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CBAHI STANDARDS

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NHS 3rd Edition V 1.1

NHS 3rd Edition V 1.1

Modified standards

•IPC. 15.3.3 
The negative pressure for the isolation room should be validated on daily basis when patient is isolated
(admitted in the room).
Weekly validation is done when the room has no patients.  A minimum of 12  air changes per hour should be
maintained by testing and documentation  
as per manufacturer's recommendation. 

•HR.4. 
The hospital maintains personnel files for all employees including temporary, visiting, part-time and volunteer
staff.
HR.4.1 The hospital has a policy guiding the initiation, management, content update, and retention time and
disposal of personnel files.
HR.4.2 Personnel files are complete and updated.
HR.4.3 Personnel files are kept confidential and only those who are authorized can access them.
HR.4.4  Personnel files contain the following minimum items:
HR.4.4.1 Qualifications; including current licensure, certification, or registration, if applicable.
HR.4.4.2 Current job description.
HR.4.4.3  References.
HR.4.4.4  Orientation, continuing education, skills, knowledge and training records.
HR.4.4.5  Performance evaluations.
HR.4.4.6  Records of leave and sickness.
HR.4.4.7  Disciplinary actions, if any.
HR.4.4.8  Other documents as required by relevant laws and regulations. 

•FMS.27.
The hospital ensures staff are trained and tested competent on the safe operation of equipment including
medical devices.
FMS.27.1. A policy is in place to ensure staff are trained on the safe operation of the current and newly
introduced equipment and medical devices.
FMS.27.2 The policy addresses the required training and competency testing of staff operating specialized
equipment.
FMS. 27.3. Only trained and competent staff handle specialized equipment and medical devices.

•LD.8.4. 
The leaders develop a process to receive and resolve ethical dilemmas (patient and non-patient related) in a
reasonable timeframe.

       

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