Gap Assessment Reporting Format

REPORT 1

August 2009

GAP ANALYSIS REPORTFOR

NABH ACCREDITAT ION PROGRAMME OF

CLIENT

PREPARED BY

Astron Hospital and Health Care Consultants Pvt. Ltd.

Quality and Accreditation Division

Publication, reproduction, photocopying, storage, or transmission electronically or otherwise, of all or any part of these documents without the prior written permission from Astron Hospital and Health Care Consultants Pvt. Ltd. New Delhi, India is strictly prohibited. It is illegal to make copies of all or any part of these documents (whether internally or externally) without the prior written permission of the copyright holder. For permission regarding the use of all or any part of the documents, contact Astron Hospital and Health Care Consultants Pvt. Ltd. New Delhi 91-11-42148131/32

Soni Hospital

Gap Analysis Report Astron Hospital and Health Care Consultants Pvt. Ltd., New Delhi

FOREWORD

Quality management system and the Accreditation process in compliance with standards, is a tool

for quality assurance and quality improvement for hospitals that in turn help ensure quality

healthcare services, standardized output, and aim for the best outcome possible. Spin offs of the

system include economy, effectiveness, leadership amongst peer institution, confidence of the

citizens in the establishment, and a culture of teamwork with a focus on service quality.

The Quality Council of India is an autonomous body under the Government of India, which has the

National Accreditation Board for Hospitals and Health Care Providers (NABH) amongst several

other boards under its fold. The NABH standards place emphasis on patient, staff, visitor and

environment safety, infection control, and quality of care. The standards are deceptively simple,

however whilst implementing them extra effort and resources will be required. Compliance will

more than compensate with the benefits that accrue, but it shall be remembered, that ‘Quality’,

like success, is a pathway, and not a destination.

With that Astron Hospital and Health Care Consultants Pvt. Ltd. wish the all the very best in their

voyage towards implementing the quality management system and accreditation of public hospitals

with the NABH.

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ACKNOWLEDGEMENT

Our heartfelt thanks to ………………………………….and the Governing Board members enabling us to carry out National accreditation Board for Hospitals & Healthcare Providers accreditation activity at their hospital. We feel privileged to be associated with this organization of repute and being a part of the quality movement initiative taken up by its authorities

We are highly thankful to,…………………………………………… for providing us a platform to initiate the accreditation activity and complete the first step that of gap assessment study in

We are profoundly grateful to,…………………………………………………… who has been very supportive right from beginning. We are sure, that with able leadership of, the objective of achieving quality standards of the level of accreditation norms will not be a distant dream.

We would like to thank, …………………………………………Medical Supdt, who has been extremely cooperative and helped us in getting the gap assessment completed. His readiness for taking up the core responsibility of coordinating and providing us with all necessary arrangement required to complete the activity of Gap Assessment.

Our sincere thanks to Nursing Superintendent, and all HODs, in-charges and staff of the hospital, who took out time from their very busy schedule, to interact with us and provide us with the information required for this study. Needless to say that this activity would not have been completed without their selfless contribution.

Lastly, we would like to thank all those whose names are not mentioned here but their contribution to this study could not be undermined.

Astron Hospital and Health Care Consultants Pvt. Ltd.

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TABLE OF CONTENTS

Section No Topic Page Number

Foreword 1

Acknowledgement 2

Table of Contents 3

1. Introduction 4

2. Organization of report 5

3. Hospital Profile 7-13

4. Physical structure requirement 14 - 23

5. Gap assessment as per NABH standards 24 -127

6. Summary table of scores 128

7. Result of NABH gap assessment 129

Annexure

Annexure ‘A’ Signage & Displays 130-131

Annexure ‘B’ Physical Safety Requirements 132-133

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SECTION 1. INTRODUCTION

1. …………………………….is one of the finest medical institutions in North India. The hospital

is governed by ……………………………………………………

2. The philosophy with which the hospital has been incepted is provision of medical care to the

needy.

3. ……………….has taken up the initiative to standardize the patient care and its management

system and initiate an activity of continual quality improvement

4. With this thought has chosen ……………………..NABH accreditation norms as a reference

to improve and standardize the health care delivery in the hospital

5. Astron Hospital and Health Care Consultants Pvt. Ltd. is a consultancy firm providing

consultancy to all spheres of hospital planning and management. Quality and accreditation

division of the consultancy is well known to provide consultancy services to hospitals,

wanting to implement quality management and accreditation systems

6. Astron has been taken up by …………………….as consultant to provide the consultancy

services in planning and helping the hospital’s team in achieving NABH accreditation

7. As a first step of this project, detailed gap analysis has been carried out to identify the

existing status of infrastructure and processes vis-à-vis NABH standards requirement

8. This report is the deliverable of gap assessment study carried out at ……………………by

Astron Hospital and Health Care Consultant, with the help of hospital’s authorities and staff

9. The report details the subjective and objective evaluation and findings of infrastructure and

NABH standards related requirements

10. All findings and suggestions presented in this report is on the basis of primary visit made by

Astron Consultants and data and information provided by the hospital

11. It is to be noted that since evaluation of NABH standards implementation in a hospital is

partly subjective, difference in score calculated for NABH compliance may vary, in case

similar study is carried out by different consultant / assessor. The analysis has been done on

the basis of standardized checkpoints and our previous experience with other hospital’s

assessment. With this limitation, it is suggested that the score shall be used only to make a

mental picture of compliance level, while focusing on all systems and standards required for

NABH accreditation

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SECTION 2. ORGANISATION OF REPORT

This report is intended to identify those structural requirements of quality management and accreditation,

which are cost intensive and takes long lead-time for addressing. Other than this a detailed gap

assessment with respect to every standards and objective elements of NABH – 2 nd edition has also been

carried out and presented in this report. The report has been prepared and submitted with the objective

of taking an early action on these gaps, so that they can be addressed within time before the hospital

applies for the accreditation pre-assessment.

Following categories of gaps and requirements have been specified in this report

o Physical structure requirements

o Gap assessment as per NABH standards

The report is organized in sections for specifying the aspects. Subsections are provided within sections,

wherever required. A brief profile of the hospital is also provided in to understand the status.

Annexure are provided at the end of the report on those aspects that requires detailing and description. A

reference has been made in the main text wherever it has an annexure to be referred.

The findings and requirements specified in this report have been prioritized as per their importance and

criticality, so that hospital can plan the action as per the resource availability and practicality aspects.

It is emphasized that these requirements are important and should be actioned upon as early as

possible, so that the same can be fulfilled within the project time. Also many of the process related

aspects required for accreditation are dependent on fulfillment of infrastructural gaps. Thus, delay in

action on fulfilling these requirements will affect the implementation of processes and in turn will

delay the entire project time.

It is suggested that hospital authorities read the report carefully and develop a plan of action to fulfill

these requirements.

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SECTION 3. HOSPITAL PROFILE

S. No. Particulars Details

1. Name of Hospital

2. Ownership Type

3. Address a.for Communicationb.for locating Hospital

2. Contact person: (for correspondence and liaison)

3. Contact numbers: (land line with area code and mobile)

4. E-mail

5. Date of establishment of hospital

6. Vision statement

7. Mission statement:

8. Any Quality certification or Accreditation received by the facility in past

11. Clinical services offered by the hospital Specialty(s):

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Specialties Number of specialist (full time) Number of specialist (visiting / honorary)

Anesthesia

Cardiology

Cardiothoracic Surgery

Dentistry

Dermatology

ENT

Gastroenterology

General Medicine

GI Surgery

General surgery

Nephrology

Neurology

Neurosurgery

O&G

Ophthalmology

Orthopedic

Outreach Services

Pediatrics

Pediatric Surgery

Pathology

Physiotherapy

Plastic surgery

Psychiatry

Radio diagnosis

Rehab

Urology

Number of Non Specialist doctors

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FACILITY DETAILS

S. No. Particulars Details1. Plot area2. Total built-up area3. Number of buildings4. Number of floors 5. Number of Lifts6. Number of ramps

BED DISTRIBUTION1. Total number of complement beds (beds on which patients are kept overnight): 2. Total number of non-compliment beds:

S. No. Categories of beds Number of beds per

room

Number of rooms

1. New Deluxe2. Super Deluxe3. Semi Deluxe4. Male Private + NSR + SSR

5. Female Private

6 General Medical Ward

7 Urology Ward

8 Pediatric Ward

9 Gynae/ Maternity Ward

10 Transit Ward

11 Orthopedic Ward

12 Neuro Sciences Ward

13 Nephrology

14 Convalescent – I

15 Convalescent – II

16 Ophthalmology

17 Day Care

18 Casualty

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19 Neonatal

20 Semi Pvt.

21 Pre Operative

INTENSIVE CARE BEDS

S. No. Designation of ICU Number of beds per

room

Number of

rooms1. Medical Intensive Care Unit2. Surgical Cardiac Care Unit3. Medical Cardiac Care Unit4. Step down Intensive Care Unit5. Paediatric Intensive Care Unit6. Surgical Intensive Care Unit7. Neuro Intensive Care Unit8. Pre-mature Care Unit /9. Intensive Pre-mature Unit

10

11

12

OPERATING SUITES

S. No. Designation of Operation theatre (Major and

Minor) and Endoscopy suites

Number

1. Terrace Operation Theatre2. New Operation Theatre3. Old Operation Theatre4. Endoscopy Room5. Cath Lab6. Dialysis7. Labour Room8. Transfusion Ward9. Emergency10. Incomplete

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11.

12.

HOSPITAL HUMAN RESOURCE

Staffing pattern

Staff category On hospital pay roll Contractual

Nursing Staff (category wise)

Nursing Superintendent

Deputy Nursing Superintendent

Asst. Nursing Superintendent

Sister Incharges

Acting Sister Incharges

Staff Nurses

Nursing Aid

Technical Staff (category wise)

Lab Technicians

OT Technicians

X-Ray Technicians

Perfusionist

Endoscopy

ECG Technicians

EEG Technicians

Technician (Nephrology)

Medical administration (category

wise)

Senior Administrative Staff

Honorary Consultants

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Resident

General administration (category

wise)

Senior Administrative staff

Maintenance

Ministerial

Housekeeping and security staff

(category wise)

Ward Boy

Ward Lady

Sweepers

Tech. Aid

Class IV (Contract)

Security (Contract)

DETAILS OF DIAGNOSTIC SERVICES

S.

No.

Diagnostic services

Laboratory Medicine (Please list scope of services)

Bio-Chemistry

Pathology

Hematology

Micro-Biology & Serology

Histopathology

Cytopathology

Imaging Sciences (Please list scope of services)

C-T

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X-Ray

Ultra Sound

Special Diagnostics

EEG

Colour Doppler

ECG

Eco

TMT

Audiometery

SUPPORT SERVICES

S. No. Service category Available / Not available1.

Pharmacy2. Blood Bank3. Medical Record Department4. CSSD5. Piped medical gas system6. Dietetics

Others

HIS & PACS

S.

No.

Administrative departments (please list)

1. Accounts/ Finance (including IP billing)

2. HRD

3. Maintenance

4. Stores & Purchases

5. IT

6. PRO

7. OPD, Reception & Enquiries

8. Medical Records

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S.

No.

Outsourced services (please list)

1. Security

2. Housekeeping

3. Kitchen

4. Laundry

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WORK LOAD DETAILS (of the current quarter)

S. No. Particulars Details

IPD indices1. Bed occupancy rate2. Average length of stay3. Average daily surgeries (major)4. Average daily surgeries (minor)5. Average daily deliveries6. Average daily admissions7. Average daily discharges

OPD indices8. Average daily OPD attendance9. Average daily new patients registration10. Average daily follow up patients11. Average daily day care patients

Emergency indices12. Average daily emergency attendance13. Average monthly emergency surgeries

Diagnostics14. Average number of Laboratory tests per day15. Average number of Radiological tests per day

Please provide following documents along with this profile (if convenient)1. Architectural plan of the facility2. List of Major equipments3. Specialty / Department wise bed allocation (if applicable)4. Last audited balance sheet

SECTION 4. PHYSICAL STRUCTURE REQUIREMENTS

This section identifies the structural deficiencies which may come across the quality management requirements as expected by NABH standards. The findings are presented department wise and is prioritized as per the necessity.

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Other than these structural deficiencies there are certain facility requirements that are necessary to demonstrate a safe and secured hospital environment. This has been listed out in Annexure ‘B’(V- Vital; E – Essential, D – Desirable; P - Priority This classification is given for the hospital to prioritize their work and plan the scope of improvement as per their resource availability and necessity)S. No. Department and observations Desirabilit

y

Priorit

y

1. EMERGENCY WARD

1.1.

1.2.

1.3.

1.4.

1.5.

1.6.

1.7.

1.8.

2. IMAGING DEPARTMENT

2.1.

2.2.

2.2.1

2.2.2

2.2.3

2.2.4

2.2.5

2.2.6

3. INPATIENT DEPARTMENT

3.1.

3.1.1.

3.1.2.

3.1.3. Support Areas-.

Clean Utility –

Dirty Utility -.

Equipment Room –

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S. No. Department and observations Desirabilit

y

Priorit

y

Treatment Rooms –

Isolation Rooms -.

3.1.4.

3.1.5.

3.1.6. Resuscitation facility

3.2. Hand washing facilities

3.2.1. Electrical Backup -

3.3. PRIVATE WARDS

3.3.1.

4. INTENSIVE CARE UNIT

4.1. .

4.2. Zoning-

4.3. The interbed distance

4.4. The Nursing Station

4.5. The ventilation.

5. DIALYSIS UNIT

5.1.

5.2. Zoning-.

5.3. The interbed distance

5.4.

5.5. The hand washing facilities

6. CSSD

6.1.

6.2.

6.3.

6.4.

7. OPERATION THEATRES

7.1.

7.2.

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S. No. Department and observations Desirabilit

y

Priorit

y

7.3.

8. LABOR ROOMS

8.1. .

9. LABORATORY

9.1.

10. OPD

10.1.

10.2.

10.3.

10.4.

10.5.

11. LAUNDRY

11.1.

12. MEDICAL RECORD DEPARTMENT

12.1. .

12.2. BIOMEDICAL WASTE MANAGEMENT

12.3.

13. PIPED MEDICAL GAS SYSTEM

13.1.

13.2.

14. SIGNAGES AND DISPLAYS

14.1.

15. FIRE FIGHTING SYSTEM

15.1.

15.2.

15.3.

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SECTION 5: GAP ASSESSMENT AS PER NABH STANDARDS

Elements Observation Scores

(0/ 5/ 10)

Recommendations

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

AAC.1: The organization defines and displays the services that it can provide.

a The services being provided are clearly defined and are in consonance with the needs of the community.

b The defined services are prominently display.

c The staff is oriented to these services.

Average Score

AAC.2: The organization has a well-defined registration and admission process.

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a.

Standardized policies and procedures are used for registering and admitting patients

b.

The policies and procedures address out- patients, in-patients and emergency patients

c.

Patients are accepted only if the organization can provide the required service

d.

The policies and procedures also address managing patients during non availability of beds.

e.

The staff is aware of these processes

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a.

Policies guide the transfer of unstable patients to another facility in an appropriate manner.

b.

Policies guide the transfer of stable patients to another facility

c.

Procedures identify staff responsible during transfer

d.

The organization gives a summary of patient’s condition and the treatment given

Average Score

AAC.4 During admission the patient and/ or family members are educated to make informed decision.

a.

The patients and/ or family members are explained about

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the proposed care.

b.

The patients and/ or family members are explained about the expected results.

c.

The patients and/ or family members are explained about the possible complications.

d.

The patients and/ or family members are explained about the expected costs.

Average Score

AAC.5 Patients cared for by the organization undergo an established initial assessment.

a.

The organization defines the content of the assessments for the out patients, in patients and emergency patients.

b.

The organization determines who can perform the assessments.

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c.

The organization defines the time frame within which the initial assessment is completed.

d.

The initial assessment for in-patients is documented within 24 hours or earlier as per the patient's condition or hospital policy.

e.

Initial assessment includes screening for nutritional needs.

f.

The initial assessment results in a documented plan of care which is monitored.

g.

The plan of care also includes preventive aspects of care.

a.

All patients are reassessed at appropriate intervals.

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b.

Staff involved in direct clinical care document reassessments.

c.

Patients are reassessed to determine their response to treatment and to plan further treatment or discharge

Average Score

AAC.7 Laboratory services are provided as per the requirements of the patients.

a.

Scope of the laboratory services are commensurate to the services provided by organization

b.

Adequately qualified and trained personnel perform and/or supervise the investigations.

c.

Policies and procedures guide collection, identification, handling, safe transportation, processing and disposal of specimens.

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d.

Laboratory results are available within a defined time frame.

e.

Critical results are intimated immediately to the concerned personnel.

f.

Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

Average Score

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

a.

The laboratory quality assurance programme is documented.

b.

The programme addresses verification and validation of test methods

c.

The programme addresses surveillance of test results

d.

The programme includes periodic calibration and

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maintenance of all equipments.

e.

The programme includes the documentation of corrective and preventive actions

Average Score

AAC.9 There is an established laboratory safety programme.

a.

The laboratory safety programme is documented.

b.

This programme is integrated with the organization's safety programme.

c.

Written policies and procedures guide the handling and disposal of infectious and hazardous materials.

d.

Laboratory personnel are appropriately trained in safe practices.

e.

Laboratory personnel are provided with appropriate safety equipment/ devices.

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Average Score

AAC.10 Imaging services are provided as per the requirement of the patients.

a.

Imaging services comply with the legal and other requirement.

b.

Scope of the imaging services are commensurate to the services provided by the organization.

c.

Adequately qualified and trained personnel perform, supervise and interpret the investigations.

d.

Policies and procedures guide identification and safe transportation of patients to imaging services.

e.

Imaging results are available within a defined time frame.

f.

Critical results are intimated immediately to the concerned personnel.

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g.

Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system

Average Score

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

a.

The quality assurance program for imaging services is documented.

b.

The programme addresses verification and validation of imaging methods.

c.

The programme addresses surveillance of imaging results.

d.

The programme includes periodic calibration and maintenance of all equipments.

e.

The programme includes the documentation of corrective and preventive actions

Average Score

AAC.12 There is an established radiation safety programme.

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a.

The radiation safety programme is documented.

b.

This programme is integrated with the organization’s safety programme

c.

Written policies and procedures guide the handling and disposal of radio-active and hazardous materials.

d.

Imaging personnel are provided with appropriate radiation safety devices

e.

Radiation safety devices are periodically tested and documented

f.

Imaging personnel are trained in radiation safety measures

g.

Imaging signage are prominently displayed in all appropriate locations

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h.

Policies and procedures guide the safe use of radioactive isotopes for imaging services.

Average Score

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

a.

During all phases of care, there is a qualified individual identified as responsible for patient’s care.

b.

Care of patients is coordinated in all care setting within the organization.

c.

Information about the patient's care and response to treatment is shared among medical, nursing and other care providers.

d.

Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/ departments.

e. The patient’s record(s) is

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available to authorized care providers to facilitated the exchange of information.

f.

Policies and procedures guide the referral of patients to other departments/ specialties.

Average Score

AAC.14 The organization has a documented discharge process.

a.

The patient’s discharge process is planned in consultation with the patient and/or family

b.

Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases)

c.

Policies and procedures are in place for patients leaving against medical advice

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d.

A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)

Average Score

AAC.15 Organization define the content of the discharge summary.

a.

Discharge summary is provided to the patients at the time of discharge.

b.

Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.

c.

Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given.

d.

Discharge summary contains follow up advice, medication and

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other instructions in an understandable manner.

e.

Discharge summary incorporates instructions about when and how to obtain urgent care.

f.

In case of death the summary of the case also includes the cause of death.

Average Score

Total Score

Chapter 2: CARE OF PATIENTS (COP)

COP.1: Uniform care of patients is provided in all settings of the organization and is guided

by the applicable laws, regulations and guidelines.

a Care delivery is uniform when similar care is provided in more than one setting

b Uniform care is guided by policies and procedures which reflect applicable laws and regulations.

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c The care and treatment orders are signed, named, timed and dated by the concerned doctor.

d The care plan is countersigned by the clinician in-charge of the patient within 24 hours.

e Evidence based medicine and clinical practice guidelines are adopted to guide patient care whenever possible.

Average Score

COP.2: Emergency services are guided by policies, procedures and applicable laws and

regulations.

a Policies and procedure for emergency care are documented.

b Policies also address handling of medico-legal cases

c The patient receives care in consonance with the policies.

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d Policies and procedures guide the triage of patients for initiation of appropriate care.

e Staff is familiar with the policies and trained on the procedures for care of emergency patients.

f Admission or discharge to home or transfer to another organization is also documented.

Average Score

COP.3: The ambulance services are commensurate with the scope of the services provided by the organizations.

a There is adequate access and space for the ambulance(s).

b Ambulance(s) is appropriately equipped.

c Ambulance(s) is manned by the trained personnel

d There is a checklist of all medical

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equipment and emergency medications.

e Equipment are checked on a daily basis.

f Emergency medications are checked daily and prior to dispatch.

g The ambulance(s) has a proper communication system.

Average Score

COP.4: Policies and procedures guide the care of patients requiring cardio-pulmonary

resuscitations.

a Documented policies and procedures guide the uniform use of resuscitation throughout the organization.

b Staff providing direct patient care is trained and periodically update in cardio pulmonary resuscitations.

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c The events during a cardio pulmonary resuscitation are recorded.

d A post-event analysis of all cardiac asserts is done by a multidisciplinary committee.

e Corrective and preventive measures are taken based on the post-event analysis.

Average Score

COP.5: Policies and procedures define rational use of blood and blood products.

a Documented policies and procedures are used to guide rational use of blood and blood products

b The transfusion services are governed by the applicable laws and regulations.

c Informed consent is obtained for donation and transfusion of blood and blood products

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d Informed consent also includes patient and family education about donation.

e Staff is trained to implement the policies.

f Transfusion reactions are analyzed for preventive and corrective actions.

a The organization has documented admission and discharge criteria for its intensive care and high dependency units.

b Staff is trained to apply these criteria

c Adequate staff and equipment are available

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d Defined procedures for situation of bed shortages are followed.

e Infection control practices are followed

f A quality assurance programme is implemented

Average Score

COP.7: Policies and procedures guide the care of vulnerable patients (elderly, physically and/ or mentally challenged and children).

a Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.

b Care is organized and delivered in accordance with the policies and procedures.

c The organization provides for a safe and secure environment for this vulnerable group.

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d A documented procedure exists for obtaining informed consent from the appropriate legal representative.

e Staff is trained to care for this vulnerable group.

Average Score

COP.8: Policies and procedures guide the care of high-risk obstetrical patients.

a The organization defines and displays whether high-risk obstetric care can be cared for or not.

b Persons caring for high-risk obstetric cases are competent

c High-risk obstetric patient’s assessment also includes maternal nutrition.

d The organization caring for high risk obstetric cases has the facilities to take care of neonates of such cases.

Average Score

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

a The organization defines and displays the scope of its paediatric services

b The policy for care of neonatal patients is in consonance with the national/ international guidelines

c Those who care for children have age specific competency

d Provisions are made for special care of children.

e Patient assessment includes detailed nutritional, growth, psychosocial and immunization assessment.

f Policies and procedures prevent child/ neonates abduction and abuse.

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g The children’s family members are educated about nutrition, immunizations and safe parenting and this is documented in the medical record.

Average Score

COP.10: Policies and procedures guide the care of patients undergoing moderate sedation.

a Competent and trained persons perform sedation.

b The person administrating and monitoring sedation is different from the person performing the procedure.

c Intra – procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood pressure, and oxygen saturation, and level of sedation.

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d Patients are monitored after sedation.

e Criteria are used to determine appropriateness of discharge from the recovery area.

f Equipment and manpower are available to rescue patients from a deeper level of sedation than that intended.

Average Score

COP.11: Policies and procedures guide the administration of anesthesia.

a There is a documented policy and procedure for the administration of anesthesia

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b Pre anaesthesia assessment is done for all patients who undergo anaesthesia administration.

c The pre-anesthesia assessment results in formulation of an anesthesia plan which is documented

d An immediate preoperative reevaluation is documented

e Informed consent for administration of anesthesia is obtained by the anesthetist

f 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

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g Each patient’s post-anesthesia status is monitored and documented

h A qualified individual applies defined criteria to transfer the patient from the recovery area

i All adverse anesthesia events are recorded and monitored

Average Score

COP.12: Policies and procedures guide the care of patients undergoing surgical

procedures.

a The policies and procedures are documented

b Surgical patients have preoperative assessment and a provisional diagnosis documented prior to surgery.

c An informed consent is obtained by the surgeon prior to the

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procedure.

d Documented policies and procedure exist to prevent adverse events like wrong site, wrong patients and wrong surgery.

e Persons qualified by law are permitted to perform the procedures that they are entitled to perform.

f A brief operative note is documented prior to transfer out of patients from recovery area.

g The operating surgeons documents the post operative plan of care

h A quality assurance programme is followed for the surgical services

i The quality assurance program includes surveillance of the operation theatre environment

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j The plan also includes monitoring of surgical site infection rates

a Documented policies and procedures guide the care of patients under restraints

b These include both physical and chemical restraint measures

c These include documentation of reasons for restraints

d These patients are more frequently monitored

e Staff receive training and periodic updating in control and restraint techniques

Average Score

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COP.14: Policies and procedures guide appropriate pain management.

a Documented policies and procedures guide the management of pain.

b The organization respects and supports the appropriate assessment and management of pain for all patients

c Patient and family are educated on various pain management techniques

Average Score

COP.15: Policies and procedures guide appropriate rehabilitative services.

a Documented policies and procedures guide the provision of rehabilitative services

b These services are commensurate with the organizational requirements

c Rehabilitative services are

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provided by a multidisciplinary team

Average Score

COP.16: Policies and procedures guide all research activities.

a Documented policies and procedures guide all research activities in compliance with national and international guidelines

b The organization has an ethics committee to oversee all research activities

c The committee has the powers to discontinue a research trial when risks outweigh the potential benefits

d Patient’s informed consent is obtained before entering them in research protocols

e Patients are informed of their right to withdraw from the

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research at any stage and also of the consequences (if any) of such withdrawal

f Patients are assured that their refusal to participate or withdrawal from participation will not compromise their access to the organization’s services

Average Score

COP.17: Policies and procedures guide nutritional therapy.

a Documented policies and procedures guide nutritional assessment and reassessment

b Patients receive food according to their clinical needs

c There is a written order for the diet

d Nutritional therapy is planned and provided in a collaborative manner

e When families provide food, they

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are educated about the patients diet limitations

f Food is prepared, handled, stored and distributed in a safe manner

Average Score

COP.18: Policies and procedures guide the end of life care.

a Documented policies and procedures guide the end of life care

b These policies and procedures are in consonance with the legal requirements

c These also address the identification of the unique needs of such patient and family

d These also include sensitively addressing issues such as autopsy and organ donation

e Staff is educated and trained in end of life care

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Average Score

Total Score

Chapter 3: MANAGEMENT OF MEDICATION (MOM)

MOM.1: Policies and procedures guide the organization of pharmacy services and usage of

medication.

a There is a documented policy and procedure for pharmacy services and medication usage

b These comply with the applicable laws and regulations

c A multidisciplinary committee guides the formulation and implementation of these policies and procedures

Average Score

MOM.2: There is a hospital formulary.

a A list of medication appropriate for the patients and organization’s resources is developed

b The list is developed collaboratively by the

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multidisciplinary committee

c There is a defined process for acquisition of these medications

d There is a process to obtain medications not listed in the formulary

Average Score

MOM.3: Policies and procedures exist for storage of medication.

a Documented policies and procedures exist for storage of medication

b Medications are stored in a clean, well lit and ventilated environment

c Sound inventory control practices guide storage of the medications

d Medications are protected from loss or theft.

e Sound alike and look alike medications are stored separately

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f There is a method to obtain medication when the pharmacy is closed

g Emergency medications are available all the time

h Emergency medications are replenished in a timely manner when used

Average Score

MOM.4: Policies and procedures exist for prescription of medications.

a Documented policies and procedures exist for prescription of medications

b The organization determines who can write orders

c Orders are written in a uniform location in the medical records

d Medication orders are clear, legible, dated, timed, named and signed

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e Policy on verbal orders is documented and implemented

f The organization defines a list of high risk medication

g High risk medication orders are verified prior to dispensing

Average Score

MOM.5: Policies and procedures guide the safe dispensing of medications.

a Documented policies and procedures guide the safe dispensing of medications

b The policies include a procedure for medication recall

c Expiry dates are checked prior to dispensing

d Labeling requirements are documented and implemented by the organization

Average Score

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MOM.6: There are defined procedures for medication administration.

a Medications are administered by those who are permitted by law to do so

b Prepared medication are labeled prior to preparation of a second drug

c Patient is identified prior to administration

d Medication is verified from the order prior to administration

e Dosage is verified from the order prior to administration

f Route is verified from the order prior to administration

g Timing is verified from the order prior to administration

h Medication administration is documented

i Polices and procedures govern patient’s self administration of medications

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j Polices and procedures govern patient’s medications brought from outside the organization.

Average Score

MOM.7: Patients and family members are educated about safe medication and food-drug interactions.

a Patient and family are educated about safe and effective use of medication

b Patient and family are educated about food-drug interactions

Average Score

MOM.8: Patients are monitored after medication administration.

a Patients are monitored after medication administration and this is documented

b Adverse drug events are defined

c Adverse drug events are reported within a specified time frame

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d Adverse drug events are collected and analyzed

e Policies are modified to reduce adverse drug events when unacceptable trends occur

Average Score

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

substances.

a Documented policies and procedures guide the use of narcotic drugs and psychotropic substances

b These policies are in consonance with local and national regulations

c A proper record is kept of the usage, administration and disposal of these drugs

d These drugs are handled by appropriate personnel in accordance with policies

Average Score

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MOM.10: Policies and procedures guide the usage of chemotherapeutic agents.

a Documented policies and procedures guide the usage of chemotherapeutic agents

b Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy

c Chemotherapy is prepared and administered by qualified personnel

d Chemotherapy drugs are disposed off in accordance with legal requirements

Average Score

MOM.11: Policies and procedures govern usage of radioactive drugs.

a Documented policies and procedures govern usage of radioactive drugs.

b These policies and procedures are in consonance with laws and

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regulations

c The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs

d Staff, patients and visitors are educated on safety precautions

a Documented policies and procedures govern procurement and usage of implantable prosthesis

b Selection of implantable prosthesis is based on scientific criteria and national/internationally recognized approvals

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c The batch and serial number of the implantable prosthesis are recorded in the patient’s medical record and the master logbook.

Average Score

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

a Documented policies and procedures govern procurement, handling, storage, distribution, usage and replenishment of medical gases.

b The policies and procedures address the safety issues at all levels

c Appropriate records are maintained in accordance with the policies, procedures and legal requirements

Average Score

Total Score

Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)

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PRE.1: The organization protects patient and family right during care and informs them

about their responsibilities.

a Patient and family rights and responsibilities are documented.

b Patients and families are informed of their rights and responsibilities in a format and language that they can understand.

c The organization’s leaders protect patient's and family rights.

d Staff is aware of their responsibility in protecting patients and family rights

e Violation of patient and family rights is recorded, reviewed and corrective/ preventive measures taken

Average Score

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PRE.2: Patient and family rights support individual beliefs, values and involve the patient

and family in decision-making processes.

a Patient and family rights address any special preferences, spiritual and cultural needs.

b Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.

c Patient and family rights include protection from physical abuse and neglect.

d Patient and family rights include treating patient information as confidential.

e Patient and family rights include refusal of treatment.

f Patient and family rights include informed consent before anaesthesia, blood and blood product transfusions and any

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invasive/ high-risk procedures/ treatment.

g Patient and family right include information and consent before any research protocol is initiated.

h Patient and family rights include information on how to voice a complaint.

i Patient and family rights include information on the expected cost of the treatment.

j Patient and family has a right to have an access to his/ her clinical records.

Average Score

PRE.3: A Documented process for obtaining patient and / or families consent exists for

informed decision making about their care.

a General consent for treatment is obtained when the patient enters the organization.

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b Patient and / or his family members are informed of the scope of such general consent.

c The organization has listed those situations where informed consent is required.

d Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand.

e The policy describes who can give consent when patient is incapable of independent decision-making.

Average Score

PRE.4: Patient and families have a right to information and education about their health

care needs.

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a When appropriate, patient and families and are educated about the safe and effective use of medication and the potential side effects of the medication.

b Patient and families are educated about diet and nutrition.

c Patient and families are educated about immunizations.

d Patient and families are educated about their specific disease process, complications and prevention strategies.

e Patient and families are educated about preventing infections.

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f Patients and family are taught in a language and format that they can understand.

Average Score

PRE.5: Patient and families have a right to information on expected costs.

a There is uniform pricing policy in a given setting (out-patient and ward category)

b The tariff list is available to patients.

c Patients and family are educated about the estimated cost of treatment.

d Patients and family are educated about the financial implications when there is a change in the patient condition or treatment setting.

Average Score

Total Score

Chapter 5: HOSPITAL INFECTION CONTROL (HIC)

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HIC.1: The organization has a well-designed, comprehensive and coordinated infection

control programme aimed at reducing/ eliminating risks to patients, visitors and providers

of care.

a The hospital infection control programme is documented which aims at preventing and reducing risk of nosocomial infections.

b The hospital has a multi-disciplinary infection control committee.

c The hospital has an infection control team.

d The hospital has designated and qualified infection control nurse(s) for this activity.

Average Score

HIC.2: The organization has an infection control manual, which is periodically updated.

a The manual identifies the various high-risk areas & procedures.

b It outlines methods of

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surveillance in the identified high-risk areas.

c It focuses on adherence to standard precautions at all times

d Equipment cleaning and sterilisation practices are included.

e An appropriate antibiotic policy is established and implemented

f Laundry and linen management processes are also included.

g Kitchen sanitation and food handling issues are included in the manual

h Engineering controls to prevent infections are included

i Mortuary practices and procedures are included as appropriate to the organization.

j The organization defines the periodicity of updating the

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infection control manual

Average Score

HIC.3: The infection control team is responsible for surveillance activities in identified

areas of the hospital.

a Surveillance activities are appropriately directed towards the identified high-risk areas

b Collection of surveillance data is an ongoing process

c Verification of data is done on regular basis by the infection control team

d In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.

e Scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.

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f Surveillance activities include monitoring the effectiveness of housekeeping services.

a The organization monitors urinary tract infections.

b The organization monitors respiratory tract infections.

c The organization monitors intra-vascular device infections

d The organization monitors surgical site infections.

e Appropriate feedback regarding HAI rates are provided on a regular basis to medical and nursing staff.

Average Score

HIC.5: Proper facilities and adequate resources are provided to support the infection

control programme.

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a Hand washing facilities in all patient care areas are accessible to health care providers.

b Compliance with proper hand washing is monitored regularly.

c Isolation/ barrier nursing facilities are available.

d Adequate gloves, masks, soaps, and disinfectants are available and used correctly.

Average Score

HIC.6: The organization takes appropriate actions to control outbreaks of infections.

a Hospital has a documented procedure for handling such outbreaks.

b This procedure is implemented during outbreaks.

c After the outbreak is over appropriate corrective actions are taken to prevent recurrence.

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Average Score

HIC.7: There are documented procedures for sterilization activities in the organization.

a There is adequate space available for sterilization activities

b Regular validation tests for sterilization are carried out and documented

c There is an established recall procedure when breakdown in the sterilization system is identified.

Average Score

HIC.8: Statutory provisions with regard to Bio-medical Waste (BMW) management are

complied with

a The hospital is authorized by prescribed authority for the management and handling of Bio-medical Waste.

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b Proper segregation and collection of Bio-medical Waste from all patient care areas of the hospital is implemented and monitored

c The organization ensures that Bio-medical Waste is stored and transported to the site of treatment and disposal in proper covered vehicles within stipulated time limits in a secure manner.

d Bio-medical Waste treatment facility is managed as per statutory provisions (if in-house) or outsourced to authorized contractor(s).

e Requisite fees, documents and reports are submitted to competent authorities on stipulated dates.

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f Appropriate personal protective measures are used by all categories of staff handling Bio-medical Waste.

Average Score

HIC.9: The infection control programme is supported by the organization's management and includes training of staff and employee

health.

a Hospital management makes available resources required for the infection control programme.

b The hospital regularly earmarks adequate funds from its annual budget in this regard.

c It conducts regular pre-induction training for appropriate categories of staff before joining concerned department(s).

d It also conducts regular “in-service” training sessions for all concerned categories of staff at least once in a year.

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e Appropriate pre and post exposure prophylaxis is provided to all concerned staff members

a The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee.

b The quality improvement programme is documented.

c There is a designated individual for coordinating and implementing the quality improvement programme

d The quality improvement programme is comprehensive

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and covers all the major elements related to quality assurance and risk management.

e The designated programme is communicated and coordinated amongst all the employees of the organization through proper training mechanism.

f The quality improvement programme is reviewed at predefined intervals and opportunities for improvement are identified.

g The quality improvement programme is a continuous process and updated at least once in a year.

Average Score

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CQI.2: The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools

for continual improvement.

a Monitoring includes appropriate patient assessment.

b Monitoring includes safety and quality control programmes of diagnostics services.

c Monitoring includes all invasive procedures

d Monitoring includes adverse drug events.

e Monitoring includes use of anesthesia.

f Monitoring includes use of blood and blood products.

g Monitoring includes availability and content of medical records.

h Monitoring includes infection control activities.

i Monitoring includes clinical research.

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j Monitoring includes data collection to support further improvements

k Monitoring includes data collection to support evaluation of these improvements

Average Score

CQI.3: The organization identifies key indicators to monitor the managerial structures,

processes and outcomes which are used as tools for continual improvement..

a Monitoring includes procurement of medication essential to meet patient needs.

b Monitoring includes reporting of activities as required by laws and regulations.

c Monitoring includes risk management.

d Monitoring includes utilisation of space, manpower and equipment.

e Monitoring includes patient satisfaction which also

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incorporates waiting time for services.

f Monitoring includes employee satisfaction

g Monitoring includes adverse events and near misses.

h Monitoring includes data collection to support further study for improvements.

i Monitoring includes data collection to support evaluation of the improvements

Average Score

CQI.4: The quality improvement programme is supported by the management.

a Hospital Management makes available adequate resources required for quality improvement programme.

b Hospital earmarks adequate funds from its annual budget in this regard.

c Appropriate statistical and

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management tools are applied whenever required.

Average Score

CQI.5: There is an established system for audit of patient care services.

a Medical and nursing staff participates in this system.

b The parameters to be audited are defined by the organization

c Patient and staff anonymity is maintained.

d All audits are documented.

e Remedial measures are implemented.

Average Score

CQI.6: Sentinel events are intensively analyzed.

a The organization has defined sentinel events.

b The organization has established processes for intense analysis of such events.

c Sentinel events are intensively analyzed when they occur

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d Corrective and preventive Actions are taken based on the findings of such analysis.

Average Score

Total Score

Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)

ROM.1: The responsibilities of the management are defined.

a Those responsible for governance lay down the organization’s mission statement

b Those responsible for governance lay down the strategic and operational plans commensurate to the organization’s mission in consultation with the various stake holders.

c Those responsible for governance approve the organization’s budget and allocate the resources required

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to meet the organization’s mission.

d Those responsible for governance monitor and measure the performance of the organization against the stated mission

e Those responsible for governance establish the organization’s organogram.

f Those responsible for governance appoint the senior leaders in the organization.

g Those responsible for governance support research activities and quality improvement plans.

h The organization complies with the laid down and applicable legislations and regulations

i Those responsible for governance address the organization’s social

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responsibility

Average Score

ROM.2: The services provided by each department are documented.

a Each organizational program, service, site or department has effective leadership

b Scope of services of each department is defined.

c Administrative policies and procedures for each department is maintained.

d Departmental leaders are involved in quality improvement.

Average Score

ROM.3: The organization is managed by the leaders in an ethical manner.

a The leaders make public the mission statement of the organization

b The leaders establish the organization’s ethical management

c The organization discloses its

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ownership

d The organization honestly portrays the services which it can and cannot provide

e The organization honestly portrays its affiliations and accreditation

f The organization accurately bills for it’s services based upon a standard billing tariff.

Average Score

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

a The designated individual has requisite and appropriate administrative qualifications

b The designated individual has requisite and appropriate administrative experience

Average Score

ROM.5: Leaders ensure that patient safety aspects and risk management issues are an

integral part of patient care and hospital management.

a The organization has an

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interdisciplinary group assigned to oversee the hospital wide safety programme

b The scope of the programme is defined to include adverse events ranging from “no harm” to “sentinel events”.

c Management ensures implementation of systems for internal and external reporting of system and process failures

d Management provides resources for proactive risk assessment and risk reduction activities.

Average Score

Total Score

Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)

FMS.1: The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility

inspection requirements.

a The management is conversant with the laws and regulations

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and knows their applicability to the organization

b Management regularly updates any amendments in the prevailing laws of the land.

c The management ensures implementation of these requirements.

d There is a mechanism to regularly update licenses/ registrations/certifications.

Average Score

FMS.2: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.

a There is a documented operational and maintenance (preventive and breakdown) plan.

b Up-to-date drawings are maintained which detail the site layout, floor plans and fire escape routes.

c There is internal and external

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sign posting in the organization in a language understood by patient, families and community.

d The provision of space shall be in accordance with the available literature on good practices (Indian or International Standards) and directives from government agencies

e There are designated individuals responsible for the maintenance of all the facilities

f Maintenance staff is contactable round the clock for emergency repairs.

g Response times are monitored from reporting to inspection and implementation of corrective actions.

Average Score

FMS.3: The organization has a program for clinical and support service equipment

management.

a The organization plans for

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equipment in accordance with its services and strategic plan

b Equipment is selected by a collaborative process.

c All equipment is inventoried and proper logs are maintained as required.

d Qualified and trained personnel operate and maintain the equipment.

e Equipment are periodically inspected and calibrated for their proper functioning

f There is a documented operational and maintenance (preventive and breakdown) plan

Average Score

FMS.4: The organization has provisions for safe water, electricity, medical gases and

vacuum systems.

a Potable water and electricity are available round the clock.

b Alternate sources are provided for in case of failure.

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c The organization regularly tests the alternate sources.

d There is a maintenance plan for piped medical gas, compressed air and vacuum installation

Average Score

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

a The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies.

b The organization has a documented safe exit plan in case of fire and non-fire emergencies

c Staff is trained for their role in case of such emergencies.

d Mock drills are held at least twice in a year

Average Score

FMS.6: The organization has a smoking limitation policy

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a The organization defines and implements its polices to reduce or eliminate smoking

b The policy has provisions for granting exceptions for patients and families to smoke

Average Score

FMS.7: The organization plans for handling community emergencies, epidemics and other

disasters.

a The hospital identifies potential emergencies.

b The organization has a documented disaster management plan.

c Provision is made for availability of medical supplies, equipment and materials during such emergencies.

d Hospital staff is trained in the hospital’s disaster management plan

e The plan is tested at least twice in a year.

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Average Score

FMS.8: The organization has a plan for management of hazardous materials

a Hazardous materials are identified within the organization

b The hospital implements processes for sorting, handling, labelling, storage, transporting and disposal of hazardous material.

c Requisite regulatory requirements are met in respect of radioactive materials

d There is a plan for managing spills of hazardous materials

e Staff is educated and trained for handling such materials.

Average Score

FMS.9: The organization has system in place to provide a safe and secure environment

a The hospital has a safety committee to identify the potential safety and security

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risks

b This committee coordinates development, implementation, and monitoring of the safety plan and policies.

c Patient safety devices are installed across the organization and inspected periodically.

d Facility inspection rounds to ensure safety are conducted at least twice in a year in patient care areas and at least once in a year in non-patient care areas.

e Inspection reports are documented and corrective and preventive measures are undertaken.

f There is a safety education programme for all staff.

Average Score

Total Score

Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)

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

a The organization maintains an adequate number and mix of staff to meet the care, treatment and service needs of the patient.

b The required job specifications and job description are well defined for each category of staff.

c The organization verifies the antecedents of the potential employee with regards to criminal/negligence background.

Average Score

HRM.2: The staff joining the organization is socialized and oriented to the hospital

environment.

a Each staff member, employee, student and voluntary worker is appropriately oriented to the organization’s mission and goals.

b Each staff member is made

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aware of hospital wide policies and procedures as well as relevant department / unit / service / programme’s policies and procedures.

c Each staff member is made aware of his/her rights and responsibilities.

d All employees are educated with regard to patients’ rights and responsibilities.

e All employees are oriented to the service standards of the organization.

Average Score

HRM.3: There is an ongoing programme for professional training and development of the

staff.

a A documented training and development policy exists for the staff.

b Training also occurs when job responsibilities change/ new equipment is introduced

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c Feedback mechanisms for assessment of training and development programme exist.

Average Score

HRM.4: Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety.

a All staff is trained on the risks within the hospital environment.

b Staff members can demonstrate and take actions to report, eliminate / minimize risks.

c Staff members are made aware of procedures to follow in the event of an incident.

d Reporting processes for common problems, failures and user errors exist

Average Score

HRM.5: An appraisal system for evaluating the performance of an employee exists as an

integral part of the human resource management process.

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a A well-documented performance appraisal system exists in the organization.

b The employees are made aware of the system of appraisal at the time of induction.

c Performance is evaluated based on the performance expectations described in job description

d The appraisal system is used as a tool for further development.

e Performance appraisal is carried out at pre defined intervals and is documented.

Average Score

HRM.6: The organization has a well-documented disciplinary procedure.

a A written statement of the policy of the organization with

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regard to discipline is in place.

b The disciplinary policy and procedure is based on the principles of natural justice.

c The policy and procedure is known to all categories of employees of the organization.

d The disciplinary procedure is in consonance with the prevailing laws.

e There is a provision for appeals in all-disciplinary cases.

Average Score

HRM.7: A grievance handling mechanism exists in the organization.

a The employees are aware of the procedure to be followed in case they feel aggrieved.

b The redress procedure addresses the grievance.

c Actions are taken to redress

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the grievance.

Average Score

HRM.8: The organization addresses the health needs of the employees.

a A pre-employment medical examination is conducted on all the employees.

b Health problems of the employees are taken care of in accordance with the organization’s policy.

c Regular health checks of staff dealing with direct patient care are done at-least once a year and the findings/ results are documented.

d Occupational health hazards are adequately addressed.

Average Score

HRM.9: There is a documented personal record for each staff member.

a Personal files are maintained in respect of all employees.

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b The personal files contain personal information regarding the employees qualification, disciplinary background and health status

c All records of in-service training and education are contained in the personal files

d Personal files contain result of all evalutions.

Average Score

HRM.10: There is a process for collecting, verifying and evaluating the credentials

(education, registration, training and experience) of medical professionals permitted to

provide patient care without supervision.

a Medical professionals permitted by law, regulation and the hospital to provide patient care without supervision is identified.

b The education, registration, training and experience of the identified medical

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professionals is documented and updated periodically.

c All such information pertaining to the medical professionals is appropriately verified when possible.

Average Score

HRM.11: There is a process for authorising all medical professionals to admit and treat patients and provide other clinical services

commensurate with their qualifications.

a Medical professionals admit and care for patients as per the laid down policies and authorisation procedures of the organization.

b The services provided by the medical professionals are in consonance with their qualification, training and registration.

c The requisite services to be provided by the medical professionals are known to them as well as the various

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departments/ units of the hospital.

Average Score

HRM.12: There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience)

of nursing staff.

a The education, registration, training and experience of nursing staff is documented and updated periodically.

b All such information pertaining to the nursing staff is appropriately verified when possible.

Average Score

HRM.13: There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members

commensurate with their qualifications and any other regulatory requirements.

a The clinical work assigned to nursing staff is in consonance with their qualification, training and registration.

b The services provided by nursing staff are in accordance

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with the prevailing laws and regulations.

c The requisite services to be provided by the nursing staff are known to them as well as the various departments / units of the hospital.

Average Score

Total Score

Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)

IMS.1: Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as

other agencies that require data and information from the Organization.

a The information needs of the organization are identified and are appropriate to the scope of the services being provided by the organization and the complexity of the organization

b Policies and procedures to meet the information needs are documented.

c These policies and procedures

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are in compliance with the prevailing laws and regulations.

d All information management and technology acquisitions are in accordance with the policies and procedures.

e The organization contributes to external databases in accordance with the law and regulations

Average Score

IMS.2: The organization has processes in place for effective management of data

a Formats for data collection are standardized

b Necessary resources are available for analyzing data.

c Documented procedures are laid down for timely and accurate dissemination of data

d Documented procedures exist for storing and retrieving data

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e Appropriate clinical and managerial staff participates in selecting, integrating and using data.

Average Score

IMS.3: The organization has a complete and accurate medical record for every patient.

a Every medical record has a unique identifier.

b Organization policy identifies those authorized to make entries in medical record.

c Every medical record entry is dated and timed

d The author of the entry can be identified

e The contents of medical record are identified and documented

f The record provides an up-to-date and chronological account of patient care

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a The medical record contains information regarding reasons for admission, diagnosis and plan of care.

b Operative and other procedures performed are incorporated in the medical record

c When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for the transfer and the name of the receiving hospital

d The medical record contains a copy of the discharge note duly signed by appropriate and qualified personnel

e In case of death, the medical record contains a copy of the death certificate indicating the cause, date and time of death.

f Whenever a clinical autopsy is

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carried out, the medical record contains a copy of the report of the same.

g Care providers have access to current and past medical record.

Average Score

IMS.5: Policies and procedures are in place for maintaining confidentiality, integrity and

security of information.

a Documented policies and procedures exist for maintaining confidentiality, security and integrity of information

b Policies and procedures are in consonance with the applicable laws

c The policies and procedures incorporate safeguarding of data/ record against loss, destruction and tampering

d The hospital has an effective

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process of monitoring compliance of the laid down policy

e The hospital uses developments in appropriate technology for improving, confidentiality, integrity and security

f Privileged health information is used for the purposes identified or as required by law and not disclosed without the patient’s authorization

g A documented procedure exists on how to respond to patients/ physicians and other public agencies requests for access to information in the medical record in accordance with the local and national law.

Average Score

IMS.6: Policies and procedures exist for retention time of records, data and information.

a Documented policies and

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procedures are in place on retaining the patient’s clinical records, data and information

b The policies and procedures are in consonance with the local and national laws and regulations

c The retention process provides expected confidentiality and security

d The destruction of medical records, data and information is in accordance with the laid down policy

Average Score

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

a The medical records are reviewed periodically.

b The review uses a representative sample based on statistical principles.

c The review is conducted by identified care providers.

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d The review focuses on the timeliness, legibility and completeness of the medical records

e The review process includes records of both active and discharged patients

f The review points out and documents any deficiencies in records

g Appropriate corrective and preventive measures undertaken are documented.

Average Score

Total Score

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SECTION 6: SUMMARY OF SCORES OF VARIOUS CHAPTERS

S. NO. CHAPTER SCORE

1 Access, Assessment And Continuity Of Care (AAC)

2 Care Of Patients (COP)

3 Management Of Medication (MOM)

4 Patient Rights And Education (PRE)

5 Hospital Infection Control (HIC)

6 Continuous Quality Improvement (CQI)

7 Responsibilities Of Management (ROM)

8 Facility Management And Safety (FMS)

9 Human Resource Management (HRM)

10 Information Management System (IMS)

AVERAGE SCORE OF ALL CAHPTERS

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SECTION 7: RESULT:

On the basis of detailed gap assessment on every standard and objective elements of NABH,

following conclusions can be derived.

1. Average score of the NABH standards (all chapters) is coming out to be 4.5 or 45%. This

score is much below the desirable value of >70% as per accreditation norms. Hence

rigorous efforts are required to be made to bring the score up from 45% to >70%

2. No chapters have scored 70% or more score individually. Thus there is a scope to improve

and strengthen the documentation and implementation in every chapter of NABH. Having

a score of 70% in every chapter, individually, is a must for accreditation

3. Compliance score of individual standards gives following quantum of deficiencies.

S. No. Chapter No. of standards with average score less than 5

No. of standards with more than one zero in its objective elements

1. Overall2. AAC3. COP4. MOM5. PRE6. HIC7. CQI8. ROM9. FMS10. HRM11. IMS

Note: It is mandatory for accreditation that no standard should have a score of less than 5 and no

standard can have more than one zero in its objective elements

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ANNEX ‘A’.SIGNAGE & DISPLAYS

Specific signage requirements that shall be addressed in signage plan of the hospital are as given

below.

………………………………………………………………………………………..

…………………………………………………………………………………………………………………

…..

…………………………………………………………………………………………………………………

………………………………………………………………………………………………………………….

All signage and displays in the hospital shall be made in minimum two languages and a symbolic

representation. The two languages shall be ‘English’ and ‘Hindi’. The dimensions of all signage and

displays shall be kept such that it should be clearly visible from distance

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ANNEX ‘B’ – Physical Safety Requirements

Following physical safety aspects shall be taken care in the hospital

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………..

…………………………………………………………………………………………………………………

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Documents

Gap Assessment Reporting Format