Business Accent

Bringing Order to Chaos

A brief guide for healthcare providers who wish to go for NABH accreditation.

Dr Akash Rajpal

Having gone through the rigorous assessors training for National Accreditation Board for Hospitals & Healthcare Providers (NABH), I understand how demanding the standards are. Moreover, as NABH is very recent, doubts persist over explanation and application of various objectives of the NABH standards. Let me explain a few NABH standards.

PRE.2.

Patient and family rights, support individual beliefs, values and involve the patient and family in decision making processes.

Objective Elements

PRE.2. A. Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.

Explanation: To ensure that inappropriate (revealing/short/broken buttons etc) patient gowns are not in circulation. Right size of gown to be given to the patients. Dignity for the patient to be observed even when the patient is semi/unconscious, while shifting the patient, etc.

PRE.2. G. Patient and family rights include information on how to voice a complaint.

Explanation: There should be a mechanism for receiving verbal complaints from the patients/their relatives. Methods could include feedback forms, suggestion boxes etc.

PRE.2. H. Patient and family rights include information on the expected cost of the treatment.

Explanation: There should be evidence by way of patients'/admitting relatives' signature that he/she has understood the encumbrances and possible increase in costs depending on further care requirements of patient.

COP.2

Emergency services are guided by policies, procedures, applicable laws and regulations.

Objective Elements

COP.2 B. Policies also address handling of medico-legal cases.

Explanation: Local laws and guidelines also have to be considered while handling medico-legal cases. Medico-legal cases should be intimated to the local police station immediately.

COP.3

Ambulance services are commensurate with the scope of the services provided by the organisation.

Objective Elements

COP.3 A. There is adequate access and space for the ambulance(s).

Explanation: Easy turnaround of vehicle is a must, and ramp must not be steep to cause inconvenience.

COP.3 C. Ambulance(s) is manned by trained personnel.

Explanation: Only well-trained staff (nurses and technicians, etc.) should man the ambulance. And proper training record of the same should be maintained as evidence.

COP.3 G. The ambulance(s) has a proper communication system.

Explanation: A working method of communicating with the base to be made available. Mobile phones accepted as compliance.

COP.7

Policies and procedures guide the care of vulnerable patients (elderly, physically and/or mentally challenged and children).

Objective Elements

COP.7 A. Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines.

Explanation: Lunacy Act 1912 (now replaced by the Mental Health Act 1987) to be referred to for details.

COP.7 C. The organisation provides for a safe and secure environment for this vulnerable group.

Explanation: Hospital to ensure provision of railing, skid free tiles, easy access to wheel chair, nearness to call bell, easy to open doors, prevention for abduction of babies, baby swap, etc.

MOM.2

There is a hospital formulary.

Objective Elements

MOM.2 A list of medication appropriate for the patients and organisation's resources is developed.

Explanation: All medicines for all available and advertised specialities to be available. For instance, narcotics under NDPS Act to be available for pain elevation clinic etc. To ensure availability of all essential drugs, daily and common use drugs, etc.

MOM.2 C. There is a defined process for acquisition of these medications.

Explanation: To include vendor selection method/policy, lead time, cold chain concerns etc.

MOM.2 D. There is a process to obtain medications not listed in the formulary.

Explanation: Short purchase policy, policies for outside purchase, allowing patient to purchase, et., but in consonance to the above point MOM 2-A.

MOM.4 Policies and procedures guide the prescription of medications.

Objective Elements

MOM.4 B. The organisation determines who can write orders.

Explanation: Keeping in mind statuary requirements, the organisation has to outline who shall write orders apart from the treating consultants. This point is of importance in instances when the treating physician may not be available and the orders may be given by him on the phone etc to the nurse/RMO. Also refer point MOM 4 E below.

MOM.4 E. Policy on verbal orders is documented and implemented.

Explanation: The organisation needs to make a policy on accepting verbal orders, especially keeping in mind the potential communication errors which may lead to a wrong medication. A policy may be in place to not to accept verbal orders (preferably) or to get it doubly checked by a senior staff member or a senior resident etc. Apart from that, verbal orders have to be countersigned by the prescribing consultant within 24 hours.

MOM.5 Policies and procedures guide the safe dispensing of medications.

Objective Elements

MOM.5 B. The policies include a procedure for medication recall.

Explanation: Policies have to be in place to recall a particular batch or a lot of medicines/consumables. This is essential in case of identified defective batch or notice from Government regarding the same. The same should also be done when an instance of wrong prescription or wrong administration of medication is identified, to ensure that the same mistake is/was not duplicated for other patients.

MOM.7 Patients and family members are educated about safe medication and food-drug interactions.

Objective Elements

MOM.7 A. Patient and family are educated about safe and effective use of medication.

Explanation: The patient and family members should be explained clearly and in detail about the medication, specially in the OPD and at the time of discharge. This should be done to avoid incidences of over dosage, allergic reaction, etc.

MOM.7 B. Patient and family are educated about food-drug interactions.

Explanation: There is a need to educate the patients and their family members about the adverse reaction of certain food items on some drugs, and the necessity to avoid such food items during the medication period. Example, alcohol contradicted with metranidazole etc.

MOM.11 Policies and procedures govern usage of radioactive or investigational drugs.

Objective Elements

MOM.11 C. The policies and procedures include the safe storage, preparation, handling, distribution and disposal of radioactive and investigational drugs.

Explanation: There was a concern that some junk dealers may sell the nuclear portion/source for making a crude bomb. BARC can be notified to dispose this nuclear source prior to disposal. BARC disposes of the same in safe controlled methods.

HIC.7 There are documented procedures for sterilisation activities in the hospital.

Objective Elements

MOM.7 C. There is an established recall procedure when breakdown in the sterilisation system is identified.

Explanation: Example: Recall of entire CSSD load for a wet item found in the dry pack.

CQI.3

The organisation identifies key indicators to monitor the managerial structures, processes and outcomes.

Objective Elements

CQI.3 D. Monitoring includes utilisation of facilities.

Explanation: Monitoring of bed occupancy, average length of stay (ALOS), ICU utilisation etc. This indicates whether we are optimally utilising our resources and can also pinpoint a deviation in the quality of care if an ALOS varies from estimated for a particular case.

CQI.3 G. Monitoring includes adverse events.

Explanation: There should be a system in place to monitor and also minimise adverse events like bed falls, accidents, drug allergy, wrong drug, etc.

CQI.6 Sentinel events are intensively analysed. Monitoring of these events are essential as occurrence of these will only reflect poor processes and lack of training of staff, both reflecting poor patient care.

Objective Elements

CQI.6 A. The organisation has defined sentinel events. Sentinele even may include neonatal abduction, rape, murder, fall from staircase, electric shock, sparks, birds in AC ducts, bed falls, bed sore after admission, fall from window/balcony, suicide, discharge against medical advice.

ROM.5

Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management.

Objective Elements

ROM.5 D. Management provides resources for proactive risk assessment and risk reduction activities.

Explanation: Similar to preventive and corrective action of ISO 9001:2000. Confusion surrounds between the difference of preventive and corrective actions. A preventive action is one where an incidence has yet not occurred, but there is a potential hazard, while a corrective action is one when an incidence has occurred and necessary corrections are put in place for immediate reprieve and further prevention.

Examples of preventive action are naked electrical wires and a check on it to prevent any electric shock and; observing that there is lack of pest control and carrying an immediate pest control activity before infestation of insects and rodents, etc.

While example of corrective action is an electric shock has occurred due to a naked wire and now the naked wires are repaired to prevent such an incident from occurring again.

FMS.1

The organisation is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements.

Objective Elements

FMS.1 D. There is a mechanism to regularly update licenses/ registrations/ certifications.

Explanation: SOP may be made with instructions as to how, when and where the licenses will be renewed and from which nodal agency. A list of licenses, consisting of renewal dates (including software package renewals) and trigger date for each, and responsible authority for renewal is a good practice.

HRM.6

The organisation has a well-documented disciplinary procedure.

Objective Elements

HRM.6 B. The disciplinary policy and procedure are based on the principles of natural justice.

Explanation: Both employee and employer shall be given enough opportunity to defend the case. Complainant cannot be the judge.

IMS.5

Policies and procedures are in place for maintaining confidentiality, integrity and security of information.

Explanation: To ensure that there is access only by authorised personnel and that processes exist to safeguard against unauthorised access, physical as well as digital, by way of lock and key, password protection etc. Protocols should be in place to disseminate the right information to the right person/patient and at the right time. Care also has to be taken while sharing data with external agencies where some tests are outsourced as the confidentiality of patients always needs to be maintained.

Information Security Management System - ISO/IEC 27001:2005 (formerly BS 7799) standards may also be referred.

The writer is a Senior Manager Medical Services Dr LH Hiranandani Hospital Mumbai
Email: akash.rajpal@hiranandanihospital.org