performed, medication and other treatment given. Follow up advice and medication and other instructions. When and how to obtain urgent care Cause of death in case of death summary Discharge summary acknowledged by patient / familyCheck for completeness of consent documents © Procedure (COP 7 d) Blood transfusion (COP 8 d) Moderate sedation (COP 13 b) Aanaesthesia (COP 14 e) Surgery (COP 15 ¢ Research (COP 20d) © MTP, HIV (PRE 4a 00000 ‘* Authorized legal representative (PRE 4 €) ‘* General consent (PRE 4 b, c) + Language of consent (PRE 4 d) AAC ST ‘* Care plan is countersigned by the clinician in-charge of the patient within 24 hours ‘AAC 13 bed [* Medico legal case documentation ¢ LAMA case file has discharge summary and risks explained Paediatric cases: COP11f,h | Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment ‘+ The children’s family members are educated about nutrition, immunization and safe parenting and this is documented in_the medical record COP I4d/f,g [+ Surgical safety checklist, Operation Notes, recovery criteria, post-operative plan of care HICS ‘Communication of notifiable diseases to concerned authorities Staff interview Data collection for quality indicators to be ver CQI4 g (i): Records not having discharge summary CQL 4gi (ii): Records not ICD codified CQI4 g Gili): Records with incomplete consents CQI4 g (iv): Percentage of missing records66 7. Hospital Information System Quick list: + Maintenance plan Licenses + Disaster back-up + Telemedicine * Confidentiality + Access to patients’ data * Retention policy ‘© Destruction of data + Fire safety . FMS 3] ‘= Maintenance plan IMS lag ‘© Identified information need list ‘* License for software ‘© Validation of software ‘* Contingency plan during downtime + Documented policies for telemedicine IMS2ae | Document control ‘* Standard format for data collection ‘* Documented procedures for data dissemination storing and retrieving data '* Resources for analysing data ‘+ Participation of staff in selecting, integrating and using data IMS Si-g ‘> Security (disaster back-up), integrity and confidentiality of data ‘+ Safeguarding data/ record against loss, destruction and tampering ‘* Technology used for improving confidentiality, security and integrity ‘* Usage of privileged health information '* Documented policies and procedures on how to handle MR information requirement IMS 6d Retention policy of patient's clinical records, data and information Maintenance of confidentiality and security at all stages Method for destruction of medical records, data and information Digital signatures, Interface with equipment67 8. Front Office, Registration, Admission &Billing Quick list: + Scope of services ‘+ Patients rights display ‘+ Registration + Generation of UHID «Admission process «Feedback / Complaints AAC Tad [© Display of scope of services. Display of services not available + Staff awareness AAC2Zat | Policy for registration and admission (OP, IP and Emergency) patients ‘* Registration of foreigners. © Generation of UHID ‘* Management of patients when beds are not available ‘* Acceptance of patients for the services provided by HCO ‘+ _ Priority of access according to clinical needs COPIOb [© Display of scope of high risk obstetric services ‘¢ Information to patients if high risk obstetric cases can be or cannot be taken COPIT | © Display of scope of paediatrics services COPT6a [© Care of vulnerable patients. Staff trained PRETa.d | Display of patient rights. Staff awareness PRE2h,i | © How tovoice a complaint ‘¢ Information on expected cost of treatment PRETaf [© Procedure for feedback / lodging complaints ‘© Complaint redressal procedure ‘+ Analysis of all complaints / feedback within a defined time frame © CAPA on analysis PREGb,c | © General consent process. Scope of general consent PRE6a, b,c | © Uniform pricing policy ina given setting ‘2 Availabilty of tariff list. Explanation about the expected cost ROM2a Display of mission, vision and values FMS 1b * Patient safety devices are installed FMS2¢ ‘= _ Signage in local language + Patient interview + _ Staff interview Data collection for quality indicators to be verified: © CQI44d (ii): Waiting time for OP consultation68 9. Biomedical Engineering Department, Medical Gases, Vacuum Quick list: Equipment planning Quaified staff Condemnation & disposal Storage of medical gas Inventory PM, Calibration Colour coding ‘Compressed air purity Operational & maint. plan FMS doh ‘> Equipment planning - in accordance with its services and strategie plan ‘+ Equipment are selected, rented, upgraded by a collaborative process. ‘© Equipment inventory, asset list review, Last three month new assets & their Physical location, asset tag and log ‘© Qualified and trained personnel operate and maintain the medical equipment ‘+ Preventive maintenance and calibration - Review of PM tracker ‘* Adherence to manufacturer guidelines ‘* Review of PM as per checklist: Anaesthesia machine, ventilator, IABP etc. ‘+ Traceability of calibration report ‘+ Preventive and breakdown maintenance plans '* Documented procedure for equipment replacement and disposal ‘+ Interview with Bio-medical head * Job Description (as per HR records) FMSSah [© Policies & procedures on procuring, ete of medical gas ‘© Safety precautions at all levels ‘* Alternate sources for medical gases, vacuum and compressed air ‘+ Records as per legal requirements '* Colour coding of pipelines ‘* Operational and Maintenance plan ‘* Adherence to manufacturer guidelines with regard to maintenance ‘¢ Training of staff when new equipment is installed ‘© Staff interview10. Pharmacy, Pharmacy Store Quick list: + Pharmacy license Storage Formulary Emergency medications Safe dispensing Fire safety Inventory LASA Narcotics Duty roster of pharmacists High risk medications MOM Taba ]* Documented policies and procedures on medication procurement, storage, y. prescription, dispensing, administration, monitoring etc. formula ‘© Separate license for each of the pharmacies ‘* Adherence to terms and conditions mentioned in the license name being mentioned in the license) ‘+ Duty roster to ensure that there is a qualified pharmacist at all times (his/her Procedure to obtain medications when the pharmacy is closed MOM 2a, Hospital formulary. Reviewed annually. Availability of formulary for clinicians to refer and adhere to Defined process of procurement of medicine and non- listed medicines Re-order levels. vendor evaluation, generation of purchase order MOM Sag environment and/or as per manufacture’s requirement Inventory control practices like FIFO Precautions against theft Identification and storage of LASA drugs Policies & procedures for storage Storage in clean, well lit & ventilated List of emergency medications is defined and is stored uniformly Availability of emergency medicines & replenished in a timely manner MOM 6a-f Procedures for safe dispensing of medicines Medication recall procedure Proper labelling on medicines. Cut strips Return of medication to pharmacy Expiry dates checked before dispensing. Procedure for near expiry Verification of High risk medication orders before dispensing MOM 9a.bd Procedure for narcotic drugs Storage. Proper record Handling. Disposal MOM IT ‘Medical supplies Data collection for quality indicators to be verified: * CQI4a(i): Percentage of drugs/ consumables procured by local purchase © CQI4a ii): Percentage of stockouts © CQI4 a (iii): Percentage of drugs/ consumables rejected before GRN * CQI4a (iv): Percentage of variations from procurement process70 11. Purchase, Stores & Materials Management Quick list: + Drugs + Consumables ‘+ Impiants & prosthesis, © Equipment © Planning Selection ‘+ Acquisition © Disposal MOM2d,e [+ Acquisition of formulary and non formulary drugs MOMTIb |e Procedures for procuring, storage / stocking, issuance and usage of implantable prosthesis and medical devices MOM Tla-d_[* Process for acquisition of medical supplies and consumables ‘* Vendor selection, indenting process, ete ‘+ Medical supplies and consumables are used in a safe manner ‘© Storage in a clean; safe and secure environment + Inventory control practices FMS3a,b.k | © Equipment planning FMS 4a.b.g |e Equipment selection + Equipment replacement and disposal Data collection for quality indicators to be verifi CQI4.a (i): Percentage of consumables procured by local purchase CQI4 a (ii): Percentage of stockouts CQI4 a (ili): Percentage of consumables rejected before GRN CQI4 a (iv): Percentage of variations from procurement processn 12. Facility Management Quick list: + Licenses * Upto date drawings + Signages * Provision of space © Controlled access * Designated individuals ‘+ Water & electricity maintenance Furniture maintenance and altemate sources Manifold room * STP «Engineering controls + Safety devices «Safety education programme + PM & calibration of equipment * Airconditioning * Green measures + Fire safety COP Ta] Validation of OT air-conditioning. HIC2k Change of HEPA filter (s) ROM 2a Various statutory requirements FMS I a,c © Fire NOC, Diesel storage, Liquid oxygen, Storage of medical cylinders, Boiler, Electrical inspectorate reports, ETP, DG sets, Lifts, LPG storage ‘+ Mechanism for renewing licenses / registrations / certifications FMS 1 bag |e Patient Safety devices ‘* Facility inspection rounds. Documentation and CAPA ‘* Identification & disposal of material not in use ‘¢ Safty education program for all staff FMS 2am | Preventive and break down maintenance plan ‘+ Response time are monitored © Upto date drawing, layout, escape route ‘© Controlled access in various areas ‘* Signage. Provision of space ‘* Designated individuals for maintenance round the clock ‘* Availability of potable water and electricity ‘© Water quality monitored quarterly ‘+ Alternate sources for electricity and water and their testing ‘+ Water quality reports ‘© Fumiture maintenance Green measures FMS Sa ‘> Equipment planning, selection, inventory ‘© Qualified and trained personnel operate and maintain, ‘© Log maintained / calibrated ‘© Preventive and breakdown maintenance / service labels on Equipment / calibration records / Refrigerator ‘+ Utility equipment periodically inspected and calibrated ‘+ Maintenance plan for water management ‘* Maintenance plan for electrical systems '* Maintenance plan for heating, ventilation and air-conditioning + Equipment replacement and disposal FMS6 ‘= Medical gases + Alarm units