1

NABH Hospital Accreditation Standards 5th Edition Self Assessment Toolkit

To be filled by AUDITOR
Scores
Systems Implementation Remarks
(Rate from 1-5)
No evidence of working
No systems in place 1 (≤ 20% compliance)
towards implementation

Some evidence of
Elementary Systems are
working towards 2 (21-40% compliance)
in place
implementation
Elements There is evidence of
Systems are partially in
working towards 3 (41-60% compliance)
place
implementation
There is evidence of
Systems are in place working towards 4 (61-80% compliance)
implementation
There is evidence of
Systems are in place working towards 5 (81-100% complaince)
implementation
Chapter1:ACCESS, ASSESSMENT AND CONTINUITY OF CARE(AAC)
AAC.1:The organisation defines and displays the healthcare services that it provides.
The healthcare services being provided are defined and are in consonance There is evidence of
5 (81-100%
AAC.1. a. with Systems are in place working towards
complaince)
the needs of the community. implementation
Each defined healthcare service should have diagnostic and treatment
There is evidence of
services 5 (81-100%
AAC.1.b. Systems are in place working towards
with suitably qualified personnel who provide out-patient, in-patient and complaince)
implementation
emergency cover.
There is evidence of
5 (81-100%
AAC.1.c. Scope of the healthcare services of each department is defined. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.1.d. The organisation's defined healthcare services are prominently displayed. Systems are in place working towards
complaince)
implementation
AAC.2:The organisation has a well-defined registration and admission process.
There is evidence of
The organisation uses written guidance for registering and admitting 5 (81-100%
AAC.2.a. Systems are in place working towards
patients. * complaince)
implementation
There is evidence of
5 (81-100%
AAC.2.b. A unique identification number is generated at the end of the registration. Systems are in place working towards
complaince)
implementation
 2

There is evidence of
Patients are accepted only if the organisation can provide the required 5 (81-100%
AAC.2.c. Systems are in place working towards
service. complaince)
implementation
The written guidance also addresses managing patients during non- There is evidence of
5 (81-100%
AAC.2.d. availability Systems are in place working towards
complaince)
of beds. * implementation
Access to the healthcare services in the organisation is prioritised according There is evidence of
5 (81-100%
AAC.2.e. to Systems are in place working towards
complaince)
the clinical needs of the patient. * implementation
AAC.3:There is an appropriate mechanism for transfer (in and out) or referral of patients.
There is evidence of
5 (81-100%
AAC.3.a. Transfer-in of patients to the organisation is done appropriately. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.3.b. Transfer- out/referral of patients to another facility is done appropriately. * Systems are in place working towards
complaince)
implementation
There is evidence of
During transfer or referral, accompanying staff are appropriate to the clinical 5 (81-100%
AAC.3.c. Systems are in place working towards
condition of the patient. complaince)
implementation
There is evidence of
The organisation gives a summary of the patient's condition and the 5 (81-100%
AAC.3.d. Systems are in place working towards
treatment given. complaince)
implementation
AAC.4:Patients cared for by the organisation undergo an established initial assessment.
The initial assessment of the outpatients, day-care, in-patients and There is evidence of
5 (81-100%
AAC.4.a. emergency Systems are in place working towards
complaince)
patients is done. * implementation
There is evidence of
5 (81-100%
AAC.4.b The initial assessment is performed by qualified personnel. * Systems are in place working towards
complaince)
implementation
The initial assessment is performed within a time frame based on the needs There is evidence of
5 (81-100%
AAC.4.c. of Systems are in place working towards
complaince)
the patient. * implementation
There is evidence of
Initial assessment of day-care and in-patients includes nursing assessment, 5 (81-100%
AAC.4.d. Systems are in place working towards
which is done at the time of admission and documented. complaince)
implementation
There is evidence of
5 (81-100%
AAC.4.e. The initial assessment for in-patients results in a documented care plan. Systems are in place working towards
complaince)
implementation
There is evidence of
The care plan is countersigned by the clinician-in-charge of the patient 5 (81-100%
AAC.4.f. Systems are in place working towards
within 24 hours. complaince)
implementation
The care plan includes the identification of special needs regarding care There is evidence of
5 (81-100%
AAC.4.g. following Systems are in place working towards
complaince)
discharge. implementation
 3

AAC.5:Patients cared for by the organization undergo a regular reassessment

Patients are reassessed at appropriate intervals to determine their response There is evidence of
5 (81-100%
AAC.5.a. to Systems are in place working towards
complaince)
treatment and to plan further treatment or discharge. implementation
There is evidence of
5 (81-100%
AAC.5.b. Out-patients are informed of their next follow-up, where appropriate. Systems are in place working towards
complaince)
implementation
For in-patients during reassessment, the care plan is monitored and There is evidence of
5 (81-100%
AAC.5.c. modified, Systems are in place working towards
complaince)
where found necessary. implementation
There is evidence of
5 (81-100%
AAC.5.d. Staff involved in direct clinical care document reassessments. Systems are in place working towards
complaince)
implementation
The organisation lays down guidelines and implements processes to identify There is evidence of
5 (81-100%
AAC.5.e. early warning signs of change or deterioration in clinical conditions for Systems are in place working towards
complaince)
initiating prompt intervention. implementation
AAC.6:Laboratory services are provided as per the scope of services of the organisation.
There is evidence of
Scope of the laboratory services is commensurate to the services provided 5 (81-100%
AAC.6.a. Systems are in place working towards
by the organisation. complaince)
implementation
There is evidence of
The infrastructure (physical and equipment) is adequate to provide the 5 (81-100%
AAC.6.b. Systems are in place working towards
defined scope of services. complaince)
implementation
There is evidence of
5 (81-100%
AAC.6.c. Human resource is adequate to provide the defined scope of services. Systems are in place working towards
complaince)
implementation
Qualified and trained personnel perform and supervise the investigations There is evidence of
5 (81-100%
AAC.6.d. and Systems are in place working towards
complaince)
report the results. implementation

Requisition for tests, collection, identification, handling, safe transportation, There is evidence of
5 (81-100%
AAC.6.e. processing and disposal of a specimen is performed according to written Systems are in place working towards
complaince)
guidance. * implementation

There is evidence of
5 (81-100%
AAC.6.f. Laboratory results are available within a defined time frame. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.6.g. Critical results are intimated to the person concerned at the earliest. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.6.h. Results are reported in a standardised manner. Systems are in place working towards
complaince)
implementation
 4

There is a mechanism to address the recall / amendment of reports There is evidence of

5 (81-100%
AAC.6.i. whenever Systems are in place working towards
complaince)
applicable. * implementation
There is evidence of
Laboratory tests not available in the organisation are outsourced to the 5 (81-100%
AAC.6.j. Systems are in place working towards
organisation(s) based on their quality assurance system. * complaince)
implementation
AAC.7:There is an established laboratory quality assurance programme.
There is evidence of
5 (81-100%
AAC.7.a. The laboratory quality assurance programme is implemented. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.7.b. The programme addresses verification and/or validation of test methods. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.7.c. The programme ensures the quality of test results. * Systems are in place working towards
complaince)
implementation
There is evidence of
The programme includes periodic calibration and maintenance of all 5 (81-100%
AAC.7.d. Systems are in place working towards
equipment* complaince)
implementation
There is evidence of
The programme includes the documentation of corrective and preventive 5 (81-100%
AAC.7.e. Systems are in place working towards
actions.* complaince)
implementation
There is evidence of
5 (81-100%
AAC.7.f. The programme addresses clinicopathological meeting(s). Systems are in place working towards
complaince)
implementation
AAC.8:There is an established laboratory safety programme.
There is evidence of
5 (81-100%
AAC.8.a. The laboratory safety programme is implemented. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.8.b. This programme is aligned with the organisation's safety programme. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.8.c. Laboratory personnel are appropriately trained in safe practices. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.8.d. Laboratory personnel are provided with appropriate safety measures. Systems are in place working towards
complaince)
implementation
AAC.9:Imaging services are provided as per the scope of services of the organisation.
There is evidence of
5 (81-100%
AAC.9.a. Imaging services comply with legal and other requirements. Systems are in place working towards
complaince)
implementation
 5

There is evidence of
Scope of the imaging services is commensurate to the services provided by 5 (81-100%
AAC.9.b. Systems are in place working towards
the organisation. complaince)
implementation
There is evidence of
The infrastructure (physical and equipment) and human resources are 5 (81-100%
AAC.9.c. Systems are in place working towards
adequate to provide for its defined scope of services. complaince)
implementation
There is evidence of
Qualified and trained personnel perform, supervise and interpret the 5 (81-100%
AAC.9.d. Systems are in place working towards
investigations. complaince)
implementation
Patients are transported in a safe and timely manner to and from the There is evidence of
5 (81-100%
AAC.9.e. imaging Systems are in place working towards
complaince)
services * implementation
There is evidence of
5 (81-100%
AAC.9.f. Imaging results are available within a defined time frame. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.9.g. Critical results are intimated immediately to the personnel concerned. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.9.h. Results are reported in a standardised manner. Systems are in place working towards
complaince)
implementation
There is a mechanism to address the recall / amendment of reports There is evidence of
5 (81-100%
AAC.9.i. whenever Systems are in place working towards
complaince)
applicable. * implementation
There is evidence of
Imaging tests not available in the organisation are outsourced to the 5 (81-100%
AAC.9.j. Systems are in place working towards
organisation(s) based on their quality assurance system. * complaince)
implementation
AAC.10:There is an established quality assurance programme for imaging services.
There is evidence of
5 (81-100%
AAC.10.a. The quality assurance programme for imaging services is implemented. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.10.b. Quality assurance programme includes tests for imaging equipment. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.10.c. Quality assurance programme includes the review of imaging protocols. Systems are in place working towards
complaince)
implementation
There is evidence of
A system is in place to ensure the appropriateness of the investigations and 5 (81-100%
AAC.10.d. Systems are in place working towards
procedures for the clinical indication. complaince)
implementation
There is evidence of
The programme addresses periodic internal/external peer review of imaging 5 (81-100%
AAC.10.e. Systems are in place working towards
results using appropriate sampling. complaince)
implementation
 6

There is evidence of
5 (81-100%
AAC.10.f. The programme addresses the clinico-radiological meeting(s). Systems are in place working towards
complaince)
implementation
There is evidence of
The programme includes periodic calibration and maintenance of all 5 (81-100%
AAC.10.g. Systems are in place working towards
equipment. * complaince)
implementation
There is evidence of
The programme includes the documentation of corrective and preventive 5 (81-100%
AAC.10.h. Systems are in place working towards
actions. * complaince)
implementation
AAC.11:There is an established safety programme in imaging services.
There is evidence of
5 (81-100%
AAC.11.a The radiation-safety programme is implemented. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.11.b. This programme is aligned with the organisation's safety programme. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
AAC.11.c. Patients are appropriately screened for safety/risk before imaging. Systems are in place working towards
complaince)
implementation
Imaging personnel and patients use appropriate radiation safety and There is evidence of
5 (81-100%
AAC.11.d. monitoring Systems are in place working towards
complaince)
devices where applicable. implementation
Radiation-safety and monitoring devices are periodically tested, and results There is evidence of
5 (81-100%
AAC.11.e. are Systems are in place working towards
complaince)
documented. * implementation
There is evidence of
Imaging and ancillary personnel are trained in imaging safety practices and 5 (81-100%
AAC.11.f. Systems are in place working towards
radiation-safety measures. complaince)
implementation
There is evidence of
5 (81-100%
AAC.11.g. Imaging signage is prominently displayed in all appropriate locations. Systems are in place working towards
complaince)
implementation
AAC.12:Patient care is continuous and multidisciplinary.
During all phases of care, there is a qualified individual identified as There is evidence of
5 (81-100%
AAC.12.a. responsible Systems are in place working towards
complaince)
for the patient's care. implementation
There is evidence of
5 (81-100%
AAC.12.b. Patient care is co-ordinated in all care settings within the organisation. Systems are in place working towards
complaince)
implementation
Information about the patient's care and response to treatment is shared There is evidence of
5 (81-100%
AAC.12.c. among Systems are in place working towards
complaince)
medical, nursing and other care -providers. implementation
 7

The Organisation implements standardiszed hand-over communication There is evidence of

5 (81-100%
AAC.12.d. during each staffing shift, between shifts and during transfers between units/ Systems are in place working towards
complaince)
departments. implementation
There is evidence of
5 (81-100%
AAC.12.e. Patient transfer within the organisation is done safely in a safe manner. Systems are in place working towards
complaince)
implementation
There is evidence of
Referral of patients to other departments/ specialities follow written 5 (81-100%
AAC.12.f. Systems are in place working towards
guidance. complaince)
implementation
The organisation ensures predictable service delivery by adhering to
defined There is evidence of
5 (81-100%
AAC.12.g. timelines and informs the patient/family and/ or caregiver whenever there is Systems are in place working towards
complaince)
a implementation
change in schedule.
The organisation has a mechanism in place to monitor whether adequate There is evidence of
5 (81-100%
AAC.12.h. clinical Systems are in place working towards
complaince)
intervention has taken place in response to a critical value alert. implementation
AAC.13:The organisation has an established discharge process.
There is evidence of
The patient's discharge process is planned in consultation with the patient 5 (81-100%
AAC.13.a. Systems are in place working towards
and/or family. complaince)
implementation
The discharge process is coordinated among various departments and There is evidence of
5 (81-100%
AAC.13.b. agencies Systems are in place working towards
complaince)
involved (including medico-legal and absconded cases). * implementation
There is evidence of
Written guidance governs the discharge of patients leaving against medical 5 (81-100%
AAC.13.c. Systems are in place working towards
advice. * complaince)
implementation
There is evidence of
A discharge summary is given to all the patients leaving the organisation 5 (81-100%
AAC.13.d. Systems are in place working towards
(including patients leaving against medical advice). complaince)
implementation
There is evidence of
5 (81-100%
AAC.13.e. The organisation adheres to planned discharge. Systems are in place working towards
complaince)
implementation
The organisation conforms to the defined timeframe for discharge and There is evidence of
5 (81-100%
AAC.13.f. makes Systems are in place working towards
complaince)
continual improvement. implementation
AAC.14:The organisation defines the content of the discharge summary.
There is evidence of
5 (81-100%
AAC.14.a. A discharge summary is provided to the patients at the time of discharge. Systems are in place working towards
complaince)
implementation
Discharge summary contains the patient's name, unique identification There is evidence of
5 (81-100%
AAC.14.b. number, Systems are in place working towards
complaince)
name of the treating doctor, date of admission and date of discharge. implementation
 8

Discharge summary contains the reasons for admission, significant findings There is evidence of
5 (81-100%
AAC.14.c. and Systems are in place working towards
complaince)
diagnosis and the patient's condition at the time of discharge. implementation
Discharge summary contains information regarding investigation results, There is evidence of
5 (81-100%
AAC.14.d. any Systems are in place working towards
complaince)
procedure performed, medication administered, and other treatment given. implementation
Discharge summary contains follow-up advice, medication and other There is evidence of
5 (81-100%
AAC.14.e. instructions Systems are in place working towards
complaince)
in an understandable manner. implementation
There is evidence of
Discharge summary incorporates instructions about when and how to obtain 5 (81-100%
AAC.14.f. Systems are in place working towards
urgent care. complaince)
implementation
There is evidence of
5 (81-100%
AAC.14.g. In case of death, the summary of the case also includes the cause of death. Systems are in place working towards
complaince)
implementation

Chapter2
:CARE
OF
PATIENT
S(COP)
COP.1:Uniform care to patients is provided in all settings of the organisation and is guided by written guidance, and the applicable laws and regulations.
There is evidence of
5 (81-100%
COP.1.a. Uniform care is provided following written guidance. * Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation has a uniform process for identification of patients and at a 5 (81-100%
COP.1.b. Systems are in place working towards
minimum, uses two identifiers. complaince)
implementation
There is evidence of
5 (81-100%
COP.1.c. Care shall be provided in consonance with applicable laws and regulations. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation adapts evidence-based clinical practice guidelines and/or 5 (81-100%
COP.1.d. Systems are in place working towards
clinical protocols to guide uniform patient care. complaince)
implementation
Clinical care pathways are developed, consistently followed across all There is evidence of
5 (81-100%
COP.1.e. settings of Systems are in place working towards
complaince)
care, and reviewed periodically. implementation
Care delivery is uniform for a given clinical condition when similar care is There is evidence of
5 (81-100%
COP.1.f. provided Systems are in place working towards
complaince)
in more than one setting. * implementation
 9

Multi-disciplinary and multi-speciality care, where appropriate, is planned

based There is evidence of
5 (81-100%
COP.1.g. on best clinical practices/clinical practice guidelines and delivered in a Systems are in place working towards
complaince)
uniform implementation
manner across the organisation.
There is evidence of
Telemedicine facility is provided safely and securely based on written 5 (81-100%
COP.1.h. Systems are in place working towards
guidance. * complaince)
implementation
COP.2:Emergency services are provided in accordance with written guidance, applicable laws and regulations.
There shall be an identified area in the organisation which is easily
There is evidence of
accessible to 5 (81-100%
COP.2.a. Systems are in place working towards
receive and manage emergency patients, with adequate and appropriate complaince)
implementation
resources.
There is evidence of
Prevention of patient over-crowding is planned, and crowd management 5 (81-100%
COP.2.b. Systems are in place working towards
measures are implemented. complaince)
implementation
There is evidence of
Emergency care is provided in consonance with statutory requirements and 5 (81-100%
COP.2.c. Systems are in place working towards
in accordance with the written guidance. * complaince)
implementation
There is evidence of
The organisation manages medico-legal cases in accordance with statutory 5 (81-100%
COP.2.d. Systems are in place working towards
requirements. * complaince)
implementation
There is evidence of
5 (81-100%
COP.2.e. Initiation of appropriate care is guided by a system of triage. * Systems are in place working towards
complaince)
implementation
Patients waiting in the emergency are reassessed as appropriate for change There is evidence of
5 (81-100%
COP.2.f. in Systems are in place working towards
complaince)
status. implementation
There is evidence of
Admission, discharge to home, or transfer to another organisation is 5 (81-100%
COP.2.g. Systems are in place working towards
documented. complaince)
implementation
In case of discharge to home or transfer to another organisation, a There is evidence of
5 (81-100%
COP.2.h. discharge/ Systems are in place working towards
complaince)
transfer note shall be given to the patient. implementation
There is evidence of
5 (81-100%
COP.2.i. The organisation shall implement a quality assurance programme. * Systems are in place working towards
complaince)
implementation
The organisation has systems in place for the management of patients There is evidence of
5 (81-100%
COP.2.j. found Systems are in place working towards
complaince)
dead on arrival and patients who die within a few minutes of arrival * implementation
COP.3:Ambulance services ensure safe patient transportation with appropriate care
 10

There is evidence of
The organisation has access to ambulance services commensurate with the 5 (81-100%
COP.3.a. Systems are in place working towards
scope of the services provided by it. complaince)
implementation
There is evidence of
5 (81-100%
COP.3.b. There are adequate access and space for the ambulance(s). Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.3.c. The ambulance(s) is fit for purpose and is appropriately equipped. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.3.d. The ambulance(s) is operated by trained personnel. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.3.e. The ambulance(s) is checked daily. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.3.f. Equipment is checked daily using a checklist. * Systems are in place working towards
complaince)
implementation
A mechanism is in place to ensure that emergency medications are There is evidence of
5 (81-100%
COP.3.g. available in Systems are in place working towards
complaince)
the ambulance. implementation
There is evidence of
5 (81-100%
COP.3.h. The ambulance(s) has a proper communication system.* Systems are in place working towards
complaince)
implementation
The emergency department identifies opportunities to initiate treatment at There is evidence of
5 (81-100%
COP.3.i. the Systems are in place working towards
complaince)
earliest when the patient is in transit to the organisation. implementation
COP.4:The organisation plans and implements mechanisms for the care of patients during community emergencies, epidemics and other disasters.
The organisation identifies potential community emergencies, epidemics There is evidence of
5 (81-100%
COP.4.a. and Systems are in place working towards
complaince)
other disasters.* implementation
There is evidence of
The organisation manages community emergencies, epidemics and other 5 (81-100%
COP.4.b. Systems are in place working towards
disasters as per a documented plan.* complaince)
implementation
Provision is made for availability of medical supplies, equipment and There is evidence of
5 (81-100%
COP.4.c. materials Systems are in place working towards
complaince)
during such emergencies. implementation
There is evidence of
5 (81-100%
COP.4.d. The plan is tested at least twice a year. Systems are in place working towards
complaince)
implementation
COP.5:Cardio-pulmonary resuscitation services are provided uniformly across the organisation.
There is evidence of
5 (81-100%
COP.5.a. Resuscitation services are available to patients at all times. Systems are in place working towards
complaince)
implementation
 11

During cardio-pulmonary resuscitation, assigned roles and responsibilities There is evidence of

5 (81-100%
COP.5.b. are Systems are in place working towards
complaince)
complied with. implementation
Equipment and medications for use during cardio-pulmonary resuscitation There is evidence of
5 (81-100%
COP.5.c. are Systems are in place working towards
complaince)
available in various areas of the organisation. implementation
There is evidence of
5 (81-100%
COP.5.d. The events during cardio-pulmonary resuscitation are recorded. Systems are in place working towards
complaince)
implementation
A multidisciplinary committee does a post-event analysis of There is evidence of
5 (81-100%
COP.5.e. cardiopulmonary Systems are in place working towards
complaince)
resuscitations. implementation
There is evidence of
Corrective and preventive measures are taken based on the post-event 5 (81-100%
COP.5.f. Systems are in place working towards
analysis. complaince)
implementation
COP.6: Nursing care is provided to patients in the organisation in consonance with clinical protocols.
There is evidence of
5 (81-100%
COP.6.a. Nursing care is provided to patients in accordance with written guidance. *
Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation develops and implements nursing clinical practice 5 (81-100%
COP.6.b. Systems are in place working towards
guidelines reflecting current standards of practice. * complaince)
implementation
Assignment of patient care is done as per current good clinical/ nursing There is evidence of
5 (81-100%
COP.6.c. practice Systems are in place working towards
complaince)
guidelines. implementation
There is evidence of
The organisation implements acuity-based staffing to improve patient 5 (81-100%
COP.6.d. Systems are in place working towards
outcomes. complaince)
implementation
There is evidence of
5 (81-100%
COP.6.e. Nursing care is aligned and integrated with overall patient care. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.6.f. Care provided by nurses is documented in the patient record. Systems are in place working towards
complaince)
implementation
Nurses are provided with appropriate and adequate equipment for providing There is evidence of
5 (81-100%
COP.6.g. safe Systems are in place working towards
complaince)
and efficient nursing care. implementation
There is evidence of
Nurses are empowered to make patient care decisions within their scope of 5 (81-100%
COP.6.h. Systems are in place working towards
practice. complaince)
implementation
COP.7:Clinical procedures are performed in a safe manner.
There is evidence of
5 (81-100%
COP.7.a. Procedures are performed based on the clinical needs of the patient. Systems are in place working towards
complaince)
implementation
 12

There is evidence of
5 (81-100%
COP.7.b. Performance of various clinical procedures is based on written guidance. * Systems are in place working towards
complaince)
implementation
There is evidence of
Qualified personnel order, plan, perform and assist in performing 5 (81-100%
COP.7.c. Systems are in place working towards
procedures. complaince)
implementation
Care is taken to prevent adverse events like a wrong patient, wrong There is evidence of
5 (81-100%
COP.7.d. procedure Systems are in place working towards
complaince)
and wrong site. * implementation
Informed consent is taken by the personnel performing the procedure, There is evidence of
5 (81-100%
COP.7.e. where Systems are in place working towards
complaince)
applicable. implementation
There is evidence of
5 (81-100%
COP.7.f. The procedure is done adhering to standard precautions. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.7.g. Patients are appropriately monitored during and after the procedure. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.7.h. Procedures are documented accurately in the patient record. Systems are in place working towards
complaince)
implementation
COP.8:Transfusion services are provided as per the scope of services of the organisation, safely.
There is evidence of
Scope of transfusion services is commensurate with the services provided 5 (81-100%
COP.8.a. Systems are in place working towards
by the organisation. complaince)
implementation
There is evidence of
5 (81-100%
COP.8.b. Transfusion of blood and blood components is done safely. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.8.c. Blood and blood components are used rationally. * Systems are in place working towards
complaince)
implementation
There is evidence of
Informed consent is obtained for transfusion of blood and blood 5 (81-100%
COP.8.d. Systems are in place working towards
components. complaince)
implementation
There is evidence of
Informed consent also includes patient and family education about the 5 (81-100%
COP.8.e. Systems are in place working towards
donation. complaince)
implementation
Blood/blood components are available for use in emergency situations There is evidence of
5 (81-100%
COP.8.f. within a Systems are in place working towards
complaince)
defined time-frame. * implementation
There is evidence of
Post-transfusion form is collected, reactions if any identified and are 5 (81-100%
COP.8.g. Systems are in place working towards
analysed for preventive and corrective actions. complaince)
implementation
 13

There is evidence of
5 (81-100%
COP.8.h. The organisation shall implement a quality assurance programme. * Systems are in place working towards
complaince)
implementation
COP.9:The organisation provides care in intensive care and high dependency units in a systematic manner.
Care of patients in intensive care and high dependency units is provided There is evidence of
5 (81-100%
COP.9.a. based on Systems are in place working towards
complaince)
written guidance. * implementation
There is evidence of
The defined admission and discharge criteria for intensive care and high 5 (81-100%
COP.9.b. Systems are in place working towards
dependency units are implemented. * complaince)
implementation
There is evidence of
5 (81-100%
COP.9.c. Adequate staff and equipment are available. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation endeavours to upgrade its physical infrastructure to meet 5 (81-100%
COP.9.d. Systems are in place working towards
national and international guidelines. complaince)
implementation
There is evidence of
5 (81-100%
COP.9.e. Defined procedures for the situation of bed shortages are followed. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.9.f. Infection control practices are followed. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.9.g. The organisation shall implement a quality assurance programme. * Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation has a mechanism to counsel the patient and/or family 5 (81-100%
COP.9.h. Systems are in place working towards
periodically. complaince)
implementation
COP.10:Organisation provides safe obstetric care.
There is evidence of
5 (81-100%
COP.10.a. Obstetric services are organised and provided safely. * Systems are in place working towards
complaince)
implementation
The organisation identifies and, provides care to high-risk obstetric cases, There is evidence of
5 (81-100%
COP.10.b. and Systems are in place working towards
complaince)
where needed, refers them to another appropriate centre. implementation
There is evidence of
5 (81-100%
COP.10.c. Persons caring for high-risk obstetric cases are competent. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.10.d. Ante-natal services are provided. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.10.e. Obstetric patient's assessment also includes maternal nutrition. Systems are in place working towards
complaince)
implementation
 14

There is evidence of
5 (81-100%
COP.10.f. Appropriate peri-natal and post-natal monitoring is performed. Systems are in place working towards
complaince)
implementation
The organisation caring for high-risk obstetric cases has the facilities to take There is evidence of
5 (81-100%
COP.10.g. care Systems are in place working towards
complaince)
of neonates of such cases. implementation
COP.11:Organisation provides safe paediatric services.
There is evidence of
5 (81-100%
COP.11.a. Paediatric services are organised and provided safely. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.11.b. Neonatal care is in consonance with the national/ international guidelines. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.11.c. Those who care for children have age-specific competency. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.11.d. Provisions are made for special care of children. Systems are in place working towards
complaince)
implementation
There is evidence of
Paediatric assessment includes growth, developmental and immunisation 5 (81-100%
COP.11.e. Systems are in place working towards
assessment. complaince)
implementation
There is evidence of
The organisation has measures in place to prevent child/neonate abduction 5 (81-100%
COP.11.f. Systems are in place working towards
and abuse. * complaince)
implementation
The child's family members are educated about nutrition, immunisation and There is evidence of
5 (81-100%
COP.11.g. safe Systems are in place working towards
complaince)
parenting. implementation
COP.12:Procedural sedation is provided in a consistent and safe manner.
There is evidence of
5 (81-100%
COP.12.a. Procedural sedation is administered in a consistent manner * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.12.b. Informed consent for administration of procedural sedation is obtained. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.12.c. Competent and trained persons administer sedation. Systems are in place working towards
complaince)
implementation
There is evidence of
The person monitoring sedation is different from the person performing the 5 (81-100%
COP.12.d. Systems are in place working towards
procedure. complaince)
implementation
 15

Intra-procedure monitoring includes at a minimum the heart rate, cardiac There is evidence of
5 (81-100%
COP.12.e. rhythm, Systems are in place working towards
complaince)
respiratory rate, blood pressure, oxygen saturation, and level of sedation. implementation
There is evidence of
5 (81-100%
COP.12.f. Patients are monitored after sedation, and the same is documented. Systems are in place working towards
complaince)
implementation
There is evidence of
Criteria are used to determine the appropriateness of discharge from the 5 (81-100%
COP.12.g. Systems are in place working towards
observation/recovery area. * complaince)
implementation
Equipment and workforce are available to manage patients who have gone There is evidence of
5 (81-100%
COP.12.h. into a Systems are in place working towards
complaince)
deeper level of sedation than initially intended. implementation
COP.13:Anaesthesia services are provided in a consistent and safe manner.
There is evidence of
5 (81-100%
COP.13.a. Anaesthesia services are provided in a consistent manner* Systems are in place working towards
complaince)
implementation
The pre-anaesthesia assessment results in the formulation of an There is evidence of
5 (81-100%
COP.13.b. anaesthesia plan Systems are in place working towards
complaince)
which is documented. implementation
There is evidence of
5 (81-100%
COP.13.c. A pre-induction assessment is performed and documented. Systems are in place working towards
complaince)
implementation
There is evidence of
The anaesthesiologist obtains informed consent for administration of 5 (81-100%
COP.13.d. Systems are in place working towards
anaesthesia. complaince)
implementation
During anaesthesia, monitoring includes regular recording of temperature,
heart There is evidence of
5 (81-100%
COP.13.e. rate, cardiac rhythm, respiratory rate, blood pressure, oxygen saturation and Systems are in place working towards
complaince)
end-tidal implementation
carbon dioxide.
There is evidence of
5 (81-100%
COP.13.f. Patient's post-anaesthesia status is monitored and documented. Systems are in place working towards
complaince)
implementation
There is evidence of
The anaesthesiologist applies defined criteria to transfer the patient from the 5 (81-100%
COP.13.g. Systems are in place working towards
recovery area. * complaince)
implementation
The type of anaesthesia and anaesthetic medications used are documented There is evidence of
5 (81-100%
COP.13.h. in Systems are in place working towards
complaince)
the patient record. implementation
Procedures shall comply with infection control guidelines to prevent cross- There is evidence of
5 (81-100%
COP.13.i. infection Systems are in place working towards
complaince)
between patients. implementation
 16

There is evidence of
5 (81-100%
COP.13.j. Intraoperative adverse anaesthesia events are recorded and monitored. Systems are in place working towards
complaince)
implementation
COP.14:Surgical services are provided in a consistent and safe manner.
There is evidence of
5 (81-100%
COP.14.a. Surgical services are provided in a consistent and safe manner. * Systems are in place working towards
complaince)
implementation
Surgical patients have a preoperative assessment, a documented pre- There is evidence of
5 (81-100%
COP.14.b. operative Systems are in place working towards
complaince)
diagnosis, and pre-operative instructions are provided before surgery. implementation
There is evidence of
5 (81-100%
COP.14.c. Informed consent is obtained by a surgeon before the procedure. Systems are in place working towards
complaince)
implementation
Care is taken to prevent adverse events like the wrong site, wrong patient There is evidence of
5 (81-100%
COP.14.d. and Systems are in place working towards
complaince)
wrong surgery. * implementation
There is evidence of
An operative note is documented before transfer out of patient from 5 (81-100%
COP.14.e. Systems are in place working towards
recovery. complaince)
implementation
There is evidence of
5 (81-100%
COP.14.f. Postoperative care is guided by a documented plan. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.14.g. Patient, personnel and material flow conform to infection control practices. Systems are in place working towards
complaince)
implementation
Appropriate facilities, equipment, instruments and supplies are available in There is evidence of
5 (81-100%
COP.14.h. the Systems are in place working towards
complaince)
operating theatre. implementation
There is evidence of
5 (81-100%
COP.14.i. The organisation shall implement a quality assurance programme. * Systems are in place working towards
complaince)
implementation
The quality assurance programme includes surveillance of the operation There is evidence of
5 (81-100%
COP.14.j. theatre Systems are in place working towards
complaince)
environment. * implementation
COP.15:The organ transplant programme is carried out safely.
The organ transplant program shall be in consonance with the legal There is evidence of
5 (81-100%
COP.15.a. requirements Systems are in place working towards
complaince)
and shall be conducted ethically. implementation
There is evidence of
5 (81-100%
COP.15.b. Care of transplant patients is guided by clinical practice guidelines. * Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation ensures education and counselling of recipient and donor 5 (81-100%
COP.15.c. Systems are in place working towards
through trained/qualified counsellors before organ transplantation. complaince)
implementation
 17

There is evidence of
The organisation shall take measures to create awareness regarding organ 5 (81-100%
COP.15.d. Systems are in place working towards
donation. complaince)
implementation
COP.16:The organisation identifies and manages patients who are at higher risk of morbidity/ mortality.
There is evidence of
5 (81-100%
COP.16.a. The organisation identifies and manages vulnerable patients. * Systems are in place working towards
complaince)
implementation
The organisation provides for a safe and secure environment for the There is evidence of
5 (81-100%
COP.16.b. vulnerable Systems are in place working towards
complaince)
patient. implementation
There is evidence of
5 (81-100%
COP.16.c. The organisation identifies and manages patients who are at a risk of fall.* Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation identifies and manages patients who are at risk of 5 (81-100%
COP.16.d. Systems are in place working towards
developing/worsening of pressure ulcers.* complaince)
implementation
The organisation identifies and manages patients who are at risk of There is evidence of
5 (81-100%
COP.16.e. developing Systems are in place working towards
complaince)
deep vein thrombosis.* implementation
There is evidence of
5 (81-100%
COP.16.f. The organisation identifies and manages patients who need restraints. * Systems are in place working towards
complaince)
implementation
COP.17:Pain management for patients is done in a consistent manner.
There is evidence of
5 (81-100%
COP.17.a. Patients in pain are effectively managed. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.17.b. Patients are screened for pain. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.17.c. Patients with pain undergo detailed assessment and periodic reassessment. Systems are in place working towards
complaince)
implementation
Pain alleviation measures or medications are initiated and titrated according There is evidence of
5 (81-100%
COP.17.d. to Systems are in place working towards
complaince)
the patient's need and response. implementation
COP.18:Rehabilitation services are provided to the patients in a safe, collaborative and consistent manner.
Scope of the rehabilitation services at a minimum is commensurate to the There is evidence of
5 (81-100%
COP.18.a. services Systems are in place working towards
complaince)
provided by the organisation. implementation
There is evidence of
5 (81-100%
COP.18.b. Rehabilitation services are provided in a consistent manner. Systems are in place working towards
complaince)
implementation
 18

There is evidence of
5 (81-100%
COP.18.c. Care providers collaboratively plan rehabilitation services. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.18.d. There are adequate space and equipment to provide rehabilitation. Systems are in place working towards
complaince)
implementation
Care is guided by functional assessment and periodic re-assessments There is evidence of
5 (81-100%
COP.18.e. which are Systems are in place working towards
complaince)
done and documented. implementation
There is evidence of
5 (81-100%
COP.18.f. Care is provided adhering to infection control and safety practices. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.18.g. Care pathways are developed, implemented, and reviewed periodically. Systems are in place working towards
complaince)
implementation
COP.19:Nutritional therapy is provided to patients consistently and collaboratively.
There is evidence of
5 (81-100%
COP.19.a. Patients admitted to the organisation are screened for nutritional risk. * Systems are in place working towards
complaince)
implementation
There is evidence of
Nutritional assessment is done for patients found at risk during nutritional 5 (81-100%
COP.19.b. Systems are in place working towards
screening. complaince)
implementation
There is evidence of
5 (81-100%
COP.19.c. The therapeutic diet is planned and provided collaboratively. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.19.d. Patients receive food according to the written order for the diet. Systems are in place working towards
complaince)
implementation
There is evidence of
When family provides food, they are educated about the patient's diet 5 (81-100%
COP.19.e. Systems are in place working towards
limitations. complaince)
implementation
COP.20:End-of-life-care is provided in a compassionate and considerate manner.
There is evidence of
5 (81-100%
COP.20.a. End-of-life care is provided in a consistent manner in the organisation. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.20.b. A multi-professional approach is used to provide end-of-life care. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
COP.20.c. End-of-life care is in consonance with the legal requirements. Systems are in place working towards
complaince)
implementation
End of life care also addresses the identification of the unique needs of There is evidence of
5 (81-100%
COP.20.d. such Systems are in place working towards
complaince)
patient and family. implementation
 19

Symptomatic treatment is provided and where appropriate measures are There is evidence of
5 (81-100%
COP.20.e. taken Systems are in place working towards
complaince)
for the alleviation of pain. implementation

Chapter3
:Manage
ment of
Medicati
on(MOM)
MOM.1:Pharmacy services and usage of medication is done safely.
There is evidence of
Pharmacy services and medication usage are implemented following written 5 (81-100%
MOM.1.a. Systems are in place working towards
guidance. * complaince)
implementation
There is evidence of
A multidisciplinary committee guides the formulation and implementation of 5 (81-100%
MOM.1.b. Systems are in place working towards
pharmacy services and medication usage. complaince)
implementation

There is a mechanism in place to facilitate the multidisciplinary committee to

There is evidence of
monitor literature reviews and best practice information on medication 5 (81-100%
MOM.1.c. Systems are in place working towards
management and use the information to update medication management complaince)
implementation
processes.

There is evidence of
5 (81-100%
MOM.1.d. There is a procedure to obtain medication when the pharmacy is closed. * Systems are in place working towards
complaince)
implementation
The organisation has a mechanism to inform relevant staff of key changes
There is evidence of
in 5 (81-100%
MOM.1.e. Systems are in place working towards
pharmacy services and medication usage to ensure uninterrupted and safe complaince)
implementation
care.
MOM.2.The organisation develops, updates and implements a hospital formulary.
A list of medications appropriate for the patients and as per the scope of the There is evidence of
5 (81-100%
MOM.2.a. organisation's clinical services is developed collaboratively by the Systems are in place working towards
complaince)
multidisciplinary committee. implementation
There is evidence of
The list is reviewed and updated collaboratively by the multidisciplinary 5 (81-100%
MOM.2.b. Systems are in place working towards
committee at least annually. complaince)
implementation
There is evidence of
5 (81-100%
MOM.2.c. The current formulary is available for clinicians to refer to. Systems are in place working towards
complaince)
implementation
 20

There is evidence of
5 (81-100%
MOM.2.d. The clinicians adhere to the current formulary. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation adheres to the procedure for the acquisition of formulary 5 (81-100%
MOM.2.e. Systems are in place working towards
medications. * complaince)
implementation
The organisation adheres to the procedure to obtain medications not listed There is evidence of
5 (81-100%
MOM.2.f. in the Systems are in place working towards
complaince)
formulary. * implementation
MOM.3:Medications are stored appropriately and are available where required.
There is evidence of
Medications are stored in a clean, safe and secure environment; and 5 (81-100%
MOM.3.a. Systems are in place working towards
incorporating the manufacturer's recommendation(s). complaince)
implementation
Sound inventory control practices guide storage of the medications There is evidence of
5 (81-100%
MOM.3.b. throughout Systems are in place working towards
complaince)
the organisation. implementation
There is evidence of
5 (81-100%
MOM.3.c. The organisation defines a list of high-risk medication(s). * Systems are in place working towards
complaince)
implementation
High-risk medications are stored in areas of the organisation where it is There is evidence of
5 (81-100%
MOM.3.d. clinically Systems are in place working towards
complaince)
necessary. implementation

High-risk medications including look-alike, sound-alike medications and There is evidence of

5 (81-100%
MOM.3.e. different concentrations of the same medication are stored physically apart Systems are in place working towards
complaince)
from each other. * implementation

There is evidence of
5 (81-100%
MOM.3.f. The list of emergency medications is defined and is stored uniformly. * Systems are in place working towards
complaince)
implementation
Emergency medications are available all the time and are replenished There is evidence of
5 (81-100%
MOM.3.g. promptly Systems are in place working towards
complaince)
when used. implementation
MOM.4:Medications are prescribed safely and rationally.
Medication prescription is in consonance with good practices/guidelines for There is evidence of
5 (81-100%
MOM.4.a. the Systems are in place working towards
complaince)
rational prescription of medications. * implementation
There is evidence of
The organisation adheres to the determined minimum requirements of a 5 (81-100%
MOM.4.b. Systems are in place working towards
prescription. * complaince)
implementation
There is evidence of
Drug allergies and previous adverse drug reactions are ascertained before 5 (81-100%
MOM.4.c. Systems are in place working towards
prescribing. complaince)
implementation
 21

There is evidence of
The organisation has a mechanism to assist the clinician in prescribing 5 (81-100%
MOM.4.d. Systems are in place working towards
appropriate medication. complaince)
implementation
There is evidence of
Implementation of verbal orders ensures safe medication management 5 (81-100%
MOM.4.e. Systems are in place working towards
practices. * complaince)
implementation
There is evidence of
Audit of medication orders/prescription is carried out to check for safe and 5 (81-100%
MOM.4.f. Systems are in place working towards
rational prescription of medications. complaince)
implementation
There is evidence of
Corrective and/or preventive action(s) is taken based on the audit, where 5 (81-100%
MOM.4.g. Systems are in place working towards
appropriate. complaince)
implementation
There is evidence of
6 (81-100%
MOM.4.h. Reconciliation of medications occurs at transition points of patient care. Systems are in place working towards
complaince)
implementation
MOM.5:Medications orders are written in a uniform manner.
There is evidence of
5 (81-100%
MOM.5.a. The organisation ensures that only authorised personnel write orders. * Systems are in place working towards
complaince)
implementation
Medication orders are written in a uniform location in the medical records, There is evidence of
5 (81-100%
MOM.5.b. which Systems are in place working towards
complaince)
also reflects the patient's name and unique identification number. implementation
There is evidence of
5 (81-100%
MOM.5.c. Medication orders are legible, dated, timed and signed. Systems are in place working towards
complaince)
implementation
There is evidence of
Medication orders contain the name of the medicine, route of administration, 5 (81-100%
MOM.5.d. Systems are in place working towards
strength to be administered and frequency/time of administration. complaince)
implementation
MOM.6:Medications are dispensed in a safe manner.
There is evidence of
5 (81-100%
MOM.6.a. Dispensing of medications is done safely. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.6.b. Medication recalls are handled effectively. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.6.c. Near-expiry medications are handled effectively. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.6.d. Dispensed medications are labelled. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.6.e. High-risk medication orders are verified before dispensing. Systems are in place working towards
complaince)
implementation
 22

There is evidence of
5 (81-100%
MOM.6.f. Return of medications to the pharmacy is addressed. * Systems are in place working towards
complaince)
implementation
MOM.7:Medications are administered safely.
There is evidence of
5 (81-100%
MOM.7.a. Medications are administered by those who are permitted by law to do so. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.7.b. Prepared medication is labelled before preparation of a second drug. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.7.c. The patient is identified before administration. Systems are in place working towards
complaince)
implementation
Medication is verified from the medication order and physically inspected There is evidence of
5 (81-100%
MOM.7.d. before Systems are in place working towards
complaince)
administration. implementation
There is evidence of
5 (81-100%
MOM.7.e. Strength is verified from the order before administration. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.7.f. The route is verified from the order before administration. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.7.g. Timing is verified from the order before administration. Systems are in place working towards
complaince)
implementation
There is evidence of
Measures to avoid catheter and tubing mis-connections during medication 5 (81-100%
MOM.7.h. Systems are in place working towards
administration are implemented. * complaince)
implementation
There is evidence of
5 (81-100%
MOM.7.i. Medication administration is documented. Systems are in place working towards
complaince)
implementation
There is evidence of
Measures to govern patient's self-administration of medications are 5 (81-100%
MOM.7.j. Systems are in place working towards
implemented. * complaince)
implementation
Measures to govern patient's medications brought from outside the There is evidence of
5 (81-100%
MOM.7.k. organisation Systems are in place working towards
complaince)
are implemented. * implementation
MOM.8:Patients are monitored after medication administration.
There is evidence of
5 (81-100%
MOM.8.a. Patients are monitored after medication administration. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
MOM.8.b. Medications are changed where appropriate based on the monitoring. Systems are in place working towards
complaince)
implementation
 23

There is evidence of
The organisation captures near miss, medication error and adverse drug 5 (81-100%
MOM.8.c. Systems are in place working towards
reaction. * complaince)
implementation
There is evidence of
Near miss, medication error and adverse drug reaction are reported within a 5 (81-100%
MOM.8.d. Systems are in place working towards
specified time frame. * complaince)
implementation
There is evidence of
Near miss, medication error and adverse drug reaction are collected and 5 (81-100%
MOM.8.e. Systems are in place working towards
analysed. complaince)
implementation
There is evidence of
5 (81-100%
MOM.8.f. Corrective and/or preventive action(s) are taken based on the analysis. Systems are in place working towards
complaince)
implementation
MOM.9:Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents are used in a safe manner.
There is evidence of
Narcotic drugs and psychotropic substances, chemotherapeutic agents and 5 (81-100%
MOM.9.a. Systems are in place working towards
radioactive agents are used safely. * complaince)
implementation
There is evidence of
Narcotic drugs and psychotropic substances, chemotherapeutic agents and 5 (81-100%
MOM.9.b. Systems are in place working towards
radioactive agents are prescribed by appropriate caregivers. complaince)
implementation
There is evidence of
Narcotic drugs and psychotropic substances, chemotherapeutic agents and 5 (81-100%
MOM.9.c. Systems are in place working towards
radioactive agents drugs are stored securely. complaince)
implementation
There is evidence of
Chemotherapy and radioactive agents are prepared properly and safely and 5 (81-100%
MOM.9.d. Systems are in place working towards
administered by qualified personnel. complaince)
implementation
A proper record is kept of the usage, administration and disposal of narcotic There is evidence of
5 (81-100%
MOM.9.e. drugs and psychotropic substances, chemotherapeutic agents and Systems are in place working towards
complaince)
radioactive agents. implementation
MOM.10:Implantable prosthesis and medical devices are used in accordance with laid down criteria.
Usage of the implantable prosthesis and medical devices is guided by
There is evidence of
scientific 5 (81-100%
MOM.10.a. Systems are in place working towards
criteria for each item and national/international recognised guidelines/ complaince)
implementation
approvals for such specific item(s).
There is evidence of
The organisation implements a mechanism for the usage of the implantable 5 (81-100%
MOM.10.b. Systems are in place working towards
prosthesis and medical devices. * complaince)
implementation
There is evidence of
Patient and his/her family are counselled for the usage of the implantable 5 (81-100%
MOM.10.c. Systems are in place working towards
prosthesis and medical device, including precautions if any. complaince)
implementation
The batch and the serial number of the implantable prosthesis and medical
There is evidence of
devices are recorded in the patient's medical record, the master logbook 5 (81-100%
MOM.10.d. Systems are in place working towards
and the complaince)
implementation
discharge summary.
 24

There is evidence of
Recall of implantable prosthesis and medical devices are handled 5 (81-100%
MOM.10.e. Systems are in place working towards
effectively. * complaince)
implementation
MOM.11:Medical supplies and consumables are stored appropriately and are available where required.
The organisation adheres to the defined process for the acquisition of There is evidence of
5 (81-100%
MOM.11.a. medical Systems are in place working towards
complaince)
supplies and consumables. * implementation
There is evidence of
Medical supplies and consumables are used in a safe manner, where 5 (81-100%
MOM.11.b. Systems are in place working towards
appropriate. complaince)
implementation
There is evidence of
Medical supplies and consumables are stored in a clean, safe and secure 5 (81-100%
MOM.11.c. Systems are in place working towards
environment; and incorporating the manufacturer's recommendation(s). complaince)
implementation
There is evidence of
Sound inventory control practices guide storage of medical supplies and 5 (81-100%
MOM.11.d. Systems are in place working towards
consumables complaince)
implementation
There is a mechanism in place to verify the condition of medical supplies There is evidence of
5 (81-100%
MOM.11.e. and Systems are in place working towards
complaince)
consumables implementation
Chapter4:Patient Rights and Education(PRE)
PRE.1.The organisation protects and promotes patient and family rights and informs them about their responsibilities during care.
There is evidence of
Patient and family rights and responsibilities are documented, displayed and 5 (81-100%
PRE.1.a. Systems are in place working towards
they are made aware of the same. * complaince)
implementation
There is evidence of
5 (81-100%
PRE.1.b. Patient and family rights and responsibilities are actively promoted. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PRE.1.c. The organisation protects patient and family rights. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation has a mechanism to report a violation of patient and family 5 (81-100%
PRE.1.d. Systems are in place working towards
rights. complaince)
implementation
There is evidence of
Violation of patient and family rights are monitored, analysed, and 5 (81-100%
PRE.1.e. Systems are in place working towards
corrective/preventive action taken by the top leadership of the organisation. complaince)
implementation
PRE.2:Patient and family rights support individual beliefs, values and involve the patient and family in decision-making processes.
There is evidence of
Patients and family rights include respecting values and beliefs, any special 5 (81-100%
PRE.2.a. Systems are in place working towards
preferences, cultural needs, and responding to requests for spiritual needs. complaince)
implementation
Patient and family rights include respect for personal dignity and privacy There is evidence of
5 (81-100%
PRE.2.b. during Systems are in place working towards
complaince)
examination, procedures and treatment. implementation
 25

There is evidence of
5 (81-100%
PRE.2.c. Patient and family rights include protection from neglect or abuse. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PRE.2.d. Patient and family rights include treating patient information as confidential. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PRE.2.e. Patient and family rights include the refusal of treatment. Systems are in place working towards
complaince)
implementation
Patient and family rights include a right to seek an additional opinion There is evidence of
5 (81-100%
PRE.2.f. regarding Systems are in place working towards
complaince)
clinical care. implementation
Patient and family rights include informed consent before the transfusion of
blood There is evidence of
5 (81-100% No research activity
PRE.2.g. and blood components, anaesthesia, surgery, initiation of any research Systems are in place working towards
complaince) in the Hospital
protocol implementation
and any other invasive/high-risk procedures/treatment.
Patient and family rights include a right to complain and information on how There is evidence of
5 (81-100%
PRE.2.h. to Systems are in place working towards
complaince)
voice a complaint. implementation
There is evidence of
Patient and family rights include information on the expected cost of the 5 (81-100%
PRE.2.i. Systems are in place working towards
treatment. complaince)
implementation
There is evidence of
5 (81-100%
PRE.2.j. Patient and family rights include access to their clinical records. Systems are in place working towards
complaince)
implementation
There is evidence of
Patient and family rights include information on the name of the treating 5 (81-100%
PRE.2.k. Systems are in place working towards
doctor,care plan, progress and information on their health care needs. complaince)
implementation
Patient rights include determining what information regarding their care There is evidence of
5 (81-100%
PRE.2.l. would be Systems are in place working towards
complaince)
provided to self and family. implementation
PRE.3:The patient and/or family members are educated to make informed decisions and are involved in the care planning and delivery process.
There is evidence of
The Patient and/or family members are explained about the proposed care, 5 (81-100%
PRE.3.a. Systems are in place working towards
including the risks, alternatives and benefits. complaince)
implementation
There is evidence of
The patient and/or family members are explained about the expected 5 (81-100%
PRE.3.b. Systems are in place working towards
results. complaince)
implementation
There is evidence of
The patient and/or family members are explained about the possible 5 (81-100%
PRE.3.c. Systems are in place working towards
complications. complaince)
implementation
 26

The care plan is prepared and modified in consultation with the patient There is evidence of
5 (81-100%
PRE.3.d. and/or Systems are in place working towards
complaince)
family members. implementation
The patient and/or family members are informed about the results of There is evidence of
5 (81-100%
PRE.3.e. diagnostic Systems are in place working towards
complaince)
tests and the diagnosis. implementation
There is evidence of
The patient and/or family members are explained about any change in the 5 (81-100%
PRE.3.f. Systems are in place working towards
patient's condition in a timely manner. complaince)
implementation
The patient and/or family members are provided multi-disciplinary There is evidence of
5 (81-100%
PRE.3.g. counselling Systems are in place working towards
complaince)
when appropriate. implementation
PRE.4:Informed consent is obtained from the patient or family about their care.
There is evidence of
The organisation obtains informed consent from the patient or family for 5 (81-100%
PRE.4.a. Systems are in place working towards
situations where informed consent is required. * complaince)
implementation
There is evidence of
5 (81-100%
PRE.4.b. Informed consent process adheres to statutory norms. Systems are in place working towards
complaince)
implementation
Informed consent includes information regarding the procedure; it's risks,
There is evidence of
benefits, alternatives and as to who will perform the procedure in a 5 (81-100%
PRE.4.c. Systems are in place working towards
language that complaince)
implementation
they can understand.
The organisation describes who can give consent when a patient is There is evidence of
5 (81-100%
PRE.4.d. incapable of Systems are in place working towards
complaince)
independent decision making and implements the same. * implementation
There is evidence of
5 (81-100%
PRE.4.e. Informed consent is taken by the person performing the procedure. Systems are in place working towards
complaince)
implementation
PRE.5:Patient and families have a right to information and education about their healthcare needs.
There is evidence of
Patient and/or family are educated in a language and format that they can 5 (81-100%
PRE.5.a. Systems are in place working towards
understand. complaince)
implementation
Patient and/or family are educated about the safe and effective use of There is evidence of
5 (81-100%
PRE.5.b. medication Systems are in place working towards
complaince)
and the potential side effects of the medication, when appropriate. implementation
There is evidence of
5 (81-100%
PRE.5.c. Patient and/or family are educated about food-drug interaction. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PRE.5.d. Patient and/or family are educated about diet and nutrition. Systems are in place working towards
complaince)
implementation
 27

There is evidence of
5 (81-100%
PRE.5.e. Patient and/or family are educated about immunisations. Systems are in place working towards
complaince)
implementation
Patient and/or family are educated on various pain management There is evidence of
5 (81-100%
PRE.5.f. techniques, Systems are in place working towards
complaince)
when appropriate. implementation
There is evidence of
Patient and/or family are educated about their specific disease process, 5 (81-100%
PRE.5.g. Systems are in place working towards
complications and prevention strategies. complaince)
implementation
There is evidence of
Patient and/or family are educated about preventing healthcare associated 5 (81-100%
PRE.5.h. Systems are in place working towards
infections. complaince)
implementation
The patients and/or family members' special educational needs are There is evidence of
5 (81-100%
PRE.5.i. identified and Systems are in place working towards
complaince)
addressed. implementation
PRE.6:Patients and families have a right to information on expected costs.
There is evidence of
The patient and/or family members are made aware of the pricing policy in 5 (81-100%
PRE.6.a. Systems are in place working towards
different settings (out-patient, emergency, ICU and inpatient). complaince)
implementation
There is evidence of
5 (81-100%
PRE.6.b. The relevant tariff list is available to patients. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PRE.6.c. The patient and/or family members are explained about the expected costs. Systems are in place working towards
complaince)
implementation
Patient and/or family are informed about the financial implications when There is evidence of
5 (81-100%
PRE.6.d. there is a Systems are in place working towards
complaince)
change in the care plan. implementation
PRE.7:The organisation has a mechanism to capture patient's feedback and to redress complaints.
The organisation has a mechanism to capture feedback from patients, There is evidence of
5 (81-100%
PRE.7.a. which Systems are in place working towards
complaince)
includes patient satisfaction. implementation
There is evidence of
5 (81-100%
PRE.7.b. The organisation has a mechanism to capture patient experience. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation redress patient complaints as per the defined mechanism. 5 (81-100%
PRE.7.c. Systems are in place working towards
* complaince)
implementation
There is evidence of
Patient and/or family members are made aware of the procedure for giving 5 (81-100%
PRE.7.d. Systems are in place working towards
feedback and/or lodging complaints. complaince)
implementation
There is evidence of
Feedback and complaints are reviewed and/or analysed within a defined 5 (81-100%
PRE.7.e. Systems are in place working towards
time frame. complaince)
implementation
 28

Corrective and/or preventive action(s) are taken based on the analysis There is evidence of
5 (81-100%
PRE.7.f. where Systems are in place working towards
complaince)
appropriate. implementation
PRE.8:The organisation has a system for effective communication with patients and/or families.
There is evidence of
5 (81-100%
PRE.8.a. Communication with the patients and/or families is done effectively. * Systems are in place working towards
complaince)
implementation
The organisation shall identify special situations where enhanced There is evidence of
5 (81-100%
PRE.8.b. communication Systems are in place working towards
complaince)
with patients and/or families would be required. * implementation
There is evidence of
Enhanced communication with the patients and/or families is done 5 (81-100%
PRE.8.c. Systems are in place working towards
effectively. * complaince)
implementation
There is evidence of
5 (81-100%
PRE.8.d. The organisation ensures that there is no unacceptable communication. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation has a system to monitor and review the implementation of 5 (81-100%
PRE.8.e. Systems are in place working towards
effective communication. complaince)
implementation

Chapter5
:Hospital
Infection
Control(
HIC)
HIC.1:The organisation has a comprehensive and coordinated Hospital Infection Prevention and Control (HIC) programme aimed at reducing/ eliminating
The hospital infection prevention and control programme is documented,
which There is evidence of
5 (81-100%
HIC.1.a. aims at preventing and reducing the risk of healthcare associated infections Systems are in place working towards
complaince)
in the implementation
hospital. *
The hospital infection prevention and control programme identifies high-risk
There is evidence of
activities, and has written guidance to prevent and manage infections for 5 (81-100%
HIC.1.b. Systems are in place working towards
these complaince)
implementation
activities.*
The infection prevention and control programme is reviewed and updated at There is evidence of
5 (81-100%
HIC.1.c. least Systems are in place working towards
complaince)
once a year. implementation
The infection prevention and control programme is reviewed based on There is evidence of
5 (81-100%
HIC.1.d. infection Systems are in place working towards
complaince)
control assessment tool. implementation
 29

There is evidence of
The organisation has a multi-disciplinary infection control committee, which 5 (81-100%
HIC.1.e. Systems are in place working towards
coordinates all infection prevention and control activities. * complaince)
implementation
There is evidence of
The organisation has an infection control team, which coordinates the 5 (81-100%
HIC.1.f. Systems are in place working towards
implementation of all infection prevention and control activities. * complaince)
implementation
The organisation has designated infection control officer as part of the There is evidence of
5 (81-100%
HIC.1.g. infection Systems are in place working towards
complaince)
control team. * implementation
The organisation has designated infection control nurse(s) as part of the There is evidence of
5 (81-100%
HIC.1.h. infection Systems are in place working towards
complaince)
control team. * implementation
There is evidence of
The organisation implements information, education and communication 5 (81-100%
HIC.1.i. Systems are in place working towards
programme for infection prevention and control activities for the community. complaince)
implementation
There is evidence of
5 (81-100%
HIC.1.j. The organisation participates in managing community outbreaks. Systems are in place working towards
complaince)
implementation
HIC.2:The organisation provides adequate and appropriate resources for infection prevention and control.
The management makes available resources required for the infection There is evidence of
5 (81-100%
HIC.2.a. control Systems are in place working towards
complaince)
programme. implementation
There is evidence of
The organisation earmarks adequate funds from its annual budget in this 5 (81-100%
HIC.2.b. Systems are in place working towards
regard. complaince)
implementation
There is evidence of
Adequate and appropriate personal protective equipment, soaps, and 5 (81-100%
HIC.2.c. Systems are in place working towards
disinfectants are available and used correctly. complaince)
implementation
Adequate and appropriate facilities for hand hygiene in all patient-care There is evidence of
5 (81-100%
HIC.2.d. areas are Systems are in place working towards
complaince)
accessible to healthcare providers. implementation
There is evidence of
5 (81-100%
HIC.2.e. Isolation/barrier nursing facilities are available. Systems are in place working towards
complaince)
implementation
HIC.3:The organisation implements the infection prevention and control programme in clinical areas.
There is evidence of
5 (81-100%
HIC.3.a. The organisation adheres to standard precautions at all times. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.3.b. The organisation adheres to hand-hygiene guidelines. * Systems are in place working towards
complaince)
implementation
 30

There is evidence of
5 (81-100%
HIC.3.c. The organisation adheres to transmission-based precautions. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.3.d. The organisation adheres to safe injection and infusion practices. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.3.e. Appropriate antimicrobial usage policy is established and documented * Systems are in place working towards
complaince)
implementation
The organisation implements the antimicrobial usage policy and monitors There is evidence of
5 (81-100%
HIC.3.f. the Systems are in place working towards
complaince)
rational use of antimicrobial agents. implementation
There is evidence of
5 (81-100%
HIC.3.g. The organisation implements an antibiotic stewardship programme. * Systems are in place working towards
complaince)
implementation
HIC.4:The organisation implements the infection prevention and control programme in support services.
There is evidence of
The organisation has appropriate engineering controls to prevent infections. 5 (81-100%
HIC.4.a. Systems are in place working towards
* complaince)
implementation
The organisation designs and implements a plan to reduce the risk of There is evidence of
5 (81-100%
HIC.4.b. infection Systems are in place working towards
complaince)
during construction and renovation. * implementation
There is evidence of
5 (81-100%
HIC.4.c. The organisation adheres to housekeeping procedures. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.4.d. Biomedical waste (BMW) is handled appropriately and safely. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.4.e. The organisation adheres to laundry and linen management processes. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.4.f. The organisation adheres to kitchen sanitation and food-handling issues. * Systems are in place working towards
complaince)
implementation
HIC.5:The organisation takes actions to prevent healthcare associated infections (HAI) in patients.
There is evidence of
The organisation takes action to prevent catheter-associated urinary tract 5 (81-100%
HIC.5.a. Systems are in place working towards
Infections. complaince)
implementation
The organisation takes action to prevent infection-related ventilator There is evidence of
5 (81-100%
HIC.5.b. associated Systems are in place working towards
complaince)
complication/ventilator-associated pneumonia. implementation
There is evidence of
The organisation takes action to prevent catheter linked blood stream 5 (81-100%
HIC.5.c. Systems are in place working towards
infections. complaince)
implementation
 31

There is evidence of
5 (81-100%
HIC.5.d. The organisation takes action to prevent surgical site infections. Systems are in place working towards
complaince)
implementation
HIC.6:The organisation performs surveillance to capture and monitor infection prevention and control data.
The scope of surveillance incorporates tracking and analysing of infection There is evidence of
5 (81-100%
HIC.6.a. risks, Systems are in place working towards
complaince)
rates and trends. implementation
There is evidence of
5 (81-100%
HIC.6.b. Verification of data is done regularly by the infection control team. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.6.c Surveillance is directed towards the identified high-risk activities. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HIC.6.d. Surveillance includes monitoring compliance with hand-hygiene guidelines. Systems are in place working towards
complaince)
implementation
Surveillance includes mechanisms to capture the occurrence of multi- There is evidence of
5 (81-100%
HIC.6.e. drugresistant Systems are in place working towards
complaince)
organisms and highly virulent infections. implementation
There is evidence of
Surveillance includes monitoring the effectiveness of housekeeping 5 (81-100%
HIC.6.f. Systems are in place working towards
services. complaince)
implementation
Feedback regarding surveillance data is provided regularly to the There is evidence of
5 (81-100%
HIC.6.g. appropriate Systems are in place working towards
complaince)
health care provider. implementation
The organisation identifies and takes appropriate action to control outbreaks There is evidence of
5 (81-100%
HIC.6.h. of Systems are in place working towards
complaince)
infections. implementation
Surveillance data is analysed, and appropriate corrective and preventive There is evidence of
5 (81-100%
HIC.6.I. actions Systems are in place working towards
complaince)
are taken. implementation
HIC.7:Infection prevention measures include sterilisation and/or disinfection of instruments, equipment and devices.
There is evidence of
The organisation provides adequate space and appropriate zoning for 5 (81-100%
HIC.7.a. Systems are in place working towards
sterilisation activities. complaince)
implementation
Cleaning, packing, disinfection and/or sterilisation, storing and the issue of There is evidence of
5 (81-100%
HIC.7.b. items Systems are in place working towards
complaince)
is done as per the written guidance. * implementation
Reprocessing of single-use instruments, equipment and devices are done There is evidence of
5 (81-100%
HIC.7.c. as per Systems are in place working towards
complaince)
written guidance. * implementation
There is evidence of
5 (81-100%
HIC.7.d. Regular validation tests for sterilisation are carried out and documented. * Systems are in place working towards
complaince)
implementation
 32

There is evidence of
The established recall procedure is implemented when a breakdown in the 5 (81-100%
HIC.7.e. Systems are in place working towards
sterilisation system is identified. * complaince)
implementation
HIC.8:The organisation takes action to prevent or reduce healthcare associated infections in its staff.
There is evidence of
The organisation implements occupational health and safety practices to 5 (81-100%
HIC.8.a. Systems are in place working towards
reduce the risk of transmitting microorganisms among health care providers. complaince)
implementation
There is evidence of
5 (81-100%
HIC.8.b. The organisation implements an immunisation policy for its staff. * Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation implements work restrictions for health care providers with 5 (81-100%
HIC.8.c. Systems are in place working towards
transmissible infections. complaince)
implementation
There is evidence of
The organisation implements measures for blood and body fluid exposure 5 (81-100%
HIC.8.d. Systems are in place working towards
prevention. complaince)
implementation
There is evidence of
Appropriate post-exposure prophylaxis is provided to all staff members 5 (81-100%
HIC.8.e. Systems are in place working towards
concerned. * complaince)
implementation
Chapter6: Patient Safety and Quality Improvement (PSQ)
PSQ.1. The organisation implements a structured patient-safety programme.
There is evidence of
The patient-safety programme is developed, implemented and maintained 5 (81-100%
PSQ.1.a. Systems are in place working towards
by a multi-disciplinary safety committee. * complaince)
implementation
There is evidence of
The patient-safety programme is comprehensive and covers all the major 5 (81-100%
PSQ.1.b. Systems are in place working towards
elements related to patient safety. complaince)
implementation
There is evidence of
The programme covers incidents ranging from "no harm" to "sentinel 5 (81-100%
PSQ.1.c. Systems are in place working towards
events". complaince)
implementation
There is evidence of
Designated patient safety officer(s) coordinates implementation of the 5 (81-100%
PSQ.1.d. Systems are in place working towards
patient safety programme. complaince)
implementation
Designated clinical safety officer(s) coordinates implementation of the There is evidence of
5 (81-100%
PSQ.1.e. clinical Systems are in place working towards
complaince)
aspects of the patient-safety programme. implementation
The patient-safety programme identifies opportunities for improvement There is evidence of
5 (81-100%
PSQ.1.f. based on Systems are in place working towards
complaince)
the review at pre-defined intervals. implementation
The organisation performs proactive analysis of patient safety risks and There is evidence of
5 (81-100%
PSQ.1.g. makes Systems are in place working towards
complaince)
improvements accordingly. implementation
 33

There is evidence of
5 (81-100%
PSQ.1.h. The patient-safety programme is reviewed and updated at least once a year. Systems are in place working towards
complaince)
implementation
The organisation adapts and implements national/international patient- There is evidence of
5 (81-100%
PSQ.1.i. safety Systems are in place working towards
complaince)
goals/solutions. implementation
PSQ.2.The organisation implements a structured quality improvement and continuous monitoring programme.
The quality improvement programme is developed, implemented and There is evidence of
5 (81-100%
PSQ.2.a. maintained Systems are in place working towards
complaince)
by a multi-disciplinary committee.* implementation
The quality improvement programme is comprehensive and covers all the There is evidence of
5 (81-100%
PSQ.2.b. major Systems are in place working towards
complaince)
elements related to quality assurance.* implementation
There is evidence of
The quality improvement programme improves process efficiency and 5 (81-100%
PSQ.2.c. Systems are in place working towards
effectiveness. complaince)
implementation
There is a designated individual for coordinating and implementing the There is evidence of
5 (81-100%
PSQ.2.d. quality Systems are in place working towards
complaince)
improvement programme.* implementation
The quality improvement programme identifies opportunities for There is evidence of
5 (81-100%
PSQ.2.e. improvement Systems are in place working towards
complaince)
based on the review at pre-defined intervals.* implementation
There is evidence of
The quality improvement programme is reviewed and updated at least 5 (81-100%
PSQ.2.f. Systems are in place working towards
once a year. complaince)
implementation
There is evidence of
Audits are conducted at regular intervals as a means of continuous 5 (81-100%
PSQ.2.g. Systems are in place working towards
monitoring.* complaince)
implementation
There is an established process in the organisation to monitor and improve There is evidence of
5 (81-100%
PSQ.2.h. the Systems are in place working towards
complaince)
quality of nursing care.* implementation
PSQ.3.The organisation identifies key indicators to monitor the structures, processes and outcomes, which are used as tools for continual improvement.
The organisation identifies and monitors key indicators to oversee the There is evidence of
5 (81-100%
PSQ.3.a. clinical Systems are in place working towards
complaince)
structures, processes and outcomes. implementation
The organisation identifies and monitors the key indicators to oversee There is evidence of
5 (81-100%
PSQ.3.b. infection Systems are in place working towards
complaince)
control activities. implementation
The organisation identifies and monitors key indicators to oversee the There is evidence of
5 (81-100%
PSQ.3.c. managerial Systems are in place working towards
complaince)
structures, processes and outcomes. implementation
The organisation identifies and monitors key indicators to oversee patient There is evidence of
5 (81-100%
PSQ.3.d. safety Systems are in place working towards
complaince)
activities. implementation
 34

There is evidence of
The organisation has a mechanism to capture patient reported outcome 5 (81-100%
PSQ.3.e. Systems are in place working towards
measures. complaince)
implementation
There is evidence of
5 (81-100%
PSQ.3.f. Verification of data is done regularly by the quality team. Systems are in place working towards
complaince)
implementation
There is evidence of
There is a mechanism for analysis of data which results in identifying 5 (81-100%
PSQ.3.g. Systems are in place working towards
opportunities for improvement. complaince)
implementation
There is evidence of
5 (81-100%
PSQ.3.h. The improvements are implemented and evaluated. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.3.i. Feedback about care and service is communicated to staff. Systems are in place working towards
complaince)
implementation
PSQ.4.The organisation uses appropriate quality improvement tools for its quality improvement activities.
There is evidence of
5 (81-100%
PSQ.4.a. The organisation undertakes quality improvement projects. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation uses appropriate analytical tools for its quality 5 (81-100%
PSQ.4.b. Systems are in place working towards
improvement activities. complaince)
implementation
There is evidence of
The organisation uses appropriate statistical tools for its quality 5 (81-100%
PSQ.4.c. Systems are in place working towards
improvement activities. complaince)
implementation
There is evidence of
The organisation uses appropriate managerial tools for its quality 5 (81-100%
PSQ.4.d. Systems are in place working towards
improvement activities. complaince)
implementation
PSQ.5.There is an established system for clinical audit.
There is evidence of
5 (81-100%
PSQ.5.a. Clinical audits are performed to improve the quality of patient care. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.5.b. The parameters to be audited are defined by the organisation. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.5.c. Medical and nursing staff participate in clinical audit. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.5.d. Patient and staff anonymity are maintained. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.5.e. Clinical audits are documented. Systems are in place working towards
complaince)
implementation
 35

There is evidence of
5 (81-100%
PSQ.5.f. Remedial measures are implemented. Systems are in place working towards
complaince)
implementation
PSQ.6.The patient safety and quality improvement programme are supported by the management.
There is evidence of
5 (81-100%
PSQ.6.a. The management creates a culture of safety. Systems are in place working towards
complaince)
implementation
The leaders at all levels in the organisation are aware of the intent of the There is evidence of
5 (81-100%
PSQ.6.b. patient safety and quality improvement programme and the approach to its Systems are in place working towards
complaince)
implementation. implementation
There is evidence of
Departmental leaders are involved in patient safety and quality 5 (81-100%
PSQ.6.c. Systems are in place working towards
improvement. complaince)
implementation
There is evidence of
The management makes available adequate resources required for patient 5 (81-100%
PSQ.6.d. Systems are in place working towards
safety and quality improvement programme. complaince)
implementation
There is evidence of
Organisation earmarks adequate funds from its annual budget in this 5 (81-100%
PSQ.6.e. Systems are in place working towards
regard. complaince)
implementation
There is evidence of
The management identifies organisational performance improvement 5 (81-100%
PSQ.6.f. Systems are in place working towards
targets. complaince)
implementation
The management uses the feedback obtained from the workforce to There is evidence of
5 (81-100%
PSQ.6.g. improve Systems are in place working towards
complaince)
patient safety and quality improvement programme. implementation
PSQ.7.Incidents are collected and analysed to ensure continual quality improvement.
There is evidence of
5 (81-100%
PSQ.7.a. The organisation implements an incident management system.* Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.7.b. The organisation has a mechanism to identify sentinel events.* Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
PSQ.7.c. The organisation has established processes for analysis of incidents. Systems are in place working towards
complaince)
implementation
There is evidence of
Corrective and preventive actions are taken based on the findings of such 5 (81-100%
PSQ.7.d. Systems are in place working towards
analysis. complaince)
implementation
The organisation incorporates risks identified in the analysis of incidents into There is evidence of
5 (81-100%
PSQ.7.e. the Systems are in place working towards
complaince)
risk management system. implementation
 36

The organisation shall have a process for informing various stakeholders in There is evidence of
5 (81-100%
PSQ.7.f. case Systems are in place working towards
complaince)
of a near miss/adverse event/sentinel event. implementation
Chapter7:Responsibilities of Management(ROM)
ROM.1:The organisation identifies those responsible for governance and their roles are defined.
There is evidence of
Those responsible for governance are identified, and their roles and 5 (81-100%
ROM.1.a. Systems are in place working towards
responsibilities are defined and documented. * complaince)
implementation
Those responsible for governance lay down the organisation's vision, There is evidence of
5 (81-100%
ROM.1.b. mission Systems are in place working towards
complaince)
and values.* implementation
Those responsible for governance approve the strategic and operational There is evidence of
5 (81-100%
ROM.1.c. plans Systems are in place working towards
complaince)
and the organisation's annual budget. implementation
There is evidence of
Those responsible for governance monitor and measure the performance of 5 (81-100%
ROM.1.d. Systems are in place working towards
the organisation against the stated mission. complaince)
implementation
There is evidence of
Those responsible for governance appoint the senior leaders in the 5 (81-100%
ROM.1.e. Systems are in place working towards
organisation. complaince)
implementation
There is evidence of
Those responsible for governance support safety initiatives and quality 5 (81-100%
ROM.1.f. Systems are in place working towards
improvement plans. complaince)
implementation
There is evidence of
Those responsible for governance support the ethical management 5 (81-100%
ROM.1.g. Systems are in place working towards
framework of the organisation. complaince)
implementation
There is evidence of
Those responsible for governance inform the public of the quality and 5 (81-100%
ROM.1.h. Systems are in place working towards
performance of services. complaince)
implementation
ROM.2:The leaders manage the organisation in an ethical manner.
There is evidence of
5 (81-100%
ROM.2.a. The leaders make public the vision, mission and values of the organisation. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
ROM.2.b. The leaders establish the organisation's ethical management framework. * Systems are in place working towards
complaince)
implementation
The ethical management framework includes processes for managing There is evidence of
5 (81-100%
ROM.2.c. issues Systems are in place working towards
complaince)
with ethical implications, dilemmas and concerns. implementation
There is evidence of
5 (81-100%
ROM.2.d. The organisation discloses its ownership. Systems are in place working towards
complaince)
implementation
 37

There is evidence of
5 (81-100%
ROM.2.e. The organisation honestly portrays its affiliations and accreditations. Systems are in place working towards
complaince)
implementation
ROM.3:The organisation is headed by a leader who shall be responsible for operating the organisation on a day-to-day basis.
The person heading the organisation has requisite and appropriate There is evidence of
5 (81-100%
ROM.3.a. administrative Systems are in place working towards
complaince)
qualifications. implementation
The person heading the organisation has requisite and appropriate There is evidence of
5 (81-100%
ROM.3.b. administrative Systems are in place working towards
complaince)
experience. implementation
The leader is responsible for and complies with the laid-down and There is evidence of
5 (81-100%
ROM.3.c. applicable Systems are in place working towards
complaince)
legislations, regulations and notifications. implementation
The leader appoints/participates in the recruitment of senior leadership of There is evidence of
5 (81-100%
ROM.3.d. the Systems are in place working towards
complaince)
organisation who will assist in the day-to-day functioning of the organisation. implementation
There is evidence of
The leader ensures that each organisational programme, service, site or 5 (81-100%
ROM.3.e. Systems are in place working towards
department has effective leadership. complaince)
implementation
There is evidence of
5 (81-100%
ROM.3.f. The performance of the organisation's leader is reviewed for effectiveness. Systems are in place working towards
complaince)
implementation
ROM.4:The organisation displays professionalism in its functioning.
The organisation has strategic and operational plans, including long-term
and There is evidence of
5 (81-100%
ROM.4.a. short-term goals commensurate to the organisation's vision, mission and Systems are in place working towards
complaince)
values implementation
in consultation with the various stakeholders.
The organisation coordinates the functioning with departments and external There is evidence of
5 (81-100%
ROM.4.b. agencies and monitors the progress in achieving the defined goals and Systems are in place working towards
complaince)
objectives. implementation
There is evidence of
5 (81-100%
ROM.4.c. The organisation plans and budgets for its activities annually. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
ROM.4.d. The functioning of committees is reviewed for their effectiveness. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
ROM.4.e. The organisation documents staff rights and responsibilities. * Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation documents the service standards that are measurable and 5 (81-100%
ROM.4.f. Systems are in place working towards
monitors them.* complaince)
implementation
 38

There is evidence of
5 (81-100%
ROM.4.g. Systems and processes are in place for change management. Systems are in place working towards
complaince)
implementation
ROM.5:Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management.
There is evidence of
5 (81-100%
ROM.5.a. Management ensures proactive risk management across the organisation.* Systems are in place working towards
complaince)
implementation
Management provides resources for proactive risk assessment and risk There is evidence of
5 (81-100%
ROM.5.b. reduction Systems are in place working towards
complaince)
activities. implementation
There is evidence of
Management ensures integration between quality improvement, risk 5 (81-100%
ROM.5.c. Systems are in place working towards
management and strategic planning within the organisation. complaince)
implementation
There is evidence of
Management ensures implementation of systems for internal and external 5 (81-100%
ROM.5.d. Systems are in place working towards
reporting of system and process failures.* complaince)
implementation
Management ensures that it has a documented agreement for all There is evidence of
5 (81-100%
ROM.5.e. outsourced Systems are in place working towards
complaince)
services that include service parameters. implementation
Management monitors the quality of the outsourced services and There is evidence of
5 (81-100%
ROM.5.f. improvements Systems are in place working towards
complaince)
are made as required. implementation
Chapter8:Facility Management and Safety(FMS)
FMS.1:The organisation has a system in place to provide a safe and secure environment.
Patient-safety devices and infrastructure are installed across the There is evidence of
5 (81-100%
FMS.1.a. organisation and Systems are in place working towards
complaince)
inspected periodically. implementation
There is evidence of
5 (81-100%
FMS.1.b. The organisation has facilities for the differently-abled. Systems are in place working towards
complaince)
implementation
There is evidence of
Facility inspection rounds to ensure safety are conducted at least once a 5 (81-100%
FMS.1.c. Systems are in place working towards
month. complaince)
implementation
There is evidence of
Inspection reports of facility rounds are documented, and corrective and 5 (81-100%
FMS.1.d. Systems are in place working towards
preventive measures are undertaken. complaince)
implementation
There is evidence of
Before construction, renovation and expansion of existing hospital, risk 5 (81-100%
FMS.1.e. Systems are in place working towards
assessment are carried out. complaince)
implementation
FMS.2:The organisation's environment and facilities operate in a planned manner and promotes environment-friendly measures.
There is evidence of
5 (81-100%
FMS.2.a. Facilities and space provisions are appropriate to the scope of services. Systems are in place working towards
complaince)
implementation
 39

There is evidence of
As-built and updated drawings are maintained as per statutory 5 (81-100%
FMS.2.b. Systems are in place working towards
requirements. complaince)
implementation
There are internal and external sign postings in the organisation in a There is evidence of
5 (81-100%
FMS.2.c. manner Systems are in place working towards
complaince)
understood by the patient, families and community. implementation
There is evidence of
5 (81-100%
FMS.2.d. Potable water and electricity are available round the clock. Systems are in place working towards
complaince)
implementation
There is evidence of
Alternate sources for electricity and water are provided as a backup for any 5 (81-100%
FMS.2.e. Systems are in place working towards
failure/shortage. complaince)
implementation
The organisation tests the functioning of these alternate sources at a There is evidence of
5 (81-100%
FMS.2.f. predefined Systems are in place working towards
complaince)
frequency. implementation
The organisation takes initiatives towards an energy-efficient and There is evidence of
5 (81-100%
FMS.2.g. environmentally Systems are in place working towards
complaince)
friendly hospital.* implementation
FMS.3:The organisation's environment and facilities operate to ensure the safety of patients, their families, staff and visitors.
Patient safety aspects in terms of structural safety of hospitals especially of
There is evidence of
critical areas are considered while planning, design and construction of new 5 (81-100%
FMS.3.a. Systems are in place working towards
hospitals complaince)
implementation
and re-planning, assessment, and retrofitting of existing hospitals.
Operational planning identifies areas which need to have extra security and There is evidence of
5 (81-100%
FMS.3.b. describes access to different areas in the hospital by staff, patients, and Systems are in place working towards
complaince)
visitors. implementation
There is evidence of
5 (81-100%
FMS.3.c. The organisation conducts electrical safety audits for the facility. Systems are in place working towards
complaince)
implementation
There is evidence of
There is a procedure which addresses the identification and disposal of 5 (81-100%
FMS.3.d. Systems are in place working towards
material(s) not in use in the organisation. * complaince)
implementation
There is evidence of
5 (81-100%
FMS.3.e. Hazardous materials are identified and used safely within the organisation.* Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
FMS.3.f. The plan for managing spills of hazardous materials is implemented. * Systems are in place working towards
complaince)
implementation
FMS.4:The organisation has a programme for the facility, engineering support services and utility system.
The organisation plans for utility and engineering equipment in accordance There is evidence of
5 (81-100%
FMS.4.a. with Systems are in place working towards
complaince)
its services and strategic plan. implementation
 40

There is evidence of
5 (81-100%
FMS.4.b. Equipment is inventoried, and proper logs are maintained as required. Systems are in place working towards
complaince)
implementation
There is evidence of
The documented operational and maintenance (preventive and breakdown) 5 (81-100%
FMS.4.c. Systems are in place working towards
plan is implemented. * complaince)
implementation
There is evidence of
Utility equipment, are periodically inspected and calibrated (wherever 5 (81-100%
FMS.4.d. Systems are in place working towards
applicable) for their proper functioning. complaince)
implementation
Competent personnel operate, inspect, test and maintain equipment and There is evidence of
5 (81-100%
FMS.4.e. utility Systems are in place working towards
complaince)
systems. implementation
There is evidence of
5 (81-100%
FMS.4.f. Maintenance staff is contactable round the clock for emergency repairs. Systems are in place working towards
complaince)
implementation
There is evidence of
Downtime for critical equipment breakdowns is monitored from reporting to 5 (81-100%
FMS.4.g. Systems are in place working towards
inspection and implementation of corrective actions. complaince)
implementation
Written guidance supports equipment replacement, identification of There is evidence of
5 (81-100%
FMS.4.h. unwanted Systems are in place working towards
complaince)
material and disposal. * implementation
FMS.5:The organisation has a programme for medical equipment management.
There is evidence of
The organisation plans for medical equipment in accordance with its 5 (81-100%
FMS.5.a. Systems are in place working towards
services and strategic plan. complaince)
implementation
There is evidence of
Medical equipment is inventoried, and proper logs are maintained as 5 (81-100%
FMS.5.b. Systems are in place working towards
required. complaince)
implementation
There is evidence of
The documented operational and maintenance (preventive and breakdown) 5 (81-100%
FMS.5.c. Systems are in place working towards
plan for medical equipment is implemented. * complaince)
implementation
There is evidence of
Medical equipment is periodically inspected and calibrated for their proper 5 (81-100%
FMS.5.d. Systems are in place working towards
functioning. complaince)
implementation
There is evidence of
5 (81-100%
FMS.5.e. Qualified and trained personnel operate and maintain medical equipment. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
FMS.5.f. Written guidance supports medical equipment replacement and disposal. * Systems are in place working towards
complaince)
implementation
There is evidence of
There is a monitoring of medical equipment and medical devices related to 5 (81-100%
FMS.5.g. Systems are in place working towards
adverse events, and compliance hazard notices on recalls. * complaince)
implementation
 41

There is evidence of
Downtime for critical equipment breakdown is monitored from reporting to 5 (81-100%
FMS.5.h. Systems are in place working towards
inspection and implementation of corrective actions. complaince)
implementation
FMS.6:The organisation has a programme for medical gases, vacuum and compressed air.
There is evidence of
Written guidance governs the implementation of procurement, handling, 5 (81-100%
FMS.6.a. Systems are in place working towards
storage, distribution, usage and replenishment of medical gases. * complaince)
implementation
There is evidence of
5 (81-100%
FMS.6.b. Medical gases are handled, stored, distributed and used in a safe manner. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
FMS.6.c. The procedures for medical gases address the safety issues at all levels. Systems are in place working towards
complaince)
implementation
Alternate sources for medical gases, vacuum and compressed air are There is evidence of
5 (81-100%
FMS.6.d. provided Systems are in place working towards
complaince)
for, in case of failure. implementation
There is evidence of
5 (81-100%
FMS.6.e. The organisation regularly tests the functioning of these alternate sources. Systems are in place working towards
complaince)
implementation
There is evidence of
There is an operational, inspection, testing and maintenance plan for piped 5 (81-100%
FMS.6.f. Systems are in place working towards
medical gas, compressed air and vacuum installation. * complaince)
implementation
FMS.7:The organisation has plans for fire and non-fire emergencies within the facilities.
There is evidence of
The organisation has plans and provisions for early detection, abatement 5 (81-100%
FMS.7.a. Systems are in place working towards
and containment of the fire, and non-fire emergencies. * complaince)
implementation
The organisation has a documented and displayed exit plan in case of fire There is evidence of
5 (81-100%
FMS.7.b. and Systems are in place working towards
complaince)
non-fire emergencies. implementation
There is evidence of
5 (81-100%
FMS.7.c. Mock drills are held at least twice a year. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
FMS.7.d. There is a maintenance plan for fire-related equipment and infrastructure * Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation has a service continuity plan in case of fire and non-fire 5 (81-100%
FMS.7.e. Systems are in place working towards
emergencies complaince)
implementation
Chapter9:Human Resource Management(HRM)
HRM.1. The organisation has a documented system of human resource planning.
Human resource planning supports the organisation's current and future There is evidence of
5 (81-100%
HRM.1.a. ability to Systems are in place working towards
complaince)
meet the care, treatment and service needs of the patient. implementation
 42

The organisation maintains an adequate number and mix of staff to meet There is evidence of
5 (81-100%
HRM.1.b. the care, Systems are in place working towards
complaince)
treatment and service needs of the patient. implementation
There is evidence of
The organisation has contingency plans to manage long- and short-term 5 (81-100%
HRM.1.c. Systems are in place working towards
workforce shortages, including unplanned shortages. complaince)
implementation
There is evidence of
The job specification and job description are defined for each category of 5 (81-100%
HRM.1.d. Systems are in place working towards
staff. * complaince)
implementation
There is evidence of
5 (81-100%
HRM.1.e. The organisation performs a background check of new staff. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.1.f. Reporting relationships are defined for each category of staff. * Systems are in place working towards
complaince)
implementation
Exit interviews are conducted and used as a tool to improve human There is evidence of
5 (81-100%
HRM.1.g. resource Systems are in place working towards
complaince)
practices. implementation
HRM.2.The organisation implements a defined process for staff recruitment.
There is evidence of
5 (81-100%
HRM.2.a. Written guidance governs the process of recruitment. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.2.b. A pre-employment medical examination is conducted on the staff. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.2.c. The organisation defines and implements a code of conduct for its staff. Systems are in place working towards
complaince)
implementation
There is evidence of
Administrative procedures for human resource management are 5 (81-100%
HRM.2.d. Systems are in place working towards
documented .* complaince)
implementation
HRM.3.Staff are provided induction training at the time of joining the organisation.
There is evidence of
5 (81-100%
HRM.3.a. Staff are provided with induction training. Systems are in place working towards
complaince)
implementation
The induction training includes orientation to the organisation's vision, There is evidence of
5 (81-100%
HRM.3.b. mission Systems are in place working towards
complaince)
and values. implementation
The induction training includes awareness on staff rights and responsibilities There is evidence of
5 (81-100%
HRM.3.c. and Systems are in place working towards
complaince)
patient rights and responsibilities. implementation
There is evidence of
5 (81-100%
HRM.3.d. The induction training includes training on safety. Systems are in place working towards
complaince)
implementation
 43

The induction training includes training on cardio-pulmonary resuscitation There is evidence of

5 (81-100%
HRM.3.e. for Systems are in place working towards
complaince)
staff providing direct patient care. implementation
There is evidence of
The induction training includes training in hospital infection prevention 5 (81-100%
HRM.3.f. Systems are in place working towards
and control. complaince)
implementation
There is evidence of
The induction training includes orientation to the service standards of the 5 (81-100%
HRM.3.g. Systems are in place working towards
organisation. complaince)
implementation
There is evidence of
5 (81-100%
HRM.3.h. The induction training includes an orientation on administrative procedures. Systems are in place working towards
complaince)
implementation
There is evidence of
The induction training includes an orientation on relevant department/unit/ 5 (81-100%
HRM.3.i. Systems are in place working towards
service/programme's policies and procedures. complaince)
implementation
HRM.4.There is an on-going programme for professional training and development of the staff.
There is evidence of
5 (81-100%
HRM.4.a. Written guidance governs training and development policy for the staff.* Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.4.b. The organisation maintains the training record. Systems are in place working towards
complaince)
implementation
There is evidence of
Training also occurs when job responsibilities change/new equipment is 5 (81-100%
HRM.4.c. Systems are in place working towards
introduced. complaince)
implementation
Feedback mechanisms are in place for improvement of training and There is evidence of
5 (81-100%
HRM.4.d. development Systems are in place working towards
complaince)
programme. implementation
There is evidence of
5 (81-100%
HRM.4.e. Evaluation of training effectiveness is done by the organisation. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation supports continuing professional development and 5 (81-100%
HRM.4.f. Systems are in place working towards
learning. complaince)
implementation
HRM.5.Staff are appropriately trained based on their specific job description.
Staff involved in blood transfusion services are trained on the handling of There is evidence of
5 (81-100%
HRM.5.a. blood Systems are in place working towards
complaince)
and blood products. implementation
There is evidence of
5 (81-100%
HRM.5.b. Staff are trained in handling vulnerable patients. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.5.c Staff are trained in control and restraint techniques. Systems are in place working towards
complaince)
implementation
 44

There is evidence of
5 (81-100%
HRM.5.d. Staff are trained in healthcare communication techniques. Systems are in place working towards
complaince)
implementation
There is evidence of
Staff involved in direct patient care are provided training on cardiopulmonary 5 (81-100%
HRM.5.e. Systems are in place working towards
resuscitation periodically. complaince)
implementation
There is evidence of
5 (81-100%
HRM.5.f. Staff are provided training on infection prevention and control. Systems are in place working towards
complaince)
implementation
HRM.6.Staff are trained in safety and quality-related aspects.
There is evidence of
5 (81-100%
HRM.6.a. Staff are trained on the organisation's safety programme. Systems are in place working towards
complaince)
implementation
There is evidence of
Staff are provided training on the detection, handling, minimisation and 5 (81-100%
HRM.6.b. Systems are in place working towards
elimination of identified risks within the organisation's environment. complaince)
implementation
There is evidence of
Staff members are made aware of procedures to follow in the event of an 5 (81-100%
HRM.6.c. Systems are in place working towards
incident. complaince)
implementation
There is evidence of
5 (81-100%
HRM.6.d. Staff are trained in occupational safety aspects. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.6.e. Staff are trained in the organisation's disaster management plan. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.6.f. Staff are trained in handling fire and non-fire emergencies. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.6.g. Staff are trained on the organisation's quality improvement programme Systems are in place working towards
complaince)
implementation
HRM.7.An appraisal system for evaluating the performance of staff exists as an integral part of the human resource management process.
There is evidence of
5 (81-100%
HRM.7.a. Performance appraisal is done for staff within the organisation.* Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.7.b. The staff are made aware of the system of appraisal at the time of induction. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.7.c. Performance is evaluated based on the pre-determined criteria. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.7.d. The appraisal system is used as a tool for further development. Systems are in place working towards
complaince)
implementation
 45

There is evidence of
5 (81-100%
HRM.7.e. Performance appraisal is carried out at defined intervals and is documented. Systems are in place working towards
complaince)
implementation
HRM.8.Process for disciplinary and grievance handling is defined and implemented in the organisation.
There is evidence of
Written guidance governs disciplinary and grievance handling 5 (81-100%
HRM.8.a. Systems are in place working towards
mechanisms.* complaince)
implementation
The disciplinary and grievance handling mechanism is known to all There is evidence of
5 (81-100%
HRM.8.b. categories Systems are in place working towards
complaince)
of staff of the organisation. implementation
There is evidence of
The disciplinary policy and procedure are based on the principles of 5 (81-100%
HRM.8.c. Systems are in place working towards
natural justice. complaince)
implementation
There is evidence of
The disciplinary and grievance procedure is in consonance with the 5 (81-100%
HRM.8.d. Systems are in place working towards
prevailing laws. complaince)
implementation
There is evidence of
5 (81-100%
HRM.8.e. There is a provision for appeals in all disciplinary cases. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
HRM.8.f. Actions are taken to redress the grievance. Systems are in place working towards
complaince)
implementation
HRM.9.The organisation promotes staff well-being and addresses their health and safety needs.
There is evidence of
5 (81-100%
HRM.9.a. Staff well-being is promoted. Systems are in place working towards
complaince)
implementation
Health problems of the staff, including occupational health hazards, are There is evidence of
5 (81-100%
HRM.9.b. taken Systems are in place working towards
complaince)
care of in accordance with the organisation's policy. implementation
Health checks of staff dealing with direct patient care are done at least once There is evidence of
5 (81-100%
HRM.9.c. a year Systems are in place working towards
complaince)
and the findings/results are documented. implementation
There is evidence of
Organisation provides treatment to staff who sustain workplace-related 5 (81-100%
HRM.9.d. Systems are in place working towards
injuries. complaince)
implementation
The organisation has measures in place for prevention and handling There is evidence of
5 (81-100%
HRM.9.e. workplace Systems are in place working towards
complaince)
violence. implementation
HRM.10.There is documented personal information for each staff member.
Personal files are maintained with respect to all staff, and their There is evidence of
5 (81-100%
HRM.10.a. confidentiality is Systems are in place working towards
complaince)
ensured implementation
 46

There is evidence of
The personal files contain personal information regarding the staff's 5 (81-100%
HRM.10.b. Systems are in place working towards
qualification, job description, verification of credentials and health status. complaince)
implementation
There is evidence of
Records of in-service training and education are contained in the personal 5 (81-100%
HRM.10.c. Systems are in place working towards
files. complaince)
implementation
There is evidence of
5 (81-100%
HRM.10.d. Personal files contain results of all evaluations and remarks. Systems are in place working towards
complaince)
implementation
HRM.11.There is a process for credentialing and privileging of medical professionals, permitted to provide patient care without supervision.
There is evidence of
Medical professionals permitted by law, regulation and the organisation to 5 (81-100%
HRM.11.a. Systems are in place working towards
provide patient care without supervision are identified. complaince)
implementation
There is evidence of
The education, registration, training and experience of the identified medical 5 (81-100%
HRM.11.b. Systems are in place working towards
professionals are documented and updated periodically. complaince)
implementation
There is evidence of
The information about medical professionals is appropriately verified when 5 (81-100%
HRM.11.c. Systems are in place working towards
possible. complaince)
implementation
Medical professionals are granted privileges to admit and care for patients There is evidence of
5 (81-100%
HRM.11.d. in Systems are in place working towards
complaince)
consonance with their qualification, training, experience and registration. implementation
The requisite services to be provided by the medical professionals are There is evidence of
5 (81-100%
HRM.11.e. known to Systems are in place working towards
complaince)
them as well as the various departments/units of the organisation. implementation
There is evidence of
5 (81-100%
HRM.11.f. Medical professionals admit and care for patients as per their privileging. Systems are in place working towards
complaince)
implementation
HRM.12.There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision
Nursing staff permitted by law, regulation and the organisation to provide There is evidence of
5 (81-100%
HRM.12.a. patient Systems are in place working towards
complaince)
care without supervision are identified. implementation
There is evidence of
The education, registration, training and experience of nursing staff are 5 (81-100%
HRM.12.b. Systems are in place working towards
appropriately verified, documented and updated periodically. complaince)
implementation
There is evidence of
The information about the nursing staff is appropriately verified when 5 (81-100%
HRM.12.c. Systems are in place working towards
possible. complaince)
implementation
There is evidence of
Nursing staff are granted privileges in consonance with their qualification, 5 (81-100%
HRM.12.d. Systems are in place working towards
training, experience and registration. complaince)
implementation
 47

The requisite services to be provided by the nursing staff are known to them There is evidence of
5 (81-100%
HRM.12.e. as Systems are in place working towards
complaince)
well as the various departments/units of the organisation. implementation
There is evidence of
5 (81-100%
HRM.12.f. Nursing professionals care for patients as per their privileging. Systems are in place working towards
complaince)
implementation
HRM.13.There is a process for credentialing and privileging of para-clinical professionals, permitted to provide patient care without supervision.
Para-clinical professionals permitted by law, regulation and the organisation There is evidence of
5 (81-100%
HRM.13.a. to Systems are in place working towards
complaince)
provide patient care without supervision are identified. implementation
The education, registration, training and experience of para clinical There is evidence of
5 (81-100%
HRM.13.b. professionals Systems are in place working towards
complaince)
are appropriately verified, documented and updated periodically. implementation
There is evidence of
Para-clinical professionals are granted privileges in consonance with their 5 (81-100%
HRM.13.c. Systems are in place working towards
qualification, training, experience and registration. complaince)
implementation
The requisite services to be provided by the para-clinical professionals are There is evidence of
5 (81-100%
HRM.13.d. known Systems are in place working towards
complaince)
to them as well as the various departments/units of the organisation. implementation
There is evidence of
5 (81-100%
HRM.13.e. Para-clinical professionals care for patients as per their privileging. Systems are in place working towards
complaince)
implementation
Chapter10:Information Management System(IMS)
IMS.1.Information needs of the patients, visitors, staff, management and external agencies are met.
The organisation identifies the information needs of the patients, visitors, There is evidence of
5 (81-100%
IMS.1.a. staff, Systems are in place working towards
complaince)
management external agencies and community. * implementation
There is evidence of
5 (81-100%
IMS.1.b. Identified information needs are captured and/or disseminated. Systems are in place working towards
complaince)
implementation
Information management and technology acquisitions are commensurate There is evidence of
5 (81-100%
IMS.1.c. with Systems are in place working towards
complaince)
the identified information needs. implementation
A maintenance plan for information technology and communication network There is evidence of
5 (81-100%
IMS.1.d. is Systems are in place working towards
complaince)
implemented. implementation
There is evidence of
Contingency plan ensures continuity of information capture, integration and 5 (81-100%
IMS.1.e. Systems are in place working towards
dissemination. complaince)
implementation
There is evidence of
The organisation ensures that information resources are accurate and meet 5 (81-100%
IMS.1.f. Systems are in place working towards
stakeholder requirements. complaince)
implementation
 48

The organisation contributes to external databases in accordance with the There is evidence of
5 (81-100%
IMS.1.g. law Systems are in place working towards
complaince)
and regulations. implementation
IMS.2.The organisation has processes in place for management and control of data and information.
There is evidence of
5 (81-100%
IMS.2.a. Processes for data collection are standardised. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.2.b. Data is analysed to meet the information needs. Systems are in place working towards
complaince)
implementation
There is evidence of
The organisation disseminates the information in a timely and accurate 5 (81-100%
IMS.2.c. Systems are in place working towards
manner. complaince)
implementation
There is evidence of
The organisation stores and retrieves data according to its information 5 (81-100%
IMS.2.d. Systems are in place working towards
needs. * complaince)
implementation
Clinical and managerial staff participate in selecting, integrating and using There is evidence of
5 (81-100%
IMS.2.e. data Systems are in place working towards
complaince)
for meeting the information needs. implementation
IMS.3.The patients cared for by the organisation have a complete and accurate medical record.
There is evidence of
5 (81-100%
IMS.3.a. The unique identifier is assigned to the medical record. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.3.b. The contents of the medical record are identified and documented. * Systems are in place working towards
complaince)
implementation
The medical record provides a complete, up-to-date and chronological There is evidence of
5 (81-100%
IMS.3.c. account Systems are in place working towards
complaince)
of patient care. implementation
There is evidence of
5 (81-100%
IMS.3.d. Authorised staff make the entry in the medical record. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.3.e. Entry in the medical record is signed, dated and timed. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.3.f. The author of the entry can be identified. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.3.g. The medical record has only authorised abbreviations. Systems are in place working towards
complaince)
implementation
IMS.4.The medical record reflects the continuity of care.
 49

There is evidence of
The medical record contains information regarding reasons for admission, 5 (81-100%
IMS.4.a. Systems are in place working towards
diagnosis and care plan. complaince)
implementation
The medical record contains the details of assessments, re-assessments There is evidence of
5 (81-100%
IMS.4.b. and Systems are in place working towards
complaince)
consultations. implementation
The medical record contains the results of investigations and the details of There is evidence of
5 (81-100%
IMS.4.c. the Systems are in place working towards
complaince)
care provided. implementation
There is evidence of
Operative and other procedures performed are incorporated in the medical 5 (81-100%
IMS.4.d. Systems are in place working towards
record. complaince)
implementation
There is evidence of
When a patient is transferred to another organisation, the medical record 5 (81-100%
IMS.4.e. Systems are in place working towards
contains the details of the transfer. complaince)
implementation
There is evidence of
5 (81-100%
IMS.4.f. The medical record contains a copy of the discharge summary. Systems are in place working towards
complaince)
implementation
There is evidence of
In case of death, the medical record contains a copy of the cause of death 5 (81-100%
IMS.4.g. Systems are in place working towards
report. complaince)
implementation
There is evidence of
5 (81-100%
IMS.4.h. Care providers have access to current and past medical record. Systems are in place working towards
complaince)
implementation
IMS.5.The organisation maintains confidentiality, integrity and security of records, data and information.
There is evidence of
The organisation maintains the confidentiality of records, data and 5 (81-100%
IMS.5.a. Systems are in place working towards
information.* complaince)
implementation
There is evidence of
5 (81-100%
IMS.5.b. The organisation maintains the integrity of records, data and information. * Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.5.c. The organisation maintains the security of records, data and information.* Systems are in place working towards
complaince)
implementation
The organisation uses developments in appropriate technology for There is evidence of
5 (81-100%
IMS.5.d. improving Systems are in place working towards
complaince)
confidentiality, integrity and security. implementation
The organisation discloses privileged health information as authorised by There is evidence of
5 (81-100%
IMS.5.e. the Systems are in place working towards
complaince)
patient and/or as required by law. implementation
Request for access to information in the medical records by There is evidence of
5 (81-100%
IMS.5.f. patients/physicians Systems are in place working towards
complaince)
and other public agencies are addressed consistently.* implementation
IMS.6.The organisation ensures availability of current and relevant documents, records, data and information and provides for retention of the same.
 50

There is evidence of
5 (81-100%
IMS.6.a. The organisation has an effective process for document control. * Systems are in place working towards
complaince)
implementation
The organisation retains patient's clinical records, data and information There is evidence of
5 (81-100%
IMS.6.b. according Systems are in place working towards
complaince)
to its requirements. * implementation
There is evidence of
5 (81-100%
IMS.6.c. The retention process provides expected confidentiality and security. Systems are in place working towards
complaince)
implementation
The destruction of medical records, data and information are in accordance There is evidence of
5 (81-100%
IMS.6.d. with Systems are in place working towards
complaince)
the written guidance.* implementation
IMS.7.The organisation carries out a review of medical records.
There is evidence of
5 (81-100%
IMS.7.a. The medical records are reviewed periodically. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.7.b. The review uses a representative sample based on statistical principles. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.7.c. The review is conducted by identified individuals. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.7.d. The review of records is based on identified parameters. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.7.e. The review process includes records of both active and discharged patients. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.7.f. The review points out and documents any deficiencies in records. Systems are in place working towards
complaince)
implementation
There is evidence of
5 (81-100%
IMS.7.g. Appropriate corrective and preventive measures are undertaken. Systems are in place working towards
complaince)
implementation