NABH - Self Assessment Toolkit

Self Assessm
applicable.
Compliance to the requirement: 10

Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total s
Non-compliance to the requirement: 0
Not Applicable: NA
Evaluation Criteria during final assessment:
No individual standard should have more than one zero to qualify. However, no zero is accepted in th
The average score for individual standard must not be less than 5.
The average score for individual chapter must not be less than 7.
The overall average score for all standards must exceed 7.
Special Note:
Self assessments should be done by the hospital in a stringent manner and if at the time
assessment and the pre assessment report then organisations can apply for final assess
SELF ASSESSM
Objective Elements
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)

AAC.1: The organisation defines and displays the services that it can provide.
a
b
The services being provided are clea

needs of the community.
The defined services are prominently
The staff is oriented to these services
AAC.2: The organisation has a well defined registration and admission process.
a.
Standardized policies and procedure

patients.
b.
The policies and procedures address

patients.
c.
Patients are accepted only if the orga
d.
The policies and procedures also add

availability of beds.
e.
The staff is aware of these processes
AAC.3 There is an appropriate mechanism for transfer or referral of patients who do not match t
a.
Policies guide the transfer of unstab

manner.
b.
Policies guide the transfer of stable p
c.
Procedures identify staff responsible
d.
The organization gives a summary o
AAC.4 During admission the patient and/ or family members are educated to make informed dec
a.
The patients and/ or family members
b.
c.

complications.
d.
AAC.5 Patients cared for by the organisation undergo an established initial assessment.
a.
The organisation defines the content

patients and emergency patients.
b.
The organisation determines who can
c.
The organisation defines the time fra

completed.
The initial assessment for in-patients
per the patient's condition or hospital
d.
e.
Initial assessment includes screening
f.
The initial assessment results in a do
g.
The plan of care also includes preven
AAC.6 All patients cared for by the organisation undergo a regular reassessment.
a.
All patients are reassessed at approp
b.
Staff involved in direct clinical care do
c.
Patients are reassessed to determine

further treatment or discharge.
AAC.7 Laboratory services are provided as per the requirements of the patients.
a.
Scope of the laboratory services are

organisation.
b.
Adequately qualified and trained pers

investigations.
Policies and procedures guide collect
transportation, processing and dispos
c.
d.
Laboratory results are available within
e.
Critical results are intimated immedia
f.
Laboratory tests not available in the o

based on their quality assurance syst
AAC.8 There is an established laboratory quality assurance programme.

a.
The laboratory quality assurance prog
b.
The programme addresses verificatio
c.
The programme addresses surveillan
d.
The programme includes periodic cal
e.
The programme includes the docume
a.
The laboratory safety programme is d
b.
This programme is integrated with the
c.
Written policies and procedures guide

hazardous materials.
d.
Laboratory personnel are appropriate
e.
Laboratory personnel are provided w
AAC.9 There is an established laboratory safety programme.
AAC.10 Imaging services are provided as per the requirement of the patients.
a.
Imaging services comply with the leg
b.
Scope of the imaging services are co

organisation.
Adequately qualified and trained pers
investigations.
c.
d.
e.
Policies and procedures guide identif

imaging services.
Imaging results are available within a
f.
Critical results are intimated immedia
g.
Imaging tests not available in the org

based on their quality assurance syst
AAC.11 There is an established quality assurance programme for imaging services.

a.
The quality assurance program for im
b.
The programme addresses verificatio
c.
The programme addresses surveillan
d.
The programme includes periodic cal
e.
The programme includes the docume
a.
The radiation safety programme is do
b.
This programme is integrated with the
c.
Written policies and procedures guide

and hazardous materials.
d.
Imaging personnel are provided with
e.
Radiation safety devices are periodic
f.
Imaging personnel are trained in radi
g.
Imaging signage are prominently dis
h.
Policies and procedures guide the sa

services.
AAC.12 There is an established radiation safety programme.
AAC.13 Patient care is continuous and multidisciplinary in nature.

a.
During all phases of care, there is a q

the patients care.
b.
Care of patients is coordinated in all c
c.
Information about the patient's care a

medical, nursing and other care provi
d.
Information is exchanged and docum

shifts, and during transfers between u
e.
The patients record(s) is available to

exchange of information.
f.
Policies and procedures guide the re

specialities.
AAC.14 The organisation has a documented discharge process.

a.
The patients discharge process is pla

family.
b.
Policies and procedures exist for coo

agencies involved in the discharge pr
c.
Policies and procedures are in place
d.
A discharge summary is given to all th

patients leaving against medical advi
AAC.15 Organisation define the content of the discharge summary.

a.
Discharge summary is provided to the
b.
Discharge summary contains the rea

diagnosis and the patients condition
c.
Discharge summary contains informa

procedure performed, medication and
d.
Discharge summary contains follow u

an understandable manner.
e.
Discharge summary incorporates inst

care.
f.
In case of death the summary of the
Chapter 2: CARE OF PATIENTS (COP)
COP.1: Uniform care of patients is provided in all settings of the organization and is guided by th
guidelines.
a
Care delivery is uniform when similar
Uniform care is guided by policies an

and regulations.
The care and treatment orders are si

concerned doctor.
The care plan is countersigned by the

hours.
Evidence based medicine and clinica

patient care whenever possible.
COP.2: Emergency services are guided by policies, procedures and applicable laws and regulati
a
Policies and procedure for emergenc
Policies also address handling of me
The patient receives care in consona
Policies and procedures guide the tria

care.
Staff is familiar with the policies and t

emergency patients.
Admission or discharge to home or tr

documented.
COP.3: The ambulance services are commensurate with the scope of the services provided by th
a
There is adequate access and space
Ambulance(s) is appropriately equipp
Ambulance(s) is manned by the train
There is a checklist of all equipment a
Equipment are checked on a daily ba
Emergency medications are checked
The ambulance(s) has a proper comm
COP.4: Policies and procedures guide the care of patients requiring cardio-pulmonary resuscita
a
Documented policies and procedures

throughout the organisation.
Staff providing direct patient care is tr

pulmonary resuscitation.
The events during a cardio pulmonar
A post-event analysis of all cardiac as

committee.
Corrective and preventive measures
COP.5: Policies and procedures define rational use of blood and blood products.
a

blood products.
The transfusion services are governe
Informed consent is obtained for don

products.
Informed consent also includes patie
Staff is trained to implement the polic
Transfusion reactions are analysed fo
COP.6: Policies and procedures guide the care of patients in the intensive Care and High Depend
a
The organisation has documented ad

care and high dependency units.
Staff is trained to apply these criteria.
Adequate staff and equipment are av
Defined procedures for situation of be
Infection control practices are followe
A quality assurance programme is im
COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically and/ or
a
Policies and procedures are docume

laws and the national and internation
Care is organised and delivered in ac
The organisation provides for a safe

group.
A documented procedure exists for o

appropriate legal representative.
Staff is trained to care for this vulnera
COP.8: Policies and procedures guide the care of high-risk obstetrical patients.
a
The organisation defines and display

for or not.
Persons caring for high-risk obstetric
High-risk obstetric patients assessme
The organization caring for high risk o

of neonates of such cases.
COP.9: Policies and procedures guide the care of paediatric patients.

a
The organisation defines and display
The policy for care of neonatal patien

international guidelines.
Those who care for children have age
Provisions are made for special care
Patient assessment includes detailed

immunization assessment.
Policies and procedures prevent child
The childrens family members are ed

safe parenting and this is documente
COP.10: Policies and procedures guide the care of patients undergoing moderate sedation.
a
Competent and trained persons perfo
The person administering and monito

performing the procedure.
Intra procedure monitoring includes

respiratory rate, blood pressure, and
Patients are monitored after sedation
Criteria are used to determine approp

area.
Equipment and manpower are availa

sedation than that intended.
COP.11: Policies and procedures guide the administration of anesthesia.

a
There is a documented policy and pro
All patients for anesthesia have a pre

individual.
The pre-anesthesia assessment resu

is documented.
An immediate preoperative re-evalua
Informed consent for administration o
During anesthesia monitoring include

cardiac rhythm, respiratory rate, bloo
and patency and level of anesthesia.
Each patients post-anesthesia status
A qualified individual applies defined

recovery area.
All adverse anesthesia events are rec
COP.12: Policies and procedures guide the care of patients undergoing surgical procedures.
a
The policies and procedures are docu
Surgical patients have preoperative a

documented prior to surgery.
An informed consent is obtained by th
Documented policies and procedure

site, wrong patients and wrong surge
Persons qualified by law are permitte

entitled to perform.
A brief operative note is documented

area.
The operating surgeons documents t
A quality assurance programme is fol
The quality assurance program includ

environment.
The plan also includes monitoring of
COP.13: Policies and procedures guide the care of patients under restraints (physical and/ or ch
a
These include both physical and chem
These include documentation of reas
These patients are more frequently m
Staff receive training and periodic upd
COP.14: Policies and procedures guide appropriate pain management.

a
The organization respects and suppo

management of pain for all patients.
Patient and family are educated on v
COP.15: Policies and procedures guide appropriate rehabilitative services.

a
These services are commensurate w
Rehabilitative services are provided b

with national and international guideli
COP.16: Policies and procedures guide all research activities.
The organization has an ethics committee
The committee has the powers to discont

potential benefits.
Patients informed consent is obtained be
Patients are informed of their right to

also of the consequences (if any) of
Patients are assured that their refusa

participation will not compromise the

reassessment.
Patients receive food according to the
There is a written order for the diet.
Nutritional therapy is planned and pr
When families provide food, they are
Food is prepared, handled, stored an
These policies and procedures are in
These also address the identification

family.
These also include sensitively addres

donation.
Staff is educated and trained in end o
COP.17: Policies and procedures guide nutritional therapy.
COP.18: Policies and procedures guide the end of life care.
Chapter 3: MANAGEMENT OF MEDICATION (MOM)
MOM.1: Policies and procedures guide the organization of pharmacy services and usage of med
a
There is a documented policy and pro

medication usage.
These comply with the applicable law
A multidisciplinary committee guides

policies and procedures.
A list of medication appropriate for th

developed.
The list is developed collaboratively b
There is a defined process for acquis
There is a process to obtain medicati
MOM.2: There is a hospital formulary.
MOM.3: Policies and procedures exist for storage of medication.

a
Medications are stored in a clean, we
Sound inventory control practices gui
Medications are protected from loss o
Sound alike and look alike medication
There is a method to obtain medicatio
Emergency medications are available
Emergency medications are replenish
MOM.4: Policies and procedures exist for prescription of medications.

a
The organization determines who can
Orders are written in a uniform locatio
Medication orders are clear, legible, d
Policy on verbal orders is documente
The organization defines a list of high
High risk medication orders are verifie
MOM.5: Policies and procedures guide the safe dispensing of medications.

a
The policies include a procedure for m
Expiry dates are checked prior to disp
Labeling requirements are document
MOM.6: There are defined procedures for medication administration.

a
Medications are administered by thos
Prepared medication are labeled prio
Patient is identified prior to administra
Medication is verified from the order p
Dosage is verified from the order prio
Route is verified from the order prior
Timing is verified from the order prior
Medication administration is documen
Polices and procedures govern patien
Polices and procedures govern patien

organization.
MOM.7: Patients and family members are educated about safe medication and food-drug interac
a
Patient and family are educated abou
Patient and family are educated abou
MOM.8: Patients are monitored after medication administration.

a
Patients are monitored after medicati
Adverse drug events are defined.
Adverse drug events are reported wit
Adverse drug events are collected an
Policies are modified to reduce adver

occur.
MOM.9: Policies and procedures guide the use of narcotic drugs and psychotropic substances.
a

psychotropic substances.
These policies are in consonance wit
A proper record is kept of the usage,
These drugs are handled by appropri
MOM.10: Policies and procedures guide the usage of chemotherapeutic agents.

a

agents.
Chemotherapy is prescribed by those

the adverse effect of chemotherapy.
Chemotherapy is prepared and admi
Chemotherapy drugs are disposed of
MOM.11: Policies and procedures govern usage of radioactive drugs.

a
The policies and procedures include

distribution, and disposal of radioactiv
Staff, patients and visitors are educat
MOM.12: Policies and procedures guide the use of implantable prosthesis.

a

implantable prosthesis.
Selection of implantable prosthesis is

internationally recognized approvals.
The batch and serial number of the im

patients medical record and the mas
MOM.13: Policies and procedures guide the use of medical gases.

a

distribution, usage and replenishmen
The policies and procedures address
Appropriate records are maintained in

and legal requirements.
Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)
PRE.1: The organization protects patient and family rights informs them about their responsibili
a
Patient and family rights and respons
b
c
Patients and families are informed of

and language that they can understa
The organizations leaders protect pa
Staff is aware of their responsibility in
Violation of patient and family rights i

preventive measures taken.
PRE.2: Patient and family rights support individual beliefs, values and involve the patient and fam
a
Patient and family rights address any

needs.
Patient and family rights include resp
examination, procedures and treatme
Patient and family rights include prote
Patient and family rights include treat
Patient and family rights include refus
Patient and family rights include infor

blood product transfusions and any in
Patient and family right include inform

protocol is initiated.
Patient and family have a right to hav
PRE.3: A documented process for obtaining patient and/ or family's consent exists for informed
a
General consent for treatment is obta
Patient and / or his family members a

consent.
The organisation has listed those situ
Informed consent includes informatio

who will perform the requisite proced
The policy describes who can give co

independent decision-making.
PRE.4: Patient and families have a right to information and education about their health care nee
a
When appropriate, patient and familie

effective use of medication and the p
Patient and families are educated ab

complications and prevention strateg
Patients and family are taught in a lan
PRE.5: Patient and families have a right to information on expected costs.

a
There is uniform pricing policy in a giv
The tariff list is available to patients.
Patients and family are educated abo
Patients and family are informed abo

change in the patient condition or trea
Chapter 5: HOSPITAL INFECTION CONTROL (HIC)
HIC.1: The organization has a well-designed, comprehensive and coordinated infection control p
eliminating risks to patients, visitors and providers of care.
a
The hospital infection control program

and reducing risk of nosocomial infec
The hospital has a multi-disciplinary i
The hospital has an infection control
The hospital has designated and qua
HIC.2: The organisation has an infection control manual, which is periodically updated.
a
The manual identifies the various hig
It outlines methods of surveillance in
It focuses on adherence to standard
Equipment cleaning and sterilisation
An appropriate antibiotic policy is esta
Laundry and linen management proc
Kitchen sanitation and food handling
Engineering controls to prevent infect
Mortuary practices and procedures a
The organization defines the periodic
HIC.3: The infection control team is responsible for surveillance activities in identified areas of t
a
Surveillance activities are appropriate

areas
Collection of surveillance data is an ongo
Verification of data is done on regular bas
In cases of notifiable diseases, informatio

authorities.
Scope of surveillance activities incorp

risks, rates and trends.
Surveillance activities include monito
HIC.4: The organization takes actions to prevent or reduce the risk of Hospital Associated Infect
employees.
a
The organization monitors urinary tra
The organization monitors respiratory
The organization monitors intra-vascu
The organization monitors surgical si
Appropriate feedback regarding HAI

medical and nursing staff.
HIC.5: Proper facilities and adequate resources are provided to support the infection control pro
a
Hand washing facilities in all patient c

providers.
Compliance with proper hand washin
Isolation/ barrier nursing facilities are
Adequate gloves, masks, soaps, and
HIC.6: The organisation takes appropriate actions to control outbreaks of infections.

a
Hospital has a documented procedur
This procedure is implemented during
After the outbreak is over appropriate

recurrence.
HIC.7: There are documented procedures for sterilisation activities in the organisation.
a
There is adequate space available fo
Regular validation tests for sterilisatio
There is an established recall proced

system is identified.
HIC.8: Statutory provisions with regard to Bio-medical Waste (BMW) management are complied
a
The hospital is authorised by prescrib

handling of Bio-medical Waste.
Proper segregation and collection of

of the hospital is implemented and m
The organization ensures that Bio-me

site of treatment and disposal in prop
limits in a secure manner.
Bio-medical Waste treatment facility i

house) or outsourced to authorised c
Requisite fees, documents and repor

stipulated dates.
Appropriate personal protective meas

handling Bio-medical Waste.
HIC.9: The infection control programme is supported by the organisations management and inc
employee health.
a
Hospital management makes availab

programme.
The hospital regularly earmarks adeq

regard.
It conducts regular pre-induction train

joining concerned department(s).
It also conducts regular in-service tr

of staff at least once in a year.
Appropriate pre and post exposure p

members
Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)
CQI.1: There is a structured quality improvement and continuous monitoring programme in the o
a
The quality improvement programme

by a multi-disciplinary committee.
There is a designated individual for c

improvement programme

elements related to quality improvem
The designated programme is comm

employees of the organization throug

opportunities for improvement are ide

once in a year.
CQI.2: The organization identifies key indicators to monitor the clinical structures, processes an
tools for continual improvement.
a
Monitoring includes appropriate patie
Monitoring includes safety and quality

services.
Monitoring includes all invasive proce
Monitoring includes adverse drug eve
Monitoring includes use of anaesthes
Monitoring includes use of blood and
Monitoring includes availability and co
Monitoring includes infection control a
Monitoring includes clinical research.
Monitoring includes data collection to
CQI.3: The organization identifies key indicators to monitor the managerial structures, processe
tools for continual improvement.
a
Monitoring includes procurement of m
Monitoring includes reporting of activ
Monitoring includes risk managemen
Monitoring includes utilisation of spac
Monitoring includes patient satisfactio

services.
Monitoring includes employee satisfa
Monitoring includes adverse events a
CQI.4: The quality improvement programme is supported by the management.

a
Hospital Management makes availab

improvement programme.
Hospital earmarks adequate funds fro
Appropriate statistical and managem
CQI.5: There is an established system for audit of patient care services.

a
Medical and nursing staff participates
The parameters to be audited are de
Patient and staff anonymity is mainta
All audits are documented.
Remedial measures are implemented
The organisation has defined sentine
The organisation has established pro
Sentinel events are intensively analys
Corrective and preventive Actions are
CQI.6: Sentinel events are intensively analysed.
Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)

ROM.1: The responsibilities of the management are defined.
a
Those responsible for governance lay
Those responsible for governance lay

commensurate to the organizations m
holders.
Those responsible for governance ap

the resources required to meet the or
Those responsible for governance m

organization against the stated missio
Those responsible for governance es
Those responsible for governance ap
Those responsible for governance su
The organization complies with the la
Those responsible for governance ad
ROM.2: The services provided by each department are documented.

a
Each organizational program, service
Scope of services of each departmen
Administrative policies and procedure
Departmental leaders are involved in
ROM.3: The organization is managed by the leaders in an ethical manner.

a
The leaders make public the mission
The leaders establish the organizatio
The organization discloses its owners
The organization honestly portrays th
The organization honestly portrays its
The organization accurately bills for it

tariff.
ROM.4: A suitably qualified and experienced individual heads the organisation.

a
The designated individual has requisi

qualifications.
The designated individual has requisi
ROM.5: Leaders ensure that patient safety aspects and risk management issues are an integral p
management.
a
The organization has an interdisciplin

wide safety programme.
The scope of the programme is defin

harm to sentinel events.
Management ensures implementation

reporting of system and process failu
Management provides resources for

activities.
Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)
FMS.1: The organization is aware of and complies with the relevant rules and regulations, laws a
inspection requirements.
a
The management is conversant with

applicability to the organization.
Management regularly updates any a
The management ensures implemen
There is a mechanism to regularly up
FMS.2: The organizations environment and facilities operate to ensure safety of patients, their f
a
There is a documented operational a

plan.
Up-to-date drawings are maintained w

escape routes.
There is internal and external sign po
understood by patient, families and c
c
d
The provision of space shall be in acc

practices (Indian or International Stan
agencies.
There are designated individuals resp

facilities.
Maintenance staff is contactable roun
Response times are monitored from r

corrective actions.
FMS.3: The organization has a program for clinical and support service equipment management
a
The organization plans for equipmen

plan.
Equipment is selected by a collabora
All equipment is inventoried and prop
Qualified and trained personnel opera
Equipment are periodically inspected
There is a documented operational a

plan.
FMS.4: The organization has provisions for safe water, electricity, medical gases and vacuum sy
a
Potable water and electricity are avai
Alternate sources are provided for in
The organisation regularly tests the a
There is a maintenance plan for pipe

installation.
FMS.5: The organization has plans for fire and non-fire emergencies within the facilities.
a
The organization has plans and provi

abatement of fire and non-fire emerg
b
c
The organization has a documented

emergencies.
Staff is trained for their role in case o
Mock drills are held at least twice in a
The organization defines and implem
The policy has provisions for granting

smoke.
FMS.6: The organization has a smoking limitation policy.
FMS.7: The organization plans for handling community emergencies, epidemics and other disas
a
The hospital identifies potential emer
The organization has a documented
Provision is made for availability of m

during such emergencies.
Hospital staff is trained in the hospita
The plan is tested at least twice in a y
FMS.8: The organization has a plan for management of hazardous materials.

a
Hazardous materials are identified wi
The hospital implements processes f

transporting and disposal of hazardou
Requisite regulatory requirements are
There is a plan for managing spills of
Staff is educated and trained for hand
FMS.9: The organisation has systems in place to provide a safe and secure environment.
a
The hospital has a safety committee

risks.
This committee coordinates developm

safety plan and policies.
Patient safety devices are installed a

periodically.
Facility inspection rounds to ensure s

patient care areas and at least once i
Inspection reports are documented a

undertaken.
There is a safety education programm
Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)

HRM.1: The organization has a documented system of human resource planning.
a
The organization maintains an adequ

treatment and service needs of the p
The required job specifications and jo

category of staff.
The organization verifies the anteced

criminal/negligence background.
HRM.2: The staff joining the organization is socialized and oriented to the hospital environment.
a
Each staff member, employee, stude

oriented to the organizations mission
Each staff member is made aware of

as relevant department / unit / service
Each staff member is made aware of
All employees are educated with rega
All employees are oriented to the ser
HRM.3: There is an ongoing programme for professional training and development of the staff.
a
A documented training and developm
Training also occurs when job respon

introduced.
Feedback mechanisms for assessme

exist.
HRM.4: Staff members, students and volunteers are adequately trained on specific job duties or
a
All staff is trained on the risks within t
Staff members can demonstrate and

risks.
Staff members are made aware of pr
Reporting processes for common pro
HRM.5: An appraisal system for evaluating the performance of an employee exists as an integra
management process.
a
A well-documented performance app
The employees are made aware of th
Performance is evaluated based on t

description.
The appraisal system is used as a to
Performance appraisal is carried out
HRM.6: The organization has a well-documented disciplinary procedure.

a
A written statement of the policy of th

place.
The disciplinary policy and procedure
The policy and procedure is known to

organization.
The disciplinary procedure is in conso
There is a provision for appeals in all
HRM.7: A grievance handling mechanism exists in the organization.

a
The employees are aware of the proc

aggrieved.
The redress procedure addresses the
Actions are taken to redress the griev
HRM.8: The organization addresses the health needs of the employees.

a
A pre-employment medical examinati
Health problems of the employees ar

organizations policy.
Regular health checks of staff dealing

once a year and the findings/ results
Occupational health hazards are ade
HRM.9: There is a documented personal record for each staff member.

a
Personal files are maintained in respe
The personal files contain personal in

qualification, disciplinary background
All records of in-service training and e
Personal files contain result of all eva
HRM.10: There is a process for collecting, verifying and evaluating the credentials (education, re
of medical professionals permitted to provide patient care without supervision.
a
Medical professionals permitted by la

patient care without supervision is ide
The education, registration, training a

professionals is documented and upd
All such information pertaining to the

when possible.
HRM.11: There is a process for authorising all medical professionals to admit and treat patients
commensurate with their qualifications.
a
Medical professionals admit and care

authorisation procedures of the organ
The services provided by the medica

qualification, training and registration
The requisite services to be provided

them as well as the various departme
HRM.12: There is a process for collecting, verifying and evaluating the credentials (education, re
of nursing staff.
a
The education, registration, training a

and updated periodically.
All such information pertaining to the

possible.
HRM.13: There is a process to identify job responsibilities and make clinical work assignments t
commensurate with their qualifications and any other regulatory requirements.
a
The clinical work assigned to nursing

training and registration.
The services provided by nursing sta

and regulations.
The requisite services to be provided

well as the various departments / unit
Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)
IMS.1: Policies and procedures exist to meet the information needs of the care providers, manag
as other agencies that require data and information from the Organization.
a
The information needs of the organiz

scope of the services being provided
organization.
Policies and procedures to meet the

regulations.
All information management and tech

the policies and procedures.
The organization contributes to extern

regulations.
IMS.2: The organization has processes in place for effective management of data.
a
Formats for data collection are stand
Necessary resources are available fo
Documented procedures are laid dow

data.
Documented procedures exist for sto
Appropriate clinical and managerial s

using data.
IMS.3: The organization has a complete and accurate medical record for every patient.
a
Every medical record has a unique id
Organisation policy identifies those a
Every medical record entry is dated a
The author of the entry can be identif
The contents of medical record are id
The record provides an up-to-date an
The medical record contains informat

diagnosis and plan of care.
Operative and other procedures perfo
When patient is transferred to anothe

date of transfer, the reason for the tra
The medical record contains a copy o

appropriate and qualified personnel.
In case of death, the medical record c

indicating the cause, date and time o
Whenever a clinical autopsy is carrie

the report of the same.
Care providers have access to curren
IMS.4: The medical record reflects continuity of care.
IMS.5: Policies and procedures are in place for maintaining confidentiality, integrity and security
a

and integrity of information.
Policies and procedures are in conso
The policies and procedures incorpor

destruction and tampering.
The hospital has an effective process

policy.
The hospital uses developments in a

confidentiality, integrity and security.
Privileged health information is used

law and not disclosed without the pat
A documented procedure exists on h

other public agencies requests for ac
accordance with the local and nationa
IMS.6: Policies and procedures exist for retention time of records, data and information.
a

records, data and information.
The policies and procedures are in co

and regulations.
The retention process provides expec
The destruction of medical records, d

laid down policy.
IMS.7: The organization regularly carries out review of medical records.

a
The medical records are reviewed pe
The review uses a representative sam
The review is conducted by identified
The review focuses on the timeliness

records.
The review process includes records
The review points out and documents
Appropriate corrective and preventive
lf Assessment Toolkit
omplying out of total samples selected)
zero is accepted in the regulatory/ legal requirements.
er and if at the time of Pre assessment it is found that there is a significant difference between the
ply for final assessment not earlier than six months from the date of completion of Pre assessme
F ASSESSMENT TOOLKIT
Interpretation
RE (AAC)
e.
s being provided are clearly defined and are in consonance with the
e community.
d services are prominently display.
A policy to be framed clearly

stating the services the hospital
can
The provide.
services so defined should be
visible prominently in an area
visible to all patients entering the
organization. The display could be
in the form of boards, citizen's
charter, scrolling messages etc.
care should be taken to ensure
that these are displayed in the
oriented to these services.
ess.
ed policies and procedures are used for registering and admitting
s and procedures address out-patients, in-patients and emergency
e accepted only if the organization can provide the required service.
s and procedures also address managing patients during non

of beds.
aware of these processes.
who do not match the organisation resources.
All the staff in the Hospital mainly

in the reception/registration, OPD,
IPD are oriented to these facts
through training programme
conducted regularly or through
Health
Care Organization (HCO)
manuals.
has prepared document (s)
detailing the policies and
The policies and procedures
procedures for registration and
address out-patients, in-patients
admission of patients which
and emergency
should
also
includeadmission
unidentified
The
staff
handling
and
patients. needs to be aware of
registration
the services that the organization
The
HCO is aware
of the
can provide.
It is also
advisable to
availability
of
alternate
have a system whereinHCOs
the staff is
where
the
may
be if
aware
as
topatients
whom to
contact
All
the
staff
handling
these
directed
in any
caseclarification
of non-availability
they
need
activities
should be orientedonofthe
of
beds. provided.
services
these policies and procedures.
ide the transfer of unstable patients to another facility in an appropriate The organization shall at the
outset define as to who is an
unstable patient. The documented
ide the transfer of stable patients to another facility.
Patients
not
in a life threatening
policy and
procedure
should
situation
(stable)
should also
be
address the methodology
of safe
transported
in apatient
identify staff responsible during transfer.
The
staffofshall
atsafe
leastmanner.
bea alife
transfer
the
in
trained
trauma/emergency
threatening
situation (like those
technician/nurse/.
He/She
shall
who
are
on
ventilator)
tosummary
another
zation gives a summary of patients condition and the treatment given. The HCO gives a case
have
training
infindings
BLS
HCO.undergone
Therethe
should
be availability
mentioning
significant
and/or
ACLS. given
of antreatment
appropriate
ambulance
and
in case of
fitted withwho
life are
support
and
patients
beingfacilities
transferred
make informed decision.
accompanied
by trained
from emergency.
For admitted
personnel.
patients
discharge
summaryby
s and/ or family members are explained about the proposed care.
The
plaina of
care as decided
has management
to be given (refer
15).
the
teamAAC
(as the
The
shall
given to
casesame
may be)
is also
to bebe
discussed
s and/ or family members are explained about the expected results.
The
patients
family are
patients
goingand
against
with the patient
and/or medical
family
explained
in
detail
by the training
advice.
members. This should be done in
physicians
or his/her team
about
s and/ or family members are explained about the possible
Possible
complications
of the
a language
the patient/attendant
the
outcomes
of
such
treatment.
ns.
treatment,
if any, The
are clearly
can understand.
above
communicated
the
patient.
information
is toto
be
documented
s and/ or family members are explained about the expected costs.
Patients
should
be
given
as
and signed
concerned
estimate
of by
thethe
expenses
on
doctor. of the treatment
account
preferably in a written form
assessment.
sation defines the content of the assessments for the out patients, in
d emergency patients.
sation determines who can perform the assessments.
sation defines the time frame within which the initial assessment is
ssessment for in-patients is documented within 24 hours or earlier as

ent's condition or hospital policy.
ssment includes screening for nutritional needs.
ssessment results in a documented plan of care which is monitored.

care also includes preventive aspects of the care.
ment.
are reassessed at appropriate intervals.
The hospital shall have a

protocol/policy by which a
standardized initial assessment of
The assessment should be done
patients is done in the OPD.
by the treating doctor, junior
Emergency and in-patients. The
doctor
or ahas
nurse.
The and
The
defined
initialHCO
assessment
could be
organization
determines
whowithin
can
documented
the
time
frame
standardized across the
hospital
do
what
assessment
and
it
should
which
the initial
assessment
is to
or it could
be
modified
depending
The
should
cover
history,
be
the
same across
the hospital.
be
completed
with
respect
to
on
the
need
of
the
department.
progress notes, investigation
OPD/
emergency/
patients.
However
it shall
beindoor
the ordered
same
in
ordered
and
treatment
The
protocol
patients
that particular
area
a
and
all
these for
are
to e.g.
be ininitial
assessment
should
coverdoctor.
his/her
paediatric OPD
weight
and
authenticated
bythe
treating
This
shall be
documented
byOut
the
nutritional
needs,
in
case
of
height may be a must whereas
it
treating
doctor
or bybe
a member
of
patients
this
should
done
may not be so for orthopaedics
his
team
in the
case
sheet.
This
The
documented
plan
of
care
where
ever
applicable.
For
OPD. The organization can have
plan
is monitored
byCRF
the actions
training
should
preventive
example
diabetics,
patients.
differentcover
assessment
criteria
for
doctor
for its effectiveness
and
as
necessary
in
the
case
and
the first visit and for department
whenever
required
a clinical
should
diet,by
drugs
etc.
the vitalinclude
parameters.
The initial
audit.
assessment
should
also include
After
the initial
assessment,
the
the nursing
assessment
for inpatient
is reassessed
periodically
patients.
and this is documented in the
case sheet. The frequency may
be different areas based on the
setting and the patient's condition
ed in direct clinical care document reassessments.
e reassessed to determine their response to treatment and to plan

tment or discharge.
ents.
Actions taken under

reassessment are documented.
the
could be the treating
Selfstaff
explanatory.
doctor or any member of the learn
as per their domain of
responsibility of care.
e laboratory services are commensurate to the services provided by the The HCO should ensure
n.
availability of laboratory services
commensurate with the health
qualified and trained personnel perform and/or supervise the
The staff employed in the lab
care services offered by it either
ns.
should be suitably qualified
by providing the same in house or
(appropriate
and trained
d procedures guide collection, identification, handling, safe
The
HCO hasdegree)
documented
by outstanding.
However, test
to carry out the
tests, Pathologist,
on, processing and disposal of specimens.
procedures
for
collection,
results required for emergency
Microbiologist
and Biochemist
identification,
handling,
safe
management
(RBS,
ABG
results are available within a defined time frame.
The HCO shall
define
the etc.)
supervise
the
staff.
transportation,
processing
must be available
itsand
turnaround
time forwithin
all tests.
The
disposal
ofSee
specimens,
to ensure
premises.
also
(f)
below
forof
HCO
should
ensure
availability
ults are intimated immediately to the concerned personnel.
The
laboratory
shall establish
safety
of thelab
specimen
till the its
outsourced
facilities.
adequate
staff, materials
andfor
biological
reference
intervals
tests and retests
(if required)
are
equipment
to
make
the
laboratory
tests not available in the organization are outsourced to organization(s) The
HCOtests.
has aThe
documented
different
laboratory
completed.
results
available
withinlimits
the tests
heir quality assurance system.
procedure
for outstanding
shall
establish
critical
for
defined
time
frame.
for
which
it has
no facilities.
This
tests
which
require
immediate
should
include.
a) List
of tests for
attention
for patient
management.
out
b) Identity
of
Thesourcing.
tests results
in the critical
personnel
in the
out sourcedto the
limit HCO
shall be
communicated
ory quality assurance programme is documented.
The
has
a documented
facilities
to ensure
safe
concerned
after proper
quality
assurance
programme
transportation
of specimens
documentation.
(preferably as per
ISO 15189and
mme addresses verification and validation of test methods.
This
holds true
for any
laboratory
completing
of tests
as- Particular
per
Medical
laboratories
developed methods.
of the
patient
requirements for
quality
and
mme addresses surveillance of test results.
The
laboratory
(orresults
inconcerned
and director
receipt of
competence).
charge)
shall
periodically
assess
at HCO. c) Manner of packaging
thethe
testspecimens
results. and their
mme includes periodic calibration and maintenance of all equipments. of
Refer to
ISO 15189.
lavbelling for identification and
this package should contain the
mme includes the documentation of corrective and preventive actions. Self
explanatory.
test rquisition
with all details as
required for testing. d) a
methodology to check the
perforance of service rendered by
the
outdocumented
sourced laboratory
as per
ory safety programme is documented.
A
well
lab safelty
the requirements
of in
thethe
HCO.
manual
is available
lab.
This takes care of the safety of
mme is integrated with the organisation's safety programme.
Lab safety programme is
the workforce as well as the
incorporated in the safety
equipments available in the lab.
of should
the hospital.
cies and procedures guide the handling and disposal of infectious and programme
The lasb staff
follow
materials.
standard precautions. The
disposal of waste is according to
personnel are appropriately trained in safe practices.
All the lab staff undergo training
Biomedical waste management
regarding safe practices in the
and handling rules, 1998.
lab.
personnel are provided with appropriate safety equipment/ devices.
Adequate safety devices are
available in the lab e.g. fire
extinguishers, dressing materials
disinfectants, etc.
s.
rvices comply with the legal and other requirement.
e imaging services are commensurate to the services provided by the

n.
qualified and trained personnel perform, supervise and interpret the
ns.
d procedures guide identification and safe transportation of patients to

vices.
sults are available within a defined time frame.
The HCO is aware of the legal

and other requirements of
imaging
services and the same
Self explanatory
are documented for information
and
compliance
by all concerned
As per
AERB guidelines.
in the HCO. The HCO maintains
and updates its compliance status
The
HCO
has
documented
of legal
and
other
requirements in
policies
and
procedures
for
a regular manner.
informing
the
patients
about
the
The organization shall document
imaging
activities,
their
turnaround time of imaging
identification and safe
results.
transportation to the imaging
services. This should also
address transfer of unstable
patients to imaging services.
ults are intimated immediately to the concerned personnel.
ts not available in the organization are outsourced to organization(s)

heir quality assurance system
ervices.
assurance program for imaging services is documented.
mme addresses verification and validation of imaging methods.
mme addresses surveillance of imaging results.
mme includes periodic calibration and maintenance of all equipments.
mme includes the documentation of corrective and preventive actions.
on safety programme is documented.
mme is integrated with the organizations safety programme.
cies and procedures guide the handling and disposal of radio-active

ous materials.
rsonnel are provided with appropriate radiation safety devices.
afety devices are periodically tested and documented.
rsonnel are trained in radiation safety measures.
gnage are prominently displayed in all appropriate locations.
d procedures guide the safe use of radioactive isotopes for imaging
Critical results shall be intimated

to the treating clinician at the
earliest
onhas
phone,
followed by
The HCO
documented
written
report.
procedure for outsourcing tests
for which it has no facilities. This
should include: a) List of tests for
out sourcing. b) Identity of
Refer to AERB
personnel
in theguidelines
out sourced
facilities to ensure safe
transportation
specimensand
and
A
document forofverification
completingofofimaging
imagingmethods
results. c)
validation
Manner
identification
shall
available.
HOD be
(orof
in-charge)
shallof
patients
and
the
test
requisition
periodically assess the
imaging
with
all
details
as
required
for
results.
Calibration
maintenance
testing and and
. d) A
methodologyoftoall
equipment
shall be carried
out by
check the selection
and
competent
persons.
perforance
of
service
rendered
by
Self explanatory.
the outsourced imaging facility as
per the requirements of the HCO.
Refer to AERB guidelines
The safety programme of the
imaging department has
reference
in and
the hospital
safety
Radioactive
hazardous
manual.
materials shall be disposed off as
per bio-medical waste
Self explanatory
management and handling rules,
1998.
Protective devices e.g. lead
aprons should be exposed to Xray
verification of cracks and
Sel for
explanatory.
damages.
Self explanatory
Document on safe use of
radioactive isotopes for imaging
services shall be available and
implemented.
hases of care, there is a qualified individual identified as responsible for The HCO to ensure that the care
s care.
of patients is always given by
appropriately qualified medical
ients is coordinated in all care setting within the organisation.
Care
of patients
is co-ordinated
personnel
(resident
doctor,
among
various
care
providers in a
consultant and/or nurse).
givenHCO
setting
viz OPD,
emergency,
about the patient's care and response to treatment is shared among
The
ensures
periodic
IP, ICU etc. The
organization
shall
rsing and other care providers.
discussions
about
each patient
ensure
that
there is effective
(covering
parameters
like patient
is exchanged and documented during each staffing shift, between
Self explanatoryof patient
communication
care, response to treatment,
during transfers between units/ departments.
requirements
amongst thecare
unusual developments
if any. etc)
providers
in
all
settings.
amongst
medical,
nursing and
s record(s) is available to authorized care providers to facilitate the
Self explanatory
other care providers.
f information.
d procedures guide the referral of patients to other departments/
s discharge process is planned in consultation with the patient and/ or
d procedures exist for coordination of various departments and

volved in the discharge process (including medico-legal cases)
d procedures are in place for patients leaving against medical advice.
The HCO has clearly defined and

documented the policies and
procedures to be adopted to
guide the personnel dealing with
referral
of patients
to other
The patient's
treating
doctor
departments
or
specialities
or
determines the readiness for
even
otherduring
healthregular
care provider
discharge
The
discharge
policies and
out
side
the HCO.
reassessments.
The same is
procedures are documented to
discussed with the patient and
ensure coordination amongst
family.
The
HCO
has a documented
various
departments
including
policy
for
the
LAMA
The
accounts so that
thecases.
discharge
treating
doctor
should
explain
the
papers are complete well within
consequences
of
this
action
to
time. For MLC the organization the
patient/attendent.
shall ensure that the police are
informed.
e summary is given to all the patients leaving the organization (including The HCO hands over the
ving against medical advice).
discharge papers to the
patient/attendent in all cases and
a copy is retained. In LAMA
cases, the declaration of the
patient/attendent is to be recorded
on
format.
summary is provided to the patients at the time of discharge.
Selfproper
explanatory
summary contains the reasons for admission, significant findings and

nd the patients condition at the time of discharge.
Self explanatory
summary contains information regarding investigation results, any

performed, medication and other treatment given.
Self explanatory
summary contains follow up advice, medication and other instructions in Self explanatory
andable manner.
summary incorporates instructions about when and how to obtain urgent The HCO should outline
conditions regarding "when" to
obtain urgent care, For example,
a post op patient should report
death the summary of the case also includes the cause of death.
Self
whenexplanatory
having fever,
bleeding/discharge from site.
n and is guided by the applicable laws, regulations and
ry is uniform when similar care is provided in more than one setting.
The organisation shall ensure that

patients with the same health
problems and care needs, receive
the same quality of healthcare
throughout the organization
irrespective of the category of
ward.
re is guided by policies and procedures which reflect applicable laws

ions.
Self explanatory
nd treatment orders are signed, named, timed and dated by the

doctor.
Self explanatory, Treatment

orders must be written daily.
an is countersigned by the clinician in-charge of the patient within 24
The treatment of the patient could

be initiated by a junior doctor but
the same should be
The
organization
could
developby
countersigned
and
authorized
clinical
protocols
the treating
doctorbased
withinon
24these
hrs.
and the same could be followed in
management of patients. These
could then be used as parameters
for
audit
of patient
These
could
icludecare.
ased medicine and clinical practise guidelines are adopted to guide

e whenever possible.
ble laws and regulations.
d procedure for emergency care are documented.
SOPs/protocols to provide either

general emergency care or
management of specific
conditions e.g. poisoning.
o address handling of medico-legal cases.

receives care in consonance with the policies.
d procedures guide the triage of patients for initiation of appropriate
iliar with the policies and trained on the procedures for care of
patients.
or discharge to home or transfer to another organisation is also

d.
The policy shall be in line with

statutary requirements w.r.t.
documentation
Self explanatoryand intimation to
police. The organization shall also
define as to what constitutes a
Self explanatory
MLC (in accordance with statutory
rules).
All the staff working in the
casualty should be oriented to the
policies and practices through
Self explanatory
training/documents.
Staff should
preferably be trained/well versed
in ACLS and BLS.
rvices provided by the organisation.
equate access and space for the ambulance(s).
(s) is appropriately equipped.
(s) is manned by the trained personnel
checklist of all equipment and emergency medications.
are checked on a daily basis.

medications are checked daily and prior to dispatch.
ance(s) has a proper communication system.
pulmonary resuscitation.
d policies and procedures guide the uniform use of resuscitation

the organisation.
ing direct patient care is trained and periodically update in cardio

resuscitation.
during a cardio pulmonary resuscitation are recorded.
nt analysis of all cardiac asserts is done by a multidisciplinary
and preventive measures are taken based on the post-event analysis.
The organization shall demarcute

a proper space for ambulance (s).
This shall
shall be
be done
demarcated
keeping
This
based on
the
in
mind easy accessibility
for
organization's
scope.
receiving
patients
and tobeenable
The ambulance
should
the
ambulance
(s)
to driver,
turn
manned by a trained
around/exit
quickly.
technician/nurse
doctor a
The
organization and/or
shall develop
depending
onensure
the situation.
checklist
and
that the
Personnel
shall
beboth
trained
ambulance
is equipped
as in
per the
This shall include
the
ACLS
and/or
BLS.
checklist.
ambulance the equipments within
it.
Self explanatory. This also
includes checking the expiry date
of drugs.
The
ambulance shall be
connected with the
hospital/control room by
wireless/mobile phones.
The organisation shall document
the procedure for same. This shall
be in consonance with accepted
These
aspects shall be covered
practices.
by hands on training. If the
organization has a CPR team
In
thecode
actual
event
of ait CPR
(e.g.
blue
team)
shall or a
mock
dril
of
the
same,
all
the in
ensure that they are all trained
activities
along
with
the
personnel
The
analysis
shall
include
ALS and are present in all the
shifts.
attended
should
be to
recorded.
cause,
steps
taken
resuscitate
and the outcome. Multidisciplinary
Self
explanatory
committee
shall include
physicians, anaesthetists and
nurses.
ucts.
d policies and procedures are used to guide rational use of blood and
ucts.
sion services are governed by the applicable laws and regulations.
onsent is obtained for donation and transfusion of blood and blood
onsent also includes patient and family education about donation.
ned to implement the policies.
n reactions are analysed for preventive and corrective actions.
This shall address the conditions

where blood and conditions where
blood products can be used.
Refer to Drugs and Cosmatics
act.
Consent should be taken for
every transfusion. However, with
the same consent you can give
self
explanatory
multiple
transfusions in the same
sitting. For example, 2 pints of
This
doctorsserially
and be
bloodshall
mayinclude
be transfused
done
by training
and/or by
using either
the same
consent.
providing
written
instruction.
However,
if the same
given over
The
organization
shallisensure
that
two days
or hours
apart then
any
transfusion
reaction
is a
separate consent
is required.
reported.
It is preferable
that the
organization capture feedback
regarding every transfusion
(including the ones without
reaction) as this would enable it to
are and High Dependency Units.
sation has documented admission and discharge criteria for its intensive The organization should develop
gh dependency units.
objective criteria and adhere to it.
ned to apply these criteria.
This shall be done by training by

deplaying the criteria.
taff and equipment are available.
The ICU should be equipped with
all necessary life saving and
monitoring
equipmebnts
asvacant
well
ocedures for situation of bed shortages are followed.
As
and when
there are no
as
suitably
trained
beds
in the manned
ICU and by
there
is a
staff.
The
exact
requirements
requirement
of
bed, a
ntrol practices are followed.
These
could
besuch
developed
shall
be
decided
byprocedure
thebe a part of
detailed policy
individually
or itand
could
organization.
However
the
should
be ininfection
place
to control
address
the
the
hospital
surance programme is implemented.
These
could
beexpected
developed
organization
is
toshall
follow
situation.
manual. Theororganization
individually
it
could
be
a
part
of
best
clinical
practices.
ensure
that the
practices
are in
the
Hospital
quality
assurance
consonance The
with organization
good clinical
y, physically and/ or mentally challenged and children). programme.
practices.
shall ensure that the programme
in explanatory
consonance with good
d procedures are documented and are in accordance with the prevailing is
Self
clinical practices.
e national and international guidelines.
anised and delivered in accordance with the policies and procedures.
HCO develops SOP's for delivery

of care
sation provides for a safe and secure environment for this vulnerable
The organization shall provide

proper envirnment taking into
account the requirement of the
The
informed
consent for this
vulnerable
group.
group of people should be
obtained from their family or legal
All
staff involved in the care of this
representative.
group shall be adequately trained
in identifying and meeting their
needs.
ted procedure exists for obtaining informed consent from the

legal representative.
ned to care for this vulnerable group.
nts.
sation defines and displays whether high-risk obstetric cases be cared
ring for high-risk obstetric cases are competent.
bstetric patients assessment also includes maternal nutrition.
The organization shall define as

to what constitutes high risk
obstetric case in consonance with
These
shall not
just be doctors
best clinical
practices.
but shall include nursing staff
also. The competency shall be
Self
explanatory
based
on qualification, experience
and training.
zation caring for high risk obstetric cases has the facilities to take care
s of such cases.
The organization shall have a

NICU with proper equipments and
staff.
sation defines and displays the scope of its dediatric services.
The scope shall also include

neonatal services, if any.
or care of neonatal patients is in consonance with the national/

al guidelines.
Self explanatory
care for children have age specific competency.
are made for special care of children.
essment includes detailed nutritional, growth, psychosocial and

on assessment.
These shall not just be for doctors

but shall include nursing staff
also. The competency shall be
Adequate
amentities forexperience
the care
based on qualification,
of
infants
and
children
to
be
and training.
available in the hospital.
Sel explanatory
d procedures prevent child/ neonates abduction and abuse.
ns family members are educated about nutrition, immunization and

ing and this is documented in the medical record.
The HCO shall ensure that there

is an adquate
security/surveillance to prevent
self
suchexplanatory.
happenings.
derate sedation.
and trained persons perform sedation.
administering and monitoring sedation is different from the person

the procedure.
Whenever parenteral route is

used this shall be carried out by a
doctor/nurse.
self explanatory
edure monitoring includes at a minimum the heart rate, cardiac rhythm, Self explanatory, The same
rate, blood pressure, and oxygen saturation, and level of sedation.
should be documented
e monitored after sedation.

used to determine appropriateness of discharge from the recovery
and manpower are available to rescue patients from a deeper level of

an that intended.
The patient's vitals shall be

monitored at regular intervals (as
decided by the organization) till
These
be developed
the
he/she shall
recovers
completelybyfrom
organization
consonance
withbe
the sedation.inThe
same should
good
critical practices.
documented.
The equipments shall include
emergency resuscitation
equipments. An anaesthesiologist
shall be available in the hospital.
documented policy and procedure for the administration of anesthesia.
HCO shall document on the

indications, the type of
anaesthesia and procedure for
for anesthesia have a pre-anesthesia assessment by a qualified
This
shall be done before the
the same.
patient is wheeled into the OT
complex. It shall be applicable for
esthesia assessment results in formulation of an anesthesia plan which Self
both explanatory
routine and emergency
ted.
cases. This assessment shall be
done
by an
It is
ate preoperative re-evaluation is documented.
this shall
beanaesthesiologist.
done by an
preferable
to
do
assessment
in
anaesthesiologist just before thea
standardized
format
patient is wheeled
in to the
onsent for administration of anesthesia is obtained by the anesthetist.
Self
explanatory
respective OT
sthesia monitoring includes regular and periodic recording of heart rate, Self explanatory
hm, respiratory rate, blood pressure, oxygen saturation, airway security
y and level of anesthesia.
nts post-anesthesia status is monitored and documented.
ndividual applies defined criteria to transfer the patient from the

ea.
anesthesia events are recorded and monitored.
gical procedures.
s and procedures are documented.
tients have preoperative assessment and a provisional diagnosis

d prior to surgery.
d consent is obtained by the surgeon prior to the procedure.
This shall be done in the recovery

area/OT and at least include
monitoring of vitals till the patient
The
organization
documents
recovers
completely
from
these
criteria
which
should
be inby
anaesthesia and shall
be done
consonance
with
good
clinical
an
anaesthesiologist.
if the
All
such
events
documented
practices.
Theseare
criteria
shall be
patient's
condition
is
unstable
and
and
monitored
for the purpose
of
applied
by
a
designated
individual
he/she
requires
ICU
care
the
taking
corrective
and
preventive
as
decided by the HCO.
same
action.shall be monitored there.
This shall include the list of
surgical procedures as well as
competency level for performing
All
patients
undergoing surgery
these
procedures.
are assessed pre operatively and
a provisional diagnosis is made
Self
explanatory
which
is documented. This shall
be applicable for both routine and
emergency cases.
d policies and procedure exist to prevent adverse events like wrong

patients and wrong surgery.
alified by law are permitted to perform the procedures that they are
perform.
ative note is documented prior to transfer out of patient from recovery
ng surgeons documents the post operative plan of care.
surance programme is followed for the surgical survices.
assurance program includes surveillance of the operation theatre

nt.
so includes monitoring of surgical site infection rates.
Procedure should be available for

preventing adverse events like
wrong patients, wrong site by a
The
HCOmechanism.
identifies the individuals
suitable
who have the required
qualification (s0, training and
This
note provides
information
experience
to perform
procedures
about
the
procedure
in cosonance with theperformed,
law.
post operative diagnosis and the
Self explanatory.
status
and shall be documented
by the surgeon/member of the
surgical
team.
This be an
integral part of the
HCO's overall quality assurance
programme. It shall focus on post
Surveillance
activities include
operative complications
e.g.
monitoring
the
quality
of air
bleeding rational
use of
provided
, rate
antibiotics,
etc. of air
Self explanatory.
exchange,cleaning
and
disinfection processes , etc.
(physical and/ or chemical).
d policies and procedures guide the care of patients under restraints.
de both physical and chemical restraint measures.
de documentation of reasons for restraints.
ents are more frequently monitored.
e training and periodic updating in control and restraint techniques.
d policies and procedures guide the management of pain.
zation respects and supports the appropriate assessment and

nt of pain for all patients.
family are educated on various pain management techniques.
This shall clearly state the

conditions/Circumstances under
which restraints shall be used .It
Physical
include
shall alsorestraints
specify as
to whoboxer's
can
bandage,
useuse
of cuffs
ec.
authorize the
of restrains.
Chemical restraints include
Self
explanatory.
sedatives.
The organization shall specify the
parameters and frequency of
monitoring and accordingly
Self
explanatory.
implement
the same.
The HCO shall define the group of

patients for whom this is
applicable. A good reference point
Self
explanatory.
for defining
these patients could
be those having pain as the
predominant
debilitating
Self explanatory.
symptom.
d policies and procedures guide the provision of rehabilitative services. Self explanatory.
ces are commensurate with the organizational requirements.
ve services are provided by a multidisciplinary team.
d policies and procedures guide all research activities in compliance

al and international guidelines.
The scope of the departments is

in consonance with the scope of
the hospital.
The team shall have treating
doctor, rehabilitation therapist,
rehabilitation nurss and other
professional experts.
Self explanatory.
An ethics committee should be

framed in the hospital to monitor
activities undertaken by various
ee has the powers to discontinue a research trial when risks outweigh the
Self
explanatory.
providers.
Any research
efits.
undertaken in the hospital
fallsunder
its ambit. This includes
rmed consent is obtained before entering them in research protocols.
Self explanatory.
both funded and non-fundes and
also student studies.
e informed of their right to withdraw from the research at any stage and Self explanatory.
consequences (if any) of such withdrawal.
ation has an ethics committee to oversee all research activities.
e assured that their refusal to participate or withdrawal from

n will not compromise their access to the organizations services.
Self explanatory.
d policies and procedures guide nutritional assessment and

ent.
Self explanatory.
ceive food according to their clinical needs.
A dietician shall do the

assessment of the patient in
consulation with the clinician and
The
dietician
shallfood.
prepare this in
advice
regarding
the form of a diet sheet and
patient shall receive food
The dietician shall ensure that this
accordingly.
is planned in consultation with the
treating doctor and the
The
dietician / nurse
shall
ensure
patient/patient's
relative
after
this
planning.
taking into regard the patient's
food
habitts services
(veg/ non-veg)
The dietary
to be and
likes
and
dislikes.
designed in a manner that there is
written order for the diet.
herapy is planned and provided in a collaborative manner.
ies provide food, they are educated about the patients diet limitations.
pared, handled, stored and distributed in a safe manner.
d policies and procedures guide the end of life care.
ies and procedures are in consonance with the legal requirements.

address the identification of the unique needs of such patient and
include sensitively addressing issues such as autopsy and organ
cated and trained in end of life care.
no criss cross of traffic. All the

activities fall in a squence. The
organization shall ensure that
hygienic
are follwed all
The HCOconditions
has a documented
throughout.
policy for providing care to
terminallly ill admitted
Self
explanatory.
patients.This
shall include
providing appropriate pain and
palliative
careand
according
to the
The religious
socio-cultural
wishes
of
the
family
and
patient.
beliefs of patients/ family shall be
addresed and respected.
If the body of the deceased is
subjected to an autopsy or for
argan donation, it should be
Self
explanatory.
discussed
with the family in a very
courteous manner.
es and usage of medication.
documented policy and procedure for pharmacy services and

usage.
The polices and procedures shall

address the issues related to
procurement, storage, formulary,
prescription, dispensing,
administration, monitoing and use
of medications.
ply with the applicable laws and regulations.
Self explanatory.
plinary committee guides the formulation and implementation of these

d procedures.
This shall be representative of

major clinical departments
administration and shall include a
pharmacist/ clinical
pharmacologist.
dication appropriate for the patients and organizations resources is
The hospital formulary shall be

prepared and be preferably
updated at regular intervals.
Refer to MOM 1c.
eveloped collaboratively by the multidisciplinary committee.
defined process for acquisition of these medications.
process to obtain medications not listed in the formulary.
d policies and procedures exist for storage of medication.
s are stored in a clean, well lit and ventilated environment.
ntory control practices guide storage of the medications.
s are protected from loss or theft.
e and look alike medications are stored separately.
method to obtain medication when the pharmacy is closed.
The process should address the

issues of vendor selection,vendor
evalation,generation of vendor
Self
explanatory
evaluation,generation
of purchase
order and receipt of goods and
receipt of goods as per rules.
These should address issues
pertaining to temperature
(refrigeraion),light, ventilation
The
organization
shall
also
preventing
entry of
pests/rodents
ensure
that
the
storage
and vermins.
requirements of he drug as
Self explanatory
specified
by the manufacturer are
adhered to.If the
recommendations
areensure
confilicting
The oranization shall
that
recommendations
in
nature,
the
it develops proper mechanisums
organization
shall follow
to prevent pilferage.
The the
manufacturer's
recommendation.
Many
drugs
in
ampoules,
or
organization could conductvials
audits
This
shall
be
applicable
to
all
tablets
may
look-alike
or
sound
at regular intervals (as defined by
areas
whereshould
medications
are
alike.
They
be segregated
the
organiztion)
to
when
pharmacy
is detect
closed such
, there
stored
including
wards.
and
stored
seperately.
instances
should be SOP to procure the
medications are replenished in a timely manner when used.
drugs.
Adequate amount of emergency
medicines should be stocked at
all times. Re-order level at definite
self
explanatory
quantity
should be done.
d policies and procedures exist for prescription of medications.
self explanatory
medications are available all the time.
zation determines who can write orders.
this shall be done by the treating

doctor.
written in a uniform location in the medical records.
all the orders for medicines are

recorded on a uniform location of
the case sheet. Electronic orders
Self
whenexplanatory
typed shall again follow the
same principles.
orders are clear, legible, dated, timed, named and signed.
erbal orders is documented and implemented.
The organization shall ensure that

it has a policy to address as to
who can give verbal orders and
how these orders will be validated
zation defines a list of high risk medication.
edication orders are verified prior to dispensing.
d policies and procedures guide the safe dispensing of medications.
s include a procedure for medication recall.
s are checked prior to dispensing.
quirements are documented and implemented by the organization.
s are administered by those who are permitted by law to do so.
medication are labeled prior to preparation of a second drug.
High risk medications are

medications involved in a high
percentage of medication errors
These
medications
shalll
or sentinel
events and
preferably
be
given
only
medications that carry
a arter
high risk
written
orders
and
it
should
be
for abuse, error, or other adverse
verified
by
the
staff
before
outcomes.Examples include
dispensing.
medications with a low therapeutic
window,
controlled
Clear policies
to besubstances,
laid down for
psychotherapeutic
dispensing
of medication e.g.
medications,and
look-alike
and
route
of administration,
dosage,
Recall
result
based
on letters
sound-alike
medications.
rate
of may
administration,
expiry
from
authoroties or
date ,regulatory
etc.
internal feedback( e.g. visible
Self
explanatory
contaminant
in IV fliud bottle)
At a minimum, labels must include
the drug name,
strenght,ffrequency of
administration ( in a language the
patient understands ) and expry
dates.
Self explanatory
Self explanatory
entified prior to administration.
Self explanatory
is verified from the order prior to administration.
Staff administering medications

should go through the treatent
orders before administration of
Self
explanatoryand then only
the medication
administer them. It is preferable
that
also check the general
Self they
explanatory
appearance of the medication)
eg .melting, clumping etc.)
Self explanatory
verified from the order prior to administration.
rified from the order prior to administration.
erified from the order prior to administration.
administration is documented.
procedures govern patients self administration of medications.
procedures govern patients medications brought from outside the

n.
nd food-drug interactions.
family are educated about safe and effective use of medication.
family are educated about food-drug interactions.
e monitored after medication administration and this is documented.

this is done in a uniform location
and it shall include the name of
At
the outsetdosage,
the HCO
could
medication,
route
of
define
if
it
would
permit
selfthe
administration, timing and
administration
of medications.
In
name
and
signature
of
the
These
shall
address
ass
toperson
what
case
the
HCO
permits
then
the
who
haspre-requisites
administered the
are
the
policy
shall include thefor such a
medication
medication
eg. invoice,
clear can
medications( which
the patient
label
with mention
the name
self administer.
If isofpreferable
,dose,
date etc)also
that theexpiry
organization
incorporates
a method
to ensure
The
organization
shall make
a list
that
the drugs
patientand
is reminded
to
of
such
accordingly
take the medication
before
every
educate
eg. digoxin.(This
could
Patient
anddocumentation
family
should
be
dose)include
and
of self
also
education
regarding
counselled
about of
their
diet aduring
administration
the immportance
taking
drug
medication
eg.
no
alcohol
when
at a specific time eg. sustained
taking
releasemetronidazle.
medications.
This shall be done by anyone
involced in direct patient care. The
organization could follow either a
pasiive ( documenting only if the
patient tellls ) or active ( enquiring
with every patient ) monitoring
mechanism.
ug events are defined.
ug events are reported within a specified time frame.
ug events are collected and analysed.

modified to reduce adverse drug events when unacceptable trends
The organization shall define as

to what constitutes an adverse
drug event. This shall be in
Self
explanatory
consonance
with best
The
organization
practices.Adverseshall
drugdefine
eventsthe
timeframe
for
reporting
once
theas
include
adversedrug
drugreaction
reactions
All
the adverse
are
adverse
drug
event
has
occured.
well
as medication
errors.
analysed
regularly by
the multidisciplinary committee
Self explanatory
otropic substances.
d policies and procedures guide the use of narcotic drugs and

c substances.
Self explanatory
ies are in consonance with local and national regulations.
This is in context of narcotic drugs

and psychotropic substances act.
cord is kept of the usage, administration and disposal of these drugs.
These shall be kept in accordance

with statutory requirements.
s are handled by appropriate personnel in accordance with policies.
Self explanatory
nts.
d policies and procedures guide the usage of chemotherapeutic
Self explanatory
apy is prescribed by those who have the knowledge to monitor and treat This shall preferably be a medical
e effect of chemotherapy.
oncologist or a person who has
been trained and had achieved
apy is prepared and administered by qualified personnel.
This
shall preferable
be staff who
competency
in the same.
have received special trainig in
preparing and administration.
apy drugs are disposed off in accordance with legal requirements.
These shall be disposed off
according to Bio-medical waste
management and handling rules
1998 or manufacturer's
recommendation.
d policies and procedures govern usage of radioactive drugs.
Self explanatory
ies and procedures are in consonance with laws and regulations.
Refer to AERB guidelines.
s and procedures include the safe storage, preparation, handling,

and disposal of radioactive drugs.
Self explanatory. This shall

however be in accordance with
AERB guidelines.
Self explanatory
nts and visitors are educated on safety precautions.
d policies and procedures govern procurement and usage of

prosthesis.
f implantable prosthesis is based on scientific criteria and national/

ally recognized approvals.
and serial number of the implantable prosthesis are recorded in the

edical record and the master logbook.
Self explanatory
relevant and sufficient scientic
data are available before
Self explanatory
selection.
It shall also look for
international (e.g. US-FDA) of
national notification (Drugs and
Cosmetics Act notification october
2005) for approval of the
particular product.
d policies and procedures govern procurement, handling, storage,

usage and replenishment of medical gases.
s and procedures address the safety issues at all levels.
records are maintained in accordance with the policies, procedures

equirements.
This shall be applicable to all

gases used in the organization . It
shall also address the issue of
This
shallrequirements
include from and
the point of
statutory
storage/source
area,
gas
supplyIt
approvals wherever applicable
lines
and
the
end
usercolour
shall
follow
a
uniform
This is the contextsafety
of themeasures
Indian
area.Appropriate
coding
system.
explosives
act of 1884,
shall be developed
and Gas
cylinder
rules for
1981
static and
implemented
all and
levels.
mobile pressure vessels (unfired)
1981.
out their responsibilities during care.

family rights and responsibilities are documented.
d families are informed of their rights and responsibilities in a format

ge that they can understand.
zations leaders protect patient's and family rights.
re of their responsibility in protecting patients and family rights.
patient and family rights is recorded, reviewed and corrective/

measures taken.
ve the patient and family in decision-making processes.

family rights address any special preferences, spiritual and cultural
Hospital should respect

patient'srights and inform them of
their
responsibilites.
self explanatory.
All the rights of the patient should
be
displye in
theincludes
form of a
Protection
also
citizens'
charter
which
should also
addressing patient"s grievances
give information of the charges
w.r.t
rights.
Traning
and sensitisation
and grievance
redressal
programmes
mechanism. shall be conducted
to
create
aeareness
among
Where
patient"s
rights
have the
been
staff.
infringed upon,management must
keep records of such violations,as
also a record of the
consequences,e.g. corrective
actions
to prevent
This could
include recurrences.
dietary
preferences and worship

requirements.
family rights include respect for personal dignity and privacy during
During all stages of patient
n, procedures and treatment.
care,be it in examination or
carrying
out a procedure,hospital
family rights include protection from physical abuse and neglect.
Self
explanotry.
Special
staff
shall ensure
thattaken
patient's
precautions
shall be
privacy
and
dignity
is
maintained
.
especially w.r.t. vulnerable
family rights include treating patient information as confidential.
Self
explanatory.
statutory
The
organization
shall
develop
patients .eg. elderly, neonates etc.
requirement
privilged
the necessaryw.r.t.
guidelines
for the
communication
shall be followed
same.
During
procedures
the
family rights include refusal of treatment.
During management the patients
at
all times. shall ensure that the
organization
should be given
the choice of
patient is exposed
just before
.The treating
doctor the
family rights include informed consent before anaesthesia, blood and treatment
self explanatory
actualsprocedure
is
undertaken.
shall discuss all the available
uct transfusions and any invasive/ high-risk procedures/ treatment.
With
regards
to photographs
options
and allow
the aptient to
/recording
procedures,the
make an informed choice
organization
ensure
that
family right include information and consent before any research
The
organization
shall
ensure
including
the shall
option
of refusal.
consent
is taken and
that the on
nitiated.
that international
conference
patient's identity
is not
harmonization
(ICH)
of revealed.
good
family rights include information on how to voice a complaint.
Grievance redressal mechanism
clinical practice (GCP) and
must be accesssible and
of Helsinki Somerset
family rights include information on the expected cost of the treatment. Declaration
Refer AAC4d.
transparent.
Information must be
(1996) and ICMR requirements
clearly available on how to voice a
are followed.
complaint.
family have a right to have an access to his/ her clinical records.
The organization shall ensur that
every patient has access to
his/her record. This shall be in
exists for informed decision making about their care. consonance with the code of
medical ethics and statutory
nsent for treatment is obtained when the patient enters the organisation. requirements.
Self explanatory
/ or his family members are informed of the scope of such general
The organization shall difine as to

what is the scope of this consent
and the same shall be
communicated to the patient
and /or his family members.
sation has listed those situations where informed consent is required.
onsent includes information on risks, benefits, alternatives and as to

rform the requisite procedure in a language that they can understand.
describes who can give consent when patient is incapable of

nt decision-making.
their health care needs.
opriate, patient and families and are educated about the safe and
e of medication and the potential side effects of the medication.
A list of procedures should be

made for which informed consent
should
be taken.
The consent
shall have the name
of the doctor performing the
procedure. If it is a "doctor under
training"
the sameshall
shalltake
be into
The organisation
specified,
however
the
name
of
consideration the statutory norms.
the
doctor next
supervising
Thisqualified
would include
of
the
procedure
shallHowever
also be in
kin/legal
guardian.
mentioned
consent
form
shall be
case of unconscious/
in
the
language
that
the
patient
unaccompanied
Self
explanatory.patients the
understands.
treating in life saving
circumstances.
families are educated about diet and nutrition
Self explanatory.
families are educated about immunisations.
Self explanatory. More applicable

for paediatric population. In adults
itSelf
could
be for influenza,
explanatory.
This could also
streptococcus
pneumonia,
be done through
patient education
typhoid, hepatitis B, Neisseria
booklets/videos/leaflets
etc.
Self
explanatory.
meningitides,
etc,
families are educated about their specific disease process,

ns and prevention strategies.
families are educated about preventing infections.
d family are taught in a language and format that they can understand. Self explanatory.
iform pricing policy in a given setting (out-patient and ward category).
st is available to patients.
d family are educated about the estimated cost of treatment.
d family are informed about the financial implications when there is a

he patient condition or treatment setting.
There should be a billing policy

which defines the charges to be
levied for various activities.
there is an updated tariff list and
Refer
to list
AAC4d.
that
this
is available to patients
when required. The organization
When
patients
from
shall charge
asare
pershifted
the tariff
list.
one
to another,
typically
to
Any setting
additional
charge should
also
and
form ICUs, the
financial
be enumerated
in the
tariff and
implication
must be clearly
the same communicated
to the
conveyed
to them.
patients. The
tariff rates should be
uniform and transparent.
ed infection control programme aimed at reducing/
al infection control programme is documented which aims at preventing Self explanatory.

ng risk of nosocomial infections.
al has a multi-disciplinary infection control committee.
This shall preferably have

Hospital Administrator, Surgeon,
Manager
(Nursing
al has an infection control team.
The teamisNursing
responsible
for daySupervisor(,
staff
form
CSSD, and
to-day functioning of infection
the
hospital
infectionThey
control
control
programme.
shall a
al has designated and qualified infection control nurse(s) for this activity. The
qualification
shall be either
nurse. Itsurveillance
could also include
support
process
and
graduate nurse or qualified nurse
invitees
form various
departments
detect
outbreaks.
They
shall
also
with competence gained by
as
deemed necessary.
participate
experience.in infection prevention
ly updated.
and control on a day-today basis.
l identifies the various high-risk areas and procedures.
methods of surveillance in the identified high-risk areas.
n adherence to standard precautions at all times.
The manual should clearly identify

the high risk areas of the hospital
e.g.
ICU,
HDU,the
OT,
Post-operative
It shall
define
frequency
and
ward,
Blood
Bank,
CSSD,
mode of surveillance. The etc.
similarly,
all high
riskshould
procedures
surveillance
system
meet
Self
explanatory.
should
be
identified
from
WHO criteria of simplicity, cost
infection
control
point ofof
view. For
minimization
timeliness
example,
cardiac
catheterization,
feedback flexibility, acceptability,
endoscopies,
surgery lasting
more
consistency, (reliability),
sensitivity
than
2
hours,
BMT
etc.
and specificity.
cleaning and sterilisation practices are included.
It shall address this at all levels e.

g. ward, OT and CSSD. It is
preferable that the organization
iate antibiotic policy is established and implemented.
The HCO shall develop a system
follows a uniform policy across
of monitoring drug susceptibility
different departments within the
(based
on culture
sensitivity)
and
d linen management processes are also included.
The
laundry
can be
in-house
organization.
The or
accordingly
develop
its
antibiotic
outsourced.
If outsourced
the
manual should
include
policy,
which shall
shall ensure
be reviewed
organization
the
it at
sterilization
and
disinfection
nitation and food handling issues are included in the manual.
Self
explanatory.
The
same
shall
periodic
intervals
(maybe
once
in
establishes
adequate
controls
to
policy,
chemicals
used/methods
be
applicable
even
if this
activity
3
months)
for
its
continuing
ensure
infection followed
control.
The
linen
and
procedures
in wards
is
outsourced.
organization
g controls to prevent infections are included.
Issues
such asThe
air conditioning
applicability.
change
policy
should
be focus
and
critical
areas.
Special
could
refer
to
ISO
22000:2005
plant and equipment
mentioned.
Washing
protocols
for
on critical
equipments
like
(food
safety)
while
addressing
cleaning
of the
AC this
actices and procedures are included as appropriate to the organization. maintenance;
The mortuary
services
in
different
categories
of
linen
ventilators,
nebulizers
etc.
issue. AHUS replacement of
ducts,
hospital
be should
provided
includingshould
blankets
be
filters;
seepage
leading
to fungal
through
walk-in
cold
rooms
or
included.
colonization;
zation defines the periodicity of updating the infection control manual.
The
organization
must have
a
mortuary
coldreplacement/repair
cabinets.
Mortuary
of
plumbing,
sewer
lines
(in
documented
policy
on
the
procedures of preserving body, or
shafts)
should
included.
Water
updation
ofand
thebe
infection
control
body parts
safety
measures
supply,
sources
andbody
system
of
manual.
It is desirable
to update
while
handling
over
to
identified areas of the hospital.
supply
quality
at
leastsources
once
in and
abeyear
based
on
relatives
should
inwater
accordance
must
be policy.
included.
Any renovation
its
trends
and outcomes
of the
with
the
e activities are appropriately directed towards the identified high-risk
The organization must be able to
work in
hospital patient with
audit
processes.
provide evidence of conducting
Infection Control team with regard
periodic
surveillance
in
surveillance data is an ongoing process
The
organization
shallactivities
ensure
that
to
architectural
segregation,
traffic
its
identified
high
risk
areas.
The
itflow,
hasuse
a process
in place
of materials
etc.to collect
specific
objectives,
case
surveillance
data
and
to
f data is done on regular basis by the infection control team
The
data soidentification
collected also
shall
definitions,
of be all
ensure
that
it
is
able
to
capture
authenticated
by thefrequency
team by
potential
indicators,
such
data.
going
through
every
data
or byall
otifiable diseases, information (in relevant format) is sent to appropriate
The
organization
shall
identity
and duration of monitoring,
using
random
sampling
that
notifiable
diseases
after so
taking
methods
of
data
collection,
along
the
process
can
be
validated.
The
into
consideration
the
local
laws,
with
schedule
of
rounds
should
be
urveillance activities incorporates tracking and analyzing of infection
This
shall
be
done at regular
team
shall
preferably
verify
every
rules,
regulations
and and
defined.
Confidentiality
and trends.
intervals
(maybe (as
monthly
and
serious
infection
defined
notifications
thereof.
The by
anonymity
must
be
ensured.
The
consolidated
into
an
annual
the
organization
report.
e activities include monitoring the effectiveness of housekeeping servicesThis
would
include
categorization
organization
shall
ensure
that this
HCO
should
clearly
mention
report) and the organization shall
of
areas/surfaces;
general
is
sent
at the specified
frequency
which
specific
targeted
take
suitable
steps
based on the
cleaning
for surfaces,
and
in theprocedures
format
as required
surveillance
(site
specific,
unitby
analysis.
furniture/
fixtures,
and
items
used
statutory
authorities.
oriented,
priority
oriented)
tal Associated Infections (HAI) in patients and
in
patient are
care.
It should
also
activities
being
carried
out.
include procedures for terminal
cleaning, blood and body fluid
zation monitors urinary tract infections.
This
can isolation
be done either
cleanup,
roomsby
and all
sending
urine
or
catheter
tip for
high risk (critical) areas. The
culture.
The
organization
shall
common
disinfectants
used, do
zation monitors respiratory tract infections.
This
can be
done by sending
this
for all
dilution
factors,
method of use
sputum
or symptomatic
ET/ tracheostomy
catheterized
patients.using a
should
be specified.
secretions
(obtained
zation monitors intra-vascular device infections.
For patients
with symptoms
suction
catheter)
ET/
suggestive
of intraofvascular
tracheostomy
tip
or
protected
device
infection
andbyhaving
zation monitors surgical site infections.
This
shall
be done
sending
specimen
brushing
(PSB)
central linefor
the
same
shall or
bemini
pus/swab
culture.
broncho-alveolar
lavage
(BAL)
for
doneby
sending the
tip for
culture.
feedback regarding HAI rates are provided on a regular basis to
The
feedback
shall
include
the do
culture.
The organization
shall
For all
peripheral
lines
clinical
d nursing staff.
rates.
and opportunities
this
forTrends
allof
patients
on the
evidence
thrombophlebitis
for
improvement.
It
couldfeatures
also
ventilator
having
clinical
would suffice.
provide
specific
inputs to reduce
suggestive
of infection.
infection control programme.
the HAI rate.
ing facilities in all patient care areas are accessible to health care
it provides necessary
infrastructure
to carry
the
e with proper hand washing is monitored regularly.
The organization
shallout
preferably
same.
display the necessary instruction
near
every had washing
area.the
The organization
shall define
Compliance
could
be
verified
by
conditions where the same shall
random
checking,
observation,
be carried
out andThe
ensure
thatbeit
loves, masks, soaps, and disinfectants are available and used correctly. Self
explanatory.
should
etc.
provides the
necessary
available
at the
point of resources
use and
to
out the activity
(e.g. that
thecarry
organization
shall ensure
clothing,
masks,
gloves
it maintains an adequateetc.).
inventory.
arrier nursing facilities are available.
fections.
s a documented procedure for handling such outbreaks.
This shall incorporate definitions

as to what constitutes an
outbreak,
identification
dure is implemented during outbreaks.
The organization
shouldand
be able
investigation
of
such
outbreaks
to identify the outbreak,
describe
and
the procedure
for
the
outbreak
by developing
utbreak is over appropriate corrective actions are taken to prevent
The
organization
should
be a
able
management.
This
shall be
case
definition,
designing
a in
datato
to
implementwith
basic
procedures
accordance
good
clinical
collection
from, collection
data
prevent
recurrence
such
as
practices.
Standard
Case an
from
thecontrol
affected,
constructing
source
if include
source
identified,
ganisation.
definitions
shall
a
unit of
epidemic
curve.
review
of
all
infection
control
time and place along with specific
equate space available for sterilization activities.
Adequacy
of space
refers
to the
polices,
and
biologicalloopholes
and/or
clinical
criteria.
CSSD
whichgaps,
should
have an area
compliance
strengthening
of
0.7sq.
m/bed,
suitable
location,
infection
polices
etc.
idation tests for sterilisation are carried out and documented.
This
shallcontrol
be done
by accepted
proper
layout
(unidirectional
flow,
method e.g. bacteriologic, strips
zoning)
and
separation
of
clean
etc.
Engineering
validations
like
established recall procedure when breakdown in the sterilisation
The
organization
shall ensure
that
and
dirty
areas.
Bowie
Dick
tape
test
and
leak
dentified.
the sterilization procedure is rate
test
needmonitored
to be carried
regularly
andout
in the
eventuality
of
a
breakdown
it has
ement are complied with.
a procedure for withdrawal of
such
items. shall apply in the
al is authorised by prescribed authority for the management and
The occupier
Bio-medical Waste.
prescribed form and get approval
thetoprescribed
authority
regation and collection of Bio-medical Waste from all patient care areas form
Wastes
be segregated
ande.g.
Pollution
control
board/committee.
ital is implemented and monitored.
collected in different colour coded
zation ensures that Bio-medical Waste is stored and transported to the

ment and disposal in proper covered vehicles within stipulated time
ecure manner.
l Waste treatment facility is managed as per statutory provisions (if inutsourced to authorised contractor(s).
ees, documents and reports are submitted to competent authorities on

ates.
personal protective measures are used by all categories of staff

o-medical Waste.
management and includes training of staff and
bags and containers as per

The
waste
is transported
to the
statutory
provisions.
Monitoring
pre-defined
site
at
definite
time
shall be done by member of
the
intervals
within 48
infection (Maximum
control committee/team.
hours) through proper transport
If
the hospital
has waste
activity
is outsourced
the
treatment
facility
within itsof this
organization. Monitoring
premises
the they
activity should
be have
done to
bybe in
The
HCO
shall
ensure
that
the
accordance
with
statutory
infection Control team.
fees
are
deposited
in
a
timely
provisions or they can outsource it
manner.
In addition
to
a central
facility. the annual
Self
explanatory.
reports have to be submitted by
the 31st of January of every year
and accident reporting has to be
carried out in the prescribed form.
anagement makes available resources required for the infection control The HCO shall ensure that the
.
resources required by the
personnel
be available
in a
al regularly earmarks adequate funds from its annual budget in this
There shallshould
be a separate
budget
sustained
manner.
This
includes
demarcated for HIC activity. This
both
and materials.
shall men
be prepared
taking into
regular pre-induction training for appropriate categories of staff before There
must
bethe
a documented
consideration
scope of the
cerned department(s).
evidence
of previous
pre-induction
training
activity and
years,
for
appropriate
categories
of staff
experience.
ucts regular in-service training sessions for all concerned categories Self explanatory.
before joining concerned
east once in a year.
department(s). it should include
pre and post exposure prophylaxis is provided to all concerned staff Self
explanatory.
the policies,
procedures and
practices of the infection control
programme.
g programme in the organization.
improvement programme is developed, implemented and maintained

isciplinary committee.
This committee shall have

representation from management,
various clinical and support
departments of the HCO. This
programme shall be develop,
implemented and maintained in a
structured manner.
improvement programme is documented.
This should be documented as a

manual. The manual shall
incorporate the
mission,vision,quality objectives,
service standards,important
indicators as identified etc. The
manual could be stand alone and
should have cross linkages with
other manuals.
designated individual for coordinating and implementing the quality

nt programme
improvement programme is comprehensive and covers all the major

elated to quality improvement and risk management.
This should preferably be a

person having a good knowledge
of accreditation standards,
statutory
Requirements, hospital quality
improvement principles and
evaluation methodologies,hospital
functioning and operations
The shall preferably cover all
aspects including documentation
of the programme, monitoring it
data collection, review of policy
and corrective action.Also refer to
CQI 1b.
ated programme is communicated and coordinated amongst all the

of the organization through proper training mechanism.
Self explanatory
improvement programme is reviewed at predefined intervals and

es for improvement are identified.
As quality improvement is a
dynamic process, it needs to be
reviewed at regular pre-defined
intervals (as defined by the HCO
in the quality improvement
manual but at least once in four
months) by conducting internal
audits. This audits shall be done
by a multi-disciplinary team
(preferable trained in NABH
standards) and objective
elements.At the end of the audit
there shall be a formal meeting to
summarise the findings and
identity areas for improvement.
During this meeting there shall be
an analysis of key indicators as
identified and determined by the
organization including the
mandatory indicators as laid down
in CQI 2 and 3. The minutes of
the review meetings should be
recorded and maintained.
improvement programme is a continuous process and updated at least Self explanatory. The inputs for
ear.
updation could be based on the
review carried out by the quality
improvement committee.
ctures, processes and outcomes which are used as
ncludes appropriate patient assessment.
The HCO shall develop

appropriate key performance
indicators suitable to it. The
following is however mandatory:i.
Time for initial assessment of
indoor and emergency patients.ii.
Percentage of cases wherein
care plan is documented and
counter-signed by the clinician.iii.
Percentage of cases wherein
screening for nutritional needs
has been done.iv. Percentage of
cases wherein the pre-defined
intial nursing assessment is
completed within 30 monutes.
ncludes safety and quality control programmes of the diagnostics

indicators suitable to it . The
following is however mansatory : i.
Number
of reporting
errors/1000 investigationa ii.
Percentage of re-dos. iii.
Percentage of reports co-relating
with clinical diagnosis. iv.
Percentage of adherence to
safety precautions by employees
working in diagnostics.
ncludes all invasive procedures.

indicators suitable to it . The
following is however mansatory :i.
Re-exploration rate ii.
Percentage of accidental
remeoval of tubes and catheters
iii. Incidence of haematoma at
puncture site iv. Percentage of
re-scheduling of procedures.
ncludes adverse drug events.

following is however mndatroy:
i.
Percentage of medication
errors.ii. Incidence of adverse
drug reactions iii. Percentage of
medication charts with illegible
writing over a given period. iv.
Percentage
of contrast
The HCO shall
developrelated
reactions.
ncludes use of anaesthesia.
ncludes use of blood and blood products.
ncludes availability and content of medical records.
ncludes infection control activities.
ncludes clinical research.
ncludes data collection to support further improvements.
Indicators suitable to it . The

following is however mandatory :
i.
Percentage of modification of
anaesthesia plan.
ii.
Percentage
of unplanned
The HCO
shall develop
ventilation
following
anaesthesia.
iii.
Percentage
of
adverse
anaesthesia
events. mansatory :i.
following is however
iv. Anaesthesia
mortality
Percentage ofrelated
transfusion
rate.
reactions.
ii. Percentage of wstage of
blood
and shall
blooddevelop
products.
The HCO
iii.
Percentage
of blood
appropriate
key performance
component
usage.
iv.
Turnaround
timemandatory
for issue ofi.
following
is however
bloodPercentage
and blood components.
of medical
records not having discharge
summary.
ii. Percentage of medical
records not having initial
assessment and the plan of care.
iii. Percentage of medical
indicators
suitable
to it. The
The
HCO
shall
develop
records
having
incomplete
and/or
following
is
however
mandatory: i.
appropriate
key performance
improper consent.
Urinary
tract infection
indicators
suitable
it. Therate.
iv. Percentage
ofto
missing
ii.
Respiratory
infection
rate.
following
records. is however mandatory:i.
iii. Intra-vascular
device
Number of research activities
infection
rate. out.
being carried
iv.
Surgical
siteof
infection
ii. Percentage
patientsrate
withdrawing from the study.
The data could be collected at
iii. Percentage of protocol
pre-defined intervals e.g.
violations/deiations reported.
monthly/quaterly. This data is
iv. Percentage of serious
analysed for improvement
adverse events (which have
opportunities and the same are
occurred in the HCO) reported to
carried out.Also refer to CQI 1f
the ethics committee within the
defined timeframe
ncludes data collection to support evaluation of these improvements.
structures, processes and outcomes which are used as
ncludes procurement of medication essential to meet patient needs.
ncludes reporting of activities as required by laws and regulations.
All improvement activities carried

out by the HCO shall have an
evaluable outcome. The same be
captured and analysed.

appropriate key performace
indicators
suitable
to it. The
The HCO shall
develop
following
is
however
mandatory: i.
Percentage
of
drugs
procured
byhowever
local purchase.
following is
mandatory:
ii.
Percentage
of stock
outs
i.
Number of birthes
and
including
deaths. emergency drugs.
iii.
of consumables
ii. Percentage
Numberof notifiable
rejected
before
preparation
of
diseases.
Goods
Receipt
Note.
iii. Submission of
iv.
Incidence ofpertaining
variations to
from
report/data/form
biothe
procurement
medical waste,PNDT act and
radiation safety within the defined
timeframe.
iv. Submission of tax returns
and deduction of taxes at the
specified time frame.
ncludes risk management.
ncludes utilisation of space, manpower and equipment.
ncludes patient satisfaction which also incorporates waiting time for
ncludes employee satisfaction.
ncludes adverse events and near misses.
ncludes data collection to support further study for improvements.
ncludes data collection to support evaluation of these improvements.
nt.
anagement makes available adequate resources required for quality

nt programme.
rmarks adequate funds from its annual budget in this regard.

statistical and management tools are applied whenever required.
d nursing staff participates in this system.
eters to be audited are defined by the organisation.

staff anonymity is maintained.

indicators
suitable
to it. The
The
HCO shall
develop
following is however
mandatory:i.
appropriate
key performace
Number
of variations
indicators
suitable
to it. The
The
HCO shall
develop
observed
mock
drills.
following isinhowever
mandatory:
appropriate
key
performace
ii.
Incidence
of
falls.
i.
Bed occupancy rate and
indicators
suitable
to it. The
iii.
Incidence
of
average
length
ofbed
stay.sores after
The
HCO
shall
develop
following
is
however
mandatory: i.
admission.
ii.
OT andkey
ICUperformace
utilization rate.
appropriate
Out
patient
satisfaction
index.
iv.
Percentage
ofto
employees
iii.
Equipment
down
indicators
suitable
it.time.
Theindex.
ii.
In patient
satisfaction
The
HCO
shall
develop
provided
pre-exposure
iv.
Nurse-patient
ratio
following
is however
iii.
Waiting
timeperformace
for mandatory:i.
services
appropriate
key
prophylaxis.
Employee
satisfaction
index.
including
diagnostics
and
out
indicators
suitable
it.
The
The
data could
be to
collected
at
.following
patient. is however mandatory: i.
pre-defined
intervals
e.g.
ii.
rate
iv. Employee
Time taken
for discharge.
Number
of attrition
sentinel
events.
monthly/quarterly.
Thisinputs
data
is
iii.
Employee
absenteeism
rate
Self
explanatory.
The
for
ii.
Percentage
of
near
misses
analysed
for
improvement
iv.
Percentage
of
employees
updations
could
be
based
on
the
analysed.
opportunities
and
the
same
are
who
are
aware
of
employees
review
carried
out
by
the
quality
iii.
Number
of security
related
carried
out.Also
refer and
also
refer to
rights,responsibilities
improvement
committee.17
incidents
including
thefts. welfare
CQI
1f.
schemes.
iv. Incidence of needle stick
.This
shall include the men,
injuries.
material,machine and
method.These
should
so as is
to
Appropriate fund
allocation
ensure
that
the
programme
done by the organization for the
functions
smoothly. of the
smooth
functioning
Self Explanatory
programme.
The HCO shall identify such

personnel. It could be a mix of
clinicians,
administrators
ans
As these audits
are
nurse.
retrospective/concurrent in nature,
itThis
is imperative
be done
means thatthat
thethis
names
of the
using
predefined
parameters
patients and the hospital staffso
who
that
The
may there
figureisinno
thebias.
audit
documents
parameters
be disease
must not be could
disclosed
or any
based,
cost
based,community
reference be made to them in
based
or based on length of stay
public discussions/conferences.
re documented.
Self explanantory
measures are implemented.
All remedial measures as

ascertained should be
documented and implements
thersof recorded to complete the
sation has defined sentinel events.
The
auditsentinel
cycle. events relating to
system or process deficiencies
sation has established processes for intense analysis of such events.
The
established
should
that are
relevant processes
and important
to
include
reportingmust
the occurrence
the organization
be clearly
of
such
events
on standardized
defined.
ents are intensively analysed when they occur.
Root
cause
analysis
of all such
incident
report
forms.
events should be carried out by a
and preventive Actions are taken based on the findings of such analysis. The
findings and committee taking
multi-disciplinary
recommendations
arrived at after
inputs from the concerned
the
analyses
should
be
units/discipline/departments
communicated to all concerned
personnel to correct the systems
and processes to prevent
recurrences.
onsible for governance lay down the organizations mission statement.
onsible for governance lay down the strategic and operational plans
rate to the organizations mission in consultation with the various stake
It is not only the head of the HCO

but te members of the board of
governors
(where
applicable)
The Governing
boars
and the who
need
to
define
it.
leaders of HCO shall define and
develop the processs for strategic

and operation plans so as to
onsible for governance approve the organizations budget and allocate The
Governing
boars and the
achieve
the organizational
es required to meet the organizations mission.
leaders
of
HCO
shall have the
mission statement.
policy for budgeting and resource
onsible for governance monitor and measure the performance of the
The
Governing
boars and
the
allocation
for attaining
its mission
n against the stated mission.
leaders
of HCO shall
develop
and periodically
review
it.
quarterly (at least) performance
onsible for governance establish the organizations organogram.
The HCO shall have a well
reports based on the strategic and
defined organization
operational plans.
structure/chart and this shall
onsible for governance appoint the senior leaders in the organization. Self explanatory
clearly document the hierarchy,
line of control,along with the
onsible for governance support research activities and quality improvemeSelf
explanatory
functions
at various levels.
zation complies with the laid down and applicable legislations and regulatSelf explanatory The
responsibility of compliance lies
with the first two level of the
onsible for governance address the organizations social responsibility. The
Governing board and Head of
hierarchy
the HCO shall willfully develop
social responsibility policy and
accordingly address it.
izational program, service, site or department has effective leadership. There needs to be a minimum
essential qualification and
relevant
experienceactivity
of the leader.
ervices of each department is defined.
Each departments
is to be
The
leader
shoul
have
domain
predefined. This could be
knowledge
ofeither
that particular
documented
at individual
ive policies and procedures for each department is maintained.
This
shall include
administrative
department
department
levelattendance,
or the HCO
procedures like
could
have a brochure
detailing
leave,conduct
replacement
etc
tal leaders are involved in quality improvement.
Self explanatory
the scope of each department.
s make public the mission statement of the organization.
s establish the organizations ethical management.
The HCO shall have a mission

statement and the same shall be
displayed
The HCO prominently.
shall function in an
ethical manner.
zation discloses its ownership.
zation honestly portrays the services which it can and cannot provide.
zation honestly portrays its affiliations and accreditations.
zation accurately bills for its services based upon a standard billing
The ownership of the hospital

e.g.trust , private ,pulic has to be
disclosed.
Self explanatory
Here portrays implies that the
HCO conveys its
affilations,accreditations for
Self explanatory
specific departments or whole
hospital wherever applicable.
on.
ated individual has requisite and appropriate administrative

ns.
Self explanatory
ated individual has requisite and appropriate administrative experience. Self explanatory
sues are an integral part of patient care and hospital
zation has an interdisciplinary group assigned to oversee the hospital

programme.
Self explanatory
of the programme is defined to include adverse events ranging from no The HCO shall have a system of
entinel events.
reporting of all the
incidents/accidents.
nt ensures implementation of systems for internal and external
The HCO has a system in place
system and process failures.
for internal and external reporting
of system and process failures.
nt provides resources for proactive risk assessment and risk reduction There
shall be
sufficient
Contingrncy
plan
shall be in place
resources
kept
contingency
to
to deal with the as
situation
of
address
the process
risk reduction
system and
failure
activities
aswithin
and when
anticipated
the the leaders
proactively
suggest.
The end
arganization.
result of these shall result of thses
shall result of these shall result in
d regulations, laws and byelaws and requisite facility
preventive actions.
ement is conversant with the laws and regulations and knows their
to the organization.
A designated management
functionary has been given the
to enlist the laws
nt regularly updates any amendments in the prevailing laws of the land. responsibility
Self explanatory
and regulation as applicable to
the HCO. This functionary has
ement ensures implementation of these requirements.
Self
explanatory
identified
the appropriate
personnel in the HCO who are
mechanism to regularly update licenses/ registrations/certifications.
Self
explanatory
supposed
to implement the
respective laws and regulations.
ty of patients, their families, staff and visitors.
documented operational and maintenance (preventive and breakdown) Self explanatory
drawings are maintained which detail the site layout, floor plans and fire A designated person maintains
tes.
the drawings.
ernal and external sign posting in the organisation in a language
Self explanatory
by patient, families and community.
on of space shall be in accordance with the available literature on good Self explanatory
ndian or International Standards) and directives from government
designated individuals responsible for the maintenance of all the
A Person in the HCO

management is designated to be
in-charge of maintenance of
facilities.The HCO has the
required number of supervisors
and tradesmen to mnage the
facilities.
ce staff is contactable round the clock for emergency repairs.
Self explanatory
imes are monitored from reporting to inspection and implementation of A Complaint attendance register
ctions.
is to be maintained to indicate the
date and time of receipt of
complaint,allotment of job and
pment management.
completion of job.
zation plans for equipment in accordance with its services and strategic Self explanatory. This shall also
take into consideration future
requirements.
is selected by a collaborative process.
Collaborative process implies that
ent is inventoried and proper logs are maintained as required.
nd trained personnel operate and maintain the equipment.
during equipment selection there

is
involvement
of end user,
Self
explanatory
management , finance ,
engineering and bio-medical
Self
explanatory
departments.
are periodically inspected and calibrated for their proper functioning.
The HCO has

weekly/monthly/annual schedules
inspection
and calibration of
documented operational and maintenance (preventive and breakdown) of
Self
explanatory
equipment which involve
measurement in an appropriate
manner. The equipment in house
ases and vacuum systems.
or out sources , Mintaining
traceability
to national
ter and electricity are available round the clock.
The HCO shall
make or
intenational
or for
manufacturer's
arrangements
supply of
guidelines/standards.
adequate electric
potablesupply
water and
ources are provided for in case of failure.
Alternate
could be
sation regularly tests the alternate sources.
electricity.
form
DG Sets. Solar energy. UPS
Self any
explanatory.
and
other suitable source.
maintenance plan for piped medical gas, compressed air and vacuum
Self explanatory.
he facilities.
zation has plans and provisions for early detection, containment and
of fire and non-fire emergencies.
The HCO has a fire and non-fire

emergency committee (FNEC) to
review
HCOs
zation has a documented safe exit plan in case of fire and non-fire
Fire exitthe
plan
shallpreparedness.
be displayed
The
HCO
has
conducted close
an to
es.
on each floor particularly
exercise
of hazard
identification
the
lifts.
Exit
doors
should
remain
ned for their role in case of such emergencies.
In
case
of
fire, designated
person
and
risk
analysis
(HIRA) and
open
on
all
the
time.
are
assigned
particular
work.
accordingly taken all necessary
are held at least twice in a year
Self
stepsexplanatory.
to eliminate or reduce such
hazards and associated risks. The
HCO has:
a) a fire plan covering fore
zation defines and implement its polices to reduce or eliminate smoking. Smoking in public places including
arising out of burning of
hospitals has been banned in this
inflammable items, explosion,
country.
has provisions for granting exceptions for patients and families to
In
view of
the circuiting
law, permission
electric
short
or acts to
of
smoke
within
of
negligence
of the
duecampus
to
hospital
may not
incompetence
of be
thegranted.
staff on duty;
b)
mics and other disasters.
deployed adequate and qualified
adequate
qualified
personnel
al identifies potential emergencies.
The
HCO and
has a
documented
plan
for this;
and
procedure for handling the
c)
acquired
adequate
situations
like
sudden
rushfighting
of
zation has a documented disaster management plan.
The
disaster
plan
mustfore
equipment
for
this
which
records
victims
of
incorporate essential elements ofa)
are
kept
up-to-date;
earthquake;
alert
code,
informationshould
and be
made for availability of medical supplies, equipment and materials
Resource
availability
d)
adequate
training
plans;
b)cards
flood;
communication,
action
for
emergencies.
according
to threat
perception.
e)
schedules
for
conduct
of
each of the staff, availabilitymock
and
fire
drills;
c)resources,
train
aff is trained in the hospitals disaster management plan.
Mock
drills with
and accident;
without f)
earmarking
of
mock
drill
records;
patients
have
to
we
carried
establishment of command out.
g)the
exit
d)civil
unrestand
outside
HCO
Only
communication
exercise
may
nucleus,
training
mock
drills.
plans
well
displayed.
remises;
also be undertaken.
The
HCO
e) major
has a dedicated emergency
fire;
illumination
system
which
f)
invasion by
enemy,
etc. comes
into effect in case of a fire.
TeseThe
plans
HCOprocedures
takes care cover
of non-fire
and
ensuring
tested at least twice in a year.
Self explanatory.
materials are identified within the organization.
The HCO has identified and listed

the hazardous materials and has
a
documented
procedure an
their
al implements processes for sorting, labelling, handling, storage,
The
HCO has conducted
sorting,
storage,
handling,
g and disposal of hazardous material.
exercise of hazard identification
transpirations,
disposal
and risk analysis
(HIRA)
egulatory requirements are met in respect of radioactive materials.
The
appropriate
personnel
mechanism,
and
method of
forin the
associated with handling
HCO
are
aware
about
the
rules
managing
hazardousspillages
materialsand
andadequate
and
regulations
such as the
training
of
the
personnel
for
these
plan for managing spills of hazardous materials.
Self explanatory.
according
taken all necessary
Atomic
Energy Act, the norms
jobs.
steps to eliminate or reduce such
issued by Atomic Energy
hazards
and associated risks. The
cated and trained for handling such materials.
Self
explanatory.
Regulatory
Board (AERB) and the
HCO has ensured display of
directives form the Health Physics
Material Safety Data Sheets
Division of Bhabha Atomic
(MSDS) for all hazardous
environment.
Research Center (BARC).
materials and has according
arranged associated training of
al has a safety committee to identify the potential safety and security
The HCO has a duly constituted
personnel who handle such
safety committee which has
materials. The situational hazards
identified the potential safety and
ttee coordinates development, implementation, and monitoring of the The
that the
also HCO
need ensures
to be covered
in above
HIRA
security risks to staff, patients and
and policies.
committee
on situation
a regular
so that anyfunctions
emergency
visitors.
basis
coordinate
development,
arisingtoout
of process
of storing,
ety devices are installed across the organization and inspected
Self explanatory
implementation
and
monitoring of
handling, storage,
transportation
.
the
andofpolicies.
andplans
disposal
such hazardous
materialstoare
effectively.
pection rounds to ensure safety are conducted at least twice in a year in Rounds
be met
carried
out by
Sharp committee.
bends in passages,
e areas and at least once in a year in non-patient care areas.
safety
protruding or dangling elements in
reports are documented and corrective and preventive measures are
Self
explanatory.
passage
ways, sudden swing of
.
swing doors, ramps, entry and exit
fromexplanatory.
lifts, are situations which
safety education programme for all staff.
Self
need to be taken care of. See
FMS 5 also. The HCO has the
requisite training need handling
and those trainings are included
in the HCO training calendar.
ning.
zation maintains an adequate number and mix of staff to meet the care, The staff should be
nd service needs of the patient.
commensurate with the workload
and the clinical requirement of the
d job specifications and job description are well defined for each
The
content of each job should be
patients.
staff.
well defined and the
qualifications, skills and
zation verifies the antecedents of the potential employee with regards to Self
explanatory
experience
required for
gligence background.
performing the job should be
clearly laid down. The job
description should be
ospital environment.
commensurate with the
qualification.
member, employee, student and voluntary worker is appropriately
The
organizations staff including
the organizations mission and goals.
the outsourced staff should be
aware and should correctly
member is made aware of hospital wide policies and procedures as well The
organizations.
interpret
the missionstaff
andincluding
goals of
department / unit / service / programmes policies and procedures.
the
outsourced
staff
should
be
the organization.
aware and should correctly
interpret the policies and
member is made aware of his/her rights and responsibilities.
The
HCO procedures
shall define of
thethe
same in
operating
consonance
statutory
organization with
as well
as that of the
requirements
and
the same
shall
es are educated with regard to patients rights and responsibilities.
The
employees
should
beinable
to
department/
unit/
service
which
be
communicated
to
the
identify
and
report
violation
of
he is performing the requisite
employees.
patient
rights as and when the
duties.
es are oriented to the service standards of the organisation.
The
HCO shall develop
same occurs.
benchmarks for different services
being provided. This shall be
based on the HCOs
opment of the staff.
ted training and development policy exists for the staff.
o occurs when job responsibilities change/ new equipment is
mechanisms for assessment of training and development programme
pecific job duties or responsibilities related to safety.
ained on the risks within the hospital environment.
ers can demonstrate and take actions to report, eliminate / minimize
A training manual incorporating

the procedure for identification of
training
needs,
the training
The training
should
focus on the
methodology,
documentation
revised job responsibilities as of
well
training,
assessment,
as on thetraining
newly introduced
This
shall
include
boththe
include
impact
of training
and
training
equipment
and technology.
In
both
internal
and
external
calendar
should
be
prepared.
case of new equipment thetraining.
For
external
byshould
the HCO
itself or
operating
staff
receive
by
the
external
agency
which
training on operational as well as
imparted
the training.
Impact of
daily maintenance
aspects.
training
at shall
user define
level should
also
The
HCO
such risks
be documented.
which
shall include patient,
visitors
and employee related
Self explanatory.
risks.
ers are made aware of procedures to follow in the event of an incident. Self explanatory.
rocesses for common problems, failures and user errors exist.
The HCO has a defined

procedure for reporting of these
events.
exists as an integral part of the human resource
mented performance appraisal system exists in the organization.
Self explanatory.
yees are made aware of the system of appraisal at the time of induction. Self explanatory.
ce is evaluated based on the performance expectations described in job Self explanatory.
sal system is used as a tool for further development.
ce appraisal is carried out at pre defined intervals and is documented.
Self explanatory. This can be

done by identifying training
requirements and accordingly
Self explanatory.
providing for the same (wherever
possible)
atement of the policy of the organization with regard to discipline is in
Self explanatory.
nary policy and procedure is based on the principles of natural justice.
This implies that both parties

(employee and employer) are give
an opportunity to present their
Self explanatory.
case
and decision is taken
accordingly.
Self explanatory.
and procedure is known to all categories of employees of the

n.
nary procedure is in consonance with the prevailing laws.
provision for appeals in all-disciplinary cases.
The HCO shall designate an

appellate authority to consider
appeals in disciplinary cases.
yees are aware of the procedure to be followed in case they feel
For definition of grievance

handling refer to glossary. The
HCO
has a written procedure for
Self explanatory
handing grievance of employees.
s procedure addresses the grievance.
taken to redress the grievance.
oyment medical examination is conducted on all the employees.
lems of the employees are taken care of in accordance with the

ns policy.
Self explanatory
Self explanatory. This shall

however be in consonance with
the
of the land.
Selflow
explanatory.
The shall be in
al health hazards are adequately addressed.
consonance with the low of the

land and good clinical practices.
Self explanatory. The result
should be documented in the
personal file.
Self explanatory.
es are maintained in respect of all employees.
Self explanatory.
al files contain personal information regarding the employees

n, disciplinary background and health status.
Self explanatory.
of in-service training and education are contained in the personal files
Self explanatory.
es contain result of all evalutions.
Evaluations would include

performance appraisals, training
assessment and outcome of
health checks.
alth checks of staff dealing with direct patient care are done at-least
r and the findings/ results are documented.
entials (education, registration, training and experience)

on.
fessionals permitted by law, regulation and the hospital to provide

e without supervision is identified.
The HCO identifies the individuals

qualification (s), training and
ion, registration, training and experience of the identified medical
Self
explanatory.
Updation
is done
experience
to provide
patient
care
als is documented and updated periodically.
after
acquisitionwith
of new
skills
in consonance
the law.
and/or qualification.
ormation pertaining to the medical professionals is appropriately verified The HCO shall do the same by
ble.
verifying the credentials from the
organization which has awarded
the qualification/training.
it and treat patients and provide other clinical services
fessionals admit and care for patients as per the laid down policies and The HCO shall identify as to what
n procedures of the organization.
each medical professional is
authorized to do.
s provided by the medical professionals are in consonance with their
Self explanatory.
n, training and registration.
te services to be provided by the medical professionals are known to

ll as the various departments/ units of the hospital.
Self explanatory.
entials (education, registration, training and experience)
ion, registration, training and experience of nursing staff is documented The HCO identifies the individuals
d periodically.
qualification (s), training and
ormation pertaining to the nursing staff is appropriately verified when
The HCO shall do the same by
experience to provide nursing
verifying the credentials from the
care to patients in consonance
organization which has awarded
with the law. Updation is done
the qualification/training6t
after acquisition of new skills
and/or qualification
work assignments to all nursing staff members

nts.
work assigned to nursing staff is in consonance with their qualification, The HCO shall identify as to what
d registration.
each nurse is authorized to do.
s provided by nursing staff are in accordance with the prevailing laws

ions.
Self explanatory
te services to be provided by the nursing staff are known to them as

various departments / units of the hospital.
Self explanatory
are providers, management of the organization as well
ation needs of the organization are identified and are appropriate to the The HCO has manual and/or
e services being provided by the organization and the complexity of the electronic Hospital Information
n.
System and/or Management
Information System information
d procedures to meet the information needs are documented.
A
document
is available
to policy
all concerned
stakeholders.
where the HIS/MIS is described.
ies and procedures are in compliance with the prevailing laws and
Self explanatory.
ion management and technology acquisitions are in accordance with

and procedures.
The HCO shall define the needs

for software and hardware
solutions as per the information
zation contributes to external databases in accordance with the law and The HCO shall define the system
requirement and future
of releasing the relevant
necessities.
information to the authority as per
statutory norms.
data.
data collection are standardized
resources are available for analyzing data.
d procedures are laid down for timely and accurate dissemination of
d procedures exist for storing and retrieving data.

clinical and managerial staff participates in selecting, integrating and
ry patient.
cal record has a unique identifier.
n policy identifies those authorized to make entries in medical record.
MIS/HIS data are collected in

standardized format from all
The
HCO shall in
make
available
areas/services
the HCO.
men, material, space and budget.
Self explanatory.
The HCO shall define data
management policy and ensure
adequate
for
There is asafeguards
multi-disciplinary
protection of
data,iswherever
committee
which
responsible
physical
of electronic
data in of
for
the appropriate
selection
stored.
indicators,
measurement of trends
and initiating action wherever
required.
This shall also apply to records on
digital media.
HCO has a written policy stating
who all con make entries.
cal record entry is dated and timed.
Self explanatory.
of the entry can be identified.
This could be by writing the full

name or by mentioning the
employee
code number,
The HCO identifies
whichwith the
help
of
stamp,
etc.
In
case
documents form part of
theof
electronic
based
records,
medical records, documents and
authorized
implements e-signature
the same. provision
as per statutory requirements
must be dept.
ts of medical record are identified and documented.
provides an up-to-date and chronological account of patient care.
al record contains information regarding reasons for admission,

nd plan of care.
The HCO shall decide the format

for maintaining the continuity in
the medical records.
Self explanatory.
nd other procedures performed are incorporated in the medical record. Self explanatory
nt is transferred to another hospital, the medical record contains the

Self explanatory. It is mandatory
sfer, the reason for the transfer and the name of the receiving hospital. to mention the clinical condition of
the patient before transfer is
effected.
al record contains a copy of the discharge note duly signed by
Self explanatory
and qualified personnel.
death, the medical record contains a copy of the death certificate

he cause, date and time of death.
a clinical autopsy is carried out, the medical record contains a copy of

f the same.
ers have access to current and past medical record.
ntegrity and security of information.
Self explanatory. The HCO

provides the death certificate as
per the international Certification
Self
explanatory.
of Cause
of Death.
The HCO provides access to
medical records to designated
health care providers (those who
are involved in the care of that
patient).
d policies and procedures exist for maintaining confidentiality, security

y of information.
The HCO shall control the

accessibility to the MRD
department.
It shallofensure
d procedures are in consonance with the applicable laws.
This is the context
Indianthe
usage
of
tracer
card
for
Evidence Act, Indian Penal Code
movement
ofMedical
the file IEthics.
and out of
and physical
Code of
s and procedures incorporate safeguarding of data/ record against loss, For
records the
HCO
the MRD so as to maintain
and tampering.
shall ensure that there is
confidentiality, security, safety and
adequate pest and rodent control
al has an effective process of monitoring compliance of the laid down
The
HCOofcarries
out regular
integrity
information.
measures. For electronic data
audits/rounds
to check
The is applicable
for both manual
there should be protection against
compliance
with
policies.
and
electronic
records.
al uses developments in appropriate technology for improving,
The HCO shall
update
virus/trojans
andreview
also aand
proper
ity, integrity and security.
its
technological
features
so as to
backup
procedure.
To prevent
improve
confidentiality,
integrity
tampering,
for physical records
health information is used for the purposes identified or as required by The
HCO shall
define the
and
security
access
shall of
beinformation.
limited only to the
disclosed without the patients authorization.
procedure for privileged
concerned health care provider. In
communication.
ted procedure exists on how to respond to patients/ physicians and
Self
explanatory.
context,
electronic
format In
thisthis
could
be
c agencies requests for access to information in the medical record in
the
release
of information
in
done
by adequate
passwords.
e with the local and national law.
accordance with the Code of
Medical Ethics 2002 should be
kept in mind.
information.
d policies and procedures are in place on retaining the patients clinical The HCO shall define the
ta and information.
retention period for each category
of
medical
records:
s and procedures are in consonance with the local and national laws
Some
of the
relatedOut-patient,
laws in this
in-patient
and
MLC.
ions.
context are Code
of Medical
Ethics 2002, Consumer Protection

This
is applicable
for both
manual
Act 1987
and relevant
state
and
electronic
system.
legislation, if any.
ction of medical records, data and information is in accordance with the Destruction can be done after the
olicy.
retention period is over and after
taking approval of the competent
authority.
on process provides expected confidentiality and security.
al records are reviewed periodically.
uses a representative sample based on statistical principles.
Self explanatory.
The HCO shall define the
principles on which sampling is
based. For example, simple
random, systemic random
sampling etc. Review shall be
based on conditions of clinical
and/or community importance,
total discharges including deaths.
is conducted by identified care providers.
Self explanatory
focuses on the timeliness, legibility and completeness of the medical
Self explanatory
process includes records of both active and discharged patients.
Self explanatory
points out and documents any deficiencies in records.
Self explanatory
corrective and preventive measures undertaken are documented.
Self explanatory
icant difference between the self

completion of Pre assessment.
Remark
The needs of the community should

be considered especially when
planning
new HCO
orexpertise
adding new
Claims ofaservices
and
services
being available should actually be
available. Display in the form of
brochures only is NOT acceptable.
Display should be at least bi-lingual.
Admission must be authorized by a

doctor.
GS1 standards in barcoding can be
used to identify and track the
patient within and outside the
hospital.
Also refer to AAC 3.
Orientation can be provided by
documentation/ training.
These patients include those who

have come to the emergency but
need to be transferred to another
Also
refer to COP
3. already
organization
or those
admitted but who now require care
A
should
accompany
in doctor
another
organization
it alsoan
unstable
patient. being shifted for
includes patients
diagnostic
tests. patients being
This shall include
Also refer toboth
COPfor3.diagnostic
transferred
and/or therapeutic purpose.
With regards to expected costs, an

estimate could be prepared and the
same given to the patient. This
estimate shall be prepared the basis
of the treatment plan. It could be
prepared by the OPD/Registration /
Admission staff in consultation with
the treating doctor.
Also
refer
HRM 10a.
In case
of to
packages
it should clearly
state the terms and conditions and
also the exceptions if any.
This could be done by the treating

doctor and/or dietician.
For definition of plan of care and
clinical audit refer to glossary.
This could also be done through
booklets/ patient information leaflets
etc. e.g. diabetes, hypertension.
Every patient shall be reassessed at
least once every day by the treating
doctor.
The nursing staff can document

patient's vitals.
For example a cardiac care HCO

must necessarily have facilities for
cardiac enzyme testing.
For adequancy of qualification refer
to NABL. 112.
The policy should be in line with
standard precautions. The disposal
of waste shall be as per the
The turnaround time could be
statutory requirements (Bio-medical
different tests and could be decided
waste management and handling
based
on practical
the nature
test andthe
If
it is not
to of
establish
rules,
1998.)
critically
of
test.
biological reference interval for a
The
authority
for control
and the
particular
analyte,
the laboratory
methods
for control,
of such
should carefully
evaluate
the
outsourcing
shall
and
published data
forbe
itsdefined
own reference
documented.
intervals.
This could be as per Occupational

Health and safety Management
System - OHSAS 18001:2007.
All the statutory requirements are

met with, like BARC clearance,
dosimeters,
sheets, lead
For
example,lead
a neuro-science
aprons,
signages,
display
as per
centre shall
have CT
and MRI.
PNDT act, reports to competent
authority, etc.
The defined timeframe could be

different for different type of tests.
The HCO shall define the critical

results which require immediate
attention
of clinician
e.g. ectopic
MOU should
be available
for all
pregnancy.
outsourced activities. See AAC 7 f
also.
This could be done on the basis of

entries either on case sheet or
lectronic patient records (EPR).
For example 1) Nurses handling
taking over notes. 2) Transfer
summary.
Referral could be for opinion, comanagement, take over. It could be
graded into immediate, urgent
priority or routine categories.
This policy could address the

reasons of LAMA for any possible
corrective and/or preventive action
by the HCO.
The instruction shall be in a manner

that the patient can easiliy
understand and avoid use of
medical terms e.g. BID, TID etc.
This could be in the form of whiat
medicines to take, when to consult
a doctor or bow to seek medical
help and contact number of the
hospital/doctor.
For example, consent before,

surgery, providing first aid to
emergency patients and police
intimation in cases of medicolegal
cases.
For electronic records the
organization shall ensure that the
same in captured in the system.
The clinician in charge implies the
treating doctor.
For definitions of evidence based
medicine and clinical practise
guidelines, refer to glossary.
Also refer to AAC5a.
Poisoning cases, road traffic

accidents, patients with coronary
disease,
etc,be
shall
be deaft
as per
This should
based
on good
hospital
policies
and
procedures.
clinical practices. For triage refer to
glossary.
Also refer to AAC 14 and 15. The

discharge note shall incorporate
salient features of investigations
done and treatment.
In case a rapid turn around of the

ambulance in required (where
checking may not be possible prior
to dispatch), only the medications
used could be topped up or the
HCO could keep an additional set of
drugs as stand by.
The document could be displayed
prominently in critical areas such as
emergency. ICU, OT etc.
This could be done using the predefined procedural checklist and by

monitoring if the prescribed activity
has been performed properly and in
the right sequence.
During subsequent resuscitations it
is preferable that implementation of
these actions is noted and training
be modified if necessary.
A good reference guide is the NABH
standards for blood banks.
Also refer to PRE3 d and e.

Consent for blood transfusion
during surgery shall be taken
This
could be
in the form
of clubbed
separately.
It should
not be
booklet/leaflet.
with the surgery consent form.
Records of the same should be
available.
For transfusion reactions refer to
glossary.
A good starting point could be

various national and international
critical care society guidelines.
Good clinical practices include

monitoring infection rates, readmission rates, re-intubation rates
etc.
Refer to disability act, mental act.
For example, play room for children,

anti-skid tiles for elderly, ramps with
railings for disabled, etc.
Refer to PRE 3e.
available.
The display should be in a

prominent location. Refer to AAC 1b
also.
It is preferable that this is done by a

dietician.
The display should be in a

prominent location. Refer to AAC 1b
also.
There are national and international
guidelines available for the cases of
neonates by WHO, etc. The
hospital should take them into
account.
For example, playroom and breast
feeding room.
The same needs to be documented.
Examples could include

identification tag, unsupervised
phototherapy leading to nurns, etc.
For example, growth chart,
immunisation chart, etc. This
(origional/copy) should be a part of
the medical record. The education
should preferably be in the
language
thenot
family
Technicianthat
shall
administer
understands.
sedation
In addition, certain other parameters

may be monitored on a case to
case basis.
For addition of anaesthesia refer to

glossary. The standard is not
applicable for local anaesthesia.
The plan should mention the type of

anaesthesia, the drug(s0 to be used
for induction and the drug to be
used for maintenance ..
Also refer to PRE 3d.
The same should be documented.
This shall be done by the operating

surgeon.
Also refer to PRE 3d.
The HCO should be able to

demonstrable methods to prevent
these events e.g. identification tags
Also
refercross
to HRM
11b. etc. Refer to
badgets,
checks,
WHO "Safe surgery saves lives"
initiative.
If it is documented by a person
other than the chief operating
surgeon the same shall be
The
plan shall include
advice
on IV
countersigned
by the chief
surgeon
fluids,
medications,
care of wound,
within 24
hours.
nursing care, observing for any
complication, etc.
For air conditioning of OT OT refer
to the glossary
All the post operative patients shall
be screened for the same.

available.
For example cancer pain,neuralgias

and arthralgia.
Pain assesssment and mangement
could be carried out using a pain
rating scale.
For example,provision of ante natal

and post natal exercises could form
a part of obstetric rehabilitaton
programme.
For example, International

conference on harmonization (ICH)
of Good clinical practice (GCP) and
declaration of Helsinki somerset
(1996) and Ethical Guidelines for
Biomedical Researchon Human
Subjects (ICMR-2000).
Refer to schedule Y of Drugs and

cosmetics act and ICMR guidelines.
For example, diabetic diet high

protein diet,total parenteral nutrition,
etc.

available.
Relevant legislations include Drugs

and cosmetics Act food and Drugs
and Psychotropic substances
Acts,Drugs and gagical Remedies
(Objectionable Advertisement) Act,
etc.
For example, pharmacy and

therapeutics committee.
For example, local purchase.
Vaccines should preferable be kept

in vaccine refrigerators (Ice Lined
Refrigerator).
The organization shall follow
inventory control practics like first in
and first out , ABC, etc.
the organization can folllow a

method of storing drugs by generic
name in an alphabetical order to
itaddress
is preferable
that .the HCO has a
this issue
24 hours pharmacy.
refer to MOM 1a
The organization can explore the

possibility of writing orders in block
letters so that the issue of legibility
is adderessed.
This shall be done at alll levels e.g.

pharmacy, ward, etc
This is applicable to all dispensing
areas wherein medicines are
dispensed either as cut strips or
from bulk containers.
Refer to statutory requiremenys. in
addition to doctors, nursing staff
may also administer.
applicable for parenteral drugs
Identification shall be done by
unique identification number( eg.
hospital number/IP number,
etc)with/without name
the records shall reflect the actual

administration.For example, if brand
Y was given in place of brand
for
example,
slf administration of
X(same
gnerically)the
insulin.
documentation shall be of brand Y.
Similarly if the order was for a tablet
of 250mg but the administsation
was1/2 a tablet of 500mg the latter
shall be documented.
Refer to glossary for "adverse drug

event"
This refers to the layout/location of

radiaton waste pipes,delay waste
pipes, delay tanks, etc.
For an example of "patient

responsibility refer to glossary.
Examples of this include falling from

the bed/trolley due to
negligence,assaultt,repeated
Example
of this include
internal examinations,manhandling
MTP,patients
of tubeculosis or any
etc.
other infections disease
In case of refusal the treating doctor
shall explain the consequences of
refusal
of consent
treatment
document
Informed
of and
the patient
is
the same for doing HIV test.
mandatory
This cannot include conset for

invasive procedures for invasive
procedures or other procedures for
which consent is required as per
this standard.
The policy for HIV testing should

follow the national policy on HIV
testing (NACO).
For example, hand washing and

avoiding overcrowding near the
patient.
Reference documents could include

Prevention of hospital acquired
infections- a practical guide (2nd
edition, 2002) by WHO, CDC
Guidelines and Manual for control
of Hospital
for controlofofthe
Hospital
For
the composition
team
Associated
Infections,
Standard
refer
to WHO,
APIC and
CDC
Operative
Procedures
guidelines.
It is preferable
for thembytoNACO,
have
Ministry
of
Health
undergone a shortand
termfamily
training
Welfare,
Govt.
India. control
programme
on of
infection
nursing by a recognized institute.
Refer to glossary for standard

precautions.
The HCO could also refer to

international guidelines while
framing the policy. Use of WHO
reference document Global strategy
for containment resistance,
2001[WHO/CDC/CSR/DRS2001.2]c
an be a good starting point.
Refer to glossary for air conditioning
in OT.
Standard precautions must be
adhered to.
The HCO should use a judicious

mix of active and passive
surveillance.
Refer to glossary for notifiable

diseases.
A simple calculation of infected
patients (numerator) provides only
limited information which would be
This is applicable even if the
difficult to interpret. Risk factor
housekeeping services are
analysis would require infected and
outsourced.
non infected patients, in order to
calculate infection and risk adjusted
rates.
The HCO may extend this activity to
asymptomatic catheterised patients
also.
It is preferable
also. It is
It is preferable
to usetoCDC
preferable
definitions.to use CDC definitions.
It is preferable to use CDC
definitions.
It is preferable to use CDC
definitions.
This could be in the form of a
bulletin/newsletter.
Optimal hand hygiene requirements

includes large washbasins, hands
free control, soap and facility for
drying hands without contamination.
The hand hygiene the hand hygiene
Refer
to glossary
guidelines
shall beofr
based on WHO
isolation/barrier
2007 guidelines nursing.
on patient safety
(website: www.who.int/patientsafety)
To define as to what constitutes an

outbreak the HCO should have
baseline rates.
The HCO shall provide for the same

in all areas where sterilization
activities
are carriedeach
out. Itload
is to
WHO recommends
preferable
to
have
separate
areas
have a number, content description,
for
receiving,
washing,
cleaning,
temp
and time
The
HCO
couldrecord
have sterile
achart,
batchstorage
packing,
sterilization,
physical/chemical
tests
daily,
weekly
processing
system
with
date and
and
issue.test, steam processing,
biological
machine number for effective recall.
and ETO processing.
For example, gloves and masks,

protective glasses, gowns, etc.
Doctors also need to be trained.
For example, hepatitis B vaccination

and PEP for needle stick injury.
For examples, core committee,

quality improvement committee,
Etc.
Refer to AAC 8, AAC 11, COP 6,

COP 12 and HIC 2 also.
Refer to guidelines for
documentation.
For example accreditation coordinator, quality management

representative, quality manager.
Refer to glossary for definition of

Risk management and Quality
improvement.
This could be bone throught regular

training programme or printed
materials
The assessors shall be either

trained internally or externall in
NABH standards. They shall assess
areas independent of their area of
work
Reporting errors need to be

captured. It is better if the
organization caputers these errors
as errors picked up before
dispatching the reports and errors
picked after the dispatch of reports.
This includes transcription errors
also.
Re-dos include tests which needed
to be repeated in view of poor
sample or improper positioning and
in case of radiology also includes
radiology also include films
wastage.To capture co-relation it
becomes mandatory that all
investigation forms have a
provisional diagnosis/relevant
clinical details written on them .The
HCO could decide as to which tests
will be monitered.To capture
adherence to safety precautions
the organization needs to do a
random check of all employees per
month (working in these areas and
including all categories of staff) and
capture data.
Adverse anaesthesia events include

events which happen during the
procedure like hypoxia, arrhythmias,
cardiac arrest etc.
Wastage includes blood products

found unfit for use
Missing records include records

within the retention
Refer to HIC 4
Refer to ICMR guidelines and GCP
for reporting time of serious adverse
events.
For example data can be collected

to study the reasons for Re Dos in
surgical patients
Data could be represented
graphically e.g. bar chart,pie chart,
etc.
For example , once the reasons for

Re Dos have been analysed and
preventive and corrective measures
undertaken then data can be
collected to confirm that reductions
have occurred in the incidence of
Re Dos.
Local purchase implies drugs
purchased outside the formulary.
For example, tax , EPF, notifiable
diseases,births and deaths,PNDT
act, AERB guidelines etc.
Mock drills include fire,nono-fire and

disaster management.
Refer to glossary for definition of
risk management
Waiting time implies the time taken
from the time that the patient
registers to the time taken for
assessment to be done by the
doctor/ diagnostic procedure to be
performed. Time taken for
discharge implies the time from
which the doctor writes for
discharge to the time for final
clearance
The bedget could be earmarked

based on previous years spending.
If
noexample
data is available
the HCO
For
,Root cause
analysis,
could
make
a
beginning
FMEA, project evalution by
and review
earmarking
a budget
but reviewing
it
technique (PERT),
Critical
path
at
the
end
of
6
months
to
make
any
method (CPM), Control charts etc.
necessary modifications.
These could be members of the
core committee/quality assurance
committee,
etc.
The auit shall
encompass all
aspects of care including clinical
and nursing.
The HCO could use a checklist with

the predefined parameters and the
audit findings could be recorded on
This should preferably be done
this sheet.
based on root cause analysis.
Refer to Glossary for definition of
sentinel events.
For definition of mission refer to

glossary.
Refer to glossary for strategic and
operational plans.Stakeholders
include the community the
organization serves.
Senior leaders include the first two

rungs of the organogram
It is not only the Head of the HCO
but the members of the Board of
governors (where applicable) who
This shall include central
need to support this.
legislations (e.g. Drugs and
Cosmetics act, MTP act,PNDT
For
example,free
camps
outreach
Act,1996),
Bio medical
waste
act,
programmes,adoption
of villages,
Air (Prevention and control
of
PHCs
etc.Act, 1981, Atomic Energy
pollution)
Requlatory Body Approvals, License
under Bio-medical Manaement and
Handling Rules, 1998, respective
state legislations (Maharashtra
Maintenance of clinical Records act,
For
example,nephrology
clinical
establishment of west
department
do all activities
Bengal) andcould
local regulations
(e.g..
like
building
byelaws).
It
could be
common for the entire
biopsy,shunts,listulas,dialysis(haem
HCO.
o, CAPD),etc.
To effectively implement this each
department could have its
department objectives/ key
performance indicators and the
responsibility of achieving them
could
be that of
leader.
For definition
of the
mission
refer to
glossary.
A good reference guide is code of
medical ethics 2002 published by
MCI.
The disclosure could be in the

registration certificate/ quality
manual
, etc. implies that the that
Here portrays
HCO conveys to the patients clearly
what it can and cannot provide. The
services that it cannot provide could
also be conveyed verbally. Refer to
Also
AAC refer
1 alsoto PRE 5. The tariff could
be devised by a tariff committee.
This implies to the individual looking

after the day to day Board of
Governors.
implies
AppropriateAppropriate
implies administrative
qualification
in
hospital
experience in a HCO.
management/ administration.
The group could have a mix of

administratorsgineers, doctors and
nurses, Refer to glossary for
Refer
to glossary
definition of
definition
of safetyfor
programme.
adverse events and sentinel events.
Reporting incident/accident should
for example, MRI machine, of the
not just be based on severity of the
HCO breaks down. In this case
incident. In fact, all incidents must
internal reporting is to be done to
be
reported.
Refer
to glossary
for definition
reporting
is to be done
to CEO of
and
risk
definition
of
risk
assessement
external reporting to be done o the
and
risk reduction.
patients.
For example, the protection

guidelines given in national building
code of India,relevant state and
local body regulations (Kerala state
building rules).
Refer glossary for definition of

preventive and breakdown
maintenance.
These signages shall guide patients
and visitors. It is preferable that
signages are bilingual. Statutory
For example Indian standards (IS
requirements shall be met.
12433) formulated by Bureau of
Indian standards (for 30 and 100
bedded hospitals and other
standards), IS 10905 for basic
requirements for general hospital
buildings.
For water quality, refer to IS 10500.
The National Building Code is a

good reference guide.
Refer to National Disaster

Management Authority guidelines.
Quantity of resources i.e. medical
stores etc. should match with the
expected workload.
This is only the minimum frequency

and this may be increased.
The hazardous materials could be

identified as per part II of
manufacture, Storage and Import of
Hazardous Chemical (Amendment)
Rules, 2000.
In addition Biological materials like
blood, body fluids and
microbiological cultures, mercury,
nuclear isotopes, medical gases,
LPG gas, steam, ETO etc are some
of the other common hazardous
materials.
The safety committee must include

representatives form facility
management, clinicians,
administrator, nursing and
paramedical staff.
It is example,
preferablegrab
that bars,
the HCO
For
bed rails,
conducts
an exercise
of Hazard
sing
posting,
safety belts
in
Identification
Riskchairs,
Analysis
stretchers
andand
wheel
alarms
During
these
rounds potential
safety
(HIRA)
and and
accordingly
both
visual
auditorytakes
whereall
risks
are
identified.
necessary steps
to eliminate
applicable,
warning
signs likeof
reduce and
such
hazards
and
radiation
or after
biohazard,
call may
bells,befire
Before
evidence
associated
risks.
safety
devices
etc.
maintained.
A good reference could be the MCI

and INC guidelines.
Refer to glossary for definition of job
description and job specification.
This report could be got firm the
district magistrate (s) of the district
(s) where the employee has served
earlier and/or from the previous
employer.
It
could
alsobebedone
obtained
fromofthe
This
could
as a part
the
regulatory
bodies
like
MCI
(Good
induction training .
Conduct Certificate).
This could be done as a part of the
induction training and the same
could be provided in the form of a
booklet. In also reinforce the correct
This
could be of
done
as a and
part of the
interpretation
policies
induction
training and the same
procedures.
could
be provided
in the
For patient
right refer
to form
PRE of
2. a
booklet.
The employees should be trained to
implement the service standards of
the organization.
The training shall be for all

categories of staff including doctors
and outsourced staff (wherever
applicable).
For example, fire and non fire

emergency, needle stick injury, etc.
Staff should be able to practically
demonstrate actions like taking care
of blood spills, medication errors
The
staff should
beevent
able to
intimate
and other
adverse
reporting
the
sequence
of
events
the
they will
systems.
undertake in the eventuality of
Reporting processes could be
occurrence of any adverse event.
checked form time to time by the
management to ensure their
implementation.
For definition of performance

appraisal refer to glossary.
To be incorporated in the service
booklet and included in the
induction training.
For definition of job description refer
to glossary.
This shall be done at least once a

year.
For definition of disciplinary

procedure refer to glossary.
This could be in the form of service

rules.
Refer to relevant labour laws and
CCS (CCA) rules.
Appellate authority should be higher
than the disciplinary authority.
The HCO could address all points in

HRM2, HRM4, HRM5, HRM6
For example, performing preemployment HIV testing is illegal.

For example, employee health and
safety policy.
The HCO could define the
parameters and it could be different
for different categories of personnel.
For
of also
occupational
The definition
HCO could
identify health
hazard
refer
to
glossary
competent individuals to perform
the same.
For definition of credentialing refer

to glossary.
A good reference could be MCIs

website.
For example, radiotherapy can only

be give by a radiation oncologist.
Where authorization is provided on
the basis of training the HCO shall
maintain a copy of the training
The
HCO
this in
record
andcould
verifyincorporate
it.
the brochure itself.
Refer to Indian Nursing Council Act,

1947
For example. An infection Control

Nurse should have had requisite inhouse / external training and
experience and the aptitude and
knowledge to perform the tasks
required of her.
For example, daily census report,

utilization rates, etc. Also refer to
CQI 2 and CQI 3.
Some of these include:-IT Act 2000

for computer based records, PNDT
Act for relevant details of all patients
undergoing ultrasound, Code of
Medical Ethics, 2002, RTI Act 2005,
For
sending
birth and
etc. example,
Relevant sate
legislation
e.g.
death
statistics,
notifiable
diseases
Maintenance
of Clinical
Records
Act
(refer
to glossary)
and pulse polio
(MOCRA)
in Maharashtra.
programme.
This is in the context of frequency of
capturing data namely daily, weekly,
monthly quarterly, yearly etc.
(Statistical bulletin).
The organization could decide on
which data needs to be shared with
whom and also the modalities (e.g.
Storage could be physical of
memos, circulars etc.) for
electronic. Wherever electronic
dissemination of such data.The
storage is done the HCO shall
organization could decide on which
ensure that there ate adequate
data needs to be shared with whom
safeguards for protection of data.
and also the modalities (e.g.
memos, circulars etc.) for
dissemination of such data.
For example, CR number, hospital
number, etc. GS1 standards and
numbering
system
can category
be used to
This
could be
different
of
identify andfortrack
the patient
personnel
different
entries,record
but it
withinbe
and
outside
the hospital.
shall
uniform
across
the HCO.
For
electronic
media
For records
example.onProgress
record
byit is
preferable
that
the
date
and
time
is
doctor and medication
automatically
by the
administrationgenerated
chat by nurse.
system.
For example, admission order, face
sheet, IP sheet, discharge
summary, doctors order consent
form etc.
For definition of plan of care refer to

glossary. After the initial visit it shall
at
least
have
a provision
Also
refer
to COP
12f. diagnosis.
The final diagnosis (IP) must be is
as per ICD 10.
If the patient has been transferred
at his/her request a note may be
added to that effect. In such
instances
name
the receiving
Dischargethe
note
is theofsame
as
hospital could be the name the
discharge summary. Also refer to
patient desires to go to. However, if
AAC
15. to AAC 15 g.
Alsopatient
refer
the
has been transferred by
the HCO it shall have an
acknowledgement form the
For definition of autopsy refer to
receiving hospital.
glossary.
For example, privileged

communication.
It is preferable that softwares when
used shall be validated and duly
authenticated.
Refer to IMS 7.
For example, moving form physical
to electronic format, remote backup
of data, etc.
Special care should be taken in
medico-legal cases.
The HCO could define the

periodicity.
The HCO shall identify and

authorize such individuals.
An adequate mix of both active and

discharged patients should be used.
For example, missing final
diagnosis, absence of OT motes in
an operated patient, etc.
Chapter 3: MANAGEMENT OF
MEDICATION
(MOM) services and usage of
organization of pharmacy
a
There is a documented policy and

procedure for pharmacy services and
medication usage.
The polices and procedures shall

address the issues related to
procurement, storage, formulary,
prescription, dispensing, administration,
monitoing and use of medications.
These comply with the applicable laws and Self explanatory.

regulations.
A multidisciplinary committee guides the

formulation and implementation of these
policies and procedures.
This shall be representative of major

clinical departments administration and
shall include a pharmacist/ clinical
pharmacologist.
MOM.2: There is a hospital formulary.

a
A list of medication appropriate for the

patients and organizations resources is
developed.
The list is developed collaboratively by the Refer to MOM 1c.

multidisciplinary
committee.
There is a defined
process for acquisition The process should address the issues
of these medications.
of vendor selection,vendor
evalation,generation of vendor
evaluation,generation of purchase order
and receipt of goods and receipt of goods
as per rules.
The hospital formulary shall be prepared

and be preferably updated at regular
intervals.
There is a process to obtain medications
Self explanatory
for storage of medication.
to temperature (refrigeraion),light,
ventilation preventing entry of
pests/rodents and vermins.
Medications are stored in a clean, well lit

and ventilated environment.
The organization shall also ensure that

the storage requirements of he drug as
specified by the manufacturer are
adhered to.If the recommendations are
confilicting recommendations in nature,
the organization shall follow the
manufacturer's recommendation. This
shall be applicable to all areas where
medications are stored including wards.
Sound inventory control practices guide

storage of the medications.
Self explanatory
MOM.3: Policies and

procedures
exist for storage of
not listed
in the formulary.
medication. a
Documented policies and procedures exist These should address issues pertaining
Medications are protected from loss or

theft.
Sound alike and look alike medications are Many drugs in ampoules, vials or tablets
stored separately.
may look-alike or sound alike. They
should be segregated and stored
seperately.
There is a method to obtain medication

when the pharmacy is closed.
Emergency medications are available all
the time.
The oranization shall ensure that it

develops proper mechanisums to prevent
pilferage. The organization could conduct
audits at regular intervals (as defined by
the organiztion) to detect such instances
when pharmacy is closed , there should

be SOP to procure the drugs.
Adequate amount of emergency
medicines should be stocked at all times.
Re-order level at definite quantity should
be done.
Emergency medications are replenished in self explanatory
for
ofdetermines
medications.
Theprescription
organization
who can write this shall be done by the treating doctor.
orders.
Orders are written in a uniform location in all the orders for medicines are recorded
the medical records.
on a uniform location of the case sheet.
Electronic orders when typed shall again
follow the same principles.
MOM.4: Policies and

procedures
exist
for
a timely
manner when
used.
prescription of
medications.
a
Documented policies and procedures exist self explanatory
c
Medication orders are clear, legible, dated, Self explanatory

timed, named and signed.
Policy on verbal orders is documented and The organization shall ensure that it has
implemented.
a policy to address as to who can give
verbal orders and how these orders will
be validated
The organization defines a list of high risk

medication.
High risk medications are medications

involved in a high percentage of
medication errors or sentinel events and
medications that carry a high risk for
abuse, error, or other adverse
outcomes.Examples include medications
with a low therapeutic window, controlled
substances, psychotherapeutic
medications,and look-alike and soundalike medications.
High risk medication orders are verified

prior to dispensing.
These medications shalll preferably be

given only arter written orders and it
should be verified by the staff before
dispensing.
MOM.5: Policies and procedures guide the safe

dispensing ofa medications.
Documented policies and procedures guide Clear policies to be laid down for
the safe dispensing of medications.
dispensing of medication e.g. route of

administration, dosage, rate of
administration, expiry date , etc.
The policies include a procedure for

medication recall.
Recall may result based on letters from

regulatory authoroties or internal
feedback( e.g. visible contaminant in IV
fliud bottle)
Expiry dates are checked prior to

dispensing.
Labeling requirements are documented
and implemented by the organization.
Self explanatory
At a minimum, labels must include the

drug name, strenght,ffrequency of
administration ( in a language the patient
understands ) and expry dates.
MOM.6: There are defined procedures for

medication administration.
a
Medications are administered by those who Self explanatory
are permitted by law to do so.
b
c
Prepared medication are labeled prior to

Self explanatory
preparation
of
a
second
drug.
Patient is identified prior to administration. Self explanatory
Medication is verified from the order prior to Staff administering medications should
administration.
go through the treatent orders before
administration of the medication and then
only administer them. It is preferable that
they also check the general appearance
of the medication) eg .melting, clumping
etc.)
Dosage is verified from the order prior to

administration.
Route is verified from the order prior to
administration.
Timing is verified from the order prior to
administration.
Medication administration is documented.
Self explanatory
Self explanatory
Self explanatory
The organization shall ensure that this is
done in a uniform location and it shall
include the name of medication, dosage,
route of administration, timing and the
name and signature of the person who
has administered the medication
Polices and procedures govern patients

self administration of medications.
At the outset the HCO could define if it

would permit self administration of
medications. In case the HCO permits
then the policy shall include the
medications which the patient can self
administer. If is preferable that the
organization also incorporates a method
to ensure that the patient is reminded to
take the medication ( before every dose)
and documentation of self administration
Polices and procedures govern patients

medications brought from outside the
organization.
These shall address ass to what are the

pre-requisites for such a medication ( eg.
invoice, clear label with mention of the
name ,dose, expiry date etc)
f
g
h
MOM.7: Patients and family members are educated

about safe medication and food-drug interactions.
Patient and family are educated about safe The organization shall make a list of such
and effective use of medication.
drugs and accordingly educate eg.
digoxin. This could also include education
regarding the immportance of taking a
drug at a specific time eg. sustained
release medications.
Patient and family are educated about

food-drug interactions.
MOM.8: Patients are monitored after medication

administration.
a
Patients are monitored after medication
administration and this is documented.
Patient and family should be counselled

about their diet during medication eg. no
alcohol when taking metronidazle.
This shall be done by anyone involced in

direct patient care. The organization
could follow either a pasiive
( documenting only if the patient tellls ) or
active ( enquiring with every patient )
monitoring mechanism.
Adverse drug events are defined.
The organization shall define as to what

constitutes an adverse drug event. This
shall be in consonance with best
practices.Adverse drug events include
adverse drug reactions as well as
medication errors.
Adverse drug events are reported within a

specified time frame.
Self explanatory
The organization shall define the
timeframe for reporting once the adverse
drug event has occured.
Adverse drug events are collected and

analysed.
All the adverse drug reaction are

analysed regularly by the multidisciplinary committee
Policies are modified to reduce adverse
Self explanatory
the usepolicies
of narcotic
drugs
and psychotropic
These
are in
consonance
with local
and national regulations.
A proper record is kept of the usage,
administration and disposal of these drugs.
These drugs are handled by appropriate
and
procedures
guide
usage
personnel
in accordance
withthe
policies.
This is in context of narcotic drugs and

psychotropic substances act.
These shall be kept in accordance with
statutory requirements.
Self explanatory
MOM.9: Policies and

guide the use
of
drugprocedures
events when unacceptable
trends
narcotic drugs
and
psychotropic
substances.
a
Documented policies and procedures guide Self explanatory
c
d
MOM.10: Policies
of chemotherapeutic
agents.
a
Documented policies and procedures guide Self explanatory
b
the usage of chemotherapeutic

Chemotherapy
is prescribed by agents.
those who This shall preferably be a medical
have the knowledge to monitor and treat
oncologist or a person who has been
the adverse effect of chemotherapy.
trained and had achieved competency in
the same.
Chemotherapy is prepared and

administered by qualified personnel.
This shall preferable be staff who have

received special trainig in preparing and
administration.
Chemotherapy drugs are disposed off in

accordance with legal requirements.
These shall be disposed off according to

Bio-medical waste management and
handling rules 1998 or manufacturer's
recommendation.
MOM.11: Policies and procedures govern usage of

radioactive drugs.
a
b
c
govern policies
usage ofand
radioactive
drugs.
These
procedures
are in
consonance
with
laws
and
regulations.
The policies and procedures include the
safe storage, preparation, handling,
distribution, and disposal of radioactive
Self explanatory
Refer to AERB guidelines.
Self explanatory. This shall however be in
accordance with AERB guidelines.
Staff, patients and visitors are educated on Self explanatory

safety precautions.
MOM.12: Policies and procedures guide the use of

implantable prosthesis.
a
Self explanatory
relevant and sufficient scientic data are
available before selection. It shall also
look for international (e.g. US-FDA) of
national notification (Drugs and
Cosmetics Act notification october 2005)
for approval of the particular product.
govern
procurement
andprosthesis
usage of is
Selection
of implantable
based on scientific criteria and national/
internationally recognized approvals.
The batch and serial number of the
Self explanatory
govern procurement, handling, storage,

distribution, usage and replenishment of
medical gases.
in the organization . It shall also address

the issue of statutory requirements and
approvals wherever applicable It shall
follow a uniform colour coding system.
The policies and procedures address the

safety issues at all levels.
This shall include from the point of

storage/source area, gas supply lines
and the end user area.Appropriate safety
measures shall be developed and
implemented for all levels.
Appropriate records are maintained in

accordance with the policies, procedures
and legal requirements.
This is the context of the Indian

explosives act of 1884, Gas cylinder rules
1981 and static and mobile pressure
vessels (unfired) 1981.
MOM.13: Policies and

procedures
guide
the use
implantable
prosthesis
are recorded
in of
the
medical gases.
a
This shall be applicable to all gases used
Comments
Pharmacy
Nursing
Relevant legislations include Drugs and

cosmetics Act food and Drugs and
Psychotropic substances Acts,Drugs
and magical Remedies (Objectionable
Advertisement) Act, etc.
The pharmacy
shall ensure that
all the rules and
Nursing shall
regulations are
ensure that
followed while
proper storage of the drugs are
medicines
approved
supoplied to the procured,
patient
stored,dispensed
Licenced
premises
registered
pharmacy
tempoerature
control
For example, pharmacy and
therapeutics committee.
For example, local purchase.
Vaccines should preferable be kept in

vaccine refrigerators (Ice Lined
Refrigerator).
The organization shall follow inventory

control practics like first in and first out ,
ABC, etc.
Nursing shall
ensure that
proper medicines
are supoplied to
the patient ,
following the 8Righjts of
medication
the organization can folllow a method of

storing drugs by generic name in an
alphabetical order to address this
issue .
it is preferable that the HCO has a 24
hours pharmacy.
refer to MOM 1a
The organization can explore the

possibility of writing orders in block
letters so that the issue of legibility is
adderessed.
This shall be done at alll levels e.g.

pharmacy, ward, etc
This is applicable to all dispensing
areas wherein medicines are dispensed
either as cut strips or from bulk
containers.
Refer to statutory requiremenys. in
addition to doctors, nursing staff may
also administer.
applicable for parenteral drugs
Identification shall be done by unique
identification number( eg. hospital
number/IP number, etc)with/without
name
the records shall reflect the actual

administration.For example, if brand Y
was given in place of brand X(same
gnerically)the documentation shall be of
brand Y. Similarly if the order was for a
tablet of 250mg but the administsation
was1/2 a tablet of 500mg the latter shall
be documented.
for example, slf administration of
insulin.
Refer to glossary for "adverse drug

event"
This refers to the layout/location of

radiaton waste pipes,delay waste pipes,
delay tanks, etc.
Doctors
The Doctors shall

ensure that the
medication
orders are written
properly and at
the same
location every
time on a
medciation order
section of the
patients medical
record-

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Self Assessm

Compliance to the requirement: 10

Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)

The services being provided are clea

The staff is oriented to these services

Standardized policies and procedure

The policies and procedures address

Patients are accepted only if the orga

The policies and procedures also add

The staff is aware of these processes

Policies guide the transfer of unstab

Policies guide the transfer of stable p

Procedures identify staff responsible

The organization gives a summary o

The patients and/ or family members

The patients and/ or family members

The patients and/ or family members

The organisation defines the content

The organisation determines who can

The organisation defines the time fra

Initial assessment includes screening

The initial assessment results in a do

The plan of care also includes preven

All patients are reassessed at approp

Staff involved in direct clinical care do

Patients are reassessed to determine

Scope of the laboratory services are

Adequately qualified and trained pers

Laboratory results are available within

Critical results are intimated immedia

Laboratory tests not available in the o

AAC.8 There is an established laboratory quality assurance programme.

The laboratory quality assurance prog

The programme addresses verificatio

The programme addresses surveillan

The programme includes periodic cal

The programme includes the docume

The laboratory safety programme is d

This programme is integrated with the

Written policies and procedures guide

Laboratory personnel are appropriate

Laboratory personnel are provided w

AAC.9 There is an established laboratory safety programme.

Imaging services comply with the leg

Scope of the imaging services are co

Policies and procedures guide identif

Critical results are intimated immedia

Imaging tests not available in the org

AAC.11 There is an established quality assurance programme for imaging services.

The quality assurance program for im

The programme addresses verificatio

The programme addresses surveillan

The programme includes periodic cal

The programme includes the docume

The radiation safety programme is do

This programme is integrated with the

Written policies and procedures guide

Imaging personnel are provided with

Radiation safety devices are periodic

Imaging personnel are trained in radi

Imaging signage are prominently dis

Policies and procedures guide the sa

AAC.12 There is an established radiation safety programme.

AAC.13 Patient care is continuous and multidisciplinary in nature.