ASHWINI HOSPITAL Doc.

No AH/PPM/AQM/50
Issue No 02
APEX QUALITY MANUAL Revision No 01
Date of Issue 20/07/2018
Revision done 19/07/2021

Date Created

Date of Implementation

Prepared by Designation:

Name:

Signature :

Reviewed by : Approved by : Issued by :

Medical Superintendent Head – Operations Chief Operating Officer

Signature Signature Signature

Distribution List of the Manual:

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S.No Name/Designation Type of Copy

1 Dr. Maya Gantayet , Managing Director Soft Copy

2 Ms. Suma Devi, Director - Finance Hard Copy

3 Dr. B.K. Reddy, Medical Soft copy

Superintendent
4 Quality Manager Soft copy

AMENDMENT SHEET
No./Date of Section and Page Details of amendment Reason for amendment Signature of the

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amendment approval authority

CONTROL OF THE MANUAL

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The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a readily identifiable and
retrievable.

The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and when the
amended versions are received.

Accreditation Coordinator is responsible for issuing the amended copies to the copyholders; the copyholder should acknowledge
the same and should return the obsolete copies to the Quality Department.

The amendment sheet, to be updated (as and when amendments received) and referred for details of amendments issued.

The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures. Review and amendment
can happen also as corrective actions to the non-conformities raised during the internal audit or assessment audits done by
internal or external audit team respectively.

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TABLE OF CONTENTS

1. BRIEF INTRODUCTION OF INSTITUTE:..................................................................................................................6

2. VISION, MISSION & QUALITY POLICY:..................................................................................................................6
3. ORGANIZATION STRUCTURE:...............................................................................................................................7
4. COMPOSITION AND TERMS OF REFERENCE OF COMMITTEES:...........................................................................8
5. STATUTORY AND REGULATORY REQUIREMENTS..............................................................................................25
6. CHAPTERWISE DOCUMENTATION:....................................................................................................................28
6.1. ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)..............................................................................28
6.2. CARE OF PATIENT (COP).................................................................................................................................39
6.3. MANAGEMENT OF MEDICATION- (MOM).....................................................................................................54
6.4. PATIENT RIGHTS AND EDUCATION (PRE).......................................................................................................61
6.5. HOSPITAL INFECTION CONTROL....................................................................................................................65
6.6. CONTINUAL QUALITY IMPROVEMENT (CQI)..................................................................................................70
6.7. RESPONSIBILITIES OF MANAGEMENT (ROM)................................................................................................79
6.8. FACILITY MANAGEMENT AND SAFETY (FMS).................................................................................................82
6.9. HUMAN RESOURCE MANAGEMENT (HRM)...................................................................................................89
6.10. INFORMATION MANAGEMENT SYSTEM (IMS)...........................................................................................95

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1. BRIEF INTRODUCTION OF INSTITUTE:

Ashwini Hospital, established in 2006, is a leading medical institute providing quality medical education and standard
health care services. Its evolving growth is based on value added medical education & research. Multi specialty facilities
like Dialysis, CT Scan, MRI, Cath Lab along with ICU, ICCU, HDU, Semi – ICU are present. The hospital also teaches
the sensitive issues in medical science and health care with simultaneous emphasis on the introduction of technology in
critical surgery, diagnosis and life support systems. Ashwini Hospital has a total number of 150 beds, Ashwini Hospital
offers therapeutic care with a focus on preventive care for a healthy society. Ashwini Hospital has a promise to serve the
society with care and human touch.

Apex Quality manual as per the guideline of NABH Standard has been developed to strictly abide by the norms of Quality
management standards. We have developed an extremely patient friendly system of physicians, nurses and other care givers
who each and every day blends the miracle of compassion with the marvel of technology to make a real difference in the lives of
our patients.

2. VISION, MISSION & QUALITY POLICY:

2.1.1. Vision: Strive to establish an ideal Healthcare Delivery Institution based on Modern Technology and Quality
Training.
2.1.2. Mission: To provide safe, ethical, well researched and cost effective health care with compassion and dedication to
ensure complete patient satisfaction.
2.1.3. Quality Policy: Continuously strive to improve the quality of services by adopting latest technology to strengthen
the processes & procedures to achieve set objectives to meet international standards

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3. ORGANIZATION STRUCTURE:
The organization Structure has been defined to document the hierarchy, line of control, coordination. Organization Structure is
disseminated to Process owners to follow a line of control and command. Since Quality system is a Top to bottom approach
hence Quality initiative and control is managed by various committees also part of the Organization Structure.

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4. SCOPE OF SERVICES
1. SCOPE OF SERVICE IN THE INSTITUTE:

1.1. Policy: The policy outlines the scope of clinical and non clinical Services at Hospital.

1.2. Scope of clinical Services

1.2.1. Anesthesiology:

The Department of Anesthesiology provides comprehensive 24 hr services (on call basis) through a group of Anesthesiologists
in all surgical specialties according to the scope of services.
The range of services offered in the department includes:
1. Anesthesia for routine surgeries
2. Anesthesia for emergency surgeries
3. Post operative analgesia and pain relief

1.2.2. Day Care Surgeries :

The following categories of day care surgeries are performed at the hospital:

1. Smile Train surgery for Cleft Lip & Palate

2. Orthopedics Day Care surgeries
3. Plastic Surgery Day Care surgeries
4. Cardiology Day Care surgeries

1.2.3. Cardiology
The department of cardiology through its qualified and trained cardiologist provide following facilities:
1. Outpatient patient consultation services.
2. Inpatient care.
3. Round the clock Non-invasive Cardiology facilities – Echo, TMT, Holter

1.2.4. General Surgery

The department of Surgery at hospital provides comprehensive round the clock surgical services. The department provides
services for all general surgical procedures including advanced gastrointestinal surgeries, rectal surgeries and laparoscopic
procedures including advanced laparoscopic surgeries.
The general surgeons work closely with other specialists involved in each patient's care to diagnose and provide timely surgical
intervention for complex conditions.

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Facilities include:

a. Gastrointestinal surgeries
b. Minimal access surgeries including laparoscopic appendicectomy, gall bladder removal, and hernia repair
c. Anorectal surgeries
d. Thoracic surgeries
e. 24 hrs surgical consultant availability on call basis.

1.2.5. General Medicine

The department of Internal Medicine has full OPD coverage for addressing complaints related to all systems and treatment of
inpatients with problems related to respiratory, endocrine, diabetic complication.

The department also offers specialty services in infectious diseases by qualified specialists and support to other services such
as surgery, OB &G, gastroenterology and neurology for medical problem.

1.2.6. Nephrology

The department of nephrology has facilities like hemodialysis, peritoneal dialysis, AV fistula etc.

1.2.7. Neurology :

a. Is designed to provide comprehensive care for all the neurological ailments.

b. Specific and exhaustive diagnostic and therapeutic protocols are available for major neurological illnesses like stroke,
epilepsy and headache.

1.2.8. Neurosurgery

State of art facilities for care of head injured patients and other acute neurosurgical diseases are available. Various complicated
neurosurgical operations are undertaken.

a. Neuroendoscopy
b. Neuro-navigation & micro-neurosurgery.
c. Backache & Neck Pain
d. Brain & Spine Injury
e. Epilepsy surgery
f. Other ailments
g. Surgery for stroke

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1.2.9. Urology

Urology dept has treatment for all medical and surgical conditions (including TURP, TURB, stone removal etc.).

1.2.10. Accident and Emergency

All cases regarding accident and emergency are dealt in this department. It has all emergency facilities like emergency crash
cart, oxygen cylinder, defibrillator, cardiac monitor etc.

2. Diagnostic Services:

2.1. Laboratory Services:

The hospital’s laboratory located in the first floor of the hospital provides comprehensive round the clock on call basis 24 hours
in the following areas:

1. Hematology
2. Clinical Pathology
3. Biochemistry
4. Serology
5. Microbiology
6. Histopathology

2.2. Radiology

The Radiology department is committed to provide safe, reliable and speedy radio diagnostic support round-the-clock on call
basis. The department has facilities for all 'conventional' radiography, including bedside radiographs for the critically ill patient
who cannot be moved.

Other modalities include the following:

a. X ray
b. Ultrasonography
c. CT Scan
d. MRI

3. Physiotherapy:

The department of Physiotherapy aims at delivering the most suitable treatment for all movement problems due to an injury
conditions, in order to enhance over all function and quality of life .Our physiotherapists assess and treat people with injuries,
disabilities etc. They also emphasize on patient education to avoid injuries and maintain a fit, healthy body. The treatment
modalities are chosen based on their physical head and tail mode.

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Services provided by the department include:

a. Interferential therapy (IFT)

b. Ultrasound therapy
c. Short wave diathermy (SWD)
d. Traction - cervical / lumbar
e. Paraffin wax therapy
f. Moist heat therapy
g. Electric Stimulations
h. Continuous passive motion
i. Exercise therapy.
j. Laser Therapy
k. Cryotherapy
l. Manual therapy

4. Pharmacy Services:

The pharmacy at Hospital caters to the need of outpatients only. All inpatient pharmaceutical requirements are met by the
Medical Store of the hospital.

5. Dietetics

Dietary department facilities like counseling and nutritional assessment are done by the dieticians for the IPD patients as well as
OPD patients.

6. Patient accommodation

Rooms

Hospital three varieties of accommodation facilities for inpatients which are :

1. General Ward Accommodations (Male & Female)

2. Special Room.
3. AC cabins
4. Non AC cabins

All rooms are adequately lit and ventilated. The private and semiprivate rooms have nurse call system which is connected to the
central nursing station.

The toilet facilities in each of these rooms have been designed.

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Services not available

1. Bone marrow transplant

2. Organ Transplant

3. PET CT

Patients are accepted if required service for patient is available otherwise patient/relatives are communicated and in case of life
threatening situation patient is stabilized and sent to higher Institution where Service is available.

The service available in the organization is provided as per the need of the community and as per the disease prevalence status
of the Community of Odisha and nearby regions. The State Medical Regulatory norms is strictly adhered to for providing
services. All patient care services are approved and inspected as per the set guidelines of Council. All these services have been
displayed in and around the hospital to guide the patient and their relative to easily locate the department/service. Pictorial
presentation and Vernacular language is ensured for all display. Staffs of each category are well trained and motivated to know
about the department and its scope.

5. COMPOSITION AND TERMS OF REFERENCE OF COMMITTEES:

CONTINUOUS QUALITY IMPROVEMENT (APEX) COMMITTEE

5.1.1. COMPOSITION OF THE COMMITTEE

SL NO NAME OF MEMBERS DESIGNATION IN INSTITUTION DESIGNATION IN COMMITTEE
1 Dr. Subrat Kumar Jena HOD – Dept. of Surgical Specialties Chairperson
2 Dr. Maya Gantayet Senior Consultant – Neurology Vice Chairperson
3 Mr. Sanjay Panda Head – Operations Member – Secretary
4 Ms. Suma Devi Director - Finance Director - Finance
5 Dr. B. K. Reddy Medical Superintendent Member
6 Dr. Sandip K Pradhan Consultant General Surgery Member
7 Mrs.Swapnarani Jena DNS Member
8 Dr. Mamta Bhatt Microbiology Member
9 Dr. Manas Nayak HOD – Critical Care Member
10 Mr. Satyajit Singh HR – Manager Member
11 Ms. Neeraj Anjana Shekhar Asst. Manager –Q Coordinator

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5.1.2. SCOPE AND FUNCTION:

1. Develop a Facility wide Quality Management Plan.
2. Integrate the overall Quality Management Plan and serve as a clearing house for improvement activities.
3. Oversee, coordinate, direct and prioritize Quality improvement activities
4. Receive reports monthly or quarterly from each department/service as appropriate and team reports on
organizational Quality improvement activities.
5. Enforce the implementation of Plan, Do, Check, and Act methodology.
6. Receive and evaluate Quality improvement team reports concerning specific activities for improving organizational
Quality.
7. Oversee, coordinate and provide appropriate Quality Improvement information to the concerned departments and
sections (both external & internal)
8. Ensure obtaining the NABH Accreditation and maintaining the same.
9. Review and revise the departmental Performance Indicators as defined by accreditation standards.
10. The Committee will oversee all aspects of quality improvement in the organization. The Committee will look in to
the following aspect & provide information on
1. Clinical & Managerial Outcome
2. Safety issues and Sentinel events
3. Patient Satisfaction index
4. Environment & Facility Management
5. Accreditation Efforts & reports submitted to Accreditation bodies (e g. NABH).
5.1.3. FREQUENCY OF MEETING: Monthly
5.1.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
5.1.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also
be circulated among the committee members
5.1.6. ADMINISTRATIVE INFORMATION: -
1. At least 50% of the scheduled members should be present for the committees to establish Quorum or else the
execution of the committee for the scheduled day would be dissolved.

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2. The minutes of the meeting would be circulated among the members of the committee after the meeting under the
signature of the Medical Superintendent & Chairperson of the Committee.
3. Incase required the chairperson of the Committee may invite a person not among the scheduled member for the
meeting.
4. Notice for all scheduling committee meeting would be circulated at least 48 hrs prior to the scheduled time and should
information pertaining to the agenda of the meeting. In case of Emergency Short notice may be made by the chairman
of the Committee Stating the reason for the same.

4.2. INFECTION CONTROL COMMITTEE

4.2.1. COMPOSITION OF THE COMMITTEE

INFECTION CONTROL COMMITTEE
SL NAME OF MEMBERS DESIGNATION IN DESIGNATION IN SIGNATURE
NO INSTITUTION COMMITTEE

1 Dr. Pratibha Samantroy Microbiology Chairperson

2 Ms. Swapna Rani Jena DNS Member - Secretary
3 Dr. Mamta Bhatt Microbiology Member
4 Dr. Sandip Pradhan Consultant – General Surgery Member
5 Dr. Manas Nayak HOD – Critical Care Member
5 Mr. Sanjay Panda Head – Operations Member
6 Ms. Neeraj Anjana Shekhar Asst. Manager Quality Coordinator
7 Mr. Debudatta Lenka Incharge Lab Member
8 Mr. Sanjeeb Kumar Sahoo CSSD Technician Member
9 Mr. Subash Sahoo OT - Incharge Member
10 Mr. Bibhutendu Bala HOD – Housekeeping Member

4.2.2. SCOPE & FUNCTIONS:

1. To review and approve a yearly program of activity for surveillance and prevention of infection in hospital.
2. To review epidemiological surveillance data and identify areas for intervention.
3. To assess and promote improved practice at all levels of the health facility\
4. To ensure appropriate staff training in infection control
5. To educate staff on medical waste segregation and management etc.
6. To set general infection control policy/ guidelines and to provide input into specific infection control issues

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7. To develop infection control procedures for all departments

8. Recommend and Authenticate protocols for Control of Hospital Infection viz. Universal Precautions
9. Develop an internal audit system to enable the deficiencies in the infection control management program.
10. Recommend materials to be adopted viz. disinfectants, bags/cans for waste segregation.
11. Recommend periodical vaccination schedules for all the categories of the Staff.
12. To communicate and cooperate with other committees of the hospital with common interests such as therapeutic
committee, safety committee.

4.2.3. FREQUENCY OF MEETING: Monthly

4.2.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.

4.2.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
4.2.6. ADMINISTRATIVE INFORMATION: -
1. Same as above.
5. CODE BLUE COMMITTEE
5.2.1. COMPOSITION OF THE COMMITTEE
SL NAME OF MEMBERS DESIGNATION IN DESIGNATION IN SIGNATURE
NO INSTITUTION COMMITTEE
1 Dr. Manas Nayak Critical Care Chairperson
2 Dr. Priyadarshi Tripathy Consultant – Cardiology Member
3 Dr. B. K. Reddy Medical Superintendent Member
4 Dr. Prasanna K Mishra Anaesthesiology Member – Secretary
5 Mrs. Swapna Rani Jena DNS Member
6 Dr. Soumyaraj Ghosh Anesthesist Member
7 Ms. Neeraj Anjana Shekhar Asst. Manager ,Quality Coordinator

5.2.2. SCOPE & FUCNTION:

1. To monitor and track response to all code blue cases in the hospital
2. Aid improve response time and easy access to emergency medical equipment including crash cart
3. Decide upon the composition and responsibilities of each member of the code blue team
4. Recommend special training initiatives for the code blue team members.
5. To identify responsibilities of individuals and departments in the event of any code blue situation.
6. To ensure regular preparedness of Code Blue Preparedness team through periodical Mock drill.

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7. To assess post event analysis of all Code Blue Cases and ensure implementation of Corrective and preventive
action
5.2.3. FREQUENCY OF MEETING: Monthly

5.2.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
5.2.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
5.2.6. ADMINISTRATIVE INFORMATION: - Same as above.
5.3. PHARMACY & THERAPEUTIC COMMITTEE
5.3.1. COMPOSITION OF THE COMMITTEE
PHARMACY & THERAPEUTIC COMMITTEE
SL NAME OF MEMBERS DESIGNATION IN INSTITUTION DESIGNATION IN SIGNATURE
NO COMMITTEE
1 Dr. Maya Gantayet Sr. Consultant Neurology Member
2 Ms. Suma Devi Director - Finance Member
3 Dr. Sandip Pradhan Consultant ,General Surgery Chairperson
4 Dr. Biswaranjan Jena Consultant -Cardiology Member
5 Dr. Sampat Dash Consultant Pulmonology Member
6 Dr. Manas Nayak HOD – Anaesthesia Member
7 Dr. Bimal K Sahu Consultant Neurosurgery Member
8 Dr. B.K. Reddy Consultant Orthopaedic Surgeon Member
9 Dr. Soumyaraj Ghosh Critical care Member
10 Dr. Kirti Ketan Pradhan Dept. of Plastic Surgery Member
11 Dr. Sourav K Rout Maxillo- facial Surgeon Member
12 Mr. Subrat Parida Quality Team Coordinator
13 Mr. Braja Kishore Behera Incharge - Pharmacy Member - Secretary
14 Mr. Swapnarani Jena DNS Member

a. The Committee would ensure formulation of policies regarding evaluation, selection, and therapeutic use of drugs and
related devices.
b. To assign responsibility to monitor the use of inpatient pharmacy daily.
c. Set system for periodic educational and advisory capacity to the medical staff, pharmacy and administration in all
matters pertaining to the purchase, stocking, distribution, prescription and use of drugs.

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d. Develop the hospital formulary and recommend on a periodical basis drug formulations to be added /deleted on the
basis of their relative therapeutic merits and safety.
e. Ensure a proper system for storing, prescribing and dispensing of narcotics and controlled drugs.
f. Develop guidelines for the hospitals antibiotic policy and review on a periodical basis the use and misuse of antibiotics.
The committee will monitor misuse and abuse of antibiotics and will have the authority to cancel the irrational
prescriptions of antibiotics and bring the names of defaulters to the medical superintendent.
g. Establish programs and procedures to promote rational prescribing practices and cost effective drug therapy.
h. Initiate and direct drug use evaluation programs and studies, and review the result of such activities.
i. Monitor reasons for adverse drug reactions or incidences and make appropriate recommendations.
j. Recommend policies and procedures for drug evaluation and clinical trials and consider requests for such drug trials
on hospital patients.
k. Plan suitable educational programs for hospital professionals on matters related to drug use.
l. To review data on medication errors on monthly basis.
m. To ensure medication advice of all discharge summaries checked prior to discharge of patient.
n. To ensure drug charts checked for its legibility and accuracy.
5.3.2. FREQUENCY OF MEETING: Once in three months
5.3.3. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
5.3.4. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
5.3.5. ADMINISTRATIVE INFORMATION: - Same as above.

6. DISASTER MANAGEMENT COMMITTEE:-

6.2.1. COMPOSITION OF THE COMMITTEE
DISASTER MANAGEMENT COMMITTEE
SL NAME OF MEMBERS DESIGNATION IN INSTITUTION DESIGNATION IN SIGNATURE
NO COMMITTEE
1 Mr. Sanjay Panda Head – Operations Chairperson  
2 Dr. Manas Nayak HOD – Emergency Member – Secretary  
3 Dr. B. K. Reddy Medical Superintendent Member  
4 Dr. Sandip K Pradhan Consultant General Surgery Member  
5 Dr. Satya Narayan Behera Consultant Orthopaedic Surgeon Member  
6 Dr. Kirti Ketan Pradhan Dept. of Plastic Surgery Member  
7 Dr. Shivashish/ Dr. Umakant EMO Member  
Khejuria
8 Manager on Duty Member  

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9 Mrs. Swapna Rani Jena DNS Member  

10 Mrs. Neeraj Anjana Shekhar Asst. Manager - Quality Member  
11 Mr. Mihir Kumar Das Mohapatra HOD - Maintenance Member  
12 Mr. Braja Kishore Behera HOD – Pharmacy Member  
13 Mr. Pradipta IT Executive Member  
14 Mr. Bibhutendu Bala HOD - Housekeeping Member  
15 Mr.Chitta Ranjan Sahoo Biomedical In-charge Member
16 Mr. Nishakar Nayak Security Officer Member
17 Mr. Ranjan Patra Transport In charge Member

6.2.2. SCOPE & FUCNTIONS:-

1. The overall scope & function of the Disaster Management Committee is to ensure proper planning coordination
and supervision of the Disaster Preparedness initiatives including Disaster Preparedness Programme.
2. To provide policy and procedures for response to both internal and external disaster situations.
3. To identify responsibilities of individuals and departments in the event of any disaster situation.
4. To prevent or reduce loss of life due to any disaster.
5. To ensure regular preparedness of Disaster Preparedness team through periodical Mock drill.
6.2.3. FREQUENCY OF MEETING: once in six months.
6.2.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
6.2.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
6.2.6. ADMINISTRATIVE INFORMATION: - Same as above.

6.3. INTERNAL COMPLAINTS COMMITTEE

6.3.1. COMPOSITION OF THE COMMITTEE

INTERNAL COMPLAINTS COMMITTEE
SL DESIGNATION IN SIGNATURE
NAME OF MEMBERS
NO DESIGNATION IN INSTITUTION COMMITTEE
1 Ms. Sujata Mohapatra Manager – Finance Chairperson

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2 Ms Suma Devi Director - Finance Member

3 Mr Sanjay Panda Head - Operations Member
4 Ms. Subhadra Nath Sr. Executive – HR Member
5 Ms. Neeraj Anjana Shekhar Asst. Manager – Quality Member – Secretary
6 Ms. Sonali Bhuyan Nursing Supervisor Coordinator

6.3.2. SCOPE & FUNCTIONS:

a. Prevent discrimination and sexual harassment against women, by promoting gender amity among employees.
b. Make recommendations to the Medical Superintendent for changes/elaborations in the Rules for employees and the
Bye-Laws, to make them gender just and to lay down procedures for the prohibition, resolution, settlement and
prosecution of acts of discrimination and sexual harassment against women and the employees;
c. Deal with cases of discrimination and sexual harassment against women, in a time bound manner, aiming at ensuring
support services to the victimized and termination of the harassment;
d. Recommend appropriate punitive action against the guilty party to the Medical Superintendent.
6.3.3. FREQUENCY OF MEETING: Quarterly
6.3.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
6.3.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
6.3.6. ADMINISTRATIVE INFORMATION: - Same as above.

6.4. CLINICAL AUDIT COMMITTEE

6.4.1. COMPOSITION OF THE COMMITTEE

CLINICAL AUDIT COMMITTEE
SL NAME OF MEMBERS DESIGNATION IN INSTITUTION DESIGNATION IN SIGNATURE
NO COMMITTEE
1 Dr. Maya Gantayet Senior Consultant – Neurology Chairperson
Member -
2 Dr. B. K. Reddy Consultant – Orthopedics Secretary
3 Dr. Soumyaraj Ghosh HOD – Critical Care Member
4 Dr. Sandip Pradhan Consultant – General Surgery Member
5 Dr. Bimal K. Sahu Consultant - Neurosurgeon Member

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6 Dr. Kirti Ketan Pradhan Plastic Surgery Member

7 Dr. Sourav K Rout Maxillo-facial Surgeon Member
8 Mrs. Swapna Rani Jena DNS Member
9 Mr. Anil Rout Executive MRD Member
10 Ms. Neeraj Anjana Shekhar Asst. Manager – Quality Coordinator
6.5. SCOPE & FUNCTIONS:
a. To ensure development of Clinical Practice Guidelines of various specialties
b. To assure consistency of patient care and treatment as per the Clinical Practice Guideline
c. To ensure that the Quality of Clinical Care is continuously monitored and improved.
d. Committee members monitor and evaluate clinical performance by conducting regular clinical audits in accordance
with national guidelines and good practice and implement improvements based on the findings of the audits.
e. Committee members make decisions based on quality information that supports effective performance monitoring and
audit.
6.6. FREQUENCY OF MEETING: Monthly
6.7. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
6.8. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
6.9. ADMINISTRATIVE INFORMATION: - Same as above.
4.8. BIOMEDICAL WASTE MANAGEMENT COMMITTEE

4.8.1. COMPOSITION OF THE COMMITTEE

BIOMEDICAL WASTE MANAGEMENT COMMITTEE

SL NAME OF MEMBERS DESIGNATION IN INSTITUTION DESIGNATION IN SIGNATURE
NO COMMITTEE
1 Dr. Mamta Bhatt HOD – Microbiology Chairperson
2 Ms. Swapna Rani Jena DNS & Infection Control Nurse Member - Secretary
3 Dr. Sandip Pradhan Consultant – General Surgery Member
4 Dr. B.K. Reddy Medical Superintendent Member
5 Dr. Manas Nayak HOD – Critical Care Member
6 Mr. Sanjay Panda Head – Operations Member
7 Ms. Neeraj Anjana Shekhar Asst. Manager Quality Coordinator
8 Mr. Bibhutendu Bala House Keeping Supervisor Member
9 Sonali Bhuyan Nursing Supervisor Member

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4.8.2. SCOPE & FUNCTION -:

1. The overall objective of the Biomedical Waste Management Committee is to develop and execute processes
pertaining to Bio Medical waste management in the Hospital.
2. To develop mechanism to ensure bio medical waste management handling rules are followed.
3. To assess the processes of bio medical waste management through an audit mechanism
4. To ensure adequate training programme of staff dealing with Bio medical waste
5. To suggest resources needed for Bio medical waste management
4.8.3. FREQUENCY OF MEETING: Once in two month
4.8.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
4.8.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
4.8.6. ADMINISTRATIVE INFORMATION: - Same as above.
4.9. CREDENTIALING & PRIVILEGING COMMITTEE
4.9.1. COMPOSITION OF THE COMMITTEE

CREDENTIALING & PRIVILEGING COMMITTEE

SL DESIGNATION IN DESIGNATION IN SIGNATURE
NAME OF MEMBERS
NO INSTITUTION COMMITTEE
1 Dr. Subrat Kumar Jena HOD – Surgical Specialties Chairperson
2 Mr. Satyajit Singh Manager - HR Member – Secretary
3 Dr. Maya Gantayet Sr. Consultant - Neurology Member
4 Dr. Sandip Pradhan Consultant – Surgery Member
5 Dr. Soumyaraj Ghosh HOD – Critical Care Member
6 Dr. B. K. Reddy Medical Superintendent Member
7 Dr. P. Tripathy Consultant - Cardiology Member
8 Ms. Subhadra Nath Executive - HR Member

4.9.2. SCOPE & FUNCTIONS-:

1. To evaluate credential of Staff who are involved in direct patient care prior to selection
2. To carry out Re-credentialing at a periodic frequency as decided in the hospital policy
3. To carry out performance monitoring annually based on the data presented by as per agreed format
4. To approve and authorize doctors for procedure and accord Clinical privileges
5. To reject the clinical privileges, if any dispute found
6. To ensure qualification and experience of nurses & doctors as per the Job responsibility defined.

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7. To undertake the process of reviewing credentials and recommending the appropriate scope of clinical practice for all
new applicants applying for scope of clinical practice to provide health care facility.
8. To conduct competency mapping of the doctors and nurses on a predefined criteria and based on the outcome Clinical
privileges are awarded to each and every Care provider.
9. To verifying current registrations, education, training, and experience
4.9.3. FREQUENCY OF MEETING: Twice in a year
4.9.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
4.9.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
4.9.6. ADMINISTRATIVE INFORMATION: - Same as above.

4.10. HOSPITAL BLOOD TRANSFUSION COMMITTEE

4.10.1. COMPOSITION OF THE COMMITTEE

HOSPITAL BLOOD TRANSFUSION COMMITTEE

SL DESIGNATION IN DESIGNATION IN
NAME OF MEMBERS SIGNATURE
NO INSTITUTION COMMITTEE
1 Dr. B. K. Reddy Medical Superintendent Chairperson  
2 Mr. Sujit Choudhury Dy – Manager, Operations Member – Secretary  
3 Dr. Maya Gantayet Sr. Consultant - Neurology Member  
4 Dr. Sandip Pradhan Consultant – Surgery Member  
5 Dr. Soumyaraj Ghosh HOD – Critical Care Member  
6 Dr. Sourav K Rout Maxillofacial Surgeon Member  
7 Dr. P. Tripathy Consultant - Cardiology Member  
8 Ms. Swapnarani Jena DNS Member

4.10.2. SCOPE & FUNCTIONS:-

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1. To develop Policies and Procedures for improving transfusion Services.

2. To promote Safe and effective transfusion Practice in hospitals in accordance with the institutional, national
or international benchmarks for the blood, blood components and associated blood products
3. To ensure Implementation of Internal and External Quality Control Measures.
4. To develop system for the investigation of reasons for transfusion reaction.
5. To ensure monitoring of turnaround time for blood and blood products
6. To ensure monitoring & reporting of wastage of blood and blood products, usage of components, blood and
blood products and turnaround time during emergencies
7. To ensure Correct Utilization of Blood & blood Products.
4.10.3. FREQUENCY OF MEETING: Quarterly
4.10.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
4.10.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also be
circulated among the committee members
4.10.6. ADMINISTRATIVE INFORMATION: - Same as above.

4.11. SAFETY AND SENTINNEL EVENT MANAGEMENT COMMITTEE

4.11.1. COMPOSITION OF THE COMMITTEE

SAFETY & RISK MANAGEMENT COMMITTEE

SL DESIGNATION IN DESIGNATION IN SIGNATURE
NAME OF MEMBERS
NO INSTITUTION COMMITTEE
1 Mr. Sanjay Panda Head - Operations Chairperson
Mr. Mihir Kumar Das
2 Mohapatra HOD - Maintenance Member - Secretary
3 Mr. Giri Kiran Kumar Radiation Safety Officer Member
4 Ms. Neeraj Anjana Shekhar Asst. Manager – Quality Coordinator
5 Mr. Pravakar Patra Safety Officer Member
6 Mr. Chitta Ranjan Sahoo Biomedical Engg. Member
7 Mr. Bibhutendu Bala HOD – Housekeeping Member
8 Mr. Bikram Keshari Sr. Executive HR Member

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4.11.2. SCOPE & FUNCTIONS:-

1. The overall objective of the safety and sentinel event management committee is to monitor, review and report
to the Medical Superintendent on whether the clinical care processes in the defined areas are efficient and
effectively implemented.
2. The objective of the Committee is to ensure proper planning, coordination and supervision of the safety and
sentinel event Preparedness initiatives including event Preparedness Programme.
3. To focus the attention of a hospital that has experienced a sentinel event on understanding the factors that
contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or
organizational culture), and on changing the hospital’s culture, systems, and processes to reduce the
probability of such an event in the future
4. To provide policy and procedures for response to safety and sentinel events.
5. To identify responsibilities of individuals and departments in any safety or sentinel events.
6. To prevent or reduce loss of life due to sentinel events.
7. To ensure regular preparedness of Safety and Sentinel Event Preparedness Team through periodical training.
4.11.3. FREQUENCY OF MEETING: Monthly

4.11.4. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.

4.11.5. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also
be circulated among the committee members

4.11.6. ADMINISTRATIVE INFORMATION: - Same as above.

4.12. MEDICAL AUDIT COMMITTEE

4.12.1. COMPOSITION OF THE COMMITTEE

MEDICAL AUDIT COMMITTEE

SL DESIGNATION IN DESIGNATION IN SIGNATURE
NAME OF MEMBERS
NO INSTITUTION COMMITTEE
1 Dr. Maya Gantayet Sr. Consultant – Neurology Chairperson
2 Dr. B. K. Reddy Medical Superintendent Member – Secretary
3 Dr. Sandip Pradhan Consultant General Surgery Member
4 Dr. P. Tripathy Consultant – Cardiology Member
5 Dr. Satyanarayan Behera Consultant – Orthopedics Member

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6 Dr. Bimal K Sahu Consultant – Neurosurgery Member

7 Dr. Mamta Bhatt Consultant – Microbiologist Member
8 Ms. Swapna Rani Jena DNS Member
9 Ms. Neeraj Anjana Shekhar Asst. Manager - Quality Member
10 Mr. Bijay Behera MRD Clerk Co-ordinator

4.12.2. SCOPE & FUNCTIONS:-

1. To improve medical record keeping through periodic review & audit of Patient care record.
2. To ensure development of the systems for proper record keeping and creating backup of records.
3. Review medical records for timely completion, clinical pertinence and overall adequacy for patient care, education
and research, administrative and legal purposes.
4. Review medical records periodically to ensure that they reflect the condition and progress of the patient, to justify
the diagnosis, warrant the investigations, treatment and end results.
5. Approve the format of the complete medical record, forms to be retained or discarded, and order of arrangement of
forms in the patient’s file.
6. Approve the various forms for requisitions, reporting, record of clinical data, certificates, etc and thereby promote
standardization of form size, form contents and design, patient demographic data, appropriate color coding, and
reduction in number and variety of forms.
7. Determine the retention policy for the patient’s file and various other records and registers.
8. Advise the medical records department on policies in relation to clinical requirements.
9. Review plans and programs of the medical records department with regard to staff, space, facilities and in- Service
training.
4.12.3. TENURE OF THE COMMITTEE: One year from the date of issue. Revision of TOR and Composition shall be done
after the completion of year.
4.12.4. MINUTES: The minutes of the meeting will be sent to MS for perusal or action whenever necessary and will also
be circulated among the committee member
4.12.5. ADMINISTRATIVE INFORMATION: - Same as above.

5. STATUTORY AND REGULATORY REQUIREMENTS

Status of Statutory Requirements as applicable

Sl no Name of licenses Licensing Status Regd. Number Date of Issue Date of Expiry
Authority

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1.       Building occupancy certificate CDA Available B.P. No. 1362/11 13.01.2012 Life Time

2.       No objection certificate from Odisha Fire Available  Certificate No. 56/CR CTC  27.11.2020  26.11.2022
the Chief Fire Officer for Fire Service
Safety.
3.       Authorization under BMW SPCB- Available 7984/SPBC 02.09.2020 31.03.2022
rules,2016,2018 Odisha
4.       Agreement with Saniclean Agreement Available 28AA878131 20.02.2017 19.02.2027
under BMW rules
5 Consent for discharge of SPCB- Available RO/CTC/CTO.84/14 31.03.2025
Sewerage and trade effluent Odisha (Consent Order) 19.08.2020
of Water (Prevention and
control of pollution Act)

6 Consent to establish under SPCB- Available RO/CTC/CTO.84/14 04/11/2016 31.03.2025

Pollution Control Board Odisha (Consent Order)
7 Registration Under Odisha CDMO- Waiting for CUT/01070/2008 25.02.2021 25.02.2026
Clinical Establishment Cuttack Fire NOC
8 Registration for Operation AERB Available 15-LOEE-52803 06.11.2020 06.11.2025
of X-ray(Bone
Densitometer) Installation
from AERB
Registration for Operation AERB Available 15-LOEE-52695 06.11.2020 06.11.2025
of X-ray (Radiography-
Fixed) Installation from
AERB
Registration for Operation AERB Available 18-LOP-243808
of X-ray (Radiography-
Mobile) Installation from
AERB
9 Registration for Operation AERB Available 16-LOEE-78062 12.04.2021 12.04.2026
of CT Scan Installation
from AERB
10 Cathlab Installation AERB Available 16-LOEE-78063 12.04.2021 12.04.2026 12.04.2
Approval from AERB
11 Registration for Operation AERB Available 15-LOEE-52692 06.11.2020 06.11.2025
of C – Arm from AERB

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12 USG Registration Under Collector Expired on

PNDT Act & District 05.11.2017,
Magistrate Renewal
, CTC applied for.

A. Immunology CDMO-Cuttack Available

Department
B OT-Complex Available

C ICU Complex -CTVS Available

D Intensive care Unit Available

E HDU Available

F Cardiology Available
Department
G Radiology Available
Department
11 RSO Approval under AERB

a. Dr. AERB Application to be

collected
B Mr. Giri Kiran AERB Available 15-RSO-67673 29/10/2015 29/10/2018
Kumar
C Mr. AERB Application to be
collected
12 Income tax PAN Commissioner
Income tax
13 Permit to operate Electrical Inspector Available
lifts under the Lifts
and escalators Act.
Thyssen Krupp Payment Receipt C-S-3-28-18-7273 01.06.2018 31.05.2019
with Accounts
Payment Receipt C-S-3-28-18-7272 01.08.2018 31.07.2019
with Accounts
Payment Receipt C-S-3-28-18-7271 01.08.2018 31.07.2019
with Accounts

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14 Wholesale drug Directorate of Drugs NA

license Control
15 License under Directorate of Drugs Available DC-167/NARC 01.01.2021 31.12.2021
Narcotic & Control
Psychotropic
Substance Act
16 Drug license to Directorate of Drugs Available CU-22008/R, CU- 12.05.2021 1.05.2026
Sell, Stock, or Control 22009/RC, CU- (Applied for)
exhibit or offer for 8065/RX
sale or distribute
17 Permission of CESU-ODISHA
power supply
18 Central sales tax Asst. Commissioner Available TIN-21731208411 30/12/2005
registration Sales tax

19 Trade License Municipal Available 252/2014 27/04/2020 31.03.2021

Commisioner

20 Registration Asst. Commissioner Available TIN-21731208411 30/12/2005

certificate for Sales tax
dealers liable to
VAT
21 Vehicle RTO Available OD05AG4526 02/04/2018 25/03/2018
Registration (Tax paid)
Certificates
22 Canteen CMC Available 12017034000290 11/07/2018 10/07/2023
Registration under
FSSAI
23 License to Store Chief Controller of Available
Compressed Gas Excise
24 Import Export 2306000174 08.05.2006
Code
25 Electrical Jaikar Techno Pvt. Available (AMC) ESN-25392382
Installations (DG Ltd. ESN-25392035
Sets-2 in nos.)

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6. CHAPTERWISE DOCUMENTATION:
6.1. ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)

6.1.1. AAC.1. The organization defines and displays the healthcare services that it provides.
6.1.1.1. Objective element
Commitment:
a. The healthcare services being provided are clearly defined and are in consonance with the needs of the
community.
b. Each defined healthcare service should have appropriate diagnostics and treatment facilities with suitably
qualified personnel who provide out-patient, in-patient and emergency cover.
c. Scope of the healthcare services of each department is defined.
d. The Organization’s defined healthcare services are prominently displayed.

6.1.1.2. Policies for Standard AAC 1:

a. The scope of services of the organization and various departments has been developed, reviewed and approved
by senior management/ stakeholder (Refer : AH/PPM/HWP/21 )
b. Planning of each defined services has been done by making provision of required diagnostic and treatment
facilities. Outpatient, Inpatient and Emergency services are available. Qualified and Trained Staff in each facility
is available to deliver optimum level patient care.
c. Defined services have been prominently displayed in each strategic locations of the hospital. This include
signage in the form of boards, permanent in nature, bilingual format and easily visible from distance of 10 meter.
Services not provided in the hospital are also displayed near the reception and entrance of emergency
department of the Hospital.
d. Regular Training of all the staff mainly in the reception/registration, OPD, IPD is imparted on Scope of Service of
the hospital. Training records are maintained for each staff by the HR department.

6.1.2. AAC 2: The organization has a well-defined registration and admission process.

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6.1.2.1. Objective Elements:

a. Commitment: The organization uses written guidance for Registering and admitting patients. *
b. CORE: A unique identification number is generated at the end of registration.
c. Commitment: Patients are accepted only if the organization can provide the required service.
d. Commitment: written guidance also addresses managing patients during non-availability of beds. *
e. Achievement: Access to the healthcare services in the organization is prioritized according to the clinical
needs of the patient.*

6.1.2.2. Policies for Standard AAC 2:

a. Hospital has prepared & implemented a documented policies and procedure for registration patient. (Refer :
AH/PPM/HRA/02 )
b. Hospital has prepared and implemented Admission policy for admitting the patient to hospital.
(Refer : AH/PPM/HRA/02 )
c. There are documented policy and procedure available for Out-patient (Refer : AH/PPM/HRA/02 )
d. There are documented policy and procedure available for In-patient (Refer : AH/PPM/HRA/02 )
e. There are documented policy and procedure available for emergency patients (Refer : AH /ES/09 )
f. There is a system available to generate unique identification number for every patient which is generated at the
end of each registration. The Unique identification number is used for the identification of the patient across the
hospital and to ensure continuity of care across the hospital. Unique number is mentioned in all patient related
record.
g. Patients are accepted/registered/admitted in the hospital only if the hospital can provide the required services.
The Staff available in admission and registration are well aware of the services that hospital provides. In case of
emergency situation, the patient is given life saving treatment before any decision of referral to other institute
where required service needed to patient is available.
h. Hospital has a documented policy guiding staff to manage the patients during non-availability of beds. (Refer-
AH/PPM/HWP/01)
i. Clinical needs of the patient is identified and prioritized to access healthcare services in the hospital in all setting.
j. Staffs are made aware of their responsibility during such situation.

6.1.3. AAC.3: There is an appropriate mechanism for transfer (in and out) or referral of patients.
6.1.3.1. Objective Elements:

Commitment:

a. Transfer-in of patients to the organization is done appropriately. *

b.Transfer-out/referral of patients to another facility is done appropriately. *

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c.During transfer or referral, accompanying staff are appropriate to the clinical condition of the patient.
d.The organization gives a summary of the patient’s condition and the treatment given.

6.1.3.2. Policies for Standard AAC 3:

a. Documented policy and procedure for the Transfer-in of patients to the hospital is available.
(Refer-AH/PPM/HWP/01)
b. Transfer –out/ referral of unstable patients to another facility is done in an appropriate manner and safely as per
the documented policy and procedure. An ambulance is available round the clock appropriately equipped and
accompanied by trained personnel. (Refer-AH/PPM/HWP/01)
a. Transfer of stable patients to another facility is guided by the transfer policy (Refer-AH/PPM/HWP/01)
b. Staff responsible for transfer of the patients is guided by the transfer policy. Every staff handling transfer of the
patients is trained in BLS. For unstable patient’s transfer, doctor also accompany patient to other healthcare
organization. (Refer-AH/PPM/HWP/01)
c. Hospital provides a brief summary of the patient’s condition and treatment given. The case summary is given which
mentions significant findings and treatment given for patients being transferred from emergency or patient being
transferred for diagnostic and/or therapeutic purposes. A discharge summary is given in case of the patient being
transferred including those of leaving against medical advice.

6.1.4. AAC.4: Patients cared for by the organization undergo an established initial assessment.

6.1.4.1. Objective Elements:

a. CORE: The initial assessment of the out–patients, day- care, in-patients and emergency patients is done.
b. Commitment: The initial assessment is performed by qualified personnel. *
c. Commitment: The initial assessment is performed within a time frame on the needs of the patient.
d. Commitment: Initial assessment of day-care and in-patients includes nursing assessment, which is done at the
time of admission and documented.
e. Achievement: The initial assessment for in-patients results in a documented care plan.
f. Achievement: Thecareplaniscountersignedbytheclinician-in-chargeofthepatientwithin24hours.
g. Excellence: The care plan includes the identification of special needs regarding care following discharge.

Policies for Standard AAC 4:

a. Content of the initial assessment has been defined and documented. Initial assessment is carried out for OP,
IP and ER. Standard format for carrying out assessment is used. Requisite parameters for the initial
assessment has been laid down which mainly contains the complaints, vitals, findings. Abridged
documentation is used wherever necessary example in day care areas (Refer-AH/PPM/HWP/01)

b. Initial assessment is performed by person qualified, registered and trained as applicable laws and regulations.
Doctors, nurses, dietician conduct the assessment as per the discipline and scope of practice. (Refer
Personnel file of Staff)

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c. Timeframe for the initial assessment for OP, IP & Emergency patient has been defined and monitored.
Emergency patient are to be assessed within 10 minutes to the arrival by CMO/registrar & within 5 minutes by
nurse. Similarly Indoor patients are to be assessed within 120 minutes by doctors in wards and 10 minutes by
intensivist in ICUs whereas assessment in wards shall be completed within 30 minutes by nurses and within 5
minutes by nurse in ICUs. Patient who comes to OP for consultation shall be assessed within 120 minutes of
registration in general OPD as well as in super specialty OPD. (Refer-AH/PPM/HWP/01)
e. Initial assessment of In-patients is documented within 24 hrs or as early as possible. Initial assessment for in-
patients covers history, progress notes, investigation ordered and treatment ordered and duly signed by
treating doctor.(Refer Medical Record )
f. Nutritional assessment is also a part of initial assessment and it covers the patient’s screening for nutritional
needs. Nutritional screening is done for all patients including OP and IP. Parameters for screening are defined.
Nutritional screening result to a detailed nutritional assessment. (Refer Medical Record)
g. Unit head or doctor of the team documents plan of care of the patient as per initial assessment results and
diagnostic results as available. Care plan is modified at the subsequent re-assessment if needed. Care plan of
the patient is countersigned by the Unit head of the patient within 24 hours of admission. (Refer Medical
Record )
6.1.5. AAC.5. Patients cared for by the organization undergo a regular reassessment.
6.1.5.1. Objective Elements:

a.CORE: Patients are reassessed at appropriate intervals to determine their response to treatment and to plan further
treatment or discharge.
b.Commitment: Out-patients are informed of their next follow-up, where appropriate.
c.Commitment:
d. For in-patients during reassessment the care plan is monitored and modified, where found necessary.
e. Staff involved in direct clinical care document reassessments.*
f. Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.
g. The organization lays down guidelines and implements processes to identify early warning signs of change or
deterioration in clinical conditions for initiating prompt intervention.

6.1.5.2. Policies for AAC 5:

a. Patients are re-assessed at periodic interval in the different setting by the doctor and nurses as per the
patient’s condition and frequency of re-assessment. ICU patients are to be more frequently re-assessed than
the ward patient. . Re-assessment is also to be done in day care settings or patients awaiting admission/bed.
(Refer-AH/PPM/HWP/01)

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b. Doctors while assessing patient in OPD shall inform patient of their next follow up which is documented in
OPD record. .(Refer Medical Record )
c. Plan of care patient is subjected to be re-modified if needed during re-assessment. Revised plan of care is
documented in the medical record such as progress notes, orders. Patient or his attendant is kept informed in
case of change in plan of care. .(Refer Medical Record )
d. Re-assessment is documented by the Treating doctor or his team member. Reassessment is done to
determine their response to treatment and further plan for treatment or discharge.(Refer Medical Record )
6.1.6. Processes have been laid down to identify early warning signs of change or deterioration in clinical conditions for
initiating prompt interventions. Staffs are trained to respond and manage such situation. (Refer-AH/PPM/HWP/01)
6.1.7. AAC 6: Laboratory services are provided as per the scope of services of the organization.
6.1.7.1. Objective Elements:
a. Commitment: Scope of the laboratory services is commensurate to the services provided by the
organization.
b. The infrastructure (physical and equipment) is adequate to provide the defined scope of services.
c. Human resource is adequate to provide the defined scope of services.
d. Qualified and trained personnel perform, supervise and interpret the investigations.
e. Requisition for tests, collection, identification, handling, safe transportation, processing and disposal of
specimens is performed according to written guidance.*
f. Laboratory results are available within a defined time frame. *
g. Critical results are intimated to the personnel concerned at the earliest.
h. Results are reported in a standardized manner.
i. There is a mechanism to address the recall / amendment of reports whenever applicable*.
j. Laboratory tests not available in the organization are outsourced to the organization(s) based on their
quality assurance system*.
6.1.7.2. Policies for AAC 6:
a. Laboratory services are provided as per the scope of Services of the Hospital. Round of the clock laboratory
service is available.
b. Laboratory is a permanent structure having state of the art equipment and competent manpower. Laboratory has
been planned as per its functional requirements. Laboratory information system exist and used for day to day
operations.
c. Availability of manpower is as per the work load. Permanent Staff including technical staff is available
d. Trained and competent staff having registration of qualification is available to process and conduct tests. Senior
Doctors are available for the Laboratory and its different units
e. Written policy and procedure is followed for the operations of laboratory. Procedure for ordering tests, collection,
identification, handling, safe transportation, processing and disposal of specimens is done as laid down in the
Manual of operations. ( Refer: AH/PPM/LS/14)

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f. Turnaround time for the tests is available for the different tests of the laboratory. Critical results have been defined
and followed. Immediate attention for patient management is done after the notification of critical values to the
concerned department.
g. All in house reports are generated through LIS (Laboratory Information System) and provided to patient after
authentication of person reporting the test. Parameters for the reporting has been defined and followed.
Outsourced laboratory results are also reported in a standardized manner by incorporating all relevant details.
h. Process to address recall/amendment of reports due to pre-analytical and post analytical error is followed.
Reports having error details are recalled /withdrawal from clinical areas, medical records, LIS and amended report
is issued with the caution to ignore the previous report. ( Refer: AH/PPM/LS/14)
i. Hospital has entered through an agreement with various external laboratory based on their Quality assurance
system. Documented procedure for outsourcing tests has been laid down and followed. Information of list of tests
outsourced, details of authorized personnel in the outsourced facilities, Turnaround time, Quality check of
outsource laboratory is documented ( Refer: AH/PPM/LS/14)
6.1.8. AAC 7: There is an established laboratory quality assurance programme.

6.1.8.1. Objective Elements:

a. Commitment: The laboratory quality assurance programme is implemented.
b. The programme addresses verification and / or validation of test methods.
c. The programme ensures the quality of test results*.
d. The programme includes periodic calibration and maintenance of all equipment.
e. The programme includes the documentation of corrective and preventive actions.
f. Excellence : The programme addresses clinicopathological meetings
6.1.8.2. Policies for AAC 7:

a. Quality assurance programme for laboratory service is documented and followed. Internal quality control,
EQAS, Inter lab comparison, validation and verification of test methods and results is done. Feedback from
treating doctor is also obtained regularly to assess the level of their satisfaction on reporting and results
acceptance. Refer (AH/PPM/LQA/15)
b. Surveillance of laboratory results like controls, external and internal quality assurance results, and non
conformances resulting from process is periodically assessed by Laboratory Director.
c. Calibration and maintenance of equipment is done by the qualified engineer. Traceability certificate of all
calibration done is maintained in the equipment file. User level preventive maintenance is done daily whereas
Company level maintenance is done at periodical interval. Corrective and preventive action of any process
failure is taken and documented.

6.1.9. AAC 8: There is an established laboratory safety programme.

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6.1.9.1. Objective Elements:

a.Commitment : The laboratory safety programme is Implemented. *
b.This programme is aligned with the organization’s safety programme.

c.Laboratory personnel are appropriately trained in safe practices.

d.Laboratory personnel are provided with appropriate safety measures.

6.1.9.2. Policies for AAC 8:

a. A documented laboratory safety manual is available. Risks and hazards associated to laboratory practices are dealt
according to the policy. All relevant safety parameters of Laboratory safety and bio hazards have been defined and
followed. Refer (AH/PPM/LSB/16)
b. Laboratory safety and Bio hazard issues are linked with Hospital wide safety programme . Principles of safety is
followed and uniform as that of the hospital’s safety programme like Fire safety, Spill management, Occupational
hazard management, Bio waste management etc Refer (AH/PPM/LSB/16)
c. Laboratory personnel are trained on the safe practices of the laboratory. In house training is conducted for the
personnel those are engaged in laboratory.
d. Required safety devices are made available in the laboratory. Adequate PPE, eye wash facility, first aid box,
immunization of staff with Tetanus and Hepatitis, fire safety measures are made available in the department and staff
are motivated to use.
6.1.10. AAC 9: Imaging services are provided as per the scope of services of the organization.
6.1.10.1. Objective Elements:
a.CORE : Imaging services comply with legal and other requirements.
b.Commitment : Scope of the imaging services is commensurate to the services provided by the organization.
c.The infrastructure (physical and equipment) and human resources are adequate to provide for its defined scope of
services.
d. Qualified and trained personnel perform, supervise and interpret the investigations.
e. Patients are transported in a safe and timely manner to and from the imaging services.
f.Imaging results are available within a defined time frame.
g.Critical results are intimated immediately to the personnel concerned.
h.Results are reported in a standardized manner.
i.There is a mechanism to address the recall / amendment of reports whenever applicable.
j.Imaging tests not available in the organization are outsourced to organization(s) based on their quality assurance system.

6.1.10.2. Policies for AAC 9:

a. Statutory provision for the imaging service is complied. Hospital is aware of the legal and all other statutory requirement
pertaining to imaging services. Legal compliances are periodically updated at regular manner and /or whenever any
modification is communicated by the licensing authority in writing. The hospital maintains AERB approval, TLD badges for
radiation staff, Lead shields, lead apron, mandatory signages, Radiation Safety officer for the department has been
approved by AERB
b. Imaging Service is available to meet the requirement of patient. Scope of the imaging service has been planned as per the
Scope of Services of the Hospital. The infrastructure, equipment and physical facilities, back up have been planned
appropriately.
c. Qualified, competent and registered professionals are involved in performing, supervision and interpretation of the
investigation.

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d. Written policies and procedures are available and followed to ensure correct patient identification, safe and timely
transportation of patients to and from the imaging areas. Patient details are verified and approved prior to any procedure.
Refer (AH/PPM/RS/13)
e. Turnaround time for the imaging results has been developed and followed for reporting. Turnaround time is monitored by
the department. Refer (AH/PPM/RS/13)
f. Critical results those require immediate attention of clinicians is identified and defined. Staff working in the department is
made aware to report critical results to the concerned department for necessary treatment management of the patient. All
such notification of critical results is documented by the radiology. Refer (AH/PPM/RS/13)
g. All in house reports are generated under the supervision of radiologist and provided to patient after authentication of
person reporting the test. Parameters for the reporting has been defined and followed. Outsourced tests are also reported
in a standardized manner by incorporating all relevant details and hospital does not alter anything in the report.
h. Process to address recall/amendment of reports due to error at any level is followed. Reports having error details are
recalled /withdrawal from clinical areas, medical records and amended report is issued with the caution to ignore the
previous report. Refer (AH/PPM/RS/13)
i. Hospital has entered through an agreement with various external laboratory based on their Quality assurance system.
Documented procedure for outsourcing tests has been laid down and followed. Information of list of tests outsourced,
details of authorized personnel in the outsourced facilities, Turnaround time, Quality check I of outsource laboratory is
documented. Refer (AH/PPM/RS/13)

6.1.11. AAC 10: There is an established quality assurance programme for imaging services.
6.1.11.1. Objective Elements:
a. Commitment : The quality assurance programme for imaging services is implemented.
b. Quality assurance programme includes tests for imaging equipment
c. Quality assurance programme includes the reviews of imaging protocols.
d. Achievement:A system is in place to ensure the appropriateness of the investigations and procedures for the clinical
indication.
e. The programme addresses periodic internal / external peer review of imaging results using appropriate sampling.
f. Excellence:The programme addresses the clinico-radiological meetings.
g. Commitment: The programme includes periodic calibration and maintenance of all equipment.
h. The programme includes the documentation of corrective and preventive actions.

6.1.11.2. Policies for AAC 10:

a. The Quality assurance programme for radiology has been documented by addressing QA test of equipment, Safety
protocols, surveillance etc. Refer (AH/PPM/RS/13)
b. Quality assurance programme addresses periodic internal and external peer review of imaging results. Peer review system
exists to review the reports and outcomes of interventional procedure performed. Peer review that is conducted with the
internal process in charge is reviewed by the Head of the department and results of the discrepancy if any is
communicated in departmental meeting. Peer review with external quality assured imaging center is also done on a
monthly basis with adequate sample size for each modality. Surveillance of quality of images and completeness of the
imaging procedures is performed to ensure that they are appropriate and justified for the imaging. The results of such
events are discussed with clinicians and record documented with corrective and preventive action. Refer (AH/PPM/RS/13)
c. Investigation requisitions are properly checked by the staff prior to the performing the procedure. Patient safety and best
practice guidelines are followed. Communication record with clinicians is maintained by the radiology if any alternate
investigations are suggested after prior review of clinical indication. (Refer departmental record)

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d. Calibration and maintenance requirement of equipment is done as per AERB guideline as well as manufacturer
recommendations. Trained Bio medical engineer/agency is involved to carry out such activities. Traceability certificate of
all calibrations done by using calibrated equipment is maintained by the In-house Bio Medical Engineering department.
Corrective and preventive action of any process failure is taken and documented.

6.1.12. AAC 11: There is an established safety programme in the Imaging services.
6.1.12.1. Objective Elements:
a Commitment:The radiation-safety programme is implemented. *

b This programme is aligned with the organization’s safety programme.

c Patients are appropriately screened for safety / risk before imaging.

d Imaging personnel and patients use appropriate radiation safety and monitoring devices where
applicable.

e Radiation-safety and monitoring devices and are periodically tested and results are documented.*

f Imaging and ancillary personnel are trained in imaging safety practice and radiation-safety measures.

g Imaging signage is prominently displayed in all appropriate locations.

a. Radiation Safety programme is documented and available to the department. Radiation Safety provision for high end
radiation prone equipments like CT machine is available. Refer (AH/PPM/RS/13)
b. Imaging safety programme is aligned with the safety programme of the hospital. Principles of safety is followed and uniform
as that of the hospital’s safety programme like Fire safety, Electrical Safety, Environmental safety, Safe transportation of
patient, Medication safety, Occupational hazard management, Bio waste management
c. Patients are educated and made aware of safety procedure prior to imaging in particular modality like MRI, CT and X-ray.
Attendants accompanying patient is also educated on safety norms. Informed consent is obtained prior to contrast injection,
moderate deep sedation etc
d. Bio medical waste management guidelines are adhered for handling, usage, and disposal of hazardous materials. MSDS
(Material Safety data sheet) is maintained by the department and well aware of action to be taken in case of exposure.
e. Required Safety devices as advised by AERB guidelines are available and used by the staff of department
f. Radiation monitoring devices (TLD badges), Lead aprons are available for every staff and periodically tested and checked.
Refer (AH/PPM/RS/13)
g. Each and every staff of the department are suitably trained on radiation safety practices at periodical interval by the
Radiation Safety officer. Record of the training is maintained in staff’s personal file.
h. Imaging Signage has been displayed in strategic locations of the department.

6.1.13. AAC 12: Patient care is continuous and multidisciplinary.

6.1.13.1. Objective Elements:

a. Commitment : During all phases of care, there is a qualified individual identified as responsible for the patient’s care.
b. Patient care is coordinated in all care settings within the organization.

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c. Information about the patient’s care and response to treatment is shared among medical, nursing and other care-providers.
d. CORE : The Organisation implements standardized hand-over communication during each staffing shift, between shift and
during transfers between units/departments.
e. Commitment:Patient transfer the Organisation is done safely in a safe manner.
f. Referral of patients to other departments / specialities follow written guidance.
g. Achievement: The organization ensures predictable service delivery by adhering tom defined timelines and informs the
patient/family and/or caregiver whenever there is a change in schedule.
h. The organization has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to
a critical value alert.
6.1.13.2. Policies for AAC 12:
a. To maintain continuity of care throughout the patient’s stay in the hospital, the Doctor, nurses with overall
responsibility for coordination and continuity of the patient’s care or particular phase of the patient’s clearly
identified. The responsible individual category of staff is identified in the patient’s record. Care of the patient is
coordinated among various credential and competent staff. All these communications are clearly documented in
the medical record.
b. Medical and Nursing professionals periodically review patient response to the treatment and plan of care is
developed and followed in a coordinated approach.
c. Handover among doctors and nursing professionals are done to exchange information related to patient related
care during each shift, between shift and during transfers between units, departments. Record for the same is
maintained.
d. Safety during patient transfer is followed. Safety belts are used before transferring. Patient / attendant is made
aware of the purpose of transfer. Handover and taken over of transfer is maintained
e. Documented policy and procedure for the referral of patients to other department and specialties is available.
(Refer-AH/PPM/HWP/01)
f. Patients and relatives are informed about any change in waiting time, reason for waiting in defined activity to
ensure continuity of care.
g. Critical values of diagnostic results are reported to the doctors of concerned inpatient area for necessary care
management of concern patient. Response of doctor to intervene on the result of critical values are recorded and
reviewed by the Nursing Superintendent and report to the Quality Assurance Committee

6.1.14. AAC.13: The organization has a documented discharge process.

6.1.14.1. Objective Elements:

a. Commitment: The patient’s discharge process is planned in consultation with the patient and/or family.
b. The discharge process is coordinated among various departments and agencies involved (including medico-legal
and absconded cases).
c. Written guidance governs the discharge of patients leaving against medical advice.
d. A discharge summary is given to all the patients leaving the organization (including patients leaving against
medical advice).
e. Achievement: The organization adheres to planned discharge.
f. Excellence: The organization conforms to the defined timeframe for discharge and makes continual improvement

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6.1.14.2. Policies for AAC 13.

a. Treating doctor always decides the readiness of patient discharge during regular re-assessment. Patient and
family members are updated about the planning process. It is discussed whether patient may need support
services and medical services at discharge. This includes giving prior intimation to patient/ his attendants for the
arrangement of social, nutritional, financial, psychological, or other support at discharge. The discharge planning
process includes the type of support service needed and the availability of such services in the hospital.
b. Various departments of the hospital coordinate amongst themselves so that the discharge processes are
completed well within time. Police intimation is given for MLC (Medico Legal case). Inpatients and outpatient
(including patients from the emergency department) have the right to refuse medical treatment and/or leave the
hospital against medical advice. However, these patients are explained that they are at risk of inadequate
treatment that may result in permanent harm or death. When a competent inpatient or outpatient requests to
leave the hospital without medical approval, the medical risks is explained by the treating doctor providing the
treatment plan or his/her designee prior to discharge. Also, normal a discharge procedure is followed however an
informed consent is obtained. Refer (AH/PPM/HD/05)
c. Discharge summary is hand over to the patient/attendant in all cases and copy of the discharge summary is
preserved in the medical record file. Discharge summary is also provided to the LAMA (Left against medical
advice) patient with all details (Treatment history, investigations, medications, instructions & other details)as like
routine discharge summary given to any normal patient.
d. Discharge of the patient is mostly completed within 2 hours for General patient however insurance patient
discharge process takes at least 4 hours due to clearance time taken by insurance agency.

6.1.15. AAC.14: Organization defines the content of the discharge summary.

6.1.15.1.Objective Elements:

a. Commitment: A discharge summary is provided to the patients at the time of discharge.

b. Discharge summary contains the patient’s name, unique identification number, name of the treating doctor,
date of admission and date of discharge.
c. Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s
condition at the time of discharge.
d. Discharge summary contains information regarding investigation results, any procedure performed, medication
administered and other treatment given.
e. Discharge summary contains follow-up advice, medication and other instructions in an understandable manner.
f. Achievement: Discharge summary incorporates instructions about when and how to obtain urgent care.
g. In case of death, the summary of the case also includes the cause of death.

6.1.15.2.Policies for AAC14:

a. The discharge summary provides an overview of the patient’s stay within the hospital. The summary is
developed by treating doctor responsible for providing follow-up care. The summary includes the following:
1. Patient’s details including UHID, Date of admission and Date of discharge
2. Reason for admission, diagnoses, and co-morbidities

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3. Significant physical and other findings

4. Diagnostic and therapeutic procedures performed
5. Significant medications administered during hospitalization and all the medications to be taken at home
6. The patient’s condition/status at the time of discharge (examples include; “condition improved, condition
unchanged and the like
7. When and how to obtain urgent care
8. Follow-up instructions
9. In case of death, the summary of the case also includes cause of death

6.2. CARE OF PATIENT (COP)

6.2.1.1. COP.1: Uniform care to patients is provided in all settings of the organization and is guided by written
guidance, and applicable laws and regulations.
Objective Elements:
a. Commitment: Uniform care is provided following written guidance.
b. CORE: The organization has a uniform process for identification of patients and at a minimum, uses two
identifiers.
c. Commitment: Care shall be provided in consonance with applicable laws and regulations.
d. Achievement: The organization adapts evidence-based clinical practice guidelines and/or clinical protocols to
guide uniform patient care.
e. Excellence: Clinical care pathways are developed, consistently followed across all settings of care, and
reviewed periodically.
f. Commitment: Care delivery is uniform for a given clinical condition when similar care is provided in more than
one setting.
g. Excellence: Multi-disciplinary and multi-specialty care, where appropriate, is planned based on best clinical
practices/clinical practice guidelines and delivered in a uniform manner across the organization.
h. Commitment: Telemedicine facility is provided safely and based on written guidance.

6.2.1.2. Policies for COP 1

a. Care delivery is uniform across the hospital for a same health problem without any discrimination. Patient
receives same quality of clinical care throughout the hospital, irrespective of the general ward category or in
Private cabins. Uniform care is followed also for all OPDs. Uniform care is guided by documented policies and
procedure. The plan of care outlines care and treatment to be provided to an individual patient. The plan of care
identifies a set of actions that the health care team will implement to resolve or support the diagnosis identified
by assessment, thus providing for measurable outcomes. The overall goal of a plan of care is to achieve optimal
clinical outcomes. The plan of care is developed within 24 hours of admission as an inpatient. Applicable
statutory norms are adhered as per the local and national laws. Informed Consent is obtained for all invasive
procedure, first aid is provided to emergency patients without delay and police intimation in case of Medico legal
cases is given. Refer : AH/PPM/HWP/21

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b. Evidence based clinical protocols are followed by care providers in their respective field to ensure uniform
patient care is maintained. All clinical staff are sensitized through training with the knowledge and skills to
recognize and intervene when patient assessments identify physiological signs that are outside of the normal
range, indicating a potential for patient deterioration. Early response to changes in a patient’s condition is critical
to potentially preventing further deterioration. Hospitals follow a systematic approach to early recognition and
intervention of patients whose condition is deteriorating may reduce cardiopulmonary arrests and patient
mortality.

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

6.2.2.1. Objective Elements:

a. Commitment: There shall be an identified area in the organization which is easily accessible to receive and
manage emergency patients, with adequate and appropriate resources.
b. Achievement: Prevention of patient over-crowding is planned, and crowd management measures are
implemented.
c. CORE: Emergency care provided in consonance with statutory requirements and in accordance with the written
guidance.
d. Commitment: The organization manage medico-legal cases in accordance with statutory requirements.
e. Initiation of appropriate careis guided by a system of triage.
f. Patients waiting in the emergency are reassessed as appropriate for change in status..
g. Admission, discharge to home ,or transfer to another organization is documented..
h. In case of discharge to home or transfer to another organization, a discharge/ transfer note shall be given to
the patient.
i. Achievement: The organization shall implement a quality assurance programme..
j. Commitment: The organization has systems in place for the management of patients found dead on arrival and
patients who die within a few minutes of arrival.

6.2.2.2. Policies for COP 2:

a. Emergency department of the hospital is well established and easily accessible from the main entrance. The
department is clearly visible from a distance and emergency patients are promptly guided and attended.
b. Documented procedure exists to follow either general emergency care or management of specific conditions.
Clinical protocols for commonly seen diseases are readily available in the department. Provision of adequate
man, materials support available in the department for round the clock functions of Emergency unit. First aid is
provided to patients coming to the hospital before transferring to another hospital in case of requirement. The
policy address issues related to Medico legal . Department is headed by Qualified and competent Staff member
to ensure patient receives proper quality of care as per the policy guideline Refer (AH/PPM/ES/09)
c. Dedicated space available to triage of the patient and it is done by trained nurse. Evidenced based triage
criteria has been defined and followed. Once identified as emergent, urgent, or requiring immediate needs,
these patients are assessed and receive care as quickly as necessary. Such patients may be assessed by a

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trained nurse. The triage process includes physiologic based criteria, where possible and appropriate. The
hospital trains staff to determine which patients need immediate care and how their care is given priority.
d. All Doctors and nurses working in the department is ACLS trained whereas attendant, Ambulance driver,
security guards and housekeeping staff are trained on BLS.
e. Evidenced based admission and discharge criteria to home or transfer to another organization is documented.
Patient with an emergency condition and the patient require transfer to a higher level of care, is stabilized
transferred after within our best capacity prior to transport. Refer (AH/PPM/ES/09)
f. Quality and Safety requirement of the department is documented and followed. Patient safety related to
transferring unstable patient, initiating treatment, Fire Safety measures, disaster management, monitoring of
outcome is part of its quality and safety requirement. Departmental HOD plays major role in inculcating
evidence based guideline in the department. Refer (AH/PPM/ES/09)
g. Brought dead policy is available and strictly followed. This includes following
1. Maintaining a log book of patients found dead on arrival
2. Police intimation and medico legal issues
3. Decision to suggest post mortem
4. Temporary storage of body in proper condition
5. Registration process
6. Documentation

COP.3: The ambulance services ensure safe patient transportation with appropriate care.

Objective Elements:
a.Commitment: The organisation has access to ambulance services commensurate with the scope of the services provided
by it.
b.There are adequate access and space for the ambulances.
c. The ambulance(s) is fit for purpose and is appropriately equipped..
d. The ambulance(s) is by trained personnel..
e.The ambulances is checked daily.
f. Equipment is checked daily using a checklist.
g. A mechanism is in place to ensure that emergency medications are available the ambulance
h. The ambulances has a proper communication system..
i. The emergency department identifies opportunities to initiate treatment at the earliest when the patient is in transit to the
organization.

Policies for COP 3:

a. Proper earmarked space is available to park the ambulance near the emergency. Entry and egress of the ambulance is
done in unidirectional manner. Movement of the ambulance is easily possible for easy accessibility for receiving patient
and enable the ambulance to exit quickly
b. Statutory requirement for ambulance management is followed as per the motor vehicle Act. Driver license for Heavy
vehicle driving, fitness certificate, Pollution Control certificate, insurance and registration of vehicle is available
c. Dedicated ambulance of BLS and ALS category is available. Equipment and accessories are upkeep and maintained
d. Trained and competent staff is deputed for ambulance management. Staffs are trained on Basic life support measures.
e. There is a provision to daily check of functional status of ambulance, equipment and medication. A pre-defined checklist
is available and used for daily checking of ambulance

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f. There is a provision of communication system for ambulances of hospital. Whole process of patient transportation is
communicated and coordinated by the communication system. Staff of ambulance is given mobile phone. Communication
made by mobile phones to the emergency department is documented in ambulance trip sheet.
g. There is a process for the ambulance where patient treatment is initiated at the earliest when patient is in transit to
hospital. Patient condition is communicated by the staff of ambulance to the emergency doctor. Necessary arrangement
is done based on the first assessment of patient by the staff of ambulance. Refer (AH/PPM/AS/03)

6.2.3. COP.4: The organization plans and implement mechanisms for the care of patients during community emergencies,
epidemics and other disasters.

6.2.3.1. Objective Elements:

a.Commitment: The organization identifies potential community emergencies, epidemics and other disasters.
b.The organization manages community emergencies, epidemics and other disasters as per a documented plan.
c. Provision is made for availability of medical supplies, equipment and materials during such emergencies.

6.2.3.2. Policies for COP 4:

a. Disaster management procedure for the hospital has been developed. Procedure for handling the situation like victim of
earthquake, flood, train accident, civil disturbance, and major fire, terrorist invade has been developed. Disaster
management Mock drills are conducted once in six month. Refer (AH/PPM/HS/26)
b. Disaster action cards, provision of disaster cupboards containing medical supplies, equipment and materials has been
made near emergency
c. Hospital has a disaster management committee to ensure timely implementation of measures required for disaster
situation. Staffs are properly trained about their roles and responsibility during disaster situation.

COP.5: Cardio-pulmonary resuscitation services are provided uniformly across the organization.

6.2.3.3. Objective Elements:

a. Commitment: Resuscitation services are available to patients at all time.
b.During cardio pulmonary resuscitation, assigned roles and responsibilities are complied with.
c.Equipment and medication for use during cardio-pulmonary resuscitation are available in various areas of the organization.
. d.The-events during cardio-pulmonary resuscitation are recorded.
e.A multidisciplinary committee does a pos-event analysis of cardiopulmonary resuscitations.
f.Corrective and preventive measures taken based on post-event analysis.

6.2.3.4. Policies for COP 5:

a. Documented Process is available for management of patient requiring cardio pulmonary resuscitation.
Resuscitation services available within the hospital, including equipment and properly trained staff, Code blue
team. Evidence based guidelines are followed for the management of CPR condition. Refer : AH/PPM/HWP/21
b. Staff of both clinical and non clinical category is trained in advanced cardiopulmonary resuscitation and Basic
life support respectively. Clinical and Nursing staff working in high risk areas are trained in ACLS where as
paramedical and other staffs are trained in BLS.

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c. All the activities along with personnel details, events of CPR are recorded during actual CPR. Response time of
code blue team, availability of equipment, medicine and other details are recorded for the analysis and
necessary action. Outcome of all CPR given is analyzed by Code Blue Committee within 3 working days.
Corrective and preventive action as suggested by Code blue committee is taken.

6.2.4. COP.6: Nursing care is provided to patients in the organization in consonance with clinical protocols

6.2.4.1. Objective Elements:

a. Commitment: Nursing care is provided to patients in accordance with written guidance

b. The organization develops and implements nursing clinical practice guidelines reflecting current standards of
practice.
c. Assignment of patient care is done as per current good clinical/nursing practice guidelines.
Excellence: The organization implements acuity-based staffing to improve patient outcomes.
d. CORE: Nursing care is aligned and integrated with overall patient care.
e. Care provided by nurses is documented in the patient record.
f. Nurses are provided with appropriate and adequate equipment for providing safe and efficient nursing care.
g. Nurses are empowered to make patient care decisions within their scope of practice.
6.2.4.2. Policies for COP 6:
a. Documented policy and procedure Manual for Nursing Care is available. Nursing Staff of various nursing units
are trained as per the nursing manual. All nursing procedures including progressive nursing procedure as well
as general nursing procedure have been incorporated in the Nursing manual. Nursing practices are rendered in
accordance with nationally accepted standard. Trained and competent staff in adequate number is assigned of
patient care based on clinical condition and guideline laid down by regulatory and professional bodies (Refer
AH/PPM/NS/34)
b. Nursing care plan of the patient is developed & followed as per the patient’s problem and complaints. Care
provided by the nurses is documented in nursing records.
c. Adequate number of equipment, accessories & consumables are provided to nursing units for carrying out the
safe and effective nursing care.
d. Nursing staff are trained and made aware of policy and procedure related to patient care in such a way so that
they can take nursing related decisions to ensure timely and effective care of the patient without delay. Nurses
are empowered to take decision in the situation of adverse drug events, Blood transfusion reaction, Code Blue
situations, Critical values alert, and development of nursing care plan and execution of the same.
e.
6.2.5. COP.7: Clinical procedures are performed in a safe manner.

6.2.5.1. Objective Elements:

a. Commitment: Procedures are performed based on the clinical need of the patient.
b. Performance of various clinical procedures is based on written guidance.
c. Qualified personnel order, plan, perform and assist in performing procedures.
d. CORE: Care is taken to prevent adverse events like a wrong patients, wrong procedure and wrong site.

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e. Informed consent is taken by the personnel performing the procedure, where applicable.
f. The procedure is done adhering to standard precautions.
g. Patients are appropriately monitored during and after the procedure.
h. Procedures are documented accurately in the patient record.*

6.2.5.2. Policies for COP 7:

a. Documented procedures are used to conduct various Clinical procedures. Each clinical procedure has certain
common guideline to follow that includes Pre-procedure instruction, Plan of the procedure, post procedure
instructions etc. Refer AH/PPM/SS/25
b. Qualified and Competent Staffs conducts procedure and pre and post operative assessment as per the
credentials and privileges awarded.
c. Documented procedure is available to avoid wrong patient, wrong site and wrong procedure. Patient is
identified at every level by using two identifiers. Patient Unique ID and Name is used to identify and confirm
patient’s identity. Immediate Pre-operative check. Procedural checklists including WHO surgical safety checklist
is used to avoid the risk of wrong site, wrong procedure and wrong patient procedure. Refer : AH/PPM/HWP/21
d. Informed consent is obtained from the patient /relatives prior to performing the procedure.
e. Standard precaution, safe practices are strictly followed. Preparation and disinfection of body parts, high level
chemical disinfection and sterilization of instruments and re-usable equipment is done appropriately.
f. Patients are monitored during and after the procedure. Monitoring of pulse, blood pressure, and respiratory rate
is done after the procedure in recovery area.
g. Procedures details are documented in the medical record of the patient.

6.2.6. COP.8: Transfusion services are provided as per the scope of services of the organization, safely.

6.2.6.1. Objective Elements:

a. Commitment: Scope of transfusion services is commensurate with the services provided by the organization.
b. CORE: Transfusion of blood and blood components is done safely.
c. Commitment: Blood and blood components are used rationally.
d. Informed consent is obtained for transfusion of blood and blood components.
e. Informed consent also includes patient and family education about the donation
f. Blood/blood components are available for use in emergency situations within a defined time-frame.
g. Achievement: Post-transfusion form is collected, reactions if any identified and are analyzed for preventive and
corrective actions
h. The organization shall implement a quality assurance peogramme.
6.2.6.2. Policies for COP 8:
a. Written policies and procedure are used to guide the rational use of blood and blood components. This includes
requisition of blood and blood components, inventory control, Informed consent, transportation of blood, no use
of premedication, proper storage and cold chain management etc (Refer AH/PPM/BB/08)
b. All statutory norms are adhered to manage blood bank in the hospital. This includes monitoring of transfusion
reactions, obtaining informed consent, patient and family education, bio medical waste management rules,
spillage management, availability of life saving drugs and quality control measures etc

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c. Periodic training is conducted for doctors and nurses by the I/C – Transfusion Services. Evidenced based
guideline for transfusion service is communicated through training programme.

6.2.7. COP.9: The organization provides care in intensive care and high dependency units in a systematic manner.

6.2.7.1. Objective Elements:

a. Care of patients in the intensive care and high dependency units is provided based on written guidance.
b. The defined admission and discharge criteria for intensive care and high dependency units are implemented.
c. Adequate staff and equipment are available.
d. Excellence: The organization endeavors to upgrade its physical infrastructure to meet national and international
guidelines.
e. Defined procedures for the situation of bed shortages are followed.
f. Infection control practices are followed.
g. The organization shall implement quality assurance programme.
h. The organization has mechanism to counsel the patient and/or family periodically.

6.2.7.2. Policies for COP 9:

a. Policy and Procedure for the Intensive care and high dependency unit is available to guide care of patient.
Refer AH/PPM/ICU/20
b. Admission and discharge criteria for Intensive care and high dependency unit are available and followed.
Evidenced based clinical parameters are used to admit and discharge patient of these units. Refer
AH/PPM/ICU/20
c. Concerned staff are adequately educated and trained to apply admission and discharge criteria as per the
defined policy
d. Each ICU of the hospital is appropriately equipped with all necessary life saving measures and monitoring
equipment. Trained and competent staffs are deputed in the area. Adequate number of Staffing pattern is
followed to manage the patient of ICU
e. Situation of bed shortage is addressed and followed as per the defined policy and procedure. Refer
AH/PPM/ICU/20
f. Infection control practices are properly followed as per the documented policy and procedure. Infection control
nurses are assigned to do monitoring of the practices of Intensive care. Refer AH/PPM/ICU/20
g. Quality Assurance programme of Intensive care area is documented and followed. Monitoring of Infection rates,
Outcome indicator, Care management and safety is part of Quality assurance system of Intensive care. Refer
AH/PPM/ICU/20
h. Patient and family members are made aware and counseled by the treating doctor and team when there us
significant changes in the condition of the patient. This activity is done at least once in a day. All communication
is documented in the patient family meting record.

6.2.8. COP.10: Organization provides safe obstetric care.

6.2.8.1. Objective Elements:
a. Commitment: Obstetric services are organized and provided safely.

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b. The organization identifies and provides care to high-risk obstetric cases, and where needed, refers them to
another appropriate Centre.
c. Persons caring for high-risk obstetric cases are competent.
d. Ante-natal services are provided.
e. Obstetric Patients assessment also includes maternal nutrition.
f. Appropriate peri-natal and post-natal monitoring is performed.
g. The organization caring for high-risk obstetric cases has the facilities to take care of neonates of such cases.

6.2.8.2. Policies for COP 10:

h. Policy and Procedure for Vulnerable patient management is available and are in accordance with the prevailing
laws and regulation. Necessary safety provision for these groups has been developed. Dedicated patient care
staff available to assist these groups. All these patients are assessed for risk of fall and same is documented in
fall risk assessment chart. Refer : AH/PPM/HWP/21
a. Provision of Special toilets, fall prevention measures, ramps with railing, playroom for children has been
developed.
b. Informed consent is obtained from their family members explaining reason for the same.
c. Staffs are trained to be courteous and empathetic while caring these groups

6.2.9. COP.11: Organization provides safe paediatric services.

6.2.9.1. Objective Elements:

a. Commitment: Paediatric services are organized and provided safely.
b. Neonatal care is in consonance with the national/international guidelines.
c. Those who care for children age-specific competency.
d. Provision are made for special care of children.
e. Paediatric assessment includes growth, developmental and immunization assessment.
f. The organization has measures in place to prevent child/neonate abduction and abuse.
g. The child family members are educated nutrition, immunization and safe parenting.

6.2.9.2. Policies for COP 11:

a. Documented policies and procedure for Obstetrics service is available. Refer AH/PPM/OBG/22
b. Hospital is capable to handle management of high risk obstetrics cases. Display of these information has been
done in prominent location in strategic locations (near the entrance, registration area, OPD )
c. Experienced and competent staffs are posted to take care of high risk obstetrics cases. Competency mapping
of staff is done at regular interval.
d. Provision of antenatal service is available. This includes Ante natal assessment, immunization, diet counseling.
Ante natal card to patient is provided with the provision of all these details.
e. Maternal nutrition is done collaboratively by doctor and dietician.
f. Provision for pre-natal, peri-natal and post natal monitoring is followed.
g. Dedicated Neonatal ICU is available with appropriate equipment and staff to take care of high risk obstetrics
cases in the facility. Competent doctors and nursing staff are made available round the clock.

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6.2.10. COP.12: Procedural sedation is provided in a consistent and safe manner.

6.2.10.1.Objective Elements:
a. Commitment: Procedural sedation is administered in a consistent manner.
b. Informed consent for administration of procedure sedation is obtained.
c. Competent and trained persons administer sedation.
d. The person monitoring sedation is different from the person performing the procedure.
e. Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm, respiratory rate, blood
pressure, oxygen saturation, and level of sedation.
f. Patient are monitored after sedation, and
g. Criteria are used to determine the appropriateness of discharge from the
observation/recovery area. *
h. Equipment and workforce are available to manage patients who have gone into a deeper level
of sedation than initially intended.

6.2.10.2.Policies for COP 12:

7. Documented procedure for the administration of moderate sedation is available. Sedation policy and procedure identifies
documentation required, informed consent procedure, patient monitoring requirement, special qualification and skill set of
staff performing procedure, Availability of staff and specialized equipment. Refer : AH/PPM/HWP/21
8. Informed consent is obtained prior to administration of moderate sedation
9. Competent and trained Staff in airway management is involved in performing sedation. Technicians are not allowed to
administer sedation. Doctor or nurse under the supervision of doctor is allowed to administer sedation.
10. Administration and monitoring of sedation during and after the procedure is done by the different staff than the staff
performing the procedure

10.2.1. COP.13: Anaesthesia services are provided in a consistent and safe manner

10.2.1.1.Objective Elements:
a.Anaesthesia services are provided in consistent and safe manner
b. The pre-anaesthesia assessment results in the formulation of an anaesthesia plan which is documented
c. A pre-induction assessment is performed and documented.
d The anaesthesiologist obtains informed consent for administration of anaesthesia.
e.During anaesthesia, monitoring includes regular recording of temperature, heart rate, cardiac
rhythm, respiratory rate, blood pressure, oxygen saturation and end- tidal carbon dioxide.
f. Patient's post-anaesthesia status is monitored and documented.
g. The anaesthesiologist applies defined criteria to transfer the patient from the recovery area. *
h. The type of anaesthesia and anaesthetic medications used are documented in the patient

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record.
i. Procedures shall comply with infection control guidelines to prevent cross- infection
between patients.
j. Intraoperative adverse anaesthesia events are recorded and monitored.

10.2.1.2. Policies for COP 13:

11. Policy and Procedure for the administration of anaesthesia is available. Refer AH/PPM/AC/01
12. Administration of anesthesia is carefully planned. The patient’s pre-anesthesia assessment is done by the Qualified
anaesthesiologist by selecting type of anaesthesia and anaesthesia care plan, Safely administer an anesthetics and
interpret findings of patient including monitoring.
13. The pre-anaesthesia process is carried out in a shortened time frame when an emergency or obstetrics patient requires
anesthesia. As the pre-anaesthesia assessment is carried out some time prior to admission or prior to the surgical
procedure. Patients are re-evaluated immediately before the induction of anaesthesia. Any changes in the plan are
documented with reason.
14. An informed consent is obtained from the patient/patient’s attendant prior to administration of anaesthesia. Patient and
family members are clearly educated on the risks, benefits and alternatives of anaesthesia by the anaesthesiologist prior
to documentation of consent. Anaesthesia consent is not clubbed with surgical consent.
15. Regular monitoring record of the patient is documented during anesthesia which includes monitoring of temperature,
heart rate, cardiac output, respiratory rate, blood pressure, oxygen saturation and end tidal carbon dioxide.
Anaesthesiologist is made available throughout the procedure. Patient’s post anaesthesia status is monitored and
documented by the anaesthesiologist.
16. Defined criteria are available and followed to transfer the patient from the recovery area. Refer AH/PPM/AC/01
17. Infection control requirements are strictly followed to prevent cross infection between patients.
18. Adverse anaesthesia events are recorded and monitored.
.

a. COP.14: Surgical services are provided in a consistent and safe manner

18.2.1.1.Objective Elements:
a. Surgical services are provided in a consistent and safe manner. *
b. Surgical patients have a preoperative assessment, a documented pre-operative diagnosis, and pre-
operative instructions are provided before surgery.
c. Informed consent is obtained by a surgeon before the procedure.

d. Care is taken to prevent adverse events like the wrong site, wrong patient and wrong surgery. *
E. An operative note is documented before transfer out of patient from recovery.

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F. Postoperative care is guided by a documented plan.

g Patient, personnel and material flow conform to infection control practices.
b. Appropriate facilities, equipment, instruments and supplies are available in the operating
theatre.
c. The organisation shall implement a quality assurance programme. *
d. The quality assurance programme includes surveillance of the operation theatre environment. *

18.2.1.2.Policies for COP 14:

COP.15: The organ transplant programme is carried out safely.

18.2.1.3. Objective Elements:

A. The organ transplant program shall be in consonance with the legal requirements and shall be
conducted ethically.
B. Care of transplant patients is guided by clinical practice guidelines. *
C. The organisation ensures education and counselling of recipient and donor through
trained/qualified counsellors before organ transplantation.
D. The organisation shall take measures to create awareness regarding organ donation.

18.2.1.4. Policies for COP 15

a. Policies and procedure for surgical services are available. Refer AH/PPM/SS/25
b. Pre-operative assessment and provisional diagnosis documented prior to surgery. This is applicable for both routine and
emergency cases. Operating surgeon documents the details.
c. Informed consent is obtained prior to the procedure. Patient/patient’s relatives are explained about the risk, procedure,
alternatives before obtaining consent.
d. Policy and procedure exists to prevent adverse events like wrong patient, wrong site and wrong surgery. WHO surgery
safety procedures are followed to avoid such incidence. Staffs are aware about the safe surgery guideline of hospital.
Refer : AH/PPM/HWP/21
e. Only qualified, credentialed and privilege personnel are permitted to perform the procedure that they are entitled to
perform.
f. Brief operative note is documented prior to transfer out of patient from recovery. The note provides information about the
procedure, pre-operative diagnosis, Surgeon details, Anaesthetist details, intra-operative procedure and key findings.
g. Post operative care plan of the patient is documented by the operating surgeon. This includes advice on IV fluids,
medication, care of wound, nursing care, etc . The plan is followed and reviewed by surgeon at least once a day.
h. Infection control measures are strictly taken for staff, outside materials prior to entry to operating complex.

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i. Operation theater complex is planned accordance to its functional flow. Provision of receiving area, pre-operative holding,
separate change room, clean utility, hand washing areas, operating rooms, waiting area, disposal zone, recovery room etc.
Adequate equipment and accessories for performing anaesthesia and surgical care is made available.
j. Quality assurance programme for Operating theatre complex is strictly followed. This includes safety, infection control,
monitoring outcome indicators, environmental safety, air conditioning norms, medication safety and antibiotic usage etc
k. Surveillance of Operation theatre complex is carried out as per the infection control procedure of the area. This includes
monitoring of Air quality, environmental culture, water quality, six monthly monitoring of integrity of HEPA filters etc.
l.

COP.16: The organisation identifies and manages patients who are at higher risk of morbidity/
mortality.

18.2.1.5. Objective Elements:

a.The organisation identifies and manages vulnerable patients. *

b. The organisation provides for a safe and secure environment for the vulnerable patient.

c. The organisation identifies and manages patients who are at a risk of fall.*

d. The organisation identifies and manages patients who are at risk of developing/worsening of
pressure ulcers.*

e. The organisation identifies and manages patients who are at risk of developing deep vein thrombosis.*
F. The organisation identifies and manages patients who need restraints. *

18.2.1.6. Policies for COP 16:

a. This standard is not shown as a scope of service and does not apply.

COP.17 Pain management for patients is done in a consistent manner.

18.2.1.7. Objective Elements:

a. Patients in pain are effectively managed. *

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b. Patients are screened for pain.

c. Patients with pain undergo detailed assessment and periodic reassessment.

d. Pain alleviation measures or medications are initiated and titrated according to the patient's need and
response

18.2.1.8. Policies for COP 17:

e. Policy and Procedure for care of patient under restraint is available Refer : AH/PPM/HWP/21
a. Physical and chemical restraints procedures are applied as per the requirement. Provision of boxer’s bandage, restraint
cuffs, beds are available for physical restraints where as sedatives are used as chemical restraints as advised by doctor
b. Reason for application of restraints are documented in the medical record
c. Patients under restraints are frequently monitored in restraint monitoring form
d. Nursing staff and doctors gets repeated training on the restraint techniques

COP.18Rehabilitation services are provided to the patients in a safe,

collaborative and consistent manner.

18.2.1.9. Objective Elements:

a.Scope of the rehabilitation services at a minimum is commensurate to the services provided by the
organisation.
b. Rehabilitation services are provided in a consistent manner.
c. Care providers collaboratively plan rehabilitation services.
d. There are adequate space and equipment to provide rehabilitation.
e. Care is guided by functional assessment and periodic re-assessments which are done and
documented.
f. Care is provided adhering to infection control and safety practices.
g. Care pathways are developed, implemented, and reviewed periodically.

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18.2.1.10. Policies for COP 18:

a. Policy and Procedure for Patient pain management is available. Refer AH/PPM/AC/01 , Refer AH/PPM/PMP/35
a. All patients are screened for pain and findings are documented with corrective and preventive action. Doctors and Nurses
consider pain as 5th vitals sign for assessment.
b. Pain assessment is done in the pain rating scoring chart. All patients are screened for pain. Post operative patients are
screened for pain and remedial measures are taken.
c. Pain alleviation measures and appropriate medications are administered according to the doctor’s advice.
d. Patient’s pain is not neglected. Hospital runs pain management clinic. Immediate pain management techniques are
adopted
e. Patient and family members are educated on various pain management techniques.

COP.19 Nutritional therapy is provided to patients consistently and collaboratively.

Objective Elements:

a. Patients admitted to the organisation are screened for nutritional risk. *

b. Nutritional assessment is done for patients found at risk during nutritional screening.
C. The therapeutic diet is planned and provided collaboratively.
d. Patients receive food according to the written order for the diet.
e. When family provides food, they are educated about the patient's diet limitations.

6.2.20.2. Policies for COP 19:

a. Policies and procedure for rehabilitative services are available. This includes policy for physiotherapy, occupational
therapy and speech therapy. These services are provided to the patient as per the requirement. Clinical departments
coordinate and take service of rehabilitation measures. Rehabilitation programme is followed for obstetric patient,
neurological and cardiology patient. Refer-AH/PPM/PMR/36
b. Infection control and safe practices are adhered for the service. Refer-AH/PPM/PMR/36
c. Multi disciplinary approach is practiced while providing these services to patient. Rehabilitation team is formed for
rehabilitative measures of patient Refer-AH/PPM/PMR/36
d. All major equipment and dedicated space is available as per the scope of rehabilitation services.

6.2.21. COP.20: End-of-life-care is provided in a compassionate and considerate manner

6.2.21.1. Objective Elements:

6.2.21.2. Policies for COP 20:

a. Policy and procedure for research activities is available. Approval from regulatory body has been obtained. All research
activities are in compliance to national and international guidelines
b. An ethics committee is available to oversee all research activities

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c. Informed consent from concerned patient is obtained prior to the initiation of any research activities. Patient has the right to
withdraw from the research any stage.
6.2.22. COP.21: Documented policies and procedures guide nutritional therapy.
6.2.22.1. Objective Elements:
a. Policies and procedure is available to guide nutritional therapy including assessment and re-assessment of the patient.
Refer AH/PPM/NDS/32
b. Patient receives diet as per the diet order. Nutritional assessment is done by qualified dietician for all patient found at risk
during nutritional screening.
c. Nutritional therapy of patient is planned and provided in a collaborative manner. This includes involvement of treating
doctor & patient and patient’s relative after taking into regard patient’s food habit
d. Written diet order is generated for each patient in diet order sheet and patient receives food according to the diet order.
Patient receives food according to their clinical needs. Treating doctor’s advice is taken into consideration while planning
patient’s diet. Provision for diabetic diet, high protein diet, total parenteral nutrition etc
e. Food is safely prepared, stored and distributed in a safe manner. Covered Food trolleys are used for carrying prepared
food to the inpatient area. Kitchen area has been designed as per the functional requirement. Dedicated food storage area,
refrigerator for perishable item, separate cleaning and washing area.
6.2.23. COP.22: Documented policies and procedures guide the end of life care.
6.2.23.1. Objective Elements:
a. Documented policies and procedures guide the end of life care.
b. These policies and procedures are in consonance with the legal requirements.
c. These also address the identification of the unique needs of such patient and family
d. Symptomatic treatment is provided and where appropriate measures are taken for the alleviation of pain.
e. Staff are educated and trained in end of life care.

6.2.23.2. Policies for COP 22:

f. Policy and Procedure for the end of life care is available. Provision of palliative care, sensitivity while
addressing death of patient, respective patient’s dead body, culture, ethos, involvement of patient and family in
aspects of end of life care is available. Refer : AH/PPM/HWP/21
a. CPR is initiated before declaring death of patient as part of end of life care policy. DNR (Do not resuscitate) is considered
illegal as per the statutory provision laid down in the nation.
b. Unique needs of the patient is respected and provided. No patient is discriminated based on caste, religion, creed and
culture. Religious sentiments and socio cultural beliefs of patients and family is addressed and respected.
c. Pain management and symptomatic treatment is provided where appropriate.
d. Staff of such category dealing with patient management is trained and educated of end of life care

6.3. MANAGEMENT OF MEDICATION- (MOM)

6.3.1. MOM.1: Pharmacy services and usage of medication is done safely

6.3.1.1. Objective Elements:

a. Pharmacy services and medication usage are implemented following written guidance. *

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b. A multidisciplinary committee guides the formulation and implementation of pharmacy services and
medication usage.
b. There is a mechanism in place to facilitate the multidisciplinary committee to monitor literature
reviews and best practice information on medication management and use the information to
update medication management processes.
c. There is a procedure to obtain medication when the pharmacy is closed. *
6.3.1.2. The organisation has a mechanism to inform relevant staff of key changes in pharmacy services and
medication usage to ensure uninterrupted and safe care
6.3.1.3. Policies for MOM 1:
a. Policy and Procedure for medication management is available and followed. Policy addresses all issues starting from
procurement, storage, formulary, prescription, dispensing, administration, monitoring and use of medication in hospital.
Refer AH/PPM/MOM/12
b. Policy and procedures meet the regulatory obligations of the Drugs and cosmetic Act, Pharmacy Act, Narcotic and
psychotropic substance Act & drugs and magical remedies Act etc
c. There is a Drugs and Therapeutic committee where major clinical and administrative heads are available to take decision
on the formulation and implementation of policies and procedure applicable. Committee meeting is conducted as per the
Terms of reference approved by the management.
d. Pharmacy of the hospital runs for 24 hours basis
.
6.3.2. MOM.2 The organisation develops, updates and implements a hospital formulary.

6.3.2.1. Objective Elements:

a. A list of medications appropriate for the patients and as per the scope of the organisati on's clinical
services is developed collaborati vely by the multidisciplinary committee.
a. The list is reviewed and updated collaboratively by the multidisciplinary committee at least
annually.
b. c.The current formulary is available for clinicians to refer to.
c. D The clinicians adhere to the current formulary.
e. The organisation adheres to the procedure for the acquisition of formulary medications. *
f.The organisation adheres to the procedure to obtain medications not listed in the formulary. *

6.3.2.2. Policies for MOM 2:

a. Drugs and Therapeutic committee has approved the hospital formulary for the hospital as per the details of National list of
essential medicine and WHO model list of essential medicine. High risk drugs and look alike sound alike drugs are part of
the formulary
b. Formulary is updated on a yearly basis by the drugs and therapeutic committee. Any addition and deletion in the formulary
is done after reviewing the non formulary drugs details those were procured in the previous year on a regular basis.
c. Copy of a formulary is made available to doctors and nurses in their respective area. This is done to ensure that
prescriptions are written from the formulary

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d. Procurement of medicine as per the details of formulary is done from approved vendors after vendor evaluation. Re-order
level and safety stock of these medicines are developed and followed to avoid untoward situation. Procurement process of
the hospital is followed for the procurement of the medicine in a timely manner. Refer AH/PPMPSM/37
e. Procedure for Local purchase is available to guide the staff in case medication listed in the formulary is not available. Local
purchase is approved by Medical Superintendent. All details pertaining to local purchase of medicine is maintained and
produced to drugs and therapeutic committee to evaluate and authorize on its subsequent inclusion in formulary. Refer
AH/PPMPSM/37

MOM.3: Medications are stored appropriately and are available where required
6.3.2.3. Objective Elements:
a.Medications are stored in a clean, safe and secure environment; and incorporating the
manufacturer's recommendation(s).
b.Sound inventory control practices guide storage of the medications throughout the organisation.
c.The organisation defines a list of high-risk medication(s). *
d.High-risk medications are stored in areas of the organisation where it is clinically necessary.
e.High-risk medications including look-alike, sound-alike medications and different concentrations of
the same medication are stored physically apart from each other. *
f. The list of emergency medications is defined and is stored uniformly. *
g.Emergency medication are available all the time and are replenished promptly when used.

d.
6.3.2.4. Policies for MOM 3:
a. Policy and procedure for the storage of the medicine is available which address issues related to provision of ambient
temperature of room, refrigeration condition, light, ventilation, pest control. Storage of the medicine is done in neat and
clean & secure environment in the shelves. Medicines are stored alphabetically and labels, dangerous drugs and look alike
sound alike medicines are stored separately in controlled area. Vaccines are kept in vaccine refrigerator with appropriate
temperature and with the provision of monitoring. Refer AH/PPM/MOM/12
b. Sound inventory practices are followed for the storage and dispensing of medication in OP Pharmacy, Central Pharmacy
and in indoor units wherever medicine is stored. Inventory control technique like ABC, VED, FSN, and FIFO methods are
followed for proper management of inventory. Free samples are not allowed to be stored in patient care areas. Clinicians
are asked to take sample medications for their use. These medicines are declared out of the regular inventory. Refer
AH/PPMPSM/37
c. Emergency medicine is defined and made available with optimum level always for the hospital and it is uniform across the
hospital. Quantity of emergency medicine varies from place to place depending upon the consumption and requirement.
Dedicated storage area has been identified and created in every in patient unit to safely storing these medicines. Labeling
of these medicines has been done to clearly visualize staff. Emergency medicine are used and re-stocked in a timely
within 2 hours to avoid shortage. Inventory of emergency medicines are checked on daily basis.
6.3.3. MOM.4: Documented policies and procedures guide the safe and rational prescription of medications.
6.3.3.1. Objective Elements:
a. Documented policies and procedures exist for prescription of medications.*
b. These incorporate inclusion of good practices/guidelines for rational prescription of medications.
c. The organization determines the minimum requirements of a prescription.*

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d. Known drug allergies are ascertained before prescribing.

e. The organization determines who can write orders.
f. Orders are written in a uniform location in the medical records which also reflects patient’s name and unique identification
number.
g. Medication orders are clear, legible, dated, timed, named and signed.
h. Medication orders contain the name of the medicine, route of administration, dose to be administered and frequency/time
of administration.
i. Documented policy and procedure on verbal orders is implemented.*
j. The organisation defines a list of high-risk medication(s).*
k. Audit of medication orders/prescription is carried out to check for safe and rational prescription of medications.
l. Reconciliation of medications occurs at transition points of patient care.
m. Corrective and/or preventive action(s) is taken based on the analysis, where appropriate.
6.3.3.2. Policies for MOM 4:
a. Policy and Procedure for the prescription of medication is available. All prescriptions are prescribed by registered doctors
and signed legibly. Prescriptions are written with molecule of drug, appropriate dose, route and time. Patient receives
medicines appropriate to their clinical needs. Minimum requirement of prescription have been defined. All doctors and
nurses are well aware of hospital’s prescription policy. Refer AH/PPM/MOM/12
b. Doctors document drug allergy if any in the medical record during assessment of patient in OP and IP area.
c. All inpatient orders are prescribed by a registered qualified doctor only.
d. Medication orders are written in medication card by the doctor. Medication card reflects prescription and administration
information on the same sheet. No phrase like CST/Continue same treatment /repeat all system of writing is not allowed.
Whenever there is a modification in the medication order already prescribed, a fresh medication order is written for the drug.
e. All medication orders are clearly, legibly written & signed with date and time mentioning on it
f. Policy and Procedure for verbal order of medication is available and followed by doctors. Verbal order is countersigned by
the doctor of treating team or treating doctor himself/herself within 24 hours of ordering. Refer AH/PPM/MOM/12
g. High risk medication list has been defined as per the guideline of ISMP (Institute for Safe medication practices). High risk
medicine includes low therapeutic window, controlled substances, psychotropic substance, look alike and sound alike
medicine and concentrated electrolyte. Refer AH/PPM/MOM/12
h. Prescription audit is conducted by the prescription audit team on a monthly basis to check safe and rational prescription of
medications. Criteria of prescription has been developed in consultation with Clinical pharmacologist which includes
legibility, use of capital letters in written orders, appropriateness of drug, dose, frequency and route of administration,
possibility of drug interaction and measures taken to avoid etc. \
i. Medication reconciliation process is followed to ensure that the list of medication that a patient is to receive is complete and
up to date in relation to past clinical conditions and present care plan. This is checked and documented at the time of
admission or transfer of patient from one setting to other. Medication reconciliation issues are addressed by doctor and
nurse during their respective hand over. Corrective and preventive measures are taken based on the findings. Refer
AH/PPM/MOM/12
6.3.4. MOM.5: Documented policies and procedures guide the safe dispensing of medications.
6.3.4.1. Objective Elements:
a. Documented policies and procedures guide the safe dispensing of medications.*
b. The procedure addresses medication recall.*
c. Expiry dates are checked prior to dispensing.
d. There is a procedure for near expiry medications.*
e. Labelling requirements are documented and implemented by the Organization.*

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f. High-risk medication orders are verified prior to dispensing.

6.3.4.2. Policies for MOM 5:

a. Documented policies and procedures guide the safe dispensing of medications. This includes route of administration,
dosage, rate of administration, expiry date etc. Physician samples are not stored and sold. Refer AH/PPM/MOM/12
b. Medication recall procedure exists. Medicine recall from internal source is intimated to appropriate regulatory authority
Refer AH/PPM/MOM/12
c. Procedure for near expiry medicine is available. Medicines having three months left prior to the expiry date is considered
as near expiry medicine. These medicines are returned to distributor. Refer AH/PPM/MOM/12
d. Labeling requirements are documented and implemented. This includes labeling with drug name, strength, frequency of
administration, and expiry dates. This is done from the dispensing area where medications are dispensed either as cut
strips or from bulk containers.
e. All high risk medications are double checked by the two staff prior to dispensing. This is applicable both in Pharmacy as
well as in inpatient areas.
6.3.5. MOM.6: There are documented policies and procedures for medication administration.

6.3.5.1. Objective Elements:

a. Medications are administered by those who are permitted by law to do so.
b. Prepared medication is labelled prior to preparation of a second drug.
c. Patient is identified prior to administration.
d. Medication is verified from the order and physically inspected prior to administration.
e. Dosage is verified from the order prior to administration.
f. Route is verified from the order prior to administration.
g. Timing is verified from the order prior to administration.
h. Medication administration is documented.
i. Documented policies and procedures govern patient’s self-administration of medications.
j. Documented policies and procedures govern patient’s own medications brought from outside the organization.
6.3.5.2. Policies for MOM 6:
a. Medications are administered by registered nursing staff in the hospital.
b. All prepared medications are labeled with name of the drug and date of loading. Loaded medications are stored safely in
controlled temperature.
c. Identification of patient is done by using two identifier (name and unique identifier number), prior to the administration of
medicine. Medication is verified from the medication order sheet and inspected that medications are administered properly.
Expiry dates, dose, route, time is checked without fail prior to administration and documentation. In case of high risk
medication administration, double check provision is available. Staff nurses are appropriately trained and empowered to
highlight prescription error while verifying order of doctor.
d. Policy and Procedure for self medication administration is available. Policy outline details about which patient can self
administer. Patient is reminded to take medicine at the time. Documentation reflects self administration of such medicine.
Refer AH/PPM/MOM/12
e. Policy and procedure for patient’s own medications brought from outside is available. This addresses various requirements
for allowing these medications. (Labeling details with name, dose, expiry date, batch number) Refer AH/PPM/MOM/12

6.3.6. MOM.7: Patients are monitored after medication administration.

6.3.6.1. Objective Elements:

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a. Documented policies and procedures guide the monitoring of patients after medication administration
b. The organisation defines those situations where close monitoring is required
c. Monitoring is done in a collaborative manner.
d. Medications are changed where appropriate based on the monitoring.
6.3.6.2. Policies for MON 7:
a. Policy and procedure to guide monitoring of patient after medication administration is available. This includes verification
of intended effect of medication, adverse drug events and medications errors if any. Refer AH/PPM/MOM/12
b. Situations have been defined where close monitoring of patient is required after medication administration. This includes
while administrating high risk medication, concentrated electrolyte, chemotherapeutic drugs etc. Monitoring of the patient
is done in a collaborative manner Refer AH/PPM/MOM/12
a. Medications are changed where appropriate based on the results of monitoring and patient’s clinical condition.
6.3.7. MOM.8: Near misses, medication errors and adverse drug events are reported and analyzed.
6.3.7.1. Objective Elements:
a. Documented procedure exists to capture near miss, medication error and adverse drug event.*
b. Near miss, medication error and adverse drug event are defined.*
c. These are reported within a specified time frame. *
d. They are collected and analyzed.
e. Corrective and/or preventive action(s) are taken based on the analysis where appropriate.
6.3.7.2. Policies for MOM 8:

a. Procedure available to capture near miss, medication error and adverse drug event. Staff are trained and sensitized to
capture these events for further analysis and remedial measures.
b. Near miss, medication error and adverse drug events have been defined. Refer AH/PPM/MOM/12
c. If medication error and adverse drug event causes harm to patient then it is reported to treating doctor and chairman of
drugs and therapeutic committee as soon as possible for analysis and action whereas near miss events are reported within
24 hours of incidence. Corrective and preventive actions are taken based on the analysis and findings.

6.3.8. MOM.9: Documented procedures guide the use of narcotic drugs and psychotropic substances.
6.3.8.1. Objective Elements:
a. Documented procedures guide the use of narcotic drugs and psychotropic substances which are in consonance with local
and national regulations.*
b. These drugs are stored in a secure manner.
c. A proper record is kept of the usage, administration and disposal of these drugs.
d. These drugs are handled by appropriate personnel in accordance with the documented procedure.
6.3.8.2. Policies for MOM 9:
j. Storage and record keeping of narcotic issues, administration, usage and disposal is done as per the statutory requirement
of Narcotic drugs and psychotropic substances Act. Refer AH/PPM/MOM/12
a. Narcotic drugs are securely stored under the provision of double lock and key and staff is identified in every shift for the
responsible of accounting and storage.
b. Only registered Doctors, pharmacists and nurses are allowed to prescribe, handle and use of narcotic drugs as per their
respective domain.
6.3.9. MOM.10: Documented policies and procedures guide the usage of chemotherapeutic agents.
6.3.9.1. Objective Elements:
a. Documented policies and procedures guide the usage of chemotherapeutic agents.*
b. Chemotherapy is prescribed by those who have the knowledge to monitor and treat the adverse effect of chemotherapy

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c. Chemotherapy is prepared in a proper and safe manner and administered by qualified personnel.
d. Chemotherapy drugs are disposed in accordance with legal requirements.
e. Patient and family are educated regarding benefits/risks of chemotherapy, precautions to be taken and possible adverse
reactions.
6.3.9.2. Policies for MOM 10:
a. Policy and procedure for the usage of chemotherapeutic agent is available. Refer AH/PPM/MOM/12
b. Chemotherapy is prescribed by medical oncologist having competency level to do so.
c. Safe environment is available to prepare chemotherapy drugs. Bio-Safety cabinet is available and used for the preparation
and mixing of chemotherapeutic agent.
d. Chemotherapeutic drugs are disposed as per the bio medical waste management and handling rules under cytotoxic
category.
e. Patient and family are educated regarding benefits/risks of chemotherapy precautions and its possible reaction. Doctors
and nursing staff of the unit are actively involved in explaining the benefits and risk and precaution
6.3.10. MOM.11: Documented policies and procedures govern usage of radioactive drugs.
6.3.10.1. Objective Elements:
a. Documented policies and procedures govern usage of radioactive drugs
b. These policies and procedures are in consonance with laws and regulations.
c. The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive drugs.
d. Staff, patients and visitors are educated on safety precautions.
6.3.10.2. Policies for MOM 11:
a. Radioactive drugs use is beyond the scope of service of the hospital.
6.3.11. MOM.12: Documented policies and procedures guide the use of implantable prosthesis and medical devices.
6.3.11.1. Objective Elements:
a. Usage of implantable prosthesis and medical devices is guided by scientific criteria for each individual item and
national/international recognized guidelines/ approvals for such specific item(s).
b. Documented policies and procedures govern procurement, storage/stocking, issuance and usage of implantable
prosthesis and medical devices incorporating manufacturer’s recommendation(s).*
c. Patient and his/her family are counselled for the usage of implantable prosthesis and medical device including precautions,
if any.
d. The batch and serial number of the implantable prosthesis and medical devices are recorded in the patient’s medical
record, the master logbook and the discharge summary.
6.3.11.2. Policies for MOM 12:
a. Selection of implantable prosthesis and medical devices are done based on following criteria (1)Selection of devices based
on available science and research (2)Special privileges for the surgeon and special training for the surgical team (3)
Unique infection control considerations (4) Special discharge instructions to the patient and the traceability of devices in
the event of a recall (5) approved from international or national body of the particular product Refer AH/PPM/MOM/12
b. Policies and procedure is available to guide procurement, storage/stocking, issuance and usage of implantable prosthesis
and medical devices Refer AH/PPM/MOM/12
c. Batch and serial number of implantable prosthesis and medical devices are recorded in the patients medical record and
the master log book and discharge summary.
6.3.12. MOM.13: Documented policies and procedures guide the use of medical supplies and consumables.
6.3.12.1. Objective Elements:
a. There is a defined process for acquisition of medical supplies and consumables.*
b. Medical supplies and consumables are used in a safe manner, where appropriate

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c. Medical supplies and consumables are stored in a clean, safe and secure environment; and incorporating manufacturer’s
recommendation(s).
d. Sound inventory control practices guide storage of medical supplies and consumables.
e. There is a mechanism in place to verify the condition of medical supplies and consumables.
6.3.12.2. Policies for MOM 13:
a. Process of procurement is available which addresses the essential issues of vendor selection, evaluation, indenting
process, generation of purchase order, receipts and quality check of materials etc.
b. Medication supplies and consumables are received, opened and stored in safe manner to maintain sterility and integrity
c. Storage conditions are appropriately followed to store materials in clean, safe and secure environment. Temperature
conditions are appropriate to store these materials.
d. Sound inventory control practices are used to guide storage of materials. This includes ABC analysis, VED, FSN and FIFO
analysis.
e. Materials received are checked for its efficacy and sterility. Opened packed are not accepted, culture results of certain
materials like cotton gauge, syringe, gloves are obtained to check efficacy and sterility.

6.4.PATIENT RIGHTS AND EDUCATION (PRE)

6.4.1. PRE.1. The organization protects patient and family rights and informs them about their responsibilities during care.
6.4.1.1. Objective Elements:
a. Patient and family rights and responsibilities are documented and displayed
b. Patients and families are informed of their rights and responsibilities in a format and language that they can understand.
c. The organization’s leaders protect patient and family rights.
d. Staffs are aware of their responsibility in protecting patient and family rights.
e. Violation of patient and family rights is recorded, reviewed and corrective/preventive measures taken.
6.4.1.2. Policies for PRE1:
a. Patient’s rights and responsibility has been documented and displayed in strategic locations like reception, IPD areas.
Refer : AH/PPM/HWP/21
b. Display of rights and responsibility charter has been done in bilingual. (English and Odiya local language). Patient’s are
made aware about their rights and responsibility by the staff of concerned unit.
c. Patient’s right and family rights are respected and given due consideration by the management. Violation if any is properly
addressed. Staffs are sensitized and trained how to protect patient and family rights.
d. Any violation of patient and family rights is recorded, reviewed and corrective and preventive measures are taken. Hospital
has developed various criteria which could be considered as infringements of patients and families rights. Example
compromising patient privacy and confidentiality, violation of cultural and religious needs, soliciting money etc.
6.4.2. PRE.2: Patient and family rights support individual beliefs, values and involve the patient and family in decision making
processes.

6.4.2.1. Objective Elements:

a. Patients and family rights include respecting any special preferences, spiritual and cultural needs.
b. Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
c. Patient and family rights include protection from neglect or abuse.
d. Patient and family rights include treating patient information as confidential.

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e. Patient and family rights include refusal of treatment.

f. Patient and family have a right to seek an additional opinion regarding clinical care.
g. Patient and family rights include informed consent before transfusion of blood and blood components, anaesthesia,
surgery, initiation of any research protocol and any other invasive / high risk procedures / treatment.
h. Patient and family rights include right to complain and information on how to voice a complaint
i. Patient and family rights include information on the expected cost of the treatment.
j. Patient and family rights include access to his / her clinical records.
k. Patient and family rights include information on Care plan, progress and information on their health care needs.

6.4.2.2. Policies for PRE 2:

a. Special preference, spiritual and cultural needs like dietary preferences and worship requirements following death is
allowed for the patient and family members as applicable
b. Patient dignity, privacy during examination, procedure and treatment is maintained. Hospital staffs are trained to effectively
implement the guidelines for patient privacy and confidentiality. Informed consent is obtained in case of photography.
Physical assault and abuse is of the patient is prohibited in any way. Special care is taken of vulnerable patients.
c. Effective measures are taken to ensure patient’s information and treatment details are kept confidential and privileged
information are not shared and discussed in public place by the staff.
d. Patient and family right also addresses refusal of treatment. Treating doctor discusses all the relevant options available
and allow patient to make an informed decision. Patient and family members are educated about the consequences if any
in case of refusal of treatment and document the same.
e. Patients are allowed to obtain second opinion regarding their treatment and care plan. Hospital does not stop patient to go
for second opinion. Access is given to doctor of all relevant clinical information and evaluation
f. Informed consent is obtained before transfusion of blood and blood components, anaesthesia, surgery, initiation of
research and any other invasive and high risk procedure/treatment
g. Patients and family members are allowed to make a complaint. Complaint and suggestion boxes have been placed in all
strategic location with procedure to make complaint. Complaint management committee is available for the redressal of all
complaints. Hospital has a designated compliance officer who is contacted directly by patient and relatives to lodge
complaint.
h. Patient and family are informed of expected cost of the treatment. Written estimate is generated and provided to patient.
i. Patient and family rights include access to his/her medical record. Copies of the medical record are given to patient.
j. Patient and family is given information on care plan and progress and information of their health care needs

6.4.3. PRE.3: The patient and/or family members are educated to make informed decisions and are involved in the care planning
and delivery process.
6.4.3.1. Objective Elements:
a. The patient and/or family members are explained about the proposed care including the risks, alternatives and benefits.
b. The patient and/or family members are explained about the expected results.
c. The patient and/or family members are explained about the possible complications.
d. The care plan is prepared and modified in consultation with patient and/or family members.
e. The care plan respects and where possible incorporates patient and/or family concerns and requests.
f. The patient and/or family members are informed about the results of diagnostic tests and the diagnosis.
g. The patient and/or family members are explained about any change in the patient’s condition in a timely manner.

6.4.3.2. Policies for PRE 3:

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a. Treating doctor and his team discuss the proposed care including the risks, alternatives and benefits, expected outcome
with the patient and patient’s family member. Details of the discussion held are documented in patient family meeting
record format.
b. Religious, cultural and spiritual views of the patient and/or family shall be considered during the process of care delivery.
c. Patient’s day to day condition, treatment, and outcome are communicated to patient and his family members.

6.4.4. PRE.4: A documented procedure for obtaining patient and/or family’s consent exists for informed decision making about their
care.
6.4.4.1. Objective Elements:
a. Documented procedure incorporates the list of situations where informed consent is required and the process for taking
informed consent.
b. General consent for treatment is obtained when the patient enters the organization.
c. Patient and/or his family members are informed of the scope of such general consent.
d. Informed consent includes information regarding the procedure, it’s risks, benefits, alternatives and as to who will perform
the procedure in a language that they can understand.
e. The procedure describes who can give consent when patient is incapable of independent decision making.*
f. Informed consent is taken by the person performing the procedure.
g. Informed consent process adheres to statutory norms.
h. Staff are aware of the informed consent procedure.
6.4.4.2. Policies for PRE 4:
a. Policy and procedure for the list of clinical procedure where informed consent is required and the process for taking
informed consent is available. This is developed keeping in mind the requirements of the standard and statutory
requirements. Refer : AH/PPM/HWP/21
b. General consent from patient is obtained when the patient enters the hospital for treatment /admission (Refer general
consent form of the hospital). Patient and family members are made aware about the scope of such general consent. The
consent is not for invasive procedure. Separate informed consent is available for invasive procedure.
c. Informed consent are designed and used as per the statutory requirement. Informed consent addresses details of
procedure, risks, benefits and alternate method clearly. Informed consent is signed by both patient or his surrogate as well
as doctors performing the procedure. Refer : AH/PPM/HWP/21
d. Statutory norms are taken into consideration for obtaining informed consent. If patient is not capable of giving consent then
next of kin/legal guardian is allowed to give consent for the patient. Refer : AH/PPM/HWP/21
e. Informed consent is obtained by the person actually performing the procedure. Informed consent is signed by the person
performing procedure not by his subordinate or nurse.
f. Informed consent process follows to statutory norms for documentation. This includes taking consent before the procedure
not after the procedure; at least one witness signing the consent form, transfusion dependent patient validity of consent is
6 months.
g. Staffs working in patient care areas are well aware about consent procedure.

6.4.5. PRE.5: Patient and families have a right to information and education about their healthcare needs.

6.4.5.1. Objective Elements:

a. Patient and/or family are educated about the safe and effective use of medication and the potential side effects of the
medication, when appropriate.
b. Patient and/or family are educated about food-drug interaction
c. Patient and/or family are educated about diet and nutrition.

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d. Patient and/or family are educated about immunizations.

e. Patient and/or family are educated about their specific disease process, complications and prevention strategies.
f. Patient and/or family are educated about preventing healthcare associated infections
g. The patients and/or family members’ special educational needs are identified and addressed
h. Patient and/or family are educated in a language and format that they can understand.
6.4.5.2. Policies for PRE 5:
a. Food drug interaction and drug –drug interaction posters have been made and displayed in strategic locations. Nurses are
aware about the safe and effective use of medication and the potential side effect of medication. Patient and family
members are educated about safe and effective use of medication.
b. Education on immunization, diet and nutrition, specific disease process and prevention strategy, life style modifications is
given. Distribution of patient education booklet/leaflets etc is done to make patient and family members aware about the
same.
c. Patient and family members are educated about preventing healthcare associated infections. This includes demonstration
of hand hygiene practices by the infection control team in front of patient and family members in the indoor units.
6.4.6. PRE.6: Patients and families have a right to information on expected costs.
6.4.6.1. Objective Elements:
a. There is a uniform pricing policy in a given setting (out-patient and ward category).
b. The relevant tariff list is available to patients.
c. The patient and/or family members are explained about the expected costs.
d. Patient and/or family are informed about the financial implications when there is a change in the patient condition or
treatment setting.
6.4.6.2. Policies for PRE 6:
a. Uniform pricing policy available which depicts the charges levied for various activities in the hospital. Tariff list is available
in the reception which patient is given when asked. Tariff details are displayed in strategic locations.
b. Written estimates are provided to patient to make them aware about the expected costs. Estimate is prepared based on
the treatment plan. Refer estimated Performa
c. Financial implications are communicated when there is sudden change in patient condition or treatment setting.
6.4.7. PRE.7: The organisation has a mechanism to capture patient’s feedback and redressal of complaints.
6.4.7.1. Objective Elements:
a. The organisation has a mechanism to capture feedbacks from patients which includes patient satisfaction and patient’s
experience.
b. The organisation has a documented complaint redressal procedure.
c. Patient and/or family members are made aware of the procedure for giving feedback and /or lodging complaints.
d. All feedback and complaints are reviewed and/or analysed within a defined time frame
e. Corrective and/or preventive action(s) are taken based on the analysis where appropriate.
6.4.7.2. Policies for PRE 7:
a. Patient feedback is collected and analyzed for necessary corrective and preventive action. Patient feedback collection
formats are used for collecting patient feedback. In addition to collecting patient feedback, the hospital capture patient
experience with his/her treating doctor/ nursing , pain management, hospital facilities and environment, cleanliness,
communication skill of staff, waiting time etc
b. Complaint redressal procedure is documented and available. This address method of lodging complaint, time frame to
address and person responsible for documenting the action taken. Refer : AH/PPM/HWP/21
6.4.8. PRE.8: The organisation has a system for effective communication with patients and /or families.
6.4.8.1. Objective Elements:
a. Documented policies and procedures guide the effective communication with the patients and/or families

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b. The organisation shall identify special situations where enhanced communication would be required.*
c. The organisation lays down an approach for effective communication in these identified situations.
d. The organisation also defines what constitutes an unacceptable communication and sensitizes the staff about the same.*
e. The organisation has a system to monitor and review the implementation of effective communication
f. The staff are trained in healthcare communication techniques periodically.

6.4.8.2. Policies for PRE 8:

a. Written policy and procedure for the effective communication with the patient/or families is documented. Various situations
have been identified where enhanced communication is required. Unacceptable communication has been highlighted. All
staffs are made aware of the policy and procedure. Refer : AH/PPM/HWP/21
b. Situations to address challenging situations like breaking bad news, handling adverse events, handling an aggressive
patient/family , declaration of death of a patient has been documented. Refer : AH/PPM/HWP/21
c. Language barriers of the patient and family members are resolved as hospital has list of interpreter of staff working in the
hospital and aware of various regional and other languages.
d. Patient and family feedback are obtained to monitor and review the implementation of effective communication.

6.5.HOSPITAL INFECTION CONTROL

6.5.1. HIC.1: The Organization has a well-designed, comprehensive and coordinated Hospital Infection Prevention and Control
(HIC) program aimed at reducing/eliminating risks to patients, visitors and providers of care.
6.5.1.1. Objective Elements:
a. The hospital infection prevention and control program is documented which aims at preventing and reducing
the risk of healthcare associated infections in all areas of the hospital.*
b. The infection prevention and control program is a continuous process and updated at least once in a year.
c. The hospital has a multi-disciplinary infection control committee, which co-ordinates all infection prevention and
control activities.*
d. The hospital has an infection control team, which coordinates implementation of all infection prevention and
control activities.*
e. The hospital has designated infection control officer as part of the infection control team.*
f. The hospital has designated infection control nurse(s) as part of the infection control team.*

6.5.1.2. Policies for HIC 1:

a. Policies and procedure for infection control and prevention programme is available which addresses various methods
which aims at preventive and reducing risk of healthcare associated infections in all areas of the hospital. Refer
AH/PPM/IC/18
b. Infection control practices are continuously reviewed on a monthly basis by the infection control committee of the hospital
and process is updated at least once a year. This includes setting risk reduction goals and strategies by the committee at
least yearly basis.
c. Hospital has a designated multi-disciplinary infection control committee which coordinates all infection prevention and
control activities. Members are selected from various specialties like Microbiologist, Infection control officer, Surgeon,
Nursing Administration, Representation from CSSD, Laundry, Burns and plastic surgery, Kitchen, infection control nurses.
It has also provision to invite any staff from other department as when required.

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d. There is an infection control team which is responsible for day to day functioning of infection prevention and control
programme. It carries out surveillance programme and detect outbreak. Various audits targeting to infection control
programme is conducted by the team. Team is different than committee however few team members are part of the
committee.
e. An infection control officer with defined roles and responsibilities plays major role in guiding and plans for the
implementation of infection control requirement. Infection control officer is a knowledgeable and competent microbiologist.
f. Certified, trained and competent Infection control nurses are made part of infection control team.

6.5.2. HIC.2: The Organization implements the policies and procedures laid down in the Infection Control Manual in all
areas of the hospital.
6.5.2.1. Objective Elements:

a. The Organization identifies the various high-risk areas and procedures and implements policies and/or
procedures to prevent infection in these areas.
b. The Organization adheres to standard precautions at all times.
c. The Organization adheres to hand-hygiene guidelines.
d. The Organization adheres to transmission-based precautions at all times.
e. The Organization adheres to safe injection and infusion practices.
f. The Organization adheres to cleaning, disinfection and sterilization practices.
g. An appropriate antibiotic policy is established and documented
h. The Organization implements the antibiotic policy and monitors rational use of antimicrobial agents.
i. The Organization adheres to laundry and linen management processes.
j. The Organization adheres to kitchen sanitation and food-handling issues.
k. The Organization has appropriate engineering controls to prevent infections.
l. The Organization adheres to housekeeping procedures.
6.5.2.2. Policies for HIC 2:
a. High risk areas of the hospital have been identified. High risk procedures have been identified from infection control point of
view and policies and procedures is implemented, directed & monitored at these areas Refer AH/PPM/IC/18
b. Standard precaution is adhered by the staff while in the patient care areas. Provision of gloves, masks, clean utility is
available. Refer AH/PPM/IC/18
c. Hand hygiene guidelines are strictly followed. Hand hygiene practices of the staff are monitored. Provision of display of
instructions for hand hygiene has been made near every hand washing area. Provision of single use tissue paper,
antimicrobial soap solutions, and hand sanitizer is done as per the WHO guideline of 2009. Refer AH/PPM/IC/18
d. Transmission based precautions are adopted at all times. Personal protective measures are used in various situations of
patient care. Refer AH/PPM/IC/18
e. Safe injection practices and infusion practices are followed strictly in all patient care areas as per the requirement. WHO
best practices for injection procedure is taken as reference to follow safe injection and infusion practices which includes
practice of single use syringe, hand hygiene, gloves, injection administration, sharp management etc Refer AH/PPM/IC/18
f. Cleaning, disinfection and sterilization practices are adhered to. Use of disinfectants is monitored. Infection control
committee approves and allows disinfectants use in the hospital. Hospital has a dedicated Central Sterile supply department
to deal with sterilization requirement of patient care areas. Refer AH/PPM/IC/18
g. Rational use of antibiotic is established by the infection control committee. Judicious use of antibiotics is monitored. Doctors
are trained to identify clinical conditions in which antimicrobial therapy are to be used. Department of Microbiology monitors

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the practices of the doctors and deviations if any is brought to the notice of doctors for necessary corrective abd preventive
action. Refer AH/PPM/IC/18
h. Laundry and linen management practices are outsourced. Patient’s linens are change on a daily basis or as when spillage is
noted. Linens are centrally collected and given in dedicated laundry area for cleaning and supply. Infected linens are
properly stored and transported to laundry room for cleaning, disinfection and washing in separate place. Covered trolleys
are used for transporting clean linen as well as dirty linen. Refer AH/PPM/IC/18
i. Kitchen safety and food handling issues are addressed. Kitchen service is outsourced. Practices of outsourced agency are
monitored and agency is directed to follow norms of hospital’s infection control policy. Kitchen sanitation, periodic screening
of food handlers, cleaning and washing protocol, water testing, housekeeping practices, food evaluation, health evaluation
of staff (Daily grooming check, test for HBSAg, parasites and salmonella once in six month and if the staff rejoins after leave
of 15 days or more) are included in kitchen safety and food handling issues Refer AH/PPM/IC/18
j. Engineering controls and facility management is done appropriately to prevent infections. This includes but not limited to
beds apace is one to two meter, planning of Operating rooms as per the norms of infection control, Air quality and water
supply, issues regarding Air conditioning (Temperature, humidity and ventilation), periodic cleaning of AC ducts, change of
HEPA filters, replacement and repair of plumbing issues, sewer lines are included. Any renovation work in hospital’s patient
care areas is planned with the guidance and necessary approval of infection control team with regard to architectural
realignment, traffic flow, use of materials etc. Refer AH/PPM/IC/18
k. Housekeeping practices are included in the infection and prevention rule of the hospital. Terminal cleaning procedure is
included. Spillage management is done by hazardous material management team comprising of trained personnel of
housekeeping. Use of disinfectants and its dilution factor and use process is known to housekeeping staff. Dry mopping is
not done in patient care areas. Wet mopping practices are propagated inside clinical areas. Refer AH/HK/31 Refer
AH/PPM/IC/18
b.
6.5.3. HIC.3: The Organization performs surveillance activities to capture and monitor infection prevention and control
data.
6.5.3.1. Objective Elements:
a. Surveillance activities are appropriately directed towards the identified high-risk areas and procedures.
b. A collection of surveillance data is an on-going process.
c. Verification of data is done on a regular basis by the infection control team.
d. The scope of surveillance activities incorporates tracking and analyzing of infection risks, rates and trends.
e. Surveillance activities include monitoring the compliance with hand-hygiene guidelines.
f. Surveillance activities include mechanisms to capture the occurrence of epidemiological significant diseases
and multi-drug-resistant organisms, and highly virulent infections.
g. Surveillance activities include monitoring the effectiveness of housekeeping services.
h. Appropriate feedback regarding healthcare associated infection ( HAIs) rates is provided on a regular basis to
appropriate personnel.
i. In cases of notifiable diseases, information (in relevant format) is sent to appropriate authorities.
6.5.3.2. Policies for HIC 3:
a. Surveillance activities are conducted on daily, weekly and monthly basis as per the plan of Infection control team.
Documents regarding surveillance in high risk areas are maintained by the Infection control officer. Surveillance activities
are also conducted in the area where demolition, construction or repair activities undertaken. Collection of data for the
surveillance programme is an ongoing process. Infection control nurses are trained to collect information as per the laid
down guideline. Refer AH/PPM/IC/18

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b. All data collected by infection control nurses are reviewed, verified and approved by the infection control team.
c. Analysis of infection risks, trend, and rates are done on a monthly basis and necessary corrective and preventive action is
initiated for the risk factors.
d. Hand hygiene practice is included as one of the essential monitoring requirement under surveillance programme of
theinfection and prevention programme. Active and passive methods for the surveillance of hand hygiene practices are
followed.
e. Hospital has a policy to monitor the occurrence of multi drug resistant organisms’ e.g MRSA and multi drug dram-
negative bacteria and monitors any suspected emergence and spread of infection with microorganisms. Refer
AH/PPM/IC/18
f. Effectiveness of housekeeping services are monitored and a essential part of surveillance activities. Routine
environmental sampling is done.
g. Doctors and nurses are given feedback about the rates, trends and remedial measures including data analyzed as part of
surveillance activities. Infection control bulletin is prepared and issued by the infection control team to make doctors and
nurses aware about the risk, trends and rates of their concern department
h. Notifiable diseases are reported to local Authority, National Health Mission as per the local laws. This is done directly in
the portal of National Health mission of notifiable disease surveillance programme

6.5.4. HIC.4: The Organization takes actions to prevent and control Healthcare Associated Infections (HAI) in patients.
6.5.4.1. Objective Elements:
a. The Organization takes action to prevent catheter associated urinary tract Infections.
b. The Organization takes action to prevent ventilator Associated Pneumonia.
c. The Organization takes action to prevent catheter linked blood stream infections.
d. The Organization takes action to prevent surgical site infections.
6.5.4.2. Policies for HIC 4:
a. Various evidenced based tools and practice guidelines are put into practice to track and take action to prevent Catheter
associated urinary tract infection, ventilator associated pneumonia, Catheter linked blood stream infections, surgical site
infections. Staffs are trained to use these tools for the prevention and control of Hospital associated infections in patients.

6.5.5. HIC.5: The Organization provides adequate and appropriate resources for prevention and control of Healthcare
Associated Infections (HAI).
6.5.5.1. Objective Elements
a. Adequate and appropriate personal protective equipment, soaps, and disinfectants are available and used
correctly.
b. Adequate and appropriate facilities for hand hygiene in all patient-care areas are accessible to healthcare
providers.
c. Isolation/barrier nursing facilities are available.
d. Appropriate pre- and post-exposure prophylaxis is provided to all staff members concerned.
6.5.5.2. Policies for HIC 5:
a. Necessary provision is made to timely and adequate supply of personal protective equipments which includes
gloves, protective eye wear, masks, apron, gown, hair cover etc to the staff of patient care areas uniformly.
Adequate soap solution having antimicrobial property, disinfectants is also made available.

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b. Facilities for hand hygiene are made at optimum level. This includes provision of large wash basins, hands free
control, soap and facility for drying hands without contamination. Hand hygiene instructions are displayed near
each wash basin and staffs are instructed to follow the technique.
c. Isolation and barrier nursing practices are followed wherever applicable. Conditions of isolation practices as
well as barrier nursing have been defined. Provision for Isolation room and air borne cases is available which
includes designated space with negative air pressure, double door system, signage to notify and resources like
hand hygiene, personal protective equipment is made.
d. Pre and post exposure prophylaxis is provided to all staff members concerned. Documentation of the all
occupational injuries sharp injuries, needle stick injuries, pre-post exposure prophylaxis records are maintained.
6.5.6. HIC.6: The Organization identifies and takes appropriate action to control outbreaks of infections.
6.5.6.1. Objective Elements:
a. Organization has a documented procedure for identifying an outbreak.*
b. Organization has a documented procedure for handling such outbreaks.*
c. This procedure is implemented during outbreaks.
d. After the outbreak is over appropriate corrective actions are taken to prevent recurrence.
6.5.6.2. Policies for HIC 6:
a. Policy and procedure for outbreak management is available. Investigation of outbreak is done according to the laid down
procedure of the hospital. Procedure is followed during sudden outbreak. Corrective and preventive action is taken to
prevent future reoccurrence. Refer AH/PPM/IC/18
6.5.7. HIC.7: There are documented policies and procedures for sterilization activities in the Organization.
6.5.7.1. Objective Elements:
a. The Organization provides adequate space and appropriate zoning for sterilization activities.
b. Documented procedure guides the cleaning, packing, disinfection and/or sterilization, storing and issue of items.*

c. Reprocessing of instruments and equipment are covered.*

d. The Organization shall have a documented policy and procedure for reprocessing of devices whenever
applicable.*
e. Regular validation tests for sterilization are carried out and documented.*
f. There is an established recall procedure when breakdown in the sterilization system is identified.*
6.5.7.2. Policies for HIC 7:
a. A well designed and planned Central Supply Sterile Department is available which is having proper layout as
per functional flow (Unidirectional flow, zoning) and separation of clean and dirty areas. Receiving and supply of
unsterile and sterile materials are done respectively from the different route. Area for receiving, washing,
cleaning and decontamination, packing, sterilization and sterile storage and issue is designated.
b. Written procedure for the cleaning, packing, disinfection and /or sterilization, storing and issue of items is
available and followed. Refer AH/CSSD/19
c. There is a re-use policy available for reprocessing and use of various accessories as per the guideline of
infection control Refer AH/CSSD/19

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d. Validation of sterilization results are done suitably. This includes chemical indicator test o daily basis, biological
indicator test done on weekly basis, class 5 indicators etc. Engineering validation like Bowie-Dick tape test,
leak test.
e. There is an established documented recall procedure followed when breakdown of sterilization equipment.
Refer AH/CSSD/19
6.5.8. HIC.8: Biomedical waste (BMW) is handled in an appropriate and safe manner.
6.5.8.1. Objective Elements:
a. The Organization adheres to statutory provisions with regard to biomedical waste.
b. Proper segregation and collection of biomedical waste from all patient-care areas of the hospital is implemented
and monitored.
c. The Organization ensures that biomedical waste is stored and transported to the site of treatment and disposal
in properly covered vehicles within stipulated time limits in a secure manner.
d. The biomedical waste treatment facility is managed as per statutory provisions (if in- house) or outsourced to
authorized contractor(s).
e. Appropriate personal protective measures are used by all categories of staff handling biomedical waste.
6.5.8.2. Policies for HIC 8:
a. All Statutory requirements of Bio medical waste management and handling rules are adhered by the hospital.
This includes approval for consent to occupy and consent to operate, authorization under Bio Medical waste
handling and management rules etc.
b. Segregation and collection of bio medical waste from all patient care areas are done as per the laid down
norms of Pollution Control board. Different color coded bins as per the Bio medical waste management
guideline 2016 is followed. Collection & transportation of bio medical waste is done by adopting all safety
provisions. Covered transport container is used to transport bio waste in a pre-defined time by the dedicated
waste handlers of the hospital. Treatment of the bio medical waste has been outsourced to authorized agency
of pollution control board. Outsource facility is visited by infection control team at least once in 6 month to
ensure waste disposal is accordance to Bio medical waste management rules. Refer AH/BMWM/06
c. Staff handling bio medical waste is provided with adequate personal protective equipment.
6.5.9. HIC.9: The infection control program is supported by the management and includes training of staff.
6.5.9.1. Objective Elements:
a. The management makes available resources required for the infection control program.
b. The Organization earmarks adequate funds from its annual budget in this regard.
c. The Organization conducts induction training for all staff.
d. The Organization conducts appropriate “in-service” training sessions for all staff at least once in a year.8
6.5.10. Policies for HIC 9:
a. Resource required for improving and maintaining infection control activities are provided. Management of the
hospital has earmarked budgetary consideration for the infection control activities.
b. Induction training of all staff is provided to make them aware about infection and prevention policy of the
hospital. Training records of the same is maintained in staff personal file

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6.6. CONTINUAL QUALITY IMPROVEMENT (CQI)

6.6.1. CQI.1: There is a structured quality improvement and continuous monitoring program in the Organization.
6.6.1.1. Objective Elements:
a. The quality improvement program is developed, implemented and maintained by a multi-disciplinary
committee.*
b. The quality improvement program is documented which is comprehensive and covers all the major elements
related to quality assurance.*
c. There is a designated individual for coordinating and implementing the quality improvement program.*
d. The quality improvement program promotes and demonstrates use of innovations to improve process efficiency
and effectiveness.
e. The designated program is communicated and coordinated amongst all the staff of the Organization through
appropriate training mechanism.
f. The quality improvement program identifies opportunities for improvement based on review at pre-defined
intervals.
g. The quality improvement program is a continuous process and updated at least once in a year.
h. Audits are conducted at regular intervals as a means of continuous monitoring.*
i. There is an established process in the Organization to monitor and improve quality of nursing care.
6.6.1.2. Policies for CQI 1:
a. Hospital has developed well documented quality management plan. The quality improvement programme is
developed, implemented and maintained by a multi-disciplinary committee/core committee Refer-
AH/PPM/HQM/41, Refer SUM/PPM/AQM/50
b. The committee has representation from management, clinical and support department of the hospital. Members
of the committee are- Dean, Medical Superintendent, Hospital Administrator, HOD Surgery, HOD Medicine,
HOD Microbiology, HOD Transfusion Medicine, Maintenance In charge, Nursing Superintendent, HR Manager,
Dy. Hospital Administrator.
c. This programme has been developed, implemented and maintained in a structured manner.
1. The quality improvement programme is documented. Refer- AH/PPM/HQM/41, Refer AH/AQM/
2. This is documented as a quality management manual. Refer- AH/PPM/HQM/41 Refer AH/AQM/
3. The manual has incorporated the mission, vision, important indicators, frequency of mock drills audit
schedules committee and their Terms of reference as identified etc.
d. The quality improvement programme is coordinated and implemented under the guidance of Accreditation
coordinator of the hospital. Accreditation coordinator of the hospital is having good knowledge of accreditation
standards, statutory requirements, hospital quality improvement plan. Accreditation coordinator is supported by
Manager Quality and quality executives for day to day operations and documentations. The designated
programme is communicated and coordinated amongst all the employees of the hospital through proper
training mechanism. Regular trainings of the hospital staff is conducted for quality programme implementation.
Refer- AH/PPM/HQM/41, Refer AH/AQM/

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e. Quality improvement programme of the hospital uses innovation and evidence based approach to improve
clinical and managerial processes. Patient safety, care delivery, cost reduction strategies are core areas of
consideration.
f. All Staff of the hospital are made aware of the structure and process of the quality improvement programme.
Each staff is made aware of their roles for the contribution to the quality improvement programme as part of
their job description. Training materials (printed and soft copies) are provided by the quality team to hospital
staff. The minutes of the review meetings and action taken plans are recorded and maintained.
g. Quality Improvement programme of the hospital is reviewed at pre-defined interval. The quality improvement
programme is a continuous process and is updated at once in a year. Quality improvement programme is
updated after review is carried out by the quality improvement committee. Various audits are conducted at
regular interval to support and maintain quality improvement structure of the hospital. Internal audit is one of the
important audit programme. Internal audit is conducted by trained auditor who is well versed with NABH
Standards. Refer- AH/PPM/HQM/41, Refer AH/AQM/
h. Quality of nursing service is monitored and improved by nursing audit programme. Nursing audit tool is used to
conduct audit of nursing care.
6.6.2. CQI.2: There is a structured patient-safety program in the Organization.
6.6.2.1. Objective Elements
a. The patient-safety program is developed, implemented and maintained by a multi-disciplinary committee.
b. The patient safety program is documented.*
c. The patient safety program is comprehensive and covers all the major elements related to patient safety and
risk management.
d. The scope of the program is defined to include adverse events ranging from “no harm” to “sentinel events”.
e. There is a designated individual for coordinating and implementing the patient-safety program.
f. The designated program is communicated and coordinated amongst all the staff of the Organization through
appropriate training mechanism.
g. The patient-safety program identifies opportunities for improvement based on review at pre-defined intervals
h. The patient-safety program is a continuous process and updated at least once in a year.
i. The Organization adapts and implements national/international patient-safety goals/solutions.

6.6.2.2. Policies for CQI 2:

a. Hospital has designated a Safety committee to develop, implement and maintain safety requirement in the
patient and non patient care areas. Safety programme of the hospital has been developed and implemented in
a structure manner with the purpose to protect patient from any harm either from environment or due to lack of
appropriate care or safety measures. Risk identification and risk reduction strategy is part of the patient safety
programme of the hospital. A designated safety officer having knowledge of both patient and general safety is
available for coordinating and implementing the patient safety programme in the hospital. Refer-
AH/PPM/HQM/41, Refer AH/AQM/
b. Safety programme of the hospital is communicated to each department, its staff through repeated and well
designed training programme. Printed materials of safety programme are provided to each department.

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c. Patient safety programme identifies opportunities for improvement based on review at pre-defined intervals of
at least once in 4 months. Scope of review includes facility inspection rounds and analysis of key safety
indicators. Safety committee of the hospital review the progress made. Refer- AH/PPM/HS/26
d. Documented patient safety programme is updated based on findings of audit and change of process. However
review and update of the process is done at least once in a year.
e. Requirement of International patient safety goals are incorporated and implemented. Refer- AH/PPM/HS/26
6.6.3. CQI.3: The Organization identifies key indicators to monitor the clinical structures, processes and outcomes,
which are used as tools for continual improvement.
6.6.3.1. Objective Elements:
a. Monitoring includes appropriate patient assessment.
b. Monitoring includes safety and quality-control programs of all the diagnostic services.
c. Monitoring includes medication management.
d. Monitoring includes use of anaesthesia.
e. Monitoring includes surgical services.
f. Monitoring includes use of blood and blood components.
g. Monitoring includes infection control activities.*
h. Monitoring includes review of mortality and morbidity indicators.*
i. Monitoring includes clinical research.*
j. Monitoring includes patient safety goals.*
k. The Organization identifies and monitors priority aspects of patient care.

6.6.3.2. Policies for CQI 3:

a. The hospital collect and document following indicators for its Clinical Structure, process, outcome. Following
indicators are collected and analyzed as per the frequency of data collection/monitoring defined in Annexure 9
of NABH Accreditation Standards of hospital.
1. Time for initial assessment of indoor & emergency patients
2. Percentage of cases (in-patients wherein care plan with desired outcomes is documented &
counter-signed by the clinician
3. Percentage of cases (in-patients) wherein screening for nutritional needs has been done
4. Percentage of cases (in-patients) wherein the nursing care plan is documented
2. Number of Reporting error/1000 investigations
3. Percentage of Re-dos
4. Percentage of reports co-relating with clinical diagnosis
5. Percentage of adherence to safety precautions by employees working in diagnostic
1. Incidence to medication errors(Medication errors per patient days)
2. Percentage of admissions with adverse drug reaction(s) (Adverse drug reaction per 100
separations
3. Percentage of Medication charts with error prone abbreviations
4. Percentage of patients receiving high risk medication developing adverse drug event

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5. Percentage of modification of anaesthesia plan

6. Percentage of unplanned ventilation following anaesthesia
7. Percentage of adverse anaesthesia events
8. Anaesthesia related mortality rate
9. Percentage of unplanned return to OT
10. Percentage of re-scheduling of surgeries
11. Percentage of cases where the organisation procedure to prevent adverse event like wrong
site,wrong patient & wrong surgery have been adhered to
12. Percent of cases who received appropriate prophylactic antibiotics within the specifed time frame
13. Percentage of cases in which the planned surgery is changed intraoperatively
14. Re-exploration rate
15. Percentage of transfusion reactions recipient.The causes include red blood cell incompatibility
allergic sensitivity to the leukocytes,platelets,plasma protein components of the transfused blood;or
potassium or citrate preservatives in the banked blood
16. Percentage of wastage of blood & blood components
17. Percentage of blood component usage
18. Turn around time for issue of blood & blood components
19. Catheter associated Urinary tract infection rate
20. Ventilation associated Pneumonia rate
21. Centraline associated Blood stream infection rate
22. Surgical site infection rate
23. Mortality rate
24. Return to ICU within 48 hrs
25. Return to emergency department within 72 hrs with similar presenting complaints
26. Re-intubation rate
27. Percentage of research activities approved by Ethic committee
28. Percentage of patients withdrawing from the study
29. Percentage of protocol violations/deviation reported
30. Percentage of serious adverse events(which have occurred in the organization )reported to ethics
committee within defined time frame
31. *
*** Data collection is done at predefined intervals (monthly/quarterly) and is different for different types of indicators to support
further improvements. This data is analyzed for improvement opportunities and the same are carried out. Data collection is done to
support evaluation of the improvements done earlier. All improvement activities carried out by the hospital have an evaluable outcome. The
same is captured and analyzed.

CQI.4: The Organization identifies key indicators to monitor the managerial structures, processes and outcomes which are used as tools for
continual improvement.

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Objective Elements:

a. Monitoring includes procurement of medication essential to meet patient needs.

b. Monitoring includes risk management.
c. Monitoring includes utilisation of space, manpower and equipment.
d. Monitoring includes patient satisfaction which also incorporates waiting time for services.
e. Monitoring includes employee satisfaction.
f. Monitoring includes adverse events and near misses.
g. Monitoring includes availability and content of medical records.
h. The Organization identifies and monitors priority managerial activities in the Organization.
6.6.3.3. Policies for CQI 4:
a. The hospital collect and document following indicators its Managerial Structure, process, outcome. Following indicators are
collected and analyzed as per the frequency of data collection/monitoring defined in Annexure 9 of NABH Accreditation
Standards of hospital.
1. Percentage of drugs & consumables procured by local purchase
2. Percentage of stock out including emergency drugs
3. Percentage of drugs & consumables rejected before preparations of good receipt note (GRN)
4. Percentage of variations from procurement process
5. Numbers of variations observed in mock drill
6. Incidence of falls
7. Incidence of hospital associated pressure ulcers after admission (Bed sore per thousand patient days)
8. Percentage of staff provided pre exposure to prophylaxis
9. Bed occupancy rate & average length of stay
*Follow amendment

10. OT & ICU Utilisation Rate

11. Critical equipment down time
12. Nurse-Patient ratio for ICUs & wards
13. Out patient satisfaction index
14. In patient satisfaction index
15. Waiting time for services including diagnostic & out patient consultation
16. Time taken for discharge
17. Employee satisfaction index
18. Employee attrition rate
19. Employee absenteeism rate
20. Percentage of employees who were aware of employee right,responsibility & welfare scheme
21. Numbers of sentinel events,reported ,collected & analysed within defined time frame
22. Percentage of near misses
23. Incidence of body fluid exposure
24. Incidence of needle stick injury
25. Percentage of medical record not having discharge summary

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26. Percentage of medical record not having codification as per International Classification of Disease(ICD)
27. Percentage of medical record having incomplete & or improper consent
28. Percentage of missing records
29. Appropriate handovers during shift change (To be done separately for doctors & nurses - (per patient per shift)
30. Incidence of patient identification error
31. Compliance to Hand hygiene practices
32. Compliance rate to Medication Prescriptions in Capitals
33. *

*** Data collection is done at predefined intervals (monthly/quarterly) and is different for different types of indicators to support
further improvements. This data is analyzed for improvement opportunities and the same are carried out. Data collection is
done to support evaluation of the improvements done earlier. All improvement activities carried out by the hospital have an evaluable
outcome. The same is captured and analyzed

6.6.4. CQI.5: There is a mechanism for validation and analysis of quality indicators to facilitate quality improvement
6.6.4.1. Objective Elements:
a. There is a mechanism for validation of data
b. There is a mechanism for analysis of data which results in identifying opportunities for improvement.
c. The opportunities for improvement are implemented and evaluated
d. The Organization uses appropriate quality improvement, statistical and management tools in its quality improvement
program
e. Feedback about care and service is communicated to staff
6.6.4.2. Policies for CQI 5:
a. Data collected for analysis of quality indicator is validated by the staff of quality department from time to time and in
response to queries or when unexplained trend occurs
b. Remedial measures require for improvement are implemented and evaluated.
c. Root -cause -analysis (RCA) and corrective and preventive action (CAPA) is used as an opportunity to improve the process
and outcome.
d. Patient’s feedback and level of satisfaction is communicated on a monthly basis.

 Follow amendment

6.6.5. CQI.6: The quality improvement program is supported by the management

6.6.5.1. Objective Elements:

a. The leaders at all levels in the Organization are aware of the intent of the quality improvement program and the
approach to its implementation.

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b. The management makes available adequate resources required for quality improvement program.
c. Organization earmarks adequate funds from its annual budget in this regard.
d. The management identifies Organizational performance improvement targets.
6.6.5.2.Policies for CQI 6:
a. Process owner /In charge of the all department of the hospital is made aware of the importance of quality
improvement programme and the approach to its implementation. Management of the hospital encourages all its
departmental leaders to actively participate in quality improvement programme of the hospital. Printed materials
as applicable to the respective areas are provided and departmental leaders are held responsible for the
implementation and sustainability of Quality improvement requirement of their concerned areas.
b. Hospital Management has provided adequate resources required for quality improvement programme. This
includes the men, material, machine and method. There is steady supply of these to ensure that the programme
functions smoothly.
1. Hospital earmarks adequate funds from its annual budget in this regard
2. Appropriate fund allocation is done by the organization for the smooth functioning of the programme.
c. Management periodically defines performance improvement targets of each department that has a role in quality
improvement programme. Key result areas for each department and departmental leaders are defined and given
to the staff of the department. Regular feedback on the progress of the targets given is taken.
6.6.6. CQI 7: There is an established system for clinical audit.
6.6.6.1. Objective Elements:
a. Medical and nursing staff participates in this system.
b. The parameters to be audited are defined by the Organization.
c. Patient and staff anonymity is maintained.
d. All audits are documented.
e. Remedial measures are implemented.
6.6.6.2. Policies for CQI 7:
a. Hospital has a Clinical audit committee for conducting audits. Medical staff participates in audit of the patient
care services.
1. Members of the clinical audit committee are-
a) HOD Surgery, Hospital Administrator, Medicine, Prof. Obstetrics and Gynecology, Prof. Pediatrics,
Nursing Superintendent, Prof. Orthopedics, Prof. ENT, Dy. Director Laboratory
2. The parameters used in auditing are defined by the Clinical Audit committee. This includes disease based
parameters suggested by NICE (National Institute for Health and Care Excellence) Guideline. Tools for
auditing are available and followed.

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3. Patient and staff anonymity is maintained in the audits.

a. Names of the patients and the hospital staff who may figure in the audit documents are not disclosed
nor are any references made in public discussions / conferences about them.
b. All audits are documented.
4. All required remedial measures are implemented.
a. All remedial measures as ascertained are documented and implemented and improvements thereof
recorded to complete the audit cycle.
6.6.7. CQI.8: Incidents are collected and analyzed to ensure continual quality improvement.

6.6.7.1. Objective Elements:

a. The Organization has an incident reporting system.*
b. The Organization has established processes for analysis of incidents
c. Corrective and preventive actions are taken based on the findings of such analysis.
d. The Organization shall have a process for informing various stakeholders in case of a near miss / adverse
event.
6.6.7.2. Policies for CQI 8:
a. The hospital has an incident reporting system Refer-AH/PPM/HWP/21
a. Hospital has listed important sentinel events that can happen in the hospital.
b. The hospital has established processes for intense analysis of such events.
c. There is an established process that includes reporting the occurrence of such events on standardized
incident report forms.
d. Sentinel events are intensively analyzed whenever they occur
e. Actions are taken upon findings of such analysis.
a. The findings and recommendations arrived at after the analysis is communicated to all concerned
personnel to correct the systems and processes to prevent recurrences.
6.6.8. CQI .9 Sentinel events are intensively analyzed.

6.6.8.1. Objective Elements:

a. The Organization has defined sentinel events.*
b. The Organization has established processes for intense analysis of such events.
c. Sentinel events are intensively analysed when they occur.
d. Corrective and preventive actions are taken based on the findings of such analysis.

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6.6.8.2. Policies for CQI 9:

a. Sentinel events in the hospital has been defined. Refer-AH/PPM/HWP/21
b. Sentinel events are captured, documented and analyzed for root causes and remedial measures
c. Sentinel events are analyzed within 24 hours of occurrence.
d. Corrective and preventive actions are taken and findings and recommendations arrived after the analysis is
communicated to all personnel concerned to correct the system and process to prevent reoccurrence.

6.7.RESPONSIBILITIES OF MANAGEMENT (ROM)

6.7.1. ROM.1: The responsibilities of those responsible for governance are defined.
6.7.1.1. Objective Elements:
a. Those responsible for governance lay down the Organization’s vision, mission and values.*
b. Those responsible for governance approve the strategic and operational plans and Organization’s annual
budget.
c. Those responsible for governance monitor and measure the performance of the Organization against the stated
mission.
d. Those responsible for governance establish the Organization’s organogram.*
e. Those responsible for governance appoint the senior leaders in the Organization.
f. Those responsible for governance support safety initiatives and quality improvement plans.
g. Those responsible for governance support research activities.
h. Those responsible for governance address the Organization’s social responsibility.
i. Those responsible for governance inform the public of the quality and performance of services.
6.7.1.2. Policies for ROM 1:
a. Mission, vision and values of the hospital has been laid down. Stakeholder and process owner of the hospital
has defined the statements in a collaborative approach. Refer- AH/PPMROM/30
b. Strategic and operational plans and annual budget is approved by the management.
c. Performance monitoring is done by the Top Management once in 6 months for the achievement and
sustainability of mission statement
d. The organization has a documented organogram. Organogram provide information about hierarchy, Line of
control, along with functions at various levels. Quality Improvement programme is given due consideration in
the organogram. Dissemination of organogram has been done to all stakeholders and process owners of the
hospital
e. Qualified and competent staffs are appointed as a senior leader in the hospital.
f. Safety initiatives and quality improvement plans are given due importance by the senior management. All risk
assessment and risk reduction activities are supported for corrective action.

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g. Research activities are supported by the management by providing resources; budget, following ethical and
legal norms.
h. Hospitals takes part in various social initiative like GO-Green initiative, free camps, outreach programme etc.
i. Outcome Performance and quality of service details are displayed strategically for the public and patient.
6.7.2. ROM.2: The Organization is responsible for and complies with the laid down and applicable legislations,
regulations and notifications.
6.7.2.1. Objective Elements:
a. The management is conversant with the applicable laws and regulations and undertakes the responsibility to
adhere to the same.
b. The management ensures that the policies and procedures pertaining to patient care are in compliance with
the prevailing laws, regulations and notifications.
c. The management has a mechanism which ensures implementation of these requirements.
d. Management has a mechanism which regularly updates any amendments in the prevailing laws of the land.
e. There is a mechanism to regularly update licenses/registrations/certifications.
6.7.2.2. Policies for ROM 2:
a. Hospital has identified its requirement for the statutory and regulatory norms. Hospital has obtained approval
from the competent licensing authorities. Hospital has developed a mechanism to ensure timely renewal and
update of all regulatory and statutory requirements. A system is available to track the status of licenses.
Application to update these statutory documents is made in accordance with the timeliness set out in the
relevant laws/ registration authority requirement so as to ensure continuity of statutory compliances. Refer-
AH/HWP/21
b. Policies and procedures pertaining to patient care area in consonance with the applicable laws and regulations
and notifications are implemented. These includes compliance to the requirement related to Bio medical waste
management rules, AERB norms, PCPNDT norms, MTP norms, Narcotic and psychotropic norms, blood bank
requirements, other notification issued by licensing authority time to time.
6.7.3. ROM.3: The services provided by each department are documented.
6.7.3.1. Objective Elements:
a. Scope of services of each department is defined.*
b. Administrative policies and procedures for each department are maintained.*
c. Each Organizational program, service, site or department has effective leadership.
d. Departmental leaders are involved in quality improvement.
6.7.3.2. Policies for ROM 3:
a. Each organizational program, service, site or department has effective leadership through the scope of
services which are defined for each department.
b. Administrative policies and procedure for each department like attendance, leave, code of conduct, service
standard has been documented.
c. Each organizational programme, service, site or department has effective leadership. Leaders of the
department are highly qualified and competent to deliver results.

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d. Departmental leaders are involved in quality improvement. Departmental leaders participate actively for a
quality improvement programme. Key performance indicator and objective and role of each department is
defined.
6.7.4. ROM.4: The Organization is managed by the leaders in an ethical manner.

6.7.4.1. Objective Elements:

a. The leaders make public the vision, mission and values of the Organization.
b. The leaders establish the Organization’s ethical management.*
c. The Organization discloses its ownership.
d. The Organization honestly portrays the services which it can and cannot provide.
e. The Organization honestly portrays its affiliations and accreditations.
f. The Organization accurately bills for its services based upon a standard billing tariff.
6.7.4.2. Policies for ROM 4:
a. Mission, vision and values of the organization has been displayed prominently in the reception and in various
departments of the hospital in bilingual.
b. There’s an Ethics committee formed headed by a Chairman to overlook all ethical issues in the hospital.
c. Hospital is a private organization registered under Siksha “O” Anusandhan University.
d. Scope of services of the hospital is clearly displayed. Documentation in respect of service not available and its
communication to patient is maintained.
e. Affiliation and accreditation of the specific department and the organization has been disclosed. Central
Laboratory of the Hospital is NABL Accredited where as hospital is register under local body which is director
medical education and training- Odisha.
f. A Schedule of Charges is available and all bills are duly verified for their accuracy. Hospital does not charge
differently for different patient in the same bed category for the same surgery procedure or medical condition.

6.7.5. ROM.5: The Organization displays professionalism in management of affairs.

6.7.5.1. Objective Elements:

a. The person heading the Organization has requisite and appropriate administrative qualifications.
b. The person heading the Organization has requisite and appropriate administrative experience.
c. The Organization prepares the strategic and operational plans including long-term and short-term goals
commensurate to the Organization’s vision, mission and values in consultation with the various stakeholders.
d. The Organization coordinates the functioning with departments and external agencies, and monitors the
progress in achieving the defined goals and objectives.
e. The Organization plans and budgets for its activities annually.
f. The performance of the senior leaders is reviewed for their effectiveness.
g. The functioning of committees is reviewed for their effectiveness.
h. The Organization documents employee rights and responsibilities.*

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i. The Organization documents the service standards.*

j. The Organization has a formal documented agreement for all outsourced services.
k. The Organization monitors the quality of the outsourced services.
6.7.5.2. Policies for ROM 5:
a. Hospital is headed by Medical superintendent who is qualified and trained in hospital management
/administration. He possesses appropriate administrative experience in hospital.
b. Departmental Leaders are involved for the preparation of strategic and operational plans so as to achieve the
mission and vision and adhere to values. Inputs from all stakeholders are taken and plan is finalized.
c. Budgets for the various activities of infection control and quality improvement activities are made and allocated.
This is done on a calendar year basis.
d. Performance of senior leaders is reviewed for their effectiveness and involvement. Key result areas of each
leader is established and provided for the particular year.
e. Effectiveness of committee functioning is reviewed on a six monthly basis by the management.
f. Employee rights and responsibility has been documented Refer AH/PPM/HRM/24
g. Service standard and code of the conduct of the hospital is documented. Staffs are sensitized to follow the
service standard of the hospital which includes soft skills, behavior, attitude, communication skills etc. Refer
AH/PPM/HRM/24

6.7.6. ROM.6: Management ensures that patient-safety aspects and risk-management issues are an integral part of
patient care and hospital management.
6.7.6.1. Objective Elements
a. Management ensures proactive risk management across the Organization.
b. Management provides resources for proactive risk assessment and risk-reduction activities.
c. Management ensures implementation of systems for internal and external reporting of system and process
failures.*
d. Management ensures that appropriate corrective and preventive actions are taken to address safety-related
incidents.
6.7.6.2. Policies for ROM 6:
a. Risk management strategy has been defined. This includes identification of clinical and non clinical risks. Risk
identification and risk reduction strategies are made and implemented. Emergency Contingency plan is
available and tested at periodic interval. Refer- AH/PPM/ROM/30
b. Resources are kept as contingency to address the risk reduction activities as when required
c. Hospital follows a system for internal and external reporting system and process failure. Contingency plan is in
place to deal with situation of system and process failure. Refer- AH/PPM/ROM/30

6.8.FACILITY MANAGEMENT AND SAFETY (FMS)

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6.8.1. FMS.1: The Organization has a system in place to provide a safe and secure environment.
6.8.1.1. Objective Elements:
a. Safety committee coordinates development, implementation, and monitoring of the safety plan and policies.
b. Patient-safety devices & infrastructure are installed across the Organization and inspected periodically.
c. The Organization is a non-smoking area.
d. There is a procedure which addresses the identification and disposal of material(s) not in use in the
Organization.*
e. Facility inspection rounds to ensure safety are conducted at least twice in a year in patient-care areas and at
least once in a year in non-patient-care areas.
f. Inspection reports are documented and corrective and preventive measures are undertaken.
g. There is a safety education program for staff.
6.8.1.2. Policies for FMS 1:
a. There is a safety committee in the hospital which functions on a monthly basis to coordinate development,
implementation and monitoring of the safety plans and policies so as to provide a safe and secure facility and
environment. Members of the committees are Hospital Administrator, Prof. Radiology (Radiation Safety
Officer), Executive Engineer-Electrical, Nursing Superintendent, Dy. Hospital Administrator, Chief Fire and
Safety officer, Officer I/c Law and Order, Housekeeping In charge. Hazard identification and risk analysis
(HIRA) in both clinical and non clinical area is conducted by the safety committee and accordingly suggest for
necessary action to eliminate or reduce such hazards and associated risks. Refer- AH/PPM/HS/26
b. Provision of patient safety devices and infrastructure have been installed which includes grab bars, bed rails,
sign posting, safety belts on stretcher and wheel chairs, alarms both visual and auditory, warning signs like
radiation or bio hazard, call bells, fire safety devices etc. Provision for physically challenged / vulnerable
person as per regulatory requirement like special toilet for physically challenged.
c. Hospital is declared as a non smoking area. Smoking is considered as punishable offence in the premises of
hospital.
d. There is a procedure for the condemnation and disposal of materials which are not in use. Condemnation
board is formed to identify and suggest for condemnation and disposal of materials. Materials are classified in
to category of Fair-wear and tear and unfair wear-tear and based on this decision for condemnation and
disposal is taken. Refer-AH/PPM/PSM/37
e. Facility inspection round is conducted once in six month by the members of the safety committee. Potential
safety risks are identified and remedial measures are suggested. Inspection report of the safety committee is
documented and corrective and preventive measures are taken. Evidence of pre- and post corrective actions
are maintained.
f. Safety education to each staff of the hospital is provided and made as part of employee induction training
programme. Training on fire safety, occupational safety, radiation safety, incident reporting, infection control
requirement as applicable is conducted. Training records are documented.
6.8.2. FMS.2: The Organization’s environment and facilities operate in a planned manner to ensure safety of patients,
their families, staff and visitors and promotes environment friendly measures.
6.8.2.1. Objective Elements:

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a. Facilities are appropriate to the scope of services of the Organization.

b. Up-to-date drawings are maintained which detail the site layout, floor plans and fire-escape routes.
c. There is internal and external sign postings in the Organization in a language understood by patient, families and
community.
d. The provision of space shall be in accordance with the available literature on good practices (Indian or
International Standards) and directives from government agencies.
e. Operational planning describes access to different areas in the hospital by staff, patients, visitors and vendors
f. Potable water and electricity are available round the clock.
g. Alternate sources for electricity and water are provided as backup for any failure / shortage.
h. The Organization regularly tests these alternate sources.
i. There are designated individuals (with appropriate equipment) responsible for the maintenance of all the
facilities.
j. Maintenance staff is contactable round the clock for emergency repairs.
k. There is a maintenance plan for facility and furniture.*
l. Response times are monitored from reporting to inspection and implementation of corrective actions.
m. The Organization takes initiatives towards an energy efficient and environmental friendly hospital.
6.8.2.2. Policies for FMS 2:
a. Planning and design of facilities of the hospital has been done appropriately to the scope of service. Functional
requirement of all departments that caters to the patient and non patient care activities has been done as per
national and local laws. Qualified and trained engineer having expertise in hospital planning designs are
engaged while planning for a newer facility.
b. Up to date drawings are maintained which details the site layout, floor plans and fire escape routes. All drawings
are maintained in secured area with a designated staff. Drawings for civil, electrical, plumbing, HVAC and piped
medical gas are maintained. Fire evacuation plans are available.
c. Provision of space planning, facility planning is done in accordance to the standard norms and guidelines of
government agencies. Example IPHS standards for facility planning, AERB guideline while planning for
Radiation facility etc.
d. Hospital follows a strict visitor control policy as part of its access policy. Unauthorized personnel, staff and
visitors are not allowed in inaccessible areas without permission from hospital administration. Access to
restricted areas in the hospital by certain staff group, visitors and vendors are controlled by security staff as per
the instruction of management.
e. Provision of potable water and electricity is made for round the clock. Quality of potable water is monitored once
in three months. Alternate source of electricity and water is available as backup for any failure/shortage.
Sufficient water supply is made available to patient care areas. Provision of underground water and DG set,
solar energy, UPS is made available for water and electricity respectively. There is a mechanism to tests these
alternate source by the department of maintenance and engineering.
f. Designated engineers for respective maintenance activities for water, electricity and civil is available for round
the clock basis. Safety and infrastructure and tools are available to facilitate any maintenance activity in a

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smooth manner. This includes availability of ladder, voltmeter, personal protective equipments like safety boots,
gloves by DG operator are properly followed.
g. Maintenance plan for facility and furniture is available. This includes regular inspections and timely repair of civil
structure like walls, servicing of furniture etc. Infection control requirements are adhered to while planning for
facility and furniture.
h. Response times are monitored from reporting to inspection and implementation of corrective action. All
complaints are recorded suitably by the maintenance department which includes time of receipt of complaint,
allotment of job, completion of the job is ratified by the user department
i. Provision for energy efficient lighting, water harvesting, more use of solar power is introduced as an initiative
towards an energy efficient and environmental friendly hospital.
6.8.3. FMS.3: The Organization has a program for engineering support services and utility system.
6.8.3.1. Objective Elements:
a. The Organization plans for equipment in accordance with its services and strategic plan.
b. Equipment are selected, rented, updated or upgraded by a collaborative process.
c. Equipments are inventoried and proper logs are maintained as required.
d. Qualified and trained personnel operate, inspect, test and maintain equipment and utility systems.
e. Utility equipment are periodically inspected and calibrated (wherever applicable) for their proper functioning.
f. There is a documented operational and maintenance (preventive and breakdown) plan.*
g. There is a maintenance plan for water management.*
h. There is a maintenance plan for electrical systems.*
i. There is a maintenance plan for heating, ventilation and air-conditioning.*
j. There is a maintenance plan for Information technology & communication network.
k. There is a documented procedure for equipment replacement and disposal.
6.8.3.2. Policies for FMS 3:
a. Procurement and planning for equipment is done in accordance with its services and strategic plan. Future
requirements of the equipment and machinery are well forecasted by the maintenance team as part of the
strategic plan.
b. Equipments are selected, rented and updated or upgraded by a collaborative process. Involvement of end user,
management, finance and engineering department is done while decision for procurement planning is initiated
c. Unique ID of each equipment and machinery is provided to each equipment and machinery. Documented
system is available to retain relevant details, quality conformance certificate/marks along with other details in the
respective equipment and machinery file of the hospital.
d. Qualified and trained personnel are involved in operating, inspection, test and maintenance of the equipment
and machinery.
e. Periodical inspection of utility equipment like medication refrigerator, pressure gauge of steam sterilizer, blood
bank refrigerators, DG sets are done by the bio medical engineering department of the hospital. Periodic
calibration of the utility equipment is also done by maintaining traceability to national or international guidelines.
Traceability certificate for the calibrator is maintained.

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f. A documented operational and maintenance plan for the equipment and machinery is available. There is a
planned preventive maintenance plan and breakdown plan for equipments. Refer-AH/PPM/MES/23
g. There is a maintenance plan for water management in the hospital. This includes periodic cleaning of water
tanks, water treatment, test for endotoxin levels of RO plant of dialysis unit every month, regular checking of pH,
TDS, hardness of water quality. . Refer-AH/PPM/MES/23
h. There is a maintenance plan for electrical systems, heating, ventilation and air conditioning, Information
technology and communication network. . . Refer-AH/PPM/MES/23
i. There is a documented procedure for equipment replacement and disposal. Unserviceable and obsolete
equipments, engineering waste materials and accessories are disposed off and records of the condemnation of
equipment, accessories are maintained. . Refer-AH/PPM/MES/23
6.8.4. FMS.4: The Organization has a program for bio-medical equipment management.
6.8.4.1. Objective Elements:
a. The Organization plans for equipment in accordance with its services and strategic plan.
b. Equipment are selected, rented, updated or upgraded by a collaborative process.
c. Equipments are inventoried and proper logs are maintained as required.
d. Qualified and trained personnel operate and maintain the medical equipment.
e. Equipment are periodically inspected and calibrated for their proper functioning.
f. There is a documented operational and maintenance (preventive and breakdown) plan for equipment.*
g. There is a documented procedure for equipment replacement and disposal.
h. The procedures addresses medical equipment recalls.
i. Response times are monitored from reporting to inspection and implementation of corrective actions.

6.8.4.2. Policies for FMS 4:

a. Procurement plan of the equipment is made in accordance the scope of service and strategic plan of the
hospital. List of essential equipment is developed as per the reference guideline of Indian Public Health Standard
(IPHS)
b. Equipments are selected, rented and updated or upgraded by a collaborative process. Involvement of end user,
management, finance and engineering department is done while decision for procurement planning is initiated
c. Unique equipment ID and history cards are provided for each equipment and machinery. Documented system is
available to retain relevant details, quality conformance certificate/marks along with other details in the
respective equipment and machinery file of the hospital.
d. Qualified and trained personnel operate and maintain the medical equipment. Training and demonstration of
equipment functioning is given by the engineer of supplier. Staffs are certified fit to operate equipment once they
pass the training of supplier. Maintenance of bio medical equipment is done by the qualified, experienced and
trained bio medical engineer of the hospital
e. Equipments are periodically inspected by the staff of bio medical engineering of the hospital. Calibration of
equipment is done as per the recommended schedule of supplier. Bio medical engineering department develops
weekly/monthly and annual schedule of inspection and calibration of equipment and executes the same.

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f. Documented operational and maintenance plan for the equipment is available. This includes operator level
inspection, inspection by bio medical engineer, preventive maintenance plan, comprehensive maintenance plan,
user training on equipment. Bio medical engineering department develops and executes planned preventive
maintenance of equipments in the hospital. . Refer-AH/PPM/MES/23
g. There is a documented procedure for equipment replacement and disposal. Unserviceable and obsolete
equipments, engineering waste materials and accessories are disposed off and records of the condemnation of
equipment, accessories are maintained . Refer-AH/PPM/MES/23
h. Recall procedure for the medical equipment is available. This includes recalls are on based on letters/hazards
notice issued from manufacturer and or from regulatory authority. Immediate action is taken when such
information of recall of equipment is obtained due to safety hazards. Bio medical engineering department
coordinates to ensure the said equipment is not put into further clinical use till the issue is resolved. . Refer-
AH/PPM/MES/23
i. Response times are monitored from reporting to inspection and implementation of corrective action. All
complaints are recorded suitably by the maintenance department which includes time of receipt of complaint,
allotment of job, completion of the job is ratified by the user department

6.8.5. FMS.5: The Organization has a program for medical gases, vacuum and compressed air.

6.8.5.1. Objective Elements:

a. Documented procedures govern procurement, handling, storage, distribution, usage and replenishment of
medical gases.
b. Medical gases are handled, stored, distributed and used in a safe manner.
c. The procedures for medical gases address the safety issues at all levels.
d. Alternate sources for medical gases, vacuum and compressed air are provided for, in case of failure.
e. The Organization regularly tests these alternate sources.
f. There is an operational, inspection, testing and maintenance plan for, piped medical gas, compressed air and
vacuum installation.*
6.8.5.2. Policies for FMS 5:
a. There is a documented procedure available for the procurement, handling, storage, distribution, usage and
replacement of medical gases in a timely manner. This includes the issue of statutory requirements and approval,
uniform color coding system, safety issues as per Indian explosive Act, gas cylinder rules and static and mobile
pressure vessels rules. . Refer-AH/PPM/MES/23
b. Safety issues are followed from the point of storage/source area, gas supply lines and the end user area. All
safety provision for medical gas supply system is implemented and monitored
c. Alternate source of medical gases, vacuum and compressed air provided in case of failure. Standby arrangement
for main source is available which includes stand by air compressor and vacuum pump, standby gas manifold /
bulk cylinders. Periodic testing of these alternate sources is done and documented.

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d. Operational plan for inspection , testing and maintenance plan for piped medical gas, compressed air and vacuum
installation . Refer-AH/PPM/MES/23
6.8.6. FMS.6: The Organization has plans for fire and non-fire emergencies within the facilities.
6.8.6.1. Objective Elements:
a. The Organization has plans and provisions for early detection, abatement and containment of fire, and non-fire
emergencies.
b. The Organization has a documented safe-exit plan in case of fire and non-fire emergencies.
c. Staff is trained for their role in case of such emergencies.
d. Mock drills are held at least twice in a year.
e. There is a maintenance plan for fire-related equipment &infrastructure
6.8.6.2. Policies for FMS 6:
a. Plans and provision for early detection, abatement and containment of fire and non fire emergencies has been
made in accordance with local fire safety norms of the State government. Fire hydrants, fire hoses
extinguishers and fire escapes are provided on each floor. Fire control panel is placed on every floor with a
centralized monitoring. Refer- AH/PPM/HS/26
b. Hospital has a safe exit plan put up at all floors and patient movement areas to be followed in case of the fire
and non-fire emergencies. (Ref-fire exit plans
c. Staff is trained for their role in case of such emergencies. This training is an on-going process and HR
department maintains a log of department wise training schedule. (Ref- Training schedules)
d. Mick drills are held at periodic interval to assess the preparedness of staff and fire safety team. Findings of the
mock drills are recorded and discussed during debriefing meeting
e. Fire safety devices and installations are periodically inspected and preventive maintenance carried out.
6.8.7. FMS.7: The Organization has a plan for management of hazardous materials.
6.8.7.1. Objective Elements:
a. Hazardous materials are identified within the Organization.*
b. The Organization implements processes for sorting, labelling, handling, storage, transporting and disposal of
hazardous material.*
c. Requisite regulatory requirements are met in respect of radioactive materials.(NA)
d. There is a plan for managing spills of hazardous materials.*
e. Staff are educated and trained for handling such materials.
6.8.7.2. Policies for FMS 7:
a. Hazardous materials are identified, sorted, stored, handled, and transported in a safe manner. There is a plan
for spillage management. Hazardous material management team is available to respond in case of hazardous
material spillage is notified

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b. Training of the staff is given to implement process for sorting, labeling, handling, storage and transportation and
disposal of hazardous material. HIRA (Hazard identification and Risk Analysis) is conducted by the safety
committee/Safety officer to notify and take remedial measures.
c. Hazmat spillage management kit is available in all patient care and areas where hazardous materials are
stored. Dedicated team and code is available and activated in case of hazardous material spillage.

6.9.HUMAN RESOURCE MANAGEMENT (HRM)

6.9.1. HRM.1. The Organization has a documented system of human resource planning.

6.9.1.1. Objective Elements:

a. Human resource planning supports the Organization’s current and future ability to meet the care, treatment
and service needs of the patient.*
b. The Organization maintains an adequate number and mix of staff to meet the care, treatment and service
needs of the patient.
c. The required job specification and job description are well defined for each category of staff.*
d. The Organization verifies the antecedents of the potential employee with regards to criminal/negligence
background.

6.9.1.2. Policies for HRM 1:

a. There is mix of staff which has been categorized as permanent, outsourced staff. Manpower planning is done
keeping strategic and operational plan of the hospital into consideration. Manpower planning addresses for
acquiring, retaining and maintaining competent staff in the right numbers to meet the needs of the patient and
community served by the hospital. Refer- AH/PPM/HRM/24
b. The required job specifications and job description are well defined for each category of staff. The content of
each job is well defined and the qualifications, skills and experience required for performing the job are clearly
laid down. The job description is commensurate with the qualification.
c. The hospital verifies the antecedents of the potential employee with regards to criminal/negligence background

6.9.2. HRM.2. The Organization has a documented procedure for recruiting staff and orienting them to the
Organization’s environment.
6.9.2.1. Objective Elements:
a. There is a documented procedure for recruitment.*
b. Recruitment is based on pre-defined criteria
c. Every staff member entering the Organization is provided induction training

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d. The induction training includes orientation to the Organization’s vision, mission and values.
e. The induction training includes awareness on employee rights and responsibilities.
f. The induction training includes awareness on patient’s rights and responsibilities.
g. The induction training includes orientation to the service standards of the Organization.
h. Every staff member is made aware of Organization's wide policies and procedures as well as relevant
department / unit / service / program’s policies and procedures.
6.9.2.2. Policies for HRM 2:
a. There is a documented procedure available for recruitment. Recruitment is undertaken in accordance with
statutory requirements which include necessary registration, qualification, skills and experience to perform
work. Refer- AH/PPM/HRM/24
b. Pre-defined criteria are used for the recruitment. Recruitment is done in a transparent manner.
c. Induction training of all new staff members within 1 month of joining. Content of induction training is defined and
followed which includes vision, mission, values, employee rights and responsibilities, patient’s rights and
responsibilities, service standard and code of conduct, hospital wide policies and procedures, Safety issues,
infection control, occupational hazards, etc . Organization specific and department specific training is provided
as part of induction training. Refer- AH/PPM/HRM/24

6.9.3. HRM.3. There is an on-going program for professional training and development of the staff.
6.9.3.1. Objective Elements:
a. A documented training and development policy exists for the staff.*
b. The Organization maintains the training record.
c. Training also occurs when job responsibilities change/ new equipment is introduced.
d. Evaluation of training effectiveness is done by the Organization
e. Feedback mechanisms are in place for improvement of training and development program.
6.9.3.2. Policies for HRM 3:
a. A documented competence assessment & training and development policy exists for the staff. . Refer-
AH/PPM/HRM/24
b. A training manual incorporating the procedure for identification of training needs, the training methodology,
documentation of training, training assessment, impact of training and the training calendar is prepared for the
hospital staff.
c. Hospital has a feedback mechanism for assessment of training and development programme. This is applicable
both for internal & external training.
6.9.4. HRM.4. Staff are adequately trained on various safety-related aspects.

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6.9.4.1. Objective Elements:

a. Staff are trained on the risks within the Organization’s environment.
b. Staff members can demonstrate and take actions to report, eliminate, or minimize risks.
c. Staff members are made aware of procedures to follow in the event of an incident.
d. Staff are trained on occupational safety aspects.
6.9.4.2. Policies for HRM 4:
a. All staff is trained on the risks within the hospital environment. These risks include needle stick injury, fire,
internal disaster and occupational health hazards
b. Hospital staff members demonstrate and take actions to report, eliminate / minimize risks.
c. Hospital staff members are made aware of procedures to follow in the event of an incident.
d. Reporting processes for common problems, failures and user errors exist in the hospital through various forms
and formats.
6.9.5. HRM.5. An appraisal system for evaluating the performance of an employee exists as an integral part of the
human resource management process.
6.9.5.1. Objective Elements:
a. A documented performance appraisal system exists in the Organization.*
b. The employees are made aware of the system of appraisal at the time of induction.
c. Performance is evaluated based on the pre-determined criteria.
d. The appraisal system is used as a tool for further development.
e. Performance appraisal is carried out at pre-defined intervals and is documented.

6.9.5.2. Policies for HRM 5

a. A well-documented performance appraisal system exists in the hospital for appraisals. This is done for all
categories of the staff starting from the person heading the hospital and including doctors who are staff.
Refer- AH/PPM/HRM/24
b. The employees are made aware of the system of appraisal at the time of induction. Employee hand book is
provided to each employee at the time of joining. Appraisal system has been detailed in the employee
guidebook.
c. Performance is evaluated based on the performance expectations described in job description. HR
Guidelines
d. The appraisal system is used as a tool for further development.

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a. Training requirements are identified and accordingly provides for the same.
b. Performance appraisal is carried out at pre defined intervals and is documented
6.9.6. HRM.6. The Organization has documented disciplinary and grievance handling policies and procedures.

6.9.6.1. Objective Elements:

a. Documented policies and procedures exist.*
b. The policies and procedures are known to all categories of staff of the Organization.
c. The disciplinary policy and procedure is based on the principles of natural justice.
d. The disciplinary and grievance procedure is in consonance with the prevailing laws.
e. There is a provision for appeals in all disciplinary cases.
f. The redress procedure addresses the grievance.
g. Actions are taken to redress the grievance.
6.9.6.2. Policies for HRM 6:
a. Hospital has a well documented disciplinary policy. Refer- AH/PPM/HRM/24
b. The disciplinary policy and procedure is based on the principles of natural justice. Refer- AH/PPM/HRM/24
c. The policy and procedure is known to all categories of employees of the organization.
d. The disciplinary procedure is in consonance with the prevailing laws.
e. There is a provision for appeals in all disciplinary cases. The Hospital has an appellate authority to
consider appeals in disciplinary cases.
6.9.7. HRM.7: The Organization addresses the health needs of the employees.
6.9.7.1. Objective Elements:
a. A pre-employment medical examination is conducted on all the staff.
b. Health problems of the employees are taken care of in accordance with the Organization’s policy.
c. Regular health checks of staff dealing with direct patient care are done at least once a year and the findings/
results are documented.
d. Occupational health hazards are adequately addressed.
6.9.7.2. Policies for HRM 7:
a. A pre-employment medical examination is conducted for all the employees of the hospital Health problems of
the employees are taken care of in accordance with the hospital policy. This is in consonance with the law of
the land and good clinical practices.
b. Regular health checks of staff dealing with direct patient care are done at-least once in a year and the
findings/ results are documented. Parameters for the health checks have been defined. Staffs are not
charged for the regular health check.

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c. Occupational health hazards are adequately addressed for the employees of the hospital.
6.9.8. HRM.8. There is documented personal information for each staff member.
6.9.8.1. Objective Elements:
a. Personal files are maintained with respect to all staff.
b. The personal files contain personal information regarding the staff’s qualification, disciplinary background and
health status.
c. All records of in-service training and education are contained in the personal files.
d. Personal files contain results of all evaluations.
6.9.8.2. Policies for HRM 8:
a. Personal files are maintained in respect of all employees. Each file is current and updated with information as
per the defined policy. Confidentiality of access to personal file is maintained. Refer- AH/PPM/HRM/24
b. The personal files contain personal information regarding the employees’ qualification, disciplinary
background and health status.
c. All records of in-service training and education are contained in the personal files. Training cards of each
employee is kept in personal file.
d. Personal files contain results of all evaluations. Evaluations include performance appraisals, training
assessment and outcome of health checks.
6.9.9. HRM.9. There is a process for credentialing and privileging of medical professionals, permitted to provide
patient care without supervision.
6.9.9.1. Objective Elements:

a. Medical professionals permitted by law, regulation and the Organization to provide patient cares without
supervision are identified.
b. The education, registration, training and experience of the identified medical professionals is documented
and updated periodically.
c. All such information pertaining to the medical professionals is appropriately verified when possible.

d. Medical professionals are granted privileges to admit and care for patients in consonance with their
qualification, training, experience and registration.
e. The requisite services to be provided by the medical professionals are known to them as well as the various
departments / units of the Organization.
f. Medical professionals admit and care for patients as per their privileging.
6.9.9.2. Policies for HRM 9:

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a. Medical professionals permitted by law, regulation and the hospital to provide patient care without
supervision is identified. The hospital identifies the individuals who have the required qualification (s),
training and experience to provide patient care in consonance with the law. Refer- AH/PPM/HRM/24
b. The education, registration, training and experience of the identified medical professionals is documented
and updated periodically. Updation is done after acquisition of new skills and/or qualification.
c. All such information pertaining to the medical professionals is appropriately verified when possible.
Hospital does the same by verifying the credentials from the organization which has awarded the
qualification/training.
d. The services provided by the Medical professionals are in consonance with their qualification, training and
registration.
e. The requisite services to be provided by the medical professionals are known to them as well as the
various departments / units of the hospital.
f. Medical professionals are awarded privileges based on the evaluation of credentialing and competency
mapping.
6.9.10. HRM.10. There is a process for credentialing and privileging of nursing professionals, permitted to provide
patient care without supervision.
6.9.10.1.Objective Elements:
a. Nursing staff permitted by law, regulation and the Organization to provide patient care without supervision
are identified.
b. The education, registration, training and experience of nursing staff is documented and updated periodically.

c. All such information pertaining to the nursing staff is appropriately verified when possible.
d. Nursing staff are granted privileges in consonance with their qualification, training, experience and
registration.
e. The requisite services to be provided by the nursing staff are known to them as well as the various
departments / units of the Organization.
f. Nursing professionals care for patients as per their privileging.
6.9.10.2.Policies for HRM 10:
a. Nursing professionals permitted by law, regulation and the hospital to provide patient care without
supervision is identified. The hospital identifies the individuals who have the required qualification (s),
training and experience to provide patient care in consonance with the law. Refer- AH/PPM/HRM/24

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b. The education, registration, training and experience of the identified nursing professionals is documented
and updated periodically. Updation is done after acquisition of new skills and/or qualification.
c. All such information pertaining to the nursing professionals is appropriately verified when possible.
Hospital does the same by verifying the credentials from the organization which has awarded the
qualification/training.
d. The services provided by the Nursing professionals are in consonance with their qualification, training and
registration.
e. The requisite services to be provided by the nursing professionals are known to them as well as the
various departments / units of the hospital.
f. Nursing professionals are awarded privileges based on the evaluation of credentialing and competency
mapping.

6.10. INFORMATION MANAGEMENT SYSTEM (IMS)

6.10.1. IMS.1. Documented policies and procedures exist to meet the information needs of the care providers,
management of the Organization as well as other agencies that require data and information from the
Organization.
6.10.1.1.Objective Elements:
a. The information needs of the Organization are identified and are appropriate to the scope of the services
being provided by the Organization.*
b. Documented policies and procedures to meet the information needs exist.*
c. All information management and technology acquisitions are in accordance with the documented policies
and procedures.
d. Documented policies and procedures guide the use of Telemedicine facility in a safe and secure manner
e. The Organization contributes to external databases in accordance with the law and regulations.
6.10.1.2.Policies for IMS 1:
a. The information needs of the organization are identified and are appropriate to the scope of the services
being provided by the hospital and the complexity of the hospital. The hospital has manual System which
provides relevant information to all concerned stakeholders. Refer-AH/PPM/IMS/33
b. Policies and procedures to meet the information needs are documented. Refer-AH/PPM/IMS/33
c. These policies and procedures are in compliance with the prevailing laws and regulations.
Refer-AH/PPM/IMS/33
d. All information management and technology acquisitions are in accordance with the policies and procedures
e. The hospital contributes to external databases in accordance with the law and regulations this includes birth
and death statistics, notifiable disease reporting, neonatal death, maternal death reporting etc.

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f. The hospital has defined the system of releasing the relevant information to the authority as per statutory
norms
6.10.2. IMS.2. The Organization has processes in place for effective control and management of data
6.10.2.1.Objective Elements:
a. The Organization has an effective process for document control.*
b. Formats for data collection are standardized.
c. Necessary resources are available for analysing data.
d. Documented procedures are laid down for timely and accurate dissemination of data.
e. Documented procedures exist for storing and retrieving data.*
f. Appropriate clinical and managerial staff participates in selecting, integrating and using data.
6.10.2.2.Policies for IMS 2:
a. Policy and procedure for document control exists. This includes periodic updating of forms, formats, policies
and procedure. Documents are created, reviewed for adequacy, authorized and released by designated
individuals. Only updated and latest documents are used. All documents are reviewed for updation as per its
planned schedule. Obsolete documents are removed from the user area and updated documents are
provided after approval. Refer- AH/HQA/41
b. Formats for data collection are standardized. Patient statistics are collected in standardized manner .
c. Provision of resources in terms of trained staff, space and facilities are made for the analyzing data.
d. Timely and accurate dissemination of data to the administration is done after data generation and analysis.
e. Documented procedure for the storing and retrieval of data which includes safeguard for protection of data.
6.10.3. IMS.3. The Organization has a complete and accurate medical record for every patient.
6.10.3.1.Objective Elements:
a. Every medical record has a unique identifier.
b. Organization policy identifies those authorized to make entries in medical record.
c. Entry in the medical record is named, signed, dated and timed.
d. The author of the entry can be identified.
e. The contents of medical record are identified and documented.*
f. The Organization has a documented policy for usage of abbreviations and develops a list based on accepted
practice
g. The record provides a complete, up-to-date and chronological account of patient care.
h. Provision is made for 24-hour availability of the patient’s record to healthcare providers to ensure continuity of
care

6.10.3.2.Policies for IMS 3:

a. Every medical record has a unique identifier. Hospital medical records are kept according to IPD numbers
for in-patient records Refer- SUM/forms and Formats/01

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b. Hospital has a policy which identifies those authorized to make entries in medical record. Progress record
entry is done by doctors and medication charts by nursing staff.
c. Every medical record entry is dated, named, signed and timed by the concerned staff. All entries are
documented immediately but no later than 1 hour of completion of the assessment/procedure.
d. The author of the entry can be identified in each medical record. For every entry in medical records author
puts his/her name against it. In case of electronic based records, authorized e-signature provision has
been made.
e. Hospital has identified the contents of the medical record and documented it. Hospital has a list of
records/documents to be added in every patient record file and the assembling order for the same.
f. Documented policy for usage of abbreviations is available. A standardized list has been made as per the
guideline of Institute of Safe medication Practice (ISMP). Staffs are motivated not to use error probe
abbreviation for avoiding confusion. Refer-AH/PPM/MRD/28
g. The record provides an up-to-date and chronological account of patient care. Hospital has a format for
maintaining the continuity in the medical records.
h. Provision is available to ensure 24 hours availability of the patient’s record to doctors to ensure continuity
of care. Policy for retrieval of medical record is available when medical record is closed. Authorized
personnel have been identified who can open the Medical record room and issue medical record. Records
of opening of medical record during off hour are maintained. Refer-AH/PPM/MRD/28
6.10.4. IMS.4. The medical record reflects continuity of care.
6.10.4.1.Objective Elements:
a. The medical record contains information regarding reasons for admission, diagnosis and care plan.
b. The medical record contains the results of tests carried out and the care provided.
c. Operative and other procedures performed are incorporated in the medical record.
d. When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for
the transfer and the name of the receiving hospital.
e. The medical record contains a copy of the discharge summary duly signed by appropriate and qualified
personnel.
f. In case of death, the medical record contains a copy of the cause of death certificate.
g. Whenever a clinical autopsy is carried out, the medical record contains a copy of the report of the same.
h. Care providers have access to current and past medical record.
6.10.4.2.Policies for IMS 4:

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a. The hospital medical record contains information regarding reasons for admission, diagnosis and plan of care.
Refer-IPD files of the patient.
b. Operative and other procedures performed are incorporated in the medical record of each operative case.
c. When patient is transferred to another hospital, the medical record contains the date of transfer, the reason for
the transfer and the name of the receiving hospital.
a. The record also contains the information regarding the clinical condition of the patient.
d. The medical record contains a copy of the discharge summary duly signed by resident doctor and treating
consultant.
e. In case of death, the medical record contains a copy of the death certificate indicating the cause, date and time
of death. Hospital provides the death certificate as per the International Certification of cause of death.
f. Doctors and other care providers have access to current and past medical records of the concerned patient
whom they are treating or providing care.
6.10.5. IMS.5. Documented policies and procedures are in place for maintaining confidentiality, integrity and security
of records, data and information.
6.10.5.1.Objective Elements:
a. Documented policies and procedures exist for maintaining confidentiality, security and integrity of records, data
and information.*
b. Documented policies and procedures are in consonance with the applicable laws.
c. The policies and procedure (s) incorporate safeguarding of data/ record against loss, destruction and tampering.

d. The Organization has an effective process of monitoring compliance of the laid down policy and procedure.

e. The Organization uses developments in appropriate technology for improving confidentiality, integrity and
security.
f. Privileged health information is used for the purposes identified or as required by law and not disclosed without
the patient’s authorization.
g. A documented procedure exists on how to respond to patients / physicians and other public agencies requests
for access to information in the medical record in accordance with the local and national law.

6.10.5.2.Policies for IMS 5:

a. Hospital has a well documented medical record policy. Documented policies and procedures exist for
maintaining confidentiality, security and integrity of information. Refer-AH/PPM/MRD/28

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b. Policy defines control of movement of the file in and out of the MRD so as to maintain confidentiality, security,
safety and integrity of information. . Refer-AH/PPM/MRD/28
1. This is applicable for both manual and electronic records.
2. Policies and procedures are in consonance with the applicable laws.
3. These are Indian Evidence Act, Indian Penal Code and Code of medical Ethics
c. The policies and procedures incorporate safeguarding of data / record against loss, destruction and tampering.
1. For physical records the hospital ensures that there is adequate pest and rodent control measures.
2. For electronic data there is protection against virus/trojans and also a proper backup procedure.
3. To prevent tampering, for physical records, access is limited only to the concerned health care provider.
d. The hospital has an effective process of monitoring compliance of the laid down policy.
1. The hospital carries out regular audits/rounds to check compliance with policies.
e. The hospital uses developments in appropriate technology for improving confidentiality, integrity and security.
f. Hospital review and update its technological features so as to improve confidentiality, integrity and security of
information.
g. Privileged health information is used for the purposes identified or as required by law and not disclosed without
the patient’s authorization. Hospital has defined the procedure for privileged communication.
h. A documented procedure exists on how to respond to patients/ physicians and other public agencies requests
for access to information in the medical record in accordance with the local and national law.
6.10.6. IMS.6. Documented policies and procedures exist for retention time of records, data and information
6.10.6.1.Objective Elements:
a. Documented policies and procedures are in place on retaining the patient’s clinical records, data and
information.*
b. The policies and procedures are in consonance with the local and national laws and regulations.
c. The retention process provides expected confidentiality and security.
d. The destruction of medical records, data and information is in accordance with the laid-down policy.
6.10.6.2.Policies for IMS 6:
i. Documented policies and procedures are in place on retaining the patient’s clinical records, data and
information. Hospital has defined the retention period for each category of medical records.
j. Refer-AH/PPM/MRD/28
1. Out-patient 4 years,
2. In-patient 10 years
3. MLC – Till the case is settled by court of law

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a. The policies and procedures are in consonance with the local and national laws and regulations.
1. These are in consonance with Code of Medical Ethics 2002, Consumer protection act 1987 and other
relevant state legislation.
b. The retention process of hospital provides expected confidentiality and security of the records.
1. Applicable for manual records.
c. The destruction of medical records, data and information is in accordance with the laid down policy.
1. Destruction is done after the retention period is over and after taking approval of the competent
authority.
6.10.7. IMS.7. The Organization regularly carries out review of medical records.
6.10.7.1.Objective Elements:

a. The medical records are reviewed periodically.

b. The review uses a representative sample based on statistical principles.
c. The review is conducted by identified individuals.
d. The review focuses on the timeliness, legibility and completeness of the medical records.
e. The review process includes records of both active and discharged patients.
f. The review points out and documents any deficiencies in records.
g. Appropriate corrective and preventive measures are undertaken within a defined period of time and are
documented.
6.10.7.2.Policies for IMS 7:
a. The medical records are reviewed periodically. A medical care audit checklist is available to review the
compliance to medical record documentation. Refer-AH/PPM/MRD/28
1. Medical records are reviewed every month based on simple random sampling method by Medical
audit team.
b. The review uses a representative sample based on statistical principles.
1. Hospital has defined the principles on which sampling is done.
2. Review is based on conditions of clinical and/or community importance, total discharges including,
total indoor patients, etc.
c. The review is conducted by Medical record and audit team having one doctor, one Medical record officer and
one nursing professional.
d. The review focuses on the timeliness, legibility and completeness of the medical records.

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e. The review process includes records of both active and discharged patients.
f. The review points out and documents any deficiencies in records.
g. Appropriate corrective and preventive measures are undertaken and are documented.

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