Hope Hospital Self Assessment Toolkit

Self As applicable%

Compliance to the requirement: 10 Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying Non-compliance to the requirement: 0 Not pplicable: N !"aluation Criteria during final assessment: # No indi indi"i "idu dual al stan standa dard rd shou should ld ha"e ha"e more more than than one one $er $ero o to to qua quali lify fy%% &o' &o'e" e"er er no no $er $ero o is is ac ac # *he a"erage score score for indi"idual standard must not be less than 5% # *he a"erage score score for indi"idual chapter must not be less than than +% # *he o"erall a"erage a"erage score for all standards must e,ceed e,ceed +%

Special Note:

elf assessments should be done by the hospital in a stringent manner and if assess assessmen mentt and and the the pre pre asses assessme sment nt repor reportt then then organ organisa isatio tions ns can can appl apply y for for fifi

SELF AS Objective Elements

Chapte !: ACCESS" ASSESSMENT AN# CONTIN$IT% OF CA&E 'AA AAC)!: The o*anisation +efines an+ +ispla,s the sevices that it can povi+e) a

*he ser"ices being pro needs of the communit

b

*he defined ser"ices a

c

*he staff is oriented to

AAC)-: AAC)-: The o*anisation has a .ell +efine+ e*istation an+ a+mission pocess) a%

tan tanda dard rdi$ i$ed ed poli polici cies es a patients%

b%

*he policies and proce patients%

c%

Patients are accepted

d%

*he policies and proce a"ailability of beds%

e%

*he staff is is a'are of th th

AAC)/ AAC)/ Thee is an appopiate mechanism fo tansfe o efeal of patients .ho +o a%

Poli Polici cie es guide uide the the tra tran manner%

b%

Policies guide the tran

c%

Proced Procedur ures es identi identify fy sta

d%

*he organi$ation gi"es

AAC)1 C)1 #0 #0in in* * a+m a+mis issi sion on the the pat patie ient nt an+2 an+2 o fami famil, l, memb membe es s ae ae e+0c e+0cat ate+ e+ to make make in a%

*he pa patients an and or or fa

b%

*he pa patients an and or or fa

c%

*he patients and or fa complications% *he pa patients an and or or fa

d%

AAC)3 AAC)3 4atients cae+ fo b, the o*anisation 0n+e*o an establishe+ initial assessm a%

*he *he orga organi nisa sati tion on defin defin patients patients and emergenc emergenc

b%

*he organisation deter

c% d%

*he *he orga organi nisa sati tion on defin defin completed% *he initial assessment per per the the pati patien ent ts s cond condit itii

e%

/ni /nitia tial ass assessm essmen entt incl inclu u

f%

*he initial assessment

g%

*he plan of care also i

AAC)5 All patients cae+ fo b, the o*anisation 0n+e*o a e*0la eassessment) a%

ll patients are reasse reasse

b%

taff in"ol"ed in direct

c%

Patien Patients ts are are reass reassess esse e further treatment or dis

AAC)6 Laboato, sevices ae povi+e+ as pe the e70iements of the patients) a%

cope cope of the laborato laboratorr organisation%

b%

dequate dequately ly qualified qualified an in"estigations% Policies Policies and procedu procedure re tran transp spor orta tati tion on proc proces ess s

c% d%

aboratory results are

e%

Critical results are inti

f%

aboratory tests not a" based on their quality a

AAC)8 Thee is an establishe+ laboato, 70alit, ass0ance po*amme) a%

*he laboratory quality

b%

*he pr programme addre

c%


d%

*he *he pro prog gramm ramme e inc inclu lud d

e%


a%

*he laboratory safety p

b%

*his programme is inte

c%

4ritten policies and pr ha$ardous ha$ardous materials%

d%

abo abora rato tory ry per perso sonn nnel el a

AAC)9 Thee is an establishe+ laboato, safet, po*amme)

e%

abo abora rato tory ry per perso sonn nnel el a

AAC)! Ima*in* sevices ae povi+e+ as pe the e70iement of the patients) a%

/magi /maging ng ser"ic ser"ices es comp comp

b%

cope of the imaging s organisation% dequate dequately ly qualified qualified an in"estigations%

c% d% e%

Policies Policies and procedu procedure re imaging ser"ices% /maging results are a"a

f%

Critical results are inti

g%

/maging tests not a"ail based on their quality a

AAC)!! Thee is an establishe+ 70alit, ass0ance po*amme fo ima*in* sevices) a%

*he quality assurance

b%


c%


d%


e%


a%

*he radiation safety pr

b%

*his programme is inte

c%

4ritten policies and pr and ha$ardous materia

d%

/maging personnel are

e%

adiation adiation safety de"ice de"ice

f%

/maging personnel are

g%

/maging si signage are p

h%

Policies Policies and procedu procedure re ser"ices%

AAC)!- Thee is an establishe+ a+iation safet, po*amme)

AAC)!/ AAC)!/ 4atient cae is contin0o0s an+ m0lti+isciplina, in nat0e) a%

6uri 6uring ng all all phas phases es of ca the patient.s care%

b%

Care of patients is coor

c%

/nformation about the p medical nursing and o

d%

/nfo /nform rmat atio ion n is e,ch e,chan ang g shifts fts an and du during tr trans

e%

*he patient.s record(s) e,change of informatio

f%

Policies Policies and procedu procedure re specialities%

AAC)!1 The o*anisation has a +oc0mente+ +ischa*e pocess) a%

*he patient.s discharge family%

b%

Policies Policies and procedu procedure re agenc agencies ies in"o in"ol"e l"ed d in th

c%

Policies Policies and procedu procedure re

d%

 discharg discharge e summary summary i patients lea"ing agains

AAC)!3 O*anisation +efine the content of the +ischa*e s0mma,) a%

6ischarge summary is

b%

6ischarge summary co diag iagnosi osis and and the the pati atie

c%

6ischarge summary co procedure performed

d%

6ischarge summary co an understandable ma

e%

6ischarge summary in care%

f%

/n case of death the su

Chapte -: CA&E OF 4ATIENTS 'CO4( CO4 CO4)!: $ni $nifo fom m ca cae e of of pat patie ient nts s is is po povi vi+e +e+ + in in all all set setti tin* n*s s of of the the o* o*an ani; i;at atio ion n an+ an+ is * *0i+elines) a

Care Care del deli" i"er ery y is uni unifo forr

b

8niform care is guided and regulations%

c

*he care care and treatmen treatmen concerned doctor%

d

*he care plan is count hours%

e

!"id !"iden ence ce base based d med medic icii patient care 'hene"er

CO4)-: CO4)-: Eme*enc Eme*enc, , sevices sevices ae ae *0i+e+ *0i+e+ b, polici policies" es" poce+ poce+0es 0es an+ an+ applica applicable ble la.s a a

Policies and procedure procedure

b

Policies also address h

c

*he *he pat patie ient nt rece recei" i"es es ca

d

Policies Policies and procedu procedure re care%

e

taff is familiar 'ith the emergency patients%

f

dmission or discharge discharge documented%

CO4 CO4)/: )/: The The amb0 amb0la lanc nce e se sev vices ices ae ae com comme mens ns0 0at ate e .ith .ith the the sco scope pe of the the se sev vices ices p a

*here is adequate acc

b

mbulance(s) is appro

c

mbulance(s) is mann

d

*here is a chec7list of

e

!quip !quipmen mentt are are chec7 chec7e e

f

!mergen !mergency cy medicatio medication n

g

*he ambulance(s) has

CO4)1: CO4)1: 4olicies an+ poce+0es *0i+e the cae cae of patients e70iin* ca+io
6ocu 6ocume ment nted ed poli polici cies es a throughout the organis

b

taff pro"iding direct p pulmonary resuscitatio

c

*he e" e"ents du during a ca

d

 post-e"ent post-e"ent analysis analysis o committee%

e

Correcti"e and pre"enti

CO4)3: 4olicies an+ poce+0es +efine ational 0se of bloo+ an+ bloo+ po+0cts) a

6ocumented policies a blood products%

b

*he transfusion ser"ice

c

/nformed consent is ob products%

d

/nformed consent also i

e

taff is trained to imple

f

*ransfusion reactions a

CO4)5: 4olicies an+ poce+0es *0i+e the cae of patients in the intensive Cae an+ a

*he organisation has d care and high depende

b

taff is trained to apply

c

dequate staff and equ

d

6efined procedures for

e

/nfection control practic

f

 quality assurance pro

CO4)6: 4olicies an+ poce+0es *0i+e the cae of v0lneable patients 'el+el," ph,sic a

Policies and procedure la's and the national a

b

Care is organised and

c

*he organisation pro"i group%

d

 documented procedu appropriate legal repre

e

taff is trained to care f

CO4)8: 4olicies an+ poce+0es *0i+e the cae of hi*h<isk obstetical patients) a

*he organisation defin for or not%

b

Persons caring for high

c

&igh-ris7 obstetric pati

d

*he organi$ation carin of neonates of such ca

CO4)9: 4olicies an+ poce+0es *0i+e the cae of pae+iatic patients) a

*he organisation defin

b

*he policy for care of n international guidelines

c

*hose 'ho care for chil

d

Pro"isions are made fo

e

Patient assessment inc immuni$ation assessm

f

Policies and procedure

g

*he children.s family m safe parenting and this

CO4)!: 4olicies an+ poce+0es *0i+e the cae of patients 0n+e*oin* mo+eate se a

Competent and trained

b

*he person administeri performing the procedu

c

/ntra 9 procedure moni respiratory rate blood

d

Patients are monitored

e

Criteria are used to det area%

f

!quipment and manpo sedation than that inte

CO4)!!: 4olicies an+ poce+0es *0i+e the a+ministation of anesthesia) a

*here is a documented

b

ll patients for anesthe indi"idual%

c

*he pre-anesthesia as is documented%

d

n immediate preoper

e

/nformed consent for a

f

6uring anesthesia mon cardiac rhythm respira and patency and le"el

g

!ach patient.s post-an

h

 qualified indi"idual a reco"ery area%

i

ll ad"erse anesthesia

CO4)!-: 4olicies an+ poce+0es *0i+e the cae of patients 0n+e*oin* s0*ical poc a

*he policies and proce

b

urgical patients ha"e documented prior to su

c

n informed consent is

d

6ocumented policies a site 'rong patients an

e

Persons qualified by la entitled to perform%

f

 brief operati"e note i area%

g

*he operating surgeon

h

 quality assurance pro

i

*he quality assurance en"ironment%



*he plan also includes

CO4)!/: 4olicies an+ poce+0es *0i+e the cae of patients 0n+e estaints 'ph,sical a

6ocumented policies a

b

*hese include both ph

c

*hese include docume

d

*hese patients are mor

e

taff recei"e training a

CO4)!1: 4olicies an+ poce+0es *0i+e appopiate pain mana*ement) a


b

*he organi$ation respe management of pain fo

c

Patient and family are

CO4)!3: 4olicies an+ poce+0es *0i+e appopiate ehabilitative sevices) a


b

*hese ser"ices are co

c

ehabilitati"e ser"ices

a

6ocumented policies a 'ith national and intern

b

*he organi$ation has an

c

*he committee has the p potential benefits%

d

Patient.s informed consen

e

Patients are informed o also of the consequenc

f

Patients are assured t participation 'ill not co

a

6ocumented policies a reassessment%

b

Patients recei"e food a

c

*here is a 'ritten order

d

Nutritional therapy is p

e

4hen families pro"ide

f

;ood is prepared hand

a


b

*hese policies and pro

c

*hese also address th family%

CO4)!5: 4olicies an+ poce+0es *0i+e all eseach activities)

CO4)!6: 4olicies an+ poce+0es *0i+e n0titional theap,)

CO4)!8: 4olicies an+ poce+0es *0i+e the en+ of life cae)

d

*hese also include sen donation%

e

taff is educated and tr

Chapte /: MANA>EMENT OF ME#ICATION 'MOM( MOM)!: 4olicies an+ poce+0es *0i+e the o*ani;ation of phamac, sevices an+ 0s a

*here is a documented medication usage%

b

*hese comply 'ith the

c

 multidisciplinary com policies and procedure

a

 list of medication app de"eloped%

b

*he list is de"eloped c

c

*here is a defined proc

d

*here is a process to o

MOM)-: Thee is a hospital fom0la,)

MOM)/: 4olicies an+ poce+0es e?ist fo stoa*e of me+ication) a


b

c

ound in"entory contro

d

e

ound ali7e and loo7 al

f

*here is a method to o

g

!mergency medication

h

!mergency medication

MOM)1: 4olicies an+ poce+0es e?ist fo pesciption of me+ications) a


b

*he organi$ation deter

c

=rders are 'ritten in a

d

e

Policy on "erbal orders

f

*he organi$ation defin

g

&igh ris7 medication or

MOM)3: 4olicies an+ poce+0es *0i+e the safe +ispensin* of me+ications) a


b

*he policies include a

c

!,piry dates are chec7

d

abeling requirements

MOM)5: Thee ae +efine+ poce+0es fo me+ication a+ministation) a

b

Prepared medication a

c

Patient is identified prio

d

e

6osage is "erified from

f

oute is "erified from t

g

*iming is "erified from t

h

i

Polices and procedure



Polices and procedure organi$ation%

MOM)6: 4atients an+ famil, membes ae e+0cate+ abo0t safe me+ication an+ foo+<+

a


b


MOM)8: 4atients ae monitoe+ afte me+ication a+ministation) a

Patients are monitored

b

d"erse drug e"ents a

c


d


e

Policies are modified to occur%

MOM)9: 4olicies an+ poce+0es *0i+e the 0se of nacotic +0*s an+ ps,chotopic s a

6ocumented policies a psychotropic substanc

b

*hese policies are in c

c

 proper record is 7ept

d

*hese drugs are handl

MOM)!: 4olicies an+ poce+0es *0i+e the 0sa*e of chemotheape0tic a*ents) a

6ocumented policies a agents%

b

Chemotherapy is presc the ad"erse effect of c

c

Chemotherapy is prepa

d

Chemotherapy drugs a

MOM)!!: 4olicies an+ poce+0es *oven 0sa*e of a+ioactive +0*s) a


b

*hese policies and pro

c

*he policies and proce distribution and dispos

d

taff patients and "isit

MOM)!-: 4olicies an+ poce+0es *0i+e the 0se of implantable posthesis) a

6ocumented policies a implantable prosthesis%

b

election of implantabl internationally recogni$

c

*he batch and serial n patient.s medical recor

MOM)!/: 4olicies an+ poce+0es *0i+e the 0se of me+ical *ases) a

6ocumented policies a distribution usage and

b

*he policies and proce

c

ppropriate records ar and legal requirements

Chapte 1: 4ATIENT &I>=TS AN# E#$CATION '4&E( 4&E)!: The o*ani;ation potects patient an+ famil, i*hts infoms them abo0t thei  a

Patient and family right

b

Patients and families a and language that they

c

*he organi$ation.s lead

d

taff is a'are of their r

e

>iolation of patient and pre"enti"e measures ta

4&E)-: 4atient an+ famil, i*hts s0ppot in+ivi+0al beliefs" val0es an+ involve the pat a

Patient and family right needs%

b

Patient and family right e,amination procedur

c


d


e


f

Patient and family right blood product transfusi

g

Patient and family right protocol is initiated%

h


i




Patient and family ha"

4&E)/: A +oc0mente+ pocess fo obtainin* patient an+2 o famil,@s consent e?ists fo a

?eneral consent for tre

b

Patient and  or his fam consent%

c

*he organisation has li

d

/nformed consent inclu 'ho 'ill perform the re

e

*he policy describes ' independent decision-

4&E)1: 4atient an+ families have a i*ht to infomation an+ e+0cation abo0t thei hea a

4hen appropriate pati effecti"e use of medica

b

Patient and families ar

c


d

Patient and families ar complications and pre"

e


f

Patients and family are

4&E)3: 4atient an+ families have a i*ht to infomation on e?pecte+ costs) a

*here is uniform pricin

b

*he tariff list is a"ailabl

c

Patients and family are

d

Patients and family are change in the patient c

Chapte 3: =OS4ITAL INFECTION CONT&OL '=IC( =IC)!: The o*ani;ation has a .ell<+esi*ne+" compehensive an+ coo+inate+ infecti eliminatin* isks to patients" visitos an+ povi+es of cae) a

*he hospital infection c and reducing ris7 of no

b

*he hospital has a mul

c

*he hospital has an inf

d

*he hospital has desig

=IC)-: The o*anisation has an infection contol man0al" .hich is peio+icall, 0p+ate a

*he manual identifies t

b

/t outlines methods of s

c

/t focuses on adherenc

d

!quipment cleaning an

e

n appropriate antibioti

f

aundry and linen man

g

@itchen sanitation and

h

!ngineering controls to

i




=IC)/: The infection contol team is esponsible fo s0veillance activities in i+entifie a

ur"eillance acti"ities a areas

b

Collection of sur"eillance

c

>erification of data is don

d

/n cases of notifiable dise authorities%

e

cope of sur"eillance a ris7s rates and trends%

f

ur"eillance acti"ities i

=IC)1: The o*ani;ation takes actions to pevent o e+0ce the isk of =ospital Associ emplo,ees) a

*he organi$ation monit

b


c


d


e

ppropriate feedbac7 r medical and nursing st

=IC)3: 4ope facilities an+ a+e70ate eso0ces ae povi+e+ to s0ppot the infection a

&and 'ashing facilities pro"iders%

b

Compliance 'ith prope

c

/solation barrier nursin

d

dequate glo"es mas

=IC)5: The o*anisation takes appopiate actions to contol o0tbeaks of infections) a

&ospital has a docume

b

*his procedure is imple

c

fter the outbrea7 is o" recurrence%

=IC)6: Thee ae +oc0mente+ poce+0es fo steilisation activities in the o*anisatio a

*here is adequate spa

b

egular "alidation test

c

*here is an established system is identified%

=IC)8: Stat0to, povisions .ith e*a+ to io
*he hospital is authoris handling of Aio-medica

b

Proper segregation an of the hospital is imple

c

*he organi$ation ensur site of treatment and di limits in a secure mann

d

Aio-medical 4aste trea house) or outsourced t

e

equisite fees docum stipulated dates%

f

ppropriate personal p handling Aio-medical

=IC)9: The infection contol po*amme is s0ppote+ b, the o*anisations mana*em emplo,ee health) a

&ospital management programme%

b

*he hospital regularly e regard%

c

/t conducts regular pre oining concerned depa

d

/t also conducts regula of staff at least once in

e

ppropriate pre and po members

Chapte 5: CONTIN$O$S D$ALIT% IM4&OEMENT 'CDI( CDI)!: Thee is a st0ct0e+ 70alit, impovement an+ contin0o0s monitoin* po*a a

*he quality impro"eme by a multi-disciplinary c

b

*he quality impro"eme

c

*here is a designated i impro"ement program

d

*he quality impro"eme elements related to qu

e

*he designated progra employees of the orga

f

*he quality impro"eme opportunities for impro

g

*he quality impro"eme once in a year%

CDI)-: The o*ani;ation i+entifies ke, in+icatos to monito the clinical st0ct0es" p tools fo contin0al impovement) a

b

c

d

e

f

g

h

i



7

CDI)/: The o*ani;ation i+entifies ke, in+icatos to monito the mana*eial st0ct0e tools fo contin0al impovement) a

b

c

d

e

f

g

h

i

CDI)1: The 70alit, impovement po*amme is s0ppote+ b, the mana*ement)

a

&ospital
b

&ospital earmar7s ade

c

ppropriate statistical a

CDI)3: Thee is an establishe+ s,stem fo a0+it of patient cae sevices) a

b

*he parameters to be

c

Patient and staff anony

d

ll audits are documen

e

emedial measures ar

a

*he organisation has d

b

*he organisation has e

c

entinel e"ents are int

d

Correcti"e and pre"enti

CDI)5: Sentinel events ae intensivel, anal,se+)

Chapte 6: &ES4ONSIILITIES OF MANA>EMENT '&OM( &OM)!: The esponsibilities of the mana*ement ae +efine+) a

*hose responsible for

b

*hose responsible for commensurate to the o holders%

c

*hose responsible for the resources required

d

*hose responsible for organi$ation against th

e


f


g


h

*he organi$ation comp

i


&OM)-: The sevices povi+e+ b, each +epatment ae +oc0mente+)

a

!ach organi$ational pr

b

cope of ser"ices of e

c

dministrati"e policies

d

6epartmental leaders

&OM)/: The o*ani;ation is mana*e+ b, the lea+es in an ethical manne) a

*he leaders ma7e publ

b

*he leaders establish t

c

*he organi$ation disclo

d

*he organi$ation hone

e

*he organi$ation hone

f

*he organi$ation accur tariff%

&OM)1: A s0itabl, 70alifie+ an+ e?peience+ in+ivi+0al hea+s the o*anisation) a

*he designated indi"id qualifications%

b

*he designated indi"id

&OM)3: Lea+es ens0e that patient safet, aspects an+ isk mana*ement iss0es ae mana*ement) a

*he organi$ation has a 'ide safety programme

b

*he scope of the progr harm to Bsentinel e"en

c

d

Chapte 8: FACILIT% MANA>EMENT AN# SAFET% 'FMS( FMS)!: The o*ani;ation is a.ae of an+ complies .ith the elevant 0les an+ e*0lati inspection e70iements) a

*he management is co applicability to the orga

b

c

*he management ensu

d

*here is a mechanism

FMS)-: The o*ani;ations envionment an+ facilities opeate to ens0e safet, of pati a

*here is a documented plan%

b

8p-to-date dra'ings ar escape routes%

c

*here is internal and e understood by patient

d

*he pro"ision of space practices (/ndian or /nt agencies%

e

*here are designated i facilities%

f

g

esponse times are m correcti"e actions%

FMS)/: The o*ani;ation has a po*am fo clinical an+ s0ppot sevice e70ipment m a

*he organi$ation plans plan%

b

!quipment is selected

c

ll equipment is in"ent

d

Dualified and trained p

e

!quipment are periodic

f

*here is a documented plan%

FMS)1: The o*ani;ation has povisions fo safe .ate" electicit," me+ical *ases an+ a

Potable 'ater and elec

b

lternate sources are p

c

*he organisation regul

d

*here is a maintenanc installation%

FMS)3: The o*ani;ation has plans fo fie an+ non
FMS)5: The o*ani;ation has a smokin* limitation polic,)

a

*he organi$ation has p abatement of fire and n

b

*he organi$ation has a emergencies%

c

taff is trained for their

d

a


b

*he policy has pro"isio smo7e%

FMS)6: The o*ani;ation plans fo han+lin* comm0nit, eme*encies" epi+emics an+ a

*he hospital identifies

b

*he organi$ation has

c

Pro"ision is made for a during such emergenci

d

&ospital staff is trained

e

*he plan is tested at le

FMS)8: The o*ani;ation has a plan fo mana*ement of ha;a+o0s mateials) a

&a$ardous materials a

b

*he hospital implemen transporting and dispo

c

equisite regulatory re

d

*here is a plan for man

e

taff is educated and tr

FMS)9: The o*anisation has s,stems in place to povi+e a safe an+ sec0e envionm a

*he hospital has a safe ris7s%

b

*his committee coordin safety plan and policie

c

Patient safety de"ices periodically%

d

;acility inspection roun patient care areas and

e

/nspection reports are underta7en%

f

*here is a safety educ

Chapte 9: =$MAN &ESO$&CE MANA>EMENT '=&M( =&M)!: The o*ani;ation has a +oc0mente+ s,stem of h0man eso0ce plannin*) a

*he organi$ation maint treatment and ser"ice

b

*he required ob specif category of staff%

c

*he organi$ation "erifie criminalnegligence ba

=&M)-: The staff joinin* the o*ani;ation is sociali;e+ an+ oiente+ to the hospital en a

!ach staff member em oriented to the organi$

b

!ach staff member is as rele"ant department

c

!ach staff member is

d

ll employees are edu

e

ll employees are orie

=&M)/: Thee is an on*oin* po*amme fo pofessional tainin* an+ +evelopment o a

 documented training

b

*raining also occurs ' introduced%

c

;eedbac7 mechanisms e,ist%

=&M)1: Staff membes" st0+ents an+ vol0ntees ae a+e70atel, taine+ on specific jo a

ll staff is trained on th

b

taff members can de ris7s%

c

taff members are ma

d

eporting processes fo

=&M)3: An appaisal s,stem fo eval0atin* the pefomance of an emplo,ee e?ists a mana*ement pocess) a

 'ell-documented per

b

*he employees are ma

c

Performance is e"aluat description%

d

*he appraisal system i

e

Performance appraisal

=&M)5: The o*ani;ation has a .ell<+oc0mente+ +isciplina, poce+0e) a

 'ritten statement of t place%

b

*he disciplinary policy

c

*he policy and proced organi$ation%

d

*he disciplinary proced

e

*here is a pro"ision for

=&M)6: A *ievance han+lin* mechanism e?ists in the o*ani;ation) a

*he employees are a' aggrie"ed%

b

*he redress procedure

c

ctions are ta7en to re

=&M)8: The o*ani;ation a++esses the health nee+s of the emplo,ees) a

 pre-employment med

b

&ealth problems of the organi$ation.s policy%

c

egular health chec7s once a year and the fin

d

=ccupational health ha

=&M)9: Thee is a +oc0mente+ pesonal eco+ fo each staff membe) a

Personal files are main

b

*he personal files cont qualification disciplinar

c

ll records of in-ser"ice

d

Personal files contain r

=&M)!: Thee is a pocess fo collectin*" veif,in* an+ eval0atin* the ce+entials 'e of me+ical pofessionals pemitte+ to povi+e patient cae .itho0t s0pevision) a

b

*he education registra professionals is docum

c

ll such information pe 'hen possible%

=&M)!!: Thee is a pocess fo a0thoisin* all me+ical pofessionals to a+mit an+ te commens0ate .ith thei 70alifications)

a

b

*he ser"ices pro"ided qualification training a

c

*he requisite ser"ices t them as 'ell as the "ar

=&M)!-: Thee is a pocess fo collectin*" veif,in* an+ eval0atin* the ce+entials 'e of n0sin* staff) a

*he education registra and updated periodicall

b

ll such information pe possible%

=&M)!/: Thee is a pocess to i+entif, job esponsibilities an+ make clinical .ok as commens0ate .ith thei 70alifications an+ an, othe e*0lato, e70iements) a

*he clinical 'or7 assig training and registratio

b

*he ser"ices pro"ided and regulations%

c

*he requisite ser"ices t 'ell as the "arious dep

Chapte !: INFO&MATION MANA>EMENT S%STEM 'IMS( IMS)!: 4olicies an+ poce+0es e?ist to meet the infomation nee+s of the cae povi as othe a*encies that e70ie +ata an+ infomation fom the O*ani;ation) a

*he information needs scope of the ser"ices b organi$ation%

b


c

*hese policies and pro regulations%

d

ll information manage the policies and proced

e

*he organi$ation contri regulations%

IMS)-: The o*ani;ation has pocesses in place fo effective mana*ement of +ata) a

;ormats for data collec

b

Necessary resources a

c

6ocumented procedur data%

d

6ocumented procedur

e

ppropriate clinical and using data%

IMS)/: The o*ani;ation has a complete an+ acc0ate me+ical eco+ fo eve, patien a

!"ery medical record h

b

=rganisation policy ide

c

!"ery medical record e

d

*he author of the entry

e

*he contents of medic

f

*he record pro"ides an

a

*he medical record co diagnosis and plan of c

b

=perati"e and other pr

c

4hen patient is transfe date of transfer the rea

d

*he medical record co appropriate and qualifi

e

/n case of death the m indicating the cause d

f

4hene"er a clinical au the report of the same%

g

Care pro"iders ha"e ac

IMS)1: The me+ical eco+ eflects contin0it, of cae)

IMS)3: 4olicies an+ poce+0es ae in place fo maintainin* confi+entialit," inte*it, a a

6ocumented policies a and integrity of informa

b


c

*he policies and proce destruction and tamper

d

*he hospital has an eff policy%

e

*he hospital uses de"e confidentiality integrity

f

Pri"ileged health infor la' and not disclosed

g

 documented procedu other public agencies r accordance 'ith the lo

IMS)5: 4olicies an+ poce+0es e?ist fo etention time of eco+s" +ata an+ infomati

a

6ocumented policies a records data and infor

b

*he policies and proce and regulations%

c

*he retention process

d

*he destruction of med laid do'n policy%

IMS)6: The o*ani;ation e*0lal, caies o0t evie. of me+ical eco+s) a

*he medical records ar

b

*he re"ie' uses a repr

c

*he re"ie' is conducte

d

*he re"ie' focuses on records%

e

*he re"ie' process inc

f

*he re"ie' points out a

g

ppropriate correcti"e

essment Toolkit

ut of total samples selected)

epted in the regulatory legal requirements%

t the time of Pre assessment it is found that there is a significant dif al assessment not earlier than si, months from the date of completi

ESSMENT TOOLKIT Intepetation

C(

ided are clearly defined and are in consonance 'ith the %

 policy to be framed clearly stating the ser"ices the hospital can pro"ide%

e prominently display%

*he ser"ices so defined should be "isible prominently in an area "isible to all patients entering the organi$ation% *he display could be in the form of boards citi$ens charter scrolling messages etc% care should be ta7en to ensure that these are displayed in the language (s) the patient understands%

these ser"ices%

ll the staff in the &ospital mainly in the rece tionre istration =P6

nd procedures are used for registering and admitting

&ealth Care =rgani$ation (&C=) has prepared document (s)

ures address out-patients in-patients and emergency

*he policies and procedures address out-patients in-patients

nly if the organi$ation can pro"ide the required ser"ice%

*he staff handling admission and registration needs to be a'are of

ures also address managing patients during non

*he &C= is a'are of the a"ailability of alternate &C=.s

ese processes%

ll the staff handling these acti"ities should be oriented of these policies and procedures%

ot match the o*anisation eso0ces) sfer of unstable patients to another facility in an appropriate *he organi$ation shall at the outset define as to 'ho is an sfer of stable patients to another facility%

Patients not in a life threatening situation (stable) should also be ff responsible during transfer% *he staff shall at least be a trained traumaemergency a summary of patient.s condition and the treatment gi"en% *he &C= gi"es a case summary mentioning the significant findings

ome+ +ecision) ily members are e,plained about the proposed care%

*he plain of care as decided by the management team (as the

ily members are e,plained about the e,pected results%

*he patients and family are e,plained in detail by the training Possible complications of the treatment if any are clearly Patients should be gi"en as estimate of the e,penses on

ily members are e,plained about the possible ily members are e,plained about the e,pected costs%

nt) s the content of the assessments for the out patients in y patients% ines 'ho can perform the assessments%

*he hospital shall ha"e a protocolpolicy by 'hich a *he assessment should be done by the treating doctor unior

s the time frame 'ithin 'hich the initial assessment is for in-patients is documented 'ithin 23 hours or earlier as on or hospital policy% des screening for nutritional needs% results in a documented plan of care 'hich is monitored% cludes pre"enti"e aspects of the care%

sed at appropriate inter"als% linical care document reassessments% d to determine their response to treatment and to plan charge%

*he &C= has defined and documented the time frame 'ithin *he should co"er history progress notes in"estigation *he protocol for patient.s initial assessment should co"er hisher *his shall be documented by the treating doctor or by a member of *he documented plan of care

fter the initial assessment the patient is reassessed periodically ctions ta7en under reassessment are documented% elf e,planatory%

ser"ices are commensurate to the ser"ices pro"ided by the *he &C= should ensure a"ailability of laboratory ser"ices d trained personnel perform andor super"ise the s guide collection identification handling safe ing and disposal of specimens%

*he staff employed in the lab should be suitably qualified *he &C= has documented procedures for collection

"ailable 'ithin a defined time frame%

*he &C= shall define the turnaround time for all tests% *he ated immediately to the concerned personnel% *he laboratory shall establish its biological reference inter"als for ailable in the organi$ation are outsourced to organi$ation(s) *he &C= has a documented ssurance system% procedure for outstanding tests

ssurance programme is documented%

*he &C= has a documented quality assurance programme

ses "erification and "alidation of test methods%

*his holds true for any laboratory de"eloped methods% *he laboratory director (or incharge) shall periodically assess

ses sur"eillance of test results% s periodic calibration and maintenance of all equipments%

efer to /= 151EF%

s the documentation of correcti"e and pre"enti"e actions%

elf e,planatory%

rogramme is documented%

 'ell documented lab safelty manual is a"ailable in the lab%

grated 'ith the organisations safety programme%

ab safety programme is incorporated in the safety *he lasb staff should follo' standard precautions% *he

cedures guide the handling and disposal of infectious and re appropriately trained in safe practices%

ll the lab staff undergo training regarding safe practices in the

re pro"ided pro"ided 'ith 'ith appropriate appropriate safety safety equipment equipment de"ices% de"ices%

ly 'ith the legal and other requirement%

dequate safety de"ices de"ices are a"ailable in the lab e%g% f ire

er"ices are commensurate to the ser"ices pro"ided by the

*he &C= is a'are of the legal and other requirements of elf e,planatory e,planatory

d trained personnel perform super"ise and interpret the

s per !A guidelines% guidelines%

s guide guide identification and safe transportation transportation of patients patients to

*he &C= &C= has has documented documented policies and procedures for *he organi$ation shall document turnaround time of imaging Critical results shall be intimated to the treating clinician at the *he &C= has documented procedure for outsourcing tests

ilable 'ithin a defined time frame% ated immediately to the concerned personnel% ble in the organi$ation are outsourced to organi$ation(s) ssurance system

rogram for imaging ser"ices is documented%

efer to !A guidelines

ses "erification and "alidation of imaging methods%

 document document for "erification "erification and "alidation of imaging methods &=6 (or in-charge) shall periodically periodically assess the imaging

ses sur"eillance sur"eillance of imaging results% s periodic calibration and maintenance of all equipments% equipments% s the documenta documentation tion of correcti" correcti"e e and pre"enti" pre"enti"e e actions% actions%

Calibration and maintenance of all equipment shall be carried out by elf e,planato e,planatory ry%%

gramme is documented%

efer to !A guidelines

grated 'ith the organi$ation.s safety programme%

*he safety programme of the imaging department has

cedures guide the handling and disposal of radio-acti"e ls%

adioacti"e and ha$ardous materials shall be disposed off as

pro pro"ided ided 'ith ith appr appro opriate iate radiat diatio ion n safe afety de"ice ices%

elf elf e,plan plana ator tory

s are periodically periodically tested and documented% trained in radiation safety measures%

Protecti"e de"ices e%g% lead aprons should be e,posed to Gel e,planatory%

rominently displayed in all appropriate locations%

elf e,planatory

s guide the safe use of radioacti"e isotopes for imaging

6ocument on safe use of radioacti"e isotopes for imaging

re there is a qualified indi"idual identified as responsible responsible for *he &C= to ensure that the care of patients is al'ays gi"en by dinated in all care setting 'ithin the organisation% organisation% atients care and response to treatment is shared among her care pro"iders%

Care of patients is co-ordinated co-ordinated among "arious care pro"iders in a *he &C= ensures periodic discussions about each patient

d and documented during each staffing shift bet'een ers bet'een units departments%

elf e,planatory e,planatory

is a"ailable to authori$ed care pro"iders pro"iders to facilitate the n%


s guide the referral of patients to other departments

*he &C= has clearly defined and documented the policies and

process is planned in consultation consultation 'ith the patient patient and or or s e,ist for coordination coordination of "arious departments departments and discharge process (including medico-legal cases)

*he patients patients treating doctor determines the readiness for *he discharge policies and procedures are documented to

s are in place for patients lea"ing against medical ad"ice%

*he &C= has a documented olic for the the < < cases% cases% *he gi"en to all the patients lea"ing the organi$ation (including *he &C= hands o"er the medical ad"ice)% discharge papers to the

pro"ided to the patients at the time of discharge%

elf e,planatory

ntains the reasons for admission significant findings and nt.s condition at the time of discharge%


ntains information regarding regarding in"estigation results any edication and other treatment gi"en%


ntains follo' up ad"ice medication and other instructions in elf e,planatory e,planatory ner% orporates instructions instruct ions about 'hen and ho' to obtain urgent *he &C= should outline conditions regarding H'henH to obtain urgent care ;or e,ample mmar mary of the the case case also lso incl inclu udes des the the caus cause e of death ath%

elf elf e,plan plana ator tory

0i+e+ b, the applicable la.s" e*0lations an+ 'hen similar care is pro"ided in more than one setting%

*he organisation shall ensure that patients 'ith the same health problems and care needs recei"e the same quality of healthcare throughout the organi$ation irrespecti"e of the category of 'ard%

by policies and procedures procedures 'hich reflect applicable la's


orders are signed named timed and dated by the

elf e,planatory *reatment orders must be 'ritten daily%

rsigned by the clinician in-charge in-charge of the patient 'ithin 23

*he treatment of the patient could be initiated by a unior doctor but

ne and clinical practise guidelines are adopted to guide ossible%

*he organi$ation could de"elop clinical protocols based on these

n+ e*0lations) for emergency care are documented%

re in consonance 'ith the policies%

*hese could iclude =Psprotocols to pro"ide either *he policy shall be in line 'ith statutary requirements '%r%t% elf e,planatory

s guide the triage of patients for initiation of appropriate appropriate


andling of medico-legal medico-legal cases%

policies and trained on the procedures procedures for care of

ll the staff 'or7ing in the casualty should be oriented to the

to home or transfer to another organisation organisation is also


vi+e+ b, the o*anisation) ss and space f or the ambulance(s)% riately equipped% d by the trained personnel ll equipment and emergency medications% medication s% on a daily basis% s are chec7ed daily and prior to dispatch% a proper communication system%

*he organi$ation shall demarcute a proper space for ambulance (s)% *his shall be done based on the organi$ations scope% *he ambulance should be manned by a trained dri"er *he organi$ation shall de"elop a chec7list and ensure that the *his shall include both the ambulance the equipments 'ithin elf e,planatory% *his also includes chec7ing the e,piry date *he ambulance shall be connected 'ith the

es0scitation) nd procedures guide the uniform use of resuscitation tion% tient care is trained and periodically update in cardio % rdio pulmonary resuscitation are recorded% f all cardiac asserts is done by a multidisciplinary multidisciplinary

*he organisation shall document the procedure for same% *his shall *hese aspects shall be co"ered by hands on training% /f the /n the actual e"ent of a CP or a moc7 dril of the same all the *he analysis shall include the cause steps ta7en to resuscitate

"e measures are ta7en based on the post-e"ent analysis%

elf e,planatory

nd procedures are used to guide rational use of blood and

*his shall address the conditions 'here blood and conditions 'here

s are go"erned by the applicable la's and regulations%

efer to 6rugs and Cosmatics act%

ained for donation and transfusion of blood and blood

Consent should be ta7en for e"ery transfusion% &o'e"er 'ith

includes patient and family education about donation%

self e,planatory

ment the policies%

*his shall include doctors and be done either by training andor by *he organi$ation shall ensure that any transfusion reaction is

re analysed for pre"enti"e and correcti"e actions%

i*h #epen+enc, $nits) ocumented admission and discharge criteria for its intensi"e *he organi$ation should de"elop ncy units% obecti"e criteria and adhere to it% these criteria% ipment are a"ailable% situation of bed shortages are follo'ed% es are follo'ed% gramme is implemented%

*his shall be done by training by deplaying the criteria% *he /C8 should be equipped 'ith all necessary life sa"ing and s and 'hen there are no "acant beds in the /C8 and there is a *hese could be de"eloped indi"idually or it could be a part of *hese could be de"eloped indi"idually or it could be a part of

ll, an+2 o mentall, challen*e+ an+ chil+en() s are documented and are in accordance 'ith the pre"ailing elf e,planatory nd international guidelines% eli"ered in accordance 'ith the policies and procedures%

&C= de"elops =Ps for deli"ery of care

es for a safe and secure en"ironment for this "ulnerable

*he organi$ation shall pro"ide proper en"irnment ta7ing into

re e,ists for obtaining informed consent from the entati"e%

*he informed consent for this group of people should be

or this "ulnerable group%

ll staff in"ol"ed in the care of this group shall be adequately trained

s and displays 'hether high-ris7 obstetric cases be cared

*he organi$ation shall define as to 'hat constitutes high ris7

-ris7 obstetric cases are competent%

*hese shall not ust be doctors but shall include nursing staff

nt.s assessment also includes maternal nutrition%

elf e,planatory

for high ris7 obstetric cases has the facilities to ta7e care es%

*he organi$ation shall ha"e a N/C8 'ith proper equipments and

s and displays the scope of its dediatric ser"ices%

*he scope shall also include neonatal ser"ices if any%

eonatal patients is in consonance 'ith the national %

elf e,planatory

ldren ha"e age specific competency%

*hese shall not ust be for doctors but shall include nursing staff

r special care of children%

dequate amentities for the care of infants and children to be

ludes detailed nutritional gro'th psychosocial and ent%

el e,planatory

s pre"ent child neonates abduction and abuse%

*he &C= shall ensure that there is an adquate

embers are educated about nutrition immuni$ation and is documented in the medical record%

self e,planatory%

ation) persons perform sedation% ng and monitoring sedation is different from the person re%

4hene"er parenteral route is used this shall be carried out by a self e,planatory

oring includes at a minimum the heart rate cardiac rhythm elf e,planatory *he same ressure and o,ygen saturation and le"el of sedation% should be documented after sedation%

*he patients "itals shall be monitored at regular inter"als (as

ermine appropriateness of discharge from the reco"ery

*hese shall be de"eloped by the organi$ation in consonance 'ith

er are a"ailable to rescue patients from a deeper le"el of ded%

*he equipments shall include emergency resuscitation

policy and procedure for the administration of anesthesia%

&C= shall document on the indications the type of

sia ha"e a pre-anesthesia assessment by a qualified

*his shall be done before the patient is 'heeled into the =*

essment results in formulation of an anesthesia plan 'hich elf e,planatory ti"e re-e"aluation is documented%

this shall be done by an anaesthesiologist ust before the

ministration of anesthesia is obtained by the anesthetist%

elf e,planatory

itoring includes regular and periodic recording of heart rate elf e,planatory ory rate blood pressure o,ygen saturation air'ay security f anesthesia%

sthesia status is monitored and documented%

*his shall be done in the reco"ery area=* and at least include

plies defined criteria to transfer the patient from the

*he organi$ation documents these criteria 'hich should be in

e"ents are recorded and monitored%

ll such e"ents are documented and monitored for the purpose of

e+0es) ures are documented%

*his shall include the list of surgical procedures as 'ell as

reoperati"e assessment and a pro"isional diagnosis rgery%

ll patients undergoing surgery are assessed pre operati"ely and

obtained by the surgeon prior to the procedure%

elf e,planatory

nd procedure e,ist to pre"ent ad"erse e"ents li7e 'rong 'rong surgery%

Procedure should be a"ailable for pre"enting ad"erse e"ents li7e

are permitted to perform the procedures that they are

*he &C= identifies the indi"iduals 'ho ha"e the required

documented prior to transfer out of patient from reco"ery

*his note pro"ides information about the procedure performed

documents the post operati"e plan of care%

elf e,planatory%

gramme is follo'ed for the surgical sur"ices%

*his be an integral part of the &C=s o"erall quality assurance

rogram includes sur"eillance of the operation theatre

ur"eillance acti"ities include monitoring the quality of air

monitoring of surgical site infection rates%

elf e,planatory%

an+2 o chemical() nd procedures guide the care of patients under restraints%

*his shall clearly state the conditionsCircumstances under

sical and chemical restraint measures%

Physical restraints include bo,ers bandage use of cuffs ec%

tation of reasons for restraints%

elf e,planatory%

e frequently monitored%

*he organi$ation shall specify the parameters and frequency of

d periodic updating in control and restraint techniques%

elf e,planatory%

nd procedures guide the management of pain%

*he &C= shall define the group of patients for 'hom this is

cts and supports the appropriate assessment and r all patients%

elf e,planatory%

ducated on "arious pain management techniques%

elf e,planatory%

nd procedures guide the pro"ision of rehabilitati"e ser"ices% elf e,planatory% mensurate 'ith the organi$ational requirements%

*he scope of the departments is in consonance 'ith the scope of

are pro"ided by a multidisciplinary team%

*he team shall ha"e treating doctor rehabilitation therapist

nd procedures guide all research acti"ities in compliance ational guidelines%

elf e,planatory%

thics committee to o"ersee all research acti"ities%

n ethics committee should be framed in the hospital to monitor

'ers to discontinue a research trial 'hen ris7s out'eigh the

elf e,planatory%

t is obtained before entering them in research protocols%

elf e,planatory%

f their right to 'ithdra' from the research at any stage and es (if any) of such 'ithdra'al%

elf e,planatory%

at their refusal to participate or 'ithdra'al from mpromise their access to the organi$ation.s ser"ices%

elf e,planatory%

nd procedures guide nutritional assessment and

elf e,planatory%

ccording to their clinical needs%

 dietician shall do the assessment of the patient in

for the diet%

*he dietician shall prepare this in the form of a diet sheet and

lanned and pro"ided in a collaborati"e manner%

*he dietician shall ensure that this is planned in consultation 'ith the

ood they are educated about the patients diet limitations%

*he dietician  nurse shall ensure this planning%

led stored and distributed in a safe manner%

*he dietary ser"ices to be designed in a manner that there is

nd procedures guide the end of life care%

*he &C= has a documented policy for pro"iding care to

edures are in consonance 'ith the legal requirements%

elf e,planatory%

identification of the unique needs of such patient and

*he religious and socio-cultural beliefs of patients family shall be

siti"ely addressing issues such as autopsy and organ

/f the body of the deceased is subected to an autopsy or for

ained in end of life care%

elf e,planatory%

a*e of me+ication) policy and procedure for pharmacy ser"ices and applicable la's and regulations% ittee guides the formulation and implementation of these %

*he polices and procedures shall address the issues related to elf e,planatory% *his shall be representati"e of maor clinical departments

ropriate for the patients and organi$ation.s resources is

*he hospital formulary shall be prepared and be preferably

llaborati"ely by the multidisciplinary committee%

efer to <=< 1c%

ess for acquisition of these medications%

*he process should address the issues of "endor selection"endor

btain medications not listed in the formulary%

elf e,planatory

nd procedures e,ist for storage of medication%

*hese should address issues pertaining to temperature

in a clean 'ell lit and "entilated en"ironment%

*he organi$ation shall also ensure that the storage

l practices guide storage of the medications%

elf e,planatory

ed from loss or theft%

*he orani$ation shall ensure that it de"elops proper mechanisums

li7e medications are stored separately%

tain medication 'hen the pharmacy is closed% s are a"ailable all the time%

'hen pharmacy is closed  there should be =P to procure the

s are replenished in a timely manner 'hen used%

dequate amount of emergency medicines should be stoc7ed at self e,planatory

nd procedures e,ist for prescription of medications%

self e,planatory

ines 'ho can 'rite orders% uniform location in the medical records%

this shall be done by the treating doctor% all the orders for medicines are recorded on a uniform location of

lear legible dated timed named and signed%

elf e,planatory

is documented and implemented%

*he organi$ation shall ensure that it has a policy to address as to

s a list of high ris7 medication%

&igh ris7 medications are medications in"ol"ed in a high

ders are "erified prior to dispensing%

*hese medications shalll preferably be gi"en only arter

nd procedures guide the safe dispensing of medications%

Clear policies to be laid do'n for dispensing of medication e%g%

rocedure for medication recall%

ecall may result based on letters from regulatory authoroties or

d prior to dispensing%

elf e,planatory

are documented and implemented by the organi$ation%

t a minimum labels must include the drug name

stered by those 'ho are permitted by la' to do so%

elf e,planatory

e labeled prior to preparation of a second drug%

elf e,planatory

r to administration%

elf e,planatory

om the order prior to administration%

taff administering medications should go through the treatent

the order prior to administration%

elf e,planatory

e order prior to administration%

elf e,planatory

he order prior to administration%

elf e,planatory

on is documented%

*he organi$ation shall ensure that this is done in a uniform location

go"ern patient.s self administration of medications%

t the outset the &C= could define if it 'ould permit self

go"ern patient.s medications brought from outside the

*hese shall address ass to 'hat are the pre-requisites for such a

0* inteactions)

ducated about safe and effecti"e use of medication%

*he organi$ation shall ma7e a list of such drugs and accordingly

ducated about food-drug interactions%

Patient and family should be counselled about their diet during

after medication administration and this is documented%

*his shall be done by anyone in"olced in direct patient care% *he

e defined%

*he organi$ation shall define as to 'hat constitutes an ad"erse

e reported 'ithin a specified time frame%

elf e,planatory e,planatory *he organi$ation shall define the

e collected and analysed%

ll the ad"erse ad"erse drug reaction reaction are analysed regularly by the multi-

reduce ad"erse drug e"ents 'hen unacceptable unacceptabl e trends

elf e,planatory

bstances) nd procedures guide the use of narcotic drugs and s%


nsonance 'ith local and national regulations%

*his is in conte,t of narcotic drugs and psychotropic substances act%

of the usage administration and disposal of these drugs%

*hese shall be 7ept in accordance 'ith statutory requirements% requirements%

d by appropriate personnel in accordance 'ith policies%


nd procedures guide the usage of chemotherapeutic chemotherape utic

elf e,planatory

ribed by those 'ho ha"e the 7no'ledge to monitor and treat *his shall preferably be a medical emotherapy% oncologist or a person 'ho has red and administered by qualified personnel%

*his shall preferable be staff 'ho ha"e recei"ed special trainig in

re disposed off in accordance 'ith legal requirements% requirements%

*hese shall be disposed off according to Aio-medical 'aste

nd procedures go"ern usage of radioacti"e drugs%


edur edures es are are in cons conson onan ance ce 'ith 'ith la's la's and and regu regula lati tion ons% s% ures include the safe storage preparation preparation handling al of radioacti"e drugs% drugs% rs are educated on safety precautions%

efe eferr to !A !A guid guidel elin ines es%% elf e,planatory% *his shall ho'e"er be in accordance 'ith elf e,planatory e,planatory

nd procedures go"ern procurement and usage of

elf e,planatory

prosthesis is based on scientific criteria and national ed appro"als%

*he organisation shall ensure that rele"ant and sufficient scientic

mber of the implantable prosthesis prosthesis are recorded in the and the master logboo7%


nd procedures go"ern procurement handling storage replenishment replenishment of medical gases%

*his shall be applicable to all gases used in the organi$ation % /t

ures address the safety issues at all le"els%

*his shall include from the point of storagesource area gas supply

maintained in accordance 'ith the policies procedures

*his is the conte,t of the /ndian e,plosi"es act of 1EE3 ?as

%

sponsibilities +0in* cae) s and responsibilities responsibilities are documented% e informed of t heir rights and responsibilities in a format can understand% ers protect patients and family rights% sponsibility in protecting patients and family rights% family rights is recorded re"ie'ed re"ie'ed and correcti"e 7en%

&ospital should respect patientsrights patientsrights and inform them of self e,planatory% Protection also includes addressing patientHs grie"ances grie"ances *raning and sensitisation programmes shall be conducted 4here patientHs rights ha"e been infringed uponmanagement must

ient an+ famil, in +ecision
*his could include dietary preferences and 'orship

s include respect for personal dignity and pri"acy during s and treatment%

6uring all stages of patient carebe it in e,amination or

s include protection from physical abuse and neglect%

elf e,planotry% pecial precautions shall be ta7en

s include treating patient information as confidential%

elf e,planatory% statutory requirement '%r%t% '%r%t% pri"ilged

s include refusal of treatment%

6uring management the patients should be gi"en the choice of self e,planatory e,planatory

s include informed consent before anaesthesia blood and ons and any in"asi"e high-ris7 procedures treatment% include information informati on and consent before any research s include information on ho' to "oice a complaint%

*he organi$ation shall ensure that international conference on ?rie"ance redressal mechanism must be accesssible and

s include information on the e,pected cost of the treatment% efer C3d% a right to ha"e an access to his her clinical records%

*he organi$ation shall ensur that e"ery patient has access to

 infome+ +ecision makin* abo0t thei cae) atment is obtained 'hen the patient enters the organisation% elf e,planatory e,planatory ily members are informed of the scope of such general

*he organi$ation organi$ation shall difine as to 'hat is the scope of this consent

ted those situations 'here informed consent is required% required%

 list of of procedures should should be made for 'hich informed consent

es information on ris7s benefits alternati"es alternati"es and as to uisite procedure in a language that they can understand%

*he consent shall ha"e the name of the doctor performing the procedure% procedure% /f it is a Hdoctor under

o can gi"e consent 'hen patient is incapable of a7ing%

*he organisation shall ta7e into consideration the statutory norms%

th cae nee+s) ent and families and are educated about the safe and tion and the potential side effects of the medication%

elf e,planatory%

educated about diet and nutrition

elf e,planatory%

educated about immunisations%

elf e,planatory%
educated about their specific disease process ention strategies% educated about pre"enting infections%

elf e,planatory%

taught in a language and format that they can understand% elf e,planatory e,planatory%

policy in a gi"en setting (out-patient and 'ard category)%

*here should be a billing policy 'hich defines the charges to be

to patients%

*he organi$ation shall ensure that

educated about the estimated cost of treatment%

efer to C3d%

informed about the financial implications 'hen there is a ndition or treatment setting%

4hen patients are shifted from one setting to another typically to and form /C8s /C8s the financia financiall

n contol po*amme aime+ at e+0cin*2 ontrol programme is documented 'hich aims at pre"enting socomial infections%

elf e,planatory%

i-disciplinary i-disciplinary infection control committee%

*his shall preferably ha"e &ospital dministrator urgeon

ction control team%

*he team is responsible for dayto-day functioning of infection

ated and qualified infection control nurse(s) for this acti"ity% *he qualification shall be either a graduate nurse or qualified nurse

+) e "arious high-ris7 areas and procedures%

*he manual should clearly identify the high ris7 areas of the hospital

ur"eillance in the identified high-ris7 areas%

/t shall define the frequency and mode of sur"eillance% *he

e to standard precautions at all times%

elf e,planatory%

d sterilisation practices are included%

/t shall address this at all le"els e% g% 'ard =* and C6% /t is

c policy is established and implemented%

*he &C= shall de"elop a system of monitoring drug susceptibility

agement processes are also included%

*he laundry can be in-house or outsourced% /f outsourced the

ood handling issues are included in the manual%

elf e,planatory% *he same shall be applicable e"en if this acti"ity /ssues such as air conditioning plant and equipment

pre"ent infections are included%

procedures are included as appropriate to the organi$ation% *he mortuary ser"ices in the hospital should be pro"ided s the periodicity of updating the infection control manual% *he organi$ation must ha"e a documented policy on the

aeas of the hospital) re appropriately directed to'ards the identified high-ris7

*he organi$ation must be able to pro"ide e"idence of conducting

data is an ongoing process

*he organi$ation shall ensure that it has a process in place to collect

on regular basis by the infection control team ses information (in rele"ant format) is sent to appropriate

cti"ities incorporates trac7ing and analy$ing of infection

*he data so collected shall be authenticated by the team by *he organi$ation shall identity all notifiable diseases after ta7ing *his shall be done at regular inter"als (maybe monthly and

clude monitoring the effecti"eness of house7eeping ser"ice *his 'ould include categori$ation of areassurfacesK general

ate+ Infections '=AI( in patients an+ ors urinary tract infections%

*his can be done either by sending urine or catheter tip for

ors respiratory tract infections%

*his can be done by sending sputum or !* tracheostomy

ors intra-"ascular de"ice infections%

;or patients 'ith symptoms suggesti"e of intra "ascular *his shall be done by sending puss'ab for culture%

ors surgical site infections% egarding &/ rates are pro"ided on a regular basis to ff%

*he feedbac7 shall include the rates% *rends and opportunities

contol po*amme) in all patient care areas are accessible to health care

*he organi$ation shall ensure that it pro"ides necessary

r hand 'ashing is monitored regularly%

*he organi$ation shall preferably display the necessary instruction

g facilities are a"ailable%

*he organi$ation shall define the conditions 'here the same shall s soaps and disinfectants are a"ailable and used correctly% elf e,planatory% *he should be a"ailable at the point of use and

nted procedure for handling such outbrea7s%

*his shall incorporate definitions as to 'hat constitutes an

mented during outbrea7s%

*he organi$ation should be able to identify the outbrea7 describe

er appropriate correcti"e actions are ta7en to pre"ent

*he organi$ation should be able to implement basic procedures to

) e a"ailable for sterili$ation acti"ities%

dequacy of space refers to the C6 'hich should ha"e an area

for sterilisation are carried out and documented%

*his shall be done by accepted method e%g% bacteriologic strips

recall procedure 'hen brea7do'n in the sterilisation

*he organi$ation shall ensure that the sterili$ation procedure is

complie+ .ith) ed by prescribed authority for the management and l 4aste%

*he occupier shall apply in the prescribed form and get appro"al

collection of Aio-medical 4aste from all patient care areas 4astes to be segregated and ented and monitored% collected in different colour coded es that Aio-medical 4aste is stored and transported to the sposal in proper co"ered "ehicles 'ithin stipulated time er%

*he 'aste is transported to the pre-defined site at definite time inter"als (
tment facility is managed as per statutory pro"isions (if inauthorised contractor(s)%

/f the hospital has 'aste treatment facility 'ithin its

nts and reports are submitted to competent authorities on

*he &C= shall ensure that the fees are deposited in a timely

rotecti"e measures are used by all categories of staff aste%

elf e,planatory%

ent an+ incl0+es tainin* of staff an+ a7es a"ailable resources required for the infection control *he &C= shall ensure that the resources required by the armar7s adequate funds from its annual budget in this

*here shall be a separate budget demarcated for &/C acti"ity% *his

induction training for appropriate categories of staff before rtment(s)%

*here must be a documented e"idence of pre-induction training

Bin-ser"ice training sessions for all concerned categories a year%

elf e,planatory%

st e,posure prophyla,is is pro"ided to all concerned staff

elf e,planatory%

me in the o*ani;ation) t programme is de"eloped implemented and maintained ommittee% t programme is documented%

*his committee shall ha"e representation from management *his should be documented as a manual% *he manual shall incorporate the mission"isionquality obecti"es ser"ice standardsimportant indicators as identified etc% *he manual could be stand alone and should ha"e cross lin7ages 'ith other manuals%

ndi"idual for coordinating and implementing the quality e *his should preferably be a person ha"ing a good 7no'ledge of accreditation standards statutory equirements hospital quality impro"ement principles and e"aluation methodologieshospital functioning and operations t programme is comprehensi"e and co"ers all the maor lity impro"ement and ris7 management%

*he shall preferably co"er all aspects including documentation of the programme monitoring it data collection re"ie' of policy and correcti"e action%lso refer to CD/ 1b%

me is communicated and coordinated amongst all the i$ation through proper training mechanism%

elf e,planatory

t programme is re"ie'ed at predefined inter"als and ement are identified%

s quality impro"ement is a dynamic process it needs to be re"ie'ed at regular pre-defined inter"als (as defined by the &C= in the quality impro"ement manual but at least once in four months) by conducting internal audits% *his audits shall be done by a multi-disciplinary team (preferable trained in NA& standards) and obecti"e elements%t the end of the audit there shall be a formal meeting to summarise the findings and identity areas for impro"ement% 6uring this meeting there shall be an analysis of 7ey indicators as identified and determined by the organi$ation including the mandatory indicators as laid do'n in CD/ 2 and J% *he minutes of the re"ie' meetings should be recorded and maintained%

t programme is a continuous process and updated at least elf e,planatory% *he inputs for updation could be based on the re"ie' carried out by the quality impro"ement committee%

cesses an+ o0tcomes .hich ae 0se+ as ropriate patient assessment%

*he &C= shall de"elop appropriate 7ey performance indicators suitable to it% *he follo'ing is ho'e"er mandatory:i% *ime for initial assessment of indoor and emergency patients%ii% Percentage of cases 'herein care plan is documented and counter-signed by the clinician%iii% Percentage of cases 'herein screening for nutritional needs has been done%i"% Percentage of cases 'herein the pre-defined intial nursing assessment is completed 'ithin J0 monutes%

ety and quality control programmes of the diagnostics

*he &C= shall de"elop appropriate 7ey performance indicators suitable to it % *he follo'ing is ho'e"er mansatory : i% Number of reporting errors1000 in"estigationa ii% Percentage of re-dos% iii% Percentage of reports co-relating 'ith clinical diagnosis% i"% Percentage of adherence to safety precautions by employees 'or7ing in diagnostics%

in"asi"e procedures%

*he &C= shall de"elop appropriate 7ey performance indicators suitable to it % *he follo'ing is ho'e"er mansatory :i% e-e,ploration rate ii% Percentage of accidental remeo"al of tubes and catheters iii% /ncidence of haematoma at puncture site i"% Percentage of re-scheduling of procedures%

erse drug e"ents%

*he &C= shall de"elop appropriate 7ey performance indicators suitable to it% *he follo'ing is ho'e"er mndatroy: i% Percentage of medication errors%ii% /ncidence of ad"erse drug reactions iii% Percentage of medication charts 'ith illegible 'riting o"er a gi"en period% i"%

of anaesthesia%

*he &C= shall de"elop appropriate 7ey performance /ndicators suitable to it % *he follo'ing is ho'e"er mandatory : i% Percentage of modification of anaesthesia plan%

of blood and blood products%

ilability and content of medical records%

*he &C= shall de"elop appropriate 7ey performance indicators suitable to it% *he follo'ing is ho'e"er mansatory :i% Percentage of transfusion reactions% ii% Percentage of 'stage of *he &C= shall de"elop appropriate 7ey performance indicators suitable to it% *he follo'ing is ho'e"er mandatory i% Percentage of medical records not ha"ing discharge summary% ii% Percentage of medical

ction control acti"ities%

*he &C= shall de"elop appropriate 7ey performance

ical research%

*he &C= shall de"elop appropriate 7ey performance indicators suitable to it% *he follo'ing is ho'e"er mandatory:i% Number of research acti"ities being carried out% ii% Percentage of patients

a collection to support further impro"ements%

*he data could be collected at pre-defined inter"als e%g% monthlyquaterly% *his data is analysed for impro"ement opportunities and the same are carried out%lso refer to CD/ 1f

a collection to support e"aluation of these impro"ements%

ll impro"ement acti"ities carried out by the &C= shall ha"e an

" pocesses an+ o0tcomes .hich ae 0se+ as

curement of medication essential to meet patient needs%

*he &C= shall de"elop appropriate 7ey performace

orting of acti"ities as required by la's and regulations%

*he &C= shall de"elop appropriate 7ey performace indicators suitable to it% *he follo'ing is ho'e"er mandatory: i% Number of birthes and deaths% ii% Numberof notifiable diseases% iii% ubmission of reportdataform pertaining to biomedical 'astePN6* act and radiation safety 'ithin the defined timeframe% i"% ubmission of ta, returns and deduction of ta,es at the specified time frame%

management% isation of space manpo'er and equipment%

*he &C= shall de"elop appropriate 7ey performace *he &C= shall de"elop appropriate 7ey performace

ient satisfaction 'hich also incorporates 'aiting time for


ployee satisfaction%


erse e"ents and near misses%


a collection to support further study for impro"ements%

*he data could be collected at pre-defined inter"als e%g%

a collection to support e"aluation of these impro"ements%

elf e,planatory% *he inputs for updations could be based on the

a7es a"ailable adequate resources required for quality e%

*his shall include the men materialmachine and

uate funds from its annual budget in this regard%

ppropriate fund allocation is done by the organi$ation for the

nd management tools are applied 'hene"er required%

elf !,planatory

ff participates in this system%

*he &C= shall identify such personnel% /t could be a mi, of

udited are defined by the organisation%

s these audits are retrospecti"econcurrent in nature

mity is maintained%

*his means that the names of the patients and the hospital staff 'ho elf e,planantory

ted%

implemented%

ll remedial measures as ascertained should be

efined sentinel e"ents%

*he sentinel e"ents relating to

stablished processes for intense analysis of such e"ents%

*he established processes should include reporting the occurrence

nsi"ely analysed 'hen they occur%

oot cause analysis of all such

"e ctions are ta7en based on the findings of such analysis% *he findings and recommendations arri"ed at after

o"ernance lay do'n the organi$ation.s mission statement%

/t is not only the head of the &C= but te members of the board of

o"ernance lay do'n the strategic and operational plans rgani$ation.s mission in consultation 'ith the "arious sta7e

*he ?o"erning boars and the leaders of &C= shall define and de"elop the processs for strategic

o"ernance appro"e the organi$ation.s budget and allocate to meet the organi$ation.s mission%

*he ?o"erning boars and the leaders of &C= shall ha"e the olic for bud etin and resource *he ?o"erning boars and the leaders of &C= shall de"elop

o"ernance monitor and measure the performance of the stated mission% o"ernance establish the organi$ation.s organogram%

*he &C= shall ha"e a 'ell defined organi$ation

o"ernance appoint the senior leaders in the organi$ation%

elf e,planatory

o"ernance support research acti"ities and quality impro"em elf e,planatory lies 'ith the laid do'n and applicable legislations and regula elf e,planatory *he responsibility of compliance lies 'ith the first t'o le"el of the o"ernance address the organi$ation.s social responsibility% *he ?o"erning board and &ead of the &C= shall 'illfully de"elop social res onsibilit olic and

gram ser"ice site or department has effecti"e leadership%

*here needs to be a minimum essential qualification and

ch department is defined%

!ach department.s acti"ity is to be predefined% *his could be

and procedures for each department is maintained%

*his shall include administrati"e procedures li7e attendance elf e,planatory

re in"ol"ed in quality impro"ement%

ic the mission statement of the organi$ation% e organi$ation.s ethical management% ses its o'nership% tly portrays the ser"ices 'hich it can and cannot pro"ide% tly portrays its affiliations and accreditations% ately bills for it.s ser"ices based upon a standard billing

al has requisite and appropriate administrati"e

*he &C= shall ha"e a mission statement and the same shall be *he &C= shall function in an ethical manner% *he o'nership of the hospital e%g%trust  pri"ate pulic has to be elf e,planatory &ere portrays implies that the &C= con"eys its elf e,planatory

elf e,planatory

al has requisite and appropriate administrati"e e,perience% elf e,planatory

n inte*al pat of patient cae an+ hospital n interdisciplinary group assigned to o"ersee the hospital %

elf e,planatory

mme is defined to include ad"erse e"ents ranging from Bno *he &C= shall ha"e a system of ts% reporting of all the mplementation of systems for internal and e,ternal process failures%

*he &C= has a system in place for internal and e,ternal reporting

resources for proacti"e ris7 assessment and ris7 reduction

*here shall be sufficient resources 7ept as contingency to

ons" la.s an+ b,ela.s an+ e70isite facilit, n"ersant 'ith the la's and regulations and 7no's their ni$ation%

 designated management functionary has been gi"en the

updates any amendments in the pre"ailing la's of the land% elf e,planatory res implementation of these requirements%

elf e,planatory

o regularly update licenses registrationscertifications%

elf e,planatory

nts" thei families" staff an+ visitos) operational and maintenance (pre"enti"e and brea7do'n)

elf e,planatory

e maintained 'hich detail the site layout floor plans and fire  designated person maintains the dra'ings% ternal sign posting in the organisation in a language families and community%

elf e,planatory

shall be in accordance 'ith the a"ailable literature on good elf e,planatory rnational tandards) and directi"es from go"ernment di"iduals responsible for the maintenance of all the ntactable round the cloc7 for emergency repairs%

 Person in the &C= management is designated to be elf e,planatory

nitored from reporting to inspection and implementation of  Complaint attendance register is to be maintained to indicate the

na*ement) for equipment in accordance 'ith its ser"ices and strategic elf e,planatory% *his shall also ta7e into consideration future y a collaborati"e process%

Collaborati"e process implies that during equipment selection there

ried and proper logs are maintained as required%

elf e,planatory

rsonnel operate and maintain the equipment%

elf e,planatory

ally inspected and calibrated for their proper functioning% operational and maintenance (pre"enti"e and brea7do'n)

*he &C= has 'ee7lymonthlyannual schedules elf e,planatory

vac00m s,stems) ricity are a"ailable round the cloc7%

rly tests the alternate sources%

*he &C= shall ma7e arrangements for supply of lternate electric supply could be form 6? ets% olar ener % 8P elf e,planatory%

plan for piped medical gas compressed air and "acuum

elf e,planatory%

ro"ided for in case of failure%

es) lans and pro"isions for early detection containment and on-fire emergencies% documented safe e,it plan in case of fire and non-fire

*he &C= has a fire and non-fire emergency committee (;N!C) to . be displayed ;ire e,it plan shall on each floor particularly close to

role in case of such emergencies% east t'ice in a year

/n case of fire designated person are assigned particular 'or7% elf e,planatory%

s and implement its polices to reduce or eliminate smo7ing% mo7ing in public places including hospitals has been banned in this ns for granting e,ceptions for patients and families to

/n "ie' of the la' permission to smo7e 'ithin the campus of

the +isastes) otential emergencies%

*he &C= has a documented plan and procedure for handling the

documented disaster management plan%

*he disaster plan must incorporate essential elements of

"ailability of medical supplies equipment and materials es%

esource a"ailability should be according to threat perception%

in the hospital.s disaster management plan%

st t'ice in a year%

elf e,planatory%

e identified 'ithin the organi$ation%

*he &C= has identified and listed the ha$ardous materials and has

s processes for sorting labelling handling storage al of ha$ardous material%

*he &C= has conducted an e,ercise of ha$ard identification

uirements are met in respect of radioacti"e materials%

*he appropriate personnel in the &C= are a'are about the rules

aging spills of ha$ardous materials%

elf e,planatory%

ained for handling such materials%

elf e,planatory%

ent) ty committee to identify the potential safety and security

*he &C= has a duly constituted safety committee 'hich has

ates de"elopment implementation and monitoring of the %

*he &C= ensures that the abo"e committee functions on a regular

re installed across the organi$ation and inspected

elf e,planatory

ds to ensure safety are conducted at least t'ice in a year in ounds to be carried out by at least once in a year in non-patient care areas% safety committee% ocumented and correcti"e and pre"enti"e measures are

elf e,planatory%

tion programme for all staff%

elf e,planatory%

ains an adequate number and mi, of staff to meet the care *he staff should be eeds of the patient% commensurate 'ith the 'or7load ications and ob description are 'ell defined for each

*he content of each ob should be 'ell defined and the

s the antecedents of the potential employee 'ith regards to elf e,planatory 7ground%

vionment) ployee student and "oluntary 'or7er is appropriately tion.s mission and goals%

*he organi$ation.s staff including the outsourced staff should be

ade a'are of hospital 'ide policies and procedures as 'ell *he organi$ation.s% staff including  unit  ser"ice  programme.s policies and procedures% the outsourced staff should be a'are and should correctly ade a'are of hisher rights and responsibilities% ated 'ith regard to patients. rights and responsibilities% ted to the ser"ice standards of the organisation%

*he &C= shall define the same in consonance 'ith statutory *he employees should be able to identify and report "iolation of *he &C= shall de"elop benchmar7s for different ser"ices

the staff) and de"elopment policy e,ists for the staff%

 training manual incorporating the procedure for identification of

en ob responsibilities change ne' equipment is

*he training should focus on the re"ised ob responsibilities as 'ell

for assessment of training and de"elopment programme

*his shall include both include both internal and e,ternal training%

b +0ties o esponsibilities elate+ to safet,) e ris7s 'ithin the hospital en"ironment% onstrate and ta7e actions to report eliminate  minimi$e

*he &C= shall define such ris7s 'hich shall include patient elf e,planatory%

e a'are of procedures to follo' in the e"ent of an incident% elf e,planatory% r common problems failures and user errors e,ist%

*he &C= has a defined procedure for reporting of these

an inte*al pat of the h0man eso0ce ormance appraisal system e,ists in the organi$ation%

elf e,planatory%

de a'are of the system of appraisal at the time of induction% elf e,planatory% ed based on the performance e,pectations described in ob elf e,planatory% used as a tool for further de"elopment%

elf e,planatory% *his can be done by identifying training

is carried out at pre defined inter"als and is documented%

elf e,planatory%

he policy of the organi$ation 'ith regard to discipline is in

elf e,planatory%

nd procedure is based on the principles of natural ustice%

*his implies that both parties (employee and employer) are gi"e

re is 7no'n to all categories of employees of the

elf e,planatory%

ure is in consonance 'ith the pre"ailing la's%

elf e,planatory%

appeals in all-disciplinary cases%

*he &C= shall designate an appellate authority to consider

are of the procedure to be follo'ed in case they feel

;or definition of grie"ance handling refer to glossary% *he

addresses the grie"ance%

elf e,planatory

ress the grie"ance%

elf e,planatory

ical e,amination is conducted on all the employees%

elf e,planatory% *his shall ho'e"er be in consonance 'ith

employees are ta7en care of in accordance 'ith the

elf e,planatory% *he shall be in consonance 'ith the lo' of the

of staff dealing 'ith direct patient care are done at-least dings results are documented%

elf e,planatory% *he result should be documented in the

$ards are adequately addressed%

elf e,planatory%

tained in respect of all employees%

elf e,planatory%

in personal information regarding the employees y bac7ground and health status%

elf e,planatory%

training and education are contained in the personal files esult of all e"alutions%

elf e,planatory% !"aluations 'ould include performance appraisals training

0cation" e*istation" tainin* an+ e?peience(

ermitted by la' regulation and the hospital to pro"ide er"ision is identified% tion training and e,perience of the identified medical ented and updated periodically%

*he &C= identifies the indi"iduals 'ho ha"e the required qualification (s) training and elf e,planatory% 8pdation is done after acquisition of ne' s7ills

rtaining to the medical professionals is appropriately "erified *he &C= shall do the same by "erifying the credentials from the

at patients an+ povi+e othe clinical sevices

dmit and care for patients as per the laid do'n policies and *he &C= shall identify as to 'hat s of the organi$ation% each medical professional is y the medical professionals are in consonance 'ith their d registration%

elf e,planatory%

o be pro"ided by the medical professionals are 7no'n to ious departments units of the hospital%

elf e,planatory%

0cation" e*istation" tainin* an+ e?peience( tion training and e,perience of nursing staff is documented *he &C= identifies the indi"iduals ly% 'ho ha"e the required rtaining to the nursing staff is appropriately "erified 'hen

*he &C= shall do the same by "erifying the credentials from the

i*nments to all n0sin* staff membes

ed to nursing staff is in consonance 'ith their qualification *he &C= shall identify as to 'hat % each nurse is authori$ed to do% y nursing staff are in accordance 'ith the pre"ailing la's o be pro"ided by the nursing staff are 7no'n to them as artments  units of the hospital%

elf e,planatory elf e,planatory

es" mana*ement of the o*ani;ation as .ell

of the organi$ation are identified and are appropriate to the *he &C= has manual andor eing pro"ided by the organi$ation and the comple,ity of the electronic &ospital /nformation ystem andor
 policy document is a"ailable 'here the &/
butes to e,ternal databases in accordance 'ith the la' and *he &C= shall define the system of releasing the rele"ant

tion are standardi$ed re a"ailable for analy$ing data% s are laid do'n for timely and accurate dissemination of s e,ist for storing and retrie"ing data%

managerial staff participates in selecting integrating and

*here is a multi-disciplinary committee 'hich is responsible

) as a unique identifier% tifies those authori$ed to ma7e entries in medical record%

*his shall also apply to records on digital media% &C= has a 'ritten policy stating 'ho all con ma7e entries%

ntry is dated and timed%

elf e,planatory%

can be identified%

*his could be by 'riting the full name or by mentioning the

l record are identified and documented%

*he &C= identifies 'hich documents form part of the *he &C= shall decide the format for maintaining the continuity in

up-to-date and chronological account of patient care%

tains information regarding reasons for admission are%

elf e,planatory%

cedures performed are incorporated in the medical record% elf e,planatory rred to another hospital the medical record contains the elf e,planatory% /t is mandatory son for the transfer and the name of the recei"ing hospital% to mention the clinical condition of the patient before transfer is tains a copy of the discharge note duly signed by d personnel%

elf e,planatory

edical record contains a copy of the death certificate te and time of death%

elf e,planatory% *he &C= pro"ides the death certificate as

opsy is carried out the medical record contains a copy of

elf e,planatory%

cess to current and past medical record%

*he &C= pro"ides access to medical records to designated

n+ sec0it, of infomation) nd procedures e,ist for maintaining confidentiality security tion%

*he &C= shall control the accessibility to the <6

s are in consonance 'ith the applicable la's%

*his is the conte,t of /ndian !"idence ct /ndian Penal Code ures incorporate safeguarding of data record against loss ;or physical records the &C= ing% shall ensure that there is

ecti"e process of monitoring compliance of the laid do'n

*he &C= carries out regular auditsrounds to chec7

lopments in appropriate technology for impro"ing and security%

*he &C= shall re"ie' and update its technological features so as to

ation is used for the purposes identified or as required by ithout the patient.s authori$ation%

*he &C= shall define the procedure for pri"ileged

re e,ists on ho' to respond to patients physicians and quests for access to information in the medical record in al and national la'%

elf e,planatory% /n this conte,t the release of information in accordance 'ith the Code of

n)

nd procedures are in place on retaining the patient.s clinical *he &C= shall define the ation% retention period for each category ures are in consonance 'ith the local and national la's

ome of the related la's in this conte,t are Code of
ro"ides e,pected confidentiality and security%

*his is applicable for both manual and electronic system% ical records data and information is in accordance 'ith the 6estruction can be done after the retention period is o"er and after

e re"ie'ed periodically%

elf e,planatory%

esentati"e sample based on statistical principles%

*he &C= shall define the principles on 'hich sampling is

d by identified care pro"iders%

elf e,planatory

the timeliness legibility and completeness of the medical

elf e,planatory

ludes records of both acti"e and discharged patients%

elf e,planatory

nd documents any deficiencies in records%

elf e,planatory

nd pre"enti"e measures underta7en are documented%

elf e,planatory

erence bet'een the self n of Pre assessment%

&emak

*he needs of the community should be considered especially 'hen planning a ne' &C= or adding ne' ser"ices

Claims of ser"ices and e,pertise being a"ailable should actually be a"ailable% 6isplay in the form of brochures only is N=* acceptable% 6isplay should be at least bi-lingual%

dmission must be authori$ed by a doctor%

lso refer to C J% =rientation can be pro"ided by documentation training%

*hese patients include those 'ho ha"e come to the emergency but lso refer to C=P J%  doctor should accompany an unstable patient% *his shall include patients being transferred both for diagnostic

4ith regards to e,pected costs an estimate could be prepared and the

lso refer to &< 10a%

*his could be done by the treating doctor andor dietician% ;or definition of Bplan of care and Bclinical audit. refer to glossary% *his could also be done through

!"ery patient shall be reassessed at least once e"ery day by the treating *he nursing staff can document patients "itals%

;or e,ample a cardiac care &C= must necessarily ha"e facilities for ;or adequancy of qualification refer to NA% 112% *he policy should be in line 'ith standard precautions% *he disposal *he turnaround time could be different tests and could be decided /f it is not practical to establish the biological reference inter"al for a *he authority for control and the methods for control of such

*his could be as per =ccupational &ealth and safety
ll the statutory requirements are met 'ith li7e AC clearance ;or e,ample a neuro-science centre shall ha"e C* and </%

*he defined timeframe could be different for different type of tests% *he &C= shall define the critical results 'hich require immediate <=8 should be a"ailable for all outsourced acti"ities% ee C + f

*his could be done on the basis of entries either on case sheet or

;or e,ample 1) Nurses handling ta7ing o"er notes% 2) *ransfer

eferral could be for opinion comanagement ta7e o"er% /t could be

*his policy could address the reasons of < for an ossible

*he instruction shall be in a manner that the patient can easiliy understand and a"oid use of *his could be in the form of 'hiat medicines to ta7e 'hen to consult a doctor or bo' to see7 medical

;or e,ample consent before surgery pro"iding first aid to emergency patients and police intimation in cases of medicolegal cases% ;or electronic records the organi$ation shall ensure that the same in captured in the system% *he clinician in charge implies the treating doctor% ;or definitions of e"idence based medicine and clinical practise

lso refer to C5a%

Poisoning cases road traffic accidents patients 'ith coronary *his should be based on good clinical practices% ;or triage refer to

lso refer to C 13 and 15% *he discharge note shall incorporate

/n case a rapid turn around of the ambulance in required ('here

*he document could be displayed prominently in critical areas such as

*his could be done using the predefined procedural chec7list and by

6uring subsequent resuscitations it is preferable that implementation of

 good reference guide is the NA& standards for blood ban7s%

lso refer to P!J d and e% Consent for blood transfusion *his could be in the form of boo7letleaflet% ecords of the same should be a"ailable% ;or transfusion reactions refer to glossary%

 good starting point could be "arious national and international

?ood clinical practices include monitoring infection rates re-

efer to disability act mental act%

;or e,ample play room for children anti-s7id tiles for elderly ramps 'ith efer to P! Je% ecords of the same should be a"ailable%

*he display should be in a prominent location% efer to C 1b

/t is preferable that this is done by a dietician%

*he display should be in a prominent location% efer to C 1b *here are national and international guidelines a"ailable for the cases of

;or e,ample playroom and breast feeding room% *he same needs to be documented% !,amples could include identification tag unsuper"ised ;or e,ample gro'th chart immunisation chart etc% *his

*echnician shall not administer sedation

/n addition certain other parameters may be monitored on a case to

;or addition of anaesthesia refer to glossary% *he standard is not

*he plan should mention the type of anaesthesia the drug(s0 to be used

lso refer to P! Jd% *he same should be documented%

*his shall be done by the operating surgeon% lso refer to P! Jd% *he &C= should be able to demonstrable methods to pre"ent lso refer to &< 11b% /f it is documented by a person other than the chief operating *he plan shall include ad"ice on /> fluids medications care of 'ound

;or air conditioning of =* =* refer to the glossary ll the post operati"e patients shall be screened for the same%

ecords of the same should be a"ailable%

;or e,ample cancer painneuralgias and arthralgia% Pain assesssment and mangement could be carried out using a pain

;or e,amplepro"ision of ante natal and post natal e,ercises could form

;or e,ample /nternational conference on harmoni$ation (/C&) efer to schedule M of 6rugs and cosmetics act and /C< guidelines%

;or e,ample diabetic diet high protein diettotal parenteral nutrition

ecords of the same should be a"ailable%

ele"ant legislations include 6rugs and cosmetics ct food and 6rugs

;or e,ample pharmacotherapeutic committee%

;or e,ample local purchase%

>accines should preferable be 7ept in "accine refrigerators (/ce ined *he organi$ation shall follo' in"entory control practics li7e first in

the organi$ation can folllo' a method of storing drugs by generic it is preferable that the &C= has a 23 hours pharmacy%

refer to <=< 1a

*he organi$ation can e,plore the possibility of 'riting orders in bloc7

*his shall be done at alll le"els e%g% pharmacy 'ard etc *his is applicable to all dispensing areas 'herein medicines are

efer to statutory requiremenys% in addition to doctors nursing staff applicable for parenteral drugs /dentification shall be done by unique identification number( eg%

the records shall reflect the actual administration%;or e,ample if brand for e,ample slf administration of insulin%

efer to glossary for Had"erse drug e"entH

*his refers to the layoutlocation of radiaton 'aste pipesdelay 'aste

;or an e,ample of Hpatient responsibility refer to glossary%

!,amples of this include falling from the bedtrolley due to !,ample of this include <*Ppatients of tubeculosis or any /n case of refusal the treating doctor shall e,plain the consequences of /nformed consent of the patient is mandatory for doing &/> test%

*his cannot include conset for in"asi"e procedures for in"asi"e *he policy for &/> testing should follo' the national policy on &/>

;or e,ample hand 'ashing and a"oiding o"ercro'ding near the

eference documents could include Pre"ention of hospital acquired -

;or the composition of the team refer to 4&= P/C and C6C

/t is preferable for them to ha"e undergone a short term training

efer to glossary for standard precautions%

*he &C= could also refer to international guidelines 'hile

efer to glossary for air conditioning in =*% tandard precautions must be adhered to%

*he &C= should use a udicious mi, of acti"e and passi"e

efer to glossary for notifiable diseases%  simple calculation of infected patients (numerator) pro"ides only *his is applicable e"en if the house7eeping ser"ices are

*he &C= may e,tend this acti"ity to asymptomatic catheterised patients /t is preferable to use C6C definitions% /t is preferable to use C6C definitions% /t is preferable to use C6C definitions% *his could be in the form of a bulletinne'sletter%

=ptimal hand hygiene requirements includes large 'ashbasins hands

efer to glossary ofr isolationbarrier nursing%

*o define as to 'hat constitutes an outbrea7 the &C= should ha"e

*he &C= shall pro"ide for the same in all areas 'here sterili$ation 4&= recommends each load to ha"e a number content description *he &C= could ha"e a batch processing system 'ith date and

;or e,ample glo"es and mas7s protecti"e glasses go'ns etc%

6octors also need to be trained%

;or e,ample hepatitis A "accination and P!P for needle stic7 inury%

;or e,amples core committee quality impro"ement committee efer to C E C 11 C=P I C=P 12 and &/C 2 also% efer to guidelines for documentation%

;or e,ample accreditation coordinator quality management representati"e quality manager%

efer to glossary for definition of is7 management and Duality impro"ement%

*his could be bone throught regular training programme or printed materials

*he assessors shall be either trained internally or e,ternall in NA& standards% *hey shall assess areas independent of their area of 'or7

eporting errors need to be captured% /t is better if the organi$ation caputers these errors as errors pic7ed up before dispatching the reports and errors pic7ed after the dispatch of reports% *his includes transcription errors also% e-dos include tests 'hich needed to be repeated in "ie' of poor sample or improper positioning and in case of radiology also includes radiology also include films 'astage%*o capture co-relation it becomes mandatory that all in"estigation forms ha"e a

d"erse anaesthesia e"ents include e"ents 'hich happen during the procedure li7e hypo,ia arrhythmias cardiac arrest etc%

4astage includes blood products found unfit for use

efer to &/C 3 efer to /C< guidelines and ?CP for reporting time of serious ad"erse e"ents%

;or e,ample data can be collected to study the reasons for Be 6o.s in surgical patients 6ata could be represented graphically e%g% bar chartpie chart etc% ;or e,ample  once the reasons for Be 6o.s ha"e been analysed and

ocal purchase implies drugs purchased outside the formulary% ;or e,ample ta,  !P; notifiable diseasesbirths and deathsPN6* act !A guidelines etc%

4aiting time implies the time ta7en from the time that the patient

*he bedget could be earmar7ed based on pre"ious year.s spending% ;or e,ample oot cause analysis ;
*hese could be members of the core committeequality assurance *he auit shall encompass all aspects of care including clinical

*he &C= could use a chec7list 'ith the predefined parameters and the *his should preferably be done based on root cause analysis%

efer to ?lossary for definition of

;or definition of mission refer to glossary% efer to glossary for strategic and operational plans%ta7eholders include the community the

enior leaders include the first t'o rungs of the organogram /t is not only the &ead of the &C= but the members of the Aoard of *his shall include central legislations (e%g% 6rugs and Cosmetics act <*P act PN6* ;or e,amplefree camps outreach programmesadoption of "illages P&Cs etc%

;or e,amplenephrology department could do all acti"ities /t could be common for the entire &C=% *o effecti"ely implement this each department could ha"e its

;or definition of mission refer to glossary%  good reference guide is Bcode of medical ethics 2002 published by *he disclosure could be in the registration certificate quality &ere portrays implies that the that &C= con"eys to the patients clearly

lso refer to P! 5% *he tariff could be de"ised by a tariff committee%

*his implies to the indi"idual loo7ing after the day to day Aoard of ppropriate implies administrati"e e,perience in a &C=%

*he group could ha"e a mi, of administratorsgineers doctors and efer to glossary for definition of ad"erse e"ents and sentinel e"ents% for e,ample </ machine of the &C= brea7s do'n% /n this case efer to glossary for definition of ris7 definition of ris7 assessement

;or e,ample the protection guidelines gi"en in national building

efer glossary for definition of pre"enti"e and brea7do'n

*hese signages shall guide patients and "isitors% /t is preferable that ;or e,ample /ndian standards (/ 123JJ) formulated by Aureau of /ndian standards (for J0 and 100

;or 'ater quality refer to / 10500%

*he National Auilding Code is a good reference guide%

efer to National 6isaster
*his is only the minimum frequency and this may be increased%

*he ha$ardous materials could be identified as per part // of

*he safety committee must include representati"es form facility

;or e,ample grab bars bed rails sing posting safety belts in 6uring these rounds potential safety ris7s are identified% Aefore and after e"idence may be maintained%

 good reference could be the
*his report could be got firm the district magistrate (s) of the district

*his could be done as a part of the induction training % *his could be done as a part of the induction training and the same could be pro"ided in the form of a *his could be done as a part of the induction training and the same ;or patient right refer to P! 2% *he employees should be trained to implement the ser"ice standards of

*he training shall be for all categories of staff including doctors

;or e,ample fire and non f ire emergency needle stic7 inury etc% taff should be able to practically demonstrate actions li7e ta7ing care *he staff should be able to intimate the sequence of e"ents the they 'ill eporting processes could be chec7ed form time to time by the

;or definition of performance appraisal refer to glossary% *o be incorporated in the ser"ice boo7let and included in the ;or definition of ob description refer to glossary%

*his shall be done at least once a year%

;or definition of disciplinary procedure refer to glossary%

*his could be in the form of ser"ice rules% efer to rele"ant labour la's and CC (CC) rules% ppellate authority should be higher than the disciplinary authority%

*he &C= could address all points in &<2 &<3 &<5 &
;or e,ample performing preemployment &/> testing is illegal% ;or e,ample employee health and safety policy% *he &C= could define the parameters and it could be different ;or definition of occupational health ha$ard refer to glossary

;or definition of credentialing refer to glossary%

 good reference could be
;or e,ample radiotherapy can only be gi"e by a radiation oncologist% 4here authori$ation is pro"ided on the basis of training the &C= shall maintain a co of the trainin *he &C= could incorporate this in the brochure itself%

efer to /ndian Nursing Council ct 1F3+

;or e,ample% n infection Control Nurse should ha"e had requisite in-

;or e,ample daily census report utili$ation rates etc% lso refer to CD/ 2 and CD/ J%

ome of these include:-/* ct 2000 for computer based records PN6*

;or e,ample sending birth and death statistics notifiable diseases

*his is in the conte,t of frequency of ca turin data namel dail 'ee7l

*he organi$ation could decide on 'hich data needs to be shared 'ith torage could be physical of electronic% 4here"er electronic

;or e,ample C number hospital number etc% ?1 standards and *his could be different category of personnel for different entries but it ;or records on electronic media it is preferable that the date and time is

;or e,ample admission order face sheet /P sheet discharge

;or definition of plan of care refer to glossary% fter the initial "isit it shall lso refer to C=P 12f% /f the patient has been transferred at hisher request a note may be added to that effect% /n such 6ischarge note is the same as discharge summary% lso refer to lso refer to C 15 g% ;or definition of autopsy refer to glossary%

;or e,ample pri"ileged communication% /t is preferable that soft'ares 'hen used shall be "alidated and duly efer to /< +% ;or e,ample mo"ing form physical to electronic format remote bac7up pecial care should be ta7en in medico-legal cases%

*he &C= could define the periodicity%

*he &C= shall identify and authori$e such indi"iduals%

n adequate mi, of both acti"e and discharged patients should be used% ;or e,ample missing final diagnosis absence of =* motes in

Hope Hospital Self Assessment Toolkit

Recommend Documents