IMPLEMENTATION OF JOINT COMMISSION INTERNATIONAL STANDARDS IN TERTIARY

CARE HEART HOSPITAL WITH SPECIAL FOCUS ON DOCUMENTATION

INDIAN INSTITUTE OF SOCIAL WELFARE AND BUSINESS MANAGEMENTCOLLEGE SQUARE WEST, KOLKATA 700 073

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IMPLEMENTATION OF JOINT COMMISSION INTERNATIONAL STANDARDS IN TERTIARY CARE HEART HOSPITAL WITH

SPECIAL FOCUS ON DOCUMENTATION

Project Report Submitted to the University of Calcutta

in Partial Fulfillment for the Award of Master of Public Systems Management (With Specialization in Environment Management)

By

KAUSTAV DEB

ROLL NO.: 107/MPS/130049

SESSION: 2013-2015

INDIAN INSTITUTE OF SOCIAL WELFARE AND BUSINESS MANAGEMENT

COLLEGE SQUARE WEST, KOLKATA 700 073

May, 2012

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DECLARATION

I, Mr. Kaustav Deb

Hereby declare that this project report is the record of authentic work carried out by me during the period from 6th March to 22nd May and has not been subjected to any other University or Institute for the award of any degree / diploma etc.

Signature:

Name of the student: Kaustav Deb

Date:

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CERTIFICATE FROM THE COMPANY / ORGANISATION

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CERTIFICATE

This is to certify that Mr KAUSTAV DEB of INDIAN INSTITUTE OF SOCIAL WELFARE AND BUSINESS MANAGEMENT has successfully completed the project work titled IMPLEMENTATION OF JOINT COMMISSION INTERNATIONAL STANDARDS IN TERTIARY CARE HEART HOSPITAL WITH SPECIAL FOCUS ON DOCUMENTATION in partial fulfillment of requirement for the completion of PGP course as prescribed by the College of Management COLLEGE NAME.

This project report is the record of authentic work carried out by him/her during the period from March to May He has worked under my guidance.

Signature NameProject Guide (Internal) Date:

Counter signed by Signature NameDirector Date:

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ACKNOWLEDGEMENT

I would like to owe a great debt of gratitude to Dr. Aninda Chatterjee (Chief Operating Officer), and Mr. Kaushik Kuthe (Assistant Manger - Human Resource) for selecting, accepting and inducting me as a Management Trainee in B.M BIRLA HEART RESEARCH CENTRE and for motivating me to be better. Also I am obliged to Mr. Sukanta Kumar Das (HOD of Quality Assurance Department ) & to the whole Quality Assurance Department for sharing their knowledge with me and for guiding me constantly. I express my extreme thanks as they provided me with all possible help and support in spite of their busy schedule. Special thanks and gratitude to Dr. Tushar PalChoudhury (Astron Quality Consultant )

I also want to convey my gratefulness to Prof. (Dr.) B.K. Chowdhury (HOD of Masters in Public System Management) Dr. Sanghamitra Sen. (Hospital and Healthcare Batch Coordinator) & Mr. Sandip Ghosh (Project Guide) of our College for sharing their experience with me, keeping faith on me & for making me what I am today.

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LIST OF ABBREVIATIONS

Section I: Accreditation Participation Requirements

Accreditation Participation Requirements - APR

Section II: Patient-Centered Standards

International Patient Safety Goals - IPSG Access to Care and Continuity of Care - ACC Patient and Family Rights - PFR Assessment of Patients - AOP Care of Patients - COP Anesthesia and Surgical Care - ASC Medication Management and Use - MMU Patient and Family Education - PFE

Section III: Health Care Organization Management Standards

Quality Improvement and Patient Safety - QPS Prevention and Control of Infections - PCI Governance, Leadership, and Direction - GLD Facility Management and Safety - FMS Staff Qualifications and Education - SQE Management of Information - MOI

Section IV: Academic Medical Center Hospital Standards

Medical Professional Education - MPE Human Subjects Research Programs - HRP

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EXECUTIVE SUMMARY This is the report of the JCI on Quality Care in Hospitals B.M BIRLA HEART RESEARCH CENTRE. It aims to provide information on the of quality, quality management and quality challenges in health care. The challenge of quality is founded on the basic principle of reducing the number of errors, which is still a great challenge for health care. Latest research demonstrates that almost every tenth patient suffers from preventable harm and adverse effects related to their care and that variation among health care providers is large and cannot be explained by patient characteristics.

The JOINT COMMISSION INTERNATIONAL, 5th Edition started its work 2014, 1st of April. A survey was carried out which demonstrated that the concepts and principles relating to quality management in health care differ from one country and culture to another. The same was true for quality system audits and the principles for their credibility and authorization (accreditation and certification). Since then many projects in health care have demonstrated that the general management and quality assurance principles apply well for health care. Projects like the 'Expert' demonstrated that health care should learn from all the different quality management programs.

This report provides an analysis, evaluation and comparison study of the JCI and NABH. Results of standards comparison show that some of the policies are not there and most of them needed to improve. In particular, comparative performance is poor in the areas of Patient care, Nursing care, Hospital leadership procedure, and biomedical waste management.

The report finds the prospects of the company in its current position are not positive. The major areas of weakness require further investigation and remedial action by management.

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CONTENT

SL NO CHAPTERS PAGE NO

1 Introduction

1.1 Background of the study 10

1.2 Company profile 11

1.3 Background of the topic 13

1.4 ORGANOGRAM 17

1.5 Need of the study 18

1.6 Objectives of the study 18

2 Research Methodology – Comparative Study

20

3

Findings 52

4 Conclusions 53

5 Bibliography 54

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INTRODUCTION

Hospitals play an important role in the health care system. They are health care institutions that have an organized medical and other professional staff, and inpatient facilities, and deliver medical, nursing and related services 24 hours per day, 7 days per week.

Hospitals offer a varying range of acute, convalescent and terminal care using diagnostic and curative services in response to acute and chronic conditions arising from diseases as well as injuries and genetic anomalies. In doing so they generate essential information for research, education and management.

Traditionally oriented on individual care, hospitals are increasingly forging closer links with other parts of the health sector and communities in an effort to optimize the use of resources for the promotion and protection of individual and collective health status.

QUALITY health care has a wide variety

of meanings. To some people, sitting in the waiting room a short time to see a doctor means “QUALITY” health care. To others, being treated politely by the doctor's staff means “QUALITY” health care. There are those who define “QUALITY” health care by how much time the doctor devotes to examining you.

By examining the number of times a hospital has provided care that has been scientifically proven to improve a medical condition and looking at the outcome after a patient has received the recommended care, you can get a picture of how well a hospital is providing quality of care. Using definitions of care that can be measured with numbers is one way to gauge the success or failure of a treatment.

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The BM Birla Heart Research Centre is acknowledged for providing quality patient care, diagnosis and treatment; and research of cardiovascular diseases. A commitment to the art and science of healing forms the core of its ethos:

Leadership and excellence in delivering quality healthcare services

Expanding the horizons of medical knowledge through biomedical research Educating and training physicians and other healthcare professionals Improving the health of our society

Apart from providing quality cardiac care to its patients, the BM Birla Heart Research Centre has several breakthroughs in angioplasty to its credit. To name a few:

Performing a less-invasive alternative to cardiac bypass surgery Earning worldwide recognition for innovative developments in the diagnosis

and treatment of heart diseases

The BM Birla Heart Research Centre caters to the entire spectrum of cardiac ailments for children as well as adults. The Centre focuses on the advanced field of cardiac surgery, with added attention to reconstructive operations on children. BMBHRC researchers put their findings into practice, thereby improving the health of society.

VisionTo be the leading super-specialty healthcare & research institute in Eastern India, with world-class standards in quality.

Mission

To offer the highest standards of medical treatment. To treat patients with care, compassion & commitment. To touch every section of society, and offer them the best in medical care.

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HIGH LEVEL ORGANIZATION CHART

Joint Commission International Accreditation is a voluntary process in which an entity separate and distinct from the health care organization which assesses the health care organization to determine ifit meets a set of requirement (standards) designed to provide a visible commitment by an organization to improve the safety and quality of care which is optimal and achievable.It is an effective quality evaluation and management tool for ensuring a safe care environment which helps continuous improvement process to reduce risk to patient and staffs.Joint Commission International is a U.S. based not for profit accreditation body which sets and designs

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Standards and processes to create a culture of ethics, safety and quality within an organization thatStrive to continually improve patient care processes and results..

Benefits of JCIJoint Commission International teaches and leads us to:

Improve patient trust by improving patient safety, quality and care. Provide a safe and efficient work environment that contributes to staff satisfaction Listen to patients and their families, respect their rights, and involve them in the care process as partners; and Helps establish collaborative leadership that sets priority for and continuous leadership for quality and patient safety at all levels.

Purpose and Goal of JCI Accreditation InitiativesThe Purpose is to give BM BIRLA HEART RESEARCH CENTRE fame by setting Goals which stimulate demonstration of continuous, sustained improvement in healthcare organization by applying international consensus standard, International Patient Safety Goals and Data Measurement Support.

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JCI addresses the following issues very intensively:1. International Patient Safety Goals2. Patient & Family Education3. Patient & Family Rights & Responsibilities4. Pain Management5. Quality Indicators & Monitoring6. Hand Wash & Prevention and Control of Infection7. Fire Safety and Emergency Codes8. Removal of Barriers to Care9. Patient Identifiers10. Care of High Risk Patients (Vulnerable patients)11. Restraint Order12. Rights of Drug administration13. Discharge Planning & Components of Discharge Summary14. Time Out15. Biomedical Waste Disposal16. Personal Protective Equipments (PPE)17. HAZMAT, Lab, Radiation, Facility Safety18. DNR (Do Not Resuscitate)19. End of Life Care20. Hospital Mandatory Trainings

JCI Standards (5th Edition)Accreditation Participation Requirements (APR): 12Chapters Total Number: 16

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Patient Centered Chapters: 8 Organization Management Chapters: 6 Academic Medical Center Hospital Chapters: 2Standards: Total Number: 304Standards are set around the important functions; they are common to allhealthcare organizations.Intent statement: Easy explanation of the standardsMeasurable Elements: Total number: 1218Measurable elements are those requirements of standards which arereviewed and assigned a score during survey.Survey: Assesses the hospitals compliance on JCI standards

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I. Accreditation Participation RequirementsAccreditation Participation Requirements (APR)-Introductory

II. The Patient Centered Standards are:1. International Patient Safety Goals (IPSG)2. Access to Care and Continuity of Care (ACC)3. Patient and Family Rights (PFR)4. Assessment of Patients (AOP)5. Care of Patients (COP)6. Anesthesia and Surgical Care (ASC)7. Medication Management and Use (MMU)8. Patient and Family Education (PFE)

III. The Organization Management Standards are:9. Quality Improvement and Patient Safety (QPS)10. Prevention and Control of Infections (PCI)11. Governance, Leadership, and Direction (GLD)12. Facility Management and Safety (FMS)13. Staff Qualifications and Education (SQE)14. Management of Information (MOI)

IV. The Academic Medical Center Hospital Standards are:15. Medical Professional Education (MPE)16. Human Subjects Research Programs (HRP)

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JCI ORGANOGRAM

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COO

GM / HS

SECTION COORDINATOR

SECTION COORDINATOR

SECTION COORDINATOR

SECTION COORDINATOR

SECTION COORDINATOR

NEED OF THE STUDY

Implementation of JCI to improve quality service in Patient centered areas and Hospital Centered areas. This study shows the comparison, equivalent policies and elements of JCI and NABH. It will also helps to find out what are the remaining policies and what are polices needed to change and what are the polices need to create.

OBJECTIVES OF THE STYDY

Comparative Study of JCI and NABH policy

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RESEARCH METHODOLOGY

Comparative Study between JCI and NABH for Patient Centered and Hospital Centered Standards.

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CARE OF PATIENTS

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard COP.1Uniform care of all patients is provided and follows applicable laws and regulations. ℗

Measurable Elements of COP.1 ME 1. The hospital’s department/service leaders collaborate to provide uniform care processes. ME 2. The provision of uniform care reflects local and regional laws and regulations. ME 3. Uniform care is provided that meets requirements a) through e) in the intent

COP.1.a.b

COP 1.c

COP.1.a

Standard COP.3The care of high-risk patients and the provision of high-risk services are guided by professional practiceguidelines, laws, and regulations. ℗

Measurable Elements of COP.3 ME 1. Hospital leadership has identified the high-risk patients and services. ME 2. When high-risk services are provided by the hospital, leadership establishes and implements guidelinesand procedures for those services and for the care of high-risk patients, for at least a) through i) of theintent. (Also see MOI.10.1, ME 4) ME 3. Staff have been trained and use the guidelines and procedures for care. ME 4. Hospital leadership identifies additional risks that may affect high-risk patients and services. ME 5. Evaluation of the high-risk services is included in the hospital’s quality improvement program

COP.8.a COP.9.a

COP.8.aCOP.8.b

COP.8.cCOP.9.e

N/A

COP.8.g

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard COP.3.3Clinical guidelines and procedures are established and implemented for the handling, use, and administration ofblood and blood products. ℗

ME 1. An individual with education, knowledge, and expertise oversees the administration of blood and bloodproducts. (Also see AOP.5.11, ME 1) ME 2. Clinical guidelines and procedures are established and implemented for the handling, use, andadministration of blood and blood products. (Also see AOP.5.11, ME 2) ME 3. Clinical guidelines and procedures address the processes for a) through e) in the intent.

N/A

COP.7.aCOP.7.b

COP.7.b

Standard COP.6Patients are supported in managing pain effectively. ℗

Measurable Elements of COP.6ME 1. Based on the scope of services provided, the hospital has processes to identify patients in pain. ME 2. When pain is an expected result of planned treatments, procedures, or examinations, patients areinformed about the likelihood of pain and options for pain management.ME 3. Patients in pain receive care according to pain management guidelines and according to patient goalsfor pain management.ME 4. Based on the scope of services provided, the hospital has processes to communicate with and toeducate patients and families about pain.ME 5. Based on the scope of services provided, the hospital has processes to educate staff about pain.

COP.16.a.b

N/A

COP.16.d

COP.16.e

N/A

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ACCESS TO CARE AND CONTINUITY OF CARE

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard ACC.1Patients who may be admitted to the hospital or who seek outpatient services are screened to identify if theirhealth care needs match the hospital’s mission and resources. ℗

Measurable Elements of ACC.1 ME 1. Based on the results of screening, it is determined if the needs of the patient match the hospital’smission and resources. (Also see GLD.3.1, ME 1) ME 2. Patients are accepted only if the hospital can provide the necessary services and the appropriateoutpatient or inpatient setting for care. ME 3. There is a process to provide the results of diagnostic tests to those responsible for determining if the patient is to be admitted, transferred, or referred. ME 4. Specific screening tests or evaluations are identified when the hospital requires them prior to admission or registration. ME 5. Patients are not admitted, transferred, or referred before the test results required for these decisions areavailable.

NA

AAC.2.d

NA

NA

NA

Standard ACC.1.2The hospital considers the clinical needs of patients and informs patients when there are waiting periods ordelays for diagnostic and/or treatment services. ℗

Measurable Elements of ACC.1.2 ME 1. Inpatients and outpatients are informed when there will be a delay in care and/or treatment. ME 2. Patients are informed of the reasons for the delay or wait and provided with information on availablealternatives consistent with their clinical needs. ME 3. The information is documented in the patient record.

NA

NA

NA

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard ACC.2.3Admission to units providing intensive or specialized services is determined by established criteria.℗

Measurable Elements of ACC.2.3 ME 1. The hospital has established entry and/or transfer criteria for admission to intensive and specializedservices or units, including research and other programs to meet special patient needs. ME 2. The criteria utilize prioritization, diagnostic, and/or objective parameters, including physiologic-basedcriteria. ME 3. Individuals from intensive/specialty units are involved in developing the criteria. ME 4. Staff are trained to apply the criteria. ME 5. The records of patients who are admitted to units providing intensive/specialized services containevidence that they meet the criteria for services.

COP.8.b

AAC.3.b COP.8.b

NA

COP.8.c

NA

Standard ACC.2.3.1Discharge from units providing intensive or specialized services is determined by established criteria. ℗

Measurable Elements of ACC.2.3.1 ME 1. The hospital has established discharge and/or transfer criteria from intensive and specialized servicesor units to a different level of care, including research and other programs. ME 2. The criteria used for discharge or transfer should include the criteria used for admission to the nextlevel of care. ME 3. Individuals from intensive or specialty units are involved in developing the criteria. ME 4. Staff are trained to apply the criteria. ME 5. The records of patients who are transferred or discharged from units providing intensive or specializedservices contain evidence that they no longer meet the criteria for services.

COP.8.b

NA

NA

COP.8.c

NA

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard ACC.4.3.2The clinical records of inpatients contain a copy of the discharge summary. ℗

Measurable Elements of ACC.4.3.2 ME 1. A discharge summary is prepared by a qualified individual. ME 2. A copy of the discharge summary is provided to the practitioner responsible for the patient’s continuingor follow-up care. ME 3. A copy of the discharge summary is provided to the patient in cases in which information regarding thepractitioner responsible for the patient’s continuing or follow-up care is unknown. ME 4. A copy of the completed discharge summary is placed in the patient's record in a time frame identifiedby the hospital.

AAC.13.a

NA

AAC.14.a

NA

Standard ACC.4.4The records of outpatients requiring complex care or with complex diagnoses contain profiles of the medicalcare and are made available to health care practitioners providing care to those patients. ℗

Measurable Elements of ACC.4.4 ME 1. The hospital identifies the types of outpatients receiving complex care and/or with complex diagnoseswho require an outpatient profile. ME 2. The information to be included in the outpatient profile is identified by the clinicians who treat thosepatients. ME 3. The hospital uses a process that will ensure the outpatient profile is available in an easy to retrieve andreview format. ME 4. The process is evaluated to see if it meets the needs of the clinicians and improves the quality and safety of outpatient clinical visits.

NA

NA

NA

NA

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ASSESSMENT OF PATIENT

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard AOP.1 All patients cared for by the hospital have their health care needs identified through an assessment process that has been defined by the hospital ℗

Measurable Elements of AOP.1ME 1. The minimum content of assessments for inpatients is defined for each clinical discipline that performsassessments and specifies the required elements of the history and physical examination.

ME 2. The minimum content of assessments for outpatients is defined for each clinical discipline thatperforms assessments and specifies the required elements of the history and physical examination. ME 3. Only qualified individuals permitted by licensure, applicable laws and regulations, or certificationperform the assessment. (Also see SQE.10) ME 4. The hospital identifies the information to be documented for the assessments

AAC.4.a

AAC.4.a

AAC.4.b

AAC.4.a.e.f.g.h.j

Standard AOP.1.1Each patient’s initial assessment includes an evaluation of physical, psychological, social, and economic factors,including a physical examination and health history ℗

Measurable Elements of AOP.1.1 ME1. All inpatients and outpatients have an initial assessment that includes a health history and physicalexamination consistent with the requirements defined in hospital policy. ME 2. Each patient receives an initial psychological assessment as indicated by his or her needs. ME 3. Each patient receives an initial social and economic assessment as indicated by his or her needs. ME 4. The initial assessment results in an initial diagnosis.

AAC.4.a

NA

NA

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AAC.4.d

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard AOP.1.2The patient’s medical and nursing needs are identified from the initial assessments, which are completed anddocumented in the clinical record within the first 24 hours after admission as an inpatient or earlier as indicatedby the patient’s condition.℗

Measurable Elements of AOP.1.2 ME 1. The initial medical assessment, including health history, physical exam, and other assessments requiredby the patient’s condition, is performed and documented within the first 24 hours of admission as aninpatient or sooner as required by patient condition. ME 2. The initial medical assessment results in a list of specific medical diagnoses that includes primary andassociated conditions requiring treatment and monitoring. ME 3. The initial nursing assessment is performed and documented within the first 24 hours of admission asan inpatient or sooner as required by patient condition. ME 4. The initial nursing assessment results in a list of specific patient nursing needs or conditions that requirenursing care, interventions, or monitoring

AAC.4.c.d

AAC.4.d

AAC.4.d.e

AAC.4.e.j

Standard AOP.1.2.1The initial medical and nursing assessments of emergency patients are based on their needs and conditions.℗

Measurable Elements of AOP.1.2.1 ME1. The medical assessment of emergency patients is based on their needs and condition and documentedin the patient record. ME2. The nursing assessment of emergency patients is based on their needs and condition and documentedin the patient record. ME 3. Before surgery is performed, there is a brief note and preoperative diagnosis documented foremergency patients requiring

AAC.4.a.c.d.g

AAC.4.a.c.d.e

COP.14.b.

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emergency surgery. (Also see ASC.7)

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard AOP.2All patients are reassessed at intervals based on their condition and treatment to determine their response totreatment and to plan for continued treatment or discharge. ℗

Measurable Elements of AOP.2 ME 1. Patients are reassessed to determine their response to treatment and plan for continued treatmentand/or discharge. (Also see COP.5, ME 3; ASC.6.1; and MMU.7, ME 1) ME 2. Patients are reassessed at intervals based on their condition and when there has been a significantchange in their condition, plan of care, or individual needs. (Also see AOP.1.7, ME 2) ME 3. A physician reassesses patients at least daily, including weekends, during the acute phase of their careand treatment.ME 4. For non-acute patients, the hospital defines, in writing, the circumstances in which, and the types ofpatients or patient populations for which, a physician’s assessment may be less than daily and identifiesthe minimum reassessment interval for these patients.ME 5. Reassessments are documented in the patient record.

AAC.5.a.e

AAC 5.a.c

NA

NA

AAC 5.c.dStandard AOP.3Qualified individuals conduct the assessments and reassessments ℗

Measurable Elements of AOP.3 ME 1. Individuals qualified to conduct patient assessments and reassessments are identified and have theirresponsibilities defined in writing. (Also see SQE.1.1, ME 2) ME 2. Only those individuals permitted by licensure, applicable laws and regulations, or certification performpatient assessments. ME 3. Emergency assessments are

AAC.4.b HRM.8.b

HRM.9.a

AAC.4.b.eHRM.10.a

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conducted by individuals qualified to do so. ME 4. Nursing assessments are conducted by individuals qualified to do so. HRM.10.a

MEDICATION MANAGEMENT AND USE STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard MMU.2Medications for prescribing or ordering are stocked, and there is a process for medications not stocked ornormally available to the hospital or for times when the pharmacy is closed. ℗

Measurable Elements of MMU.2ME 1. There is a list of medications stocked in the hospital or readily available from outside sources.ME 2. The process used to develop the list (unless determined by regulation or an authority outside thehospital) includes representation from all those who prescribe and manage medications in the hospital.ME 3. There is a process for obtaining medications during the night or when the pharmacy is closed.

MOM 2.a

MOM 2.b

MOM 1.d

Standard MMU.3Medications are properly and safely stored. ℗

Measurable Elements of MMU.3 ME 1. Medications are stored under conditions suitable for product stability, including medications stored onindividual patient care units.ME 2. Controlled substances are accurately accounted for according to applicable laws and regulations. ME 3. Medications and chemicals used to prepare medications are accurately labeled with contents, expiration dates, and warnings.ME 4. All medication storage areas, including medication storage areas on patient care units, are periodicallyinspected to ensure that medications are stored properly. ME 5. Medications are protected from loss or theft throughout the hospital.

MOM 3.a.b.d.e

MOM 3.c

MOM 5.e

MOM 3.c

NA

Standard MMU.3.1There is a process for storage of medications and nutrition products that require special consideration. ℗

Measurable Elements of MMU.3.1ME 1. The hospital establishes and implements a process for how nutrition products requiring special considerations are stored.ME 2. The hospital establishes and implements a process for how

NA

MOM 11 a.c

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radioactive, investigational, and similar medications are stored. (Also see FMS.5) ME 3. The hospital establishes and implements a process for how sample medications are stored and controlled.ME 4. The hospital establishes and implements a process for how medications brought in by the patient are identified and stored.

NA

NA

Standard MMU.3.2Emergency medications are available, monitored, and safe when stored out of the pharmacy. ℗

Measurable Elements of MMU.3.2ME 1. Emergency medications are available in the units where they will be needed or are readily accessible within the hospital to meet emergency needs. (Also see MMU.2)ME 2. The hospital establishes and implements a process for how emergency medications are stored,maintained, and protected from loss or theft.ME 3. Emergency medications are monitored and replaced in a timely manner after use or when expired or damaged.

MOM 3 - e, f, g

MOM 3.b.e,

NA

Standard MMU.3.3The hospital has a medication recall system. ℗

Measurable Elements of MMU.3.3ME 1. There is a medication recall system in place.ME 2. The hospital establishes and implements a process for use of medications known to be expired or outdated.ME 3. The hospital establishes and implements a process for the destruction of medications known to be expired or outdated.

MOM 5 b

NA

NA

Standard MMU.4Prescribing, ordering, and transcribing are guided by policies and procedures. ℗

Measurable Elements of MMU.4ME 1. The hospital establishes and implements a process for the safe prescribing, ordering, and transcribing of medications in the hospital.ME 2. The hospital establishes and implements a process for managing illegible prescriptions and orders, including measures to prevent continued occurrence.ME 3. Staff are trained in correct prescribing, ordering, and transcribing processes. ME 4. Patient records contain a list of current medications taken prior to admission, and this information is made available to the pharmacy and the patient’s health care practitioners. ME 5. Initial medication orders are

MOM 4 - a, b,h

NA

NA

NA

NA

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compared to the list of medications taken prior to admission, according to the hospital’s established process.

PATIENT AND FAMILY RIGHTS

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard PFR.1The hospital is responsible for providing processes that support patients’ and families’ rights during care. ℗

Measurable Elements of PFR.1ME 1. Hospital leadership works to protect and to advance patient and family rights.ME 2. Hospital leadership understands patient and family rights as identified in laws and regulations and inrelation to the cultural practices of the community or individual patients served.ME 3. The hospital respects the right of patients, and in some circumstances the right of the patient’s family,to have the prerogative to determine what information regarding their care would be provided to familyor others, and under what circumstances.ME 4. All staff are knowledgeable about patient rights and can explain their responsibilities in protectingpatient rights.

PRE.1.A

N/A

PRE 3.a.b.c

PRE.1.d

Standard PFR.1.3The patient’s rights to privacy and confidentiality of care and information are respected.

Measurable Elements of PFR.1.3ME 1. Staff members identify patient expectations and needs for privacy during care and treatment.ME 2. A patient’s expressed need for privacy is respected for all clinical interviews, examinations,procedures/treatments, and transport.ME 3. Confidentiality of patient information is maintained according to laws and regulations. (Also see MOI.2and MOI.7)ME 4. Patients are requested to grant permission for the release of information not covered by laws andregulations.

PRE.2.b

PRE.2.b

PRE.2.d

N/A

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard PFR.3The hospital informs patients and families about its process to receive and to act on complaints, conflicts, anddifferences of opinion about patient care and the patient’s right to participate in these processes. ℗

Measurable Elements of PFR.3ME 1. Patients are informed about the process for voicing complaints, conflicts, and differences of opinion.ME 2. Complaints, conflicts, and differences of opinion are investigated by the hospital.ME 3. Complaints, conflicts, and differences of opinion that arise during the care process are resolved.ME 4. Patients and families participate in the resolution process.

PRE 7.b

PRE 7.c

PRE 7.d

NA

Standard PFR.5.1Patient informed consent is obtained through a process defined by the hospital and carried out by trained staff ina manner and language the patient can understand. ℗

Measurable Elements of PFR.5.1ME 1. The hospital develops and implements a clearly defined informed consent process.ME 2. Designated staff are trained in the process ME 3. Patients learn about the process for granting informed consent in a manner and language that thepatient understands.ME 4. Patients give informed consent consistent with the process.ME 5. There is a uniform recording of informed consent.

PRE 4.a

NA

PRE 4.d

PRE 4.d

PRE 4.a

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ANESTHESIA AND SURGICAL CARE STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard ASC.3The administration of procedural sedation is standardized throughout the hospital. ℗

Measurable Elements of ASC.3ME 1. The administration of procedural sedation is standardized throughout the hospital.ME 2. Standardization of procedural sedation includes identifying and addressing at least a) through e) in theintent.ME 3. Emergency medical technology and supplies are readily available and customized to the type of sedationbeing performed and the age and medical condition of the patient.ME 4. An individual with advanced life-support training must be immediately available when proceduralsedation is being performed. (Also see COP.3.2)

COP 12.a

COP 12.a

NA

NA

Standard ASC.3.1Practitioners responsible for procedural sedation and individuals responsible for monitoring patients receivingsedation are qualified. ℗

Measurable Elements of ASC.3.1ME 1. Health care practitioners responsible for providing procedural sedation are competent in at least a)through d) of the intent.ME 2. The individual responsible for patient monitoring during procedural sedation is competent in at leastelements e) through h) in the intent.ME 3. Procedural sedation competencies for all staff involved in sedation are documented in the personnel files.

COP 12.c

COP 12.c

HRM 8.b HRM 9.d

Standard ASC.3.2Procedural sedation is administered and monitored according to professional practice guidelines. ℗

Measurable Elements of ASC.3.2ME 1. There is a presedation assessment performed and documented that includes at least a) through e) toevaluate risk and appropriateness of

COP 12.a

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procedural sedation for the patient. (Also see AOP.1, MEs 1 and 2)ME 2. A qualified individual monitors the patient during the period of sedation and documents themonitoring.ME 3 Established criteria are used and documented for the recovery and discharge from procedural sedation.

COP 12.d

COP 12.g

International Patient Safety Goals

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard IPSG.1The hospital develops and implements a process to improve accuracy of patient identifications. ℗

Measurable Elements of IPSG.1 ME 1. Patients are identified using two patient identifiers, not including the use of the patient’s room numberor location. ME 2. Patients are identified before providing treatments and procedures. ME 3. Patients are identified before any diagnostic procedures. (Also see AOP.5.7, ME 2)

NA

NA

NA

Standard IPSG.2The hospital develops and implements a process to improve the effectiveness of verbal and/or telephonecommunication among caregivers. ℗

Measurable Elements of IPSG.2 ME 1. The complete verbal order is documented and read back by the receiver and confirmed by theindividual giving the order. ME 2. The complete telephone order is documented and read back by the receiver and confirmed by theindividual giving the order.ME 3. The complete test result is documented and read back by the receiver and confirmed by the individual giving the result.

MOM.4.i

MOM.4.i

MOM.4.i

Standard IPSG.3The hospital develops and implements a process to improve the safety of high-alert medications. ℗

Measurable Elements of IPSG.3 ME 1. The hospital has a list of all high-alert medications, including look-alike/sound-alike medications, that isdeveloped from hospital-specific data. ME 2. The hospital implements strategies to improve the safety of high-alert medications, which may includespecific storage, prescribing,

MOM.4.j

MOM 3.b MOM 3.d

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preparation, administration, or monitoring processes. ME 3. The location, labeling, and storage of high-alert medications, including look-alike/sound-alikemedications, is uniform throughout the hospital.

MOM 3.b MOM 3.d

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard IPSG.4The hospital develops and implements a process for ensuring correct-site, correct-procedure, andcorrect-patient surgery. ℗

Measurable Elements of IPSG.4 ME 1. The hospital uses an instantly recognizable mark for surgical- and invasive procedure–site identificationthat is consistent throughout the hospital. ME 2. Surgical- and invasive procedure–site marking is done by the person performing the procedure. ME 3. The hospital uses a checklist or other process to document, before the procedure, that the informedconsent is appropriate to the procedure; that the correct site, correct procedure, and correct patient areidentified; and that all documents and medical technology needed are on hand, correct, and functional.

COP.6.c

COP 14.d

NA

NA

Standard IPSG.5The hospital adopts and implements evidence-based hand-hygiene guidelines to reduce the risk of healthcare–associated infections. ℗

Measurable Elements of IPSG.5ME 1. The hospital has adopted currently published, evidence-based hand-hygiene guidelines.ME 2. The hospital implements an effective hand-hygiene program throughout the hospital.ME 3. Hand-washing and hand-disinfection procedures are used in accordance with hand-hygiene guidelines throughout the hospital.

HIC 2.c.

HIC.2.c

HIC.2.c.

Standard IPSG.6The hospital develops and implements a process to reduce the risk of patient harm resulting from falls. ℗

Measurable Elements of IPSG.6 ME 1. The hospital implements a process for assessing all inpatients and those outpatients whose condition,diagnosis, situation, or location identifies them as at high risk for falls. ME 2. The hospital implements a

COP.9.aCOP.9.c

COP.9.aCOP.9.c

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process for the initial and ongoing assessment, reassessment, andintervention of inpatients and outpatients identified as at risk for falls based on documented criteria. ME 3. Measures are implemented to reduce fall risk for those identified patients, situations, and locationsassessed to be at risk.

COP.9.e

STAFF QUALIFICATION AND EDUCATION STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard SQE.1.1Each staff member’s responsibilities are defined in a current job description.℗

Measurable Elements of SQE.1.1 ME 1. Each staff member not permitted to practice independently has a job description. ME 2. Those individuals identified in a) through d) in the intent, when present in the hospital, have jobdescriptions appropriate to their activities and responsibilities or have been privileged if noted as analternative. (Also see AOP.3, ME 1) ME 3. Job descriptions are current according to hospital policy

HRM 1.C ,

HMB 1.C

HRM 1.c

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Standard SQE.5There is documented personnel information for each staff member.℗

Measurable Elements of SQE.5 ME 1. Personnel files for each staff member are standardized and current and maintained according tohospital policy. ME 2. Personnel files contain the qualifications of the staff member. ME 3. Personnel files contain the job description of the staff member when applicable. ME 4. Personnel files contain the work history of the staff member. ME 5. Personnel files contain the results of evaluations. ME 6. Personnel files contain a record of in-service education attended by the staff member.

HRM.8.a,

HRM 8.b,

NA

NA

HRM 8.d

HRM 8.6

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

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Standard SQE.5There is documented personnel information for each staff member.℗

Measurable Elements of SQE.5 ME 1. Personnel files for each staff member are standardized and current and maintained according tohospital policy. ME 2. Personnel files contain the qualifications of the staff member. ME 3. Personnel files contain the job description of the staff member when applicable. ME 4. Personnel files contain the work history of the staff member. ME 5. Personnel files contain the results of evaluations. ME 6. Personnel files contain a record of in-service education attended by the staff member.

HRM.8.a,

HRM 8.b

NA

NA,

HRM 8.d

HRM 8.6

Standard SQE.6A staffing strategy for the hospital, developed by the leaders of hospital departments and services, identifies thenumber, types, and desired qualifications of staff. ℗

Measurable Elements of SQE.6 ME 1. The hospital’s department/service leaders develop a written strategy for staffing the hospital in amanner that complies with local laws and regulations. ME 2. The number, types, and desired qualifications of staff are identified in the strategy using a recognizedstaffing method. (Also see AOP.6.2, ME 5) ME 3. The strategy addresses the assignment and reassignment of staff.

NA

NA

NA

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard SQE.8.2The hospital provides a staff health and safety program. ℗

Measurable Elements of SQE.8.2 ME 1. The hospital provides, and incorporates into the hospital quality and safety program, a staff health andsafety program that is responsive to urgent and nonurgent staff needs through direct treatment andreferral. ME 2. The hospital identifies epidemiologically significant infections, as well as staff that are at high risk forexposure to and transmission of infections, and implements a staff vaccination and immunizationprogram. ME 3. The hospital provides evaluation, counseling, and follow-up of staff exposed to infectious diseases thatis coordinated with the infection prevention and control program.

result of workplace violence.

HRM.7.b,

HIC 5.d

HIC 5.d

ME 4. The hospital identifies areas for potential workplace violence and implements measures to reduce therisk. ME 5. The hospital provides evaluation, counseling, and follow-up treatment of staff who are injured as a

NA

NA

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FACILITY MANAGEMENT AND SAFETY

STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard FMS.2The hospital develops and maintains a written program(s) describing the processes to manage risks to patients,families, visitors, and staff. ℗

Measurable Elements of FMS.2ME 1. There are written programs that address the risk areas a) through f) in the intent.ME 2. The programs are current and are fully implemented.ME 3. The hospital has a process to review and to update the program(s) when changes in the hospital’senvironment occur or at a minimum, on an annual basis. ME 4. When independent entities are present within the patient care facilities to be surveyed, the hospitalensures that the entities comply with all aspects of the facility management programs identified in a)through d) of the intent.

FMS 3. a to e

FMS 3. a to e

NA

NA

Standard FMS.4The hospital plans and implements a program to provide a safe physical facility through inspection and planningto reduce risks. ℗

Measurable Elements of FMS.4ME 1. The hospital has a program to provide a safe physical facility.ME 2. The hospital has a documented, current, accurate inspection of its physical facilities. ME 3. The program includes assessing safety and security during times of construction and renovation and implementing strategies to reduce risks. (Also see PCI.7.5)

FMS.1.a

FMS.1.d

N.A.

Standard FMS.4.1The hospital plans and implements a program to provide a secure environment for patients, families, staff, andvisitors. ℗

Measurable Elements of FMS.4.1ME 1. The hospital has a program to provide a secure environment, including monitoring and securing areas identified as security risks. (Also see AOP.5.3 and AOP.6.3)ME 2. The program ensures that all staff, contract workers, and vendors are identified.ME 3. All security risk areas and restricted areas are identified, documented, monitored, and kept secure.

N.A.

N.A

N.A.

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard FMS.6The hospital develops, maintains, and tests an emergency management program to respond to emergencies,epidemics, and natural or other disasters that have the potential of occurring within their community. ℗

Measurable Elements of FMS.6ME 1. The hospital has identified the major internal and external disasters, such as community emergencies,epidemics, and natural or other disasters, as well as major epidemic events that pose significant risks ofoccurring, taking into consideration the hospital’s geographic location.ME 2. The hospital identifies the probable impact that each type of disaster will have on all aspects of care andservices.ME 3. The hospital establishes and implements a disaster program that identifies its response to likelydisasters, including items a) through g) in the intent.ME 4. The entire program, or at least critical elements c) through g) of the program, is tested annually.ME 5. At the conclusion of every test, debriefing of the test is conducted.

FMS 7.a

FMS.7.a

FMS.7.b

F.M.S.7.e. (*)

FMS 7. e

Standard FMS.7The hospital establishes and implements a program for the prevention, early detection, suppression, abatement,and safe exit from the facility in response to fires and nonfire emergencies. ℗

Measurable Elements of FMS.7ME 1. The hospital establishes and implements a program to ensure that all occupants of the hospital’sfacilities are safe from fire, smoke, or other nonfire emergencies.ME 2. The program includes the documented assessment of fire risks, including when construction is presentin or adjacent to the facility.ME 3. The program includes the early detection of fire and smoke.ME 4. The program includes the abatement of fire and containment of smoke.ME 5. The program includes the safe exit from the facility when fire and nonfire emergencies occur.

F.M.S.6.a

FMS 6.a

FMS.6.a

FMS.6.b

FMS.6.b

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PREVENTION AND CONTROL OF INFECTIONS STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard PCI.5The hospital designs and implements a comprehensive program to reduce the risks of health care–associatedinfections in patients and health care workers. ℗

Measurable Elements of PCI.5 ME 1. There is a comprehensive program that crosses all levels of the hospital, to reduce the risk of healthcare–associated infections in patients. ME 2. There is a comprehensive program that crosses all levels of the hospital to reduce the risk of healthcare–associated infections in health care workers. (Also see SQE.8.2) ME 3. The program incorporates a range of strategies that includes systematic and proactive surveillanceactivities to determine usual (endemic) rates of infection.

HIC 4.a.b.c.d.

HIC 5. a.b.c.d

HIC 3.a.b.c.d.e.f.h

ME 4. The program includes systems to investigate outbreaks of infectious diseases. ME 5. Risk-reduction goals and measurable objectives are established and reviewed.

HIC 6.a.b.c.d

NA

Standard PCI.6The hospital uses a risk-based approach in establishing the focus of the health care–associated infectionprevention and reduction program. ℗

Measurable Elements of PCI.6 ME 1. The hospital has established the focus of the program through the collection of data related to a)through f) in the intent. ME 2. The data collected in a) through f) are analyzed to identify priorities for reducing rates of infection. ME 3. Infection control strategies are implemented to reduce the rates of infection for the identified priorities.

HIC 3.b

HIC 3.d

HIC 2.a HIC 3.e.f.

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard PCI.7The hospital identifies the procedures and processes associated with the risk of infection and implementsstrategies to reduce infection risk. ℗

Measurable Elements of PCI.7 ME 1. The hospital has identified those processes associated with infection risk. (Also see MMU.5, ME 1) ME 2. The hospital has implemented strategies, education, and evidence-based activities to reduce infectionrisk in those processes. ME 3. The hospital identifies which risks require policies and/or procedures, staff education, practicechanges, and other activities to support risk reduction.

HIC 3.a

NA

NA

Standard PCI.7.3The hospital implements practices for safe handling and disposal of sharps and needles. ℗

Measurable Elements of PCI.7.3 ME 1. The hospital identifies and implements practices to reduce the risk of injury and infection from thehandling and management of sharps and needles. ME 2. Sharps and needles are collected in dedicated, closable, puncture-proof, leakproof containers that arenot reused. ME 3. The hospital disposes of sharps and needles safely or contracts with sources that ensure the properdisposal of sharps containers in dedicated hazardous waste sites or as determined by national laws andregulations.

HIC 5.d. HIC 8.c

HIC 8.b.c

HIC 8.a.b.c.d

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard

Standard PCI.8The hospital provides barrier precautions and isolation procedures that protect patients, visitors, and staff fromcommunicable diseases and protects immunosuppressed patients from acquiring infections to which they are uniquely prone. ℗

Measurable Elements of PCI.8ME 1. Patients with known or suspected contagious diseases are isolated in accordance with recommendedguidelines. (Also see ACC.6)ME 2. Patients with communicable diseases are separated from patients and staff who are at greater risk due toimmunosuppression or other reasons.ME 3. Negative-pressure rooms are monitored routinely and available for infectious patients who requireisolation for airborne infections; when negative-pressure rooms are not immediately available, roomswith HEPA filtration systems with a minimum of 12 air changes per hour may be used.ME 4. Cleaning of infectious rooms during the patient’s hospitalization and after discharge follow infectioncontrol guidelines.

HIC 2.eHIC 5.c

HIC 2.e

HIC 5.c

NA

Standard PCI.8.1The hospital develops and implements a process to manage a sudden influx of patients with airborne infectionsand when negative-pressure rooms are not available. ℗

Measurable Elements of PCI.8.1ME 1. The hospital develops and implements a process to address managing patients with airborne infectionsfor short periods of time when negative-pressure rooms are not available.ME 2. The hospital develops and implements a process for managing an influx of patients with contagiousdiseases.ME 3. Staff are educated in the management of infectious patients when there is a sudden influx or whennegative-pressure rooms are not available.

HIC 5.c

NA

HIC 9.d

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MANAGEMENT OF INFORMATION STANDARD MEASURABLE ELEMENTS NABH 3rd Edition standard

Standard MOI.2Information privacy, confidentiality, and security including data integrity are maintained. ℗

Measurable Elements of MOI.2 ME 1. The hospital has a written process that protects the confidentiality, security, and integrity of data andinformation. ME 2. The process is based on and consistent with laws and regulations. ME 3. The process identifies the level of confidentiality maintained for different categories of data andinformation. ME 4. Those persons who need or have a job position permitting access to each category of data and information are identified. ME 5. Compliance with the process is monitored.

IMS 5.a

IMS 5.b

IMS 5.a.c

IMS 3.b

NA

Standard MOI.3The hospital determines the retention time of records, data, and information. ℗

Measurable Elements of MOI.3 ME 1. The hospital determines the retention time of patient clinical records and other data and information. ME 2. The retention process provides expected confidentiality and security. ME 3. Records, data, and information are destroyed in a manner that does not compromise confidentiality andsecurity.

IMS 6.a

IMS 6.c

IMS 6.d

Standard MOI.5The data and information needs of those in and outside the hospital are met on a timely basis in a format thatmeets user expectations and with the desired frequency.

Measurable Elements of MOI.5 ME 1. Data and information dissemination meet user needs. ME 2. Users receive data and information on a timely basis. ME 3. Users receive data and information in a format that aids its intended use.

IMS 1.b

IMS 1.b

IMS 2.a

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STANDARD MEASURABLE ELEMENTS NABH 3rd Edition standard

Standard MOI.10The hospital initiates and maintains a standardized clinical record for every patient assessed or treated anddetermines the record’s content, format, and location of entries. ℗

Measurable Elements of MOI.10 ME 1. A clinical record is initiated for every patient assessed or treated by the hospital. ME 2. Patient clinical records are maintained through the use of an identifier unique to the patient or someother effective method. ME 3. The specific content, format, and location of entries for patient clinical records is standardized anddetermined by the hospital.

IMS 3.a

CQI 2.j

IMS 3.e

Standard MOI.10.1The clinical record contains sufficient information to identify the patient, to support the diagnosis, to justify thetreatment, and to document the course and results of treatment.

Measurable Elements of MOI.10.1 ME 1. Patient clinical records contain adequate information to identify the patient. ME 2. Patient clinical records contain adequate information to support the diagnosis. (Also see AOP.1.1) ME 3. Patient clinical records contain n adequate information to justify the care and treatment. (Also seeAOP.1.2) ME 4. Patient clinical records contain adequate information to document the course and results of treatment.(Also see COP.2.1, ME 6; COP.3, ME 2; ASC.5; and ASC.7)

CQI 2.j IMS 3.a

NA

NA

NA

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QUALITY IMPROVEMENT AND PATIENT SAFETY STANDARD MEASURABLE ELEMENTS NABH STANDARDS 3RD

EDITIONStandard QPS.1A qualified individual guides the implementation of the hospital’s program for quality improvement and patientsafety and manages the activities needed to carry out an effective program of continuous quality improvementand patient safety within the hospital. ℗

Measurable Elements of QPS.1 ME 1. An individual(s) who is experienced in the methods and processes of improvement is selected to guide the implementation of the hospital’s quality and patient safety program. ME 2. The individual(s) with oversight for the quality program selects and supports qualified staff for theprogram and supports those staff with quality and patient safety responsibilities throughout the hospital. (Also see SQE.1) ME 3. The quality program provides supp ort and coordination to department/service leaders for likemeasures across the hospital and for the hospital’s priorities for improvement. (Also see GLD.11)

CQI 1.c CQI 2.e

CQI 1.c CQI 2.e

CQI 1.d

ME 4. The quality program implements a training program for all staff that is consistent with staff’s roles inthe quality improvement and patient safety program. (Also see SQE.14.1, ME 1 and SQE.16.1, ME 1) ME 5. The quality program is responsible for the regular communication of quality issues to all staff

CQI 1.e CQI 2.f

CQI 1.e CQI 2.f

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STANDARD MEASURABLE ELEMENTS NABH STANDARDS 3RD EDITION

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Standard QPS.6The hospital uses an internal process to validate data. ℗

Measurable Elements of QPS.6 ME 1. Data validation is used by the quality program as a component of the improvement process selected byleadership. ME 2. Data are validated when any of the conditions noted in a) through f) in the intent are met. ME 3. An established methodology for data validation is used. ME 4. Hospital leadership assumes accountability for the validity of the quality and outcome data made public.(Also see GLD.3.1, ME 3)

NA

NA

NA

NA

Standard QPS.7The hospital uses a defined process for identifying and managing sentinel events ℗

Measurable Elements of QPS.7 ME 1. Hospital leadership has established a definition of a sentinel event that at least includes a) through f)found in the intent. ME 2. The hospital completes a root cause analysis of all sentinel events in a time period specified by hospitalleadership that does not exceed 45 days from the date of the event or when made aware of the event. ME 3. Hospital leadership takes action on the results of the root cause analysis.

CQI 8.a

CQI 8.c

CQI 8.d

Standard QPS.8Data are always analyzed when undesirable trends and variation are evident from the data. ℗

Measurable Elements of QPS.8 ME 1. Intense analysis of data takes place when adverse levels, patterns, or trends occur. ME 2. All confirmed transfusion reactions, if applicable to the hospital, are analyzed. (Also see COP.3.3) ME 3. All serious adverse drug events, if applicable and as defined by the hospital, are analyzed. (Also see

CQI 7 - c

CQI 3.k

MOM 8.d

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MMU.7) ME 4. All significant medication errors, if applicable and as defined by the hospital, are analyzed. (Also seeMMU.7.1) ME 5. All major discrepancies between preoperative and postoperative diagnoses are analyzed. (Also seeASC.7.2)

MOM 8.d

NA

ME 6. Adverse events or patterns of adverse events during moderate or deep sedation and anesthesia use areanalyzed. (Also see ASC.3.2 and ASC.5) ME 7. Other adverse events defined by the hospital are analyzed

CQI 3.k

CQI 7.c

GOVERNANCE , LEADERSHIP AND DIRECTION

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STANDARD MEASURABLE ELEMENTS NABH STANDARDS 3RD EDITION

Standard GLD.1Governance structure and authority are described in bylaws, policies and procedures, or similar documents. ℗

Measurable Elements of GLD.1 ME 1. The hospital’s governance structure is described in a written document(s), and those responsible for governance of the hospital are identified by name and governance function.ME 2. Governance responsibilities and accountabilities are described in the document(s).ME 3. The document(s) describes how the governing entity will be evaluated and the criteria approved for theevaluation process. ME 4. There is an annual evaluation conducted of the governing entity, and the results are documente ME 5. The document(s) describes when and how governance and senior management authority can be delegated.

NA

ROMA 1. A to I

NA

NA

NA

Standard GLD.1.2Those responsible for governance approve the hospital’s program for quality and patient safety and regularlyreceive and act on reports of the quality and patient safety program. ℗

Measurable Elements of GLD.1.2ME 1. Those responsible for governance annually approve the hospital’s program for quality and patientsafety.ME 2. Those responsible for governance at least quarterly receive and act on reports of the quality and patientsafety program, including reports of adverse and sentinel events. (Also see QPS.4.1, ME 5)ME 3. Minutes reflect actions taken and any follow-up on those actions.

ROM 1.f

NA

NA

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STANDARD MEASURABLE ELEMENTS NABH STANDARDS 3RD EDITION

Standard GLD.2A chief executive(s) is responsible for operating the hospital and complying with applicable lawsand regulations. ℗

Measurable Elements of GLD.2ME 1. The education and experience of the chief executive(s) match the requirements in the positiondescription.ME 2. The chief executive(s) manages the hospital’s day-to-day operations, including those responsibilitiesdescribed in the position description.ME 3. The chief executive(s) recommends policies, strategic plans, and budgets to the governing body. ME 4. The chief executive(s) ensures compliance with approved policies.ME 5. The chief executive(s) ensures compliance with applicable laws and regulations.ME 6. The chief executive(s) responds to any reports from inspecting and regulatory agencies.

NA

NA

NA

NA

ROM 2.a

NA

Standard GLD.3.2Hospital leadership ensures effective communication throughout the hospital. ℗

Measurable Elements of GLD.3.2ME 1. Hospital leadership ensures that processes are in place for communicating relevant informationthroughout the hospital in a timely manner.ME 2. Hospital leadership ensures effective communication among clinical and nonclinical departments,services, and individual staff members.ME 3. Hospital leadership communicates the hospital’s vision, mission, goals, policies, and plans to staff.

NA

NA

ROM 4.a

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STANDARD MEASURABLE ELEMENTS NABH STANDARDS 3RD EDITION

Standard GLD.6Hospital leadership is accountable for the review, selection, and monitoring of clinical or nonclinicalcontracts. ℗

Measurable Elements of GLD.6ME 1. Hospital leadership is accountable for contracts to meet patient and management needs.ME 2. The hospital has a written description of the nature and scope of those services to be provided through contractual agreements.ME 3. Health professional staff contracts require credential review comparable to the hospital’s review process.ME 4. Department/service leaders share accountability for the review, selection, and monitoring of clinicaland nonclinical contracts. (Also see AOP.5.1, ME 5 and AOP.6.1, ME 5)ME 5. When contracts are renegotiated or terminated, the hospital maintains the continuity of patient services.

NA

NA

NA

ROM 5.k

NA

Standard GLD.10Each department/service leader identifies, in writing, the services to be provided by the department, andintegrates or coordinates those services with the services of other departments. ℗

Measurable Elements of GLD.10ME 1. Department/service leaders have selected and use a uniform format and content for planningdocuments.ME 2. The departmental or service documents describe the current and planned services provided by eachdepartment or service.ME 3. The departmental or service documents guide the provision of identified services.ME 4. The departmental or service documents address the staff knowledge and skills needed to assess and tomeet patient needs.ME 5. There is coordination and/or integration of services within and with other departments and services.

NA

ROM 3.a.

ROM 3.a.b

ROM 3.a.b

NA

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STANDARD MEASURABLE ELEMENTS NABH STANDARDS 3RD EDITION

Standard GLD.12The hospital’s framework for ethical management addresses operational and business issues, includingmarketing, admissions, transfer, discharge, and disclosure of ownership and any business and professionalconflicts that may not be in patients’ best interests. ℗

Measurable Elements of GLD.12ME 1. Hospital leadership establishes a framework for the hospital’s ethical management that promotes aculture of ethical practices and decision making to ensure the protection of patients and their rights.ME 2. The ethical framework ensures that patient care is provided within business, financial, ethical, and legalnorms.ME 3. The hospital ensures nondiscrimination in employment practices and provision of patient care in thecontext of the cultural and regulatory norms of the country.ME 4. Hospital leadership examines national and international ethical norms for incorporation whendeveloping the hospital’s framework for ethical conduct

ROM 4.b

ROM 4.b

NA

ROM 4.b

Standard GLD.12.1Hospital leadership establishes a framework for ethical management that promotes a culture of ethical practicesand decision making to ensure that patient care is provided within business, financial, ethical, and legal normsand protects patients and their rights. ℗

Measurable Elements of GLD.12.1ME 1. The hospital discloses its ownership and any conflicts of interest. (Also see AOP.5, ME 5 and AOP.6,ME 5)ME 2. The hospital honestly portrays its services to patients.ME 3. The hospital accurately bills for services and ensures that financial incentives and paymentarrangements do not compromise patient care.

NA

ROM 4.d

ROM 4.f

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FINDINGS This report provides an analysis, evaluation and comparison study of the JCI and NABH. Results of standards comparison show that some of the policies are not there and most of them needed to improve. In particular, comparative performance is poor in the areas of Patient care, Nursing care, Hospital leadership procedure, and biomedical waste management.

The report finds the prospects of the company in its current position are not positive. The major areas of weakness require further investigation and remedial action by management.

1. There are some existing policies which are equivalent to JCI as this hospital is already accredited by NABH.

2. There are some policies which are needed to improve to reach and complete the JCI criteria.

3. There are policies which are not yet implemented or exist. Those policies needed to create.

4. There are some policies which are NOT APPLICABLE for the prior hospital.

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CONCLUSIONS Not all the documents and policies are available in the hospital. Improvements in every area of the company are needed if the company is, in the first instance, to survive and then grow. The key areas of reform are the liquidity of the company and the quantity and quality of patient service areas. Management must address these areas simultaneously if the company is to overcome its present poor record.

LimitationsIt must be remembered that this analysis is limited: a greater depth of understanding and evaluation can only occur with utilization of other resource. Only after this process can a full appreciation of the company’s current situation and possible future occur.

Prospects

At this point the company does not have strong future prospects in the areas improvement if it continues on its current path. 

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BIBLIOGRAPHY Www. Google.com

www.jointcommissioninternational.org

www.slideshare.com

www.nabh.co

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