sa tool kit dr. k.c.mohan

7/29/2019 Sa Tool Kit Dr. k.c.mohan

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Partial compliance to the requirement: 5 (if any of the sample is found to be noncomplying out of total samples selected)

No individual standard should have more than one zero to qualify. However, no zero is accepted in the regulatory/ legal requirements.

The average score for individual standard must not be less than 5.The average score for individual chapter must not be less than 7.

The overall average score for all standards must exceed 7.

Self Assessment Toolkit

rgansat on s requre to prov e se assessment report n t e ormat e ssessment oo t gven e ow. t e entres are to e properyfilled up. Regarding scoring following criteria would be applicable.

Compliance to the requirement: 10

Non-compliance to the requirement: 0

Not Applicable: NA

Evaluation Criteria during final assessment:


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Documentation

(Yes/ No)

Implementation

(Yes/ No)

Evidence(cross reference to

documents/

manuals etc.)

Scores

(0/ 5/ 10)

a policy manual -sec-1 and 2

bDisplay board

c Training records

a. policy-A-2,

document-A-2.1

b. policy-A-2,

document-A-2.2c.

policy-A-2

d. policy-A-2

e. Training records

a. policy-A-3

b. policy-A-3

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

appropriate manner.

Policies guide the transfer of stable patients to another facility.

Standardized policies and procedures are used for registering and admitting

patients.

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

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

The policies and procedures also address managing patients during non

availability of beds.

The staff is aware of these processes.

AAC.3 There is an appropriate mechanism for transfer or referral of patients

who do not match the organisation resources.

Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF

CARE (AAC)AAC.1: The organisation defines and displays the services that it can

provide.

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

The defined services are prominently display.

The staff is oriented to these services.

AAC.2: The organisation has a well defined registration and admission

process.

SELF ASSESSMENT TOOLKIT

Elements


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c. document-A-3.1

d. Case paper

a. policy-A-4

b. policy-A-4

c. policy-A-4

d. policy-A-4

a. policy-A-5

b. document-A-5.1

c. policy-A-5

d. policy-A-5,

document-A-5.1

e. Case sheet / Diet

note book

f. document-A-5.1

g. document-A-5.1

a. policy-A-5document-A-5.1

b. policy-A-5

document-A-5.1

All patients are reassessed at appropriate intervals.

Staff involved in direct clinical care document reassessments.

The organisation defines the time frame within which the initial assessment is

completed.

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

Initial assessment includes screening for nutritional needs.

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

The plan of care also includes preventive aspects of the care.

AAC.6 All patients cared for by the organisation undergo a regular

reassessment.

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

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

complications.

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

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

assessment.The organisation defines the content of the assessments for the out patients, in

patients and emergency patients.

The organisation determines who can perform the assessments.

Procedures identify staff responsible during transfer.

The organization gives a summary of patients condition and the treatment

given.

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

make informed decision.The patients and/ or family members are explained about the proposed care.


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c. policy-A-5,

document-A-5.1

a. policy-A-7

b. policy-A-7

c. policy-A-7,

document-A-7.2

d. policy-A-7

e. document -A -7.3

f. policy A-3

a. policy-A-8

b. policy-A-8, QAP

c. policy-A-8, QAP

d. do

e. do

a. policy-A-9

b. document-A-7.4

c. document-A-7.4

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

Written policies and procedures guide the handling and disposal of infectious and

hazardous materials.

The programme addresses verification and validation of test methods.

The programme addresses surveillance of test results.

The programme includes periodic calibration and maintenance of all equipments.

The programme includes the documentation of corrective and preventive actions.

AAC.9 There is an established laboratory safety programme.

The laboratory safety programme is documented.

Policies and procedures guide collection, identification, handling, safe

transportation, processing and disposal of specimens.

Laboratory results are available within a defined time frame.

Critical results are intimated immediately to the concerned personnel.

Laboratory tests not available in the organization are outsourced to

organization(s) based on their quality assurance system.

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

The laboratory quality assurance programme is documented.

Patients are reassessed to determine their response to treatment and to plan

further treatment or discharge.

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

patients.Scope of the laboratory services are commensurate to the services provided by

the organisation.

Adequately qualified and trained personnel perform and/or supervise the

investigations.


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d. document-A-7.4

e. document-A-7.4

a. licenses

b. policy Sec-2

c. Employee files

d. document-A-10.1

e. policy-A-10

f. policy-A-7,

document-A-7.3

g. Policy A-3

a. policy-A-11

b. policy-A-11

c. policy-A-11

d. policy-A-11,

e. policy-A-11,

a. policy-A-12

b. policy-A-12

AAC.12 There is an established radiation safety programme.

The radiation safety programme is documented.

This programme is integrated with the organizations safety programme.

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

services.The quality assurance program for imaging services is documented.

The programme addresses verification and validation of imaging methods.

The programme addresses surveillance of imaging results.

The programme includes periodic calibration and maintenance of all equipments.

The programme includes the documentation of corrective and preventive actions.

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

organisation.

Adequately qualified and trained personnel perform, supervise and interpret the

investigations.

Policies and procedures guide identification and safe transportation of patients toimaging services.

Imaging results are available within a defined time frame.

Critical results are intimated immediately to the concerned personnel.

Imaging tests not available in the organization are outsourced to organization(s)

based on their quality assurance system

Laboratory personnel are appropriately trained in safe practices.

Laboratory personnel are provided with appropriate safety equipment/ devices.

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

Imaging services comply with the legal and other requirement.


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7/39

a. dischargesummary

b. do

c. do

d. do

e. do

f. Death summary

apolicy-B-1

b

policy-B-1

cpatient's record

dpatient's record

epolicy-B-1

a policy-B-2,document-B-

Policies and procedure for emergency care are documented.

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

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

and regulations.

The care and treatment orders are signed, named, timed and dated by the

concerned doctor.

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

hours.

Evidence based medicine and clinical practise guidelines are adopted to guide

patient care whenever possible.

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

applicable laws and regulations.

Discharge summary contains information regarding investigation results, any

procedure performed, medication and other treatment given.

Discharge summary contains follow up advice, medication and other instructions

in an understandable manner.

Discharge summary incorporates instructions about when and how to obtain

urgent care.

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

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.

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

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

Discharge summary contains the reasons for admission, significant findings and

diagnosis and the patients condition at the time of discharge.


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b document-B-3.1,

policy-B-3

c medical records

ddocument-B-2.5

etraining record

fmedical records

a ow we are

usin IFTb

c

d

e

f

g

a - -

6,document-B-

btraining record

cdocument-B-6.1

ddocument-B-6.2

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

committee.

Emergency medications are checked daily and prior to dispatch.

The ambulance(s) has a proper communication system.

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

pulmonary resuscitation.Documented policies and procedures guide the uniform use of resuscitation

throughout the organisation.

Staff providing direct patient care is trained and periodically update in cardio

pulmonary resuscitation.

The events during a cardio pulmonary resuscitation are recorded.

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

services provided by the organisation.There is adequate access and space for the ambulance(s).

Ambulance(s) is appropriately equipped.

Ambulance(s) is manned by the trained personnel

There is a checklist of all equipment and emergency medications.

Equipment are checked on a daily basis.

Policies also address handling of medico-legal cases.

The patient receives care in consonance with the policies.

Policies and procedures guide the triage of patients for initiation of appropriate

care.

Staff is familiar with the policies and trained on the procedures for care of

emergency patients.

Admission or discharge to home or transfer to another organisation is also

documented.


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erecords

apolicy-B-7

blicense

cdocument-D-2.1

ddo

etraining record

frecords

apolicy-B-8

btraining record

c Adequate

dPolicy B-8

edocument-B-8.2

fImplimented

a policy-B-

9,document-B-9.1

Adequate staff and equipment are available.

Defined procedures for situation of bed shortages are followed.

Infection control practices are followed.

A quality assurance programme is implemented.

COP.7: Policies and procedures guide the care of vulnerable patients

(elderly, physically and/ or mentally challenged and children).Polic ies and procedures are documented and are in accordance with the

prevailing laws and the national and international guidelines.

Informed consent also includes patient and family education about donation.

Staff is trained to implement the policies.

Transfusion reactions are analysed for preventive and corrective actions.

COP.6: Policies and procedures guide the care of patients in the intensive

Care and High Dependency Units.The organisation has documented admission and discharge criteria for its

intensive care and high dependency units.

Staff is trained to apply these criteria.

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

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

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

blood products.

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

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

products.


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brecords

cDocument B-9.1

ddocument-B-2.1

etraining record

a

Policy B-10

bEmployee files

cpolicy-B-10

dNICU

apolicy-B-11

bpolicy-B-11

cEmployee files

dpediatric ward

e

policy-B-11

fCode pink

Those who care for children have age specific competency.

Provisions are made for special care of children.

Patient assessment includes detailed nutritional, growth, psychosocial and

immunization assessment.

Policies and procedures prevent child/ neonates abduction and abuse.

Persons caring for high-risk obstetric cases are competent.

High-risk obstetric patients assessment also includes maternal nutrition.

The organization caring for high risk obstetric cases has the facilities to take care

of neonates of such cases.

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

The organisation defines and displays the scope of its pediatric services.

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

international guidelines.

Care is organised and delivered in accordance with the policies and procedures.

The organisation provides for a safe and secure environment for this vulnerable

group.

A documented procedure exists for obtaining informed consent from the

appropriate legal representative.

Staff is trained to care for this vulnerable group.

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

patients.The organisation defines and displays whether high-risk obstetric cases be cared

for or not.


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gpolicy-B-11

apolicy-B-12

bdo

cdo

drecords

edocument-B-12.1

fAvailable

apolicy-B-13

b records

cpolicy-B-13

dmedical records

edocument-D-2.1

f

Medical records

gMedical records

During anesthesia monitoring includes regular and periodic recording of heart

rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation, airway

security and patency and level of anesthesia.

Each patients post-anesthesia status is monitored and documented.

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

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

All patients for anesthesia have a pre-anesthesia assessment by a qualifiedindividual.

The pre-anesthesia assessment results in formulation of an anesthesia plan

which is documented.

An immediate preoperative re-evaluation is documented.

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

Competent and trained persons perform sedation.

The person administering and monitoring sedation is different from the person

performing the procedure.

Intra procedure monitoring includes at a minimum the heart rate, cardiac

rhythm, respiratory rate, blood pressure, and oxygen saturation, and level of

Patients are monitored after sedation.

Criteria are used to determine appropriateness of discharge from the recovery

area.

Equipment and manpower are available to rescue patients from a deeper level of

sedation than that intended.

The childrens family members are educated about nutrition, immunization and

safe parenting and this is documented in the medical record.

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

moderate sedation.


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hdocument-B-12.1

iMedical records

apolicy-B-14

bdo

c

document-D-2.1

d po cy- -

7,document-C-

epersonnel files

f policyB-14,

records

gMedical records

hPolicy B-14

iPolicy B-14

jpolicy-B-14

apolicy-B-15

bdocument-B-15.1

A quality assurance programme is followed for the surgical survices.

The quality assurance program includes surveillance of the operation theatre

environment.

The plan also includes monitoring of surgical site infection rates.

COP.13: Policies and procedures guide the care of patients under restraints

(physical and/ or chemical).Documented policies and procedures guide the care of patients under restraints.

These include both physical and chemical restraint measures.

Surgical patients have preoperative assessment and a provisional diagnosis

documented prior to surgery.

An informed consent is obtained by the surgeon prior to the procedure.

Documented policies and procedure exist to prevent adverse events like wrong

site, wrong patients and wrong surgery.

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

entitled to perform.

A brief operative note is documented prior to transfer out of patient from recovery

area.

The operating surgeons documents the post operative plan of care.

A qualified individual applies defined criteria to transfer the patient from the

recovery area.

All adverse anesthesia events are recorded and monitored.

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

surgical procedures.The policies and procedures are documented.


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cMedical records

dpolicy-B-15

etraining record

apolicy-B-16

b

do

ctraining record

apolicy-B-17

bpolicy-sec-1

c manpower plan,

policy-sec-1

a

b

c

d

Documented policies and procedures guide all research activities in compliance

with national and international guidelines.

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

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

potential benefits.

Patients informed consent is obtained before entering them in research protocols.

Patient and family are educated on various pain management techniques.

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

Documented pol icies and procedures guide the provision of rehabilitative

services.

These services are commensurate with the organizational requirements.

Rehabilitative services are provided by a multidisciplinary team.

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

These include documentation of reasons for restraints.

These patients are more frequently monitored.

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

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

Documented policies and procedures guide the management of pain.

The organization respects and supports the appropriate assessment and

management of pain for all patients.


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e

f

apolicy-B-18

bdiet note

cdiet note

dpolicyB-18

epolicy B18

fkitchen

a policy-B19

bacts & law

cpolicy-B-19

ddo

etraining record

Staff is educated and trained in end of life care.

Chapter 3: MANAGEMENT OF MEDICATION (MOM)

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

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

Documented policies and procedures guide the end of life care.

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

These also address the identif ication of the unique needs of such patient and

family.

These also include sensitively addressing issues such as autopsy and organ

donation.

COP.17: Policies and procedures guide nutritional therapy.

Documented policies and procedures guide nutr itional assessment and

reassessment.

Patients receive food according to their clinical needs.

There is a written order for the diet.

Nutritional therapy is planned and provided in a collaborative manner.

When families provide food, they are educated about the patients diet limitations.

Patients are informed of their r ight to withdraw from the research at any stage

and also of the consequences (if any) of such withdrawal.

Patients are assured that their refusal to participate or withdrawal fromparticipation will not compromise their access to the organizations services.


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apolicy-C-1

blicenses

c rugs

Formulary

apolicy-C-1

bdo

cdocument-C-1.1

ddo

a policy-C-2

bdo

cdocument-C-2.1

ddo

edo

fdo

Documented policies and procedures exist for storage of medication.

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

Sound inventory control practices guide storage of the medications.

Medications are protected from loss or theft.

Sound alike and look alike medications are stored separately.

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

MOM.2: There is a hospital formulary.

A list of medication appropriate for the patients and organizations resources is

developed.The list is developed collaboratively by the multidisciplinary committee.

There is a defined process for acquisition of these medications.

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

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

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

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

These comply with the applicable laws and regulations.

A multidisciplinary committee guides the formulation and implementation of these

policies and procedures.


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gdo

hdo

apolicy-C-3

bdo

cmedical record

ddo

epolicy-C-3

fdoc-C-3.1

gpolicy-C-3

apolicy-C-4

bdo

cdo

ddo

The policies include a procedure for medication recall.

Expiry dates are checked prior to dispensing.

Labeling requirements are documented and implemented by the organization.

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

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

Policy on verbal orders is documented and implemented.

The organization defines a list of high risk medication.

High risk medication orders are verified prior to dispensing.

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

Documented policies and procedures guide the safe dispensing of medications.

Emergency medications are available all the time.

Emergency medications are replenished in a timely manner when used.

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

Documented policies and procedures exist for prescription of medications.

The organization determines who can write orders.

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


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apolicy-C-5

bdocument-C-5.1

cdo

ddo

epolicy-C-4

fdo

gdo

hrecords

ipolicy-C-5

j policy-C-6

apolicy-C-5, C-6

bdo

apolicy-C-7

b do

Patients are monitored after medication administration and this is documented.

Adverse drug events are defined.

Polices and procedures govern patients self administration of medications.

Polices and procedures govern patients medications brought from outside the

MOM.7: Patients and family members are educated about safe medication

and food-drug interactions.Patient and family are educated about safe and effective use of medication.

Patient and family are educated about food-drug interactions.

MOM.8: Patients are monitored after medication administration.

Patient is identified prior to administration.

Medication is verified from the order prior to administration.

Dosage is verified from the order prior to administration.

Route is verified from the order prior to administration.

Timing is verified from the order prior to administration.

Medication administration is documented.

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

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


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cdocument-C-7.1

d adverse event

record

epolicy-C-7

apolicy-C-8

blicenses

cPolicy C-8

dpersonnel files

a

b

c

d

a

b

Chemotherapy is prescribed by those who have the knowledge to monitor andtreat the adverse effect of chemotherapy.

Chemotherapy is prepared and administered by qualified personnel.

Chemotherapy drugs are disposed off in accordance with legal requirements.

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

Documented policies and procedures govern usage of radioactive drugs.

These policies and procedures are in consonance with laws and regulations.

Documented policies and procedures guide the use of narcotic drugs and

psychotropic substances.

These policies are in consonance with local and national regulations.

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

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

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

agents.Documented policies and procedures guide the usage of chemotherapeutic

agents.

Adverse drug events are reported within a specified time frame.

Adverse drug events are collected and analysed.

Policies are modified to reduce adverse drug events when unacceptable trends

occur.

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

psychotropic substances.


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c

d

a

b

c

apolicy-C-10

b document-C-

10.1

cpolicy-C-10

apolicy-D-1

b display,

document-D-1.1

cdoc-D-1.3

dtraining record

Patient and family rights and responsibilities are documented.

Patients and families are informed of their rights and responsibilities in a format

and language that they can understand.

The organizations leaders protect patient's and family rights.

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

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

Documented policies and procedures govern procurement, handling, storage,

distribution, usage and replenishment of medical gases.

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

Appropriate records are maintained in accordance with the policies, procedures

and legal requirements.

Chapter 4: PATIENT RIGHTS AND EDUCATION (PRE)

PRE.1: The organization protects patient and family rights informs them

about their responsibilities during care.

The policies and procedures include the safe storage, preparation, handling,

distribution, and disposal of radioactive drugs.

Staff, patients and visitors are educated on safety precautions.

MOM.12: Policies and procedures guide the use of implantable prosthesis.

Documented policies and procedures govern procurement and usage of

implantable prosthesis.

Selection of implantable prosthesis is based on scientific criteria and national/

internationally recognized approvals.

The batch and serial number of the implantable prosthesis are recorded in the

patients medical record and the master logbook.


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ecomplaint book

apolicy-D

bpolicy-D

cpolicy-D

dpolicy-D

e policy-D-2

f

policy-D-2

gpolicy-D

hpolicy-D-3

ipolicy-D

jpolicy-D

adocument-D-2.1

bdo

cdocument-D-2.2

d

policy-D

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

consent.

The organisation has listed those situations where informed consent is required.

Informed consent includes information on risks, benefits, alternatives and as to

who will perform the requisite procedure in a language that they can understand.

Patient and family right include information and consent before any research

protocol is initiated.

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

Patient and family rights include information on the expected cost of the

treatment.

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

PRE.3: A documented process for obtaining patient and/ or family's consent

exists for informed decision making about their care.General consent for treatment is obtained when the patient enters the

organisation.

Patient and family rights address any special preferences, spiritual and cultural

needs.

Patient and family rights include respect for personal dignity and privacy during

examination, procedures and treatment.

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

Patient and family rights include treating patient information as confidential.

Patient and family rights include refusal of treatment.

Patient and family rights include informed consent before anaesthesia, blood and

blood product transfusions and any invasive/ high-risk procedures/ treatment.

Violation of patient and family rights is recorded, reviewed and corrective/

preventive measures taken.

PRE.2: Patient and family rights support individual beliefs, values andinvolve the patient and family in decision-making processes.


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epolicy-D

a

policy-D

bpolicy-B-18

cpolicy-D

dpolicy-D

e

policy-Df

policy-D

apolicy-D-3

b

cpolicy-D

dpolicy-D

a infection control

committee

b do

The hospital infection control programme is documented which aims at

preventing and reducing risk of nosocomial infections.

The hospital has a multi-disciplinary infection control committee.

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

The tariff list is available to patients.

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

Patients and family are informed about the financial implications when there is a

change in the patient condition or treatment setting.

Chapter 5: HOSPITAL INFECTION CONTROL (HIC)

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.

Patient and families are educated about diet and nutrition

Patient and families are educated about immunisations.

Patient and families are educated about their specific disease process,

complications and prevention strategies.

Patient and families are educated about preventing infections.

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

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

The policy describes who can give consent when patient is incapable of

independent decision-making.

PRE.4: Patient and families have a right to information and education abouttheir health care needs.

When appropriate, patient and famil ies and are educated about the safe and

effective use of medication and the potential side effects of the medication.


22/39

cdo

d do

a infection control

manual, policy-E

bdo

cdo

d do

ed0

fdo

gdo

hdo

i

do

jdo

ado

brecords

c records

dpolicy-E-2

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

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

authorities.

Engineering controls to prevent infections are included.

Mortuary practices and procedures are included as appropriate to the

organization.

The organization defines the periodicity of updating the infection control manual.

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

identified areas of the hospital.Surveillance activities are appropriately directed towards the identified high-risk

areas

Collection of surveillance data is an ongoing process

It outlines methods of surveillance in the identified high-risk areas.

It focuses on adherence to standard precautions at all times.

Equipment cleaning and sterilisation practices are included.

An appropriate antibiotic policy is established and implemented.

Laundry and linen management processes are also included.

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

The hospital has an infection control team.

The hospital has designated and qualified infection control nurse(s) for thisactivity.

HIC.2: The organisation has an infection control manual, which is

periodically updated.

The manual identifies the various high-risk areas and procedures.


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epolicy-E-1

fpolicy-E-1

apolicy-E-3

bdo

cdo

ddo

edo

aAvailable

b

monitoring

cAvailable

davailable

a infection control

manual

brecords

c recordsAfter the outbreak is over appropriate corrective actions are taken to preventrecurrence.

Compliance with proper hand washing is monitored regularly.

Isolation/ barrier nursing facilities are available.

Adequate gloves, masks, soaps, and disinfectants are available and used

correctly.

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

infections.Hospital has a documented procedure for handling such outbreaks.

This procedure is implemented during outbreaks.

The organization monitors respiratory tract infections.

The organization monitors intra-vascular device infections.

The organization monitors surgical site infections.

Appropriate feedback regarding HAI rates are provided on a regular basis to

medical and nursing staff.

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

infection control programme.Hand washing facilities in all patient care areas are accessible to health care

providers.

Scope of surveillance activities incorporates tracking and analyzing of infection

risks, rates and trends.

Surveillance activities include monitoring the effectiveness of housekeepingservices.

HIC.4: The organization takes actions to prevent or reduce the risk of

Hospital Associated Infections (HAI) in patients and employees.

The organization monitors urinary tract infections.


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a CSSD

b- -

3,document-E-

c infection control

manual

alicenses

b BMW register

c

doutsourced

erecords

f

using

a infection control

programme

bTNHSP

cTraining records

dtraining record

HIC.9: The infection control programme is supported by the organisations

management and includes training of staff and employee health.

Hospital management makes available resources required for the infection

control programme.

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

regard.

It conducts regular pre-induction training for appropriate categories of staff before

joining concerned department(s).

It also conducts regularin-service training sessions for all concerned categories

of staff at least once in a year.

The hospital is authorised by prescribed authority for the management and

handling of Bio-medical Waste.

Proper segregation and collection of Bio-medical Waste from all patient careareas of the hospital is implemented and monitored.

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.

Bio-medical Waste treatment facility is managed as per statutory provisions (if in-

house) or outsourced to authorised contractor(s).

Requisite fees, documents and reports are submitted to competent authorities on

stipulated dates.

Appropriate personal protective measures are used by all categories of staff

handling Bio-medical Waste.

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

organisation.

There is adequate space available for sterilization activities.

Regular validation tests for sterilisation are carr ied out and documented.

There is an established recall procedure when breakdown in the sterilisation

system is identified.

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

management are complied with.


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erecords

apolicy-F,

bdo

c qua y

assurance

dpolicy-F,

etraining record

f committee

record

gpolicy-F,

a

assurance

bdo

cdo

ddo

edo

fdo

Monitoring includes all invasive procedures.

Monitoring includes adverse drug events.

Monitoring includes use of anaesthesia.

Monitoring includes use of blood and blood products.

The designated programme is communicated and coordinated amongst all the

employees of the organization through proper training mechanism.

The quality improvement programme is reviewed at predefined intervals and

opportunities for improvement are identified.

The quali ty improvement programme is a continuous process and updated at

least once in a year.

CQI.2: The organization identifies key indicators to monitor the clinical

structures, processes and outcomes which are used as tools for continual

improvement.

Monitoring includes appropriate patient assessment.

Monitoring includes safety and quality control programmes of the diagnostics

services.

Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)

CQI.1: There is a structured quality improvement and continuous monitoring

programme in the organization.

The quality improvement programme is developed, implemented and maintained

by a multi-disciplinary committee.

The quality improvement programme is documented.

There is a designated individual for coordinating and implementing the quality

improvement programme

The quality improvement programme is comprehensive and covers all the majorelements related to quality improvement and risk management.

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

members


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gdo

hdo

i

jdo

kdo

ado

bdo

cdo

ddo

edo

fdo

gdo

hdo

ido

ado

Monitoring includes data collection to support evaluation of these improvements.

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

management.Hospital Management makes available adequate resources required for qualityimprovement programme.

Monitoring includes risk management.

Monitoring includes utilisation of space, manpower and equipment.

Monitoring includes patient satisfaction which also incorporates waiting time for

services.

Monitoring includes employee satisfaction.

Monitoring includes adverse events and near misses.

Monitoring includes data collection to support further study for improvements.

Monitoring includes clinical research.

Monitoring includes data collection to support further improvements.

Monitoring includes data collection to support evaluation of these improvements.

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

structures, processes and outcomes which are used as tools for continual

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

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

Monitoring includes availability and content of medical records.

Monitoring includes infection control activities.


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bdo

c

do

a Policy-F-2.1,

2.2,2.3

bdo

cdo

ddo

edo

a policy-F-2.4

bdo

c do

ddo

apolicy sec-2

b

policy-G-1

cDMS

Those responsible for governance lay down the organizations mission statement.

Those responsible for governance lay down the strategic and operational plans

commensurate to the organizations mission in consultation with the various stake

holders.

Those responsible for governance approve the organizations budget and

allocate the resources required to meet the organizations mission.

The organisation has defined sentinel events.

The organisation has established processes for intense analysis of such events.

Sentinel events are intensively analysed when they occur.

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

analysis.

Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)

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

Medical and nursing staff participates in this system.

The parameters to be audited are defined by the organisation.

Patient and staff anonymity is maintained.

All audits are documented.

Remedial measures are implemented.

CQI.6: Sentinel events are intensively analysed.

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

Appropriate statistical and management tools are applied whenever required.

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


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dJDHS

e organisationalchart

fDMS

g

hacts & law

i scope of

services

a

b scope of

services

c policies &

procedurald

assurance

apolicy- sec-1

bpolicy -G-2

cpolicy- sec-1

dpolicy-sec-1

ecitizen charter

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

The organization honestly portrays its affiliations and accreditations.

Administrative policies and procedures for each department is maintained.

Departmental leaders are involved in quality improvement.

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

The leaders make public the mission statement of the organization.

The leaders establish the organizations ethical management.

The organization discloses its ownership.

Those responsible for governance support research activities and quality

improvement plans.

The organization complies with the laid down and applicable legislations and

regulations.

Those responsible for governance address the organizations social

responsibility.

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

Each organizational program, service, site or department has effective

leadership.

Scope of services of each department is defined.

Those responsible for governance monitor and measure the performance of the

organization against the stated mission.

Those responsible for governance establish the organizations organogram.

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


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f

apersonal files

bpersonal files

asafety committee

b scope of the

committee

c scope of the

committee

dProvided

a

Laws and

b

Laws and

c Facility Rounds

Recordd

document-F-1.1

FMS.1: The organization is aware of and complies with the relevant rules and

regulations, laws and byelaws and requisite facility inspection requirements.

The management is conversant with the laws and regulations and knows their

applicability to the organization.

Management regularly updates any amendments in the prevail ing laws of the

land.

The management ensures implementation of these requirements.

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

FMS.2: The organizations environment and facilities operate to ensure

safety of patients, their families, staff and visitors.

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

issues are an integral part of patient care and hospital management.

The organization has an interdisciplinary group assigned to oversee the hospital

wide safety programme.

The scope of the programme is defined to include adverse events ranging from

no harm to sentinel events.

Management ensures implementation of systems for internal and external

reporting of system and process failures.

Management provides resources for proactive risk assessment and risk reduction

activities.

Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)

The organization accurately bills for its services based upon a standard bil ling

tariff.

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

organisation.The designated individual has requisite and appropriate administrative

qualifications.

The designated individual has requisite and appropriate administrative

experience.


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apolicy-F-2

blayout board

cdisplay

d

Plan Available

ePWD

fAvailable

grecords

aAvailable

bTNMSC

crecords

d personal files

ecalibration record

fdoc-F-2.1

aAvailable

bProvided

c records

Equipment are periodically inspected and calibrated for their proper functioning.

There is a documented operational and maintenance (preventive and

breakdown) plan.

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

gases and vacuum systems.Potable water and electricity are available round the clock.

Alternate sources are provided for in case of failure.

The organisation regularly tests the alternate sources.

Response times are monitored from reporting to inspection and implementationof corrective actions.

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

equipment management.The organization plans for equipment in accordance with its services and

strategic plan.

Equipment is selected by a collaborative process.

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

Qualified and trained personnel operate and maintain the equipment.

There is a documented operational and maintenance (preventive and

breakdown) plan.

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

There is internal and external sign posting in the organisation in a language

understood by patient, families and community.

The provision of space shall be in accordance with the available literature on

good practices (Indian or International Standards) and directives from

government agencies.

There are designated individuals responsible for the maintenance of all the

facilities.

Maintenance staff is contactable round the clock for emergency repairs.


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dRecords

afire safety plan

b

emergency

c training record

dtraining record

apolicy-F-2

b

a

emergency

bdo

c do

dtraining record

emock drills

a BMW Mgmt.

Plan

b do

Provision is made for availability of medical supplies, equipment and materialsduring such emergencies.

Hospital staff is trained in the hospitals disaster management plan.

The plan is tested at least twice in a year.

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

Hazardous materials are identified within the organization.

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

FMS.6: The organization has a smoking limitation policy.

The organization def ines and implement its polices to reduce or eliminatesmoking.

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

smoke.

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

epidemics and other disasters.The hospital identifies potential emergencies.

The organization has a documented disaster management plan.

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

installation.

FMS.5: The organization has plans for fire and non-fire emergencies withinthe facilities.The organization has plans and provisions for early detection, containment and

abatement of fire and non-fire emergencies.

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

emergencies.

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

Mock drills are held at least twice in a year


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c

d quality

assurance plan

etraining record

apolicy-sec-4

bmeeting record

c

record

drecord

erecord

ftraining record

apersonal files

bjob profile of staff

cpersonal files

atraining record

The organization maintains an adequate number and mix of staff to meet the

care, treatment and service needs of the patient.

The required job specifications and job description are well defined for each

category of staff.

The organization verifies the antecedents of the potential employee with regards

to criminal/negligence background.

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

hospital environment.Each staff member, employee, student and voluntary worker is appropriately

oriented to the organizations mission and goals.

Patient safety devices are installed across the organization and inspected

periodically.

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.

Inspection reports are documented and corrective and preventive measures are

undertaken.

There is a safety education programme for all staff.

Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)

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

Requisite regulatory requirements are met in respect of radioactive materials.

There is a plan for managing spills of hazardous materials.

Staff is educated and trained for handling such materials.

FMS.9: The organisation has systems in place to provide a safe and secure

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

risks.

This committee coordinates development, implementation, and monitoring of the

safety plan and policies.


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b

training record

ctraining record

dtraining record

etraining record

apolicy-I-1

b training record

cdoc-I-1.1

atraining record

btraining record

c training record

dtraining record

apolicy-I-2

b

induction training

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

exists as an integral part of the human resource management process.

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

The employees are made aware of the system of appraisal at the time of

induction.

Feedback mechanisms for assessment of training and development programme

exist.

HRM.4: Staff members, students and volunteers are adequately trained on

specific job duties or responsibilities related to safety.All staff is trained on the risks within the hospital environment.

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

risks.

Staff members are made aware of procedures to follow in the event of anincident.

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

Each staff member is made aware of his/her r ights and responsibilities.

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

All employees are oriented to the service standards of the organisation.

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

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

Training also occurs when job responsibilities change/ new equipment isintroduced.

Each staff member is made aware of hospital wide policies and procedures as

well as relevant department / unit / service / programmes policies and

procedures.


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cpolicy-I-2

ddo

erecord

apolicy-I-3

bdo

c do

ddo

edo

apolicy-I-4

b document-I-4.1

crecords

apersonal files

bpolicy-I-5

cpersonal files

Health problems of the employees are taken care of in accordance with the

organizations policy.

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

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

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

aggrieved.

The redress procedure addresses the grievance.

Actions are taken to redress the grievance.

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

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

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

A written statement of the policy of the organization with regard to discipline is in

place.

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

The policy and procedure is known to all categories of employees of theorganization.

The disciplinary procedure is in consonance with the prevailing laws.

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

Performance is evaluated based on the performance expectations described in

job description.

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

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


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dpolicy-I-5

apersonal files

bpersonal files

cpersonal files

dpersonal files

apersonal files

bpersonal files

cpersonal files

a medical audit

record

bpolicy-I-6

cdo

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

their qualifications.Medical professionals admit and care for patients as per the laid down policies

and authorisation procedures of the organization.

The services provided by the medical professionals are in consonance with their

qualification, training and registration.

The requisite services to be provided by the medical professionals are known to

them as well as the various departments/ units of the hospital.

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

Personal files contain result of all evalutions.

HRM.10: There is a process for collecting, verifying and evaluating thecredentials (education, registration, training and experience) of medical

professionals permitted to provide patient care without supervision.

Medical professionals permitted by law, regulation and the hospital to provide

patient care without supervision is identified.

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

professionals is documented and updated periodically.

All such information pertaining to the medical professionals is appropriately

verified when possible.

Occupational health hazards are adequately addressed.

HRM.9: There is a documented personal record for each staff member.Personal files are maintained in respect of all employees.

The personal f iles contain personal information regarding the employees

qualification, disciplinary background and health status.


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apolicy-I-6

bpersonal files

apersonal files

bNCI Guidelines

ctraining record

a

policy-J

bpolicy-J

cdo

dHMIS

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.

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.

Policies and procedures to meet the information needs are documented.

These policies and procedures are in compliance with the prevail ing laws and

regulations.

All information management and technology acquisitions are in accordance with

the policies and procedures.

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

possible.

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.

The clinical work assigned to nursing staff is in consonance with their

qualification, training and registration.

The services provided by nursing staff are in accordance with the prevailing laws

and regulations.

The requisite services to be provided by the nursing staff are known to them as

well as the various departments / units of the hospital.

Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)

HRM.12: There is a process for collecting, verifying and evaluating the

credentials (education, registration, training and experience) of nursing staff.

The education, registration, training and experience of nursing staff is

documented and updated periodically.


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eHMIS

a policy-J-2

bmedical record

cdocument-J-2.1

ddo

e

aMRD.No.

bpolicy-J-3

cpatients records

dpatients records

e patients records

fpatients records

apatients records

bdo

c

do

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

IMS.4: The medical record reflects continuity of care.

The medical record contains information regarding reasons for admission,

diagnosis and plan of care.

Operative and other procedures performed are incorporated in the medical

record.

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.

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

every patient.Every medical record has a unique identifier.

Organisation policy identifies those authorized to make entries in medical record.

Every medical record entry is dated and timed.

The author of the entry can be identified.

The contents of medical record are identified and documented.

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

data.Formats for data collection are standardized

Necessary resources are available for analyzing data.

Documented procedures are laid down for timely and accurate dissemination of

data.

Documented procedures exist for storing and retrieving data.

Appropriate clinical and managerial staff participates in selecting, integrating and

using data.

The organization contributes to external databases in accordance with the law

and regulations.


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ddo

edo

fdo

gdo

apolicy-J-5

b policy-J-3

cdo

d self assessment

tool kit

eHMIS

fpolicy-J-5

gdoc-J-2.1

apolicy-J-4

bacts & law

cpolicy-J-4

dpolicy-J-4

Documented policies and procedures are in place on retaining the patients

clinical records, data and information.

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

and regulations.

The retention process provides expected confidentiality and security.

The destruction of medical records, data and information is in accordance with

the laid down policy.

The policies and procedures incorporate safeguarding of data/ record against

loss, destruction and tampering.

The hospital has an effective process of monitoring compliance of the laid down

policy.

The hospital uses developments in appropriate technology for improving,

confidentiality, integrity and security.

Privileged health information is used for the purposes identified or as required by

law and not disclosed without the patients authorization.

A documented procedure exists on how to respond to patients/ physicians andother public agencies requests for access to information in the medical record in

accordance with the local and national law.

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

information.

In case of death, the medical record contains a copy of the death certificate

indicating the cause, date and time of death.

Whenever a clinical autopsy is carried out, the medical record contains a copy of

the report of the same.

Care providers have access to current and past medical record.

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

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

and integrity of information.

Policies and procedures are in consonance with the applicable laws.

The medical record contains a copy of the discharge note duly signed by

appropriate and qualified personnel.


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a medical auditrecord

bdo

cdo

ddo

edo

f do

gdo

The review uses a representative sample based on statistical principles.

The review is conducted by identified care providers.

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

records.

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

The review points out and documents any deficiencies in records.

Appropriate corrective and preventive measures undertaken are documented.

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

The medical records are reviewed periodically.

sa tool kit dr. k.c.mohan

Documents