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; , NABH-Aocreditalion Standardstor Hospitals
. The 3rd edition of accreditation standard is divided into 10 chapters, ...
C . Accreditation Standards for Hospitals
Table of_ Contents
Access, Assessmentand Continuity of Cae (AAC)
Carelof Pa...
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Intent ofthe chapter:
Patients are well informed of the service...
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Summary o...
}'Assessment and Continuity of Care (AAC)
Standards and Objective Elements
The services being provided are clearly defin...
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Standard
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Objective Elements 9‘
a. Documented policies and procedures are used for registering...
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Access Assessment and Continuity of Care (AAC)
Remark(s): For unplanned transfers and in case of suspected unstable pati...
Assessment and Continuity of Care (AAC)
The organisation gives a summary of patient’s condition and the treatment given. ...
Access Assessment and Continuity of Care (AAC) .
b. The organisation determines who can perform the initial assessment....
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Assessment and Continuity of Care (AAC)
-‘Please note that the maximum time allowed for ...
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-a Assessment and Continuity of Care (AAC)
Reasse I o b ' a —care atients before discharging) or
patients awaiting admiss...
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Assessment and Continuity of Care (AAC)
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~Docu_mented procedures guide ordering of tests, collection, identification...
g. Results are reported in a standardised manner.
organisation (or in case of outsourced laboratory, the name of the ...
“me (preferably as per ISO 15189 Medical laboratories — Particular
ents for quality and competence).
s): Quality assura...
Access Assessment and Continuity of Care (AAC)
/ Methods extended to a component, analysis or matrix not previously '
t...
ment and Continuity of Care (AAC)
is programme is aligned with the organisation'ssa...
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Access Assessment and Continuity of Care (AAC)
Standard
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Objective Elements
a. Imaging se...
Assessment and Continuity of Care (AAC)
Documentedpolicies and procedures guide identification and safe transportati...
Access Assessment and Continuity of Care (AAC)
. .______
i. Imaging tests not available in the organisation are outsou...
ent and Continuity of Care (AAC)
programme includes periodic calibration and maintenance of all equipment. *
Q - ...
d.
Access Assessment and Continuity of Care (AAC)
Imaging personnel are provided with appropriate radiation safety d...
tpare may be provided by a team, the hospital record shall
- ing responsible for patient care.
and other care-providers...
Access Assessment and Continuity of Care (AAC)
f. r The patient’s record(s) is available to the authorised care-provider...
I try of Care (AAC)
qarooedures exist for coordination of various departments and
-~«. in the discharge process (includi...
Access Assessment and Continuity of Care (AAC) 1 _
Remark(s): The discharge summary shall be signed by the treating doct...
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and Continuity of Care (AAC)
of death, the summary of the ca...
Care of Patients (COP)
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intent of the chapter:
The org...
ergency services are guided by documented policies, procedures and
‘cable laws and regulations.
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Care of Patients (COP)
Documented policies and procedures guide the care o...
tive Elements
Care delivery is unifonn for a given health problem when simi
in more than one setting. *
Interpretation:...
Care of Patients (COP)
Objective Elements
a. Policies and procedures for emergency care are documented and are . i,
...
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with the policies and trained on the procedures for care of
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. ..: Al| the staff working...
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c. Ambulance(s) are appropriately equipped. -.
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v- tation: The ambulance shall be connected with the organisation/ control .
by wireless/ mobile phones.
re...
Care of Patients (COP)
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c. The events during a cardio-pulrnonary resuscitation are recorded. I ‘
Interpretation: in ...
ieflect current standards of nursing services and practice, relevant
fit-. and purposes of the services.
"on: Nursing p...
Care of Patients (COP)
f. Nurses are provided with adequate equipment for providing safe and efficie
nursing services...
_ ‘ mtion: Self-explanatory.
'nsent shalt be taken by the person performing the procedure or a member
_ er team. In ca...
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Care of Patients (COP) -g
Standard
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Objective Elements fl
a. Documented policies and procedures are use...
- is obtained for donation and transfusion of blood and blood
1 : Consent should be taken for every transfusion. Howeve...
Care of Patients (COP)
Post—'transfusion form is collected, reactions if any identified and are analysed -‘F’, ,
preven...
s): A good starting point could be various national and international
care society guidelines.
trained to apply these c...
Care of Patients (COP)
Further, a good starting point could be various national and international critic
care society gu...
'ned to care for this vulnerable group.
‘n: All staff involved in the careof this group shall be adequately
identifying...
Care of Patients (COP)
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d.
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Documented procedures guide provision of ante-natal services. *
Interpretation:
...
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Care of Patients (COP)
h. .The children’s family members are educated about nutrition, immunisation at A5
safe parenti...
.. ' ring includesat a minimum the heart rate. cardiac rhythm,
' - . p_ressu_re, _o)_tygen saturation, _ and level of. ...
Care of Patients (COP)
Standard 1
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a. There is’ a documented "policy and procedurel for the admi...
" operative re-evaluation is performed and documented. ‘
ET his is essentiallyea-pre-induction assessmentandi shall be don...
GareofPa1ients(COP
g. Patient's post. -,anaesthesia°statuslismonitored and documented. ~
Interpretation: This shall...
__: outset, the organisation shall define the various adverse
. These essentially are adverse events following the
A~. ...
Care of Patients (COP)
d. Documented policies and procedures exist to prevent adverse events like wro V’...
P)
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personnel and material flow conforms to infection control practices.
tion: The layoutof the theatre sho...
Care of Patients (COP
Oblective Elements
a. Documented policies and procedures guide the care of patients under rest...
ted policies and procedures guide the management of pain. *
tion: it shall include" as to hcwipatients are screened for ...
In case the hospital does not have facilities for pain management it could r ii ’
such patients to centres specialising in...
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vided adhering to infection control and safe practices.
. - ‘on: Self-explanatory.
s): Safe practices include ...
Care of Patients (GOP)
Remark(s): '~Refer to Schedule Y. of Drugs andicosmeti
cs-‘Act and to IC
guidelines. ‘ P *
Th...
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(s): Nutritional assessment shall be -done by a dietician for al...
ii
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Care of Patients (GOP)
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iv. cleaning supplies stored in a separate location way from food;
separate de...
NABH Standards 3rd Edition
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NABH Standards 3rd Edition

NABH Standards
Published on: Mar 3, 2016
Published in: Healthcare      
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Transcripts - NABH Standards 3rd Edition

  • 1. NA1I'11c111=111.AC. (1;RIE[D>l1I1I‘1'=1I111<iD11B0ARD 110R 11©§1111A15 AND HEAMLFHCARE : WDERSTGNAWI)
  • 2. - . 010000000000oooooooooooooooooooo _ . _i , _V. ‘_. .. ‘ ' - 4. r 1 1. 1 p 1 Aurm 6lRLA— ME Momm, 1o. _1_0p_. . (039 1+osD1.‘rAi_ 011; Sr 05 Nationail Accréditaiion Board for Hospitals and Healthcare Piroviders (NABH)- Accreditation Standards for Hcspitals S 3“ Edition A November2011 1
  • 3. 0000000000-01000000000OOOOOOOOOOOOOOOQOOOQ l 1- _ “ '_. r'_ " ‘I _‘ -‘ , A. ’+: j:”? ‘ NABH- Accreditation Standards for Hospitals 1 _ FOREWORD 2nd edition of NABI-‘l standard has been in practice 'for'tour years (2008-12) and was . time thatlit was revised and upgraded to"3rd edition. Theguiding principles for revision , of the standards hasbeen mainly the experience of stake holders including assessors, hospitals staff, members’ of accreditation and technicai committees e'tc. .‘Secretariat of NABH did bulk of jobbycollecting and assimilating the feedback information, linking’ ' ' with "relevant chapters and passing on to the technical‘ committee. It “was finally the v , Technical Committee which went in to thought process and came out with the edition, which is now in your hands. The accreditation standard is not expected to be prescriptive. it only lays down the ' requirements aandit isfup to healthcare organization to’-come outwith the systems, processes and 'mode”ct measuring perfonnance indicators, which" can demonstrate compliance to the requirements as specified in the standard. Technical Committee has I _ put in best efforts, so as_ to be as objective and pragmatic as possible. There‘ can more than one way, by which a healthcare organization can comply with therequirement of the standard. In order to provide more information, 3rd edition comes along "with integrated guidance . notes within the standard. The interpretation and guidance notes follow everyoobjective element. It is felt that this wcutd enable hospitals . and assessors in removing any ambiguities with regard to the essence of the standard , and I or its objectives. Accreditation as we say isgbasically a framework, which help healthcare organization to ' R. establishnobjective systems aimed at patient safety and quality of care. Documentation 1 -plays" important role in defining of such systems. Wherever thereare references to documented requirements, it ‘needs be clearly understood that such documentation need to be established, understood at all levels, reviewed at regular intervals, controlled and evidenced for its effective implementation by way of records. _ =5
  • 4. ‘£”1Q peudde pue p0O1SJ8pUl‘l si spiepuets to ietdeqo uoee jo1ue1u1_ eu), teut pamsue eq 1snuJ u ‘iejnoiued U| vuigiqeoijdde to U0lSl’l| OX9 ejqeue o1 SJOSSSSSE to west st; pue HQVN 01 p9plAOJd eqtsnw uogieougsni pue uogeuejdxe etenbepe ‘U0l1€2luE5.l0 iejnoiued e U! p8l| ddB sq touueo pJBpUB1S e . t01Uel1.l8|8 ue ‘1U9UJ8|6 ue to tied a 8J6L| M 'S]. USLU6|3 e/ utoelqo eut pue spiepuets HQVN out S1e3l. U U0l1’€ZlUB5J0 aut Mou to uogteoijnuepi zpetejei SDJBDUBIS Hat/ N '9 stuennsuoo jEOlp6uJ Buiusyx Buipnjoug segued p81S3J61Ul pue stueired ‘suets 1S5U0u. lB ‘uoueziueoio eut Aq umop pl8| seinpeoord pue S9lOl| Od eui, ‘jo UOll, B1U9LLl6|dLll[ Buunsue pue jo sseuaieme 5Ul10l. Ll0.ld ‘buiuuep Zp61B|3J saiouod U0l1'9ZlLl'85.lQ '1: 'S1U3|. .U8Jlnb€J / Uotejnfiei pue / iiotntets ‘nabs: to U0l1B1U6u. l9|dll. ll e/ u1'oeue out Buuouuoui pue uum Bug/ ijduioo ‘fiuglljituepi Ip91'9]9.l Motejnfiaa '3 'uog1oe; s11es eeziojdtue 5UlJ01lUOU. l pue S1U8Ll. .l3Jjnb9J1U8l1Bd jO SSSUSJBMB ‘Buiugen, Bugob-uo ‘eoueteduioo 5Lll. I01lUOLlJ Zp91B|91 ee/ iojdtug '3 1 seteioosse pue S9l| lLUBj ueui pue stueued to uouetoedxa out 5Ul193lLl Aierxuoeue epnjoug p| i'l0M siuj ‘area to Atuenb pue SDJEDUBIS tueuneen ‘Mates 5Ul. l01lUOUJ 2p91E|8J tueged ‘L tsmonoj se one sense; its): out to euros 'eOUEljdl. UOO jo eouepg/ xe a/ tuoeiqo epinold Aneuu pue gets out Aq peurvio ‘peiueuiejduu ‘peuuep ‘Res em se ere SLUBISKS eseuj 'pJEpUE1S aut ug ue/ ufi S1U8uJ6JllTb9J 5U§19J0d. l0OUl_ uietszts ojtueuiip pue e/ utoeiqo usnqetse o1 peeu mm U0l1EZlUB5J0 out ‘jeieuefi U| 'eouep1_n6 pasodoid out to Aujiqeoitoeid 9L|1015UlpJ03OE1!1U9l1Je| dU. 'l pue Ll0lJ,9.lOSlp st! esn pjnom U0l1BZlU'85J0 eut pesn si ejqeiejeid/ pjnoo/ ueo 8S8JL| d out eiau/ V ‘ewes out l. U9LU3|dl. U! UOl1BZluB5J0 eut taut 6/l], BJ8dUJl_ si ti pesn sg pjnous/ ueus prom out J8/8J9L| N qeudsouse jo uiatsfis Kujenb eqt 5UlI'O. ldLUl_ to urge eut uum p916.ldJ91lJl pue DQSMEUE ‘peieutefi etep fpauituepi eq O13/Bl. ] ueqs 8S9L| _j_ ', M0112puBuJ, se peuguepg S1UGtU9Jll'1bSJ out, to euros are eieut ‘setou eouepinb peteioosse pue piepuets eut U| 5l91!d5°H 10159-l99U91S U°lll? l!P9J33V 'H‘8VN . . COO. 1 1' I
  • 5. ; , NABH-Aocreditalion Standardstor Hospitals . The 3rd edition of accreditation standard is divided into 10 chapters, which _have been further divided into .102 standards (as compared to 100 in 2nd edition). Put together ', :there are 636 objective elements( as comparedto 514 in 2nd edition) incorporated within these standards. The increase in objective elements is to put increased emphasis _ gar: -Jpatient safety and also to encourage healthcare organizations to pursue continuous V _ quality improvements. Objective elements are required to be complied with in order to meet . t_herequirement of a particular Standard. Similarly, standards are required to be ' with, in order to meet the requirement of a particular Chapter. Finally, all ‘chapters are deciding factor to say whether a hospital is meeting the requirements of ii. Accreditation Standard. In the beginning of each Chapter, Intent is given to highlight -- the summary of the chapter. The, intent statement provides a brief explanation of a . ,ehapter's'rationale, meaning, and significance. Intent statements may contain detailed -1 expectations of the chapter that ‘are evaluated in the on-site ‘assessment process. For -most of the objectiveelements, interpretation is provided justrto further elaborate on u how that objective elementcan be'met. 1 A ' Theseustandards are equaliy applicable -to government. -and private hospitals, and are «appticable to whole organisation. -Standards are dynamic and would be under constant review process. Comments and suggestions for improvement are appreciated. Wevseek your in keeping these standards adequate to the need of industry. . —g 1.Dr. Girdhard. Gyani ’ ' Secretary General V E r_ Quaiity Council of India & CEO NABH ooéoooooooac i i i .3. i i
  • 6. C . Accreditation Standards for Hospitals Table of_ Contents Access, Assessmentand Continuity of Cae (AAC) Carelof Patients (COP) 2 " Management of Medication (MOM) Patient Rights and Education (PRE) ' Hospital Infection Control (HIC) » * 1 1 99-115 Continuous Quality improvement (CQI) 1 *. Responsibilities of Management (ROM) Facility Management and Safety (FMS) Human Resource Management (HRM) lnfomiation Management System (IMS) . 183-196 a I ‘Essential Documentation Glossary ‘ Annexure 1: Reference Guide on Sentinel Events Annexure 2: Clinical Audit « Annexure Fatient Responsibilities (Indicative Guide) ©-National Accreditation Board for Hospitals and Healtfxzre Proverb
  • 7. Al. ‘.G6SS—AS%SSm$| 'It and Continuity of Care (AAC) 7 ' Intent ofthe chapter: Patients are well informed of the services that an organisation provides. This will - facilitate in appropriately matching patients with _the organisation's resources. Only those" patients who can be cared for by the organisation are admitted to the organisation. Emergency patients receive | ife—stabilising treatment and are then either . __; admitted (it resources are available) or transferred appropriately to an organisation that -has the resources to take care of such patients. Out—patients who do not match the . organisation's resources are similarly referred to organisations. that have the matching resources’-. ' Patients that match the organisations resources are admitted using a defined . process. Patients cared for by the organisation undergo an established initial assessment and periodic and regular reassessments. . Assessr‘nents include -planning. for utilisation of laboratory and imaging services. The laboratory and imaging services are provided by competent staff in a safe environment for bothpatients andistaft. These assessments result in formulation of a definite plan of care. "Patientcare is multidisciplinary in nature and encourages continuity of care through swell-defined transfer and discharge protocols. These protocols include transfer of adequate information with the patient. ' A ' ' . ’<'§liafianaIAoaeditanbnBoadfarlHosprta! sarmFharmm§m-Prowders‘ V T V "'1 °_9‘V°.00.0O00-oogoooooooooohoorooooooooooooooooo(*5
  • 8. ;__ . yqqlpiqlvunvn -uuunn‘-nmdntrrwlvr-‘IN; - Access Assessment and Continuity of Care (AAC) _ . V » . _ Summary of Standards The organisation defines and displays the services that it can provide. ' The organisation hasea well-defined registration and admission process. _ There is an appropri'ate'mechanisn1 for transfer (in and out) or referral of patierits-. ' ‘ ‘ ‘ ‘ is y. ‘ 1'" assessment. .. T . Patients cared. for‘by the organisation undergoa regular reassessment. V ‘ Laboratory servicesyare. provided as per theiscope of. -services of the « I organisation. T i There is‘ an established laboratory-quality assurance ‘programme. ‘ 4 There is an established laboratory-safetyprograemme. ‘ I A I 5 g ; imaging A services are provided as per the scope of services . of_ they : organisation. 5. There is an estabiished quality-assurance ‘programme for imaging services. There is an established radiation-safetyi= ‘programVme; ‘= Patient care is continuous andmultidisciplinary in nature.
  • 9. }'Assessment and Continuity of Care (AAC) Standards and Objective Elements The services being provided are clearly defined and are in consonance with the I’ needs of the community. ' Interpretation: The organisation shall define this keeping in mind the scope of services applied for. «Remark(s): 'The needs of the community should be considered especially when planning a new organisation oreadding new services. The same could be captured through the feedback mechanism. The defined services are prominently displayed. Interpretation: The services so defined should be displayed prominently in an area visible to all atients entering the organisation. The display couldbe in the form of boards, citizen's charter, etc. They should be of permanent nature. Care _____________ should be taken to ensure that these are displayed in the l'anguage(s) the patient , , understands. Remark(s): Claims of services and expertise being available should actually be available. Display in the form of brochures only is NOT acceptable. Display should be at least bi-lingual (English and the state language/ language spoken by_ the ma'ori P of 0 le in. rea). c. The staff isoriented to these servi e . - Interpretation: All the staff in the hospital mainly in the reception/ registration, _ OPD, IPD are oriented to these facts through regular training programme or I through manuals. Remark(s): Records of all such training shall be available. © National Accreditation Board for Hospitals and Healthmre Providers
  • 10. ______? Standard :33. 3343‘ Objective Elements 9‘ a. Documented policies and procedures are used for registering and admitting V patients. * H _ Interpretation: Organisation shall prepare document(s) detailing the_ policies and procedures for registration and admission of patients which should also include unidentified patients. All patients who are assessed in the hospital shall be registered. Remark(s): All admissions must be authorised by a doctor. b. The documented procedures address out-patients, in—patients and emergency V patients. * Interpretation: Self-explanatory. i Remark(s): It is preferable if each one of these is se aratel addressed. c. A unique identification number is generated at the end of registration. Interpretation: The organisation shall ensure that every patient gets a unique number which is generated at the end of registration of the first interaction that ‘ . the patient has with the organisation. I Remark(s): This number shall be used for identification of the patient across the hospital and to ensure continuity of care across the hospital. All hospital records of the patient shall have this number. “Unique" implies that this is a one-time affair. Please note that a particular patient can have only one unique number. However, in case of multiple visits (OP/ IP) a different number could be generated in addition to the above-mentioned unique number each time. To ensure continuity 1' of care these numbers shall be linked to the unique number. r-"X ; /"1 ( La ' C . Q C. ‘ . T I" . -' I C. C 9.. - L. C 4 5 . ..V. } © National Accreditation Board for Hospitals and Healrhcare Providers —. ..». ... ... ... __. ... .._u-. ... _.. _.. ... ... .. ..
  • 11. O " '" ’ 0- at-COOOOOCOOCOOOOOOCOCCOOOCOOO Oi Assessment and Continuity of Care (AAC) Patients are accepted only if the organisation can provide the required service. 44 C. Interpretation: The staff handling admission and registration needs to be awart? “ ' of the services that the organisation can provide. It is also advisable to have a system wherein the staff is aware as to whom to contact if they need any clarification on the services provided. 'DThe documented policies and procedures also address managing patients during non-availability ‘of beds. * figg Q (9 Interpretation: The organisation is aware of the availability of alternate organisations where the patients may be directed in case of non—availability of beds. In case the organisation admits these patients in a temporary holding area ' ‘ it shall ensure that there is adequate infrastructure to take care of these patients. Further, the organisation shall define as to how long atients are ke t o tempora beds before a decision to transfer out is taken. The documented procedure also addresses man in atients when bed space Remark(s): Also refer to AAC 3. The staff is aware of these processes. ~ Interpretation: All the staff handling these activities should be oriented to these ‘ policies and procedures. Remark(s): Orientation can be provided by documentation/ training. : : 3 ma; > 7*-. -'* ‘$5,. 4% L34 at *0 be YV0«cQes2ein¥pl<'Mw«9<§ Documented policies and procedures guide the transfer-in of patients to the Objective Elements ab organisation. " Interpretation: This shall address both planned and unplanned transfers. a ". V . -.. ..r-». ‘.1. . .a. v. »_. .~u. —.. ._x. . . l l
  • 12. Access Assessment and Continuity of Care (AAC) Remark(s): For unplanned transfers and in case of suspected unstable patients, the organisation could. send a trained ACLS person with the ambulance. However, this shall be guided by the information received. b. Documented policies and procedures’ guide the transfer-outlreferral ‘of unstable 5 patients to another facility in an appropriate manner. * §i)g‘°R{ QT — Interpretation: The organisation shall at the. outset define as to who an unstable patient is. This shall be defined based on physiological -criteria. The documented procedure should address the methodology of safe transfer of the patient in a life-threatening situation organisation. There should be availability of an appropriate ambulance fitted with- life support facilities and accompanied by trained personnel. Remark(s): These patients include those who have come to the emergency but need to be transferred to another organisation or those already admitted but who now require care -in another organisation. It also includes patients being shifted for diagnostic tests. Also refer to COP 3. c. Documented policies and procedures guide the transfer- out/ referral of stable y patients to another facility in an appropriate manner. * éhdslg Pi‘ r Interpretation: Patients not in a life threatening situation (stable) should also be p ‘ transported in a safe manner. I-? emark(s): Also refer to CoP 3. d. The documented procediires identify staff responsibleduring, transferlreferral. * Interpretation: The staff accompanying shall at least be attained trauma/ I > emergency technician/ nurse. He/ she shall have undergone training in BLS and/ or . T‘ ACLS. Further, the procedure shall identify the responsible staff for various steps A of the procedure. V Remark(s): A doctor should accompany an unstable patient. @ National Accreditation Board for Hospitals andt-teattfmre Providers ' 6 T . - l
  • 13. Assessment and Continuity of Care (AAC) The organisation gives a summary of patient’s condition and the treatment given. . © National Accreditation Board for Hospitals and Heafthcare Providers 7 1 A Interpretation: The organisation gives a case summary mentioning the significant findings and treatment given in case of patients who are being transferred from emergency. A copy of the same shall be retained by the organisation. For admitted patients a discharge summary has to be given (refer AAC1 4) . I q§g@ given to . patients- going -against medical advice. , Ffemark(s): This shall include patients being transferred both for diagnostic and/ or therapeutic purposes. The organisation defines and documents the content of the initial assessment for the out—patients, in-patients and emergency patients. *- Interpretation: Theorganisation shall have a format using which a standardised initial assessment of patients is done in the OPD, "emergency and in-patients. The initial assessment could be standardised across the hospital or it could be modified depending on the need of the department. However, it shall be the same in that particular area, e. g. in paediatric OPD the weight and height may be a must, whereas it may not be so for orthopaedics OPD. In emergency department, this shall include recording the vital parameters. A H The format shall be designed to ensure that the laid—down parameters are captured. Fierna_rk(s): Every initial assessment shall contain the presenting complaints, vital signs (temperature, pulse, BP and respiratory rate) and salient examination findings (especially of the system concemed). This-shall incorporate initial assessment_ by doctors and nursing staff in case of in-patients. Refer AAC 4e
  • 14. Access Assessment and Continuity of Care (AAC) . b. The organisation determines who can perform the initial assessment. * P Interpretation: The assessment could be done by various categories of staff. The organisation determines who can do what assessment and it should be the e organisation. Assessments are performed by each discipline J same across th registration and applicable laws and regulations. Only ‘ within its scope of practice, doctors/ nurses shall conduct the assessments. Remark(s): Also refer to HRM 9a. The organisation defines the time frame within which the initial assessment is V completed based on patient’s needs. * Interpretation: The organisation has defined and documented the time frame within which the initial assessment is to be completed with respect to OPDI emergencyl indoor patients. The time frame shall be from the time that the patient has registered (or in case of emergency: come tothe emergency) till the that the initial assessment is documented by the treating consultant. A ' Remark(s): The time frame shall be reasonable and match with the V organisational resources and patient load. In case of out-patients there could be ming with appointment and for “walk-in" time a separate timeframe for patients co patients. Patient's needs mean the condition of the patient. d. The initial assessment for in—patients is documented ‘within 24 hours or earlier as per the patient’s condition as defined in the organisation's policy. * y Interpretation: This should cover history, examination including vital signs and documentation of any drug allergies. It should mention the provisional diagnosis. : For an admitted patient, if a detailed assessment has been done earlier (either in OPD within the past seven days or emergency), it need not begl written in detail again. However, there shall be a comment linking the assessment to the earlier assessment and the findings of all such assessments shall be reviewed and/ or verified. @ National Aocred i _£ » _ itation Board for Hospitals and Heafthcare Providers 8
  • 15. ii Qgfl O-.9 ii 0_# QJO fl. h. Assessment and Continuity of Care (AAC) -‘Please note that the maximum time allowed for documentation is 24 hours. However, the organisation shall define and document the appropriate time depending on the patient’s condition and the scope of its services. initial assessment of in-patients includes nursing assessment which is done at the time of admission and documented. Interpretation: This shall identify the nursing needs and also help identify any special needs of the patient. it shall be completed within a defined time frame. This assessment shall help in identifying the nursing needs of the patient. Remark(s); A checklist or template could be used for the same. initial assessment includes screening for nutritional needs. Interpretation: The protocol for patient’s initial assessment should cover his/ her I nutritional needs. This is only a screening for nutritional needs and not a complete assessment. A detailed nutritionalassessment shall be done wherever necessary. _ ‘ Remark(s): This could be done by the treating doctor/ nurse/ dietician. Questionnaires could be used for the same. Nutritional screening shall be done for all stable atients incluging QB and [E Where appropriate the organisation. could‘ ‘consider providing a nutritional 1‘-1a assessment for out- patients also. _: _¢n— The initial assessment results in . a documgented. plan of care. Interpretation: This shall be documented by the treating doctor or by a member of his team in the patient record. Re_mark(s): For definition of "plan of care" refer to glossary. This is applicable only for day-care and in-patients. The plan of care also includes preventive aspects of the care where appropriate. . lnterpretatIon: .The documented plan of care shouldcover reventive actions as necessary in the case and could include diet, drugs etc. In conditions where it is ; = @ NaiJonaIAacreditai1on Board for Hospitals and HeaImr2're_Providers 9
  • 16. P”? 9I9J! d5°H 10} W909 U°! J91IP9J°°V IEUOIJEN @ Ol » 319}? !/l°-‘d 9J994!Il?9H uotoop Bunsen : (s)lpetuey 'uonlpuoo A syiuensd ui sefiusuo tusomufits O18SUOdS9.l ul euop eq osis usqs stuetussesssea 'plsM en: ui_ tuensd s 01 pelsduloo linuenben elotu pessesssel eq 01 peeu noi ui stuensd '6'e ‘uonipuoo sguensd ant pus Buines etn uo pessq ssels tuelengp ul liouenben eq_L '1eeus esso en; ug petueulnoop si sun pus ‘tueulssesss ismug etn J91}V: UO_I1310.Id. I6JU( 's| slue1ug etslldoldds is pessesssel els stuensd stueuleia ennoeiqo 9L|1 liq lisp lilelie eouo tssei ls passesssel eq usus luensd lilelia '9 : (s)luewey 'lilo1sus| dxe-neg : uo! IBteJd. ia; u( eowes '8I! lB1l| [q'Bl. |S. l DUE 6ll1U9I8.ld ‘SMIBJRO SIB SW05 9Il1B‘3lpU! 9L| _[_ lo elso ‘tueunsen en; lo snnsel pensep lo sisofi sepnioui also to usid en; 1 oguno en; :(s)lusweu 'Sm0ll vz UlLl1lM [nous ewes out lnq 'ld1oop Bunsen sin S3l_| dlUl efilsqo ui us; an out liq p6SlJOl|1l’l'€ pus pBU5lS1B1ul'lOO eq p teen en; :uQns, ta. idJa1u1 'SJl'lOL| Va lotoop fiuns JOIDOD J0l_Un[ s liq petsniug eq pinoo tuensd 9l. |1;O1U8uI UlL|1lM1U8l1Ed en), lo efilsuo-ul_ usioiuno eut liq p6l. l5lS. l31Ul’lOO st also lo usid eu_| _ '1 'U0lSU9I| .l9dAq‘S91ai1Bl_p '6'e ‘ole p eq osis pinoo si_n_| _ : (s)lusway S191}'B9| UO!1BUJ. l0}Ul 1U8l18d/ S].6l)| O0q q5n0Il]1 SUO .19 p9Al. l.l2 si Sl_SOU6Blp snunep s ss uoos ss euop eq “sus eulss en; (lseioun/ epsui 1 etslodlooug o1 eiqissod 1ou tou sgsoufisip '6'e) lueuissesss lo awn eqt ts sin (ow) also to liununuoo pus tuemssessv sseoov
  • 17. -a Assessment and Continuity of Care (AAC) Reasse I o b ' a —care atients before discharging) or patients awaiting admission/ bed. Out-patients are informed of their next follow-up, where appropriate. Interpretation: Self-explanatory. '70 ‘OR ‘(~(_l@ {,3 mgulritgg , The reassessment notes shall reflect the patient’s response to treatment and at a minimum capture the symptoms (change or fresh) and vital signs. FIemark(s): This would not be applicable in cases where patient has come for just an opinion or the patient’s condition does not warrant repeat visits. For in-patients during reassessment the plan of care is monitored and modified, where found necessary. A A Q g‘ ‘ Interpretation: The plan of care shall be dynamic and modified where necessary by the treating doctor according to the patient’s condition. Staff involved in direct clinical care document reassessments. Interpretation: Actions taken under reassessment are documented. The staff could be the treating doctor or any member of the team as per their domain of responsibility of care. At a minimum, the documentation shall include vitals, systemic examination findings and medication orders. FIemark(s): The nursing staff can document patient’s vitals. Only phrases like "patient weIl"; .“condition better" would not be acceptable. _o5o3<= =ooo Patients are reassessed to determine their response to treatment and to plan ‘further treatment or discharge. Interpretation: Self-explanatory. 9 ° ‘.5’-‘KE love National Accreditation Board for Hospitals and Healthcare Providers GOO .0
  • 18. El » srapmola elsaqi/ seH pus slezgdsog 10] prizes uogsiipeloov lsuolzelv @ 01 lelel uonsogusnb to liosnbeps J0:| :(s)l[lsway 'nsts 3l. {19SlA. l9dnS1Sll. ll9LlO0lq pus _1Sl50|0l_qO. lOl_UJ ‘_1Sl50|0l. |1Bd stsei en; tno lillso oi peuisn pus (eelfiep 919l. ldOJddB) peglisnb liiqstins eq plnous qsi eln ul pelioidule gets any . 'UQI1BJ3.Id. I3,lUl 'sLT6tTs6i‘i§57ul en; teldletui pusestruedns fulloiled |6UUOSJ6d peugsn pus penilsnb liielsnbepv 'o j(st| nsel uodel ct pespoinns eidoed Bugpnioug) lemodustu lo tueuldinbe etsnbeps to nos) 01 enp pelisiep 1e_6 tou pinons suodeg : (s)l1leway 'S60§IJ3S lilotsloqsl S1lJ€Al|8p lire/ inoene 3 01 eiqs eq plnons lemodusul pus tueuldlnbe 9lqBllBAB en; .'l. IOflE19Jd. I9Jul fseogrues to edoos peunep sn lo; epgrlold o1 etsnbeps si (lelviodusul pus isoislilld) elntonnssnui en; ‘q 'senmos; qs1 p9OJl'lOS1l'l0 lo; M016q (u) osrs ees V _ _ _ _ _ stulizue oslplso . l0}S9!1l| lOE} 8IBLl liulssseoeu tsnul uoltsslusfilo also osiplso s ‘9|dl1lBX9 10:] : (s)llJsrueu 'S6Sll. U9Jd st! unnlm eiqsnsris 6q1Sl'll1.l (‘ote gay ‘s9a) lueulefisusul liouefileule lo; pelinbel snnsel lsei ‘lelieMoH 's1se1 liouefileule op oi senniosi erlsu tssei is 01 UOl1BSlUB5.lO en: lo; eiqsleield st 11 ‘lenns tou seop also tuensd pus nocio ein punol elqsuslls els seoyues ) : eseqi, istn elnsue usqs U0l1ESluE5.l0 eu‘_)_ 'f3ugolnos1n’o“‘li‘q lo esnon ug etuss 8 6 ti liq pelenoseoglues 6.lBOu1|9el. l em 01 91€Jl’lSU9LUU. l0O seolrues Mo As elnsue plnous UOl1ESlUE5JO eu_| _ : uone1aJd. ia; ul . ‘U0l1'8SlU'e5JO eul liq pepylold seog/ ues 9L|101 61BJl‘lSU9LLllJJ00 els S80lI. laS lilotsloqsi em )0 edoos ‘s Sll. l3ul9|3 3I! ]33[q0
  • 19. Assessment and Continuity of Care (AAC) 5? ~Docu_mented procedures guide ordering of tests, collection, identification, andling, safe transportation, processing and disposal of specimens. * Interpretation: The organisation has documented procedures for ordering, collection, identification, handling, safe transportation, processing, and disposal ; - of specimens, to ensure safety of the specimen till the tests and retests (if required) are completed. The organisation shall ensure that the unique A: identification number is used for identification of the patient. in addition, it could use another number (for example, lab number) to identify the sample. -_Remark(s): This should be in line with standard precautions. The disposal of waste shall be as per the statutogy reguirements (Bio-medical waste management and handling rules, 1998.) i Laboratory results are available within a defined time frame. * Interpretation: The organisation shall define the turnaround time for all tests. The organisation should ensure availability. of adequate staff, materials and equipment to make the laboratory results available within the defined time frame. I’-i'emark(s): The turnaround time could be different for different tests and could be decided based on the nature of test, criticality of test and urgenc of test result (as desired by the treating doctor). Critical results are intimated immediately to the personnel concerned. * Interpretation: The laboratory shall establish its biological reference intervals for different tests. The laboratory shall establish anddocument critical limits for tests which require immediate attention for patient management and the same shall be documented. The critical test results shall be communicated to the personnel concerned and this shall be documented. I-'Iemark(s): If it is not practical to establish the biological reference interval for a particular analysis the laboratory should carefully evaluate the published data for its own reference intervals. C . . fife C 0 0:30 0 . . 6 National Aocredrtalion Board for Hospitals and Healthcare Providers 1 3
  • 20. g. Results are reported in a standardised manner. organisation (or in case of outsourced laboratory, the name of the same), the :7.“ _ Q5 patient’s name, the unique identification number, reference range of the test 4' _, ’ (where applicable) and the name and signature of the" person reporting the test - 9); ; . result. I i s 3 Ffemark(s): All reports from the outsourced laboratory shall incorporate these ‘ : l[ features and the organisation shall not alter/ modify anything in the report. A ‘ C In case of outsourced test results, the same shall be on that lab's letterhead. I 5‘ J<a, Qe. (S1510 . h. Laboratory tests not available in the organisation are outsourced to i Q organisation(s) based on their quality assurance system. _ '5: Interpretation: The organisation has documented procedure for outsourcing ' tests for which it has no facilities. This should include: ' i. A list of tes1s. for. outsourcing. _ . fig Qg? 2 . . -/7/" . I i. ” ll. Identity of personnel in the outsourced facilities to ensure safe i, _,' transportation of specimens and completing of tests as per requirements , . of the patient concerned and receipt of results at organisation. 7 3 iii. Manner of packaging of the specimens and their labelling for identification ) k and this package should contain the test requisition with all details as . required for testing. iv. A methodology to check the performance of service rendered by -the I { ‘N outsourced laboratory, as per the requirements of the organisation. i Remark(s): The organisation shall have an MoU/ agreement for the same, which ’ ": incorporates quality assurance and requirements of this standard. w . — « ‘-—. »-iiv. '—i-c s r. . » . .«. _. J. L, . . ._ ————— © National Accreditation Board for Hospitals and Healthcare Providers 14 4 Access Assessment and Continuity of Care (AAC) , 1 -4 "€$ Interpretation: At a minimum, the report shall include the name of the
  • 21. “me (preferably as per ISO 15189 Medical laboratories — Particular ents for quality and competence). s): Quality assurance includes internal quality control, external quality ', pre-analytic phase, test standardisation, post-analytic phase, ent and organisation. A ratory shall participate in external qualitylassurance programme when Le. When such programmes are not available, the laboratory could go samples with another laboratory for purposes of peer comparison. ramme addresses verification and/ or validation of test methods. * - tation: This holds true for any laboratory-developed methods. ard methods need verification to ensure that the laboratory is capable of ing the analysis. tion of an analytical procedure is the demonstration that a laboratory is le of replicating with an acceptable level of performance a standard iiiethod. Verification under conditions of use is demonstratedby meeting system- suitability specifications established for the method, as well as a demonstration of accuracy and precision or other method parameters for the type of method. F “Venfication of Standard Method Performance is defined for two _situations, (1) for ritying method performance with each analytical batch (EAB) and (2) the first - of a standard method within the laboratory. Non-standard and laboratory-developed methods need method validation. iuethods requiring validation are: . : ' / Modified official methods / In-house developed methods Accreditafion Board for Hospimls and Healthcare Providers 15 of iiiirrvlso in in ace. in 0 so are om
  • 22. Access Assessment and Continuity of Care (AAC) / Methods extended to a component, analysis or matrix not previously ' tested or included in validation v’ Changes involving new technology or automation Verification usually includes accuracy, precision and linearity. Validation in addition includes sensitivity and specificity. c. The programme addresses surveillance of test results. * Interpretation: The laboratory director shall periodically assess the test results. This shall be done in a structured manner. The organisation shall specify the frequency and the sample size that it shall use for the surveillance. d. The programme includes periodic calibration and maintenance of all equipment. ‘ Interpretation: Refer to ISO 15189. Remark(s): Traceability certificate(s) of all calibration done shall also be documented and maintained. e. The programme includes the documentation of corrective and preventive actions. * Interpretation: Self-explanatory. Standard Objective Elements a. The laboratory-safety programme is documented. * Interpretation: A well-documented lab safety manual is available in the lab. This takes care of the safety of the workforce as well as the equipment available in the lab. It shall be in consonance with the risks and hazards identified. Ftemark(s): This could be as per Occupational Health and Safety Management f System -OHSAS 18001 :1999. ___: © National Accreditation Board for Hospitals and Healthcare Providers _ 16
  • 23. ment and Continuity of Care (AAC) is programme is aligned with the organisation'ssafety programme. -- retation: Lab-safety programme is aligned with the safety programme of organisation. The broad principles shall be the same as that of the ‘ : anisation’s safety programme. Written procedures guide the handling and disposal of infectious and hazardous R to § E (0 Interpretation: The lab staff should follow standard precautions. The disposal of ste is according to biomedical waste management and handling rules, 1998. Remark(s): Materiai safety and data sheets (where applicable) shall be available ’ and staff well versed in the same. Laboratory personnei are appropriately trained in safe practices. Interpretation: All the lab staff undergo training regarding safe practices in the lab. Laboratory personnel are provided with appropriate safety equipment/ devices. -glnterpretation: Adequate safety devices are available in the lab, e. g. fire extinguishers, dressing materials, disinfectants etc. This should be sufficient to address the safety issue. At a minimum, standard precautions are adhered to. oooooqoqoomooamoooooogopp; L I. -'temark(s): All lab staff shall be appropriately immunised. especially against Hepatitis B. Nafional Accreditation Board for Hospitals and Healthcare Providers 17 ooppoofioflfihoo
  • 24. . L11! Access Assessment and Continuity of Care (AAC) Standard -fiat ~19’- Objective Elements a. Imaging services comply with legal and other requirements. Interpretation: The organisation is aware of the legal and other requirements-of j imaging services and the same are documented for infonnation and compliance 1. by all concemed in the organisation. The organisation maintains and updates its ? compliance status of legal and other requirements in_ a regular manner. Bemark(s): All the statutory requirements are met with such as BARC clearance, A ‘dosimeters, lead sheets, lead aprons, signage, display as per PNDT act, reports : to competent authority, etc. The organisation shall have an RSO (of appropriate level). I b. Scope of the imaging services is commensurate to the services provided by the Q organisation. ‘ Interpretation: Self-explanatory. ’ g Remark(s): For example, a neuro-science centre shall have CT and MRI. c. The infrastructure (physical and manpower) is adequate to provide for its define 1 scope of services. q Interpretation: The equipment available and manpower should be able t s‘ 3 effectively deliver its imaging services. Q Ftemark(s): Reports should not get delayed due tolack of adequate equipmenfli or manpower (including people authorised to report results). O :9 d. Adequately qualified and trained personnel perform, supervise and interpret th investigations. Interpretation: As per AERB guidelines. @ National Accreditation Board for Hospitals and Healthcare Providers
  • 25. Assessment and Continuity of Care (AAC) Documentedpolicies and procedures guide identification and safe transportation of patients to imaging services. * Interpretation: The organisation has documented policies and procedures for informing the patients about the imaging activities, their identification and safe transportation to the imaging services. This should also address transfer of unstable patients to imaging services. Remark(s): The patients shall also be transported back in a safe manner. Imaging results are available within a defined time frame. * Interpretation: The organisation shall document turnaround time results for all modalities. Remark(s): The defined time frame could be different for different type of tests and could be decided based on the nature of test; criticality of test and urgency of -test result (as desired by the treating doctor). of imaging Critical results are intimated immediately to the personnel concerned I. *- . Interpretation: Critical results shall be intimated to the treating clinician at the earliest on phone, followed by a written report. The same shall be documented. Remark(s): The organisation shall define and document thecritical results which require immediate attention of clinician, e. g. ectopic pregnancy. Results are reported inga standardised manner. , Interpretation: At a minimum, the report shall include the name of the hospital (or in case of outsourced imaging centre, the name of the same), the patient’s 500900oo$o‘oooao3iboobOooo““ O '. , name, the unique id, entif_icationAnumber, and the name and signature of the 3! person reporting the test result. M . In case of tele-radiology, thereshall be the name of the reporting doctor and a :8 remark to that effect. : _ V . Remark(s): All reports from the outsourced imaging centre shall incorporate . these features and the hospital shall not alter/ modify anything in the report. 0 O 00; mo:
  • 26. Access Assessment and Continuity of Care (AAC) . .______ i. Imaging tests not available in the organisation are outsourced to organisation(s) based on their quality assurance system. Interpretation: The organisation has documented procedure for outsourcing tests for which it has no facilities. This should include: i. list of tests for outsourcing, ii. identity of personnel in the outsourced facilities to ensure safe A transportation of specimens and completing of imaging results, iii. manner of identification of patients and the test requisition with all details as required for testing and 3 iv. a methodology to check the selection and performance of service rendered by the outsourced imaging facility as per the requirements of the organisation. '‘ FIemark(s): The organisation shall have an MoU/ agreement for the same, which I incorporates quality assurance and requirements of this standard. Standard _ A. p . . . ,, ., , . . , A kw. Objective Elements . . . ,, «_ a. The quality assurance programme for imaging services is documented. 5 ‘hr Interpretation: Refer to AERB guidelines. Flemark(s): Some examples include congruence of optical and radiation field, if‘, L focal spot size, output consistency, leakage rate, etc. b. The programme addresses verification and/ or validation of imaging methods. : Interpretation: This holds true for any in-house developed methods. c. The programme addresses surveillance of imaging results. * V Interpretation: The head of the department shall periodically assess the imaging results. This shall be done in a structured manner. The organisation shall specify *1’. ‘ the frequency and the sample size that it shall use for the surveillance. av 20 @ National Accreditation Board for Hospitals and Healthcare Providers
  • 27. ent and Continuity of Care (AAC) programme includes periodic calibration and maintenance of all equipment. * Q - retation: Calibration and maintenance of all equipment shall be carried out . :ing " competent persons. 0 ' rk(s): Traceability certificate(s) of all calibration done by calibrated O ipment shall be documented and maintained. Qate . programme includes the documentation of corrective -and preventive laails -'ons. * : p -rpretation: Self-explanatory. 3 ice. %the ,7 . _ : ‘rich 1 : . ‘ Elements pp 1 _ . - The radiation-safety programme is documented. * _. Interpretation: Refer to AERB guidelines Bemark(s): RSO. shall devise, implement and monitor the process. 0 Q This programme is aligned with the organisation's safety programme. 0 interpretation: Imaging safety programme is aligned with the safety programme 0 of the organisation. The broad principles shall be the same as that of the fild, '. . organisation's safety programme. . . . Handling, usage and disposal of radio-activeand hazardous materials are as per ; : statutory requirements. Interpretation: Document on safe use of radioactive isotopes for imaging . services shall be available and implemented. . Radioactive and hazardous materials shall be disposed of as per guidelines laid down by competent bodies. Fl’emarIr(s): Material safety and data sheets (where applicable) shall be available and staff well versed in the same. ' K ' nal Accreditation Board for Hospitals and Healthrzre Providers
  • 28. d. Access Assessment and Continuity of Care (AAC) Imaging personnel are provided with appropriate radiation safety devices. Interpretation: Self-explanatory. This includes lead aprons, shields and dosimetersto name a few. I-? emark(s): The number of such devices shall be adequate to ensure that _all_ workers have proper protection. Radiation-safety devices are periodically tested ‘and results documented. Interpretation: Protective devices, e. g. lead aprons, should be exposed to X-ray; for verification of cracks and damages. 4 I It is preferable that the film of the same be stored (either physical or electronic). pp‘ Remark(s): This shall be done at least once a year. ' - * Where appropriate corrective and/ or preventive action shall be taken if . I documented. Imaging personnel are trained in radiation-safety measures. Interpretation: Self-explanatory. Imaging signage are prominently displayed in all appropriate locations. Interpretation: Self-explanatory. 4 Remark(s): This includes safety signage and display of signage as required b regulatory authorities. ‘ Objective Elements a. . .~. .;‘_, @ National Axreditafian Board for Hospitals and Heaithcare Providers During all phases of care, there is a qualified individual identified as responsibi for the patient’s care. “’ ’ Interpretation: The organisation shall ensure that the care of patients is alway given by appropriately—qualified medical personnel (resident doctor, consultant» and/ or nurse).
  • 29. tpare may be provided by a team, the hospital record shall - ing responsible for patient care. and other care-providers. : The organisation ensures periodic discussions about each ‘on: Self-explanatory. s): For example, ' handing-taking over notes retatIon: The organisation shall ensure that intra-organisation transfers are ‘adhering to safe practices. The patients shall be transported in a safe -. ». her and a proper handover and takeover shall be documented. . - Acci'editatr'on Board for Hospitals and Heairhcare Providers 23
  • 30. Access Assessment and Continuity of Care (AAC) f. r The patient’s record(s) is available to the authorised care-providers to facilitat ‘ the exchange of information. ’ ‘ Interpretation: Self~explanatory. Remark(s): The record could be kept in the nursing station for that area. g. Documented procedures guide the referral of patients to? other departments '3 -specialities. * ‘I up p Y Interpretation: The organisation has clearly defined and documented th : procedures to be adopted to guide the personnel dealing with referral of patient v to other departments or specialties 4 The organisation shall ensure that where appropriate a multi-disciplinary tea shall provide care. . . Established criteria or policies should be used to determine the-appropriatene p of tran'sfe'rs within the organisation. ' 1} Remark(s): . Referral could be for opinion, co-management and takeover. It ‘ be graded into immediate-, urgent, priority or routine category. ' All referrals shall be based on clinical significance andfor better outcome. ’ All referrals shall be seen in a defined time frame. This could be different has on the urgency of referral. Objective Elements a. The patient’s discharge process is pianned in consultation with the patient and/ ‘ family. Interpretation: The patient’s treating doctor determines the readiness discharge during regular reassessments. The same is discussed with the patie 57 and family. @ National Accreditation Board for Hospitals and Heaitiicare Providers 2 A
  • 31. I try of Care (AAC) qarooedures exist for coordination of various departments and -~«. in the discharge process (including medico-legal and ’ The discharge procedures are documented to ensure amongst various departments including accounts so that the papers are complete well within time. For MLC the organisation shall the police are informed. :5-in case of discharges notihappening on a particular ‘day, the areplanned keeping this in mind. - - policies and procedures are in place for patients leaving against advice and patients being "discharged on request. * . ».». u*The organisation has a documented policy for such cases. The doctor should explain the consequences of this action to the “attendant. ‘s): '-This policy could address the reasons of LAMA forany possible in - and/ or preventive action by the organisation. ‘. o -patients leaving against medical advice and on request). - tation: The organisation- hands‘ over the discharge papers to the attendant in all cases and a copy is retained. In LAMA cases, the
  • 32. Access Assessment and Continuity of Care (AAC) 1 _ Remark(s): The discharge summary shall be signed by the treating doctor or at member of his/ her team. 2 b. Discharge summary contains the patient’s name, unique identification number, date of admission and date of discharge. Interpretation: Self-explanatory. c. Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge. Interpretation: Self-explanatory. d. Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given. Interpretation: Self-explanatory. e. Discharge summary contains follow-up advice, medication and other instructions in an understandable manner. Interpretation: Self-explanatory. This shall also incorporate preventive aspects, ‘ where appropriate. M Remark(s): The instructions shall be in a manner that the patient can easily understand and avoid use of medical terms, e. g. BID, TID, etc. . _., A 1‘. Discharge summary incorporates instructions about when and how to obtain urgent care. Interpretation: The organisation should outline conditions regarding ‘when’ to obtain urgent care. For example, a post-op patient should report when having fever, bleeding/ discharge from site. . Hemark(s): This could be in the form of what medicines to take, when to consult a doctor or how to seek medical help and contact number of the hospital/ doctor. H I @ National Accreditation Board for Hospitals and Healthcare Providers 26
  • 33. 0. , O‘__’_6|,0__, O_ 0. , o,o?0 9.43 in . . -,I , . and Continuity of Care (AAC) of death, the summary of the case also includes the cause of death. - A tation: Self-explanatory. V ' (s): In case of MLC, this shall not be applicable. I . . Accreditation Board for Hospitals and Heaidrcare Providers
  • 34. Care of Patients (COP) . .'. :.. ._. tn. .., ».. ... ..u. . . ... .. I L. ‘ , . intent of the chapter: The organisation provides uniform care to all patients in different settings. The differe T. settings include care provided in outpatient units, various categories of wards, intensiv care units, ‘procedure rooms and operation theatre. When similar care is provided i « these different settings, care delivery is uniform. Policies, procedures, applicable la A ' and regulations guide emergency and ambulance services, cardio-pulmona: ‘~ / " resuscitation, use of blood and blood products, care of patients in the intensive care an ’__‘ high dependency units. ~ , l l l l r I l Policies, procedures, applicable laws and regulations also guide care of vulnerabl patients (elderly, physically and/ or mentally-challenged and children), high—ri obstetrical patients, paediatric patients, patients undergoing moderate sedatio ‘E administration of anaesthesia, patients undergoing surgical procedures, patients und ’ _‘ restraints, research activities and end of life care. _ T e . Pain management, nutritional" therapy and rehabilitative services are also address with a view to providing comprehensive health care. The standards aim to guide and encourage patient safety as the overall principle . I r~‘ providing care to patients. @Natr'onaI Accreditation Board for Hospitals and Heaithcare Providers
  • 35. ergency services are guided by documented policies, procedures and ‘cable laws and regulations. ‘blood products. r‘: ‘:, :- ' = 'Documented policies and procedures guide the care of patients in the intensive care and high dependency units. ‘Documented policies and procedures guide the care of vulnerable patients (elderly, physically and/ or mentally-challenged and children). ‘ Documented policies and procedures guide obstetric care. A Documented policies and procedures guide paediatric services. t Documented policies and procedures guide the care of patients 3 undergoing moderate sedation. l Documented . poiicies and procedures guide the administration of ‘ anaesthesia. iglocredita tion Board for Hospitals and Heaithmre Providers
  • 36. .. .». ... . . .u. «‘»-. --»<- . Care of Patients (COP) Documented policies and procedures guide the care of patient undergoing surgical procedures. Documented policies and procedures guide the care of patients unde ’ Documented policies and procedures guide all research activities. Documented policies and procedures guide the end of life care. * This implies that this objective element requires documentation. © National Accreditation Board for Hospitals and Healthcare Providers
  • 37. tive Elements Care delivery is unifonn for a given health problem when simi in more than one setting. * Interpretation: lar care is provided The organisation shall ensure that patients with the same health problems and care needs receive the same quality of health care throughout the organisation, irrespective of the category of ward. Further, in case the organisation has separate OPDs for different category of patients the methodology for care delivery shall be uniform in all OPDs. Uniform care is guided by documented policies and procedures. Interpretation: Self-explanatory. These reflect applicable laws, regulations and guidelines. Interpretation: Self-explanatory. Where applicable, to the norms laid down by government by rele establishment act or any such similar legislation. Remark(s): For example, consent before surgery, emergency patients and police intimation in cases of medi the organisation shall adhere vant legislations like clinical providing first aid to co-legal cases. The organisation adopts evidence-based medicine and clinical practice guidelines to guide uniform patient care. Interpretation: Self-explanatory. Remark(s): For definitions of “evidence -based medicine” and “clinical practice guidelines", refer to glossary. . Iional Awreditation Board for Hospitals and Healthcare Providers
  • 38. Care of Patients (COP) Objective Elements a. Policies and procedures for emergency care are documented and are . i, consonance with statutory requirements. * Interpretation: These could include SoPs/ protocols to provide. either gener emergency care ormanagement oi. specific conditions, e. g. poisoning, , 7 _It shall address both -adult . and paediatric patients. The procedure sha incorporate at a minimum identification, assessment-and provision of care. Remark(s): ~Also refer to AAC 4a. Objective eleme_nts b, (1 shall be addressed. All patients coming- to the hospital: -shall be, provided basic medicai car stabilised before transferring them to another centre. b. This also addresses handling of medico-legal cases. * _ Interpretation: The policy shall be in line with statutory requirements w. rf documentation and intimation to police. The organisation shall -also define as t what constitutes an. MLC -(in accordance’ with statutory rules). c. The patients receive care in consonance with the policies. Interpretation: Self-explanatory. , I-? emark(s): v Poisoning cases, road-traffic accidents, patients with corona disease, etc. shall be dealt as per hospital policies and procedures. d. Documented policies and procedures guide the triage of patients for initiation e A appropriate care. * Interpretation: Self-explanatory. Triage shall be done only by qualified/ train individuals. » Flemark(s): This should be based on good clinical practices. For “triage” refers glossary. @ National Accreditation for Hospitals and Healthcare -Providers
  • 39. I with the policies and trained on the procedures for care of ‘It- . ..: Al| the staff working in the area should be oriented to the policies 's1hrough training/ documents. Staff should be trained in BLS and gtrained/ well versed in ACLS also. . r discharge to home or transfer to another organisation is also ,7? ‘M s): Also refer to AAC 13 and 14. The discharge note shall incorporate ‘tures of investigations done and treatment. A is adequate access and space for the ambuiance(s). retation: The organisation shall demarcate a proper space for g f . -- ‘lance(s): Th‘i_s shall: be‘ demarca'ted»keeping in = mind"easy accessibility for 6 . iving patients and to enable the ambulance(s) to turn around/ exit quickly. at ‘ s s '5 V ambulance adheres to statutory requirements. a F ifirterpretation: Self-lexplanatory. are-mark(s): This is in the context of Motor Vehicle Act. Si - . . ‘Accreditation Board for Hospitals andHea1thcare Providers ' . 33 '3
  • 40. 0 , c. Ambulance(s) are appropriately equipped. -. _ Interpretation: This shall be done based on the organisation’s scope. .3 Flemark(s): This shall be in consonance with ACLS or BL. S guidelines? expected that any ambulance shall be equipped with at least basic life suppoti Equipment for both adult and paediatric patients shall be present. ‘ ~ «. ’ I d. ‘ Ambulance(s) are manned by trained personnel. . Interpretation The ambulance should be manned by a trained dr'. technician/ nurse and/ or doctor depending on the situation Personnel shab : , trained in BLS and/ or ACLS. Q I-? emark(s): Driver shall have a valid driving licence. 0 O 5% v_ e. Ambulance(s) is checked on a daily basis. 0 ' i Interpretation: Self-explanatory. : b Remark(s): The check shall clearly indicate the functioning status V of _ ambulance like lights, siren, beacon lights, etc. .. . In addition, the ambulance shall undergo servicing as per the set schedule. Q — 5, ‘ l . ~ T ‘o f. Equipment are checked on a daily basis using a checklist. . Interpretation: Self-explanatory. . Remark(s): The check shall clearly indicate the functioning status offi; ' equipment. - - : if ” P . . . . . i . 0; . g Emergency medications are checked daily and prior to dispatch using a checlw Interpretation: Self-explanatory. . - This also includes checking the expiry date of drugs. .' _ Ffemark(s): In case a rapidturnaround of the ambulance / is required (WXU 3' checking may not be possible prior to dispatch), only -the medications used - be topped up or the organisation could keep an additional set of drugs as A ‘ bv- s 9:: it *5 "it . j " . @ National Accreditation Board for Hospitals and Healthcare Providers _
  • 41. v- tation: The ambulance shall be connected with the organisation/ control . by wireless/ mobile phones. retation: The organisation shall document the procedure for same. This . . 2 be in consonance with accepted practices. Where appropriate, it shall ‘organisation shall ensure that adequate and appropriate resources (both 3%. 1n”é_n and material) are provided. ‘ irk(s'): The protocols could be displayed prominently in critical areas such emergency, ICU, OT, etc. ' in providing direct patient care is trained and periodically updated in cardio- pulmonary resuscitation. hterpretation: These aspects shall be covered by hands on training. If the organisation has a CPR team (e. g. code blue team) it shall ensure that it is trained in ACLS and is present in all shifts. T _ 2 ark(s): All ‘doctors, rehabilit-ation‘staff'and nursing staff must at least be s _. tiained to provide BLS. All doctors and nurses working in intensive care/ high dependency units should fit-idergo appropriate training (ACLS or PALS or NALS). ' . . Accreditation Board for Hospitals and Healthizre Providers 35
  • 42. Care of Patients (COP) I c. The events during a cardio-pulrnonary resuscitation are recorded. I ‘ Interpretation: in the actual event’-of -a CPR or a mock drill of the same, all t activities along with the personnel attended ‘shouldbe recorded. * 7.. .’. Remark(s): This could be done using the pre-defined procedural checklist a i I by monitoring if the prescribed activity has been performed properly and int i v . « . ;~ right sequence. _ L . 7 d. A post-event analysis of all cardio—pulmonary resuscitations is done by; multidisciplinary committee. Interpretation: The analysis shall include the cause, steps taken to resuscita 2‘ andthe outcome. , Multidisciplinary committee shall be independent from the code blue team (as i; as possible) and include at least one physician/ cardiologist, anaesthesiologi one memberifrom the code blue team and nurse. _ _ Remark(s): Analysis should be completed within a defined time frame. e. Corrective and preventive measures are taken based on the post—event analysi Interpretation: Self-explanatory. _ V Remark(s): Corrective and preventive measures should be completed within R defined time frame. _ _ _ l During subsequent resuscitations it is preferable thatirnplementation of the_ actions is noted and training be modified, ifvnecessary. A T’ Standard Objective Elements ' ; a. There are documented policies and procedures for all activities of the nursi_ services. " Interpretation: Self-explanatory. ditation Board for Hospitals and Healthcare Providers © National Awre
  • 43. ieflect current standards of nursing services and practice, relevant fit-. and purposes of the services. "on: Nursing practice is in accordance with nationally accepted ‘ and shall include: A documented individualised patient-focused nursing care plan for each patient to achieve appropriate outcomes; monitoring of the patient to assess the outcome of the care of patient; modifying the care when necessary; pompleting —the. care; , _ , ‘planning and follow-up, to include discharge planning that reflects C continuity ofcare. ‘ _ 4_ _ (s): These shall be-documented in the nursing manual (refer to objective a”). ‘rk(s): Assignment could be patient-Aacuity based. ing care Ais aligned and integrated with overall patient care. retation: This shall be provided as per the nursing plan of care. The ' ing plan of care shall be aligned with the plan of care of the patient. ) ark(s): Uniformity and continuity of care should be practised. Care provided by. nurses is documented in the patient record. nterpretation: Se If-explan atory. Remark(s_): This includes all nursing-related care and not just monitoring of vitals _ andAdocumentation of medication administration. A A’ Accreditation Board for Hospitals and Healthcare Providers _ 37
  • 44. Care of Patients (COP) f. Nurses are provided with adequate equipment for providing safe and efficie nursing services. Interpretation: Self-explanatory. _ _ There‘ shall be adequate number of sphygmomanometers, thermometer A weighing scale(s), etc. g. Nurses are empowered to take nursing-related decisions to ensure timely care ‘A patients. Interpretation: Self-explanatory. Objective Elements a. Documented procedures are used to guide the performance of various clini ' ‘. procedures. * : Interpretation: This is a broad guideline which is common to all the procedur 3 It shall incorporate as to who will do the procedure, the p_re; proced A instructions, conduct of the procedure and post-procedure instructions. 3 j. b. Only qualified personnel order, plan, perform and assist in perfonn procedures. A A Interpretation: Self-explanatory. Remark(s): The organisation could conduct a clinical audit of various procedug; especially w. r.t. indications. r if c. Documented procedures exist to prevent adverse events like wrongw site, wrcfij ‘ 0 patient and wrong pr‘ocedure. - * Interpretation: The unique hospital ID shall be used for identifying patients. in addition, the organisation should have a procedure to identify the side: procedure, where appropriate. © NationaI Accreditation Board for Hospitals and Healthcare Providers
  • 45. _ ‘ mtion: Self-explanatory. 'nsent shalt be taken by the person performing the procedure or a member _ er team. In case the procedure is being done by a person intAraining, ,it pecify the same. All such procedures shall be supervised by the treating «retation: Self-explanatory. (s): in case the organisation has a policy g __s_i_r_1_g| e use devices it A . -ensure that they are properly sterili§_eg_. _E, u_rth_er, the integrity of the devices —be checked. It shall define the number of times it will be re-used and p a mechanism to monitor the same. (A : _nts are appropriately monitored during and after the procedure. - - retation: Self~explanatory. rk(s): At a minimum this shall include pulse, blood pressure and eratory rate. _ ures are documented accurately in the patient record. ' relation: The documentation shall mention the name of the procedure, the the post-procedure care. ark(s): All documentation shall have name, date, time and signature. Accreditation Board for Haspimls and Heaithmre Providers 39 r . _. . , Lmqt . . v
  • 46. Q Care of Patients (COP) -g Standard . V»-'_ Objective Elements fl a. Documented policies and procedures are used to guide rational use of bloofi A Q blood products. * Interpretation: This shall address the conditions where blood and B products can be used. It shall also address inventory and ordering schefi (planned and unplanned). . Q Q b. Documented procedures govern transfusion of blood and blood products. * , ‘ interpretation: This shall at a minimum include how the orders are including pre-medications if any (rate needs to be mentioned for paefi patients), transport of blood, how the blood/ blood product is verified pit transfusion, how the patient is identified and how the patient is monitored. ' O Remark(s): This shall include procedure for availability and transfusfi blood/ blood components for emergency usefln emergency. A '3 A good reference guide is the NABH standards for blood banks. ‘ In case the organisation does not have a blood bank, it shall have an Moufi blood bank/ organisation having a blood bank and ensure that patient car? not suffer. Verification, transportation, cold chain and delive. y at the right 3 should be taken care of. Blood shall be transported from the external bloog in a safe and proper manner. 0 A G c. The transfusion services are governed by the applicable laws and regulatig Interpretation: Self-explanatory. Remark(s): Refer to Drugs and Cosmetics Act. . .._. .«-. :rn; q-g--hm‘-uun>«dn‘r: a:eiihnv)a-it-a-ra-row « © National Accreditation Board for Hospitals and Healthmre Providers
  • 47. - is obtained for donation and transfusion of blood and blood 1 : Consent should be taken for every transfusion. However, with the . ,you can give multiple transfusions in the same sitting; For O . . pints of blood may be transfused serially using the same consent. I. d - A _ - azthe same is given over two days or hours apart, then a separate w - - uired. misc refer to PRE4 d. A r patients who aretransfusion dependent (e. g. haemophilla, thalassemia : consent can be taken once in six months, However, before every a verbal approval shall be taken. consent also includes patient and family education about donation. n tion: Self-explanatory. s): This could be in the form of a booklet/ leaflet. This has to be given consent form. l§0n A j . - . .. .. - rganisation defines the process for availability and transfusion of . ood components for use in emergency. ’ 0 A - tation: The organisation shall define as to what constitutes use in ency and accordingly develop procedures. A A A A r1r(s): This is applicable even if the organisation doesn't have the blood facility in-house. A A ‘ be avaiiable for use in emergency. in emergency includes both for emergency use (stand-by) and in ergency. - m Accreditation Board for Hospitals and Healthcare Providers 41 . “preferable that the organisation alsodefine the time frame within which blood
  • 48. Care of Patients (COP) Post—'transfusion form is collected, reactions if any identified and are analysed -‘F’, , preventive and corrective actions. _i Interpremtion: The organisation shall ensure that any transfusion reaction A reported. it is preferable that the organisation capture feedback regarding eve 3;, - transfusion (including the ones without reaction) as this would enable it At capture all’-transfusion reactions. These are then analysed (by individtfa committee asdecided by the organisation) and appropriate corrective! preventiv action is taken. The organisation shall maintain a record of transfusion reactions. A: Remark(s): For “transfusion reactions" refer to glossary. A Staff is trained to implement the policies. _ Interpretation: This shall include doctors and can be done either by trainin‘ and/ or by providing. written instructions. AA Ffemark(s): Records of the same should be available. A .1 Standard 2% _ Objective Elements a. Documented policies and procedures are used to guide the care of patients -‘ ~, the intensive care and high dependency units. * A Interpretation: At a minimum this should include as to how care is organis‘ how patients are monitored and the nurse-patient ratio. A I-'temark(s): This could also incorporate objective elements b, f, g, h. The organisation has documented admission and discharge criteria for ' intensive care and high dependency units. * _ Interpretation: The organisation should develop criteria based on physiolo parameters and adhere to it. t A‘A*AA @ National Accreditation Board for Hospitals and Healthcare Providers ‘
  • 49. s): A good starting point could be various national and international care society guidelines. trained to apply these criteria. an tion: This shall be done by training and/ or by displaying the criteria. V te staff and equipment are available. retation: The lCU should be equipped with all necessary life-saving and _‘ng equipment as well as suitably manned by trained staff. The exact : ed procedures for situation of bed shortages are followed. * retation: As and when there are no vacant beds in the ICU and there is a ement of such bed, a detailed policy and procedure should be. in place to ‘ ss the situation. A tron control practices are documented and followed. * » retation: These could be developed individually or it could be a part of the tion control manual. The organisation shall ensure that the practices are in SD E to in '2' o 3 U) . o c 9.7‘. “'5' ID V) in E In § 9 o ‘9. in 3 3 m "I 3' (D o —‘ to SD 2 (D E’. 5 3 U) 3' E. (D 3 U1 5 <0 1-0‘ 3' 2’. programme is in consonance with good clinical practices. _ mark(s): Good clinical practices include rnonitoring infection rates, re- mission rates, re= intubation rates, etc. "T '
  • 50. Care of Patients (COP) Further, a good starting point could be various national and international critic care society guidelines. Objective Elements a. Policies and procedures are documented and are in accordance with th prevailing laws and the national and international guidelines. * Interpretation: At a minimum, it shall incorporate as to who the vulnerab patients are, who is responsible for identifying these patients, risk managem _ in these patients and monitoring of these patients (at least twice a day). All these patients shall be assessed for risk of falls and the same documented. ‘ Remark(s): Refer to disability act, mental act. Care is organised and delivered in accordance with the policies and procedure Interpretation: Organisation develops SoPs for delivery of care. The organisation provides for a safe and secure environment for this vulnera group. A t k Interpretation: The organisation shall provide proper environment taking i account the requirement of the vulnerable group. Bemark(s): For example, playroom for children, anti-skid tiles for elderly, ram with railings for disabled, etc. _ A documented procedure exists for obtaining informed consent from appropriate legal representative. * Interpretation: The informed consent for this group of people should be obtain from their family or legal representative. I Remar1r(s): Refer to PRE 3e. @ National Accreditation Board for l-tlospimls and Healthcare Providers
  • 51. 'ned to care for this vulnerable group. ‘n: All staff involved in the careof this group shall be adequately identifying and meeting their needs. ): Records of the same should be available. retation: The organisation shall define as to what constitutes. high-risk etric case in consonance with best clinical practices. in ' ark(s): The display should be’ in a prominent location (either near the entrance or registration counter or near the OPD). This is applicable only if it e organisation caringftor high-risk obstetric cases has the facilities to take care such mothers. Refer to AAC 1b also. Persons caring for high-risk obstetric cases are competent. '~ lnterpremtion: These shall not just be doctors but shall include nursing staff also. The competency shall be based on qualification, experience and training. Remark(s): It is preferable that persons caring for high-risk obstetric cases either have adequate experience or additional training for taking care of such patients. . Accreditation eoattitor Hospitals and Heaittmre Pm Viders V H 45
  • 52. Care of Patients (COP) 1‘ d. '3’. Documented procedures guide provision of ante-natal services. * Interpretation: This shall at a minimum include assessment, immunisation, 5 counselling and frequency of visits. Remark(s): There shall be an ante-natal card for every such patient. A Obstetric patient’s assessment also includes maternal nutrition. e Interpretation: Self-explanatory. A ,2. Remark(s): It is preferable that this is done by a dietician. f. Appropriate pre-natal, peri-natal and post-natal monitoring is performed an; ". documented. P ' A Interpretation: This is the context of matemal and foetal monitoring. .3 ‘ i g. The organisation caring for high-risk obstetric cases has the facilities to take car of neonates of such cases. Interpretation: The organisation shall have an NICU (level I, ll or Ill) appropriate equipment and staff. Standard ,4. Objective Elements a. There is a documented policy and procedure for paediatric services. * Interpretation: At a minimum this shall include assessment of these patient organisation of care and addressing special needs. Remark(s): This could include objective element also. i to i b. The organisation defines and displays the scope of its paediatric services. Interpretation: The scope shalt also includeneonatal services, if any. Remark(s): The display -should be in a prominent location (either near th : :1 entrance or registration counter or near the OPD). Refer to AAC 1b also. 9 A. @ National Accreditation Board for Hospitals and Heaithcare Providers *
  • 53. K’ oc, ogpcogoo§ooo fiooofod HI aoocQooooooo! aO for care of neonatal patients is in consonance with the national/ “ * guidelines. ‘ n: Self-explanatory. 5 ): There are national and international guidelines available for the case by WHO, etc. The hospital should take them into account. i1|’sha" actively promote breast feeding practice. into care for children have age-specific competency. tion: These shallnot just be for doctors but shall include nursing staff competency shall be based on qualification, experience and training. ‘ . ns are made for "special care of children. tion: Adequate amenities for the care of infants and children to be in the hospital. V (s): For exampie, ~playroom and breastfeeding room. assessment includes detailed nutritional, growth, psychosocial and nisation assessment. _retation: Self-explanatory. rk(s): The same needs to be documented. could be done using a standard format like a checklist or questionnaire. fiigerpretation: The organisation shall ensure that there is an adequate rity/ surveillance to prevent such happenings. £emark(s): Examples could include identification tag. One example of abuse is imsupenrised phototherapy leading to burns. . Accreditation Board for Hospitals and Healthcare Providers . ' ' 47
  • 54. Care of Patients (COP) h. .The children’s family members are educated about nutrition, immunisation at A5 safe parenting and this is documented in the medical record. _ Interpretation: Self-explanatory. Rem'ark(s): For example, growth chart, immunisation chart, etc. (originavcopy) should be a part of the medical record. . The education should preferably be in the language that the family understand I‘. " Standard Objective Elements a. Documented procedures guide the administration of moderate sedation. ‘ "F Interpretation: At a minimum, this shall include identification of procedu: where this is required, the mechanism’ for writing orders, the pre-proced assessment, monitoring during and after the procedure and t discharge/ transfer out criteria after theprocedure. V b. Informed consent for administration of moderate sedation is obtained. Interpretation: Self-explanatory. This shall be taken by the person perfor ' "1 the procedure/ administering sedation. ~ ~ M‘ ‘ ‘‘ Ftemark(s): Also refer to PRE 4d. ‘ii : - c. Competent and trained persons perform sedation. V‘ -5 Interpretation: Whenever parenteral route is used this shall be carried out A 5’ doctor/ nurse. . :.~_, ,_‘; s¢. .. _. ‘;. _.m Remark(s): Technician shall not administer sedation. ‘. d. The person administering and monitoring sedation is different from the pe ‘ ‘ performing the procedure. Interpretation: Self-explanatory. © National Accreditation Board for Hospitals and Healthcare Providers
  • 55. .. ' ring includesat a minimum the heart rate. cardiac rhythm, ' - . p_ressu_re, _o)_tygen saturation, _ and level of. sedation. . -explanatory. - documented. ition, certain other parameters may be monitored on a case-to- . -- be monitored on anmlonitor during the procedure and the documented. However, in case of rhythm abnormalities the documented. ' I i‘ ored after sedation and the same documented. . The patient’s. vitals shall be monitored at regular intervals (as tgejorganisation) till he/ she recovers completely from the _sed__ation. » a minimum, the heart rate, respiratory Q rate, blood pressure, and level of sedation are monitored. The levelof sedation can using a checklist which incorporat_es_the various components of sedafion (minimal, moderate and deep). ' filiélflm fl ‘ «geese I - _, :_These_shall_be developed and documented by the organisation in +- with physiologic parameters and good clinical practices. , Q . is . ): .T_h_e criteriashall be applied by a qualified individual and the same Q ed, 3*» : . T ~ ~ . . e T 1 _ t and manpower are available to manage patients who have_gone into *' _ level of sedation than initially intended. i the V , A 1’. _ tion: The equipment shall includetemergency resuscitation , e_quipment. rs n . n trained in -manaigementlanaestilesiologist shall be available in spital.
  • 56. Care of Patients (COP) Standard 1 A " “ -‘ a. There is’ a documented "policy and procedurel for the administration‘ _ana’e'sthe'sia. ' *4.’ ‘ s . ]ri'terpremtion: ‘'"CJrganisation shallidocument on the "indications, the eanaesthesia ar'td'proc‘edure fo‘r~the same. R, er_nark(s). '-‘For of~‘anaesthesia” refer to glossary. The standard is I ’ appllcable'tdi‘leeel anaesthesia. Patients lor"ana'esthesia have ‘a pr. e?arlaesti1es'ia"assessrnent niduali ’ anaesthesioibgist. " T" _'“ ‘A s. . doneflefcre "the the ' . . coinpiex. ltshall be'applieebletor. fhoth'rdutine'dnd"eiiiergeney'_eesee? ' ’ -RemaI. 'k(s): -lt is preferable ‘assessment in a standardisedforrnat. ‘ The pre-anaesthesia assessment_ may even be carried out prior to admission‘ " "eased: ‘elective sutgeiies. which ie. ’ddcurn'e}ited. ' _ H. The’ ‘ plan ' should’ niezrition "the iprernedications; ‘ type . . anaesthesia, the drug(s) to be used for induction and the drug to be used. maintenance. lt-should also mention about other concomitant medicationsand T rliiide, ’ special" 'tno‘niterlng' requlfenienisnhere: episrepriate “and anticipated . anaesthesiacare. ‘ T I‘ H; _ ' ‘ Remaiir(s}: This' couldbe using" a template. H The"pre-ariaesth" is as‘seeernent’teeult's in'ien’nu'latien of aii“anae'sthesia - A
  • 57. " operative re-evaluation is performed and documented. ‘ ET his is essentiallyea-pre-induction assessmentandi shall be done ' legist just before the patient-is wheeled. into the respective OT. ‘ anges to the anaesthesia plan shall be documented; -when anaesthesia -must be provided on ‘an "urgent basis‘, the pre- assessment and pre-induction assessment may be perfonned ' ’ lowing one another, or-simultaneously, butshould be documented sent "for "adrrlinistratione of~"ana'esttlesia¢ isobtained by ‘the - ist. - ' T T T - : "Self-explan‘atory. « ' , and/ or, family are educated on the risks, benefits, =and»alternatives of by the anaesthesiologist. ' ' i T }; '_T: his shall be. separ, ate-from . the_surgery; co‘nsent. T TPRE-4d. * - 0 0 ' ‘-, , 099 9.. .! 7' 9 sssthesia monitoring inciudesfregular recording of temperature, heart c rhythm, respiratory rate, blood pressure, oxygen saturation and end i-: _ tion; Self, -explanatory. T Tshouldbedocumented. — -- 7 A . regicrtalganaesthesia instead‘: ofier_td tidal carbon dioxideithe-‘adequacy 'atioTn shall be evaluated by continual observation of ‘qualitative ‘clinical siologist shall be pr_esentTthrou’gho'uti the procedu‘re. 'T T eardiae niytiim may belmonitored on-Ta iinonitot dtiriitgtiie procedure and the , need notbe docurnented. :_. However, in*case-‘of-rt1ythm‘abnormalities the O . __O. ,,O, Q i i i
  • 58. GareofPa1ients(COP g. Patient's post. -,anaesthesia°statuslismonitored and documented. ~ Interpretation: This shall be done in the recovery area/ OT and ‘at least in 2 monitoring-of vitals till the patient recovers -completely from anaesthesia and ~' be done. by an anaesthesiologist. .If the ‘patient’s condition is unstable and = -~ requires ICU--care the same shall be monitored-there. T h. - . The. -anaesthesiologist applies defined criteria to transfer the patient from recovery area. * , i Interpretation: The organisation documents these criteria which should LT. . --based on physiologic parameters and in consonancewith good~c| inicaJ-practis i. The type of anaesthesia and anaesthetic. medications-used varedocument T. thepatient record. lnrerpretatr'on: Self-explanatory. — , ' '” ' : - lt shall have the name of the anaesthesiologist who perfonned tl'lepro. cedure T also the names of individuals (with their designation) -helped in T s procedure. _Bemar_k(s): The do. cum. entation shall have name, date, time and signature. " . .A1 j. Procedures shall comply with infection control guidelines to«pr_event—— c A infection between patients. T Interpretation: Self-explanatory. ' T . . The guidelines shall beldocumented either separately or as apart of the inf v. T control manual. Remark(s): This could include management of circuits, infection co measures during administration etc. k. Adverse anaesthesia events are recorded and monitored. Interpretation: All such events are documented and monitored for the pu - of taking corrective and preventive action. @ National ATccredTT r'tétr'ToTn Board for T! -lospimls and TPrbl/ iders
  • 59. __: outset, the organisation shall define the various adverse . These essentially are adverse events following the A~. .—r~ hesia. 7 -- have a mechanism to ensure that all adverse events are the same by incorporating in. the anaesthesia record a -A This shall include the list of surgical procedures as well as 3 ‘level for performing theseiprocedures. ' H ed consent is obtained by a surgeon prior to the procedure. , tion: SeIt-explanatory. fl consent shallbe taken by the operating surgeon or a member othis team. in gone taken for the same) a fresh consent needs to be taken. (s): Also refer to PRE 4d. JR‘ éitiieditafion Board for Hospitals and Healrhcare Providers ' 53 3 ".4 . ._
  • 60. Care of Patients (COP) d. Documented policies and procedures exist to prevent adverse events like wro V’ Site, wrong patient‘ and wrong surgery. * P " -' Interpretation: Procedure should be available for preventing adverse events Ii’ WV 0719 Patients. Wrong site by a suitable mechanism. . Remark(s): The organisation should be able to demonstrate methods to prev‘ these events, e. g. identification tags, badges, cross-checks, time-outs etc. Ref 5 "L to WHO “Safe surgery saves lives” initiative. «T. .1 f, ". e. Personsguafified by law are permitted to perform the procedures that they ' , » entitled to perform. - _ . . . . 3 ‘ Interpretation: The organisation identifies theindividuals who have the requir qualification(s), training and experience to perform procedures _in consonanf with the law. - ; ; Remark(s): Also refer to HRM 9d. ’ ‘ ” f. A brief operative note is documented prior to transfer out of patient from recovf area. lnterpremtion: Thisinote provides information about the procedure perform as post-operative diagnosis and the status of the patient before shifting and shall a! .' "~ documented by the surgeon/ member of the surgical team. ‘L _ h At a minimum, it shalt include the surgery performed, namelof the surgeon ( name of anaesthesiologist, salient steps of the procedure and the key findi «'5 V: V“ intra-op. I 4 it Remark(s): If it is documented by a person other than the chief-operati surgeon the same shall be countersigned by the chief surgeon. ' The operating surgeon documents the post-operative plan of care. 3‘ 1’ Interpretation: Self-explanatory. ‘ Remark(s): The plan shall include advice on IV fluids, medication, care em» wound, nursing care, observing for any complications, etc. i '_f; This plan coutd be written in collaboration with the anaesthesiologist. A © National Accreditation Board for Hospitals and Heatfhcare Providers
  • 61. P) 9:0 a- personnel and material flow conforms to infection control practices. tion: The layoutof the theatre should be such that the mix of sterile terile patients does not happen or if it is not possible the mix is reduced _~bare minimum. rt ‘é| ,..0i' 0 -9 23-5-, _riate facilities and equipment/ appliances/ instrumentation are available in . ‘J Prion: The organisationhshalll ensure that the operating theatre has or pre-‘op holding, iseparatelchanging rooms for males and females, shingarea, operating rooms, waiting area for relatives, storage area, it area for waste and linen and recovery room. I -, ... ,,, .‘v . . 4‘: -, n to the equipment required "for anaesthesia and surgery, there shall be for resuscitation, radiation protection (where applicable) etc. €30, i-so assurance programrneflis followed for the surgical services. * A n tion: This shall be an integral part of the organisation's overall quality ce programme. it shall focus on post-operative complications, e. g. g, rational use of antibiotics, etc. A A L’ . vI-9; quality assurance programme includes surveillance of the operationgtheatre ‘ ent. *' I ' Z l A I A . Q 0,. , ‘gr’; ‘.31 . , ' _ uni ' ”'tation: 'Surveilla'nce activitiésflinclude the daily monitoring of humidity mperature; at least monthly monitoring of pressure differential, and at least nthly monitoring of integrity of filter. _ _ T A on, efficacy of OT ‘cleaning and disinfection processes ‘shall be la red. . I 7 ; (s). ' For air-conditioning ofAOT refer to the guidelines issued by NABH. i 0 0 0 0 oso 0 , _
  • 62. Care of Patients (COP Oblective Elements a. Documented policies and procedures guide the care of patients under restraint Interpretation: This shall clearly state the conditions/ circumstances under wh' restraints shall be used. It shall also specify as to who can authorise the use restraints, the frequency of monitoring these patients andthe validity of restra, orders. b. These include both physical and chemical restraint measures. 3 Interpretation: Physical restraints include boxers bandage, useof cuffs, e __ Chemical restraints include sedatives. " A ' 1 c. These include documentation of reasons for restraints. Interpretation: Self-explanatory. d. These patients are more frequently monitored. V _ Interpretation: The organisation shall specify the parameters and frequency. " monitoring and accordingly implement the same. e. Staff receives training and periodic updating in control and restraint techniques: Interpretation: Self-explanatory. ' Remark(s): It is applicable to all personnel involved in care of patients. The staff shall be updated at least once a year. Records of the same should , maintained. @ National Accreditation Board for Hospitals and Hesifhcare Providers
  • 63. ted policies and procedures guide the management of pain. * tion: it shall include" as to hcwipatients are screened for pain, the ism to ensure that a detailed pain assessment is done (when necessary), ation techniques and monitoring. ts are screened for pain. tation: Every patient entering the hospital shall be screened for pain. ‘I be consideredthe fifth vital sign. ‘ (s): This could be done by incorporating a sub-heading in the initial , ment for pain. ». with pain undergo detailed assessment and periodic re-assessment. retation: A detailed pain assessment is done when pain is the tive patients. _‘ pain assessment shall include intensity of pain (can be done_ using . a pain- ‘ular reassessment. rk(s): For example; cancer? -pain, ~neuraigia and arthralgia. ' — r
  • 64. In case the hospital does not have facilities for pain management it could r ii ’ such patients to centres specialising in pain management. Remark(s): Pain management includes medical, surgical and anaesth_ 2 techniques. . ‘ " A appropriate. Interpretation: Self-explan atory. Remark(s): This could be done only for patients who are likely to have long-tel pain in view of the underlying condition not being treatable. 3 Standard 2 Objective Elements a. ‘ Documented policies and procedures guide the provision of rehabilitat V services. * i Interpretation: Self-explan atory. Remark(s): This includes physiotherapy, occupational therapy and i’ therapy. ~. -. ’ These services are commensurate with the organisational requirements. Interpretation: the hospital. I. The scope of the departments is in consonance with the scope Remark(s): For example, provision of ante-natal and post-natal exercises co form a part of obstetric rehabilitation programme. A Care is guided by functional assessment and periodic re done and documented by qualified individualis). Interpretation: Self-explanatory. A Rem: -1rk(s): This can be done using a scale. 5 -assessment which
  • 65. ) vided adhering to infection control and safe practices. . - ‘on: Self-explanatory. s): Safe practices include ensuing that when using hot wax there are no Q -* T L‘ e-patient. 2: ive services are provided by a multidisciplinary team. 1 ion: The team shall have a treating doctor, a rehabilitation therapist, arm! nurses and other professional experts. rs adequate space and equipment to perform these activities. .~ on: Self-explanatory. s): The equipment shall be as per the scope of rehabilitation services vii-lowever, equipment for resuscitation shall be available in these areas. ents O Q spe H .9 2 : ented policies and procedures guide all research activities in compliance OT {rational and intemational guidelines. * C - tation: Self-explanatory. Q - earch undertaken in the hospital falls under its ambit. This includes both Dscope _ fand non-funded and also student studies. . :1 rk(s): For example, International Conference on Harmonisation (ICH) of rges co V _ n 4 Clinical Practice (GOP) and Declaration of Hetsinki Somerset (1996) and . _ l 5- ' w. -Guidelines for Biomedical Research on Human Subjects (ICMR-2000). ': wh'ch organisation has an ethics committee to oversee all research activities. retation: An ethics committee should be framed in the hospital to monitor ‘es undertaken by various providers. The committee has the powers to fiontinue a research trial when risks outweigh the potential benefits. Accreditation Board for Hospitals and Healthcare Providers 59
  • 66. Care of Patients (GOP) Remark(s): '~Refer to Schedule Y. of Drugs andicosmeti cs-‘Act and to IC guidelines. ‘ P * The committee has the powers to discontinue a research trial when ri outweigh the potential benefits. Interpretation: ‘-Self-explanatory. Patients’ informed consent isrobtained before entering them in resea protocols. Interpretation. -.Self-explanatory. - I ~ Remark(s): This shall be done in a language that the patient understands. e. Patients are informed of their -right to withdraw from-therresearch at any stal '. and also of the consequences (if any) of such withdrawal. »__‘ - Interpretation: Self-explanatory. Remar_k(s): ;T-his shall be “done in a _lan_g_uage that the patient unde_rstand_s_. . _ . } 7 participation will not compromise their access to the organisatiohls 'lnterpreta'tion: ~Seif-explanatory. " ‘ ' ' ' ll ' T H Objective Elements a. Documented policies and procedures guide. nutritional assessment reassessment. * A interpretation: -This shalt at a minimum incorp'orate~as‘to”i= =in . whom»nutritio assessment will be done, how it will be done, how the diet is prepared — ensured that the patient receives food as per the diet order. -’ : - © National Accreditation Board for Hospitals and Healthmre Providers
  • 67. " (s): Nutritional assessment shall be -done by a dietician for all patients I at risk duringnutritionai. screening. nts receive food according to their clinical needs. a tation: A dietician shall do the assessment of the patient in consultation the clinician and. .advice regarding food. :rk(s): For example, diabetic diet, high-protein diet, total parenteral ‘on, etc. e isa written order for the. diet. retation: The dietician shall prepare this in the form of a-diet sheet and nt shall receive food accordingly. _ ark(s): This shall be written in a uniform location in the medical recordfi ' i ' 'ona| therapy" is planned and provided in a collaborative manner. ' tation: The dietician shall ensure that this is planned in consultation with ztreatingl doctor and the patient/ patient’s relative after taking into regard the ‘ent's food habits (veglnon-veg) and likes and dislikes. fen families provide food, they are educated about the patient’s diet iimitations. hrpretation: The dieticianlnurse shall ensure this during planning. d is prepared, handled, stored and distributed in a safe mariner. _ sure that hygienic conditions are followed all throughout. her indicative points are: I 4 dedicated T I V food storagelrefrigeratioh areas exist to ensure food preservation; ' food storage areaslrefrigerators are maintained appropriately; all food products are stored "off the floor; ~
  • 68. ii ' if Care of Patients (GOP) . +__ iv. cleaning supplies stored in a separate location way from food; separate dedicated food preparation areas exist; Objective Elements a. Documented policies and procedures guide the end of life care. * ; Interpretation: The organisation has a documented policy and procedure providing end of life care to terminally ill-admitted patients. This shall include: i i. providing appropriate pain and palliative care according to the wishes s the family and patient; _ ii. sensitively addressing such issues as autopsy and organ donation; iii. respecting the patient’s values, religion, and cultural preferences; iv. involving the patient and family in all aspects of care; and v. responding to the psychological‘, emotional, spiritual, and cultural concer of the patient and family (where possible). ' element “c” and shall be prepared keeping in mind objective element “b”. Refer to glossary for definition of “end of life”. , , 3 b. These policies and procedures are in consonance with the legal requirements. Interpretation: Se| f4explanatory. Remark(s): Decisions like “Do not resuscitate/ Do not intubate/ Allow natu j. death etc. " shall be only as per the statutory laws, and within the guidelin framed by the legal system. ' @ National Accreditation Board for Hospitals and Healthcare Providers Remark(s): The procedure should also incorporate requirements of object’ V vi. measures are in place to ensure that flies do not come in contact wi prepared/ stored food; * . . 1 g vii. food distribution to patients occurs where possible in temperatu B 9-Q appropriate food service trolleys (hot food kept hot and cold food ke. ' " cold). Standard , ; FA ’ H «as. Egg‘ R5 4% "'-nu. .. . , « , ,. ._6, ¢‘. ‘ -6. ‘K -_ M , ,r‘'‘ ' iQQQ' »ao»~ i . = ‘O

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