Components of Standards Development

1. Components of Standards Development Multiple Information Sources • Scientific literature • JCI Standards • UK Healthcare Quality Standards • Thailand Standards • AHA Draft Standards • JCI Survey compliance data • Research Findings • Individual input from field experts and key stakeholders • ISO 9001-2000

2. Hospital Standards Organized around important functions • Focus on patient and staff safety • Set standards that all organizations must pass • To be revised periodically and raise the “bar” • Achieve International recognition

3. NABH Standards • 10 Chapters • 100 Standards • 503 Objective Elements

4. Standards and Objective Elements • A standard is a statement that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care • Objective element is a measurable component of a standard • Acceptable compliance with objective elements determines the overall compliance with a standard

5. Section I:Patient-Centered Standards STD OE • Access, Assessment and Continuity of Care (AAC) 15 78 • Patients Rights and Education (PRE) 5 29 • Care of Patients (COP) 18 105 • Management of Medications (MOM) 13 61 • Hospital Infection Control (HIC) 9 44

6. Section II: Health Care Organization Management Standards STD OE • Continuous Quality Improvement (CQI) 6 37 • Responsibilities of Management (ROM) 5 20 • Facility Management & Safety (FMS) 9 41 • Human Resource Management (HRM) 13 47 • Information Management Systems (IMS) 7 41 100 503

7. NABH STANDARDS

8. Introduction • NABH standards for hospitals have been prepared by Technical Committee of NABH and contain complete set of standards for evaluation of hospitals for grant of accreditation. The standards provide framework for quality assurance and quality improvement for hospitals • NABH Standards contains 10 chapters,100 standards and 503 objective elements.

9. Details of chapters. • Access ,Assessment and continuity of care (AAC) • Patient Right and Education (PRE). • Care of Patients(COP). • Management of Medication (MOM). • Hospital Infection Control (HIC). • Continuous Quality Improvement(CQI) • Responsibility of Management (ROM). • Facility Management and Safety (FMS). • Human Resource Management (HRM) • Information Management System (IMS).

10. Chapter 1.ACCESS,ASSESSMENT AND CONTINIUITY OF CARE (AAC)

11. AAC.1The organization defines and displays the services that it can provide Objective Elements • The services being provided are clearly defined. • The defined services are prominently displayed. • The staff is oriented to these services

12. AAC.2The organization has a well defined registration and admission process Objective elements • Standardized policies and procedures are used for registering and admitting patients • The policies and procedures address out- patients, in-patients and emergency patients

13. Cont… • Patients are accepted only if the organization can provide the required service • The policies and procedures also address managing patients during non availability of beds • The staff is aware of these processes

14. AAC.3There is an appropriate mechanism for transfer or referral of patients who do not match the organizational resources Objective elements • Policies guide the transfer of unstable patients to another facility in an appropriate manner • Policies guide the transfer of stable patients to another facility

15. Cont… • Procedures identify staff responsible during transfer • The organization gives a summary of patient’s condition and the treatment given

16. AAC.4During admission the patient and /or the family members are educated to make informed decisions • Objective elements • The patients and/or family members are explained about the proposed care • The patients and/or family members are explained about the expected results

17. Cont… • The patients and/or family members are explained about the possible complications • The patients and/or family members are explained about the expected costs.

18. AAC.5Patients cared for by the organization undergo an established initial assessment • Objective elements • The organization defines the content of the assessments for the out–patients, in-patients and emergency patients. • The organization determines who can perform the assessments.

19. cont… • The organization defines the time frame within which the initial assessment is completed. • The initial assessment for in-patients is documented within 24 hours or earlier as per the patient’s condition or hospital policy. • Initial assessment includes screening for nutritional and psychosocial needs.

20. Cont… • The initial assessment results in a documented plan of care. • The plan of care also includes preventive aspects of the care

21. AAC.6All patients cared for by the organization undergo a regular reassessment • Objective elements. • All patients are reassessed at appropriate intervals. • Staff involved in direct clinical care document reassessments. • Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

22. AAC.7Laboratory services are provided as per the requirements of the patients • Objective elements • Scope of the laboratory services are commensurate to the services provided by the organization • Adequately qualified and trained personnel perform and/or supervise the investigations.

23. cont.. • Policies and procedures guide collection, identification, handling, safe transportation and disposal of specimens. • Laboratory results are available within a defined time frame. • Critical results are intimated immediately to the concerned personnel. • Laboratory tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

24. AAC.8There is an established laboratory quality assurance programme • Objective elements • The laboratory quality assurance programme is documented. • The programme addresses verification and validation of test methods. • The programme addresses surveillance of test results.

25. cont… • The programme includes periodic calibration and maintenance of all equipments. • The programme includes the documentation of corrective and preventive actions

26. AAC.9There is an established laboratory safety programme • Objective elements. • The laboratory safety programme is documented. • This programme is integrated with the organization’s safety programme.

27. cont… • Written policies and procedures guide the handling and disposal of infectious and hazardous materials. • Laboratory personnel are appropriately trained in safe practices. • Laboratory personnel are provided with appropriate safety equipment / devices.

28. AAC.10Imaging services are provided as per the requirements of the patients • Objective elements • Imaging services comply with legal and other requirements. • Scope of the imaging services are commensurate to the services provided by the organization. • Adequately qualified and trained personnel perform and/or supervise the investigations.

29. cont… • Policies and procedures guide identification and safe transportation of patients to imaging services. • Imaging results are available within a defined time frame. • Critical results are intimated immediately to the concerned personnel. • Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

30. AAC.11There is an established Quality assurance programme for imaging services • Objective elements • The quality assurance programme for imaging services is documented. • The programme addresses verification and validation of imaging methods • The programme addresses surveillance of imaging results

31. cont… • The programme includes periodic calibration and maintenance of all equipments. • The programme includes the documentation of corrective and preventive actions

32. AAC.12There is an established radiation safety programme Objective elements • The radiation safety programme is documented. • This programme is integrated with the organization’s safety programme. • Written policies and procedures guide the handling and disposal of radio-active and hazardous materials.

33. cont… • Imaging personnel are provided with appropriate radiation safety devices • Radiation safety devices are periodically tested and documented. • Imaging personnel are trained in radiation safety measures. • Imaging signage are prominently displayed in all appropriate locations. • Policies and procedures guide the safe use of radioactive isotopes for imaging services.

34. AAC.13Patient care is continuous and multidisciplinary in nature Objective elements • During all phases of care, there is a qualified individual identified as responsible for the patient’s care. • Care of patients is coordinated in all care settings within the organization.

35. cont… • Information about the patient’s care and response to treatment is shared among medical, nursing and other care providers. • Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments. • The patient’s record (s) is available to the authorized care providers to facilitate the exchange of information. • Policy and procedures guide the referral of patients to other department / specialty.

36. AAC.14The organization has a documented discharge process Objective elements • The patient’s discharge process is planned. • Policies and procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal cases

37. cont… • Policies and procedures are in place for patients leaving against medical advice • A discharge summary is given to all the patients leaving the organization (including patients leaving against medical advice)

38. AAC.15Organisation defines the content of the discharge summary • Objective elements • Discharge summary is provided to the patients at the time of discharge • Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.

39. cont… • Discharge summary contains information regarding investigation results, any procedure performed, medication and other treatment given • Discharge summary contains follow up advice, medication and other instructions in an understandable manner.

40. cont… • Discharge summary incorporates instructions about when and how to obtain urgent care • In case of death the summary of the case also includes the cause of death.Patient records also contain a copy of the discharge /case summary

41. Chapter .2PATIENT RIGHT AND EDUCATION (PRE)

42. PRE.1The organization protects patient and family rights during care Objective element • Patient and family rights are documented. • Patients and families are informed of their rights in a format and language that they can understand

43. cont… • The organization’s leaders protect patient’s rights • Staff is aware of their responsibility in protecting patients rights • Violation of patient rights is reviewed and corrective/preventive measures taken

44. PRE.2.Patient rights support individual beliefs, values and involve the patient and family in decision making processes Objective elements • Patient rights include respect for personal dignity and privacy during examination, procedures and treatment • Patient rights include protection from physical abuse or neglect

45. cont… • Patient rights include treating patient information as confidential • Patient rights include refusal of treatment • Patient rights include informed consent before anesthesia, blood and blood product transfusions and any invasive / high risk procedures / treatment

46. cont… • Patient rights include information and consent before any research protocol is initiated • Patient rights include information on how to voice a complaint • Patient rights include information on the expected cost of the treatment • Patient has a right to have an access to his / her clinical records

47. PRE.3A documented process for obtaining patient and / or families consent exists for informed decision making about their care Objective elements • General consent for treatment is obtained when the patient enters the organization

48. cont… • Patient and/or his family members are informed of the scope of such general consent • The organization has listed those procedures and treatment where informed consent is required • Informed consent includes information on risks , benefits, alternatives and as to who will perform the requisite procedure in a language that they can understand • The policy describes who can give consent when patient is incapable of independents decision making.

49. PRE.4Patient and families have a right to information and education about their healthcare needs • Objective elements • When appropriate, patient and families are educated about the safe and effective use of medication and the potential side effects of the medication • Patient and families are educated about diet and nutrition

50. cont… • Patient and families are educated about immunizations • Patient and families are educated about their specific disease process, complications and prevention strategies • Patient and families are educated about preventing infections • Patients are taught in a language and format that they can understand