How to acheive NABH Standards in PHC & CHC Part 2-4

How to achieve NABH “Process” Standards in PHCs

Dr J L MeenaState Quality Assurance Officer

Department of Health & Family welfare

Government of Gujarat

Email:- [email protected]

Web:- www.gujhealth.gov.in/quality-assurance-program.htm149

mailto:[email protected]

http://www.gujhealth.gov.in/quality-assurance-program.htm

SECTION – B:Process Standards

8. Access to the Facility

Objective Elements• The facility should be easily assessable by

approachable all weather roads.• There should be transport facility from main

road to the facility campus in case it is at significant distance.

• Adequate sign posting to be available at various strategic location so as to guide patients to the facility.

The facility should be easily assessable by approachable all weather roads.

There should be transport facility from main road to the facility campus in case it is at significant

distance.

Adequate sign posting to be available at various strategic location so as to guide patients to the

facility.

Objective Elements• At least 1 medical officer and 1 nurse shall be

available at all times in the facility.• 3 medical officers and 3 staff nurses shall be

available on-call on 24X7 basis.• Staff shall attend to any emergency at all times

beyond the normal OPD or working hours.• At least 1 staff member should be available at

all times to provide guidance or basic information to the patients and their families.

9. Availability of Staff

At least 1 medical officer and 1 nurse shall be available at all times in the facility.

3 medical officers and 3 staff nurses shall be available on-call on 24X7 basis.

Staff shall attend to any emergency at all times beyond the normal OPD or working hours.

Exchange a few words with the clients

At least 1 staff member should be available at all times to provide guidance or basic information to the patients and

their families.

• Facility should have Assistant Professor from Medical College designated as its Radiological Surveillance Officer.

• Facility should be guarded by Security personnel 24X7.

• Available staff should be immunized and insured for health / hospitalization.

9. Availability of Staff Cont…

Facility should have Assistant Professor from Medical College designated as its

Radiological Surveillance Officer.

Facility should be guarded by Security personnel 24X7.

Available staff should be immunized and insured for health / hospitalization.



Objective Elements• All patients to under go a unified assessment

with privacy and dignity.• The nurse / ANM should carry out assessment

in terms of noting the vitals, height and weight of the patient in a pre designated area of the OPD card.

• Medical officer to documented the findings of the patient in a definite area in the OPD card.

• Advise for medication and investigation to be documented in predefined areas of the card.

10. Evaluation of the Patients

All patients to under go a unified assessment with privacy and dignity.

The nurse / ANM should carry out assessment in terms of noting the vitals, height and weight of the patient in a

pre designated area of the OPD card.

Medical officer to documented the findings of the patient in a definite area in the OPD card.

Advise for medication and investigation to be documented in predefined areas of the card.

• The documentation to be legible, timed, dated, named and signed by the medical officers.

• The instructions to be communicated to the patient in an understandable (variable and written) manner.

• The assessment of the patient is uniform in all settings i.e. casualty, OPD, Wards etc.

• Records of all such assessments to be maintained (for time limits as per regulations) in the facility.

10. Evaluation of the Patients Cont…

The documentation to be legible, timed, dated, named and signed by the medical officers.

The instructions to be communicated to the patient in an understandable (variable and written)

manner.

The assessment of the patient is uniform in all settings i.e. casualty, OPD, Wards etc.

Records of all such assessments to be maintained (for time limits as per regulations) in the facility.



Objective Elements• The staff should be courteous, humane and

empathetic.• Care shall commensurate with the amenities

available.• Care should be provided in manner in which

dignity and privacy of patient is maintained.• Organization should have Care, Admission,

Referral and Discharge Policies.• Organization should have written SOPs on care.

11. Care of Patients

The staff should be courteous, humane and empathetic.

Care shall commensurate with the amenities available.

Care should be provided in manner in which dignity and privacy of patient is maintained.

Organization should have Care, Admission, Referral and Discharge Policies.

Organization should have written SOPs on care.

Quality Manual

Infection Control Manual

Policies and SPOs

Job charts of employees

Disaster Management Manual

Forms and Formats

• Organization should have written Consent Policy.• Care shall be comprehensive in nature i.e.

preventive, promotive, curative and rehabilitative in nature.

• Documentation for all procedures carried out in the facility to be mentioned in the case records.

• All the instruction by the medical officer to be legible, dated, timed, named and signed.

• Patient admitted in the hospital to be evaluated for their progress at least twice a day.

11. Care of Patients Cont…

Organization should have written Consent Policy.

Care shall be comprehensive in nature i.e. preventive, promotive, curative and rehabilitative

in nature.

Documentation for all procedures carried out in the facility to be mentioned in the case records.

All the instruction by the medical officer to be legible, dated, timed, named and signed.

Patient admitted in the hospital to be evaluated for their progress at least twice a day.

• Patient's condition to be communicated to the family members.

• A discharge summary to be given to the patients on their separation from hospital i.e. discharge, LAMA, Referral.

• In case of death a death summary to be given to the patients family.

• A general consent to be obtained for all patients accepted in the facility.


Patient's condition to be communicated to the family members.

A discharge summary to be given to the patients on their separation from hospital i.e. discharge, LAMA, Referral.

In case of death a death summary to be given to the patients family.

A general consent to be obtained for all patients accepted in the facility.

• An informed consent to be obtained for patients undergoing any procedures.

• A list of procedures for which informed consent to be obtained shall be available in the facility.

• The consent for shall be in vernacular / local language.

• Consent shall be obtained either by the medical officer or the nurse.


An informed consent to be obtained for patients undergoing any procedures.

A list of procedures for which informed consent to be obtained shall be available in the facility.

The consent for shall be in vernacular / local language.

Consent shall be obtained either by the medical officer or the nurse.

Objective Elements• Organization should have written infection Control

Policy.• Organization should have identified / ear marked

resources for infection control.• Organization should have written protocols on cleaning

of the infection prone areas (OT, Wards and Labour room) and equipments used in patient care.

• The center shall take all precautions to control infection.

• Adherence to standard precautions to be maintained by all staff.

12. Control of Infection

Organization should have written infection Control Policy.

INDEX

S.

No

.

Contents Pa

ges

1. Responsibility for

implementation

4

2. Quality Core Group-IV

3. Amendment Sheets 5

4. Executive Summary

5. Part-I; General Information 7

6. Part-II; Infection control 9

7. Part-III; Bio-medical waste

handling and management

32

8. Part-IV; Sanitation, Hygiene

and potable water

39

9. Annexure 42

Organization should have identified / ear marked resources for infection control.

Organization should have written protocols on cleaning of the infection prone areas (OT, Wards and Labour room)

and equipments used in patient care.

The center shall take all precautions to control infection.

Adherence to standard precautions to be maintained by all staff.

• Mopping (by disinfectants) of all areas of the center to be carried out at least twice a day.

• Carbolisation of the OT, Labour Room, Laboratory to be carried out at least twice a day.

• Availability of running tap water for hand washing of staff to be maintained 24 hours a day.

• The hospital environment to be kept clean from litters, pest and stray animals.

• Adequate lighting arrangement and cross ventilation to be present in all areas.

12. Control of Infection Cont…

Mopping (by disinfectants) of all areas of the center to be carried out at least twice a day.

Carbolisation of the OT, Labour Room, Laboratory to be carried out at least twice a day.

Availability of running tap water for hand washing of staff to be maintained 24 hours a day.

The hospital environment to be kept clean from litters, pest and stray animals.

Adequate lighting arrangement and cross ventilation to be present in all areas.

• Sanitation of the toilets and hygiene of the staff to be maintained.

• Adequate amount of bleaching lotion to be available for disinfection purposes.

• The labour room, OT and ward areas to be washed with soap and water regularly and a documentation there of to be maintained.

• Autoclaving of all the instruments and linen uses in the labour room, OT, dressing room to be done.

• Quality checks of the autoclave to be maintained by using quick strips.

12. Control of Infection Cont…

Sanitation of the toilets and hygiene of the staff to be maintained

Adequate amount of bleaching lotion to be available for disinfection purposes

The labour room, OT and ward areas to be washed with soap and water regularly and a

documentation there of to be maintained

Autoclaving of all the instruments and linen uses in the labour room, OT, dressing room to be done

Quality checks of the autoclave to be maintained by using quick strips.

Objective Elements• Hospital waste generated shall be managed in

accordance with the Biomedical waste management and handling rules 1998.

• General waste to be collected in Green bags.• The yellow bags to be subjected to deep burial and a

pit for the same to be created with in the hospital premise according to the dimensions specified by the biomedical rules 1998.

• Facilities for syringe and needle distruction to be available and practiced.

• Chemical treatment of plastics to be carried out by using freshly prepared bleaching lotion.

13. Hospital Waste Management

S.no. Type of Waste Quantity(Kg / day)

%

1 Infectious Waste

A Pathological & Anatomical 1.5 6

B Sharp including syringe 1 4

C Non Sharp waste 7.5 30

Total 10 40

2 General WasteTotal 15 60

Grand Total 25 100

Type of Biomedical Waste Generate 30 beds Hospitals

Hospital waste generated shall be managed in accordance with the Biomedical waste management and handling rules 1998

General waste to be collected in Green bags.

General waste to be collected in Green bags.

The yellow bags to be subjected to deep burial and a pit for the same to be created with in the hospital premise according to the dimensions specified by

the biomedical rules 1998

The yellow bags to be subjected to deep burial and a pit for the same to be created with in the hospital premise according to the dimensions specified by

the biomedical rules 1998

Facilities for syringe and needle distraction to be available and practiced

Chemical treatment of plastics to be carried out by using freshly prepared bleaching lotion

• A site for composting of biodagradable waste to be available with in the hospital premises.

• Annual report to be submitted to the competent authority by 31st January every year.

• Accident spillage of waste shall be reported and handled as per the BMW Guidelines.

• Segregation of wastes to be done in maximum of 3 bags (Black, Yellow & Blue).

• Organization should have resources to train all health personnel on handling BMW as per regulations.

13. Hospital Waste Management Cont…

A site for composting of bio degradable waste to be available with in the hospital premises.

Annual report to be submitted to the competent authority by 31st January every year

ANNUALREPORT (FORM II)

(To be submitted to the prescribed authority by 31 January every year).PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

1 . Particulars of the applicant:

(i) Name of the authorized person( MO):-

(ii) Name of the institution:

Address

Tel. No

Fax No.

2. Categories of waste generated and quantity on a monthly average basis:

3. Brief details of the treatment facility:

In case of off-site facility:

Name & address of the operator

4. Category-wise quantity of waste treated:

5. Mode of treatment with details:

6. Any other information:

7. Certified that the above report is for the period from Date .............TO..................

Place............... Signature

Date................ Designation

Annual report to be submitted to the competent authority by 31st January every year

Accident spillage of waste shall be reported and handled as per the BMW Guidelines



BIOMEDICALWASTE ACCIDENT REPORTING (FORM III)

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

1. Date and time of accident:-

2. Sequence of events leading to accident:-

3. The waste involved in accident :

4. Assessment of the effects of the accidents on human health

and the

environment:-

5. Emergency measures taken:-

6. Steps taken to alleviate the effects of accidents :-

7. Steps taken to prevent the recurrence of such an accident:-Place............... Signature

Date................ Designation

Segregation of wastes to be done in maximum of 3 bags (Green, Yellow & Blue)

Organization should have resources to train all health personnel on handling BMW as per

regulations.

Objective Elements• The facility should have Reverse Osmosis (RO)

Plant.• The center shall promote sanitation hygiene and

availability of potable water in the community by involving the Panchayati Raj Institute (PRI).

• The center shall distribute chlorine tablets to the community and educate them about their usage.

• The perils of open defecation to be informed to the community.

14. Sanitation, Hygiene and Potable Water

The facility should have Reverse Osmosis (RO) Plant.

The facility should have Reverse Osmosis (RO) Plant.

The center shall promote sanitation hygiene and availability of potable water in the community by

involving the Panchayati Raj Institute (PRI).

The center shall distribute chlorine tablets to the community and educate them about their usage.

The peril of open defecation to be informed to the community.

• Creation of soak pit and trench lavatories to be carried out by involving the PRI.

• Health education and maintenance of hygiene to be done by adopting the principles of school health and involving public opinion makers.

• A plan to combat disasters, epidemics in the community shall be ready in the facility, communicated to all concerned and rehearsed at least twice a year.

14. Sanitation, Hygiene and Potable Water Cont…

Creation of soak pit and trench lavatories to be carried out by involving the PRI.

Health education and maintenance of hygiene to be done by adopting the principles of school health

and involving public opinion makers.

A plan to combat disasters, epidemics in the community shall be ready in the facility,

communicated to all concerned and rehearsed at least twice a year.

Mock drill and training

PHC Mahuwas, Navsari


PHC Tankal, Kandolpada & Mahuwas, Navsari


PHC Tankal & Kandolpada Navsari


PHC Tankal, Navsari


DH Gandhinagar, Gandhinagar


Objective Elements• The health workers and related staff to be

involved in counseling the community regarding population stabilization, safe sex, hygiene, breast feeding, anemia, nutrition, spacing of children, Vitamin-A deficiency etc.

• Appropriate IEC tools to be available so as to create awareness amongst the community for availing the services of the center.

• Trust to be given for reproductive and child health services.

15. Counseling and IEC

The health workers and related staff to be involved in counseling the community regarding population stabilization, safe sex, hygiene, breast feeding, anemia, nutrition, spacing of children, Vitamin-A

deficiency etc.

Appropriate IEC tools to be available so as to create awareness amongst the community for availing

the services of the center.





Trust to be given for reproductive and child health services

• Staff of the center to disseminate the plans and programs (specific to the area) of the Government by using all IEC tools available e.g. posters, pamphlets, wall hangings, paintings, audiovisual tools etc.

• Counseling shall also include knowledge about HIV / AIDS and other communicable diseases.

• Organization should have policy of printing "name & contact number of doctor" on the cards (OPD & Discharge), IEC tools used.

15. Counseling and IEC Cont…

Staff of the center to disseminate the plans and programs (specific to the area) of the Government by using all IEC tools available e.g.

posters, pamphlets, wall hangings, paintings, audiovisual tools etc.

Counseling shall also include knowledge about HIV / AIDS and other communicable diseases

Organization should have policy of printing "name & contact number of doctor" on the cards (OPD &

Discharge), IEC tools used

Objective Elements• The organization shall give impetus to the

preventive aspect of health care.• The staff (Doctors, Nurses, ANMs, LHVS,

Pharmacist, Health Educator, Health Assistants) shall maintain open channels of communication with the patients and their families.

• Immunization shall commensurate with the universal immunization program.

• Expecting mothers to be given two doses of tetanus immunization in their antenatal checkups.

16. Preventive Health

The organization shall give impetus to the preventive aspect of health care.

The staff (Doctors, Nurses, ANMs, LHVS, Pharmacist, Health Educator, Health Assistants) shall maintain

open channels of communication with the patients and their families.

Immunization shall commensurate with the universal immunization program

Expecting mothers to be given two doses of tetanus immunization in their antenatal checkups.

• New borns to be immunized according to the schedule and a card stating their immunization status and growth pattern along with the mile stones to be available with all parents.

• Field health workers shall educate about adolescent health and life style management.

Organization should be involved in : Management of disease outbreaks-

identification, classification (water-borne, vector-borne, vaccine ref-entable), incidence reporting, investigation, data collation, analysis and reporting.

16. Preventive Health Cont…

New borns to be immunized according to the schedule and a card stating their immunization status and growth pattern along with the mile

stones to be available with all parents

New borns to be immunized according to the schedule and a card stating their immunization status and growth pattern along with

the mile stones to be available with all parents

Field health workers shall educate about adolescent health and life style management

Management of disease outbreaks-identification, classification (water-borne, vector-borne, vaccine ref-entable), incidence reporting,

investigation, data collation, analysis and reporting“District Authority”.

Water quality surveillance. Disaster mapping-identification,

preparedness (equipments, antidotes, emergency care, referral services) and networking.

• Organization should have identified resources (equipments & drugs) for handling such preventive programmes / actions.

16. Preventive Health Cont…

Water quality surveillance.

Disaster mapping-identification, preparedness (equipments, antidotes, emergency care,

referral services) and networking.

Organization should have identified resources (equipments & drugs) for handling such

preventive programmes / actions.

Objective Elements• The center shall participate in all the National

Health programs as stated in IPHS.• Community mobilization and their

participation to make the program successful is responsibility of the center.

• Report of such program shall be submitted to the authorities periodically by the MOIC.

17. Participation in National Health Programs

The center shall participate in all the National Health programs as stated in IPHS

Community mobilization and their participation to make the program successful is responsibility of

the center

Report of such program shall be submitted to the authorities

periodically by the MOIC.

18. Referral Services

Objective Elements• The center shall practice a bi-directional or

standardized referral system as per the policy.• The referral cards (with contact numbers) according to

the colour coding to be available and a document there of to be maintained.

• Patient shall be referred from the FRU / Sub-center or referral to CHC or District Hospital.

• All such patient to be followed up for their profress by the MOIC.

• Entries of the transferring in or out to be maintained in register or the computer.

The center shall practice a bi-directional or standardized referral system as per the policy

The referral cards (with contact numbers) according to the colour coding to be available and a

document there of to be maintained

Patient shall be referred from the FRU / Sub-center or referral to CHC or District Hospital

All such patient to be followed up for their progress by the MOIC

Entries of the transferring in or out to be maintained in register or the computer

Entries of the transferring in or out to be maintained in register or the computer

19. Community Mobilization with PRI

Objective Elements• The organization shall have a continuous interaction

with the PRI.• All meeting should be planned and that the agenda of

meeting should be area specific and / or as per the requirements of the community.

• All meeting to be documented.• Diseases profile along with seasonal variation to be

discussed and appropriate proactive intervention to be planed.

• Gatekeeper approach in in mobilizing the community shall be follow.

The organization shall have a continuous interaction with the PRI “Gramsabha”

All meeting should be planned and that the agenda of meeting should be area specific and / or as per

the requirements of the community

All meeting to be documented

Diseases profile along with seasonal variation to be discussed and appropriate proactive intervention

to be planed

Gatekeeper approach in in mobilizing the community shall be follow

20. Social Responsibility

Objective Elements• The center shall understand that it is an

integral part of the society.• The center shall carry out camps, melas, and

healthy competitions etc. periodically.• Respect to the senior citizens and active

participation in school health shall be documented.

The center shall understand that it is an integral part of the society

The center shall carry out camps, melas, and healthy competitions etc. periodically

Respect to the senior citizens and active participation in school health shall be

documented

Respect to the senior citizens and active participation in school health shall be

documented

• Training to the community on household remedies and first aid shall to be carried out and documented.

• A sense of ownership of the facility by the community to be created.

• Centre shall participate in all cultural activities in the community.

20. Social Responsibility Cont…

Training to the community on household remedies and first aid shall to be carried out and

documented

A sense of ownership of the facility by the community to be created

Centre shall participate in all cultural activities in the community

Health for All

Healthcare

How to acheive NABH Standards in PHC & CHC Part 2-4