Respobsibilities of Management-NABH Manual

Chapter 7
Responsibilities of Management
(ROM)
Dr Neha Tank Modha,
Gujarat Ayurved University, Jamnagar

Intent of the standards
• The standards encourage the governance of the
organization in a professional and ethical
manner.
• The organization complies with the laid down
and applicable legislations and regulations.
• The responsibilities of the leaders at all levels
are defined.
• The services provided by each department are
documented.
• Leaders ensure that patient safety and risk
management issues are an integral part of
patient care and hospital management.

Summary of Standards
ROM.1. The responsibilities of the management are
defined.
ROM.2. The organization complies with the laid-down
and applicable legislations and regulations.
ROM.3. The services provided by each department are
documented.
ROM.4. The organization is managed by the leaders in
an ethical manner.
ROM.5. The organisation displays professionalism in
management of affairs.
ROM.6. Management ensure that patient safety aspects
and risk management issues are an integral part of patient
care and hospital management

ROM.1. The responsibilities of
the management are defined.
Objective Elements
a. Those responsible for governance lay down the
organization’s vision and mission statement
• Interpretation: It is not only the head of the organisation
but the members of the board of governors (where
applicable) who need to define it. For definition of
"vision and mission" refer to glossary.
b. Those responsible for governance approve the strategic
and operational plans and organization’s budget.
• Interpretation: Refer to glossary for “strategic and
operational plans”.

c. Those responsible for governance approve the organization’s
budget and allocate the resources required to meet the
organization’s mission.
• Interpretation: Self-explanatory.
d. Those responsible for governance monitor and measure the
performance of the organization against the stated mission.
• Interpretation: The governing board and the head of the
organisation shall develop quarterly (at least) performance
reports based on the strategic and operational plans.
Performance shall be discussed in management review
meeting and action items are regularly followed up.

e. Those responsible for governance establish the
organization’s organogram.
• Interpretation: The organisation shall have a well-defined organisation
structure/chart and this shall clearly document the hierarchy, line of
control, along with the functions at various levels. Organogram is
transparent and is disseminated to all stakeholders. The organogram shall
incorporate various committees.
f. Those responsible for governance appoint the senior leaders
in the organization.
• Interpretation: Senior leaders include the first two rungs of the
organogram.
• Appointment of senior leaders shall be through selection committee.
g. Those responsible for governance support safety initiatives
and quality improvement plans.
• Interpretation: All risk assessment and risk reduction is known and
measures to reduce are discussed for corrective actions.

h. Those responsible for governance support research
activities
• Interpretation: Support in research shall include providing
resource, budget, following ethical and legal norms.
i. Those responsible for governance address the organization’s
social responsibility.
• Interpretation: The governing board and head of the organisation
shall will fully develop social responsibility policy and accordingly
address it. E.g. free camps, out reach programmes, adoption of
villages, PHCs, etc.

ROM.2.Theorganisationcomplieswiththe laid
downandapplicablelegislationsand
regulations.
a. The management is conversant with the laws and regulations
and knows their applicability to the organisation.
Interpretation:
• This shall include central legislations (e.g. The indian medicine central
council act, 1970, State board act eg. Travancore-cochin Medical
Practitioners act 1953, Drugs and Cosmetics act and MTP act, PNDT Act,
1996), Bio Medical Waste Act, Air (Prevention and Control of Pollution)
Act, 1981, Atomic Energy Regulatory Body Approvals, License under Bio-
medical Management and Handling Rules, 1998, respective of state
legislations (Karnataka Private Medical Establishments act 2007,
Maharashtra Maintenance of Clinical Records act, Clinical establishment of
West Bengal) and local regulations (e.g. building by elaws).
• A designated management functionary could be given the responsibility to
enlist the laws and regulation as applicable to the organisation. This
functionary in turn could identify the appropriate personnel in the
organisation who are supposed to implement the respective laws and
regulations.

ROM.2.Theorganisationcomplieswiththe laid
downandapplicablelegislationsand
regulations.
b. The management ensures implementation of these
requirements.
• Interpretation: All relevant clauses under the rules and acts are
abided by the organisation.
c. Management regularly updates any amendments in the
prevailing laws of the land.
d. There is a mechanism to regularly update licenses/
registrations/ certifications.
• Interpretation: E.g. license for lifts, DG sets, etc. The organisation
could develop a tracker sheet for this purpose.

ROM.3.Theservicesprovidedbyeach
departmentaredocumented.
a. Scope of services of each department is defined.
• Interpretation: Each department's activity is to be predefined. This
could be documented either at individual department level or the
organisation could have a brochure detailing the scope of each
department. This includes clinical and nonclinical departments. E.g.
Kayachikitsa department can provide medical services for swasa
roga, udararoga, yakritroga, sandhi roga, etc.
b. Administrative policies and procedures for each department
are maintained.
• Interpretation: This shall include all administrative procedures like
attendance, leave, conduct, replacement, etc. This shall be
documented. It could be common for the entire organisation.

ROM.3. The services provided by each
department are documented.
c. Each organizational program, service, site or department
has effective leadership.
• Interpretation: There needs to be a minimum essential
qualification and relevant experience of the leader. The leader
should have domain knowledge of that particular department.
d. Departmental leaders are involved in quality
improvement.
• Interpretation: To effectively implement this, each department
could have its department objectives/key performance
indicators and the responsibility of achieving them could be that
of the leader. Also refer CQI 3 & 4.

ROM.4. The organization is managed
by the leaders in an ethical manner.
a. The leaders make public the mission statement of the
organization.
Interpretation:
• This shall be done by displaying the same prominently. For definition of
"mission" refer to glossary. Only a display on its website would not be
appropriate. It is preferable that the same be translated and displayed in
the local language also.
b. The leaders establish the organization’s ethical management.
Interpretation:
• The organisation shall function in an ethical manner. Transparency in its
actions shall be one of its guiding principles. Handling of complaints,
grievances, clinical care delivery and research shall be some of the areas
to address.
c. The organisation’s established ethical management shall be
documented.

d. The organization discloses its ownership.
Interpretation:
• The ownership of the hospital e.g. trust, private, public has to be
disclosed. The disclosure could be in the registration
certificate/quality manual, etc.
e. The organization honestly portrays the services which it can
and cannot provide.
Interpretation:
• Documentation with respect of service non-availability and its
communication to patients is maintained. Here portrays implies
that the organisation conveys to the patients clearly what it can and
cannot provide.
• The services that it cannot provide could also be conveyed verbally.
Refer to AAC 1
ROM.4. The organization is
managed by the leaders in an
ethical manner.

f. The organization honestly portrays its affiliations and
accreditations.
Interpretation:
• Here implies that the organisation convey is affiliations,
accreditations for specific departments or whole hospital wherever
applicable.
g. The organization accurately bills for it’s services based upon a
standard billing tariff.
Interpretation:
• Also refer to PRE 6. The tariff could be devised by a tariff
committee.
ROM.4. The organization is managed
by the leaders in an ethical manner.

ROM.5. The organisation displays
professionalism in management of
affairs.
a. The person heading the organisation has requisite and appropriate
administrative qualifications.
Interpretation:
• This implies to the individual looking after the day-to-day
operations and not to the chairman of the Board of Governors.
Appropriate implies qualification in hospital
management/administration.
b. The person heading the organisation has requisite and
appropriate administrative experience.
Interpretation:
• Appropriate implies administrative experience in a hospital.

c. The organisation prepares the strategic and operational plans
including long-term and short-term goals commensurate to the
organisation’s vision, mission and values in consultation with the
various stakeholders.
Interpretation:
• The leader(s) shall define and develop the process for strategic and
operation plans so as to achieve the organisational vision and
mission statement and adhere to the values. It shall be discussed
with all stakeholders.
• One of the inputs that should be considered while finalising these
plans shall be the findings of the “risk-management plan” (refer to
ROM 6a). This shall at least be done on an annual basis.
• Refer to glossary for “strategic and operational plans”.
• Stakeholders include the community the organisation serves.
affairs.

affairs.
d. The organisation coordinates the functioning with
departments and external agencies, and monitors the progress
in achieving the defined goals and objectives.
Interpretation:
• The reasons for not achieving any particular goal shall be analysed
and appropriate action shall be taken. This could be done through
management review meetings.
e. The organisation plans and budgets for its activities annually.
Interpretation:
• Adequate budget shall also be allocated for infection control and
quality-improvement activities. This could be either done on a
calendar year basis or financial year (April-March) basis. It is
preferable that every department has a budget.

affairs.
f. The functioning of committees is reviewed for their
effectiveness.
Interpretation:
• This shall be done by the management. The review at a minimum
shall include if the purpose of having the committee is being met, if the
committee is meeting at the prescribed frequency and if the committee is
suggesting remedial measures and if there is adequate monitoring. For an
effective review, it is preferable that the organisation documents the scope of
every committee, the roles and responsibilities assigned to various members
and the frequency of meetings.
• Agenda shall be prepared for all meetings and documentation of each
committee meeting is kept.
g. The organisation documents employee rights and
responsibilities.
Interpretation:
• The organisation shall define the same in consonance with statutory
requirements.

affairs.
h. The organisation has a formal documented agreement for all
outsourced services.
Interpretation:
• The agreement shall specify the service parameters. Even if a sister
concern is providing services, there shall be an agreement with that
unit.
i. The organisation monitors the quality of the outsourced
services.
Interpretation:
• The frequency of monitoring shall be determined by the
organisation. This shall be done keeping in mind the criticality of
that service towards providing patient care. It is preferable that the
monitoring be done as per the service standards laid down or as
per the requirements of this standard.

ROM.6.Managementensurethatpatientsafetyaspects
andriskmanagementissuesareanintegralpartofpatient
careandhospitalmanagement.
a. Management ensures proactive risk management across the
organisation.
Interpretation:
• This shall include clinical and non-clinical (strategic, financial, operational
and hazard) risks. It shall include risk identification, prioritisation and risk
alleviation. This shall be documented as a “risk management plan”. It shall
include the various risks identified, the action taken for risk alleviation of
each of these risks and the mechanism for informing staff regarding the
same. Further, the risk management plan shall be monitored and reviewed
for continued effectiveness at least annually. The results of the review
shall be communicated to the relevant stakeholders in the organisation.
This could be done using a matrix.
• Clinical-risk assessment could include:
i. Medication management, covering issues such as adverse drug
reactions and medication errors.
ii. Equipment risks e.g. fire/injury risks from use of swedana.

b. Management provides resources for proactive risk
assessment and risk reduction activities.
Interpretation:
• There shall be sufficient resources kept as contingency to address
the risk reduction activities as and when the leaders proactively
suggest. The end result of these shall result in preventive actions.
Refer to glossary for definition of “Risk assessment” and “Risk
reduction”.

c. Management ensures implementation of systems for
internal and external reporting of system and process
failures.
Interpretation:
• The organization has a system in place for internal and external
reporting of system and process failures. Contingency plan shall
be in place to deal with the situation of system and process
failure anticipated within the organization.
• For example, Swedna yantra or autoclave machine breaks down.
In this case internal reporting is to be done to head of the
department and external reporting to be done to the patients.
The system for reporting shall be documented.

d. Management ensures that appropriate corrective and
preventive actions are taken to address safety-related
incidents.
Interpretation:
• This shall be taken after an analysis. The analysis could be done by
the safety committee and preferably a root-cause must be
identified.

Respobsibilities of Management-NABH Manual

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Respobsibilities of Management-NABH Manual