4 TH Ed CHK List

1
CONTENTS
Clinical Areas
Department/Area Page Number

S. No
1. Emergency 4
2. Ambulance 6
3. Out Patient Department 7
4. Wards 9
5. Specialized Wards: Paediatric, OBG, & Labour Room, 13

Chemotherapy Unit
6. Palliative Care 15
7. Day care 16
8. Dialysis Unit 17
9. Intensive Care, Neonatal / Paediatric ICU and High 19

Dependency Units
10. Operation Theatre 24
11. Recovery Room 27
12. Endoscopy / Bronchoscopy 28
13. Rehabilitation 30
14. Radiology 31
15. Nuclear Medicine 32
16. Cardiac Catheterization lab 33
17. Collection centre (lab) 35
18. Laboratory: Haematology / Biochemistry / Pathology / 36

Microbiology / Histopathology / Cytology
19. Blood Bank and Transfusion Services 38
20. Radiation therapy / Radioactive drugs 39
21. Nutrition Therapy 40
22. Research Activities 41
23. Hospital Infection Control 42
24. Organ transplant 44
25. Dental 45
2
Non Clinical Areas

S. No
1. Document Review 48
2. Quality Management 49
3. Management / Administration 50
4. Committees 51
5. Human Resource Department 52
6. Medical Record Department (MRD) 54
7. Hospital Information System (HIS) 56
8. Front office: Registration, Admission and Billing counters 57
9. Biomedical Equipment Management: Equipment, 58

Medical Gases, Vacuum System etc.
10. Pharmacy 59
11. Purchase, Store and Materials Management 60
12. Facility Management: Engineering and Maintenance 61
13. Safety Program 62
14. Housekeeping 63
15. Laundry and Linen 64
16. Kitchen / Canteen 65
17. Mortuary 66
18. CSSD 67
Interviews

S. No
1. Patient and family interview 69
2. Staff interview - Care of patients 70
3. Staff interview – HR 70
4. Staff interview – Safety 70
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CLINICAL AREAS
4
1. Emergency Room
Quick list:
• Policies and procedures on • Identified area for emergency
“dead on arrival”, transfer / care, defined beds
discharge process, non • Triage
availability of beds • MLC
• Access to emergency • Disaster management
• Quality assurance • BMW
• Ambulance communication • Infection control
• Medication management • Case records –documentation
• CPR • Fire safety
• Equipment / furniture maint’nce • Medical gas
AAC 1 c • Defined services are displayed prominently

FMS 2 c, d • Signposting and directional signages (bilingual) from approach road
• Adequacy of access to Emergency (easy and unobstructed). Flow of patients,
unobstructed
AAC 2 e • Managing non-availability of beds
COP 9 e
COP 9 b • Admission criteria and priorities for ICU
AAC 3 a-e • Patient transfer (in and out) / In case of transfer of patients: check
stability/unstable/transfer 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
AAC 4 a, b, c, • Predefined initial assessment
g • Time frame for doing and documenting initial assessment
• Staff awareness on above policies
AAC 12 d • Structured clinical handover by doctors & nurses; transfer summary
AAC 13 d • Discharge summary for LAMA
COP 2 a-g • Identified area for emergency care; defined no. of beds; adequate manpower
• 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
COP 2 h • Discharge note given – home, another hospital
AAC 3 e
COP 2 i • Quality assurance programme
CQI 3 a(i), • Capture of quality indicators
h(iii)
COP 2 j • Policy on “dead on arrival”
COP 3 h, i • Communication with ambulance – evidence
• Identifies opportunities for to initiate treatment for in transit patients
5
COP 4 • Disaster management plan

• Mock drills of disaster management (at least twice a year)
• Staff awareness on Disaster management plan
COP 5 a-c • Documented policies and procedures on uniform use of resuscitation
• Display of CPR protocols
• The events during a CPR are recorded
• Training in CPR – BLS / ALS
COP 6 a, b, e, • Documented policies and procedures for all activities of the Nursing
f, g Services in Emergency
• Current standards of nursing services and practice
• Nursing Plan of Care
• Nursing Care documentation
• Nursing empowerment
COP 7 a-g • 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
COP 13 a-h • Moderate (conscious) sedation, monitoring, consent
• Medication storage, inventory, expiry dates, storage conditions, emergency
MOM 3 b-g
crash carts, LASA, high risk medications
MOM 4 a-h • Prescription of medicines. Medication orders
• High risk medications defined
MOM 6 a-h • Medication administration. Staff interview on administration
• Medication administration documentation
MOM 7 a-d • Patient monitoring after medication administration
• Check where close monitoring is required
• Change of medications based on monitoring
HIC 2 c-f • Instructions for hand washing displayed near every hand washing area
• Adherence to safe injection and infusion practices
• Sterilized sets: expiry dates, storage conditions
HIC 5 a, b • Availability of hand hygiene facilities
• Availability of PPEs, soaps and disinfectants; and their correct usage
HIC 7 b, c, f • Storage of sterilised items
• Re-use of instruments and equipments
• Recall procedure
HIC 8 b, e • Segregation of bio-medical waste; Use of PPE
PRE 8 b, c, f • Communication with patients & relatives
• Patient interview
• Staff interview
Data collection for quality indicators to be verified:

• CQI 3 a (i): Time for initial assessment
• CQI 3 h (iii): return to Emergency with 72 hrs with similar presenting complaints
• CQI 3 j : Communication errors, patient identification errors, hand hygiene compliance,
compliance to medication prescription in capitals
• CQI 4 b (i): No of variations in mock drills (disaster management)
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2. Ambulance
COP 3 a • Adequacy of parking for Ambulances

COP 3 b • Adherence to Statutory requirements
o Type of ambulance: ALS/BLS/PTA
o RC book and Fitness certificate
o License of driver (s)
o Insurance
o Emission check (PUC)
COP 3 c • Ambulance: adequate equipment in working order
COP 3 d • Ambulance: manned by trained personnel
COP 3 e, f, g • Check list of Ambulance, drugs and equipment
COP 3 h • Communication system of Ambulance
COP 3 i • Identifies opportunities for to initiate treatment for in transit patients
ROM 5 j, k • Formal documented agreement (MOU) for outsourced ambulance services,
if any
• Monitoring of the quality of the outsourced ambulance services
• Staff interview
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3. Out Patient Department
Quick list:
• Initial assessment • Display of scope in Obs/Paed
• Priority access in clinical needs • Admission process
• Follow-up date • Drug reconciliation in
• Patients’ rights displayed admissions
• 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 2 a-e • Patient admission from OPD. Managing non availability of beds
• Patient transfer
AAC 2 f • Access prioritised according to clinical needs
AAC 3 b-e • Referral of patients
AAC 4 a, b, c, • Predefined initial assessment
f, g, h, i • 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
AAC 5b • Out-patients are informed of their next follow up where appropriate
COP 10 c, d • Care of vulnerable patients - Policy and procedure, safe and secure
environment, informed consent from the appropriate legal representative
COP 11 b, d, e • Care of high risk obstetrical patients – display the scope
• Ante- natal card; frequency of visits. Maternal nutrition assessment
COP 12 b, e, • Care of paediatric patients: display the scope , provisions for special care of
f, h children, detailed nutritional, growth, psychosocial and immunization
assessment, parent education on nutrition, immunization and safe parenting
and documentation of the same
MOM 3 c • Mechanism for physician’s sample
• Prescriptions in CAPITAL letters
MOM 4 l • Drug reconciliation
PRE 1 a, d • Patients’ rights displayed, staff awareness
PRE 4 b, c • General consent for treatment
• Patient and/or his family members interview for the scope of general consent
PRE 6 a, b • Uniform pricing policy. Availability of tariff list to patients
PRE 7 a-c • Documented complaint redressal procedure
• Patient and/or family members interview for awareness of the procedure for
lodging complaints
HIC 5 a, b • Availability of hand hygiene facilities
HIC 8 b, e • Segregation of bio-medical waste
• Use of PPE
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FMS 2 k • Facility & furniture maintenance

FMS 6 • 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.
FMS 7 a, b, d, • Identification of hazmat. Sorting, labelling, handling, storage, transporting
e and disposal of hazardous materials
• Spills management plan of hazardous materials. Staff awareness
• Staff awareness on above policies and procedures
• Staff Interview – Care of Patients
• Staff interview – HR
• Staff Interview – Safety

• CQI 3 j (iv) : Compliance to medication prescription in capitals
• CQI 4 d (i): Out-patient satisfaction index
• CQI 4 d (iii): Waiting time for out-patient consultation
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4. Wards
Quick list:
• Initial assessment & reassess’nt • Admission process
• Care plan • Discharge & disch. Summary
• Nursing care • Early warning signs
• CPR • Case records – documentation
• 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 • Hazmat
• Patient feedback • Fire safety
• Medical gas • BMW
• Equipment / furniture maint’nce • Infection control
• Hand hygiene
AAC 4 a-i • 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
AAC 5 a, c, 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 5 f • Identifies early warning signs.
• Staff training
AAC 12 a-i • Qualified individual identified as responsible for the patient’s care
• Multidisciplinary care & co-ordination among various depts. / staff / shifts
• Handing and taking over (Hands-off Care) and documentation
• Transfer of patients between departments/units. Referrals
• Adequate clinical intervention in response to a critical alert
AAC 13 a-e • Discharge planning in consultation with patient, family, coordinating with
various depts.., including MLCs
• Summary given to all including LAMA and discharge on request
• Defines time taken for discharge; monitors delay
AAC 14 a-g • Content of discharge summary. Receipt acknowledged
COP 1 a, d • Uniform care; evidence based medicine & clinical practice guidelines
COP 5 a, b e • CPR – Policy and procedure, staff trained in CPR, Documentation of events
during CPR, Communication of CAPA measures
COP 6 a-g • 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 adequate equipment
• Empowerment for nursing related decisions
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COP 7 a-g • Documented procedures of various clinical procedures

• Qualifications of the personnel, who are performing procedures
• Prevention of adverse events - wrong site, patient and procedure
• Monitoring of patients during and after the procedure
• Documentation of the procedures accurately in the patient record
COP 8 b, d, g, • Rational use of blood and blood products; transfusion
h • Informed consent
• Monitoring transfusion reactions; post transfusion forms
COP 10 a-e • Care of vulnerable patients -
COP 15 a-d • 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 17 a-e • Policies & procedures on the care of patients under restraints
• Documentation of reasons for restraints; monitoring and frequency
• Staff awareness on control and restraint techniques; monitoring
COP 18 a-e • Policies & procedures on pain management
• Pain screening; pain assessment and periodic re-assessment
• Education of patient and/or family on pain management techniques
COP 21 a-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 safely
• Mechanism for physician’s sample
MOM 3 c, b-g • Medication storage, inventory, expiry dates, storage conditions, emergency
MOM 4 a-i • Prescription of medicines (CAPITAL letters)
• Medication orders
• Verbal orders
MOM 6 a-j • Medication management
• Staff interview on the methodology of administration
• Patient’s self-administration of medicines
• Management of medications got from outside the HCO
MOM 8 a-c • Near miss, medication error and adverse drug event are defined
• Reporting within a specified time frame
MOM 9 a-d • Narcotic drugs procedure
• Storage; handling; documentation
PRE 1 a, b, d • Patients’ rights: displayed. Staff awareness
PRE 2 a-k
PRE 2 b • Patient’s right to privacy during examination / procedures
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PRE 3 • Patient/family explained : care plan, risks, complications, tests, change in

condition
PRE 4 a-h • Informed consent
PRE 5 a-h • Patient and family education about their health care needs (medications,
food drug interaction, diet and nutrition, immunisations)
• Cleaning, disinfection and sterilisation practices
HIC 3 e-h • Hand hygiene surveillance
• MDRO surveillance
• Housekeeping
• Feedback on HAI
HIC 5 a-d • Hand hygiene facilities, instructions for proper hand hygiene
• Check Isolation / Barrier nursing facility available
• Check adequate soap, masks, gloves and disinfectants are available
• Pre & post exposure prophylaxis
HIC 8 b, e • Segregation of bio-medical waste . Use of PPE
FMS 1 c • Non-smoking Area
FMS 2 b-d • Floor plans; Fire Escape routes; Layout of beds, spacing, visual privacy;
Signages
FMS 3 c-f, • All equipment are inventoried and log maintained / calibrated
FMS 4 c-f • PM labels on Equipment/calibration records/Refrigerator
FMS 5 a-d • Colour coding of gas pipelines
• Medical gases handling, storage and usage safely
• Storage of oxygen cylinders/Condition of Humidifiers
IMS 3 a, c, d • Medical record unique identification no. / Named, signed, dated and timed
entry / author are clear, up-to-date and chronological
IMS 4 b • Test results are there in case sheet
IMS 4 c • Operative and other procedures are documented in case records
• Staff interview

• CQI 3 a (ii): Percentage of cases - care plan documented , countersigned
• CQI 3 a (iii): Percentage of cases - nutritional screening
• CQI 3 a (iv): Percentage of cases - nursing care plan
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• CQI 3 c (i): Incidence of medication errors

• CQI 3 c (ii): Percentage of admissions with ADRs
• CQI 3 c (iii): Percentage of medication charts with error prone abbreviations
• CQI 3 e (iii): Percentage of cases – prevent adverse events like wrong site, patient, surgery
• CQI 3 f (i): Percentage of transfusion reactions
• CQI 3 g (i): CAUTI
• CQI 3 g (iv): SSI
• CQI 3 j (i): Incidence of communication errors including handovers
• CQI 3 j (ii): Incidence of patient identification errors
• CQI 3 j (iii): Compliance to hand hygiene
• CQI 3 j (iv): Compliance to medication prescription in capitals
• CQI 4 b (ii): Incidence of falls
• CQI 4 b (iii): Incidence of pressure ulcers
• CQI 4 c (iv): Nurse-patient ratio
• CQI 4 d (ii): In-patient satisfaction index
• CQI 4 d (iv): Time taken for discharge
• CQI 4 f (i): Sentinel events
• CQI 4 f (ii): Near misses
• CQI 4 f (iii): Blood and body fluid exposure
• CQI 4 f (iv): Needle stick injuries
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Special Care Wards
a) Paediatric
Quick list: (in addition to wards)

• Provision for special care of children
• Prevention of child abduction
• Credentialing & privileging
COP 12 a-h • 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 parenting
HRM 9 a-f • Credentialing and privileging of doctors and nurses
HRM 10 a-f
b) Obstetrics & Gynaecology and Labour Room

• High risk obs
• MTP
• Pre, peri &post natal monitoring
COP 1 c • MTP: register, consents, confiedntiality

ROM 2 b
PRE 2d
COP 11 a-g • 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 9 • Procedure for handling narcotics/ license/ documentation of usage/ disposal/
handled by competent staff
HRM 10 a-f
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c) Chemotherapy Unit

• Chemotherapy management
• Narcotics
• Disposal of chemo drugs
MOM 6 • 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
MOM 10 a-e • Chemotherapeutic drug usage procedure
• Chemotherapy prescription
• Preparation, administration and disposal of chemotherapy drugs
• Biosafety cabinet class II (preferably class II A)
• Check knowledge of monitoring and treatment of adverse effects
• Disposal
• Patient & family education
• Staff training
HRM 10 a-f
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5. Palliative Care
Quick list:
• Pain management
• End of life care
• Narcotics
COP 18a • Define the group of patients for whom palliative care is applicable
COP 18c • Appropriate assessment and management of pain
COP 18e • Patient and family education on various pain management techniques
COP 22 a-e • End of life care – Documented policies and procedures
• In consonance with legal requirements
• Treatment and measures for alleviation of pain
• Staff awareness on end of life care
• Staff interview
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6. Day care
Quick list:
• Initial assessment • Consents
• Nursing • Medication management
• Narcotics • Monitoring after procedure
AAC 4 a • Documentation of initial assessment

COP 13 b • Consent for moderate sedation
COP 7 d • Informed consent for procedures
COP 7 f • Monitoring at least for 2 hours after the procedure
COP 7 g • Procedures documented in the patient record
COP 13 b • Informed consent for moderate sedation
COP 14 e • Informed consent for anaesthesia
COP 14 i • Type of anaesthesia and medications documented
COP 15 c,d • Informed consent for surgery
• Documented policies to prevent wrong site, wrong patient, wrong surgery
COP 15 f, g • Surgery notes and post-op care plan documented
• Staff interview

• CQI 4 f (iii & iv): Body fluid exposure and needle stick injury
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7. 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
COP 5 b • Training in CPR

COP 6 c • Counselling before organ transplantation
MOM 3e,f,g • Emergency drug management
MOM 6 a-h • Medication administration. Staff interview on administration
PRE 4a,d-h • Informed consent
HIC 2a-i, k, l • Policies and procedures to prevent infection
• Overall adherence to infection control
• Re-use policy of tubes, how safely it was kept and the labelling requirement
to prevent exchange/ensure patient’s safety.
• Hand hygiene
• Equipment cleaning and disinfection
• Antibiotic policy. Linen management. Housekeeping. Engineering
controls. Safe injection practices
HIC 3 a-d • Surveillance to monitor infection prevention and control
• Verification of data
• Tracking and analysing of infection risks, rates and trends
• Housekeeping
• Feedback on HAI
HIC 5 a-d • Availability of hand hygiene facilities
• Isolation facilities are available
• Pre and post exposure prophylaxis
HIC 8 b, e • Segregation of bio-medical waste. Use of PPE
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HIC 7 b, c • Storage of sterilised sets

• Procedure guidelines for dialyzer reprocessing
FMS 3 g • Quality of RO water. Monthly endotoxin levels
FMS 3 c-f • All equipment are inventoried and log maintained / calibrated
FMS 4 a, c-f • Preventive maintenance/service labels on Equipment/calibration records
FMS 5 a-d • Colour coding of gas pipelines
• Staff interview

• CQI 3 g (iii): CLABSI
• CQI 4 c (iii): Critical equipment downtime
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8. ICU, PICU, NICU, HDU
Quick list:
• 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
• End of life care • Engineering controls
• Credentialing & privileging • Compressed air purity
• Equipment / furniture maint’nce • Referrals
• Quality assurance • Patients’ rights
AAC 2 e • Policy for Bed shortage in ICU

AAC 4 a-i • 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
AAC 5 a, c, 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 12 a-i • Qualified individual identified as responsible for the patient’s care
• Multidisciplinary nature of patient care and co-ordination among various
departments / units / staff / shifts
• Handing and taking over (Hands-off Care) 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 13 a-e • Discharge planning in consultation with patient, family, coordinating with
various depts.., including MLCs
• Summary given to all including LAMA and discharge on request
• Defines time taken for discharge; monitors delay
AAC 14 a-g • Content of discharge summary
COP 1 d • Evidence based medicine and clinical practice guidelines
• Display of CPR protocols
20
COP 6 a-g • 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
• Prevention of adverse events - wrong site, patient and procedure
COP 9 a-h • Documented policies and procedures on the care of patients
• Admission 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 10 a-e • Care of vulnerable patients -
COP 12 a-h • 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 assessment,
provision for preventing child/neonate abduction and abuse
• Parent education on nutrition, immunization and safe parenting
COP 13 a-h • Moderate sedation. Consent. Monitoring
COP 15 a-d • 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 17 a-e • 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
COP 21 a-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
21
COP 22 a-e • End of life care – Documented policies and procedures

• In consonance with legal requirements
• Treatment and measures for alleviation of pain
• Staff awareness on end of life care
• Mechanism for physician’s sample
MOM 3 a, b-g • Medication storage, inventory, expiry dates, storage conditions, emergency
• Verbal orders
MOM 4 k • Prescription audit
PRE 2 a-k
PRE 3 • Patients & family explained : care plan, risks, complications, tests, change in
condition
PRE 4 a, d-h • Informed consent
PRE 5 a-h • Patient and family education about their health care needs (medications,
food drug interaction, diet and nutrition, immunisations)
• Re-use policy of tubes, how safely it was kept and the labelling requirement
to prevent exchange/ensure patient’s safety.
• Hand hygiene
• Instructions for hand washing displayed near every hand washing area
• Housekeeping
• Feedback on HAI
HIC 4a-d • Collection of Infection control data
• Availability of various HAI rates of that area and action taken based on this
22
FMS 2 b-g • Floor plans; Fire Escape routes; Signages
• Layout of ICU (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 4 g • Procedure for equipment replacement & disposal
FMS 5 a-f • Colour coding of gas pipelines
• Compressed air purity
• Alternate sources for medical gases, vacuum & compressed air Operational
and maintenance plan
HRM 10 a-f
IMS 4 b • Test results are there in case sheet
IMS 4 c • Operative and other procedures are documented in case records
• Staff interview

• CQI 3 a (ii): Percentage of cases - care plan documented , countersigned
• CQI 3 a (iii): Percentage of cases - nutritional screening
• CQI 3 a (iv): Percentage of cases - nursing care plan
• CQI 3 c (iv): Percentage of high risk medications with ADRs
23

• CQI 3 g (ii): VAP
• CQI 3 h (ii): Return to ICU within 48 hours
• CQI 3 h (iv): Re-intubation rate
• CQI 4 b (ii): Incidence of falls
• CQI 4 b (iii): Incidence of pressure ulcers
• CQI 4 c (ii): ICU utilisation rate
• CQI 4 c (iii): Critical equipment down time
• CQI 4 d (ii): In-patient satisfaction index
• CQI 4 d (iv): Time taken for discharge
24
• Operation Theatre
Quick list:
• Anaesth assessment and plan • Consents
• Adverse anaesth events • Vulnerable patients
• Prevention of wrong site, etc • Medication management
• Blood transfusion • Medication orders
• Medical gas • Narcotics
• Compressed air purity • Adequate equipment
• Engineering controls • Equipment / furniture maint’ance
• Hand hygiene • Hazmat
• Sterilisation • Patients’ rights
• Re-use policy • Case records –documentation
• Quality assurance • Fire safety
COP 6 a-g • Documented policies and procedures for Nursing Services in OT

• Assignment of patient care. Nursing Plan of Care documented
COP 14 a-k • Administration of anaesthesia – Policy and procedure
• Pre-anaesth assessment. Anaesthesia plan. Immediate pre-op 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 15 a-k • Surgical procedures - Policy and procedure
• 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
• Surveillance of OT environment. Monitoring of SSI
MOM 3 a, b-g
MOM 12 a-d • 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
PRE 4 a, d-h • Informed consent
25
HIC 2a-i, k, l • Policies to prevent infection. Overall adherence to infection control

• Re-use policy.
• Hand hygiene. Instructions for hand washing displayed
HIC 7 a-f • Sterilisation disinfection activities; validation
• Storage of sterilised items
• Re-use of instruments and equipments. Recall procedure
• Layout of OT (no mix of sterile and unsterile)
• Compressed air purity
• Alt. sources for gases, vacuum & compressed air. Operational & maint. plan
FMS 7 a, b, d, • Identification of hazmat. Sorting, labelling, handling, storage, disposal
e Spills management plan of hazardous materials. Staff awareness
HRM 10 a-f
IMS 4 c • Operation notes documented in case records
• Staff interview

• CQI 3 d (i): Modification of anaesthesia plan
• CQI 3 d (ii): Unplanned ventilation following anaesthesia
• CQI 3 d (iii): Adverse anaesthesia events
• CQI 3 (iv): Anaesthesia related mortality rate
26
• CQI 3 e (i): Unplanned return to OT

• CQI 3 e (iii): Re-scheduling of surgeries
• CQI 3 e (iv): Percentage of cases – prophylactic antibiotics within specified time
• CQI 3 e (iv): Re exploration
• CQI 3 e (iv): Change in original surgery
• CQI 4 c (ii): OT utilisation rate
• CQI 4 c (iii): Critical equipment down time
27
9. Recovery Room
Quick list:
• Nursing care • CPR
• Pain management • Documentation of hand-over
• Blood transfusion • Vulnerable patients
• Discharge criteria • Fire safety
• Medication management • Narcotics
• Restraint policy • Medication orders
• Hazmat • Patients’ rights
• Case records –documentation
COP 14 g, h • Monitoring post anaesthesia. Criteria for transfer / discharge from recovery
area
COP 15 f, g • Operating notes and post-operative plan of care
MOM 3 a, b-g
• Medication orders. High risk medications defined
• Verbal orders
MOM 6 a-h • Medication management. Staff interview on the methodology of
administration. Documentation
MOM 7a-d • Patient monitoring after medication administration
• Close monitoring requirement situations
• Staff interview
28
10. 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 • Sterilisation / disinfection
• Patients’ rights • Hazmat
COP 13 a-h • 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 3 a, b-g
• Verbal orders
PRE 4 d-g • Informed consent
• Re-use policy.
• Hand hygiene
• Antibiotic policy. Linen management. Housekeeping. Safe injection
practices
29
HIC 5 a, b, d • Hand hygiene facilities, instructions for proper hand hygiene

• Alternate sources for medical gases, vacuum & compressed air Operational
and maintenance plan
HRM 10 a-f
• Staff interview
30
11. Rehabilitation / Physiotherapy
Quick list:
• Vulnerable patients • Scope of dept
• Functional assessment • Biomedical waste management
• Infection control • Patients’ rights
• Hazmat • Case records –documentation
• Equipment / furniture maint’ance • Fire safety
COP 19 a-f • Policies and procedures on rehabilitative services

• Scope of the department
• Adequate space and equipments
• Multidisciplinary team approach
• Registration if applicable
• Assessment and Reassessment
• Functional assessment scales
• Adherence to infection control and safe practices
COP 10 b, c, e • Care of vulnerable patients
• Safe and secure environment
• Safety of patients
FMS 2 k • Maintenance plan for facility and furniture
• Staff interview
31
12. Radiology
Quick list:
• Statutory requirements • Radiation signages
• TAT, critical alert • Recall / amendment of reports
• Patient screening for safety • Safe transfer of patients
• PPE • Vulnerable patients
• Patients’ rights • Infection control
• Medication management • MOU for outsourced
• Hazmat investigations
• BMW • Equipment / furniture maint’ance
• Quality assurance • Fire safety
AAC 1 b • Service in scope should have appropriate diagnostic backup

AAC 9 a • Comply with BARC/AERB legal requirements
ROM 2 b
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)
• 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
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
AAC 11a-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, PC-PNDT act
MOM 3 a, b-g • Medication storage, inventory, expiry dates, storage, emergency crash carts,
PRE 4 d • Informed consent
HIC 2 e • Safe injection and infusion practices
• Patient & staff interview

• CQI 3 b (i): Reporting errors
• CQI 3 b (i): Re-dos
• CQI 3 b (i): Clinical correlation
• CQI 3 b (i): Adherence to safety precautions
• CQI 4 d (iii): Waiting time for diagnostics
32
13. Nuclear Medicine
Quick list:
• Patient screening for safety • Recall / amendment of reports
• PPE • Safe transfer of patients
• Patients’ rights • Vulnerable patients
• Medication management • Infection control
• Hazmat • Equipment / furniture maint’ance
• BMW • Fire safety

ROM 2 b
AAC 9b-i • Scope. Adequate infrastructure (physical and manpower)
• Turnaround time. Standardized reporting of results
AAC 10a-e • Quality assurance programme documented. Peer review of reports and
protocols. Appropriateness of investigation.
• Documentation of corrective and preventive actions
AAC 11a-g • 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
MOM 3 a, b-g
MOM 11a-d • Documented procedures on usage of radioactive drugs
• Storage, preparation, handling, distribution and disposal of radioactive drugs
• Staff, patient and visitor education on safety precautions
HIC 2 e • Safe injection and infusion practices
• Staff interview

33
14. Cardiac Catheterisation Lab
Quick list:
• CPR • Safe transfer of patients
• Moderate sedation • Vulnerable patients
• Narcotics • Equipment / furniture maint’ance
• Reuse policy • Fire safety
• Case records –documentation • BMW
• PPE • Hazmat
• Patients’ rights

ROM 2 b
AAC 9b-h • Scope. Adequate infrastructure (physical and manpower)
checked
• Staff training.
MOM 3 a, b-g
• Verbal orders
34

MOM 12 a-d • Procedure for procuring, storage / stocking, issuance and usage of
implantable prosthesis and medical devices
• Counselling of patient and/or family for the usage of implantable prosthesis
and medical device including precautions, if any
• Re-use policy.
• Hand hygiene
• Antibiotic policy. Linen management. Housekeeping. Safe injection
practices
• Staff interview

35
15. Collection centre (lab)
Quick list:
• Specimen transport • Patient privacy
• PPE • Infection control
• Spill management • Needle stick injuries
• Hand hygiene
AAC 6 e • Procedures for collection, safe handling, safe transportation

AAC 8 d, e • Staff trained in safe practices
• Provided with PPE. Lab staff immunised
PRE 2 b • Patient’s right to privacy during specimen collection
HIC 2 e • Safe injection
HIC 5 a, b • Adequate PPE, soaps, disinfectants
• Adequate hand hygiene facility
HIC 5 d • PEP for needle stick injuries
FMS 7 d, e • Training on spill management
36
16. Laboratories
Quick list:
• TAT, critical alert • Test reports
• 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 • Fire safety
AAC 1 b • Service in scope should have appropriate diagnostic backup

AAC 6 a-j • Scope commensurate with services.
• Adequate infrastructure and manpower. Qualified personnel
• Documented procedures for collection, processing, etc
• TAT.
• Critical results (of outsourced investigations also)
• Reported in a standardised manner. Signatures
• Outsourced investigations report
• Mechanism for recall / amendment of reports
• Quality assurance of outsourced investigations
AAC 7 a-e • 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
AAC 8 a-e • 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 / etc.
• Immunisation
• Reagent storage. Handling spills
PRE 4 d, g • HIV consent
HIC 2 b-f, l • Overall adherence to infection control
• Hand hygiene.
• Instructions for hand washing displayed
• Use of PPE
• Housekeeping. Safe injection practices
HIC 8 b,e • Segregation of bio-medical waste
37

IMS 4 b • Test results are there in case sheets
• Staff interview

• CQI 3 b (i): Re-dos
38
17. 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
COP 8 c • Blood bank licence

ROM 2 b
COP 8 a-h • Policies for rational use, transfusion
• Informed consent for donation and transfusion
• Turn around time of availability of blood
• Process for availability and transfusion in emergency
• Transfusion reactions analysis
• Staff awareness on above
HIC 2 b-f, l • Overall adherence to infection control
• Hand hygiene. Instructions for hand washing displayed
• Use of PPE
• Housekeeping. Safe injection practices
HIC 8 b,e • Segregation of bio-medical waste
FMS 6a,b,c • Documented plan for handling fire and non-fire emergencies
• Safe Exit plan in case of fire and non-fire emergencies
• Signage pertaining to fire exits
• Patient & staff interview

• CQI 3 f (i): Transfusion reactions
• CQI 3 f (ii): Wastage of blood and blood products
• CQI 3 f (iii): Percentage of component usage
• CQI 3 f (iv): TAT
39
18. Radiotherapy
Quick list:
• PPE • Safe transfer of patients
• Patients’ rights • Vulnerable patients
• Hazmat • MOU for outsourced
• BMW investigations
• Quality assurance • Equipment / furniture maint’ance
• Case records –documentation • Fire safety

ROM 2 b
AAC 9b-j • Scope. Adequate infrastructure (physical and manpower)
• Turnaround time. Critical results intimation
• Documented procedures for outsourcing tests
checked
• Staff training.
MOM 3 a, b-g
MOM 11a-d • Documented procedures on usage of radioactive drugs
• Storage, preparation, handling, distribution and disposal of radioactive drugs
• Staff, patient and visitor education on safety precautions
• Staff interview
40
19. Nutrition Therapy
Quick list:
• Nutritional assessment & • Maternal & paed nutritional
reassessment assessment
• Safe storage and distribution of • Documentation
food
• Capturing of CQI 3 & 4 data • Patient interviews
AAC 4 f • Initial assessment includes nutritional assessment

COP 21 a-f • 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
• Families are educated about the patients diet limitations
COP 11 e • Maternal nutrition assessment
COP 12 f • Paediatric nutritional assessment
PRE 5 b, c • Patient and/or family interview on food-drug interactions
• Patient and/or family interview on diet and nutrition
41
20. Research
Quick list:
• Ethics committee • Patients’ rights
• Documentation • Capturing of CQI 3 & 4 data
• Staff & patient interviews
COP 20 a-f • Policies and procedures

• Ethics committee
• Check for any discontinued trials and its reason
• Informed consent
PRE 2 g • Informed consent before initiation of any research protocol

• CQI 3 i (i): Research activities approved by ethics committee
• CQI 3 i (ii): Patients withdrawing from study
• CQI 3 i (iii): Protocol violations
• CQI 3 i (iv): Serious adverse events
42
21. Hospital Infection Control
Quick list:
• Documented HIC • ICO, ICN
• High risk areas & surveillance • HAIs
• Antibiotic policy • BMW
• Hand hygiene • Pre / post exposure prophylaxis
• Isolation policy • Outbreaks
• HIC Budget • Training
HIC 1 a-f • Documented Infection Control Programme & updated at least annually
• Risk reduction goals
• Updation of Infection Prevention and Control Programme
• HIC committee – Composition, functions, frequency of meetings, minutes
• Inf control team, ICO, ICN(s)
• Privileging of ICO & ICNs
HIC 2 a-l • Identified high risk areas and procedures with methods of surveillance
• Adherence to: standard precautions, hand hygiene guidelines, safe injection
and infusion practices, transmission based precautions, equipment cleaning,
disinfection and sterilization practices
• Use of appropriate PPE
• Use of disinfectants monitored. Dilution protocols established
• Antibiotic policy & its implementation
• Laundry and linen management. kitchen sanitation and food handling uses
• No brooming or dry dusting
• Engineering controls. housekeeping procedures
HIC 3 a-h • Surveillance in identified high-risk areas and procedures
• HIC surveillance data
• Verification of surveillance data
• MDROs monitored
• Tracking and analysing of infection risks, rates and trends, monitoring the
compliance with hand hygiene guidelines, effectiveness of housekeeping
services
• Feedback of HAI rates, trends and opportunities for improvement
• Notifiable diseases
HIC 4 a-d • HAI rates. Action to prevent HAI
HIC 5 a-d • Optimal hand hygiene facilities. Instructions for proper hand hygiene
HIC 6a-d • Outbreak definition. Identification of outbreak of infections
• Handling of outbreak of infections. Implementation of laid down procedure
during outbreaks. Implementation of CAPA to prevent recurrence
HIC 8a-e • Authorization for generation of BMW. Adherence to statutory norms
• Segregation, collection, stored and transported.
• Usage of appropriate personal protective measures
• Visit by the hospital authorities to the disposal site
HIC 9a-d • Resources, budget and training - infection control programme
• Staff interview
43

• CQI 3gi (ii): VAP
• CQI 4 b (iv): Percentage of staff provided pre-exposure prophylaxis
• CQI 4 f (iii): Incidence of blood and body fluid exposure
• CQI 4 f (iv): Incidence of needle stick injuries
44
22. Organ transplant
Quick list:
• Legal requirements • Policies & procedures
• Qualified counsellors • Creating awareness
• Transplant ICU • Privileging
COP 9 a-h • Admission discharge criteria to transplant ICU

• Adequate staff & equipment
• Infection control practices
• Quality assurance programme
• Patients and family counselled
COP 16 a • Legal requirements
ROM 2 b • Submission of reports
COP 16 b • Documented policies and procedures on indications, donor & recipient
fitness, education & consents, care paths
COP 16 c • Qualified counsellors
• Evidence of counselling documented in required statutory formats & case
sheets
COP 16 d • Creating awareness – standees, posters, hand-outs, etc
HRM 9 d • Privileging of doctors
HRM 10 d • Privileging of nurses
• Staff interview
45
23. Dental
Quick list:
• Initial assessment & reass’ment • Safe transfer of patients
• Pain management • Infection control
• Vulnerable patients • CPR
• Medication orders • Case records –documentation
• Medication management • Patients’ rights
• Hazmat • Fire safety
• Equipment / furniture maint’ance • BMW

ROM 2 b
checked
• Staff training.
MOM 12 a-d • Procedure for procuring, storage, & usage of implantas
• Counselling of patient and/or
• Verbal orders
46

• Knowledge to pick adverse drug events and reporting of the same
PRE 2 a-k
HIC 2a,d,f • Adherence to: standard precautions, hand hygiene guidelines, safe injection
and infusion practices, equipment cleaning, disinfection and sterilization
practices
• antibiotic policy
HIC 3a,c,d,e • Surveillance in identified high-risk areas and procedures
• HIC surveillance data and Verification of surveillance data
• Tracking and analysing of infection risks, rates and trends
• Monitoring the compliance with hand hygiene guidelines
HRM 10 a-f
• Staff interview
47
NON CLINICAL AREAS

48
1. Document Review
Quick list:
• Vision, Mission, Values • Apex manual
• HIC manual • Safety manual
• Updation of manuals • Organogram
• Licenses • Document control
• NABH Application Form contents

• Self-assessment checklist
• Internal assessment report
• Scope of services of the organization
CQI 1 a,b,g,h • Documented Quality Improvement programme (QIP)
• Committees-composition and functioning
• Records: Attendance, minutes etc.
• Apex Quality Manual
• Continuous Quality Improvement Manual
• Audits Report
ROM 1 a, d • Organization structure (Organogram)
• Vision and mission, strategic plans
• Manuals of all departments
ROM 2 a-d • List of statutory applicable acts / rules
• Licenses / certificates / registrations
• Other certificates/correspondence to meet statutory obligations
• Mechanism to regularly update licences/certificates/ registrations
ROM 3a-d • Departmental Manuals
• Scope of services of each department
HIC 2 • HIC Manual
CQI 2b • Safety Manual
IMS 2a • Control of documents, forms and formats
49
2. Quality Management
Quick list:
• QIP committee • Safety programme
• Quality assurance (emergency, • Internal audits
lab, ICU, OT)
• Capturing of CQI 3 & 4 data • Validation of data
• Quality improvement targets • Staff & patient interviews
• Incidents and sentinel events • Clinical audits
MOM 4 k • Prescription audit, at least once a month

CQI 1a-i • Documented and annually updated QIP. Committee-composition and
functioning. Designated individual for QIP. Innovations
• Input from the various committees
• Quality assurance (ICU, OT, Emergency, Lab)
• Review of QIP (once in 3 months) and identification of opportunities for
improvement. Training for communicating QIP
• Internal audits (once in 6 months)
• Process to monitor and improve quality of nursing. Identification of KPIs
reflecting nursing care.
CQI 2a-j • Documented annually updated safety programme. Committee - composition
and functioning. Designed individual for safety.
• Review of patient safety programme and identification of opportunities for
improvement activities (once in 4 months). Risk management.
• National/international patient safety goals/solutions
CQI 3a-k • Data for all indicators mentioned in the NABH Standards Guidebook.
CQI 4a-i Check raw data. Verify collection methodology of data.
CQI 5 • Validation of data. Data analysis. Improvement activities carried out based
on analysis and results of the improvement activity.
• Use of appropriate tools in QIP
• Feedback about patient care to staff
CQI 6 a-d • Leaders aware of intent of QIP
• Availability of resources required for QIP. Quality improvement budget
• Identification organizational performance improvement targets
CQI 7 • At least 4 Clinical audits: Both medical & nursing.
• Predefined parameters. Patient & staff anonymity. Remedial measures.
CQI 8 a-d • Incident reporting system. Processes for analysis of incidents. CAPA.
• Communication of feedback to stakeholders
CQI 9 a-d • Definition of sentinel events. Procedure for reporting and analysis
• Analysis . Corrective and preventive action
• Communication of feedback to stakeholders
IMS 2 f • Clinical and managerial staff participate in integrating data (selection of
indicators, trends, initiating action)
50
3. Top Management / ROM interview
Quick list:
• Operational & strategic planning • Ethical management
• Actions on recommendations of • Mechanism to update statutory
committees requirements
• Risk management • Support for quality, infection
control
HIC 1 • Hospital prevention and control programme

HIC 9 a, b • Budget - HIC
CQI 6 a-d • Availability of resources required for QIP
• Quality improvement budget
• Identification organizational performance improvement targets
ROM 1 a-i • Vision, Mission and value statement.
• Operational and strategic plans. Budget
• Organogram and appointment of senior leaders
• Support for safety initiatives, research and quality improvement plans
• Social responsibility. Inform quality & performance of services to the public
ROM 2 a-d • Adherence to statutory requirements
• Mechanism to update amendments and adherence to same
ROM 3 a-d • Scope of services of various departments including designated heads
• Administrative policies and procedures for each department
• Effective leadership for all programme, service, site and department
• Involvement of department heads in quality initiatives
ROM 4 a-f • Ethical management. Displaying vision, mission and values
• Revealing ownership
• Services available / not available. Affiliations and accreditations
• Billing based on standard billing tariff
ROM 5a-k • Administrative qualification & experience of head
• Strategic and operational plans. Long term and short term goals
• Annual plans and budgets.
• Review of performance of the senior leaders for their effectiveness
• Review of functioning of committees for their effectiveness
• Documented employee rights and responsibilities
• Documented service standards
• MOU for all outsourced services. Monitoring of the quality of MOU
ROM 6 a-d • Risk management
• Internal and external reporting of process and system failures
• CAPA taken to address safety related incidents
PRE 1 c, e • Protection of patient rights by addressing grievance
HRM 2, 3, 4 • Training and Development program
HRM 6 • Grievance handling
HRM 7 • Staff health programme
51
4. Committees
Quick list:
• Scope • Composition of committee
• Frequency of meetings as per • Action taken on
SOP recommendations
• Minutes of meetings
COP 5 c,d,e • Composition and functioning of Resuscitation committee

• Analysis of all cardiac arrests
• Corrective and preventive measures taken based on analysis
COP 20 b, c • Ethics committee. Composition as per ICMR guidelines
• Powers of this committee
MOM 1 c • Drugs & therapeutic committee or anything similar
MOM 2 a, b • Development of formulary and updation
MOM 8 • Analysis of adverse drug eventscx
HIC 1c • Infection control committee composition and functioning
CQI 2 a-j • Safety committee composition and functioning
FMS 1 a, b • Scope, development, implementation & monitoring of safety programme
CQI 7 • Clinical audit committee
CQI 1 a, b • Quality improvement committee - Composition and functioning
• Quality Improvement plan
ROM 1 f • Management support for QIP and safety
ROM 2b • Anti-sexual harassment committee
HRM 6 • Disciplinary & grievance committee
IMS 2 a • Document control
IMS 3 f • Abbreviation policy in manuals
IMS 7 c-g • Medical records committee
52
5. Human Resource Department
Quick list:
• HR planning • Recruitment procedure
• Training & development • Training on safety
• Appraisal • Disciplinary & grievance
• Health needs • Personal file
• Credentialing & privileging • Job description
HRM 1a-d • Human resource planning

• Job specification/Job description for each category of staff
• Criminal /negligence antecedents verification of the potential employee
HRM 2a-h • Documented procedure for recruitment of staff
• Pre-defined criteria of recruitment
• Induction training: Orientation to vision, mission and goals, Policies and
procedures (hospital and departmental), Rights and responsibilities-patient
and employee, Service standards, Performance appraisal (HRM 5b)
HRM 3 a • Training requirements as per the standard
o Orientation to services (AAC 1 d)
o Disaster management (COP 4 d)
o CPR (COP 5 b)
o Blood and blood products (COP 8 h)
o Vulnerable patients (COP 10 e)
o Restraint techniques (COP 17 e)
o End of life care (COP 22 e)
o Patients rights (PRE 2)
o Communication (PRE 8 f)
o Infection control (HIC 9 c,d)
o Quality improvement (CQI 1 e)
o Employee rights (ROM 5 h)
HRM 3 b-d • Training policy. Training calendar. Training records
• Training effectiveness
• Training feedback for assessment of training programme and tool to improve
the training programme
HRM 4 a-d • Staff demonstrate and take actions to report, eliminate / minimize risks
• Reporting format
• Awareness of procedures to follow in the event of an incident
• Training on occupational safety aspects
• Training on risks
o Lab safety (AAC 8 d)
o Radiation safety (AAC 11g, MOM 11 d)
o Safety (CQI 2 f)
o Hazardous materials (FMC 7 e)
o Fire and non-fire emergencies (FMC 6 a, c)
o Safety education programme (FMS 1 g)
HRM 5 a-e • Documented performance appraisal system based on job description
• Employee made aware of the system
• Appraisal at pre-determined criteria. Used as tool for further development
53
HRM 6 a-g • Documented disciplinary procedure based on principles of natural justice

and in consonance with laws
• Documented grievance handling mechanism
• Provision of appeal
• Redressal procedure to addresses the grievance
• Actions for grievance redressal
• Internal complaints committee
HRM 7a-d • Pre-employment medical examination
• Medical benefits for employees
• Regular health check (at least once a year) of staff involved in patient care
• Health check of employees exposed to radiation as per statutory
requirements
• Occupational health hazards addressed
HRM 8a-d • Personal file for every employee containing information on
o Educational qualification
o Disciplinary background
o Health status
o In service training and education
o Performance appraisal
• Confidentiality maintained
HRM 9a-f • Credentialing of doctors. Updating of credentials
• Verification where appropriate
• Privileging of doctors. Communication of same
HRM 10a-f • Credentialing of nurses. Updating of credentials
• Verification where appropriate
• Privileging of nurses. Communication of same
ROM 2b • Policy on prevention of sexual harassment (committee)
• Staff interview

• CQI 4 e (i): Employee satisfaction index
• CQI 4 e (ii): Employee attrition rate
• CQI 4 e (iii): Absenteeism rate
• CQI 4 e (iv): Percentage of employees aware of employee rights & responsibilities
54
6. Medical Records Department
Quick list:
• Security & confidentiality • Retention policy
• Destruction of case records • System for access to records
• Medical record audit • Case records sampling
• Transfer notes • Statutory documents
• Birth and death report • Fire safety
FMS 6 a • Plans for fire

IMS 1 e • Birth and Death report to concerned authorities
• Communication pertaining to notifiable diseases
• Voluntary participation in any database/registry
IMS 3 a-h • 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
IMS 4 a-h • Medical record has reason for admission / diagnosis/ plan of care/ Operative
and other Procedure sheet
• 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 5 a-g • Security, integrity and confidentiality of data and information
• Safeguarding data/ record against loss, destruction and tampering
• Technology used for improvin confidentiality, security and integrity
• Usage of privileged health information
• Documented policies on how to handle MR information requirement
IMS 6 a-d • 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 7 a-g • 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 14 b-g • 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
55
• Check for completeness of consent documents

o Procedure (COP 7 d)
o Blood transfusion (COP 8 d)
o Moderate sedation (COP 13 b)
o Aanaesthesia (COP 14 e)
o Surgery (COP 15 c
o Research (COP 20 d)
o MTP, HIV (PRE 4 a
• Authorized legal representative (PRE 4 e)
• General consent (PRE 4 b, c)
• Language of consent (PRE 4 d)
AAC 4 i • Care plan is countersigned by the clinician in-charge of the patient within 24
hours
AAC 13 b,c,d • Medico legal case documentation
• LAMA case file has discharge summary and risks explained
Paediatric cases:
COP 12 f, 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 15 d, f, g • Surgical safety checklist, Operation Notes, recovery criteria, post-operative
plan of care
ROM 2 Random check for statutory documents
• MTP register
• Birth and death registration
• Consent document under MTP act
• Consent document under PNDT act
• Completeness of death certificates
HIC 3 i • Communication of notifiable diseases to concerned authorities
• Staff interview

• CQI 4 g (i): Records not having discharge summary
• CQI 4gi (ii): Records not ICD codified
• CQI 4 g (iii): Records with incomplete consents
• CQI 4 g (iv): Percentage of missing records
56
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 j • Maintenance plan

IMS 1a-e • Identified information need list
• License for software
• Validation of software
• Contingency plan during downtime
• Documented policies for telemedicine
IMS 2 a-e • 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 5a-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 6 a-d • 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
57
8. Front Office, Registration, Admission &Billing
Quick list:
• Scope of services • Patients rights display
• Registration • Generation of UHID
• Admission process • Feedback / Complaints
AAC 1 a, c, d • Display of scope of services. Display of services not available.

• Staff awareness
AAC 2 a-f • 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
COP 10 b, e • Care of vulnerable patients. Staff trained
COP 11 b • Display of scope of high risk obstetric services
• Information to patients if high risk obstetric cases can be or cannot be taken
COP 12 b • Display of scope of paediatrics services
PRE 1 a, d • Display of patient rights. Staff awareness
PRE 2 h, i • How to voice a complaint
• Information on expected cost of treatment
PRE 7 a-d • Procedure for feedback / lodging complaints
• Complaint redressal procedure
• Analysis of all complaints / feedback within a defined time frame
• CAPA on analysis
PRE 4 b, c • General consent process. Scope of general consent
PRE 6 a, b, c • Uniform pricing policy in a given setting
• Availability of tariff list. Explanation about the expected cost
ROM 4 a • Display of mission, vision and values
FMS 1 b • Patient safety devices are installed
FMS 2 c • Signage in local language
• Staff interview

• CQI 4 d (iii): Waiting time for OP consultation
58
9. Biomedical Engineering Department, Medical Gases, Vacuum
Quick list:
• Equipment planning • Inventory
• Qualified staff • PM, Calibration
• Condemnation & disposal • Colour coding
• Storage of medical gas • Compressed air purity
• Operational & maint. plan
FMS 4a-g • Equipment planning - in accordance with its services and strategic 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)
FMS 5a-f • Policies & procedures on procuring, etc 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
HRM 3c • Training of staff when new equipment is installed
• Staff interview
59
10. Pharmacy, Pharmacy Store
Quick list:
• Pharmacy license • Duty roster of pharmacists
• Storage • Inventory
• Formulary • LASA
• Emergency medications • High risk medications
• Safe dispensing • Narcotics
• Fire safety
MOM 1a,b,d • Documented policies and procedures on medication procurement, storage,

formulary, prescription, dispensing, administration, monitoring etc.
• Separate license for each of the pharmacies
• Adherence to terms and conditions mentioned in the license
• Duty roster to ensure that there is a qualified pharmacist at all times (his/her
name being mentioned in the license)
• Procedure to obtain medications when the pharmacy is closed
MOM 2a,c,d,e • Hospital formulary. Reviewed annually.
• Defined process of procurement of medicine and non- listed medicines
• Availability of formulary for clinicians to refer and adhere to
• Re-order levels, vendor evaluation, generation of purchase order
MOM 3a-g • Policies & procedures for storage Storage in clean, well lit & ventilated
environment and/or as per manufacture’s requirement
• Inventory control practices like FIFO
• Precautions against theft
• Identification and storage of LASA drugs
• List of emergency medications is defined and is stored uniformly
• Availability of emergency medicines & replenished in a timely manner
MOM 5a-f • Procedures for safe dispensing of medicines
• Medication recall procedure
• Expiry dates checked before dispensing. Procedure for near expiry
• Proper labelling on medicines. Cut strips
• Verification of High risk medication orders before dispensing
MOM 9a,b,d • Procedure for narcotic drugs
• Storage. Proper record
• Handling. Disposal
MOM 13 • Medical supplies

• CQI 4 a (i): Percentage of drugs/ consumables procured by local purchase
• CQI 4 a (ii): Percentage of stockouts
• CQI 4 a (iii): Percentage of drugs/ consumables rejected before GRN
• CQI 4 a (iv): Percentage of variations from procurement process
60
11. Purchase, Stores & Materials Management
Quick list:
• Drugs • Consumables
• Implants & prosthesis • Equipment
• Planning • Selection
• Acquisition • Disposal
MOM 2 d, e • Acquisition of formulary and non formulary drugs

MOM 12b • Procedures for procuring, storage / stocking, issuance and usage of
implantable prosthesis and medical devices
MOM 13a-d • Process for acquisition of medical supplies and consumables
• Vendor selection, indenting process, etc
• Medical supplies and consumables are used in a safe manner
• Storage in a clean; safe and secure environment
• Inventory control practices
FMS 3 a, b, k • Equipment planning
FMS 4 a, b, g • Equipment selection
• Equipment replacement and disposal

• CQI 4 a (i): Percentage of consumables procured by local purchase
• CQI 4 a (ii): Percentage of stockouts
• CQI 4 a (iii): Percentage of consumables rejected before GRN
• CQI 4 a (iv): Percentage of variations from procurement process
61
• Facility Management
Quick list:
• Licenses • Up to date drawings
• Signages • Provision of space
• Controlled access • Designated individuals
• Water & electricity maintenance • Furniture maintenance
and alternate sources
• Manifold room • STP
• Engineering controls • Safety devices
• Safety education programme • PM & calibration of equipment
• Airconditioning • Green measures
• Fire safety
COP 15 k • Validation of OT air-conditioning

HIC 2 k • Change of HEPA filter (s)
ROM 2 a-e • Various statutory requirements
FMS 1 a, c o 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 b,d-g • Patient Safety devices
• Facility inspection rounds. Documentation and CAPA
• Identification & disposal of material not in use
• Safety education program for all staff
FMS 2 a-m • Preventive and break down maintenance plan
• Response time are monitored
• Up to 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
• Furniture maintenance
• Green measures
FMS 3a-i • 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
FMS 5 • Medical gases
• Alarm units
62
12. Safety Programme
Quick list:
• Safety committee • Patient safety goals
• Identify opportunities for • Emergency situations identified
improvement activities
• Patient safety devices • Facility rounds
• Disposal of non functioning • Fire plans
items
• Fire fighting equipment & • Mock drills
personnel
• Hazmat • Spill management
• MSDS
CQI 2 a -i • Safety committee. Patient safety programme; updated annually

• Designed individual for coordinating safety programme
• Review & identification of opportunities for improvement activities
• Patient safety goals/solutions
FMS 1 a-f • Safety committee coordinating safety plan & policies
• Patient safety devices installed.
• Disposal of non functioning items
• Patient Safety devices
• Facility inspection rounds. Documentation and CAPA
• Safety education program for all staff
FMS 6a-e • Plans for handling fire and non-fire emergencies which includes exit plan,
adequate personnel, equipment, training plans, mock drills, emergency
illumination system
• Identifies emergency situations
• Fire exit plans displayed. Exit doors open always.
• Staff training. Mock drill schedule and record - twice a year mock drill
• Smoke detectors, fire alarms, fire alarm control panel etc. (where applicable)
• Fire exit, fire extinguishers, no smoking signs etc.
• Maintenance plan for fire related equipment
FMS 7 a-e • Identified hazardous materials
• Documented procedure for sorting, storing, handling etc.
• Regulatory requirements for radioactive substances
• Availability of MSDS for all such material
• Spill management plan. Staff awareness
63
13. Housekeeping
Quick list:
• Surveillance • Checklist
• Biomedical waste handling • Hazmat
HIC 2 f • Monitoring of disinfectants used

HIC 3 g • Checklist for surveillance
• Effectiveness of housekeeping services
HIC 8 b, e • BMW collection

• Use of PPE while handling PPE
• Staff Interview on handling spills – safety

64
14. Laundry & Linen
Quick list:
• Layout/space of laundry • Machinery maintenance plan
• Hazmat • Washing protocols
• Soiled linen • Linen segregation
• Policy for change of linen • Infection control
• If outsourced quality assurance • Machine maintenance
• Fire safety
HIC 2 i • Laundry and linen management processes

• Policy for change of linen
• Washing protocols for different categories
• Process flow
• Segregation of linen
• Soiled linen management
• Bags and labels
• Quality control system. Infection prevention and control
• Quality control of outsourced activity (if outsourced)
ROM 5 j, k • Monitoring of terms quality in case this activity (if outsourced)

FMS 1 g • Electrical safety practices
• Staff awareness on safety practices
FMS 2 d • Layout / space
FMS 3 f • Maintenance plan of machinery
FMS 6 a-c, e • Fire safety awareness and fire-fighting equipment
65
15. Kitchen / Canteen
Quick list:
• Preparation of food • Storage & distribution
• Washing facility • Food handlers screening
• Health check-up of staff • Machine maintenance
• Fire safety
COP 21 e • Food is prepared, handled, stored and distributed safely

HIC 2 j o Storage of raw materials especially pest control, dry storage, cold
storage
o Washing facility
o Unidirectional / non cross-over of flow of activities (clean/dirty)
o Hygiene and cleanliness
o Pest control
o Food handlers use personal protective gear
o Screening for food handlers
ROM 2 a, b • License for canteen
• Any usage of domestic gas cylinders
FMS 6 a-c, e • Fire safety awareness and fire-fighting equipment
HRM 7a,d • Health status of employees – Immunization for Typhoid and Hepatitis
A/Stool culture and sensitivity
66
16. Mortuary
Quick list:
• Mortuary facilities
• Infection control
• Machine maintenance
HIC 2 k, l • Mortuary facilities

• Cold storage and back-up power
• Staff safety and personal protective equipment
• Disinfection
67
17. CSSD
Quick list:
• Cleaning & disinfection • Space & zoning
• Policies & procedures • Reprocessing of instruments
• Validation • Recall procedure
• ETO safety • Reuse policy
• Staff training • Machine
HIC 2f • Equipment cleaning, disinfection and sterilization practices

HIC 7 a-f • Space and zoning for sterilization activities
• Layout - Unidirectional flow, segregation of areas
• Documented policies and procedures on cleaning, packing, disinfection
and/or sterilization, storing and issue of items
• Reprocessing of instruments and equipments - policies and procedures
• Shelf life of sets
• Regular validation testing for sterilization carried out and documented
• Recall procedure when breakdown in sterilization system
• ETO Chimney
• Re-use medical devices policy
FMS 3 d, e, i • Qualified and trained personnel operate and maintain equipment

FMS 4 f, g • Operational and maintenance (preventive and breakdown) plan of equipment
• Procedure for equipment replacement and disposal
68
INTERVIEWS
69
1. Patient and family interview

AAC 5 b • Information on next follow up in OPD where appropriate
AAC 13 a • Consultation on planned discharge
COP 12 h • Education about nutrition, immunization and safe parenting
COP 18 f • Pain management techniques
COP 18 e, f • Information on their right to withdraw from the research at any stage and
also of the consequences (if any) of such withdrawal
COP 21 f • Diet limitations
MOM 11 d • Education on safety precautions of radioactive drugs.
MOM 12 c • Counselling for the usage of implantable prosthesis and medical device
PRE 1 b • Awareness of patient and family rights and responsibilities
PRE 2 a-j • Patients and family rights include:
o respecting any special preferences, spiritual and cultural needs
o respect for personal dignity and privacy during examination
o protection from physical abuse or neglect
o treating patient information as confidential
o refusal of treatment
o informed consent
o right to complain and information on how to voice a complaint
o information on the expected cost of the treatment
o access to his / her clinical records
o information on plan of care, progress , etc
PRE 3 a-g • Education / Explanation on:
o Proposed care including the risks, alternatives and benefits
o Expected results
o Disease process, complications and prevention strategies
o Results of diagnostic tests and the diagnosis
o Any change in the patient’s condition
PRE 4 c,d • Information on scope of General consent
• Information on Informed consent regarding the procedure, risks, benefits,
alternatives and as to who will perform the requisite procedure in
understandable language
PRE 5 a-g • Information and Education on:
o Proposed care including the risks, alternatives and benefits
o Safe and effective use of medication and the potential side effects
o food-drug interactions
o diet and nutrition
o immunizations
o organ donation, when appropriate
o specific disease process, complications and prevention strategies
o prevention of healthcare associated infections
PRE 6 c, d • Estimated costs of treatment
• Financial implications when there is change in condition / treatment setting
PRE 7 b • Procedure for lodging complaints
• Complaint redressal procedure
70
2. Staff interview - Care of patients

AAC 12 c, d • Information sharing about patient from shift to shift
COP 5 b • CPR
COP 8 e • Rational use of blood and blood products
COP 9 c • Admission / discharge criteria in ICU
COP 10 e • Vulnerable group
COP 13 c, d • Moderate sedation
COP 16 c, d • Organ transplant
COP 17 e • Restraint control and restraint techniques
COP 18 b, c • Pain screening, assessment & reassessment; management
COP 22 e • End of life care
MOM 4 j, l • List of high risk medications; Drug reconciliation
MOM 6 b-h • Labelling prior to making a secondary medicine
• Patient identification before administering medication
MOM 7 b • Monitoring after medication administration
MOM 8 b • Awareness of adverse drug events and reporting mechanisms
PRE 1d • Awareness on patient rights and responsibilities
PRE 8 f • Healthcare communication techniques
HIC 9 c, d • Infection control programme
CQI 1 e • Quality improvement programme
3. Staff interview-HR
HRM 2 d-e • Induction training
o Mission, goals and service standards of organization, Employee
rights and responsibilities, Patients’ rights, Service standards
o Hospital and department policies and procedures
HRM 5 b • Performance appraisal
HRM 7 a, b • Pre-employment health check, annual health check
• Occupational health hazards
4. Staff interview-Safety
AAC 8 d,e • Lab safety
AAC 11 e • Radiation safety
COP 2 d • Disaster management plan
MOM 11 d • Safety precautions in radioactive drugs
HIC 8 b • Segregation of BMW
CQI 2 f • Safety education
FMS 6 c • Fire and non-fire emergencies
FMS 7 e • Handling spills
COP 12 g • Child / neonate abduction
HRM 4 b, c • Risk management. Incident reporting system
HRM 4 d • Occupational safety

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1

Department/Area Page Number

3. Out Patient Department 7

5. Specialized Wards: Paediatric, OBG, & Labour Room, 13

9. Intensive Care, Neonatal / Paediatric ICU and High 19

11. Recovery Room 27

12. Endoscopy / Bronchoscopy 28

15. Nuclear Medicine 32

16. Cardiac Catheterization lab 33

17. Collection centre (lab) 35

18. Laboratory: Haematology / Biochemistry / Pathology / 36

20. Radiation therapy / Radioactive drugs 39

21. Nutrition Therapy 40

22. Research Activities 41

23. Hospital Infection Control 42

24. Organ transplant 44

Non Clinical Areas

Department/Area Page Number

5. Human Resource Department 52

6. Medical Record Department (MRD) 54

7. Hospital Information System (HIS) 56

8. Front office: Registration, Admission and Billing counters 57

9. Biomedical Equipment Management: Equipment, 58

11. Purchase, Store and Materials Management 60

12. Facility Management: Engineering and Maintenance 61

13. Safety Program 62

15. Laundry and Linen 64

16. Kitchen / Canteen 65

Department/Area Page Number

AAC 1 c • Defined services are displayed prominently

COP 4 • Disaster management plan

Data collection for quality indicators to be verified:

COP 3 a • Adequacy of parking for Ambulances

3. Out Patient Department

FMS 2 k • Facility & furniture maintenance

Data collection for quality indicators to be verified:

AAC 4 a-i • Predefined initial assessment

COP 7 a-g • Documented procedures of various clinical procedures

PRE 3 • Patient/family explained : care plan, risks, complications, tests, change in

Data collection for quality indicators to be verified:

• CQI 3 c (i): Incidence of medication errors

Special Care Wards

Quick list: (in addition to wards)

COP 12 a-h • Policy for Care of neonatal patients

b) Obstetrics & Gynaecology and Labour Room

Quick list: (in addition to wards)

COP 1 c • MTP: register, consents, confiedntiality

Quick list: (in addition to wards)

MOM 6 • Check labelling prior to preparation of a second drug

AAC 4 a • Documentation of initial assessment

Data collection for quality indicators to be verified:

COP 5 b • Training in CPR

HIC 7 b, c • Storage of sterilised sets

Data collection for quality indicators to be verified:

8. ICU, PICU, NICU, HDU

AAC 2 e • Policy for Bed shortage in ICU

COP 6 a-g • Documented policies and procedures for Nursing Services

COP 22 a-e • End of life care – Documented policies and procedures

Data collection for quality indicators to be verified:

• CQI 3 f (i): Percentage of transfusion reactions

COP 6 a-g • Documented policies and procedures for Nursing Services in OT

HIC 2a-i, k, l • Policies to prevent infection. Overall adherence to infection control

Data collection for quality indicators to be verified: