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REPORT 1 August 2009
GAP ANALYSIS REPORT FOR NABH ACCREDITATION PROGRAMME OF
CLIENT
PREPARED BY Astron Hospital and Health Care Consultan Consultants ts Pvt. Ltd. Quality and Accreditation Division
Publ Public icati ation, on, repr reprod oduc ucti tion on,, phot photoc ocop opyi ying, ng, stor storag age, e, or trans transmi miss ssio ion n electronically or otherwise, of all or any part of these documents without the
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Gap Analysis Report Soni Hospital
FOREWORD
Qual Qualit ity y
mana manage geme ment nt syst system em and and
the the
Accr Accred edit itat atio ion n
pro process cess in
compliance with standards, is a tool for quality assurance and quality improvement for hospitals that in turn help ensure quality healthcare services, standardized output, and aim for the best outcome possible. Spin offs of the system system include include economy economy,, effective effectiveness, ness, leadership leadership amongst
peer
insti stitution,
confidence
of
the
citizens
in
the
establ establish ishmen ment, t, and and a cultur culture e of teamw teamwor ork k with with a focus focus on servi service ce quality. The The Qual Qualit ity y Coun Counci cill of Indi India a is an auto autono nomo mous us body body unde underr the the Government of India, which has the National Accreditation Board for Hospital Hospitals s and Health Care Providers Providers (NABH) (NABH) amongst amongst several other boards under its fold. The NABH standards place emphasis on patient, staff, visitor and environment safety, infection control, and quality of car care.
The
stan tandards
are are
dece eceptive tively ly
simp simplle,
howev wever
whilst ilst
impl implem emen enti ting ng them them extr extra a effo effort rt and and reso resour urce ces s will will be requ requir ired ed.. Compliance will more than compensate with the benefits that accrue, ‘Quali lity ty’, ’, like like succ succes ess, s, is a but but it shal shalll be reme rememb mber ered ed,, that that ‘Qua pathway, and not a destination.
With that Astron Hospital and Health Care Consultants Pvt. Ltd. wish the all the very best in their voyage towards implementing the quality manageme management nt system system and accredit accreditatio ation n of public public hospital hospitals s with the NABH.
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FOREWORD
Qual Qualit ity y
mana manage geme ment nt syst system em and and
the the
Accr Accred edit itat atio ion n
pro process cess in
compliance with standards, is a tool for quality assurance and quality improvement for hospitals that in turn help ensure quality healthcare services, standardized output, and aim for the best outcome possible. Spin offs of the system system include include economy economy,, effective effectiveness, ness, leadership leadership amongst
peer
insti stitution,
confidence
of
the
citizens
in
the
establ establish ishmen ment, t, and and a cultur culture e of teamw teamwor ork k with with a focus focus on servi service ce quality. The The Qual Qualit ity y Coun Counci cill of Indi India a is an auto autono nomo mous us body body unde underr the the Government of India, which has the National Accreditation Board for Hospital Hospitals s and Health Care Providers Providers (NABH) (NABH) amongst amongst several other boards under its fold. The NABH standards place emphasis on patient, staff, visitor and environment safety, infection control, and quality of car care.
The
stan tandards
are are
dece eceptive tively ly
simp simplle,
howev wever
whilst ilst
impl implem emen enti ting ng them them extr extra a effo effort rt and and reso resour urce ces s will will be requ requir ired ed.. Compliance will more than compensate with the benefits that accrue, ‘Quali lity ty’, ’, like like succ succes ess, s, is a but but it shal shalll be reme rememb mber ered ed,, that that ‘Qua pathway, and not a destination.
With that Astron Hospital and Health Care Consultants Pvt. Ltd. wish the all the very best in their voyage towards implementing the quality manageme management nt system system and accredit accreditatio ation n of public public hospital hospitals s with the NABH.
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ACKNOWLEDGEMENT
Our heartfelt thanks to ………………………………….and the Governing Board members enabling us to carry out National accreditation Board for Hospi Hospital tals s & Health Healthcar care e Prov Provide iders rs accre accredit ditati ation on activi activity ty at their their hospital. We feel privileged to be associated with this organization of repute and being a part of the quality movement initiative initiative taken up by its authorities We are are high highly ly than thankf kful ul to,… to,……… ………… ………… ………… ………… ………… ………… ………… …… for for prov provid idin ing g us a plat platfo form rm to init initia iate te the the accr accred edit itat atio ion n acti activi vity ty and and complete the first step that of gap assessment study in We are profoundly grateful to,…………………………………………………… who has been very supportive right from beginning. We are sure, that with able leadership of, the objective of achieving quality standards of the level of accreditation norms will not be a distant dream. We would like to thank, …………………………………………Medical Supdt, who has been extremely cooperative and helped us in getting the gap asse assess ssm ment ent comp complleted eted.. His readine iness for for taki takin ng up the the core core respo responsi nsibi bilit lity y of coor coordin dinati ating ng and and prov providi iding ng us with with all necess necessary ary arrangement required to complete the activity of Gap Assessment. Our Our sinc sincer ere e than thanks ks to Nurs Nursin ing g Supe Superi rint nten ende dent nt,, and and all all HO HODs Ds,, inincharges and staff of the hospital, who took out time from their very busy schedule, to interact with us and provide us with the information required for this study. Needless to say that this activity would not have been completed without their selfless contribution. Last Lastly ly,, we woul would d like like to than thank k all thos those e whos whose e name names s are are not not ment mentio ione ned d here here but but thei theirr cont contri ribu buti tion on to this this stud study y coul could d not not be undermined. Astron Hospital and Health Care Consultants Pvt. Ltd.
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TABLE OF CONTENTS
Section
Topic
Page Number
No
1. 2. 3. 4. 5.
Foreword Acknowledgement Table of Contents Introduction Organization of report Hospital Profile Physical structure requirement Gap assessment as per NABH standards Summary table of scores Result of NABH gap assessment
1 2 3 4 5 7-13 14 - 23 24 -127 128 129
6. 7. Annexure Annexure Signage & Displays
130-131
‘A’ Annexure
132-133
Physical Safety Requirements
‘B’
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SECTION 1. INTRODUCTION 1. …………………………….is one of the finest medical institutions in
North
India.
The
hospital
is
governed
by
…………………………………………………… 2. The philosophy with which the hospital has been incepted is
provision of medical care to the needy . 3. ……………….has taken up the initiative to standardize the patient
care and its management system and initiate an activity of continual quality improvement 4. With this thought has chosen ……………………..NABH accreditation
norms as a reference to improve and standardize the health care delivery in the hospital 5. Astron Hospital and Health Care Consultants Pvt. Ltd. is a
consultancy firm providing consultancy to all spheres of hospital planning and management. Quality and accreditation division of the consultancy is well known to provide consultancy services to hospitals,
wanting
to
implement
quality
management
and
accreditation systems 6. Astron has been taken up by
…………………….as consultant to
provide the consultancy services in planning and helping the hospital’s team in achieving NABH accreditation 7. As a first step of this project, detailed gap analysis has been carried out to identify the existing status of infrastructure and processes vis-à-vis NABH standards requirement 8. This report is the deliverable of gap assessment study carried out
at ……………………by Astron Hospital and Health Care Consultant, with the help of hospital’s authorities and staff 9. The report details the subjective and objective evaluation and findings
of
infrastructure
and
NABH
standards
related
requirements 10.
All findings and suggestions presented in this report is on 5
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the basis of primary visit made by Astron Consultants and data and information provided by the hospital 11. It is to be noted that since evaluation of NABH standards
implementation in a hospital is partly subjective, difference in score calculated for NABH compliance may vary, in case similar study is carried out by different consultant / assessor. The analysis has been done on the basis of standardized checkpoints and our previous experience with other hospital’s assessment. With this limitation, it is suggested that the score shall be used only to make a mental picture of compliance level, while focusing on all systems and standards required for NABH accreditation
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SECTION 2. ORGANISATION OF REPORT
•
This report is intended to identify those structural requirements of quality management and accreditation, which are cost intensive and takes long lead-time for addressing. Other than this a detailed gap assessment with respect to every standards and objective elements of NABH – 2 nd edition has also been carried out and presented in this report. The report has been prepared and submitted with the objective of taking an early action on these gaps, so that they can be addressed within time before the hospital
applies for the accreditation pre-assessment. •
Following categories of gaps and requirements have been specified in this report
•
o
Physical structure requirements
o
Gap assessment as per NABH standards
The report is organized in sections for specifying the aspects. Subsections are provided within sections, wherever required. A brief profile of the hospital is also provided in to understand the status.
•
Annexure are provided at the end of the report on those aspects that requires detailing and description. A reference has been made in the main text wherever it has an annexure to be referred.
•
The findings and requirements specified in this report have been prioritized as per their importance and criticality, so that hospital can plan the action as per the resource availability and practicality aspects.
•
It is emphasized that these requirements are important and should be actioned upon as early as possible, so that the same can be fulfilled within the project time. Also many of the process related aspects required for accreditation are dependent on fulfillment of infrastructural gaps. Thus, delay in action on fulfilling these requirements will affect the implementation of processes and in turn will delay the entire project time.
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•
It is suggested that hospital authorities read the report carefully and develop a plan of action to fulfill these requirements.
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SECTION 3. HOSPITAL PROFILE
S. No.
Particulars
Details
1 Name of Hospital . 2 Ownership Type . 3 Address .
a.
b.
for Communi cation for locating Hospital
2 Contact person: .
(for correspondence and liaison) 3 Contact .
numbers: (land line with area code and mobile)
4 E-mail . 5 Date .
establishment hospital
of of
6 Vision statement .
7 Mission statement: .
8 Any .
Quality certification or Accreditation received by the
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facility in past 11. Clinical services offered by the hospital Specialty(s):
Specialties
Number of (full time)
specialist Number of specialist (visiting / honorary)
Anesthesia Cardiology Cardiothoracic Surgery Dentistry Dermatology ENT Gastroenterology General Medicine GI Surgery General surgery Nephrology Neurology Neurosurgery O&G Ophthalmology Orthopedic Outreach Services Pediatrics Pediatric Surgery Pathology Physiotherapy Plastic surgery
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Psychiatry Radio diagnosis Rehab Urology Number of Non Specialist doctors
FACILITY DETAILS S. No. 1.
2.
Particulars
Details
Plot area Total built-up area
3.
Number of buildings
4.
Number of floors
5.
Number of Lifts
6.
Number of ramps
BED DISTRIBUTION 1. Total number of complement beds (beds on which patients are kept overnight): 2. Total number of non-compliment beds: S. No. 1.
Categories of beds
Number of
Number of
beds per room
rooms
New Deluxe
2.
Super Deluxe
3.
Semi Deluxe
4.
Male Private + NSR + SSR
5.
Female Private
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6
General Medical Ward
7
Urology Ward
8
Pediatric Ward
9
Gynae/ Maternity Ward
10 Transit Ward 11 Orthopedic Ward 12 Neuro Sciences Ward 13 Nephrology 14 Convalescent – I 15 Convalescent – II 16 Ophthalmology 17 Day Care 18 Casualty 19 Neonatal 20 Semi Pvt. 21 Pre Operative INTENSIVE CARE BEDS S.
Designation of ICU
No. 1.
Medical Intensive Care Unit
2.
Surgical Cardiac Care Unit
3.
Medical Cardiac Care Unit
4.
Step down Intensive Unit
5.
Paediatric Intensive Care Unit
6.
Surgical Intensive Care Unit
7.
Neuro Intensive Care Unit
8.
Pre-mature Care Unit /
9.
Intensive Pre-mature Unit
Number of beds
Number of
per room
rooms
Care
10 11 12
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OPERATING SUITES S.
Designation of Operation theatre
No.
(Major and Minor) and Endoscopy
Number
suites
1.
Terrace Operation Theatre
2.
New Operation Theatre
3.
Old Operation Theatre
4.
Endoscopy Room
5.
Cath Lab
6.
Dialysis
7.
Labour Room
8.
Transfusion Ward
9.
Emergency
10.
Incomplete
11. 12.
HOSPITAL HUMAN RESOURCE Staffing pattern Staff category
On
hospital
pay Contractual
roll Nursing
Staff
(category
wise)
Nursing Superintendent Deputy Superintendent
Nursing
Asst. Nursing Superintendent
Sister Incharges Acting Sister Incharges
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Staff Nurses Nursing Aid Technical Staff (category wise)
Lab Technicians OT Technicians X-Ray Technicians Perfusionist Endoscopy ECG Technicians EEG Technicians Technician (Nephrology)
Medical
administration
(category wise)
Senior Administrative Staff Honorary Consultants Resident
General
administration
(category wise)
Senior Administrative staff Maintenance Ministerial Housekeeping security
staff
and (category
wise)
Ward Boy Ward Lady Sweepers
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Tech. Aid Class IV (Contract) Security (Contract)
DETAILS OF DIAGNOSTIC SERVICES S.
Diagnostic services
No. Laboratory Medicine (Please list scope of services)
Bio-Chemistry Pathology Hematology Micro-Biology & Serology Histopathology Cytopathology Imaging Sciences (Please list scope of services)
C-T X-Ray Ultra Sound Special Diagnostics
EEG Colour Doppler ECG Eco TMT Audiometery SUPPORT SERVICES S.
Service category
Available / Not available
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No. 1.
Pharmacy
2.
Blood Bank
3.
Medical Record Department
4.
CSSD
5.
Piped medical gas system
6.
Dietetics Others HIS & PACS
S.
Administrative
No.
departments (please list)
1.
Accounts/ Finance (including IP billing)
2.
HRD
3.
Maintenance
4.
Stores & Purchases
5.
IT
6.
PRO
7.
OPD, Reception & Enquiries
8.
Medical Records
S.
Outsourced services (please
No.
list)
1.
Security
2.
Housekeeping
3.
Kitchen
4.
Laundry
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WORK LOAD DETAILS (of the current quarter) S.
Particulars
Details
No. IPD indices 1.
Bed occupancy rate
2.
Average length of stay
3.
Average daily surgeries (major)
4.
Average daily surgeries (minor)
5.
Average daily deliveries
6.
Average daily admissions
7.
Average daily discharges OPD indices
8.
Average daily OPD attendance
9.
Average daily registration
new
patients
10. Average daily follow up patients 11. Average daily day care patients Emergency indices 12 Average daily emergency attendance . 13. Average monthly emergency surgeries Diagnostics 14 .
Average number of Laboratory tests per day
15. Average number of Radiological tests per day Please provide following documents along with this profile (if convenient) 1. Architectural plan of the facility 2. List of Major equipments 3. Specialty / Department wise bed allocation (if applicable) 4. Last audited balance sheet
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SECTION 4. PHYSICAL STRUCTURE REQUIREMENTS This section identifies the structural deficiencies which may come across the quality management requirements as expected by NABH standards. The findings are presented department wise and is prioritized as per the necessity. Other than these structural deficiencies there are certain facility requirements that are necessary to demonstrate a safe and secured hospital environment. This has been listed out in Annexure ‘B’ (V- Vital; E – Essential, D – Desirable; P - Priority This classification is given for the hospital to prioritize their work and plan the scope of improvement as per their resource availability and necessity) S. Department and observations Desirab Prior
No. 1. 1
ility
ity
EMERGENCY WARD
. 1 .
1. 2. 1. 3. 1. 4. 1. 5. 1. 6. 1.
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S.
Department and observations
No.
Desirab Prior ility
ity
1. 8. 2.
IMAGING DEPARTMENT 2 . 1 .
2. 2. 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 2.2.6 3. 3
INPATIENT DEPARTMENT
. 1 .
3 . 1 . 1 . 3
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S.
Department and observations
No.
Desirab Prior ility
ity
3 Support Areas-. . Clean Utility – 1 Dirty Utility -. . Equipment Room – 3 Treatment Rooms – . Isolation Rooms -. 3 . 1 . 4 . 3 . 1 . 5 . 3 Resuscitation facility . 1 . 6 . 3. Hand washing facilities
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S.
Department and observations
No.
Desirab Prior ility
ity
3 Electrical Backup . 2 . 1 . 3. PRIVATE WARDS 3. 3 . 3 . 1 . 4. 4
INTENSIVE CARE UNIT .
. 1 .
4. Zoning2. 4. The interbed distance 3. 4. The Nursing Station
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S.
Department and observations
No.
Desirab Prior ility
ity
4. The ventilation. 5. 5.
DIALYSIS UNIT 5 . 1 .
5. Zoning-. 2. 5. The interbed distance 3. 5. 4. 5. The hand washing facilities 5. 6.
CSSD
6. 1. 6. 2. 6. 3.
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S.
Department and observations
No. 6.
Desirab Prior ility
ity
4. 7.
OPERATION THEATRES
7.
•
1. 7. 2. 7. 3. 8.
8.
LABOR ROOMS .
1. 9.
LABORATORY
9. 1. 10. 1
OPD
0. 1. 1 0. 2. 1 0.
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S.
Department and observations
No.
Desirab Prior ility
ity
1 0. 4. 1 0. 5. 11. 1
LAUNDRY •
1. 1. 12. 1
MEDICAL RECORD DEPARTMENT .
2. 1. 1
BIOMEDICAL WASTE MANAGEMENT
2. 2. 1 2. 3. 13. 1
PIPED MEDICAL GAS SYSTEM
3. 1.
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S.
Department and observations
No. 1
Desirab Prior ility
ity
3. 2. 14. 1
SIGNAGES AND DISPLAYS
4. 1. 15. 1
FIRE FIGHTING SYSTEM
5. 1. 1 5. 2. 1 5. 3.
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SECTION 5: GAP ASSESSMENT AS PER NABH STANDARDS Elements
Observation
Scores (0/
Recommendations
5/
10) Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC) AAC.1: The organization defines and displays the services that it can provide.
a
The services being provided are clearly defined and are in consonance with the needs of the community.
b
The defined services are prominently display.
c
The staff is oriented to these services.
Average Score
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AAC.2: The organization has a well-defined registration and admission process.
a.
Standardized policies and procedures are used for registering and admitting patients
b.
The policies and procedures address outpatients, inpatients and emergency patients
c.
Patients are accepted only if the organization can provide the required service
d.
The policies procedures
and also
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AAC.2: The organization has a well-defined registration and admission process.
a.
Standardized policies and procedures are used for registering and admitting patients
b.
The policies and procedures address outpatients, inpatients and emergency patients
c.
Patients are accepted only if the organization can provide the required service
d.
The policies and procedures also address managing patients during non availability of beds.
e. The staff is aware of these processes
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a.
Policies guide the transfer of unstable patients to another facility in an appropriate manner.
b. Policies transfer patients facility c.
guide the of stable to another
Procedures identify staff responsible during transfer
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a.
Policies guide the transfer of unstable patients to another facility in an appropriate manner.
b. Policies transfer patients facility
guide the of stable to another
c.
Procedures identify staff responsible during transfer
d.
The organization gives a summary of patient’s condition and the treatment given
Average Score
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AAC.4 AAC.4 During During admiss admission ion the patient patient and/ and/ or family family membe members rs are educat educated ed to make make informed decision.
a. The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the proposed care. b. The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the expected results. c.
The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the possible complications.
d. The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the
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AAC.4 AAC.4 During During admiss admission ion the patient patient and/ and/ or family family membe members rs are educat educated ed to make make informed decision.
a. The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the proposed care. b. The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the expected results. c.
The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the possible complications.
d. The The pati patien ents ts and/ and/ or fam family ily membe emberrs are are expl explai aine ned d abou aboutt the the expected costs. Average Score AAC.5 Patients cared for by the organization undergo an established initial assessment.
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a.
The organization define defines s the conten contentt of the assessments for the out patients, in patients and emergency patients.
b.
The organization dete determ rmin ines es who who can can perform the assessments.
c.
The organization defines the time frame within within which the initial initial assessment is completed.
d.
The initial initial assess assessmen mentt for in-patients is
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a.
The organization define defines s the conten contentt of the assessments for the out patients, in patients and emergency patients.
b.
The organization dete determ rmin ines es who who can can perform the assessments.
c.
The organization defines the time frame within within which the initial initial assessment is completed.
d.
The initial initial assess assessmen mentt for in-patients is docume documente nted d within within 24 hours or earlier as per the patient's patient's condition condition or hospital policy.
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e.
Initial assessment include includes s screen screening ing for nutritional needs.
f.
The initi initial al assess assessmen mentt results in a documented plan plan of care which which is monitored.
g. The The plan of care care also also inc include ludes s prev preven enti tive ve aspects of care.
a.
All patients a re reassessed at appropriate intervals.
b.
Staff involved involved in direct
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e.
Initial assessment include includes s screen screening ing for nutritional needs.
f.
The initi initial al assess assessmen mentt results in a documented plan plan of care which which is monitored.
g. The The plan of care care also also inc include ludes s prev preven enti tive ve aspects of care.
a.
All patients a re reassessed at appropriate intervals.
b.
Staff involved involved in direct clinical clinical care document document reassessments.
c.
Patients are reassessed to determine their respon response se to treatm treatment ent and to plan furt urther treatment or discharge
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Average Score AAC.7
Laboratory
services
requirements of the patients.
a.
Scope of laboratory services commensurate to services provided organization
the are the by
b.
Adequately qualified and trained personnel perform and/or supervise the investigations.
c.
Policies procedures collection, identification,
and guide
are
provided
as
per
the
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Average Score AAC.7
Laboratory
services
are
provided
as
per
the
requirements of the patients.
a.
Scope of laboratory services commensurate to services provided organization
the are the by
b.
Adequately qualified and trained personnel perform and/or supervise the investigations.
c.
Policies and procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens.
d.
Laboratory results are available within a
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defined time frame.
e.
Critical results are intimated immediately to the concerned personnel.
f.
Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.
Average Score AAC.8 There is an established laboratory quali ty assurance programme.
a.
The laboratory quality
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defined time frame.
e.
Critical results are intimated immediately to the concerned personnel.
f.
Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.
Average Score AAC.8 There is an established laboratory quali ty assurance programme.
a.
The laboratory quality assurance programme is documented.
b.
The programme addresses verification and validation of test methods
33
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c.
The programme addresses surveillance of test results
d.
The programme includes periodic calibration and maintenance of all equipments.
e.
The programme includes the documentation of corrective and preventive actions
Average Score AAC.9 There is an established laboratory safety programme.
a.
The laboratory safety
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c.
The programme addresses surveillance of test results
d.
The programme includes periodic calibration and maintenance of all equipments.
e.
The programme includes the documentation of corrective and preventive actions
Average Score AAC.9 There is an established laboratory safety programme.
a.
The laboratory safety programme is documented.
b.
This programme is integrated with the organization's safety programme.
34
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c. Written policies and procedures guide the handling and disposal of infectious and hazardous materials. d. Laboratory personnel are appropriately trained in safe practices. e.
Laboratory personnel are provided with appropriate safety equipment/ devices.
Average Score AAC.10 Imaging services are provided as per the requirement of the patients.
a.
Imaging
services
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c. Written policies and procedures guide the handling and disposal of infectious and hazardous materials. d. Laboratory personnel are appropriately trained in safe practices. e.
Laboratory personnel are provided with appropriate safety equipment/ devices.
Average Score AAC.10 Imaging services are provided as per the requirement of the patients.
a.
Imaging services comply with the legal and other requirement.
b. Scope of the imaging services are commensurate to the services provided by
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the organization.
c.
Adequately qualified and trained personnel perform, supervise and interpret the investigations.
d.
Policies and procedures guide identification and safe transportation of patients to imaging services.
e. Imaging results are available within a defined time frame. f.
Critical results are intimated immediately
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the organization.
c.
Adequately qualified and trained personnel perform, supervise and interpret the investigations.
d.
Policies and procedures guide identification and safe transportation of patients to imaging services.
e. Imaging results are available within a defined time frame. f.
Critical results are intimated immediately to the concerned personnel.
g.
Imaging tests available in organization outsourced
not the are to
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organization(s) based on their quality assurance system Average Score AAC.11 There is an established quality assurance programme for imaging services.
a.
The quality assurance program for imaging services is documented.
b.
The programme addresses verification and validation of imaging methods.
c.
The programme addresses surveillance of imaging results.
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organization(s) based on their quality assurance system Average Score AAC.11 There is an established quality assurance programme for imaging services.
a.
The quality assurance program for imaging services is documented.
b.
The programme addresses verification and validation of imaging methods.
c.
The programme addresses surveillance of imaging results.
d.
The programme includes periodic calibration and maintenance of all equipments.
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e.
The programme includes the documentation of corrective and preventive actions
Average Score AAC.12 There is an established radiation safety programme.
a. The radiation programme documented. b.
safety is
This programme is integrated with the organization’s safety programme
c. Written policies and procedures guide the handling and disposal
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e.
The programme includes the documentation of corrective and preventive actions
Average Score AAC.12 There is an established radiation safety programme.
a. The radiation programme documented. b.
safety is
This programme is integrated with the organization’s safety programme
c. Written policies and procedures guide the handling and disposal of radio-active and hazardous materials. d.
Imaging personnel are provided with appropriate radiation safety devices
38
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e.
Radiation safety devices are periodically tested and documented
f.
Imaging personnel are trained in radiation safety measures
g.
Imaging signage are prominently displayed in all appropriate locations
h.
Policies and procedures guide the safe use of radioactive isotopes for imaging services.
Average Score AAC.13 Patient care is continuous and multidisciplinary in nature.
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e.
Radiation safety devices are periodically tested and documented
f.
Imaging personnel are trained in radiation safety measures
g.
Imaging signage are prominently displayed in all appropriate locations
h.
Policies and procedures guide the safe use of radioactive isotopes for imaging services.
Average Score AAC.13 Patient care is continuous and multidisciplinary in nature.
a. During all phases of care, there is a qualified individual identified as responsible for patient’s care.
39
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b.
Care of patients is coordinated in all care setting within the organization.
c.
Information about the patient's care and response to treatment is shared among medical, nursing and other care providers.
d.
Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/
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b.
Care of patients is coordinated in all care setting within the organization.
c.
Information about the patient's care and response to treatment is shared among medical, nursing and other care providers.
d.
Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/ departments.
e.
The patient’s record(s) is available to authorized care providers to facilitated the exchange of
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information.
f.
Policies and procedures guide the referral of patients to other departments/ specialties.
Average Score AAC.14
The
organization
process.
a.
The patient’s discharge process is planned in consultation with the patient and/or family
b.
Policies and procedures
has
a
documented
discharge
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information.
f.
Policies and procedures guide the referral of patients to other departments/ specialties.
Average Score AAC.14
The
organization
has
a
documented
discharge
process.
a.
The patient’s discharge process is planned in consultation with the patient and/or family
b.
Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases)
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c.
Policies and procedures are in place for patients leaving against medical advice
d.
A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)
Average Score AAC.15 Organization define the content of the discharge summary.
a.
Discharge summary is provided to the patients at the time of discharge.
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c.
Policies and procedures are in place for patients leaving against medical advice
d.
A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)
Average Score AAC.15 Organization define the content of the discharge summary.
a.
Discharge summary is provided to the patients at the time of discharge.
b. Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of
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discharge.
c.
Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given.
d. Discharge summary contains follow up advice, medication and other instructions in an understandable
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discharge.
c.
Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given.
d. Discharge summary contains follow up advice, medication and other instructions in an understandable manner. e. Discharge summary incorporates instructions about when and how to obtain urgent care.
43
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f.
In case of death the summary of the case also includes the cause of death.
Average Score Total Score Chapter 2: CARE OF PATIENTS (COP) COP.1: Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws, regulations and guidelines.
a
Care delivery is uniform when similar care is provided in more than one setting
b
Uniform care is guided by policies and procedures which
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f.
In case of death the summary of the case also includes the cause of death.
Average Score Total Score Chapter 2: CARE OF PATIENTS (COP) COP.1: Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws, regulations and guidelines.
a
Care delivery is uniform when similar care is provided in more than one setting
b
Uniform care is guided by policies and procedures which reflect applicable laws and regulations.
c
The care and treatment orders are signed, named, timed and dated by the concerned
44
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doctor.
d
The care plan is countersigned by the clinician in-charge of the patient within 24 hours.
e
Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible.
Average Score COP.2: Emergency services are guided by policies, procedures and applicable laws and regulations.
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doctor.
d
The care plan is countersigned by the clinician in-charge of the patient within 24 hours.
e
Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible.
Average Score COP.2: Emergency services are guided by policies, procedures and applicable laws and regulations.
a
Policies and procedure for emergency care are documented.
45
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b
Policies also handling of legal cases
address medico-
c
The patient receives care in consonance with the policies.
d
Policies and procedures guide the triage of patients for initiation of appropriate care.
e
Staff is familiar with the policies and trained on the procedures for care of emergency patients.
f
Admission or discharge to home or transfer to another organization is
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b
Policies also handling of legal cases
address medico-
c
The patient receives care in consonance with the policies.
d
Policies and procedures guide the triage of patients for initiation of appropriate care.
e
Staff is familiar with the policies and trained on the procedures for care of emergency patients.
f
Admission or discharge to home or transfer to another organization is also documented.
Average Score COP.3: The ambulance services are commensurate with the scope of the services provided by the organizations.
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a
There is adequate access and space for the ambulance(s).
b
Ambulance(s) is appropriately equipped.
c
Ambulance(s) is manned by the trained personnel
d
There i s a c hecklist o f all medical equipment and emergency medications.
e
Equipment are checked on a daily basis.
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a
There is adequate access and space for the ambulance(s).
b
Ambulance(s) is appropriately equipped.
c
Ambulance(s) is manned by the trained personnel
d
There i s a c hecklist o f all medical equipment and emergency medications.
e
Equipment are checked on a daily basis.
f
Emergency medications are checked daily and prior to dispatch.
g
The ambulance(s) has a proper communication system.
Average Score
47
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COP.4: Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitations.
a
Documented policies and procedures guide the uniform use of resuscitation throughout the organization.
b
Staff providing direct patient care is trained and periodically update in cardio pulmonary resuscitations.
c
The events during a cardio pulmonary resuscitation are recorded.
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COP.4: Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitations.
a
Documented policies and procedures guide the uniform use of resuscitation throughout the organization.
b
Staff providing direct patient care is trained and periodically update in cardio pulmonary resuscitations.
c
The events during a cardio pulmonary resuscitation are recorded.
d
A post-event analysis of all cardiac asserts is done by a multidisciplinary committee.
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e
Corrective and preventive measures are taken based on the post-event analysis.
Average Score COP.5: Policies and procedures define rational use of blood and blood products.
a
Documented policies and procedures are used to guide rational use of blood and blood products
b
The transfusion services are governed by the applicable laws and regulations.
c
Informed
consent
is
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e
Corrective and preventive measures are taken based on the post-event analysis.
Average Score COP.5: Policies and procedures define rational use of blood and blood products.
a
Documented policies and procedures are used to guide rational use of blood and blood products
b
The transfusion services are governed by the applicable laws and regulations.
c
Informed consent is obtained for donation and transfusion of blood and blood products
49
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d
Informed consent also includes patient and family education about donation.
e
Staff is trained to implement the policies.
f
Transfusion reactions are analyzed for preventive and corrective actions.
a
The organization has documented admission and discharge criteria
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d
Informed consent also includes patient and family education about donation.
e
Staff is trained to implement the policies.
f
Transfusion reactions are analyzed for preventive and corrective actions.
a
The organization has documented admission and discharge criteria for its intensive care and high dependency units.
b
Staff is trained to apply these criteria
50
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c
Adequate equipment available
staff
and are
d
Defined procedures for situation of bed shortages are followed.
e
Infection control practices are followed
f
A quality assurance programme is implemented
Average Score COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically and/ or mentally challenged and children).
a
Policies and procedures are documented and
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c
Adequate equipment available
staff
and are
d
Defined procedures for situation of bed shortages are followed.
e
Infection control practices are followed
f
A quality assurance programme is implemented
Average Score COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically and/ or mentally challenged and children).
a
Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.
51
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b
Care is organized and delivered in accordance with the policies and procedures.
c
The organization provides for a safe and secure environment for this vulnerable group.
d
A documented procedure exists for obtaining informed consent from the appropriate legal representative.
e
Staff is trained to care for this vulnerable group.
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b
Care is organized and delivered in accordance with the policies and procedures.
c
The organization provides for a safe and secure environment for this vulnerable group.
d
A documented procedure exists for obtaining informed consent from the appropriate legal representative.
e
Staff is trained to care for this vulnerable group.
Average Score COP.8: Policies and procedures guide the care of high-risk obstetrical patients.
a
The organization defines and displays whether high-risk
52
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obstetric care can be cared for or not.
b
Persons caring for highrisk obstetric cases are competent
c
High-risk obstetric patient’s assessment also includes maternal nutrition.
d
The organization caring for high risk obstetric cases has the facilities to take care of neonates of such cases.
Average Score COP.9: Policies and procedures guide the care of paediatric
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obstetric care can be cared for or not.
b
Persons caring for highrisk obstetric cases are competent
c
High-risk obstetric patient’s assessment also includes maternal nutrition.
d
The organization caring for high risk obstetric cases has the facilities to take care of neonates of such cases.
Average Score COP.9: Policies and procedures guide the care of paediatric patients.
a
The organization defines and displays the scope of its paediatric services
53
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b
The p ol olicy for care o f neonat neonatal al patien patients ts is in cons conson onan ance ce with with the the nation national/ al/ intern internati ationa onall guidelines
c
Those who care for children have age specific competency
d
Pro Provisi vision ons s ar are mad made e for for special care of children.
e
Patient assessment includes detailed nutr nutrit itio iona nal, l, grow growth th,, psychosocial and immunization assessment.
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b
The p ol olicy for care o f neonat neonatal al patien patients ts is in cons conson onan ance ce with with the the nation national/ al/ intern internati ationa onall guidelines
c
Those who care for children have age specific competency
d
Pro Provisi vision ons s ar are mad made e for for special care of children.
e
Patient assessment includes detailed nutr nutrit itio iona nal, l, grow growth th,, psychosocial and immunization assessment.
f
Policies and and pro procedures ures prevent child/ neonates neonates abduction and abuse.
54
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g
The children’s family members are educated about nutrition, immunizations and safe pare parent ntin ing g and and this this is documented in the medical record.
Average Score COP.10: COP.10: Policies Policies and procedures procedures guide the care of patients undergoing moderate sedation.
a
Competent and and tra trained persons perform sedation.
b
The person administrating and and monito monitoring ring sedati sedation on is different from the
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g
The children’s family members are educated about nutrition, immunizations and safe pare parent ntin ing g and and this this is documented in the medical record.
Average Score COP.10: COP.10: Policies Policies and procedures procedures guide the care of patients undergoing moderate sedation.
a
Competent and and tra trained persons perform sedation.
b
The person administrating and and monito monitoring ring sedati sedation on is different from the person person perfor performin ming g the procedure.
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c
Intra – procedure monito monitoring ring includ includes es at a mini minimu mum m the the hear heartt rate rate,, card cardia iac c rhyt rhythm hm,, respir respirato atory ry rate, rate, blood blood pres pressu sure re,, and oxyge oxygen n saturation, and level of sedation.
d
Patients are monit nitored after sedation.
e
Criteria are used determine appropriateness
to of
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c
Intra – procedure monito monitoring ring includ includes es at a mini minimu mum m the the hear heartt rate rate,, card cardia iac c rhyt rhythm hm,, respir respirato atory ry rate, rate, blood blood pres pressu sure re,, and oxyge oxygen n saturation, and level of sedation.
d
Patients are monit nitored after sedation.
e
Criteria are used to determine appropriateness of dischar harge from the recovery area.
f
Equipment a nd manpower are available to rescue patients from a deeper level of
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sedation intended.
than
that
Average Score COP.11: Policies and procedures guide the administration of anesthesia.
a
There is a documented policy and procedure for the administration of anesthesia
b
Pre anaesthesia assessment is done for all patients who undergo anaesthesia administration.
c
The
pre-anesthesia
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sedation intended.
than
that
Average Score COP.11: Policies and procedures guide the administration of anesthesia.
a
There is a documented policy and procedure for the administration of anesthesia
b
Pre anaesthesia assessment is done for all patients who undergo anaesthesia administration.
c
The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented
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d
An immediate preoperative reevaluation is documented
e
Informed consent for administration of anesthesia is obtained by the anesthetist
f
During anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency
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d
An immediate preoperative reevaluation is documented
e
Informed consent for administration of anesthesia is obtained by the anesthetist
f
During anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway security and patency and level of anesthesia
g
Each patient’s postanesthesia status is monitored and documented
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h
A qualified individual applies defined criteria to transfer the patient from the recovery area
i
All a dverse a nesthesia events are recorded and monitored
Average Score COP.12: Policies and procedures guide the care of patients undergoing surgical procedures.
a
The policies procedures documented
and are
b
Surgical patients have preoperative t d
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h
A qualified individual applies defined criteria to transfer the patient from the recovery area
i
All a dverse a nesthesia events are recorded and monitored
Average Score COP.12: Policies and procedures guide the care of patients undergoing surgical procedures.
a
The policies procedures documented
and are
b
Surgical patients have preoperative assessment and a provisional diagnosis documented prior to surgery.
c
An informed consent is obtained by the surgeon prior to the
59
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procedure.
d
Documented policies and procedure exist to prevent adverse events like wrong site, wrong patients and wrong surgery.
e
Persons qualified by law are permitted to perform the procedures that they are entitled to perform.
f
A brief operative note is documented prior to transfer out of patients from recovery area.
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procedure.
d
Documented policies and procedure exist to prevent adverse events like wrong site, wrong patients and wrong surgery.
e
Persons qualified by law are permitted to perform the procedures that they are entitled to perform.
f
A brief operative note is documented prior to transfer out of patients from recovery area.
g
The operating surgeons documents the post operative plan of care
h
A quality assurance programme is followed for the surgical services
60
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i
The quality assurance program includes surveillance of the operation theatre environment
j
The p lan a lso i ncludes monitoring of surgical site infection rates
a
Documented policies and procedures guide the care of patients under restraints
b
These
include
both
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i
The quality assurance program includes surveillance of the operation theatre environment
j
The p lan a lso i ncludes monitoring of surgical site infection rates
a
Documented policies and procedures guide the care of patients under restraints
b
These include both physical and chemical restraint measures
c
These include documentation of reasons for restraints
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d
These patients are more frequently monitored
e
Staff receive training and periodic updating in control and restraint techniques
Average Score COP.14: Policies
and
procedures guide appropriate
management.
a
Documented policies and procedures guide the management of pain.
b
The organization respects and supports the appropriate
pain
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d
These patients are more frequently monitored
e
Staff receive training and periodic updating in control and restraint techniques
Average Score COP.14: Policies
and
procedures guide appropriate
pain
management.
a
Documented policies and procedures guide the management of pain.
b
The organization respects and supports the appropriate assessment and management of pain for all patients
c
Patient a nd f amily a re educated on various pain management
62
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techniques
Average Score COP.15:
Policies
and
rehabilitative services.
a
Documented policies and procedures guide the provision of rehabilitative services
b
These services are commensurate with the organizational requirements
c
Rehabilitative services are provided by a multidisciplinary team
Average Score
procedures
guide
appropriate
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techniques
Average Score COP.15:
Policies
and
procedures
guide
appropriate
rehabilitative services.
a
Documented policies and procedures guide the provision of rehabilitative services
b
These services are commensurate with the organizational requirements
c
Rehabilitative services are provided by a multidisciplinary team
Average Score COP.16: Policies and procedures guide all research activities.
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a
Documented policies and procedures guide all research activities in compliance with national and international guidelines
b
The organization has an ethics committee to oversee all research activities
c
The committee has the powers to discontinue a research trial when risks outweigh the potential benefits
d
Patient’s consent
is
informed obtained
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a
Documented policies and procedures guide all research activities in compliance with national and international guidelines
b
The organization has an ethics committee to oversee all research activities
c
The committee has the powers to discontinue a research trial when risks outweigh the potential benefits
d
Patient’s informed consent is obtained before entering them in research protocols
64
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e
Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal
f
Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization’s services
Average Score COP.17: Policies and procedures guide nutritional therapy.
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e
Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal
f
Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization’s services
Average Score COP.17: Policies and procedures guide nutritional therapy.
a
Documented policies and procedures guide nutritional assessment and reassessment
65
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b
Patients receive food according to their clinical needs
c
There is a written order for the diet
d
Nutritional therapy is planned and provided in a collaborative manner
e
When families provide food, they are educated about the patients diet limitations
f
Food is prepared, handled, stored and distributed in a safe manner
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b
Patients receive food according to their clinical needs
c
There is a written order for the diet
d
Nutritional therapy is planned and provided in a collaborative manner
e
When families provide food, they are educated about the patients diet limitations
f
Food is prepared, handled, stored and distributed in a safe manner
Average Score COP.18: Policies and procedures guide the end of life care.
a
Documented policies and procedures guide the end of life care
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b
These policies and procedures are in consonance with the legal requirements
c
These also address the identification of the unique needs of such patient and family
d
These also include sensitively addressing issues such as autopsy and organ donation
e
Staff is educated and trained in end of life care
Average Score Total Score
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&
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
Gap Analysis Report Soni Hospital
b
These policies and procedures are in consonance with the legal requirements
c
These also address the identification of the unique needs of such patient and family
d
These also include sensitively addressing issues such as autopsy and organ donation
e
Staff is educated and trained in end of life care
Average Score Total Score Chapter 3: MANAGEMENT OF MEDICATION (MOM) MOM.1: Policies and procedures guide the organization of pharmacy services and usage of medication.
67
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a
There is a documented policy and procedure for pharmacy services and medication usage
b
These c omply w ith t he applicable laws and regulations
c
A multidisciplinary committee guides the formulation and implementation of these policies and procedures
Average Score MOM.2: There is a hospital formulary.
a
A list of medication appropriate for the
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
Gap Analysis Report Soni Hospital
a
There is a documented policy and procedure for pharmacy services and medication usage
b
These c omply w ith t he applicable laws and regulations
c
A multidisciplinary committee guides the formulation and implementation of these policies and procedures
Average Score MOM.2: There is a hospital formulary.
a
A list of medication appropriate for the patients and organization’s resources is developed
b
The list is developed collaboratively by the multidisciplinary
68
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committee
c
There is a defined process for acquisition of these medications
d
There is a process to obtain medications not listed in the formulary
Average Score MOM.3:
Policies
and
procedures
medication.
a
Documented policies and procedures exist for storage of medication
b
Medications are stored
exist
for
storage
of
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committee
c
There is a defined process for acquisition of these medications
d
There is a process to obtain medications not listed in the formulary
Average Score MOM.3:
Policies
and
procedures
exist
for
storage
of
medication.
a
Documented policies and procedures exist for storage of medication
b
Medications are stored in a clean, well lit and ventilated environment
c
Sound inventory control practices guide storage of the medications
69
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d
Medications are protected from loss or theft.
e
Sound alike and look alike medications are stored separately
f
There is a method to obtain medication when the pharmacy is closed
g
Emergency medications are available all the time
h
Emergency medications are replenished in a timely manner when used
Average Score
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&
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
Gap Analysis Report Soni Hospital
d
Medications are protected from loss or theft.
e
Sound alike and look alike medications are stored separately
f
There is a method to obtain medication when the pharmacy is closed
g
Emergency medications are available all the time
h
Emergency medications are replenished in a timely manner when used
Average Score MOM.4: Policies and procedures exist for prescription of medications.
a
Documented policies and procedures exist for prescription of medications
70
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b
The organization determines who can write orders
c
Orders a re w ritten i n a uniform location in the medical records
d
Medication orders are clear, legible, dated, timed, named and signed
e
Policy on verbal orders is documented and implemented
f
The organization defines a list of high risk medication
g
High
risk
medication
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
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b
The organization determines who can write orders
c
Orders a re w ritten i n a uniform location in the medical records
d
Medication orders are clear, legible, dated, timed, named and signed
e
Policy on verbal orders is documented and implemented
f
The organization defines a list of high risk medication
g
High risk medication orders are verified prior to dispensing
Average Score MOM.5: Policies and procedures guide the safe dispensing of medications.
71
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a
Documented policies and procedures guide the safe dispensing of medications
b
The policies include a procedure for medication recall
c
Expiry dates checked prior dispensing
d
Labeling requirements are documented and implemented by the organization
are to
Average Score MOM.6:
There
administration.
are
defined
procedures
for
medication
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
Gap Analysis Report Soni Hospital
a
Documented policies and procedures guide the safe dispensing of medications
b
The policies include a procedure for medication recall
c
Expiry dates checked prior dispensing
d
Labeling requirements are documented and implemented by the organization
are to
Average Score MOM.6:
There
are
defined
procedures
for
medication
administration.
a
Medications are administered by those who are permitted by law to do so
b
Prepared medication are labeled prior to
72
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preparation of a second drug c
Patient is identified prior to administration
d
Medication is verified from the order prior to administration
e
Dosage is verified from the order prior to administration
f
Route is v erified from the order prior to administration
g
Timing is verified from the order prior to administration
h
Medication
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&
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
Gap Analysis Report Soni Hospital
preparation of a second drug c
Patient is identified prior to administration
d
Medication is verified from the order prior to administration
e
Dosage is verified from the order prior to administration
f
Route is v erified from the order prior to administration
g
Timing is verified from the order prior to administration
h
Medication administration documented
i
is
Polices a nd p rocedures govern patient’s self administration of medications
73
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j
Polices a nd p rocedures govern patient’s medications brought from outside the organization.
Average Score MOM.7: Patients and family members are educated about safe medication and food-drug interactions.
a
Patient and family are educated about safe and effective use of medication
b
Patient and family are educated about fooddrug interactions
Average Score MOM.8:
Patients
are
monitored
after
medication
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
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j
Polices a nd p rocedures govern patient’s medications brought from outside the organization.
Average Score MOM.7: Patients and family members are educated about safe medication and food-drug interactions.
a
Patient and family are educated about safe and effective use of medication
b
Patient and family are educated about fooddrug interactions
Average Score MOM.8:
Patients
are
monitored
after
medication
administration.
a
Patients are monitored after medication administration and this is documented
74
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b
Adverse drug are defined
events
c
Adverse drug events are reported within a specified time frame
d
Adverse drug events are collected and analyzed
e
Policies are modified to reduce adverse drug events when unacceptable trends occur
Average Score MOM.9: Policies and procedures guide the use of narcotic drugs and psychotropic substances.
a
Documented
policies
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b
Adverse drug are defined
events
c
Adverse drug events are reported within a specified time frame
d
Adverse drug events are collected and analyzed
e
Policies are modified to reduce adverse drug events when unacceptable trends occur
Average Score MOM.9: Policies and procedures guide the use of narcotic drugs and psychotropic substances.
a
Documented policies and procedures guide the use of narcotic drugs and psychotropic substances
b
These policies are in consonance with local
75
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and regulations
national
c
A proper record is kept of the usage, administration and disposal of these drugs
d
These drugs are handled by appropriate personnel in accordance with policies
Average Score MOM.10:
Policies
and
procedures
chemotherapeutic agents.
a
Documented policies and procedures guide the usage of
guide
the
usage
of
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and regulations
national
c
A proper record is kept of the usage, administration and disposal of these drugs
d
These drugs are handled by appropriate personnel in accordance with policies
Average Score MOM.10:
Policies
and
procedures
guide
the
usage
of
chemotherapeutic agents.
a
Documented policies and procedures guide the usage of chemotherapeutic agents
b
Chemotherapy is prescribed by those who have the knowledge to monitor
76
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and treat the adverse effect of chemotherapy c
Chemotherapy is prepared and administered by qualified personnel
d
Chemotherapy drugs are disposed off in accordance with legal requirements
Average Score MOM.11: Policies and procedures govern usage of radioactive drugs.
a
Documented policies and procedures govern usage of radioactive drugs.
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&
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and treat the adverse effect of chemotherapy c
Chemotherapy is prepared and administered by qualified personnel
d
Chemotherapy drugs are disposed off in accordance with legal requirements
Average Score MOM.11: Policies and procedures govern usage of radioactive drugs.
a
Documented policies and procedures govern usage of radioactive drugs.
b
These policies and procedures are in consonance with laws and regulations
77
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c
The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs
d
Staff, patients and visitors are educated on safety precautions
a
Documented policies and procedures govern procurement and usage of implantable
H o s p i t a l
&
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
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c
The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs
d
Staff, patients and visitors are educated on safety precautions
a
Documented policies and procedures govern procurement and usage of implantable prosthesis
b
Selection of implantable prosthesis is based on scientific criteria and national/internationally recognized approvals
78
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c
The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook.
Average Score MOM.13: Policies and procedures guide the use of medical gases.
a
Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases.
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&
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
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c
The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook.
Average Score MOM.13: Policies and procedures guide the use of medical gases.
a
Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases.
b
The policies and procedures address the safety issues at all levels
79
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c
Appropriate records are maintained in accordance with the policies, procedures and legal requirements
Average Score Total Score Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE) PRE.1: The organization protects patient and family right during care and informs them about their responsibilities.
a
Patient and rights responsibilities documented.
family and are
b
Patients and families are informed of their
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Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi r
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c
Appropriate records are maintained in accordance with the policies, procedures and legal requirements
Average Score Total Score Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE) PRE.1: The organization protects patient and family right during care and informs them about their responsibilities.
a
Patient and rights responsibilities documented.
family and are
b
Patients and families are informed of their rights and responsibilities in a format and language that they can understand.
80
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c
The organization’s leaders protect patient's and family rights.
d
Staff i s aware o f their responsibility in protecting patients and family rights
e
Violation of patient and family rights is recorded, reviewed and corrective/ preventive measures taken
Average Score PRE.2: Patient and family rights support individual beliefs, values and involve the patient and family in decision-making processes.
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c
The organization’s leaders protect patient's and family rights.
d
Staff i s aware o f their responsibility in protecting patients and family rights
e
Violation of patient and family rights is recorded, reviewed and corrective/ preventive measures taken
Average Score PRE.2: Patient and family rights support individual beliefs, values and involve the patient and family in decision-making processes.
a
Patient and family rights address any special preferences, spiritual and cultural needs.
81
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b
Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
c
Patient and family rights include protection from physical abuse and neglect.
d
Patient and family rights include treating patient information as confidential.
e
Patient
and
family
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b
Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
c
Patient and family rights include protection from physical abuse and neglect.
d
Patient and family rights include treating patient information as confidential.
e
Patient and family rights include refusal of treatment.
82
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f
Patient and family rights include informed consent before anaesthesia, blood and blood product transfusions and any invasive/ high-risk procedures/ treatment.
g
Patient and family right include information and consent before any research protocol is initiated.
h
Patient and family rights include information on how to voice a complaint.
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&
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f
Patient and family rights include informed consent before anaesthesia, blood and blood product transfusions and any invasive/ high-risk procedures/ treatment.
g
Patient and family right include information and consent before any research protocol is initiated.
h
Patient and family rights include information on how to voice a complaint.
i
Patient and family rights include information on the expected cost of the treatment.
83
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j
Patient a nd f amily h as a right to have an access to his/ her clinical records.
Average Score PRE.3: A Documented process for obtaining patient and / or families consent exists for informed decision making about their care.
a
General consent for treatment is obtained when the patient enters the organization.
b
Patient and / or his family members are informed of the scope of such general
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&
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j
Patient a nd f amily h as a right to have an access to his/ her clinical records.
Average Score PRE.3: A Documented process for obtaining patient and / or families consent exists for informed decision making about their care.
a
General consent for treatment is obtained when the patient enters the organization.
b
Patient and / or his family members are informed of the scope of such general consent.
c
The organization has listed those situations where informed consent is required.
84
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d
Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand.
e
The policy describes who can give consent when patient is incapable of independent decisionmaking.
Average Score PRE.4: Patient and families have a right to information and education about their health care needs.
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d
Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand.
e
The policy describes who can give consent when patient is incapable of independent decisionmaking.
Average Score PRE.4: Patient and families have a right to information and education about their health care needs.
a
When appropriate, patient and families and are educated about the safe and effective use of medication and the
85
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potential side effects of the medication.
b
Patient and families are educated about diet and nutrition.
c
Patient and families are educated about immunizations.
d
Patient and families are
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potential side effects of the medication.
b
Patient and families are educated about diet and nutrition.
c
Patient and families are educated about immunizations.
d
Patient and families are educated about their specific disease process, complications and prevention strategies.
86
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e
Patient and families are educated about preventing infections.
f
Patients and family are taught in a language and format that they can understand.
Average Score PRE.5: Patient and families have a right to information on expected costs.
a
There is uniform pricing policy in a given setting (out-patient and ward category)
b
The tariff list is available to patients.
c
Patients and family are
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e
Patient and families are educated about preventing infections.
f
Patients and family are taught in a language and format that they can understand.
Average Score PRE.5: Patient and families have a right to information on expected costs.
a
There is uniform pricing policy in a given setting (out-patient and ward category)
b
The tariff list is available to patients.
c
Patients and family are educated about the estimated cost of treatment.
87
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d
Patients and family are educated about the financial implications when there is a change in the patient condition or treatment setting.
Average Score Total Score Chapter 5: HOSPITAL INFECTION CONTROL (HIC) HIC.1: The organization has a well-designed, comprehensive and
coordinated
infection
control
programme
aimed
at
reducing/ eliminating risks to patients, visitors and providers of care.
a
The hospital infection control programme is documented which aims at preventing and
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d
Patients and family are educated about the financial implications when there is a change in the patient condition or treatment setting.
Average Score Total Score Chapter 5: HOSPITAL INFECTION CONTROL (HIC) HIC.1: The organization has a well-designed, comprehensive and
coordinated
infection
control
programme
aimed
at
reducing/ eliminating risks to patients, visitors and providers of care.
a
The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections.
b
The hospital has a multi-disciplinary infection control committee.
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c
The hospital has an infection control team.
d
The hospital has designated and qualified infection control nurse(s) for this activity.
Average Score HIC.2: The organization has an infection control manual, which is periodically updated.
a
The manual identifies the various high-risk areas & procedures.
b
It outlines methods of surveillance in the identified high-risk areas.
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c
The hospital has an infection control team.
d
The hospital has designated and qualified infection control nurse(s) for this activity.
Average Score HIC.2: The organization has an infection control manual, which is periodically updated.
a
The manual identifies the various high-risk areas & procedures.
b
It outlines methods of surveillance in the identified high-risk areas.
c
It focuses on adherence to standard precautions at all times
d
Equipment cleaning and sterilisation practices are included.
89
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e
An appropriate antibiotic policy is established and implemented
f
Laundry and management processes are included.
linen also
g
Kitchen sanitation and food handling issues are included in the manual
h
Engineering controls to prevent infections are included
i
Mortuary practices and procedures are
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e
An appropriate antibiotic policy is established and implemented
f
Laundry and management processes are included.
linen also
g
Kitchen sanitation and food handling issues are included in the manual
h
Engineering controls to prevent infections are included
i
Mortuary practices and procedures are included as appropriate to the organization.
j
The organization defines the periodicity of updating the infection control
90
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manual
Average Score HIC.3:
The
infection
control
team
is
responsible
surveillance activities in identified areas of the hospital.
a
Surveillance activities are appropriately directed towards the identified high-risk areas
b
Collection of surveillance data is an ongoing process
c
Verification of data is done on regular basis by the infection control
for
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manual
Average Score HIC.3:
The
infection
control
team
is
responsible
for
surveillance activities in identified areas of the hospital.
a
Surveillance activities are appropriately directed towards the identified high-risk areas
b
Collection of surveillance data is an ongoing process
c
Verification of data is done on regular basis by the infection control team
d
In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.
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e
Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.
f
Surveillance activities include monitoring the effectiveness of housekeeping services.
a
The organization monitors urinary tract infections.
b
The
organization
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e
Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.
f
Surveillance activities include monitoring the effectiveness of housekeeping services.
a
The organization monitors urinary tract infections.
b
The organization monitors respiratory tract infections.
c
The organization monitors intra-vascular device infections
d
The organization monitors surgical site
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infections. e
Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.
Average Score HIC.5: Proper facilities and adequate resources are provided to support the infection control programme.
a
Hand washing facilities in all patient care areas are accessible to health care providers.
b
Compliance with proper hand washing is monitored regularly.
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infections. e
Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.
Average Score HIC.5: Proper facilities and adequate resources are provided to support the infection control programme.
a
Hand washing facilities in all patient care areas are accessible to health care providers.
b
Compliance with proper hand washing is monitored regularly.
c
Isolation/ barrier nursing facilities are available.
d
Adequate gloves, masks, soaps, and disinfectants are
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available correctly.
and
used
Average Score HIC.6: The organization takes appropriate actions to control outbreaks of infections.
a
Hospital has a documented procedure for handling such outbreaks.
b
This procedure is implemented during outbreaks.
c
After the outbreak is over appropriate corrective actions are taken to prevent
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available correctly.
and
used
Average Score HIC.6: The organization takes appropriate actions to control outbreaks of infections.
a
Hospital has a documented procedure for handling such outbreaks.
b
This procedure is implemented during outbreaks.
c
After the outbreak is over appropriate corrective actions are taken to prevent recurrence.
Average Score HIC.7: There are documented procedures for sterilization activities in the organization.
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a
There is adequate space available for sterilization activities
b
Regular validation tests for sterilization are carried out and documented
c
There is an established recall procedure when breakdown in the sterilization system is identified.
Average Score HIC.8: Statutory provisions with regard to Bio-medical Waste (BMW) management are complied with
a
The
hospital
is
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a
There is adequate space available for sterilization activities
b
Regular validation tests for sterilization are carried out and documented
c
There is an established recall procedure when breakdown in the sterilization system is identified.
Average Score HIC.8: Statutory provisions with regard to Bio-medical Waste (BMW) management are complied with
a
The hospital is authorized by prescribed authority for the management and handling of Bio-medical Waste.
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b
Proper segregation and collection of Biomedical Waste from all patient care areas of the hospital is implemented and monitored
c
The organization ensures that Biomedical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner.
d
Bio-medical
Waste
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b
Proper segregation and collection of Biomedical Waste from all patient care areas of the hospital is implemented and monitored
c
The organization ensures that Biomedical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner.
d
Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorized contractor(s).
96
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e
Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.
f
Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste.
Average Score HIC.9: The infection control programme is supported by the organization's management and includes training of staff a nd employee health.
a
Hospital makes
management available required for
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e
Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.
f
Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste.
Average Score HIC.9: The infection control programme is supported by the organization's management and includes training of staff a nd employee health.
a
Hospital management makes available resources required for the infection control programme.
b
The hospital regularly earmarks adequate funds from its annual budget in this regard.
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c
It conducts regular preinduction training for appropriate categories of staff before joining concerned department(s).
d
It also conducts regular “in-service” training sessions for all concerned categories of staff at least once in a year.
e
Appropriate pre and post exposure prophylaxis is provided to all concerned staff members
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c
It conducts regular preinduction training for appropriate categories of staff before joining concerned department(s).
d
It also conducts regular “in-service” training sessions for all concerned categories of staff at least once in a year.
e
Appropriate pre and post exposure prophylaxis is provided to all concerned staff members
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a
The quality improvement programme is developed, implemented and maintained by a multidisciplinary committee.
b
The improvement programme documented.
c
quality is
There is a designated individual for coordinating and implementing the quality improvement programme
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a
The quality improvement programme is developed, implemented and maintained by a multidisciplinary committee.
b
The improvement programme documented.
quality is
c
There is a designated individual for coordinating and implementing the quality improvement programme
d
The quality improvement programme is comprehensive and covers all the major elements related to
99
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quality assurance and risk management.
e
The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism.
f
The quality improvement programme is reviewed
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quality assurance and risk management.
e
The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism.
f
The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified.
100
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g
The quality improvement programme is a continuous process and updated at least once in a year.
Average Score CQI.2: The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools for continual improvement.
a
Monitoring appropriate assessment.
includes patient
b
Monitoring includes safety and quality control programmes of diagnostics services.
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g
The quality improvement programme is a continuous process and updated at least once in a year.
Average Score CQI.2: The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools for continual improvement.
a
Monitoring appropriate assessment.
includes patient
b
Monitoring includes safety and quality control programmes of diagnostics services.
c
Monitoring includes all invasive procedures
d
Monitoring includes adverse drug events.
e
Monitoring includes use of anesthesia.
101
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f
Monitoring includes use of blood and blood products.
g
Monitoring includes availability and content of medical records.
h
Monitoring infection activities.
i
Monitoring includes clinical research.
j
Monitoring includes data collection to support further improvements
k
Monitoring includes data collection to
includes control
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f
Monitoring includes use of blood and blood products.
g
Monitoring includes availability and content of medical records.
h
Monitoring infection activities.
i
Monitoring includes clinical research.
j
Monitoring includes data collection to support further improvements
k
Monitoring includes data collection to support evaluation of these improvements
includes control
Average Score CQI.3: The organization identifies key indicators to monitor the managerial structures, processes and outcomes which are used as tools for continual i mprovement..
102
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a
Monitoring includes procurement of medication essential to meet patient needs.
b
Monitoring includes reporting of activities as required by laws and regulations.
c
Monitoring includes risk management.
d
Monitoring includes utilisation of space, manpower and equipment.
e
Monitoring includes patient satisfaction which also incorporates
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a
Monitoring includes procurement of medication essential to meet patient needs.
b
Monitoring includes reporting of activities as required by laws and regulations.
c
Monitoring includes risk management.
d
Monitoring includes utilisation of space, manpower and equipment.
e
Monitoring includes patient satisfaction which also incorporates waiting time for services.
f
Monitoring includes employee satisfaction
g
Monitoring includes adverse events and
103
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near misses.
h
Monitoring includes data collection to suppor supportt furthe furtherr study study for improvements.
i
Monitoring includes data collection to suppor supportt evalua evaluatio tion n of the improvements
Average Score CQI.4: The quality improvement programme is supported by the management.
a
Hospital Management makes available adeq adequa uate te reso resour urce ces s requ requir ired ed for for qual qualit ity y
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near misses.
h
Monitoring includes data collection to suppor supportt furthe furtherr study study for improvements.
i
Monitoring includes data collection to suppor supportt evalua evaluatio tion n of the improvements
Average Score CQI.4: The quality improvement programme is supported by the management.
a
Hospital Management makes available adeq adequa uate te reso resour urce ces s requ requir ired ed for for qual qualit ity y improvement programme.
b
Hospital earmarks adequ adequat ate e fund funds s from from its its annu annual al budg budget et in this regard.
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c
Appr ppropri priate statistical and management tools are applie applied d wheneve wheneverr required.
Average Score CQI.5: There is an established system for audit of patient care services.
a
Medical and nursing staff participates in this system.
b
The parameters to be audited are defined by the organization
c
Patient a nd anonymity maintained.
d
All
audits
staff is are
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c
Appr ppropri priate statistical and management tools are applie applied d wheneve wheneverr required.
Average Score CQI.5: There is an established system for audit of patient care services.
a
Medical and nursing staff participates in this system.
b
The parameters to be audited are defined by the organization
c
Patient a nd anonymity maintained.
staff is
d
All audits documented.
are
e
Remed emedia iall mea measu surres are are implemented.
Average Score CQI.6: Sentinel events are intensively analyzed.
a
The
organization
h as
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defined events.
sentinel
b
The organization has establ establish ished ed proces processes ses for intens intense e analys analysis is of such events.
c
Sentinel events are inte intens nsiv ivel ely y anal analyze yzed d when they occur
d
Corrective and preventive preventive Actions Actions are taken bas based on the findings of such analysis.
Average Score Total Score Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)
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defined events.
sentinel
b
The organization has establ establish ished ed proces processes ses for intens intense e analys analysis is of such events.
c
Sentinel events are inte intens nsiv ivel ely y anal analyze yzed d when they occur
d
Corrective and preventive preventive Actions Actions are taken bas based on the findings of such analysis.
Average Score Total Score Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM) ROM.1: The responsibilities responsibilities of the management management are defined.
a
Those responsible for gove govern rnanc ance e lay lay down down the organization’s n’s mission statement
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b
Those responsible for governance lay down the strategic and operational plans commensurate to the organization’s mission in consultation with the various stake holders.
c
Those responsible for governance approve the organization’s budget and allocate the resources required to meet the organization’s mission.
d
Those responsible for governance monitor
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b
Those responsible for governance lay down the strategic and operational plans commensurate to the organization’s mission in consultation with the various stake holders.
c
Those responsible for governance approve the organization’s budget and allocate the resources required to meet the organization’s mission.
d
Those responsible for governance monitor and measure the performance of the organization against the stated mission
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e
Those responsible for governance establish the organization’s organogram.
f
Those responsible for governance appoint the senior leaders in the organization.
g
Those responsible for governance support research activities and quality improvement plans.
h
The organization complies with the laid down and applicable legislations and
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e
Those responsible for governance establish the organization’s organogram.
f
Those responsible for governance appoint the senior leaders in the organization.
g
Those responsible for governance support research activities and quality improvement plans.
h
The organization complies with the laid down and applicable legislations and regulations
i
Those responsible for governance address the organization’s social responsibility
Average Score
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ROM.2: The
services provided by each department are
documented.
a
Each organizational program, service, site or department has effective leadership
b
Scope of services of each department is defined.
c
Administrative policies and procedures for each department is maintained.
d
Departmental leaders are involved in quality improvement.
Average Score
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ROM.2: The
services provided by each department are
documented.
a
Each organizational program, service, site or department has effective leadership
b
Scope of services of each department is defined.
c
Administrative policies and procedures for each department is maintained.
d
Departmental leaders are involved in quality improvement.
Average Score ROM.3: The organization is managed by the leaders in an ethical manner.
a
The leaders make public the mission statement of the organization
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b
The leaders establish the organization’s ethical management
c
The organization discloses its ownership
d
The organization honestly portrays the services which it can and cannot provide
e
The organization honestly portrays its affiliations and accreditation
f
The organization accurately bills for it’s services based upon a standard billing tariff.
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b
The leaders establish the organization’s ethical management
c
The organization discloses its ownership
d
The organization honestly portrays the services which it can and cannot provide
e
The organization honestly portrays its affiliations and accreditation
f
The organization accurately bills for it’s services based upon a standard billing tariff.
Average Score ROM.4: A suitably qualified and experienced individual heads the organization.
a
The designated individual has requisite and appropriate
110
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administrative qualifications b
The designated individual has requisite and appropriate administrative experience
Average Score ROM.5: Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management.
a
The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme
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administrative qualifications b
The designated individual has requisite and appropriate administrative experience
Average Score ROM.5: Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management.
a
The organization has an interdisciplinary group assigned to oversee the hospital wide safety programme
b
The scope of the programme is defined to include adverse events ranging from “no harm” to “sentinel events”.
111
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c
Management ensures implementation of systems for internal and external reporting of system and process failures
d
Management provides resources for proactive risk assessment and risk reduction activities.
Average Score Total Score Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS) FMS.1: The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.
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c
Management ensures implementation of systems for internal and external reporting of system and process failures
d
Management provides resources for proactive risk assessment and risk reduction activities.
Average Score Total Score Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS) FMS.1: The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.
a
The management is conversant with the laws and regulations and knows their applicability to the
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organization
b
Management regularly updates any amendments in the prevailing laws of the land.
c
The management ensures implementation of these requirements.
d
There i s a mechanism to regularly update licenses/ registrations/certificatio ns.
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organization
b
Management regularly updates any amendments in the prevailing laws of the land.
c
The management ensures implementation of these requirements.
d
There i s a mechanism to regularly update licenses/ registrations/certificatio ns.
Average Score FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
a
There is a documented operational and maintenance
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(preventive breakdown) plan.
and
b
Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.
c
There is internal and external sign posting in the organization in a language understood by patient, families and community.
d
The provision of space shall be in accordance with the available literature on good
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(preventive breakdown) plan.
and
b
Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.
c
There is internal and external sign posting in the organization in a language understood by patient, families and community.
d
The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies
e
There are designated
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individuals responsible for the maintenance of all the facilities f
Maintenance staff is contactable round the clock for emergency repairs.
g
Response times are monitored from reporting to inspection and implementation of corrective actions.
Average Score FMS.3: The organization has a program for clinical and support service equipment management.
a
The organization plans for equipment in
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individuals responsible for the maintenance of all the facilities f
Maintenance staff is contactable round the clock for emergency repairs.
g
Response times are monitored from reporting to inspection and implementation of corrective actions.
Average Score FMS.3: The organization has a program for clinical and support service equipment management.
a
The organization plans for equipment in accordance with its services and strategic plan
b
Equipment is selected by a collaborative process.
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c
All equipment is inventoried and proper logs are maintained as required.
d
Qualified and trained personnel operate and maintain the equipment.
e
Equipment are periodically inspected and calibrated for their proper functioning
f
There is a documented operational and maintenance (preventive and breakdown) plan
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c
All equipment is inventoried and proper logs are maintained as required.
d
Qualified and trained personnel operate and maintain the equipment.
e
Equipment are periodically inspected and calibrated for their proper functioning
f
There is a documented operational and maintenance (preventive and breakdown) plan
Average Score FMS.4: The
organization has
provisions for
safe water,
electricity, medical gases and vacuum systems.
a
Potable water and electricity are available round the clock.
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b
Alternate sources are provided for in case of failure.
c
The organization regularly tests the alternate sources.
d
There is a maintenance plan for piped medical gas, compressed air and vacuum installation
Average Score FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.
a
The organization has plans and provisions for early detection,
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b
Alternate sources are provided for in case of failure.
c
The organization regularly tests the alternate sources.
d
There is a maintenance plan for piped medical gas, compressed air and vacuum installation
Average Score FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.
a
The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies.
b
The organization has a documented safe exit plan in case of fire and
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non-fire emergencies c
Staff is trained for their role in case of such emergencies.
d
Mock d rills a re h eld a t least twice in a year
Average Score FMS.6: The organization has a smoking limitation policy
a
The organization defines and implements its polices to reduce or eliminate smoking
b
The policy has provisions for granting
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non-fire emergencies c
Staff is trained for their role in case of such emergencies.
d
Mock d rills a re h eld a t least twice in a year
Average Score FMS.6: The organization has a smoking limitation policy
a
The organization defines and implements its polices to reduce or eliminate smoking
b
The policy has provisions for granting exceptions for patients and families to smoke
Average Score FMS.7:
The
organization
plans
for
handling
community
emergencies, epidemics and other disasters.
a
The hospital identifies
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potential emergencies. b
The organization has a documented disaster management plan.
c
Provision is made for availability of medical supplies, equipment and materials during such emergencies.
d
Hospital staff is trained in the hospital’s disaster management plan
e
The plan is t ested at least twice in a year.
Average Score FMS.8: The organization has a plan for management of
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potential emergencies. b
The organization has a documented disaster management plan.
c
Provision is made for availability of medical supplies, equipment and materials during such emergencies.
d
Hospital staff is trained in the hospital’s disaster management plan
e
The plan is t ested at least twice in a year.
Average Score FMS.8: The organization has a plan for management of hazardous materials
a
Hazardous materials are identified within the organization
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b
The hospital implements processes for sorting, handling, labelling, storage, transporting and disposal of hazardous material.
c
Requisite regulatory requirements are met in respect of radioactive materials
d
There is a plan for managing spills of hazardous materials
e
Staff is educated and trained for handling such materials.
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b
The hospital implements processes for sorting, handling, labelling, storage, transporting and disposal of hazardous material.
c
Requisite regulatory requirements are met in respect of radioactive materials
d
There is a plan for managing spills of hazardous materials
e
Staff is educated and trained for handling such materials.
Average Score FMS.9: The organization has system in place to provide a safe and secure environment
a
The hospital has a safety committee to identify the potential
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safety risks
and
security
b
This committee coordinates development, implementation, and monitoring of the safety plan and policies.
c
Patient safety devices are installed across the organization and inspected periodically.
d
Facility inspection rounds to ensure safety are conducted at least
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safety risks
and
security
b
This committee coordinates development, implementation, and monitoring of the safety plan and policies.
c
Patient safety devices are installed across the organization and inspected periodically.
d
Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas.
e
Inspection reports are
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documented and corrective and preventive measures are undertaken. f
There is a safety education programme for all staff.
Average Score Total Score Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM) HRM.1: The organization has a documented system of human resource planning.
a
The organization maintains an adequate number and mix of staff to meet the care,
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documented and corrective and preventive measures are undertaken. f
There is a safety education programme for all staff.
Average Score Total Score Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM) HRM.1: The organization has a documented system of human resource planning.
a
The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient.
b
The required job specifications and job description are well defined for each category of staff.
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c
The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.
Average Score HRM.2: The staff joining the organization is socialized and oriented to the hospital environment.
a
b
Each staff member, employee, student and voluntary worker is appropriately oriented to the organization’s mission and goals. h
ff
b
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c
The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.
Average Score HRM.2: The staff joining the organization is socialized and oriented to the hospital environment.
a
Each staff member, employee, student and voluntary worker is appropriately oriented to the organization’s mission and goals.
b
Each staff member is made aware of hospital wide policies and procedures as well as relevant department / unit / service / programme’s policies
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and procedures. c
Each s taff member i s made aware of his/her rights and responsibilities.
d
All employees are educated with regard to patients’ rights and responsibilities.
e
All employees are oriented to the service standards of the organization.
Average Score HRM.3: There is an ongoing programme for professional training and development of the staff.
a
A documented training
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and procedures. c
Each s taff member i s made aware of his/her rights and responsibilities.
d
All employees are educated with regard to patients’ rights and responsibilities.
e
All employees are oriented to the service standards of the organization.
Average Score HRM.3: There is an ongoing programme for professional training and development of the staff.
a
A documented training and development policy exists for the staff.
b
Training also occurs when job responsibilities change/
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new equipment introduced
c
is
Feedback mechanisms for assessment of training and development programme exist.
Average Score HRM.4: Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety.
a
All staff is trained on the risks within the hospital environment.
b
Staff members can demonstrate and take
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new equipment introduced
c
is
Feedback mechanisms for assessment of training and development programme exist.
Average Score HRM.4: Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety.
a
All staff is trained on the risks within the hospital environment.
b
Staff members can demonstrate and take actions to report, eliminate / minimize risks.
c
Staff members are made aware of procedures to follow in
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the event incident. d
of
an
Reporting processes for common problems, failures and user errors exist
Average Score HRM.5: An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process.
a
A well-documented performance appraisal system exists in the organization.
b
The employees are made aware of the system of appraisal at
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the event incident. d
of
an
Reporting processes for common problems, failures and user errors exist
Average Score HRM.5: An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process.
a
A well-documented performance appraisal system exists in the organization.
b
The employees are made aware of the system of appraisal at the time of induction.
c
Performance is evaluated based on the performance expectations described in job
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description
d
The appraisal system is used as a tool for further development.
e
Performance appraisal is carried out at pre defined intervals and is documented.
Average Score HRM.6: The organization has a well-documented disciplinary procedure.
a
A written statement of the policy of the organization with regard to discipline is in place.
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description
d
The appraisal system is used as a tool for further development.
e
Performance appraisal is carried out at pre defined intervals and is documented.
Average Score HRM.6: The organization has a well-documented disciplinary procedure.
a
A written statement of the policy of the organization with regard to discipline is in place.
b
The disciplinary policy and procedure is based on the principles of natural justice.
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c
The policy and procedure is known to all categories of employees of the organization.
d
The disciplinary procedure is in consonance with the prevailing laws.
e
There is a provision for appeals in alldisciplinary cases.
Average Score HRM.7:
A
grievance
handling
organization.
a
The employees aware of
are the
mechanism
exists
in
the
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c
The policy and procedure is known to all categories of employees of the organization.
d
The disciplinary procedure is in consonance with the prevailing laws.
e
There is a provision for appeals in alldisciplinary cases.
Average Score HRM.7:
A
grievance
handling
mechanism
exists
in
the
organization.
a
The employees are aware of the procedure to be followed in case they feel aggrieved.
b
The redress procedure addresses the grievance.
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c
Actions are taken to redress the grievance.
Average Score HRM.8: The organization addresses the health needs of the employees.
a
A pre-employment medical examination is conducted on all the employees.
b
Health problems of the employees are taken care of in accordance with the organization’s policy.
c
Regular health checks of staff dealing with direct patient care are
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c
Actions are taken to redress the grievance.
Average Score HRM.8: The organization addresses the health needs of the employees.
a
A pre-employment medical examination is conducted on all the employees.
b
Health problems of the employees are taken care of in accordance with the organization’s policy.
c
Regular health checks of staff dealing with direct patient care are done at-least once a year and the findings/ results are documented.
d
Occupational hazards
health are
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adequately addressed. Average Score HRM.9: There is a documented personal record for each staff member.
a
Personal files are maintained in respect of all employees.
b
The personal files contain personal information regarding the employees qualification, disciplinary background and health status
c
All
records
of
in
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adequately addressed. Average Score HRM.9: There is a documented personal record for each staff member.
a
Personal files are maintained in respect of all employees.
b
The personal files contain personal information regarding the employees qualification, disciplinary background and health status
c
All records of inservice training and education are contained in the personal files
d
Personal files contain result of all
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evalutions. Average Score HRM.10: There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of medical professionals permitted to provide patient care without supervision.
a
Medical professionals permitted by law, regulation and the hospital to provide patient care without supervision is identified.
b
The education, registration, training and experience of the
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evalutions. Average Score HRM.10: There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of medical professionals permitted to provide patient care without supervision.
a
Medical professionals permitted by law, regulation and the hospital to provide patient care without supervision is identified.
b
The education, registration, training and experience of the identified medical professionals is documented and updated periodically.
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c
All such information pertaining to the medical professionals is appropriately verified when possible.
Average Score HRM.11: There is a process for authorising all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications.
a
Medical professionals admit and care for patients as per the laid down policies and authorisation procedures of the organization.
b
The services provided
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c
All such information pertaining to the medical professionals is appropriately verified when possible.
Average Score HRM.11: There is a process for authorising all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications.
a
Medical professionals admit and care for patients as per the laid down policies and authorisation procedures of the organization.
b
The services provided by the medical professionals are in consonance with their qualification, training and registration.
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c
The requisite services to be provided by the medical professionals are known to them as well as the various departments/ units of the hospital.
Average Score HRM.12: There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of nursing staff.
a
The education, registration, training and experience of nursing staff is documented and updated periodically.
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c
The requisite services to be provided by the medical professionals are known to them as well as the various departments/ units of the hospital.
Average Score HRM.12: There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of nursing staff.
a
The education, registration, training and experience of nursing staff is documented and updated periodically.
b
All such information pertaining to the nursing staff is appropriately verified when possible.
Average Score
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HRM.13: There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members commensurate with their qualifications and any other regulatory requirements.
a
The clinical work assigned to nursing staff is in consonance with their qualification, training and registration.
b
The services provided by nursing staff are in accordance with the prevailing laws and regulations.
c
The requisite services to be provided by the nursing staff are known
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HRM.13: There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members commensurate with their qualifications and any other regulatory requirements.
a
The clinical work assigned to nursing staff is in consonance with their qualification, training and registration.
b
The services provided by nursing staff are in accordance with the prevailing laws and regulations.
c
The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the hospital.
Average Score Total Score Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)
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IMS.1: Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require data and information from the Organization.
a
The information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organization
b
Policies and procedures to meet the information needs are documented.
c
These
policies
and
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IMS.1: Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require data and information from the Organization.
a
The information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organization
b
Policies and procedures to meet the information needs are documented.
c
These policies and procedures are in compliance with the prevailing laws and regulations.
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d
All information management and technology acquisitions are in accordance with the policies and procedures.
e
The organization contributes to external databases in accordance with the law and regulations
Average Score IMS.2: The organization has processes in place for effective management of data
a
Formats collection
for
data are
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d
All information management and technology acquisitions are in accordance with the policies and procedures.
e
The organization contributes to external databases in accordance with the law and regulations
Average Score IMS.2: The organization has processes in place for effective management of data
a
Formats for collection standardized
data are
b
Necessary resources are available for analyzing data.
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c
Documented procedures are laid down for timely and accurate dissemination of data
d
Documented procedures exist for storing and retrieving data
e
Appropriate clinical and managerial staff participates in selecting, integrating and using data.
Average Score IMS.3: The organization has a complete and accurate medical record for every patient.
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c
Documented procedures are laid down for timely and accurate dissemination of data
d
Documented procedures exist for storing and retrieving data
e
Appropriate clinical and managerial staff participates in selecting, integrating and using data.
Average Score IMS.3: The organization has a complete and accurate medical record for every patient.
a
Every medical record has a unique identifier.
b
Organization policy identifies those authorized to make
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entries in record.
medical
c
Every medical record entry is dated and timed
d
The author of the entry can be identified
e
The contents of medical record are identified and documented
f
The record provides an up-to-date and chronological account of patient care
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entries in record.
medical
c
Every medical record entry is dated and timed
d
The author of the entry can be identified
e
The contents of medical record are identified and documented
f
The record provides an up-to-date and chronological account of patient care
a
The medical record contains information regarding reasons for admission, diagnosis and plan of care.
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b
Operative and other procedures performed are incorporated in the medical record
c
When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for the transfer and the name of the receiving hospital
d
The medical record contains a copy of the discharge note duly signed by appropriate and qualified
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b
Operative and other procedures performed are incorporated in the medical record
c
When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for the transfer and the name of the receiving hospital
d
The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel
e
In case of d eath, the medical record contains a copy of the death certificate indicating the cause,
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date and death.
time
of
f
Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same.
g
Care providers have access to current and past medical record.
Average Score IMS.5: Policies and procedures are in place for maintaining confidentiality, integrity and security of information.
a
Documented policies and procedures exist for maintaining
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date and death.
time
of
f
Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same.
g
Care providers have access to current and past medical record.
Average Score IMS.5: Policies and procedures are in place for maintaining confidentiality, integrity and security of information.
a
Documented policies and procedures exist for maintaining confidentiality, security and integrity of information
b
Policies and procedures are in consonance with the
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applicable laws c
The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tampering
d
The hospital has an effective process of monitoring compliance of the laid down policy
e
The hospital developments appropriate
uses in
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applicable laws c
The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tampering
d
The hospital has an effective process of monitoring compliance of the laid down policy
e
The hospital uses developments in appropriate technology for improving, confidentiality, integrity and security
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f
Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization
g
A documented procedure exists on how to respond to patients/ physicians and other public agencies requests for access to information in the medical record in accordance with
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f
Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization
g
A documented procedure exists on how to respond to patients/ physicians and other public agencies requests for access to information in the medical record in accordance with the local and national law.
Average Score IMS.6: Policies and procedures exist for retention time of records, data and information.
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a
Documented policies and procedures are in place on retaining the patient’s clinical records, data and information
b
The policies and procedures are in consonance with the local and national laws and regulations
c
The retention process provides expected confidentiality and security
d
The destruction of medical records, data
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a
Documented policies and procedures are in place on retaining the patient’s clinical records, data and information
b
The policies and procedures are in consonance with the local and national laws and regulations
c
The retention process provides expected confidentiality and security
d
The destruction of medical records, data and information is in accordance with the laid down policy
Average Score IMS.7: The
organization regularly
carries
out
review of
medical records.
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a
The medical records are reviewed periodically.
b
The review uses a representative sample based on statistical principles.
c
The review conducted identified providers.
d
The review focuses on the timeliness, legibility and completeness of the medical records
e
The
review
is by care
process
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a
The medical records are reviewed periodically.
b
The review uses a representative sample based on statistical principles.
c
The review conducted identified providers.
d
The review focuses on the timeliness, legibility and completeness of the medical records
e
The review process includes records of both active and discharged patients
f
The review points out and documents any deficiencies in records
is by care
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g
Appropriate corrective and preventive measures undertaken are documented.
Average Score Total Score
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Appropriate corrective and preventive measures undertaken are documented.
Average Score Total Score
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SECTION 6: SUMMARY OF SCORES OF VARIOUS CHAPTERS S. NO.
CHAPTER
1
Access, Assessment And Continuity Of Care (AAC)
2
Care Of Patients (COP)
3
Management Of Medication (MOM)
4
Patient Rights And Education (PRE)
5
Hospital Infection Control (HIC)
6
Continuous Quality Improvement (CQI)
7
Responsibilities Of Management
SCORE
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SECTION 6: SUMMARY OF SCORES OF VARIOUS CHAPTERS S. NO.
CHAPTER
1
Access, Assessment And Continuity
SCORE
Of Care (AAC) 2
Care Of Patients (COP)
3
Management Of Medication (MOM)
4
Patient Rights And Education (PRE)
5
Hospital Infection Control (HIC)
6
Continuous Quality Improvement (CQI)
7
Responsibilities Of Management (ROM)
8
Facility Management And Safety (FMS)
9
Human Resource Management (HRM)
10
Information Ma Management System (IMS) AVERAGE SCORE OF ALL CAHPTERS
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SECTION 7: RESULT:
On the basis of detailed gap assessment on every standard and objective elements of NABH, following conclusions can be derived. 1. Average score of the NABH standards (all chapters) is coming out
to be 4.5 or 45%. This score is much below the desirable value of >70% as per accreditation norms. Hence rigorous efforts are required to be made to bring the score up from 45% to >70% 2. No chapters have scored 70% or more score individually. Thus
there is a scope to improve and strengthen the documentation and implementation in every chapter of NABH. Having a score of 70% in every chapter, individually, is a must for accreditation 3. Compliance Compliance score score of individual individual standards standards gives following following quantum of deficiencies. S. No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Chapter
No. of standards with average score less than 5
No. of standards with more than one zero in its objective elements
Overall AAC COP MOM PRE HIC CQI ROM FMS HRM IMS
Note: It is mandatory for accreditation that no standard should have a score of less than 5 and no standard can have more than one zero in its objective elements
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ANNEX ‘A’.SIGNAGE & DISPLAYS
Specific signage requirements that shall be addressed in signage plan of the hospital are as given below. ……………………………………………………………………………………….. …………………………………………………………………………………………… ……………………….. …………………………………………………………………………………………… …………………… …………………………………………………………………………………………… ……………………. All signage and displays in the hospital shall be made in minimum two languages and a symbolic representation. The two languages shall be ‘English’ and ‘Hindi’. The dimensions of all signage and displays shall be kept such that it should be clearly visible from distance
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