NABH Full Accreditation Implement Pathway

1. WELCOME TO
ALL
Sivakumar Murugesan MHM.,MLM.,BGL.,MBA(UK)
Consultant-Hospital Project Planning, Patient
Safety and Quality Accreditation

2. Vision of
Quality
Practices
Presented by
Medpoint Healthcare

3. -Staff Well Aware of QI
-Strong Infrastructure
-Qualified Staff with
involvement
-Committed Steering Team
-Positive Management Attitude
-Active Committees work
-Periodic internal audit
-Equipment calibration
-Continue staff training
Accreditation Needs

4. Our Quality Improvement
Journey
Now

5. Uniformly Staff are aware of the hospitals
scope of services in the
reception/registration, OPD, IPD areas

6. FRONT OFFICE
-Treatment cost
estimation available
-Need to initiate
Preventive education
programme
-Staff are aware of
transfer of stable and
unstable patients

7. CASUALTY
-Emergency Sinage must be visible
-Scope of services should be displayed
-available emergency care guidelines
for
-admission/discharge/transfer out
-Death log book
-ACLS trained staff must be posted

8. CASUALTY
- add informed consent for moderate sedation
-Continue training need for CPR with pre/post test
marks
-Disaster management plan
-Documented sterilization and cleaning of instrument
/equipment

9. CASUALTY
Standard requirements for space between beds and head
clearance should met at least 2 feet for head clearance 6 feet for
between the beds

10. Crash cart
-Check list
Avoid mixed storage
of medicines in crash
card
-Good placements of
articles and
equipments

11. LABORATORY
- Display Scope of service -.
-display TAT .
-Safe storage of hazard materials and also labeled.
-Availability of Calibration and maintenance -records.
-High alert values are document and also staff are aware of it.
-CAPA must be evidenced for QC

12. LABORATORY
-Report Authentication by Sr.Staff or MD
-Report should be in printed format
-Avoid Food Storage in side the lab
-To fix eye splashes in lab
-Use patient ID number
-Safe sample transport
-Wear PPE

13. IMAGING
SERVICES
-Critical Value must be defined both X-ray & Scan
-Ward staff are aware of critical value and also highlighted in
case sheets
-Scope of services must be displayed both X-ray/Scan
-TAT must be displayed both X-ray/Scan
-To fix Continue staffs safety training
-Evidence of CAPA in QC

14. PHARMACY&
MEDICATION OF
MANAGEMENT
Medications are stored in a clean, safe
and secure environment

15. PHARMACY&
MEDICATION OF
MANAGEMENT
High Alert drugs must be defined but stored safely across
the hospital. And also done double check before
administering

16. PHARMACY&
MEDICATION OF
MANAGEMENT

17. High Alert Drug Storage

18. PHARMACY&
MEDICATION OF
MANAGEMENT

19. Define LASA drugs and stored in separately

20. Define LASA drugs and stored in separately

21. PHARMACY&
MEDICATION OF
MANAGEMENT
OP & IP prescriptions must be written in capital letters.
orders must be uniformly clear, legible, dated and signed by
the consultants. Should not be like as “BD”. Kindly avoid
repeat all,CST

22. PHARMACY&
MEDICATION OF
MANAGEMENT

23. PHARMACY&
MEDICATION OF
MANAGEMENT
Medication Order should have been in uniform location and
also countersign by DMO or NS after administering by staff

24. PHARMACY&
MEDICATION OF
MANAGEMENT
.
-Need Continue training to staff /drs regarding
medication errors
-Availability of Drug formulary.
-Cut piece policy
-Good inventory system like like fast, slow and no
moving

25. Documentation of Adverse drug reaction.

29. Medication errors can occur
anywhere
Monitoring
Prescribing
Repackaging Dispensing
Administration

30. CARE OF PATIENTS
-Staff are aware of documenting initial assessment within 24
hrs.
- Document emergency initial assessments.
-patient and family are adequately educated about the
nutrition and safe parenting.
-Should provide defibrillator in required place
-Draft clinical practice guidelines
Need structured Clinical
handover by doctors and
nurses

31. CARE PLAN
Detailed Documentation require patient care plan in the IP
initial assessment results. .The care plan must be uniformly
countersigned by the clinician in-charge of the patient within
24 hours

32. CARE OF PATIENTS
Periodic discussions about each patient MUST BE
evidenced. Like covering parameters such as patient care,
response to treatment, unusual developments if any, etc.It
could be done on the basis of entries on case sheet .

33. CARE OF VULNERABLE
PATIENTS

34. CARE OF VULNERABLE
PATIENTS
-Safe and secure environment should be provided for the
vulnerable group. For example, playroom for children, fall
preventive measures for elderly, ramps with railings for
disabled, etc.
-Need Separate consent form

35. CARE OF VULNERABLE
PATIENTS

36. DIALYSIS
Patient privacy.
Nephrologists should sign in consent form.
To fix eye splashes in washing area.
Proper cleaning practices.
Pre-Exposure prophylaxis shall be given regularly
UHID uniformly should mention in the patient dialyzer boxes

37. ICU
Adopt infection control

38. ICU
-PPE box must be placed at
outside ICU
-scope of service must be
displayed
-Periodically Staff training in
CPR
-Critical care monitoring
should be documented
-Documentation of Patients and
families counseling
- bilingual Informed consent
form in ICU

40. Patients Restraints
--Consent required
-Monitoring patients on restraints, Level of
sedation monitoring, Bundle care for prevention
of HAI shall be documented

41. Patients Restraints

42. Patients Restraints

43. Patients Restraints

44. LABOUR WARD
--Documentation of
Cleaning protocols
- To prepare Clinical guide
lines for high risk
pregnancy.
-adhere infection control
practices at the labor room
like rusted cot, stand and
also seepage area .

45. BLOOD TRANSFUSION
-HIV consent should obtain.
.-Informed consent also
includes patient and family
education about the blood
donation.
-reactions are monitored and
analyzed

46. OBSTETRICAL PATIENTS
-Maternal nutrition shall be given to OP/IP
patients.
-Nutritional assessment shall be done.
-standard pain ratings are monitor properly.
-Staff Need continue training on high risk
pregnancy.
-document high risk in case sheets and also
display high risk cases undertaking

47. OBSTETRICAL PATIENTS
- NICU staff are adequately trained in the
Neonate resuscitation
- Define care of neonatal patients.
-Scope of services shall be defined and
displayed.
-Staff should aware of prevent infant abduction.
- Insert ID bands for babies.

48. PEDIATRIC PATIENTS
- Nutrition, immunization and safe
parenting education shall be
documented
- Should arrange children play
room.
- Pediatric initial assessment
should be evidenced

49. POST OPERATIVE WARD
-Infection control practices to
be strengthened.
-Pain assessment must be
done when the pain is the
predominant

50. ANAESTHESIA
-Prepared medicines are labeled before second
preparation
-Anesthesia monitoring includes oxygen saturation,
airway security, patency and End tidal carbon dioxide
were lacking in the medical records uniformly
-Adverse anesthesia events are defined and
monitored

51. ANAESTHESIA CONSENT
-Consent form also included on the indications, the
type of anesthesia used
-Need attender signature in anesthesia form
- Uniformly anesthetist sign with seal in anesthesia
consent form

52. -An immediate preoperative re-evaluation shall be
documented
-
-Uniformly post-anesthesia status shall be monitored
and also document in anesthesia records
ANAESTHESIA EVALUATION

53. -Consent form must be bilingually
-HIV consent form should be obtained for surgery
/procedure
SURGERY & PROCEDURES

54. POST OPERATIVE CARE
-Detailed post operative plan should be documented.
The plan shall include advice on IV fluids,
medications, care of wound, nursing care, observing
for any complication
-Need documented on post-operative complications,
e.g. bleeding, rational use of antibiotics

55. ENDOSCOPY
-Instrument cleaning practices are documented
--Need adequate monitoring instrument cleaning , standard
precautions after completion of out side consultants procedure.
--HIC need to be improved
-Consent form must be obtained
-Booster dose for Hep B to be given for all staff

56. OPERATION THEATRE
-- OTs should be well equipped
-implant register at OT must be provided
-culture report should have name of the organism
- Earmarked OT sterile zone. Need zoning policy
-Infection control should monitor

57. CSSD
-Equipment cleaning, disinfection and sterilization protocols shall
be effectively followed by the scrub nurses.
- Instruments cleaning method should be strengthen and also
document it.

58. CSSD
-Leak rate test /Bowie –dick test needs to be carried out
-Hot water provisions must be given to wash
instruments
-PPE box must be kept outside the receiving point
-Recall procedure in place

59. CSSD

60. CSSD

61. CSSD

62. WARD
-Brooms, mops, buckets
should not be spotted
- documentation of hand
over while on duty
change or transfer
-Medication order in the
patient files shall be
signed and dated

63. WARD
-Room number should
display in GW
-LASA drugs separately
stored
-High risk drugs are
stored in properly.

64. WARD
-Disposable or unused items should be
immediately removed.

65. WARD
-Wash basins are also clean on a scheduled basis
and this enhances infection transmission
-This supervision needs urgency in order to prevent
the use of arbitrary dilution methods of mixing
disinfectants with water for swabbing and cleaning
floors by the sanitary workers
-Policy for re-use of the gloves needs consideration.
As frequency of reuse of gloves cannot be
established, this is a major area for concern for
infection control.

66. NURSING CARE
-Nursing manual should be documented
-Uniformly staff are aware of clinical care
guidelines. Need periodic training programme.
-Staff are aware of transfer of unstable patients
within or outside the organization
-staff are aware of documenting initial assessment
within 24 hours

67. NURSING CARE
-Should follow practice of personal
protective measures in handling of
patients across the hospital.

68. NURSING CARE- MEDICATION SAFETY
-high risk medication orders should
be evidenced adequately for proper
prescribing and dispensing of them.
-Prepared medication shall be labeled
prior to preparation of a second drug.
This is applicable when drugs are
prepared and loaded but administered
after an interval.
-Staff are uniformly aware of
segregation of medicine like look a
Like/Sound a Like and High risk
medicines

69. NURSING CARE- HIGH ALERT VALUES
-Staff in the clinical areas should aware of critical or high alert values. -
Critical values will be informed by the diagnostic staff. The ward staff
must write the reporting person in the nurse’s record as well as in the lab
flow chart with high lighter

70. NURSING CARE- Adverse Drug events
-Adverse Drug events capture methodology knowledge is lacking for
majority of the staff. The staff is not aware of the documentation and
reporting within specified time frame. -ADR register should be
maintained in all wards. ADR form to be kept in all wards

71. NURSING CARE- Restraint techniques
-Staff receives training and periodic updating in control and restraint
techniques. It is applicable to all personnel involved in the care of
patients. The staff shall be updated at least once a year. Records of the
same should be maintained. But uniformly not trained

72. -Need CAPA for against Leave
against Medical Advice patients.
-Transfer out summary, shall be
evidenced. there must be, where to
transfer, condition to be mentioned.
-Should not use abbreviation in
significant findings and diagnosis
content of summary
-discharge summary should have
instruction on when and how to
obtain urgent care /Preventive
aspects (write it in Tamil and English).
-Should mention vital signs in
discharge status in discharge
summary. Don’t write patient
discharged at stable
DISCHARGE
PROCESS

73. DISCHARGE
PROCESS

74. PHYSIOTHERAPY
-Rehabilitative education signage’s should be
displayed inside the department. leaflets are also
available.
-Physiotherapist aware of adhering to infection control
and safe practices during Care is provided. Eg: Safe
practices include ensuring that when using hot wax
there are no burns to the patient.
-Scope of services are defined and displayed

75. PHYSIOTHERAPY-Handling Cardiac Cases
-Physiotherapy staff must know the BLS.
-Aware of Cardiac patients identification or high lighting “cardiac
patient” in case sheets
-To prepare clinical care guidelines for cardiac patients on how to
give physiotherapy. If cardiac patient need to get physio, crash
cart will be provided with one staff or equipment for resuscitation
shall be available in these areas

76. HOSPITAL INFECTION
CONTROL
-Separate collection point required
for BMW.Waste disposal corridor
should be closed without hole.
Walls must be fully closed to avoid
entering of insects and rodents.
Bio hazard caution signage must
be available in the corridor.
-Bio medical waste segregation
practices are uniformly followed in
most of the areas surveyed

77. HOSPITAL INFECTION
CONTROL

78. HOSPITAL INFECTION
CONTROL
-. Trolleys should be made available to
carry the contaminated and dirty linen
within the hospital.
-It is preferable that housekeeping staff be
adequately equipped with impermeable
gowns, masks and gloves while handling
the soiled linen. Dirty Linen handling staff
should be motivated to wear these gloves,
etc on a compulsory basis.
-Sorting of non-infective dirty linen and
infected linen and packing them in sacks
in the wards, needs to be supervised as
per the standard waste management
procedures

79. HOSPITAL INFECTION
CONTROL
-An exceptionally disproportionate area of
hospital is occupied by condemned
material awaiting disposal. This is
absolutely not acceptable in terms of
good infection control practices since
they may become Fomites for
transmission of infective agents.
-Cleanliness and general hygiene ensure
the across the hospital. Special cleaning
schedule to be prepared at least 15 days
once.

80. HOSPITAL INFECTION
CONTROL
-Find buildings seepage and take CAPA across the
hospital. It becomes a reservoir and nidus of growth of
microorganisms and fungi. Hence, it should be looked
into as soon as possible.
-.

81. HOSPITAL INFECTION
CONTROL
-.
-Hand washing facilities for staff and even the patients, shall be
ensured. Use of towel and soap is obsolete. Disinfectant gel in fixed
dispensers and paper towels should be provided to ensure hand
hygiene as well as prevent wastage or even theft of soap meant for
public use. Waste bin must be provided.

82. HOSPITAL INFECTION
CONTROL
- To define and monitor reprocessing of devices whenever
applicable. List which are meant for reuse. .
-The cleaning protocols should be documented in the Labor room.
-Need Separate budget for CQI.
-The HCO has the practice of using sterile cheatle forceps for
taking the sterile items from the drums, but we suggest that the
cidex solution should be used in the cheatle forceps container but
it changed daily.

83. LINEN AND LAUNDRY DEPARTMENT
-Algae should be removed.
-Should earmark dirty/soiled
line/normal linen washing area

84. LINEN AND LAUNDRY DEPARTMENT
-Laundry department should have
adequate standardized segregation
practices for the flow of the clean and
dirty linen traffic. Dirty linen and clean
linen are transported through the same
route
-Closed container trolley may be used
for this issue

85. LINEN AND LAUNDRY DEPARTMENT
-It is advised that machine may be used for cleaning of all
the hospital laundry. This is a very vital component of the
infection control chain of processes

86. LINEN AND LAUNDRY DEPARTMENT
-House keeping staff should wear safety equipments. They shall be
provided with heavier elbow level gloves, Aprons and Boots.

87. LINEN AND LAUNDRY DEPARTMENT
-Should have proper inventory system adhere .There should proper
inventory system and stock maintain in linen dept. There should be
maintain movement register and other relevant register in dept

88. LINEN AND LAUNDRY DEPARTMENT

89. HOUSE KEEPING,
-Ensure General cleanliness, ventilation and lighting of
the department .
-Housekeeping staff should have a designated space to
keep their consumables. Hence, brooms, mops, buckets
were spotted at many sites in the hospital.
-Housekeeping staff working in the HCO should know
process about the nature of solvents used in the different
areas

90. HOUSE KEEPING,
-Ensure routine cleaning in
external environment. Routine
cleaning is necessary to ensure a
hospital internal & external
environment which is visibly
clean and free from dust and soil.
-Housekeeping trolley must be
provided

91. DIETARY
DEPARTMENT
-To use Protocol for
therapeutic food
preparation. There should
be preparation of
therapeutic food under the
guidance of Dietician
-There should be written
order for the IP diet. Need
Diet chart

92. BIO-MEDICAL ENGINEERING
-Use Individual ID on the equipment
-Should have preventive /breakdown maintenance
program.
-Certified companies must be contracted to frequently
calibrate the equipment Alternatively, in-house
engineers can be provided with training by
professionals,
-Should have structured break down maintenance
-Complaint register should be provided across the
hospital

93. HOSPITAL FACILITY SAFETY
-Fix fire extinguishers in
appropriate place. At least requires
75 feet gap.
-Fix Smoke detectors and fire
alarm
-Maintenance plan for fire-related
equipment & infrastructure

94. HOSPITAL FACILITY SAFETY
-The Fire safety sinage must
provide in relevant areas around
the hospital .Fire exit signage s
should be visible
-Ensure enough signs indicating
emergency exits.

95. HOSPITAL FACILITY SAFETY
-The safe escape route should display in floor wise.
The existing displayed floor plan does not indicate
the location of the person on the floor. It should
indicate the location of the person as a reference
(i.e.) 'you are here'. The fire and emergency exit
signage should have bilingual.

96. HOSPITAL FACILITY SAFETY
-It is mandatory to have a danger signage on the
entrance door suggesting electrical station ahead.
Further, display First Aid measures for Electrical
Shocks, at the high voltage points and the generator
room

97. HOSPITAL FACILITY SAFETY
-Electrical panel must be covered

98. HOSPITAL FACILITY SAFETY
-Ceiling of the room must be cleaned. Cleaning for the
service station should be incorporated in the
maintenance schedule of the housekeeping staff.
Remove cobweb /dust across the hospital.

99. HOSPITAL FACILITY SAFETY
-The Hospital should have maintenance plan for Medical Gas, piped
gas, vacuum and compressed air. Need checklist for the same.
Loaded cylinder must be in corridor with chained. Medical gases are
piped through metal pipes that are not checked for corrosion, leaks
or joint leaks. Ensure refilling date record on the oxygen cylinders.
-Avoid rusted cylinder

100. HOSPITAL HAZARD MATERIALS
-List out hospitals all hazardous materials and their storage,
handling and sorting procedure .
-Labeling all hazard materials storage place and display caution
signages
--Prepare MSDS /Safe storage lace

101. SAFETY TRAINING PROGRAMME
-Training programme shall be conducted for fire and non fire
emergencies and occupational health safety.
-To prepare monthly training calendar

102. HOSPITAL FACILITY SAFETY
-Internal and external signages should display appropriately
across the HCO. Eg: Fire & safety signage's, directional
signages (for ICU, Ward, Dialysis), and scope of services.
-Facility inspection rounds must be conducted both non
clinical areas and clinical areas at least yearly once
-Review Code blue, red team activities
-The grab bars in patient toilets and call bells in patient rooms
must be provided

103. HOSPITAL FACILITY SAFETY
-Directional arrows with brief descriptions to the various Departments and
even the cafeteria should be clearly demarcated. Direction arrows for
Toilets are practically important because of their universal usage.
Directional signage must be placed in all corridors connecting different
departments
-Many places were found wires are opened that it must be closed. There is
no maintenance plan for electrical systems including heating, ventilation
and air-conditioning.
-All racks and shelves (pharmacy and MRD) and boxes of material, must
have external stickers on them which will identify their contents

104. HUMAN RESOURCE
DEPARTMENT
-Should have Mission
and vision statement
existent for the
institution and also staff
are aware of it. Need
continue training for
hospital growth

105. HUMAN RESOURCE
DEPARTMENT
-All employees are
aware of the scope of
services
-Employees are given
formal orientation at the
time of joining

106. HUMAN RESOURCE
DEPARTMENT
-Sexual Harassment
Committee should be in
place and staffs are
aware of the same.
--Display Committee
contact person with
number across the
hospital

107. HUMAN RESOURCE
DEPARTMENT
-Staff rules and regulation are documented
-The rules must be based on your hospital policy

108. HUMAN RESOURCE
DEPARTMENT
-All staffs are trained in
relevant risks within
the hospital
environment
-The staff members are
n uniformly able to
demonstrate and take
actions to report,
eliminate or minimize
risks

109. HUMAN RESOURCE
DEPARTMENT
-Training records are not
available to prove the training
occurs routine ongoing
training, new staff training
(induction), when job
responsibilities change
-To prepare monthly training
calendar

110. HUMAN RESOURCE
DEPARTMENT
-New Employee Trainings required
for the following topics
-1. Mission and Vision statement
-2. Standard Operating Procedures
(SOP)
-3. Induction and orientation on
manual (hospitals facility
information)
-4. Personnel policy
-5. Employee rights and
responsibility
-6. Patient’s rights and
responsibilities

111. HUMAN RESOURCE
DEPARTMENT
-Adequately addressed
health problems of
employees and occupational
health hazards
-To list out occupational
health hazard and also give
training according to the
same

112. HUMAN RESOURCE
DEPARTMENT
-The organization should
have a grievance procedure
and disciplinary procedure
practiced and train the
employees on the same. -
Employee grievance
committee must be formed.
To conduct grievance day
every month and document.
Grievance form to be given to
staff once the meeting is
over.

113. PATIENT RIGHTS AND
EDUCATION
-Staff are uniformly aware of their
responsibility in protecting patient
and family rights. Training and
sensitization programmes shall be
conducted to create awareness
among the staff
-Violation of patient and family
rights must be recorded, reviewed
and corrective / preventive
measures taken. The patient
feedback form (by incorporating
patient rights worded
appropriately) could be used as a
tool to capture violation of patient
rights.

114. PATIENT RIGHTS AND
EDUCATION
-Documentation of Patient refusal of
treatment and also the treating
doctor shall explain the
consequences of refusal of
treatment and document the same
in the case sheets

115. PATIENT RIGHTS AND
EDUCATION
-Create standard mechanism to
voice patient complaints like
display PRO/AO contact number,
suggestion box, and feedback form.
-Complaint mechanism must be
accessible and re dressal of
complaint must be fair and
transparent.
-reviewed and/or analyzed within a
defined time frame.

116. PATIENT RIGHTS AND
EDUCATION
-Document patient or families are
educated about
- plan of care, preventive aspects,
possible complications,
medications, the expected results
and the cost
-It must be explained in. Separate
form and also attached in each case
sheet.
- the format and language
understood by the patient

117. PATIENT RIGHTS AND
EDUCATION
-Ensure patient and/or family
education regarding;
- effective use of medication and the
potential side effects, food-drug
interactions., diet and nutrition,
immunizations, specific disease
process, complications and
prevention strategies., preventing
healthcare associated infections,
-This could also be done through
patient education
booklets/videos/leaflets, charts etc

118. -Vision and mission statement should
display in all place
-Scope of services of each department
is defined and displayed except
OG/Pediatric
-functioning of committees is reviewed
and monitored for their effectiveness.
-Employee rights and responsibilities
are defined.
-Separate sub budget for infection
control and quality-improvement
activities

119. MEDICAL RECORDS
-Abbreviation should be avoided
specially for diagnosis-list out approved
abbreviations
-Drug chart to be counter signed by
consultant or MO
-MLC case documents are not inserted
in case sheets.
-The record is not provides a complete,
up-to-date and chronological account of
patient care.
-Consent should obtain before the
consultant

120. MEDICAL RECORDS -Uniformly medical records contain
detailed plan of care.
-medical records should have date and
time of entries and the author of f
entries could be identified.
- document Condition of the discharge
in case sheets
Should mention UHID in patient case
sheets.
-Medical records shall be identified
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.

121. MEDICAL RECORDS
DEPARTMENT -In case of death, the medical record
should label death seal in front of the
chart
-The medical records are reviewed
periodically- timeliness, legibility and
completeness, points out and
documents any deficiencies in records.
-The Medical records department
should have entry & movement
register and deficiency chart
-Pest Control measures should have in
place.
- Ensure Policy needs for availability of
medical records to the patient, security
issues, monthly statistics and review

122. MEDICAL RECORDS
DEPARTMENT
-Notifiable disease & other statistic
shall be maintained in the department,
-a. Bed occupancy rate
-b. Average length of stay
-c. % of caesarean section
-d. Morbidity trends and indices
-e. Age, Sex and Disease specific
Mortality Rates and Trends
-f. Prevalence and Incidence of
Notifiable diseases
-It also display all the above indices in
the form of charts, on the walls of the
MRD section

123. CONTINUE QUALITY
IMPROVEMENT
- Conduct Periodic Clinical audit: Death based, disease based, cost
based, community based or based on morbidity (length of stay).
--Capture :Clinical Indicator
--Review-Committee Meetings
--Periodic conduct Facility Safety Rounds both in clinical/non clinical
areas
-- Equipment Calibration
--Periodic internal audit
--Continue training prgramme

125. Applying Accreditation Standards
for Quality Improvement
Initiation Documentation
Monitoring
Implementation

126. Initiation
Initiation
Sensitization
Constitution of teams
Understanding
Standards
Customizing Applicability
Action Plan

127. Documentation
Policies
Processes/Protocols
Guidelines
Criteria
Programmes
Roles and Responsibilities
Manuals
Formats for records and documents
Organisational and
departmental line of hierarchy

128. Documentation topics
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Registration policy and procedure
Admission policy and procedure
Transfer of unstable patients to
another facility
Transfer of stable patients to another
facility
Standardized initial assessment of
patients in the OPD, emergency and
IPD.
Processing and disposal of specimens
in laboratory.
Handling and disposal of infectious
materials
Identification and safe transportation
of patients to imaging services.
Handling and disposal of radio-active
and hazardous materials.
Safe use of radioactive isotopes for
imaging services.
Referral of patients to other
departments / specialties.
Discharge policy and process
LAMA policy and process
Informed Consent policy and process
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
Pricing Policy
Uniform care policy and processes
Emergency care policy and
processes
Medico-legal cases
Triaging ofpatients
Uniform use of resuscitation
Rational use of blood and blood
products
Care of patients in ICU and HDU
Situation of bed shortage in
ICU/HDU
Care of vulnerable patients
Care of high risk obstetrical patients
Care of paediatric patients
Prevention of child/neonate
abduction or abuse
Care of patients undergoing
moderate sedation
Administration of anaesthesia
Care of patients undergoing surgical
procedures
Prevention of adverse events

129. 32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
Restraints techniques
Pain management guidelines
Rehabilitative services polices
Research activities policies and
protocols
Nutritional assessment and
reassessment
End of life care
Procurement, Storage, prescription and
dispensing of Medications
Administration of medications
Monitoring of medications
Patient’s self administration of
medication
Medication brought from outside the
organisation
Adverse drug events
Use of narcotic drugs and psychotropic
substance
Usage of chemotherapeutic agents
Usage of radioactive and investigational
drugs
Safe storage, preparation, handling,
distribution and disposal or radioactive
and investigational drugs.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
Procurement of implantable prosthesis
Procurements, handling, storage,
distribution, usage and replenishment
of medical gases.
Antibiotic policy
Laundry and linen management
Kitchen sanitation and food handling
Engineering controls for infection
control
Mortuary practices an procedures
Surveillance, data collection and
monitoring of HAI
Isolation/barrier nursing
Outbreak control procedures
Quality control for sterilization
Handling of bio-medical waste
Quality assuranceprogrammes
Operational and maintenance plan
Smoking policy
Human resource planning

130. Self
Assessments
Intra-departmental
Inter-departmental
Core team assessment
Assessment by External Agency

132. THANK YOU