NABH STANDARDS PREPARED BY DR.ANJALATCHI MUTHUKUMAR.ppt

NABH standard indicator for hospital improvement and quality standard of care and safety

1. National Accreditation Board for Hospitals & Healthcare Providers
Prepared by Prepared by
Dr.Anjalaatchi MuthukumarDr.Anjalaatchi Muthukumar
Professor cum Vice principal Professor cum Vice principal
Era college of Nursing , ELMCHEra college of Nursing , ELMCH
Sarfrazganj, lucknow 226003 Sarfrazganj, lucknow 226003
National accreditation board National accreditation board
for hospitals and health care for hospitals and health care
providers providers

2. National Accreditation Board for Hospitals & Healthcare Providers

NABH, an acronym for National Accreditation Board for Hospitals &
Healthcare Providers, was established in year 2006. It is a constituent
board of Quality Council of India, set up to establish and operate
accreditation programme for healthcare organizations.

Organisations like the Quality Council of India ( QCI ) and its National
Accreditation Board for Hospitals and Healthcare providers have
designed an exhaustive healthcare standard for hospitals and healthcare
providers. This standard consists of stringent 600 plus objective elements
for the hospital to achieve in order to get the NABH accreditation. The
objective of the board is to ensure that a patient walking into the hospital
has a smooth and convenient experience with registration, admission, pre-
surgery, surgery and post-surgery protocols, discharge from the hospital
to follow up with the hospital after discharge. NABH assesses
administrative aspects too, so that clear and transparent policies and
protocols are maintained. In a nutshell, NABH aims at streamlining the
entire operations of a hospital.
INTRODUCTION INTRODUCTION

3. National Accreditation Board for Hospitals & Healthcare Providers

NABH is equivalent to Joint Commission of the United states and
other international standards like Haute Authorité de Santé
( France ), Australian Council on Healthcare Standards and the
Japan Council for Quality in Health Care. Its standards have been
accredited by ISQua ( International Society for Quality in Health
Care ), the apex body accrediting such boards, hence making
NABH accreditation at par with the world’s most leading hospital
accreditation.

Till date about 350 hospitals in India have achieved accreditation
by NABH. It is indeed a proud moment for Healing Hands
Clinic to be recognized by this board that pays scrupulous
attention to patient care and convenience.
CONTINUED CONTINUED

4. National Accreditation Board for Hospitals & Healthcare Providers
{{
Components of Standards Components of Standards
DevelopmentDevelopment
Multiple Information SourcesMultiple Information Sources

Scientific literatureScientific literature

JCI StandardsJCI Standards

UK Healthcare Quality StandardsUK Healthcare Quality Standards

Thailand StandardsThailand Standards

AHA Draft StandardsAHA Draft Standards

JCI Survey compliance dataJCI Survey compliance data

Research FindingsResearch Findings

Individual input from field experts and key stakeholdersIndividual input from field experts and key stakeholders

ISO 9001-2000ISO 9001-2000

5. National Accreditation Board for Hospitals & Healthcare Providers
Organized around important functionsOrganized around important functions

Focus on patient and staff safetyFocus on patient and staff safety

Set standards that all organizations must passSet standards that all organizations must pass

To be revised periodically and raise the “bar”To be revised periodically and raise the “bar”

Achieve International recognitionAchieve International recognition
Hospital StandardsHospital Standards

6. National Accreditation Board for Hospitals & Healthcare Providers

10 Chapters10 Chapters

100 Standards100 Standards

503 Objective Elements503 Objective Elements
NABH StandardsNABH Standards

7. National Accreditation Board for Hospitals & Healthcare Providers

A standard is a A standard is a statement statement that defines the that defines the
structures and processes that must be structures and processes that must be
substantially in place in an organization to substantially in place in an organization to
enhance the quality of careenhance the quality of care

Objective element is a measurable component Objective element is a measurable component
of a standardof a standard

Acceptable compliance with objective elements Acceptable compliance with objective elements
determines the overall compliance with a determines the overall compliance with a
standardstandard
Standards and Objective Standards and Objective
ElementsElements

8. National Accreditation Board for Hospitals & Healthcare Providers
STDSTDOEOE

Access, Assessment and Continuity of Care Access, Assessment and Continuity of Care (AAC)(AAC) 1515 7878

Patients Rights and Education Patients Rights and Education (PRE)(PRE) 55 2929

Care of Patients Care of Patients (COP)(COP) 18 10518 105

Management of Medications Management of Medications (MOM)(MOM) 1313 6161

Hospital Infection Control Hospital Infection Control (HIC)(HIC) 99 4444
Section I:Section I:
Patient-Centered StandardsPatient-Centered Standards

9. National Accreditation Board for Hospitals & Healthcare Providers
STDSTDOEOE

Continuous Quality Improvement Continuous Quality Improvement (CQI)(CQI) 66 3737

Responsibilities of Management Responsibilities of Management (ROM)(ROM) 55 2020

Facility Management & Safety Facility Management & Safety (FMS)(FMS) 99 4141

Human Resource Management Human Resource Management (HRM)(HRM) 1313 4747

Information Management Systems Information Management Systems (IMS)(IMS) 77 4141
100100 503503
Section II: Section II:
Health Care Organization Health Care Organization
Management StandardsManagement Standards

10. National Accreditation Board for Hospitals & Healthcare Providers
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NABH STANDARDSNABH STANDARDS

11. National Accreditation Board for Hospitals & Healthcare Providers

NABH standards for hospitals have been NABH standards for hospitals have been
prepared by Technical Committee of prepared by Technical Committee of
NABH and contain complete set of NABH and contain complete set of
standards for evaluation of hospitals for standards for evaluation of hospitals for
grant of accreditation. The standards grant of accreditation. The standards
provide framework for quality assurance provide framework for quality assurance
and quality improvement for hospitalsand quality improvement for hospitals

NABH Standards contains 10 NABH Standards contains 10
chapters,100 standards and 503 objective chapters,100 standards and 503 objective
elements.elements.
Introduction Introduction

12. National Accreditation Board for Hospitals & Healthcare Providers
1)1)Access ,Assessment and continuity of care (AAC)Access ,Assessment and continuity of care (AAC)
2)2)Patient Right and Education (PRE).Patient Right and Education (PRE).
3)3)Care of Patients(COP).Care of Patients(COP).
4)4)Management of Medication (MOM).Management of Medication (MOM).
5)5)Hospital Infection Control (HIC).Hospital Infection Control (HIC).
6)6)Continuous Quality Improvement(CQI)Continuous Quality Improvement(CQI)
7)7)Responsibility of Management (ROM).Responsibility of Management (ROM).
8)8)Facility Management and Safety (FMS).Facility Management and Safety (FMS).
9)9)Human Resource Management (HRM)Human Resource Management (HRM)
10)10)Information Management System (IMS).Information Management System (IMS).
Details of chapters. Details of chapters.

13. National Accreditation Board for Hospitals & Healthcare Providers
Chapter 1.Chapter 1.
ACCESS,ASSESSMENT ACCESS,ASSESSMENT
AND CONTINIUITY OF AND CONTINIUITY OF
CARE (AAC)CARE (AAC)

14. National Accreditation Board for Hospitals & Healthcare Providers
Objective ElementsObjective Elements
a)a)The services being provided are clearly defined.The services being provided are clearly defined.
b)b)The defined services are prominently displayed.The defined services are prominently displayed.
c)c)The staff is oriented to these servicesThe staff is oriented to these services
AAC.1AAC.1
The organization defines and displays The organization defines and displays
the services that it can providethe services that it can provide

15. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)Standardized policies and procedures are used for registering Standardized policies and procedures are used for registering
and admitting patientsand admitting patients
b)b)The policies and procedures address out- patients, in-patients The policies and procedures address out- patients, in-patients
and emergency patientsand emergency patients
AAC.2AAC.2
The organization has a well The organization has a well
defined registration and admission defined registration and admission
processprocess

16. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Patients are accepted only if the organization can provide the Patients are accepted only if the organization can provide the
required servicerequired service
d)d)The policies and procedures also address managing patients The policies and procedures also address managing patients
during non availability of bedsduring non availability of beds
e)e)The staff is aware of these processesThe staff is aware of these processes
Cont…Cont…

17. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)Policies guide the transfer of unstable patients to another Policies guide the transfer of unstable patients to another
facility in an appropriate mannerfacility in an appropriate manner
b)b)Policies guide the transfer of stable patients to another facilityPolicies guide the transfer of stable patients to another facility
AAC.3AAC.3
There is an appropriate mechanism There is an appropriate mechanism
for transfer or referral of patients who for transfer or referral of patients who
do not match the organizational do not match the organizational
resourcesresources

18. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Procedures identify staff responsible during transferProcedures identify staff responsible during transfer
d)d)The organization gives a summary of patient’s condition and The organization gives a summary of patient’s condition and
the treatment giventhe treatment given
Cont…Cont…

19. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a) The patients and/or family members are explained about The patients and/or family members are explained about
the proposed carethe proposed care
b)b)The patients and/or family members are explained about the The patients and/or family members are explained about the
expected resultsexpected results
AAC.4AAC.4
During admission the patient and /or During admission the patient and /or
the family members are educated to the family members are educated to
make informed decisionsmake informed decisions

20. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The patients and/or family members are The patients and/or family members are
explained about the possible complications explained about the possible complications
d)d)The patients and/or family members are The patients and/or family members are
explained about the expected costs.explained about the expected costs.
Cont…Cont…

21. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization defines the content of the assessments for the The organization defines the content of the assessments for the
out–patients, in-patients and emergency patients. out–patients, in-patients and emergency patients.
b)b)The organization determines who can perform the The organization determines who can perform the
assessments. assessments.
AAC.5AAC.5
Patients cared for by the Patients cared for by the
organization undergo an organization undergo an
established initial assessmentestablished initial assessment

22. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The organization defines the time frame within which the The organization defines the time frame within which the
initial assessment is completed. initial assessment is completed.
d)d)The initial assessment for in-patients is documented within 24 The initial assessment for in-patients is documented within 24
hours or earlier as per the patient’s condition or hospital policy. hours or earlier as per the patient’s condition or hospital policy.
e)e)Initial assessment includes screening for nutritional and Initial assessment includes screening for nutritional and
psychosocial needs. psychosocial needs.
cont…cont…

23. National Accreditation Board for Hospitals & Healthcare Providers
f)f)The initial assessment results in a The initial assessment results in a
documented plan of care.documented plan of care.
g)g)The plan of care also includes preventive The plan of care also includes preventive
aspects of the careaspects of the care
Cont…Cont…

24. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)All patients are reassessed at appropriate intervals.All patients are reassessed at appropriate intervals.
b)b)Staff involved in direct clinical care document reassessments.Staff involved in direct clinical care document reassessments.
c)c)Patients are reassessed to determine their response to Patients are reassessed to determine their response to
treatment and to plan further treatment or discharge. treatment and to plan further treatment or discharge.
AAC.6AAC.6
All patients cared for by the All patients cared for by the
organization undergo a regular organization undergo a regular
reassessmentreassessment

25. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Scope of the laboratory services are commensurate to the Scope of the laboratory services are commensurate to the
services provided by the organizationservices provided by the organization
b)b)Adequately qualified and trained personnel perform and/or Adequately qualified and trained personnel perform and/or
supervise the investigations. supervise the investigations.
AAC.7AAC.7
Laboratory services are provided Laboratory services are provided
as per the requirements of the as per the requirements of the
patientspatients

26. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Policies and procedures guide collection, identification, Policies and procedures guide collection, identification,
handling, safe transportation and disposal of specimens. handling, safe transportation and disposal of specimens.
d)d)Laboratory results are available within a defined time frame.Laboratory results are available within a defined time frame.
e)e)Critical results are intimated immediately to the concerned Critical results are intimated immediately to the concerned
personnel.personnel.
f)f)Laboratory tests not available in the organization are Laboratory tests not available in the organization are
outsourced to organization(s) based on their quality assurance outsourced to organization(s) based on their quality assurance
system. system.
cont..cont..

27. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The laboratory quality assurance programme is documented. The laboratory quality assurance programme is documented.
b)b)The programme addresses verification and validation of test The programme addresses verification and validation of test
methods. methods.
c)c)The programme addresses surveillance of test results. The programme addresses surveillance of test results.
AAC.8AAC.8
There is an established laboratory There is an established laboratory
quality assurance programmequality assurance programme

28. National Accreditation Board for Hospitals & Healthcare Providers
d)d)The programme includes periodic The programme includes periodic
calibration and maintenance of all calibration and maintenance of all
equipments.equipments.
e)e)The programme includes the documentation The programme includes the documentation
of corrective and preventive actionsof corrective and preventive actions
cont…cont…

29. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)The laboratory safety programme is documented. The laboratory safety programme is documented.
b)b)This programme is integrated with the organization’s safety This programme is integrated with the organization’s safety
programme.programme.
AAC.9AAC.9
There is an established laboratory There is an established laboratory
safety programmesafety programme

30. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Written policies and procedures guide the Written policies and procedures guide the
handling and disposal of infectious and handling and disposal of infectious and
hazardous materials. hazardous materials.
d)d)Laboratory personnel are appropriately Laboratory personnel are appropriately
trained in safe practices.trained in safe practices.
e)e)Laboratory personnel are provided with Laboratory personnel are provided with
appropriate safety equipment / devices.appropriate safety equipment / devices.
cont…cont…

31. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Imaging services comply with legal and other requirements.Imaging services comply with legal and other requirements.
b)b)Scope of the imaging services are commensurate to the Scope of the imaging services are commensurate to the
services provided by the organization.services provided by the organization.
c)c)Adequately qualified and trained personnel perform and/or Adequately qualified and trained personnel perform and/or
supervise the investigations. supervise the investigations.
AAC.10AAC.10
Imaging services are provided as per Imaging services are provided as per
the requirements of the patientsthe requirements of the patients

32. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Policies and procedures guide identification and safe Policies and procedures guide identification and safe
transportation of patients to imaging services.transportation of patients to imaging services.
e)e)Imaging results are available within a defined time frame.Imaging results are available within a defined time frame.
f)f)Critical results are intimated immediately to the concerned Critical results are intimated immediately to the concerned
personnel.personnel.
g)g)Imaging tests not available in the organization are outsourced Imaging tests not available in the organization are outsourced
to organization(s) based on their quality assurance system. to organization(s) based on their quality assurance system.
cont…cont…

33. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The quality assurance programme for imaging services is The quality assurance programme for imaging services is
documented. documented.
b)b)The programme addresses verification and validation of The programme addresses verification and validation of
imaging methods imaging methods
c)c)The programme addresses surveillance of imaging results The programme addresses surveillance of imaging results
AAC.11AAC.11
There is an established Quality There is an established Quality
assurance programme for imaging assurance programme for imaging
servicesservices

34. National Accreditation Board for Hospitals & Healthcare Providers
d)d)The programme includes periodic The programme includes periodic
calibration and maintenance of all calibration and maintenance of all
equipments.equipments.
e)e)The programme includes the documentation The programme includes the documentation
of corrective and preventive actionsof corrective and preventive actions
cont…cont…

35. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)The radiation safety programme is documented. The radiation safety programme is documented.
b)b)This programme is integrated with the organization’s safety This programme is integrated with the organization’s safety
programme.programme.
c)c)Written policies and procedures guide the handling and Written policies and procedures guide the handling and
disposal of radio-active and hazardous materials. disposal of radio-active and hazardous materials.
AAC.12AAC.12
There is an established radiation There is an established radiation
safety programmesafety programme

36. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Imaging personnel are provided with appropriate radiation Imaging personnel are provided with appropriate radiation
safety devicessafety devices
e)e)Radiation safety devices are periodically tested and Radiation safety devices are periodically tested and
documented.documented.
f)f)Imaging personnel are trained in radiation safety measures.Imaging personnel are trained in radiation safety measures.
g)g)Imaging signage are prominently displayed in all appropriate Imaging signage are prominently displayed in all appropriate
locations.locations.
h)h)Policies and procedures guide the safe use of radioactive Policies and procedures guide the safe use of radioactive
isotopes for imaging services. isotopes for imaging services.
cont…cont…

37. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)During all phases of care, there is a qualified individual During all phases of care, there is a qualified individual
identified as responsible for the patient’s care.identified as responsible for the patient’s care.
b)b)Care of patients is coordinated in all care settings within the Care of patients is coordinated in all care settings within the
organization.organization.
AAC.13AAC.13
Patient care is continuous Patient care is continuous
and multidisciplinary in and multidisciplinary in
naturenature

38. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Information about the patient’s care and Information about the patient’s care and
response to treatment is shared among medical, response to treatment is shared among medical,
nursing and other care providers. nursing and other care providers.
d)d)Information is exchanged and documented Information is exchanged and documented
during each staffing shift, between shifts, and during each staffing shift, between shifts, and
during transfers between units/departments.during transfers between units/departments.
e)e)The patient’s record (s) is available to the The patient’s record (s) is available to the
authorized care providers to facilitate the authorized care providers to facilitate the
exchange of information.exchange of information.
f)f)Policy and procedures guide the referral of Policy and procedures guide the referral of
patients to other department / specialty.patients to other department / specialty.
cont…cont…

39. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a) The patient’s discharge process is planned.The patient’s discharge process is planned.
b)b)Policies and procedures exist for coordination of various Policies and procedures exist for coordination of various
departments and agencies involved in the discharge process departments and agencies involved in the discharge process
(including medico-legal cases(including medico-legal cases
AAC.14AAC.14
The organization has a The organization has a
documented discharge processdocumented discharge process

40. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Policies and procedures are in place for Policies and procedures are in place for
patients leaving against medical advice patients leaving against medical advice
d)d)A discharge summary is given to all the A discharge summary is given to all the
patients leaving the organization (including patients leaving the organization (including
patients leaving against medical advice)patients leaving against medical advice)
cont…cont…

41. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a) Discharge summary is provided to the patients at the time of Discharge summary is provided to the patients at the time of
dischargedischarge
b)b)Discharge summary contains the reasons for admission, Discharge summary contains the reasons for admission,
significant findings and diagnosis and the patient’s condition significant findings and diagnosis and the patient’s condition
at the time of discharge.at the time of discharge.
AAC.15AAC.15
Organisation defines the content Organisation defines the content
of the discharge summaryof the discharge summary

42. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Discharge summary contains information Discharge summary contains information
regarding investigation results, any regarding investigation results, any
procedure performed, medication and other procedure performed, medication and other
treatment giventreatment given
d)d)Discharge summary contains follow up Discharge summary contains follow up
advice, medication and other instructions in advice, medication and other instructions in
an understandable manner.an understandable manner.
cont…cont…

43. National Accreditation Board for Hospitals & Healthcare Providers
e)e)Discharge summary incorporates Discharge summary incorporates
instructions about when and how to obtain instructions about when and how to obtain
urgent careurgent care
f)f)In case of death the summary of the case In case of death the summary of the case
also includes the cause of death.Patient also includes the cause of death.Patient
records also contain a copy of the records also contain a copy of the
discharge /case summarydischarge /case summary
cont…cont…

44. National Accreditation Board for Hospitals & Healthcare Providers
Chapter .2Chapter .2
PATIENT RIGHT AND PATIENT RIGHT AND
EDUCATION (PRE)EDUCATION (PRE)

45. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementObjective element
a)a)Patient and family rights are documented.Patient and family rights are documented.
b)b) Patients and families are informed of their rights in a format Patients and families are informed of their rights in a format
and language that they can understandand language that they can understand
PRE.1PRE.1
The organization protects patient The organization protects patient
and family rights during careand family rights during care

46. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The organization’s leaders protect patient’s The organization’s leaders protect patient’s
rightsrights
d)d)Staff is aware of their responsibility in Staff is aware of their responsibility in
protecting patients rightsprotecting patients rights
e)e)Violation of patient rights is reviewed and Violation of patient rights is reviewed and
corrective/preventive measures taken corrective/preventive measures taken
cont…cont…

47. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)Patient rights include respect for personal dignity and privacy Patient rights include respect for personal dignity and privacy
during examination, procedures and treatmentduring examination, procedures and treatment
b)b)Patient rights include protection from physical abuse or Patient rights include protection from physical abuse or
neglectneglect
PRPREE.2..2.
Patient rights support individual Patient rights support individual
beliefs, values and involve the beliefs, values and involve the
patient and family in decision patient and family in decision
making processesmaking processes

48. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Patient rights include treating patient Patient rights include treating patient
information as confidentialinformation as confidential
d)d)Patient rights include refusal of treatmentPatient rights include refusal of treatment
e)e)Patient rights include informed consent Patient rights include informed consent
before anesthesia, blood and blood product before anesthesia, blood and blood product
transfusions and any invasive / high risk transfusions and any invasive / high risk
procedures / treatmentprocedures / treatment
cont…cont…

49. National Accreditation Board for Hospitals & Healthcare Providers
f)f)Patient rights include information and Patient rights include information and
consent before any research protocol is consent before any research protocol is
initiatedinitiated
g)g)Patient rights include information on how to Patient rights include information on how to
voice a complaintvoice a complaint
h)h)Patient rights include information on the Patient rights include information on the
expected cost of the treatmentexpected cost of the treatment
i)i)Patient has a right to have an access to his / Patient has a right to have an access to his /
her clinical recordsher clinical records
cont…cont…

50. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)General consent for treatment is obtained when the patient General consent for treatment is obtained when the patient
enters the organizationenters the organization
PRPREE.3.3
A documented process for A documented process for
obtaining patient and / or families obtaining patient and / or families
consent exists for informed consent exists for informed
decision making about their caredecision making about their care

51. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Patient and/or his family members are informed Patient and/or his family members are informed
of the scope of such general consentof the scope of such general consent
c)c)The organization has listed those procedures and The organization has listed those procedures and
treatment where informed consent is requiredtreatment where informed consent is required
d)d)Informed consent includes information on risks , Informed consent includes information on risks ,
benefits, alternatives and as to who will perform benefits, alternatives and as to who will perform
the requisite procedure in a language that they the requisite procedure in a language that they
can understandcan understand
e)e)The policy describes who can give consent when The policy describes who can give consent when
patient is incapable of independents decision patient is incapable of independents decision
making.making.cont…cont…

52. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)When appropriate, patient and families are educated about the When appropriate, patient and families are educated about the
safe and effective use of medication and the potential side safe and effective use of medication and the potential side
effects of the medicationeffects of the medication
b)b)Patient and families are educated about diet and nutritionPatient and families are educated about diet and nutrition
PRE.4PRE.4
Patient and families have a right Patient and families have a right
to information and education to information and education
about their healthcare needsabout their healthcare needs

53. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Patient and families are educated about Patient and families are educated about
immunizationsimmunizations
d)d)Patient and families are educated about their Patient and families are educated about their
specific disease process, complications and specific disease process, complications and
prevention strategiesprevention strategies
e)e)Patient and families are educated about Patient and families are educated about
preventing infectionspreventing infections
f)f)Patients are taught in a language and format Patients are taught in a language and format
that they can understandthat they can understand
cont…cont…

54. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)There is uniform pricing policy in a given setting (out-patient There is uniform pricing policy in a given setting (out-patient
and ward category)and ward category)
b)b)The tariff list is available to patientsThe tariff list is available to patients
c)c)Patients are educated about the estimated costs of treatmentPatients are educated about the estimated costs of treatment
PRE.5.PRE.5.
Patient and families have a right Patient and families have a right
to information on expected coststo information on expected costs

55. National Accreditation Board for Hospitals & Healthcare Providers
d.d.Patients are informed about the estimated Patients are informed about the estimated
costs when there is a change in the patient costs when there is a change in the patient
condition or treatment setting condition or treatment setting
cont…cont…

56. National Accreditation Board for Hospitals & Healthcare Providers
Chapter 3.Chapter 3.
Care of Patients (COP)Care of Patients (COP)

57. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Care delivery is uniform when similar care is provided in Care delivery is uniform when similar care is provided in
more than one settingmore than one setting
b)b)Uniform care is guided by policies and procedures which Uniform care is guided by policies and procedures which
reflect applicable laws and regulationsreflect applicable laws and regulations
COP.1COP.1
Uniform care of patients is guided Uniform care of patients is guided
by the applicable laws and by the applicable laws and
regulationsregulations

58. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The care and treatment orders are signed, The care and treatment orders are signed,
named, timed and dated by the concerned named, timed and dated by the concerned
doctordoctor
d)d)The care plan is countersigned by the The care plan is countersigned by the
clinician in-charge of the patient within 24 clinician in-charge of the patient within 24
hourshours
e)e)Evidence based medicine and clinical Evidence based medicine and clinical
practice guidelines are adopted to guide practice guidelines are adopted to guide
patient care whenever possiblepatient care whenever possible
cont…cont…

59. National Accreditation Board for Hospitals & Healthcare Providers
Objective elementsObjective elements
a)a)Policies and procedure for emergency care are documentedPolicies and procedure for emergency care are documented
b)b)Policies also address handling of medico-legal casesPolicies also address handling of medico-legal cases
c)c)The patients receive care in consonance with the policies The patients receive care in consonance with the policies
COP.2COP.2
Emergency services are guided by Emergency services are guided by
policies, procedures, applicable policies, procedures, applicable
laws and regulationslaws and regulations

60. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Policies and procedures guide the triage of Policies and procedures guide the triage of
patients for initiation of appropriate carepatients for initiation of appropriate care
e)e)Staff is familiar with the policies and trained Staff is familiar with the policies and trained
on the procedures for care of emergency on the procedures for care of emergency
patientspatients
f)f)Admission or discharge to home or transfer Admission or discharge to home or transfer
to another organization is also documentedto another organization is also documented
cont…cont…

61. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)There is adequate access and space for the ambulance(s)There is adequate access and space for the ambulance(s)
b)b)Ambulance(s) is appropriately equippedAmbulance(s) is appropriately equipped
c)c)Ambulance(s) is manned by trained personnelAmbulance(s) is manned by trained personnel
COP.3COP.3
The ambulance services are The ambulance services are
commensurate with the scope of commensurate with the scope of
the services provided by the the services provided by the
organizationorganization

62. National Accreditation Board for Hospitals & Healthcare Providers
d)d)There is a checklist of all equipment and There is a checklist of all equipment and
emergency medicationsemergency medications
e)e)Equipment are checked on a daily basisEquipment are checked on a daily basis
f)f)Emergency medications are checked daily Emergency medications are checked daily
and prior to dispatchand prior to dispatch
g)g)The ambulance(s) has a proper The ambulance(s) has a proper
communication systemcommunication system
cont…cont…

63. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the uniform use of Documented policies and procedures guide the uniform use of
resuscitation throughout the organizationresuscitation throughout the organization
b)b)Staff providing direct patient care is trained and periodically Staff providing direct patient care is trained and periodically
updated in cardio pulmonary resuscitationupdated in cardio pulmonary resuscitation
COP.4COP.4
Policies and procedures guide the Policies and procedures guide the
care of patients requiring cardio-care of patients requiring cardio-
pulmonary resuscitationpulmonary resuscitation

64. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The events during a cardio-pulmonary The events during a cardio-pulmonary
resuscitation are recordedresuscitation are recorded
d)d)An analysis of all cardiac arrests is doneAn analysis of all cardiac arrests is done
e)e)A multidisciplinary committee monitors the A multidisciplinary committee monitors the
effectiveness of cardio-pulmonary effectiveness of cardio-pulmonary
resuscitationresuscitation
cont…cont…

65. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures are used to guide Documented policies and procedures are used to guide
rational use of blood and blood productsrational use of blood and blood products
b)b)The transfusion services are governed by the applicable laws The transfusion services are governed by the applicable laws
and regulationsand regulations
COP.5COP.5
Policies and procedures define Policies and procedures define
rational use of blood and blood rational use of blood and blood
productsproducts

66. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Informed consent is obtained for donation and transfusion of Informed consent is obtained for donation and transfusion of
blood and blood productsblood and blood products
d)d)Informed consent also includes patient and family education Informed consent also includes patient and family education
about donationabout donation
e)e)Staff is trained to implement the policiesStaff is trained to implement the policies
f)f)Transfusion reactions are analyzed for preventive and Transfusion reactions are analyzed for preventive and
corrective actionscorrective actions
Cont…Cont…

67. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization has documented admission and discharge The organization has documented admission and discharge
criteria for its intensive care and high dependency unitscriteria for its intensive care and high dependency units
b)b)Staff is trained to apply these criteriaStaff is trained to apply these criteria
COP.6COP.6
Policies and procedures guide the Policies and procedures guide the
care of patients in the Intensive care care of patients in the Intensive care
and high dependency unitsand high dependency units

68. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Adequate staff and equipment are availableAdequate staff and equipment are available
d)d)Defined procedures for situation of bed Defined procedures for situation of bed
shortages are followedshortages are followed
e)e)Infection control practices are followedInfection control practices are followed
f)f)The unique needs of end of life patients are The unique needs of end of life patients are
identified and cared foridentified and cared for
g)g)A quality assurance program is A quality assurance program is
implementedimplemented
cont…cont…

69. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Policies and procedures are documented and are in Policies and procedures are documented and are in
accordance with the prevailing laws and the national and accordance with the prevailing laws and the national and
international guidelinesinternational guidelines
COP.7COP.7
Policies and procedures guide the Policies and procedures guide the
care of vulnerable patients care of vulnerable patients
(elderly, children, physically (elderly, children, physically
and/or mentally challenged)and/or mentally challenged)

70. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Staff is trained to care for this vulnerable groupStaff is trained to care for this vulnerable group
c)c)Care is organized and delivered in accordance Care is organized and delivered in accordance
with the policies and procedureswith the policies and procedures
d)d)The organization provides for a safe and The organization provides for a safe and
secure environment for this vulnerable groupsecure environment for this vulnerable group
e)e)A documented procedure exists for obtaining A documented procedure exists for obtaining
informed consent from the appropriate legal informed consent from the appropriate legal
representativerepresentative
cont…cont…

71. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)The organization defines and displays whether high risk The organization defines and displays whether high risk
obstetric cases can be cared for or notobstetric cases can be cared for or not
b)b)Persons caring for high risk obstetric cases are competentPersons caring for high risk obstetric cases are competent
COP.8COP.8
Policies and procedures guide the Policies and procedures guide the
care of high risk obstetrical care of high risk obstetrical
patientspatients

72. National Accreditation Board for Hospitals & Healthcare Providers
c)c)High risk obstetric patient’s assessment also High risk obstetric patient’s assessment also
includes maternal nutritionincludes maternal nutrition
d)d)The organization has the facilities to take The organization has the facilities to take
care of neonates of high risk pregnanciescare of neonates of high risk pregnancies
cont…cont…

73. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements..
a)a)The organization defines and displays the scope of its The organization defines and displays the scope of its
pediatric servicespediatric services
b)b)The policy for care of neonatal patients is in consonance with The policy for care of neonatal patients is in consonance with
the national/ international guidelinesthe national/ international guidelines
c)c)Those who care for children have age specific competencyThose who care for children have age specific competency
COP.9COP.9
Policies and procedures Policies and procedures
guide the care of pediatric guide the care of pediatric
patientspatients

74. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Provisions are made for special Provisions are made for special
care of childrencare of children
e)e)Patient assessment includes Patient assessment includes
detailed nutritional, growth, detailed nutritional, growth,
psychosocial and immunization psychosocial and immunization
assessmentassessment
f)f)Policies and procedures prevent Policies and procedures prevent
child/ neonate abduction and child/ neonate abduction and
abuseabuse
cont…cont…

75. National Accreditation Board for Hospitals & Healthcare Providers
g)g)The children’s family The children’s family
members are educated members are educated
about nutrition, about nutrition,
immunization and safe immunization and safe
parenting and this is parenting and this is
documented in the medical documented in the medical
recordrecord
cont…cont…

76. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Competent and trained persons perform sedationCompetent and trained persons perform sedation
b)b)The person administering and monitoring sedation is different The person administering and monitoring sedation is different
from the person performing the procedurefrom the person performing the procedure
COP.10COP.10
 

 

Policies and procedures guide Policies and procedures guide
the care of patients undergoing the care of patients undergoing
moderate sedationmoderate sedation

77. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Intra-procedure monitoring includes at a minimum the heart Intra-procedure monitoring includes at a minimum the heart
rate, cardiac rhythm, respiratory rate, blood pressure, oxygen rate, cardiac rhythm, respiratory rate, blood pressure, oxygen
saturation, and level of sedationsaturation, and level of sedation
d)d)Patients are monitored after sedationPatients are monitored after sedation
e)e)Criteria are used to determine appropriateness of discharge Criteria are used to determine appropriateness of discharge
from the recovery areafrom the recovery area
f)f)Equipment and manpower are available to rescue patients Equipment and manpower are available to rescue patients
from a deeper level of sedation than that intendedfrom a deeper level of sedation than that intended
cont…cont…

78. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)There is a documented policy and procedure for the There is a documented policy and procedure for the
administration of anesthesiaadministration of anesthesia
b)b)All patients for anesthesia have a pre-anesthesia assessment by All patients for anesthesia have a pre-anesthesia assessment by
a qualified individuala qualified individual
COP.11COP.11
Policies and procedures guide the Policies and procedures guide the
administration of anesthesiaadministration of anesthesia

79. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The pre-anesthesia assessment results in The pre-anesthesia assessment results in
formulation of an anesthesia plan which is formulation of an anesthesia plan which is
documented documented
d)d)An immediate preoperative reevaluation is An immediate preoperative reevaluation is
documented documented
e)e)Informed consent for administration of anesthesia is Informed consent for administration of anesthesia is
obtained by the anesthetistobtained by the anesthetist
f)f)During anesthesia monitoring includes regular and During anesthesia monitoring includes regular and
periodic recording of heart rate, cardiac rhythm, periodic recording of heart rate, cardiac rhythm,
respiratory rate, blood pressure, oxygen saturation, respiratory rate, blood pressure, oxygen saturation,
airway security and patency and level of anesthesiaairway security and patency and level of anesthesia
cont…cont…

80. National Accreditation Board for Hospitals & Healthcare Providers
g)g)Each patient’s post-anesthesia status is Each patient’s post-anesthesia status is
monitored and documentedmonitored and documented
h)h)A qualified individual applies defined A qualified individual applies defined
criteria to transfer the patient from the criteria to transfer the patient from the
recovery arearecovery area
i)i)All adverse anesthesia events are recorded All adverse anesthesia events are recorded
and monitoredand monitored
cont…cont…

81. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The policies and procedures are documentedThe policies and procedures are documented
b)b)Surgical patients have a preoperative assessment and a Surgical patients have a preoperative assessment and a
provisional diagnosis documented prior to surgeryprovisional diagnosis documented prior to surgery
COP.12COP.12
Policies and procedures guide the Policies and procedures guide the
care of patients undergoing care of patients undergoing
surgical proceduressurgical procedures

82. National Accreditation Board for Hospitals & Healthcare Providers
c)c)An informed consent is obtained by a surgeon prior to the An informed consent is obtained by a surgeon prior to the
procedureprocedure
d)d)Documented policies and procedures exist to prevent adverse Documented policies and procedures exist to prevent adverse
events like wrong site, wrong patient and wrong surgeryevents like wrong site, wrong patient and wrong surgery
e)e)Persons qualified by law are permitted to perform the Persons qualified by law are permitted to perform the
procedures that they are entitled to performprocedures that they are entitled to perform
f)f)An operative note is documented prior to transfer out of An operative note is documented prior to transfer out of
patient from recovery areapatient from recovery area
cont…cont…

83. National Accreditation Board for Hospitals & Healthcare Providers
g)g)The operating surgeon documents the post-The operating surgeon documents the post-
operative plan of careoperative plan of care
h)h)A quality assurance program is followed for A quality assurance program is followed for
the surgical servicesthe surgical services
i)i)The quality assurance program includes The quality assurance program includes
surveillance of the operation theatre surveillance of the operation theatre
environmentenvironment
j)j)The plan also includes monitoring of The plan also includes monitoring of
surgical site infection ratessurgical site infection rates
cont…cont…

84. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)Documented policies and procedures guide the care of Documented policies and procedures guide the care of
patients under restraintspatients under restraints
b)b)These include both physical and chemical restraint measuresThese include both physical and chemical restraint measures
COP.13COP.13
Policies and procedures guide the Policies and procedures guide the
care of patients under restraints care of patients under restraints
(physical and / or chemical)(physical and / or chemical)

85. National Accreditation Board for Hospitals & Healthcare Providers
c)c)These include documentation of reasons for These include documentation of reasons for
restraintsrestraints
d)d)These patients are more frequently These patients are more frequently
monitoredmonitored
e)e)Staff receive training and periodic updating Staff receive training and periodic updating
in control and restraint techniquesin control and restraint techniques
cont…cont…

86. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the management Documented policies and procedures guide the management
of painof pain
b)b)The organization respects and supports the appropriate The organization respects and supports the appropriate
assessment and management of pain for all patientsassessment and management of pain for all patients
c)c)Patient and family are educated on various pain management Patient and family are educated on various pain management
techniquestechniques
COP.14COP.14
Policies and procedures guide Policies and procedures guide
appropriate pain managementappropriate pain management

87. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the provision of Documented policies and procedures guide the provision of
rehabilitative servicesrehabilitative services
b)b)These services are commensurate with the organizational These services are commensurate with the organizational
requirementsrequirements
c)c)Rehabilitative services are provided by a multidisciplinary Rehabilitative services are provided by a multidisciplinary
teamteam
COP.15COP.15
Policies and procedures guide Policies and procedures guide
appropriate rehabilitative servicesappropriate rehabilitative services

88. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)Documented policies and procedures guide all research Documented policies and procedures guide all research
activities in compliance with national and international activities in compliance with national and international
guidelinesguidelines
b)b)The organization has an ethics committee to oversee all The organization has an ethics committee to oversee all
research activitiesresearch activities
c)c)The committee has the powers to discontinue a research trial The committee has the powers to discontinue a research trial
when risks outweigh the potential benefitswhen risks outweigh the potential benefits
COP.16COP.16
Policies and procedures guide Policies and procedures guide
all research activitiesall research activities

89. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Patient’s informed consent is obtained before entering them in Patient’s informed consent is obtained before entering them in
research protocolsresearch protocols
e)e)Patients are informed of their right to withdraw from the Patients are informed of their right to withdraw from the
research at any stage and also of the consequences (if any) of research at any stage and also of the consequences (if any) of
such withdrawalsuch withdrawal
f)f)Patients are assured that their refusal to participate or Patients are assured that their refusal to participate or
withdrawal from participation will not compromise their withdrawal from participation will not compromise their
access to the organization’s services access to the organization’s services
cont…cont…

90. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide nutritional Documented policies and procedures guide nutritional
assessment and reassessmentassessment and reassessment
b)b)Patients receive food according to their clinical needsPatients receive food according to their clinical needs
c)c)There is a written order for the dietThere is a written order for the diet
d)d)Nutritional therapy is planned and provided in a Nutritional therapy is planned and provided in a
collaborative mannercollaborative manner
COP.17COP.17
Policies and procedures guide Policies and procedures guide
nutritional therapynutritional therapy

91. National Accreditation Board for Hospitals & Healthcare Providers
e)e)When families provide food, they are When families provide food, they are
educated about the patients diet limitationseducated about the patients diet limitations
f)f)Food is prepared, handled, stored and Food is prepared, handled, stored and
distributed in a safe mannerdistributed in a safe manner
cont…cont…

92. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the end of life careDocumented policies and procedures guide the end of life care
b)b)These policies and procedures are in consonance with the legal These policies and procedures are in consonance with the legal
requirementsrequirements
c)c)These also address the identification of the unique needs of These also address the identification of the unique needs of
such patient and familysuch patient and family
COP.18COP.18
Policies and procedures guide the Policies and procedures guide the
end of life careend of life care

93. National Accreditation Board for Hospitals & Healthcare Providers
d)d)These also include sensitively addressing These also include sensitively addressing
issues such as autopsy and organ donationissues such as autopsy and organ donation
e)e)Staff is educated and trained in end of life Staff is educated and trained in end of life
carecare
cont…cont…

94. National Accreditation Board for Hospitals & Healthcare Providers
Chapter4.Chapter4.
MANAGEMENT OF MANAGEMENT OF
MEDICATION (MOM)MEDICATION (MOM)

95. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)There is a documented policy and procedure for pharmacy There is a documented policy and procedure for pharmacy
services and medication usageservices and medication usage
b)b)These comply with the applicable laws and regulationsThese comply with the applicable laws and regulations
MOM.1MOM.1
Policies and procedures guide the Policies and procedures guide the
organization of pharmacy services organization of pharmacy services
and usage of medicationand usage of medication

96. National Accreditation Board for Hospitals & Healthcare Providers
c)c)A multidisciplinary committee guides the A multidisciplinary committee guides the
formulation and implementation of these formulation and implementation of these
policies and procedurespolicies and procedures
cont…cont…

97. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)A list of medication appropriate for the patients and A list of medication appropriate for the patients and
organization’s resources is developedorganization’s resources is developed
b)b)The list is developed collaboratively by the multidisciplinary The list is developed collaboratively by the multidisciplinary
committeecommittee
c)c)There is a defined process for acquisition of these medicationsThere is a defined process for acquisition of these medications
d)d)There is a process to obtain medications not listed in the There is a process to obtain medications not listed in the
formularyformulary
MOM.2MOM.2
There is a hospital formularyThere is a hospital formulary

98. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures exist for storage of Documented policies and procedures exist for storage of
medicationmedication
b)b)Medications are stored in a clean, well lit and ventilated Medications are stored in a clean, well lit and ventilated
environmentenvironment
c)c)Sound inventory control practices guide storage of the Sound inventory control practices guide storage of the
medications medications
MOM.3MOM.3
Policies and procedures exist for Policies and procedures exist for
storage of medication.storage of medication.

99. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Medications are protected from loss or theftMedications are protected from loss or theft
e)e)Sound alike and look alike medications are stored separatelySound alike and look alike medications are stored separately
f)f)There is a method to obtain medication when the pharmacy is There is a method to obtain medication when the pharmacy is
closedclosed
g)g)Emergency medications are available all the timeEmergency medications are available all the time
h)h)Emergency medications are replenished in a timely manner Emergency medications are replenished in a timely manner
when used when used
cont…cont…

100. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures exist for prescription of Documented policies and procedures exist for prescription of
medications medications
b)b)The organization determines who can write ordersThe organization determines who can write orders
c)c)Orders are written in a uniform location in the medical recordsOrders are written in a uniform location in the medical records
MOM.4MOM.4
Policies and procedures guide the Policies and procedures guide the
prescription of medicationsprescription of medications

101. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Medication orders are clear, legible, dated, Medication orders are clear, legible, dated,
named and signednamed and signed
e)e)Policy on verbal orders is documented and Policy on verbal orders is documented and
implementedimplemented
f)f)The organization defines a list of high risk The organization defines a list of high risk
medicationmedication
g)g)High risk medication orders are verified High risk medication orders are verified
prior to dispensingprior to dispensing
cont…cont…

102. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the safe Documented policies and procedures guide the safe
dispensing of medicationsdispensing of medications
b)b)The policies include a procedure for medication recallThe policies include a procedure for medication recall
c)c)Expiry dates are checked prior to dispensingExpiry dates are checked prior to dispensing
d)d)LabelingLabeling requirements are documented and implemented by requirements are documented and implemented by
the organizationthe organization
MOM.4MOM.4
Policies and procedures guide the Policies and procedures guide the
safe dispensing of medicationssafe dispensing of medications

103. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Medications are administered by those who are permitted by Medications are administered by those who are permitted by
law to do solaw to do so
b)b)Prepared medication are Prepared medication are labeledlabeled prior to preparation of a prior to preparation of a
second drugsecond drug
c)c)Patient is identified prior to administrationPatient is identified prior to administration
MOM.5MOM.5
There are defined procedures for There are defined procedures for
medication administrationmedication administration

104. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Medication is verified from the order prior Medication is verified from the order prior
to administrationto administration
e)e)Dosage is verified from the order prior to Dosage is verified from the order prior to
administrationadministration
f)f)Route is verified from the order prior to Route is verified from the order prior to
administrationadministration
g)g)Timing is verified from the order prior to Timing is verified from the order prior to
administrationadministration
cont…cont…

105. National Accreditation Board for Hospitals & Healthcare Providers
h)h)Medication administration is documentedMedication administration is documented
i)i)Polices and procedures govern patient’s self administration of Polices and procedures govern patient’s self administration of
medicationsmedications
j)j)Polices and procedures govern patient’s medications brought Polices and procedures govern patient’s medications brought
from outside the organizationfrom outside the organization
cont…cont…

106. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Patient and family are educated about safe and effective use of Patient and family are educated about safe and effective use of
medicationmedication
b)b)Patient and family are educated about food-drug interactionsPatient and family are educated about food-drug interactions
MOM.7MOM.7
Patients and family members are Patients and family members are
educated about safe medication educated about safe medication
and food-drug interactionsand food-drug interactions

107. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Patients are monitored after medication administration and Patients are monitored after medication administration and
this is documentedthis is documented
b)b)Adverse drug events are definedAdverse drug events are defined
c)c)Adverse drug events are reported within a specified time Adverse drug events are reported within a specified time
frameframe
MOM.8MOM.8
Patients are monitored after Patients are monitored after
medication administrationmedication administration

108. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Adverse drug events are collected and Adverse drug events are collected and
analysedanalysed
e)e)Policies are modified to reduce adverse Policies are modified to reduce adverse
drug events when unacceptable trends occurdrug events when unacceptable trends occur
cont…cont…

109. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the use of narcotic Documented policies and procedures guide the use of narcotic
drugs and psychotropic substancesdrugs and psychotropic substances
b)b)These policies are in consonance with local and national These policies are in consonance with local and national
regulationsregulations
MOM.9MOM.9
Policies and procedures guide the Policies and procedures guide the
use of narcotic drugs and use of narcotic drugs and
psychotropic substancespsychotropic substances

110. National Accreditation Board for Hospitals & Healthcare Providers
c)c)A proper record is kept of the usage, A proper record is kept of the usage,
administration and disposal of these drugsadministration and disposal of these drugs
d)d)These drugs are handled by appropriate These drugs are handled by appropriate
personnel in accordance with policiespersonnel in accordance with policies
cont…cont…

111. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures guide the usage of Documented policies and procedures guide the usage of
chemotherapeutic agentschemotherapeutic agents
b)b)Chemotherapy is prescribed by those who have the Chemotherapy is prescribed by those who have the
knowledge to monitor and treat the adverse effect of knowledge to monitor and treat the adverse effect of
chemotherapychemotherapy
MOM.10MOM.10
Policies and procedures guide Policies and procedures guide
the usage of chemotherapeutic the usage of chemotherapeutic
agentsagents

112. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Chemotherapy is prepared and Chemotherapy is prepared and
administered by qualified personneladministered by qualified personnel
d)d)Chemotherapy drugs are disposed off in Chemotherapy drugs are disposed off in
accordance with legal requirementsaccordance with legal requirements
cont…cont…

113. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)Documented policies and procedures govern usage of Documented policies and procedures govern usage of
radioactive or investigational drugsradioactive or investigational drugs
b)b)These policies and procedures are in consonance with laws These policies and procedures are in consonance with laws
and regulationsand regulations
MOM.11MOM.11
Policies and procedures govern Policies and procedures govern
usage of radioactive or usage of radioactive or
investigational drugsinvestigational drugs

114. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The policies and procedures include the safe storage, The policies and procedures include the safe storage,
preparation, handling, distribution and disposal of radioactive preparation, handling, distribution and disposal of radioactive
and investigational drugsand investigational drugs
d)d)Staff, patients and visitors are educated on safety precautionsStaff, patients and visitors are educated on safety precautions
cont…cont…

115. National Accreditation Board for Hospitals & Healthcare Providers

Objective elements.Objective elements.
a)a)Documented policies and procedures govern procurement and Documented policies and procedures govern procurement and
usage of implantable prosthesisusage of implantable prosthesis
b)b)Selection of implantable prosthesis is based on scientific Selection of implantable prosthesis is based on scientific
criteria and internationally recognized approvalscriteria and internationally recognized approvals
MOM.12MOM.12
Policies and procedures guide the Policies and procedures guide the
use of implantable prosthesisuse of implantable prosthesis

116. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The batch and serial number of the The batch and serial number of the
implantable prosthesis are recorded in the implantable prosthesis are recorded in the
patient’s medical record and the master patient’s medical record and the master
logbooklogbook
cont…cont…

117. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures govern procurement, Documented policies and procedures govern procurement,
handling, storage, distribution, usage and replenishment of handling, storage, distribution, usage and replenishment of
medical gases.medical gases.
b)b)The policies and procedures address the safety issues at all The policies and procedures address the safety issues at all
levelslevels
MOM.13MOM.13
Policies and procedures guide the Policies and procedures guide the
use of medical gasesuse of medical gases

118. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Appropriate records are maintained in Appropriate records are maintained in
accordance with the policies, procedures accordance with the policies, procedures
and legal requirements. and legal requirements.
Cont…Cont…

119. National Accreditation Board for Hospitals & Healthcare Providers
Chapter 5Chapter 5
HOSPITAL INFECTION HOSPITAL INFECTION
CONTROL (HIC)CONTROL (HIC)

120. National Accreditation Board for Hospitals & Healthcare Providers
HIC.1HIC.1
The organization has a well-The organization has a well-
designed, comprehensive and designed, comprehensive and
coordinated Hospital Infection coordinated Hospital Infection
Control (HIC) programme aimed Control (HIC) programme aimed
at reducing/ eliminating risks to at reducing/ eliminating risks to
patients, visitors and providers of patients, visitors and providers of
care.care.

121. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The hospital has a multi-disciplinary infection control The hospital has a multi-disciplinary infection control
committee.committee.
b)b)The hospital has an infection control team.The hospital has an infection control team.
c)c)The hospital has designated and qualified infection control The hospital has designated and qualified infection control
nurse(s) for this activitynurse(s) for this activity
d)d)The hospital infection control programme is documented.The hospital infection control programme is documented.

122. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The manual identifies the various high-risk areas.The manual identifies the various high-risk areas.
b)b)It outlines methods of surveillance in the identified high-risk It outlines methods of surveillance in the identified high-risk
areas.areas.
HIC.2HIC.2
The hospital has an infection The hospital has an infection
control manual, which is control manual, which is
periodically updated.periodically updated.

123. National Accreditation Board for Hospitals & Healthcare Providers
c)c)It focuses on adherence to standard It focuses on adherence to standard
precautions at all times.precautions at all times.
d)d)Equipment cleaning and sterilisation Equipment cleaning and sterilisation
practices are included.practices are included.
e)e)An appropriate antibiotic policy is An appropriate antibiotic policy is
established and implemented. established and implemented.
f)f)Laundry and linen management processes Laundry and linen management processes
are also included.are also included.
Cont…Cont…

124. National Accreditation Board for Hospitals & Healthcare Providers
g)g)Kitchen sanitation and food handling issues Kitchen sanitation and food handling issues
are included in the manualare included in the manual
h)h)Engineering controls to prevent infections Engineering controls to prevent infections
are included are included
i)i)Mortuary practices and procedures are Mortuary practices and procedures are
included as appropriate to the organizationincluded as appropriate to the organization
Cont…Cont…

125. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Surveillance activities are appropriately directed towards the Surveillance activities are appropriately directed towards the
identified high-risk areas.identified high-risk areas.
b)b)Collection of surveillance data is an ongoing process.Collection of surveillance data is an ongoing process.
HIC.3HIC.3
The infection control team is The infection control team is
responsible for surveillance responsible for surveillance
activities in identified areas of the activities in identified areas of the
hospital.hospital.

126. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Verification of data is done on regular basis Verification of data is done on regular basis
by the infection control team.by the infection control team.
d)d)In cases of notifiable diseases, information In cases of notifiable diseases, information
(in relevant format) is sent to appropriate (in relevant format) is sent to appropriate
authorities.authorities.
e)e)Scope of surveillance activities incorporates Scope of surveillance activities incorporates
tracking and analyzing of infection risks, tracking and analyzing of infection risks,
rates and trends.rates and trends.
Cont…Cont…

127. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization monitors urinary tract infections.The organization monitors urinary tract infections.
b)b)The organization monitors respiratory tract infections. The organization monitors respiratory tract infections.
HIC.4HIC.4
The hospital takes actions to The hospital takes actions to
prevent or reduce the risks of prevent or reduce the risks of
Hospital Associated Infections Hospital Associated Infections
(HAI) in patients and employees.(HAI) in patients and employees.

128. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The organization monitors intra-vascular The organization monitors intra-vascular
device infections.device infections.
d)d)The organization monitors surgical site The organization monitors surgical site
infections.infections.
e)e)Appropriate feedback regarding HAI rates Appropriate feedback regarding HAI rates
are provided on a regular basis to medical are provided on a regular basis to medical
and nursing staff.and nursing staff.
Cont…Cont…

129. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Hand washing facilities in all patient care areas are accessible Hand washing facilities in all patient care areas are accessible
to health care providers.to health care providers.
b)b) Compliance with proper hand washing is monitored Compliance with proper hand washing is monitored
regularly.regularly.
HIC.5HIC.5
Proper facilities and adequate Proper facilities and adequate
resources are provided to support resources are provided to support
the infection control programmethe infection control programme

130. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Isolation/ barrier nursing facilities are Isolation/ barrier nursing facilities are
available.available.
d)d)Adequate gloves, masks, soaps, and Adequate gloves, masks, soaps, and
disinfectants are available and used disinfectants are available and used
correctly.correctly.
Cont…Cont…

131. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Hospital has a documented procedure for handling such Hospital has a documented procedure for handling such
outbreaks.outbreaks.
b)b)This procedure is implemented during outbreaks. This procedure is implemented during outbreaks.
c)c)After the outbreak is over appropriate corrective actions are After the outbreak is over appropriate corrective actions are
taken to prevent recurrencetaken to prevent recurrence
HIC.6HIC.6
The hospital takes appropriate action The hospital takes appropriate action
to control outbreaks of infections.to control outbreaks of infections.

132. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)There is adequate space available for sterilization activitiesThere is adequate space available for sterilization activities
b)b)Regular validation tests for sterilisation are carried out and Regular validation tests for sterilisation are carried out and
documented.documented.
c)c)There is an established recall procedure when breakdown in There is an established recall procedure when breakdown in
the sterilisation system is identifiedthe sterilisation system is identified
HIC.7HIC.7
There are documented procedures for There are documented procedures for
sterilisation activities in the hospital.sterilisation activities in the hospital.

133. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The hospital is authorised by prescribed authority for the The hospital is authorised by prescribed authority for the
management and handling of Bio-medical Waste.management and handling of Bio-medical Waste.
b)b)Proper segregation and collection of Bio-medical Waste from Proper segregation and collection of Bio-medical Waste from
all patient care areas of the hospital is implemented and all patient care areas of the hospital is implemented and
monitored.monitored.
HIC.8HIC.8
Statutory provisions with regard Statutory provisions with regard
to Bio-medical Waste (BMW) to Bio-medical Waste (BMW)
management are complied withmanagement are complied with

134. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The organization ensures that Bio-medical The organization ensures that Bio-medical
Waste is stored and transported to the site of Waste is stored and transported to the site of
treatment and disposal in proper covered treatment and disposal in proper covered
vehicles within stipulated time limits in a vehicles within stipulated time limits in a
secure manner.secure manner.
d)d)Bio-medical Waste treatment facility is Bio-medical Waste treatment facility is
managed as per statutory provisions (if in-managed as per statutory provisions (if in-
house) or outsourced to authorised house) or outsourced to authorised
contractor(s).contractor(s).
Cont…Cont…

135. National Accreditation Board for Hospitals & Healthcare Providers
e)e)Requisite fees, documents and reports are Requisite fees, documents and reports are
submitted to competent authorities on submitted to competent authorities on
stipulated dates.stipulated dates.
f)f)Appropriate personal protective measures Appropriate personal protective measures
are used by all categories of staff handling are used by all categories of staff handling
Bio-medical WasteBio-medical Waste
Cont…Cont…

136. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Hospital management makes available resources required for Hospital management makes available resources required for
the infection control programmethe infection control programme
b)b)The hospital regularly earmarks adequate funds from its The hospital regularly earmarks adequate funds from its
annual budget in this regard.annual budget in this regard.
HIC.9HIC.9
The infection control programme is The infection control programme is
supported by hospital management supported by hospital management
and includes training of staff and and includes training of staff and
employee healthemployee health

137. National Accreditation Board for Hospitals & Healthcare Providers
c)c)It conducts regular pre-induction training It conducts regular pre-induction training
for appropriate categories of staff before for appropriate categories of staff before
joining concerned department(s).joining concerned department(s).
d)d)It also conducts regular “in-service” training It also conducts regular “in-service” training
sessions for all concerned categories of staff sessions for all concerned categories of staff
at least once in a year.at least once in a year.
e)e)Appropriate pre and post exposure Appropriate pre and post exposure
prophylaxis is provided to all concerned prophylaxis is provided to all concerned
staff membersstaff members
Cont…Cont…

138. National Accreditation Board for Hospitals & Healthcare Providers
Chapter 6Chapter 6
CONTINUOUS QUALITY CONTINUOUS QUALITY
IMPROVEMENT (CQI)IMPROVEMENT (CQI)

139. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The quality assurance programme is developed, implemented The quality assurance programme is developed, implemented
and maintained by a multi-disciplinary committee. and maintained by a multi-disciplinary committee.
b)b)The quality assurance programme is documented.The quality assurance programme is documented.
CQI.1CQI.1
There is a structured quality There is a structured quality
assurance and continuous assurance and continuous
monitoring programme in the monitoring programme in the
organizationorganization

140. National Accreditation Board for Hospitals & Healthcare Providers
c)c)There is a designated individual for There is a designated individual for
coordinating and implementing the quality coordinating and implementing the quality
assurance programme assurance programme
d)d)The quality assurance programme is The quality assurance programme is
comprehensive and covers all the major comprehensive and covers all the major
elements related to quality assurance and elements related to quality assurance and
risk management.risk management.
Cont…Cont…

141. National Accreditation Board for Hospitals & Healthcare Providers
e)e)The designated programme is The designated programme is
communicated and coordinated amongst all communicated and coordinated amongst all
the employees of the organization through the employees of the organization through
proper training mechanism.proper training mechanism.
f)f)The quality assurance programme is The quality assurance programme is
reviewed at predefined intervals and reviewed at predefined intervals and
opportunities for improvement are opportunities for improvement are
identified.identified.
Cont…Cont…

142. National Accreditation Board for Hospitals & Healthcare Providers
g)g)The quality assurance programme is a The quality assurance programme is a
continuous process and updated at least continuous process and updated at least
once in a year.once in a year.
Cont…Cont…

143. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Monitoring includes appropriate patient assessment.Monitoring includes appropriate patient assessment.
b)b)Monitoring includes diagnostics services’ safety and quality Monitoring includes diagnostics services’ safety and quality
control programmes.control programmes.
c)c)Monitoring includes all invasive procedures.Monitoring includes all invasive procedures.
CQI.2CQI.2
The organization identifies key The organization identifies key
indicators to monitor the clinical indicators to monitor the clinical
structures, processes and outcomesstructures, processes and outcomes

144. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Monitoring includes adverse drug events.Monitoring includes adverse drug events.
e)e)Monitoring includes use of anaesthesia.Monitoring includes use of anaesthesia.
f)f)Monitoring includes use of blood and blood Monitoring includes use of blood and blood
products.products.
g)g)Monitoring includes availability and content Monitoring includes availability and content
of medical records.of medical records.
h)h)Monitoring includes infection control Monitoring includes infection control
activities.activities.
i)i)Monitoring includes clinical research.Monitoring includes clinical research.
Cont…Cont…

145. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements

Monitoring includes procurement of medication essential to meet Monitoring includes procurement of medication essential to meet
patient needs.patient needs.

Monitoring includes reporting of activities as required by laws Monitoring includes reporting of activities as required by laws
and regulations.and regulations.
CQI.3CQI.3
The organisation identifies key The organisation identifies key
indicators to monitor the managerial indicators to monitor the managerial
structures, processes and outcomesstructures, processes and outcomes

146. National Accreditation Board for Hospitals & Healthcare Providers

Monitoring includes risk management.Monitoring includes risk management.

Monitoring includes utilisation of facilities.Monitoring includes utilisation of facilities.

Monitoring includes patient satisfaction.Monitoring includes patient satisfaction.

Monitoring includes employee satisfaction.Monitoring includes employee satisfaction.

Monitoring includes adverse events.Monitoring includes adverse events.

Monitoring includes data collection to support further study for Monitoring includes data collection to support further study for
improvements.improvements.

Monitoring includes data collection to support evaluation of the Monitoring includes data collection to support evaluation of the
improvements.improvements.
Cont…Cont…

147. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Hospital Management makes available adequate resources Hospital Management makes available adequate resources
required for quality improvement programme.required for quality improvement programme.
b)b)Hospital earmarks adequate funds from its annual budget in Hospital earmarks adequate funds from its annual budget in
this regard.this regard.
c)c)Appropriate statistical and management tools are applied Appropriate statistical and management tools are applied
whenever requiredwhenever required
CQI.4CQI.4
The quality improvement The quality improvement
programme is supported by the programme is supported by the
managementmanagement

148. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Medical staff participates in this system.Medical staff participates in this system.
b)b)The parameters to be audited are defined by the organisation.The parameters to be audited are defined by the organisation.
c)c)Patient and clinician anonymity is maintained.Patient and clinician anonymity is maintained.
d)d)All audits are documented.All audits are documented.
e)e)Remedial measures are implemented.Remedial measures are implemented.
CQI.5CQI.5
There is an established system for There is an established system for
audit of patient care servicesaudit of patient care services

149. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organisation has defined sentinel events.The organisation has defined sentinel events.
b)b)The organisation has established processes for intense analysis of The organisation has established processes for intense analysis of
such events.such events.
c)c)Sentinel events are intensively analysed when they occur.Sentinel events are intensively analysed when they occur.
d)d)Actions are taken upon findings of such analysisActions are taken upon findings of such analysis
CQI.6CQI.6
Sentinel events are intensively Sentinel events are intensively
analysedanalysed

150. National Accreditation Board for Hospitals & Healthcare Providers
Chapter 7Chapter 7
RESPONSIBILITIES OF RESPONSIBILITIES OF
MANAGEMENT (ROM)MANAGEMENT (ROM)

151. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization has a documented organogram The organization has a documented organogram
b)b)Those responsible for governance appoint the senior leaders in Those responsible for governance appoint the senior leaders in
the organizationthe organization
c)c)Those responsible for governance support the quality Those responsible for governance support the quality
improvement plan improvement plan 
ROM.1ROM.1
The responsibilities of the The responsibilities of the
management are definedmanagement are defined

152. National Accreditation Board for Hospitals & Healthcare Providers
d)d)The organization complies with the laid The organization complies with the laid
down and applicable legislations and down and applicable legislations and
regulationsregulations
e)e)Those responsible for governance address Those responsible for governance address
the organization’s social responsibilitythe organization’s social responsibility
Cont…Cont…

153. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Each organizational program, service, site or Each organizational program, service, site or
department has effective leadership department has effective leadership
b)b)Scope of services of each department is definedScope of services of each department is defined
c)c)Administrative policies and procedures for Administrative policies and procedures for
each department is maintainedeach department is maintained
d)d)Departmental leaders are involved in quality Departmental leaders are involved in quality
improvementimprovement
ROM.2ROM.2
The services provided by each The services provided by each
department are documenteddepartment are documented

154. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The leaders make public the mission statement of the The leaders make public the mission statement of the
organizationorganization
b)b)The leaders establish the organization’s ethical managementThe leaders establish the organization’s ethical management
c)c)The organization discloses its ownershipThe organization discloses its ownership
ROM.3ROM.3
The organization is managed The organization is managed
by the leaders in an ethical by the leaders in an ethical
mannermanner

155. National Accreditation Board for Hospitals & Healthcare Providers
d)d)The organization honestly portrays the The organization honestly portrays the
services which it can and cannot provideservices which it can and cannot provide
e)e)The organization accurately bills for it’s The organization accurately bills for it’s
servicesservices
Cont…Cont…

156. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The designated individual has requisite and appropriate The designated individual has requisite and appropriate
administrative qualifications.administrative qualifications.
b)b)The designated individual has requisite and appropriate The designated individual has requisite and appropriate
administrative experience.administrative experience.
ROM.4ROM.4
A suitably qualified and experienced individual heads A suitably qualified and experienced individual heads
the organisationthe organisation

157. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization has an interdisciplinary group assigned to The organization has an interdisciplinary group assigned to
oversee the hospital wide safety programme.oversee the hospital wide safety programme.
ROM.5ROM.5
Leaders ensure that patient safety Leaders ensure that patient safety
aspects and risk management aspects and risk management
issues are an integral part of issues are an integral part of
patient care and hospital patient care and hospital
managementmanagement

158. National Accreditation Board for Hospitals & Healthcare Providers
b)b)The scope of the programme is defined to The scope of the programme is defined to
include adverse events ranging from “no include adverse events ranging from “no
harm” to “sentinel events”. harm” to “sentinel events”.
c)c)Management ensures implementation of Management ensures implementation of
systems for internal and external reporting systems for internal and external reporting
of system and process failures. of system and process failures.
d)d)Management provides resources for Management provides resources for
proactive risk assessment and risk reduction proactive risk assessment and risk reduction
activities.activities.
Cont…Cont…

159. National Accreditation Board for Hospitals & Healthcare Providers
Chapter 8Chapter 8
FACILITY MANAGEMENT FACILITY MANAGEMENT
AND SAFETY (FMS)AND SAFETY (FMS)

160. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The management is conversant with the laws and regulations The management is conversant with the laws and regulations
and knows their applicability to the organization.and knows their applicability to the organization.
FMS.1FMS.1
The organization is aware of and The organization is aware of and
complies with the relevant rules complies with the relevant rules
and regulations, laws and byelaws and regulations, laws and byelaws
and requisite facility inspection and requisite facility inspection
requirementsrequirements

161. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Management regularly updates any Management regularly updates any
amendments in the prevailing laws of the amendments in the prevailing laws of the
land.land.
c)c)The management ensures implementation of The management ensures implementation of
these requirements. these requirements.
d)d)There is a mechanism to regularly update There is a mechanism to regularly update
licenses/ registrations/certificationslicenses/ registrations/certifications
Cont…Cont…

162. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)There is a documented operational and maintenance There is a documented operational and maintenance
(preventive and breakdown) plan.(preventive and breakdown) plan.
FMS.2FMS.2
The organization’s The organization’s
environment and facilities environment and facilities
operate to ensure safety of operate to ensure safety of
patients, staff and visitorspatients, staff and visitors

163. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Up-to-date drawings are maintained which detail the site Up-to-date drawings are maintained which detail the site
layout, floor plans and fire escape routes. layout, floor plans and fire escape routes.
c)c)The provision of space shall be in accordance with the The provision of space shall be in accordance with the
available literature on good practices (Indian or International available literature on good practices (Indian or International
Standards) and directives from government agencies.Standards) and directives from government agencies.
d)d)There are designated individuals responsible for the There are designated individuals responsible for the
maintenance of all the facilities. maintenance of all the facilities.
Cont…Cont…

164. National Accreditation Board for Hospitals & Healthcare Providers
e)e)Maintenance staff is contactable round the Maintenance staff is contactable round the
clock for emergency repairs. clock for emergency repairs.
f)f) Response times are monitored from Response times are monitored from
reporting to inspection and implementation reporting to inspection and implementation
of corrective actions.of corrective actions.
Cont…Cont…

165. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization plans for equipment in accordance with its The organization plans for equipment in accordance with its
services and strategic planservices and strategic plan
b)b)Equipment is selected by a collaborative process.Equipment is selected by a collaborative process.
c)c)All equipment is inventoried and proper logs are maintained All equipment is inventoried and proper logs are maintained
as required.as required.  
FMS.3FMS.3
The organization has a program The organization has a program
for clinical and support service for clinical and support service
equipment managementequipment management

166. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Qualified and trained personnel operate and Qualified and trained personnel operate and
maintain the equipment.maintain the equipment.
e)e)Equipment are periodically inspected and Equipment are periodically inspected and
calibrated for their proper functioning.calibrated for their proper functioning.
f)f)There is a documented operational and There is a documented operational and
maintenance (preventive and breakdown) maintenance (preventive and breakdown)
plan.plan.
Cont…Cont…

167. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Potable water and electricity are available round Potable water and electricity are available round
the clock.the clock.
b)b)Alternate sources are provided for in case of Alternate sources are provided for in case of
failure.failure.
c)c)The organisation regularly tests the alternate The organisation regularly tests the alternate
sources.sources.
d)d)There is a maintenance plan for piped medical There is a maintenance plan for piped medical
gas and vacuum installation.gas and vacuum installation.

  
FMS.4FMS.4
The organization has provisions for The organization has provisions for
safe water, electricity, medical gases safe water, electricity, medical gases
and vacuum systemsand vacuum systems

168. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization has plans and provisions for early detection, The organization has plans and provisions for early detection,
abatement and containment of fire and non-fire emergencies.abatement and containment of fire and non-fire emergencies.
FMS.5FMS.5
The organization has plans for fire The organization has plans for fire
and non-fire emergencies within and non-fire emergencies within
the facilitiesthe facilities

169. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Staff is trained for their role in case of such Staff is trained for their role in case of such
emergencies.emergencies.
c)c)The organization has a documented safe exit The organization has a documented safe exit
plan in case of fire and non-fire emergencies.plan in case of fire and non-fire emergencies.
d)d)Mock drills are held at least twice in a yearMock drills are held at least twice in a year
Cont…Cont…

170. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The organization defines its polices to reduce or eliminate The organization defines its polices to reduce or eliminate
smokingsmoking
b)b)The policy has provisions for granting exceptions for patients The policy has provisions for granting exceptions for patients
and families to smokeand families to smoke
FMS.6FMS.6
The organization has a smoking The organization has a smoking
limitation policylimitation policy

171. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The hospital identifies potential emergencies.The hospital identifies potential emergencies.
b)b) The organization has a documented disaster management The organization has a documented disaster management
plan.plan.
FMS.7FMS.7
The organization plans for handling The organization plans for handling
community emergencies, epidemics community emergencies, epidemics
and other disastersand other disasters

172. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Provision is made for availability of medical Provision is made for availability of medical
supplies, equipment and materials during supplies, equipment and materials during
such emergencies. such emergencies.
d)d)Hospital staff is trained in the hospital’s Hospital staff is trained in the hospital’s
disaster management plandisaster management plan
e)e)The plan is tested at least twice in a year.The plan is tested at least twice in a year.
Cont…Cont…

173. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Hazardous materials are identified within the organizationHazardous materials are identified within the organization
b)b)The hospital implements processes for sorting, handling, The hospital implements processes for sorting, handling,
storage, transporting and disposal of hazardous material.storage, transporting and disposal of hazardous material.
FMS.8FMS.8
The organization has a plan for The organization has a plan for
management of hazardous management of hazardous
materialsmaterials

174. National Accreditation Board for Hospitals & Healthcare Providers
d)d)Requisite regulatory requirements are met in Requisite regulatory requirements are met in
respect of radioactive materials.respect of radioactive materials.
e)e)There is a plan for managing spills of There is a plan for managing spills of
hazardous materialshazardous materials
f)f) Staff is educated and trained for handling Staff is educated and trained for handling
such materials.such materials.
Cont…Cont…

175. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The hospital has a safety committee to identify the potential safety The hospital has a safety committee to identify the potential safety
and security risks.and security risks.
b)b)This committee coordinates development, implementation, and This committee coordinates development, implementation, and
monitoring of the safety plan and policies.monitoring of the safety plan and policies.
FMS.9FMS.9
The hospital has system in place The hospital has system in place
to provide a safe and secure to provide a safe and secure
environmentenvironment

176. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Facility inspection rounds to ensure safety Facility inspection rounds to ensure safety
are conducted at least twice in a year in are conducted at least twice in a year in
patient care areas and at least once in a year patient care areas and at least once in a year
in non-patient care areas.in non-patient care areas.
d)d)Inspection reports are documented and Inspection reports are documented and
corrective and preventive measures are corrective and preventive measures are
undertaken.undertaken.
e)e) There is a safety education programme for There is a safety education programme for
all staff.all staff.
Cont…Cont…

177. National Accreditation Board for Hospitals & Healthcare Providers
Chapter9Chapter9
HUMAN RESOURCE HUMAN RESOURCE
MANAGEMENTMANAGEMENT

178. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The The organizationorganization maintains an adequate number and mix of maintains an adequate number and mix of
staff to meet the care, treatment and service needs of the staff to meet the care, treatment and service needs of the
patient.patient.
HRM.1HRM.1
The The organizationorganization has a has a
documented system of human documented system of human
resource planningresource planning

179. National Accreditation Board for Hospitals & Healthcare Providers
b)b)The required job specifications and job The required job specifications and job
description are well defined for each description are well defined for each
category of staff.category of staff.
c)c)The The organizationorganization verifies the antecedents of verifies the antecedents of
the potential employee with regards to the potential employee with regards to
criminal/negligence background.criminal/negligence background.
Cont…Cont…

180. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Each staff member, employee, student and voluntary worker is Each staff member, employee, student and voluntary worker is
appropriately oriented to the appropriately oriented to the organization’sorganization’s mission and goals. mission and goals.
HRM.2HRM.2
The staff joining the organization is The staff joining the organization is
socialized and oriented to the socialized and oriented to the
hospital environmenthospital environment

181. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Each staff member is made aware of hospital wide policies and Each staff member is made aware of hospital wide policies and
procedures as well as relevant department / unit / service / procedures as well as relevant department / unit / service /
programme’s policies and procedures.programme’s policies and procedures.
c)c)Each staff member is made aware of his/her rights and Each staff member is made aware of his/her rights and
responsibilities.responsibilities.
d)d)All employees are educated with regard to patients’ rights and All employees are educated with regard to patients’ rights and
responsibilities.responsibilities.
e)e)All employees are oriented to the service standards of the All employees are oriented to the service standards of the
organisationorganisation
Cont…Cont…

182. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)A documented training and development policy exists for the A documented training and development policy exists for the
staff.staff.
b)b)Training also occurs when job responsibilities change/ new Training also occurs when job responsibilities change/ new
equipment is introduced.equipment is introduced.
c)c)Feedback mechanisms for assessment of training and Feedback mechanisms for assessment of training and
development programme exist.development programme exist.
HRM.3HRM.3
There is an ongoing programme There is an ongoing programme
for professional training and for professional training and
development of the staffdevelopment of the staff

183. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)All staff is trained on the risks within the hospital All staff is trained on the risks within the hospital
environment. environment.
b)b)Staff members can demonstrate and take actions to report, Staff members can demonstrate and take actions to report,
eliminate / minimize risks.eliminate / minimize risks.
HRM.4HRM.4
Staff members, students and Staff members, students and
volunteers are adequately trained volunteers are adequately trained
on on specific job duties or specific job duties or
responsibilities related to safetyresponsibilities related to safety

184. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Staff members are made aware of Staff members are made aware of
procedures to follow in the event of an procedures to follow in the event of an
incident. incident.
d)d)Reporting processes for common problems, Reporting processes for common problems,
failures and user errors existfailures and user errors exist
Cont…Cont…

185. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)A well-documented performance appraisal system exists in A well-documented performance appraisal system exists in
the the organizationorganization..
HRM.5HRM.5
An appraisal system for evaluating An appraisal system for evaluating
the performance of an employee the performance of an employee
exists as an integral part of the exists as an integral part of the
human resource management human resource management
processprocess

186. National Accreditation Board for Hospitals & Healthcare Providers
b)b)The employees are made aware of the system of appraisal at The employees are made aware of the system of appraisal at
the time of induction. the time of induction.
c)c)Performance is evaluated based on the performance Performance is evaluated based on the performance
expectations described in job description. expectations described in job description.
d)d)The appraisal system is used as a tool for further development. The appraisal system is used as a tool for further development.
e)e)Performance appraisal is carried out at pre defined intervals Performance appraisal is carried out at pre defined intervals
and is documented.and is documented.
Cont…Cont…

187. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)A written statement of the policy of the A written statement of the policy of the organizationorganization with with
regard to discipline is in place. regard to discipline is in place.
b)b)The disciplinary policy and procedure is based on the The disciplinary policy and procedure is based on the
principles of natural justice. principles of natural justice.
HRM.6HRM.6
The The organizationorganization has a well- has a well-
documented disciplinary documented disciplinary
procedureprocedure

188. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The policy and procedure is known to all The policy and procedure is known to all
categories of employees of the categories of employees of the organizationorganization. .
d)d)The disciplinary procedure is in consonance The disciplinary procedure is in consonance
with the prevailing laws. with the prevailing laws.
e)e)There is a provision for appeals in all There is a provision for appeals in all
disciplinary cases.disciplinary cases.
Cont…Cont…

189. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The employees are aware of the procedure to be followed in The employees are aware of the procedure to be followed in
case they feel aggrieved.case they feel aggrieved.
b)b)The redress procedure addresses the grievance. The redress procedure addresses the grievance.
c)c)Actions are taken to redress the grievanceActions are taken to redress the grievance
HRM.7HRM.7
A grievance handling mechanism A grievance handling mechanism
exists in the exists in the organizationorganization

190. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)A pre-employment medical examination is conducted on all A pre-employment medical examination is conducted on all
the employees. the employees.
b)b)Health problems of the employees are taken care of in Health problems of the employees are taken care of in
accordance with the accordance with the organization’sorganization’s policy. policy.
HRM.8HRM.8
The organizationThe organization addresses the addresses the
health needs of the employeeshealth needs of the employees

191. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Regular physical and medical checks are Regular physical and medical checks are
done at-least once a year and the findings/ done at-least once a year and the findings/
results are documented.results are documented.
d)d)Occupational health hazards are adequately Occupational health hazards are adequately
addressed.addressed.
Cont…Cont…

192. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Personal files are maintained in respect of all employees.Personal files are maintained in respect of all employees.
b)b)The personal files contain personal information regarding the The personal files contain personal information regarding the
employees qualification, disciplinary background and health employees qualification, disciplinary background and health
statusstatus
HRM.9HRM.9
There is documented There is documented
personal information for personal information for
each staff membereach staff member

193. National Accreditation Board for Hospitals & Healthcare Providers
c)c)All records of in-service training and All records of in-service training and
education are contained in the personal files.education are contained in the personal files.
d)d)Personal files contain results of all Personal files contain results of all
evaluationsevaluations
Cont…Cont…

194. National Accreditation Board for Hospitals & Healthcare Providers
HRM.10HRM.10
There is a process for collecting, verifying There is a process for collecting, verifying
and evaluating the and evaluating the credentials (education, credentials (education,
registration, training and experience) of registration, training and experience) of
medical medical professionals permitted to provide professionals permitted to provide
patient care without supervisionpatient care without supervision

195. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Medical professionals permitted by law, regulation and the Medical professionals permitted by law, regulation and the
hospital to provide patient care without supervision is hospital to provide patient care without supervision is
identified.identified.
b)b)The education, registration, training and experience of the The education, registration, training and experience of the
identified medical professionals is documented and updated identified medical professionals is documented and updated
periodically.periodically.
c)c)All such information pertaining to the medical professionals is All such information pertaining to the medical professionals is
appropriately verified when possible. appropriately verified when possible. 

196. National Accreditation Board for Hospitals & Healthcare Providers
HRM.11HRM.11
There is a process for authorising There is a process for authorising
all medical professionals to admit all medical professionals to admit
and treat patients and provide and treat patients and provide
other clinical services other clinical services
commensurate commensurate with their with their
qualificationsqualifications

197. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Medical professionals admit and care for patients as per the Medical professionals admit and care for patients as per the
laid down policies and authorisation procedures of thelaid down policies and authorisation procedures of the
organizationorganization
b)b)The services provided by the medical professionals are in The services provided by the medical professionals are in
consonance with their qualification, training and registration.consonance with their qualification, training and registration.
c)c)The requisite services to be provided by the medical The requisite services to be provided by the medical
professionals are known to them as well as the various professionals are known to them as well as the various
departments / units of the hospital.departments / units of the hospital.

198. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The education, registration, training and experience of nursing The education, registration, training and experience of nursing
staff is documented and updated periodically.staff is documented and updated periodically.
HRM.12HRM.12
There is a process for collecting, There is a process for collecting,
verifying and evaluating the verifying and evaluating the
credentials (education, credentials (education,
registration, training and registration, training and
experience) of nursing experience) of nursing staffstaff

199. National Accreditation Board for Hospitals & Healthcare Providers
b)b)All such information pertaining to the All such information pertaining to the
nursing staff is appropriately verified when nursing staff is appropriately verified when
possiblepossible
Cont…Cont…

200. National Accreditation Board for Hospitals & Healthcare Providers
HRM.13HRM.13
There is a process to identify job There is a process to identify job
responsibilities and make clinical work responsibilities and make clinical work
assignments to all nursing staff members assignments to all nursing staff members
commensurate with their qualifications commensurate with their qualifications
and any other regulatory requirementsand any other regulatory requirements

201. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The clinical work assigned to nursing staff is in consonance The clinical work assigned to nursing staff is in consonance
with their qualification, training and registration.with their qualification, training and registration.
b)b)The services provided by nursing staff are in accordance with The services provided by nursing staff are in accordance with
the prevailing laws and regulations.the prevailing laws and regulations.
c)c)The requisite services to be provided by the nursing staff are The requisite services to be provided by the nursing staff are
known to them as well as the various departments / units of known to them as well as the various departments / units of
the hospitalthe hospital

202. National Accreditation Board for Hospitals & Healthcare Providers
Chapter.10Chapter.10
INFORMATION INFORMATION
MANAGEMENT SYSTEM MANAGEMENT SYSTEM
(IMS)(IMS)

203. National Accreditation Board for Hospitals & Healthcare Providers
IMS.1IMS.1
Policies and procedures exist to meet the Policies and procedures exist to meet the
information needs of the care providers, information needs of the care providers,
management of the organization as well management of the organization as well
as other agencies that require data and as other agencies that require data and
information from the organizationinformation from the organization

204. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The information needs of the organization are identified and The information needs of the organization are identified and
are appropriate to the scope of the services being provided by are appropriate to the scope of the services being provided by
the organization and the complexity of the organizationthe organization and the complexity of the organization
b)b)Policies and procedures to meet the information needs are Policies and procedures to meet the information needs are
documented.documented.
c)c)These policies and procedures are in compliance with the These policies and procedures are in compliance with the
prevailing laws and regulations.prevailing laws and regulations.

205. National Accreditation Board for Hospitals & Healthcare Providers
d)d)All information management and All information management and
technology acquisitions are in accordance technology acquisitions are in accordance
with the policies and procedures.with the policies and procedures.
e)e)The organization contributes to external The organization contributes to external
databases in accordance with the law and databases in accordance with the law and
regulationsregulations
Cont…Cont…

206. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Formats for data collection are standardized Formats for data collection are standardized
b)b)Necessary resources are available for analyzing dataNecessary resources are available for analyzing data
IMS.2IMS.2
The organization has processes in The organization has processes in
place for effective management of place for effective management of
datadata

207. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Documented procedures are laid down for Documented procedures are laid down for
timely and accurate dissemination of data timely and accurate dissemination of data
d)d)Documented procedures exist for storing Documented procedures exist for storing
and retrieving dataand retrieving data
e)e)Appropriate clinical and managerial staff Appropriate clinical and managerial staff
participates in selecting, integrating and participates in selecting, integrating and
using data.using data.
Cont…Cont…

208. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Every medical record has a unique identifier.Every medical record has a unique identifier.
b)b)Organization policy identifies those authorized to make Organization policy identifies those authorized to make
entries in medical record.entries in medical record.
IMS.3IMS.3
The organization has a complete The organization has a complete
and accurate medical record for and accurate medical record for
every patientevery patient

209. National Accreditation Board for Hospitals & Healthcare Providers
c)c)Every medical record entry is dated and Every medical record entry is dated and
timed.timed.
d)d)The author of the entry can be identifiedThe author of the entry can be identified
e)e)The contents of medical record are identified The contents of medical record are identified
and documentedand documented
f)f)The record provides an up-to-date and The record provides an up-to-date and
chronological account of patient carechronological account of patient care
Cont…Cont…

210. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The medical record contains information regarding reasons for The medical record contains information regarding reasons for
admission, diagnosis and plan of care.admission, diagnosis and plan of care.
b)b)Operative and other procedures performed are incorporated Operative and other procedures performed are incorporated
in the medical record in the medical record
IMS.4IMS.4
The medical record reflects The medical record reflects
continuity of carecontinuity of care

211. National Accreditation Board for Hospitals & Healthcare Providers
c)c)When patient is transferred to another When patient is transferred to another
hospital, the medical record contains the hospital, the medical record contains the
date of transfer, the reason for the transfer date of transfer, the reason for the transfer
and the name of the receiving hospitaland the name of the receiving hospital
d)d)The medical record contains a copy of the The medical record contains a copy of the
discharge note duly signed by appropriate discharge note duly signed by appropriate
and qualified personneland qualified personnel
Cont…Cont…

212. National Accreditation Board for Hospitals & Healthcare Providers
e)e)In case of death, the medical record contains In case of death, the medical record contains
a copy of the death certificate indicating the a copy of the death certificate indicating the
cause, date and time of death.cause, date and time of death.
f)f)Whenever a clinical autopsy is carried out, Whenever a clinical autopsy is carried out,
the medical record contains a copy of the the medical record contains a copy of the
report of the same.report of the same.
g)g)Care providers have access to current and Care providers have access to current and
past medical record.past medical record.
Cont…Cont…

213. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures exist for maintaining Documented policies and procedures exist for maintaining
confidentiality, security and integrity of informationconfidentiality, security and integrity of information
IMS.5IMS.5
Policies and procedures are in place for Policies and procedures are in place for
maintaining confidentiality, integrity and maintaining confidentiality, integrity and
security of informationsecurity of information

214. National Accreditation Board for Hospitals & Healthcare Providers
b)b)Policies and procedures are in consonance Policies and procedures are in consonance
with the applicable laws with the applicable laws
c)c)The policies and procedures incorporate The policies and procedures incorporate
safeguarding of data/ record against loss, safeguarding of data/ record against loss,
destruction and tamperingdestruction and tampering
d)d)The hospital has an effective process of The hospital has an effective process of
monitoring compliance of the laid down monitoring compliance of the laid down
policy policy
Cont…Cont…

215. National Accreditation Board for Hospitals & Healthcare Providers
e)e)The hospital uses developments in appropriate technology for The hospital uses developments in appropriate technology for
improving, confidentiality, integrity and securityimproving, confidentiality, integrity and security
f)f)Privileged health information is used for the purposes Privileged health information is used for the purposes
identified or as required by law and not disclosed without the identified or as required by law and not disclosed without the
patient’s authorizationpatient’s authorization
Cont…Cont…

216. National Accreditation Board for Hospitals & Healthcare Providers
g)g)A documented procedure exists on how to A documented procedure exists on how to
respond to patients / physicians and other respond to patients / physicians and other
public agencies requests for access to public agencies requests for access to
information in the clinical record in information in the clinical record in
accordance with the local and national law.accordance with the local and national law.
Cont…Cont…

217. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)Documented policies and procedures are in place on retaining Documented policies and procedures are in place on retaining
the patient’s clinical records, data and informationthe patient’s clinical records, data and information
b)b)The policies and procedures are in consonance with the local The policies and procedures are in consonance with the local
and national laws and regulationsand national laws and regulations
IMS.6IMS.6
Policies and procedures exist for Policies and procedures exist for
retention time of records, data and retention time of records, data and
informationinformation

218. National Accreditation Board for Hospitals & Healthcare Providers
c)c)The retention process provides expected The retention process provides expected
confidentiality and securityconfidentiality and security
d)d)The destruction of medical records, data and The destruction of medical records, data and
information is in accordance with the laid information is in accordance with the laid
down policy down policy
Cont…Cont…

219. National Accreditation Board for Hospitals & Healthcare Providers

Objective elementsObjective elements
a)a)The medical records are reviewed periodicallyThe medical records are reviewed periodically
b)b)The review uses a representative sampleThe review uses a representative sample
c)c)The review is conducted by identified care providers.The review is conducted by identified care providers.
IMS.7IMS.7
The organization regularly carries The organization regularly carries
out medical auditsout medical audits

220. National Accreditation Board for Hospitals & Healthcare Providers
d)d)The review focuses on the timeliness, The review focuses on the timeliness,
legibility and completeness of the medical legibility and completeness of the medical
recordsrecords
e)e)The review process includes records of both The review process includes records of both
active and discharged patientsactive and discharged patients
f)f)The review points out and documents any The review points out and documents any
deficiencies in recordsdeficiencies in records
g)g)Appropriate corrective and preventive Appropriate corrective and preventive
measures undertaken are documented.measures undertaken are documented.
Cont…Cont…

221. National Accreditation Board for Hospitals & Healthcare Providers
Thank youThank you