Nabh iv edition for clinical team Doctors and Nurses 2017

QAD
2017
NABH Info for Clinical & Nursing Team

Why Quality?
 PDCA
 ISO
 JCI …………….
 QCI
 NABH
 NABET
 NABT

NABH IV Edition
2 - parts
10 - Chapters
105 - Standards
689 - Objectives

NABH Chapters
 Patient Centered:
Chapter 1: Access, Assessment and Continuity of Care (AAC)
Chapter 2: Care of Patients (COP)
Chapter 3: Management of Medication (MOM)
Chapter 4: Patient Rights and Education (PRE)
Chapter 5: Hospital Infection Control (HIC)
 Organization Centered:
Chapter 6: Continual Quality Improvement (CQI)
Chapter 7: Responsibilities of Management (ROM)
Chapter 8:Facility Management and Safety (FMS)
Chapter 9: Human Resource Management (HRM)
Chapter 10: Information Management System (IMS)

 AAC.1: The organisation defines and displays the healthcare services that it
provides.
 AAC.2: The organisation has a well-defined registration and admission process.
 AAC.3: There is an appropriate mechanism for transfer (in and out) or referral of
patients.
 AAC.4: Patients cared for by the organisation undergo an established initial
assessment.
 AAC.5: Patients cared for by the organisation undergo a regular reassessment.

 AAC.6: Laboratory services are provided as per the scope of services of
the organisation.
 AAC.7: There is an established laboratory quality assurance programme.
 AAC.8: There is an established laboratory safety programme.

 AAC.9: Imaging services are provided as per the scope of services of the
organisation.
 AAC.10: There is an established quality assurance programme for imaging
services.

 AAC.11: There is an established safety programme in the Imaging
services.
 AAC.12: Patient care is continuous and multidisciplinary in nature.
 AAC.13: The organisation has a documented discharge process.
 AAC.14: Organisation defines the content of the discharge summary.

 COP.1: Uniform care to patients is provided in all settings of the
organisation and is guided by the applicable laws, regulations and
guidelines.
COP.2: Emergency services are guided by documented policies, procedures,
applicable laws and regulations.

COP.3: The ambulance services are commensurate with the scope of the
services provided by the organisation.

COP.4: The organisation plans for handling community emergencies,
epidemics and other disasters.

COP.5: Documented policies and procedures guide the care of patients
requiring cardio-pulmonary resuscitation.

 COP.6: Documented policies and procedures guide nursing care.
 COP.7:Documented procedures guide the performance of various procedures.
 COP.8: Documented policies and procedures define rational use of blood and
blood components.
 COP.9: Documented policies and procedures guide the care of patients in the
intensive care and high dependency units.
 COP.10: Documented policies and procedures guide the care of vulnerable
patients.

 COP.11: Documented policies and procedures guide obstetric care.
 COP.12: Documented policies and procedures guide paediatric services.
 COP.13: Documented policies and procedures guide the care of patients
undergoing moderate sedation.
 COP.14: Documented policies and procedures guide the administration of
anaesthesia.
 COP.15: Documented policies and procedures guide the care of patients
undergoing surgical procedures.

 COP.16: Documented policies and procedures guide organ transplant programme in the
organisation.
 COP.17: Documented policies and procedures guide the care of patients under restraints
(physical and/or chemical).
 COP.18: Documented policies and procedures guide appropriate pain management.
 COP.19: Documented policies and procedures guide appropriate rehabilitative services.
 COP.20: Documented policies and procedures guide all research activities.

 COP.21: Documented policies and procedures guide nutritional therapy.
 COP.22: Documented policies and procedures guide the end of life care.

 MOM.1: Documented policies and procedures guide the organisation of
pharmacy services and usage of medication.
 MOM.2. There is a hospital formulary.
 MOM.3: Documented policies and procedures guide the storage of medication.
 MOM.4: Documented policies and procedures guide the safe and rational
prescription of medications.
 MOM.5: Documented policies and procedures guide the safe dispensing of
medications.

 MOM.6:There are documented policies and procedures for medication
administration.
 MOM.7: Patients are monitored after medication administration.
 MOM.8: Near misses, medication errors and adverse drug events are reported
and analysed.
 MOM.9: Documented procedures guide the use of narcotic drugs and
psychotropic substances.
 MOM.10: Documented policies and procedures guide the usage of
chemotherapeutic agents.

 MOM.11: Documented policies and procedures govern usage of
radioactive drugs.
 MOM.12: Documented policies and procedures guide the use of
implantable prosthesis and medical devices.
 MOM.13: Documented policies and procedures guide the use of medical
supplies and consumables.

 PRE.1. The organisation protects patient and family rights and informs them about their
responsibilities during care.
 PRE.2: Patient and family rights support individual beliefs, values and involve the patient and family
in decision making processes.
 PRE.3: The patient and/or family members are educated to make informed decisions and are involved
in the care planning and delivery process
 PRE.4: A documented procedure for obtaining patient and/or family’s consent exists for informed
decision making about their care.
 PRE.5: Patient and families have a right to information and education about their healthcare needs.

 PRE.6: Patients and families have a right to information on expected costs.
 PRE.7: The organisation has a mechanism to capture patient’s feedback
and redressal of complaints.
 PRE.8: The organisation has a system for effective communication with
patients and /or families.

 HIC.1: The organisation has a well-designed, comprehensive and coordinated Hospital Infection
Prevention and Control (HIC) programme aimed at reducing/eliminating risks to patients, visitors
and providers of care.
 HIC.2: The organisation implements the policies and procedures laid down in the Infection
Control Manual in all areas of the hospital.
 HIC.3: The organisation performs surveillance activities to capture and monitor infection
prevention and control data.
 HIC.4: The organisation takes actions to prevent and control Healthcare Associated Infections
(HAI) in patients.
 HIC.5: The organisation provides adequate and appropriate resources for prevention and control
of Healthcare Associated Infections (HAI).

 HIC.6: The organisation identifies and takes appropriate action to control
outbreaks of infections.
 HIC.7: There are documented policies and procedures for sterilization
activities in the organisation.
 HIC.8: Biomedical waste (BMW) is handled in an appropriate and safe
manner.
 HIC.9: The infection control programme is supported by the management
and includes training of staff.

Things need to be taken care
 Universal Points
 Patient and Employee Right
 Code Blue/Red/Yellow and White/RRT
 Induction Process
 HIC Practices
 PPE
 Safety Practices
 MSDS
 Not available Services
 Health check up
 IPSG
 Patient Identifier – UHID No - Digits

 Safe injection Practices
 Employee Vaccination
 Blood and Body Fluid exposure
 Vision
 Mission
 Core Values
 Discharge Summary
 Manuals
 QAD
 HIC
 Safety
 Departmental

 Time Out
 Hand Hygiene
 PPE
 End of life care
 Sedation

Our Outside Image
NABH Clinical QI
Clinical Bundle
NABH Mandatory QI

Initiate Immediate…….
THANK YOU

Nabh iv edition for clinical team Doctors and Nurses 2017

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Nabh iv edition for clinical team Doctors and Nurses 2017