CHECKLIST FOR NABH Clinical Areas 1. Emergency Room and Ambulance Emergency Room: Primary COP 2a-e Policies/procedure/protocols for emergency care Procedure for handling MLC case (including capturing identification marks and police intimation) Emergency care/ admission/ discharge documentation Triage, contents of triage policy: categories, ask for demo/ policy on handling of mass casualties (reference guidebook for entry level SHCO) FMS 4 d Mock drills of disaster management (internal disasters like fire) COP 2 b Training in CPR – BLS/ ALS, triage AAC 2 a –b Registration of emergency patients 24 x 7 / COP 6a Patient admission/ time for admission request completion Availability of registration form and consent for admission Transfer out form and transfer out record check stability/unstable/transfer notes. Referral of patients Staff awareness regarding the same Managing non availability of beds AAC 2 b Admission criteria and priorities for ICU AAC 3 a –d Predefined initial assessment Time frame for doing and documenting initial assessment Initial Nursing assessment Staff awareness regarding the same Staff qualification – Doctors – MBBS and PG in various specialities Nurses – GNM/B.Sc Nursing / M.Sc Nursing (Diploma , degree and PG in nsg) – AAC 3 b Reference guidebook for SHCO entry level 1st ed) AAC 1b, FMS 1a , COP 2a Signposting and Directional signage’s (which language) from approach road Adequacy of access to Emergency (easy and unobstructed). Flow of patients, unobstructed Care records and treatment is signed and dated by concerned doctor Adherence to clinical practice guidelines Scope of obstetrics services – obstetric emergencies Transport of neonates (staff awareness) Scope of paediatric services Staff awareness regarding same COP 10a IV sedatives in emergency: conscious sedation, monitoring, consent MOM 2 a,b Safe storage of medications MOM 2 e Emergency drug management, expiry of medications, LASA , high risk COP 1a COP 5 a,c COP 6 a storage, MOM 3a-d MOM 5a-e Prescription of medicines Legibility of handwriting SOP on prescription of high risk medications Medication administration Staff interview on the methodology of administration Patient identification prior to medication administration Storage, prescription of narcotics – if applicable Medication administration documentation Emergency Room: Secondary Patient interview PRE 1a-g Patients charter display and awareness among staff AAC2a, COP Informed consent for admission, procedures, anaesthesia and surgery HIC 2a Availability of hand washing facilities HIC 2 b Adequacy of supplies HIC 2 c PEP protocol staff awareness HIC 3 b Segregation of bio-medical waste COP 3 a –e Rational use of blood and blood products – Policy and procedure Informed consent Monitoring transfusion reactions 7e, COP 8b COP6 d Staff awareness on above policies Code Pink – staff awareness if neonatal and obstetrics emergencies are routed through ER MOM 5 a-e Medication administration, identification of patient prior administration Ambulance: Primary COP 2a Adequacy of parking for Ambulances COP 3d Communication system of Ambulance COP 3d Check list of Ambulance, drugs and equipment COP 3e Ambulance: adequate equipment in working order COP 2 b Training of personnel on BLS/ACLS ROM 1b Statutory requirements o RC book o License of driver (s) o Yellow Badge of driver o Insurance o Emission check o Fitness Certificate Formal documented agreement (MOU) for outsourced ambulance Secondary ROM 3 a services, if any Monitoring of the quality of the outsourced ambulance services Patient interview Staff interview to 2. Out Patient Department OPD- Primary Scope of services displayed bilingually Staff orientation about scope of services AAC 2 a Policy and procedure of registration of patient – OP, IP ROM 2d Availability of the billing process requirements ( Administrative AAC 1 a department) AAC 3a-d COP 5a,c display of the billing tariff Predefined initial assessment and re-assessment Time frame for doing and documenting initial assessment Initial assessment to include nursing assessment . Documented plan of care including preventive aspects of the care Care of high risk obstetrical patients – display, maternal nutrition assessment, antenatal records COP 6a-e Care of paediatric patients o display the scope o provisions for special care of children o detailed nutritional, growth, psychosocial and immunization assessment o parent education on nutrition, immunization and safe parenting and documentation of the same. Staff awareness on above policies Patient interview MOM 1a Documented policies and procedures on prescription of medications MOM 2 a-e Storage of vaccines, LASA, high risk medications, Expiry dates of medications Minimum requirements of a prescription Check who writes prescription orders Orders are written in a uniform location in the medical records Medication orders are clear, legible, dated, timed, named and signed MOM 3 a -d Medication orders contain the name of the medicine, route of administration, dose to be administered and frequency/time of administration Secondary AAC 2a Patient admission from OPD AAC 2b Managing non availability of beds Patient transfer Referral of patients General consent for treatment Patient and/or his family members interview for the scope of general PRE 1d consent PRE 2 a Cost of treatment discussed with patient / relatives HIC 2a,b Hand washing facilities, adequate gloves, masks, soaps, and disinfectants HIC 3b Bio-medical waste segregation Staff Interview – Care of Patients Staff interview – HR Staff Interview – Safety Staff interview - billing procedure, scope of services Patient Interview 3. Wards Primary: Patients’ case file AAC 3a –d Predefined initial assessment and re-assessment Time frame for doing and documenting initial assessment - finished within 24 hours AAC 4b-d Initial Nursing Assessment Reassessment – frequency of reassessment, documentation of response to treatment, plan for further treatment or discharge AAC 4ª Qualified individual identified as responsible for care – Qualification of working nurses and doctors AAC 2b AAC 4d , Transfer of patients between departments/units/ out of hospital Transfer note Referral of patients to other departments/specialties, referral form Discharge planning in coordination with various departments, Check for discharge summary including medico-legal cases / LAMA/ discharge at AAC 7a-b request AAC 7c-e Content of discharge summary COP 1a-b Care and treatment orders are signed, named, timed and dated by the doctor Plan of care countersigned by the clinician in charge within 24 hours (optional) Clinical practice guidelines COP 2b, CPR – Policy and procedure, staff trained in BLS/ALS, COP 3a,c,d,e Rational use of blood and blood products - Policy and procedure, informed consent, patient and family education about donation, monitoring transfusion reactions COP 8a-c Care of patients undergoing surgical procedures - Policy and procedure, preoperative assessment and provisional diagnosis documented prior to surgery, informed consent obtained by a surgeon, documented policies and procedures to prevent adverse events, surgical safety checklist COP 7 b-g Pre-anaesthesia assessment, anaesthesia plan, immediate pre-operative re-evaluation, informed consent, anaesthesia monitoring form, pain assessment and management MOM 1a Documented policies and procedures on prescription of medications MOM 2 a-e Storage of medications, LASA, high risk medications, Expiry dates of medications Minimum requirements of a prescription Check who writes prescription orders Orders are written in a uniform location in the medical records Medication orders are clear, legible, dated, timed, named and signed Medication MOM 3 a -d orders administration, contain dose to the be name of the medicine, route of administered and frequency/time of administration MOM5e Narcotic drugs procedure Storage Handling Documentation Patients and families are informed of their rights and responsibilities in Secondary PRE 1a-g, a format and language that they can understand PRE 1d Staff awareness on protecting patient and family rights General consent for treatment Consent for procedure Patient and/or his family members interview for the scope of general consent PRE 2 a-b Patient and family education on following aspects in the language that they understand o Plan of care o Preventive aspects o Possible complications o Medications o Expected cost of treatment o Expected result PRE 1a HIC 1a-d HIC 2a-b Patient privacy protected Cleanliness and general hygiene, cleaning and disinfection protocols Sterilized sets: expiry dates, storage conditions Check hand washing facilities for staff in all care area, instructions for proper hand washing Check Adequate soap, masks, gloves and disinfectants are available HIC 3b Segregation of bio-medical waste FMS 4b Signage Fire exit ,fire extinguishers, signs etc. Floor plans All equipment are inventoried and log maintained / calibrated Preventive FMS 3c,e maintenance/service labels on Equipment/calibration records/Refrigerator FMS 4c Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers FMS 2 b Preventive and breakdown maintenance IMS 1a,c,d Medical record unique no. / Dated and timed entry / author are clear IMS 2 a-b up-to-date and chronological order of case records information regarding reasons for admission, diagnosis and plan of care Patient interview Staff interview 4. Specialized Wards Paediatric Primary COP 6a-e Care of paediatric patients - display the scope, age specific competency, provisions for special care of children, detailed nutritional, growth, psychosocial and immunization assessment, provision for preventing child/neonate abduction and abuse Parent education on nutrition, immunization and safe parenting and documentation of the same Secondary: Checklist of ward OBG and Labour Room Primary COP 5 a-c Care of obstetrical patients – o Display of scope of obstetric services stating whether high risk obstetric cases can be cared for or not o Assessment of maternal nutrition o Competence of staff handling high risk obstetrical patients o Ante –natal check –up records o Post-natal care o Facilities to take care of neonates of high risk pregnancies, NICU/PICU with proper equipment and staff to take care of neonates of high risk obstetric cases Secondary: Checklist of ward Chemotherapy Unit (NA) No special standard on this exists however if it is in the scope of services of organization then can be treated as high risk medications administration Primary MOM 3d Chemotherapeutic drug procedure – for indenting, prescribing, list of medications stated under high risk medications MOM5a-e Preparation, administration and disposal of chemotherapy drugs 5 Dialysis Unit Primary HIC 1b-d, Overall adherence to infection control 2a-b Re-use policy of tubes, how safely it was kept and the labelling requirement to prevent exchange/ensure patient’s safety. Check Adequate soap, masks, gloves and disinfectants are available FMS 3 a Quality of RO water PRE 1d Policy on consent. Who can give consent when patient is incapable FMS 2 b All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records Secondary Patient interview Staff interview COP 2 b Training in CPR – BLS/ ALS MOM 2 e Emergency drug management HIC 2d Sterilized sets: expiry dates, storage conditions HIC 2 a-b Check hand washing facilities for staff in all care area, instructions for proper hand washing Check Adequate soap, masks, gloves and disinfectants are available HIC 3 b Segregation of bio-medical waste FMS 4d Documented plan for maintenance of medical gas and vacuum system SOP on handling, storage, usage and replenishment of medical gases Medical gases handling, storage and usage safely Medical gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers FMS 4 a-b Documented plan for handling fire and non-fire emergencies Safe Exit plan in case of fire and non-fire emergencies Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Smoke detectors, fire alarms, fire alarm control panel etc. (where applicable) FMS 1 c Fire exit, fire extinguishers, no smoking signs etc. Identification of hazardous materials Implementation of the processes for sorting, labelling, handling, storage, transporting and disposal of hazardous materials Spills management plan of hazardous materials Staff awareness Patient interview Staff interview 7. Intensive Care, Neonatal/ Paediatric ICU and High Dependency Units Primary COP 4a-b Policy on admission. If they have written about admission and discharge criteria for ICU/HDU/NICU/PICU then to check for adherence or else just a general check on which types of patients are admitted Adherence to infection control practices Adequacy of staff and equipment AAC 2b Policy for Bed shortage in ICU AAC 3a,c,d Predefined initial assessment Time frame for doing and documenting initial assessment Reassessment – frequency of reassessment, documentation of response AAC 4b,d to treatment, plan for further treatment or discharge COP 2 b Documented policies and procedures on use of resuscitation /CPR/ adequate trained staff and equipment COP 3a-e Rational use of blood and blood products - Policy and procedure, informed consent, patient and family education about donation, monitoring transfusion reactions COP 6b Age specific competency in case of Paediatric and Neonate population COP 6c Nutritional assessment Growth assessment Immunization assessment MOM 2 e Emergency drug management MOM 3a-c Medicine orders are written in a uniform location clear, legible, dated, timed, named, signed MOM 5a-e MOM 6a-b MOM 5e Written order for high risk medication Medication administration Medication administration documentation Patient monitoring after medication administration Knowledge to pick adverse drug events and reporting of the same Narcotic drug procedure Handling HIC 1 FMS 1d Documentation Collection of Infection control data Availability of various HAI rates of that area and action taken based on this Layout of beds, spacing, visual privacy (optional / unless gross problems in spacing between the beds) FMS 2b All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator FMS 3c, 4c Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers PRE 2a Patient interview o Explanation of plan of care, preventive aspects, possible complications, medications, expected results and cost of care Secondary AAC 3a-d Initial assessment, nursing assessment IMS2b Documented plan of care AAC 4a Qualified individual identified as responsible for care Referral of patients to other departments/specialties AAC 4b-d Re assessment documented AAC 4d , Discharge planning in coordination with various departments, including medico-legal cases / LAMA, discharge summary to all AAC 7 a AAC 7c-f Content of discharge summary / death summary COP 1a-b Care and treatment orders are signed, named, timed and dated by the concerned doctor – consultant HIC 2 a-b Clinical practice guidelines followed Check hand washing facilities for staff in all care area instructions for proper hand washing Check if adequate soap, masks, gloves and disinfectants are available Hand washing HIC 3 b Bio-medical waste PRE 1d Policy on consent. Who can give consent when patient is incapable/ Informed consent situations/ performing doctor’s name. FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. IMS 1a-e, Medical record unique no. / dated and timed entry / author is clear, up-to-date and chronological. Patient / family interview Staff interview IMS 1 e 7. Operation Theatre Primary COP 71a-i Pre-Anaesthesia assessment and immediate pre-operative assessment Consent for anaesthesia and surgery Monitoring during and post anaesthesia Criteria for discharge to recovery area Monitoring of adverse anaesthesia events COP 8a-e Care of patients undergoing surgical procedures - procedure Preoperative assessment and provisional diagnosis documented prior to surgery Informed consent obtained by a surgeon Qualified persons perform the procedures that they are entitled to perform(privileging based on credentials) COP8f-g Documented procedures to prevent adverse events Operating notes and post-operative plan of care Surgical safety checklist Availability of appropriate facilities and equipments/appliances/instrumentation in OT Patient, staff and material flow conforms to infection control practices(Layout of OT - no mix of sterile and un sterile) COP8 f Surveillance of OT environment Monitoring of SSI (optional) / wrong site, wrong patient, surgeries MOM 2a-e MOM 5 e MOM 1b Storage of medications Expiry dates, clean safe storage, LASA, high risk medications storage Emergency drug management Narcotic drug procedure Handling Documentation Procedure for procuring and using implants wrong PRE 1d, PRE Entry of batch and serial number in patient’s case file & master log book Consent 2 a-b o Name of procedure o Name of doctor o Explanation of risks, benefits and alternatives if any o Language (that the patient understands) used for taking consent o Completeness of the consent form in all aspects Cleaning and disinfection practices defined and monitored Equipment cleaning (if any) Sterilization/disinfection activities being performed Sterilized sets: expiry dates, storage conditions HIC 1e Linen disinfection (if any) in OT HIC 2 a-b Check hand washing facilities for staff in all care area, instructions for HIC1c HIC 1d proper hand washing Check Adequate soap, masks, gloves and disinfectants are available FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. FMS 2b Documented operational and maintenance (preventive and breakdown)plan All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator FMS 3c, 4c Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers Secondary COP 2 b CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of events during CPR, Communication of corrective and preventive measures COP 3a-e Rational use of blood and blood products - Policy and procedure, informed consent, patient and family education about donation, monitoring transfusion reactions HIC 3 b Segregation of bio-medical waste Patient interview Staff interview 8. Recovery Room Primary COP 7g-h COP 8e Discharge criteria Patient monitoring post anaesthesia Operating notes and post-operative plan of care Staff interview Medicine orders are written in a uniform location clear, legible, dated, Secondary MOM 3a-d timed, named, signed Verbal orders(optional) Written order for high risk medication Medication administration Staff interview on the methodology of administration Medication administration documentation Patient’s self-administration of medicines (optional) Management of medications got from outside (optional) Patient monitoring after medication administration Knowledge to pick adverse drug events and reporting of the same Narcotic drug procedure Handling Documentation FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. MOM 5a-d MOM 6a-b MOM 5e 9. Endoscopy (No specific standard for this but if it is in the scope of services of HCO, then to follow following) Primary Sedation policy implementation Check who gives sedation and who monitors patient Documentation of monitoring activities Availability of equipment and manpower MOM 2 e Emergency drug management PRE 1d, Consent COP 7a PRE 2a-b HIC 1d HIC 2 a-b o Name of procedure o Name of doctor o Explanation of risks, benefits and alternatives if any o Language (that the patient understands) used for taking consent o Completeness of the consent form in all aspects Equipment cleaning (if any) Sterilized sets: expiry dates, storage conditions Check hand washing facilities for staff in all care area, instructions for proper hand washing FMS2b Check Adequate soap, masks, gloves and disinfectants are available All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator FMS 4c Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers Secondary AAC 4a Qualified individual identified as responsible for care – Qualification of working nurses and doctors COP 2 b CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of events during CPR, Communication of corrective and preventive measures COP 3a-e Rational use of blood and blood products – Policy and procedure, informed consent, patient and family education about donation, monitoring transfusion reactions COP 8b,c,d Documented procedures on prevention of adverse events like wrong site, wrong patient and wrong procedure Informed consent taken by the doctor performing the procedure COP8 e Documentation of the procedures in the patient record HIC 3 b Segregation of bio-medical waste MOM 3a-d Medicine orders are written in a uniform location clear, legible, dated, timed, named, signed MOM 5a-d MOM 6a-b MOM 5e FMS 2b Verbal orders(optional) Written order for high risk medication Medication administration Staff interview on the methodology of administration Medication administration documentation Patient’s self-administration of medicines (optional) Management of medications got from outside (optional) Patient monitoring after medication administration Knowledge to pick adverse drug events and reporting of the same Narcotic drug procedure Handling Documentation Patient interview Staff interview Documented operational and maintenance (preventive and breakdown)plan All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels records/Refrigerator FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. on Equipment/calibration 10. Imaging: X Ray/ USG/ CT Scan/ MRI Primary AAC 6a-d Scope of imaging services - Radiation hazard, PC-PNDT act etc. Display of imaging signages Performing and reporting of tests Technician qualified as per AERB Turnaround time - Check results are available in defined time frame Critical results intimation Radiation safety programme including usage of safety equipment and TLD badges Adherence to standard precautions and safe practices Staff trained in safe practice; staff have safety equipment/ fire extinguisher/ dressing materials/ etc. Safety devices periodically checked Availability of safety equipment FMS 2b Documented operational and maintenance (preventive and breakdown)plan All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator Secondary MOM 2 e Emergency drug management PRE 1d Policy on consent. Who can give consent when patient is incapable/ Informed consent situations/ performing doctor’s name FMS 2b All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels records/Refrigerator FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. Patient interview Staff interview on Equipment/calibration 11. Cardiac Catheterization lab Primary AAC 6-d Scope of imaging services - Radiation hazard, PC-PNDT act Display of imaging signages Performing and reporting of tests Technician qualified as per AERB Turnaround time - Check results are available in defined time frame Critical results intimation Radiation safety programme including usage of safety equipment and TLD badges Adherence to standard precautions and safe practices Staff trained in safe practice; staff have safety equipment/ fire extinguisher/ dressing materials/ etc. Safety devices periodically checked Availability of safety equipment MOM 1a-b PRE 1d HIC 1c Procedure for procuring and using implants Entry of batch and serial number in patient’s case file and master log book Process for taking informed consent Who can give consent when patient is incapable Staff awareness on informed consent procedure Informed consent taken by the doctor performing the procedure Consent o Name of procedure o Name of doctor o Explanation of risks, benefits and alternatives if any o Language (that the patient understands) used for taking consent Completeness of the consent form in all aspects Equipment cleaning and disinfection Equipment cleaning (if any) Sterilization/disinfection activities being performed Sterilized sets: expiry dates, storage conditions HIC 1e Linen disinfection (if any) in cath lab HIC 2 a-b Check hand washing facilities for staff in all care area, instructions for HIC 1d proper hand washing Check Adequate soap, masks, gloves and disinfectants are available Secondary COP 2 b CPR – Policy and procedure, staff trained in BLS/ALS, Documentation of events during CPR, Communication of corrective and preventive measures MOM 2 e Emergency drug management MOM 3a-d Medicine orders are written in a uniform location clear, legible, dated, timed, named, signed MOM 5a-d MOM 6a-b MOM 5e FMS 2b Verbal orders(optional) Written order for high risk medication Medication administration Staff interview on the methodology of administration Medication administration documentation Patient’s self-administration of medicines (optional) Management of medications got from outside (optional) Patient monitoring after medication administration Knowledge to pick adverse drug events and reporting of the same Narcotic drug procedure Handling Documentation Documented operational and maintenance (preventive and breakdown)plan All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator FMS 3c, 4c Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. Patient interview Staff interview 12. Laboratory: Haematology/ Biochemistry/ Pathology/ Microbiology Primary AAC 5a-f Standard operating procedures Appropriate use of logos (e.g. NABL) and scope of lab accreditation (if accredited) Technician qualified Turn-around time - Results are available in defined time frame Procedures for collection, identification, handling, safe transportation, processing and disposal of specimens AAC 5e Alert and Panic levels - Critical results intimated immediately Documented procedures of out sourcing test Measurement uncertainties Signatures Outsourcing and controls Documented lab safety programme Documented policies and procedures for disposal of infectious and hazardous materials Awareness of safety among employees - Staff trained in safe practice Staff have safety equipment / fire extinguisher / dressing materials / etc. Usage of gloves Reagent storage Handling spills Secondary HIC 3 b Segregation of bio-medical waste FMS 2b Documented operational and maintenance (preventive and breakdown)plan All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. Patient interview Staff interview 13. Blood Bank Primary COP 3a-e Blood bank license and adherence to its terms and conditions Adherence to part X B and Schedule F of part XII B and/or XII C of drugs and cosmetics rules Informed consent Staff awareness on above Transfusion reactions documentation and reporting PRE 1d Informed consent on HIV MOM 2e Emergency medication management HIC 3 b Segregation of bio-medical waste Patient interview on blood donation Staff interview FMS 1a Signage FMS 4 A-B Fire exit ,fire extinguishers, no smoking signs etc. FMS 2b Documented Secondary operational and maintenance (preventive and breakdown)plan All equipment are inventoried and log maintained / calibrated Preventive maintenance/service labels on Equipment/calibration records/Refrigerator FMS 3c, 4c Gas and vacuum supply / Storage of oxygen cylinders/Condition of Humidifiers 14. Radiation therapy/Radioactive drugs Primary AAC 6a-d Comply with BARC/AERB legal requirements Scope of imaging services Performing and reporting of tests Technician qualified as per AERB Turnaround time - Check results are available in defined time frame Critical results intimation Safety programme including usage of safety equipment and TLD badges Use of personal protective equipment Isolation barriers for radioactive areas Adherence to standard precautions and safe practices Staff trained in safe practice Safety equipment/ fire extinguisher/ dressing materials/ etc. Safety devices periodically checked Imaging signage - Radiation hazard MOM 7a-b Documented procedures on usage of radioactive drugs Storage, preparation, handling, distribution and disposal of radioactive drugs/ isotopes (Iv 192, Cs XX, Co 60) Staff, patient and visitor education on safety precautions Secondary MOM 2 e Emergency drug management PRE 1d Policy on consent. Who can give consent when patient is incapable/ Informed consent situations/ performing doctor’s name FMS 2b All equipment are inventoried and log maintained / calibrated Preventive maintenance/service records/Refrigerator Patient interview Staff interview 15. Nutrition Therapy Primary COP 6 b COP 7c COP 7 e Maternal nutrition assessment Nutritional assessment of children Family education on child’s nutrition Patient interview Secondary labels on Equipment/calibration 16. Hospital Infection Control (HIC) Primary HIC 1 HIC 1a-e Documented Infection Control Programme – HIC manual HIC committee and team Qualified HIC nurse (optional) Identified methods of surveillance Adherence to o standard precautions o hand hygiene guidelines o equipment cleaning and sterilization practices o disinfection and sterilization practices o laundry and linen management Effectiveness of housekeeping services Facilities for hand washing, Monitoring of hand washing Adequacy of supplies like gloves, masks, soaps, and disinfectants HIC 2c Pre and post exposure prophylaxis HIC 3a-e Authorization for generation of bio-medical waste Adherence to various conditions of the act Usage of appropriate personal protective equipment Visit by the hospital authorities to the disposal site Training - Induction and in service training on occupational health HIC 2a-b HRM 2a, hazards, risks in hospital environment HRM 4 b Pre and post exposure prophylaxis Staff interview Secondary Non Clinical Areas 1. Document Review Primary NABH Application contents, Internal assessment report, Scope of the organization Documented Quality Improvement programme (QIP) Committees-composition and functioning Records: Attendance, minutes etc. ROM 1a Organization structure ROM 2 a Vision and mission, strategic plans Manuals of all departments List of statutory applicable acts/rules Licenses Other certificates/correspondence to meet statutory obligations CQI 1a,b FMS 1b 2. Quality Management Primary CQI 1a-g Documented Quality Improvement programme (QIP) Committee-composition and functioning Designed individual Documented Patient Safety program Quality assurance and risk management Annual update of QIP to review of QIP and identification of improvement activities CQI 2a-b Data for key performance indicators that are selected by HCO Clinical: mortality rate, percentage of cases where preoperative antibiotic was given, incidence of catheter-associated UTI, number of surgical site infections, number of errors in reporting of Lab investigations. Nonclinical: OPD waiting time, patient satisfaction rate, number of stock outs of emergency medications, number of errors in billing. Check raw data Verify collection methodology of data i.e Formula or sample size, and method of data collection is determined Data analysis Indicators are discussed and measures taken to improve the quality Staff interview Secondary 3. Management/Administration Primary ROM 1 a The organogram is present. The organogram is approved by the Top management. All departments are represented in the organogram. All management levels are represented. The hierarchy is accurate. Cross-reporting, if any, is represented. Involvement of department heads in quality initiatives Support for quality improvement activities Adherence to statutory requirements at least registration with appropriate authorities ROM 2 a-d ROM 3 a-b Displaying mission Ethical management Revealing ownership Billing based on standard tariff Multi-disciplinary committees o Quality and Safety Committee o Infection Control Committee o Pharmacy and Therapeutics Committee o Blood Transfusion Committee o Medical Records Committee o CPR Committee (Optional) ROM 4a-b Qualification and experience of person heading the organization PRE 1a-g Protection of patient rights by addressing grievance CQI 1a-c Availability of resources Monitoring of KPI / QI HIC 1 HIC programme HIC 2b Resource Allocation quality improvement/ HIC HRM 1 Staff mix based on patient care needs HRM 2 Training and Development program HRM 3 Grievance handling HRM 4 Staff health programme Secondary 4. Committees Primary Composition and functioning of Resuscitation committee Staff training on handling emergencies Pharmaco-therapeutic committee or anything similar Development of hospital formulary MOM 6a Monitoring of adverse drug events ROM 3 Quality and Safety committee composition and functioning Scope of programme Development, implementation and monitoring of safety plans Infection Control committee composition and functioning Scope of programme Development, implementation and monitoring of infection control COP 2 b ROM 3 ROM 3 surveillance activities ROM 3 ROM 3 Blood Transfusion committee composition and functioning Scope of programme Development, implementation and monitoring of transfusion reactions Medical Records committee composition and functioning Scope of programme Development, implementation and monitoring of medical records audits Any other committee as required by state/local regulations Secondary 5. Human Resource Department (HR) Primary HRM 1a-b HRM 3a-c Staff planning SOP on recruitment Training procedure Training identification Training calendar Training records and effectiveness Training requirements as per the standard o Blood and blood products (COP 3) o Infection control (HIC 1) o Safety Education program comprising of Fire and non-fire emergencies, Hazardous materials, occupational Safety (FMS 1e) HRM 3 o Risks within the hospital environment (HRM 2a) o Emergency Management of patients / CPR o Job responsibilities (HRM 2c) o Training on introduction of new equipment (HRM 2 c) o Training on change of job responsibilities (HRM 2 c) o Grievance Handling (HRM 3b) o Induction training – preferably on following Orientation to mission and goals (ROM 2 a) Policies and procedures (hospital and department) (HRM 2c ) Rights and responsibilities-patient and employee (PRE 1) Service standards (optional) Procedure for disciplinary action is available Procedure is available for addressing complaints of sexual harassment in the workplace Procedure is available for addressing grievance-handling Grievance handling procedure is reviewed and approved by Top management on a yearly basis All concerned documents and materials have the updated procedure Records of disciplinary proceedings are maintained Records of grievance handling proceedings are maintained Records of proceedings that handle complaints of sexual harassment in the workplace are maintained confidentially. HRM 3 b Training records Staff interviews o to check staff awareness and understanding of the disciplinary procedure o the grievance handling procedure o dealing with sexual harassment at the workplace HRM 4a-b Pre-employment medical examination Medical benefits for employees Regular health check (at least once a year) of staff involved in patient care Health check of employees exposed to radiation as per statutory requirements Occupational health hazards Employee State Insurance Act : applicability List of staff whose gross salary is less than Rs. 15,000 per month Updated every month HRM 4 b Eligible new staff enrolled under ESI Remittance of amount to ESI Monthly remittance - Timely remittance (within 21 days) Staff interview shows awareness of the provisions under ESI Pre-exposure prophylaxis given for concerned staff Post-exposure prophylaxis given following an incident Provision of safety measures – personal protective equipment. Audited during facility tour. HRM 5a-b Personal file for every employee containing information on o Educational qualification o Disciplinary background o Health status o In service training (optional) o Performance appraisal (optional) Staff interview AAC 1c Staff training on scope of services – front office AAC 5e Training of lab personnel in safety AAC 6d Training of imaging personnel in safety COP2 b CPR training COP 2e BLS training to ambulance staff, ACLS training to doctors and nurses in Secondary ER / Ambulance COP 6b Age specific training records of paediatric staff COP 6 d Code Pink training COP 6b, 8d Qualification of paediatric staff and surgeons CQI 1 Training on Quality improvement (CQI 1) 6. Medical Record Department (MRD) Primary Medical record unique no Policy on authorized person to make entry Every entry is dated and timed Author is clear Contents of medical record are identified IMS2 a Records are up to date and chronologically arranged IMS 2 b-f Medical record has reason for admission / diagnosis/ plan of care/ IMS 1a-e Operative and Procedure sheet Transferring patients medical records have date of transfer/reasons/name of receiving hospital (COP2c) Signed Discharge note/copy of death certificate with cause, date and time of death IMS 3a-b Copt of clinical autopsy report (where applicable) Access to current and past medical record Security, integrity and confidentiality of data Usage of privileged health information Documented policies and procedures on how to handle MR information requirement The audited sample of case sheets are well protected from loss, theft and tampering. The process of retrieval of files is implemented. Missing files are traced. Adequate fire detection and fire fighting equipment is available and mock drills are conducted. IMS 4a-c Retention Policy Maintenance of confidentiality and security at all stages Method for destruction of medical records Documented procedures are in place for retaining the patients' clinical records, data and information. The documented procedures are implemented. The audited sample of case sheets are well preserved for the duration of the retention period. The process of destruction of medical records is defined and implemented. If the process of destruction is outsourced, adequate measures are taken to safeguard against leakage of information from these records. AAC 7b-f Discharge summary o reason for admission, findings, diagnosis, condition at the time of discharge o investigation results, procedure performed, medication and other treatment given o follow up advice and medication instructions o when and how to obtain urgent care COP 3d, 7e, Check for completeness of consent documents 8b, PRE 1d, Consent for anaesthesia, blood transfusion, and surgical procedures PRE 2b Authorized legal representative General consent Language of consent Plan of care is present in the case files Medico legal case documentation LAMA case file has discharge summary and risks explained AAC4d, IMS2b AAC 7a Paediatric cases: PRE 3a, COP 6c, e Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment The children’s family members are educated about nutrition, immunization and safe parenting and this is documented in medical record COP 7 b, c, d, evaluation , anaesthesia monitoring, f COP 7e, Pre anaesthesia assessment, anaesthesia plan , immediate pre op Informed anaesthesia consent the COP 7 h, recovery criteria COP 8e, Informed consent for surgery COP 8 c d, Surgical safety checklist, COP 8e Operation Notes, , post-operative plan of care ROM 1 b Random check for statutory documents MTP register Birth and death registration Consent document under MTP act Consent document under PNDT act Completeness of death certificates Medico legal cases documentation Any other applicable documents Staff interview Secondary 7. Hospital Information System (HIS) Primary ROM 1b IMS 3a-b License for software Validation of software Security, integrity and confidentiality of data Safeguarding data/ record against loss, destruction and tampering Usage of privileged health information Documented policies and procedures on how to handle MR information requirement 8. Front office: Registration, Admission and Billing counters Primary AAC 1a-c AAC 2a-b Display of scope Orientation of staff with respect to available services Procedure for registration and admission (OP, IP and Emergency) Management of patients when beds are not available (given in guidebook for SHCO) Awareness of staff Display of patient rights and responsibilities PRE 1d General consent process ROM 2d Uniform pricing policy in a given setting Availability of tariff list Display of mission Information to patients if high risk obstetric cases can be or cannot be PRE (intent of std) ROM 2a Secondary COP 5a taken COP 6a Display of scope of paediatrics services FMS 1a Signage in local language Patient interview Staff interview 9. Biomedical Equipment Management: Equipment, Medical Gases, Vacuum System etc. Primary FMS 2a-bf Equipment inventory , asset list review, asset tag and log Training of staff when new equipment is installed (HRM 2c) Preventive maintenance and calibration-- Review of PM tracker Adherence to manufacturer/ international guidelines with regard to preventive maintenance and frequency of calibration Review of Preventive Maintenance record as per checklist like Anaesthesia ventilator, IABP etc. FMS3 c and Traceability of calibration report Preventive and breakdown maintenance plans Interview with bio-medical head Documented policies and procedures on procuring, handling, storing, distributing and replenishing of medical gas FMS4c FMS 4c Safety precautions at all levels Records as per legal requirements Colour coding of pipelines (given in guidebook for entry level SHCO) Maintenance plan Adherence to manufacturer/ international guidelines with regard to maintenance Secondary Scope of department Staff interview 10. Medication Management: Pharmacy and Pharmacy Store Primary MOM 1a,b Documented procedures on medication procurement, storage, formulary, prescription, dispensing, administration, monitoring etc. Separate license for each of the pharmacies. Adherence to terms and conditions mentioned in the license. Duty roster to ensure that there is a qualified pharmacist at all times (his/her name being mentioned in the license). Documented procedures for procurement and usage of implantable prostheses MOM 3a-e Documented policies and procedures for storage Storage of medicines in clean, well lit and ventilated environment and/or as per manufacture’s requirement MOM 3a-d Inventory control practices like FIFO Stock of medicines Precautions against theft Identification and storage of sound alike and look alike drugs Procedure to obtain medications when pharmacy is closed Availability of emergency medicines Prescription adheres to statutory requirements and the Code of Medical Ethics Check who writes prescription orders Prescription orders are written in a uniform location in the medical records Medication orders are clear, legible, dated, timed, named and signed Medication orders administration, contain dose to the be name of the medicine, route of administered and frequency/time of administration Identified high risk medicines Check for the procedure of prescribing High risk medications same is available Procedure for dispensing these medicines MOM 4a-b Policy and Procedures for dispensing Expiry date check before dispensing High risk medications are verified prior to dispensing – check process of verification MOM 5e MOM 6a-b MOM 7 a-b Procedure for narcotic drugs Storage Proper record Handling – use and disposal Adverse Drug events defined and monitored Time frame of reporting the adverse events Policies and procedures for use, storage, preparation, handling, distribution and disposal of radioactive drugs Secondary ROM 3a Multidisciplinary committee PRE 2a Patient interview on safe and effective use of medicines MOM 1a Procedures for procuring implants FMS 2a Equipment planning Equipment selection Scope of department Staff interview 11. Purchase Primary Secondary 12. Facility Management: Engineering and Maintenance Primary ROM 1b FMS 1 a,b Various statutory requirements o Fire o Diesel storage o Liquid oxygen and storage of medical cylinders. o Boiler o Electrical inspectorate reports. o ETP o DG sets Signage Up to date drawing, layout, escape route Presence of staff round the clock for emergency repairs FMS 2b FMS 3a-c FMS 1c,d.e Preventive and break down maintenance plan Response time Provision of space Designated individual for maintenance Availability of potable water and electricity Alternate sources and their testing Water quality reports Hazardous material and other potential safety and security risk identified Safety devices Facility inspection rounds twice a year in patient care areas and once in nonpatient care areas FMS 3 c. 4c Documentation of facility inspection report CAPA , RCA for facility rounds Safety education program for all staff Protocol for operating medical gas and vacuum installations shall be managed as per policy. Daily, weekly, monthly and annual maintenance schedule. FMS 4 a Uniform colour coding of medical gas pipelines. Safety signage present Actual storage of empty and filled cylinders By-pass in case of emergencies and back up Valves shut off in different loops Chained cylinders Mechanism of loading and unloading cylinders Leak detection systems Daily, weekly and monthly checks by operator Annual overhaul Standardized colour coding of pipelines Condition of the cylinders, colour coding. Personnel protective equipment for the staff Fire detection systems as per norms Fire fighting systems as per norms Checking or testing records of the detection and fighting systems FMS 4b Leak detection systems as per norms Emergency communication systems Plan for managing fire and nonfire emergencies Staff training Awareness of staff on the plan Emergency Floor Plans Emergency Evacuation Plan Green-coloured exit signage is clearly visible. Emergency lighting. Emergency floor plans are visible on all the floors and at conspicuous places. An emergency evacuation plan exists. Staff are trained in the emergency evacuation plan. Staff are aware of their roles during an emergency evacuation. Mock drills are conducted to test the plan. Staff Interview Secondary HRM 13. Safety program Primary ROM 3 Documented plan for handling fire and non-fire emergencies which includes exit plan FMS 1a Signage pertaining to fire exits Open and easily accessible fire exits without any obstruction Mock drill schedule and record - Twice a year mock drill Smoke detectors, fire alarms, fire alarm control panel etc. (where applicable) FMS 4ª Safety Manual Safety Committee - composition and functioning Non fire emergencies (Community emergencies, epidemics disasters) identified FMS 1c Documented disaster management plan Provision of supplies Tested at least twice a year Identified hazardous materials Hazardous materials identified have documented procedure for sorting, storing, handling etc. Availability of MSDS for all such material Spill management plan Staff awareness ROM 3b Safety committee meeting minutes FMS 1d,e Facility inspection rounds Awareness of staff by training on patient safety program Staff interview on their role in case of emergencies and on safety Secondary aspects and 14. Housekeeping Primary HIC 1b,c FMS 1c Effectiveness of housekeeping services Disinfection process Identified hazardous materials Hazardous materials identified have documented procedure for sorting, storing, handling etc. Availability of MSDS for all such material Spill management plan Staff awareness Staff Interview on handling spills–safety Secondary 15. Laundry and Linen Primary HIC 1e FMS 2b FMS 4a Process flow Segregation of linen Disinfection Bags and labels Quality control system Quality control of outsourced activity (if outsourced) (optional) Maintenance plan of machinery Layout/ space Electrical safety practices Staff awareness on safety practices Identified hazardous materials Hazardous materials identified have documented procedure for sorting, Secondary FMS 1c storing, handling etc. Availability of MSDS for all such material Spill management plan Staff awareness Monitoring of terms and conditions (T & C) in case this activity is outsourced 16. Kitchen/Canteen ( Optional ) Primary HIC 1c, HIC 2b ROM 1b FMS 2a,b FMS 4 a-d HRM 4a-b 17. Mortuary Primary HIC 1a,b, Mortuary facilities HIC 2b, Cold storage and back-up power Staff safety and personal protective equipment Disinfection FMS 2a-b Maintenance plan of machinery FMS 4a-d Electrical safety practices Staff awareness on safety practices Fire safety Interviews 1. Patient and family interview PRE 2 a-b Explanation on o Proposed care – plan of care o Expected results o Possible complications o Preventive aspects o Medications o Expected costs COP 6e Educated about nutrition, immunization and safe parenting PRE 2 b Safe and effective use of medicines PRE 1 Awareness of rights and responsibilities PRE1 Involvement of patient and family in decision making CQI 2 Feedback 2. Staff interview-Care of patients AAC 5c Safe practices in laboratory COP 2 a Handling of emergencies and medico legal cases COP 3c Use of blood and blood products COP 6d Child abduction FMS 1c Safety training HRM 1c Use of equipments –specially new HRM 1 c Change of job description or department FMS2b Technicians trained in safe operation of the equipment Staff training on equipment handling FMS4a Handling of fire and non fire emergencies MOM 5b-d Labelling prior to making a secondary medicine Patient identification before administering medication MOM 6a Awareness of adverse drug events and reporting mechanisms PRE 1d Awareness on patient rights and responsibilities HIC 1a Infection control programme CQI 1b Quality improvement programme 3. Staff interview-HR ROM 2a Mission, goals and service standards of organization HRM 2c Hospital and department policies and procedures HRM 3a Disciplinary procedure HRM 3a Grievance handling HRM 4a-b Organization’s policy with respect to health problems Occupational health hazards Pre and post exposure prophylaxis HIC 2c 4. Staff interview-Safety FMS 1e Fire and non-fire emergencies FMS 1e Disaster management plan FMS 1e Handling spills FMS 1e Safety education FMS 1e Risk management Incident reporting system
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