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Changes in Clinical Standards -NABH 4th Edition 2016
Dr. Mahboob ali khan Phd Renowned Healthcare Quality Consultant
Section I:Patient-Centered Standards
Access, Assessment and Continuity of Care (AAC)
3rd edition
4th edition
14/86 14/96
2
3
3rd Edition
AACStandard NUMBER OE
SCOPE 1 3REGISTRATION & ADMISSION 2 6TRANSFER & REFERRAL 3 5INITIAL ASSESSMENT 4 10REASSESSMENT 5 5LAB 6 8LAB QA 7 5LAB SAFETY 8 5IMAGING 9 9IMAGING QA 10 5IMAGING SAFETY 11 7CONTINUOUS/MULTIDISCIPLINARY CARE 12 7DISCHARGE PROCESS 13 4DISCHARGE SUMMARY 14 7TOTAL 14 86
4th Edition
AAC
Standard
NUMBER OE
SCOPE 1 4 REGISTRATION & ADMISSION 2 7
TRANSFER & REFERRAL 3 5
INITIAL ASSESSMENT 4 9
REASSESSMENT 5 6
LAB 6 10
LAB QA 7 5
LAB SAFETY 8 5
IMAGING 9 10
IMAGING QA 10 6
IMAGING SAFETY 11 8 CONTINUOUS/MULTIDISCIPLINARY CARE 12 9
DISCHARGE PROCESS 13 5
DISCHARGE SUMMARY 14 7
TOTAL 14 96
Overall Impact of improvements: AAC Each Service in the scope should be justifiable
◦ appropriate diagnostics and treatment facilities ◦ suitably qualified personnel ◦ out-patient, in-patient and emergency cover
Display ‘not in scope’ Imaging services
◦ Screening of Patients◦ Peer review◦ Surveillance methodology
Overall Impact of improvements: AAC Equipment and Manpower of pathology & radiology
depts◦ Adequacy
Actions on critical results ◦ Lab and Imaging◦ Focus on response
Critical results of outsourced servicesAddressing of reporting errors
◦ Amend or recall Structured handovers
◦ Transitions of care
Overall Impact of improvements: AAC Care Plan to reflect the desired outcome.Coordination of care: timelines
◦ Monitoring ◦ Acting on delays◦ Informing stakeholders
Access is prioritized◦ More sick patients are seen earlier.
Early warning systemTime taken for discharge
◦ Monitor timelines
Section I:Patient-Centered Standards
3rd edition
4th edition
Care of Patients (COP) 20/136 22/149
7
8
3rd Edition COP Standard
NUMBEROE
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
OBSTETRIC CARE 10 7
PAEDIATRIC SERVICES 11 8
MODERATE SEDATION 12 8
ADMINISTRTAION OF ANESTHESIA
13 11
4th Edition COP Stand
ard NUMB
ER
OE
UNIFORM CARE, LAWS, REGULATIONS & GUIDELINES
1 4
EMERGENCY SERVICES 2 10AMBULANCE SERVICES 3 9HANDLING COMMUNITY EMERGENCIES, EPIDEMICS AND OTHER DISASTERS
4 5
CARDIO PULMONARY RESUSCITATION
5 5
DOCUMENTED POLICIES and PROCEDURES GUIDE NURSING CARE
6 7
Documented procedures guide the performance of various procedures.
7 7
RATIONAL USE OF BLOOD & BLOOD PRODUCTS
8 8
INTENSIVE CARE & HIGH DEPENDENCY UNITS
9 8
VULNERABLE PATIENTS 10 5HIGH RISK OBSTETRIC CARE 11 7
9
3rd Edition
COPStandard NUMBER OE
SURGICAL PROCEDURES 14 11
RESTRAINTS 15 5
PAIN MANAGEMENT 16 5
REHABILITATIVE SERVICES 17 6
RESEARCH ACTIVITIES 18 6
NUTRITIONAL THERAPY 19 6
END OF LIFE CARE 20 5
TOTAL 20 136
4th Edition COP Standa
rd NUMBE
R
OE
PAEDIATRIC SERVICES 12 8
MODERATE SEDATION 13 8ADMINISTRTAION OF ANESTHESIA
14 11
SURGICAL PROCEDURES 15 11
ORGAN TRANSPLANT PROGRAM
16 4
RESTRAINTS 17 5PAIN MANAGEMENT 18 4
REHABILITATIVE SERVICES 19 6
RESEARCH ACTIVITIES 20 6
NUTRITIONAL THERAPY 21 6
END OF LIFE CARE 22 5
TOTAL 22 149
Overall Impact of improvements: COP
• Emergency Department- Access- QA - Brought in dead - Communication with ambulance during
transit• Organ transplant
- Full standard• Monitoring of patients after procedures• Disaster Management
- Focus on role of Emergency services- Patient care
Overall Impact of improvements: COP
• Counseling of patients on progress- ICU setting
• Clarity on informed consent when needed repeatedly for Blood Transfusions- Single consent with endorsements on repeat
• Consent for Moderate sedation• Reason for restraint• Functional assessment (rehab)
- Reassessment• Pain alleviation
- Initiate and Titrate based on need
Section I:Patient-Centered Standards
3rd edition
4th edition
Management of Medication (MOM) 13/73 13/76
12
13
3rd Edition
MOMStandar
d NUMBER OE
ORGANIZATION & USAGE OF PHARMACY 1 4HOSPITAL FORMULARY 2 5STORAGE OF MEDICATION 3 7PRESCRIPTIONS OF MEDICATIONS 4 12SAFE DISPENSING OF MEDICATIONS 5 6
MEDICATION ADMINISTRATION 6 10PATIENT MONITORING 7 4NEAR MISSES, MEDICATION ERRORS, ADR’s 8 5NARCOTIC DRUGS & PSYCHOTROPIC SUBSTANCES 9 4CHEMOTHERAPEUTIC AGENTS 10 4RADIOACTIVE DRUGS 11 4IMPLANTABLE PROSTHESIS & MEDICAL DEVICES 12 4MEDICAL SUPPLIES & CONSUMABLES 13 4TOTAL 13 73
4th Edition
MOM
Standard
NUMBER OE
ORGANIZATION & USAGE OF PHARMACY 1 4HOSPITAL FORMULARY 2 5STORAGE OF MEDICATION 3 7PRESCRIPTIONS OF MEDICATIONS 4 13SAFE DISPENSING OF MEDICATIONS 5 6MEDICATION ADMNISTRATION 6 10PATIENTS ARE MONITORED AFTER MEDICATION ADMINISTRATION 7 4NEAR MISSES, MEDICATION ERRORS ,ADVERSE DRUG EVENTS ARE REPORTED & ANALYSED 8 5NARCOTIC DRUGS & PSYCHOTROPIC SUBSTANCES 9 4CHEMOTHERAPEUTIC AGENTS 10 5RADIOACTIVE DRUGS 11 4IMPLANTABLE PROSTHESIS 12 4MEDICAL GASES 13 5TOTAL 13 76
Overall Impact of improvements: MOMStrengthening of Inventory management
- All areas in HCO- Stock outs
Physician samples tracking and management - Address safety in storage, usage and prevent
medication errors.Prescriptions have to be in Capital letters
- All areas in HCO
LASA drug list to be formed from formularyReconciliation of medications/orders at transitions
of care
Overall Impact of improvements: MOM
Special training for chemo therapeutic drugs and bio safety cabinets
Patient education for chemo drugsStrengthen medication administration Strengthen medical supplies
Section I:Patient-Centered Standards
3rd edition
4th edition
Patients Rights And Education (PRE) 7/46 8/54
16
17
3rd Edition
PRE
Standard
NUMBER OE
PROTECTION OF RIGHTS & INFORMATION ABOUT RESPONSIBILITY OF CARE 1 5
SUPPORTING INDIVIDUAL BELIEFS & VALUES 2 10
EDUCATING PATIENT/ FAMILY MEMBERS TO MAKE INFORMED DECISIONS 3 7
INFORMED CONSENT 4 8
RIGHT TO INFORMATION & EDUCATION ABOUT HEALTHCARE NEEDS 5 8
RIGHT TO INFORMATION ON EXPECTED COSTS 6 4
COMPLAINT REDRESSAL PROCESS 7 4
TOTAL 7 46
4th Edition
PREStanda
rd NUMBE
ROE
PROTECTION OF RIGHTS & INFORMATION ABOUT RESPONSIBILITY OF CARE
1 5
SUPPORTING INDIVIDUAL BELIEFS & VALUES 2 11
INFORMED CONSENT 3 7PATIENT AND/OR FAMILY’S CONSENT EXISTS FOR MAKING INFORMED DECISION ABOUT THEIR CARE
4 8
RIGHT TO INFORMATION & EDUCATION ABOUT HEALTHCARE NEEDS
5 8
RIGHT TO INFORMATION ON EXPECTED COSTS 6 4
PATIENT’S FEEDBACK AND REDRESSAL OF COMPLAINTS.
7 5
EFFECTIVE COMMUNICATION WITH PATIENTS AND /OR FAMILIES
8 6
TOTAL 8 54
Overall Impact of improvements: PRE• Patient right to get another opinion
- Respect and facilitate the right• New standard on communication
- Acceptable and effective communication- Communication in specific situation- Avoiding and identifying unacceptable
communication• Stress on capturing patient experience in addition
to feedback• Patient educational need identification and
addressing it
Section I:Patient-Centered Standards
3rd edition
4th edition
Hospital Infection control (HIC) 9/51 9/54
19
20
3rd Edition
HIC
Standard
NUMBER OE
HOSPITAL INFECTION CONTROL PROGRAMME 1 6
INFECTION CONTROL MANUAL 2 11SURVEILLANCE ACTIVTIES 3 8HOSPITAL ASSOCIATED INFECTIONS 4 4
PREVENTION & CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS 5 4
CONTROL OUTBREAKS OF INFECTION 6 4
STERILIZATION ACTIVITIES 7 5
BIOMEDICAL WASTE MEASURES (BMW) 8 5
TRAINING OF STAFF TO SUPPORT HIC PROGRAMME 9 4
TOTAL 9 51
4th Edition
HIC
Standard
NUMBER OE
HOSPITAL INFECTION CONTROL PROGRAMME 1 6
INFECTION CONTROL MANUAL 2 12
SURVEILLANCE ACTIVTIES 3 9
HOSPITAL ASSOCIATED INFECTIONS 4 4
SUPPORT TO INFECTION CONTROL PROGRAMME 5 4
CONTROL OUTBREAKS OF INFECTION 6 4
STERILIZATION ACTIVITIES 7 6
BIOMEDICAL WASTE MEASURES (BMW) 8 5
TRAINING OF STAFF TO SUPPORT HIC PROGRAMME 9 4
TOTAL 9 54
Overall Impact of improvements: HICClinical privileging of ICN – empowerment of ICNsRational and safe use of disinfectantsEnhanced participation of stakeholders by sharing
of HIC dataPromote rational use of antimicrobials and monitor
its usageMonitoring of MDROs & infection containment due
to MDROs Improved patient safety due to pre-defined
informed reuse of devices