IMPLEMENTING NABH

WELCOME PARTICIPANTS!
“A customer is the most important visitor on our
premises. He is not dependent on us.

We are dependent on him. He is not an

interruption in our work. He is the purpose of it.

He is not an outsider in our business. He is part of

it.

We are not doing him a favor by serving him. He

is doing us a favor by giving us an opportunity
to do so.”

2
3
“WE are part of the oldest living civilization of Earth",
the Indian tradition dates back to 8000 BC

4
 10 Interesting facts about India:

•The famous board game, called Chess, was invented in India.

•In India's 100,000 years of history, it has never invaded any other country.
•India is the 7th largest country in the world, the largest democracy and one of the
oldest civilizations.
•India was one of the richest countries in the world before the British invasion in 17th
century.
•The value of "pi" used in mathematics was first calculated by the Indian
mathematician Budhayana in 6th century.
•India is one of the largest exporter of computer software products. It exports software
to over 90 countries.
•India is home to the world's largest pilgrimage destination called the Vishnu Temple.
The temple is located in the city of Tirupati. About an average of 30,000 people visit
this temple donating about $6 million US dollars, everyday.
•India originated Yoga about 5,000 years ago.
•India has the most number of mosques. It has 300,000 mosques which is much more
than the Muslim world. 5

•Christians and Jews have been living in India since 52 A.D. and 200 B.C. respectively.
Healthcare

Healthcare
Infrastructure

Health Expenditure &

Quality Assurance Affordability

Quality Healthcare
for all

Intelligence
Reduction of
information
Disease Burden

6
Drivers of growth for the Indian Healthcare Sector

• Increase in Population: Expected increase in population from 1.1 billion

in 2009-2010 to 1.4 billion by 2026.

• Shift in demographics: 60 percent of the population in the younger age

bracket and an expected increase of geriatric population from current 96
million to around 168 million by 2026.

This represents a huge patient base and creates a market for preventive,
curative and geriatric care opportunities.

• Rise in disposable income: Households in the above INR 200,000 per

annum bracket can benefit from an increase in disposable income from
14 percent in 2009-2010 to 26 percent in 2014-2015 making healthcare
more affordable.

Sources: Crisil Research Hospitals Annual Review November 2010; NFHS Survey; KPMG Analysis
2010,
Drivers of growth for the Indian Healthcare Sector
(contd)

• Increase in incidence of lifestyle-related diseases: likely to be a

marked increase in the incidence of lifestyle-related diseases,

such as cardiovascular, oncology and diabetes, when compared

to the communicable and infectious diseases

• Rising Literacy: Growing general awareness, patient

preferences and better utilization of institutionalized care as a

result of increase in literacy rates

Sources: Crisil Research Hospitals Annual Review November 2010; NFHS Survey; KPMG Analysis
2010,
CAGR
21%
Source: WHO World Health Statistics, 2010
Healthcare Financing

Sources: Centrum Healthcare Sector,

October 2010; KPMG Emerging Trends in
Healthcare, February 2011
Private firms are now thought to provide about
60% of all outpatient care in India and as much
as 40% of all in-patient care. It is estimated that
nearly 70% of all hospitals and 40% of hospital
beds in the country are in the private sector.

PWC: Healthcare in India: Emerging market report 2007

 CAGR:
19%

Source: Centrum Healthcare Sector, October

DRIVERS OF QUALITY

Clinic Establishment Act

14
NABH: National Accreditation Board
for Hospitals and Healthcare
Organizations

15
Recently Launched-
Wellness Centre Standards
Disease Estimates

16
17
Projected Death by
Causes
Proportion mortality - % of all
deaths

Source: World Health Organization - NCD Country Profiles , 2011.

Source: World Health Organization - NCD Country Profiles , 2011.
Burden of Non-Communicable
Diseases

Source: WHO World Health Statistics, 2010

There exists a large unmet demand for
physicians and nurses…..
• India lags world average and other emerging economies in
number of physicians and nurses per 10,000 people
Physicians per 10,000 Nurses per 10,000 people 1
people1 98
27

17
14 14

29 28
6
13 10
U Indi Brazi Chin World U Indi Brazi Chin World
S a l a avg S a l a avg

• India needs ~ 0.96 mn physicians just to meet world standards (14/10,000)

• Thereafter, India will need ~30,000 physicians every year to meet demands of a growing population
• Assuming same growth in Medical seats as between 2000-2010, India is going to be short by ~ 80,000 Medical
seats every year till 2020 Demand – Supply 0.3
in mn 1.9 projections for 2020
-0.7
1.2 -0.2
0.1

Demand in Supply in
Demand in Supply in
2020 2 2020
2020 India 2020 UP
22 people
0.9 beds per 1000
WHO Health Statistics, 2010
1
CRISIL: Detailed PPP framework for Safai Paramedical College
2
ACCREDITATION

 Public recognition of the achievement of

accreditation standards by a healthcare
organization, demonstrated through an
independent external assessment of that
organization’s level of performance in
relation to the standard.
(ISQua)

23
ACCREDITATION
 Accreditation relies on establishing
technical competence of healthcare
organization in terms of accreditation
standards in delivering services with
respect to its scope.
 It focuses on learning, self development,

improved performance and reducing risk.

 Accreditation is based on optimum
standards, professional accountability
and encourages healthcare organization
to pursue continual excellence.
24
REGULATION
 An instrument mandated by the Government
to impose set of conditions, which a
healthcare organization must comply with,
before and after it is permitted to operate in
the country.

 It is based on minimum standards,

inspection, enforcement and public
accountability

25
REGULATION VS ACCREDITATION
 Regulation is mandatory
 Accreditation is voluntary

 Accreditation is promoted by way of incentives and

market forces
 In order to achieve best of both worlds, regulation in

time to come can simply rely on accreditation!!

26
BENEFITS OF
ACCREDITATION
PATIENTS
 Accreditation benefits all stake holders.
 Patient is the biggest beneficiary.

 Accreditation results in higher quality of care

and patient safety.

 The patients get services by credentialed

medical staff.
 Rights of patients are respected and
protected.
 Patient satisfaction is regularly evaluated.

28
HEALTHCARE ORGANIZATIONS…
 Accreditation to a healthcare organization
stimulates continuous improvement.
 It enables the organization in demonstrating

commitment to quality care.

 It raises community confidence in the
services provided by the organization.
 It also provides opportunity to healthcare

unit to benchmark with the best.

29
HEALTHCARE ORGANIZATIONS
 Staff in an accredited healthcare organization
are satisfied lot as it provides for continuous
learning, good working environment,
leadership and above all ownership of clinical
processes.
 It improves overall professional development

of Clinicians and Paramedical staff and

provides leadership for quality improvement
within medicine and nursing.

30
THIRD PARTIES
 Provides an objective system of
empanelment by insurance and other third
parties.

 Accreditation provides access to reliable and

certified information on facilities,
infrastructure and level of care.

31
DRIVING FACTORS FOR
ACCREDITATION
 Consumer Protection Act
 Clinical Establishment Act
 Insurance Companies regulation
 Empanelment by CGHS, ECHS, Corporate
etc.
 Community Awareness & Response
 Health Tourism

32
CHALLENGES & OPPORTUNITIES
 Awareness on Accreditation
 Health industry
 Consumers
 Regulators

 Creating enabling mechanism to assist

hospitals on accreditation

33
NABH STANDARDS FOR
HOSPITALS
 Think beyond your immediate work
 Learn about other departments
 Imagine everything as if you were a patient
 Read, learn and learn..there is an ocean to be crossed
 Behavioral issues:
 Respect
 Mentor
 Motivate, encourage
 Fair, unbiased
 Probe: eye for details
 Observant
 Team player
 Ask: Why, how, by whom
 How to implement
 Be ready to accept failures and slow progress…

35
SECTION I:
PATIENT-CENTERED STANDARDS
SECTION II:
MANAGEMENT CENTERED
STANDARDS
 Access, Assessment & Continuity of
Care (AAC)
INTENT - AAC
• There are 14 Standards and 86 Objective elements.

• Patients are well informed of the services that an

organization provides.
• Appropriately matching patients with the organization’s
resources – Both in OPD & IPD settings.
• IPD admissions follows a defined process
• Admitted patients undergo an established initial assessment
& regular reassessments.
• Assessments include planning for utilization of laboratory
and imaging services.
• Patient care is multidisciplinary & encourages continuity of
care
• Well defined transfer and discharge protocols.

39
 AAC.1. STANDARD

The organization defines and

displays the services that it
can provide.
 AAC.1. OBJECTIVE ELEMENTS

a) The services being provided are clearly defined

and are in consonance with the needs of the
community.
b) The defined services are prominently displayed.
c) The staff is oriented to these services.
AAC.2. STANDARD

The organisation has a well

defined registration and
admission process.
AAC.2. OBJECTIVE ELEMENTS…
a) Documented policies and procedures are
used for registering and admitting patients.
b) The documented procedures address out-
patients, in-patients and emergency
patients.
c) A unique identification number is
generated at the end of registration.
AAC.2. OBJECTIVE ELEMENTS
d) Patients are accepted only if the
organisation can provide the required
service.
e) The documented policies and procedures
also address managing patients during
non availability of beds.
f) The staff is aware of these processes.
AAC.3. STANDARD

There is an appropriate
mechanism for transfer (in
and out) or referral of
patients.
AAC.3. OBJECTIVE ELEMENTS…
a) Documented policies and procedures
guide the transfer-in of patients to the
organisation.

b) Documented policies and procedures guide

the transfer-out/referral of unstable
patients to another facility in an
appropriate manner.
AAC.3. OBJECTIVE ELEMENTS
c) Documented policies and procedures guide
the transfer- out/referral of stable patients
to another facility in an appropriate
manner.
d) The documented procedures identify staff
responsible during transfer/referral.
e) The organisation gives a summary of
patient’s condition and the treatment
given.
AAC.4. STANDARD

Patients cared for by the

organisation undergo an
established initial
assessment.
AAC.4. OBJECTIVE ELEMENTS…
a) The organisation defines and documents
the content of the initial assessment for
the out–patients, in-patients and
emergency patients.
b) The organisation determines who can
perform the initial assessment.
c) The organisation defines the time frame
within which the initial assessment is
completed based on patient’s needs.
 AAC.4. OBJECTIVE ELEMENTS…

d) The initial assessment for in-patients is

documented within 24 hours or earlier as per
the patient’s condition as defined in the
organisation’s policy.

e) Initial assessment of in-patients includes

nursing assessment which is done at the time of
admission and documented.
AAC.4. OBJECTIVE ELEMENTS…
f) Initial assessment includes screening for
nutritional needs.

g) The initial assessment results in a

documented plan of care.

h) The plan of care also includes preventive

aspects of the care where appropriate.
AAC.4. OBJECTIVE ELEMENTS…

i) The plan of care is countersigned by the

clinician in-charge of the patient within 24
hours.

j) The plan of care includes goals or desired

results of the treatment, care or service.
AAC.5. STANDARD

Patients cared for by the

organisation undergo a
regular reassessment.
AAC.5. OBJECTIVE ELEMENTS…
a) Patients are reassessed at appropriate
intervals.
b) Out-patients are informed of their next
follow up where appropriate.
c) For in-patients during reassessment the
plan of care is monitored and modified
where found necessary.
AAC.5. OBJECTIVE ELEMENTS…

d) Staff involved in direct clinical care

document reassessments.

e) Patients are reassessed to determine their

response to treatment and to plan further
treatment or discharge.
AAC.6. STANDARD

Laboratory services are

provided as per the scope
of services of the
organisation.
AAC.6. OBJECTIVE ELEMENTS…

a) Scope of the laboratory services are

commensurate to the services provided
by the organisation.
b) The infrastructure (physical and
manpower) is adequate to provide for its
defined scope of services.
c) Adequately qualified and trained
personnel perform, supervise and
interpret the investigations.
AAC.6. OBJECTIVE ELEMENTS…

d) Documented procedures guide ordering of

tests, collection, identification, handling,
safe transportation, processing and
disposal of specimens.

e) Laboratory results are available within a

defined time frame.
AAC.6. OBJECTIVE ELEMENTS
f) Critical results are intimated immediately to
the personnel concerned.
g) Results are reported in a standardised
manner.
h) Laboratory tests not available in the
organisation are outsourced to organisation
(s) based on their quality assurance
system.
AAC.7. STANDARD

There is an established
laboratory quality
assurance programme.
AAC.7. OBJECTIVE ELEMENTS…
a) The laboratory quality assurance
programme is documented.

b) The programme addresses verification

and/or validation of test methods.

c) The programme addresses surveillance of

test results.
AAC.7. OBJECTIVE ELEMENTS

d) The programme includes periodic calibration

and maintenance of all equipment.

e) The programme includes the documentation of

corrective and preventive actions.
AAC.8. STANDARD

There is an established
laboratory safety
programme.
AAC.8. OBJECTIVE ELEMENTS…

a) The laboratory safety programme is

documented.

b) This programme is aligned with the

organisation’s safety programme.
AAC.8. OBJECTIVE ELEMENTS

c) Written procedures guide the handling and

disposal of infectious and hazardous materials.
d) Laboratory personnel are appropriately trained
in safe practices.
e) Laboratory personnel are provided with
appropriate safety equipment / devices.
AAC.9. STANDARD

Imaging services are

provided as per the scope
of services of the
organisation.
AAC.9. OBJECTIVE ELEMENTS…

a) Imaging services comply with legal

and other requirements.
b) Scope of the imaging services is
commensurate to the services
provided by the organisation.
c) The infrastructure (physical and
manpower) is adequate to provide
for its defined scope of services.
AAC.9. OBJECTIVE ELEMENTS…
d) Adequately qualified and trained personnel
perform, supervise and interpret the
investigations.
e) Documented policies and procedures guide
identification and safe transportation of
patients to imaging services.
f) Imaging results are available within a
defined time frame.
AAC.9. OBJECTIVE ELEMENTS
g) Critical results are intimated immediately
to the personnel concerned.
h) Results are reported in a standardised
manner.
i) Imaging tests not available in the
organisation are outsourced to
organisation (s) based on their quality
assurance system.
AAC.10. STANDARD

There is an established
quality assurance
programme for imaging
services.
AAC.10. OBJECTIVE ELEMENTS…
a) The quality assurance programme for
imaging services is documented.
b) The programme addresses verification
and/or validation of imaging methods.
c) The programme addresses surveillance of
imaging results.
AAC.10. OBJECTIVE ELEMENTS

d) The programme includes periodic calibration

and maintenance of all equipment.

e) The programme includes the documentation of

corrective and preventive actions.
AAC.11. STANDARD

There is an established
radiation safety
programme.
AAC.11. OBJECTIVE ELEMENTS…
a) The radiation safety programme is
documented.
b) This programme is aligned with the
organisation’s safety programme.
c) Handling, usage and disposal of radio-
active and hazardous materials are as per
statutory requirements.
AAC.11. OBJECTIVE ELEMENTS
d) Imaging personnel are provided with appropriate
radiation safety devices.
e) Radiation safety devices are periodically tested
and results documented.
f) Imaging personnel are trained in radiation safety
measures.
g) Imaging signage are prominently displayed in all
appropriate locations.
AAC.12. STANDARD

Patient care is continuous

and multidisciplinary in
nature.
AAC.12. OBJECTIVE ELEMENTS…

a) During all phases of care, there is a qualified

individual identified as responsible for the
patient’s care.

b) Care of patients is coordinated in all care

settings within the organisation.
AAC.12. OBJECTIVE ELEMENTS…
c) Information about the patient’s care and
response to treatment is shared among
medical, nursing and other care providers.

d) Information is exchanged and documented

during each staffing shift, between shifts,
and during transfers between
units/departments.
AAC.12. OBJECTIVE ELEMENTS
e) Transfers between departments/units are
done in a safe manner.
f) The patient’s record (s) is available to the
authorised care providers to facilitate the
exchange of information.
g) Documented procedures guide the referral
of patients to other departments /
specialities.
AAC.13. STANDARD

The organisation has a

documented discharge
process.
AAC.13. OBJECTIVE ELEMENTS…
a) The patient’s discharge process is planned
in consultation with the patient and/or
family.
b) Documented procedures exist for
coordination of various departments and
agencies involved in the discharge process
(including medico-legal and absconded
cases).
AAC.13. OBJECTIVE ELEMENTS
c) Documented policies and procedures are in
place for patients leaving against medical
advice and patients being discharged on
request.
d) A discharge summary is given to all the
patients leaving the organisation (including
patients leaving against medical advice
and on request).
AAC.14. STANDARD

Organisation defines the

content of the discharge
summary.
AAC.14. OBJECTIVE ELEMENTS…

a) Discharge summary is provided to the

patients at the time of discharge.

b) Discharge summary contains the patient’s

name, unique identification number, date
of admission and date of discharge.
AAC.14. OBJECTIVE ELEMENTS…
c) Discharge summary contains the reasons
for admission, significant findings and
diagnosis and the patient’s condition at the
time of discharge.
d) Discharge summary contains information
regarding investigation results, any
procedure performed, medication
administered and other treatment given.
AAC.14. OBJECTIVE ELEMENTS
e) Discharge summary contains follow up
advice, medication and other instructions
in an understandable manner.
f) Discharge summary incorporates
instructions about when and how to obtain
urgent care.
g) In case of death, the summary of the case
also includes the cause of death.
INTENT - AAC
• There are 14 Standards and 86 Objective elements.

• Patients are well informed of the services that an

organization provides.
• Appropriately matching patients with the organization’s
resources – Both in OPD & IPD settings.
• IPD admissions follows a defined process
• Admitted patients undergo an established initial assessment
& regular reassessments.
• Assessments include planning for utilization of laboratory
and imaging services.
• Patient care is multidisciplinary & encourages continuity of
care
• Well defined transfer and discharge protocols.

92
SUMMARY OF AAC

NABH - 3rd Edition

No. of
Objective
Access Assessment & Continuity of Care Standard No. Elements
Scope 1 3
Registration & admission 2 6
Transfer & referral 3 5
Initial assessment 4 10
Regular Reassessment 5 5
Laboratory Services 6 8
Laboratory Quality Assurance Program 7 5
Laboratory Safety Programme 8 5
Imaging Services 9 9
Imaging Quality Assurance Program 10 5
Radiation Safety Program 11 7
Continuous & Multidisciplinary care 12 7
Documented Discharge process 13 4
Discharge summary 14 7
TOTAL 14 93 86
KEY POLICIES REQUIRED
S. Name of Policy S. Name of Policy
No. No.
1 Admission Policy 11 Leave Against Medical
Advice/ Discharge on
2 Bed Management Policy
Request
3 Scope of services ICU 12 Admission & Discharge
4 ICU Admission Criteria Policy ICU

5 Transfer & Referral Policy 13 Admission and discharge

policy for HDU
6 Initial Assessment Policy
7 Patient Re Assessment
Policy
8 Safe Transportation of
Patients (Intra hospital)
9 Continuity of Care
10 Discharge Policy 94
KEY FORMS/ FORMATS
REQUIRED

S. Forms
No.
1. Transfer Form
a. Inter hospital
b. Intra hospital
2. Discharge Summary
3. Initial Assessment Format
a. Out patients
b. In patients
c. Emergency patients

95
MANUALS REQUIRED
S. Name of Manual
No.
1 Front Office Manual
2 Induction Manual
There can be a
3 Laboratory Manual “Central Safety
Manual” which can
4 Laboratory Quality
include the Laboratory
Assurance Manual
Safety Manual and
5 Laboratory Safety Manual Radiation Safety
6 Imaging Manual Manual

7 Imaging Quality Assurance

Manual
8 Radiation Safety Manual

96
KEY DEPARTMENTS/
PERSONNEL INVOLVED
Departments: Staff:
• Front office • All Doctors
• Lab Services • All Nurses
• Imaging Department • Staff handling Reception &
• All Clinical departments Registrations
• OPD staff
• IPD staff
• Lab Services staff
• Imaging department staff

97
IMPLEMENTATION ISSUES
 Scope of services - Needs of the community
should be considered especially planning a new
organization or adding new services.
 Training of the staff for orientation to services

provided.
 Staff to be trained for unplanned transfers

 ACLS/ BLS training

 Implementation and documentation of Laboratory

Quality Assurance program

 Implementation and documentation of Imaging

Quality Assurance program

98
INTENT

 Uniform care

 Encourage patient safety as the overall principle

for providing care to patients
SECTION I:
PATIENT-CENTERED STANDARDS
CARE OF PATIENTS (COP)
CHAPTER 2: CARE OF PATIENT
There are Standards broadly applicable to:
• 13 Standards
• 136 Objective
 Emergency & Day care services
elements
 Ambulance services
 Nursing Department
 Blood Bank
 All Intensive Care Areas & HDUs
 OBG Department
 Pediatric Department
 All Surgical departments
 Anesthesia Department
 Outpatient Department
 Physiotherapy & Rehabilitation
department
 Research Department
 Dietetics Department

102
COP.1. STANDARD

Uniform care to patients is

provided in all settings of
the organisation and is
guided by the applicable
laws, regulations and
guidelines.
COP.1. OBJECTIVE ELEMENTS…

a) Care delivery is uniform for a given health

problem when similar care is provided in more
than one setting.

b) Uniform care is guided by documented policies

and procedures.
COP.1. OBJECTIVE ELEMENTS

c) These reflect applicable laws, regulations

and guidelines.

d) The organisation adopts evidence based

medicine and clinical practice guidelines to
guide uniform patient care.
COP.2. STANDARD

Emergency services are

guided by documented
policies, procedures,
applicable laws and
regulations.
COP.2. OBJECTIVE ELEMENTS…
a) Policies and procedure for emergency care
are documented and are in consonance
with statutory requirements.
b) This also address handling of medico-legal
cases.
c) The patients receive care in consonance
with the policies.
COP.2. OBJECTIVE ELEMENTS…
d) Documented policies and procedures guide
the triage of patients for initiation of
appropriate care.

e) Staff is familiar with the policies and

trained on the procedures for care of
emergency patients.
COP.2. OBJECTIVE ELEMENTS

f) Admission or discharge to home or transfer to

another organisation is also documented.

g) In case of discharge to home or transfer to

another organisation a discharge note shall be
given to the patient.
COP.3. STANDARD

The ambulance services

are commensurate with
the scope of the services
provided by the
organization.
COP.3. OBJECTIVE ELEMENTS…
a) There is adequate access and space for the
ambulance (s).
b) The ambulance adheres to statutory
requirements.
c) Ambulance(s) are appropriately equipped.
d) Ambulance(s) are manned by trained
personnel.
e) Ambulance (s) is checked on a daily basis.
COP.3. OBJECTIVE ELEMENTS
f) Equipment are checked on a daily basis
using a checklist.
g) Emergency medications are checked daily
and prior to dispatch using a checklist.
h) The ambulance(s) have a proper
communication system.
COP.4. STANDARD

Documented policies and

procedures guide the care
of patients requiring
cardio-pulmonary
resuscitation.
COP.4. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide
the uniform use of resuscitation throughout
the organisation.

b) Staff providing direct patient care is

trained and periodically updated in cardio
pulmonary resuscitation.
COP.4. OBJECTIVE ELEMENTS

c) The events during a cardio-pulmonary

resuscitation are recorded.
d) A post-event analysis of all cardiac arrests is
done by a multidisciplinary committee.
e) Corrective and preventive measures are taken
based on the post-event analysis.
COP.5. STANDARD

Documented policies and

procedures guide nursing
care.
COP.5. OBJECTIVE ELEMENTS…
a) There are documented policies and
procedures for all activities of the nursing
services.

b) These reflect current standards of nursing

services and practice, relevant regulations
and purposes of the services.
COP.5. OBJECTIVE ELEMENTS…

c) Assignment of patient care is done as per

current good practice guidelines.
d) Nursing care is aligned and integrated with
overall patient care.
e) Care provided by nurses is documented in
the patient record.
COP.5. OBJECTIVE
ELEMENTS
f) Nurses are provided with adequate
equipment for providing safe and efficient
nursing services.

g) Nurses are empowered to take nursing-

related decisions to ensure timely care of
patients.
COP.6. STANDARD

Documented procedures
guide the performance of
various procedures.
COP.6. OBJECTIVE ELEMENTS…
a) Documented procedures are used to guide
the performance of various clinical
procedures.
b) Only qualified personnel order, plan,
perform and assist in performing
procedures.
c) Documented procedures exist to prevent
adverse events like wrong site, wrong
patient and wrong procedure.
COP.6. OBJECTIVE ELEMENTS
d) Informed consent is taken by the personnel
performing the procedure, where
applicable.
e) Adherence to standard precautions and
asepsis is adhered to during the conduct of
the procedure.
f) Patients are appropriately monitored during
and after the procedure.
g) Procedures are documented accurately in
the patient record.
COP.7. STANDARD

Policies and procedures

define rational use of blood
and blood products.
COP.7. OBJECTIVE ELEMENTS…
a) Documented policies and procedures are
used to guide rational use of blood and
blood products.
b) Documented procedures govern
transfusion of blood and blood products.
c) The transfusion services are governed by
the applicable laws and regulations.
COP.7. OBJECTIVE ELEMENTS…
d) Informed consent is obtained for donation
and transfusion of blood and blood
products.
e) Informed consent also includes patient and
family education about donation.
f) The organisation defines the process for
availability and transfusion of blood/blood
components for use in emergency.
COP.7. OBJECTIVE ELEMENTS

g) Post-transfusion form is collected, reactions

if any identified and are analysed for
preventive and corrective actions.

h) Staff are trained to implement the policies.

COP.8. STANDARD

Documented policies and

procedures guide the care
of patients in the intensive
care and high dependency
units.
COP.8. OBJECTIVE ELEMENTS…
a) Documented policies and procedures are
used to guide the care of patients in the
intensive care and high dependency units.
b) The organisation has documented
admission and discharge criteria for its
intensive care and high dependency units.
c) Staff is trained to apply these criteria.
COP.8. OBJECTIVE ELEMENTS
d) Adequate staff and equipment are
available.
e) Defined procedures for situation of bed
shortages are followed.
f) Infection control practices are documented
and followed.
g) A quality-assurance programme is
documented and implemented.
COP.9. STANDARD

Documented policies and

procedures guide the care
of vulnerable patients
(elderly, children,
physically and/or mentally
challenged).
COP.9. OBJECTIVE ELEMENTS…
a) Policies and procedures are documented
and are in accordance with the prevailing
laws and the national and international
guidelines.

b) Care is organised and delivered in

accordance with the policies and
procedures.
COP.9. OBJECTIVE ELEMENTS
c) The organisation provides for a safe and
secure environment for this vulnerable
group.
d) A documented procedure exists for
obtaining informed consent from the
appropriate legal representative.
e) Staff are trained to care for this vulnerable
group.
COP.10. STANDARD

Documented policies and

procedures guide obstetric
care.
COP.10. OBJECTIVE ELEMENTS…
a) There is a documented policy and
procedure for obstetric services.
b) The organisation defines and displays
whether high-risk obstetric cases can be
cared for or not.
c) Persons caring for high-risk obstetric cases
are competent.
d) Documented procedures guide provision of
ante-natal services.
COP.10. OBJECTIVE ELEMENTS
e) Obstetric patient’s assessment also
includes maternal nutrition.
f) Appropriate pre-natal, peri-natal and post-
natal monitoring is performed and
documented.
g) The organisation caring for high risk
obstetric cases has the facilities to take
care of neonates of such cases.
COP.11. STANDARD

Documented policies and

procedures guide paediatric
services.
COP.11. OBJECTIVE ELEMENTS…
a) There is a documented policy and
procedure for paediatric services.
b) The organisation defines and displays the
scope of its pediatric services.
c) The policy for care of neonatal patients is
in consonance with the national/
international guidelines.
COP.11. OBJECTIVE ELEMENTS…
d) Those who care for children have age-
specific competency.
e) Provisions are made for special care of
children.
f) Patient assessment includes detailed
nutritional, growth, psychosocial and
immunisation assessment.
COP.11. OBJECTIVE ELEMENTS

g) Documented policies and procedures prevent

child/ neonate abduction and abuse.

h) The children’s family members are educated

about nutrition, immunisation and safe
parenting and this is documented in the
medical record.
COP.12. STANDARD

Documented Policies and

procedures guide the care
of patients undergoing
moderate sedation.
COP.12. OBJECTIVE ELEMENTS…
a) Documented procedures guide the
administration of moderate sedation.
b) Informed consent for administration of
moderate sedation is obtained.
c) Competent and trained persons perform
sedation.
COP.12. OBJECTIVE ELEMENTS…
d) The person administering and monitoring
sedation is different from the person
performing the procedure.
e) Intra-procedure monitoring includes at a
minimum the heart rate, cardiac rhythm,
respiratory rate, blood pressure, oxygen
saturation, and level of sedation.
COP.12. OBJECTIVE ELEMENTS
f) Patients are monitored after sedation and
the same documented.
g) Criteria are used to determine
appropriateness of discharge from the
recovery area.
h) Equipment and manpower are available to
manage patients who have gone into a
deeper level of sedation than initially
intended.
COP.13. STANDARD

Documented policies and

procedures guide the
administration of
anaesthesia.
COP.13. OBJECTIVE ELEMENTS…
a) There is a documented policy and
procedure for the administration of
anaesthesia.
b) Patients for anaesthesia have a pre-
anaesthesia assessment by a qualified
anaesthesiologist.
c) The pre-anaesthesia assessment results in
formulation of an anesthesia plan which is
documented.
COP.13. OBJECTIVE ELEMENTS…
d) An immediate pre-operative re-
evaluation is performed and
documented.
e) Informed consent for administration
of anaesthesia is obtained by the
anaesthesiologist.
f) During anaesthesia monitoring includes
regular recording of temperature, heart
rate, cardiac rhythm, respiratory rate,
blood pressure, oxygen saturation and
end tidal carbon dioxide.
COP.13. OBJECTIVE ELEMENTS…
g) Patient’s post-anaesthesia status is
monitored and documented.
h) The anaesthesiologist applies defined
criteria to transfer the patient from the
recovery area.
i) The type of anaesthesia and anaesthetic
medications used are documented in the
patient record.
COP.13. OBJECTIVE ELEMENTS

j) Procedures shall comply with infection

control guidelines to prevent cross-
infection between patients.

k) Adverse anesthesia events are recorded

and monitored.
COP.14. STANDARD

Documented policies and

procedures guide the care
of patients undergoing
surgical procedures.
COP.14. OBJECTIVE ELEMENTS…
a) The policies and procedures are
documented.
b) Surgical patients have a preoperative
assessment and a provisional diagnosis
documented prior to surgery.
c) An informed consent is obtained by a
surgeon prior to the procedure.
COP.14. OBJECTIVE ELEMENTS…
d) Documented policies and procedures exist
to prevent adverse events like wrong site,
wrong patient and wrong surgery.

e) Persons qualified by law are permitted to

perform the procedures that they are
entitled to perform.
COP.14. OBJECTIVE ELEMENTS…

f) A brief operative note is documented prior

to transfer out of patient from recovery
area.
g) The operating surgeon documents the
post-operative plan of care.
h) Patient, personnel and material flow
conforms to infection control practices.
COP.14. OBJECTIVE ELEMENTS…
i) Appropriate facilities and equipment/
appliances/instrumentation are available
in the operating theatre.
j) A quality assurance program is followed for
the surgical services.
k) The quality assurance program includes
surveillance of the operation theatre
environment.
COP.15. STANDARD

Documented policies and

procedures guide the care
of patients under restraints
(physical and/or chemical).
COP.15. OBJECTIVE ELEMENTS

a) Documented policies and procedures guide the

care of patients under restraints.
b) These include both physical and chemical
restraint measures.
c) These include documentation of reasons for
restraints.
d) These patients are more frequently monitored.
e) Staff receives training and periodic updating in
control and restraint techniques.
COP.16. STANDARD

Documented policies and

procedures guide
appropriate pain
management.
COP.16. OBJECTIVE ELEMENTS

a) Documented policies and procedures guide the

management of pain.
b) All patients are screened for pain.
c) Patients with pain undergo detailed assessment
and periodic re-assessment.
d) The organisation respects and supports
management of pain for such patients.
e) Patient and family are educated on various pain
management techniques where appropriate.
COP.17. STANDARD

Documented policies and

procedures guide
appropriate rehabilitative
services.
COP.17. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide
the provision of rehabilitative services.
b) These services are commensurate with the
organisational requirements.
c) Care is guided by functional assessment
and periodic re-assessment which is done
and documented by qualified individual (s).
COP.17. OBJECTIVE ELEMENTS

d) Care is provided adhering to infection

control and safe practices.
e) Rehabilitative services are provided by a
multidisciplinary team.
f) There is adequate space and equipment to
perform these activities.
COP.18. STANDARD

Documented policies and

procedures guide all
research activities.
COP.18. OBJECTIVE ELEMENTS…
a) Documented policies and procedures
guide all research activities in
compliance with national and
international guidelines.
b) The organisation has an ethics
committee to oversee all research
activities.
c) The committee has the powers to
discontinue a research trial when
risks outweigh the potential benefits.
COP.18. OBJECTIVE ELEMENTS

d) Patients’ informed consent is obtained before

entering them in research protocols.
e) Patients are informed of their right to withdraw
from the research at any stage and also of the
consequences (if any) of such withdrawal.
f) Patients are assured that their refusal to
participate or withdrawal from participation will
not compromise their access to the
organisation’s services.
COP.19. STANDARD

Documented policies and

procedures guide
nutritional therapy.
COP.19. OBJECTIVE ELEMENTS…
a) Documented policies and procedures guide
nutritional assessment and reassessment.

b) Patients receive food according to their

clinical needs.

c) There is a written order for the diet.

COP.19. OBJECTIVE ELEMENTS
d) Nutritional therapy is planned and provided
in a collaborative manner.
e) When families provide food, they are
educated about the patient’s diet
limitations.
f) Food is prepared, handled, stored and
distributed in a safe manner.
COP.20. STANDARD

Documented policies and

procedures guide the end
of life care.
COP.20. OBJECTIVE ELEMENTS…

a) Documented policies and procedures guide

the end of life care.
b) These policies and procedures are in
consonance with the legal requirements.
c) These also address the identification of the
unique needs of such patient and family.
COP.20. OBJECTIVE ELEMENTS…

d) Symptomatic treatment is provided and where

appropriate measures are taken for alleviation
of pain.

e) Staff is educated and trained in end of life care.

SUMMARY OF COP

NABH - 3rd Edition

No. of
Objective
Care of Patients Standard No. Elements
Uniform care 1 4
Emergency services 2 7
Ambulance services 3 8
Cardio pulmonary resuscitation 4 5
Nursing care 5 7
Various procedures 6 7
Rational use of blood & blood
products 7 8
Intensive care & high dependency
units 8 7
Vulnerable patients 9 5

189
SUMMARY OF COP (CONTD…)

NABH - 3rd Edition

No. of
Objective
Care of Patients Standard No. Elements
Obstetric care 10 7
Pediatric services 11 8
Moderate sedation 12 8
Administration of anesthesia 13 11
Total 13 136

190
CHAPTER 2: CARE OF PATIENT
There are Standards broadly applicable to:
• 13 Standards
• 136 Objective
 Emergency & Day care services
elements
 Ambulance services
 Nursing Department
 Blood Bank
 All Intensive Care Areas & HDUs
 OBG Department
 Pediatric Department
 All Surgical departments
 Anesthesia Department
 Outpatient Department
 Physiotherapy & Rehabilitation
department
 Research Department
 Dietetics Department

191
INTENT - COP
 Care delivery to be “uniform” in different settings. Eg. Out patients,
various categories of wards, ICU’s, procedure rooms & Operation
theatres.
 The following services are guided by policies, procedures, applicable
laws & regulations:
o Emergency & Ambulance services
o Cardio pulmonary resuscitation
o Use of blood and blood products
o Intensive care & High dependency units
 The care of following patients are guided by policies, procedures,
applicable laws & regulations:
o Vulnerable patients
o High risk obstetrical patients
o Pediatric patients
o Patients undergoing moderate sedation & administration of anesthesia
o Patients undergoing surgical procedures
o Patients under restraints, research activities and end of life care

192
INTENT - COP
 With a view to provide comprehensive health care, COP also
addresses:
o Pain management
o Nutritional therapy
o Rehabilitative services

 To guide and encourage patient safety as the overall principle for

providing care to patients.

193
KEY POLICIES REQUIRED
S. Name of Policy
No.
1 Uniform Care Delivery
•OPD’s
•IPD’s
•ICU’s & HDU’s
•Procedure rooms
•Operation theatres

2 Emergency care for patients including Ambulance services

& Medico legal cases
3 Code Blue Policy (including Adult, pediatric & neonatal
patients)
4 Patient Identification policy
5 Policy – Rationale use of Blood & Blood products
6 Policy – Vulnerable patients
7 Policy – Obstetric services (including high risk obstetric
cases)
8 Policy – Pediatric Services
194
KEY POLICIES REQUIRED
S. Name of Policy
No.
9 Policy on Moderate sedation
10 Policy on Anesthesia
11 Patient Restraint policy
12 Pain Management Policy
13 Policy on Vulnerable patients
14 Policy on Rehabilitative services
15 Policy on Research Activities
16 Policy on Nutritional therapy
17 Policy – End of life care
18 Policy - Fall prevention

195
MANUALS REQUIRED

S. No. Manuals required

1 COP Manual
2 Nursing Manual

196
KEY FORMS/ FORMATS REQUIRED
S. Forms
No.
1. MLC format (as per statutory rules)
2. Ambulance check list including
•Functioning status
•Equipments
•Emergency Medications
•Communication system

3. Code Blue:
•Mock drill audit sheet
•Code blue report
4. Procedure documentation form
5. Blood transfusion:
•Informed consent for transfusion of Blood and blood products
•Post Transfusion form
6. Checklist for pediatric assessment including:
•Detailed nutritional growth
•Psychosocial assessment
•Immunization assessment 197
KEY FORMS/ FORMATS REQUIRED
(CONTD…)
S. Forms
No.
7. Moderate Sedation:
•Informed Consent form
•Format for intra procedure monitoring
8. Anesthesia:
•Form including Pre Anesthesia, Intra Anesthesia & Post
Anesthesia check up
•Informed Consent form
9. Surgery:
•Informed Consent for Surgery(s)
•Operation note format
10. Patient Restraint Form/ checklist
11. Pain Assessment form including:
•Intensity
•Character
•Frequency
•Location
•Duration
•Referral/ radiation 198
KEY FORMS/ FORMATS REQUIRED
(CONTD…)
S. Forms
No.
12. Informed Consent - Research trial
13. Form – Nutritional assessment
14. Form - End of life care

Summary - Informed Consent(s):

•Moderate sedation
•Transfusion of Blood and blood
products
•Research trial
•Anesthesia
•Surgery (s)

199
S. No. Brochures
1 Patient & family education about Blood & blood
products donation
2 Children's family members education on nutrition,
immunization and safe parenting.
3 Patient & family education on Pain management
technique

S. No. Posters & Displays

1 CPR Posters
2 Standee/ placard on High risk obstetric facilities
3 Standee/ placard on Scope of Pediatric services

200
CODE BLUE COMMITTEE
Members:
Preferably Cardiologist, Administrator, Emergency representative, Medicine representative,
Surgery representative, Anesthesia representative, Nursing representative, Quality
Manager

Responsibilities:
 To review the composition of the Code Blue Team
 To assign roles and responsibilities to the members of the team
 To review all cardiac arrest case files with the aims of –
 Assessing the adequacy of response
 To look for scope for improvement in the same
 To help initiate and maintain an education and training program in resuscitation, for floor
nurses and doctors
 To design Code Blue flow sheet, form and audit sheet
 To ensure the availability and maintenance of the equipment / drugs required
 To encourage doctors to undergo ACLS certification

201
BLOOD TRANSFUSION
COMMITTEE
Members:

Preferably, Head of the Hospital, Senior Pathologist & Head of Blood bank, Blood Bank Technician,
Transfusion Nurse, Anesthesia Representative, Internal Medicine Representative, General Surgery
Representative, Nursing Head & Medical Quality representative.

Responsibilities:

Ensure safe and effective use of blood and components:

Policy development, implementation and review
Training and education
Blood utilization review
Performance monitoring and improvement
Promote blood donation/transfusion awareness

202
ETHICS COMMITTEE
Members:

Preferably, Clinician(s), Social Scientist, Senior Pharmacologist (non affiliated with Institute), Quality
manager, legal expert (non affiliated with Institute), social worker

Primary Purpose:

Review and approve all types of research proposals involving human participants with a view to safeguard
the dignity, rights, safety and well being of all actual and potential research participants.
Committee has the powers to discontinue a research trial when risks out weigh the potential benefits.

203
Thank you

204