This document discusses the importance and benefits of hospital accreditation in India. It notes that accreditation will help hospitals comply with quality standards due to the increasing role of health insurance, rise in medical lawsuits, and emphasis on patient rights. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) was established to develop accreditation standards tailored for India. The document outlines the 10 steps for obtaining accreditation and highlights that accreditation leads to high quality patient care, satisfied staff, and objective empanelment with insurance providers.
Access, Assessment and Continuity of Care (AAC) NABHDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 1 Access, Assessment and Continuity of Care (AAC). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services.
These are in contrast to ad hoc committees, department and unit committees.
NABH 5th edition hospital std april 2020anjalatchi
A. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Respobsibilities of Management-NABH ManualDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 7 Responsibilities of Management (ROM). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
Access, Assessment and Continuity of Care (AAC) NABHDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 1 Access, Assessment and Continuity of Care (AAC). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
Hospital Committees are regular standing committees prescribed by regulatory agencies and deemed necessary by hospital administration in formulating policies, coordinating and monitoring hospital-wide activities that are considered critical in the delivery of quality health care services.
These are in contrast to ad hoc committees, department and unit committees.
NABH 5th edition hospital std april 2020anjalatchi
A. National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations.
Medical Records is a foremost important in the healthcare accreditation bodies like JCI,NABH are very adherent about its documentation,retention and confidentiality.
Respobsibilities of Management-NABH ManualDr Joban
This ppt is prepared on the basis of the NABH standards (2nd edition).it contains simple presentation of chapter 7 Responsibilities of Management (ROM). It may be useful for the trainers, AHCOs and the Vaidyas who are undergoing NABH accreditation.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
The presentation describes in brief the patients need, expectations and how to develop the patient care and feedback system to obtain maximum patient satisfaction.
Hospital marketing -Multi specilality hospital By Dr Kavita Soni Dr.Kavita Soni
Hospital Marketing has been viewed from a different perspective these days.It has become a major tool for business development in health care sector.The only challenge to incorporate and customize the core marketing concept to go well with hospital setting
Animated flow diagrams illustrating how transferable commercial letters of credit work. Part of a series on structures for mitigating risk in international trade and financing export sales. Extracted from training classes developed and conducted by Global Trade Risk Management Strategies LLC.
THIS PRESENTATION TALKS ABOUT THE KEY ELEMENTS REQUIRED FOR A HOSPITAL MARKETING PLAN. THIS CAN BE USED AS A REFERENCE FOR OTHER SERVICE MARKETING INDUSRTIES.
THANKS
REYAZ K SIDDIQUI
This is a high level view of aspects of sales and marketing for hospitals. There would be variations and details based on the actual hospital, specialties, service area demographic etc.
The slide is all about Healthcare Marketing. How you can develop marketing strategies in healthcare market.
Healthcare is booming industry & in accordance with marketing concepts it is very necessary to do marketing of services.
NABH ACCREDITATION: Choosing the right hospital-Mahboob ali khan MHA, CPHQ, P...Healthcare consultant
There are a number of hospitals in India that offer a multitude of medical services. In a medical emergency, the nearest hospital is chosen. However, when there is time to choose a hospital, how should one choose?
NABH accreditation is voluntary process and no need to be anxious. NABH has made it very easy. It is good to send one of the responsible executive to undergo POI training program by NABH. Details are available at www.nabh.co.
How to achieve the NICE guidelines on Managing Medicines in Care HomesKarisBrummitt
The NICE Quality Standard on Managing Medicines in Care Homes is due for publication in March 2015. A NICE Quality Standard is a concise set of statements designed to drive and measure improvements in quality. They are based on national guidelines (including NICE guidelines which consist of around 90 recommendations) and can be used to review services, highlight areas where quality needs to be improved and offer suggestions as to how this can be achieved.
Managing the unexpected in
a healthcare organisation is a
challenging and arduous task.
Experience of other
industries like aviation, nuclear
power etc. have proved that
it is possible to achieve this.
Hospital administrator should
ensure that clear, early,
complete and simple financial
communication is provided
both at the admission and
at the discharge occasion to
create patient-friendly financial
services for customer delight.
This effort shall enhance
both the brand value and
bottom line of the healthcare
organisation
Manpower is a
Health care organisation’s greatest asset and the development
of this asset is critical for
continued financial health of
the organisation
Health care organisation should provide top priority to the health hazards resulting from use of malfunctioning equipment in the present era of medical
device driven healthcare.
Clinical Audit is a method of confirming the quality of clinical services and identify the need for improvement. A skill hospital administrator should learn and practice.
Medication error is a most common problem in a health care organisation.Its prevention can improve patient satisfaction,organisation brand value and bottom line.
The implementation of Risk management in a health care organisation ensure safe health care,increased patient satisfaction , improved bottom line and brand value.
Suicide in a hospital is known risk factor and recognized as sentinel event by JCI &NABH. Health care provider should know what to do in a post suicdide scenario.
In the present era of Pvt Health care industry in India with rising penetration of health care insurance,the need of Revenue Cycle Management is of paramount importance for organisation bottom line
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
1. Dr. A. K. KHANDELWAL
ASSESOR OF NATIONAL ACCREDITATION
BOARD FOR HOSPITAL AND HEALTH SERVICE
PROVIDER
MEDICAL DIRECTOR
ANANDALOKE HOSPITAL NEUROSCIENCES
CENTRE
SILIGURI
ACCREDITATION FOR HOSPITALS
2. WHY ACCREDITATION?
The increasing role of health insurance
Rise in number of medico-legal cases
Awakening of patients about their rights
.Medical tourism .
3. Indian Hospitals would have to apply for Health
care accreditation standards that will make them
comply to Quality standards.
An accreditation system will help to monitor the
quality of hospitals and treatment given to
patients
4. A need for a uniform country-specific accreditation
standards and accrediting body, to implement these
is realised by healthcare providers across the
country.
International standards too expensive and may
ultimately not suit the majority of healthcare
organisations in India.
Therefore the need for developing our own standards
is now being urgently felt.
5. National Accreditation Board for Hospital and
Healthcare Service Providers (NABH) under the
aegis of Quality Council of India (QCI) with the
cooperation of ministry of Health & family
Welfare,Govt of India, is constituted
The draft was prepared after studying various
international standards like JCAHO, JCI, Australian,
European, Thai Standards, besides various Indian
models available.
6. How does NABH score over various ISO
standards?
ISO is a certification and not an
accreditation.
ISO is generic and not specific to healthcare
industry.
ISO does not call for clinical audits, it centres
only on systems.
Accreditation on the other hand, focuses on
competency in terms of its staff, equipment,
premises, facilities etc with respect to the
scope of services being rendered by the
healthcare organisation
7. A public recognition of the achievement of
accreditation standards by a healthcare
organization, demonstrated through an
independent external peer assessment of that
organization's level of performance in relation to
the standards.
What is Accreditation
8. Benefits of Accreditation
Accreditation provides high quality of care
and patient safety.
The staff in a accredited hospital are
satisfied.
Accreditation to a hospital stimulates
continuous improvement.
Accreditation provides an objective system
of empanelment by insurance and other
third parties.
9. Ten steps to Accreditation:
Step 1 Obtain copy of NABH standards
Step 2 Carry out self assessment on status of
compliance with the NABH standards.
Step 3 Identify gap areas and prepare action
plan to bridge the gaps.
Step 4 Ensure that NABH standards are
implemented and integrated with hospital
functioning
Step 5 Obtain copy and submit application
form for assessment
10. .Step 6 Pay the accreditation fee
Step 7 Receive from NABH the assessment
programme including dates and names of
assessors
Step 8 Facilitate the assessment
Step 9 Receive recommendation on accreditation
.Step 10 Maintain quality improvement
programme based on continuous monitoring of
patient care services.
11. Access ,Assessment, And Continuity of Care
1. The organization defines and displays the
services it can provide.
2. The organization has a well defined registration
and admission process.
3. There is an appropriate mechanism for transfer
or referral of patients who do not match the
organization resources.
4. During admission the patients and/ or the
family members are educated to make informed
decision.
5. Patients care for by the organization undergo
an established initial assessment.
12. 6. All patients care for by the organization
undergo a regular assessment
7. Laboratory services are provided as per the
requirement of the patients.
8. There is an established laboratory quality
assurance programme.
9. There is an established laboratory safety
programme.
10.Imaging services are provided as per the
requirement of the patients.
11.There is an established quality assurance
programme for imaging services.
13. 12.There is an established radiation safety
programme.
13.Patient care is continuous and multi
disciplinary in nature.
14.The organization has a documented discharge
process.
15.Organization defines the content of the
discharge summary.
14. Patients Rights and Education
1. The organization protects patients and family
rights during care.
2. Patients and family rights support individual
beliefs, values and involve the patient and the
family in the decision making process.
3. A documented process for obtaining patient
and/ or families consent exists for informed
decision making about their care.
4. Patients and families have a right to information
and education about their health care needs.
5. Patients and families have a right to information
on expected costs.
15. Care of patients
1. Uniform care of patients is guided by the applicable
laws and regulations.
2. Emergency services are guided by the policies,
procedure and applicable laws and regulations.
3. The ambuance services are commensurate with the
scope of the services provided by the organisation.
4. Policies and procedures guide the care of patients
requiring cardiopulmonary resuscitation.
5. Policies and procedures define rational use of
blood and blood products.
6. Policies and procedures guide the care of
vulnerable patients in the Intensive care and high
dependency units.
16. 7. Policies and procedures guide the care of vulnerable
patients (elderly, physically and / or mentally challenged
and children )
8. Policies and procedures guide the care of high risk
obstetrical patients.
9. Policies and procedures guide the care of pediatric
patients.
10.Policies and procedures guide the care of patients
undergoing moderate sedation.
11.Policies and procedures guide the administration of
anesthesia.
17. 12.Policies and procedures guide the care of patients
undergoing surgical procedures.
13.Policies and procedures guide the care of patients
under restraints.
14.Policies and procedures guide appropriate pain
management.
15. Policies and procedures guide appropriate
rehabilitative services.
16.Policies and procedures guide all research activities.
17.Policies and procedures guide Nutritional therapy.
18.Policies and procedures guide the end of life care.
18. MANAGEMENT OF MEDICATION
1. Policies and procedures guide the organization of
pharmacy services and usage of medication.
2. There is a hospital formulary.
3. Policies and procedures exist for storage of
medication.
4. Policies and procedures exist for prescription of
medications.
5. Policies and procedures guide the safe dispensing
of medications.
6. Patients are monitered after medication
administration.
19. 7. There are defined procedures for medication
administration.
8. Patients and family members are educated about safe
medication and food drug interactions.
9. Policies and procedures guide the use of narcotic drugs
and psychotropic substances.
10. Policies and procedures guide the usage of
chemotherapeutic agents.
11.Policies and procedures gover usage of radioactive or
investigational drugs.
12. Policies and procedures guide the use of implantable
prosthesis.
13.Policies and procedures guide the use of medical gases.
20. HOSPITAL INFECTION CONTROL
1. The organization has a well designed, comprehensive
and coordinated infection control programme aimed at
reduction / eliminating risk to patients, visitors and
providers of care.
2. The organization has an infection control manual,
which is periodically updated.
3. The infection control team is responsible for
surveillance activities in the identified areas of the
organization.
4. The organization takes actions to prevent or reduce
the risk of Hospital Associated infections (HIA) in
patients and employees.
21. 5. Proper facilities and adequate resources are
provided to support the infection control
programme.
6. The organization takes appropriate actions to control
outbreak of infections.
7. There are documented procedures for sterilization
activities in the organization.
8. Statutory provisions with regard to biomedical
Waste (BMW) management are complied with.
9. The infection control programme is supported by the
organization’s management and includes training of
staff and employee health.
22. CONTINUOUS QUALITY IMPROVEMENT
1. There is structured quality assurance and continuous
monitoring programme in the organization.
2. The organization identifies key indicators to monitor
the clinical structures, processes and outcomes.
3. The organization identifies key indicators to monitor
the managerial structures, processes and outcomes.
4. The quality improvement programme is supported by
the management.
5. There is an established system for audit of patient
care services.
6. Sentinel events are intensively analyzed.
23. RESPONSIBILITY OF MANAGEMENT
1. The responsibilities of the management are defined.
2. The services provided by each department are
documented.
3. The organization is managed by the leaders in an
ethical manner.
4. A suitably qualified and experienced individual heads
the organization.
5. Leaders ensures that patient safety aspects and risk
management issues are an integral part of patient care
and hospital management.
24. FACILITY MANAGEMENT AND SAFETY
1. The organization is aware of and complies with the
relevent rules and regulations, laws and byelaws and
requisite facility inspection requirement.
2. The organization’s environment and facilities operate
to ensure safety of patients, their families, staff and
visitors.
3. The organization has a programme for clinical and
support service equipment management.
4. The organization has provisions for safe water,
electricity, medical gases and vacuum systems.
25. 5. The organization has plans for fire and non-fire
emergencies within the facilities.
6. The organization has a smoking policy.
7. The organization plans for handling community
emergencies, epidemics and other disasters.
8. The organization has a plan for management of
hazardous materials.
9. The organization has systems in place to provide
a safe and secure environment.
26. HUMAN RESOURCE MANAGEMENT
1. The organization has a documented system of
human resource planning.
2. The staff joining the organization is socialized and
oriented to the hospital environment .
3. There is an ongoing programme for professional
training and development of the staff.
4. Staff members, students and volunteers are
adequately trained on specific job duties or
responsibilities related to safety.
5. An appraisal system for evaluating the performance
of an employee exists as an integral part of the
human resource management process.
27. 6. The organization has a well documented disciplinary
procedure.
7. A grievance handling mechanism exists in the
organization.
8. The organization addresses the health needs of the
employees.
9. There is a documented personal record for each staff
member.
10.There is a process for collecting, verifying and
evaluating the credentials (education, registration,
training and experience ) of medical professionals
permitted to provide patient care without supervision
28. 11.There ia a process for authorization all medical
professionals to admit and treat patients and provide
other clinical services commensurate with their
qualifications.
12.There is a process for collecting, verifying and
evaluating the credentials (education, registration,
training and experience ) of nursing staff.
13.There is a process to identify job responsibilities
and make clinical work assignments to all nursing
staff members commensurate with their
qualifications and other regulatory requirements.
29. INFORMATION MANAGEMENT SYSTEM
1. 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.
2. The organization has processes in places for
effective management of data.
3. The organization has a complete and accurate
medical record for every patient.
4. The medical record reflects continuity of care.
30. 5. Policies and procedures are in place for maintaining
confidentiality, integrity and security of information.
6. Policies and procedures exist for retention time of
records, data and information.
7. The organization regularly carries out medical
audits.