Sr.

Standard Objective Elements Interpretation

No.
01. AAC. 4.g. Patient Cared for by the organization
undergo an established initial
assessment.
AAC. 7.f. There is an established laboratory
quality assurance programme.
AAC.10.b. There is an established quality
assurance programme for imaging
services.
AAC.10.c. There is an established quality
assurance programme for imaging
services.
AAC.10.f. There is an established quality
assurance programme for imaging
services.
AAC.13.e. The organisation has an established
discharge process.
COP.1.b. Uniform care to patients is provided
in all settings of the organization and
is guided by written guidance, and the
applicable laws and regulations.
The care plan includes the Identification of special needs is critical groups of
identification of special needs patients like extremes of age, restricted mobility,
regarding care following discharge continuing nursing and rehabilitation needs,
assistance with activities of daily living etc. The
organization could begin the process of identifying
special discharge needs early in the assessment
process.
The programme addresses the The organization conducts the clinicopathological
clinicopathological meeting(s). meeting(s) at pre-defined intervals for correlating the
histopathology reports with referring clinicians and
uses the same as a tool for improving quality.
Quality assurance programme Some examples of tests for imaging equipment
includes tests for imaging include congruence of optical and radiation field,
equipment. focal spot size, output consistency, leakage rate,
magnetic field homogeneity, slice position accuracy ,
phantom checks etc. The tests, as applicable, shall be
performed.
Safety equipment shall undergo testing, as stated in
AAC 11e.
Quality assurance programme The review of imaging protocols ensures optimum
includes the review of imaging image quality with minimum possible dosage to the
protocols. patient(s). The imaging protocols should be in
accordance with guidelines given by professional
bodies / academic literature and where relevant based
on the clinical diagnosis.
The programme addresses the clinic- The organization conducts the clinic-radiological
radiological meeting(s). meeting(s) at pre-defined intervals for correlating the
imaging results (at a minimum CT and MRI) with
referring clinicians and uses the same as a tool for
improving the quality of its imaging results.
The organization adheres to planned Discharge is planned at least 24 hours in advance.
discharge. Planning shall include preparation of the draft
discharge summary, refund of medications, patient
education on continued care. Unplanned discharges
are minimized.
Also refer to AAC 4g.
The organization has a uniform The mechanism for identification of patients shall be
process for identification of patients uniform across the organization. For example, the use
and at a minimum, uses two of ID bands with the patients name and unique
identifiers. identification number. For any care related aspect, ast

COP.1.e.
COP. 1.g. Uniform care to patients is provided
in all settings of the organization and
is guided by written guidance, and the
applicable laws and regulations.
COP.2.b. Emergency services are provided in
accordance with written guidance,
applicable laws and regulations.
a minimum, two identifiers shall be used. One of the
identifiers shall be the unique identification number
generated at the time of registration.
Also, refer to AAC 2b
Clinical care pathways are Clinical care pathways shall be multidisciplinary, and
developed, consistently followed based on the evidence base and/or best clinical
across all settings of care, and practices. These provide the team, detailed guidance
reviewed periodically. at various stages of care. At a minimum, the
organization shall develop two clinical care pathways
every year. The clinical care pathways shall be
reviewed annually at the minimum, and revised as
appropriate.
Multidisciplinary and multi- Whenever the patient’s clinical condition warrants
speciality care, where appropriate, is care from multiple disciplines e.g. doctors, nurses,
planned based pm best clinical rehabilitation specialist, dietician, psychologist, etc
practices/clinical practice guidelines and/or multiple specialties e.g. cardiology,
and delivered in uniform manner endocrinology, surgery, internal medicine;
across the organization. multidisciplinary and multi-speciality care plan
should be charted out based on established best
clinical practices/clinical practice guidelines for the
specific clinical condition. An integrated care plan,
including professional, nursing, nutritional,
supportive care, should be developed and
implemented appropriately by the representatives of
various disciplines and specialties.
Some examples of scenarios where multidisciplinary
care plan is required are care of a cancer patient to be
determined by a multidisciplinary tumor board;
diabetes patient to be cared for by multiple specialists
to prevent and manage end-organ damage;
palliative/end-of life care to be provided to terminally
ill patients; long-stay patients.
Prevention of patient over-crowding Prevention of patient overcrowding in the emergency
is planned, and crowd management department includes monitoring the footfall trends
measures are implemented. and developing a strategy to prevent and manage
overcrowding. It is expected that high footfall times
will be anticipated and adequate human resources
assigned and strategies to manage overcrowding are
put in place.
Crowd management should include having an
appropriate policy for patient
relatives/attendants/visitors.
COP.2.f. Patients waiting in the emergency A patient’s condition may worsen or improve, and so
are reassessed as appropriate for the a reassessment in needed for early identification of
change in status. deterioration or improvement, and modification of
care accordingly.
COP.3a. Ambulance services ensure safe The organization has access to Commensurate to its scope of services, the
patient transportation with ambulance services commensurate organization may provide in-house or use out-
appropriate care with the scope of the services sourced ambulance service for safe patient transport
provided by it. with appropriate care.
The organization should decide the appropriate level
of an ambulance to be provided based on the National
Ambulance Code AIS-125
COP.5.b. Cardio-pulmonary resuscitation During cardio-pulmonary The team members have a clear understanding of
services are provided uniformly resuscitation, assigned roles and their roles and responsibilities during the
across the organization responsibilities are compiled with. resuscitation to effectively function as a team.
COP.5.c. Equipment and medications for use At a minimum emergency medications and
during cardio-pulmonary equipment for intubation should be available in all
resuscitation are available in various patient care areas including the blood bank,
areas of the organization. radiology, OPD, rehabilitation services areas,
endoscopy and in areas where any procedure is
performed. Other equipment like defibrillator should
be easily accessible to ensure that there is no delay in
cardio-pulmonary resuscitation. It is preferable that
the minimum emergency medication is standardized
across the organization.
COP.6.b. Nursing care is provided to patients in The organization develops and Care of patients in specifies clinical situations shall
the organization in consonance with implements nursing clinical practice be guided by nursing clinical practice guidelines
clinical protocols. guidelines reflecting current based on best clinical practices. The nursing clinical
standards of practice. care guidelines/pathways shall be reviewed annually
at the minimum, and revised as appropriate.
Examples of nursing clinical practice guidelines
include prevention of fall. Prevention of development
of pressure ulcers in an in-patient, and deep venous
thrombosis risk assessment and prevention.
COP.6.d. The organization implements acuity- Patient outcomes are linked to acuity-based staffing
based staffing to improve patient of nursing personnel, in terms of numbers and
outcomes. competence. Examples of outcomes include
incidence of pressure sores, falls, medication
administration errors, ventilator-associated
pneumonia, etc.
COP.7.a. Clinical procedures are performed in Procedures are performed based on The decision to perform a procedure shall be based
a safe manner. the clinical needs of the patient. on the clinical needs of the patient, in consonance
 with standard treatment guidelines and/or sound
clinical practice for the given condition/procedure. A
qualified medical practitioner decides if the
procedure is indicated. When multiple procedure
options exits, the decision should be based on which
option is likely to provide the best yield/outcome, and
also taking into consideration, the patient wishes and
safety. The organization could conduct a clinical
audit of various procedures to achieve the best
possible outcomes.
COP.8.a. Transfusion services are provided as Scope of transfusion services is The organization should have blood/blood
per the scope of services of the commensurate with services components available from either and in-house or
organization, safety. provided by the organization. out-sourced registered blood bank. In case the
organization uses an out-sourced blood bank, it shall
have an MoU and ensure that patient care does not
suffer for want of blood/blood components. The
blood shall be transported from the external blood
bank safely and properly. A good reference guide is
the NABH standards for blood banks.
COP.9.d. The organization provides care in The organization endeavors to The infrastructure and equipment should be
intensive care and high dependency upgrade its physical infrastructure to upgraded, commensurate with the scope and
units in a systematic manner. meet national and international complexities of functioning to meet the national and
guidelines. international guidelines.
A good starting point could be various national and
international critical care society guidelines.
COP.16.c. The organization identifies and The organization identifies and A validated tool shall be used for the assessment of
manages patients who are at higher manages patients who are at a risk of the risk of fall patents found at a risk of fall shall be
risk of morbidity/mortality. fall managed according to written guidance. A good
guide is “Universal fall precautions”.
COP.16.d. The organization identifies and A validated tool shall be used for assessment of the
manages patients who are at risk of risk of pressure ulcers. For example, the Braden
developing/worsening of pressure scale, the European and US National pressure ulcer
ulcers. advisory panels (EPUAP and NPUAP) staging
system to look for worsening of pressure ulcers.
Patients found at risk of pressure ulcers shall be
managed according to written guidance.
COP.16.e. The organization identifies and A validation tool shall be used for assessment of the
manages patients who are at risk of risk of development of deep vein thrombosis. Patients
developing deep vein thrombosis. found at risk of deep vein thrombosis shall be
managed according to written guidance.
COP.18.b. Rehabilitation services are provided Rehabilitation services are provided The organization shall provide rehabilitation services
to the patients in a safe, collaborative in a consistent manner. in a consistent manner by adapting/adopting standard
 and consistent manner. treatment guidelines/sound clinical practices.
COP.18.g. Care pathways are developed, Care pathways shall be based on evidence and/or
implemented, and reviewed sound clinical practices. These provide the team,
periodically. detailed guidance at various stages of rehabilitation.
Development of care pathways is continuous process.
COP.20.b. End-of-life care is provided in a A multi professional approach is The team could include a doctor, nurse, clinical
compassionate and considerate used to provide end-of-life care. psychologist, rehabilitation expert etc. it is preferable
manner. that someone trained in palliative care heads the
team.
MOM.1.c. Pharmacy services and usage of There is a mechanism in place to This includes information on rational use, medication
medication is done safely. facilitate the multidisciplinary errors, medication management, adverse drug
committee to monitor literature reactions and patient safety, especially in the context
reviews and best practice of high-risk medications.
information on medication
management and use the information
to update medication management
processes.
MOM.1.e. The organization has a mechanism to The organization has a process to communicate
inform relevant staff of key changes medication shortages. Including stock-outs to
in pharmacy services and medication relevant staff (Clinicians and nurses). The relevant
usage to ensure uninterrupted and staff should also be informed of the recall of a drug
safe care. within 24 hours and serious adverse events associated
with medication usage. The pharmacy-in-charge or a
designated authority shall be responsible for
communication. Communication shall be
documented.
Also refer to MOM 2, MOM 5b, MOM 9e
MOM 2.d. The organization develops updates The clinicians adhere to the current The organization shall ensure that the prescriptions
and implements a hospital formulary. formulary. are as per the formulary. It shall monitor the
frequency of prescriptions being rejected / local
purchase done because it contained non-formulary
drugs.
MOM.3.d. Medications are stored appropriately High-risk medications are stored in High-risk medications are stored in pre-determined
and are available where required. areas of the organization where it is areas of the organization, e.g. certain wards, OT,
clinically necessary. ICU, Clinical needs shall determine the availability
of these drugs in such areas. Where applicable
(narcotics), it shall be guided by regulations. In all
such areas. Safeguards shall be in place to prevent
inadvertent administration.
MOM.4.d. Medications are prescribed safely and The organization has a mechanism to The organization needs to provide its clinicians with
rationally. assist the clinician in prescribing a mechanism (s) to help identify drug interactions,
appropriate medication. food-drug interactions, therapeutic duplication, dose

MOM.6.f Medications are dispensed in a safe
manner.
MOM.7.h. Medications are administered safety
MOM.10.e. Implantable prosthesis and medical
devices are in accordance with laid
down criteria.
adjustments etc. This could either be in electronic or
physical form.
Return of medications to the The organization should have written guidance to
pharmacy is addressed. direct the return of medications to the pharmacy. At a
minimum, the written guidance should address the
list of medications which would be accepted for
return (either by inclusion or exclusion) and
minimum conditions to be met for return of
medications. It is preferable that any drug which has
a specific temperature storage requirement not be
accepted for return once it has gone out of the
organization premises. The minimum conditions to
be met for return of medications could include the
drug name, strength , batch number and expiry date
matching the bill; no visible damage etc.
Measures to avoid catheter and The organization ensures that inadvertent
tubing mis-connections during administration of a drug through a wrong route is
medication administration are avoided. This could be done by using design features
implemented. that prevent misconnections and prompt the user to
take the correct action. Intravenous (IV) extension
tubes should not be used for epidurals, irrigation,
drains, and central lines or to extend enteric feeding
tubes. Care must be taken to position functionally
dissimilar tubes used in patient care away from one
another. Staff administering medications could trace
all lines from their origin to the connection port to
verify attachments before making any connections or
reconnections, or administering medications,
solutions, or other products.
Recall of implantable prosthesis and Recall may be based on communication from
medical devices are handled regulatory authorities, manufacturer or internal
effectively feedback. Recall procedure in response to internal
feedback also includes providing information to
appropriate regulatory authority and manufacturer.
Also, refer to MOM 1e, FMS 5g
 NABH 5th Edition

10 Chapters

Standards: 100 (as compared to 105 standards in 4th edition)

Objective Elements: 651 (as compared to 683 OEs in 4th edition)

CORE COMMITMENT ACHIEVEMENT EXCELLENCE

102 459 60 30

Mandatorily assessed Assessed during Assessed during Surveillance Assessed during

during each assessment Final assessment Re-accreditation

Changes in Chapters

Patient centered Management centered

1. Access, Assessment & Continuity of Care (AAC) 6. Patient Safety & Quality Improvement (PSQ)
2. Care of Patients (COP) 7. Responsibility of Management (ROM)
3. Management of Medication (MOM) 8. Facility Management & Safety (FMS)
4. Patient Rights & Education (PRE) 9. Human Resource Management (HRM)
5. Hospital Infection Control (HIC) 10. Information Management System (IMS)