QUALITY CONTROL TF .pptx

7/27/2019 QUALITY CONTROL TF .pptx

1/150


2/150

AAC 1A Score(0/5/10)

CONTENT The services being provided are clearly

defined and are in consonance with the

needs of the community.

10

INTERPRETATION The organization shall define this

keeping in mind the scope of services

applied for.REMARKS The needs of the community should be

considered especially when planning a

new organization or adding new

services. The same could be capturedthrou h the feedback mechanism.


3/150

AAC 6B Score(0/5/1

CONTENT

The Infrastructure (physical andmanpower) is adequate to provide for

its defined scope of services.(For Labs)

10

INTERPRETATION The available equipment and manpower

should be able to effectively deliver its

laboratory services.

REMARKS Reports should not get delayed due to

lack of adequate equipment or

manpower (including people authorized

to report results).


4/150

COP -1CScor

(0/5/

CONTENT These reflect (Uniform Care Policy) applicable

laws, regulations and guidelines.

INTERPRETATIONSelf explanatory. Where applicable, the

organization shall adhere to the norms laid down

by government by relevant legislations like clinical

establishment act or any such similar legislation.

REMARKS For example, consent before surgery, providing

first aid to emergency patients and police

intimation in cases of medico-legal cases.

DEF


5/150

COP- 3DS

(0/

CONTENT Ambulance(s) are manned by trainedpersonnel. 10

INTERPRETATIONThe ambulance should be manned by a

trained driver, technician/nurse and/or

doctor depending on the situation.

Personnel shall be trained in BLS and/or

ACLS.

REMARKS Driver shall have a valid driving license


6/150

COP -3E Score(0/5/10)

CONTENT Ambulance(s) is checked on adaily basis

10

INTERPRETATION Self-explanatory.

REMARKS The check shall clearly

indicate the functioningstatus of the ambulance like

lights, siren, beacon lights etc.

In addition, the ambulance

shall undergo servicing as per

the set schedule


7/150

COP-3F Score

(0/5/10)

CONTENT Equipment are checked on

a daily basis using a

checklist

10

INTERPRETATION Self-explanatory

REMARKS The check shall clearly

indicate the functioning

status of the equipment


8/150

COP-3G Score

(0/5/10)

CONTENTEmergency medication are

checked daily and prior to dispatch

using checklist

10

INTERPRETATION

Self explanatory .This also includeschecking expiry dates of drugs.

REMARKSIn case of rapid turnaround of the

ambulance is required , only

medication used could be topped


9/150

COP-8D Sco

(0/5/

CONTENT Adequate staff and equipment(In ICUs)are

available

10

INTERPRETATION The ICU should be equipped with all necessary

life-saving and monitoring equipment as well as

suitably manned by trained staff. The exact

requirements shall be decided by the

organization based on the scope and

complexity of its services. However, the

organization is expected to follow best clinical

practices

REMARKS A good reference guide for nursing manpoweris the Indian Nursing Council recommendations.


10/150

COP 8G Sco(0/5

CONTENT A qualityassurance programme(Critical Care) is

documented and implemented

5

INTERPRETATION These could be developed individually or it could be a

part of the organizations quality-assurance

programme. The organization shall ensure that the

programme is in consonance with good clinical

practices.

REMARKS Good clinical practices include monitoring infection

rates, re-admission rates, re-intubation rates etc.

Further a good starting point could be various national

and international critical care society guidelines.

Ant

Po

Infe

R

Def
http://localhost/var/www/apps/conversion/tmp/scratch_3/EQUIPMENT%20LIST%20-%20ICU%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Antibiotic%20policy.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INFECTION%20CONTROL%20TF%20.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INFECTION%20CONTROL%20TF%20.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INFECTION%20CONTROL%20TF%20.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INFECTION%20CONTROL%20TF%20.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/INFECTION%20CONTROL%20TF%20.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Antibiotic%20policy.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/EQUIPMENT%20LIST%20-%20ICU%20.xlsx


11/150

COP -9A Scor(0/5/1

CONTENT Policies and procedures (Vulnerable) are

documented and are in accordance with theprevailing laws and the national and

international guidelines

10

INTERPRETATION At a minimum, it shall incorporate as to who the

vulnerable patients are, who is responsible for

identifying these patients, risk management inthese patients and monitoring of these patients

(at least twice a day). All these patients shall be

assessed for risk of falls and the same

documented.

REMARKS Refer to disability act, mental act.

Polic

Fa

Assess

Fall

Assessm
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Intinal%20Assessment%20Form.odthttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Intinal%20Assessment%20Form.odthttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/FALL%20RISK%20ASSESSMENT%20TOOL-VULNERABLE%20PATIENT'S%20POLICY.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/FALL%20RISK%20ASSESSMENT%20TOOL-VULNERABLE%20PATIENT'S%20POLICY.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/FALL%20RISK%20ASSESSMENT%20TOOL-VULNERABLE%20PATIENT'S%20POLICY.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Intinal%20Assessment%20Form.odthttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Intinal%20Assessment%20Form.odthttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.doc


12/150

COP- 11B Scor

(0/5/1

CONTENT The organization defines and displays thescope of its paediatric services

5

INTERPRETATION The scope shall also include neonatal

services, if any.

REMARKS The display should be in a prominent

location (either near the entrance or

registration counter or near the OPD)

Refer to AAC 1b also.

Se

De
http://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/MASTER%20LIST%20(SOS,PHE,HE).xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/MASTER%20LIST%20(SOS,PHE,HE).xlsx


13/150

COP- 14D Sco(0/5/

CONTENT Documented policies and procedure exist to

prevent adverse events like wrong site, wrong

patient and wrong surgery.*

1

INTERPRETATION Procedure should be available for preventing

adverse events like wrong patients, wrong site by a

suitable mechanism.REMARKS The organization should be able to demonstrate

methods to prevent these events, e.g.

identification tags, badges, cross-checks, time-out

etc. Refer to WHO Safe surgery saves lives

initiative.

P

WH

S
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/27.%20OT%20Protocol.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/COP-%2014%20D%20(WHO%20SAFE%20SURGERY).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/COP-%2014%20D%20(WHO%20SAFE%20SURGERY).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/COP-%2014%20D%20(WHO%20SAFE%20SURGERY).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/27.%20OT%20Protocol.pdf


14/150

COP -16D Score(0/5/10

CONTENT The organization respects and supportsmanagement of pain for such patients. 5

INTERPRETATION Self explanatory. In case the hospital

does not have facilities for pain

management it could refer suchpatients to centres specializing in pain

management.

REMARKS Pain management includes medical,

surgical and anaesthesia techniques.

ASSE

F

PERC
http://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/ASSESSMENT%20FORMS/Surgery.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/ASSESSMENT%20FORMS/Surgery.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/PATIENT%20FILE%20AUDIT%20.ppthttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/PATIENT%20FILE%20AUDIT%20.ppthttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/ASSESSMENT%20FORMS/Surgery.doc


15/150

COP -17E Score(0/5/10)

CONTENT Rehabilitative services areprovided by a multidisciplinary

team

10

INTERPRETATION The team shall have a treating

doctor, a rehabilitation therapist,

rehabilitation nurses and other

professional experts.

REMARKS

Physiothera

Qualificatio
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/PHYSIOTHERAPHY%20QUALIFICATION.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/PHYSIOTHERAPHY%20QUALIFICATION.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/PHYSIOTHERAPHY%20QUALIFICATION.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/PHYSIOTHERAPHY%20QUALIFICATION.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.doc


16/150

COP-18 B Score(0/5/10)

CONTENT The organization has an ethics

committee to oversee all researchactivities.

10

INTERPRETATION An ethics committee should be

framed in the hospital to monitor

activities undertaken by various

providers. The committee has the

powers to discontinue a research trial

when risks outweigh the potential

benefits.

REMARKS Refer to schedule Y of drugs and

cosmetics Act and to ICMR guidelines

COMM

DRUG

COSM

IC
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/D&C_Rules_Schedule_Y.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/D&C_Rules_Schedule_Y.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/COP18B(DRUGS%20AND%20COSMETICS).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/COP18B(DRUGS%20AND%20COSMETICS).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/BOOK%20LINKS/D&C_Rules_Schedule_Y.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.doc


17/150

MOM 1C Sco(0/5

CONTENT A multidisciplinary committee guides the formulationand implementation of these policies and

procedures.

1

INTERPRETATION This shall be representative of major clinical

departments, administration and shall include a

pharmacist/ clinical pharmacologist. The objective ofthis committee, its composition, frequency of

meetings, quorum required and the minutes of the

meeting shall be documented. At a minimum the

committee shall meet once in three months.

REMARKS For example pharmaco-therapeutic committee.
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdf


18/150

PRE 1A Scor

(0/5/

CONTENT Patient and family rights and responsibilities are

documented and displayed.*

10

INTERPRETATION Organization should respect Patients rights and

inform them of their responsibilities. All the rights

of the patients should be displayed in the form of a

citizens charter, which should also give information

of the charges and grievance redressal mechanism.

REMARKS Display should be at least bi-lingual (English and the

State language/language spoken by the majority of

people in the area). The documented patient rights

shall include all the points mentioned in PRE 2. For

example of patient responsibility refer to glossary
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdf


19/150

PRE- 1B Score

(0/5/10)

CONTENT Patients and families are informed oftheir rights and responsibilities in a

format and language that they can

understand.

10

INTERPRETATION Self explanatory.REMARKS This could be done in the form of

permanent displays at strategic

locations within the organization.

Pamphlets could be provided regarding

the same

BOAR

PAMPHLE
http://localhost/var/www/apps/conversion/tmp/scratch_3/Patient%20Rights%20&%20Responsibility%20(1).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/INFORMATION%20FOR%20ATTENDANTS.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/INFORMATION%20FOR%20ATTENDANTS.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Patient%20Rights%20&%20Responsibility%20(1).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdf


20/150

PRE -1C Score(0/5/10)

CONTENT The organizations leadersprotect patientsrights.

10

INTERPRETATION Protection also includes

addressing patients grievancesw.r.t rights.

REMARKS

PAMPH

CITIZ

CHAR
http://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/INFORMATION%20FOR%20ATTENDANTS.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/INFORMATION%20FOR%20ATTENDANTS.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/INFORMATION%20FOR%20ATTENDANTS.pdf


21/150

PRE -1E S(0

CONTENT Violation of patient rights is reviewed and

corrective/preventive measures taken.

INTERPRETATION Where patients' rights have been infringed upon,

management must keep records of such violations, as also a

record of the consequences, e.g. corrective actions to prevent

recurrences. The organization shall have a mechanism to

capture the sameREMARKS The organization could develop an indicative list of such items

and train the staff accordingly. For example, repeated

examinations, no examination soliciting money. The patient

feedback form (by incorporating patient rights worded

appropriately) could be used as a tool to capture violation of

patient rights


22/150

PRE-2A Score

(0/5/10)

CONTENT Patient and family rights address

any special preferences, spiritual

and cultural needs.

10

INTERPRETATION This could include dietary

preferences and worship

requirements

REMARKS


23/150

PRE- 2B Scor(0/5/1

CONTENT Patient rights include respect for personal dignity and

privacy during examination, procedures and treatment.

10

INTERPRETATION During all stages of patient care, be it in examination or

carrying out a procedure, hospital staff shall ensure that

patients privacy and dignity is maintained. The

organization shall develop the necessary guidelines for

the same. During procedures the organization shallensure that the patient is exposed just before the actual

procedure is undertaken. With regards to

photographs/recording procedures; the organization

shall ensure that consent is taken and that the patients

identity is not revealed.

REMARKS


24/150

PRE- 2C Scor

(0/5/

CONTENT Patient and family rights includeprotection from physical abuse or

neglect.

10

INTERPRETATION Self explanatory. Special precautions

shall be taken especially w.r.t vulnerablepatients e.g. elderly, neonates etc.

REMARKS Examples of this falling from the

bed/trolley due to negligence, assault,

repeated internal examinations,

manhandling etc


25/150

PRE- 2D Score(0/5/1

CONTENT Patient and family rights include treating

patient information as confidential

10

INTERPRETATION Self explanatory. Statutory requirements

w.r.t. privileged communication shall be

followed at all times. Confidential

information including HIV status shall not be

revealed without patients permission. It

shall not be written / pasted on the cover of

the medical record.

REMARKS Examples of privileged communications

include MTP, patients of tuberculosis or anyother infectious disease
http://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


26/150

PRE -2G

Score

(0/5/10

CONTENT Patient and family rights include right

to complain and information on how

to voice a complaint

5

INTERPRETATION Grievance redressal mechanism must

be accessible and transparent.Displayed information must be

clearly available on how to voice a

complaint.

REMARKS


27/150

PRE -2H Score

(0/5/10)

CONTENT Patient and family rights

include information on

the expected cost of the

treatment

10

INTERPRETATION Self explanatory

REMARKS Refer PRE 6c
http://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


28/150

PRE -2J Score

(0/5/10

CONTENT Patient and family rights include

information on plan of care,

progress and information on their

health care needs.

5


REMARKS Refer AAC 4g and PRE 5

Percenta

DEFICIE
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/PATEINT%20FILE%20TF%20.ppthttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/PATEINT%20FILE%20TF%20.ppt


29/150

DEFICIENCY PRE 2J

Only 16.6% of Care Plan is Documented and countersigned by consult


30/150

PRE- 3E Score(0/5/10)

CONTENT The care plan respects and where

possible incorporates patients

and/or family concerns and

requests.

10

INTERPRETATION The religious, cultural and spiritual

views of the patients and/or familyshall be considered during the

process of care delivery.

REMARKS Incorporating patient and/or family

requests shall be limited by the

statutory requirements.

DIETRY

PRAYER RO
http://localhost/var/www/apps/conversion/tmp/scratch_3/DIETRY%20PREFERENCE.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/PRAYER%20ROOM.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/PRAYER%20ROOM.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/DIETRY%20PREFERENCE.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


31/150

PRE-6A Score

(0/5/10)

CONTENT There is uniform pricing policy

in a given setting (out-patient

and ward category).

10

INTERPRETATION There should be a billing policywhich defines the charges to

be levied for various activities

REMARKS

BILLING PO

CITIZEN

CHARTER
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Billing_Policy.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Billing_Policy.docx


32/150

PRE- 6B Score(0/5/10

CONTENT The tariff list is available to patients. 10INTERPRETATION The organization shall ensure that there is

an updated tariff list and that this list is

available to patients when required. The

organization shall charge as per the tariff

list. Any additional charge should also be

enumerated in the tariff and the same

communicated to the patients. The tariff

rates should be uniform and transparent.

REMARKS

SCREEN

BILLING

ESTIM

CIT

CHA
http://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SCREEN%20SHOT%20-%20BILLING.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SCREEN%20SHOT%20-%20BILLING.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Estimated%20Bill.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Estimated%20Bill.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SCREEN%20SHOT%20-%20BILLING.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SCREEN%20SHOT%20-%20BILLING.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


33/150

PRE -6C Score(0/5/10)

CONTENT The patient and/or family members areexplained about the expected costs

10

INTERPRETATION Patients should be given an estimate of

the expenses on account of the

treatment preferably in a written form.

REMARKS The estimate shall be prepared on the

basis of the treatment plan. It could be

prepared by the OPD / Registration /

Admission staff in consultation with

treating doctor.
http://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


34/150

PRE -6D Score

(0/5/10

CONTENT Patient and/or family are informedabout the financial implications when

there is a change in the patient

condition or treatment setting

INTERPRETATION When patients are shifted from onesetting to another, typically to and

from ICUs, the financial implications

must be clearly conveyed to them

REMARKS


35/150

PRE- 7A Scor

(0/5/1

CONTENT The organization has a documented complaint

redressal procedure.*

5

INTERPRETATION This shall incorporate the mechanism for lodging

complaints (including verbal or telephonic

complaints), method of compiling them,

analysing complaints including the time frame,

the person(s) responsible and documenting the

action taken.

REMARKS It is for the organization to decide if it wants to

give credence to anonymous complaints
http://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


36/150

PRE-7B Sco

(0/5

CONTENT Patient and/or family members are madeaware of the procedure for lodging

complaints.

5

INTERPRETATION Self explanatory. This shall be either by display

or providing written information.

REMARKS It is important that the organization creates an

environment of trust wherein the patient

would be comfortable to air his/her views.

CIT

D
http://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.doc


37/150

PRE- 7C Score

(0/5/10

CONTENT All complaints are analysed. 10

INTERPRETATION The entire process shall be

documented.

REMARKS Where appropriate the patient and/orfamily could be involved in the

discussions and also informed regarding

outcome.

PATIENTS FE

BACK
http://localhost/var/www/apps/conversion/tmp/scratch_3/IPD%20&%20OPD%20FEEDBACK.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/IPD%20&%20OPD%20FEEDBACK.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/IPD%20&%20OPD%20FEEDBACK.xlsx


38/150

PRE 7D Score

(0/5/10)

CONTENT Corrective and/or preventive

action(s) are taken based on the

analysis where appropriate

5


REMARKS

PATIENTS FEEDBACK
http://localhost/var/www/apps/conversion/tmp/scratch_3/IPD%20&%20OPD%20FEEDBACK.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/IPD%20&%20OPD%20FEEDBACK.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/IPD%20&%20OPD%20FEEDBACK.xlsx


39/150

HIC 5D Score

(0/5/10)

CONTENT Appropriate pre and post-exposure

prophylaxis is provided to all staffmembers concerned.

5

INTERPRETATION Self-explanatory. Infection control nurse

maintains documentation of all

occupational injuries and pre- and post-

exposure prophylaxis records

REMARKS For example, hepatitis B vaccination and

PEP for needle stick injury

DEFICIENY

VACCINATION
http://localhost/var/www/apps/conversion/tmp/scratch_3/VACCINATED.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/VACCINATED.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/POST%20EXPOSURE%20PROPHYLAXIS_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/POST%20EXPOSURE%20PROPHYLAXIS_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/VACCINATED.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/VACCINATED.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


40/150

HIC 9A Score

(0/5/10

CONTENT The management makes available

resources required for the infection control

programme

INTERPRETATION The organization shall ensure that the

resources required by the personnel should

be available in a sustained manner. This

includes both men and materials.

REMARKS


41/150

HIC -9B Scor

(0/5/1

CONTENT The organization earmarks adequate funds from

its annual budget in this regard

INTERPRETATION There shall be a separate budget demarcated for

HIC activity. This shall be prepared taking into

consideration the scope of the activity and

previous years experience.

REMARKS


42/150

CQI-1A Score

(0/5/10)

CONTENT There is a structured quality improvementand continuous monitoring programme in

the organization

5

INTERPRETATION This committee shall have representation

from management, various clinical and

support departments of the HCO. Thisprogramme shall be developed,

implemented and maintained in a structured

manner.

REMARKS For example core committee, quality

improvement committee etc.
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdf


43/150

CQI 1B Score

(0/5/10)

CONTENT The quality improvement programme is

documented.*

5

INTERPRETATION This should be documented as a manual.

The manual shall incorporate the

mission, vision, quality policy, quality

objectives, service standards, importantindicators as identified etc. The manual

could be stand alone and should have

cross linkages with other manuals.

REMARKS Refer to AAC 7, AAC 10, COP 8 and COP

14 also.

DEFICIE

SERVI

INDUCT

MANU
http://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/MASTER%20LIST%20(SOS,PHE,HE).xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/SOS,%20PHE/MASTER%20LIST%20(SOS,PHE,HE).xlsx


44/150

CQI1C Sco

(0/5/

CONTENT This should(Quality Improvement Program)be

documented keeping in mind requirements of OEsd, f, g and i. It should also incorporate the various

indicators as required by CQI 3 and 4. There is a

designated individual for coordinating and

implementing the quality improvement program.

5

INTERPRETATION This should preferably be a person having a good

knowledge of accreditation standards, statutory

requirements, hospital quality improvement

principles and evaluation methodologies, hospital

functioning and operations.

REMARKS For example accreditation co-coordinator, quality

management representative, quality manager

D


45/150

CQI -1D Sco

(0/5/

CONTENT The quality improvement programme is

comprehensive and covers all the majorelements related to quality assurance and

supports innovation.

5

INTERPRETATION This shall preferably cover all aspects including

documentation of the programme, monitoringit, data collection, review of policy and

corrective action. Also refer to CQI 1b.

REMARKS Refer to glossary for definition of quality

assuranceand qualityimprovement

D


46/150

CQI -1E Sco

(0/5/

CONTENT The designated programme is communicated and

coordinated amongst all the employees of theorganization through proper training mechanism.

1

INTERPRETATION Self explanatory.

REMARKS This could be done through a regular training

programme or printed materials

T

C
http://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/TRAINING%20CALENDER%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/TRAINING%20CALENDER%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/TRAINING%20CALENDER%20.xlsx


47/150

CQI-1F Sco

(0/5/

CONTENT The quality improvement programme identifies

opportunities for improvement based on review at pre-defined intervals.

5

INTERPRETATION As quality improvement is a dynamic process, it needs to

be reviewed at regular pre-defined intervals (as defined

by the organisation in the quality improvement manual

but at least once in four months). The review shall

include internal audits (refer to CQI 1h), organisationalperformance indicators (refer to CQI 5c), analysis of key

indicators as identified and determined by the

organisation including mandatory indicators as laid down

in CQI 3 and 4. The minutes of the review meetings

should be recorded and maintained.

REMARKS This also applies to other quality-assurance programmes

like lab imaging, ICU and surgical services.

M

D
http://localhost/var/www/apps/conversion/tmp/scratch_3/MONTHLY%20UPDATE.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MONTHLY%20UPDATE.doc


48/150

CQI -1G Sco(0/5/

CONTENT The quality improvement programme is a

continuous process and updated at least once in ayear.

0

INTERPRETATION Self explanatory. The inputs for updation could be

based on the review carried out by the qualityimprovement committee.

REMARKS

DEF


49/150

CQI- 1H Sco(0/5/

CONTENT Audits are conducted at regular intervals as a means

of continuous monitoring

1

INTERPRETATION This audit shall be done by a multi-disciplinary team

(preferably trained in NABH standards) including all

the applicable standards and objective elements. All

the areas of the organization shall be covered. At

the end of the audit, there shall be a formal

meeting to summarise the findings and corrective

and preventive measure shall be taken and

documented.

REMARKS The assessors shall be either trained internally or

externally in NABH standards. They shall assess

areas independent of their area of work. All auditsshall be documented.
http://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


50/150

CQI -1I Sco(0/5/

CONTENT There is an established process in the organization

to monitor and improve quality of nursing andcomplete patient care.

1

INTERPRETATION Self-explanatory.

REMARKS This could be done through clinical audits

Nur

TRA

SU

R

AN
http://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/MASTER%20SHEET%20FORMS.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/TRAINING%20CALENDER%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/NURSING%20SUPERVISOR%20REPORT_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/NURSING%20SUPERVISOR%20REPORT_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/ANS%20REPORT.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/ANS%20REPORT.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/NURSING%20SUPERVISOR%20REPORT_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/NURSING%20SUPERVISOR%20REPORT_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/TRAINING%20CALENDER%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/TRAINING%20TIME%20TABLE.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/MASTER%20SHEET%20FORMS.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


51/150

CQI -2J Sco(0/5/

CONTENT The organization uses at least two identifiers to

identify patients across the organization

1

INTERPRETATION This shall be used for identifying patient for all

care-related events like medication

administration, conducting procedures etc.

REMARKS One of the identifiers shall be the unique hospital

ID generated at the time of

registration/admission.
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Vulnerable%20Patients%20policy.doc


52/150

CQI -3J Sco(0/5/

CONTENT Monitoring includes data collection to support

further improvements

1

INTERPRETATION The data could be collected at pre-defined

intervals, e.g. monthly/quarterly. This data is

analyzed for improvement opportunities and the

same are carried out. Also refer to CQI 1f.

REMARKS For example, data can be collected to study the

reasons for re-dos in surgical patients. Data

could be represented graphically, e.g. bar chart,

pie chart etc.

Au
http://localhost/var/www/apps/conversion/tmp/scratch_3/Quality%20Indicators.xlsbhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MONTHLY%20UPDATE.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Quality%20Indicators.xlsbhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


53/150

CQI- 3K Sco(0/5/


evaluation of these improvements

0

INTERPRETATION

All improvement activities carried out by the

organization shall have an evaluable outcome.

The same shall be captured and analyzed.

REMARKS For example once the reasons for re-dos have

been analyzed and preventive and corrective

measures undertaken then data can be collected

to confirm that reductions have occurred in the

incidence of re-dos


54/150

CQI -4C(0

CONTENT Monitoring includes utilization of space, manpower and

equipment.

INTERPRETATION The organization shall develop appropriate key performance

indicators suitable to it. The following is however mandatory:

i. BOR & ALOS

ii. OT and ICU Utilization

iii.Crtical Equipment Downtime

iv. Nurse Patient ratio for ICU and wardREMARKS Any equipment the failure of which could impede patient care

shall be considered critical. Some examples are ventilators,

cardiac monitors and pulse-oximeter. However every

organization shall identify its list of critical equipment and

accordingly capture the indicator. The downtime has to be

captured irrespective of whether it has a backup or not.

O

N

IC

IC
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/NURSE%20PATIENT%20RATIO.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/ICU%20UTILIZATION%20RATE.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/ICU%20EQUIPMENT%20UTILIZATIONhttp://localhost/var/www/apps/conversion/tmp/scratch_3/ICU%20EQUIPMENT%20UTILIZATIONhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/ICU%20UTILIZATION%20RATE.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/NURSE%20PATIENT%20RATIO.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


55/150

CQI -4D S(0/

CONTENT Monitoring includes patients satisfaction which also

incorporates waiting time for servicesINTERPRETATION The organization shall develop appropriate key performance

indicators suitable to it. The following is however mandatory:

i. Out-patient satisfaction index;

ii. In-patient satisfaction index;

iii. Waiting time for services including diagnostics and out-

patient consultation;iv. Time taken for discharge

REMARKS Waiting time implies the time taken from the time that the

patient registers to the time taken for assessment to be done

by the doctor/diagnostic procedure to be performed. Time

taken for discharge implies the time from which the doctor

writes for discharge to the time for final clearance.

S

S
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/OPD%20AND%20IPD/OPD%20ANALYSIS/OPD%20PRESENTATION.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/OPD%20AND%20IPD/IPD%20ANALYSIS/IPD%20presentation.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/OPD%20AND%20IPD/IPD%20ANALYSIS/IPD%20presentation.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/OPD%20AND%20IPD/OPD%20ANALYSIS/OPD%20PRESENTATION.pptxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


56/150

DEFICIENCY CQI 4D

Time of Discharge order was not Mentioned in 83% files.

Analysis of Time Taken for Discharge is not satisfactory.


57/150

CQI -4E Sco(0/5/

CONTENT Monitoring includes employees satisfaction 5

INTERPRETATION The organization shall develop appropriate key

performance indicators suitable to it. The following is

however mandatory:

i. Employee satisfaction index;

ii. Employee attrition rate;iii. Employee absenteeism rate;

iv.Percentage of employees who are aware of

employee rights, responsibilities and welfare schemes

REMARKS
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/AWARNESS%20OF%20EMPLOYEE%20RIGHTS%20_CQI%204E%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/employee%20satisfaction(2014)http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/AWARNESS%20OF%20EMPLOYEE%20RIGHTS%20_CQI%204E%20.xlsxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


58/150

CQI -4H Sco(0/5/


further improvement

5

INTERPRETATION The data could be collected at pre-defined

intervals, e.g. monthly/quarterly. This data isanalysed for improvement opportunities and the

same are carried out. Also refer to CQI 1f.

REMARKS For example waiting time in OPD.


59/150

CQI -4I Sco(0/5/


evaluation of these improvements

0

INTERPRETATION All improvement activities carried out by the

organization shall have an evaluable outcome.The same shall be captured and analysis

REMARKS

D


60/150

CQI -5A Sco(0/5/

CONTENT The management makes available adequate

resources required for quality improvementprogramme

INTERPRETATION This shall include the men, material, machine and

method. These should be in steady supply so as toensure that the programme functions smoothly.

REMARKS


61/150

CQI -5B Sco(0/5/

CONTENT Organization earmarks adequate funds from its

annual budget in this regard

INTERPRETATION Appropriate fund allocation is done by the

organization for the smooth functioning of the

programme

REMARKS The budget could be earmarked based on

previous years spending. If no data is available

the organization could make a beginning by

earmarking a budget but reviewing it at the end

of six months any necessary modifications.


62/150

CQI -5C Sco(0/5/

CONTENT The management identifies organizational

performance improvement target.

INTERPRETATION The management shall identify organization and

department level quality objectives, set targets,monitor them (at least once in four months) and

modify the target (at least annually)

REMARKS The targets should be shared with the faculty and

staff and regular feedback taken.


63/150

CQI -5D Sco(0/5/

CONTENT The management supports and implements use

of appropriate quality improvement, statisticaland management tools in its quality improvement

programme


REMARKS For example Root Cause analysis, FMEA, Project

Evaluation and Review Technique (PERT), Critical

Path Method (CPM), Control Charts etc.


64/150

CQI- 6A Sco(0/5/

CONTENT Medical and nursing staff participates in this

system

1

INTERPRETATION The organization shall identify such personnel. It

could be a mix clinicians, administrators andnurses.

REMARKS These could be members of the core committee /

quality assurance committee etc.

Al

W
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/NABH%20workshop_attended.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/NABH%20workshop_attended.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/All_committees_report.pdf


65/150

CQI -6B Sco(0/5/

CONTENT The parameters to be audited are defined by the

organization.

1

INTERPRETATION As these audits are retrospective / concurrent in

nature, it is imperative that this be done using

predefined parameters so that there is no bias. The

parameters could be disease based, cost based,

community based or based on morbidity (length of

stay). It shall lay down the objectives, theparameters that are going to be captured develop a

checklist where required, sampling and data

collection guidelines and preparation of report.

REMARKS The audit shall encompass all aspects of care

including clinical and nursing.

IN

S
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/SUMMARY%20-%20QUALITY%20INDICATORS.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/SUMMARY%20-%20QUALITY%20INDICATORS.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/SUMMARY%20-%20QUALITY%20INDICATORS.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/INDICATORS%20-/SUMMARY%20-%20QUALITY%20INDICATORS.xlshttp://localhost/var/www/apps/conversion/tmp/scratch_3/FORMS/Sentinel%20Events%20Reporting%20Form_0001.pdf


66/150

CQI -6C Sco(0/5/

CONTENT Patient and staff anonymity is maintained

INTERPRETATION This means that the names of the patients and

the hospital staff who may figure in the audit

documents must not be disclosed or any

reference be made to them in public discussions /

conferences.

REMARKS This is at the stage of report preparation and

dissemination. The staff participating in the audit

shall maintain patient and staff anonymity and

not reveal names


67/150

CQI -6D Sco(0/5/

CONTENT All audits are documented. 5


REMARKS The organization could use a checklist with the

predefined parameters and the audit findings

could be recorded on this sheet.


68/150

CQI -6E Sco(0/5/

CONTENT Remedial measures are implemented. 0

INTERPRETATION All remedial measures as ascertained should be

documented and implemented and improvementsthereof recorded to complete the audit cycle.

REMARKS This should preferably be done based on root cause

analysis.

D


69/150

CQI -7B Sco(0/5/

CONTENT The organization has a process to collect feedback

and receive complaints.*

1


REMARKS This shall be communicated to the patients using

displays or brochures.

CCH

IND

M

SUG
http://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/SUGGESTION%20BOX%20.JPGhttp://localhost/var/www/apps/conversion/tmp/scratch_3/SUGGESTION%20BOX%20.JPGhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/Citizen%20Charter%20DMC%20&%20H%20Sep%202013.doc


70/150

CQI -7E Sco(0/5/

CONTENT Feedback about care and service is communicated

to staff.

1

INTERPRETATION At a minimum, patient satisfaction levels shall be

communicated on a monthly basis.

REMARKS This could be done using internal communication. It

is equally important that positive feedback about

care and service is communicated to staff.

FEE

SAT
http://localhost/var/www/apps/conversion/tmp/scratch_3/Feedback%20on%20Pt.Satisfaction.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Feedback%20on%20Pt.Satisfaction.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/Feedback%20on%20Pt.Satisfaction.pdf


71/150

CQI -8A Sco(0/5/

CONTENT The organization has defined sentinel events.* 1

INTERPRETATION The sentinel events relating to system or process

deficiencies that are relevant and important to theorganization must be clearly defined. This list of the

identified and relevant sentinel events shall be

documented.

REMARKS Refer to glossary for definition of sentinelevents

SE
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/SENTINEL%20EVENT%20POLICY%20.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/SENTINEL%20EVENT%20POLICY%20.doc


72/150

ROM -1A Sco(0/5/

CONTENT Those responsible for governance lay down the

organizationsvision, mission and values.*

1

INTERPRETATION It is not only the head of the HCO but the members of

the board of governors (where applicable) who needto define it.

REMARKS For definition of mission,vision,and valuesrefer

to glossary
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.doc


73/150

ROM 1B Sco(0/5/

CONTENT Those responsible for governance approve the

strategic and operational plans and organisationsbudget.


REMARKS Refer to glossary for strategic and operational

plans. Also refer to ROM 5c,e


74/150

ROM -1C Sco(0/5/

CONTENT Those responsible for governance monitor and

measure the performance of the organizationagainst the stated mission.

INTERPRETATION The Governing board and the head of organisation

shall develop quarterly (at least ) performancereports based on strategic and operational plans.

REMARKS Performance shall be discussed in the management

review meeting and action items are regularly

followed up.


75/150

ROM 1D Sco(0/5/

CONTENT Those responsible for governance establish the

organizationsorganogram.*

1

INTERPRETATION The organization shall have a well defined

organization structure / chart and this shall clearly

document the hierarchy, line of control, along with

the functions at various levels.

REMARKS Organogram is transparent and is disseminated to

all stake holders. The organogram shall incorporate

various committees.

OR
http://localhost/var/www/apps/conversion/tmp/scratch_3/organo%20updated.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/organo%20updated.docx


76/150

ROM -1E Sco(0/5/

CONTENT Those responsible for governance appoint the

senior leaders in the organisation.

1


REMARKS Senior leaders include the first two rungs of the

organogram. Appointment of senior leaders shall be

through selection committee.

CO

RE
http://localhost/var/www/apps/conversion/tmp/scratch_3/consultant%20recruitment%20criteria-UGC(BFUHS).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/consultant%20recruitment%20criteria-UGC(BFUHS).pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/consultant%20recruitment%20criteria-UGC(BFUHS).pdf


77/150

ROM -1F Sco(0/5/

CONTENT Those responsible for governance support safety

initiative and quality improvement plans.


REMARKS All risk assessment and risk reduction is known and

measures to reduce are discussed for corrective

actions.


78/150

ROM -1G Sco(0/5/

CONTENT Those responsible for governance support research

activities.


REMARKS Support in research shall include providing

resource, budget, following ethical and legal norms.


79/150

ROM -1H Sco(0/5/

CONTENT Those responsible for governance address the

organizationssocial responsibility.

1

INTERPRETATION The governing board and head of the organization

shall willfully develop social responsibility policyand accordingly address it.

REMARKS For example, free camps, outreach programmes,

adoption of villages, PHCs etc.
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/CAMPS_(2013-14).pdf


80/150

ROM -1I Sco(0/5/

CONTENT Those responsible for governance inform the public

of the quality and performance of services.

0


REMARKS This could be in the form of display of brochures.

This could include results of surveys done by

independent third parties and results of

benchmarking done by professional bodies.


81/150

ROM-2A S(0/

CONTENT The management is conversant with the laws and

regulations and knows their applicability to the organization

INTERPRETATION Self Explanatory. This shall include central legislations (e.g.

Drugs and Cosmetics act and MTP act, PNDT Act 1996), Bio

Medical Waste Act. Air (Prevention and Control of Pollution)

Act 1981, Atomic Energy Regulatory Body Approvals, License

under Bio-medical Management and Handling Rules, 1998,

respective of state legislations Maharashtra Maintenance of

Clinical Records act, Clinical establishment of West Bengal)

and local regulations (e.g. building byelaws).

REMARKS A designated management functionary could be given the

responsibility to enlist the laws and regulation as applicable

to the organization. This functionary in turn could identify

the appropriate personnel in the organization who are

supposed to implement the respective laws and regulations.
http://localhost/var/www/apps/conversion/tmp/scratch_3/HOSPITAL%20LICENSE/LICENSE%20TRACK%20SHEET%20.xlsx


82/150

ROM -2B Sco(0/5/

CONTENT The management ensures implementation of these

requirements

1


REMARKS All relevant clause under the rules and act are

abided by the organization.


83/150

ROM -2C Sco(0/5/

CONTENT Management regularly updates any amendments

in the prevailing laws of the land

1


REMARKS


84/150

ROM -2D Sco(0/5/

CONTENT There is a mechanism to regularly update

licenses/ registrations/certifications

1


REMARKS For example license for lifts, DG sets etc. The

organization could develop a tracker sheet for this

purpose.


85/150

ROM -3B Sco(0/5/

CONTENT Administrative policies and procedures for each

department are maintained.*

1

INTERPRETATION This shall include all administrative procedures

like attendance leave, conduct, replacement, etc.This shall be documented.

REMARKS It could be common for the entire organization

Atten

Tim

Lea
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86/150

ROM -3C Sco(0/5/

CONTENT Each organizational programme, service, site or

department has effective leadership.

1

INTERPRETATION There needs to be a minimum essential

qualification and relevant experience of the leader.The leader should have domain knowledge of that

particular department

REMARKS
http://localhost/var/www/apps/conversion/tmp/scratch_3/TECHNICAL/ALL%20-Consultant%20(Qualification).xlsx


87/150

ROM -3D Sco(0/5/

CONTENT Departmental leaders are involved in quality

improvement.

1


REMARKS The effectively implement this, each department

could have the department objective/key

performance indicators and the responsibility of

achieving them could be that of the leader

A
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88/150

ROM -4A Sco(0/5/

CONTENT The leaders make public the vision, mission and

values of the organization.

5

INTERPRETATION This shall be done by displaying the same

prominently.

REMARKS For definition of mission, vision and values

refer to glossary. Only a display on its website would

not be appropriate. It is preferable that the same be

translated and displayed in the local language also

DE


89/150

ROM -4B Sco(0/5/

CONTENT The leaders establish the organizations ethical

management.

1

INTERPRETATION The organization shall function in an ethical manner.

Transparency in its actions shall be one of its

guiding principles. Handling of complaints,

grievances, clinical care delivery and research shallbe some of the areas to address.

REMARKS A good reference guide is Codeof medical ethics-

2002 published by MCI. The organizations

established ethical management shall be

documented
http://localhost/var/www/apps/conversion/tmp/scratch_3/Manuals_list.xls


90/150

ROM -4C Sco(0/5/

CONTENT The organization discloses its ownership 1

INTERPRETATION The ownership of the hospital e.g. trust, private,

public has to be disclosed

REMARKS The disclosure be in the registration

certificate/quality manual etc.


91/150

ROM -4D Sco(0/5/

CONTENT The organization honestly portrays the services

which it can and cannot provide.

5

INTERPRETATION Self explanatory. Documentation with respect of

service non-availability and its communication to

patients is maintained.

REMARKS Here portrays implies that the organization conveys

to the patients clearly what it can and cannot

provide. The services that it cannot provide could

also be conveyed verbally. Refer to AAC 1 also.

S

AV
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92/150

ROM -4E Sco(0/5/

CONTENT The organization honestly portrays its affiliations and

accreditations.

1


REMARKS Here implies that the organization convey is

affiliations, accreditations for specific departments or

whole hospital wherever applicable


93/150

ROM -4F Sco(0/5/

CONTENT The Organization accurately bills for its services

based upon a standard billing traiff.

1


REMARKS Also Refer to PRE- 6.The Traiff could be devised by

tariff committee.

Es

Cit
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94/150

ROM -5A Sco(0/5/

CONTENT The person heading the organization has requisite

and appropriate administrative qualifications

1


REMARKS This implies to the individual looking after the day-

to-day operations and not to the chairman of the

Board of Governors. Appropriate implies

qualification in hospital

management/administration
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95/150

ROM -5B Sco(0/5/

CONTENT The person heading the organization has requisite

and appropriate administrative experience.

1


REMARKS Appropriate implies administrative experience in a

hospital
http://localhost/var/www/apps/conversion/tmp/scratch_3/Qualification%20list%20.xlsx


96/150

ROM -5C Sco(0/5/

CONTENT The organization prepares the strategic and operational

plans including long-term and short-term goals

commensurate to the organizations vision, mission and

values in consultation with the various stakeholders

INTERPRETATION The leader(s) shall define and develop the process for

strategic and operation plans so as to achieve the

organizational vision and mission statement and adhere

to the values. It shall be discussed with all stakeholders.One of the inputs that should be considered while

financing these plans shall be the findings of the risk

management plan (refer to ROM 6a). This shall at least

be done on an annual basis

REMARKS Refer to glossary for strategic and operational plans.

Stake holders include the community the organization

services


97/150

ROM -5D Sco(0/5/

CONTENT The organization coordinates the functioning with

departments and external agencies, and monitorsthe progress in achieving the defined goals and

objectives.

INTERPRETATION Self-explanatory. The reasons for not achieving any

particular goal shall be analyzed and appropriateaction shall be taken.

REMARKS This could be done through management review

meetings.


98/150

ROM -5E Sco(0/5/

CONTENT The organization plans and budgets for its activities

annually

INTERPRETATION Self-explanatory. Adequate budget shall also be

allocated for infection control and quality-improvement activities.

REMARKS This could be either done on a calendar year basis

or financial year (April-March) basis. It is preferable

that every department has a budget.


99/150

ROM-5F Sco(0/5/

CONTENT The performances of the senior leaders is reviewed

for their effectiveness

INTERPRETATION Self-explanatory. Key result areas of each leader can

be established or it can be done throughperformance appraisal.

REMARKS This shall be done by those responsible for

governance


100/150

ROM -5G Sco(0/5/

CONTENT The functioning of committees is reviewed for their

effectiveness

0

INTERPRETATION This shall be done by the management. The review

at a minimum shall include if the purpose of having

the committee is being met, if the committee is

meeting at the prescribed frequency and if the

committee is suggesting remedial measures and if

there is adequate monitoring.REMARKS For an effective review, it is preferable that the

organization documents the scope of every

committee, the role and responsibilities assigned to

various members and the frequency of meetings.

Agenda shall be prepared for all meetings and

documentation of each committee meeting is kept.

M

D
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101/150

ROM -5H Sco(0/5/

CONTENT The organization documents employee rights and

responsibilities.*

1

INTERPRETATION Self-explanatory. The organization shall define the

same in consonance with statutory requirements.

REMARKS


102/150

ROM -5I Sco(0/5/

CONTENT The organization documents the service standards.* 1

INTERPRETATION Self explanatory. The organization shall develop

benchmarks for different services being provided.This shall be based on the organizationsvalues and

focus on development of soft skills, behavior,

attitude, communication skills etc.

REMARKS


103/150

ROM -5J Sco(0/5/

CONTENT The organization has a formal documented

agreement for all outsourced services

5

INTERPRETATION The agreement shall specify the service parameters.

REMARKS Even if a sister concern is providing services, there

shall be an agreement with that unit

A
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104/150

ROM -5K Sco(0/5/

CONTENT The organization monitor Quality of Outsourced

services

INTERPRETATION The Frequency of Meeting shall be determined by

the organization .This shall be done keeping in mind

the criticality of the service towards providing

patient care.

REMARKS It is preferable that the monitoring be done as per

the service standards laid down or as per the

requirement of the organization.

Ou

ROM 6A S
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105/150

ROM -6A(0

CONTENT Management ensures proactive risk management across the

organization

INTERPRETATION This shall include clinical and non-clinical (strategic, financial,operational and hazard) risks. It shall include risk identification,

prioritization and risk alleviation. This shall be documented as a risk

management plan. It shall include the various risks identified, the

action taken for risk alleviation of each of these risks and the

mechanism for informing staff regarding the same. Further, the risk

management plan shall be monitored and reviewed for continued

effectiveness at least annually. The results of the review shall becommunicated to the relevant stakeholders in the organization.

REMARKS This could be done using a matrix. Clinical-risk assessment could

include:

i. Medication management, covering issues such as

patient/service-user allergies and antibiotic resistance;

ii. ii. Equipment risks, e.g. fire/injury risks from use of laser; and

iii. iii. Risks resulting from long-term conditions.
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106/150

ROM -6B Sco(0/5/

CONTENT Management provides resources for proactive risk

assessment and risk reduction activities

0

INTERPRETATION There shall be sufficient resources kept as

contingency to address the risk reduction activities

as and when the leaders proactively suggest. The

end-result of these shall result in preventive actions

REMARKS Refer to glossary for definition of riskassessment

and riskreduction.


107/150

ROM -6C Sco(0/5/

CONTENT Management ensures implementation of systems

for internal and external reporting of system andprocess failures.*

INTERPRETATION The organization has a system in place for internal

and external reporting of system and process

failures. Contingency plan shall be in place to deal

with the situation of system and process failureanticipated within the organization.

REMARKS For example, MRI machine of the organization

breaks down. In this case internal and external

reporting to be done to the patients. The system for

reporting shall be documented


108/150

FMS -2A Sco(0/5/

CONTENT Facilities are appropriate to the scope of services of

the organization

5


REMARKS

DEFI


109/150

FMS -2H Sco(0/5/

CONTENT There are designated individuals responsible for the

maintenance of all the facilities

1

INTERPRETATION A person in the organization is designated to be in-

charge of maintenance of facilities. The organization

has the required number of supervisors and

tradesmen to manage the facilities. The necessaryinfrastructure and tools shall be provided by the

organization.

REMARKS

RO
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110/150

FMS -3A Sco(0/5/

CONTENT The organization plans for equipment in accordance

with its services and strategic plan.

INTERPRETATION Self explanatory. This shall also take into

consideration future requirements.

REMARKS The plans should be fully implemented and there

should be a process for periodic review of plans


111/150

FMS -3B Sco(0/5/

CONTENT Equipment is selected by a collaborative

process.

1

INTERPRETATION Collaborative process implies that during

equipment selection there is involvement of

end user, management, finance, engineering

and bio-medical departments.

REMARKS


112/150

FMS -3D Sco(0/5/

CONTENT Qualified and trained personnel operate and

maintain the equipment and utility systems

1


REMARKS The person could be qualified by experience of

training.

QU
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113/150

FMS -4A Sco(0/5/

CONTENT The organization plans for equipment in accordance

with its services and strategic plan

1

INTERPRETATION Self-explanatory. This shall also take into

consideration future requirements. The equipment

shall be appropriate to its scope of services

REMARKS A good reference for minimum equipment is the

IPHS guidelines


114/150

FMS -4B Sco(0/5/

CONTENT Equipment are selected, rented, updated or

upgraded by a collaborative process.

10

INTERPRETATION Collaborative process implies that during

equipment selection there is involvement of end-

user, management, finance, engineering and

biomedical departments

REMARKS Engineering / Facilities Dept..The organization could

define different financial clearance in accordance

with the policy. For example, purchase of BP

apparatus can be done by the departmental head.


115/150

HRM -1A Sco(0/5/

CONTENT Human resource planning supports the

organizationscurrent and future ability to meet thecare, treatment and service needs of the patient.*

INTERPRETATION This shall be done in a structured manner keeping in

mind the scope of services, mission and the

healthcare needs of the community that it serves. It

shall use recognized methods for determining levelsof staffing

REMARKS It shall match the strategic and operational plan of

the organization.


116/150

HRM -1B Sco(0/5/

CONTENT The organization maintains an adequate number

and mix of staff to meet the care, treatment andservice needs of the patient.

1

INTERPRETATION The staff should be commensurate with the

workload and the clinical requirement of the

patient

REMARKS A good reference could be the MCI and INC

guidelines


117/150

HRM -1C Sco(0/5/

CONTENT The required job specification and job description

are well defined for each category of staff.*

10

INTERPRETATION The content of each job should be well defined and

the qualifications, skills and experience required for

performing the job should be clearly laid down. The

job description should be commensurate with the

qualification.

REMARKS Refer to glossary for definition of jobdescription

and jobspecification. For a job which requires the

skills of a doctor or a nurse the minimum

qualification shall be an MBBS and GNM degree

respectively.

D
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118/150

HRM -1D Sco(0/5/

CONTENT The organization verifies the antecedents of the

potential employee with regards tocriminal/negligence background

10


REMARKS This report can be obtained from the district

magistrates office of the district where the

employee has served earlier and/or from theprevious employer. In case of fresh graduate, the

same could be obtained from the last institution

attended. In case of a doctor or a nurse, a good

standing certificate may be obtained from the

regulatory body.

VERIF

ANT

S
http://localhost/var/www/apps/conversion/tmp/scratch_3/HRM%201%20D%20Verification%20of%20Character%20&%20Antecedent.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/HRM%201%20D%20Verification%20of%20Character%20&%20Antecedent.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/HRM%201%20D%20Verification%20of%20Character%20&%20Antecedent.pdf


119/150

HRM -2E Sco(0/5/

CONTENT The induction training includes awareness on

employee rights and responsibilities

10


REMARKS

IN

T

CH

IN

M

S
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120/150

HRM -5A Sco(0/5/

CONTENT A documented performance appraisal system exists

in the organization.*

1

INTERPRETATION Self explanatory. This shall be done for all categories

of employees starting from the person heading the

organization and including doctors who are

employees.

REMARKS For definition of performance appraisal refer to

glossary

HR

S
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Human%20Resource%20Manual-Final.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Human%20Resource%20Manual-Final.pdf


121/150

HRM -5B Sco(0/5/

CONTENT The employees are made aware of the system of

appraisal at the time of induction.

1


REMARKS This could be incorporated in the service booklet

and included in the induction training

IN

T

CH

S
http://localhost/var/www/apps/conversion/tmp/scratch_3/INDUCTION%20TRAINING%20CHECKLIST.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/INDUCTION%20TRAINING%20CHECKLIST.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/INDUCTION%20TRAINING%20CHECKLIST.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/INDUCTION%20TRAINING%20CHECKLIST.pdf


122/150

HRM -5C Sco(0/5/

CONTENT Performance is evaluated based on the pre-

determined criteria

1


REMARKS

S
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123/150

HRM -5D Sco(0/5/

CONTENT The appraisal system is used as a tool for further

development.

5

INTERPRETATION Self explanatory. This can be done by identifying

training requirements and accordingly providing for

the same (wherever possible).

REMARKS Key result areas are identified for each staff and

training need assessment is also done

DE

S


124/150

HRM -5E Sco(0/5/

CONTENT Performance appraisal is carried out at pre defined

intervals and is documented.

1


REMARKS This shall be done at least once a year

6 Sco


125/150

HRM -6A Sco(0/5/

CONTENT Documented policies and procedures exist.* 10


REMARKS For definition of disciplinary procedure and

grievance handling refer to glossary. The

documentation shall be done keeping in mind

objective elements c,d and e.

HR

IN

M

HRM 6B Sco
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Human%20Resource%20Manual-Final.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/Human%20Resource%20Manual-Final.pdf


126/150

HRM -6B Sco(0/5/

CONTENT The policies and procedures are known to all

categories of staff of the organization

1


REMARKS All the staff should be aware of the disciplinary

procedure and the process to be followed in case

they feel aggrieved

IN

M

HO

HRM 6C Sco
http://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.dochttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/Hospital_Wide_Policies_Pocket_Book_Print_Copy.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/TRAINING/Hospital_Wide_Policies_Pocket_Book_Print_Copy.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_3/MANUAL/INDUCTION%20MANUAL.doc


127/150

HRM -6C Sco(0/5/

CONTENT The disciplinary policy and procedure is based on

the principles of natural justice

10

INTERPRETATION This implies that both parties (employee and

employer) are given an opportunity to present

their case and decision is taken accordingly.

REMARKS

HRM 6D Sco


128/150

HRM -6D Sco(0/5/

CONTENT The disciplinary procedure is in consonance with

the prevailing laws.

10


REMARKS Refer to relevant labour laws and CCS (CCA) rules.

Anti-sexual harassment committee should also be

established in the organization

HRM 6E Sco


129/150

HRM -6E Sco(0/5/

CONTENT There is a provision for appeals in all disciplinary

cases.

1

INTERPRETATION The organization shall designate an appellate

authority to consider appeals in disciplinary cases

REMARKS Appellate authority should be higher than the

disciplinary authority

HRM 6F Sco


130/150

HRM -6F Sco(0/5/

CONTENT The redress procedure addresses the grievance 1


REMARKS

HRM 7A Sco


131/150

HRM -7A Sco(0/5/

CONTENT A pre-employment medical examination is

conducted on all the employees

1


REMARKS This shall however be in consonance with the law of

the land. For example performing pre-employment

HIV testing without consent is illegal

M

EXA

HRM 7B Sco
http://localhost/var/www/apps/conversion/tmp/scratch_3/HRM%20-8%20B.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/HRM%20-8%20B.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/HRM%20-8%20B.pdf


132/150

HRM -7B Sco(0/5/

CONTENT Health problems of the employees are taken care of

in accordance with the organizationspolicy

1


REMARKS This shall be in consonance with the law of the land

and good clinical practices For example employee

health and safety policy

HRM 7C Sco


133/150

HRM -7C Sco(0/5/

CONTENT Regular health checks of staff dealing with direct

QUALITY CONTROL TF .pptx

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