National Accreditation Board for Hospitals and Health Care Workers (NABH)

1. National Accreditation Board for Hospitals and Health Care Workers (NABH) STANDARDS FOR HOSPITALS

2. Accreditation • Official approval of an organization • Accredited • Officially approved • Accreditation Standard • It is defined as a statement of an expectation or requirement which makes it possible to deliver quality care or services

3. PROCCESS STRUCTURE OUTCOME HEALTH CARE ORGANIZATION

4. ORGANIZATION OF NABH

5. ORGANIZATION OF NABH( Contd)

6. Preparing for Accreditation

7. Accreditation Procedure Feed back to & necessary corrective action by Health Care Organization

8. Accreditation Procedure (Contd)

9. Standards for Accreditation

10. PATIENT CENTERED Access, Assessment & Continuity of Care (AAC) Pts Right & Education (PRE) Care of Patient (COP) Mgt of Medication (MOM) Hosp Infection Control (HIC) ORGANIZATION CENTERED Continuous Quality Improvement (CQI) Responsibility of Mgmt (ROM) Facility Mgmt & Safety (FMS) Human Resource Mgmt (HRM) Information Mgmt System (IMS) Standards: 2 sets

11. Chapter 1 Access, Assessment and Continuity of Care (AAC)

12. AAC.1. The organization defines and displays the services that it can provide. • The services being provided are clearly defined and are in consonance with the needs of the community. • The defined services are prominently displayed. • The staff is oriented to these services.

13. AAC.2. The organization has a well defined registration & admission process • Standardised policies & procedures • are used for registering & admitting pts. • address out-pts, in-pts & emergency pts. • also address managing patients during NA beds. • Pts accepted only if the orgn can provide reqd service. • The staff is aware of these processes.

14. AAC.3.An appropriate mechanism for transfer or referral of patients who do not match the Org resources. • Policies guide • the transfer of unstable patients to another facility in an appropriate manner. • the transfer of stable patients • Procedures identify staff responsible during transfer. • The organization gives a summary of patient's condition and the treatment given.

15. AAC.4. During admission the patient and I or the family members are educated to make informed decisions. • The patients and/or family members are • explained about the proposed care. • explained about the expected results. • explained about the possible complications. • explained about the expected costs.

16. AAC.5. Patients cared for by the organization undergo an estd initial assessment. • The organization • defines content of the assessments for OPD, IPD and emergency pts. • determines who performs the assessments. • defines the time frame for initial assessment. • The initial assessment for in-patients is documented within 24 hours or earlier as per the patient's condition or hospital policy. • Initial assessment includes screening for nutritional needs. • The initial assessment results in a documented plan of care which is monitored. • The plan of care also includes preventive aspects of the care.

17. AAC.6. All patients cared for by the organization undergo a regular reassessment • All patients are reassessed at appropriate intervals. • Staff involved in direct clinical care document reassessments. • Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

18. AAC.7. Lab services are provided as per the requirements of the patients. • Scope of the lab services commensurate to services provided by the organization. • Adequately qualified and trained personnel perform and/or supervise the investigations. • Policies and procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens. • Laboratory results are available within a defined time frame. • Critical results are intimated immediately to the concerned personnel. • Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

19. AAC.8. There is an established laboratory quality assurance programme. • The laboratory quality assurance programme is documented. • The programme • addresses verification and validation of test methods. • addresses surveillance of test results. • includes periodic calibration and maintenance of all equipments. • includes the documentation of corrective and preventive actions

20. AAC.9. There is an established laboratory safety programme. • The programme is documented. • This programme is integrated with the organization's safety programme. • Written policies and procedures guide the handling and disposal of infectious and hazardous materials. • Laboratory personnel are appropriately trained in safe practices. • Laboratory personnel are provided with appropriate safety equipment / devices

21. AAC.10. Imaging services are provided as per the requirements of the patients. • Imaging services comply with legal & other requirements. • Scope of the imaging services are commensurate to the services provided by the organization. • Adequately qualified and trained personnel perform, supervise and interpret the investigations. • Policies and procedures guide identification and safe transportation of patients to imaging services. • Imaging results are available within a defined time frame. • Critical results are intimated immediately to the concerned personnel. • Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system

22. AAC.11. There is an established quality assurance programme for imaging services. • The programme is documented. • The programme addresses • verification and validation of imaging methods. • surveillance of 'imaging results. • The programme includes • periodic calibration and maintenance of all equipments. • the documentation of corrective and preventive actions

23. AAC.12. There is an established radiation safety programme. • The programme is documented. • This programme is integrated with the organization's safety programme. • Written policies and procedures guide the handling and disposal of radio-active and hazardous materials. • Imaging personnel are provided with appropriate radiation safety devices. • Radiation safety devices are periodically tested and documented. • Imaging personnel are trained in radiation safety measures. • Imaging signage are prominently displayed • Policies and procedures guide the safe use of radioactive isotopes for imaging services

24. AAC.13. Patient care is continuous and multidisciplinary in nature. • During all phases of care, there is a qualified individual identified as responsible for the patient's care. • Care of patients is coordinated in all care settings within the organization. • Information about the patient's care and response to treatment is shared among medical, nursing and other care providers. • Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments. • The patient's record is available to the authorized care providers to facilitate the exchange of information. • Policies and procedures guide the referral of patients to other departments/ specialities.

25. AAC.14. The organization has a documented discharge process. • The patient's discharge process is planned in consultation with the patient and/or family. • Policies and procedures • exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases). • are in place for patients leaving against medical advice. • A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice).

26. AAC.15. Organization defines the content of the discharge summary. • Discharge summary is provided to the patients at the time of discharge. • Discharge summary contains • the reasons for admission, significant findings and diagnosis and the patient's condition at the time of discharge. • contains information regarding investigation results, any procedure performed, medication and other treatment given. • follow up advice, medication and other instructions in an understandable manner. • instructions about when and how to obtain urgent care

27. Chapter 2 Care of Patients (COP)

28. COP.1. Uniform care of patients is provided in all settings of the organization & is guided by the applicable laws, regulations & guidelines.   • Care delivery is uniform when similar care is provided in more than one setting. • Uniform care is guided by policies and procedures which reflect applicable laws and regulations. • The care and treatment orders are signed, named, timed and dated by the concerned doctor. • The care plan is countersigned by the clinician in-charge of the patient within 24 hours. • Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible.

29. COP.2. Emergency services are guided by policies, procedures and applicable laws and regulations.   • Policies and procedure for emergency care are documented. • Policies also address handling of medico-legal cases. • The patients receive care in consonance with the policies. • Policies and procedures guide the triage of patients for initiation of appropriate care. • Staff is familiar with the policies and trained on the procedures for care of emergency patients. • Admission or discharge to home or transfer to another organization is also documented

30. COP.3. The ambulance services are commensurate with the scope of the services provided by the organization. • There is adequate access and space for the ambulance(s). • Ambulance(s) is appropriately equipped. • Ambulance(s) is manned by trained personnel. • There is a checklist of all equipment and emergency medications. • Equipment are checked on a daily basis. • Emergency medications are checked daily and prior to dispatch. • The ambulance(s) has a proper communication system.

31. COP.4. Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation. • Documented policies and procedures guide the uniform use of resuscitation throughout the organization. • Staff providing direct patient care is trained and periodically updated in cardio • pulmonary resuscitation. • The events during a cardio-pulmonary resuscitation are recorded. • A post-event analysis of all cardiac arrests is done by a multidisciplinary committee. • Corrective and preventive measures are taken based on the post-event analysis.

32. COP.5. Policies and procedures define rational use of blood and blood products. • Documented policies and procedures are used to guide rational use of blood and blood products. • The transfusion services are governed by the applicable laws and regulations. • Informed consent is obtained for donation and transfusion of blood and blood products. • Informed consent also includes patient and family education about donation. • Staff is trained to implement the policies. • Transfusion reactions are analyzed for preventive and corrective actions.

33. COP.6. Policies and procedures guide the care of patients in the Intensive Care and High Dependency Units.   • The organization has documented admission and discharge criteria for its intensive • care and high dependency units. • Staff is trained to apply these criteria. • Adequate staff and equipment are available. • Defined procedures for situation of bed shortages are followed. • Infection control practices are followed. • A quality assurance program is implemented.

34. COP.7. Policies and procedures guide the care of vulnerable physically and/or mentally challenged and children).   • Policies and procedures are documented and are in accordance with the prevailing • laws and the national and international guidelines. • Care is organized and delivered in accordance with the policies and procedures. • The organization provides for a safe and secure environment for this vulnerable group. • A documented procedure exists for obtaining informed consent from the appropriate legal representative. • Staff is trained to care for this vulnerable group.

35. COP.8. Policies and procedures guide the care of high risk obstetrical patients. • The organization defines and displays whether high risk obstetric cases can be cared • for or not. • Persons caring for high risk obstetric cases are competent. • High risk obstetric patient's assessment also includes maternal nutrition. • The organization caring for high risk obstetric cases has the facilities to take care of neonates of such cases.

36. COP.9. Policies and procedures guide the care of Pediatric patients. • The organization defines and displays the scope of its pediatric services. • The policy for care of neonatal patients is in consonance with the national! international guidelines. • Those who care for children have age specific competency. • Provisions are made for special care of children. • Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment. • Policies and procedures prevent child/ neonate abduction and abuse. • The children's family members are educated about nutrition, immunization and safe parenting and this is documented in the medical record.

37. COP.10. Policies and procedures guide the care of patients undergoing moderate sedation. • Competent and trained persons perform sedation. • The person administering and monitoring sedation is different from the person performing the procedure. • Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, • respiratory rate, blood pressure, oxygen saturation, and level of sedation. • Patients are monitored after sedation. • Criteria are used to determine appropriateness of discharge from the recovery area. • Equipment and manpower are available to rescue patients from a deeper level of sedation than that intended.

38. COP.11. Policies and procedures guide the administration of anesthesia. • There is a documented policy and procedure for the administration of anesthesia. • All patients for anesthesia have a pre-anesthesia assessment by a qualified individual. • The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented .. • An immediate preoperative re-evaluation is documented. • Informed consent for administration of anesthesia is obtained by the anesthetist. • During anesthesia monitoring includes regular and periodic recording of heart rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation,· airway security and patency and level of anesthesia. • Each patient's post-anesthesia status is monitored and documented. • A qualified individual applies defined criteria to transfer the patient from the recovery area. • All adverse anesthesia events are recorded and monitored.

39. COP.12. Policies and procedures guide the care of patients undergoing surgical procedures. • The policies and procedures are documented. • Surgical patients have a preoperative assessment and a provisional diagnosis documented prior to surgery. • An informed consent is obtained by a surgeon prior to the procedure. • Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery. • Persons qualified by law are permitted to perform the procedures that they are entitled • to perform. • A brief operative note is documented prior to transfer out of patient from recovery area. • The operating surgeon documents the post-operative plan of care. • A quality assurance program is followed for the surgical services. • The quality assurance program includes surveillance of the operation theatre environment. • The plan also includes monitoring of surgical site infection rates.

40. COP.13. Policies and procedures guide the care of patients under restraints. • These include both physical and chemical restraint measures. • These include documentation of reasons for restraints. • These patients are more frequently monitored. • Staff receive training and periodic updating in control and restraint techniques.

41. COP.14. Policies and procedures guide appropriate pain management. • Documented policies and procedures guide the management of pain. • The organization respects and supports the appropriate assessment and management of pain for all patients. • Patient and family are educated on various pain management techniques.

42. COP.15. Policies and procedures guide appropriate rehabilitative services. • Documented policies and procedures guide the provision of rehabilitative services. • These services are commensurate with the organizational requirements. • Rehabilitative services are provided by a multidisciplinary team.

43. COP.16. Policies and procedures guide all research activities. • Documented policies and procedures guide all research activities in compliance with national and international guidelines. • The organization has an ethics committee to oversee all research activities. • The committee has the powers to discontinue a research trial when risks outweigh the potential benefits. • Patient's informed consent is obtained before entering them in research protocols. • Patients are informed of their right to withdraw from the research at any stage and also of the consequences (if any) of such withdrawal. • Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization's services.

44. COP.17. Policies and procedures guide nutritional therapy. • Documented policies and procedures guide nutritional assessment and reassessment. • Patients receive food according to their clinical needs. • There is a written order for the diet. • Nutritional therapy is planned and provided in a collaborative manner. • When families provide food, they are educated about the patients diet limitations. • Food is prepared, handled, stored and distributed in a safe manner.

45. COP.18. Policies and procedures guide the end of life care. • Documented policies and procedures guide the end of life care. • These policies and procedures are in consonance with the legal requirements. • These also address the identification of the unique needs of such patient and family. • These also include sensitively addressing issues such as autopsy and organ donation. • Staff is educated and trained in end of life care.

46. Chapter 3 Management of Medication (MOM)

47. MOM.1. Policies and procedures guide the organization of pharmacy services and usage of medication.   • There is a documented policy and procedure for pharmacy services and medication usage. • These comply with the applicable laws and regulations. • A multidisciplinary committee guides the formation and implementation of these policies and procedures.

48. MOM.2. There is a hospital formulary. • A list of medication appropriate for the patients and organization's resources is • developed. • The list is developed collaboratively by the multidisciplinary committee. • There is a defined process for acquisition of these medications. • There is a process to obtain medications not listed in the formulary.

49. MOM.3. Policies and procedures exist for storage of medication. • Documented policies and procedures exist for storage of medication. • Medications are stored in a clean, well lit and ventilated environment. • Sound inventory control practices guide storage of the medications. • Medications are protected from loss or theft. • Sound alike and look alike medications are stored separately. • There is a method to obtain medication when the pharmacy is closed. • Emergency medications are available all the time. • Emergency medications are replenished in a timely manner when used.

50. MOM.4. Policies and procedures exist for prescription of medications. • Documented policies and procedures exist for prescription of medications. • The organization determines who can write orders. • Orders are written in a uniform location in the medical records. • Medication orders are clear, legible, dated, timed, named and signed. • Policy on verbal orders is documented and implemented. • The organization defines a list of high risk medication. • High risk medication orders are verified prior to dispensing