tu

rI
:

The organisation provides uniform care to all patients in various settings. The settings include care provideci in
outpatient units, day care facilities, in-patient units including critical care units, procedure rooms and operation
theatre. Vvhen similar care is provided in these different settings, care delivery is uniform. Written guidance,
applicable laws and regulations guide emergency and ambulance services, cardio-pulmonary resuscitation, use
of blood and blood components, care of patients inthe criticalcare and high dependen€y units.

Written guidance, applicable laws and regulations also guide the care of patients who are at higher risk of
morbidity/mortality, high+isk obstetric patients, paediatdc patients, patients undergoing procedural sedation,
administration of anaesthesia, patients undergoing surgioalprocedures and end of life care.

Pain management, nutritional therapy and rehabilitative services are also addressed to provide comprehensive
health care.

The management should have written guidelines for organ donation and procurement. The transplant
programme ensures that it has the rightskill mix ot staff and other related support systems to ensure safe and high
qualityof care.

The standards aim to guide and encourage patient safety as the overarching principle for providing care
to patients.

coP1. Uniform care to patients is provided in all settings of the organisation and is
guided by written guidance, and the applicable laws and regulations.

coP.2. Emergency services are provided in accordance with written guidance, applicable
laws and regulations.

coP3. Ambulance services ensure safe patient transportation with appropriate care.

coP4 The organisation plans and implements rdechanisms for the care of patients
during community emergencies, epidemics and other disasters.

coP.s. Cardio-pulmonary resuscitation services are provided uniformly across the

organisation.

coP6. Nursing care is provided to patients in the organisation in consonance with

clinical.Brotocols.

coP7. Clinical.prooedures are performed safely-

coP.8. Transfusion services are provided as per the scope of services of the
organisation, safely.
 l-
I

NABH

t
t The organisation Provides
care in intensive care and high
dependency units in a

t systematic manner'

t Organisatioh provides S afe

Organ sation p rovl de safe

obstetric care
pae diatric SE rvices

L Proced U ral sedation s

provided co nsistently and safely

L provided in a con sistent and

safe manne (.

tt- An aesthesia services are

Su rg cal seNice are

The org an tran s plant

provid ed in a consistent and
safe mannet

pro s ram me I s carrl ed out S afely.

an d manag ES patients who

ale at h igh e I NSk of
t- The organi sati on
morbidity/mortality'
id e ntifies

t- n a cons I stent mannel

I
L.-
Pa tn manage me nt for patients S don

Rehabil itation services are

consistent mannet
p rovid ed to the p atie nts ln a safe
coll abo rative and

to patients consistently and collaborativelY

Nuuiti on al theraPY p rovl d ed
L- End of li e care p rovl ded
n a com passiona te and considerate
manner

t--
t--
t:
t_
l_ Standard
L
L
Obiective Elements
written guldance'
*
Commitment a' Unilorm Gare Is provlded followlng
ensure that
needs to implement mechanisms'-to
lnterpretation: The or'ganisation is uniform ''
out-patienVin-patienVemergency
tn" tll-tr,l" p"ii"nt recJves in

Also referto 4A6 +, AAc 5, PRE 4'

@ Achievement @l Excellence
92 ffis@js
@ CQRE Sfl commitment

-I
 NABH
(
I t
Standard
t
Emergency seryices are provided in accordance
with wrltten ' I

coP.2. guidance, applicable laws and regulations'

1 I
_..1

Obiective Elements
commitmenta.TherEshallbeanidentiliedareaintheorganisationwhlchiseaslly
patle3";ts, wlth adequate and
accessible to rceeive and manaEe emergenc'i
aPProPriate resources'

lnterDretation:Theidentifiedareatotreatemergencypatientsshouldbeeasily
and directions in an
**;"irr"-i"i in" initiatio! of care. There should be signgge
area- The organisation shall also
*o#""iJr" ,*n", r"Eing to the emergency Emergency *
in" .l"i,um number Jf beds based on its scope glservices. ,rD
"p""irv equipment and-human
services shoulo have the adequate and appropriate rL
patients. At a minimum, basic
resources to receive and initiate care of emergency
appropriate
,".,""i.,iion equipmenl, equipment for monitoring Vital parameters,
consumables andiife-siving and emergencycaredrugsshall beavailable'

Thepersonneloperatingtheemergencyareashouldbeprivilegedtoworkinthis
areaand have access to ongoing training'
!

Also referto FMS 2d' HRM 5' HHM 6' HBM 1 1 HR[/ 12' HRIV 13'
'

Prevention of patient over-crowding ls planned' and

crowd management
Achievement b
measures are lmPlemented.
the emergency department
lnterpretatlon: Prevention of patient overcrowding in
prevent and manage
in"frir, ,onito,ing the footfall trends and developing a strategy to
and adequate
overoowding. lt is expected that nlgh f*tf"lt timeJWtt
oe anticipdted'
6rr"n r""o"ur""a assigned and stritegies to manage overcrowding are put in place'
-
policy for patient
crowd management should include having an appropriate
t

relatives/attendants/visitors.

Emergency care is provided in consonance with

statutory requlrements and
CQRE c *
in accordance with the written guidance'
guidelines/SQPs/protQcols to
lnterpretation: Written guidance should include
speciiic conditions' e'g'
provide general emergency care as wellas management of
diseasi' etc ltshalladdress
I"i"""itg, ."a uaffiJdcciipnts, patients with coronary incorporate at a minimum
lotn paediatric patients/The procedure shall
"na services are
"ar1
iUu",itia"ti"n, assessment and pr6vision of care ln case, emergency
does not have facilities for
o,it oitf'" ."op" of the organisation, or the organisation
condition' at a minimum' such
appropriate emergency care ol a given clinical
proviOea witn trst-q1O beJore transierring them to another
centre'
ollJi"
'.=' cnarrOe
patient safetyr"
Processes should be in place to ensure

Also, refer to COP 1 a-e.

@ cone--* @ commltment I A"nt"'"t"'t

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i-
 '1

NABH
I

Co{nmitment d. The organisafion manages t eddco'tegal cises in accordance wlth statutory

requlrements. r "i

lnterpletation:ThecareproMded,especiallythedocumentationandintimationto
requirements' The
appropriate authorities, shall be in accordance with statutory
case (by
organisation shall also define as to what constitutes a medico-legal
statutory guidelines).

e tnitiatlon ot appropriate care isguided by a system oftriage' *

Commitment
personnel Written
lnterpretation: Triage shall be done only by qualified/trained
guid ance based on evide should guide these activities.
of the emergoncy
The triage should be Part ot the routine dayto-day functioning
large number of patients
department and not from the perspective ot managing a
non-trauma patients
during a disaster. The criteria could be separate fortrauma and
a visual triage
and adults and children. ll several clients are waiting to be triaged,
assessment may be conducted.

For "triage" reJertothe glossary.

Patients walting in the emergency are reassessed as appropriate

lor the
Commitment f
change in status.

lnterpretation: A patient's condition may worsen or improve' and so

a
or improvement' and
reassessment is needed for early identification of deterioration
modification of care accordinglY,

Commitment S. Admission, discharge to homE, or transler to anothel organisation is

documented.

lnterpretation:TheorganisationShallmaintaindocumentationtoindicateifa
carelwas
patient who came to the emergency was sent home after providing initial
for a short
admitted for further care in the organisalion/admitted in an emergency
staff should have
stay and then discharged/transferred to another organisation The
aclearunderstandingofthescopeoftheactivitie.softheorganisationandthe
patients who
procedure of referral and transfer to an appropriate another centre, of
care.
cannot be cared forin-house, after administering the due firslaid/emergency

Also, referto AAC 3b

Commitment h.tncaseofdlschargetohomeortransfertoanotherorganisatlon'a
dlscharge/transfer note shall be giventothe patient'
findings,
lnterpretation: The discharge^ransfer note shall contajl salient clinical
The
investigations done, treatment given, and condition dt discharge/transfer.
basis/reasons for discharge'ortransfer should be documented'

@fl cone I commitment E Achievemenl Excellence

$$ ;ffiareuea
 NABH
(i *
shall l4Pledent a quality assurance ptogramme'
Achievement 1. Ttre orglnrc*lon
'
lor quality assurance coruld be developed
lnterprotation: The written guidance
the organisation's overall. quality-improvement
indfuidually, or it could be a part ol
programme' The quality p'og*'*" should involve all aspects of the
"'"u'"'"" The Emergency department should
functioning in the Emergency department' part of its
including care outcomes' as
collect data on key performancsindicators'
of a care outcome measure is return
quality improvement programme' An example
tt," departmentlor the same complaint'
" "*"rg"n","
ThecollecteddataShouldbecollated,analysedandUsedforfurtherimprovements.
for sustenance'
The improvements should be monitored

place for the management of patients found

Commitment i The organlsation has systems in *
within afew minutes of arrlval
dead on arrival and patients who die
for managing situations where a
lnterpretation: There is written guidance arrival (after
within a few minutes of
patient is either found dead on arrival or dies
wriiten guidance should conform to the
a failed attempt at resuscitation) The
relevant local laws.'

Thewrittenguidanceincaseofapatientfounddeadonarrival(broughtindead)to
the emergencY dePartment address:
patients found dead on anival'
{, a) Maintaining a loqpookof a post-mortem'
b) whetherto
The decision on dei{orm
certificate of cause of death '
ci me aecision regarding the issue of medical
of the bodyin appropriate conilitions'
Q Thetemporarystorage
bodies'
. e)
\*/ , What to do in case of uncleiJned/unaccompanied

few minutes afterarrival (after alailed attempt at

ln case of death oi a patient within a
address:
resuscitation), the written guidance shall
patients and recording the entire
a) Process of registration of such
resuscitation events '
The decision on whetherto perform
apost-mortem'
b)
The temporary storage of the body in
appropriate conditions'
c)
of cause ol death and handing over
ol the body'
d) lssue of Medicalcertificate

@fl CQBE E Commitment

,!l,i',.''.,...I,..
E Achlevement E Excellence
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t_

NABH

(
Standard

t_ Obiective Elements
t.. Comm ment a' The organisation
has accessto ambulance servlces
commensurate wlth the

L ""op"
ol th"
="*ices
provlded byit'

lnterpretatlon: Commensurate to
its scope of services' the organisation
may
L- out-sourced ambulance service
provide in-house or use
for safe patient transport

with aPPropriate care'

the appropriate level of an ambulance to
be
The organisation should decide
Code AIS-145'
o'o'''i"i J"J on the National Ambulance

for'the ambulance(s)'
Commitment b There are adequate access and space
demarcate a proper space for the
lnterpretation: The organisation shall for
shallbe done keeping in mind easy accessibility
ambulance(s). The demarcation and
quicklv. Adequate
;;;t;;,,""s and enabling the ambutance(s) to exit
'o;;"i;i;"rne should exisito guide the ambulance
drivers to the ambulance
organisation
d-epartment' It is preferable that the
entry and route to the emergency
has an ambulance Parking bay'

Commitment c' Theambulance(s)isfltlorpurposeandlsapproprlatelyeqrrjpped.

as an ambulance.. shall adhere to statutory
lnterpretation: The vehicle used
e.g. registration as an ambulance
undlr the Motor Vehicle Act' valid
requirement,
of thevehicle'
,il"r. poilution controlcertificate' and insurance
""nir,"*, support equipment'
shall have at least basic life
It is expected that any ambulance
-iin scope'
i"r ,Jr, and paediatric patients' Based on. the organisation's
and resuscitatlye equipment' nlay be
additional equipment, e.g' moniipring
available in the ambulance'
AIS-'I 25'
Referto NationalAmbulance code

The ambulance(s) is operated

bytralned personnel'
Commitment d
lnterpretation:Theambulanceshouldbeoperaledbyadriverwithavalidlicence'
doctor mey be there depsnding on the
Additionally, technician/nurse and/or
in the ambulance shall have
scope ol the ambulance PersonhEl
"*"ii"" "'.0
i*,.i"n i.i"t"*e support, and be trained in basic cardiopulmonary
resuscitation'

@ C9BE @ Commttment @ Achlevement @ Excellencs

98re
 ql

NABH

Commitment e, The ambulance(s) ls checked daily.

lnterpretation: The check shall indicate thefunctioning status of the ambulance like
lights, siren, beacon lights, etc. Also, the ambulance shall undergo servicing as per
the set schedule. The ambulanceshould have adequate fuelatalltimes.

Commitment l. Equlpment ischecked dally uslng a checklist. *

lnterpretatlon: The checks shall indicate the functioning status of the equipment
based on adocumented check{isl.

Commitment S A mechanism ls ln place to ensure that emergency medicatlons are available

in the ambulance.

Interpretation: Emergency medications are available in the ambulance during

patient transport. Based on a check-list, a daily check is done to ensure
availability and expiry dates oJ emergency medications and documented. After
the return from every trip, medications used should be topped up and the same
verlfied a

Commitment h. The ambulance(s) has a propercommunication system.*

lnterpretation: The ambulance shall be connected with the organisation/control

room by wireless/mobile phones. The communication system should encompass
the whole process of patient transport. There should be written guidance by the
organisation as to how a call for patient transport is received, who are the people
expected to respond and organise the transport. The communication ensures that
the ambulance leaves the hospital within a predefined timeframe based upon the
patient's needs.

Achievement i The emergency department identifies opportunities to lnlUate treatment at

lhe earliestwhen the patient isln transit to the organlsation.
lnterpretation: From the time of first communicatlon with the patienv patient's
attendant, afile is created to record appropriate information, attempts are made to
gather important clinical information (patients age, weight, provisional diagnosis
and ongoing treatment at the refening organisalion). This information is used by the
ambulance personnel ofthe receiving organisation to be better prepared to assess,
initiate emergency carelnterventions during transit and kansport the patient safely.
During the transit, when required, there is an exchange of information between the
ambulance personnel and the medical professional at the receiving organisation,
The information will help the doctor at the receiving organisation guide the
ambulance personnel to facilitate the management during the transit. When the
patient is being shifted by an external agency, wherever possible, an attempt is
made by the doctor of thd receiving organisation to communicate with the
ambulance personnel of the exblnal agency to ascertain the clinical situation and
make appropriate suggestibns. However, the medical professional in the
ambulance would be responsible for decision-making regarding the
care/interventions during the transit.

$ffi cone $ commitmenr @ a"hi"r"r"n, @fl Exceuence

 NABH
( {
Standard

Obiective Elements
l_ communlty emergencies' epidemlcs
L Commitment a. The orqanlsation identifies potentlal
and other dlsasters.*

lnterpretation: The organisation shall

identify potential community emergencies'
to cause a sudden. rush of victims Some
epidemics and other disasters likely
civil. unrest outside the
;r;;; include earthquat<e' ttooo' train accident'
;;i;;r'";; majorfire and outbreak otdisease/epidemics'
or"mises,

Theseshallbeidentifiedbasedongeographicallocationand.thecommunityServed
organisation ln an induslrial town should
by the organisation. For exampb] an
in its vicinity'
iaentitytnJlnaustrialhazard that may occur

emergencles' epidemics and other

Commitment b The organisation manages community
plan'*
disasters as pera documented
incorporate essentialelements of alelt code'
tnterpretation: The disaster plan must
cards for each ol the staff' availability and
information and communication, action
supplies' equipment'
;;;;ki"s of resources including adequacy of medical.
ot command nucleus' training and mock
materials, trained personnel, establLhment could
during the event' The emelgency room
drills, and managing clinical activities
National Disaster Management Authority
follow triage policy according to the
(NDMA) guidelines.

ltshouldalsoincludeaspectslikeactivatinganddeactivatingplan;receive,identify
and treatment tor casualties;
*r'"g" ."*rtles; defined areas for reception
"nO
transportation aids; communication
aids; manage visitors' and control the
relocate/discharge admitted patients
movement of individuals and vehicles'
wherever needed.
local laws and national plans on disaster
The plans should conform to the relevant
management. Agood reference is NDMA guidelines'

and
Commitment c. Provislon ls made lor availability ol medlcal supplies, equlpment
materlals durlng such emergencles'

lnterpretatton:Resourceavailabilityshouldbeaccordingtothreatperception'The
numberofresources'i.e.medicalconsumables,equipment'etc.tobe
commensuratewith the expectedworkload'

Achievement Excellence
CERE Commitment 100@
 i

NAB
,( I
commitment d. The plan istested at leasttwice atear.

lnterpretation: Testing twice ayear is only the minimum frequency, and this may be
of
increased. ln case the organisation has different plans for differentdisasters, each
the plans shall be tested at leasttwice ayea(

The plan can be tested using a table-top exercise, or a mock drill At a minimum' at
leasi one mock drill should be held once in 12 months. This shall test all the
componentsof the plan and notiust awareness.ln the case of amockdrill, simulated
patients (not real) shall be used. After e'/ery table-top exercise/mock drill, the
variations are identified, the reason forthe same is analysed, debriefing conducted
and where appropriate the necessary corrective and/or preventive actionsare taken.

Standard
Cardio-pulmonary resuscltation services are provlded uniformly
coP.5.
across the organisatlon.

Objective Elenrents
Commitment a. Resuscltation services are availableto patients at alltimes.

lnterpretation: The organisation shall document the procedure for cardio-

pulmonary resuscitation for adults across all areas in the organisation. This shall be
in consonance with accepted practices. Where appropriate, it shall also address
paediatric and neonatal patients. The organisation shall ensure that adequate and
appropriate resources (both men and material) are plovided. Basic llfe support
should be initiated as soon as a condition requiring CPH is identified. This is
implemented in all areas of the organisation. The protocols could be displayed
prominentlyin allcriticalareas such as emergency' lCU, Of, etc.

Commitment b. Durlng cardlo-pulmonary resuscitatlon, asslgned roles and responsibilities

are complied with.

lnterpretation: The team members have a clear understanding of their roles and
responsibilities during the resuscitationto effectively function as ateam.

Commitment e Equipment and medications for use durlng eardlo'pulmonary resuscitation

are available invarlous areas of the organisatlon'

tnterpretatlon: At a minimum, emergency medications and equipment for

intubation should be available in all patient care areas including the blood bank,,
radiolqgy, OPD, rehalilltaliop services areas, eado]lpPYi and. in areas where any
procedure is performdd. Other equipment Iike defibrillator should be easily aceessible
to ensure that there is no delay in cardio-pulmonary resuscitation. lt is preferable that
the minimum emergency medication is standardised acrossthe organisation.

@ cone @ commitmenr @ A"hi"'"'"nt ffi! Excettence

I

NABH
:
I
cqrnftr"lt d, The events during cardio-pulmonary resuscitation are recorded. t
.j
lnterpretatlon: ln the actual event of cardio-pulmonary resuscitation, ora mock drill
of the same, allthe'activities along with the personnel attended should be recorded.
At the minimum, it will include timeliness of _response, availability of*iuman
resources, equipment,.qugs, and barrierqif any. The recording could be done using
the pre-defined procedural checkist and by monitoring whether the prescribed
activity has been performed properlyand inthe rightsequence.

Commitment o. A multldlsciplinary committee does a post-event analysls of cardlo- -

pulmonary resuscitations.

lnterpretatlon: The analysis shall focus on the initiation of CPR, time of arrival of the
team, availability of required resources, recording of the sequence of events
during CPR (including technique) and the overall coordination. The organisation
shall also monitor the outcomes. The multidisciplinary committee shall be
independent?nd include at least one physician/cardiologist, anaesthesiologist,
one member from the code blue team and nurse. The analysis should be
completed within a defined time frame.

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

lnierpretatlon: Corrective and preventive measures should be completed within

a defined time frame. The findings of the post-event analysis are communicated
to the personnel participating in the CPR. Any lapses should be discussed, with
the view to improve the outcomes in future. During subsequentJesuscitations, it
is preferable that implementation of these actions is noted and training be
modified, if necessary.

Standard
. ,1;i
care ts tn 1n
coP.6. ,: i.a

Objective Elements
Commitment a. Nursing car6 is provlded to patlents ln accordance with wrltten guldance. *

lnterpretation: The written guidance could be in the form of a nursing

manua/SOps
incorporating various basic nursing practices and procedures. Examples ofihe-se
are monitoring vitalpararneters, administration of medications, basic hygiene h6-qdb
ofthe patient, etc.

@ CEHE Commitment Achievement @

t-
Excellence
102E;:#,EEe

I
 i-
:.

F'
NABH
/i
nursir{E cllnical practlce
Achievement b'' The organtsation develops and imptements *
standards of praclice'
guidelines rellecting current
situations shall be guided by
lnterpretation: Care of patients in specific clinical
practices' The nursing
nuJng cfini"af practice guidelines based on best clinical
be reviewed annually at the minimum' and
clinicaf care guidelines/pathways shall
revised as appropriate.
guidelines include preventian of fall' prevention
Examples of nursing clinical practice
an in-patient' and deep venous thrombosis risk
of J"r"fop.unt of fressure ulcers in
assessment and prevention'

per current good cllnical/ nursing

Commitment c Assignment ol patient Gare ls done as
practice guldelines'

Interpretatlon:Assignmentshallbebasedonthepatient,sclinicalrequirements'
align with the guidelines laid down by
the competence of the nursing staff , and shall
regutatory and professional bodies in this regard

The organisation implements acuity'based staffing to Improve

patient
Excellence d.
outcomes.

lnterpretation:Patientoutcomesarelinkedtoacuity-basedstaffingofnursing
of outcomes include
puoonnuf , in terms of numbers and competence Examples
errors, ventilator-
in"ia"n"" of pressure sores, falls, medication administration
associated Pneumonia, etc

patient care'
CQRE e Nursing care is aligned and integrated wlth overall
per the nursing care plan' which is
lnterpretation: Care shall be provided as
patient Wherever a patient care plan
individualised as per the clinical needs of the
plan shallbe alignedwith the same' Uniformity
has been developed, the nursing care
and continuity ol care should be practised'

Components of the nursing care plan include:

/ Assessment
r' Plan ol care
/ lmplementation ol care
/ Evaluation
/ Modification of plan of careas may be required

:
Care provided bynurses is documented
inthe patigJ.:&record'
Commitment f
lnterp]etatlon:Thedocumentationincludesallnursing-relatedcareandnotiust
medication adm-inistration. The nursing
moniioring of vitals and documentation ol
individual patient'
progress ;hall bedocumented in atimely mannerforthe :
E.

@ C9RE $commlrment t Achievement @ Excellence

103 ..'' ,,-"
 NABH

equipment 'for (
Commitment S. Nurses are provlded with the appropriate and adequatel
provlding safe and efficlent nursing care'

lnterpretation: There shall be an adequate number of

sphygmomanometers'
equipmenvgadgets necessaryfor
thermometers, weighing scale(s), and other basic
shall be appropriate
lunctioning in the designated area. Further, the equipment
area should be of
for the area. For example, the BP cuffs in the Paediatric
appropriate size

Nurses are empowered to make patlent care decislons

withln their scope of
Commitment h.
practlce.
decisions that come
lnterpretation: The organisation should define the patient care
aware of the same and be
undei the scope of nursing practice' Nurses should be
in atimely manner'
able to make appropriate nursing-related decisions

For"nursing empowerment' refertothe glossary'

Standard

Obiective Elements

commitmenta.Proceduresareperformedbasedonthecllnicalngedsofthepalient'
on the clinical
lnterpretation: The decision to perform a procedure shall be based
guidelines and/or
needs of the patient, in consonance with standard treatment
sound clinical practice for the given condition/procedure' A
qualified medical
procedure options
practitioner decides if the procedure is indicated' When multiple
to provide the best
exist, the decision should be based on which option
is likely
yield/outcome,andalsotakingintoconsideration,thepatientwishesandsafety'The
procedures to achieve the best
trganisation could conduct aclinical audit olvarious
possible outcomes,

guldance' *
Commitment b. Perlormanceof various cllnical procedures ls based onwritten

tnterpretatlon:Thewrittenguidancelsabroadguidelineapplicabletoall
pro".dur"" - diagnostic, therapeutic, and supportive' The witten guidance shall
pre-procedure instructions where
incorporate as to who will do the procedure, the
post-procedureinstructions and care'
applicab[-e, ths conduct otthe procedure and

procedure'
It is preferable that a briet assessment is done priorto performing the

@! CARE @ Commitmenl @ Achievement Excellence

104 *4rr,@l
?:

NABH
ti
Commitment c. Oualified personnel order, plan, pertorm dnd hssist ln pertormlng
procedures.

lnterpretation: The personnel performing or assisting a procedure shall be

privileged forthe same.

Also, referto HRM 1 1d, HRM 12d, HRM '13c.

rr.nErE .l Cere is r.Eken to pie'-'ent adverse events like a wrong patien!, wrono
procedure and wrong site. *

lnlerpretation: The organisation shall use a documented check-list to prevent

adverse events like awrong patient, wrong procedure and wrong site. This check-list
could be based on theWHO safe-surgery saves lives check-list or its modification. At
least two identiliers should be used to identify the patient out of which one shall be
the unique identification number. Besides, the organisation should have a proqedure
to identify the site of the procedure, where appropriate. The organisation identifies
those procedures within its scope where a pre-procedure checklist could be used to
mitigatethe riskof wrong-site/side, wrong patient and wrong procedure.

Responsibility for ensuring the correct site (including side where

applicable)/patienvprocedureverification restswth allteam members. However, the
person performing the procedure carries ultimate responsibility. ln case the
procedure is being performed by a person in training, the supervising clinician
carries ullimate responsibility.

ln emergencies, all attempts should still be madeto identifythe correct site (including
side where applicable)/patienVprocedure according to the laid down guidance,
although it may not be possible or appropriate to complete all'the checks. Any
exceptions to the full protocol should be documented in the medical record.

Patient and/or relatives should be involved in ensuring correct patient, correct

procedure and correct sitewhenever possible.

Also, refer to AAC 2b, COP 1b.

Commitment e lntormed consent ls taken by the irersonnel performing the procedure,

where applicable.

lnterpretatlon: The consent shall be taken by the person performing the procedure
or adoctor from the treating team. ln case the procedure is being done by a person in
training, it shall specify the same, and shall be supervised by the treating doctor.
Also, refer to PRE 4e.

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CQRE @l commitment @ Achievement @ Excellence

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 NABH
Commitment t. The procedure is done adherlng to standard precaufions,
li
lnterpre(atioil The components of standard precautions include hand hygiene,
appropriate use of personal protective eqi.ripment, cleaning and disinfection of
equipment, and needle-stick and sharps injury prevention. Appropriate preparation
of body parts and the use of disinfected/sterilised instruments is ensured.

AIso, referto HlC3a.

Commitment !,. Patients are appropriately monitored during and after the procedure,

lnterpretation: At a minimum, for invasive procedures, this shall include pulse,

blood pressure and respiratory rate and any other parameter as clinically required.
The extent and duration of monitoring may be tailored to the need based on the
complexityof the procedure andthe co-morbidities of the patient,

Commitment h Procedures are documented accurately in the patieht record.

lnterpretation: The documentation shall mention the name of the procedure, the
person who performed the procedure, salient steps of the procedure, key findings
and the post-procedure care. All documentaflon shall have name, date, time and
signature.

Also, referto IMS 3e,

Standard

Objective Elements
Commitment a Scope ol transfuslon services is commensurate with the services provided
by the organisatlon.

lnterpretatlon: The organisation shour"d have bloodhrood components avairable

from either an in-house or out-sourced registered blood bank. ln case the
organisation uses an out-sourced blood bank, it shall have an Mou and ensure that
patient care does not suffer for want of bloocl/blood components. The blood shall
be
transported from the external blood bank safely and properly, A good reference
guide isthe NABH standards for blood banks.

@ CQRE Commitment Achievement

E Excellence
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