Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
Transcript of Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
1/29
!,79,.425,3.09490706:7020391,341908,250814:3/94-0343.42534:941949,8,2508800.90/
4.:2039,943
084
2502039,943
084
;/03.0.74887010703.094
/4.:20398
2,3:,809.
$.4708
$$$
,
- $$$
. %#'
,
-
.
/
0 %#'
,
-
,5907$$$$$$%%&%
#
$9,3/,7/0/ 54.08 ,3/ 574.0/:708 ,70 :80/ 147 7089073 ,3/ ,/2993
5,90398
%0 54.08 ,3/ 574.0/:708 ,//7088 4:95,90398 35,90398 ,3/ 020703.
5,90398
%0 47,38,943 ,8 , 0 /0130/ 70897,943 ,3/ ,/28843
574.088
%0 47,38,943 /01308 ,3/ /85,8 90 807;.08 9,9 9 .,3
574;/0%0 807;.08 -03 574;/0/ ,70 .0,7 /0130/ ,3/ ,70 3 .43843,3.0 9 90
300/84190.422:39
%0/0130/807;.08,7057423039/85,
%089,118470390/949080807;.08
020398
!,90398,70,..0590/4319047,3,943.,3574;/090706:70/807;.0
%0 54.08 ,3/ 574.0/:708 ,84 ,//7088 2,3,3 5,90398 /:73 343,;,,-941-0/8
%089,118,,70419080574.08808
%070 8 ,3 ,557457,90 20.,382 147 97,38107 47 701077, 41 5,90398
4/43492,9.9047,38,9437084:7.08
!4.08 :/0 90 97,38107 41 :389,-0 5,90398 94 ,34907 1,.9 3 ,3
,557457,902,3307
!4.08:/09097,381074189,-05,9039894,349071,.9
43.425,3.09490706:7020394955.,-0
;,:,9437907,/:7313,,880882039
$01880882039%449
7,38,9438706:70/94574;/0801,8808820397054793901472,9$01880882039%449;03-0490039708,7094-0574507
10/:5#0,7/38.4731443.7907,4:/-0,55.,-0
425,3.09490706:702039
O43/;/:,89,3/,7/84:/,;024709,3430074946:,140;07340748,..0590/39070:,9470,706:7020398
O%0,;07,08.4701473/;/:,89,3/,7/2:89349-00889,3
O%0,;07,08.4701473/;/:,.,59072:89349-00889,3
O%04;07,,;07,08.470147,89,3/,7/82:890.00/
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
2/29
/
,
-
.
/
,
-
.
/
0
1
,
-
.
,
-
.
/
0
1
%0 47,3,943 ;08 , 8:22,7 41 5,90398 .43/943 ,3/ 90 970,92039
;03
%0708,3089,-80/,-47,9476:,9,88:7,3.05747,220
39,,8808820393.:/088.700331473:97943,300/8
5,90398 .,70/ 147 - 90 47,38,943 :3/074 , 70:,7
70,880882039
5,90398,7070,880880/,9,557457,903907;,8
$9,113;4;0/3/70.9.3.,.,70/4.:203970,8808820398
!,90398 ,70 70,880880/ 94 /0907230 907 70854380 94 970,92039 ,3/ 94 5,3
1:7907970,9203947/8.,70
,-47,947 807;.08 ,70 574;/0/ ,8 507 90 706:7020398 41 90
5,90398$.450 41 90 ,-47,947 807;.08 ,70 .422038:7,90 94 90 807;.08 574;/0/ -
9047,38,943
/06:,90 6:,10/ ,3/ 97,30/ 50784330 5071472 ,3/47 8:507;80 90
3;089,9438!4.08 ,3/ 574.0/:708 :/0 .40.943 /0391.,943 ,3/3 8,10
97,385479,943574.0883,3//8548,41850.2038
,-47,947 90898 349 ,;,,-0 3 90 47,3,943 ,70 4:984:7.0/ 94
47,3,9438-,80/439076:,9,88:7,3.088902
,-47,947708:98,70,;,,-093,/0130/92017,20
79.,708:98,70392,90/220/,909490.43.0730/50784330
:73,/28843905,9039,3/471,2202-078,700/:.,90/94
2,0314720//0.843
%05,90398,3/471,2202-078,7005,30/,-4:9905745480/.,70
%05,90398,3/471,2202-078,7005,30/,-4:990050.90/708:98
%0 5,90398 ,3/ 47 1,2 202-078 ,70 05,30/ ,-4:9 90 5488-0
.425.,9438%05,90398,3/471,2202-078,7005,30/,-4:990050.90/.4898
!,90398 .,70/ 147 - 90 47,38,943 :3/074 ,3 089,-80/ 39,
,880882039%0 47,38,943 /01308 90 .439039 41 90 ,8808820398 147 90 4:9 5,90398 3
5,90398,3/020703.5,90398
%047,38,943/090723084.,3507147290,8808820398
%039,,880882039708:983,/4.:20390/5,341.,70.82439470/
%05,341.,70,843.:/08570;039;0,850.984190.,70
%0 47,38,943 /01308 90 920 17,20 93 . 90 39, ,880882039 8
.425090/%0 39, ,880882039 147 35,90398 8 /4.:20390/ 93 4:78 47 0,707 ,8
507905,90398.43/943474859,54.
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
3/29
.
/
0
,
-
.
/
0
,
-
.
/
0
1
,
-
.
/
0
,
-
,-47,94750784330,70574;/0/9,557457,908,10906:52039/0;.08
%0708,3089,-80/6:,9,88:7,3.05747,2201472,3
807;.08%06:,9,88:7,3.05747,21472,3807;.088/4.:20390/
79903 54.08 ,3/ 574.0/:708 :/0 90 ,3/3 ,3/ /8548, 41 310.94:8 ,3/
,,7/4:82,907,8
,-47,94750784330,70,557457,9097,30/38,1057,.9.08
%05747,220,//7088088:7;0,3.0419089708:98
79.,708:98,70392,90/220/,909490.43.0730/50784330
2,3 90898 349 ,;,,-0 3 90 47,3,943 ,70 4:984:7.0/ 94 47,3,9438
-,80/439076:,9,88:7,3.088902
%05747,2203.:/085074/..,-7,943,3/2,3903,3.041,06:520398
%05747,2203.:/0890/4.:2039,94341.4770.9;0,3/570;039;0,.9438
%0708,3089,-80/,-47,9478,1095747,220
%0,-47,9478,1095747,2208/4.:20390/
/06:,90 6:,10/ ,3/ 97,30/ 50784330 5071472 8:507;80 ,3/ 39075709 90
3;089,9438
!4.08 ,3/ 574.0/:708 :/0 /0391.,943 ,3/ 8,10 97,385479,943 41 5,90398 94
2,3807;.08
2,3708:98,70,;,,-093,/0130/92017,20
%85747,22083907,90/99047,38,94388,1095747,220
2,3807;.08,70574;/0/,850790706:70203941905,90398
2,3807;.08.4259900,,3/4907706:702039
$.450 41 90 2,3 807;.08 ,70 .422038:7,90 94 90 807;.08 574;/0/ - 90
47,38,943
%05747,220,//708808;071.,943,3/;,/,943412,32094/8
%05747,220,//7088088:7;0,3.0412,3708:98
%05747,2203.:/085074/..,-7,943,3/2,3903,3.041,06:520398
%05747,2203.:/0890/4.:2039,94341.4770.9;0,3/570;039;0,.9438
%0708,3089,-80/7,/,9438,1095747,220
%07,/,9438,1095747,2208/4.:20390/
%85747,22083907,90/99047,3,94388,1095747,220
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
4/29
0
1
,
-
.
/
0
1
,
-
.
/
,
-
.
/
0
1
!4.08 ,3/ 574.0/:708 089 147 .447/3,943 41 ;,74:8 /05,7920398 ,3/
,03.083;4;0/390/8.,70574.0883.:/320/.40,.,808
%0 5,90398 70.47/8 8 ,;,,-0 94 ,:9470/ .,70 574;/078 94 1,.9,90 90
0.,304131472,943
!4.08 ,3/ 574.0/:708 :/0 90 701077, 41 5,90398 94 4907 /05,7920398850.,908
!4.08,3/574.0/:708,7035,.01475,903980,;3,,38920/.,,/;.0
%047,38,943,8,/4.:20390//8.,70574.088
%0 5,90398 /8.,70 574.088 8 5,330/ 3 .438:9,943 9 90 5,9039 ,3/ 47
1,2
31472,943 ,-4:9 90 5,90398 .,70 ,3/ 70854380 94 970,92039 8 8,70/ ,243
20/.,3:783,3/4907.,70574;/078
31472,943 8 0.,30/ ,3/ /4.:20390/ /:73 0,. 89,113 819 -09003
8198,3//:7397,381078-09003:398/05,7920398
7,38,943/013090.4390394190/8.,708:22,7
/8.,70 8:22,7 8 ;03 94 , 90 5,90398 0,;3 90 47,3,943
3.:/35,903980,;3,,38920/.,,/;.0
8.,70 8:22,7 3.47547,908 3897:.9438 ,-4:9 03 ,3/ 4 94 4-9,3
:7039.,70
8.,708:22,78574;/0/94905,90398,99092041/8.,70
8.,70 8:22,7 .439,38 90 70,8438 147 ,/28843 831.,39 13/38 ,3/
/,3488,3/905,90398.43/943,99092041/8.,70
8.,70 8:22,7 .439,38 31472,943 70,7/3 3;089,943 708:98 ,3
574.0/:7050714720/20/.,943,3/4907970,92039;03
8.,70 8:22,7 .439,38 144 :5 ,/;.0 20/.,943 ,3/ 4907 3897:.94383,3:3/0789,3/,-02,3307
3.,8041/0,9908:22,74190.,80,843.:/0890.,:8041/0,9
!,9039.,708.4393:4:8,3/2:9/8.53,733,9:70
:73 , 5,808 41 .,70 9070 8 , 6:,10/ 3/;/:, /03910/ ,8 7085438-0147905,90398.,70
,70415,903988.447/3,90/3,.,7080993939047,38,943
#,/,9438,109/0;.08,705074/.,90890/,3//4.:20390/
2,350784330,7097,30/37,/,9438,10920,8:708
2,383,0,7057423039/85,0/3,,557457,904.,9438
!4.08 ,3/ 574.0/:708 :/0 90 8,10 :80 41 7,/4,.9;0 8494508 147 2,3
807;.08
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
5/29
,
-
.
/
0
,
-
.
/
0
1
,
-
.
/
0
1
,
-
,5907#!%%$!
!&31472.,70415,903988574;/0/3,809938419047,3,943
,3/8:/0/-90,55.,-0,870:,9438,3/:/0308
,70/0;078:314720382,7.,708574;/0/324709,343080993
%0 .,70 5,3 8 .4:3907830/ - 90 .3.,3 3.,70 41 90 5,9039 93
4:78
;/03.0 -,80/ 20/.30 ,3/ .3., 57,.980 :/0308 ,70 ,/4590/ 94 :/0
5,9039.,70030;075488-0
! 20703. 807;.08 ,70 :/0/ - 54.08 574.0/:708 ,3/
,55.,-0,8,3/70:,9438
&31472 .,70 8 :/0/ - 54.08 ,3/ 574.0/:708 . 7010.9 ,55.,-0 ,8
,3/70:,9438
%0 .,70 ,3/ 970,92039 47/078 ,70 830/ 3,20/ 920/ ,3/ /,90/ - 90.43.0730//4.947
!4.08,3/574.0/:70147020703..,70,70/4.:20390/
!4.08,84,//7088,3/34120/.40,.,808
%05,903970.0;08.,703.43843,3.099054.08
!4.08 ,3/ 574.0/:708 :/0 90 97,0 41 5,90398 147 39,943 41 ,557457,90
.,70
$9,11 8 1,2,7 9 90 54.08 ,3/ 97,30/ 43 90 574.0/:708 147 .,70 41
020703.5,90398
/28843 47 /8.,70 94 420 47 97,38107 94 ,34907 47,38,943 8 ,84
/4.:20390/
!%0,2-:,3.0807;.08,70.422038:7,909908.4504190
807;.08574;/0/-9047,38,943%0708,/06:,90,..088,3/85,.014790,2-:,3.08
2-:,3.088,557457,9006:550/
2-:,3.0882,330/-9097,30/50784330
%0708,.0.8941,06:52039,3/020703.20/.,9438
6:52039,70.0.0/43,/,-,88
20703.20/.,9438,70.0.0//,,3/574794/85,9.
%0,2-:,3.08,8,574507.422:3.,94388902
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 5,90398 706:73 .,7/4
5:243,7708:8.9,9434.:20390/ 54.08 ,3/ 574.0/:708 :/0 90 :31472 :80 41 708:8.9,943
974:4:99047,38,943
$9,11 574;/3 /70.9 5,9039 .,70 8 97,30/ ,3/ 5074/., :5/,90 3 .,7/4
/ 5489 0;039 ,3,88 41 , .,7/,. ,880798 8 /430 - , 2:9/8.53,7
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
6/29
/
0
,
-
.
/
0
1
,
-
.
/
0
1
,
-
.
/
0
,
-
54890;039 ,3,88 41 , .,7/,. ,880798 8 /430 - , 2:9/8.53,7
.4229900
4770.9;0,3/570;039;020,8:708,709,03-,80/439054890;039,3,88
! !4.08 ,3/ 574.0/:708 /0130 7,943, :80 41 -44/ ,3/ -44/
574/:.984.:20390/ 54.08 ,3/ 574.0/:708 ,70 :80/ 94 :/0 7,943, :80 41 -44/ ,3/
-44/574/:.98
%097,381:843807;.08,704;0730/-90,55.,-0,8,3/70:,9438
314720/ .438039 8 4-9,30/ 147 /43,943 ,3/ 97,381:843 41 -44/ ,3/ -44/
574/:.98
314720/.438039,843.:/085,9039,3/1,20/:.,943,-4:9/43,943
$9,11897,30/9425020399054.08
%7,381:84370,.9438,70,3,80/147570;039;0,3/.4770.9;0,.9438
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 78 4-89097.,
5,90398%0 47,38,943 /01308 ,3/ /85,8 0907 78 4-89097. .,808 -0 .,70/
14747349
!078438.,73147784-89097..,808,70.42509039
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 ;:307,-0 5,90398
0/0758.,,3/472039,.,030/,3/./703!4.08 ,3/ 574.0/:708 ,70 /4.:20390/ ,3/ ,70 3 ,..47/,3.0 9 90
570;,3,8,3/903,943,,3/39073,943,:/0308
,70847,380/,3//0;070/3,..47/,3.099054.08,3/574.0/:708
%0 47,38,943 574;/08 147 , 8,10 ,3/ 80.:70 03;7432039 147 98 ;:307,-0
74:5
/4.:20390/ 574.0/:70 0898 147 4-9,33 314720/ .438039 1742 90
,557457,900,705708039,9;0
$9,11897,30/94.,7014798;:307,-074:5
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 5,90398 3 90 39038;0
,70,3/0503/03.&398%0 47,38,943 ,8 /4.:20390/ ,/28843 ,3/ /8.,70 .7907, 147 98
39038;0.,70,3//0503/03.:398
$9,11897,30/94,559080.7907,
/06:,9089,11,3/06:52039,70,;,,-0
0130/574.0/:70814789:,94341-0/8479,08,701440/
310.943.4397457,.9.08,701440/
6:,9,88:7,3.05747,220825020390/
. 78 4-89097. 5,90398 ,880882039 ,84 3.:/08 2,9073, 3:97943
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
7/29
.
/
,
-
.
/
0
1
,
-
.
/
0
1
,
-
.
/
0
3220/,905704507,9;0700;,:,9438/4.:20390/
314720/.438039147,/23897,94341,308908,84-9,30/-90,30890989
!!4.08,3/574.0/:708:/090,/23897,94341,308908,
%0708,/4.:20390/54.,3/574.0/:7014790,/23897,94341,308908,
5,90398 147 ,308908, ,;0 , 570,308908, ,880882039 - , 6:,10/
3/;/:,
%0 570,308908, ,880882039 708:98 3 1472:,943 41 ,3 ,308908, 5,3
.8/4.:20390/
397, 574.0/:70 2439473 3.:/08 ,9 , 232:2 90 0,79 7,90 .,7/,.
792 70857,947 7,90 -44/ 57088:70 ,3/ 403 8,9:7,943 ,3/ 0;0 41!,90398,702439470/,190780/,943
7907, ,70 :80/ 94 /0907230 ,557457,903088 41 /8.,70 1742 90 70.4;07
,70,
6:52039 ,3/ 2,35407 ,70 ,;,,-0 94 708.:0 5,90398 1742 , /00507 0;0 41
80/,9439,39,93903/0/
42509039,3/97,30/5078438507147280/,943
%0 507843 ,/2389073 ,3/ 2439473 80/,943 8 /1107039 1742 90 507843
5071472390574.0/:70
%4804.,70147./703,;0,0850.1..4250903.
!74;8438,702,/0147850.,.,7041./703
!,9039 ,880882039 3.:/08 /09,0/ 3:97943, 749 58.484., ,3/
22:3,943,880882039
!4.08,3/574.0/:708570;039./3043,908,-/:.943,3/,-:80
784-89097.5,9039 8,880882039,843.:/082,9073,3:97943
%0 ./7038 1,2 202-078 ,70 0/:.,90/ ,-4:9 3:97943 22:3,943 ,3/
8,105,70393,3/988/4.:20390/39020/.,70.47/
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 5,90398 :3/0743
24/07,9080/,943
%0 47,3,943 .,73 147 78 4-89097. .,808 ,8 90 1,.908 94 9,0 .,70
413043,908418:..,808
!!4.08,3/574.0/:708:/090.,70415,0/,97.5,90398
%047,38,943/01308,3//85,8908.4504198/0/,97.807;.08
%0 54. 147 .,70 41 3043,9, 5,90398 8 3 .43843,3.0 9 90 3,943,
39073,943,:/0308
,. 5,90398 5489,308908, 89,9:8 8 2439470/ ,3/ /4.:20390/
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
8/29
,
-
.
/
0
1
,
-
.
/
0
,
- %0 47,3,943 70850.98 ,3/ 8:554798 90 ,557457,90 ,880882039 ,3/
%0803.:/0/4.:2039,9434170,843814770897,398
4.:20390/54.08,3/574.0/:708:/0902,3,02039415,3
%0805,90398,7024701706:0392439470/
$9,1170.0;097,33,3/5074/.:5/,933.43974,3/70897,3990.36:08
!!4.08,3/574.0/:708:/0,557457,905,32,3,02039
%05,3,843.:/082439473418:7.,890310.9437,908
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 5,90398 :3/07 70897,398
58.,,3/47.02.,4.:20390/54.08,3/574.0/:708:/090.,70415,90398:3/0770897,398
%0803.:/0-4958.,,3/.02.,70897,3920,8:708
-701 4507,9;0 3490 8 /4.:20390/ 5747 94 97,38107 4:9 41 5,9039 1742 70.4;07
,70,
%04507,938:70438/4.:203989054894507,9;05,341.,70
6:,9,88:7,3.05747,22081440/147908:7.,8:7;.08
%0 6:,9 ,88:7,3.0 5747,2 3.:/08 8:7;0,3.0 41 90 4507,943 90,970
03;7432039
$:7., 5,90398 ,;0 5704507,9;0 ,880882039 ,3/ , 574;843, /,3488
/4.:20390/5747948:707
3314720/.43803984-9,30/-908:704357479490574.0/:70
4.:20390/ 54.08 ,3/ 574.0/:70 089 94 570;039 ,/;0780 0;0398 0 743
8907435,90398,3/7438:707
!078438 6:,10/ - , ,70 5072990/ 94 5071472 90 574.0/:708 9,9 90 ,70
03990/945071472
6:,10/ 3/;/:, ,5508 /0130/ .7907, 94 97,38107 90 5,9039 1742 90
70.4;07,70,
,/;0780,308908,0;0398,7070.47/0/,3/2439470/
! !4.08 ,3/ 574.0/:708 :/0 90 .,70 41 5,90398 :3/0743
8:7.,574.0/:708%054.08,3/574.0/:708,70/4.:20390/
,.5,9039 85489 ,308908,89,9:882439470/,3//4.:20390/
! ! / / / 9 -9 9
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
9/29
,
-
.
,
-
.
/
0
1
,
-
.
/
0
1
,
-
.
/
4.:20390/ 54.08 ,3/ 574.0/:708 :/0 , 7080,7. ,.9;908 3 .425,3.0
93,943,,3/39073,943,:/0308
!!4.08,3/574.0/:708:/0,557457,9070,-9,9;0807;.08
%047,3,943,8,309.8.4229900944;07800,7080,7.,.9;908
4.:20390/ 54.08 ,3/ 574.0/:708 :/0 90 574;843 41 70,-9,9;0
807;.08
%080807;.08,70.422038:7,9099047,3,943,706:7020398
#0,-9,9;0807;.08,70574;/0/-,2:9/8.53,790,2
!!4.08,3/574.0/:708:/0,7080,7.,.9;908
%0 .4229900 ,8 90 54078 94 /8.4393:0 , 7080,7. 97, 03 788 4:90 90
549039,-030198
!,90398314720/.43803984-9,30/-0147003907390237080,7.57494.48
%08054.08,3/574.0/:708,703.43843,3.09900,706:7020398
!,90398 ,70 314720/ 41 907 79 94 9/7, 1742 90 7080,7. ,9 ,3 89,0
,3/,844190.43806:03.081,3418:.9/7,,
!,90398 ,70 ,88:70/ 9,9 907 701:8, 94 5,79.5,90 47 9/7,, 1742
5,79.5,943349.42574280907,..088949047,3,9438807;.08
!!4.08,3/574.0/:708:/03:97943,907,5
4.:20390/ 54.08 ,3/ 574.0/:708 :/0 3:97943, ,880882039 ,3/
70,880882039
!,9039870.0;0144/,..47/394907.3.,300/8
%0708,7990347/0714790/09
:97943,907,585,330/,3/574;/0/3,.4,-47,9;02,3307
031,208574;/0144/90,700/:.,90/,-4:9905,90398/0929,9438
44/85705,70/,3/0/89470/,3//897-:90/3,8,102,3307
!!4.08,3/574.0/:708:/09003/4110.,70
4.:20390/54.08,3/574.0/:708:/09003/4110.,70
%080 ,84 ,//7088 90 /0391.,943 41 90 :36:0 300/8 41 8:. 5,9039 ,3/
1,2
%080 ,84 3.:/0 80389;0 ,//70883 88:08 8:. ,8 ,:9458 ,3/ 47,3
,5907 % %
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
10/29
,
-
.
,
-
.
/
,
-
.
/
0
1
,
-
.
!4.08 ,3/ 574.0/:708 :/0 90 47,3,943 41 5,72,.
807;.08,3/:8,04120/.,943%070 8 , /4.:20390/ 54. ,3/ 574.0/:70 147 5,72,. 807;.08 ,3/
20/.,943:8,0
%080.425990,55.,-0,8,3/70:,9438
2:9/8.53,7 .4229900 :/08 90 1472:,943 ,3/ 2502039,943 41
908054.08,3/574.0/:708
%0708,4859,1472:,7
89 41 20/.,943 ,557457,90 147 90 5,90398 ,3/ 47,3,9438 7084:7.08 8
/0;0450/
!4.08,3/574.0/:7080891478947,04120/.,943
4.:20390/54.08,3/574.0/:7080891478947,04120/.,943
0/.,9438,7089470/3,.0,309,3/;039,90/03;7432039
$4:3/3;03947.4397457,.9.08:/08947,0419020/.,9438
0/.,9438,7057490.90/1742488479019
$4:3/,0,3/44,020/.,9438,7089470/805,7,90
20703.20/.,9438,70,;,,-0,90920
20703.20/.,9438,707050380/3,9202,330703:80/
!4.08,3/574.0/:7080891475708.759434120/.,9438
4.:20390/54.08,3/574.0/:7080891475708.759434120/.,9438
%047,3,943/090723084.,379047/078
%0898/0;0450/.4,-47,9;0-902:9/8.53,7.4229900
%0708,/0130/574.088147,.6:894341908020/.,9438
%0708,574.088944-9,320/.,9438349890/3901472:,7
,5907%%
7/078,70799033,:314724.,94339020/.,70.47/8
%0708,2094/944-9,320/.,94303905,72,.8.480/
0 !4.43;07-,47/0788/4.:20390/,3/25020390/
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
11/29
1
,
-
.
/
,
-
.
/
0
1
,
-
%054.083.:/0,574.0/:7014720/.,94370.,
%238;0710/17429047/07574794,/23897,943
0/.,943,/23897,9438/4.:20390/
!4.08,3/574.0/:7084;0735,90398801,/23897,9434120/.,9438
!4.08 ,3/ 574.0/:708 4;073 5,90398 20/.,9438 -74:9 1742 4:98/0 9047,3,943
4.:20390/54.08,3/574.0/:708:/0908,10/8503834120/.,9438
57/,908,70.0.0/574794/850383
#4:908;0710/17429047/07574794,/23897,943
%047,3,943/01308,89417820/.,943
!,90398 ,3/ 1,2 202-078 ,70 0/:.,90/ ,-4:9 8,10 20/.,943
,3/144//7:3907,.9438
,-03706:7020398,70/4.:20390/,3/25020390/-9047,3,943
%070,70/0130/574.0/:70814720/.,943,/23897,943
0/.,9438,70,/2389070/-94804,705072990/-,94/484
!705,70/20/.,943,70,-00/5747945705,7,94341,80.43//7:
7820/.,94347/078,70;0710/574794/850383
!4.08,3/574.0/:708:/0908,10/8503834120/.,9438
!,90398/03910/574794,/23897,943
0/.,9438;0710/17429047/07574794,/23897,943
48,08;0710/17429047/07574794,/23897,943
!,9039,3/1,2,700/:.,90/,-4:98,10,3/0110.9;0:804120/.,943
!,9039,3/1,2,700/:.,90/,-4:9144//7:3907,.9438
!,90398,702439470/,190720/.,943,/23897,943
- /;0780/7:0;0398,70/0130/
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
12/29
.
/
0
,
-
.
/
,
-
.
/
,
-
.
/
,
-
.
024907,585705,70/,3/,/2389070/-6:,10/50784330
024907,5/7:8,70/85480/4113,..47/,3.090,706:7020398
!4.08,3/574.0/:7084;073:8,0417,/4,.9;0/7:8
/;0780/7:0;0398,707054790/93,850.10/92017,20
/;0780/7:0;0398,70.40.90/,3/,3,80/
!4.08 ,70 24/10/ 94 70/:.0 ,/;0780 /7: 0;0398 03 :3,..059,-0 9703/8
4..:7
!4.08 ,3/ 574.0/:708 :/0 90 :80 41 3,7.49. /7:8 ,3/
58.49745.8:-89,3.084.:20390/ 54.08 ,3/ 574.0/:708 :/0 90 :80 41 3,7.49. /7:8 ,3/
58.49745.8:-89,3.08
%08054.08,703.43843,3.094.,,3/3,943,70:,9438
57450770.47/80594190:8,0,/23897,943,3//8548,419080/7:8
%0 54.08 ,3/ 574.0/:708 3.:/0 90 8,10 8947,0 5705,7,943 ,3/3
/897-:943,3//8548,417,/4,.9;0/7:8
!4.08 ,3/ 574.0/:708 :/0 90 :8,0 41 .024907,50:9.,0398
024907,5 8 5708.7-0/ - 9480 4 ,;0 90 340/0 94 243947 ,3/
970,990,/;07800110.941.024907,5
4.:20390/ 54.08 ,3/ 574.0/:708 :/0 90 :8,0 41 .024907,50:9.
,0398
!4.08,3/574.0/:708:/090:804125,39,-057489088
$9,115,90398,3/;89478,700/:.,90/438,109570.,:9438
%0 -,9. ,3/ 807, 3:2-07 41 90 25,39,-0 57489088 ,70 70.47/0/ 3 90
5,9039820/.,70.47/,3/902,89074-44
4.:20390/ 54.08 ,3/ 574.0/:708 4;073 574.:702039 ,3/ :8,0 41
25,39,-057489088
$00.943 41 25,39,-0 57489088 8 -,80/ 43 8.0391. .7907, ,3/ 3,943,
39073,943,70.430/,5574;,8
%080/7:8,70,3/0/-,557457,90507843303,..47/,3.0954.08
4.:20390/54.08,3/574.0/:7084;073:8,0417,/4,.9;0/7:8
%08054.08,3/574.0/:708,703.43843,3.09,8,3/70:,9438
, 4.:20390/ 54.08 ,3/ 574.0/:708 4;073 574.:702039 ,3/3 8947,0
/ 9 - 9 / 9 1 /
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
13/29
-
. 557457,90 70.47/8 ,70 2,39,30/ 3 ,..47/,3.0 9 90 54.08 574.0/:708
,3/0,706:7020398
/897-:943:8,0,3/70503820394120/.,,808
%054.08,3/574.0/:708,//7088908,10988:08,9,0;08
,5907 !%% #%$ &% !#
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
14/29
,
-
.
/
0
,
-
.
/
0
1
,
-
.
/
0
$9,118,,70419077085438-9357490.935,90398,3/1,2798
'4,943 41 5,9039 ,3/ 1,2 798 8 70.47/0/ 70;00/ ,3/ .4770.9;0
570;039;020,8:7089,03
!,90398 ,3/ 1,208 ,70 314720/ 41 907 798 ,3/ 7085438-908 3 , 1472,9
,3/,3:,09,990.,3:3/0789,3/
%047,3,94380,/07857490.95,90398,3/1,2798
!# %0 47,3,943 57490.98 5,9039 ,3/ 1,2 798 314728 902
,-4:99077085438-908/:73.,70
!,9039,3/1,2798,3/7085438-908,70/4.:20390/
!,9039,3/1,27983.:/0701:8,41970,92039
!# !,9039 ,3/ 1,2 798 8:55479 3/;/:, -0018 ;,:08 ,3/
3;4;0905,9039,3/1,23/0.8432,3574.08808!,9039 ,3/ 1,2 798 ,//7088 ,3 850., 57010703.08 8579:, ,3/ .:9:7,
300/8
!,9039,3/1,27983.:/057490.943174258.,,-:80,3/300.9
!,9039,3/1,27983.:/0970,935,903931472,943,8.431/039,
!,9039 ,3/ 1,2 798 3.:/0 70850.9 147 507843, /39 ,3/ 57;,. /:73
0,23,943574.0/:708,3/970,92039
!,9039 ,3/ 1,2 798 3.:/0 31472,943 43 90 050.90/ .489 41 90
970,92039
!,9039,3/1,2,;0,7994,;0,3,..08894807.3.,70.47/8
!,9039 ,3/ 1,2 798 3.:/0 314720/ .438039 -01470 ,3,08908, -44/ ,3/
-44/574/:.997,381:8438,3/,33;,8;078574.0/:708970,92039
!,9039 ,3/ 1,2 79 3.:/0 31472,943 ,3/ .438039 -01470 ,3 7080,7.
57494.4839,90/
!,9039,3/1,27983.:/031472,94343494;4.0,.425,39
!# /4.:20390/ 574.088 147 4-9,33 5,9039 ,3/ 47 1,28 .438039
0898147314720//0.8432,3,-4:9907.,700307, .438039 147 970,92039 8 4-9,30/ 03 90 5,9039 039078 90
47,38,943!,9039 ,3/ 47 8 1,2 202-078 ,70 314720/ 41 90 8.450 41 8:. 0307,
.438039
%047,38,943,8890/948089:,9438070314720/.4380398706:70/
314720/ .438039 3.:/08 31472,943 43 788 -030198 ,9073,9;08 ,3/ ,8 94
4507147290706:890574.0/:703,,3:,09,990.,3:3/0789,3/
%0 54. /08.7-08 4 .,3 ;0 .438039 03 5,9039 8 3.,5,-0 41
3/0503/039/0.8432,3
,5907!%%#%$&%!#
, 03 ,557457,90 5,9039 ,3/ 1,208 ,3/ ,70 0/:.,90/ ,-4:9 90 8,10 ,3/
0110.9;0 :80 41 20/.,943 ,3/ 90 549039, 8/0 0110.98 41 90 20/.,943
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
15/29
-
.
/
0
1
,
-
.
/
!,9039 ,3/ 1,208 ,70 0/:.,90/ ,-4:9 907 850.1. /80,80 574.088
.425.,9438,3/570;03943897,9008
!,9039,3/1,208,700/:.,90/,-4:9570;0393310.9438
!,90398 ,3/ 1,2 ,70 9,:9 3 , ,3:,0 ,3/ 1472,9 9,9 90 .,3:3/0789,3/
!#!,9039,3/1,208,;0,799431472,94343050.90/.4898
0110.9;0:804120/.,943,3/90549039,8/00110.98419020/.,943
!,9039,3/1,208,700/:.,90/,-4:9/09,3/3:97943
!,9039,3/1,208,700/:.,90/,-4:922:38,9438
%0708:3147257.354.3,;03809934:95,9039,3/,7/.,9047
%09,711898,;,,-0945,90398
!,90398,3/1,2,700/:.,90/,-4:9900892,90/.48941970,92039
!,90398 ,3/ 1,2 ,70 314720/ ,-4:9 90 13,3., 25.,9438 03 9070 8 ,
.,303905,9039.43/94347970,9203980993
,5907$!%%%#
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
16/29
,
-
.
/
,
-
.
/
0
1
,
-
.
/
0
1
330073.43974894570;039310.9438,703.:/0/
%0 47,38,943 ,8 ,3 310.943 .43974 2,3:, . 8
5074/.,:5/,90/
%0 310.943 .43974 90,2 8 7085438-0 147 8:7;0,3.0 ,.9;908 3
/03910/,70,841904859,
$:7;0,3.0 ,.9;908 ,70 ,557457,90 /70.90/ 94,7/8 90 /03910/ 78
,70,8
40.943418:7;0,3.0/,9,8,34343574.088
'071.,94341/,9,8/4304370:,7-,88-90310.943.4397490,2
$.450 41 8:7;0,3.0 ,.9;908 3.47547,908 97,.3 ,3/ ,3,3 41 310.943
7887,908,3/9703/8
%0 4859, 310.943 .43974 5747,220 8 /4.:20390/ . ,28 ,9
570;0393,3/70/:.378413484.42,310.9438
%02,3:,/03910890;,74:878,70,8,3/574.0/:708
3,557457,90,39-49.54.8089,-80/,3/25020390/
,:3/7,3/3032,3,02039574.08808,70,843.:/0/
9.038,39,943,3/144/,3/388:08,703.:/0/3902,3:,
%0 47,3,943 9,08 ,.9438 94 570;039 47 70/:.0 90 78 41
3 .,808 41 3491,-0 /80,808 31472,943 3 700;,39 1472,9 8 8039 94 ,557457,90
,:947908
479:,7 57,.9.08 ,3/ 574.0/:708 ,70 3.:/0/ ,8 ,557457,90 94 90
47,3,943
%0 4859, ,8 /083,90/ ,3/ 6:,10/ 310.943 .43974 3:7808 147 98
,.9;9
914.:80843,/0703.09489,3/,7/570.,:9438,9,9208
6:52039.0,33,3/89078,94357,.9.08,703.:/0/
%04859,,8,2:9/8.53,7310.943.43974.4229900
%04859,,8,3310.943.4397490,2
94:93082094/8418:7;0,3.0390/03910/78,70,8
%0 47,3,943 ,8 , 0/0830/ .42570038;0 ,3/
.447/3,90/ 310.943 .43974 5747,220 ,20/ ,9 70/:.3 023,93
788945,90398;89478,3/574;/07841.,70
%047,3,943/01308905074/.941:5/,9390310.943.439742,3:,
$:7;0,3.0 ,.9;908 3.:/0 2439473 90 0110.9;03088 41 4:800053
807;.08
, %047,3,9432439478:73,797,.9310.9438
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
17/29
-
.
/
0
,
-
.
/
,
-
.
,
-
.
,
-
.
/
0
1
%047,3,943243947870857,94797,.9310.9438
420/., ,890 970,92039 1,.9 8 2,3,0/ ,8 507 89,9:947 574;8438 1 3
4:80474:984:7.0/94,:94780/.4397,.9478
%047,3,94324394788:7.,890310.9438
557457,90 100/-,. 70,7/3 7,908 ,70 574;/0/ 43 , 70:,7 -,88 94
20/.,,3/3:78389,11
%047,3,9432439478397,;,8.:,7/0;.0310.9438
%0 47,3,943 038:708 9,9 420/., ,890 8 89470/ ,3/ 97,3854790/ 94 90
890 41 970,92039 ,3/ /8548, 3 574507 .4;070/ ;0.08 93 895:,90/ 920
2983,80.:702,3307
,3/ ,83 1,.908 3 , 5,9039 .,70 ,70,8 ,70 ,..088-0 94 0,9 .,70
574;/078
!74507 1,.908 ,3/ ,/06:,90 7084:7.08 ,70 574;/0/ 94 8:55479 90310.943.439745747,220
425,3.09574507,3/,8382439470/70:,7
%070 ,70 /4.:20390/ 574.0/:708 147 89078,943 ,.9;908 3 90
47,38,943
84,943-,77073:7831,.908,70,;,,-0
/06:,90 4;08 2,88 84,58 ,3/ /8310.9,398 ,70 ,;,,-0 ,3/ :80/
.4770.9
1907 90 4:9-70, 8 4;07 ,557457,90 .4770.9;0 ,.9438 ,70 9,03 94 570;039
70.:7703.0
%0 47,38,943 9,08 ,557457,90 ,.9438 94 .43974 4:9-70,8 41
310.94384859,,8,/4.:20390/574.0/:70147,3/38:.4:9-70,8
%8574.0/:70825020390//:734:9-70,8
%0708,/06:,9085,.0,;,,-01478907,943,.9;908
#06:890 1008 /4.:20398 ,3/ 7054798 ,70 8:-2990/ 94 .42509039 ,:947908 43
895:,90//,908
557457,90 507843, 57490.9;0 20,8:708 ,70 :80/ - , .,904708 41 89,11
,3/3 4 20/., ,890
#0:,7;,/,9439089814789078,943,70.,770/4:9,3//4.:20390/
%0 4859, 8 ,:94780/ - 5708.7-0/ ,:9479 147 90 2,3,02039 ,3/
,3/341420/.,,890
!74507 8070,943 ,3/ .40.943 41 420/., ,890 1742 , 5,9039 .,70
,70,841904859,825020390/,3/2439470/
%070 8 ,3 089,-80/ 70., 574.0/:70 03 -70,/43 3 90 89078,943
889028/03910/
$9,9:947 574;8438 9 70,7/ 94 420/., ,890
2,3,02039,70.4250/9
%0 310.943 .43974 5747,220 8 8:554790/ - 90 47,38,9438
9 / / 9 1 9 11 / 9
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
18/29
,
-
.
/
0
%0 4859, 70:,7 0,72,78 ,/06:,90 1:3/8 1742 98 ,33:, -:/09 3 98
70,7/
2,3,02039,3/3.:/0897,334189,11,3/0254000,9
9 .43/:.98 70:,7 5703/:.943 97,33 147 ,557457,90 .,904708 41 89,11 -01470
433.43.0730//05,7920398
9 ,84 .43/:.98 70:,7 3807;.0 97,33 8088438 147 , .43.0730/ .,904708
4189,11,90,8943.03,0,7
557457,90 570 ,3/ 5489 0548:70 5745,8 8 574;/0/ 94 , .43.0730/ 89,11
202-078
4859, 2,3,02039 2,08 ,;,,-0 7084:7.08 706:70/ 147 90 310.943
.439745747,220
,5907%&&$"&%!#'%"
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
19/29
,
-
.
/
0
1
,
-
.
/
0
1
,
-
" %070 8 , 897:.9:70/ 6:,9 2574;02039 ,3/ .4393:4:8 2439473
5747,22039047,3,943
%06:,92574;020395747,2208/4.:20390/
%0 6:,9 2574;02039 5747,220 8 /0;0450/ 25020390/ ,3/ 2,39,30/
-,2:9/8.53,7.4229900
%070 8 , /083,90/ 3/;/:, 147 .447/3,93 ,3/ 25020393 90 6:,9
2574;020395747,220
%0 6:,9 2574;02039 5747,220 8 70;00/ ,9 570/0130/ 3907;,8 ,3/
455479:39081472574;02039,70/03910/
%0 6:,9 2574;02039 5747,220 8 .42570038;0 ,3/ .4;078 , 90 2,47
002039870,90/946:,92574;02039,3/782,3,02039
%0 /083,90/ 5747,220 8 .422:3.,90/ ,3/ .447/3,90/ ,24389 , 90
0254008419047,3,943974:57450797,3320.,382
4394733.:/08,3;,8;0574.0/:708
4394733.:/08705479341,.9;908,8706:70/-,8,3/70:,9438
%0 6:,9 2574;02039 5747,220 8 , .4393:4:8 574.088 ,3/ :5/,90/ ,9
0,8943.03,0,7
4394733.:/08310.943.43974,.9;908
4394733.:/08,/;0780/7:0;0398
4394733.:/08:8041,3,08908,
" %0 47,3,943 /039108 0 3/.,9478 94 243947 90 .3.,
897:.9:708 574.08808 ,3/ 4:9.4208 . ,70 :80/ ,8 9448 147 .4393:,
2574;02039
4394733.:/08,557457,905,9039,880882039
439473 3.:/08 8,109 ,3/ 6:,9 .43974 5747,2208 41 90 /,3489.8
807;.08
4394733.:/08:8041-44/,3/-44/574/:.98
4394733.:/08,;,,-9,3/.4390394120/.,70.47/8
4394733.:/08574.:7020394120/.,943088039,9420095,9039300/8
4394733.:/08.3.,7080,7.
" %0 47,3,943 /039108 0 3/.,9478 94 243947 90 2,3,07,
897:.9:708 574.08808 ,3/ 4:9.4208 . ,70 :80/ ,8 9448 147 .4393:,
2574;02039
4394733.:/08/,9,.40.943948:554790;,:,9434190802574;020398
4394733.:/08/,9,.40.943948:554791:79072574;020398
/ 4394733.:/08:98,9434185,.02,35407,3/06:52039
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
20/29
0
1
,
-
.
,
-
.
/
0
,
-
.
/
"%0708,3089,-80/88902147,:/9415,9039.,70807;.08
0/.,,3/3:78389,115,79.5,90839888902
4859, ,3,02039 2,08 ,;,,-0 ,/06:,90 7084:7.08 706:70/ 147 6:,9
2574;020395747,220
4859,0,72,78,/06:,901:3/8174298,33:,-:/0939870,7/
557457,9089,989.,,3/2,3,020399448,70,550/030;07706:70/
439473 3.:/08 5,9039 8,981,.943 . ,84 3.47547,908 ,93 920 147
807;.08
4394733.:/080254008,981,.943
4394733.:/08,/;07800;0398,3/30,728808
4394733.:/08/,9,.40.943948:554791:790789:/1472574;020398
4394733.:/08/,9,.40.943948:554790;,:,9434190802574;020398
" %0 6:,9 2574;02039 5747,220 8 8:554790/ - 90
2,3,02039
%047,38,943,8/0130/8039300;0398
%047,38,943,8089,-80/574.08808147390380,3,88418:.0;0398
$039300;0398,7039038;0,3,80/03904..:7
4770.9;0 ,3/ 570;039;0 .9438 ,70 9,03 -,80/ 43 90 13/38 41 8:.
,3,88
%05,7,20907894-0,:/90/,70/0130/-9047,38,943
,:/98,70/4.:20390/
#020/,20,8:708,7025020390/
"$039300;0398,7039038;0,3,80/
!,9039,3/89,11,3432982,39,30/
,5907#$!$%$%#
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
21/29
,
-
.
/
0
1
,
-
.
/
,
-
.
/
0
1
,
%4807085438-01474;073,3.0,5543990803470,/07839047,3,943
%480 7085438-0 147 4;073,3.0 8:55479 7080,7. ,.9;908 ,3/ 6:,9
2574;020395,38
%0 47,3,943 .42508 9 90 ,/ /43 ,3/ ,55.,-0 08,9438 ,3/
70:,9438
%480 7085438-0 147 4;073,3.0 ,//7088 90 47,3,9438 84.,
7085438-9
,. 47,3,943, 5747,2 807;.0 890 47 /05,792039 ,8 0110.9;0
0,/0785
#%0807;.08574;/0/-0,./05,792039,70/4.:20390/
#%07085438-90841902,3,02039,70/0130/
%4807085438-01474;073,3.0,/439047,3,94382884389,902039
%480 7085438-0 147 4;073,3.0 , /43 90 897,90. ,3/ 4507,943, 5,38
.422038:7,90949047,3,9438288433.438:9,943990;,74:889,0
4/078
%4807085438-01474;073,3.0,5574;09047,3,9438-:/09,3/,4.,90
907084:7.08706:70/9420099047,3,943828843
$.45041807;.08410,./05,7920398/0130/
/23897,9;054.08,3/574.0/:7081470,./05,79203982,39,30/
05,792039,0,/078,703;4;0/36:,92574;02039
# 8:9,- 6:,10/ ,3/ 050703.0/ 3/;/:, 0,/8 90
47,38,943
%047,3,943/8.480898430785
%047,3,9434308954797,890807;.08.9.,3,3/.,3349574;/0
%0 47,3,943 ,..:7,90 -8 147 98 807;.08 -,80/ :543 , 89,3/,7/ -3
9,711
%047,3,9434308954797,898,11,9438,3/,..70/9,9438
%480 7085438-0 147 4;073,3.0 243947 ,3/ 20,8:70 90 5071472,3.0 41 90
47,3,943,,3899089,90/28843
%4807085438-01474;073,3.0089,-89047,3,943847,347,2
#%047,3,94382,3,0/-900,/0783,309.,2,3307
%00,/0782,05:-.902884389,902039419047,3,943
%00,/078089,-89047,3,943809.,2,3,02039
% / 9 / / / 9 / 9 / 9 9 - %0 /083,90/ 3/;/:, ,8 706:890 ,3/ ,557457,90 ,/23897,9;0
050703.0
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
22/29
,
-
.
/
,3,02039 038:708 2502039,943 41 889028 147 39073, ,3/ 09073,
70547934188902,3/574.0881,:708
,3,02039 574;/08 7084:7.08 147 574,.9;0 78 ,880882039 ,3/ 78 70/:.943
,.9;908
# 0,/078 038:70 9,9 5,9039 8,109 ,850.98 ,3/ 78 2,3,02039
88:08,70,33907,5,79415,9039.,70,3/4859,2,3,02039
%0 47,3,943 ,8 ,3 3907/8.53,7 74:5 ,8830/ 94 4;07800 90 4859,
/08,1095747,220
%0 8.450 41 90 5747,220 8 /0130/ 94 3.:/0 ,/;0780 0;0398 7,33 1742
34,72948039300;0398
,5907%%$%$
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
23/29
,
-
.
/
,
-
.
/
0
1
,
-
.
/
0
1
,
-
.
$ %0 47,3,943 8 ,,70 41 ,3/ .42508 9 90 700;,39 7:08 ,3/
70:,9438,8,3/-0,8,3/706:8901,.93850.943706:7020398
%0 2,3,02039 8 .43;078,39 9 90 ,8 ,3/ 70:,9438 ,3/ 348 907
,55.,-9949047,3,943
%0708,20.,3829470:,7:5/,90.0380870897,9438.0791.,9438
%070 8 39073, ,3/ 09073, 83 54893 3 90 47,38,943 3 , ,3:,0:3/078944/-5,90391,208,3/.422:39
,3,02039 70:,7 :5/,908 ,3 ,203/20398 3 90 570;,3 ,8 41 90
,3/
%02,3,02039038:7082502039,943419080706:7020398
":,10/,3/97,30/507843304507,90,3/2,39,39006:52039
6:52039,705074/.,3850.90/,3/.,-7,90/1479075745071:3.9433
%0708,/4.:20390/4507,943,,3/2,3903,3.0570;039;0,3/-70,/43
5,3
%070 ,70 /083,90/ 3/;/:,8 7085438-0 147 90 2,3903,3.0 41 , 90
1,.908
,3903,3.089,118.439,.9,-074:3/90.4.147020703.705,78
$ %0 47,3,9438 03;7432039 ,3/ 1,.908 4507,90 94 038:70
8,109415,903989071,20889,11,3/;89478
%0708,/4.:20390/4507,943,,3/2,3903,3.0570;039;0,3/-70,/43
5,3
&594/,90 /7,38 ,70 2,39,30/ . /09, 90 890 ,4:9 1447 5,38 ,3/
17008.,5074:908
%0 574;843 41 85,.0 8, -0 3 ,..47/,3.0 9 90 ,;,,-0 907,9:70 43
44/ 57,.9.08 3/,3 47 39073,943, $9,3/,7/8 ,3/ /70.9;08 1742
4;0732039,03.08
$ %0 47,3,943 ,8 , 5747,2 147 .3., ,3/ 8:55479 807;.006:520392,3,02039
%0 47,3,943 5,38 147 06:52039 3 ,..47/,3.0 9 98 807;.08 ,3/
897,90.5,3
6:520398800.90/-,.4,-47,9;0574.088
06:5203983;039470/,3/57450748,702,39,30/,8706:70/
#0854380 9208 ,70 2439470/ 1742 7054793 94 3850.943 ,3/ 2502039,943
41.4770.9;0,.9438
$ %0 47,3,943 ,8 574;8438 147 8,10 ,907 00.97.9 20/.,
,808,3/;,.::2889028!49,-0,907,3/00.97.9,70,;,,-074:3/90.4.
9073,9084:7.08,70574;/0/1473.,80411,:70
%047,38,94370:,79089890,9073,9084:7.08
, %0 47,3,943 ,8 5,38 ,3/ 574;8438 147 0,7 /090.943 .439,32039 ,3/
$ %0 47,3,943 ,8 5,38 147 170 ,3/ 343170 020703.08 93901,.908
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
24/29
,
-
.
/
,
-
,
-
.
/
0
,
-
.
/
0
,
-
.
/
0
!,9039 8,109 /0;.08 ,70 389,0/ ,.7488 90 47,3,943 ,3/ 3850.90/
5074/.,
%0 47,3,943 ,8 5,38 ,3/ 574;8438 147 0,7 /090.943 .439,32039 ,3/
,-,90203941170,3/343170020703.08
4859,89,11897,30/3904859,8/8,89072,3,020395,3
%047,3,943,8,/4.:20390//8,89072,3,020395,3
!74;843 8 2,/0 147 ,;,,-9 41 20/., 8:5508 06:52039 ,3/ 2,907,8
/:738:.020703.08
%05,3890890/,90,899.03,0,7
%0 4859, ,8 , 8,109 .4229900 94 /0391 90 549039, 8,109 ,3/ 80.:79
788
%8 .4229900 .447/3,908 /0;0452039 2502039,943 ,3/ 2439473 41 90
8,1095,3,3/54.08
,.9 3850.943 74:3/8 94 038:70 8,109 ,70 .43/:.90/ ,9 0,89 9.0 3 , 0,7
35,9039.,70,70,8,3/,90,8943.03,0,733435,9039.,70,70,8
3850.943 7054798 ,70 /4.:20390/ ,3/ .4770.9;0 ,3/ 570;039;0 20,8:708 ,70
/ 9
4./78,700/,90,899.03,0,7
$%047,3,943,8,824329,94354.
%0 47,3,943 ,8 , /4.:20390/ 8,10 09 5,3 3 .,80 41 170 ,3/ 343170
020703.08
%04859,/039108549039,020703.08
,,7/4:82,907,8,70/03910/939047,3,943
%0 47,3,943 /01308 ,3/ 2502039 98 54.08 94 70/:.0 47 023,90
8243
$%047,3,943,8,5,31472,3,0203941,,7/4:82,907,8
$9,11897,30/1479077403.,80418:.020703.08
$ %0 47,38,943 ,8 889028 3 5,.0 94 574;/0 , 8,10 ,3/ 80.:70
03;7432039
#06:89070:,947706:7020398,70209370850.9417,/4,.9;02,907,8
%0708,5,31472,3,385841,,7/4:82,907,8
$9,1180/:.,90/,3/97,30/147,3/38:.2,907,8
%0 4859, 25020398 574.08808 147 84793 ,-03 ,3/3 8947,0
97,3854793,3//8548,41,,7/4:82,907,
%0 54. ,8 574;8438 147 7,393 0.059438 147 5,90398 ,3/ 1,208 94
8240
$ %0 47,3,943 5,38 147 ,3/3 .422:39 020703.08
05/02.8,3/4907/8,89078
,5907$%#
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
25/29
,
-
.
,
-
.
/
0
,
-
.
,
-
.
/
,
-
# %0 47,3,943 ,8 , /4.:20390/ 88902 41 :2,3 7084:7.0
5,333%0 47,3,943 2,39,38 ,3 ,/06:,90 3:2-07 ,3/ 2 41 89,11 94 2009 90
.,70970,92039,3/807;.0300/841905,9039
%0 706:70/ 4- 850.1.,9438 ,3/ 4- /08.75943 ,70 0 /0130/ 147 0,.
.,90474189,11
%0 47,3,943 ;07108 90 ,390.0/0398 41 90 549039, 025400 9 70,7/8
94.723,3003.0-,.74:3/
0254008,700/:.,90/970,7/945,90398798,3/7085438-908
0254008,70470390/9490807;.089,3/,7/8419047,38,943
# %070 8 ,3 4343 5747,220 147 574108843, 97,33 ,3/
/0;0452039419089,11
# %0 89,11 433 90 47,3,943 8 84.,0/ ,3/ 470390/ 94 90
4859,03;7432039,. 89,11 202-07 025400 89:/039 ,3/ ;4:39,7 4707 8 ,557457,90
470390/949047,3,943828843,3/4,8
,. 89,11 202-07 8 2,/0 ,,70 41 4859, /0 54.08 ,3/ 574.0/:708 ,8
0 ,8 700;,39 /05,792039 :39 807;.0 5747,2208 54.08 ,3/
574.0/:708
,.89,11202-0782,/0,,7041807798,3/7085438-908
/4.:20390/97,33,3//0;045203954.08981479089,11
%7,33 ,84 4..:78 03 4- 7085438-908 .,30 30 06:52039 8
3974/:.0/
00/-,. 20.,3828 147 ,880882039 41 97,33 ,3/ /0;0452039 5747,220089
# $9,11 202-078 89:/0398 ,3/ ;4:390078 ,70 ,/06:,90 97,30/ 43
850.1.4-/:908477085438-90870,90/948,10989,11897,30/439078893904859,03;7432039
$9,11 202-078 .,3 /0243897,90 ,3/ 9,0 ,.9438 94 705479 023,90 2320
788
$9,11 202-078 ,70 2,/0 ,,70 41 574.0/:708 94 144 3 90 0;039 41 ,3
3./039
#054793574.08808147.42243574-0281,:708,3/:807077478089
# 3 ,557,8, 88902 147 0;,:,93 90 5071472,3.0 41 ,3 025400
0898,8,33907,5,794190:2,37084:7.02,3,02039574.088
0/4.:20390/5071472,3.0,557,8,88902089839047,3,943
%0 0254008 ,70 2,/0 ,,70 41 90 88902 41 ,557,8, ,9 90 920 41
3/:.943
! 1 9 / - / 9 1 9 9 / - /
/
0
%0,557,8,889028:80/,8,9441471:7907/0;0452039
!071472,3.0,557,8,8.,770/4:9,9570/0130/3907;,8,3/8/4.:20390/
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
26/29
,
-
.
/
0
,
-
.
,
-
.
/
,
-
.
/
,
%0/8.53,754.,3/574.0/:708-,80/4390573.508413,9:7,:89.0
%0 54. ,3/ 574.0/:70 8 343 94 , .,904708 41 0254008 41 9047,3,943
%0/8.53,7574.0/:7083.43843,3.0990570;,3,8
%0708,574;843147,550,83,/8.53,7.,808
#%047,3,943,8,0/4.:20390//8.53,7574.0/:70
79903 89,902039 41 90 54. 41 90 47,3,943 9 70,7/ 94 /8.530 8 3
5,.0
#70;,3.0,3/320.,382089839047,3,943
%0 0254008 ,70 ,,70 41 90 574.0/:70 94 -0 1440/ 3 .,80 90 100
,70;0/
%070/7088574.0/:70,//7088089070;,3.0
.9438,709,039470/70889070;,3.0
#%047,3,943,//708808900,9300/841900254008
%0 507843, 108 .439,3 507843, 31472,943 70,7/3 90 0254008
6:,1.,943/8.53,7-,.74:3/,3/0,989,9:8
70.47/8413807;.097,33,3/0/:.,943,70.439,30/390507843,108
0/., 574108843,8 5072990/ - , 70:,943 ,3/ 90 4859, 94 574;/0
!07843,108.439,3708:941,0;,:9438
# %070 8 , 574.088 147 .40.93 ;0713 ,3/ 0;,:,93 90
.70/039,8 0/:.,943 70897,943 97,33 ,3/ 050703.0 41 20/.,
574108843,85072990/94574;/05,9039.,7094:98:507;843
#%0708,/4.:20390/507843,70.47/1470,.89,11202-07
!07843,108,702,39,30/370850.941,0254008
5700254203920/.,0,23,9438.43/:.90/43,900254008
0,9 574-028 41 90 0254008 ,70 9,03 .,70 41 3 ,..47/,3.0 9 90
47,3,943854.
#0:,7 0,9 .0.8 41 89,11 /0,3 9 /70.9 5,9039 .,70 ,70 /430 ,90,89
43.0,0,7,3/9013/38708:98,70/4.:20390/
..:5,943,0,9,,7/8,70,/06:,90,//70880/
-
.
%0 0/:.,943 70897,943 97,33 ,3/ 050703.0 41 90 /03910/ 20/.,574108843,88/4.:20390/,3/:5/,90/5074/.,
8:. 31472,943 5079,33 94 90 20/., 574108843,8 8 ,557457,90
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
27/29
,
-
.
,
-
,
-
.
%0 .3., 47 ,8830/ 94 3:783 89,11 8 3 .43843,3.0 9 907
6:,1.,94397,33,3/70897,943
# %070 8 , 574.088 147 .40.93 ;0713 ,3/ 0;,:,93 90
.70/039,80/:.,94370897,94397,33,3/050703.0413:78389,11
8:. 31472,943 5079,33 94 90 3:783 89,11 8 ,557457,90 ;0710/ 03
5488-0
%0 706:890 807;.08 94 -0 574;/0/ - 90 3:783 89,11 ,70 343 94 902 ,80,890;,74:8/05,7920398:39841904859,
;0710/035488-0
# %070 8 , 574.088 147 ,:94783 , 20/., 574108843,8 94
,/29 ,3/ 970,9 5,90398 ,3/ 574;/0 4907 .3., 807;.08 .422038:7,90
99076:,1.,9438
# %070 8 , 574.088 94 /0391 4- 7085438-908 ,3/ 2,0 .3.,
47 ,88320398 94 , 3:783 89,11 202-078 .422038:7,90 9 907
6:,1.,9438,3/,3490770:,947706:7020398
0/., 574108843,8 ,/29 ,3/ .,70 147 5,90398 ,8 507 90 ,/ /43 54.08
,3/,:9478,943574.0/:708419047,3,943
%0 807;.08 574;/0/ - 90 20/., 574108843,8 ,70 3 .43843,3.0 9 9076:,1.,94397,33,3/70897,943
%0 706:890 807;.08 94 -0 574;/0/ - 90 20/., 574108843,8 ,70 343 94
902,80,890;,74:8/05,7920398:39841904859,
%0 0/:.,943 70897,943 97,33 ,3/ 050703.0 41 3:783 89,11 8
/4.:20390/,3/:5/,90/5074/.,
%0 807;.08 574;/0/ - 3:783 89,11 ,70 3 ,..47/,3.0 9 90 570;,3 ,8
,3/70:,9438
,5907#%%$$%$
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
28/29
,
-
.
/
0
,
-
.
/
0
,
-
.
/
0
1
,
-
.
%070.47/574;/08,3:594/,90,3/.74344.,,..4:39415,9039.,70
%080 54.08 ,3/ 574.0/:708 ,70 3 .425,3.0 9 90 570;,3 ,8 ,3/
70:,9438
4.:20390/ 574.0/:708 ,70 ,/ /43 147 920 ,3/ ,..:7,90 /88023,943 41
/,9,
4.:20390/574.0/:70808914789473,3/70970;3/,9,
$ !4.08 ,3/ 574.0/:708 089 94 2009 90 31472,943 300/8 41 90
.,70 574;/078 2,3,02039 41 90 47,3,943 ,8 0 ,8 4907 ,03.08
9,9706:70/,9,,3/31472,9431742907,3,943
31472,943 2,3,02039 ,3/ 90.344 ,.6:89438 ,70 3 ,..47/,3.0 9
9054.08,3/574.0/:708
%0 47,3,943 .4397-:908 94 09073, /,9,-,808 3 ,..47/,3.0 9 90 ,
,3/70:,9438
$%047,3,943,8574.0880835,.01470110.9;02,3,0203941
/,9,
472,98147/,9,.40.943,7089,3/,7/0/
0.088,77084:7.08,70,;,,-0147,3,3/,9,
%0 31472,943 300/8 41 90 47,3,943 ,70 /03910/ ,3/ ,70 ,557457,90 94
90 8.450 41 90 807;.08 -03 574;/0/ - 90 47,3,943 ,3/ 90 .42509
419047,3,943
!4.08,3/574.0/:7089420099031472,943300/8,70/4.:20390/
557457,90 .3., ,3/ 2,3,07, 89,11 5,79.5,908 3 800.93 3907,93 ,3/
:83/,9,
$ %0 47,3,943 ,8 , .425090 ,3/ ,..:7,90 20/., 70.47/ 147
0;075,9039;0720/.,70.47/,8,:36:0/039107
7,38,94354./0391089480,:9470/942,0039708320/.,70.47/
;0720/.,70.47/03978/,90/,3/920/
%0,:94741900397.,3-0/03910/
%0.43903984120/.,70.47/,70/03910/,3//4.:20390/
$%020/.,70.47/7010.98.4393:941.,70
%0 20/., 70.47/ .439,38 31472,943 70,7/3 70,8438 147 ,/28843
/,3488,3/5,341.,70
507,9;0 ,3/ 4907 574.0/:708 50714720/ ,70 3.47547,90/ 3 90 20/.,
70.47/
03 5,9039 8 97,3810770/ 94 ,34907 4859, 90 20/., 70.47/ .439,38 90
/,90 41 97,38107 90 70,843 147 90 97,38107 ,3/ 90 3,20 41 90 70.0;3
9
0
1
3 .,80 41 /0,9 90 20/., 70.47/ .439,38 , .45 41 90 /0,9 .0791.,903/.,9390.,:80/,90,3/92041/0,9
030;07 , .3., ,:9458 8 .,770/ 4:9 90 20/., 70.47/ .439,38 , .45 41
9 9 1 9
-
8/8/2019 Self Assessment Toolkit-NABH Hosp Standard-2nd Edi(1)
29/29
,
-
.
/
0
1
,
-
.
/
,
-
.
/
0
1
%070903943574.088574;/08050.90/.431/039,9,3/80.:79
$ !4.08 ,3/ 574.0/:708 ,70 3 5,.0 147 2,39,33 .431/039,9
39079,3/80.:794131472,943
4.:20390/ 54.08 ,3/ 574.0/:708 089 147 2,39,33 .431/039,9
80.:79,3/390794131472,943
!4.08,3/574.0/:708,703.43843,3.0990,55.,-0,8
%0 54.08 ,3/ 574.0/:708 3.47547,90 8,10:,7/3 41 /,9, 70.47/ ,,389
488/0897:.943,3/9,25073
%0 4859, ,8 ,3 0110.9;0 574.088 41 2439473 .425,3.0 41 90 ,/ /43
54.
%0 4859, :808 /0;04520398 3 ,557457,90 90.344 147 2574;3
.431/039,939079,3/80.:79
9070547941908,20
,70574;/078,;0,..08894.:77039,3/5,8920/.,70.47/
557457,90.4770.9;0,3/570;039;020,8:708:3/079,03,70/4.:20390/
%070;0574.0883.:/0870.47/841-49,.9;0,3//8.,70/5,90398
%070;0543984:9,3//4.:20398,3/01.03.08370.47/8
%070;0:808,705708039,9;08,250-,80/4389,989.,573.508
%070;08.43/:.90/-/03910/.,70574;/078
%0 70;0 14.:808 43 90 9203088 0-9 ,3/ .4250903088 41 90 20/.,
70.47/8
!7;00/ 0,9 31472,943 8 :80/ 147 90 5:754808 /03910/ 47 ,8 706:70/ -
,,3/349/8.480/94:9905,90398,:947,943
/4.:20390/ 574.0/:70 0898 43 4 94 708543/ 94 5,90398 58.,38 ,3/4907 5:-. ,03.08 706:0898 147 ,..088 94 31472,943 3 90 20/., 70.47/ 3
,..47/,3.09904.,,3/3,943,,
$%047,3,94370:,7.,77084:970;04120/.,70.47/8
%020/.,70.47/8,7070;00/5074/.,
4.:20390/ 54.08 ,3/ 574.0/:708 ,70 3 5,.0 43 709,33 90 5,90398
.3.,70.47/8/,9,,3/31472,943
%0 54.08 ,3/ 574.0/:708 ,70 3 .43843,3.0 9 90 4., ,3/ 3,943, ,8
,3/70:,9438
%0 /0897:.943 41 20/., 70.47/8 /,9, ,3/ 31472,943 8 3 ,..47/,3.0 9
90,//4354.
$ !4.08 ,3/ 574.0/:708 089 147 70903943 920 41 70.47/8 /,9, ,3/
31472,943