Nabh 5 Std April 2020

NATIONAL ACCREDITATION
BOARD FOR HOSPITALS AND

HEALTHCARE PROVIDERS
(NABH)
th
APRIL 2020
NABH
ACCREDITATION
STANDARDS
FOR
HOSPITALS
APRIL 2020
National Accreditation
Board for Hospitals and
Healthcare Providers
(NABH)
Accreditation Standards for

Hospitals (5th edition) April
2020
ISBN 978-81-944877-5-3
9 788194 487753
© All Rights Reserved

No part of this book may be reproduced or transmitted in any form without
permission in writing from the author.
April 2020
It is my pleasure and pride to release the 5th
Edition of Hospital Accreditation Standard of
National Accreditation Board for Hospitals and
Healthcare Providers. Over the years, successive
NABH standards have brought about a significant
FOREWOR
change in the approach taken by the healthcare
units in managing and delivering the healthcare
services to the patients. NABH standards are
accredited by International Society for Quality
in Health Care (ISQUa). NABH standards focus on
patient safety and quality of the delivery of
services by the hospitals in the changing
healthcare environment. Without being
prescriptive, the objective elements remain
informative and guide the organisation in
conducting its operations with focus on patient
safety.
This edition has some changes that were

incorporated to accommodate the suggestions
made by various stakeholders. For the first
time, there are core objective elements related to
the Patient Safety Goals that have to be complied
mandatorily irrespective of the compliance to
other elements. There are total 651 Objective
Elements out of which 102 are in core category
which will be mandatorily assessed during each
assessment, 459 are in commitment category
which will be assessed during final assessment,
60 are in achievement category which will be
assessed during surveillance assessment and 30
are in excellence category which will be
assessed during re- accreditation.This will help
the healthcare organisation in step wise
progression to mature quality system covering
the full accreditation cycle. The scoring
methodology is changed to a graded system to
help recognising even progressive efforts by the
organisation in implementation of the standards.
The chapter on Continuous Quality Improvement
is now replaced with Patient Safety and Quality
to increase the focus on this aspect of
D
healthcare. Each chapter has a bibliography for

reference and this will provide organisations a
resource for taking quality beyond the
requirements of the objective elements.
In view of these, I expect that the healthcare

organisations will indeed benefit by the efforts of
the technical committee which developed this
standard for National Accreditation Board for
Hospitals and Healthcare Providers.
Dr. Atul Mohan Kochhar

CEO, NABH
CONTENTS
Chapter 1 Access Assessment and Continuity of Care (AAC) 1
Chapter 2 Care of Patients (COP) 13
Chapter 3 Management of Medication (MOM) 30
Chapter 4 Patient Rights and Education (PRE) 39
Chapter 5 Hospital Infection Control (HIC) 47
Chapter 6 Patient Safety and Quality Improvement (PSQ) 57
Chapter 7 Responsibilities of Management (ROM) 65
Chapter 8 Facility Management and Safety (FMS) 72
Chapter 9 Human Resource Management (HRM) 79
Chapter 10 Information Management System (IMS) 91
Glossary 98
Chapter
1 Access Assessment and
Continuity of Care (AAC)
Intent of the chapter:
Patients are informed of the services provided by the organisation. Only those patients who can be
cared for by the organisation are admitted. Emergency patients receive life-stabilising treatment
and are then either admitted (if resources are available) or transferred appropriately to an
organisation that has the resources to take care of such patients. Out-patients who do not match
the organisation's resources are similarly referred to organisations that have the required
resources.
Patients that match the organisation's resources are admitted using a defined process. Patients
cared for by the organisation undergo an established initial assessment and periodic
reassessments.
These assessments result in the formulation of a care plan.
The organisation provides laboratory and imaging services commensurate to its scope of services.
The laboratory and imaging services are provided by competent staff in a safe environment for
both patients and staff. Patient care is continuous and multidisciplinary. Transfer and discharge
protocols are well defined, with adequate information provided to the patient.
Summary of Standards
AAC.1. The organisation defines and displays the healthcare services that it provides.
AAC.2. The organisation has a well-defined registration and admission process.
AAC.3. There is an appropriate mechanism for transfer (in and out) or referral of
patients.
AAC.4. Patients cared for by the organisation undergo an established initial
assessment.
AAC.5. Patients cared for by the organisation undergo a regular reassessment.
AAC.6. Laboratory services are provided as per the scope of services of the
organisation.
AAC.7. There is an established laboratory quality assurance programme.
AAC.8. There is an established laboratory safety programme.
AAC.9. Imaging services are provided as per the scope of services of the
organisation.
AAC.10. There is an established quality assurance programme for imaging services.
AAC.11. There is an established safety programme in imaging services.
AAC.12. Patient care is continuous and multidisciplinary.
AAC.13. The organisation has an established discharge process.
AAC.14. The organisation defines the content of the discharge summary.
* This implies that this objective element requires documentation.

1
STANDARDS AND OBJECTIVE ELEMENTS
Standard
The organisation defines and displays the healthcare services that it
AAC.1.
Objective Elements
Commitment a. The healthcare services being provided are defined and are in
consonance with the needs of the community.
Commitme b. Each defined healthcare service should have diagnostic and

nt
treatment services with suitably qualified personnel who provide out-
patient, in-patient and emergency cover.
c. Scope of the healthcare services of each department is defined. *

Commitme
d. The organisation's defined healthcare services are prominently displayed.
nt
Commitme
nt
Standard
The organisation has a well-defined registration and admission proc
AAC.2.
Objective Elements
Commitment a. The organisation uses written guidance for registering and admitting
patients. *
C RE b. A unique identification number is generated at the end of the registration.
Commitmen c. Patients are accepted only if the organisation can provide the required
service.
t
d. The written guidance also addresses managing patients during non-
Commitmen availability of beds. *
t e. Access to the healthcare services in the organisation is prioritised

according to the clinical needs of the patient. *
Achieveme
nt
C RE
Commitme Achieveme Excellence
nt nt
2
NABH Accreditation Standards for Hospitals
Standard
There is an appropriate mechanism for transfer (in and out) or referr
AAC.3.
Objective Elements
Commitment a. Transfer-in of patients to the organisation is done appropriately. *
Commitme b. Transfer- out/referral of patients to another facility is done appropriately. *
nt c. During transfer or referral, accompanying staff are appropriate to

the clinical condition of the patient.
Commitme
d. The organisation gives a summary of the patient's condition and
nt
the treatment given.
Commitme
nt
Standard
Patients cared for by the organisation undergo an established initial
AAC.4.
Objective Elements
C RE a. The initial assessment of the outpatients, day-care, in-patients and
emergency patients is done. *
Commitmen b The initial assessment is performed by qualified personnel. *

t
Commitmen c. The initial assessment is performed within a time frame based on the
t needs of the patient. *
Commitmen d. Initial assessment of day-care and in-patients includes nursing

t assessment, which is done at the time of admission and
documented.
Achieveme e. The initial assessment for in-patients results in a documented care

nt plan.
Achieveme f. The care plan is countersigned by the clinician-in-charge of the patient
nt within 24 hours.
Excellence g. The care plan includes the identification of special needs regarding
care following discharge.
C RE
nt nt
3
Standard
AAC.5. Patients cared for by the organisation undergo a regular reassessmen
Objective Elements
C RE
a. Patients are reassessed at appropriate intervals to determine their
response to treatment and to plan further treatment or discharge.
Commitmen b. Out-patients are informed of their next follow-up, where appropriate.
t c. For in-patients during reassessment, the care plan is monitored

and modified, where found necessary.
Achieveme
d. Staff involved in direct clinical care document reassessments.
nt
e. The organisation lays down guidelines and implements processes to
identify early warning signs of change or deterioration in clinical
Commitmen
conditions for initiating prompt intervention.
Commitmen
Standard
Laboratory services are provided as per the scope of services of th
AAC.6.
Objective Elements
Commitment a. Scope of the laboratory services is commensurate to the services
provided by the organisation.
Commitme
nt Commitment
Commitme
Commitment
nt
Commitme
nt
b. The scope of services.
infrastruct
ure c. Human resource is adequate to provide the defined scope of services.
(physical
and d. Qualified and trained personnel perform and supervise the
equipmen investigations and report the results.
t) is
adequate e. Requisition for tests, collection, identification, handling, safe
to provide transportation, processing and disposal of a specimen is performed
the according to written guidance. *
defined
f. Laboratory results are available within a defined time frame. *
C RE
nt nt
4
NABH Accredi ta ti on St an dar ds for Ho spit al s
Commitmen g. Critical results are intimated to the person concerned at the earliest. *
t h. Results are reported in a standardised manner.
Commitmen i. There is a mechanism to address the recall / amendment of

reports whenever applicable. *
t
j. Laboratory tests not available in the organisation are outsourced to
Achieveme
the organisation(s) based on their quality assurance system. *
nt
Commitmen
t
Standard
AAC.7. There is an established laboratory quality assurance programme.
Objective Elements
Commitment a. The laboratory quality assurance programme is implemented. *
Commitme b. The programme addresses verification and/or validation of test methods. *
nt c. The programme ensures the quality of test results. *
Commitme d. The programme includes periodic calibration and maintenance of all

equipment. *
nt
e. The programme includes the documentation of corrective and preventive
Commitme actions. *
nt f. The programme addresses clinicopathological meeting(s).
Commitme
nt
Excellence
Standard
AAC.8. There is an established laboratory safety programme.
Objective Elements
Commitme
a. The laboratory safety programme is implemented. *
nt
Commitme b. This programme is aligned with the organisation's safety programme.
nt c. Laboratory personnel are appropriately trained in safe practices.
Commitme d. Laboratory personnel are provided with appropriate safety measures.
nt
Commitme
nt
C RE
nt nt
5
Standard
Imaging services are provided as per the scope of services of the org
AAC.9.
Objective Elements
C RE
a. Imaging services comply with legal and other requirements.
Commitmen b. Scope of the imaging services is commensurate to the services

t
c. The infrastructure (physical and equipment) and human resources are

Commitmen
adequate to provide for its defined scope of services.
t
d. Qualified and trained personnel perform, supervise and interpret the

investigations.
Commitmen
t
e. Patients are transported in a safe and timely manner to and from
the imaging services *
Commitmen
t f. Imaging results are available within a defined time frame. *
g. Critical results are intimated immediately to the personnel concerned. *

Commitmen
h. Results are reported in a standardised manner.
t
i. There is a mechanism to address the recall / amendment of
Commitmen reports whenever applicable. *
t j. Imaging tests not available in the organisation are outsourced to

the organisation(s) based on their quality assurance system. *
Commitmen
Achieveme
nt
Commitmen
t
Standard
There is an established quality assurance programme for imaging s
AAC.10.
Objective Elements
Commitme
a. The quality assurance programme for imaging services is implemented. *
nt
Commitme b. Quality assurance programme includes tests for imaging equipment.

nt
c. Quality assurance programme includes the review of imaging protocols.
Commitme
nt
C RE
nt nt
6
NABH Accreditation Standards for
Achieveme d. A system is in place to ensure the appropriateness of the

nt
investigations and procedures for the clinical indication.
e. The programme addresses periodic internal/external peer review

Achieveme
of imaging results using appropriate sampling.
nt
f. The programme addresses the clinico-radiological meeting(s).

Excellence
g. The programme includes periodic calibration and maintenance of all
equipment. *
Commitmen
h. The programme includes the documentation of corrective and preventive
t actions. *
Commitmen
Standard
AAC.11. There is an established safety programme in imaging services.
Objective Elements
Commitment a The radiation-safety programme is implemented. *
Commitment b. This programme is aligned with the organisation's safety programme.
Commitment c. Patients are appropriately screened for safety/risk before imaging.
Commitment d. Imaging personnel and patients use appropriate radiation safety and
monitoring devices where applicable.
Commitment e. Radiation-safety and monitoring devices are periodically tested, and

results are documented. *
Commitment f. Imaging and ancillary personnel are trained in imaging safety

practices and radiation-safety measures.
Commitment g. Imaging signage is prominently displayed in all appropriate locations.
C Commitm Achievem Excelle

7
Standard
AAC.12. Patient care is continuous and multidisciplinary.
Objective Elements
Commitment a. During all phases of care, there is a qualified individual identified as
responsible for the patient's care.
b. Patient care is co-ordinated in all care settings within the organisation.

Commitme
c. Information about the patient's care and response to treatment is
nt shared among medical, nursing and other care -providers.
Commitme d. The Organisation implements standardiszed hand-over

communication during each staffing shift, between shifts and during
nt transfers between units/ departments.
C RE
Commitmen e. Patient transfer within the organisation is done safelyin a safe manner.
t f. Referral of patients to other departments/ specialities follow written

guidance.
Commitmen
g. The organisation ensures predictable service delivery by adhering to
t defined timelines and informs the patient/family and/ or caregiver
whenever there is a change in schedule.
Achieveme
h. The organisation has a mechanism in place to monitor whether
nt
adequate clinical intervention has taken place in response to a critical
value alert.
Excellence
Standard
AAC.13. The organisation has an established discharge process.
Objective Elements
Commitment a. Thepatient'sdischargeprocessisplannedinconsultationwiththepatientand/
orfamily.
Commitmen Commitment Commitment

t
Achievement Excellence

8
b. The for discharge and makes continual improvement.

discharge
process is
coordinate
d among
various
departme
nts and
agencies
involved
(including
medico-
legal and
absconded
cases). *
c. Written guidance
governs the
discharge of
patients leaving
against medical
advice. *
d. A
discharge
summary
is given
to all the
patients
leaving
the
organisati
on
(including
patients
leaving
against
medical
advice).
e. The organisation
adheres to
planned
discharge.
f. The
organisati
on
conforms
to the
defined
timeframe

9
Standard
AAC.14. The organisation defines the content of the discharge summary.
Objective Elements
Commitme
a. A discharge summary is provided to the patients at the time of discharge.
nt
Commitmen b. Discharge summary contains the patient's name, unique

t identification number, name of the treating doctor, date of admission
and date of discharge
Commitmen c. Discharge summary contains the reasons for admission, significant

t
findings and diagnosis and the patient's condition at the time of
discharge.
Commitmen
d. Discharge summary contains information regarding investigation
t
results, any procedure performed, medication administered, and
other treatment given.
Commitmen
t e. Discharge summary contains follow-up advice, medication and other
instructions in an understandable manner.
Achieveme f. Discharge summary incorporates instructions about when and how

nt to obtain urgent care.
g. In case of death, the summary of the case also includes the cause of death.
Commitmen
t

1
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1
Chapter
2 Care of Patients (COP)
The organisation provides uniform care to all patients in various settings. The settings include care
provided in outpatient units, day care facilities, in-patient units including critical care units,
procedure rooms and operation theatre. When similar care is provided in these different
settings, care delivery is uniform. Written guidance, applicable laws and regulations guide
emergency and ambulance services, cardio-pulmonary resuscitation, use of blood and blood
components, care of patients in the critical care and high dependency units.
Written guidance, applicable laws and regulations also guide the care of patients who are at
higher risk of morbidity/mortality, high-risk obstetric patients, paediatric patients, patients
undergoing procedural sedation, administration of anaesthesia, patients undergoing surgical
procedures and end of life care.
Pain management, nutritional therapy and rehabilitative services are also addressed to provide
comprehensive health care.
The management should have written guidelines for organ donation and procurement. The
transplant programme ensures that it has the right skill mix of staff and other related support
systems to ensure safe and high quality of care.
The standards aim to guide and encourage patient safety as the overarching principle for
providing care to patients.
COP.1. Uniform care to patients is provided in all settings of the
organisation and is guided by written guidance, and the
applicable laws and regulations.
COP.2. Emergency services are provided in accordance with written
guidance, applicable laws and regulations.
COP.3. Ambulance services ensure safe patient transportation with appropriate

care.
COP.4. The organisation plans and implements mechanisms for the care
of patients during community emergencies, epidemics and other
disasters.
COP.5. Cardio-pulmonary resuscitation services are provided uniformly across the
organisation.
COP.6. Nursing care is provided to patients in the organisation in

consonance with clinical protocols.
COP.7. Clinical procedures are performed safely.

COP.8. Transfusion services are provided as per the scope of
services of the organisation, safely.
13
COP.9. The organisation provides care in intensive care and high
dependency units in a systematic manner.
COP.10. Organisation provides safe obstetric care.

COP.11. Organisation provides safe paediatric services.
COP.12. Procedural sedation is provided consistently and safely.
COP.13. Anaesthesia services are provided in a consistent and safe manner.
COP.14. Surgical services are provided in a consistent and safe manner.
COP.15. The organ transplant programme is carried out safely.
COP.16. The organisation identifies and manages patients who are at higher risk of
morbidity/mortality.
COP.17. Pain management for patients is done in a consistent manner.
COP.18. Rehabilitation services are provided to the patients in a safe, collaborative
and consistent manner.
COP.19. Nutritional therapy is provided to patients consistently and collaboratively.
COP.20. End of life care is provided in a compassionate and considerate manner.
Standard
Uniform care to patients is provided in all settings of the organisatio
COP.1.
Objective Elements
Commitme
a. Uniform care is provided following written guidance. *
nt
C RE b. The organisation has a uniform process for identification of patients

and at a minimum, uses two identifiers.
Commitment c. Care shall be provided in consonance with applicable laws and regulations.

1
Achieveme
d. The organisation adapts evidence-based clinical practice
nt
guidelines and/or clinical protocols to guide uniform patient care.
Excellence e. Clinical care pathways are developed, consistently followed across all
settings of care, and reviewed periodically.
Commitme f. Care delivery is uniform for a given clinical condition when similar
nt care is provided in more than one setting. *
g. Multi-disciplinary and multi-speciality care, where appropriate, is

Excellence planned based on best clinical practices/clinical practice guidelines
and delivered in a uniform manner across the organisation.
h. Telemedicine facility is provided safely and securely based on written

Commitme guidance. *
nt
Standard
Emergency services are provided in accordance with written guidan
COP.2.
Objective Elements
Commitment a. There shall be an identified area in the organisation which is easily
accessible to receive and manage emergency patients, with
adequate and appropriate resources.
Achieveme
nt Commitment
C RE
Commitmen
t
Commitmen
Commitmen

1
b. Prevention emergency are reassessed as appropriate for change in status.

of patient
over- g. Admission, discharge to home, or transfer to another organisation
crowding is documented.
is
planned,
and crowd
managem
ent
measures
are
implement
ed.
c. Emergenc
y care is
provided
in
consonanc
e with
statutory
requireme
nts and in
accordanc
e with the
written
guidance.
*
d. The
organisati
on
manages
medico-
legal
cases in
accordanc
e with
statutory
requireme
nts. *
e. Initiation of
appropriate care
is guided by a
system of triage.
*
f. Patients
waiting in
the
1
Commitmen
h. In case of discharge to home or transfer to another organisation, a
t
discharge/ transfer note shall be given to the patient.
i. The organisation shall implement a quality assurance programme. *

Achieveme
nt
Commitme j. The organisation has systems in place for the management of

nt
patients found dead on arrival and patients who die within a few
minutes of arrival *
Standard
Ambulance services ensure safe patient transportation with approp
COP.3.
Objective Elements
Commitme
a. The organisation has access to ambulance services
nt
commensurate with the scope of the services provided by it.
Commitme Commitment Achievement
nt
Commitme
nt
Commitme
nt
Commitme
nt
Commitme
nt
Commitme
nt

1
b. There are opportunities to initiate treatment at the earliest when the patient is
adequate access in transit to the organisation.
and space for the
ambulance(s).
c. The
ambulance(s) is
fit for purpose
and is
appropriately
equipped.
d. The
ambulance(s) is
operated by
trained
personnel.
e. The
ambulance(s) is
checked daily.
f. Equipment is
checked daily
using a checklist.
*
g. A
mechanis
m is in
place to
ensure
that
emergenc
y
medicatio
ns are
available
in the
ambulanc
e.
h. The
ambulance(s)
has a proper
communication
system.*
i. The
emergenc
y
departme
nt
identifies
1
Standard
The organisation plans and implements mechanisms for the care of p
COP.4.
Objective Elements
Commitme
a. The organisation identifies potential community emergencies,
nt
epidemics and other disasters.*
Commitme b. The organisation manages community emergencies, epidemics

nt
and other disasters as per a documented plan.*
c. Provision is made for availability of medical supplies, equipment and

Commitme
materials during such emergencies.
nt
d. The plan is tested at least twice a year.

Commitme
nt
Standard
Cardio-pulmonary resuscitation services are provided uniformly a
COP.5.
Objective Elements
Commitment a. Resuscitation services are available to patients at all times.
Commitme
nt Commitment
Commitme
nt
Commitme
nt
Commitme
nt

1
b. During preventive measures are taken based on the post-event analysis.

cardio-
pulmonar
y
resuscitati
on,
assigned
roles and
responsibi
lities are
complied
with.
c. Equipmen
t and
medicatio
ns for use
during
cardio-
pulmonar
y
resuscitati
on are
available
in various
areas of
the
organisati
on.
d. The events
during cardio-
pulmonary
resuscitation are
recorded.
e. A
multidisci
plinary
committe
e does a
post-
event
analysis
of
cardiopul
monary
resuscitat
ions.
f. Corrective and
2
Standa
Nursing care is provided to patients in the organisation in consonan
COP.6.
Objective Elements
Commitme
a. Nursing care is provided to patients in accordance with written guidance. *
nt
Achieveme b. The organisation develops and implements nursing clinical practice

nt guidelines reflecting current standards of practice. *
c. Assignment of patient care is done as per current good clinical/

Commitmen nursing practice guidelines.
t
d. The organisation implements acuity-based staffing to improve patient
outcomes.
Excellence
C RE e. Nursing care is aligned and integrated with overall patient care.
Commitme f. Care provided by nurses is documented in the patient record.
nt g. Nurses are provided with appropriate and adequate equipment for

providing safe and efficient nursing care.
Commitme
h. Nurses are empowered to make patient care decisions within their scope of
nt practice.
Commitme
nt
Standard
COP.7. Clinical procedures are performed in a safe manner.
Objective Elements
Commitme
Commitment
nt
Commitme Commitment Commitment Commitment

nt
Commitme
nt C RE

2
Standa
a. Procedures are monitored during and after the procedure.
performed based
on the clinical h. Procedures are documented accurately in the patient record.
needs of the
patient.
b. Performance of
various clinical
procedures is
based on written
guidance. *
c. Qualified
personnel order,
plan, perform
and assist in
performing
procedures.
d. Care is
taken to
prevent
adverse
events
like a
wrong
patient,
wrong
procedure
and
wrong
site. *
e. Informed
consent is
taken by
the
personnel
performin
g the
procedure
, where
applicable
.
f. The procedure is
done adhering to
standard
precautions.
g. Patients are
appropriately

2
Standa
Transfusion services are provided as per the scope of services of th
COP.8.
Objective Elements
Commitmen
a. Scope of transfusion services is commensurate with the services
t
b. Transfusion of blood and blood components is done safely. *

C RE
c. Blood and blood components are used rationally. *
Commitme
d. Informed consent is obtained for transfusion of blood and blood
nt
components.
Commitme
e. Informed consent also includes patient and family education about the
donation.
nt
f. Blood/blood components are available for use in emergency
Commitme
situations within a defined time-frame. *
nt
g. Post-transfusion form is collected, reactions if any identified and are
Commitme analysed for preventive and corrective actions.
nt h. The organisation shall implement a quality assurance programme. *
Achieveme
nt
Achieveme
nt
Standard
The organisation provides care in intensive care and high dependen
COP.9.
Objective Elements
Commitmen Excellence
t
Commitment Commitment Achievement Commitment

Commitmen
t
Commitmen
t
2
Standa
a. Care of e. Defined procedures for the situation of bed shortages are followed. *
patients in
f. Infection control practices are followed. *
intensive
care and g. The organisation shall implement a quality assurance programme. *
high
dependen h. The organisation has a mechanism to counsel the patient and/or
cy units is family periodically.
provided
based on
written
guidance.
*
b. The
defined
admission
and
discharge
criteria for
intensive
care and
high
dependen
cy units
are
implement
ed. *
c. Adequate staff
and equipment
are available.
d. The
organisati
on
endeavour
s to
upgrade
its
physical
infrastruct
ure to
meet
national
and
internation
al
guidelines.

2
Standard
COP.10. Organisation provides safe obstetric care.
Objective Elements
Commitme
a. Obstetric services are organised and provided safely. *
nt
Commitme b. The organisation identifies and, provides care to high-risk obstetric

nt cases, and where needed, refers them to another appropriate centre.
c. Persons caring for high-risk obstetric cases are competent.

Commitme
d. Ante-natal services are provided. *
nt
e. Obstetric patient's assessment also includes maternal nutrition.
Commitme
f. Appropriate peri-natal and post-natal monitoring is performed.
nt
g. The organisation caring for high-risk obstetric cases has the facilities
Commitme to take care of neonates of such cases.
nt
Commitme
nt
Commitme
nt
Standard
COP.11. Organisation provides safe paediatric services.
Objective Elements
Commitment a. Paediatric services are organised and provided safely. *
Commitme nt Commitment Commitment
nt
Commitment
Commitme

2
Commitme b. Neonatal care is in consonance with the national/ international guidelines. *

nt
c. Those who care for children have age-specific competency.
d. Provisions are made for special care of children.
e. Paediatric assessment includes growth, developmental and

immunisation assessment.
f. The organisation has measures in place to prevent child/neonate

abduction and abuse. *
g. The child's family members are educated about nutrition,

immunisation and safe parenting.

2
Standard
COP.12. Procedural sedation is provided in a consistent and safe manner.
Objective Elements
Commitme
a. Procedural sedation is administered in a consistent manner *
nt
b. Informed consent for administration of procedural sedation is obtained.
Commitme
nt
Commitme c. Competent and trained persons administer sedation.
nt
d. The person monitoring sedation is different from the person
Commitme performing the procedure.
nt
e. Intra-procedure monitoring includes at a minimum the heart rate,
cardiac rhythm, respiratory rate, blood pressure, oxygen saturation,
Commitme and level of sedation.
nt
f. Patients are monitored after sedation, and the same is documented.
Commitme g. Criteria are used to determine the appropriateness of discharge

from the observation/recovery area. *
nt
h. Equipment and workforce are available to manage patients who have
Commitme
gone into a deeper level of sedation than initially intended.
nt
Commitme
nt
Standard
COP.13. Anaesthesia services are provided in a consistent and safe manner.
Objective Elements
Commitme
a. Anaesthesia services are provided in a consistent manner*
nt
C RE b. The pre-anaesthesia assessment results in the formulation of an

anaesthesia plan which is documented.
Commitme nt Commitment

2
c. A pre-induction
assessment is d. The anaesthesiologist obtains informed consent for administration of
performed and anaesthesia.
documented.
C RE e. During anaesthesia, monitoring includes regular recording of

temperature, heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation and end- tidal carbon dioxide.

2
Commitmen f. Patient's post-anaesthesia status is monitored and documented.
t g. The anaesthesiologist applies defined criteria to transfer the patient

from the recovery area. *
Commitmen
h. The type of anaesthesia and anaesthetic medications used are
t
documented in the patient record.
i. Procedures shall comply with infection control guidelines to

Commitmen
prevent cross- infection between patients.
t
j. Intraoperative adverse anaesthesia events are recorded and monitored.

Commitmen
t
Achieveme
nt
Standard
COP.14. Surgical services are provided in a consistent and safe manner.
Objective Elements
Commitme
a. Surgical services are provided in a consistent and safe manner. *
nt
Commitme b. Surgical patients have a preoperative assessment, a documented

nt pre-operative diagnosis, and pre-operative instructions are provided
before surgery.
Commitment c. Informed consent is obtained by a surgeon before the procedure.
C RE nt Commitment
Commitme
nt
Commitme
nt
Commitme

2
d. Care is and wrong surgery. *

taken to
prevent e. An operative note is documented before transfer out of patient from
adverse recovery.
events
f. Postoperative care is guided by a documented plan.
like the
wrong
g. Patient, personnel and material flow conform to infection control practices.
site,
wrong
h. Appropriate facilities, equipment, instruments and supplies are
patient
available in the operating theatre.
Achieveme i. The organisation shall implement a quality assurance programme. *
nt j. The quality assurance programme includes surveillance of the

operation theatre environment. *
Achieveme
nt

3
Standard
COP.15. The organ transplant programme is carried out safely.
Objective Elements
C RE
a. The organ transplant program shall be in consonance with the legal
requirements and shall be conducted ethically.
Commitme b. Care of transplant patients is guided by clinical practice guidelines. *
nt c. The organisation ensures education and counselling of recipient

and donor through trained/qualified counsellors before organ
Commitme
transplantation.
nt
C RE d. The organisation shall take measures to create awareness

regarding organ donation.
Standard
The organisation identifies and manages patients who are at highe
COP.16.
Objective Elements
Commitment a. The organisation identifies and manages vulnerable patients. *
Commitme b. The organisation provides for a safe and secure environment for the
nt vulnerable patient.
c. The organisation identifies and manages patients who are at a risk of fall.*
C RE
C RE d. The organisation identifies and manages patients who are at risk

of developing/worsening of pressure ulcers.*
C RE e. The organisation identifies and manages patients who are at risk of

developing deep vein thrombosis.*
Commitme f. The organisation identifies and manages patients who need restraints. *
nt

3
Standard
COP.17. Pain management for patients is done in a consistent manner.
Objective Elements
Commitme
a. Patients in pain are effectively managed. *
nt
b. Patients are screened for pain.
Commitme
c. Patients with pain undergo detailed assessment and periodic reassessment.
nt
d. Pain alleviation measures or medications are initiated and titrated
according to the patient's need and response.
Commitme
nt
Commitme
nt
Standard
Rehabilitation services are provided to the patients in a safe, colla
COP.18.
Objective Elements
Commitme
a. Scope of the rehabilitation services at a minimum is commensurate to
nt
the services provided by the organisation.
Commitme nt
nt
Commitment Excellence
Commitme
nt
Commitme
nt
Commitme

3
b. Rehabilitation
services are
provided in a
consistent
manner.
c. Care providers
collaboratively
plan
rehabilitation
services.
d. There are
adequate space
and equipment
to provide
rehabilitation.
e. Care is
guided by
functional
assessme
nt and
periodic
re-
assessme
nts which
are done
and
document
ed.
f. Care is provided
adhering to
infection control
and safety
practices.
g. Care pathways
are developed,
implemented,
and reviewed
periodically.

3
Standard
Nutritional therapy is provided to patients consistently and collabor
COP.19.
Objective Elements
Commitme
a. Patients admitted to the organisation are screened for nutritional risk. *
nt
Commitme b. Nutritional assessment is done for patients found at risk during

nt nutritional screening.
c. The therapeutic diet is planned and provided collaboratively.

Commitme
d. Patients receive food according to the written order for the diet.
nt
e. When family provides food, they are educated about the patient's diet
Commitme limitations.
nt
Commitme
nt
Standard
COP.20. End-of-life-care is provided in a compassionate and considerate man
Objective Elements
Commitment a. End-of-life care is provided in a consistent manner in the organisation. *
Achieveme Commitment
nt
Commitmen
Commitmen

3
b. A multi-
professional
approach is used
to provide end-
of-life care.
c. End-of-life care is
in consonance
with the legal
requirements.
d. End of life
care also
addresses
the
identificati
on of the
unique
needs of
such
patient
and
family.
e. Symptoma
tic
treatment
is
provided
and where
appropriat
e
measures
are taken
for the
alleviation
of pain.

3
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39. Roback, M., Green, S., Andolfatto, G., Leroy, P., & Mason, K. (2018). Tracking and Reporting
Outcomes Of Procedural Sedation (TROOPS): Standardized Quality Improvement and
Research Tools from the International Committee for the Advancement of Procedural
Sedation. British Journal of Anaesthesia, 120(1), 164-172. doi:10.1016/j.bja.2017.08.004
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Clinical pathways: effects on professional practice, patient outcomes, length of stay and
hospital costs. Cochrane Database of Systematic Reviews.
doi:10.1002/14651858.cd006632.pub2
41. Salins, N., Muckaden, M., Nirabhawane, V., Simha, S., Macaden, S., Kulkarni, P., & Joad, A.
(2014). End of life care policy for the dying: Consensus position statement of indian association
of palliative care. Indian Journal of Palliative Care, 20(3), 171. doi:10.4103/0973-
1075.138384
42. Semrau, K. E., Hirschhorn, L. R., Marx Delaney, M., Singh, V. P., Saurastri, R., Sharma, N., …
Gawande, A. A. (2017). Outcomes of a Coaching-Based WHO Safe Childbirth Checklist
Program in India. New England Journal of Medicine, 377(24), 2313-2324.
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43. Sessler, D. I. (2016). Perioperative thermoregulation and heat balance. The Lancet,
387(10038), 2655-2664. doi:10.1016/s0140-6736(15)00981-2
44. Singh, D., & Jain, G. (2018). Chapter-49 Declaration of Brain Death in India: Current
Status. Critical Care Update 2017, 273-279. doi:10.5005/jp/books/13063_50
45. Society of Critical care Medicine. (2018, August 22). Guidelines Online. Retrieved August
5, 2019, from https://www.sccm.org/Research/Guidelines/Guidelines
4
46. Sury, M., & Greenaway, S. (2018). The NICE Guidelines and Pediatric Sedation in the United
Kingdom. The Pediatric Procedural Sedation Handbook, 306-312.
doi:10.1093/med/9780190659110.003.0048
4
47. Tripathi, L., & Kumar, P. (2014). Challenges in pain assessment: Pain intensity scales. Indian
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ua=1
4
Chapter
3 Management of
Medication (MOM)
The organisation has a safe and organised medication process. The availability, safe storage,
prescription, dispensing and administration of medications is governed by written guidance.
The pharmacy should have oversight of all medications stocked out of the pharmacy. The
pharmacy should ensure correct storage (as regards to temperature, light; high-risk medications
including look-alike, sound-alike, etc.), expiry dates and maintenance of documentation.
The availability of emergency medication is stressed upon. The organisation should have a
mechanism to ensure that the emergency medications are standardised throughout the
organisation, readily available and replenished promptly. There should be a monitoring mechanism
to ensure that the required medications are always stocked and well within expiry dates.
Every high-risk medication order should be verified by an appropriate person to ensure
accuracy of the dose, frequency and route of administration. Safety is paramount when using
narcotics, chemotherapeutic agents and radioactive agents.
The process also includes monitoring of patients after administration and procedures for reporting
and analysing near-misses, medication errors and adverse drug reactions.
Medications also include blood, implants and
devices. Medical supplies and consumables are
available for use.
MOM.1. Pharmacy services and usage of medication is done safely.
MOM.2. The organisation develops, updates and implements a hospital formulary.
MOM.3. Medications are stored appropriately and are available where required.
MOM.4. Medications are prescribed safely and rationally.
MOM.5. Medication orders are written in a uniform manner.
MOM.6. Medications are dispensed in a safe manner.
MOM.7. Medications are administered safely.
MOM.8. Patients are monitored after medication administration.
MOM.9. Narcotic drugs and psychotropic substances, chemotherapeutic agents
and radioactive agents are used safely.
MOM.10. Implantable prosthesis and medical devices are used in
accordance with laid down criteria.
MOM.11. Medical supplies and consumables are stored appropriately and are
available where required.
30
STANDARDS AND OBJECTIVE
ELEMENTS
Standard
MOM.1. Pharmacy services and usage of medication is done safely.
Objective Elements
Commitment a. Pharmacy services and medication usage are implemented
following written guidance. *
Commitme b. A multidisciplinary committee guides the formulation and

nt implementation of pharmacy services and medication usage.
c. There is a mechanism in place to facilitate the multidisciplinary

Excellence committee to monitor literature reviews and best practice information
on medication management and use the information to update
medication management processes.
d. There is a procedure to obtain medication when the pharmacy is closed. *

Commitme
e. The organisation has a mechanism to inform relevant staff of key
nt changes in pharmacy services and medication usage to ensure
uninterrupted and safe care.
Commitme
nt
Standard
MOM.2. The organisation develops, updates and implements a hospital form
Objective Elements
C RE
a. A list of medications appropriate for the patients and as per the scope
of the organisation's clinical services is developed
collaboratively by the multidisciplinary committee.
Commitme nt
nt
Commitment
Commitme
nt
Excellence
Commitme

3
b. The list is
reviewed
and
updated
collaborati
vely by
the
multidisci
plinary
committe
e at least
annually.
c. The current
formulary is
available for
clinicians to
refer to.
d. The clinicians
adhere to the
current
formulary.
e. The
organisati
on adheres
procedure
for the
acquisitio
n of
formulary
medicatio
ns. *
f. The
organisati
on
adheres
to the
procedure
to obtain
medicatio
ns not
listed in
the
formulary.
*

3
Standard
MOM.3. Medications are stored appropriately and are available where requ
Objective Elements
C RE
a. Medications are stored in a clean, safe and secure environment;
and incorporating the manufacturer's recommendation(s).
Commitme b. Sound inventory control practices guide storage of the medications

nt throughout the organisation.
C RE c. The organisation defines a list of high-risk medication(s). *
Achieveme d. High-risk medications are stored in areas of the organisation where it

nt is clinically necessary.
C RE e. High-risk medications including look-alike, sound-alike medications

and different concentrations of the same medication are stored
physically apart from each other. *
Commitment f. The list of emergency medications is defined and is stored uniformly. *
C RE g. Emergency medications are available all the time and are

replenished promptly when used.
Standard
MOM.4. Medications are prescribed safely and rationally.
Objective Elements
Commitme
a. Medication prescription is in consonance with good
nt
practices/guidelines for the rational prescription of medications. *
C RE b. The organisation adheres to the determined minimum requirements

of a prescription. *
Commitme c. Drug allergies and previous adverse drug reactions are

nt ascertained before prescribing.
d. The organisation has a mechanism to assist the clinician in

Excellence prescribing appropriate medication.
C RE e. Implementation of verbal orders ensures safe medication management

practices. *

3
Achieveme f. Audit of medication orders/prescription is carried out to check for

nt
safe and rational prescription of medications.
Achieveme g. Corrective and/or preventive action(s) is taken based on the

nt audit, where appropriate.
C RE h. Reconciliation of medications occurs at transition points of patient care.
Standard
MOM.5. Medications orders are written in a uniform manner.
Objective Elements
Commitment a. The organisation ensures that only authorised personnel write orders. *
Commitme b. Medication orders are written in a uniform location in the medical

nt records, which also reflects the patient's name and unique
identification number.
Commitme c. Medication orders are legible, dated, timed and signed.
nt d. Medication orders contain the name of the medicine, route of

administration, strength to be administered and frequency/time of
Commitme administration.
nt
Standard
MOM.6. Medications are dispensed in a safe manner.
Objective Elements
Commitme
a. Dispensing of medications is done safely. *
nt
Commitme b. Medication recalls are handled effectively. *
nt c. Near-expiry medications are handled effectively. *
Commitme
nt

3
C RE d. Dispensed medications are labelled. *
C RE e. High-risk medication orders are verified before dispensing.
Commitme f. Return of medications to the pharmacy is addressed. *

nt

3
Standard
MOM.7. Medications are administered safely.
Objective Elements
Commitme
a. Medications are administered by those who are permitted by law to do so.
nt
b. Prepared medication is labelled before preparation of a second drug.
Commitme
c. The patient is identified before administration.
nt
Commitme
nt
C RE d. Medication is verified from the medication order and physically
inspected before administration.
Commitme e. Strength is verified from the order before administration.
nt f. The route is verified from the order before administration.
Commitme g. Timing is verified from the order before administration.
nt
Commitme
nt
C RE h. Measures to avoid catheter and tubing mis-connections during
medication administration are implemented. *
Commitme i. Medication administration is documented.
nt j. Measures to govern patient's self-administration of medications are

implemented. *
Commitme
k. Measures to govern patient's medications brought from outside the
nt organisation are implemented. *
Commitme
nt
Standard
MOM.8. Patients are monitored after medication administration.

3
Objective Elements
Commitme
a. Patients are monitored after medication administration. *
nt
b. Medications are changed where appropriate based on the monitoring.
Commitme
c. The organisation captures near miss, medication error and adverse drug
reaction. *
nt C RE
Commitme d. Near miss, medication error and adverse drug reaction are
nt reported within a specified time frame. *
e. Near miss, medication error and adverse drug reaction are collected and
Commitme analysed.
nt f. Corrective and/or preventive action(s) are taken based on the analysis.
Commitme
nt

3
Standa
Narcotic drugs and psychotropic substances, chemotherapeutic age
MOM.9.
Objective Elements
Commitme
a. Narcotic drugs and psychotropic substances, chemotherapeutic
nt
agents and radioactive agents are used safely. *
Commitme b. Narcotic drugs and psychotropic substances, chemotherapeutic

nt
agents and radioactive agents are prescribed by appropriate
caregivers.
Commitme
c. Narcotic drugs and psychotropic substances, chemotherapeutic
nt
agents and radioactive agents drugs are stored securely.
d. Chemotherapy and radioactive agents are prepared properly and

Commitme
nt safely and administered by qualified personnel.
e. A proper record is kept of the usage, administration and disposal of

Commitme narcotic drugs and psychotropic substances, chemotherapeutic
nt agents and radioactive agents.
Standard
Implantable prosthesis and medical devices are used in accordanc
MOM.10.
Objective Elements
Commitment a. Usage of the implantable prosthesis and medical devices is guided by
scientific criteria for each item and national/international recognised
guidelines/ approvals for such specific item(s).
Commitmen
t
Achievement
Commitmen
t
Commitmen
t

3
Standa
b. The in the patient's medical record, the master logbook and the discharge
organisati summary.
on
implement e. Recall of implantable prosthesis and medical devices are handled
s a effectively. *
mechanis
m for the
usage of
the
implantabl
e
prosthesis
and
medical
devices. *
c. Patient
and
his/her
family are
counselled
for the
usage of
the
implantabl
e
prosthesis
and
medical
device,
including
precaution
s if any.
d. The batch
and the
serial
number of
the
implantabl
e
prosthesis
and
medical
devices
are
recorded
3
Standa
Medical supplies and consumables are stored appropriately and are
MOM.11.
Objective Elements
Commitme
a. The organisation adheres to the defined process for the acquisition
nt
of medical supplies and consumables. *
Commitme b. Medical supplies and consumables are used in a safe manner, where
appropriate.
nt
c. Medical supplies and consumables are stored in a clean, safe
Commitme and secure environment; and incorporating the manufacturer's
recommendation(s).
nt
d. Sound inventory control practices guide storage of medical
supplies and consumables
Commitme
nt
e. There is a mechanism in place to verify the condition of medical
supplies and consumables
Commitme
nt

4
References:
1. Agency for Healthcare Research and Quality Patient Safety Network. (2019, January).
Medication Errors and Adverse Drug Events. Retrieved August 2, 2019, from
http://psnet.ahrq.gov/primer.aspx?primerID=23
2. Agency for Healthcare Research and Quality Patient Safety Network. (2019, January).
Medication Reconciliation. Retrieved August 2, 2019, from
https://psnet.ahrq.gov/primers/primer/1
3. Clinical Excellence Commission (CEC). (n.d.). High-Risk Medicines. Retrieved August 2,
2019, from http://www.cec.health.nsw.gov.au/programs/high-risk-medicines
4. Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, Government of
India. (2018, December 27 ) . National List of Essential Medicines. Retrieved August
2 , 2019 , f rom http://pharmaceuticals.gov.in/important-document/national-list-essential-
medicines
5. Graham, L. R., Scudder, L., & Stokowski, L. (2015, October 22). Seven (Potentially) Deadly
Prescribing Errors. Retrieved from http://www.medscape.com/features/slideshow/prescribing-
errors#page=1
6. Indian Pharmacopoeia Commission, National Coordination Centre. (2017, 1).
Pharmacovigilance Programme of India. Retrieved August 2, 2019, from
https://ipc.gov.in//PvPI/pv_home.html
7. Institute for Safe Medication Practices. (2010, January 12). Guidelines for Standard Order Sets.
Retrieved August 2, 2019, from https://www.ismp.org/guidelines/standard-order-sets
8. Institute for Safe Medication Practices. (2011). ISMP Acute Care Guidelines for Timely
Administration of Scheduled Medications. Retrieved August 2, 2019, from
https://www.ismp.org/sites/default/files/ attachments/2018-02/tasm.pdf
9. Institute for Safe Medication Practices. (2016). FDA and ISMP Lists of Look-Alike Drug
Names with Recommended Tall Man Letters. Retrieved August 2, 2019, from
https://www.ismp.org/sites/default/files/ attachments/2017-11/tallmanletters.pdf
10. Institute for Safe Medication Practices. (2017, October 2). List of Error-Prone Abbreviations.
Retrieved August 2, 2019, from https://www.ismp.org/recommendations/error-prone-
abbreviations-list
11. Institute for Safe Medication Practices. (2018, August 23). High-Alert Medications in Acute
Care Settings. Retrieved August 2, 2019, from https://www.ismp.org/recommendations/high-
alert-medications-acute-list
12. Institute for Safe Medication Practices. (2019, February 28). List of Confused Drug Names.
Retrieved August 2, 2019, from https://www.ismp.org/recommendations/confused-drug-names-
list
13. Kahn, S., & Abramson, E. L. (2018). What is new in paediatric medication safety? Archives
of Disease in Childhood, 104(6), 596-599. doi:10.1136/archdischild-2018-315175
14. National Coordinating Council for Medication Error Reporting and Prevention. (2015,
January 29). Recommendations to Enhance Accuracy of Prescription/Medication Order
Writing. Retrieved August 2, 2019, from https://www.nccmerp.org/recommendations-
enhance-accuracy-prescription-writing
4
September 2). Recommendations to Reduce Medication Errors Associated with Verbal
Medication Orders and Prescriptions. Retrieved August 2, 2019, from
https://www.nccmerp.org/recommendations-reduce- medication-errors-associated-verbal-
medication-orders-and-prescriptions
4
September 1). Recommendations to Enhance Accuracy of Dispensing Medications.
Retrieved August 2, 2019, from https://www.nccmerp.org/recommendations-enhance-
accuracy-dispensing-medications
January 29). Recommendations to Enhance Accuracy of Prescription/Medication Order
Writing. Retrieved August 2, 2019, from https://www.nccmerp.org/recommendations-
enhance-accuracy-prescription-writing
September 2). Recommendations to Enhance Accuracy of Administration of Medications.
Retrieved August 2, 2019, from https://www.nccmerp.org/recommendations-enhance-
accuracy-administration-medications
January 30). About Medication Errors. Retrieved August 2, 2019, from
https://www.nccmerp.org/about-medication-errors
20. Tully, A. P., Hammond, D. A., Li, C., Jarrell, A. S., & Kruer, R. M. (2019). Evaluation of Medication
Errors at the Transition of Care From an ICU to Non-ICU Location. Critical Care Medicine,
47(4), 543-549. doi:10.1097/ccm.0000000000003633
21. World Health Organization. (n.d.). Avoiding Catheter and Tubing Mis-Connections. Retrieved
August 2, 2019, from https://www.who.int/patientsafety/solutions/patientsafety/PS-
Solution7.pdf?ua=1
22. World Health Organization. (n.d.). How to Investigate Drug Use in Health Facilities:
Selected Drug Use I n d i c a t o r s - E D M R e s e a r c h S e r i e s N o . 0 0 7 . R e t r i e v
e d A u g u s t 2 , 2 0 1 9 , f r o m http://apps.who.int/medicinedocs/en/d/Js2289e/
23. World Health Organization. (n.d.). Improving Medication safety. Retrieved August 2, 2019,
from http://www.who.int/patientsafety/education/curriculum/who_mc_topic-11.pdf
24. World Health Organization. (n.d.). Look-Alike, Sound-Alike Medication Names. Retrieved
August 2, 2019, from https://www.who.int/patientsafety/solutions/patientsafety/PS-
Solution1.pdf?ua=1
25. World Health Organization. (n.d.). Rational use of medicines. Retrieved August 2, 2019,
from https://www.who.int/medicines/areas/rational_use/en/
26. World Health Organization. (n.d.). The High 5s Project -Standard Operating Protocol
Assuring Medication Accuracy at Transitions in Care: Medication Reconciliation. Retrieved
August 2, 2019, from
https://www.who.int/patientsafety/implementation/solutions/high5s/h5s-sop.pdf
27. World Health Organization. (n.d.). WHO Model Lists of Essential Medicines. Retrieved August 2,
2019, from https://www.who.int/medicines/publications/essentialmedicines/en/
4
Chapter 4
Patient Rights and
Education (PRE)
The organisation defines, protects and promotes the patient and family's rights and
responsibilities. The staff is aware of these rights and is trained to protect them. Patients are
informed of their rights and educated about their responsibilities at the time of entering the
organisation.
The expected costs of treatment and care are explained clearly to the patient
and/or family. Patients are educated about the mechanisms available for
addressing grievances.
Informed consent is obtained from the patient or family for specified procedures/care. The key
components of information shall include risks, benefits and alternatives.
Patients and families have a right to get information and education about their healthcare needs in a
language and manner that is understood by them.
The organisation develops effective patient-centred communication.
PRE.1. The organisation protects and promotes patient and family rights and
informs them about their responsibilities during care.
PRE.2. Patient and family rights support individual beliefs, values and involve
the patient and family in decision-making processes.
PRE.3. The patient and/or family members are educated to make informed
decisions and are involved in the care planning and delivery process.
PRE.4. Informed consent is obtained from the patient or family about their care.
PRE.5. Patient and families have a right to information and education
about their healthcare needs.
PRE.6. Patients and families have a right to information on expected costs.

PRE.7. The organisation has a mechanism to capture patient's feedback
and to redress complaints.
PRE.8. The organisation has a system for effective communication with

patients and/or families.
4
Standard
The organisation protects and promotes patient and family rights a
PRE.1.
Objective Elements
Commitmen
a. Patient and family rights and responsibilities are documented,
t
displayed and they are made aware of the same. *
b. Patient and family rights and responsibilities are actively promoted. *

Achieveme
nt
C RE c. The organisation protects patient and family rights.
C RE d. The organisation has a mechanism to report a violation of patient and family

rights.
C RE e. Violation of patient and family rights are monitored, analysed,

and corrective/preventive action taken by the top leadership of the
organisation.
Standard
Patient and family rights support individual beliefs, values and invo
PRE.2.
Objective Elements
Commitment a. Patients and family rights include respecting values and beliefs,
any special preferences, cultural needs, and responding to requests
for spiritual needs.
Commitme Commitment
nt
Commitme
nt C RE
Commitme
nt

4
b. Patient
and family
rights
include
respect
for
personal
dignity
and
privacy
during
examinati
on,
procedure
s and
treatment
.
c. Patient and
family rights
include
protection from
neglect or
abuse.
d. Patient and
family rights
include treating
patient
information as
confidential.
e. Patient and
family rights
include the
refusal of
treatment.
f. Patient
and family
rights
include a
right to
seek an
additional
opinion
regarding
clinical
care.

4
C RE g. Patient and family rights include informed consent before the

transfusion of blood and blood components, anaesthesia, surgery,
initiation of any research protocol and any other invasive/high-risk
procedures/treatment.
Commitmen
t
h. Patient and family rights include a right to complain and information
on how to voice a complaint.
Achieveme
i. Patient and family rights include information on the expected
nt
cost of the treatment.
j. Patient and family rights include access to their clinical records.

Commitmen
k. Patient and family rights include information on the name of the

t
treating doctor, care plan, progress and information on their health
Commitmen care needs.
t l. Patient rights include determining what information regarding their

care would be provided to self and family.
Commitmen
t
Standard
The patient and/or family members are educated to make informed
PRE.3.
Objective Elements
C RE t
Commitmen Commitment
t
Achievement
Commitmen
Achieveme
nt
Commitmen
4
a. The and/or family members are informed about the results of diagnostic
Patient tests and the diagnosis.
and/or
family f. The patient and/or family members are explained about any
members change in the patient's condition in a timely manner.
are
explained g. The patient and/or family members are provided multi-disciplinary
about the counselling when appropriate.
proposed
care,
including
the risks,
alternative
s and
benefits.
b. The patient
and/or family
members are
explained about
the expected
results.
c. The
patient
and/or
family
members
are
explained
about the
possible
complicati
ons.
d. The care
plan is
prepared
and
modified
in
consultati
on with
the
patient
and/or
family
members.
e. The
patient
4
Standard
PRE.4. Informed consent is obtained from the patient or family about their c
Objective Elements
C RE
a. The organisation obtains informed consent from the patient or family
for situations where informed consent is required. *
Commitme
b. Informed consent process adheres to statutory norms.
nt C RE
c. Informed consent includes information regarding the procedure; it's
risks, benefits, alternatives and as to who will perform the procedure
in a language that they can understand.
Commitme
d. The organisation describes who can give consent when a patient is
nt
incapable of independent decision making and implements the same.
*
C RE
e. Informed consent is taken by the person performing the procedure.
Standard
Patient and families have a right to information and education abou
PRE.5.
Objective Elements
C RE Commitment
Commitmen Commitment
t
Achievement
Commitme
nt
Commitme
nt
Commitme
nt
Commitme
nt

4
a. Patient on various pain management techniques, when appropriate.

and/or
family are g. Patient and/or family are educated about their specific disease
educated process, complications and prevention strategies.
in a
h. Patient and/or family are educated about preventing healthcare
language
associated infections.
and
format i. The patients and/or family members' special educational needs are
that they identified and addressed.
can
understan
d.
b. Patient
and/or
family are
educated
about the
safe and
effective
use of
medicatio
n and the
potential
side
effects of
the
medicatio
n, when
appropriat
e.
c. Patient and/or
family are
educated about
food-drug
interaction
d. Patient and/or
family are
educated about
diet and
nutrition.
e. Patient and/or
family are
educated about
immunisations.
f. Patient
and/or
family are
educated
5
Standard
PRE.6. Patients and families have a right to information on expected costs
Objective Elements
C RE
a. The patient and/or family members are made aware of the pricing
policy in different settings (out-patient, emergency, ICU and
inpatient).
Commitme b. The relevant tariff list is available to patients.
nt c. The patient and/or family members are explained about the expected costs.
Commitme d. Patient and/or family are informed about the financial implications
when there is a change in the care plan.
nt
Commitme
nt
Standard
The organisation has a mechanism to capture patient's feedback
PRE.7.
Objective Elements
Commitme
nt a. The organisation has a mechanism to capture feedback from
patients, which includes patient satisfaction.
Achievement b. The organisation has a mechanism to capture patient experience.
C RE c. The organisation redress patient complaints as per the defined mechanism.

*
Commitme nt
nt
Commitme
nt
Commitme
5
d. Patient
and/or
family
members
are made
aware of
the
procedure
for giving
feedback
and/or
lodging
complaint
s.
e. Feedback
and
complaint
s are
reviewed
and/or
analysed
within a
defined
time
frame.
f. Corrective
and/or
preventiv
e
action(s)
are taken
based on
the
analysis
where
appropriat
e.

5
Standard
The organisation has a system for effective communication with pa
PRE.8.
Objective Elements
Commitment a. Communication with the patients and/or families is done effectively. *
Commitmen b. The organisation shall identify special situations where enhanced

t communication with patients and/or families would be required. *
c. Enhanced communication with the patients and/or families is done

Commitmen effectively. *
t d. The organisation ensures that there is no unacceptable communication.
Commitmen e. The organisation has a system to monitor and review the

implementation of effective communication.
t
Achieveme
nt

5
References:
1. Badarudeen, S., & Sabharwal, S. (2010). Assessing Readability of Patient Education Materials:
Current Role in Orthopaedics. Clinical Orthopaedics and Related Research®, 468(10), 2572-
2580. doi:10.1007/s11999- 010-1380-y
2. Baile, W. F. (2000). SPIKES--A Six-Step Protocol for Delivering Bad News: Application to the
Patient with Cancer. The Oncologist, 5(4), 302-311. doi:10.1634/theoncologist.5-4-302
3. Baile, W. F. , & Parker, P. A . ( 2017 ) . Brea ki n g bad news. Oxford Medi ci n e Online.
doi:10.1093/med/9780198736134.003.0012
4. Boissy, A., & Gilligan, T. (2016). Communication the Cleveland Clinic Way: How to Drive a
Relationship- Centered Strategy for Exceptional Patient Experience. New York, NY: McGraw Hill
Professional.
5. Burgener, A. M. (2017). Enhancing Communication to Improve Patient Safety and to
Increase Patient Satisfaction. The Health Care Manager, 36(3), 238-243.
doi:10.1097/hcm.0000000000000165
6. Emedicinehealth. (2017, November 20). Patient Rights: Confidentiality & Informed
Consent. Retrieved August 2, 2019, from
https://www.emedicinehealth.com/patient_rights/article_em.htm
7. Gaglio, B. (2016). Health Literacy-An Important Element in Patient-Centered Outcomes
Research. Journal of Health Communication, 21(sup2), 1-3.
doi:10.1080/10810730.2016.1184359
8. Hong, J., Nguyen, T. V., & Prose, N. S. (2013). Compassionate care: Enhancing physician-
patient communication and education in dermatology. Journal of the American Academy
of Dermatology, 68(3), 364.e1-364.e10. doi:10.1016/j.jaad.2012.10.060
9. Ian Anderson Continuing Education Program in End-of-Life Care. (n.d.). Communication with
patients and families. Retrieved August 2, 2019, from
https://www.cpd.utoronto.ca/endoflife/Modules/ COMMUNICATIONS%20MODULE.pdf
10. Lamba, S., Tyrie, L. S., Bryczkowski, S., & Nagurka, R. (2016). Teaching Surgery Residents
the Skills to Communicate Difficult News to Patient and Family Members: A Literature
Review. Journal of Palliative Medicine, 19(1), 101-107. doi:10.1089/jpm.2015.0292
11. Lippincott Solutions. (2017, August 22). 5 Strategies for Providing Effective Patient
Education. Retrieved August 2, 2019, from
http://lippincottsolutions.lww.com/blog.entry.html/2017/08/22/5_strategies_forpro- kDDq.html
12. Marcus, C. (2014). Strategies for improving the quality of verbal patient and family education:
a review of the literature and creation of the EDUCATE model. Health Psychology and
Behavioral Medicine, 2(1), 482-495. doi:10.1080/21642850.2014.900450
13. Mullick, P., Kumar, A., Prakash, S., & Bharadwaj, A. (2015). Consent and the Indian medical
practitioner. Indian Journal of Anaesthesia, 59(11), 695. doi:10.4103/0019-5049.169989
14. Munro, C. L., & Savel, R. H. (2013). Communicating and Connecting With Patients and
Their Families. American Journal of Critical Care, 22(1), 4-6. doi:10.4037/ajcc2013249
15. Nandimath, O. (2009). Consent and medical treatment: The legal paradigm in India.
Indian Journal of Urology, 25(3), 343. doi:10.4103/0970-1591.56202
16. Neff Newitt, V. (2017). The Art of Breaking Bad News to Patients. Oncology Times, 39(17),
5
1. doi:10.1097/01.cot.0000525219.72486.bd
5
17. Nouri, S. S., & Rudd, R. E. (2015). Health literacy in the "oral exchange": An important element
of patient- provider communication. Patient Education and Counseling, 98(5), 565-571.
doi:10.1016/j.pec.2014.12.002
18. Provider-Patient Communication. (2016). Health Communication for Health Care
Professionals. doi:10.1891/9780826124425.0004
19. Reader, T. W., Gillespie, A., & Roberts, J. (2014). Patient complaints in healthcare systems: a
systematic review and coding taxonomy. BMJ Quality & Safety, 23(8), 678-689.
doi:10.1136/bmjqs-2013-002437
20. Roberts, H., Zhang, D., & Dyer, G. S. (2016). The Readability of AAOS Patient Education
Materials. The Journal of Bone and Joint Surgery, 98(17), e70. doi:10.2106/jbjs.15.00658
21. Rosenbaum, M. E., Ferguson, K. J., & Lobas, J. G. (2004). Teaching Medical Students and
Residents Skills for Delivering Bad News: A Review of Strategies. Academic
Medicine, 79(2), 107-117. doi:10.1097/00001888-200402000-00002
22. U S National Library of Medicine. (n.d.). Patient Rights: MedlinePlus. Retrieved August 2,
2019, from https://medlineplus.gov/patientrights.html
23. Williams, A. M., Muir, K. W., & Rosdahl, J. A. (2016). Readability of patient education
materials in ophthalmology: a single-institution study and systematic review. BMC
Ophthalmology, 16(1). doi:10.1186/s12886-016-0315-0
5
Chapter 5
Hospital
Infection
Control (HIC)
The organisation implements an effective healthcare associated infection prevention and control
programme. The programme is documented and aims at reducing/eliminating infection risks to
patients, visitors and providers of care. The programme is implemented across the organisation,
including clinical areas and support services.
The organisation provides proper facilities and adequate resources to support the infection
prevention and control programme. The organisation measures and acts to prevent or reduce the
risk of healthcare associated infection in patients and staff.
The organisation has an effective antimicrobial management programme through regularly
updated antibiotic policy based on local data and monitors its implementation. Programme
also includes monitoring of antimicrobials usage in the organisation.
Surveillance activities are incorporated in the infection prevention and control
programme. The programme includes disinfection/sterilisation activities and biomedical
waste (BMW) management.
HIC.1. The organisation has a comprehensive and coordinated Hospital
Infection Prevention and Control (HIC) programme aimed at
reducing/eliminating risks to patients, visitors, providers of care and
community.
HIC.2. The organisation provides adequate and appropriate resources for
infection prevention and control.
HIC.3. The organisation implements the infection prevention and control

programme in clinical areas.
HIC.4. The organisation implements the infection prevention and control

programme in support services.
HIC.5. The organisation takes actions to prevent healthcare associated

Infections (HAI) in patients.
HIC.6. The organisation performs surveillance to capture and monitor

infection prevention and control data.
HIC.7. Infection prevention measures include sterilization and/or

disinfection of instruments, equipment and devices.
5
HIC.8. The organisation takes action to prevent or reduce healthcare
associated infections in its staff.
5
Standard
The organisation has a comprehensive and coordinated Hospital Infe
HIC.1.
Objective Elements
C RE
a. The hospital infection prevention and control programme is
documented, which aims at preventing and reducing the risk of
healthcare associated infections in the hospital. *
Commitmen b. The hospital infection prevention and control programme identifies

t
high-risk activities, and has written guidance to prevent and manage
infections for these activities.*
c. The infection prevention and control programme is reviewed and

Commitmen updated at least once a year.
t
d. The infection prevention and control programme is reviewed based
on infection control assessment tool.
Achieveme
nt
e. The organisation has a multi-disciplinary infection control committee,
which coordinates all infection prevention and control activities. *
Commitmen
t f. The organisation has an infection control team, which coordinates the
implementation of all infection prevention and control activities. *
g. The organisation has designated infection control officer as part of

Commitmen
t the infection control team. *
h. The organisation has designated infection control nurse(s) as part of

Commitmen the infection control team. *
t
i. The organisation implements information, education and
communication programme for infection prevention and control
Commitmen activities for the community.
t
j. The organisation participates in managing community outbreaks.
Commitmen
t
Commitmen
t

5
Standa
The organisation provides adequate and appropriate resources fo
HIC.2.
Objective Elements
C RE
a. The management makes available resources required for the
infection control programme.
Commitme b. The organisation earmarks adequate funds from its annual budget in this
regard.
nt
c. Adequate and appropriate personal protective equipment, soaps, and
Commitme disinfectants are available and used correctly.
nt d. Adequate and appropriate facilities for hand hygiene in all patient-

care areas are accessible to healthcare providers.
C RE
Achievement e. Isolation/barrier nursing facilities are available.
Standard
The organisation implements the infection prevention and control p
HIC.3.
Objective Elements
C RE a. The organisation adheres to standard precautions at all times. *
C RE b. The organisation adheres to hand-hygiene guidelines. *
Commitment c. The organisation adheres to transmission-based precautions. *
C RE d. The organisation adheres to safe injection and infusion practices. *
Commitment e. Appropriate antimicrobial usage policy is established and documented *
C RE f. The organisation implements the antimicrobial usage policy and

monitors the rational use of antimicrobial agents.
Excellence g. The organisation implements an antibiotic stewardship programme. *

6
Standa
The organisation implements the infection prevention and control
HIC.4.
Objective Elements
Commitment a. The organisation has appropriate engineering controls to prevent infections.
*
Commitme b. The organisation designs and implements a plan to reduce the risk
nt of infection during construction and renovation. *
C RE c. The organisation adheres to housekeeping procedures. *
C RE d. Biomedical waste (BMW) is handled appropriately and safely.
Commitme e. The organisation adheres to laundry and linen management processes. *
nt f. The organisation adheres to kitchen sanitation and food-handling issues. *
Commitme
nt
Standard
The organisation takes actions to prevent healthcare associated i
HIC.5.
Objective Elements
Commitme nt
nt
Commitme
nt
Commitme
nt
Commitme

6
Standa
a. The
organisati
on takes
action to
prevent
catheter-
associate
d urinary
tract
Infections.
b. The
organisati
on takes
action to
prevent
infection-
related
ventilator
associate
d
complicati
on/ventila
tor-
associate
d
pneumoni
a.
c. The organisation
takes action to
prevent catheter
linked blood
stream
infections.
d. The organisation
takes action to
prevent surgical
site infections.

6
Standard
The organisation performs surveillance to capture and monitor infe
HIC.6.
Objective Elements
C RE a. The scope of surveillance incorporates tracking and analysing of
infection risks, rates and trends.
Commitment b. Verification of data is done regularly by the infection control team.
Commitment c Surveillance is directed towards the identified high-risk activities.
C RE d. Surveillance includes monitoring compliance with hand-hygiene

guidelines.
Commitment e. Surveillance includes mechanisms to capture the occurrence of
multi-drug- resistant organisms and highly virulent infections.
C RE f. Surveillance includes monitoring the effectiveness of housekeeping

services.
Commitment g. Feedback regarding surveillance data is provided regularly to the
appropriate health care provider.
Commitment h. The organisation identifies and takes appropriate action to control

outbreaks of infections.
Commitment I. Surveillance data is analysed, and appropriate corrective and

preventive actions are taken.
Standard
Infection prevention measures include sterilisation and/or disinfecti
HIC.7.
Objective Elements
Commitme Commitment
nt
C RE
Commitme
nt
Commitme
nt

6
a. The d recall procedure is implemented when a breakdown in the

organisati sterilisation system is identified. *
on
provides
adequate
space
and
appropriat
e zoning
for
sterilisatio
n
activities.
b. Cleaning,
packing,
disinfectio
n and/or
sterilisatio
n, storing
and the
issue of
items is
done as
per the
written
guidance.
*
c. Reprocess
ing of
single-use
instrumen
ts,
equipmen
t and
devices
are done
as per
written
guidance.
*
d. Regular
validation tests
for sterilisation
are carried out
and
documented. *
e. The
establishe
6
Standard
The organisation takes action to prevent or reduce healthcare asso
HIC.8.
Objective Elements
Commitme
nt a. The organisation implements occupational health and safety practices
to reduce the risk of transmitting microorganisms among health care
providers.
Commitmen b. The organisation implements an immunisation policy for its staff. *
t c. The organisation implements work restrictions for health care

providers with transmissible infections.
Achieveme
d. The organisation implements measures for blood and body fluid
nt exposure prevention.
e. Appropriate post-exposure prophylaxis is provided to all staff

Commitmen members concerned. *
t
Commitmen
t

6
References:
1. ACOG Committee Opinion No. 769. (2019). Reprocessed Single-Use Devices. Obstetrics &
Gynecology, 133(3), e235-e237. doi:10.1097/aog.0000000000003124
2. Agency for Healthcare Research and Quality. (2014, August 25). Environmental Cleaning for
the Prevention of Healthcare-Associated Infections (HAI). Retrieved August 2, 2019, from
https://effectivehealthcare. ahrq.gov/topics/healthcare-infections/research-protocol
3. Association for Professionals in Infection Control and Epidemiology. (2013, September
10). Use Personal Protective Equipment. Retrieved August 2, 2019, from
https://professionals.site.apic.org/protect-your- patients/using-ppe-the-right-way/
4. Association of Occupational Health Professionals in Healthcare. (2014, April 24).
Recommended work restrictions for communicable diseases in health care workers.
https://aohp.org/aohp/Portals/0/Documents/MemberServices/templateandform/WR4CD-
HCW.pdf
5. Banach, D. B., Bearman, G., Barnden, M., Hanrahan, J. A., Leekha, S., Morgan, D. J., …
Wiemken, T. L. (2018). Duration of Contact Precautions for Acute-Care Settings. Infection
Control & Hospital Epidemiology, 39(2), 127-144. doi:10.1017/ice.2017.245
6. Banach, D. B., Johnston, B. L., Al-Zubeidi, D., Bartlett, A. H., Bleasdale, S. C., & Deloney, V.
M. (2017). Outbreak Response and Incident Management: SHEA Guidance and Resources
for Healthcare Epidemiologists in United States Acute-Care Hospitals. Infection Control &
Hospital Epidemiology, 38(12), 1393-1419. doi:10.1017/ice.2017.212
7. Bearman, G., Bryant, K., Leekha, S., Mayer, J., Munoz-Price, L. S., Murthy, R., … White, J.
(2014). Healthcare Personnel Attire in Non-Operating-Room Settings. Infection Control &
Hospital Epidemiology, 35(2), 107- 121. doi:10.1086/675066
8. Centers for Disease Control and Prevention. (2003, June 6). Guidelines for Environmental
Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare
Infection Control Practices Advisory C o m m i t t e e ( HICPAC). R e t r i e v e d August 2 ,
2019 , f rom h ttps:// www. cdc. gov/ mmwr/ preview/mmwrhtml/rr5210a1.htm
9. Centers for Disease Control and Prevention. (2006, April). Outline For Healthcare-
Associated Infections S u r v e i l l a n c e . R e t r i e v e d A u g u s t 2 , 2 0 1 9 , f r o m h t t
p s : / / w w w. c d c . g o v / n h s n / P D F S / OutlineForHAISurveillance.pdf
10. Centers for Disease Control and Prevention. (2018, November 6). CDC - Health Care
Workers, Prevention Controls, Infectious Agents - NIOSH Workplace Safety and Health
Topic. Retrieved August 2, 2019, from
https://www.cdc.gov/niosh/topics/healthcare/prevention.html
11. Centers for Disease Control and Prevention. (2019, May 24). Disinfection & Sterilization
Guidelines | Guidelines Library | Infection Control | CDC. Retrieved August 2, 2019, from
https://www.cdc.gov/ infectioncontrol/guidelines/disinfection/index.html
12. Centers for Disease Control and Prevention. (2019, June 18). CAUTI Guidelines |
Guidelines Library | Infection Control | CDC. Retrieved August 2, 2019, from
https://www.cdc.gov/infectioncontrol/ guidelines/CAUTI/index.html
13. Centers for Disease Control and Prevention. (2019, July 22). Isolation Precautions. Retrieved
August 2, 2019, from https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html
6
14. Centers for Disease Control and Prevention. (2019, March 25). Surgical Site Infection |
Guidelines | Infection Control | CDC. Retrieved August 2 , 2019 , f rom https://
www.cdc.gov/infectioncontrol/ guidelines/ssi/index.html
15. Centers for Disease Control and Prevention. (2019, April 9). MDRO Management |
Guidelines Library | Infection Control | CDC. Retrieved August 2, 2019, from
https://www.cdc.gov/infectioncontrol/ guidelines/mdro/index.html
16. Centers for Disease Control and Prevention. (2019, April 1). BSI | Guidelines Library |
Infection Control | CDC. Retrieved August 2, 2019, from
https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html
17. Centers for Disease Control and Prevention. (2019, July 25). Transmission-Based
Precautions. Retrieved August 2, 2019, from
https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html
18. Centers for Disease Control and Prevention. (2019, June 3). Healthcare-associated infections |
HAI | CDC. Retrieved August 2, 2019, from https://www.cdc.gov/hai/index.html
19. Centers for Disease Control and Prevention. (2019, June 26). Recommended Vaccines for
Healthcare Workers. Retrieved August 2, 2019, from https://www.cdc.gov/vaccines/adults/rec-
vac/hcw.html
20. Centers for Disease Control and Prevention. (2019, July 22). PEP | HIV Basics | HIV/AIDS | CDC.
Retrieved August 2, 2019, from https://www.cdc.gov/hiv/basics/pep.html
21. Centers for Disease Control and Prevention. (2019, February 5). Postexposure Prophylaxis.
Retrieved August 2, 2019, from https://www.cdc.gov/hepatitis/hbv/pep.htm
22. Centers for Disease Control and Prevention. (n.d.). Checklist for Prevention of Central Line
Associated Blood Stream Infections. Retrieved August 2, 2019, from
https://www.cdc.gov/hai/pdfs/bsi/checklist-for- CLABSI.pdf
23. De Sousa Martins, B., Queiroz e Melo, J., Logarinho Monteiro, J., Rente, G., & Teixeira Bastos, P.
(2019). Reprocessing of Single-Use Medical Devices: Clinical and Financial Results.
Portuguese Journal of Public Health, 1-7. doi:10.1159/000496299
24. Dolan, S. A., Arias, K. M., Felizardo, G., Barnes, S., Kraska, S., Patrick, M., & Bumsted, A.
(2016). APIC position paper: Safe injection, infusion, and medication vial practices in
health care. American Journal of Infection Control, 44(7), 750-757.
doi:10.1016/j.ajic.2016.02.033
25. Fishman, N. (2012). Policy Statement on Antimicrobial Stewardship by the Society for
Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America
(IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infection Control & Hospital
Epidemiology, 33(4), 322-327. doi:10.1086/665010
26. Han, J. H., Sullivan, N., Leas, B. F., Pegues, D. A., Kaczmarek, J. L., & Umscheid, C. A.
(2015). Cleaning Hospital Room Surfaces to Prevent Health Care-Associated Infections. Annals
of Internal Medicine, 163(8), 598. doi:10.7326/m15-1192
27. Indian Council of Medical Research. (2017). Treatment Guidelines for Antimicrobial Use in
Common Syndromes. Retrieved August 2 , 2019 , f rom https://
www.icmr.nic.in/sites/default/files/
guidelines/treatment_guidelines_for_antimicrobial.pdf
28. Indian Council of Medical Research. (n.d.). Hospital Infection Control Guidelines. Retrieved
from
6
https://www.icmr.nic.in/sites/default/files/guidelines/Hospital_Infection_control_guidelines.
pdf
6
29. Lee, T. B., Montgomery, O. G., Marx, J., Olmsted, R. N., & Scheckler, W. E. (2007).
Recommended practices for surveillance: Association for Professionals in Infection Control and
Epidemiology (APIC), Inc. American Journal of Infection Control, 35(7), 427-440.
doi:10.1016/j.ajic.2007.07.002
30. McDonald, L. C., Gerding, D. N., Johnson, S., Bakken, J. S., Carroll, K. C., Coffin, S. E., …
Wilcox, M. H. (2018). Clinical Practice Guidelines for Clostridium difficile Infection in Adults and
Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for
Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66(7), 987-994.
doi:10.1093/cid/ciy149
31. Ministry of Health & Family Welfare, Government of India. 51. National Centre for Disease
Control, Directorate General of Health Services. (2016). Guidelines for Antimicrobial Use in
Infectious Diseases. Retrieved August 2, 2019, from
http://pbhealth.gov.in/AMR_guideline7001495889.pdf
32. Ministry of Health & Family Welfare, Government Of India. (n.d.). Swachhta Guidelines for
Public Health F a c i l i t i e s . R e t r i e v e d August 2 , 2019 , f rom h ttp:// t r i p u r a n r h m .
gov. i n/ QA/ G u i d e l i n e / SwachhtaGuidelinesforPublicHealthFacilities.pdf
33. Ministry of Health and Family Welfare, Government of India. National AIDS Control
Organization. (n.d.). National Technical Guidelines on Anti Retroviral Treatment. Retrieved
August 2, 2019, from http://naco.gov.in/sites/default/files/NACO%20-%20National
%20Technical%20Guidelines% 20on%20ART_October%202018%20%281%29.pdf
34. Munoz-Price, L., Banach, D., Bearman, G., Gould, J., Leekha, S., Morgan, D., . . . Wiemken,
T. (2015). Isolation Precautions for Visitors. Infection Control & Hospital Epidemiology,
36(7), 747-758. doi:10.1017/ice.2015.67
35. Munoz-Price, L., Bowdle, A., Johnston, B., Bearman, G., Camins, B., Dellinger, E., . . . Birnbach,
D. (2019). Infection prevention in the operating room anesthesia work area. Infection Control &
Hospital Epidemiology, 40(1), 1-17. doi:10.1017/ice.2018.303
36. Occupational Safety and Health Administration. (2018, October 24). Safety and Health Topics |
Bloodborne Pathogens and Needlestick Prevention. Retrieved August 2, 2019, from
https://www.osha.gov/SLTC/ bloodbornepathogens/index.html
37. Occupational Safety and Health Administration. (2019, June 11). Safety and Health Topics
| Healthcare - I n f ect i ou s Di s e a s e s . Ret r i ev ed Au gu st 2 , 2 0 1 9 , f r om h t t ps:
/ / w w w. osh a. gov / SLTC/ healthcarefacilities/infectious_diseases.html
38. Petersen, B. T., Cohen, J., Hambrick, R. D., Buttar, N., Greenwald, D. A., Buscaglia, J. M., …
Eisen, G. (2017). Multisociety guideline on reprocessing flexible GI endoscopes: 2016
update. Gastrointestinal Endoscopy, 85(2), 282-294.e1. doi:10.1016/j.gie.2016.10.002
39. Sfeir, M., Simon, M. S., & Banach, D. (2017). Isolation Precautions for Visitors to Healthcare
Settings. Infection Prevention, 19-27. doi:10.1007/978-3-319-60980-5_4
40. Society for Healthcare Epidemiology of America. (n.d.). Compendium of Strategies to
Prevent HAIs. Retrieved August 2, 2019, from https://www.shea-online.org/index.php/practice-
resources/priority- topics/compendium-of-strategies-to-prevent-hais
41. The Society for Healthcare Epidemiology of America. (n.d.). SHEA Expert Guidance: Infection
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https://www.shea- online.org/index.php/practice-resources/41-current-guidelines/635-shea-
expert-guidance-infection- prevention-in-the-operating-room-anesthesia-work-area
6
42. Swaminathan, S., Prasad, J., Dhariwal, A. C., Guleria, R., Misra, M. C., Malhotra, R., …
Srikantiah, P. (2017). Strengthening infection prevention and control and systematic
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procedures toolkit. Retrieved August 2, 2019, from
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sequence=1
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Prevention and Control Programmes at the National and Acute Health Care Facility Level.
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7
Chapter 6
Patient Safety and
Quality Improvement
(PSQ)
The standards encourage an environment of patient safety and continual quality improvement. The
patient safety and quality programme should be documented and involve all areas of the organisation
and all staff members.
National/international patient-safety goals/solutions are implemented.
The organisation should collect data on structures, processes and outcomes, especially in
areas of high-risk situations. The collected data should be collated, analysed and used for
further improvements. Appropriate quality tools shall be used for carrying out quality
improvement activities. Clinical audits shall be used as a tool to improve the quality of patient
care. The improvements should be sustained. Department leaders play an active role in patient
safety and quality improvement.
The organisation should have a robust incident reporting system. Sentinel events shall be defined. All
incidents are investigated, and appropriate action is taken.
The management should support the patient safety and quality programme.
PSQ.1. The organisation implements a structured patient-safety programme.
PSQ.2. The organisation implements a structured quality improvement and
continuous monitoring programme.
PSQ.3. The organisation identifies key indicators to monitor the structures,

processes and outcomes, which are used as tools for continual
improvement.
PSQ.4. The organisation uses appropriate quality improvement tools for its quality
improvement activities.
PSQ.5. There is an established system for clinical audit.

PSQ.6. The patient safety and quality improvement programme are supported by
the management.
PSQ.7. Incidents are collected and analysed to ensure continual quality

improvement.
7
ELEMENTS
Standard
PSQ.1. The organisation implements a structured patient-safety programm
Objective Elements
C RE
a. The patient-safety programme is developed, implemented and
maintained by a multi-disciplinary safety committee. *
Commitme b. The patient-safety programme is comprehensive and covers all the

nt
major elements related to patient safety.
c. The programme covers incidents ranging from "no harm" to "sentinel

Commitme events".
nt d. Designated patient safety officer(s) coordinates implementation of

the patientsafety programme.
Commitme
e. Designated clinical safety officer(s) coordinates implementation of
nt the clinical aspects of the patient-safety programme.
f. The patient-safety programme identifies opportunities for

Excellence improvement based on the review at pre-defined intervals.
g. The organisation performs proactive analysis of patient safety risks

Commitme and makes improvements accordingly.
nt
h. The patient-safety programme is reviewed and updated at least once a
year.
Excellence
I. The organisation adapts and implements national/international
patient-safety goals/solutions.
Commitme
nt C RE
Standard
The organisation implements a structured quality improvement and
PSQ.2.
Objective Elements
C RE
Excellence
Commitme
nt

7
a. The
quality
improvem
ent
programm
e is
developed
,
implemen
ted and
maintaine
d by a
multi-
disciplinar
y
committe
e.*
b. The
quality
improvem
ent
programm
e is
comprehe
nsive and
covers all
the major
elements
related to
quality
assurance
.*
c. The
quality
improvem
ent
programm
e
improves
process
efficiency
and
effectiven
ess.

7
Commitme d. There is a designated individual for coordinating and implementing

nt
the quality improvement programme.*
Commitme e. The quality improvement programme identifies opportunities for

nt
improvement based on the review at pre-defined intervals.*
f. The quality improvement programme is reviewed and updated at

Commitme
least once a year.
nt
g. Audits are conducted at regular intervals as a means of continuous

monitoring.*
Commitme
nt
C RE h. There is an established process in the organisation to monitor and

improve the quality of nursing care.*
Standard
The organisation identifies key indicators to monitor the structures, proces
PSQ.3.
Objective Elements
Commitme
nt a. The organisation identifies and monitors key indicators to oversee
the clinical structures, processes and outcomes.
C RE b. The organisation identifies and monitors the key indicators to

oversee infection control activities.
Commitme c. The organisation identifies and monitors key indicators to oversee the
nt managerial structures, processes and outcomes.
d. The organisation identifies and monitors key indicators to oversee

C RE patient safety activities.
Excellence
Commitment Achievement
Commitmen
Commitmen

7
e. The
organisati
on has a
mechanis
m to
capture
patient
reported
outcome
measures.
f. Verification of
data is done
regularly by the
quality team.
g. There is a
mechanis
m for
analysis of
data
which
results in
identifying
opportunit
ies for
improvem
ent.
h. The
improvements
are implemented
and evaluated.
i. Feedback about
care and service
is communicated
to staff.

7
Standa
The organisation uses appropriate quality improvement tools for i
PSQ.4.
Objective Elements
C RE a. The organisation undertakes quality improvement projects.
Commitme b. The organisation uses appropriate analytical tools for its

nt quality improvement activities.
c. The organisation uses appropriate statistical tools for its

Commitme quality improvement activities.
nt
d. The organisation uses appropriate managerial tools for its
quality improvement activities.
Commitme
nt
Standard
PSQ.5. There is an established system for clinical audit.
Objective Elements
Commitme
a. Clinical audits are performed to improve the quality of patient care.
nt
Commitment b. The parameters to be audited are defined by the organisation.
Achievement c. Medical and nursing staff participate in clinical audit.
Commitme d. Patient and staff anonymity are maintained.
nt e. Clinical audits are documented.
Commitme f. Remedial measures are implemented.
nt
Commitme
nt

7
Standa
The patient safety and quality improvement programme are suppo
PSQ.6.
Objective Elements
Achieveme
a. The management creates a culture of safety.
nt
b. The leaders at all levels in the organisation are aware of the intent of
Commitmen the patient safety and quality improvement programme and the
approach to its implementation.
t
c. Departmental leaders are involved in patient safety and quality
improvement.
d. The management makes available adequate resources required for

Commitmen
patient safety and quality improvement programme.
t
e. Organisation earmarks adequate funds from its annual budget in this
regard.
Commitmen
f. The management identifies organisational performance improvement
t targets.
g. The management uses the feedback obtained from the workforce to

Commitmen improve patient safety and quality improvement programme.
Achieveme
nt
Excellence
Standard
Incidents are collected and analysed to ensure continual quality im
PSQ.7.
Objective Elements
C RE a. The organisation implements an incident management system.*
Commitment b. The organisation has a mechanism to identify sentinel events.*

7
Standa
Commitmen c. The organisation has established processes for analysis of incidents.
t d. Corrective and preventive actions are taken based on the findings of such
analysis.
Commitmen
e. The organisation incorporates risks identified in the analysis of
t incidents into the risk management system.
Achieveme f. The organisation shall have a process for informing various

stakeholders in case of a near miss/adverse event/sentinel event.
nt
Excellence

7
References:
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Safety Primer: Update on Safety Culture. Retrieved August 2, 2019, from
https://psnet.ahrq.gov/perspectives/ perspective/144/update-on-safety-culture
2. Agency for Healthcare Research and Quality. Patient Safety Network. (2019, January). Root
Cause Analysis. Retrieved August 2, 2019, from https://psnet.ahrq.gov/primers/primer/10/Root-
Cause-Analysis
3. Agency for Healthcare Research and Quality. Patient Safety Network. (2019, January).
Culture of Safety. Retrieved from http://psnet.ahrq.gov/primer.aspx?primerID=5
Reporting Patient Safety Events. Retrieved from
https://psnet.ahrq.gov/primers/primer/13/reporting-patient-safety- events%20on%20April
%2016
5. Agency for Healthcare Research and Quality. Patient Safety Primers. (2019, January). Detection
of Safety Hazards. Retrieved August 2, 2019, from
https://psnet.ahrq.gov/primers/primer/24/Detection-of-Safety- Hazards
6. Agency for Healthcare Research and Quality. (2012, September). International Use of the
Surveys on Patient Safety Culture. Retrieved August 2, 2019, from
http://www.ahrq.gov/professionals/quality-patient-
safety/patientsafetyculture/pscintusers.html
7. Agency for Healthcare Research and Quality. (n.d.). Section 4: Ways To Approach the Quality
Improvement Process (Page 1 of 2). Retrieved August 2, 2019, from
https://www.ahrq.gov/cahps/quality- improvement/improvement-guide/4-approach-qi-
process/index.html
8. Agency for Healthcare Research and Quality. (n.d.). TeamStepps: Strategies and Tools to
Enhance Performance and Patient Safety. Retrieved August 2, 2019, from
http://www.ahrq.gov/professionals/ education/curriculum-tools/teamstepps/index.html
9. American Society for Quality. (n.d.). 7 Basic Quality Tools: Quality Management Tools.
Retrieved August 2, 2019, from https://asq.org/quality-resources/seven-basic-quality-tools
10. American Society for Quality. (n.d.). Quality Statistics - Statistical Methods for Quality
Improvement. Retrieved August 2, 2019, from https://asq.org/quality-resources/statistics
11. American Society for Quality. (n.d.). What is Root Cause Analysis (RCA)?. Retrieved August 2,
2019, from https://asq.org/quality-resources/root-cause-analysis
12. Canadian Patient Safety Institute. (2012). Canadian Incident Analysis Framework. Retrieved
https://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Documents/Canadian
% 20Incident%20Analysis%20Framework.PDF
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How to perform a root cause analysis for workup and future prevention of medical errors: a
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14. Dimick, J. B. (2010). What Makes a "Good" Quality Indicator? Archives of Surgery, 145(3),
295. doi:10.1001/archsurg.2009.291
7
15. Donabedian, A. (1983). Quality Assessment and Monitoring. Evaluation & the Health
Professions, 6(3), 363- 375. doi:10.1177/016327878300600309
8
16. Doyle, C., Lennox, L., & Bell, D. (2013). A systematic review of evidence on the links between
patient experience and clinical safety and effectiveness. BMJ Open, 3(1), e001570.
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17. Ewen, B. M., & Bucher, G. (2013). Root Cause Analysis. Home Healthcare Nurse, 31(8),
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Evidence That Publishing Patient Care Performance Data Improves Quality of Care. Annals of
Internal Medicine, 148(2), 111. doi:10.7326/0003-4819-148-2-200801150-00006
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August 2, 2019, from http://www.ihi.org/resources/Pages/Tools/Quality-Improvement-
Essentials-Toolkit.aspx
23. Jones, P., Shepherd, M., Wells, S., Le Fevre, J., & Ameratunga, S. (2014). Review article: What
makes a good healthcare quality indicator? A systematic review and validation study.
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24. Krause, C. (2017). The Case for Quality Improvement. Healthcare Quarterly, 20(1),
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25. Kötter, T., Blozik, E., & Scherer, M. (2012). Methods for the guideline-based development of quality
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-a systematic review. Implementation Science, 7(1). doi:10.1186/1748-5908-7-21
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(2014). Standardization in patient safety: the WHO High 5s project. International Journal for
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28. Limb, C., Fowler, A., Gundogan, B., Koshy, K., & Agha, R. (2017). How to conduct a clinical
audit and quality i m p r o v e m e n t p r o j e c t . I n t e r n a t i o n a l J o u r n a l o f S u r g
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29. Lindblad, S., Ernestam, S., Van Citters, A., Lind, C., Morgan, T., & Nelson, E. (2016). Creating a
culture of health: evolving healthcare systems and patient engagement. QJM, hcw188.
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30. Medicine, I. O., Board on Health Care Services, & Committee on Patient Safety and Health
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org/-/ media/ assets/ policy- guidelines/docs/endorsed-documents/endorsed-
documents-improving-root-cause-analyses-actions- prevent-harm.ashx
8
32. NEJM Catalyst. (2019, April 17). What is Risk Management in Healthcare? Retrieved
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8
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8
Chapter 7
Responsibilities of
Management (ROM)
The management of the healthcare organisation is aware of and manages all the key components
of governance. Those responsible for governance are identified and their roles defined. The
standards encourage the governance of the organisation professionally and ethically. The
responsibilities of management are defined. The responsibilities of the leaders at all levels are
defined. The management executes its responsibility for compliance with all applicable
regulations.
Leaders ensure that patient-safety and risk-management issues are an integral part of patient care
and hospital management.
Note: "Responsible for Governance' refers to the governing entity of the healthcare organisation
and can exist in many configurations. For example, the owner(s), the board of directors, or in
the case of public hospitals, the respective Ministry (Health/Railways/Labour).
ROM.1. The organisation identifies those responsible for governance and
their roles are defined.
ROM.2. The organisation is ethically managed by the leaders.

ROM.3. The organisation is headed by a leader who shall be responsible for
operating the organisation on a day-to-day basis.
ROM.4. The organisation displays professionalism in its functioning.

ROM.5. Management ensures that patient-safety aspects and risk-
management issues are an integral part of patient care and
hospital management.
8
Standard
The organisation identifies those responsible for governance and t
ROM.1.
Objective Elements
C RE
a. Those responsible for governance are identified, and their roles
and responsibilities are defined and documented. *
Commitmen
t b. Those responsible for governance lay down the organisation's
vision, mission and values.*
Commitmen c. Those responsible for governance approve the strategic and

t operational plans and the organisation's annual budget.
d. Those responsible for governance monitor and measure the

Achieveme performance of the organisation against the stated mission.
nt
e. Those responsible for governance appoint the senior leaders in the
organisation.
Commitmen
f. Those responsible for governance support safety initiatives and
t quality improvement plans.
Commitmen g. Those responsible for governance support the ethical management

framework of the organisation.
t
h. Those responsible for governance inform the public of the quality
and performance of services.
Achieveme
nt
Excellence
Standard
ROM.2. The leaders manage the organisation in an ethical manner.
Objective Elements
Commitme
a. The leaders make public the vision, mission and values of the organisation.
nt
C RE b. The leaders establish the organisation's ethical management framework. *

8
Excellence c. The ethical management framework includes processes for
managing issues with ethical implications, dilemmas and concerns.
Commitme d. The organisation discloses its ownership.
nt e. The organisation honestly portrays its affiliations and accreditations.
Commitme
nt

8
Standard
The organisation is headed by a leader who shall be responsible for
ROM.3.
Objective Elements
Commitme
nt a. The person heading the organisation has requisite and appropriate
administrative qualifications.
Commitme b. The person heading the organisation has requisite and appropriate
nt
administrative experience.
C RE c. The leader is responsible for and complies with the laid-down and
applicable legislations, regulations and notifications.
Commitmen d. The leader appoints/participates in the recruitment of senior

t
leadership of the organisation who will assist in the day-to-day
functioning of the organisation.
Excellence
e. The leader ensures that each organisational programme, service,
site or department has effective leadership.
Achieveme
f. The performance of the organisation's leader is reviewed for effectiveness.
nt
Standard
ROM.4. The organisation displays professionalism in its functioning.
Objective Elements
Commitme
nt a. The organisation has strategic and operational plans, including long-
term and short-term goals commensurate to the organisation's vision,
mission and values in consultation with the various stakeholders.
Achieveme Commitment Commitment

nt
Excellence
Commitmen
Achieveme
nt

8
b. The them.*
organisatio
n g. Systems and processes are in place for change management.
coordinate
s the
functioning
with
departmen
ts and
external
agencies
and
monitors
the
progress
in
achieving
the
defined
goals and
objectives.
c. The organisation
plans and
budgets for its
activities
annually.
d. The functioning
of committees is
reviewed for
their
effectiveness.
e. The organisation
documents staff
rights and
responsibilities. *
f. The
organisati
on
document
s the
service
standards
that are
measurabl
e and
monitors

8
Standard
Management ensures that patient-safety aspects and risk-manageme
ROM.5.
Objective Elements
C RE
a. Management ensures proactive risk management across the organisation.*
Commitmen
t b. Management provides resources for proactive risk assessment and
risk- reduction activities.
Commitmen c. Management ensures integration between quality improvement,

t risk management and strategic planning within the organisation.
d. Management ensures implementation of systems for internal and

Achieveme external reporting of system and process failures.*
nt
e. Management ensures that it has a documented agreement for all
outsourced services that include service parameters.
Commitmen
t f. Management monitors the quality of the outsourced services and
improvements are made as required.
Achieveme
nt

8
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26. Jondle, D., Maines, T. D., Burke, M. R., & Young, P. (2013). Modern risk management through
the lens of the ethical organizational culture. Risk Management, 15(1), 32-49.
doi:10.1057/rm.2012.11
27. Kaya, G. K., Ward, J. R., & Clarkson, P. J. (2018). A framework to support risk assessment in
hospitals. International Journal for Quality in Health Care, 31(5), 393-401.
doi:10.1093/intqhc/mzy194
28. Kaya, G. K., Ward, J. R., & Clarkson, P. J. (2018). A framework to support risk assessment in
hospitals. International Journal for Quality in Health Care, 31(5), 393-401.
doi:10.1093/intqhc/mzy194
29. Kuhn, A. M. (2002). The need for risk management to evolve to assure a culture of safety.
Quality and Safety in Health Care, 11(2), 158-162. doi:10.1136/qhc.11.2.158
30. Mannion, R., & Davies, H. (2018). Understanding organisational culture for healthcare quality
improvement. BMJ, k4907. doi:10.1136/bmj.k4907
31. McDonagh, K. J. (2006). Hospital Governing Boards: A Study of Their Effectiveness in
Relation to Organizational Performance. Journal of Healthcare Management, 51(6), 377-389.
doi:10.1097/00115514- 200611000-00007
32. McSherry, R., Wadding, A., & Pearce, P. (n.d.). Healthcare Governance Through Effective
Leadership. Effective Healthcare Leadership, 58-75. doi:10.1002/9780470774984.ch5
33. Medscape. (n.d.). Common Ethical Dilemmas for Doctors. Retrieved August 3, 2019, from
https://www.medscape.com/courses/section/898063
9
34. O E C D. ( n . d . ) . G 2 0 / O E C D P r i n c i p l e s o f C o r p o r a t e G o v e r n a n c e . R e
t r i e v e d f r o m https://www.oecd.org/daf/ca/Corporate-Governance-Principles-ENG.pdf
35. Organizational Management-How to Run a Meeting and Make Decisions. (n.d.). Developing
Human Service Leaders, 149-168. doi:10.4135/9781506330389.n11
36. Orlikoff, J. E., & Totten, M. K. (2007). Center for Healthcare Governance: effective board
development: showing the way toward exceptional governance. Healthc Exec., 22(3), 68-70.
37. Personal Characteristics of Effective Boards and Members. (2015). Audit Committee
Essentials, 33-39. doi:10.1002/9781119201472.ch3
38. Quality and Patient Safety Directorate. (n.d.). Quality and Patient Safety Clinical Governance
Development: an a ssu ra n ce check for health service pro v i ders. R etri ev ed August
3 , 2019 , f rom https://www.pna.ie/images/0405124.pdf
39. Rego, A., Araújo, B., & Serrão, D. (2015). The mission, vision and values in hospital
management. Journal of Hospital Administration, 5(1). doi:10.5430/jha.v5n1p62
40. Strategic Planning: Why It Makes a Difference, and How to Do It. (2009). Journal of Oncology
Practice, 5(3), 139-143. doi:10.1200/jop.0936501
41. Suchy, K. (2010). A Lack of Standardization: The Basis for the Ethical Issues Surrounding
Quality and Performance Reports. Journal of Healthcare Management, 55(4), 241-251.
doi:10.1097/00115514- 201007000-00005
42. Trybou, J., Gemmel, P., Desmidt, S., & Annemans, L. (2017). Fulfillment of administrative and
professional obligations of hospitals and mission motivation of physicians. BMC Health
Services Research, 17(1). doi:10.1186/s12913-017-1990-0
43. Useem, M. (n.d.). How well-run boards make decisions. Harv Bus Rev., 84(11), 130-6.
44. World Health Organization. (2017). Strategizing National Health in the 21st Century: A
Handbook. Retrieved from
http://apps.who.int/iris/bitstream/10665/250221/41/9789241549745-eng.pdf?ua=1
9
Chapter 8
Facility
Management and
Safety (FMS)
The standards guide the provision of a safe and secure environment for patients, their families,
staff and visitors. The organisation attends to the facility, equipment, and internal physical
environment for improving patient safety and quality of services by consistently addressing issues
that may arise out of the same. The organisation does this through proactive risk analysis, safety
rounds, training of staff on the enhancement of safety and management of disasters. To ensure
this, the organisation conducts regular facility inspection rounds and takes the appropriate action
to ensure safety.
The organisation provides for safe water, electricity, medical gases and
vacuum systems. The organisation has a programme for medical and utility
equipment management.
The organisation plans for fire and non-fire emergencies within the
facilities. The organisation is a no-smoking area.
The organisation safely manages hazardous
materials. The organisation works towards measures on
being energy efficient.
FMS.1. The organisation has a system in place to provide a safe
and secure environment.
FMS.2. The organisation's environment and facilities operate in a planned manner

and promotes environment-friendly measures.
FMS.3. The organisation's environment and facilities operate to ensure the

safety of patients, their families, staff and visitors.
FMS.4. The organisation has a programme for the facility, engineering support
services and utility system.
FMS.5. The organisation has a programme for medical equipment management.

FMS.6. The organisation has a programme for medical gases, vacuum and
compressed air.
FMS.7. The organisation has plans for fire and non-fire emergencies within the
9
facilities.
9
Standard
The organisation has a system in place to provide a safe and secure
FMS.1.
Objective Elements
C RE
a. Patient-safety devices and infrastructure are installed across the
organisation and inspected periodically.
Commitme
b. The organisation has facilities for the differently-abled.
nt C RE
c. Facility inspection rounds to ensure safety are conducted at least once a
month.
Commitme
nt
d. Inspection reports of facility rounds are documented, and corrective
and preventive measures are undertaken.
Excellence
e. Before construction, renovation and expansion of existing hospital,
risk assessment are carried out.
Standard
The organisation's environment and facilities operate in a planned
FMS.2.
Objective Elements
Commitme
a. Facilities and space provisions are appropriate to the scope of services.
nt
b. As-built and updated drawings are maintained as per statutory
requirements.
Commitme
nt
C RE c. There are internal and external sign postings in the organisation in
a manner understood by the patient, families and community.
C RE d. Potable water and electricity are available round the clock.
Commitme e. Alternate sources for electricity and water are provided as a

nt backup for any failure/shortage.
f. The organisation tests the functioning of these alternate sources at a

Commitme predefined frequency.
nt
g. The organisation takes initiatives towards an energy-efficient and
environmentally friendly hospital.*
Excellence

9
Standard
The organisation's environment and facilities operate to ensure the
FMS.3.
Objective Elements
Excellenc
e a. Patient safety aspects in terms of structural safety of hospitals
especially of critical areas are considered while planning, design and
construction of new hospitals and re-planning, assessment, and
retrofitting of existing hospitals.
Commitmen b. Operational planning identifies areas which need to have extra

t security and describes access to different areas in the hospital by
staff, patients, and visitors.
Achieveme c. The organisation conducts electrical safety audits for the facility.
nt d. There is a procedure which addresses the identification and disposal

of material(s) not in use in the organisation. *
Commitmen
C RE e. Hazardous materials are identified and used safely within the organisation.*
Commitment f. The plan for managing spills of hazardous materials is implemented. *
Standard
The organisation has a programme for the facility, engineering sup
FMS.4.
Objective Elements
Commitme
nt
Commitment
Commitme
nt C RE
Commitme
nt

9
a. The e. Competent personnel operate, inspect, test and maintain equipment

organisati and utility systems.
on plans
for utility
and
engineeri
ng
equipmen
t in
accordanc
e with its
services
and
strategic
plan.
b. Equipment is
inventoried, and
proper logs are
maintained as
required.
c. The
document
ed
operation
al and
maintena
nce
(preventiv
e and
breakdow
n) plan is
implemen
ted. *
d. Utility
equipmen
t, are
periodicall
y
inspected
and
calibrated
(wherever
applicable
) for their
proper
functionin
g.

9
Commitment f. Maintenance staff is contactable round the clock for emergency repairs.
Achieveme g. Downtime for critical equipment breakdowns is monitored from

nt reporting to inspection and implementation of corrective actions.
h. Written guidance supports equipment replacement, identification of

Commitmen unwanted material and disposal. *
t
Standard
FMS.5. The organisation has a programme for medical equipment managem
Objective Elements
Commitme
nt a. The organisation plans for medical equipment in accordance with its
services and strategic plan.
Commitment b. Medical equipment is inventoried, and proper logs are maintained as

required.
C RE c. The documented operational and maintenance (preventive and

breakdown) plan for medical equipment is implemented. *
Commitmen d. Medical equipment is periodically inspected and calibrated for

t
their proper functioning.
e. Qualified and trained personnel operate and maintain medical equipment.

Commitme
f. Written guidance supports medical equipment replacement and disposal. *
nt
g. There is a monitoring of medical equipment and medical devices
Commitme related to adverse events, and compliance hazard notices on recalls.
*
nt
h. Downtime for critical equipment breakdown is monitored from
Commitme
reporting to inspection and implementation of corrective actions.
nt
Achieveme
nt

9
Standard
The organisation has a programme for medical gases, vacuum and co
FMS.6.
Objective Elements
Commitme
nt a. Written guidance governs the implementation of procurement,
handling, storage, distribution, usage and replenishment of medical
gases. *
C RE b. Medical gases are handled, stored, distributed and used in a safe manner.
Commitme c. The procedures for medical gases address the safety issues at all levels.
nt
C RE d. Alternate sources for medical gases, vacuum and compressed air

are provided for, in case of failure.
Commitme e. The organisation regularly tests the functioning of these alternate sources.
nt f. There is an operational, inspection, testing and maintenance plan

for piped medical gas, compressed air and vacuum installation. *
Commitme
nt
Standard
The organisation has plans for fire and non-fire emergencies withi
FMS.7.
Objective Elements
C RE
a. The organisation has plans and provisions for early detection,
abatement and containment of the fire, and non-fire emergencies. *
Commitmen Commitment Achievement

t
Commitmen

1
b. The
organisati
on has a
document
ed and
displayed
exit plan
in case of
fire and
non-fire
emergenc
ies.
c. Mock drills are

held at least
twice a year.
d. There is a
maintenance
plan for fire-
related
equipment and
infrastructure *
e. The
organisati
on has a
service
continuity
plan in
case of
fire and
non-fire
emergenci
es

1
References:
1. Aggarwal, R., Mytton, O. T., Greaves, F., & Vincent, C. (2010). Technology as applied to patient
safety: an overview. Quality and Safety in Health Care, 19(Suppl 2), i3-i8.
doi:10.1136/qshc.2010.040501
2. Association for the Advancement of Medical Instrumentation. (n.d.). EQ89: Guidance for the
use of medical equipment maintenance strategies and procedures. Retrieved
August 3 , 2019 , f rom https://www.aami.org/productspublications/ProductDetail.aspx?
ItemNumber=2421
3. BOC. (n.d.). Handle medical gases safely. Retrieved from http://www.boc-
healthcare.com.au/en/ images/HCD186_Gases%20safety%20pocket
%20guide_V3_FA_web_tcm350-131320.pdf
4. British Compressed Gases Association. (n.d.). Medical Gases. Retrieved August 3, 2019,
from http://www.bcga.co.uk/pages/index.cfm?page_id=29&title=medical_gases
5. British Standards Institution. (n.d.). BS EN 12021:2014. Retrieved August 3, 2019,
from https://shop.bsigroup.com/ProductDetail?pid=000000000030315779
6. Bureau of Indian Standards. (2016). National Building Code of India, 2016. New Delhi.
7. Coulliette, A. D., & Arduino, M. J. (2015). Hemodialysis and Water Quality. Semin Dial, 26(4), 427-
438.
8. Department of Health: Estates and Facilities Division. (2006). Medical Gas Pipeline
Systems. London, England: The Stationery Office.
9. Dhillon, V. S. (2015). Green Hospital and Climate Change: Their Interrelationship and the Way
Forward. JOURNAL OF CLINICAL AND DIAGNOSTIC RESEARCH.
doi:10.7860/jcdr/2015/13693.6942
10. Government of India. Ministry of Health and Family Welfare. (n.d.). Medical Devices Rules
2017. Retrieved A u gu st 3 , 2 0 1 9 , f r o m h t t ps: / / m o h f w. go v. i n / s i t e s/ de f a
u l t / f i l e s/ Me d i ca l % 2 0 D e v i ce % 20Rules%2C%202017.pdf
11. Government of India. National Disaster Management Authority. (n.d.). National Disaster
Management Guidelines. Hospital Safety. Retrieved August 3, 2019, from
https://ndma.gov.in/images/guidelines/ Guidelines-Hospital-Safety.pdf
12. Government of India. National Health MIssion. (n.d.). Biomedical Equipment Management and
Maintenance Program. Retrieved August 3, 2019, from
https://nhm.gov.in/New_Updates_2018/NHM_Components/
Health_System_Stregthening/BEMMP/Biomedical_Equipment_Revised_Guidelines.pdf
13. Gudlavalleti, V. (2018). Challenges in Accessing Health Care for People with Disability in the
South Asian Context: A Review. International Journal of Environmental Research and Public
Health, 15(11), 2366. doi:10.3390/ijerph15112366
14. Hart, J. R. (2018). Medical Gas and Vacuum Systems Handbook. National Fire Protection Association.
15. Health Facilities Management. (2015, December 2). Infrastructures to improve patient safety.
Retrieved August 3, 2019, from https://www.hfmmagazine.com/articles/1827-infrastructures-
to-improve-patient-safety
16. International Organization for Standardization. (n.d.). ISO 10524-1:2018. Retrieved August 3,
2019, from https://www.iso.org/standard/67190.html
1
1
20. International Organization for Standardization. (n.d.). ISO 11197:2016. Retrieved August
3, 2019, from https://www.iso.org/standard/60316.html
22. International Organization for Standardization. (n.d.). ISO 15002:2008. Retrieved August
23. International Organization for Standardization. (n.d.). ISO 7396-1:2016. Retrieved August
28. National Fire Protection Association. (2018, January). Medical Gas Cylinder Storage.
https://www.nfpa.org/~/media/4B6B534171E04E369864672EBB319C4F.pdf
29. National Health Mission. Ministry of Health & Family Welfare, Government of India. (n.d.).
Indian Public Health Standards. Retrieved August 3, 2019, from
https://nhm.gov.in/index1.php?lang=1&level= 2&sublinkid=971&lid=154
30. Sarangi, S., Babbar, S., & Taneja, D. (n.d.). Safety of the medical gas pipeline system.
Journal of Anaesthesiology Clinical Pharmacology, 34(1), 99-102. Retrieved from
http://www.joacp.org/text.asp?2018/ 34/1/99/227571
31. World Health Organization. (2011). Guidelines for Drinking-water Quality (Fourth Edition).
https://apps.who.int/iris/bitstream/handle/10665/44584/9789241548151_eng.pdf?sequence=1
32. World Health Organization. (2014). Safe Management of Wastes from Health-Care
Activities(2nd ed.). Retrieved from https:// apps. who. int/ iris/ bitstream/ handle/
10665/ 85349/ 9789241548564_ eng.pdf?sequence=1
33. World Health Organization. (n.d.). Hospital safety index: guide for evaluators - 2nd ed.
https://www.who.int/hac/techguidance/hospital_safety_index_evaluators.pdf
1
Chapter 9
Human Resource
Management (HRM)
The most important resource of the organisation is its human resource. Human resources are
an asset for the effective and efficient functioning of the organisation. The management plans on
identifying the right number and skill mix of staff required to render safe care to the patients.
Recruitment of staff is accomplished by having a uniform and standardised system. The
organisation must orient the staff to its environment and also orient them to specific duties and
responsibilities related to their position. The organisation should plan to have an ongoing
professional training/in-service education to enhance the competencies and skills of the staff
continually.
A systematic and structured appraisal system must be used for staff development. The
organisation uses this as an opportunity to discuss, motivate, identify gaps in the performance
of the staff.
The organisation promotes the physical and mental well-being of staff. A grievance handling
mechanism and disciplinary procedure should be in place.
Credentialing and privileging of health-care professionals (medical, nursing and other para-clinical
professional) are done to ensure patient safety.
A document containing all such personal information has to be maintained for all staff.
Note: The term "employee" refers to all salaried personnel working in the organisation. The term
"staff" refers to all personnel working in the organisation including employees, "fee for service"
medical professionals, part-time workers, contractual personnel and volunteers.
HRM.1. The organisation has a documented system of human resource
planning.
HRM.2. The organisation implements a defined process for staff recruitment.
HRM.3. Staff are provided induction training at the time of joining the organisation.
HRM.4. There is an on-going programme for professional training and
development of the staff.
HRM.5. Staff are appropriately trained based on their specific job description.
HRM.6. Staff are trained in safety and quality-related aspects.
HRM.7. An appraisal system for evaluating the performance of staff exists as an
integral part of the human resource management process.
1
HRM.8. Process for disciplinary and grievance handling is defined and
implemented in the organisation.
HRM.9. The organisation promotes staff well-being and addresses their health
and safety needs.
HRM.10. There is documented personal information for each staff member.

HRM.11. There is a process for credentialing and privileging of medical
professionals, permitted to provide patient care without
supervision.
HRM.12. There is a process for credentialing and privileging of nursing
professionals, permitted to provide patient care without
supervision.
HRM.13. There is a process for credentialing and privileging of para-clinical
professionals, permitted to provide patient care without supervision.
1
ELEMENTS
Standard
HRM.1. The organisation has a documented system of human resource plann
Objective Elements
Excellence
a. Human resource planning supports the organisation's current and
future ability to meet the care, treatment and service needs of the
C RE patient.
b. The organisation maintains an adequate number and mix of staff to

Achieveme meet the care, treatment and service needs of the patient.
nt
c. The organisation has contingency plans to manage long- and short-
term workforce shortages, including unplanned shortages.
Commitmen
d. The job specification and job description are defined for each category of
t staff. *
Commitmen e. The organisation performs a background check of new staff.
t f. Reporting relationships are defined for each category of staff. *
Commitmen g. Exit interviews are conducted and used as a tool to improve

human resource practices.
t
Achieveme
nt
Standard
HRM.2. The organisation implements a defined process for staff recruitme
Objective Elements
C RE a. Written guidance governs the process of recruitment. *
Commitment b. A pre-employment medical examination is conducted on the staff.
C RE c. The organisation defines and implements a code of conduct for its staff.
Commitment d. Administrative procedures for human resource management are

documented .*

1
Standard
HRM.3. Staff are provided induction training at the time of joining the organisatio
Objective Elements
C RE a. Staff are provided with induction training.
Commitme b. The induction training includes orientation to the organisation's

nt vision, mission and values.
c. The induction training includes awareness on staff rights and

Commitme responsibilities and patient rights and responsibilities.
nt
d. The induction training includes training on safety.
Commitme e. The induction training includes training on cardio-pulmonary

resuscitation for staff providing direct patient care.
nt
f. The induction training includes training in hospital infection
Commitme
prevention and control.
nt
g. The induction training includes orientation to the service
standards of the organisation.
Commitme
h. The induction training includes an orientation on administrative procedures.
nt
i. The induction training includes an orientation on relevant
department/unit/ service/programme's policies and procedures.
Commitme
nt
Commitme
nt
Commitme
nt
Standard
There is an on-going programme for professional training and dev
HRM.4.
Objective Elements
C RE a. Written guidance governs training and development policy for the staff.*
Commitme nt Commitment Commitment

1
b. The organisation maintains the training record.

Excellence
c. Training also occurs when job responsibilities change/new equipment is
Achieveme introduced.
nt d. Feedback mechanisms are in place for improvement of training and

development programme.
e. Evaluation of training effectiveness is done by the organisation.
f. The organisation supports continuing professional development and

learning.

1
Standard
HRM.5. Staff are appropriately trained based on their specific job description.
Objective Elements
Commitme a. Staff involved in blood transfusion services are trained on the
nt handling of blood and blood products.
Commitme b. Staff are trained in handling vulnerable patients.

nt
Commitme c Staff are trained in control and restraint techniques.
nt
Commitme d. Staff are trained in healthcare communication techniques.
nt
C RE e. Staff involved in direct patient care are provided training on
cardiopulmonary resuscitation periodically.
Commitme f. Staff are provided training on infection prevention and control.

nt
Standard
HRM.6. Staff are trained in safety and quality-related aspects.
Objective Elements
Commitme
a. Staff are trained on the organisation's safety programme.
nt
b. Staff are provided training on the detection, handling, minimisation
Commitme and elimination of identified risks within the organisation's
environment.
nt
c. Staff members are made aware of procedures to follow in the event of an
incident.
Commitme
d. Staff are trained in occupational safety aspects.
nt
Commitme
nt
C RE
Commitment
C RE

1
e. Staff are trained

in the
organisation's
disaster
management
plan.
f. Staff are trained

in handling fire
and non-fire
emergencies.
g. Staff are trained

on the
organisation's
quality
improvement
programme

1
Standa
An appraisal system for evaluating the performance of staff exists
HRM.7.
Objective Elements
Commitment a. Performance appraisal is done for staff within the organisation.*
Commitmen b. The staff are made aware of the system of appraisal at the time of
induction.
t
c. Performance is evaluated based on the pre-determined criteria.
Commitmen
d. The appraisal system is used as a tool for further development.
t
e. Performance appraisal is carried out at defined intervals and is documented.
Achieveme
nt
Commitmen
Standard
Process for disciplinary and grievance handling is defined and impl
HRM.8.
Objective Elements
Commitment a. Written guidance governs disciplinary and grievance handling
mechanisms.*
Commitme b. The disciplinary and grievance handling mechanism is known to all

nt categories of staff of the organisation.
c. The disciplinary policy and procedure are based on the principles

Commitme of natural justice.
nt
C RE d. The disciplinary and grievance procedure is in consonance

with the prevailing laws.
Commitme Commitment
nt

1
Standa
e. There is a
provision for
appeals in all
disciplinary
cases.
f. Actions are
taken to redress
the grievance.

1
Standa
The organisation promotes staff well-being and addresses their he
HRM.9.
Objective Elements
Achievement a. Staff well-being is promoted.
Commitme b. Health problems of the staff, including occupational health hazards,

nt are taken care of in accordance with the organisation's policy.
c. Health checks of staff dealing with direct patient care are done at
Commitme least once a year and the findings/results are documented.
nt
d. Organisation provides treatment to staff who sustain workplace-related
injuries.
Commitme
nt
C RE e. The organisation has measures in place for prevention and handling

workplace violence.
Standard
HRM.10. There is documented personal information for each staff member.
Objective Elements
Commitme
nt a. Personal files are maintained with respect to all staff, and their
confidentiality is ensured
Commitme b. The personal files contain personal information regarding the staff's
nt
qualification, job description, verification of credentials and health
status.
Commitme
c. Records of in-service training and education are contained in the personal
files.
nt
d. Personal files contain results of all evaluations and remarks.
Commitme
nt

1
Standard
There is a process for credentialing and privileging of medical profes
HRM.11.
Objective Elements
C RE a. Medical professionals permitted by law, regulation and the
organisation to provide patient care without supervision are
identified.
Commitme
nt
b. The education, registration, training and experience of the
identified medical professionals are documented and updated
Commitme periodically.
nt
c. The information about medical professionals is appropriately
verified when possible.
C RE
d. Medical professionals are granted privileges to admit and care for
patients in consonance with their qualification, training, experience
Commitme and registration.
nt
e. The requisite services to be provided by the medical professionals are
known to them as well as the various departments/units of the
Commitme organisation.
nt
f. Medical professionals admit and care for patients as per their privileging.
Standard
There is a process for credentialing and privileging of nursing profe
HRM.12.
Objective Elements
C RE a. Nursing staff permitted by law, regulation and the organisation to
provide patient care without supervision are identified.
Commitme b. The education, registration, training and experience of nursing staff

nt
are appropriately verified, documented and updated periodically.
c. The information about the nursing staff is appropriately verified when

Commitme possible.
nt C RE d. Nursing staff are granted privileges in consonance with their

qualification, training, experience and registration.
Commitme
nt

1
Commitme e. The requisite services to be provided by the nursing staff are known
nt to them as well as the various departments/units of the organisation.
f. Nursing professionals care for patients as per their privileging.

1
Standard
There is a process for credentialing and privileging of para-clinical p
HRM.13.
Objective Elements
C RE a. Para-clinical professionals permitted by law, regulation and the
organisation to provide patient care without supervision are
identified.
Commitme b. The education, registration, training and experience of para clinical

nt
professionals are appropriately verified, documented and updated
periodically.
C RE c. Para-clinical professionals are granted privileges in consonance with

their qualification, training, experience and registration.
Commitme d. The requisite services to be provided by the para-clinical

nt professionals are known to them as well as the various
departments/units of the organisation.
Commitme e. Para-clinical professionals care for patients as per their privileging.

nt

1
References:
1. Academy Quality Management Committee. (2018). Academy of Nutrition and Dietetics:
Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist. Journal of the Academy
of Nutrition and Dietetics, 118(1), 141-165. Retrieved from
https://doi.org/10.1016/j.jand.2017.10.002
2. American College of Obstetricians and Gynecologists. (2016, September). Guiding Principles
for Privileging of Innovative Procedures in Gynecologic Surgery. Retrieved August 4, 2019,
from https://www.acog.org/-
/media/Committee-Opinions/Committee-on-Patient-Safety-and-Quality-Improvement/
co674.pdf? dmc=1&ts=20190804T1641474075
3. Aswathappa, K. (2013). Human Resource Management 6E (7th ed.). New York, NY:
Tata McGraw- Hill Education.
4. Barnett, S. D. (2015). Growing Pains of Credentialing Research: Discussions from the Institute
of Medicine Workshop. The Journal of Continuing Education in Nursing, 46(2), 53-55.
doi:10.3928/00220124-20150121-11
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Challenge for Medical and Nursing Regulators. Healthcare Policy | Politiques de
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1
Chapter 10
Information
Management System
(IMS)
The goal of information management in the organisation is to ensure that the right information is
available to the right person at the right time.
Information management includes management of hospital information system as well as all
modalities of information communicated to staff, patients, visitors and community in general.
Data and information management must be directed to meet the organisation's needs and support
the delivery of quality patient care. The information needs are provided in an authenticated, secure
and accurate manner at the right time and place.
Confidentiality, integrity and security of records, data and information is maintained.
Confidentiality of protected health information is paramount and is safeguarded across all
information processing, storing and disseminating platforms.
Information management also includes periodic review, revision and withdrawal of obsolete
information to avoid confusion among staff, patients and visitors.
The organisation maintains a complete and accurate medical record for every patient. Various
aspects of the medical record like contents, staff authorised to make entries and retention of
records are addressed effectively by the organisation. The medical record is available for
appropriate care providers. The medical records are reviewed at regular intervals.
IMS.1. Information needs of the patients, visitors, staff, management and
external agencies are met.
IMS.2. The organisation has processes in place for management and control
of data and information.
IMS.3. The patients cared for by the organisation have a complete and
accurate medical record.
IMS.4. The medical record reflects the continuity of care.

IMS.5. The organisation maintains confidentiality, integrity and security of
records, data and information.
IMS.6. The organisation ensures availability of current and relevant documents,

records, data and information and provides for retention of the same.
IMS.7. The organisation carries out a review of medical records.
1
Standard
Information needs of the patients, visitors, staff, management and e
IMS.1.
Objective Elements
C RE
a. The organisation identifies the information needs of the patients,
visitors, staff, management external agencies and community. *
Commitmen b. Identified information needs are captured and/or disseminated.
t c. Information management and technology acquisitions are

commensurate with the identified information needs.
Commitmen
d. A maintenance plan for information technology and communication
t
network is implemented.
e. Contingency plan ensures continuity of information capture,

Commitmen integration and dissemination.
t
f. The organisation ensures that information resources are accurate
and meet stakeholder requirements.
Achieveme
nt
g. The organisation contributes to external databases in accordance
with the law and regulations.
Excellence
Commitmen
t
Standard
The organisation has processes in place for management and contr
IMS.2.
Objective Elements
Commitme nt Commitment Commitment Commitment
nt
Commitme

1
a. Processes for
data collection
are
standardised.
b. Data is analysed
to meet the
information
needs.
c. The organisation
disseminates the
information in a
timely and
accurate
manner.
d. The organisation
stores and
retrieves data
according to its
information
needs. *
e. Clinical
and
manageri
al staff
participat
e in
selecting,
integratin
g and
using data
for
meeting
the
informatio
n needs.

1
Standa
The patients cared for by the organisation have a complete and ac
IMS.3.
Objective Elements
Commitment a. The unique identifier is assigned to the medical record.
Commitment b. The contents of the medical record are identified and documented. *
C RE c. The medical record provides a complete, up-to-date and

chronological account of patient care.
Commitme d. Authorised staff make the entry in the medical record. *
nt e. Entry in the medical record is signed, dated and timed.
Commitme f. The author of the entry can be identified.
nt g. The medical record has only authorised abbreviations.
Commitme
nt
Commitme
nt
Standard
IMS.4. The medical record reflects the continuity of care.
Objective Elements
Commitme nt Commitment
nt
Commitment Commitment Commitment

Commitme
nt
Commitme
nt
Commitme

1
Standa
a. The patient is transferred to another organisation, the medical
medical record contains the details of the transfer.
record
contains f. The medical record contains a copy of the discharge summary.
informati
g. In case of death, the medical record contains a copy of the cause of death
on report.
regarding
reasons h. Care providers have access to current and past medical record.
for
admission
,
diagnosis
and care
plan.
b. The
medical
record
contains
the
details of
assessme
nts, re-
assessme
nts and
consultati
ons.
c. The
medical
record
contains
the
results of
investigati
ons and
the
details of
the care
provided.
d. Operative and
other procedures
performed are
incorporated in
the medical
record.
e. When a
1
Standa
The organisation maintains confidentiality, integrity and security o
IMS.5.
Objective Elements
C RE a. The organisation maintains the confidentiality of records, data and
information.*
C RE b. The organisation maintains the integrity of records, data and information. *
C RE c. The organisation maintains the security of records, data and information.*
Achieveme d. The organisation uses developments in appropriate technology for

nt improving confidentiality, integrity and security.
e. The organisation discloses privileged health information as

Commitmen authorised by the patient and/or as required by law.
t
f. Request for access to information in the medical records by
patients/physicians and other public agencies are addressed
Commitmen
consistently.*
t
Standard
The organisation ensures availability of current and relevant docum
IMS.6.
Objective Elements
C RE
a. The organisation has an effective process for document control. *
C RE
b. The organisation retains patient's clinical records, data and
information according to its requirements. *
Commitme
c. The retention process provides expected confidentiality and security.
nt
d. The destruction of medical records, data and information are in
Commitme accordance with the written guidance.*
nt

1
Standard
IMS.7. The organisation carries out a review of medical records.
Objective Elements
C RE
a. The medical records are reviewed periodically.
Commitme
b. The review uses a representative sample based on statistical principles.
nt
c. The review is conducted by identified individuals.
Commitme
d. The review of records is based on identified parameters.
nt
e. The review process includes records of both active and discharged patients.
Commitme
f. The review points out and documents any deficiencies in records.
nt
g. Appropriate corrective and preventive measures are undertaken.
Commitme
nt
Commitme
nt
Commitme
nt

1
References:
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Health Information Technology. Retrieved September 1, 2019, from
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Quality- Improvement/ co621. pdf?dmc=1& ts= 20190901T1157446882
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Introduction.pdf
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135515
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EHR_Standards_for_India_as_notified_by_MOHFW_2016.pdf
14. Myuran, T., Turner, O., Ben Doostdar, B., & Lovett, B. (2017). The e-CRABEL score: an updated
method for auditing medical records. BMJ Quality Improvement Reports, 6(1),
u211253.w4529. doi:10.1136/ bmjquality.u211253.w4529
1
15. National Institute of Biologicals, Ministry of Health & Family Welfare, Government of India.
(n.d.). Haemovigilance Programme of India. Retrieved from
http://nib.gov.in/haemovigilance.html
1
16. Patient Safety Network, Agency for Healthcare Research and Quality. (2012, July). Patient
Safety and Health Information Technology: Learning from Our Mistakes. Retrieved
September 1, 2019, from https://psnet.ahrq.gov/perspectives/perspective/124/patient-
safety-and-health-information-technology- learning-from-our-mistakes
17. Royal College of Physicians. (2015, October 26). Generic medical record keeping
standards. Retrieved September 2, 2019, from
https://www.rcplondon.ac.uk/projects/outputs/generic-medical-record-keeping- standards
18. Schweitzer, M., & Hoerbst, A. (2015). A Systematic Investigation on Barriers and Critical
Success Factors for Clinical Information Systems in Integrated Care Settings. Yearbook of
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(2001). Strategic information management plans: the basis for systematic information
management in hospitals. International Journal of Medical Informatics, 64(2-3), 99-109.
doi:10.1016/s1386-5056(01)00219-2
1
Glossary
The commonly-used terminologies in the NABH standards are briefly described and explained
herein to remove any ambiguity regarding their comprehension. The definitions narrated have
been taken from various authentic sources as stated, wherever possible. Notwithstanding the
accuracy of the explanations given, in the event of any discrepancy with a legal requirement
enshrined in the law of the land, the provisions of the latter shall apply.
Accreditation is self-assessment and external peer review process

used by health care organisations to accurately assess their level
Accreditation
of performance in relation to established standards and to
implement ways to improve the health care system
continuously.
Accreditation The evaluation process for assessing the compliance of an

assessment organisation with the applicable standards for determining its
accreditation status.
Emergency medical care for sustaining life, including
Advance life support
defibrillation, airway management, and drugs and medications.
A response to a drug which is noxious and unintended and which

Adverse drug occurs at doses normally used in man for prophylaxis,
reaction diagnosis, or therapy of disease or for the modification of
physiologic function.
An injury related to medical management, in contrast to
complications of the disease. Medical management includes all
aspects of care, including diagnosis and treatment, failure to
Adverse event
diagnose or treat, and the systems and equipment used to deliver
care. Adverse events may be preventable or non- preventable.
(WHO Draft Guidelines for Adverse Event Reporting and
Learning Systems)
It is defined as death occurring within 24 hours of
Anaesthesia Death administration of anaesthesia due to cases related to
anaesthesia. However, death may occur even afterwards due to
the complications.
All activities including history taking, physical examination,
Assessment laboratory investigations that contribute towards determining
the prevailing clinical status of the patient.
The nursing of patients with infectious diseases in isolation to

prevent the spread of infection.
As the name implies, the aim is to erect a barrier to the passage
Barrier nursing of infectious pathogenic organisms between the contagious
patient and other patients and staff in the hospital, and thence
to the outside world. The nurses wear gowns, masks, and gloves,
and they observe strict rules that minimise the risk of passing on
infectious agents.
1
Basic life support (BLS) is the level of medical care which is used
Basic life support for patients with life-threatening illnesses or injuries until the
patient can be given full medical care
1
Activities which are associated with the repair and servicing of

Breakdown site infrastructure, buildings, plant or equipment within the site's
maintenance agreed building capacity allocation which have become
inoperable or unusable because of the failure of component
parts.
A rule governing the internal management of an
organisation. It can supplement or complement the government
Byelaws
law but cannot countermand it,
e.g. municipal by-laws for construction of hospitals/nursing
homes, for disposal of hazardous and/or infectious waste
Set of operations that establish, under specified conditions, the
relationship between values of quantities indicated by a
Calibration
measuring instrument or measuring system, or values
represented by a material measure or a reference material, and
the corresponding values realised by standards.
A plan that identifies patient care needs, lists the strategy to
meet those needs, documents treatment goals and objectives,
outlines the criteria for ending interventions, and documents
Care Plan the individual's progress in meeting specified goals and
objectives. The format of the plan may be guided by specific
policies and procedures, protocols, practice guidelines or a
combination of these. It includes preventive, promotive,
curative and rehabilitative aspects of care.
Citizen's Charter is a document which represents a systematic

effort to focus on the commitment of the organisation towards
Citizen's charter its citizens in respects of standard of services, information,
choice and consultation, non-discrimination and accessibility,
grievance redress, courtesy and value for money.
(Reference: https://goicharters.nic.in/faq.htm)
A quality improvement process that seeks to improve patient
care and outcomes through systematic review of care against
Clinical audit
explicit criteria and the implementation of change. (Reference:
Principles for Best Practice in Clinical Audit 2002, NICE/CHI)
It is a surgical procedure that consists of an examination of a

corpse by dissection to identify the cause, mode and manner of
Clinical autopsy
death or to evaluate any disease or injury that may be present
for research or educational purposes.
Clinical care pathways are standardised evidence-based,

multidisciplinary management plans. They identify an
Clinical care pathway
appropriate sequence of clinical interventions, timeframes,
milestones and expected outcomes for a homogenous patient
group.
1
Clinical practice guidelines are systematically developed

Clinical practice
guidelines statements to assist practitioner and patient decisions about
appropriate health care for specific clinical circumstances.
1
Demonstrated ability to apply knowledge and skills (para 3.9.2 of

Competence ISO 9000: 2015). Knowledge is the understanding of facts and
procedures. Skill is the ability to perform a specific action.
Restricted access to information to individuals who have a

need, a reason and permission for such access. It also includes
Confidentiality
an individual's right to personal privacy as well as the privacy
of information related to his/her healthcare records.
1. The willingness of a party to undergo

examination/procedure/ treatment by a healthcare
provider. It may be implied (e.g. patient registering in
OPD), expressed which may be written or verbal.
Informed consent is a type of consent in which the
healthcare provider has a duty to inform his/her patient
about the procedure, its potential risk and benefits,
Consent
alternative procedure with their risk and benefits so as to
enable the patient to make an informed decision of his/her
health care.
2. In law, it means active acquiescence or silent compliance by

a person legally capable of consenting. In India, the legal
age of consent is 18 years. It may be evidenced by words
or acts or by silence when silence implies concurrence.
Actual or implied consent is necessarily an element in
every contract and every agreement.
The statistical tool used in quality control to (1) analyse and
understand process variables, (2) determine process
capabilities, and to (3) monitor effects of the variables on the
difference between target and actual performance. Control
Control Charts charts indicate upper and lower control limits, and often
include a central (average) line, to help detect the trend of
plotted values. If all data points are within the control limits,
variations in the values may be due to a common cause and
process is said to be 'in control'. If data points fall outside the
control limits, variations may be due to a special cause, and the
process is said to be out of control.
Correction Action to eliminate the detected non-conformity (Reference: ISO
9000:2015)
Action to eliminate the cause of a non-conformity and to prevent
Corrective action
recurrence. (Reference: ISO 9000:2015)
The process of obtaining, verifying and assessing the

Credentialing
qualification of a healthcare provider.
Data Data is a record of the event.
A part of a patient record that summarises the reasons for

Discharge summary admission, significant clinical findings, procedures performed,
1
treatment rendered, patient's condition on discharge and any

specific instructions given to the patient or family (for example
follow-up medications).
1
A sequence of activities to be carried out when staff does not

Disciplinary
procedure conform to the laid-down norms, rules and regulations of the
healthcare organisation.
The preparation, packaging, labelling, record keeping, and
transfer of a prescription drug to a patient or an intermediary,
Drug dispensing
who is responsible for the administration of the drug.
(Reference: Mosby's Medical Dictionary, 9th edition, 2009,
Elsevier.)
The giving of a therapeutic agent to a patient, e.g. by infusion,
Drug Administration
inhalation, injection, paste, pessary, suppository or tablet.
Effective Communication is a communication between two or

more persons wherein the intended message is successfully
Effective
delivered, received and understood.
communication
The effective communication also includes several other skills
such as non- verbal communication, engaged listening, ability to
speak assertively, etc.
Employees All members of the healthcare organisation who are employed full
time and are paid suitable remuneration for their services as per
the laid-down policy.
Helps all those with an advanced, progressive, incurable

illness to live as well as possible until they die. It enables the
supportive and palliative care needs of both patient and family to
End-of-life Care
be identified and met throughout the last phase of life and into
bereavement. It includes management of pain and other
symptoms and provision of psychological, social, spiritual and
practical support.
Enhanced communication is using the methods of
communication to ensure meaning and understanding through
Enhanced the recognition of the limitations of others. The intent is to
communication
ensure purposeful, timely and reliable communication. The
communication must be sensitive, empathetic and inclusive.
Ethics Moral principles that govern a person's or group's behaviour.
Evidence-based medicine is the conscientious, explicit, and

Evidence-based
judicious use of current best evidence in making decisions
medicine
about the care of individual patients.
The person(s) with a significant role in the patient's life. It mainly

includes spouse, children and parents. It may also include a
Family
person not legally related to the patient but can make healthcare
decisions for a patient if the patient loses decision-making
ability.
Failure Mode and A method used to prospectively identify error risks within a
Effect Analysis particular process.
(FMEA)
1
An approved list of drugs. Drugs contained in the formulary

Formulary
are generally those that are determined to be cost-effective and
medically effective.
1
A broad statement describing a desired future condition or

achievement without being specific about how much and
when. (Reference: American Society for Quality)
Goal
The term "goals" refers to a future condition or performance level
that one intends to attain. Goals can be both short- and longer-
term. Goals are ends that guide actions. (Reference: Malcolm
Baldridge National Quality Award)
Grievance- The sequence of activities carried out to address the grievances of
handling patients, visitors, relatives and staff.
procedures
Substances dangerous to human and other living organisms.
Hazardous materials
They include radioactive or chemical materials.
Waste materials dangerous to living organisms. Such materials

require special precautions for disposal. They include the
Hazardous waste biologic waste that can transmit disease (for example, blood,
tissues) radioactive materials, and toxic chemicals. Other
examples are infectious waste such as used needles, used
bandages and fluid soaked items.
Healthcare-associated infection (HAI), also referred to as
Healthcare- "nosocomial" or "hospital" infection, is an infection occurring in a
associated patient during the process of care in a hospital or other health
infection care facility which was not present or incubating at the time of
admission. (Reference: World Health Organization)
The generic term is used to describe the various types of
Healthcare
organisation that provide healthcare services. This includes
organisation
ambulatory care centres, hospitals, laboratories, etc.
A high-dependency unit (HDU) is an area for patients who

High-dependency require more intensive observation, treatment and nursing care
unit than are usually provided for in a ward. It is a standard of care
between the ward and full intensive care.
High-risk/high-alert medications are medications involved in a
high percentage of medication errors or sentinel events and
medications that carry a high risk for abuse, error, or other
High Risk/High
Alert adverse outcomes.
Medications Examples include medications with a low therapeutic index,
controlled substances, psychotherapeutic medications, and
look-alike and sound- alike medications.
It is defined as written or verbal reporting of any event in the
Incident reporting process of patient care, that is inconsistent with the deserved
patient outcome or routine operations of the healthcare facility.
Organised education/training usually provided in the

In-service education/
workplace for enhancing the skills of staff members or for
training
teaching them new skills relevant to their jobs/tasks.
1
A statistical measure of the performance of functions, systems or

Indicator processes over time. For example, hospital acquired infection
rate, mortality rate, caesarean section rate, absence rate, etc.
Information Processed data which lends meaning to the raw data.
A brief explanation of the rationale, meaning and

Intent
significance of the standards laid down in a particular chapter.
The method of supervising the intake, use and disposal of various

goods in hands. It relates to supervision of the supply, storage
Inventory control and accessibility of items in order to ensure an adequate supply
without stock-outs/excessive storage. It is also the process of
balancing ordering costs against carrying costs of the inventory
so as to minimise total costs.
Separation of an ill person who has a communicable disease
(e.g.,measles, chickenpox, mumps, SARS) from those who are
healthy. Isolation prevents transmission of infection to others
Isolation
and also allows the focused delivery of specialised health care
to ill patients. The period of isolation varies from disease-to-
disease. Isolation facilities can also be extended to patients for
fulfilling their individual, unique needs.
1. It entails an explanation pertaining to duties,
responsibilities and conditions required to perform a job.
2. A summary of the most important features of a job,
including the general nature of the work performed (duties
Job description and responsibilities) and level (i.e., skill, effort,
responsibility and working conditions) of the work
performed. It typically includes job specifications that
include employee characteristics required for competent
performance of the job. A job description should describe
and focus on the job itself and not on any specific individual
who might fill the job.
1. The qualifications/physical requirements, experience and
skills required to perform a particular job/task.
Job specification
2. A statement of the minimum acceptable qualifications
that an incumbent must possess to perform a given job
successfully.
The combination of all technical and administrative actions,
including supervision actions, intended to retain an item in, or
Maintenance
restore it to, a state in which it can perform a required function.
(Reference: British Standard 3811:1993)
Any fixed or portable non-drug item or apparatus used for

Medical equipment
diagnosis, treatment, monitoring and direct care of a patient.
1
A medication error is any preventable event that may cause or

lead to inappropriate medication use or patient harm while the
medication is in the control of the health care professional,
patient, or consumer.
Medication error Such events may be related to professional practice, health care
products, procedures, and systems, including prescribing;
order communication; product labelling, packaging, and
nomenclature; compounding; dispensing; distribution;
administration; education; monitoring; and use. (Reference:
The National Coordinating Council for Medication Error
Reporting and Prevention)
A written order by a physician, dentist, or other designated
health professionals for a medication to be dispensed by a
Medication Order
pharmacy for administration to a patient. (Reference: Mosby's
Medical Dictionary, 10th edition, Elsevier)
An organisation's purpose. This refers to the overall function of

an organisation. The mission answers the question, "What is this
Mission organisation attempting to accomplish?" The mission might
define patients, stakeholders, or markets served, distinctive
or core competencies or technologies used.
The performance and analysis of routine measurements aimed at

identifying and detecting changes in the health status or the
Monitoring environment, e.g. monitoring of growth and nutritional status, air
quality in operation theatre. It requires careful planning and use of
standardised procedures and methods of data collection.
A generic term which includes representatives from various

Multidisciplinary
disciplines, professions or service areas.
A near-miss is an unplanned event that did not result in injury,

illness, or damage--but had the potential to do so.
Near-miss
Errors that did not result in patient harm, but could have, can be
categorised as near-misses.
This is used synonymously with a near miss. However, some

authors draw a distinction between these two phrases.
A near-miss is defined when an error is realised just in the nick of
time, and abortive action is instituted to cut short its translation.
In no harm scenario, the error is not recognised, and the deed
is done, but fortunately for the healthcare professional, the
No harm expected adverse event does not occur. The distinction
between the two is important and is best exemplified by reactions
to administered drugs in allergic patients. A prophylactic
injection of cephalosporin may be stopped in time because it
suddenly transpires that the patient is known to be allergic to
penicillin (near-miss). If this vital piece of information is
1
overlooked, and the cephalosporin administered, the patient may

fortunately not develop an anaphylactic reaction (no harm event).
1
Certain specified diseases, which are required by law to be

notified to the
public health authorities. Under the international health regulation
(WHO's
International Health Regulations 2005), the following diseases
are always
notifiable to WHO:
(a) Smallpox
(b) Poliomyelitis due to wild-type poliovirus
(c) Human influenza caused by a new subtype
(d) Severe acute respiratory syndrome (SARS).
In India, the following is an indicative list of diseases which

are also
notifiable, but may vary from state to state:
Notifiable
(a) Polio
disease
(b) Influenza
(c) Malaria
(d) Rabies
(e) HIV/AIDS
(f) Louse-borne typhus
(g) Tuberculosis
(h) Leprosy
(i) Leptospirosis
(j) Viral hepatitis
(k) Dengue fever
Empowerment for nurses may consist of three components: a

workplace that has the requisite structures to promote
empowerment; a psychological belief in one's ability to be
empowered; and acknowledgement that there is power in the
relationships and caring that nurses provide.
It could include structural empowerment and psychological
empowerment. Structural empowerment refers to the presence or
absence of empowering conditions in the workplace. Kanter's
(1993) theory of structural empowerment includes a
discussion of organisational behaviour and empowerment.
Nursing According to this theory, empowerment is promoted in work
empowerment
environments that provide employees with access to
information, resources, support, and the opportunity to learn and
develop. Psychological empowerment is related to a sense of
motivation towards the organisational environment, based on
the dimensions of meaning, competence, self- determination,
and impact
Evidence of nursing empowerment include initiating and carrying
out CPR even in the absences of physicians, implementing
standard protocols in the ICU such as weaning a patient off
ventilator, tapering or titrating inotropic as per standard
1
policies, nurse-led discussions during patient rounds,

preparing nursing budgets, decisions to procure equipment
that aid and ease nursing care, empowered to correct, stop
non-compliance to protocols defined by the hospital.
1
A specific statement of a desired short-term condition or

Objective achievement includes measurable end-results to be
accomplished by specific teams or individuals within time limits.
(Reference: American Society for Quality)
It is that component of standard which can be measured
Objective element objectively on a rating scale. Acceptable compliance with the
measurable elements will determine the overall compliance with
the standard.
The hazards to which an individual is exposed during the
Occupational course of the performance of his job. These include physical,
health hazard
chemical, biological, mechanical and psychosocial hazards.
The operational plan is the part of your strategic plan. It defines

how you will operate in practice to implement your action and
Operational plan monitoring plans - what your capacity needs are, how you will
engage resources, how you will deal with risks, and how you will
ensure the sustainability of the organisation's achievements.
Organogram A graphic representation of the reporting relationship in an

organisation.
Hiring of services and facilities from other organisation based
upon one's own requirement in areas where such facilities are
either not available or else are not cost-effective. For example,
outsourcing of house-keeping, security, laboratory/certain
Outsourcing
special diagnostic facilities. When an activity is outsourced to
other institutions, there should be a memorandum of
understanding that clearly lays down the obligations of both
organisations: the one which is outsourcing and the one who is
providing the outsourced facility. It also addresses the quality-
related aspects.
The location where a patient is provided health care as per his
Patient-care setting
needs, e.g. ICU, speciality ward, private ward and general ward.
A document which contains the chronological sequence of

Patient record/ events that a patient undergoes during his stay in the healthcare
medical record/ organisation. It includes demographic data of the patient,
clinical record assessment findings, diagnosis, consultations, procedures
undergone, progress notes and discharge summary.
Patient-reported Patient-reported experience measures are questionnaires

experience
measures (PREMs) measuring the patients' perceptions of their experience whilst
receiving care.
Patient- Patient-reported outcome measures are questionnaires
reported
outcome measuring the patients' views of their health status.
measures
(PROMs)
Patient satisfaction is a measure of the extent to which a patient
is content with the health care which they received from their
Patient Satisfaction
1
and
health care provider. Patient satisfaction is thus a proxy but a
very effective indicator to measure the success of Health care
providers.
1
Patient Experience is the sum of all interactions, shaped by an

organisation's culture, that influence patient perceptions across
Patient Experience
the continuum of care.
It is a holistic perception that the patient forms about the
healthcare provider based on the overall interactions/ care
touchpoints.
It is the process of evaluating the performance of staff during

Performance a defined period of time with the aim of ascertaining their
appraisal suitability for the job, the potential for growth as well as
determining training needs.
Medical Equipment that is used to deliver care/intervene at or
near the site of patient care. These are primarily Point-of-care
Point of
testing (POCT), or bedside testing equipment that helps in
care
equipmen reducing turn-around times. POCT Machine examples;
t Glucometer, ABG Analyser, Stat Lab at ICU/ER, portable USG
etc.
They are the guidelines for decision-making,e.g. admission,
Policies
discharge policies, antibiotic policy,etc.
Action to eliminate the cause of a potential non-conformity.

Preventive action
(Reference ISO 9000:2015)
It is a set of activities that are performed on plant equipment,

Preventive
maintenance machinery, and systems before the occurrence of a failure in
order to protect them and to prevent or eliminate any
degradation in their operating conditions.
The maintenance carried out at predetermined intervals or
according to prescribed criteria and intended to reduce the
probability of failure or the degradation of the functioning of an
item.
A prescription is a document given by a physician or other
healthcare practitioner in the form of instructions that govern
the care plan for an individual patient.
Prescription Legally, it is a written directive, for compounding or dispensing
and administration of drugs, or for other service to a particular
patient.
(Reference: Miller-Keane Encyclopedia and Dictionary of
Medicine, Nursing, and Allied Health, Seventh Edition, Saunders)
It is the process for authorising all medical professionals to admit
Privileging and treat patients and provide other clinical services
commensurate with their qualifications and skills.
Confidential information furnished (to facilitate

Privileged
diagnosis and treatment) by the patient to a professional
communication
authorised by law to provide care and treatment.
1
Procedural sedation is a technique of administering sedatives

or dissociative agents with or without analgesics to induce a state
that allows the patient to tolerate unpleasant procedures while
Procedural sedation maintaining cardiorespiratory function. Procedural sedation
and analgesia (PSA) is intended to result in a depressed level
of consciousness that allows the patient to maintain
oxygenation and airway control independently. (Reference: The
American College of Emergency Physicians)
1. A specified way to carry out an activity or a process
(Para 3.4.5 of ISO 9000: 2015).
Procedure 2. A series of activities for carrying out work which when
observed by all help to ensure the maximum use of
resources and efforts to achieve the desired output.
Process A set of interrelated or interacting activities which transforms

inputs into outputs (Para 3.4.1 of ISO 9000: 2015).
Programme A sequence of activities designed to implement

policies and accomplish objectives.
Protocol A plan or a set of steps to be followed in a study, an

investigation or an intervention.
1. Degree to which a set of inherent characteristics fulfil

requirements (Para 3.1.1 of ISO 9000: 2015).
Characteristicsimplyadistinguishingfeature(Para 3.5.1 of ISO
Quality 9000: 2015). Requirements are a need or expectation
that is stated, generally implied or obligatory (Para 3.1.2 of
ISO 9000:2015).
2. Degree of adherence to pre-established criteria or standards.
Part of quality management focussed on providing confidence
Quality assurance
that quality requirements will be fulfilled (Para 3.2.11 of ISO
9000:2015).
Ongoing response to quality assessment data about a service in
Quality improvement
ways that improve the process by which services are provided to
consumers/patients.
Radiation safety refers to safety issues and protection from
radiation hazards arising from the handling of radioactive
materials or chemicals and exposure to Ionizing and Non-Ionizing
Radiation.
This is implemented by taking steps to ensure that people will
not receive excessive doses of radiation and by monitoring all
Radiation Safety sources of radiation to which they may be exposed.(Reference:
McGraw-Hill Dictionary of Scientific & Technical Terms)
In a Healthcare setting, this commonly refers to X-ray machines,
CT/PET CT Scans, Electron microscopes, Particle accelerators,
Cyclotron etc. Radioactive substances and radioactive waste are
also potential Hazards. Imaging Safety includes safety measures
to be taken while performing an MRI, Radiological interventions,
Sedation, Anaesthesia, Transfer of patients, Monitoring patients
during imaging procedure etc.
1
It implies a continuous and ongoing assessment of the patient,

Re-assessment
which is recorded in the medical records as progress notes.
Medication reconciliation is the process of creating the most

accurate list possible of all medications a patient is taking -
Reconciliation including drug name, dosage, frequency, and route - and
of comparing that list against the physician's admission, transfer,
medications and/or discharge orders, with the goal of providing correct
medications to the patient at all transition points within the
hospital. (Reference: Institute for Healthcare Improvement)
It implies all inputs in terms of men, material, money,

Resources machines, minutes (time), methods, metres (space), skills,
knowledge and information that are needed for the efficient and
effective functioning of an organisation.
Devices used to ensure safety by restricting and controlling a
Restraints person's movement. Many facilities are "restraint-free" or use
alternative methods to help modify behaviour. Restraint may be
physical or chemical (by use of sedatives).
Risk abatement Risk abatement means minimising the risk or minimising the impact
of that risk.
Risk assessment is the determination of the quantitative or
Risk assessment qualitative value of risk related to a concrete situation and a
recognised threat (also called hazard). Risk assessment is a step
in a risk management procedure.
Clinical and administrative activities to identify, evaluate and

Risk management
reduce the risk of injury.
Risk mitigation is a strategy to prepare for and lessen the effects

Risk mitigation of threats and disasters. Risk mitigation takes steps to reduce the
negative effects of threats and disasters.
The conceptual framework of elements considered with the

possibilities to minimise vulnerabilities and disaster risks
throughout society to avoid (prevention) or to limit (mitigation
Risk reduction and preparedness) the adverse impacts of hazards, within the
broad context of sustainable development.
It is the decrease in the risk of a healthcare facility, given
activity, and treatment process with respect to patient, staff,
visitors and community.
Root Cause Analysis (RCA) is a structured process that
uncovers the physical, human, and latent causes of any
undesirable event in the workplace. Root cause analysis (RCA) is
a method of problem-solving that tries to identify the root
Root Cause causes of faults or problems that cause operating events.
Analysis (RCA) RCA practice tries to solve problems by attempting to identify
and correct the root causes of events, as opposed to simply
addressing their symptoms. By focusing correction on root
1
causes, problem recurrence can be prevented. The process

involves data collection; cause charting, root cause
identification and recommendation generation and
implementation.
1
The degree to which the risk of an intervention/procedure, in

Safety
the care environment is reduced for a patient, visitors and
healthcare providers.
Safety programme A programme focused on patient, staff and visitor safety.
Scope of services Range of clinical and supportive activities that are provided by a
healthcare organisation.
Security Protection from loss, destruction, tampering, and unauthorised

access or use.
The administration to an individual, in any setting for any purpose,
by any route, moderate or deep sedation. There are three levels
of sedation:
Minimal sedation (anxiolysis) - A drug-induced state during
which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired, ventilatory
and cardiovascular functions are not affected.
Sedation
Moderate sedation/analgesia (conscious sedation) - A drug-
induced depression of consciousness during which patients
respond purposefully to verbal commands either alone or
accompanied by light tactile stimulation. No interventions are
needed to maintain a patent airway.
Deep sedation/analgesia - A drug-induced depression of
consciousness during which patients cannot be easily aroused
but respond purposefully after repeated or painful stimulation.
Patients may need help in maintaining a patent airway.
A relatively infrequent, unexpected incident, related to system
or process deficiencies, which leads to death or major and
enduring loss of function for a recipient of healthcare
Sentinel events services.
Major and enduring loss of function refers to sensory,
motor, physiological, or psychological impairment not present at
the time services were sought or begun. The impairment lasts
for a minimum period of two weeks and is not related to an
underlying condition.
A balanced approach for an organisation to address economic,
social and environmental issues in a way that aims to benefit
Social responsibility
people, communities and society,e.g. adoption of villages for
providing health care, holding of medical camps and proper
disposal of hospital wastes.
Practitioner decisions based on available knowledge, principles
Sound clinical
and practices for specific clinical situations.
practice
In addition to routine carried by the healthcare professionals,
patients and family have special educational needs depending
on the situation. For example, a post-surgical patient who has
to take care of his wound, nasogastric tube feeding, patient on
Special
tracheostomy getting discharged who has to be taken care of by
Educational
the family etc. The special educational needs are also greatly
needs of the
influenced by the literacy, educational level, language,
1
patient emotional barriers and physical and cognitive limitations.

Hence it is important for the staff to determine the special
educational needs and the challenges influencing the effective
education.
1
All personnel working in the organisation including employees,

Staff "fee-for- service" medical professionals, part-time workers,
contractual personnel and volunteers.
1. A method of infection control in which all human blood

and other bodily fluids are considered infectious for HIV,
HBV and other bloodborne pathogens, regardless of patient
history. It encompasses a variety of practices to prevent
occupational exposure, such as the use of personal
protective equipment (PPE), disposal of sharps and safe
Standard housekeeping
precautions
2. A set of guidelines protecting first aiders or healthcare
professionals from pathogens. The main message is: "Don't
touch or use anything that has the victim's body fluid on it
without a barrier." It also assumes that all body fluid of a
patient is infectious, and must be treated accordingly.
Standard Precautions apply to blood, all body fluids,
secretions, and excretions (except sweat) regardless of whether
or not they contain visible blood, non-intact skin and mucous
membranes
A statement of expectation that defines the structures and
Standards
process that must be substantially in place in an organisation to
enhance the quality of care.
It is the process of killing or removing microorganisms including
Sterilisation their spores by thermal, chemical or irradiation means.
Strategic planning is an organisation's process of defining its

strategy or direction and making decisions on allocating its
resources to pursue this strategy, including its capital and
people. Various business analysis techniques can be used in
strategic planning, including SWOT analysis (Strengths,
Strategic plan Weaknesses, Opportunities and Threats), e.g. Organisation can
have a strategic plan to become a market leader in the
provision of cardiothoracic and vascular services. The resource
allocation will have to follow the pattern to achieve the target.
The process by which an organisation envisions its future and
develops strategies, goals, objectives and action plans to achieve
that future.
The continuous scrutiny of factors that determines the
occurrence and distribution of diseases and other conditions of ill
Surveillance health. It implies watching over with great attention, authority
and often with suspicion. It requires professional analysis and
sophisticated interpretation of data leading to
recommendations for control activities.
A table-top exercise is an activity in which key personnel assigned

emergency management roles and responsibilities are gathered
1
Table-top exercise
to discuss, in a non-threatening environment, various simulated
emergency situations.
(Reference:
https://uwpd.wisc.edu/content/uploads/2014/01/What_is_a_
tabletop_exercise.pdf)
1
Traceability is the ability to trace the history, application, use and

Traceability location of an item or its characteristics through recorded
identification data. (Reference: ISO 9000:2015)
A transfusion reaction is a problem that occurs after a patient

Transfusion reaction
receives a transfusion of blood.
Triage is a process of prioritising patients based on the

Triage severity of their condition so as to treat as many as possible
when resources are insufficient for all to be treated
immediately.
Turnaround Ttime (TAT) means the amount of time taken to

Turn-around-time
complete a process or fulfil a request.
A patient whose vital parameters need external assistance

Unstable patient
for their maintenance.
A validated tool refers to a questionnaire/scale that has been

developed to be administered among the intended
respondents. The validation processes should have been
Validated tool
completed using a representative sample, demonstrating
adequate reliability (the ability of the instrument to produce
consistent results) and validity (the ability of the instrument to
produce true results).
Validation is verification, where the specified requirements are

Validation
adequate for the intended use.
The fundamental beliefs that drive organisational behaviour

Values
and decision-making.
This refers to the guiding principles and behaviours that

embody how an organisation and its people are expected to
operate. Values reflect and reinforce the desired culture of an
organisation.
Verbal orders are those orders given by a physician with
Verbal order
prescriptive authority to a licensed person who is authorised by
the organisation.
Verification is the provision of objective evidence that a given
Verification
item fulfils specified requirements.
An overarching statement of the way an organisation wants to be,

an ideal state of being at a future point.
Vision This refers to the desired future state of an organisation. The
vision describes where the organisation is headed, what it intends
to be, or how it wishes to be perceived in the future.
1
Those patients who are prone to injury and disease by virtue

of their age, sex, physical, mental and immunological
Vulnerable patient
status,e.g. infants, elderly, physically- and mentally-
challenged, semiconscious/unconscious, those on
immunosuppressive and/or chemotherapeutic agents.
Incidents where staff are abused, threatened or assaulted in
circumstances related to their work, including commuting to and
Workplace violence
from work, involving an explicit or implicit challenge to their
safety, well-being or health. (Adapted from European
Commission)
1
NATIONAL ACCREDITATION BOARD
FOR HOSPITALS & HEALTHCARE PROVIDERS
(NABH)
ITPI Building, 5th Floor, 4A, IP Estate, Ring Road, New Delhi-
110002 Email: helpdesk@nabh.co | Website:
www.nabh.co
ISBN 978-81-944877-5-3
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NATIONAL ACCREDITATION

BOARD FOR HOSPITALS AND

Accreditation Standards for

© All Rights Reserved

This edition has some changes that were

healthcare. Each chapter has a bibliography for

In view of these, I expect that the healthcare

Dr. Atul Mohan Kochhar

Chapter 2 Care of Patients (COP) 13

Chapter 3 Management of Medication (MOM) 30

Chapter 4 Patient Rights and Education (PRE) 39

Chapter 5 Hospital Infection Control (HIC) 47

Chapter 6 Patient Safety and Quality Improvement (PSQ) 57

Chapter 7 Responsibilities of Management (ROM) 65

Chapter 8 Facility Management and Safety (FMS) 72

Chapter 9 Human Resource Management (HRM) 79

Chapter 10 Information Management System (IMS) 91

Intent of the chapter:

* This implies that this objective element requires documentation.

Commitme b. Each defined healthcare service should have diagnostic and

c. Scope of the healthcare services of each department is defined. *

C RE b. A unique identification number is generated at the end of the registration.

t e. Access to the healthcare services in the organisation is prioritised

Commitme b. Transfer- out/referral of patients to another facility is done appropriately. *

nt c. During transfer or referral, accompanying staff are appropriate to

Commitmen b The initial assessment is performed by qualified personnel. *

Commitmen d. Initial assessment of day-care and in-patients includes nursing

Achieveme e. The initial assessment for in-patients results in a documented care

Commitmen b. Out-patients are informed of their next follow-up, where appropriate.

t c. For in-patients during reassessment, the care plan is monitored

t h. Results are reported in a standardised manner.

Commitmen i. There is a mechanism to address the recall / amendment of

Commitme b. The programme addresses verification and/or validation of test methods. *

nt c. The programme ensures the quality of test results. *

Commitme d. The programme includes periodic calibration and maintenance of all

nt f. The programme addresses clinicopathological meeting(s).

Commitme b. This programme is aligned with the organisation's safety programme.

nt c. Laboratory personnel are appropriately trained in safe practices.

Commitme d. Laboratory personnel are provided with appropriate safety measures.

Commitmen b. Scope of the imaging services is commensurate to the services

c. The infrastructure (physical and equipment) and human resources are

d. Qualified and trained personnel perform, supervise and interpret the

g. Critical results are intimated immediately to the personnel concerned. *

t j. Imaging tests not available in the organisation are outsourced to

Commitme b. Quality assurance programme includes tests for imaging equipment.

Achieveme d. A system is in place to ensure the appropriateness of the

e. The programme addresses periodic internal/external peer review

f. The programme addresses the clinico-radiological meeting(s).

Commitment b. This programme is aligned with the organisation's safety programme.

Commitment c. Patients are appropriately screened for safety/risk before imaging.

Commitment e. Radiation-safety and monitoring devices are periodically tested, and

Commitment f. Imaging and ancillary personnel are trained in imaging safety

Commitment g. Imaging signage is prominently displayed in all appropriate locations.

C Commitm Achievem Excelle

b. Patient care is co-ordinated in all care settings within the organisation.

Commitme d. The Organisation implements standardiszed hand-over

t f. Referral of patients to other departments/ specialities follow written

Commitmen Commitment Commitment

C Commitm Achievem Excelle

b. The for discharge and makes continual improvement.