Building a quality culture in India through NABH 6th STD.pdf

Quality Improvement Programme
to Creating Quality Culture in India
Dr J L Meena
Govt of India

Quality is a Team
Work, Never Achieve
by a Single Person
Quality Never
Improve without
Truth
Jo Aap Ko
Chahiye, Bo
Dusron Ko Do
Quality Coming
from your Heart
Self Assessment
is the Best
Assessment for
Quality
Dr. J. L. Meena
Total 639 Objective Elements
❖ 100 are in core category which will be
mandatorily assessed during each
assessment,
❖ 457 are in commitment category which
will be assessed during final
assessment,
❖ 60 are in achievement category which
will be assessed during surveillance
assessment
❖ 17 are in excellence category which will
be assessed during re- accreditation.
This will help the healthcare organisation
in step wise progression to mature quality
system covering the full accreditation cycle.

Introduction
Dr. J. L. Meena
The standards provide framework for quality
assurance and quality improvement for hospitals.
The standards focus on patient safety and quality of
care. The standards call for continuous monitoring
of sentinel events and comprehensive corrective
action plan leading to building of quality culture at
all levels and across all the functions.

Outline of NABH Standards
Access,
Assessment and
Continuity of
Care (AAC).
Care of Patients
(COP).
Management of
Medication
(MOM).
Patient Rights
and Education
(PRE).
Infection
Prevention &
Control (IPC).
Patient Safety
& Quality
Improvement
(PSQ).
Responsibility of
Management
(ROM).
Facility
Management &
Safety (FMS).
Human
Resource
Management
(HRM).
Information
Management
System (IMS).
Patient
Centered
Standards
Organisation
Centered
Standards
Dr. J. L. Meena

A Real Case Study
A 30 years old man came along
C/O:- Weakness, headache and body ache etc. from the epidemic area of Dengue fever with
H/O fever – 3 days in a reputed hospital.
O/E:- Temperature - N
B/P- N
CR: - NAD
& Pulse - N
Adv by Doctor:-
-Cap Domestal 1-0-1. (6)
-Tab Gastricaplus 1-0-1 (6)
-Tab. Nise 1 S o S . (4)
The patient went home (about 25 kilometers) because the doctor says, There is no need for
hospitalization and no need for blood test.
Dr. J. L. Meena

The next day at 8:00 am patients came again with
C/O:- General Weakness, Vomiting.
O/E:- Pulse-weak, B/P- 90/70, Dehydration, CVS:- S1 & S2 (N) & Tachycardia.
Adv by Doctor:-
-ECG, LFT, MP, Widal, Blood Group, Serum Creatinine & Dengue Test.
Test Result:-
Total Platelet count:- 8,000/c.mm (Normal 1,50,000-4,50,000 /c.mm)
Dengue Test:- NS1: Antigen:- Reactive, IgG: Antibody: Non-reactive, IgM: Antibody : Non-reactive.
Refer the patient to higher center at 6:15 PM when he was very serious (pulse rate:- 44/ minute, SPO2:- 64%
with refer note as per below.-
Dear Doctor, Refer this pt. with thrombocytopenia and abdominal distention. Kindly do needfull. Without any
skilled staff.
Pt examine by higher center Doctors:- O/E:- pt. brought dead with pupils fixed dilated, no peripheral pulse, no
Breath & A "flat line" on an ECG.
A Real Case Study
Dr. J. L. Meena

Socio economic effect on his family:-
His wife is House wife, with two children one female child
and one male child below 5yrs age.
No parents, no any brothers.
Home lone (about 25 lacs) is on going.
A Real Case Study
Dr. J. L. Meena

Think seriously ?????
❖Could this death have been prevented ?
❖Was the method of investigation appropriate ?
❖Why delay in testing ?
❖Was the timing of referral right ?
❖Why didn't the skilled person accompany the
serious patient???
Dr. J. L. Meena

Learn a Lesson
Please examine your patient properly to prevent
unacceptable events in the future & focus on
“ACCESS, ASSESSMENT
AND CONTINUITY OF CARE (AAC)”
Dr. J. L. Meena

Chapters, Standards & Objective Elements
Chapters Standards
Objective
Elements
Core Commitment Achievement Excellence
AAC 13 87 6 68 9 4
COP 20 135 13 107 12 4
MOM 11 68 13 48 6 1
PRE 8 52 12 32 7 1
IPC 8 49 13 33 3 0
PSQ 7 46 8 28 7 3
ROM 6 37 4 23 8 2
FMS 7 43 11 29 2 1
HRM 13 76 16 56 4 0
IMS 7 45 9 33 2 1
Total 100 639 105 457 60 17

Intent of the chapter
Access Assessment and Continuity of Care (AAC)
➢ Patients are informed of the services provided by the organisation. Scope of each healthcare services including diagnostic
and therapeutic services shall be well defined and the same shall be made available to the patients and their families.
➢ Only those patients who can be cared for by the organisation are admitted.
➢ Emergency patients receive life-stabilising treatment and are then either admitted (if resources are available) or
transferred appropriately to an organisation that has the resources to take care of such patients.
➢ Out-patients who do not match the organisation's resources are similarly referred to organisations
that have the required resources.
➢ Patients that match the organisation's resources are admitted using a defined process. Patients cared for by the
organisation undergo an established initial assessment and periodic reassessments.
These assessments result in the formulation of a care plan.
➢ The organisation provides laboratory and imaging services commensurate to its scope of services.
The laboratory and imaging services are provided by competent staff in a safe environment for both patients and staff.
➢ Patient care is continuous and multidisciplinary.
➢ Preventive and promotive healthcare services are part of patient care.
➢ Transfer and discharge protocols are well defined, with adequate information provided to the patient.
➢ Continuity of patient care is extended to the community through home health care services.
1
1
Dr. J. L. Meena

Summary of Standards
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
and safety programme.
AAC.8.
Imaging services are provided as per the scope of
services of the organisation.
AAC.9.
There is an established quality assurance and
safety programme for imaging services.
AAC.10.
Patient care is continues and muti-
disciplinary
AAC.11.
The preventive and promotive health
services are provided in a safe, collaborative
and consistent manner.
AAC.12. The organisation has an established discharge
process.
AAC.13. The organisation defines the content of the
discharge summary.
1
2
Dr. J. L. Meena

Summary of Objective Elements
Objective
Elements
AAC 1 AAC 2 AAC 3 AAC 4 AAC 5 AAC 6 AAC 7 AAC 8 AAC 9 AAC 10 AAC 11 AAC 12 AAC 13
a Commitment Commitment Commitment CORE CORE Commitment Commitment CORE Commitment Commitment Commitment Commitment Commitment
b Commitment CORE Commitment Commitment Commitment Commitment Commitment Achievement Achievement Commitment Commitment Commitment Commitment
c Commitment Commitment Commitment Commitment Commitment Commitment Commitment Achievement Achievement Commitment Commitment Commitment Commitment
d Commitment Commitment Commitment Commitment Commitment Commitment Excellence Commitment Excellence CORE Commitment Commitment Commitment
e Achievement CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment Achievement Commitment
f Achievement Commitment Commitment Commitment Commitment Commitment Achievement
g
Excellence
Commitment Commitment Commitment Commitment Achievement Commitment
h Commitment Achievement Commitment
Excellence
i Achievement Commitment Commitment
j Commitment Commitment
k Commitment
Summary Standards 13 OE 87 CORE 6
Commitment
68
Achievement
9 Excellence 4
Dr. J. L. Meena

AAC 1 - The organisation defines and displays
the healthcare services that it provides.
Objective Elements
a) The healthcare services being provided are defined and are in consonance with
the needs of the community.
b) Each defined clinical service shall have diagnostic and treatment services
with suitably qualified personnel who provide out-patient, in-patient and
emergency cover.
c) Scope of the healthcare services of each department is defined.
d) The organisation's defined clinical services are prominently displayed.
14
Dr. J. L. Meena
C RE Commitment Achievement Excellence

AAC 2 - The organisation has a well-defined
registration and admission process.
Objective Elements
a) The organisation uses written guidance for registering and admitting patients. *
b) A unique identification number is generated at the end of the registration.
c) Patients are accepted only if the organisation can provide the required service.
d) The written guidance also addresses managing patients during non-availability of
beds. *
e) Access to the healthcare services in the organisation is prioritised according to the
clinical needs of the patient. *
15
Dr. J. L. Meena

AAC 3 - There is an appropriate mechanism for
transfer (in and out) or referral of patients.
a. Transfer-in of patients to the organisation is done appropriately. *
b. Transfer- out/referral of patients to another facility is done appropriately. *
c. During transfer or referral, accompanying staff are appropriate to the clinical
condition of the patient.
d. The organisation gives a summary of the patient's condition and the
treatment given.
16
Dr. J. L. Meena
Objective Elements

AAC 4 - Patients cared for by the organisation
undergo an established initial assessment.
Objective Elements
a) The initial assessment of the outpatients, day-care, in-patients and emergency patients is
done. *
b) The initial assessment is performed by qualified personnel. *
c) The initial assessment is performed within a time frame based on the needs of the
patient. *
d) Initial assessment of day-care and in-patients includes nursing assessment, which is done
at the time of admission and documented.
e) The initial assessment for in-patients results in a documented care plan.
f) The care plan is countersigned by the clinician-in-charge of the patient within 24 hours.
g) The care plan includes the identification of special needs regarding care following
discharge.
17
Dr. J. L. Meena

AAC 5 - Patients cared for by the organisation
undergo a regular reassessment.
a) Patients are reassessed at appropriate intervals to determine their response
to treatment and to plan further treatment or discharge.
b) Out-patients are informed of their next follow-up, where appropriate.
c) For in-patients during reassessment, the care plan is monitored and
modified, where found necessary.
d) Staff involved in direct clinical care document reassessments.
e) The organisation lays down guidelines and implements processes to identify
early warning signs of change or deterioration in clinical conditions for
initiating prompt intervention*.
18
Dr. J. L. Meena
Objective Elements

AAC 6 - Laboratory services are provided as per
the scope of services of the organisation.
Objective Elements
a) Scope of the laboratory services is commensurate to the services provided by the organisation.
b) The infrastructure (physical and equipment) is adequate to provide the defined scope of services.
c) Human resource is adequate to provide the defined scope of services.
d) Qualified and trained personnel perform and supervise the investigations and report the results.
e) Requisition for tests, collection, identification, handling, safe transportation, processing and
disposal of a specimen is performed according to written guidance. *
f) Laboratory results are available within a defined time frame. *
g) Critical results are intimated to the person concerned at the earliest. *
h) Results are reported in a standardised manner.
i) There is a mechanism to address the recall / amendment of reports whenever applicable. *
j) Laboratory tests not available in the organisation are outsourced to the organisation(s) based on
their quality assurance system. *
19
Dr. J. L. Meena

Qualification for Laboratories as
per NABL 112
M.D. (Pathology):- Histopathology, Cytopathology, Clinical Pathology, Haematology,
Clinical Biochemistry, Nuclear Medicine (in-vitro tests), routine Microbiology and
Serology, Genetics, Flow Cytometry and Molecular Biology.
M.D. (Microbiology):- Microbiology and Serology, Flow Cytometry, Molecular
Biology, Clinical Pathology, routine Haematology and routine Biochemistry.
Ph.D. (Microbiology) with M.Sc. (Medical Microbiology):- Microbiology and
Serology, Clinical Pathology, Flow Cytometry, Molecular Biology
M.D. (Biochemistry):- Clinical Biochemistry, Clinical Pathology, Nuclear Medicine
(in-vitro tests), Flow Cytoretry, Molecular Biology, Routine Hematology, Routine
Microbiology and Serology
Ph.D. (Biochemistry) with M.Sc. (Biochemistry): - Clinical Biochemistry, Clinical
Pathology, Nuclear Medicine (in-vitro tests), Flow Cytoretry, Molecular Biology
Dr. J. L. Meena

M.S. (Anatomy)/ Ph.D. with M.Sc. (Human Anatomy)/ Ph.D. (Genetics)/ Ph.D. (Applied
Biology):- Genetics
Medical Degree with specialized (post graduate) qualification in nuclear medicine such as
Diploma in Radiation Medicine (DRM), M.D./ Ph.D./ M.Sc. in Nuclear Medicine:- Nuclear
Medicine. It is necessary that the person concerned holds a certificate from BARC on the use
of radioisotopes and RIA, this is the mandatory requirement of AERB.
M. D. in Lab Medicine:- Clinical Pathology, Haematology, Clinical Biochemistry, Nuclear
Medicine (in-vitro tests), routine Microbiology and Serology
DCP with 7 years experience:-Histopathology, Cytopathology, Clinical Pathology,
Haematology, Clinical Biochemistry, Nuclear Medicine (in-vitro tests), routine Microbiology
and Serology
M B B S with three years experience in medical laboratory:- Routine Clinical Biochemistry,
routine Haematology, routine Microbiology and Serology, and Clinical Pathology.
per NABL 112
Dr. J. L. Meena

M.Sc. in Medical Biochemistry with 5 years experience or M.Sc. in Medical Biochemistry with 7 years
experience in Medical laboratory:- Clinical Biochemistry, Clinical Pathology, routine Haematology, routine
Microbiology and Serology.
M.Sc. in Medical Microbiology with 5 years experience or M.Sc. In Microbiology with 7 7 years years
experience in Medical laboratory:- Microbiology and Serology, Clinical Pathology, routine Clinical Biochemistry,
routine Haematology.
Note:-
1. DNB is equivalent to M.D./M.S. in the respective discipline as stated above.
2. D.M. in Haematological disciplines can be a supervisor a n d authorized signatory for Haematological tests,
Flow Cytometry and Molecular Biology.
3. NABL may relax qualifications in those exceptional cases where persons have demonstrated competence
and established their credentials.
in addition to the above, the persons supervising and performing the following tests should demonstrate
evidence of adequate training, competence and experience: bone marrow examination, tests for coagulation,
flow cytometry, molecular biology, karyotyping, HLA typing and special biochemistry.
per NABL 112
Dr. J. L. Meena

The technical person performing the tests should have one of the following
qualifications:-
➢ Graduate in Medical Laboratory Technology Diploma in Medical Laboratory
Technology with the course of at least two years duration Diploma/ certificate
in Medical Laboratory Technology with the course of at least one year duration
and two years of experience in a medical laboratory.
➢ Graduate in Science with one year experience in a medical laboratory.
➢ Diploma in medical radiation and radioisotope technology (DMRIT)
➢ Cytotechnologist - 'a, b, c and d' with additional certification in cytotechnology
by the Indian Academy of Cytology for screening of exfoliative cytology.
Qualification norms for technical
staff in Laboratory as per NABL 112
Dr. J. L. Meena

➢ A laboratory may employ up to 25% of the staff with science in matriculation
having at least 10 years experience in a medical laboratory.
➢ The qualifications and experience for the phlebotomist shall be same as
above. In addition, trained nurses may collect blood samples.
➢ The laboratory shall have a system of imparting necessary training to
technical staff at various levels.
➢ There shall be a system so that a technical person receives adequate training
in the operation of new analytical equipment and/ or performance of new
test
➢ before he / she is assigned such work.
Qualification norms for technical
staff in Laboratory as per NABL 112
Dr. J. L. Meena

AAC 7 - There is an established laboratory quality
assurance and safety programme.
Objective Elements
a) The laboratory quality assurance programme is implemented. *
b) The programme ensures the quality of test results through
internal quality control. *
c) The Laboratories participates in proficiency testing /external quality
assurance scheme
d) The programme addresses clinicopathological meeting(s)
e) The laboratory safety programme is implemented. *
f) Laboratory personnel are appropriately trained in safe practices.
g) Laboratory personnel are provided with appropriate safety
measures. 25
Dr. J. L. Meena

What is OHSAS 18001:1999
This Occupational Health and Safety Assessment Series
(OHSAS) specification gives requirements for an occupational
health and safety (OH&S) management system, to enable an
organization to control its OH&S risks and improve its
performance. It does not state specific OH&S performance
criteria, nor does it give detailed specifications for the design
of a management system.
Dr. J. L. Meena

This Occupational Health and Safety Assessment Series
(OHSAS) specification gives requirements for an occupational
health and safety (OH&S) management system, to enable an
organization to control its OH&S risks and improve its
performance. It does not state specific OH&S performance
criteria, nor does it give detailed specifications for the design
of a management system.
What is OHSAS 18001:1999
Dr. J. L. Meena

An OHSAS 18001 system needs t o
cover . . .
➢ Organization employee (full-time and part time)
➢ Subcontractor and suppliers
➢ Visitors
➢ Organization's own equipment / f a c i l i t i e s
➢ Rented and borrowed equipment / facilities
Dr. J. L. Meena

Several important definitions Definition -
OHSAS18001 Analogous to ISO 9001 &
ISO 14001
Dr. J. L. Meena

Physical Hazards
➢ Electricity: leakage, statics, sparks
➢ Noise
➢ Vibration
➢ Radiation: x-ray, a particle, particle, UV, laser
➢ Fire
➢ Extreme high/low temperature
➢ Dusts
➢ Fall from heights
➢ Ambient: lighting, ventilation, temperature, humidity
➢ Signage: lack of, unclear, inappropriate
➢ Signals: lack of, unclear, inappropriate
Dr. J. L. Meena

Chemical and biological
Hazards
Dr. J. L. Meena

Physiological / psychological /
behavioral Hazards
Dr. J. L. Meena

Hazard identification, risk
assessment and risk c o n t r o l
➢ Methods for hazard identification and risk
➢ Assessment should : -
➢ Proactive
➢ Provide for classification of risks and identification
➢ Consistent with operating experience a n d t h e capabilities of risk control
measures employed
➢ Provide input into:-
* Determination of facility requirements
* Identification of training needs
* Development of operational controls
➢ Provide for monitoring of required actions
Dr. J. L. Meena

Legal and other requirements
Establish and maintain procedure for : -
➢ Identifying and accessing
• Applicable legal requirements
• Applicable "other requirements"
➢ Keep this information up-to-date
➢ Communicate relevant information to employees and other
interested parties
Dr. J. L. Meena

AAC 8 - Imaging services are provided as per
the scope of services of the organisation.
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 equipment) and human resources are adequate to provide for its
defined scope of services.
d) Qualified and trained personnel perform, supervise and interpret the investigations.
e) Imaging results are available within a defined time frame. *
f) Critical results are intimated immediately to the personnel concerned. *
g) Results are reported in a standardised manner.
h) There is a mechanism to address the recall / amendment of reports whenever applicable. *
i) Imaging tests not available in the organisation are outsourced to the organisation(s) based on their
quality assurance system. *
35
Dr. J. L. Meena

AAC 9- There is an established quality
assurance and safety programme for
imaging services.
Objective Elements
a) The quality assurance programme for imaging services is implemented. *
b) A system is in place to ensure the appropriateness of the investigations and procedures for the clinical
indication.
c) The programme addresses periodic internal/external peer review of imaging results using appropriate sampling.
d) The programme addresses the clinico-radiological meeting(s).
e) The programme includes the documentation of corrective and preventive actions.*
f) The radiation-safety programme is implemented. *
g) Patients are appropriately screened for safety/risk before imaging.
h) Imaging personnel and patients use appropriate radiation safety and monitoring devices where applicable.
i) Radiation-safety and monitoring devices are periodically tested, and results are documented. *
j) Imaging and ancillary personnel are trained in imaging safety practices and radiation-safety measures.
k) Imaging signage is prominently displayed in all appropriate locations.
36
Dr. J. L. Meena

AAC 10 - Patient care is continuous and
multidisciplinary.
Objective Elements
a) During all phases of care, there is a qualified individual identified as responsible for the patient's
care.
b) Patient care is co-ordinated in all care settings within the organisation.
c) Information about the patient's care and response to treatment is shared among medical, nursing
and other care -providers.
d) The Organisation implements standardiszed hand-over communication during each staffing shift,
between shifts and during transfers between units/ departments.
e) Patient transfer within the organisation is done safelyin a safe manner.
f) Referral of patients to other departments/ specialities follow written guidance.
g) The organisation ensures predictable service delivery by adhering to defined timelines and informs
the patient/family and/ or caregiver whenever there is a change in schedule.
h) The organisation has a mechanism in place to monitor whether adequate clinical intervention has
taken place in response to a critical value alert.
37
Dr. J. L. Meena

AAC 11 – The preventive and promotive health
services are provided in a safe collaborative and
consistent manner.
Objective Elements
a) Written guideline governs the implementation of preventive and promotive care
as per the scope of services.*
b) Organisation shall define evidenced based and contextual age-appropriate
screening for non-communicable diseases.
c) Mental health screening and appropriate intervention is advised for patients
wherever applicable.
d) Evidence based and contextual paediatric and adult immunisation shall be advised
wherever applicable.
e) A multi disciplinary approach is adopted in imparting health education on life style
modifications. 38
Dr. J. L. Meena

AAC 12 - The organisation has an established
discharge process.
Objective Elements
a) The patient's discharge process is planned in consultation with the patient and/or family.
b) The discharge process is coordinated among various departments and agencies involved (including
medico-legal and absconded cases). *
c) Written guidance governs the discharge of patients leaving against medical advice. *
d) A discharge summary is given to all the patients leaving the organisation (including patients leavingagainst
medical advice).
e) The organisation adheres to planned discharge.
f) The care shall be provided by expanding access to health practices through domiciliary visits, wherever
applicable.
g) The organisation monitors the discharge time, sets appropriate benchmarks and makes continual
improvement.
39
Dr. J. L. Meena

AAC 13 - The organisation defines the content of
the discharge summary.
Objective Elements
a) A discharge summary is provided to the patients at the time of discharge.
b) Discharge summary has a standardized contents (e.g. the patient's name, unique
identification number, name of the treating doctor, date of admission and date of
discharge, reasons for admission, significant findings, diagnosis and the patient’s
condition, investigations results, procedure performed, medications, any other
treatment, name of treating doctors and other doctors involved in the treatment.
c) Discharge summary contains follow-up advice, medication and other instructions in an
understandable manner.
d) Discharge summary incorporates instructions about when and how to obtain urgent
care.
e) In case of death, the summary of the case also includes the cause of death.
40
Dr. J. L. Meena

Summary of AAC
Access Assessment and Continuity of Care (AAC) are foundational to enhancing healthcare quality, with each
component addressing distinct yet interconnected aspects of system performance. Below are detailed insights into
their importance for quality improvement:
❖ *Access Assessment*
Access Assessment focuses on evaluating and improving patients' ability to receive timely and appropriate
healthcare services. It involves:
➢ *Timeliness*: Measuring wait times for appointments, emergency care, or diagnostics to ensure prompt
intervention, which is critical for acute conditions (e.g., reducing mortality in heart attack cases).
➢ *Availability*: Assessing the adequacy of resources—such as healthcare providers, facilities, and equipment—
relative to population needs. For instance, rural areas often face shortages, necessitating targeted interventions.
➢ *Affordability*: Identifying financial barriers (e.g., insurance gaps) that prevent care-seeking, ensuring equitable
access across socioeconomic groups.
➢ *Barriers Identification*: Pinpointing logistical issues (e.g., transportation, language barriers) or systemic
inefficiencies (e.g., referral delays) to streamline patient entry into care.
Dr. J. L. Meena

Summary of AAC
By systematically analyzing these factors, Access Assessment provides data-driven insights for quality
improvement. For example, reducing appointment wait times from 30 days to 7 days can improve
patient satisfaction and prevent condition worsening, directly impacting health outcomes.
❖ *Continuity of Care*
Continuity of Care ensures consistent, coordinated healthcare delivery over time, fostering a seamless
patient experience. Key elements include:
➢ *Relational Continuity*: Maintaining ongoing relationships between patients and providers, which
builds trust and improves communication. Studies show this reduces hospitalizations by up to 20%
in chronic disease management (e.g., diabetes).
➢ *Informational Continuity*: Ensuring medical histories, test results, and treatment plans are shared
across providers via interoperable records, minimizing errors like duplicate testing or conflicting
prescriptions.
➢ *Management Continuity*: Coordinating care across specialties and settings (e.g., hospital to
home), especially for complex cases, to prevent gaps that lead to readmissions—estimated at 1 in 5
Medicare patients within 30 days.
Dr. J. L. Meena

Summary of AAC
Continuity reduces fragmentation, a common quality issue in disjointed systems, and
supports longitudinal care, which is vital for preventive health and chronic illness
stability.
❖ *Synergy for Quality Improvement*
Together, AAC drives systemic enhancements:
➢ *Process Optimization*: Access data informs resource allocation (e.g., hiring
more staff), while continuity ensures efficient care transitions, reducing waste.
➢ *Patient-Centered Outcomes*: Timely access paired with consistent follow-up
improves adherence to treatment plans, boosting recovery rates and satisfaction.
➢ *Equity and Efficiency*: Addressing access disparities (e.g., underserved
communities) and maintaining care continuity lowers overall costs—e.g.,
preventable emergency visits cost the U.S. $8.3 billion annually.
Dr. J. L. Meena

Summary of AAC
In practice, AAC might involve a clinic using access
audits to cut wait times by 15% and implementing
electronic health records to ensure 95% of patients see
the same provider consistently. Such efforts elevate
care quality, aligning with goals of safety, effectiveness,
and patient empowerment.
Dr. J. L. Meena

Please examine your patient properly to prevent
unacceptable events in the future & focus on
“ACCESS, ASSESSMENT
AND CONTINUITY OF CARE (AAC)”
Dr. J. L. Meena

THANKS
“Want your support for Continues Improvement”

Uniform care to patients is crucial in all
healthcare settings to ensure consistency,
quality, and patient safety.
Here are some key points highlighting the importance of uniform care:
Benefits of Uniform Care
1. Consistency: Uniform care ensures that patients receive consistent treatment and care, regardless of the healthcare
setting.
2. Quality: Uniform care promotes high-quality care, as healthcare providers follow established protocols and guidelines.
3. Patient Safety: Uniform care reduces the risk of medical errors and adverse events, ensuring patient safety.
4. Improved Outcomes: Uniform care can lead to improved patient outcomes, as healthcare providers follow evidence-
based practices.
Key Elements of Uniform Care
1. Standardized Protocols: Establishing standardized protocols and guidelines for care.
2. Training and Education: Providing ongoing training and education for healthcare providers.
3. Quality Improvement: Continuously monitoring and improving the quality of care.
4. Patient-Centered Care: Focusing on patient-centered care, tailoring care to individual needs and preferences.
Dr. J. L. Meena

Importance of Uniform Care in Different Settings
1. Hospitals: Uniform care is essential in hospitals, where patients receive complex care and
treatment.
2. Clinics: Uniform care is important in clinics, where patients receive routine care and
treatment.
3. Long-Term Care: Uniform care is crucial in long-term care settings, where patients require
ongoing care and support.
Conclusion
Uniform care to patients is essential in all healthcare settings to ensure consistency, quality,
and patient safety. By establishing standardized protocols, providing ongoing training and
education, and focusing on patient-centered care, healthcare providers can deliver high-
quality care and improve patient outcomes.
Uniform care to patients is crucial in all
healthcare settings to ensure consistency,
quality, and patient safety.
Dr. J. L. Meena

Emergency care is a critical component
of healthcare systems worldwide, and its
importance cannot be overstated
Why emergency care matters:
1. **Life-Saving Intervention**: Emergency care provides immediate treatment for acute illnesses and injuries, such as heart attacks,
strokes, trauma, or severe infections. Rapid response can mean the difference between life and death.
2. **Time-Sensitive Treatment**: Many medical conditions, like severe bleeding, respiratory distress, or cardiac arrest, require urgent
attention within a narrow window of time to prevent irreversible damage or fatalities.
3. **First Line of Defense**: Emergency departments serve as the entry point to healthcare for many people, especially in crises. They
stabilize patients and coordinate further care, acting as a safety net for those without immediate access to other medical services.
4. **Public Health Impact**: Effective emergency care reduces the burden on hospitals by managing acute cases efficiently. It also helps
control outbreaks (e.g., infectious diseases) by identifying and isolating cases quickly.
5. **Support for Vulnerable Populations**: For individuals without regular healthcare access—due to financial, geographic, or social
barriers—emergency care is often their only option for treatment.
6. **Disaster Response**: During natural disasters, accidents, or mass casualty events, emergency care systems are essential for triaging
patients, managing resources, and saving as many lives as possible.
In essence, emergency care is a cornerstone of any functioning society, ensuring that people have access to immediate, skilled medical
attention when they need it most. It bridges the gap between sudden health crises and long-term recovery. Did you have a specific aspect
of emergency care in mind that you’d like me to dive deeper into?
Dr. J. L. Meena

The triage system plays a crucial role in
emergency situations, particularly in
healthcare settings.
Some key points highlighting the importance of triage:
Importance of Triage System
1. Prioritization: Triage allows healthcare professionals to prioritize patients based on the severity of their condition, ensuring that those
who need immediate attention receive it first.
2. Efficient Resource Allocation: Triage helps allocate resources, such as medical staff, equipment, and facilities, more efficiently, ensuring
that patients receive the care they need in a timely manner.
3. Reduced Mortality: Effective triage can help reduce mortality rates by ensuring that patients receive timely and appropriate care.
4. Improved Patient Outcomes: Triage can lead to improved patient outcomes by ensuring that patients receive care that is tailored to
their specific needs.
Key Elements of Triage
1. Assessment: Rapid assessment of patients to determine the severity of their condition.
2. Categorization: Categorization of patients into different levels of priority based on their condition.
3. Prioritization: Prioritization of patients based on their level of need.
4. Re-evaluation: Continuous re-evaluation of patients to ensure that their needs are being met.
Benefits of Triage System
✓ Improved Patient Care: Triage ensures that patients receive timely and appropriate care.
✓ Reduced Wait Times: Triage helps reduce wait times for patients, ensuring that they receive care in a timely manner.
✓ Increased Efficiency: Triage improves the efficiency of healthcare services, ensuring that resources are allocated effectively.
Dr. J. L. Meena

Ambulance services play a critical role in preventing
death by providing rapid response and emergency
medical care in life-threatening situations.
Their importance can be broken down into several key aspects:
1. **Speedy Response Time**: Ambulances are often the first point of contact in emergencies like heart attacks, strokes, accidents, or severe injuries. The
faster medical attention arrives, the higher the chance of survival. For example, in cases of cardiac arrest, every minute without CPR or defibrillation reduces
survival odds by 7-10%.
2. **Pre-Hospital Care**: Paramedics and emergency medical technicians (EMTs) are trained to stabilize patients on-site and during transport. They can
administer oxygen, control bleeding, perform CPR, or use defibrillators—interventions that can mean the difference between life and death before reaching a
hospital.
3. **Transportation to Proper Facilities**: Ambulances don’t just move patients; they ensure they get to the right place quickly, whether it’s a trauma center,
stroke unit, or cardiac care facility. This targeted transport can be vital, as delays or wrong destinations can worsen outcomes.
4. **Equipped for Emergencies**: Modern ambulances are essentially mobile mini-hospitals, carrying tools like ventilators, medications, and diagnostic
equipment. This allows treatment to begin immediately, bridging the gap between the emergency and hospital care.
5. **Public Health Impact**: Beyond individual cases, ambulance services reduce overall mortality rates in communities. Studies have shown that well-
funded and efficient emergency medical services (EMS) lower death rates from trauma, sudden illnesses, and disasters.
In short, ambulance services are a lifeline—reducing preventable deaths by acting fast, delivering skilled care, and connecting patients to definitive
treatment. Without them, many would succumb to conditions that are treatable with timely intervention.
Dr. J. L. Meena

Mechanisms for the care of patients during
community emergencies, epidemics and other
disasters.
To address the "best" mechanisms for the care of patients during community emergencies, epidemics, and other disasters, I can provide an
overview based on my knowledge of disaster preparedness and healthcare systems. These mechanisms generally focus on preparedness,
coordination, resource management, and patient-centered care. Here are some of the best practices:
1. **Preparedness and Planning**
- **Emergency Response Plans:** Develop and regularly update comprehensive disaster response plans tailored to specific types of emergencies
(e.g., natural disasters, pandemics, or mass casualty events). These plans should include protocols for patient triage, evacuation, and treatment.
- **Training and Drills:** Conduct regular training for healthcare providers, including simulations of disaster scenarios to ensure staff are
familiar with protocols and can respond effectively under pressure.
- **Stockpiling Resources:** Maintain stockpiles of essential medical supplies, such as personal protective equipment (PPE), ventilators,
medications, and vaccines, to ensure availability during a crisis.
2. **Coordination and Communication**
- **Centralized Command Structure:** Establish a clear incident command system (ICS) to coordinate efforts between hospitals, public health
agencies, emergency services, and government bodies.
- **Inter-Agency Collaboration:** Foster partnerships between healthcare facilities, local governments, NGOs, and community organizations to
ensure a unified response.
- **Effective Communication:** Set up reliable communication channels to disseminate information to healthcare providers, patients, and the
public. This includes using telemedicine for remote consultations and public health messaging to prevent misinformation.
Dr. J. L. Meena

3. **Triage and Resource Allocation**
- **Triage Systems:** Implement triage protocols to prioritize patients based on the severity of their condition,
especially when resources are limited. For example, during a pandemic, patients with severe respiratory distress might be
prioritized for ventilators.
- **Surge Capacity:** Expand hospital capacity by setting up temporary treatment facilities, such as field hospitals, or
converting non-medical spaces (e.g., convention centers) into care units.
- **Ethical Frameworks:** Use ethical guidelines for resource allocation, ensuring fairness and transparency in decisions
about who receives care when resources are scarce.
4. **Patient-Centered Care**
- **Continuity of Care:** Ensure that patients with chronic conditions (e.g., diabetes, dialysis patients) can continue
receiving treatment during a disaster by maintaining access to medications and services.
- **Mental Health Support:** Provide psychological support for patients and healthcare workers, as disasters and
epidemics often lead to increased stress, anxiety, and trauma.
- **Vulnerable Populations:** Prioritize care for vulnerable groups, such as the elderly, children, pregnant women, and
those with disabilities, who may have unique needs during a crisis.
disasters.
Dr. J. L. Meena

5. **Infection Control and Epidemic Management**
- **Isolation and Quarantine:** Set up isolation units for infectious diseases to prevent the spread within healthcare
facilities, as seen during outbreaks like Ebola or COVID-19.
- **Vaccination and Prophylaxis:** Rapidly deploy vaccination campaigns or prophylactic treatments (e.g., antivirals) to
control the spread of infectious diseases.
- **Contact Tracing:** Implement robust contact tracing to identify and isolate cases early, reducing community
transmission.
6. **Community Engagement**
- **Public Education:** Educate the public on preventive measures, such as hand hygiene, social distancing, and
evacuation procedures, to reduce the burden on healthcare systems.
- **Volunteer Networks:** Train community volunteers to assist with non-medical tasks, such as distributing supplies or
providing basic first aid, to support healthcare workers.
- **Local Resources:** Leverage community resources, such as schools or religious centers, as distribution points for
medical care or supplies.
disasters.
Dr. J. L. Meena

7. **Technology and Innovation**
- **Telemedicine:** Use telehealth platforms to provide care remotely, reducing the risk of exposure during epidemics and ensuring
access for patients in hard-to-reach areas.
- **Data Systems:** Implement real-time data tracking for patient numbers, resource availability, and disease spread to inform
decision-making.
- **Mobile Clinics:** Deploy mobile medical units to deliver care directly to affected communities, especially in rural or disaster-
stricken areas.
8. **Post-Disaster Recovery**
- **Follow-Up Care:** Provide ongoing care for patients recovering from injuries or illnesses caused by the disaster, including
rehabilitation services.
- **Lessons Learned:** Conduct after-action reviews to identify what worked and what didn’t, updating plans to improve future
responses.
- **Rebuilding Trust:** Work to restore community trust in the healthcare system by addressing any failures and ensuring
transparency.
These mechanisms are considered "best" because they are proactive, adaptable, and focused on both immediate response and long-
term recovery. They also balance the needs of individual patients with the broader goal of protecting public health.
disasters.
Dr. J. L. Meena

Cardio-pulmonary resuscitation (CPR) services
are crucial for saving lives in emergency
situations.
Some key points highlighting the importance of CPR services:
Importance of CPR Services
1. Saves Lives: CPR can significantly increase the chances of survival for individuals experiencing cardiac arrest or other life-
threatening emergencies.
2. Restores Blood Circulation: CPR helps maintain blood circulation and oxygenation to vital organs, such as the brain and heart,
until medical help arrives.
3. Reduces Risk of Brain Damage: Prompt CPR can reduce the risk of brain damage and other long-term health consequences.
4. Empowers Bystanders: CPR training empowers bystanders to take action in emergency situations, increasing the likelihood of a
positive outcome.
5. Supports Medical Response: CPR services complement medical response efforts, providing critical care until professional help
arrives.
Benefits of CPR Services
- Increased Survival Rates: CPR services can lead to increased survival rates for cardiac arrest and other emergencies.
- Improved Patient Outcomes: Prompt CPR can improve patient outcomes, reducing the risk of long-term health consequences.
- Enhanced Community Preparedness: CPR services can enhance community preparedness and response to emergencies.
Dr. J. L. Meena

Timely CPR can significantly reduce the
risk of death and improve survival rates.
According to the American Heart Association (AHA), CPR can double or triple a person's chances of survival if performed
promptly and correctly.
Survival Rates with Timely CPR
- Cardiac Arrest: CPR can increase survival rates for cardiac arrest by 20-40% if performed within 4-6 minutes of the event.
- Out-of-Hospital Cardiac Arrest: CPR can improve survival rates for out-of-hospital cardiac arrest by 10-30% if performed
promptly.
- In-Hospital Cardiac Arrest: CPR can improve survival rates for in-hospital cardiac arrest by 15-25% if performed promptly.
Factors Affecting Survival Rates
- Time to CPR: The sooner CPR is started, the better the chances of survival.
- Quality of CPR: Proper technique and depth of chest compressions are crucial for effective CPR.
- Underlying Medical Conditions: The presence of underlying medical conditions can affect survival rates.
Importance of Prompt CPR
- Early Intervention: Prompt CPR can help restore blood circulation and oxygenation to vital organs.
- Increased Survival Chances: Timely CPR can significantly increase the chances of survival and improve patient outcomes.
Dr. J. L. Meena

Proper nursing care is essential for promoting
health, preventing illness, and improving
patient outcomes.
Some key points highlighting the importance of proper nursing care and its impact:
Importance of Proper Nursing Care
1. Promotes Health and Well-being: Nursing care helps patients recover from illnesses, injuries, or surgeries, and promotes overall health
and well-being.
2. Prevents Complications: Proper nursing care can prevent complications, such as infections, pressure ulcers, and falls, which can lead to
prolonged hospital stays and increased healthcare costs.
3. Improves Patient Outcomes: Nursing care can improve patient outcomes by providing timely and effective interventions, such as
medication administration, wound care, and vital sign monitoring.
4. Enhances Patient Satisfaction: Proper nursing care can enhance patient satisfaction by providing emotional support, education, and
empowerment, which can lead to better health outcomes and increased patient loyalty.
Impact of Proper Nursing Care
✓ Reduced Hospital Readmissions: Proper nursing care can reduce hospital readmissions by providing patients with the necessary
education, support, and resources to manage their conditions effectively.
✓ Improved Quality of Life: Nursing care can improve patients' quality of life by promoting independence, mobility, and functional ability.
✓ Increased Patient Safety: Proper nursing care can increase patient safety by preventing errors, adverse events, and near misses.
✓ Cost-Effective Care: Nursing care can provide cost-effective care by reducing healthcare costs, improving patient outcomes, and
promoting efficient use of resources.
Dr. J. L. Meena

Following “Clinical Protocols” for
treatment is crucial for several reasons
Importance of Treatment as per Clinical Protocol
1. Ensures Standardized Care: Clinical protocols provide a standardized approach to treatment, ensuring that patients receive consistent
and high-quality care.
2. Improves Patient Outcomes: Adhering to clinical protocols can improve patient outcomes by reducing the risk of complications,
hospital readmissions, and mortality.
3. Enhances Patient Safety: Clinical protocols help minimize the risk of medical errors, adverse events, and near misses, promoting a safer
healthcare environment.
4. Supports Evidence-Based Practice: Clinical protocols are often based on the latest research and evidence, ensuring that patients receive
treatments that are proven to be effective.
5. Facilitates Communication and Collaboration: Clinical protocols promote clear communication and collaboration among healthcare
providers, ensuring that patients receive comprehensive and coordinated care.
Benefits of Following Clinical Protocols
✓ Reduced Healthcare Costs: Following clinical protocols can help reduce healthcare costs by minimizing unnecessary tests, procedures,
and treatments.
✓ Improved Quality of Care: Clinical protocols can improve the quality of care by ensuring that patients receive timely and effective
interventions.
✓ Enhanced Patient Satisfaction: Following clinical protocols can enhance patient satisfaction by providing patients with clear
information, education, and support.
Dr. J. L. Meena

Safe blood transfusion services are crucial for
ensuring the well-being and safety of patients
receiving blood transfusions.
Some key points highlighting the importance of safe blood transfusion services:
Importance of Safe Blood Transfusion Services
1. Prevents Transfusion-Transmitted Infections: Safe blood transfusion services help prevent the transmission of infectious diseases, such
as HIV, hepatitis, and malaria, through blood transfusions.
2. Reduces Risk of Adverse Reactions: Proper screening and testing of blood products can reduce the risk of adverse reactions, such as
allergic reactions, hemolytic reactions, and transfusion-related acute lung injury (TRALI).
3. Ensures Compatibility: Safe blood transfusion services ensure that blood products are compatible with the recipient's blood type,
reducing the risk of hemolytic reactions.
4. Promotes Patient Safety: Safe blood transfusion services promote patient safety by ensuring that blood products are handled, stored,
and transfused properly.
5. Supports Effective Treatment: Safe blood transfusion services support effective treatment by providing patients with the blood products
they need to manage their medical conditions.
Benefits of Safe Blood Transfusion Services
✓ Improved Patient Outcomes: Safe blood transfusion services can improve patient outcomes by reducing the risk of complications and
promoting effective treatment.
✓ Reduced Healthcare Costs: Safe blood transfusion services can reduce healthcare costs by minimizing the risk of adverse reactions and
transfusion-transmitted infections.
✓ Enhanced Patient Trust: Safe blood transfusion services can enhance patient trust by providing patients with confidence in the safety
and quality of blood transfusions.
Dr. J. L. Meena

Intensive care units (ICUs) and high dependency units
(HDUs) play a crucial role in providing specialized care
to critically ill patients.
Some key points highlighting the importance of ICUs and HDUs in a systematic manner:
Importance of ICUs and HDUs
1. Specialized Care: ICUs and HDUs provide specialized care to critically ill patients who require close
monitoring and life-sustaining interventions.
2. Multidisciplinary Team: ICUs and HDUs are staffed by a multidisciplinary team of healthcare
professionals, including intensivists, nurses, and therapists, who work together to provide
comprehensive care.
3. Advanced Life Support: ICUs and HDUs are equipped with advanced life support technologies, such
as mechanical ventilation, dialysis, and cardiac support, to sustain patients' vital functions.
4. Close Monitoring: ICUs and HDUs provide close monitoring of patients' vital signs, laboratory
results, and other parameters to quickly identify any changes in their condition.
5. Timely Interventions: ICUs and HDUs enable timely interventions, such as emergency surgeries, to
address life-threatening conditions.
Dr. J. L. Meena

Intensive care units (ICUs) and high dependency units
(HDUs) play a crucial role in providing specialized care
to critically ill patients.
Benefits of ICUs and HDUs
- Improved Patient Outcomes: ICUs and HDUs can improve patient outcomes by providing specialized care and timely
interventions.
- Reduced Mortality Rates: ICUs and HDUs can reduce mortality rates by providing advanced life support and close monitoring.
- Enhanced Patient Safety: ICUs and HDUs can enhance patient safety by providing a safe and controlled environment for critically
ill patients.
- Cost-Effective Care: ICUs and HDUs can provide cost-effective care by reducing the length of stay and minimizing complications.
Systematic Approach to ICUs and HDUs
- Standardized Protocols: ICUs and HDUs should have standardized protocols for admission, treatment, and discharge to ensure
consistency and quality of care.
- Evidence-Based Practice: ICUs and HDUs should be guided by evidence-based practice to ensure that patients receive the best
possible care.
- Continuous Quality Improvement: ICUs and HDUs should have a continuous quality improvement process to identify areas for
improvement and implement changes.
- Collaboration and Communication: ICUs and HDUs should have effective collaboration and communication among healthcare
professionals to ensure that patients receive comprehensive and coordinated care.
Dr. J. L. Meena

Maternal and child deaths due to unsafe
delivery are significant public health concerns,
particularly in low-resource settings.
According to the World Health Organization (WHO) and the United Nations Population Fund
(UNFPA), here are some key statistics:
Maternal Deaths
- Approximately 290,000 maternal deaths occur each year, with around 70,000 due to excessive
bleeding (postpartum hemorrhage).
- In 2015, UNFPA estimated that 303,000 women died from pregnancy or childbirth-related causes.
- The main causes of maternal death worldwide are:
- Hemorrhage (27.1% of maternal deaths)
- Hypertensive disorders
- Sepsis
- Obstructed labor
- Complications from unsafe abortion
Dr. J. L. Meena

Maternal and child deaths due to unsafe
delivery are significant public health concerns,
particularly in low-resource settings.
According to the World Health Organization (WHO) and the United Nations Population Fund (UNFPA), here are some key
statistics:
Child Deaths
- The three main causes of newborn deaths are:
- Prematurity
- Intrapartum-related complications
- Sepsis
- Congenital anomalies are also a growing concern, especially in low-mortality settings.
Regional Disparities
- Sub-Saharan Africa and South Asia bear the largest burden of maternal mortality, with the lowest percentage of births
attended by skilled providers (45% and 41%, respectively).
Prevention Strategies
- Improving access to prenatal care
- Skilled birth attendance with emergency backup
- Emergency obstetric care
- Postnatal care Dr. J. L. Meena

Safe obstetric care is crucial for ensuring the
health and well-being of mothers and their
babies.
Here are some key points highlighting the importance of safe obstetric care:
Importance of Safe Obstetric Care
1. Reduces Maternal Mortality: Safe obstetric care can reduce maternal mortality rates by providing
timely and effective interventions during pregnancy, childbirth, and postpartum.
2. Prevents Complications: Safe obstetric care can prevent complications, such as hemorrhage,
eclampsia, and obstructed labor, which can be life-threatening for mothers and their babies.
3. Promotes Healthy Births: Safe obstetric care can promote healthy births by ensuring that
mothers receive proper prenatal care, skilled attendance during childbirth, and postpartum
support.
4. Enhances Newborn Health: Safe obstetric care can enhance newborn health by ensuring that
babies receive proper care and attention immediately after birth.
5. Supports Breastfeeding: Safe obstetric care can support breastfeeding by providing mothers with
the necessary education and support to initiate and maintain breastfeeding.
Dr. J. L. Meena

Safe obstetric care is crucial for ensuring the
health and well-being of mothers and their
babies.
Here are some key points highlighting the importance of safe obstetric care:
Benefits of Safe Obstetric Care
- Improved Maternal and Newborn Outcomes: Safe obstetric care can improve maternal
and newborn outcomes by reducing the risk of complications and promoting healthy births.
- Reduced Healthcare Costs: Safe obstetric care can reduce healthcare costs by minimizing
the need for costly interventions and complications.
- Increased Patient Satisfaction: Safe obstetric care can increase patient satisfaction by
providing mothers with a positive and empowering experience during pregnancy,
childbirth, and postpartum.
- Enhanced Quality of Care: Safe obstetric care can enhance the quality of care by
promoting evidence-based practice and continuous quality improvement.
Dr. J. L. Meena

Safe pediatric services are crucial for
ensuring the health and well-being of
children.
Some key points highlighting the importance of safe pediatric services:
Importance of Safe Pediatric Services
1. Prevents Medical Errors: Safe pediatric services can prevent medical errors, such as medication
errors, misdiagnosis, and surgical errors, which can have serious consequences for children's health.
2. Promotes Healthy Development: Safe pediatric services can promote healthy development by
providing children with regular check-ups, vaccinations, and screenings to detect any potential health
issues early.
3. Enhances Patient Safety: Safe pediatric services can enhance patient safety by providing a safe and
welcoming environment for children, reducing the risk of hospital-acquired infections, and promoting
infection control practices.
4. Supports Family-Centered Care: Safe pediatric services can support family-centered care by
involving parents and caregivers in the care process, providing them with education and support, and
promoting a collaborative approach to care.
5. Reduces Healthcare Costs: Safe pediatric services can reduce healthcare costs by minimizing the
need for costly interventions, reducing hospital readmissions, and promoting efficient use of
resources.
Dr. J. L. Meena

Safe pediatric services are crucial for
ensuring the health and well-being of
children.
Some key points highlighting the importance of safe pediatric services:
Benefits of Safe Pediatric Services
- Improved Health Outcomes: Safe pediatric services can improve health
outcomes by providing children with timely and effective interventions, reducing
the risk of complications, and promoting healthy development.
- Increased Patient Satisfaction: Safe pediatric services can increase patient
satisfaction by providing children and their families with a positive and
empowering experience, promoting trust and confidence in the healthcare
system.
- Enhanced Quality of Care: Safe pediatric services can enhance the quality of
care by promoting evidence-based practice, continuous quality improvement,
and a commitment to patient safety and well-being.
Dr. J. L. Meena

Informed consent is a crucial aspect of healthcare, and
hospitals play a significant role in ensuring that patients
provide informed consent for medical treatment.
Here are some key points highlighting the importance of informed consent:
Importance of Informed Consent
1. Patient Autonomy: Informed consent respects patients' autonomy and right to make decisions about their care.
2. Informed Decision-Making: Informed consent enables patients to make informed decisions about their treatment, including the risks,
benefits, and alternatives.
3. Trust and Confidence: Informed consent helps build trust and confidence between patients and healthcare providers.
4. Legal and Ethical Requirements: Informed consent is a legal and ethical requirement for healthcare providers.
Key Elements of Informed Consent
1. Clear and Concise Information: Providing clear and concise information about the treatment, including the risks, benefits, and alternatives.
2. Patient Understanding: Ensuring that patients understand the information provided.
3. Voluntary Consent: Ensuring that patients provide voluntary consent, free from coercion or undue influence.
4. Documentation: Documenting the informed consent process and the patient's consent.
Benefits of Informed Consent
- Improved Patient Outcomes: Informed consent can lead to improved patient outcomes, as patients are more likely to adhere to treatment
plans.
- Reduced Liability: Informed consent can reduce liability for healthcare providers, as patients are aware of the risks and benefits of treatment.
- Increased Patient Satisfaction: Informed consent can lead to increased patient satisfaction, as patients feel more informed and involved in
their care.
Dr. J. L. Meena

Procedural sedation is a critical aspect of
medical care, and providing it in a consistent
and safe manner is essential.
Some key points to consider:
Importance of Consistent and Safe Procedural Sedation
1. Patient Safety: Ensuring patient safety during procedural sedation is paramount.
2. Effective Sedation: Providing effective sedation to minimize discomfort and anxiety.
3. Reduced Complications: Minimizing complications and adverse events associated with procedural sedation.
4. Improved Patient Outcomes: Improving patient outcomes by ensuring safe and effective procedural sedation.
Key Elements of Consistent and Safe Procedural Sedation
1. Standardized Protocols: Establishing standardized protocols for procedural sedation.
2. Trained Healthcare Providers: Ensuring healthcare providers are trained and competent in procedural sedation.
3. Monitoring and Assessment: Continuously monitoring and assessing patients during procedural sedation.
4. Emergency Preparedness: Being prepared for emergencies and having a plan in place for managing complications.
Benefits of Consistent and Safe Procedural Sedation
- Improved Patient Satisfaction: Patients are more likely to be satisfied with their care when procedural sedation is provided in a consistent
and safe manner.
- Reduced Anxiety and Discomfort: Procedural sedation can help reduce anxiety and discomfort associated with medical procedures.
- Improved Outcomes: Consistent and safe procedural sedation can lead to improved patient outcomes and reduced complications.
Dr. J. L. Meena

Anesthesia services play a crucial role in
ensuring the safety and comfort of patients
during surgery.
Some key points highlighting the importance of anesthesia services:
Importance of Anesthesia Services
1. Pain Management: Anesthesia services provide effective pain management, allowing patients to undergo surgery without
experiencing significant pain or discomfort.
2. Patient Safety: Anesthesia services ensure patient safety by monitoring vital signs, managing anesthesia levels, and responding to any
complications that may arise during surgery.
3. Relaxation and Sedation: Anesthesia services provide relaxation and sedation, helping patients to remain calm and comfortable
during surgery.
4. Surgical Success: Anesthesia services are essential for the success of surgical procedures, as they enable surgeons to perform complex
operations without causing undue stress or discomfort to the patient.
Benefits of Anesthesia Services
- Improved Patient Outcomes: Anesthesia services can improve patient outcomes by reducing the risk of complications, promoting faster
recovery, and enhancing overall patient satisfaction.
- Reduced Anxiety and Stress: Anesthesia services can reduce anxiety and stress for patients undergoing surgery, making the experience
more comfortable and manageable.
- Enhanced Surgical Experience: Anesthesia services can enhance the surgical experience by providing patients with a safe, comfortable,
and pain-free environment.
Dr. J. L. Meena

The surgical process is a complex and highly
specialized field that requires careful consideration of
various factors to ensure optimal patient outcomes.
Some key points highlighting the importance of the surgical process as per indication:
Importance of Surgical Process
1. Accurate Diagnosis: A thorough diagnosis is essential to determine the underlying condition and develop an effective treatment
plan.
2. Preoperative Planning: Careful planning and preparation are crucial to ensure that the patient is adequately prepared for surgery.
3. Surgical Technique: The choice of surgical technique depends on the specific indication, and the surgeon must be skilled and
experienced in the chosen technique.
4. Intraoperative Care: Close monitoring and care during surgery are essential to prevent complications and ensure optimal outcomes.
5. Postoperative Care: Proper postoperative care is critical to prevent complications, promote healing, and ensure a smooth recovery.
Benefits of Surgical Process
- Improved Patient Outcomes: A well-planned and executed surgical process can lead to improved patient outcomes, reduced
complications, and faster recovery times.
- Enhanced Patient Safety: A focus on patient safety during the surgical process can help prevent errors, reduce risks, and promote a
safe and effective treatment experience.
- Increased Efficiency: A streamlined surgical process can help reduce costs, improve resource utilization, and enhance the overall
efficiency of the healthcare system.
Dr. J. L. Meena

Deaths due to the surgical process can
occur due to various factors.
Causes of Death due to Surgical Process
1. Complications during surgery: Bleeding, infection, or other complications during surgery can be life-threatening.
2. Anesthesia-related issues: Problems with anesthesia, such as allergic reactions or respiratory depression, can lead to
serious complications.
3. Pre-existing medical conditions: Patients with pre-existing medical conditions may be at higher risk for complications
during surgery.
4. Surgical errors: Mistakes made during surgery, such as wrong-site surgery or retained foreign objects, can have serious
consequences.
5. Postoperative care: Inadequate postoperative care can lead to complications, such as infection or respiratory problems.
Prevention and Safety Measures
- Proper patient evaluation: Thorough evaluation of patients before surgery can help identify potential risks.
- Experienced surgical team: Working with an experienced surgical team can reduce the risk of complications.
- Monitoring and equipment: Proper monitoring and equipment can help detect potential issues early.
- Emergency preparedness: Having emergency protocols in place can help respond to complications quickly and effectively.
Dr. J. L. Meena

The organ transplant program is a complex and highly
specialized field that requires careful consideration of
various factors to ensure safe and successful outcomes.
Some key points highlighting the importance of safety in organ transplant programs:
Importance of Safety in Organ Transplant Programs
1. Donor Selection: Careful selection of organ donors is crucial to ensure that the organs are healthy and free from diseases.
2. Recipient Evaluation: Thorough evaluation of potential recipients is necessary to determine their suitability for transplantation.
3. Surgical Expertise: The surgical team must have the necessary expertise and experience to perform the transplant procedure safely and
effectively.
4. Immunosuppression Management: Effective management of immunosuppression is critical to prevent rejection and ensure the long-
term success of the transplant.
5. Post-Transplant Care: Proper post-transplant care is essential to monitor for complications and ensure the recipient's overall health and
well-being.
Benefits of Safe Organ Transplant Programs
- Improved Patient Outcomes: Safe organ transplant programs can lead to improved patient outcomes, reduced complications, and
increased graft survival rates.
- Enhanced Patient Safety: A focus on safety in organ transplant programs can help prevent errors, reduce risks, and promote a safe and
effective treatment experience.
- Increased Efficiency: A well-organized and safe organ transplant program can help reduce costs, improve resource utilization, and
enhance the overall efficiency of the healthcare system.
Dr. J. L. Meena

Identifying and managing patients who are at
higher risk of morbidity/mortality is crucial in
healthcare.
High-Risk Patient Identification
1. Medical History: Reviewing patients' medical histories to identify pre-existing conditions that may increase their risk.
2. Age and Comorbidities: Considering patients' age and comorbidities, such as diabetes, hypertension, or chronic obstructive pulmonary disease
(COPD).
3. Current Health Status: Assessing patients' current health status, including vital signs, laboratory results, and physical examination findings.
4. Surgical or Procedural Risks: Evaluating the risks associated with surgical or procedural interventions.
High-Risk Patient Management
1. Multidisciplinary Care: Assembling a multidisciplinary team to provide comprehensive care and management.
2. Personalized Care Plans: Developing personalized care plans tailored to each patient's unique needs and risks.
3. Close Monitoring: Closely monitoring patients' vital signs, laboratory results, and physical examination findings to quickly identify any changes or
concerns.
4. Timely Interventions: Implementing timely interventions to address potential complications or issues.
Benefits of High-Risk Patient Management
✓ Improved Patient Outcomes: Effective management of high-risk patients can lead to improved patient outcomes, reduced morbidity, and
mortality.
✓ Enhanced Patient Safety: A focus on high-risk patient management can help prevent errors, reduce risks, and promote a safe and effective
treatment experience.
✓ Reduced Healthcare Costs: Effective management of high-risk patients can help reduce healthcare costs by minimizing the need for costly
interventions and complications. Dr. J. L. Meena

Consistent pain management for patients is
crucial for their comfort, well-being, and
recovery.
Importance of Consistent Pain Management
1. Patient Comfort: Effective pain management helps patients feel more comfortable and relaxed, reducing anxiety and stress.
2. Improved Outcomes: Consistent pain management can lead to improved patient outcomes, such as faster recovery times and reduced
complications.
3. Enhanced Patient Satisfaction: Patients who receive effective pain management are more likely to be satisfied with their care and treatment.
4. Reduced Risk of Chronic Pain: Consistent pain management can help reduce the risk of chronic pain and related issues.
Key Elements of Consistent Pain Management
- Assessment and Evaluation: Regular assessment and evaluation of patients' pain levels and needs.
- Personalized Care Plans: Development of personalized care plans tailored to each patient's unique needs and circumstances.
- Multimodal Approach: Use of a multimodal approach to pain management, including medications, therapies, and other interventions.
- Ongoing Monitoring: Ongoing monitoring of patients' pain levels and response to treatment.
Benefits of Consistent Pain Management
- Improved Patient Outcomes: Consistent pain management can lead to improved patient outcomes, reduced complications, and faster recovery
times.
- Enhanced Patient Satisfaction: Patients who receive effective pain management are more likely to be satisfied with their care and treatment.
- Reduced Healthcare Costs: Effective pain management can help reduce healthcare costs by minimizing the need for costly interventions and
complications.
Dr. J. L. Meena

Rehabilitation services play a crucial role in helping patients recover from
injuries, illnesses, or surgeries. Here are some key points highlighting the
importance of providing rehabilitation services in a safe, collaborative,
and consistent manner:
Importance of Safe Rehabilitation Services
1. Patient Safety: Ensuring patient safety is paramount in rehabilitation services to prevent further injuries or complications.
2. Effective Treatment: Safe rehabilitation services enable effective treatment and care, promoting optimal patient outcomes.
3. Building Trust: Providing safe rehabilitation services helps build trust between patients and healthcare providers, fostering a positive care experience.
Collaborative Approach to Rehabilitation
1. Interdisciplinary Team: A collaborative approach involves an interdisciplinary team of healthcare professionals working together to provide comprehensive
care.
2. Patient-Centered Care: Collaborative care focuses on patient-centered care, taking into account individual needs and goals.
3. Improved Outcomes: A collaborative approach can lead to improved patient outcomes, increased patient satisfaction, and enhanced quality of life.
Consistent Rehabilitation Services
1. Standardized Care: Consistent rehabilitation services ensure standardized care, reducing variability and improving patient outcomes.
2. Evidence-Based Practice: Consistent care is guided by evidence-based practice, ensuring that patients receive the most effective treatments.
3. Improved Patient Experience: Consistent rehabilitation services promote a positive patient experience, enhancing patient satisfaction and loyalty.
Benefits of Safe, Collaborative, and Consistent Rehabilitation Services
- Improved Patient Outcomes: Safe, collaborative, and consistent rehabilitation services can lead to improved patient outcomes, increased patient
satisfaction, and enhanced quality of life.
- Enhanced Patient Safety: A focus on safety in rehabilitation services can help prevent further injuries or complications, promoting a safe and effective care
experience.
- Increased Efficiency: Consistent rehabilitation services can help reduce healthcare costs, improve resource utilization, and enhance the overall efficiency of
the healthcare system.
Dr. J. L. Meena

Inadequate nutritional therapy can have
significant effects on patients.
Some potential consequences:
Physical Effects
1. Malnutrition: Inadequate nutritional therapy can lead to malnutrition, which can cause weight loss, fatigue, and
weakness.
2. Delayed Healing: Malnutrition can impede the healing process, leading to prolonged recovery times.
3. Increased Risk of Complications: Malnutrition can increase the risk of complications, such as infections and organ
failure.
Emotional and Psychological Effects
1. Anxiety and Depression: Inadequate nutritional therapy can contribute to anxiety and depression.
2. Decreased Quality of Life: Malnutrition can significantly decrease a patient's quality of life.
3. Loss of Hope: Inadequate nutritional therapy can lead to feelings of hopelessness and despair.
Impact on Healthcare System
1. Increased Healthcare Costs: Inadequate nutritional therapy can lead to increased healthcare costs.
2. Prolonged Hospital Stays: Malnutrition can result in prolonged hospital stays.
3. Increased Risk of Readmission: Inadequate nutritional therapy can increase the risk of readmission.
Dr. J. L. Meena

End-of-life care is a critical aspect of healthcare that focuses on
providing comfort, support, and dignity to patients with terminal
illnesses or nearing the end of life.
Some key points highlighting the importance of providing end-of-life care in a compassionate and considerate manner:
Importance of Compassionate End-of-Life Care
1. Patient-Centered Care: Compassionate end-of-life care prioritizes patient-centered care, focusing on individual needs,
values, and preferences.
2. Emotional Support: Providing emotional support and empathy helps patients and their families cope with the
challenges of end-of-life care.
3. Pain Management: Effective pain management is crucial to ensure patients' comfort and alleviate suffering.
4. Dignity and Respect: Compassionate care promotes dignity and respect for patients, acknowledging their autonomy and
individuality.
Benefits of Compassionate End-of-Life Care
- Improved Patient Experience: Compassionate end-of-life care can lead to improved patient experiences, increased
satisfaction, and enhanced quality of life.
- Support for Families: Compassionate care also provides support for families and caregivers, helping them cope with the
emotional and practical challenges of end-of-life care.
- Enhanced Quality of Care: A focus on compassionate care can lead to improved quality of care, increased patient safety,
and more effective symptom management.
Dr. J. L. Meena

Care of Patients (COP)
➢ The organisation provides uniform care to all patients in various settings. The settings include care provided in
outpatient units, day care facilities, in-patient units including critical care units, procedure rooms and
operation theatre. When similar care is provided in these different settings, care delivery is uniform. Written
guidance, applicable laws and regulations guide emergency and ambulance services, cardio-pulmonary
resuscitation, use of blood and blood components, care of patients in the critical care and high dependency
units.
➢ Written guidance, applicable laws and regulations also guide the care of patients who are at higher risk of
morbidity/mortality, high-risk obstetric patients, paediatric patients, patients undergoing procedural sedation,
administration of anaesthesia, patients undergoing surgical procedures and end of life care.
➢ Pain management, nutritional therapy and rehabilitative services are also addressed to provide
comprehensive health care.
➢ The management should have written guidelines for organ donation and procurement. The transplant
programme ensures that it has the right skill mix of staff and other related support systems to ensure safe and
high quality of care.
➢ The delivery of care and services to the patients are coordinated and integrated by all healthcare providers.
The standards aim to guide and encourage patient safety as the overarching principle for providing care to
patients.
39
Dr. J. L. Meena

COP.1.
Uniform care to patients is provided in all settings of the organisation and
is guided by written guidance.*
COP.11. Organisation provides safe paediatricservices.
COP.12. Procedural sedation is provided consistently and safely.
COP.2.
Emergency services are provided in accordance with written guidance,
applicable laws and regulations.
COP.13.
Anaesthesia services are provided in a consistent and safe
manner.
COP.3.
Ambulance services ensure safe patient transportation with appropriate
care. COP.14. Surgical services are provided in a consistent and safe manner.
COP.4.
The organisation plans and implements mechanisms for the care of
patients during community emergencies, epidemics and other disasters. COP.15. The organ transplant programme is carried out safely.
COP.16.
The organisation identifies and manages patients who are at
higher risk of morbidity/mortality.
COP.5.
Cardio-pulmonary resuscitation services are provided uniformly across the
organisation.
COP.6.
Nursing care is provided to patients in the organisation in consonance with
clinical protocols.
COP.17. Pain management for patients is done in a consistent manner.
COP.18.
Rehabilitation services are provided to the patients in a safe,
collaborative and consistent manner.
COP.7. Clinical procedures are performed safely.
COP.8.
Transfusion services are provided as per the scope of services of the
organisation, safely.
COP.19.
Nutritional therapy is provided to patients consistently and
collaboratively.
COP.9.
The organisation provides care in intensive care and high dependency
units in a systematic manner.
COP.20.
End of life care is provided in a compassionate and considerate
manner.
COP.10. Organisation provides safe obstetric care.
40
Dr. J. L. Meena

Objective
Elements
COP 1 COP 2 COP 3 COP 4 COP 5 COP 6 COP 7 COP 8 COP 9 COP 10
a Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment
b CORE Achievement Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment
c Commitment CORE Commitment Commitment Commitment
Achievement
Commitment Commitment Commitment Commitment
d Excellence Commitment Commitment Commitment Commitment Commitment CORE CORE Commitment Commitment
e Excellence Commitment Commitment Commitment Commitment Commitment Commitment Commitment Achievement
f
Commitment
Commitment Commitment
Commitment
Commitment Commitment Achievement Achievement Commitment
g Commitment
Achievement
Achievement Commitment Commitment
h Achievement Commitment
i
Commitment
Commitment
j Commitment
k Commitment
Summary Standards -20 OE - 136 CORE 13 Commitment 107 Achievement 12
Excellence
4

Objective
Elements
COP 11 COP 12 COP 13 COP 14 COP 15 COP 16 COP 17 COP 18 COP 19 COP 20
a Commitment Commitment Commitment Commitment CORE CORE Commitment Commitment Commitment Commitment
b Commitment Commitment Commitment Commitment Commitment CORE Commitment Commitment Commitment Achievement
c Commitment Commitment CORE Commitment Commitment CORE Commitment Commitment Commitment Commitment
d Commitment Commitment Commitment CORE CORE CORE Commitment Commitment Commitment Commitment
e Commitment Commitment CORE Commitment Commitment Commitment Commitment Commitment
f Commitment Commitment Commitment Commitment Commitment
g Commitment Commitment Commitment Commitment Excellence
h
Excellence
Commitment Commitment Commitment
i Commitment Achievement
j Achievement Achievement
Summary Standards -20 OE - 136 CORE 13 Commitment 107 Achievement 12 Excellence 4

COP 1 - Uniform care to patients is provided in all
settings of the organisation and is guided by written
guidance.
Objective Elements
a) Uniform care is provided following written guidance. *
b) The organisation has a uniform process for identification of patients and at a minimum,
uses two identifiers.
c) The organisation adapts evidence-based clinical practice guidelines and/or clinical
protocols to guide uniform patient care.
d) Clinical care pathways are developed, consistently followed across all settings of care, and
reviewed Pperiodically.
e) Multi-disciplinary and multi-speciality care, where appropriate, is planned based on best
clinical practices/clinical practice guidelines and delivered in a uniform manner across the
organisation.
f) Telemedicine facility is provided safely and securely based on written guidance. *
43
Dr. J. L. Meena

COP 2 - Emergency services are provided in
accordance with written guidance, applicable
laws and regulations.
Objective Elements
a) There shall be an identified area in the organisation which is easily accessible to receive and manage
emergency patients, with adequate and appropriate resources.
b) Prevention of patient over-crowding is planned, and crowd management measures are implemented.
c) Emergency care is provided in consonance with statutory requirements and in accordance with the written
guidance. *
d) Initiation of appropriate care is guided by a system of triage. *
e) Patients waiting in the emergency are reassessed as appropriate for change in status.
f) Admission, discharge to home, or transfer to another organisation is documented.
g) In case of discharge to home or transfer to another organisation, a discharge/ transfer note shall be given to
the patient.
h) The organisation shall implement a quality assurance programme. *
i) The organisation has systems in place for the management of patients found dead on arrival and patients
who die within a few minutes of arrival *
44
Dr. J. L. Meena

COP 3 - Ambulance services ensure safe patient
transportation with appropriate care
Objective Elements
a) The organisation has access to ambulance services commensurate with the scope of the
services provided by it.
b) There are adequate access and space for the ambulance(s).
c) The ambulance(s) is fit for purpose and is appropriately equipped.
d) The ambulance(s) is operated by trained personnel.
e) The ambulance(s) is checked daily for functioning status, medical equipments,
emergency medications and consumables.
f) The ambulance(s) has a proper communication system.*
g) The emergency department identifies opportunities to initiate treatment at the earliest
when the patient is in transit to the organisation.
45
Dr. J. L. Meena

COP 4 - The organisation plans and implements
mechanisms for the care of patients during community
emergencies, epidemics and other disasters.
Objective Elements
a) The organisation identifies potential community emergencies,
epidemics and other disasters.*
b) The organisation manages community emergencies, epidemics and
other disasters as per a documented plan.*
c) Provision is made for availability of medical supplies, equipment
and materials during such emergencies.
d) The plan is tested at least twice a year.
46
Dr. J. L. Meena

COP 5 - Cardio-pulmonary resuscitation
services are provided uniformly across the
organisation.
Objective Elements
47
Dr. J. L. Meena
a) Resuscitation services are available to patients at all times.
b)During cardio-pulmonary resuscitation, assigned roles and responsibilities are
complied with.
c) Equipment and medications for use during cardio-pulmonary resuscitation are
available in various areas of the organisation.
d)The events during cardio-pulmonary resuscitation are recorded.
e) A multidisciplinary committee does a post-event analysis of cardiopulmonary
resuscitations.
f) Corrective and preventive measures are taken based on the post-event
analysis.

COP 6 - Nursing care is provided to patients in
the organisation in consonance with clinical
protocols.
Objective Elements
a) Nursing care is provided to patients in accordance with written guidance. *
b) Assignment of patient care is done as per current good clinical/ nursing practice
guidelines.
c) The organisation implements acuity-based staffing to improve patient outcomes.
d) Nursing care is aligned and integrated with overall patient care which is documented.*
e) Nurses are provided with appropriate and adequate equipment for providing safe and
efficient nursing care.
f) Nurses are empowered to make patient care decisions within their scope of practice.
48
Dr. J. L. Meena

COP 7 - Clinical procedures are performed in a
safe manner.
Objective Elements
a) Clinical procedures are performed based on the clinical needs of the patient.
b)Performance of various clinical procedures is based on written guidance and
done in a safe manner. *
c) Qualified personnel order, plan, perform and assist in performing procedures.
d)Care is taken to prevent adverse events like a wrong patient, wrong procedure
and wrong site. *
e) Informed consent is taken by the personnel performing the procedure, where
applicable.
f) Patients are appropriately monitored during and after the procedure.
g) Procedures are documented accurately in the patient record.
49
Dr. J. L. Meena

COP 8 - Transfusion services are provided as
per the scope of services of the organisation,
safely.
Objective Elements
a) Scope of transfusion services is commensurate with the services provided by the
organisation.
b) The organisation shall establish and implement processes for blood / component collection, testing, storage
and distribution under written guidance. *
c) Blood and blood components are are stored safely from the time of collection till transfusion.
d) The organisation ensures safe and rational use of blood and blood components.*
e) Blood/blood components are available for use in emergency situations within a defined time-frame. *
f) The organisation shall ensure that post-transfusion form is collected, reactions if any identified and are
analysed for preventive and corrective actions.*
g) The organisation shall implement a quality assurance programme. *
50
Dr. J. L. Meena

COP 9 - The organisation provides care in
intensive care and high dependency units in a
systematic manner.
Objective Elements
a) Care of patients in intensive care and high dependency units is provided based on written
guidance. *
b) The defined admission and discharge criteria for intensive care and high dependency units
are implemented. *
c) Adequate staff and equipment are available.
d) Defined procedures for the situation of bed shortages are followed. *
e) Infection prevention and control practices are followed. *
f) The organisation shall implement a quality assurance programme. *
g) The organisation has a mechanism to counsel the patient and/or family periodically.
51
Dr. J. L. Meena

COP 10 - Organisation provides safe
obstetric care.
Objective Elements
a) Obstetric services are organised and provided safely. *
b) The organisation identifies and, provides care to high-risk obstetric cases, and where needed, refers them to
another appropriate centre.
c) Persons caring for high-risk obstetric cases are competent.
d) Ante-natal services are provided. *
e) Organisationencourages andwelcomes the presence ofa birthcompanionduring labour.
f) Organisation treats pregnant women and her companion cordially and respectfully, ensures privacy and
confidentiality for pregnant women during her stay.
g) The treating doctor explains danger signs and important care activities to pregnant woman and her companion.
h) Obstetric patient's assessment also includes maternal nutrition.
i) Appropriate peri-natal and post-natal monitoring is performed.
j) The organisation caring for high-risk obstetric cases has the facilities to take care of neonates of such cases.
k) Organisation shall adhere to legal and defined Assisted Reproductive Technology (ART) practices.
52
Dr. J. L. Meena

COP 11 - Organisation provides safe paediatric
services.
Objective Elements
a) Paediatric services are organised and provided safely. *
b) Neonatal care is in consonance with the national/ international guidelines. *
c) Those who care for children have age-specific competency.
d) Provisions are made for special care of children.
e) Paediatric assessment includes growth, developmental, immunization
and nutritional assessment.
f) The organisation has measures in place to prevent child/neonate abduction
and abuse. *
g) The child's family members are educated about nutrition, immunisation and
safe parenting.
h) The organisation provides for adolescent friendly health care services.
53
Dr. J. L. Meena

COP 12 - Procedural sedation is provided in a
consistent and safe manner.
Objective Elements
a) Procedural sedation is administered in a consistent manner *
b) Informed consent for administration of procedural sedation is obtained.
c) Competent and trained persons administer sedation.
d) The person 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.
f) Patients are monitored after sedation, and the same is documented.
g) Criteria are used to determine the appropriateness of discharge from the
observation/recovery area. *
h) Equipment and workforce are available to manage patients who have gone into a deeper
level of sedation than initially intended.
54
Dr. J. L. Meena

COP 13 - Anaesthesia services are provided in a
Objective Elements
a) Anaesthesia services are provided in a consistent manner*
b) The pre-anaesthesia assessment results in the formulation of an anaesthesia plan which is
documented.
c) A pre-induction assessment is performed and documented.
d) The anaesthesiologist obtains informed consent for administration of anaesthesia.
e) During anaesthesia, monitoring includes regular recording of temperature, heart rate, cardiac
rhythm, respiratory rate, blood pressure, oxygen saturation and end- tidal carbon dioxide.
f) Patient's post-anaesthesia status is monitored and documented.
g) The anaesthesiologist applies defined criteria to transfer the patient from the recovery area. *
h) The type of anaesthesia and anaesthetic medications used are documented in the patient record.
i) Procedures shall comply with infection control guidelines to prevent cross- infection between
patients.
j) Intraoperative adverse anaesthesia events are recorded and monitored.
55
Dr. J. L. Meena

COP 14 - Surgical services are provided in a
Objective Elements
a) Surgical services are provided in a consistent and safe manner. *
b) Surgical patients have a preoperative assessment, a documented pre-operative diagnosis, and pre-
operative instructions are provided before surgery.
c) Informed consent is obtained by a surgeon before the procedure.
d) Care is taken to prevent adverse events like the wrong site, wrong patient and wrong surgery. *
e) An operative note is documented before transfer out of patient from recovery.
f) Postoperative care is guided by a documented plan.
g) Patient, personnel and material flow conform to infection prevention and control practices.
h) Appropriate facilities, equipment, instruments and supplies are available in the operating theatre.
i) The organisation shall implement a quality assurance programme. *
j) The quality assurance programme includes surveillance of the operation theatre environment. *
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Dr. J. L. Meena

Building a quality culture in India through NABH 6th STD.pdf

REVISED GUIDELINES FORAIR
CONDITIONINGIN OPERATION
THEATRES(2018)
A. The air conditioning requirements for operation theatre in HCO have been revisited in the context of
points raised by various HCOs during surveys. These standards were examined by Technical committee
and various latest international and national standards on air conditioning were reviewed. Retrofitting in
the HCOs constructed before these guidelines came in to being was also considered. SHCOs and Eye HCOs
were also considered while recommending certain new requirements.
B. Though these guidelines are desirable under all programs, they are NOT MANDATORY for the SHCOs and
HCOs implementing pre-entry certification standards.
C. Modular Operation Theatre is NOT A MANDATORY REQUIREMENT under any program. It is totally left to
HCO whether they want to install it.
D. For this purpose operation theatres have been divided into two groups:
1. Type A (Erstwhile Super specialty OT): Type A OT means operation theatres for Neurosciences,
Orthopaedics (Joint Replacement), Cardiothoracic and Transplant Surgery (Renal, Liver, heart etc.).
2. Type B (Erstwhile General OT): This includes operation theatres for Ophthalmology, day-care surgeries
and all other basic surgical disciplines.
Dr. J. L. Meena

REQUIREMENTS – Type A
(Erstwhile Super Specialty OT)
1. Air Changes Per Hour: Minimum total air changes should be 20 based on biological load and the location.
The fresh air component of the air change is required to be minimum 4 air changes out of total minimum 20
air changes.
If Healthcare Organization (HCO) chooses to have 100% fresh air system then appropriate energy saving
devices like heat recovery wheel, run around pipes etc. should be installed.
2. Air Velocity: The airflow needs to be unidirectional and downwards on the OT table. The air face velocity of
25-35 FPM (feet per minute) from non-aspirating unidirectional laminar flow diffuser/ceiling array is
recommended.
3. Positive Pressure: The minimum positive pressure recommended is 2.5 Pascal (0.01 inches of water). There
is a requirement to maintain positive pressure differential between OT and adjoining areas to prevent
outside air entry into OT. Positive pressure will be maintained in OT at all times (operational & non-
operational hours)
Dr. J. L. Meena

4. Air handling in the OT including air Quality: Air is supplied through Terminal HEPA (High-Efficiency
Particulate Air) filters in the ceiling. The HEPA can be at AHU level if it not feasible at terminal level inside OT.
The minimum size of the filtration area should extend one foot on all sides of the OT table.
5. Air Filtration: The AHU (i.e. air handling unit) must be an air purification unit and air filtration unit. There
must be two sets of washable flange type filters of efficiency 90%down to 10 microns and 99% down to 5
microns with aluminium / SS 304 frame within the AHU. The necessary service panels to be provided for
servicing the filters, motors & blowers. HEPA filters of efficiency 99.97% down to 0.3 microns or higher
efficiency are to be provided. Air quality at the supply i.e. at grille level should be Class 100/ISO Class 5 (at rest
condition). Note : class 100 means a cubic foot of air should not have more than 0.5 microns or larger.
6. Temperature & Relative Humidity: It should be maintained 21 degree C ± 3 degree C (except for Joints
replacement where it should be 18 degree C ± 20C) with corresponding relative humidity between 20 to 60%,
though the ideal RH is considered to be 55%. Appropriate devices to monitor and display these conditions
inside the OT may be installed.
REQUIREMENTS – Type A
(Erstwhile Super Specialty OT)
Dr. J. L. Meena

REQUIREMENTS – Type B
(Erstwhile General OT)
1. Air Changes Per Hour: Same as Type A OT requirements above
2. Air Velocity: Same as Type A OT requirements above.
3. Positive Pressure: Same as Type A OT requirements above
4. Air Filtration: The AHU (i.e. air handling unit) must be an air purification unit and air filtration unit.
There must be two sets of washable flange type filters of efficiency 90% down to 10 microns and
99% down to 5 microns with aluminium/ SS 304 frame within the AHU. The necessary service
panels to be provided for servicing the filters, motors & blowers. HEPA filters of efficiency 99.97%
down to 0.3 microns or higher efficiency may be provided. The Air quality at the supply i.e. at
grille level should be class 1000/ISO Class 6 ( at rest condition). Note: Class 1000 means a cubic
foot of air must have no more than 1000 particles measuring 0.5 microns or larger.
5. Temperature and Humidity: The temperature should be maintained at 210C ± 3 0C inside the OT at
all times with corresponding relative humidity between 20 to 60%. Appropriate devices to
monitor and display these conditions inside the OT may be installed.
Dr. J. L. Meena

Design considerations for Operation
Theatres
A. The AHU of each OT should be dedicated one and should not be linked to air conditioning of any other area in the OT and
surroundings.
B. One AHU for multiple OTs is permitted provided there is a back-up/contingency plan to accommodate surgeries in other OTs in the
eventuality of failure of infection control in these OTs. Redundancy in terms of multiple fans for return and input air with UPS and
DG set supply is provided to such type of common AHU. Direct drive fans will be required in such common AHU. The specific
evidence of validation for the above will have to be provided either by the vendor/third party.
C. Outdoor Air intakes: The location of outdoor air intake for an AHU must not be located near potential contaminated sources like DG
exhaust hoods, lab exhaust vents, and vehicle parking area. C. Window & split A/c should not be used in any type of OT because they
are pure re- circulating units and have pockets for microbial growth which cannot be sealed. D. For old constructions and for
retrofitting (constructed/renovated prior to 2015)
1. Where space is a constraint, ceiling suspended AHU is permitted provided there is accessibility for maintenance of filters and other
parts of AHU.
2. Dx unit with AHU is recommended for OTs where retrofitting solution is possible. It is also recommended as cost effective solution
for OTs in SHCO/Eye care hospitals.
3. All requirements spelt out for new constructions and Type A and Type B OTs above in terms of air changes, particle count, positive
pressure, temperature, humidity and air velocity will have to be met by such OTs in old constructions/HCOs. E. During the non-
functional hours AHU blower will be operational round the clock (may be without temperature control). Variable frequency devices
(VFD) may be used to conserve energy. Air changes can be reduced to 25% during non-operating hours thru VFD provided positive
pressure relationship is not disturbed during such
Dr. J. L. Meena

REVISED GUIDELINES FORAIR
CONDITIONINGIN OPERATION
THEATRES(2018)
Maintenance of the system
Validation of system should be done every 6 months and as per ISO 14644 standards. This
should include:
✓ Temperature and Humidity check
✓ Air particulate count
✓ Air Change Rate Calculation
✓ Air velocity at outlet of terminal filtration unit /filters
✓ Pressure Differential levels of the OT with respect to ambient / adjoining areas
✓ Validation of HEPA Filters by appropriate tests.
Preventive Maintenance of the system: It is recommended that periodic preventive
maintenance be carried out in terms of cleaning of pre filters, micro vee filters at the interval
of 30 days. Preventive maintenance of all the parts of AHU is carried out as per manufacturer
recommendations.
Dr. J. L. Meena

COP 15 - The organ transplant programme is
carried out safely.
Objective Elements
a) The organ transplant program shall be in consonance with the
legal requirements and shall be conducted ethically.
b) Care of transplant patients is guided by clinical practice
guidelines. *
c) The organisation ensures education and counselling of recipient
and donor through trained/qualified counsellors before organ
transplantation.
d) The organisation shall take measures to create awareness
regarding organ donation.
64
Dr. J. L. Meena

COP 16- The organisation identifies and
manages patients who are at higher risk of
morbidity/ mortality.
Objective Elements
a) The organisation identifies and manages vulnerable patients. *
b) The organisation identifies and manages patients who are at a
risk of fall.*
c) The organisation identifies and manages patients who are
at risk of developing/worsening of pressure ulcers.*
d) The organisation identifies and manages patients who are
at risk of developing deep vein thrombosis.*
e) The organisation identifies and manages patients who need
restraints. *
65
Dr. J. L. Meena

Care of patients under
restraints
it's essential to prioritize their safety, dignity, and well-being. Here are some key considerations:
Key Principles
1. Least Restrictive Option: Use the least restrictive restraint possible to ensure patient safety.
2. Individualized Care: Tailor restraint use to the individual patient's needs and circumstances.
3. Regular Assessment: Regularly assess the patient's condition and the need for restraints.
4. Alternative Methods: Explore alternative methods to restraints, such as de-escalation techniques or environmental modifications.
Care Considerations
1. Patient Monitoring: Continuously monitor the patient's physical and emotional well-being.
2. Restraint Type: Choose the most appropriate type of restraint for the patient's needs (e.g., physical, chemical, or environmental).
3. Restraint Application: Apply restraints in a way that minimizes discomfort and promotes patient safety.
4. Patient Communication: Communicate with the patient and their family about the use of restraints and the patient's care plan.
Best Practices
1. Follow Facility Policies: Adhere to facility policies and procedures regarding restraint use.
2. Staff Training: Ensure staff are trained on restraint use, patient assessment, and alternative methods.
3. Patient-Centered Care: Prioritize patient-centered care and involve the patient and their family in care decisions.
4. Continuous Quality Improvement: Regularly review and improve restraint use and care practices.
Dr. J. L. Meena

COP 17 - Pain management for patients is done
in a consistent manner.
Objective Elements
67
Dr. J. L. Meena
a) Patients in pain are effectively managed. *
b) Patients are screened for pain.
c) Patients with pain undergo detailed assessment and
periodic reassessment.
d) Pain alleviation measures or medications are initiated and
titrated according to the patient's need and response.

COP 18 - Rehabilitation services are provided to
the patients in a safe, collaborative and
consistent manner.
Objective Elements
a) Scope of the rehabilitation services at a minimum is commensurate to the
services provided by the organisation.
b)Rehabilitation services are provided in a consistent manner.
c) Care providers collaboratively plan rehabilitation services.
d)There are adequate space and equipment to provide rehabilitation.
e) Care is guided by functional assessment and periodic re-assessments which
are done and documented.
f) Care is provided adhering to infection control and safety practices.
g) Care pathways are developed, implemented, and reviewed periodically.
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Dr. J. L. Meena

PRIORITY RATING SCALE V1.0 (PRS)
FOR THE REHABILITATION SERVICES
PLAN
Dr. J. L. Meena

No An individual is defined to include
consideration of caregiver and/or family
in all contexts
Dr. J. L. Meena

Collaborative Decision Making
"LEARN"
L - Listen with empathy and understanding of the client's
perception of the problem.
E - Explain your perception of the problem.
A - Acknowledge and discuss the differences and similarities.
R - Recommend intervention.
N - Negotiate agreement.
Dr. J. L. Meena

Process of Goal Setting
➢ Encourage the client to talk about the rehabilitation concerns that
brought them to see you.
➢ Ask the client if they have any ideas about what would resolve the
concerns.
➢ Find out what the client has done already that is helping the problem.
➢ Help the client transform the concerns and ideas to statements of client
goals.
➢ Ensure that you capture and capitalize on the strengths you uncover
during this process ie., strengths that will help the client accomplish the
desired outcomes
Dr. J. L. Meena

COP 19 - Nutritional therapy is provided to
patients consistently and collaboratively.
Objective Elements
75
Dr. J. L. Meena
a) Patients admitted to the organisation are screened for nutritional
risk. *
b) Nutritional assessment is done for patients found at risk during
nutritional screening.
c) The therapeutic diet is planned and provided collaboratively.
d) Patients receive food according to the written order for the diet.
e) When family provides food, they are educated about the patient's
diet limitations.

COP 20 - End-of-life-care is provided in a
compassionate and considerate manner.
Objective Elements
a) End-of-life care is provided in a consistent manner in the
organisation. *
b) A multi-professional approach is used to provide end-of-life care.
c) End-of-life care is in consonance with the legal requirements.
d) End of life care also addresses the identification of the unique
needs of such patient and family.
e) Symptomatic treatment is provided and where appropriate
measures are taken for the alleviation of pain.
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Dr. J. L. Meena

Summary of Care of Patient (COP)
"Care of Patients" emphasizes the importance of providing high-quality, patient-centered care. This
approach prioritizes the patient's needs, preferences, and values, ensuring that care is tailored to
their unique circumstances.
Key Aspects of Patient-Centered Care
1. Respect for Patient Autonomy: Recognizing patients' rights to make informed decisions about
their care.
2. Effective Communication: Fostering open and empathetic communication between patients,
families, and healthcare providers.
3. Individualized Care: Tailoring care to meet the unique needs and preferences of each patient.
4. Emotional Support: Providing emotional support and empathy to patients and their families.
5. Continuous Improvement: Striving for continuous quality improvement to ensure the best
possible patient outcomes.
Dr. J. L. Meena

Benefits of Patient-Centered Care
➢ Improved Patient Satisfaction: Patients are more likely to be satisfied with their care when their
needs and preferences are respected.
➢ Better Health Outcomes: Patient-centered care can lead to improved health outcomes, as
patients are more likely to adhere to treatment plans and make informed decisions about their
care.
➢ Increased Efficiency: Patient-centered care can also lead to increased efficiency, as healthcare
providers are better equipped to meet the unique needs of each patient.
Conclusion
The NABH chapter on "Care of Patients" provides a comprehensive framework for delivering high-
quality, patient-centered care. By prioritizing patient needs, preferences, and values, healthcare
providers can improve patient satisfaction, health outcomes, and efficiency.
Summary of Care of Patient (COP)

Intent of the chapter:
Management of Medication (MOM)
➢ The organisation has a safe and organised medication process. The availability, safe storage, prescription, dispensing
and administration of medications is governed by written guidance. The organisation designates a medical safety officer.
➢ The organisation develops, implements and updates the hospital formulary. The pharmacy shall have oversight
of all medications stocked out of the pharmacy. The pharmacy shall ensure correct storage (as regards to temperature,
light; high-risk medications including look-alike, sound- alike, etc.), expiry dates and maintenance of documentation.
➢ The availability of emergency medication is stressed upon. The organisation should have a mechanism to ensure that
the emergency medications are standardised throughout the organisation, readily available and replenished promptly.
There should be a monitoring mechanism to ensure that the required medications are always stocked and well within
expiry dates.
➢ Every high-risk medication order should be verified by an appropriate person to ensure accuracy of the dose, frequency
and route of administration. Safety is paramount when using narcotics, chemotherapeutic agents and radioactive agents
and radiopharmaceuticals. Reconciliation of medications occurs at transition points of patient care as part of patient safety.
➢ The medication management process also includes monitoring of patients after administration and procedures for
reporting and analysing near-misses, medication errors and adverse drug reactions.
➢ Medications also include blood, implants and devices. Medical supplies and consumables are available for use.
6
Dr. J. L. Meena

A Case Study
The Institute of Medicine reports 44,000 to 98,000 people
die in hospitals annually as a result of medical errors that
could have been prevented (Kohn, Corrigan, & Donaldson,
2000). Medication errors accounted for 7,391 deaths in
1993, compared to 2,876 deaths in 1983 (Kohn et al., 2000).
These medication errors and the adverse reactions
connected with them result in increased length of stay,
increased cost, patient disability, and death.
C RE Commitment Achievement Excellence Dr. J. L. Meena

A Case Study
The medication delivery process is complex and involves
hand-offs between many individuals and departments. Errors
may occur at any of the process steps:- prescription,
transcription, dispensing, or administration. Most error-
reporting systems rely on voluntary self-reporting and are
imbedded into what remain largely punitive management
systems. Nurses widely report reluctance to disclose
medication errors, particularly if an error does not result in
patient harm . .

Common Cause of Medical
Mistakes
➢ Ignorance
➢ Inexperience
➢ Faulty judgment
➢ Hesitation
➢ Fatigue

➢ Job overload
➢ Breaks in concentration
➢ Faulty communication
➢ Failure to monitor closely
➢ System flaws
Common Cause of Medical
Mistakes

Why doctors err..
1. Physician Stressors:-
➢ Feeling hurried or distracted, usually because other patients were
waiting to be seen or because the time of the visit was stressful
(e.g., night, weekend, off-duty hours, quitting time.)
➢ Feeling fatigued.
➢ Being misled by advice or anticipated advice from other
physicians.
➢ Avoiding a medical intervention because of its cost .

2. Process-of-Care Factors:-
➢ Being too focused on one diagnosis or treatment plan.
➢ Not being aggressive enough in diagnosing or treating (e.g., didn't
diagnose cancer because of the patient's young age).
➢ Lacking an adequate follow-up plan.
➢ Not asking advice.
Why doctors err..

3. Patient-Related Factors
➢ Being misled by a normal or negative history, physical
examination, laboratory result, or imaging study, which
overshadowed other signs that the patient had a significant illness.
➢ Not responding with aggressive treatment because the patient
either underreported symptoms or insisted on an inappropriately
conservative treatment.
➢ Having an attitude of dislike or unusual fondness
➢ toward the patient that hinders objectivity.
Why doctors err..

4. Physician Characteristics
➢ Lacking knowledge a bout the medical aspects of the case
because of inexperience.
➢ Having too much pride in his or her own abilities which
leads to a wrong decision.
Why doctors err..

Simple Truths about errors in
medicine
There is a well-established body of research about errors in medicine, and
most experts agree on the following:
1. Errors will happen. Since no human is perfect, errors are bound to happen, and
this includes physicians and their staffs working in the delivery of health care
services.
2. Since errors can be expected, systems must be designed to prevent and absorb
them.
3. Errors are not synonymous with negligence. Medicine's ethos of infallibility leads,
wrongly, to a culture that sees mistakes as an individual problem and remedies
them with blame and punishment instead of looking for root causes and fixing
problems by improving systems.
4. Creating a culture supportive of errors reporting is the starting point in reducing
future medical errors.

Type of Medical Mistakes

Different types of Adverse
Medication Events
1. Wrong drug
2. Wrong dose and/or frequency
3. Wrong form
4. Wrong route
5. Wrong rate
6. Wrong time
7. Wrong preparation
8. Wrong patient

9. Wrong documentation
10. Omitted drug or dose
11. Allergy information missing
12. Inadequate or inappropriate
monitoring
13. Administered when c e a s e d or
w i t h h e l d
14. Administered but not signed
15. Extra dose given on over dose.
Different types of Adverse
Medication Events

MOM.1. Pharmacy services and usage of medication is done safely.
MOM.2. The organisation develops, updates and implements a hospital formulary.
MOM.3. Medications are stored appropriately and are available where required.
MOM.4. Medications are prescribed safely and rationally.
MOM.5. Medication orders are written in a uniform manner.
MOM.6. Medications are dispensed in a safe manner.
MOM.7. Medications are administered safely.
MOM.8. Patients are monitored after medication administration.
MOM.9.
Narcotic drugs and psychotropic substances, chemotherapeutic agents and radio-
pharmaceuticals are used safely.
MOM.10. Implantable prosthesis and medical devices are used in accordance with laid down criteria.
MOM.11. Medical supplies and consumables are stored appropriately and are available where required.
19
Dr. J. L. Meena

Objective
Elements
MOM 1 MOM 2 MOM 3 MOM 4 MOM 5 MOM 6 MOM 7 MOM 8 MOM 9 MOM 10 MOM 11
a Commitment CORE CORE CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment
b Commitment Commitment Commitment CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment
c Achievement Commitment CORE Commitment Commitment Commitment Commitment CORE Commitment Commitment Commitment
d Commitment
Achievement
Achievement Excellence Commitment CORE CORE Commitment Commitment Commitment Commitment
e
Commitment
Commitment CORE CORE CORE Commitment Commitment Commitment Achievement Commitment
f Commitment Commitment CORE Commitment Commitment Commitment
g CORE Achievement Commitment
h Achievement CORE
i Commitment
j Commitment
k Commitment
Summary Standards - 11 OE 68 CORE 13 Commitment 48 Achievement 6 Excellence 1
Dr. J. L. Meena

MOM 1 - Pharmacy services and usage of
medication is done safely.
Objective Elements
a) Pharmacy services and medication usage are implemented following written
guidance. *
b) A multidisciplinary committee guides the formulation and implementation of
pharmacy services and medication management.
c) There is a mechanism in place to facilitate the multidisciplinary committee to
monitor literature reviews and best practice information on medication
management and use the information to update medication management
processes.
d) There is a procedure to obtain medication when the pharmacy is closed or in case
of stock outs. *
e) The organisation has a mechanism to inform relevant staff of key changes in
pharmacy services and medication usage to ensure uninterrupted and safe care.
21
Dr. J. L. Meena

MOM 2 - The organisation develops, updates
and implements a hospital formulary.
Objective Elements
a) A list of medications appropriate for the patients and as per the scope of the
organisation's clinical services is developed collaboratively by the multidisciplinary
committee.
b) The list is reviewed and updated collaboratively by the multidisciplinary committee
at least annually.
c) The current formulary is available for clinicians to refer to.
d) The clinicians adhere to the current formulary.
e) The organisation adheres to the procedure for the acquisition of formulary
medications. *
f) The organisation adheres to the procedure to obtain medications not listed in the
formulary. *
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Dr. J. L. Meena

MOM 3 - Medications are stored appropriately
and are available where required.
Objective Elements
a) Medications are stored in a clean, safe and secure environment; and incorporating the
manufacturer's recommendation(s).
b) Sound inventory control practices guide storage of the medications throughout the
organisation.
c) The organisation defines a list of high-risk medication(s). *
d) High-risk medications are stored in areas of the organisation where it is clinically necessary.
e) High-risk medications including look-alike, sound-alike medications and different
concentrations of the same medication are stored physically apart from each other. *
f) The list of emergency medications is defined and is stored uniformly. *
g) Emergency medications are available all the time and are replenished promptly when used.
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Dr. J. L. Meena

Temperature monitoring of the drug
storage area
In fact, most prescription and nearly all over the counter drugs are
required to be kept at controlled room temperature. The United
States Pharmacopeia (USP) has defined Controlled Room
Temperature (CRT) as: "A temperature maintained thermostatically
that encompasses the usual and customary working environment of
20 to 25°C (68 to 77°F); and that allows for excursions between 15
and 30°C (59 and 86°F) that are experienced in pharmacies,
hospitals, and warehouses.” you need to be aware that storage at
high temperatures can quickly degrade the potency and stability of
drug.

Temperature monitoring of the
drug storage area
Temperatures, other than what the manufacturer recommends, can
degrade the drugs, making them less effective and putting patients in
potential danger. Abbott Labs, Synthroid's manufacturer, recommends
that patients replace their thyroid meds if they've been stored at
temperatures above 86°F for any length of time.
Formoterol, a drug used for asthma and COPD is exposed to high heat for
a prolonged period of time, the powder turns clumpy and brown,
delivering less than half of its intended dosage.
Catechins provide antioxidant benefits and are found in various
supplements. Those supplements stored at high temperatures, lose the
most catechins.
Dr. J. L. Meena

ABC Analysis
The annual expenditure of individual items was arranged in
descending order. The cumulative cost of all the items was
calculated. The cumulative percentage of expenditure and the
cumulative percentage of number of items were calculated.
This list was then subdivided into three categories: A, B and C,
based on the cumulative cost percentage of 70%, 20% and
10%, respectively.
Dr. J. L. Meena

'A' items - 20% of the items accounts for 70% of the
annual consumption value of the items.
'B' items - 30% of the items accounts for 20% of the
annual consumption value of the items .
'C' items - 50% of the items accounts for 10% of the
annual consumption value of the items
Dr. J. L. Meena
ABC Analysis

Distribution of ABC Class
Dr. J. L. Meena

Application of Weighed Purchasing
condition
Dr. J. L. Meena

VED Analysis
The VED criticality analysis of all the listed items was performed by classifying
the items into vital (V), essential (E) and desirable (D) categories. The items
critically needed for the survival of the patients and those that must be
available at all times were included in the V category. The items with a lower
criticality need and those that may be available in the hospital were included
in the E group. The remaining items with lowest criticality, the shortage of
which would not be detrimental to the health of the patients, were included
in the D group. The VED status of each item was discussed with justification
by a group comprising of physician, surgeon, pediatrician a n d pharmacist.
Dr. J. L. Meena

ABC – VED Matrix Analysis
Dr. J. L. Meena

Dr. J. L. Meena
ABC – VED Matrix Analysis

Comparison of ABC, VED and ABC-VED
matrix analysis of different studies in
India
Dr. J. L. Meena

How to do FSN / FNS Analysis
Dr. J. L. Meena

There following steps in doing
the FSN analysis
➢ Calculation of average stay a n d t h e consumption rate of
the material in Store house : -
➢ FSN Classification of materials based on average stay in the
inventory.
➢ F S N Classification of t h e material based on consumption
rate.
➢ Finally classifying based on above FSN analysis.
Dr. J. L. Meena

Process of FSN analysis
Dr. J. L. Meena

Process of FSN analysis
Average stay of the material = Cumulative No of Inventory
Holding Days/ Total quantity received + Opening Balance)
=1161/115 =10.09 Days
Consumption Rate = Total Issue Qty/Total Period Duration
=46/15 =3.06 Nos / Day
Dr. J. L. Meena

Now list down the material with
average stay and consumption rate
Dr. J. L. Meena

Now Carry out the FSN analysis on
the basis of Average Stay only
Dr. J. L. Meena

Now Carry out the FSN analysis on
the basis of consumption rate
Dr. J. L. Meena

Now carry out final classification by
combining both as under
Dr. J. L. Meena

First - In / First - Out Procedure
(FIFO)
A method of inventory management in which the first
products received are the first products issued. This
methods generally minimizes the chance of drug
expiration.
Dr. J. L. Meena

First Expiry / First Out Procedure
(FEFO)
A method of inventory management in which products with
the earliest expiry date are the first products issued,
regardless of the order in which they are received. This
method is more demanding than FIFO (see below) but should
be used for short-dated products such as vaccines.
Dr. J. L. Meena

Look – Alike / Sound – Alike Drugs
for Surgical Facilities e.g.
Dr. J. L. Meena

Dr. J. L. Meena
Look – Alike / Sound – Alike Drugs
for Surgical Facilities e.g.

MOM 4 - Medications are prescribed safely and
rationally.
Objective Elements
a) Medication prescription is in consonance with good practices/guidelines for the rational
prescription of medications. *
b) The organisation adheres to the determined minimum requirements of a prescription. *
c) Drug allergies and previous adverse drug reactions are ascertained before prescribing.
d) The organisation has a mechanism to assist the clinician in prescribing appropriate
medication.
e) Reconciliation of medications occurs at transition points of patient care.
f) Verbal orders are iimplemented by ensuring safe medication management practices. *
g) Audit of medication orders/prescription is carried out to check for safe and rational
prescription of medications.
h) Corrective and/or preventive action(s) is taken based on the audit, where appropriate.
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Dr. J. L. Meena

Narrow Therapeutic Index
Drugs with narrow therapeutic index (NTI-drugs) are drugs
with small differences between therapeutic and toxic doses.
The pattern of drug- related problems (DRPs) associated with
these drugs has not been explored.
Dr. J. L. Meena

Dr. J. L. Meena
Narrow Therapeutic Index

MOM 5 - Medications orders are written in a
uniform manner.
Objective Elements
a) The organisation ensures that only authorised personnel write
orders. *
b) Medication orders are written in a uniform location in the medical
records, which also reflects the patient's name and unique
identification number.
c) Medication orders are legible, dated, timed and signed.
d) Medication orders contain the name of the medicine, route of
administration, strength to be administered and frequency/time of
administration.
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Dr. J. L. Meena

MOM 6 - Medications are dispensed in a safe
manner.
Objective Elements
a) Dispensing of medications is done safely. *
b) Medication recalls are handled effectively. *
c) Near-expiry medications are handled effectively. *
d) Dispensed medications are labelled. *
e) High-risk medication orders are verified before dispensing.
f) Return of medications to the pharmacy is addressed. *
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Dr. J. L. Meena

MOM 7 - Medications are administered safely.
Objective Elements
a) Medications are administered by those who are permitted by law to do so.
b) Prepared medication is labelled before preparation of a second drug.
c) The patient is identified before administration.
d) Medication is verified from the medication order and physically inspected before administration.
e) Strength is verified from the order before administration.
f) The route is verified from the order before administration.
g) Timing is verified from the order before administration.
h) Measures to avoid catheter and tubing mis-connections during medication administration are
implemented. *
i) Medication administration is documented.
j) Measures to govern patient's self-administration of medications are implemented. *
k) Measures to govern patient's medications brought from outside the organisation are
implemented. *
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Dr. J. L. Meena

MOM 8 - Patients are monitored after medication
administration.
Objective Elements
a) Patients are monitored after medication administration. *
b) Medications shall be changed based on the monitoring where appropriate.
c) The organisation captures near miss, medication error and adverse drug
reaction. *
d) Near miss, medication error and adverse drug reaction are reported within
a specified time frame. *
e) Near miss, medication error and adverse drug reaction are collected and
analysed.
f) Corrective and/or preventive action(s) are taken based on the analysis.
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Dr. J. L. Meena

Adverse drug events are defined
Category Description Effect
Category A An error occurred that may have the capacity to cause error No Error
Category B An Error occurred but the error did not reach the patient Error, but No Harm
Category C An Error occurred that reached the patient but did not cause
patient harm
Error, but No Harm
Category D An error occurred that reached the patient and required monitoring
to confirm that it resulted in no harm to the patient and / or required intervention to preclude
harm
Error, but No Harm
Category E An Error occurred that may have contributed to or resulted in
temporary harm to the patient and required intervention
Error + Harm
Category F An error occurred that may have contributed to or resulted in
temporary harm to the patient and required initial or prolonged hospitalization
Error + Harm
Category G An error occurred that may have contributed to or resulted in
permanent patient harm
Error + Harm
Category H An error occurred that required intervention necessary to sustain
life
Error + Harm
Category I An error occurred that may have contributed to or resulted in the Error + Death

MOM 9 - Narcotic drugs and psychotropic
substances, chemotherapeutic agents and
radio-pharmaceuticals are used safely.
Objective Elements
a) Narcotic drugs and psychotropic substances, chemotherapeutic agents and
radioactive agents are used safely. *
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Dr. J. L. Meena
b) Narcotic drugs and psychotropic substances, chemotherapeutic agents and
radioactive agents are prescribed by appropriate caregivers.
c) Narcotic drugs and psychotropic substances, chemotherapeutic agents and
radioactive agents drugs are stored securely.
d) Chemotherapy and radio-pharmaceuticals shall be prepared properly and safely
and administered by qualified personnel.
e) A proper record is kept of the usage, administration and disposal of narcotic drugs
and psychotropic substances, chemotherapeutic agents and radio-pharmaceuticals.

Drug Antidote Action Compresses
Nitrogen Mustard Sodium thiosulfate IV & SQ* Chemical neutralization Cold
Mitomycin
(topical Dimethyl Sulfoxide
[DMSO])
& oxygen radical scavenger Cold
Doxorubicin (topical DMSO)** & oxygen radical scavenger Cold
Daunorubicin (topical DMSO)** & oxygen radical scavenger Cold
Dactinomycin (topical DMSO)** & oxygen radical scavenger Cold
Vincristine No antidote available Drug absorption & dispersion Warm
Vinblastine No antidote available Drub absorption & dispersion Warm
Vindesine No antidote available Drub absorption & dispersion Warm
Dr. J. L. Meena
Chemotherapy drugs are disposed off in
accordance with legal requirements

MOM 10 - Implantable prosthesis and medical
devices are used in accordance with laid down
criteria.
Objective Elements
a) Usage of the implantable prosthesis and medical devices is guided by scientific
criteria for each item and national/international recognised guidelines/ approvals
for such specific item(s).
b) The organisation implements a mechanism for the usage of the implantable
prosthesis and medical devices. *
c) Patient and his/her family are counselled for the usage of the implantable
prosthesis and medical device, including precautions if any.
d) The batch and the serial number of the implantable prosthesis and medical
devices are recorded in the patient's medical record, the master logbook and the
discharge summary.
e) Recall of implantable prosthesis and medical devices are handled effectively. *
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Dr. J. L. Meena

Selection of implantable prosthesis is based on
scientific criteria and internationally recognized
approvals
Steps Activity Responsibility
1 Signing of demand for the procurement of Implantable Prosthesis Head of user dept.
2 Estimation of the demand depending the current trend of patient Head of user dept.
3 Matching the selection criteria Head of user dept.
4 Formulation of policy and procedure guide for procurement and usage MOM Committee
PROCEDURE FOR USAGE OF IMPLATABLE PROSTHESIS:
1 Identification of the patient Nursing staff
2 Identification of the implant OT technician/ ICU Nurse
3 Sterilization of the prosthesis OT Technician
4 Use of the prosthesis in the patient Consultant In- Charge
5 Endorsing the and number in the OT well as patient sheet and the empty box to
the patient which contains the sticker of serial number and batch number.
OT Technician/ ICU Nurse
Dr. J. L. Meena

MOM 11 - Medical supplies and consumables are
stored appropriately and are available where
required.
Objective Elements
a) The organisation adheres to the defined process for the acquisition of
medical supplies and consumables. *
b)Medical supplies and consumables are used in a safe manner, where
appropriate.
c) Medical supplies and consumables are stored in a clean, safe and secure
environment; and incorporating the manufacturer's recommendation(s).
d)Sound inventory control practices guide storage of medical supplies and
consumables
e) There is a mechanism in place to verify the condition of medical supplies and
consumables
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Dr. J. L. Meena

PHARMACOTHERAPEUTIC COMMITTEE
Scope of Work
➢Develop and issue Policy on formulary and
medication management
➢Supervise purchases and procurement
➢Supervise and management of pharmacy
➢Monitor and evaluate adverse drug
reactions
➢Manage the control of drugs
➢Supervise drug information service
Dr. J. L. Meena

Function of the Committee
➢There is a documented policy and procedure for pharmacy services and medication usage.
➢Policies and procedures guide the organization of pharmacy services and usage of
medication.
➢The policies and procedures shall address the issues related to procurement, storage,
formulary, prescription, dispensing, administration, monitoring and use of medications.
➢A list of medication appropriate for the patient's and the organization's resources is
developed.
➢Policies and procedures guide the prescription of medications.
➢Policies and procedures guide the safe dispensing of medications.
➢Policies and procedures guide the use of narcotic drugs and psychotropic substances.
➢Policies and procedures govern usage of radioactive or investigational drugs.
➢Policies and procedures guide the usage of chemotherapeutic agents.
➢Policies and procedures guide the use of implantable prosthesis.
➢Policies and procedures guide the shortage of medication.
Dr. J. L. Meena

How to Function
Name of Committee Members:-
CoH
Agenda identified by Committee:-
Date of Committee Meetings:-
Meeting Minutes of the Committee Meetings:-
Action Taken Report on the Agenda:-
Frequency of Meeting:- Monthly
Dr. J. L. Meena

Intent of the chapter:
Patient Rights and Education (PRE)
➢ The organisation defines, protects and promotes the patient and family's rights and
responsibilities. The staff is aware of these rights and is trained to protect them. Patients
are informed of their rights and educated about their responsibilities at the time of
entering the organisation.
➢ The expected costs of treatment and care are explained clearly to the patient and/or family.
➢ Patients are educated about the mechanisms available for addressing grievances.
➢ Informed consent is obtained from the patient or family for specified procedures/care. The
key components of information shall include risks, benefits and alternatives.
➢ Patients and families have a right to get information and education about their healthcare
needs in a language and manner that is understood by them.
➢ The organisation has a mechanism to capture the patient experience including patient
reported experience measures (PREM).
➢ The organisation develops effective patient-centred communication.
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Dr. J. L. Meena

Health is a subject closer to everybody's heart. Improvement of one's health
and health of one's family is a universal aspiration. However health has been
always given a low priority status in the nation's political and social agenda.
With the increasing privatization of the health care services in the country, the
state is slowly accepting its responsibility to provide health care to the people.
Medical profession contributes to the healthcare to the extent of only 25-
30%- Approximately 70% various input in the health care is by various sectors
like the pharmaceutical industry, hospitals, blood banks etc. This 70% inputs
are mostly managed on a commercial basis and therefore patient as a
consumer must have certain rights. These rights of a patient as a consumer are
more important than the rights of a general consumer because patient usually
has very little choice in the treatment.
Dr. J. L. Meena

WHAT PRECAUTIONS SHOULD
PATIENTS TAKE TO PROTECT THEIR
RIGHTS?
In India there is very little perception about
the rights of the patients even amongst the
educated persons. There fore blatant
violation of patient’s rights is a routine
occurrence.
Dr. J. L. Meena

However the situation can be changed if
every citizen takes certain precautions while
undergoing treatment or while taking
drugs/vaccines etc .
RIGHTS?
Dr. J. L. Meena

❖ In case of surgical treatment or invasive investigations and
procedures, please make sure that you have understood
the nature of the operation. You have the right to know
the details of the surgery as well as the details like the
expected time of post-operative recovery, expenses likely
to be incurred for the surgery, the risks involved, whether
there is any non-surgical treatment for your ailment etc.
RIGHTS?
Dr. J. L. Meena

❖Please make sure the details are understood by
you before you sign the consent form. The
consent form should be in your mother tongue
or the language known to you.
RIGHTS?
Dr. J. L. Meena

❖ At the time of discharge, please make sure that you
have been given copies of all the relevant records.
As per the decision of the Bombay High Court
(Raghunath Raheja v/s Maharashtra Medical
Council), every patient or his legal heirs have the
right to get the copies of all the case papers on
payment of relevant charges.
RIGHTS?
Dr. J. L. Meena

❖ At the time of discharge from the hospital,
please make sure that you have received the bills
for all the payments made by you. You have the
right to get details of the bill like details of drugs
administered to you, the details of investigations
etc .
RIGHTS?
Dr. J. L. Meena

❖In case of any treatment, you have the
right to ask for a second opinion.
However, the second opinion should be
taken ONLY with the consent of your
physician.
RIGHTS?
Dr. J. L. Meena

❖ If you have any doubts about the
treatment you should request the doctor
to clarity them. Doctor-Patient
communication is of vital importance for
the success of any treatment.
RIGHTS?

❖Please make sure that the doctor has
given you all the instructions for the
medicines prescribed. You have the right
to get all the relevant information about
the drugs prescribed to you .
RIGHTS?
Dr. J. L. Meena

❖ In case of invasive/costly investigations,
you have the right to know of the
alternatives as well as the necessity of the
investigations.
RIGHTS?
Dr. J. L. Meena

❖ As a patient, you have the right to take second
opinion and/or change the doctor. However, this
right should be exercised very judiciously and
cautiously. 'Doctor Shopping is not in the interest
of consumers and can cause serious harm due to
irregular treatment .
RIGHTS?
Dr. J. L. Meena

❖ Please always preserve all the bills of the purchase of
medicines.
❖ If you have any complaints about the
treatment/investigations/drugs etc., first approach the
concerned doctor/hospital. Many times the complaints are
due to misunderstanding and failure in communication.
These can be resolved at the local level. Many hospitals have
their own patient redressal cell. You must first approach such
Patient Redressal Cell.
RIGHTS?
Dr. J. L. Meena

❖ If you find that your complaint remains unresolved,
then please write down Your grievance giving all
the relevant details in a sequential format and take
the advice of a Consumer Organisation in your area
before taking any legal action. Please remember
that most of the times the complaints can be
resolved at the hospital level.
RIGHTS?
Dr. J. L. Meena

❖ If you are participating in any trial for drugs/therapeutic
devise/treatment protocol, you have the right to refuse to
participate in the trial. Please make sure that you have
understood all the details like duration, risks involved, the
expected complications etc. Also make sure that the
doctor/hospital conducting the trial has agreed to treat
completely any complication arising out of the trial, free of cost.
Please make sure that the consent form includes all the details.
RIGHTS?
Dr. J. L. Meena

❖As a patient you have to expect the medical
record pertaining to your illness be treated as
confidential. If the details are to be used in a
medical conference, please make sure that
your consent has been obtained by the
doctor/hospital.
RIGHTS?
Dr. J. L. Meena

❖In case of HIV positive patients, the
details can only be disclosed with the
patient’s permission. You have to be
vigilant to see the HIV reports are not
disclosed to the employers I friends
other unauthorized persons.
RIGHTS?
Dr. J. L. Meena

Key Provisions Under the
NMC Act, 2019
1. *Section 8 - Powers and Functions of the NMC*:
- The NMC is empowered to ensure compliance with ethical standards and regulate the
conduct of medical professionals and institutions. This includes addressing complaints related
to violations of patient rights, such as denial of care, lack of informed consent, or negligence.
2. *Section 10 - Constitution of Boards*:
- The Ethics and Medical Registration Board (EMRB), one of the autonomous boards under
the NMC, is responsible for maintaining ethical standards and handling complaints against
registered medical practitioners. Violations of patient rights can fall under its purview if they
constitute professional misconduct.
Dr. J. L. Meena

3. *Section 30 - Professional Misconduct and Penalties*:
- This section allows the NMC, through the EMRB, to take disciplinary action against doctors
for professional misconduct. Misconduct can include neglecting patient rights, such as failing
to provide adequate care, breaching confidentiality, or not obtaining informed consent.
- Penalties can range from reprimands and suspension of a doctor’s license to permanent
removal from the medical register. The NMC can also impose fines up to ₹1 crore on
institutions (e.g., hospitals) for non-compliance with regulations, though specific fines for
patient rights violations are determined case-by-case.
4. *Section 54 - Punishment for Offenses*:
- This section outlines penalties for practicing medicine without proper registration or
violating NMC regulations, which indirectly supports patient rights by ensuring only qualified
professionals provide care.
Key Provisions Under the
NMC Act, 2019

Patient Rights and Violations
Patient rights in India are not explicitly codified in a single law but are derived from various
legal and ethical frameworks, including:
- The *Code of Medical Ethics Regulations, 2002* (issued by the erstwhile Medical Council of
India, now under NMC oversight), which mandates respect for patient autonomy,
confidentiality, and proper care.
- The *Consumer Protection Act, 2019*, which allows patients to seek redressal for deficient
services, including violations of their rights by doctors or hospitals.
- Judicial precedents and constitutional rights under Article 21 (Right to Life and Health).
Examples of patient rights violations that could trigger NMC action include:
- Refusal to treat a patient without valid reason.
- Failure to obtain informed consent before procedures.
- Negligence leading to harm or death.
- Breach of patient confidentiality.
Dr. J. L. Meena

Disciplinary Process
- *Complaint Filing*: A patient or their representative can file a complaint with
the State Medical Council (SMC), which forwards serious cases to the
NMC/EMRB.
- *Investigation*: The SMC or EMRB investigates the matter, which may involve
reviewing medical records, interviewing parties, and consulting experts.
- *Action*: If a doctor or hospital is found guilty of violating patient rights
through misconduct or negligence, the NMC can:
- Suspend or revoke the doctor’s license.
- Impose fines or penalties on hospitals.
- Recommend criminal prosecution in extreme cases (e.g., under Section 304A
of the Indian Penal Code for causing death by negligence).
Dr. J. L. Meena

Hospitals and Institutional Accountability
Hospitals can also be held accountable under the NMC Act if
they fail to comply with regulations or enable violations of
patient rights. For instance:
- If a hospital employs unregistered practitioners, it can face
penalties under Section 34 (fines up to ₹10 lakh).
- Systemic failures, such as inadequate facilities or staff
leading to patient harm, may result in fines or derecognition
of the institution.
Dr. J. L. Meena

Practical Examples
- *Negligence Cases*: If a doctor’s negligence violates a patient’s right
to proper care and results in harm, the NMC can suspend their license
and impose fines.
- *Denial of Treatment*: Refusing emergency care without
justification could lead to disciplinary action under ethical guidelines
enforced by the NMC.
- *Lack of Transparency*: Failing to provide medical records to
patients (a right recognized under MCI/NMC regulations) could be
deemed misconduct.
Dr. J. L. Meena

Limitations
- The NMC primarily focuses on professional
misconduct and regulatory compliance rather than
directly adjudicating patient rights disputes, which are
often handled by consumer courts or civil courts.
- Enforcement depends on the efficiency of State
Medical Councils and the EMRB, which may vary across
regions.
Dr. J. L. Meena

Summary
The NMC has the authority to punish doctors and hospitals
for violations of patient rights if they fall under professional
misconduct or regulatory breaches. The severity of
punishment depends on the nature of the violation, ranging
from warnings to license revocation for doctors and fines or
derecognition for hospitals. For specific cases, patients can
also seek parallel remedies through consumer courts or
criminal justice systems.
Dr. J. L. Meena

CONSUMER COURTS:-
The complaints against the medical profession can be filed in the consumer
courts. The complaint should be written on a simple paper giving all the details
and the compensation demanded. These courts can only give compensation.
Following are the monetary limits of compensation that can be granted by the
consumer courts
AVENUES FOR REDRESSAL OF
PATIENTS COMPLAINTS
District Consumer Court Up to Rs 20 lakh
State Commission Rs 20 Lakhs to Rs 1 Crore
National Commission Above Rs 1 crore
Dr. J. L. Meena

CIVIL COURTS : -
The redressal of the patient's complaints through the civil courts is
lengthy, time consuming and many times counterproductive. There is
a tremendous backlog of cases and the cases take anywhere between
10 to 15 years to complete.
CRIMINAL COURTS:-
The redressal of the complaints under criminal law is not very
common and recourse to this method should be taken only in
exceptional cases.
AVENUES FOR REDRESSAL OF
PATIENTS COMPLAINTS
Dr. J. L. Meena

PATIENTS & FAMILY RIGHT &
RESPONSIBILITY (Respect)
Rights : -
> To be treated with respect and courtesy.
> To receive safe, considerate, ethical and cost effective
medical care .
> To have your your individual cultural, spiritual and
psychosocial needs respected.
> To have your privacy and personal dignity maintained.
> To expect that information regarding your care will be
treated as confidential.
Dr. J. L. Meena

Responsibilities:-
> To respect hospital personnel.
> To respect care givers' efforts to provide care
for other patients.
> To respect hospital property.
> To be considerate of other patients and to see that
your visitors do the same.
RESPONSIBILITY (Respect)
Dr. J. L. Meena

PATIENTS & FAMILY RIGHT & CoH
RESPONSIBILITY (Treatment)
Rights:-
> To receive treatment regardless of race, religion or any other
discrimination prohibited by law.
> To receive emergency treatment regardless of ability to pay.
• To expect reasonable continuity of care and to be informed of
available and realistic care options when hospital care is no longer
appropriate.
> To have your needs for pain management addressed and treated.
> To be free from the use of restraints and/or seclusion unless
clinically necessary.
Dr. J. L. Meena

Responsibilities : -
> To follow your care givers' instructions and help them in their
efforts to return you to health.
>To inform your care givers if you think there may be problems in
following their instructions.
> To participate in decision making about your medical care.
>To recognize the impact of life style on your personal health.
> To ask your treating physician if he/she has any conflicts of interests
that directly affect your care.
PATIENTS & FAMILY RIGHT & CoH
RESPONSIBILITY (Treatment)
Dr. J. L. Meena

RESPONSIBILITY (Advance Directives)
Rights : -
› To have an advance directive (living will and/or durable power of
attorney for health care decisions).
> To obtain information regarding an advance directive.
> To have your advance directive (if you have one) included in your
medical record.
›To have your advance directive followed to the extent that is
medically appropriate and lawful.
Dr. J. L. Meena

Responsibilities:-
> To inform the hospital if you have an advance
directive.
> To give the hospital a copy of your written advance
directive (if you have one).
RESPONSIBILITY (Advance Directives)
Dr. J. L. Meena

RESPONSIBILITY (Information)
Rights:-
> To understand your diagnosis and treatment, as well as the possible
outcomes, risks and benefits of your care.
• To have information regarding your medical treatment explained to your
family member or other appropriate individual when you are unable to
participate in decisions about your care.
> To access a foreign language or American Sign Language interpreter and/or
adaptive equipment (including TDDs) if needed.
• To be advised of hospital policies, procedures, rules and regulations that may
affect your care.
Dr. J. L. Meena

Rights:-
> To be aware of any proposed hospital research in which you may be involved.
> To be aware that the hospital's bioethics committee is available to you to
discuss ethical issues related to your care
> To understand that your caregivers may be both teachers and students
> To know the names/titles of your caregivers
> To see your medical records (in accordance with hospital policy and/or the
law)
> To review your bill and to have any questions or concerns you have
adequately addressed
Dr. J. L. Meena

Responsibilities:-
> To provide the hospital with accurate and complete
information about your medical history.
> To ask your care givers for more information if you do not
understand your illness or treatment
> To provide the hospital with necessary payment and/or
insurance information.
Dr. J. L. Meena

RESPONSIBILITY (Involvement)
Rights
> To be involved in decisions concerning your care
>To have your family members and/or others involved in decisions about your
care
> To exclude your family members and/or others from participating in decisions
about your care
> To discuss any treatment planned for you
> To give your informed consent or informed refusal for treatment
> To leave the hospital or request a transfer (in accordance with hospital policy
and/or the law)
> To refuse to be treated by a student
> To consent or decline to participate in clinical research
Dr. J. L. Meena

Responsibilities
>To stand by hospital rules and regulations
> To keep your appointments
> To pay your bills on time
> To inform the hospital if you believe your rights have been
violated.
RESPONSIBILITY (Involvement)
Dr. J. L. Meena

How to reduce Patients
dissatisfaction
Creating a culture, support the patient
right and responsibility
Dr. J. L. Meena

Objective Elements
46
Dr. J. L. Meena
PRE.1.
The organisation protects and promotes 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. Informed consent is obtained from the patient or family 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 to redress complaints.
PRE.8. The organisation has a system for effective communication with patients and/or families.

Objective
Elements
PRE 1 PRE 2 PRE 3 PRE 4 PRE 5 PRE 6 PRE 7 PRE 8
a Commitment Commitment CORE CORE CORE CORE Commitment Commitment
b Achievement Commitment Achievement Commitment Commitment Commitment Achievement Commitment
c CORE Commitment Commitment CORE Commitment Commitment CORE Commitment
d CORE CORE Commitment Commitment Commitment Commitment Commitment Commitment
e CORE Commitment Achievement CORE Commitment Commitment Achievement
f Commitment Commitment Commitment
g CORE Commitment
h Commitment Commitment
j Commitment Excellence
k Commitment
l Achievement
Summary Standards -8 OE-52 CORE -12 Commitment - 32 Achievement 7 Excellence 1

PRE 1 - The organisation protects and promotes
patient and family rights and informs them about
their responsibilities during care
Objective Elements
a) Patient and family rights and responsibilities are documented, displayed and
they are made aware of the same. *
b) Patient and family rights and responsibilities are actively promoted. *
c) The organisation protects patient and family rights.
d) The organisation has a mechanism to report a violation of patient and family
rights.
e) Violation of patient and family rights are monitored, analysed, and
corrective/preventive action taken by the top leadership of the organisation.
48
Dr. J. L. Meena

PRE – 2 Patient and family rights support
individual beliefs, values and involve the patient
and family in decision-making processes.
Objective Elements
a) Patients and family rights include respecting values and beliefs, any special preferences, cultural needs, and responding
to requests for spiritual needs.
b) Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.
c) Patient and family rights include protection from neglect or abuse.
d) Patient and family rights include treating patient information as confidential.
e) Patient and family rights include the refusal of treatment.
f) Patient and family rights include a right to seek an additional opinion regarding clinical care.
g) Patient and family rights include informed consent before the transfusion of blood and blood components, anaesthesia,
surgery, initiation of any research protocol and any other invasive/high-risk procedures/treatment.
h) Patient and family rights include a right to complain and information on how to voice a complaint.
i) Patient and family rights include information on the expected cost of the treatment.
j) Patient and family rights include access to their clinical records.
k) Patient and family rights include information on the name of the treating doctor, care plan, progress and information on
their health care needs.
l) Patient rights include determining what information regarding their care would be provided to self and family.
49
Dr. J. L. Meena

PRE 3 - The patient and/or family members are educated
to make informed decisions and are involved in the care
planning and delivery process.
Objective Elements
a) The Patient and/or family members are explained about the proposed care (including the
risks, benefits, alternatives), expected result and possible complications.
b) The care plan is prepared and modified in consultation with the patient and/or family
members.
c) The patient and/or family members are informed about the results of diagnostic tests and
the diagnosis.
d) The patient and/or family members are explained about any change in the patient's
condition in a timely manner.
e) The patient and/or family members are provided multi-disciplinary counselling when
appropriate.
50
Dr. J. L. Meena

PRE 4 - Informed consent is obtained from the
patient or family about their care.
Objective Elements
51
Dr. J. L. Meena
a) The organisation obtains informed consent from the patient or family for
situations where informed consent is required. *
b) Informed consent process adheres to statutory norms.
c) Informed consent includes information regarding the procedure; it's risks,
benefits, alternatives and as to who will perform the procedure in a
language that they can understand.
d) The organisation describes who can give consent when a patient is
incapable of independent decision making and implements the same. *
e) Informed consent is taken by the person performing the procedure.

PRE 5 - Patient and families have a right to
information and education about their
healthcare needs.
Objective Elements
a) Patient and/or family are educated in a language and format that they can understand.
b) Patient and/or family are educated about the safe and effective use of medication and the
potential side effects of the medication, when appropriate.
c) Patient and/or family are educated about food-drug interaction
d) Patient and/or family are educated about diet and nutrition.
e) Patient and/or family are educated about immunisations.
f) Patient and/or family are educated on various pain management techniques, when appropriate.
g) Patient and/or family are educated about their specific disease process, complications and
prevention strategies.
h) Patient and/or family are educated about preventing healthcare associated infections.
i) The patients and/or family members' special educational needs are identified and addressed.
j) The organisation ha a mechanism to promote patient engagement to enhance clinical outcome,
safety and quality.
52
Dr. J. L. Meena

PRE 6 - Patients and families have a right to
information on expected costs.
Objective Elements
53
Dr. J. L. Meena
a)The patient and/or family members are made aware of the pricing
policy in different settings (out-patient, emergency, ICU and
inpatient).
b)The relevant tariff list is available to patients.
c)The patient and/or family members are explained about the
expected costs.
d)Patient and/or family are informed about the financial implications
when there is a change in the care plan.

PRE 7 - The organisation has a mechanism to
capture patient's feedback and to redress
complaints.
Objective Elements
a) The organisation has a mechanism to capture feedback from patients, which
includes patient satisfaction.
b)The organisation has a mechanism to capture patient experience.
c) The organisation redress patient complaints as per the defined mechanism. *
d)Patient and/or family members are made aware of the procedure for giving
feedback and/or lodging complaints.
e) Feedback and complaints are reviewed and/or analysed within a defined time
frame.
f) Corrective and/or preventive action(s) are taken based on the analysis where
appropriate.
54
Dr. J. L. Meena

PRE 8 - The organisation has a system for
effective communication with patients and/or
families.
Objective Elements
55
Dr. J. L. Meena
a)Communication with the patients and/or families is done effectively. *
b)The organisation shall identify special situations where enhanced
communication with patients and/or families would be required. *
c)Enhanced communication with the patients and/or families is done
effectively. *
d)The organisation ensures that there is no unacceptable communication.
e)The organisation has a system to monitor and review the
implementation of effective communication.

Case Study
In the *United States*, the Centers for Disease Control and
Prevention (CDC) estimated that in 2015, approximately 687,000
HAIs occurred in acute care hospitals, with about 72,000 patients
dying during their hospitalizations with an HAI. However, not all
these deaths are directly attributable to the HAI alone, as many
patients have underlying conditions that contribute to mortality.
Earlier estimates, such as from a 2007 study based on 2002 data,
suggested around 99,000 deaths annually were associated with
HAIs, though this number has likely decreased due to improved
prevention efforts.
Dr. J. L. Meena

Case Study
Globally, the *World Health Organization (WHO)* reports that HAIs affect
hundreds of millions of patients each year. In high-income countries, about 7
out of every 100 hospitalized patients acquire at least one HAI, while in low-
and middle-income countries, this rises to 15 out of 100. On average, 1 in 10
affected patients dies from an HAI. The WHO also notes that over 24% of
patients with healthcare-associated sepsis and 52.3% of those in intensive care
units with sepsis die each year, with mortality rates doubling or tripling when
infections are resistant to antibiotics. While exact global death tolls are not
precisely tallied, these percentages suggest millions of deaths annually when
applied to the estimated 136 million cases of healthcare-associated antibiotic-
resistant infections worldwide.
Dr. J. L. Meena

Case Study
In *Europe*, the European Centre for Disease
Prevention and Control (ECDC) estimates that more than
3.5 million HAI cases occur annually in the EU/EEA, with
around 9 million cases when including long-term care
facilities. Approximately 37,000 deaths are directly
attributed to HAIs each year, though they contribute to
135,000 deaths overall when factoring in complications.
Dr. J. L. Meena

Case Study
Healthcare-associated infections are a major public health
problem. According to the Centers for Disease Control and
Prevention (CDC), there were an estimated 1.7 million
healthcare associated infections and 99,000 deaths from
those infections in 2002. A recent CDC report estimated the
annual medical costs of health care – associated infections
to U.S. hospitals to be between $28 and $45 billion, adjusted
to 2007 dollars.
Reference : -http://www.heaith.ny.gov/statistics/facilities/hospital/hospital_acquired_infections/
Dr. J. L. Meena

Case Study
Hospitals in India have a high burden of infections in their ICUs
and wards, many of which are resistant to antibiotic treatment,
according to the Global Antibiotic Resistance Partnership (GARP)-
India Working Group and the Center for Disease Dynamics,
Economics & Policy (CDDEP). The 2011 GARP report, Situation
Analysis: Antibiotic Use and Resistance in India also states that a
large proportion of these hospital acquired infections (HAI) are
preventable with increased infection control measures.
Reference:- http://www.expresshealthcare.in/201111/market16.shtml
Dr. J. L. Meena

Case Study
GARP research estimates that of the approximately 190,000
neonatal deaths in India each year due to sepsis - a bacterial
infection that overwhelms the bloodstream -, over 30 per cent
are attributable to antibiotic resistance. Antibiotic resistant
hospital infections can be especially deadly because
antibiotics are used intensely in hospitals compared with the
community, and frequent use drives the development of
highly resistant bacteria.
Reference:- http://www.expresshealthcare.in/201111/market16.shtml
Dr. J. L. Meena

Case Study
A prospective study of 71 burn patients at the Post
Graduate Institute of Medical Education and Research
in Chandigarh found that up to 59 patients (83 %) had
hospital- acquired infections: 35 % of pathogens
isolated from wounds and blood were S. aureus , 24 %
were P aeruginosa, and 16 % were B- haemolytic
streptococci.
Reference: - http://www.expresshealthcare.in/201111/market16.shtml
Dr. J. L. Meena

Case Study
A six-month study conducted in 2001 of the intensive care units
(ICUs) at the All India Institute of Medical Sciences (AlIMS), found
that 140 of 1,253 patients (11 %) had 152 hospital-acquired
infections, where P aeruginosa made up 21 % of isolates, 23 %
were S aureus, 16 % Klebsiella spp., 15 % Acinetobacter
baumannii and eight percent Escherichia coli. Further, a study of
493 patients in a tertiary teaching hospital in Goa also found that
103 people (21 percent) developed 169 infections.
Reference: - http://www.expresshealthcare.in/201111/market16.shtml
Dr. J. L. Meena

Introduction
A *Healthcare-Associated Infection (HAI)* is an infection that
a patient acquires while receiving treatment in a healthcare
setting, such as a hospital, clinic, nursing home, or outpatient
facility. These infections are not present or incubating at the
time of admission and typically manifest 48 hours or more
after a patient enters the healthcare environment. HAIs are a
significant concern globally because they can complicate
patient recovery, prolong hospital stays, increase healthcare
costs, and, in severe cases, lead to life-threatening conditions.
Dr. J. L. Meena

Introduction
HAIs can be caused by a wide range of pathogens, including bacteria,
viruses, fungi, and occasionally parasites. Common examples include
methicillin-resistant Staphylococcus aureus (MRSA), Clostridium
difficile (C. diff), urinary tract infections (often linked to catheter use),
surgical site infections, and ventilator-associated pneumonia. These
infections often arise due to factors such as invasive medical
procedures (e.g., surgery or catheter insertion), the use of medical
devices, prolonged antibiotic use (which can lead to resistant strains),
or poor hygiene practices in healthcare settings.
Dr. J. L. Meena

Introduction
The concept of HAIs evolved from the older term "nosocomial
infections," which specifically referred to hospital-acquired infections.
The broader term "healthcare-associated infection" emerged to
reflect the reality that such infections can occur across various
healthcare environments, not just hospitals. According to the World
Health Organization (WHO) and the Centers for Disease Control and
Prevention (CDC), HAIs affect millions of patients worldwide each
year, with an estimated 1 in 31 hospital patients in the United States
experiencing an HAI on any given day, based on recent data.
Dr. J. L. Meena

Introduction
Efforts to prevent HAIs focus on strict infection control
measures, such as hand hygiene, sterilization of
equipment, proper use of antibiotics, and patient
isolation when necessary. Despite advancements in
medical care, HAIs remain a persistent challenge due to
the complexity of healthcare environments and the rise
of antimicrobial resistance, making ongoing research
and vigilance critical to reducing their impact.
Dr. J. L. Meena

Healthcare-Associated Infections (HAIs) can
significantly extend a patient’s length of stay
(LOS) in a hospital
The exact increase depends on factors such as the type of infection, the patient’s underlying health, and the
healthcare setting. Based on available research, here’s what we know:
➢ *General Increase*: Studies consistently show that HAIs lead to an excess LOS ranging from a few days to
several weeks. A comprehensive study in NHS Scotland, using a multi-state model to account for time-
dependent bias, estimated the average extra LOS attributable to HAIs at 7.8 days (95% CI: 5.7–9.9 days).
This contrasts with simpler comparisons that overestimate it at 27 days, highlighting the importance of
proper statistical methods.
*By Infection Type*: The increase varies by infection:
➢ *Pneumonia*: Often the most impactful, adding around 16.3 days (95% CI: 7.5–25.2 days) in some studies,
though ventilator-associated pneumonia can push this higher.
➢ *Bloodstream Infections (BSI)*: Typically increase LOS by about 11.4 days (95% CI: 5.8–17.0 days), with
some research showing up to 12.8 days for specific cases.
➢ *Surgical Site Infections (SSI)*: Add approximately 9.8 days (95% CI: 4.5–15.0 days).
➢ *Urinary Tract Infections (UTI)*: Less severe, often adding 6.7 to 10 days, depending on the context.
Dr. J. L. Meena

➢ *Regional Variations*: In a study across 68 hospitals in China, HAIs increased LOS by an average of
10.4 days, with regional differences ranging from 8.2 to 12.6 days. In contrast, a study in a Chinese
university hospital estimated a lower average of 2.56 days, suggesting variability based on local
factors or methodology.
➢ *Specific Contexts*: For trauma patients in the U.S., HAIs like sepsis or pneumonia can double or
triple LOS compared to uninfected patients, with median stays jumping from 12 days to over 60 days
in severe cases. In Canada, an average of 6 days to 26 days with an HAI, though this lacks peer-
reviewed backing and may reflect worst-case scenarios.
The increase in LOS due to HAIs is thus highly variable but typically falls between 7 to 16 days on
average, with outliers exceeding 20 days for severe infections like pneumonia or multidrug-resistant
cases. These figures underscore the burden HAIs place on healthcare systems, prolonging stays and tying
up resources. However, precise estimates require adjusting for patient demographics, infection timing,
and hospital-specific factors, as crude comparisons often inflate the numbers.
Healthcare-Associated Infections (HAIs) can
significantly extend a patient’s length of stay
(LOS) in a hospital
Dr. J. L. Meena

Healthcare-Associated Infections (HAIs),
impose a significant cost burden on healthcare
systems, patients, and society.
1. *Direct Medical Costs*
➢ *Extended Hospital Stays*: HAIs often require patients to stay longer in the hospital. For
example, infections like central line-associated bloodstream infections (CLABSIs) or surgical site
infections (SSIs) can extend stays by days or even weeks.
➢ *Additional Treatments*: Patients may need antibiotics, surgeries, or intensive care unit (ICU)
management, all of which drive up costs. For instance, treating a ventilator-associated
pneumonia (VAP) might involve expensive medications and specialized equipment.
➢ *Diagnostic Testing*: Identifying and monitoring HAIs requires lab tests, imaging, and other
diagnostics, adding to the overall expense.
Estimated Costs: Studies suggest that the average cost per HAI case in the U.S. ranges from $20,000
to $45,000, depending on the infection type and severity. For example:
- CLABSIs: ~$30,000–$70,000 per case.
- SSIs: ~$10,000–$25,000 per case.
- MRSA infections: Up to $60,000 per case.
Dr. J. L. Meena

2. *Indirect Costs*
➢ *Lost Productivity*: Patients with HAIs may face extended recovery times, leading to missed workdays for
themselves and caregivers. This is especially significant for working-age adults.
➢ *Legal and Insurance Costs*: Hospitals may face lawsuits or increased insurance premiums due to
preventable infections, indirectly raising operational costs.
➢ *Mortality Costs*: HAIs contribute to thousands of deaths annually (e.g., approximately 99,000 deaths per
year in the U.S.), which carries an economic toll through lost human capital.
3. *Systemic Burden*
➢ *Healthcare System Strain*: HAIs consume resources like hospital beds, staff time, and supplies, reducing
capacity for other patients.
➢ *Penalties and Reimbursement Losses*: In some countries, like the U.S., programs such as Medicare’s
Hospital-Acquired Condition (HAC) Reduction Program penalize hospitals with high HAI rates by reducing
reimbursements, adding financial pressure.
➢ *Prevention Investments*: Hospitals must spend on infection control measures (e.g., staff training,
sterilization equipment), which, while cost-effective long-term, represent upfront costs.
Dr. J. L. Meena

4. *Global Perspective*
➢ In high-income countries, HAIs affect 5–15% of hospitalized patients, with annual costs estimated at
$9.8 billion in the U.S. alone (per a 2013 study, adjusted for inflation).
➢ In low- and middle-income countries, the burden is higher due to limited resources, with HAI
prevalence sometimes exceeding 20%, amplifying economic strain where healthcare budgets are
already stretched.
5. *Prevention vs. Treatment*
➢ Investing in prevention (e.g., hand hygiene protocols, catheter care bundles) is significantly cheaper
than treating HAIs. For example, preventing a single CLABSI can save up to $70,000, while prevention
programs might cost a fraction of that per patient.
In summary, HAIs create a multifaceted cost burden through increased medical expenses, lost
productivity, and systemic inefficiencies. Reducing their incidence through evidence-based practices not
only improves patient outcomes but also alleviates financial pressure on healthcare systems.
Dr. J. L. Meena

➢ Lack / poorly implementation of hospital infection control
procedures and policies.
➢ Use of equipment which is not to clean, disinfect or sterilize.
➢ Increasing specialization bringing together patients susceptible to
some type of infection
➢ Increased use and trial use of antibiotics resulting in drug
resistance.
➢ Effective sterilization system a s yet not fully understood by all
concerned.
➢ Unhygienic condition of the healthcare facilities.
Why is infection such a
problem ???
Dr. J. L. Meena

➢ Very young people - premature babies and very sick
children
➢ Very old people - the frail and the elderly
➢ Those with medical conditions - such as diabetes
➢ People with defective immunity – people with
diseases that compromise their immune system or
people who are being treated with chemotherapy or
steroids.
Some people are more
susceptible
Dr. J. L. Meena

Other risk factors
➢ Length of stay - a long hospital stay can increase the risk: for example, admission for complex or
multiple illnesses.
➢ Operations and surgical procedures - the length and type of surgery can also impact.
➢ Hand washing techniques - inadequate hand washing by hospital staff and patients may increase
your risk.
➢ Antibiotics - overuse of antibiotics can lead to resistant bacteria, which means that antibiotics
become less effective.
➢ Equipment - invasive procedures can introduce infection into the body: for example, procedures
that require the use of equipment such as urinary catheters, drips and infusions, respiratory
equipment and drain tubes.
➢ Wounds - wounds, incisions (surgical cuts), burns and ulcers are all prone to infection.
➢ High-risk areas - some areas of the hospital are more likely to have infection, such as intensive care
units (ICU) and high dependency units (HDU).
Dr. J. L. Meena

Types of infections
The most common types of infection acquired in hospitals
are:-
➢ Urinary tract infections (UTI)
➢ Wound infection
➢ Pneumonia (lung infection)
➢ Bloodstream infection.
Note:- infections are treated with antibiotics and usually
respond well. Occasionally, infections can be serious and life
threatening.
Dr. J. L. Meena

“Superbugs”
Some bacteria are hard to treat because they are resistant to
standard antibiotics. These bacteria are sometimes called
'superbugs'
examples of superbugs are:
Staphylococcus aureus - often called 'golden staph' or
methicillin-resistant Staphylococcus aureus (MRSA).
Resistant Enterococcus - also referred to as vancomycin-
resistant Enterococcus (VRE).
Dr. J. L. Meena

Controlling infection
Spread of infection can be controlled and reduced
by:-
❖Strict hospital infection prevention and control
procedures and policies.
❖Correct and frequent hand washing by all
hospital staff and patients.
❖Cautious use of antibiotic medication.
Dr. J. L. Meena

How to reduce your risk
Dr. J. L. Meena

(Before admission)
➢ Stop smoking - smoking can interfere with healing processes. It
also damages the airways, which can make lung infections more
likely.
➢ Maintain a healthy weight - people who are overweight are more
prone to infection.
➢ Inform your doctor of all existing or recent illness - a cold or the
flu can lead to a chest infection, so let your doctor or the hospital
staff know if you are not well.
➢ Manage diabetes - if you are a diabetic, make sure that your blood
sugar levels are under control.
Dr. J. L. Meena

(During your stay)
➢ Make sure that you wash your hands properly, especially after using the
toilet. Remind hospital staff to do the same before and after they attend to
you.
➢ Let your nurse know if the site around the needle is not clean and dry if you
have an IV drip.
➢ Tell your nurse if the dressings are not clean, dry and attached around any
wounds you may have.
➢ Let your nurse know if tubes or catheters feel displaced.
➢ Do your deep breathing exercises - the staff will instruct you. This is very
important because they can help prevent a chest infection.
➢ Ask relatives or friends who have colds or are unwell not to visit.
Dr. J. L. Meena

How to Improving patient care by reducing the risk of
Dr. J. L. Meena

Intent of the Chapter
Infection Prevention & Control (IPC)
➢ The organisation implements an effective healthcare associated infection prevention and
control programme. The programme is documented and aims at reducing/eliminating
infection risks to patients, visitors and providers of care. The programme is implemented
across the organisation, including clinical areas and support services.
➢ The organisation provides proper facilities and adequate resources to support the infection
prevention and control programme. The organisation measures and acts to prevent or
reduce the risk of healthcare associated infection in patients and staff.
➢ The organisation has an effective antimicrobial management programme through regularly
updated antibiotic policy based on local data and monitors its implementation. Programme
also includes monitoring of antimicrobials usage in the organisation.
➢ Surveillance activities are incorporated in the infection prevention and control programme.
The programme includes disinfection/sterilisation activities and biomedical waste (BMW)
management.
33
Dr. J. L. Meena

Infection Prevention and Control (IPC)
IPC.1.
The organisation has a comprehensive and coordinated Hospital Infection Prevention and Control
(HIC) programme aimed at reducing/eliminating risks to patients, visitors, providers of care and
community.
IPC.2. The organisation provides adequate and appropriate resources for infection prevention and control.
IPC.3. The organisation implements the infection prevention and control programme in clinical areas.
IPC.4. The organisation implements the infection prevention and control programme in support services.
IPC.5. The organisation takes actions to prevent healthcare associated Infections (HAI) in patients.
IPC.6.
The organisation performs surveillance to capture and monitor infection prevention and control
data.
IPC.7.
Infection prevention measures include sterilization and/or disinfection of instruments, equipment
and devices.
IPC.8. The organisation takes action to prevent or reduce healthcare associated infections in its staff.
34
Dr. J. L. Meena

Infection Prevention and Control (IPC)
Objective
Elements
IPC 1 IPC 2 IPC 3 IPC 4 IPC 5 IPC 6 IPC 7 IPC 8
a Commitment Commitment CORE CORE CORE CORE Commitment Commitment
b Achievement Commitment Achievement Commitment Commitment Commitment Achievement Commitment
c CORE Commitment Commitment CORE Commitment Commitment CORE Commitment
d CORE CORE Commitment Commitment Commitment Commitment Commitment Commitment
e CORE Commitment Achievement CORE Commitment Commitment Achievement
f Commitment Commitment Commitment
g CORE Commitment
h Commitment Commitment
j Commitment Excellence
Summary Standards -8 OE-52 CORE -12 Commitment - 32 Achievement 7 Excellence 1

IPC 1 - The organisation has a comprehensive and
coordinated Infection Prevention and Control (IPC)
programme aimed at reducing/ eliminating risks to
patients, visitors, providers of care and community.
Objective Elements
a) The infection prevention and control programme is documented, which aims at preventing and
reducing the risk of healthcare associated infections in the hospital. *
b) The infection prevention and control programme identifies high-risk activities, and has written guidance to prevent
and manage infections for these activities.*
c) The infection prevention and control programme is reviewed and updated at least once a year.
d) The infection prevention and control programme is reviewed based on infection prevention and control assessment tool.
e) The organisation has a multi-disciplinary infection prevention and control committee, which co-ordinates all infection
prevention and control activities. *
f) The organisation has an infection prevention and control team, which coordinates the implementation of all infection
prevention and control activities. *
g) The organisation has designated infection prevention and control officer as part of the infection prevention and control
team. *
h) The organisation has designated infection prevention and control nurse(s) as part of the infection prevention and control
team. *
i) The organisation implements information, education and communication programme for infection prevention and
control activities for the community.
j) The organisation participates in managing community outbreaks.
36
Dr. J. L. Meena

CDC Guidelines and Manua lf or Control of
Hospital Associated Infections,
➢ CDC position statement on reuse of single dose vials 2012
➢ Basic Infection Control and Prevention Plan for Outpatient Oncology settings
(October 2011)
➢ Guide to infection prevention in outpatient settings: Minimum expectations for
safe care (July 2011 version)
➢ CDC issues checklist for infection prevention in out-patient settings to
accompany new guide (July, 2011)
➢ Guideline for the prevention and control of norovirus gastroenteritis outbreaks
in healthcare settings (2011)
➢ Guideline for disinfection a n d sterilization in healthcare facilities, (2008)
➢ Guideline for isolation precautions: Preventing transmission of infectious agents
in healthcare settings (2007)
Dr. J. L. Meena

CDC Guidelines and Manua lf or Control of
Hospital Associated Infections,
➢ Injection practices for patient safety (2007)
➢ Guideline - Management of multidrug-resistant organisms in healthcare settings (2006)
➢ Public reporting of healthcare-associated infections (2005)
➢ Bloodstream infection: Guideline for the prevention of intravascular catheter-related infections
(2011)
➢ Dental health (2003)
➢ Dialysis - Multidose vials infection control (2008)
➢ Environmental infection control (2003)
➢ Hand hygiene (2002)
➢ Infection control - health care personnel ( 1 9 9 8 )
➢ Occupational exposures (2005)
➢ Pneumonia (2003)
➢ Surgical site infection (1999)
➢ Tuberculosis (2005)
➢ Urinary tract infection: CA-UTI (2009)
Dr. J. L. Meena

Key points for audit
➢ Audit means checking practice against a standard. It examines the
actual situation and compares it to written policies or another
benchmark.
➢ Audit can help to improve health care service by providing a blame-
free mechanism for changes in practice. It can also be used for risk
assessment, strategic planning, and root cause analysis.
➢ An audit team is essential to carry out a proper audit through good
planning, performance, and feedback of results.
➢ Audit results may be provided to others through various types of
reporting.
Dr. J. L. Meena

Reporting of audits could be in
the form of:
Weekly reports:- Providing rapid feedback on incidental issues while
they are still fresh (e.g., during outbreaks or after occupational sharp
injuries).
Monthly reports:- A monthly report should include sections about
surveillance, audit results, education, training, and consultations.
Quarterly reports:- These are formal reports including
recommendations and management of issues.
Annual reports:- A summary of audits carried out during the year and
the resulting improvement or changes during the rapid and annual
audit plans, illustrated as appropriate with graphs.
Dr. J. L. Meena

IPC 2 - The organisation provides adequate and
appropriate resources for infection prevention
and control.
Objective Elements
41
Dr. J. L. Meena
a) The management makes available resources required for the infection
prevention and control programme including allocation of adequate
funds from its annual budget.
b) Adequate and appropriate personal protective equipment, soaps, and
disinfectants are available and used correctly.
c) Adequate and appropriate facilities for hand hygiene in all patient-care areas
are accessible to healthcare providers.
d) Isolation/barrier nursing facilities are available.

Types of hand wash procedure
➢ Social hand wash
➢ Hygienic hand wash
➢ Surgical hand wash
Dr. J. L. Meena

Social hand wash
Why should a social hand wash be performed?
Social hand wash is performed to render the hands physically clean and to
remove transient micro-organisms. It is an infection control practice with a
clearly demonstrated efficacy and remains the cornerstone of efforts to
reduce the spread of infection (Larson 1989).
When should a social hand wash be performed?
The times that hand hygiene should be performed have been summarised
into the "Your 5 Moments for Hand Hygiene", as these are considered the
most fundamental times for the levels of hand hygiene to be undertaken
during care delivery a
Dr. J. L. Meena

Examples of when to perform a social
hand wash (Before)
➢ The beginning of the shift
➢ Preparing, handling and eating food
➢ Donning gloves
➢ Any patient contact
➢ Clean/aseptic procedures
➢ Entering/leaving clinical areas
➢ Entering/leaving isolation cubicles
➢ Preparing/giving medications
➢ Using a computer keyboard in a clinical area
Dr. J. L. Meena

Examples of when to perform a social
hand wash (After)
➢ The end of a shift
➢ Any patient contact
➢ Bed making
➢ Contact with patient surroundings
➢ Visiting the toilet
➢ The removal of gloves
➢ Hands become visibly soiled
➢ Handling laundry/waste
➢ Using a computer keyboard in a clinical area
➢ The administration of medications
➢ Blood and/or body fluid exposure risk

What solution should be used for
performing a social hand wash?
➢ Liquid soap (plain or antimicrobial)
➢ The soap comes in disposable cartridges and must not be
re-used or "topped-up".
➢ Bar soap should not be used in clinical areas .
Dr. J. L. Meena

How should a social hand wash be
performed?
➢ Social hand washing should take at least 30 seconds :
➢ Wet hands under running warm water.
➢ Dispense one dose of soap into cupped hands.
➢ Rub hands palm to palm.
➢ Right palm over the back of the other hand with interlaced fingers
and vice versa.
➢ Palm to palm with fingers interlaced.
➢ Back of fingers to opposing palms with fingers interlocked.
➢ Rotational rubbing of left thumb clasped in right palm and vice
versa .
Dr. J. L. Meena

➢ Rotational rubbing, backwards and forwards with clasped fingers of right
hand in left palm and vice versa.
➢ Rinse hands with warm water.
➢ Dry thoroughly with paper towel.
➢ Cloth towels must not be used.
➢ Warm air hand dryers may be used in non-clinical areas.
➢ Turn off taps using a 'hands-free' technique (eg elbows). Where this is not
possible, the paper towel used to dry the hands can be used to turn off the
tap.
➢ Dispose of the paper towel without re-contaminating hands .
➢ Do not touch bin lid with hands.
How should a social hand wash be
performed?
Dr. J. L. Meena

Alcohol gel/foam
➢ This can be used on visibly clean hands a s an alternative to a social hand wash.
➢ Alcohol gel/foam: Will not remove dirt and organic matter and can only be used when
hands are not visibly soiled.
➢ Should not be used prior to handling medical gas cylinders because of the risk of ignition
(explosion).
➢ Is NOT effective against Clostridium difficile and Norovirus. When caring for a patient
with either of these organisms, hands must be washed with soap and water.
➢ Soap and alcohol-based handrub should not be used concomitantly (World Health
Organisation (WHO) 2009).
➢ When applying alcohol handrub leave to dry naturally on the skin.
➢ Hands should be washed with soap and water after several consecutive applications of
handrub (Epic2 Guidelines 2007).
Dr. J. L. Meena

Hygienic hand wash CoH
Why should a hygienic hand wash be performed?
To remove or destroy transient micro-organisms and to substantially reduce resident
micro-organisms during times when surgical procedures are performed.
When should a hygienic hand wash be performed?
Before all aseptic procedures on the ward.
What should be used for performing a hygienic hand wash ?
An approved antiseptic detergent (eg 4% Chlorhexidine gluconate or 7.5% Povidone
iodine).
How should a hygienic hand wash be performed?
See above instructions on 'How should a social hand wash be performed?'
Dr. J. L. Meena

Surgical hand wash CoH
Why should a surgical hand wash be performed?
To remove or destroy transient micro-organisms and to substantially reduce
resident micro-organisms during times when surgical procedures are performed.
It is intended to decrease the risk of wound infections should surgical gloves
become damaged
When should a surgical hand wash be performed?
Before all surgical/invasive procedures.
What should be used for performing a surgical hand wash ?
An approved antiseptic detergent (eg 4% Chlorhexidine gluconate or 7 . 5 %
Povidone iodine).
Dr. J. L. Meena

How should a surgical hand wash be
performed?
➢ When performing a surgical hand wash, the level of the hands should always remain above the
elbows.
➢ Always use sensor or elbow operated taps.
➢ Apply antiseptic detergent to the hands and wrists and wash for at least one minute up to the
elbow.
➢ A sterile brush may be used for the first application of the day, but continual use is inadvisable.
➢ Using a pre-packed sterile brush, clean under the nails only of both hands.
➢ Rinse thoroughly.
➢ Apply a second application of antiseptic detergent and wash hands and two thirds of the
forearms with either Povidone iodine for at least one minute, or Chlorhexidine gluconate for at
least two minutes.
➢ Rinse thoroughly.
➢ One sterile towel should be used to blot dry the first hand and arm and another sterile towel
for the second hand and arm.
Dr. J. L. Meena

The use of gloves
➢ The use of gloves does not replace the need for hand hygiene by either hand rubbing or hand
washing (WHO 2009)
➢ Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin/mucous
membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body
fluids, secretions or excretions, or sharp or contaminated instruments. Some procedures not
normally requiring gloves may require gloves when infection is present eg eye care (Epic2 2007)-
➢ Gloves can have pores that may allow micro-organisms to pass through and hands should be cleaned
before and after wearing gloves (Epic2 2007).
➢ Gloves should be single use and changed between dirty and clean procedures and between patients
(Larson 1989).
➢ Gloved hands should not be washed or cleaned with alcohol hand rubs, gels or wipes (Walsh 1987)-
➢ Sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented
and alternatives to natural rubber latex gloves must be available (Epic2 2007).
Dr. J. L. Meena

➢ Artificial fingernails or extenders should not be worn when having direct
contact with patients.
➢ Natural nails should be kept short (tips less than 0.5cm long).
➢ The wearing of rings and wrist jewellery (including watches) during health
care is strongly discouraged. If religious or cultural influences strongly
condition the health care worker’s attitude, the wearing of a simple
wedding ring (band) during routine care may be acceptable, but in high-risk
settings, such as the operating theatre, all rings and other jewellery should
be removed (WHO 2009).
➢ Cuts and abrasions must be covered with waterproof dressings.
Other aspects of hand
hygiene
Dr. J. L. Meena

Other aspects of hand
hygiene
➢ Bare below the elbows - in order to ensure that hand scan be easily
decontaminated, only clothing that does not go past the elbow should be
worn. Suit jackets, long sleeves, wrist watches, bracelets and rings (other
than a plain wedding band) should not be worn.
➢ Bare below the elbows' applies to all clinical staff wearing a uniform, anyone
entering a patient's bed space or room, when having clinical patient contact
and anyone entering PICU, NICU or CICU.
➢ Bare below the elbows' is not required for anyone visiting a ward (with the
exception of PICU, NICU or CICU) that does not enter a patient's bed space or
room.
Dr. J. L. Meena

Hand care advice:
➢ Always wet hands thoroughly before washing.
➢ Ensure water is warm (neither hot nor cold).
➢ Do not use more soap product than recommended by the manufacturer ('One squirt is
enough').
➢ During hand washing, thoroughly rinse off residual soap.
➢ Dry hands completely by carefully patting rather than rubbing with a paper towel.
➢ Donning gloves while hands are still wet from either washing or applying alcohol gel,
increases the risk of skin irritation.
➢ Use emollient creams regularly, especially before breaks and after finishing work.
Ensure all parts of the hand a r e covered.
➢ Check your skin for early signs of dermatitis and report concerns to Occupational
Health.
➢ Early detection can help prevent more serious dermatitis from developing.
Dr. J. L. Meena

ISO 22000:2005
➢ To plan, implement, operate, maintain and update a food safety management system aimed
at providing products that, according to their intended use, are safe for the consumer,
➢ To demonstrate compliance with applicable statutory and regulatory food safety
requirements,
➢ To evaluate and assess customer requirements and demonstrate conformity with those
mutually agreed customer requirements that relate to food safety, in order to enhance
customer satisfaction,
➢ To effectively communicate food safety issues to their suppliers, customers and relevant
interested parties in the food chain,
➢ To ensure that the organization conforms to its stated food safety policy,
➢ To demonstrate such conformity to relevant interested parties, and
➢ To seek certification or registration of its food safety management system by an external
organization, or make a self - assessment or self-declaration of conformity to ISO 22000:2005.
Dr. J. L. Meena

Why isolation rooms are so
important ???
An isolation room in a hospital is a critical component of infection control and patient care. Its primary purpose is to prevent
the spread of infectious diseases while ensuring the safety of patients, healthcare workers, and visitors.
1. *Controlling Infectious Diseases*: Isolation rooms are designed to contain pathogens—such as bacteria, viruses, or fungi—
that can spread through air, droplets, or contact. This is especially vital for highly contagious diseases like tuberculosis, MRSA,
or airborne viruses such as COVID-19. By separating infected patients, hospitals reduce the risk of outbreaks.
2. *Protecting Vulnerable Patients*: Hospitals often treat immunocompromised individuals, such as those undergoing
chemotherapy, organ transplants, or with chronic conditions. Isolation rooms help shield these patients from exposure to
infections that could be life-threatening due to their weakened immune systems.
3. *Types of Isolation*:
- *Negative Pressure Rooms*: Used for airborne infections (e.g., measles, influenza), these rooms prevent contaminated air
from escaping into other areas by maintaining lower air pressure inside.
- *Positive Pressure Rooms*: These protect vulnerable patients by keeping infectious agents out, often used for burn victims
or post-surgical patients.
- *Contact Isolation*: For diseases spread by touch (e.g., C. diff), these rooms limit direct and indirect contact with the
patient.
Dr. J. L. Meena

Why isolation rooms are so
important ???
An isolation room in a hospital is a critical component of infection control and patient care. Its primary purpose is to
prevent the spread of infectious diseases while ensuring the safety of patients, healthcare workers, and visitors.
4. *Safety of Healthcare Workers*: Isolation protocols, combined with personal protective equipment (PPE), reduce the
risk of staff contracting or transmitting infections. This is crucial for maintaining a functional workforce, especially
during pandemics.
5. *Reducing Hospital-Acquired Infections (HAIs)*: HAIs, like sepsis or pneumonia, can increase morbidity, mortality,
and healthcare costs. Isolation rooms help break the chain of transmission, lowering these risks.
6. *Public Health Impact*: By containing infectious agents within a controlled environment, hospitals contribute to
broader community safety, preventing pathogens from spreading beyond their walls.
In practice, isolation rooms are equipped with specialized ventilation systems, sealed doors, and sometimes anterooms
to enhance containment. They require strict adherence to protocols—like hand hygiene and PPE use—which
underscores their role as a cornerstone of modern medical care. Without them, hospitals would struggle to manage
infectious diseases effectively, putting entire populations at risk.
Dr. J. L. Meena

IPC 3 - The organisation implements the
infection prevention and control programme in
clinical areas.
Objective Elements
a) The organisation adheres to standard precautions at all times. *
b) The organisation adheres to hand-hygiene guidelines. *
c) The organisation adheres to transmission-based precautions. *
d) The organisation adheres to safe injection and infusion practices. *
e) Appropriate antimicrobial usage policy is established and
documented *
f) Theorganisation implements the antimicrobial usage policy and
monitors the rational use of antimicrobial agents.
62
Dr. J. L. Meena

An effective antimicrobial management
program is crucial to preventing infections and
promoting responsible antibiotic use.
Key Components
1. Antibiotic Policy: Develop and regularly update an antibiotic policy based on local data and guidelines.
2. Monitoring and Surveillance: Monitor antibiotic use and resistance patterns to inform policy updates and
interventions.
3. Education and Training: Provide ongoing education and training for healthcare professionals on antibiotic
use and resistance.
4. Stewardship: Implement antibiotic stewardship programs to promote responsible antibiotic use.
Benefits
1. Reduced Antibiotic Resistance: Effective antimicrobial management programs can reduce antibiotic
resistance.
2. Improved Patient Outcomes: Responsible antibiotic use can improve patient outcomes and reduce the risk
of adverse events.
3. Cost Savings: Optimizing antibiotic use can result in cost savings for healthcare organizations.
Dr. J. L. Meena

Implementation Strategies
1. Multidisciplinary Team: Establish a multidisciplinary team to develop and implement the
antimicrobial management program.
2. Data-Driven Decision Making: Use local data to inform antibiotic policy updates and
interventions.
3. Regular Review and Update: Regularly review and update the antibiotic policy to ensure it
remains effective and relevant.
Best Practices
1. Collaboration: Collaborate with healthcare professionals, patients, and families to promote
responsible antibiotic use.
2. Transparency: Ensure transparency in antibiotic use and resistance patterns to inform decision-
making.
3. Continuous Quality Improvement: Continuously monitor and evaluate the effectiveness of the
antimicrobial management program.
An effective antimicrobial management
program is crucial to preventing infections and
promoting responsible antibiotic use.
Dr. J. L. Meena

IPC 4 - The organisation implements the
infection prevention and control programme in
support services.
Objective Elements
65
Dr. J. L. Meena
a) The organisation has appropriate engineering controls to prevent
infections. *
b) The organisation designs and implements a plan to reduce the risk of
infection during construction and renovation. *
c) The organisation adheres to housekeeping procedures. *
d) Biomedical waste (BMW) is handled appropriately and safely.
e) The organisation adheres to laundry and linen management processes. *
f) The organisation adheres to kitchen sanitation and food-handling issues. *

Highlights the importance of housekeeping
procedures in preventing HAIs.
➢ **Regular Cleaning and Disinfection**: Housekeeping staff in healthcare settings are responsible for cleaning and
disinfecting surfaces, floors, and equipment. High-touch areas like bed rails, doorknobs, and medical devices must be
cleaned frequently to reduce the risk of pathogen transmission.
➢ **Proper Waste Management**: Safe disposal of medical waste, such as used needles, bandages, or other contaminated
materials, prevents the spread of infections. Housekeeping teams ensure that waste is segregated, collected, and disposed
of according to protocols.
➢ **Sterilization of Shared Spaces**: Operating rooms, patient rooms, and common areas need to be thoroughly cleaned
between uses to eliminate pathogens. This includes changing linens, sanitizing mattresses, and ensuring air quality is
maintained through proper ventilation.
➢ **Compliance with Protocols**: Organizations that adhere to strict housekeeping procedures follow guidelines set by
health authorities, such as the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO).
This ensures consistency and effectiveness in infection control.
➢ **Training and Awareness**: Housekeeping staff should be trained in infection control practices, including the correct use
of personal protective equipment (PPE), disinfectants, and cleaning techniques to minimize cross-contamination.
Dr. J. L. Meena

Handling biomedical waste (BMW) safely and
appropriately is crucial to preventing Hospital-
Acquired Infections (HAIs)
Some key considerations:
Segregation and Storage
1. Segregation: Segregate BMW into different categories, such as infectious, non-
infectious, and hazardous waste.
2. Storage: Store BMW in designated areas, using leak-proof containers and proper
labeling.
Transportation and Disposal
1. Transportation: Transport BMW using dedicated vehicles and containers, following local
regulations and guidelines.
2. Disposal: Dispose of BMW through approved methods, such as incineration, autoclaving,
or chemical treatment.
Dr. J. L. Meena

Some key considerations:
Infection Control Practices
1. Personal Protective Equipment (PPE): Wear PPE, including gloves, masks, and gowns, when handling
BMW.
2. Hand Hygiene: Practice proper hand hygiene after handling BMW.
Training and Education
1. Staff Training: Provide ongoing training and education for staff on BMW handling and disposal
procedures.
2. Awareness: Promote awareness among staff, patients, and visitors about the importance of proper
BMW handling and disposal.
Regulatory Compliance
1. Local Regulations: Comply with local regulations and guidelines for BMW handling and disposal.
2. Accreditation Standards: Meet accreditation standards for BMW management, such as those set by the
Joint Commission or the World Health Organization (WHO).
Handling biomedical waste (BMW) safely and
appropriately is crucial to preventing Hospital-
Acquired Infections (HAIs)
Dr. J. L. Meena

IPC 5 - The organisation takes actions to prevent
healthcare associated infections (HAI) in
patients.
Objective Elements
a) The organisation takes action to prevent catheter-associated
urinary tract Infections.
b) The organisation takes action to prevent infection-related
ventilator associated complication/ventilator-associated
pneumonia.
c) The organisation takes action to prevent catheter linked blood
stream infections.
d) The organisation takes action to prevent surgical site infections.
70
Dr. J. L. Meena

IPC 6 - The organisation performs surveillance
to capture and monitor infection prevention and
control data.
Objective Elements
a) The scope of surveillance incorporates tracking and analysing of infection risks, rates and
trends.
b) Verification of data is done regularly by the infection prevention and control team.
c) Surveillance is directed towards the identified high-risk activities.
d) Surveillance includes monitoring compliance with hand-hygiene guidelines.
e) Surveillance includes mechanisms to capture the occurrence of multi-drug- resistant
organisms and highly virulent infections.
f) Surveillance includes monitoring the effectiveness of housekeeping services.
g) Feedback regarding surveillance data is provided regularly to the appropriate health care
provider.
h) The organisation identifies and takes appropriate action to control outbreaks of
infections.*
i) Surveillance data is analysed, and appropriate corrective and preventive actions are taken.
71
Dr. J. L. Meena

IPC 7 - Infection prevention measures include
sterilisation and/or disinfection of instruments,
equipment and devices.
Objective Elements
a) The organisation provides adequate space and appropriate zoning for
sterilisation activities.
b) Cleaning, packing, disinfection and/or sterilisation, storing and the issue of
items is done as per the written guidance. *
c) Reprocessing of single-use instruments, equipment and devices are done as
per written guidance. *
d) Regular validation tests for sterilisation are carried out and documented. *
e) The established recall procedure is implemented when a breakdown in the
sterilisation system is identified. *
72
Dr. J. L. Meena

IPC 8 - The organisation takes action to
prevent or reduce healthcare associated
infections in its staff.
Objective Elements
73
Dr. J. L. Meena
a) The organisation implements occupational health and safety practices to
reduce the risk of transmitting microorganisms among health care
providers.*
b) The organisation implements an immunisation policy for its staff. *
c) The organisation implements work restrictions for health care providers
with transmissible infections.
d) The organisation implements measures for blood and body fluid exposure
prevention.
e) Appropriate post-exposure prophylaxis is provided to all staff members
concerned. *

Case study
Quality problems are reflected today in the
wide variation in use of health care services,
the underuse and overuse of some services,
and misuse of others .
Dr. J. L. Meena

Evidence of Quality Problems
Variation in services : - There continues to be a
pattern of wide variation in health care practice,
including regional variations and small-area
variations. This is a clear indicator that health
care practice has not kept pace with the evolving
science of health care to ensure evidence-based
practice.
Dr. J. L. Meena

Underuse of services:- Millions of people do not receive
necessary care and suffer needless complications that add
to costs and reduce productivity. Each year, an estimated
18,000 people die because they do not receive effective
interventions. For example, a study of Medicare patients
who had suffered heart attacks found that only 21 percent
of eligible patients received beta blockers. The mortality
rate among patients who received beta blockers was 43
percent lower than it was among nonrecipients.
Dr. J. L. Meena

Underuse of services : - A case study examined
the use of beta blockers before heart bypass
surgery and found that patients who received
beta blocker therapy before surgery had lower
rates of death and fewer complications both
during and after surgery than patients who did
not receive this therapy.
Dr. J. L. Meena

Overuse of services:- Each year, millions of Americans
receive health care services that are unnecessary,
increase costs, and may even endanger their health.
Research has shown that this occurs across all
populations.
For example, an analysis of hysterectomies performed
on women in seven health plans found that one in six
operations was inappropriate .
Dr. J. L. Meena

Overuse of services:- A study examining the use of
antibiotics for treating ear infections in children on Medicaid
found that expensive antibiotics were used far more often
than indicated.
According to the findings, if only half the prescriptions
written in 1992 for more expensive antibiotics had been
written for amoxicillin, a less expensive but equally effective
antibiotic, Colorado’s Medicaid program would have saved
nearly $400,000 that year.
Dr. J. L. Meena

Misuse of services:- For example, a study of injuries to
patients treated in hospitals in New York State found that 3.7
percent experienced adverse events; 13.6 percent of these
events led to death, and 2.6 percent led to permanent
disability. About one-fourth of these adverse events resulted
from negligence. A national study found that over a 10-year
period (1983-93), deaths due to medication errors rose more
than two-fold with 7,391 deaths attributed to medication
errors in 1993 alone.
Dr. J. L. Meena

Disparities in quality:- Although quality problems affect all
populations, they may be most marked for members of
ethnic and racial minority populations. Researchers at the
University of Alabama at Birmingham examined the use of
thrombolysis ("clot busters") for patients who had
experienced a heart attack and found that while this
evidence-based life-saving treatment was underused for all,
black Medicare beneficiaries were significantly less likely
than whites to receive this treatment.
Dr. J. L. Meena

Healthcare Safety Medicine vs.
Airline Industry
Headline: "Can you be as safe in a hospital as you are
in a jet?”
➢ Medical mistakes in hospitalized patients account
for a minimum of 120 deaths annually.
➢ This equates to a crash of a Boeing 747 every week
killing all on board.
Dr. J. L. Meena

Healthcare Costs Errors
Headline: "Medication errors in 2006 added $3.5
billion to the cost of healthcare”
Headline: "80,000 catheter-related bloodstream
infections occur in intensive care units in the US
each year"
Dr. J. L. Meena

Healthcare Backlash Boston
Globe
Headline: "We pay for medical errors"
By Richard Lord and Dr. Marylou Buyse. 9/12/2007
"WHAT IF your mechanic forgot to replace the lug nuts after
changing one of your tires and you got into a serious accident
when the wheel came off? You wouldn't expect your
mechanic to send you a bill for the repairs, would you?"
"Unfortunately, that's what happens in healthcare; we pay a
high price for mistakes."
Dr. J. L. Meena

Institute of Medicine Quality Aims
✓ Safe
✓ Effective
✓ Patient centered
✓ Timely
✓ Efficient
✓ Equitable
Dr. J. L. Meena

Safe
Avoid injury to patients from the care that is intended to
help them
Examples
> Prescription of medication that patient is allergic.
> Failure to address an abnormal lab or X ray result.
> Failure to perform the correct procedure.
Dr. J. L. Meena

Effective
Avoid overuse of ineffective care and underuse of
effective care
Examples
Obtaining lab or X ray tests that don't change
treatment plan
Dr. J. L. Meena

Patient centered
Provide care that is respectful of and responsive
to individual patient preferences, needs and
values
Examples
Shared decision making for treatment options
Dr. J. L. Meena

Timely
Reduce waits and harmful delays for both those
who receive care and those who give care
Dr. J. L. Meena

Efficient
Avoid waste including waste of supplies,
equipment, ideas and energy
Example
Necessary supplies, personnel, and medications in
room for patient procedure
Dr. J. L. Meena

Equitable
Provide care that does not vary in quality due
to gender, ethnicity, geographic location or
socioeconomic status.
Dr. J. L. Meena

Creating a quality culture in a
hospital
Creating a quality culture in a hospital is about fostering an environment where patient
safety, excellence in care, and continuous improvement are at the core of every action and
decision. It’s not just about implementing policies—it’s about shaping attitudes, behaviors,
and systems so that everyone, from clinicians to support staff, is aligned toward delivering
the best outcomes. Below are practical, actionable steps grounded in proven strategies, with
a focus on clarity and realism.
1. Leadership Commitment and Role Modeling
2. Engage and Empower Staff
3. Focus on Systems, Not Blame
4. Invest in Training and Education
5. Prioritize Patient-Centered Care
6. Leverage Data and Technology
7. Sustain Momentum Through Accountability
Dr. J. L. Meena

hospital
1. Leadership Commitment and Role Modeling
Why it matters: A quality culture starts at the top. If leaders don’t prioritize quality, neither will the
staff.
How to do it:
- *Set a clear vision*: Define what "quality" means for your hospital—e.g., zero preventable
harm, high patient satisfaction, or evidence-based care. Communicate this vision relentlessly
through town halls, emails, and daily huddles.
- *Walk the talk*: Leaders should visibly participate in quality initiatives, like joining safety
rounds or engaging in root cause analyses after incidents. For example, a CEO who spends time on
the floor listening to nurses’ concerns signals that quality isn’t just a buzzword.
- *Align incentives*: Tie performance evaluations and bonuses for leadership to quality metrics,
like reducing hospital-acquired infections or improving patient experience scores.
- *Example*: At Mayo Clinic, leaders are expected to embody the “patient-first” philosophy,
which trickles down to every employee through consistent messaging and accountability.
Dr. J. L. Meena

hospital
2. Engage and Empower Staff
Why it matters: Frontline staff—nurses, techs, and even housekeeping—see the real-time gaps in
care. A culture that ignores them stifles improvement.
How to do it:
- *Create psychological safety*: Encourage staff to speak up about errors or risks without fear
of blame. Use tools like anonymous reporting systems or regular “safety huddles” to discuss near-
misses.
- *Involve everyone in problem-solving*: Form multidisciplinary quality improvement teams
(e.g., doctors, nurses, pharmacists) to tackle specific issues, like reducing medication errors. Give
them real authority to test solutions.
- *Recognize contributions*: Celebrate small wins publicly—e.g., a nurse who catches a
potential error or a team that reduces wait times. Recognition could be as simple as a shout-out in
a newsletter or a monthly award.
- *Example*: Virginia Mason Medical Center uses a “Patient Safety Alert” system where any
employee can stop a process if they see a risk, empowering even junior staff to act.
Dr. J. L. Meena

3. Focus on Systems, Not Blame
Why it matters: Most errors stem from flawed systems, not bad people. A punitive culture drives
mistakes underground.
How to do it:
- *Adopt a “just culture” framework*: Distinguish between human error (needs coaching), risky
behavior (needs correction), and reckless behavior (needs discipline). This builds trust while
maintaining accountability.
- *Use data transparently*: Share quality metrics—like infection rates or readmissions—with all
staff. Break it down by unit so teams see their impact and can brainstorm fixes.
- *Standardize processes*: Implement evidence-based protocols (e.g., surgical checklists) to
reduce variability. Regularly review these to ensure they’re practical, not just bureaucratic.
- *Example*: After a high-profile error, Johns Hopkins Hospital embraced a systems-focused
approach, leading to tools like CUSP (Comprehensive Unit-based Safety Program), which cut
infections by empowering unit-level teams to analyze and improve workflows.
hospital
Dr. J. L. Meena

4. Invest in Training and Education
Why it matters: A quality culture requires skills, not just good intentions. Staff need tools to
identify and solve problems.
How to do it:
- *Offer continuous learning*: Provide training on quality improvement methods like Lean, Six
Sigma, or PDSA (Plan-Do-Study-Act) cycles. Make it accessible—short modules for busy clinicians
work better than long seminars.
- *Simulate scenarios*: Use mock codes or role-playing to practice handling emergencies or
tricky patient interactions. This builds confidence and teamwork.
- *Teach communication skills*: Train staff in tools like SBAR (Situation-Background-Assessment-
Recommendation) to ensure clear handoffs, which prevent errors during shift changes.
- *Example*: Cleveland Clinic’s training programs emphasize both technical skills and empathy,
ensuring staff can deliver high-quality care while connecting with patients.
hospital
Dr. J. L. Meena

5. Prioritize Patient-Centered Care
Why it matters: Quality isn’t just clinical outcomes—it’s how patients feel. A hospital that ignores
the human side risks disengagement.
How to do it:
- *Involve patients and families*: Create advisory councils with patients to give feedback on
everything from food to discharge processes. Act on their input visibly.
- *Measure experience rigorously*: Use surveys like HCAHPS (Hospital Consumer Assessment of
Healthcare Providers and Systems) to track patient satisfaction, but don’t stop there—hold focus
groups to dig deeper.
- *Personalize care*: Train staff to listen actively and address patients by name. Small gestures,
like explaining procedures in plain language, build trust.
- *Example*: Planetree, a network of hospitals, embeds patient-centered principles—like healing
environments and family involvement—into its culture, leading to higher satisfaction and better
outcomes.
hospital
Dr. J. L. Meena

6. Leverage Data and Technology
Why it matters: You can’t improve what you don’t measure. Technology can spot trends and
streamline care—if used wisely.
How to do it:
- *Track meaningful metrics*: Focus on outcomes that matter, like 30-day readmissions or sepsis
mortality, not just compliance checkboxes. Use dashboards to make data visible and actionable.
- *Implement smart tech*: Electronic health records (EHRs) with decision-support tools can flag
risks, like drug interactions. But ensure the tech is user-friendly—clunky systems frustrate staff and
hurt quality.
- *Close the loop*: When data shows a problem (e.g., high fall rates), form rapid-response teams
to test solutions and report back on progress.
- *Example*: Intermountain Healthcare uses data analytics to drive its quality initiatives,
identifying patterns in adverse events and deploying targeted interventions, like standardized
antibiotic protocols.
hospital
Dr. J. L. Meena

7. Sustain Momentum Through Accountability
Why it matters: Culture change fades without follow-through. People need to see that quality is
non-negotiable.
How to do it:
- *Set clear goals*: Use SMART (Specific, Measurable, Achievable, Relevant, Time-bound)
objectives, like reducing pressure ulcers by 20% in six months.
- *Audit and feedback*: Regularly review progress on quality initiatives. Share successes and
setbacks openly to keep everyone engaged.
- *Embed quality in hiring*: Screen new hires for alignment with your quality vision. Ask
behavioral questions like, “Tell me about a time you improved a process.”
- *Example*: Kaiser Permanente’s performance improvement system ties quality goals to every
level of the organization, with regular reviews to ensure accountability without micromanaging.
hospital
Dr. J. L. Meena

Challenges to Watch For
- *Resistance to change*: Some staff may see quality initiatives as extra work. Counter this by
showing quick wins and involving skeptics in planning.
- *Burnout*: Overloading staff with new protocols can backfire. Prioritize high-impact changes
and give time for adjustment.
- *Resource constraints*: Quality improvement needs funding and time. Make a case to the
board by showing ROI—like how reducing infections cuts costs.
Final Thought
Building a quality culture in a hospital isn’t a one-time project—it’s a continuous journey. It
requires aligning people, processes, and purpose around the shared goal of exceptional care. Start
small with a pilot project, like improving hand hygiene compliance, and scale up as you build trust
and momentum. Listen to your staff and patients—they’ll show you where the real opportunities
lie.
hospital
Dr. J. L. Meena

Role of Regular Monitoring of
Quality indicators.
1. *Patient Safety and Outcomes*: Monitoring indicators like hospital-acquired infections (e.g., CLABSI or SSI)
or medication errors helps catch preventable harm early. For example, tracking central line-associated
bloodstream infections can lead to better protocols, reducing patient morbidity. Studies show hospitals with
robust monitoring systems see lower adverse event rates—some report up to a 20% drop in preventable
complications after implementing targeted interventions.
2. *Care Quality Improvement*: Quality indicators highlight gaps in care. For instance, if 30-day readmission
rates for heart failure patients spike, it signals a need for better discharge planning or follow-up care.
Continuous monitoring allows hospitals to test interventions and measure progress. The Institute for
Healthcare Improvement notes that hospitals using real-time data dashboards can improve compliance with
evidence-based practices by 15-25%.
3. *Regulatory Compliance and Accreditation*: Agencies like The Joint Commission / NABH or CMS require
hospitals to track specific indicators to maintain accreditation or avoid penalties. For example, CMS’s Hospital
Value-Based Purchasing Program ties reimbursement to performance on quality metrics like patient
experience and efficiency. Regular monitoring ensures hospitals meet these standards and avoid financial
hits—penalties can cost hospitals millions annually. Dr. J. L. Meena

4. *Resource Optimization*: Indicators like length of stay or staff-to-patient ratios help identify
inefficiencies. A hospital noticing prolonged stays in its ICU might streamline workflows or improve bed
management, freeing up resources. Data from the American Hospital Association suggests hospitals that
monitor operational metrics closely can reduce costs per patient by 5-10% without compromising care.
5. *Patient Trust and Satisfaction*: Public reporting of quality metrics, like HCAHPS scores, influences how
patients perceive hospitals. Consistent monitoring and improvement in areas like communication or pain
management boost satisfaction, which can enhance a hospital’s reputation and patient volume. Hospitals in
the top quartile for patient experience often see 10% higher market share in competitive regions.
6. *Proactive Risk Management*: Tracking near-misses or sentinel events (e.g., wrong-site surgeries) helps
hospitals address systemic issues before they escalate. Root cause analysis tied to these indicators can
prevent future incidents. For context, the Agency for Healthcare Research and Quality estimates that
proactive monitoring reduces serious safety events by up to 30% in high-performing facilities.
Role of Regular Monitoring of
Quality indicators.
Dr. J. L. Meena

Harm from inaccurate or inadequate
monitoring of quality indicators in hospitals
1. *Patient Safety Risks*
- *Missed or Delayed Diagnoses*: Incorrect monitoring may fail to identify patterns of diagnostic errors, leading to untreated or improperly treated
conditions.
- *Medication Errors*: Without proper oversight of indicators like medication administration accuracy, patients may receive wrong drugs, incorrect doses, or
experience adverse drug interactions.
- *Hospital-Acquired Infections (HAIs)*: Poor tracking of infection control metrics (e.g., hand hygiene compliance or catheter-associated infections) can lead
to higher rates of preventable infections like MRSA or sepsis.
- *Surgical Complications*: Inadequate monitoring of surgical quality indicators (e.g., wrong-site surgeries or post-operative complications) can result in
avoidable harm or death.
2. *Worsened Patient Outcomes*
- *Increased Mortality*: Failure to monitor indicators like mortality rates for specific conditions (e.g., heart attack or stroke) can obscure systemic issues,
delaying interventions and leading to preventable deaths.
- *Higher Readmission Rates*: If readmission rates are not tracked accurately, hospitals may miss opportunities to improve discharge planning or follow-up
care, resulting in patients returning with worsened conditions.
- *Chronic Condition Mismanagement*: For patients with chronic diseases (e.g., diabetes or hypertension), poor monitoring of care quality can lead to
uncontrolled symptoms and long-term complications like organ damage.
3. *Systemic Failures*
- *Resource Misallocation*: Incorrect data on quality indicators can lead to misinformed decisions, such as understaffing critical units or neglecting high-risk
areas like intensive care.
- *Erosion of Trust*: Inaccurate reporting or failure to address quality issues can undermine confidence in the hospital among patients, families, and the
public.
- *Regulatory and Legal Consequences*: Hospitals may face penalties, lawsuits, or loss of accreditation if quality failures are uncovered, particularly if they
result in widespread harm. Dr. J. L. Meena

4. *Specific Examples of Harm*
- *Case Example: Infections*: If a hospital does not accurately monitor central line-associated bloodstream infections (CLABSIs), it might fail to implement
timely interventions, leading to outbreaks that harm multiple patients.
- *Case Example: Medication Safety*: A hospital that overlooks high rates of opioid over-administration due to poor monitoring could see increased cases
of respiratory depression or overdose.
- *Case Example: Equity Issues*: If quality indicators related to disparities (e.g., differences in outcomes by race or socioeconomic status) are ignored,
marginalized groups may receive substandard care, perpetuating health inequities.
5. *Contributing Factors to Incorrect Monitoring*
- *Data Inaccuracy*: Errors in data collection, such as incomplete records or misreported metrics, can skew quality assessments.
- *Lack of Standardization*: Inconsistent definitions or measurement methods across departments can lead to unreliable indicator tracking.
- *Insufficient Training*: Staff may not be adequately trained to collect or interpret quality data, leading to oversights.
- *Technology Failures*: Reliance on outdated or faulty electronic health record systems can result in missed or incorrect data.
- *Cultural Issues*: A hospital culture that prioritizes throughput over safety may downplay the importance of rigorous quality monitoring.
6. *Mitigating Harm*
To reduce harm, hospitals can:
- Implement robust, real-time data collection systems.
- Standardize quality indicators based on evidence-based guidelines (e.g., those from the Agency for Healthcare Research and Quality or WHO).
- Train staff regularly on quality monitoring protocols.
- Foster a culture of transparency where staff feel safe reporting errors.
- Use audits and external reviews to validate internal monitoring processes.
Harm from inaccurate or inadequate
monitoring of quality indicators in hospitals
Dr. J. L. Meena

The International Patient Safety Goals
(IPSG)
These goals aim to address critical areas where healthcare organizations can enhance safety, reduce risks, and improve the quality of care. They are widely
adopted by hospitals and healthcare facilities to ensure consistent and safe practices.
The *7 International Patient Safety Goals* (as of the latest updates) and their *importance*:
1. *Identify Patients Correctly*
- *Goal*: Ensure the correct patient receives the intended treatment, procedure, or medication.
- *Standards*: Use at least two patient identifiers (e.g., name, date of birth, or medical record number) before administering medications, performing
procedures, or collecting specimens.
- *Importance*:
- Prevents errors such as wrong-patient surgeries, medication errors, or diagnostic mix-ups.
- Enhances trust in healthcare systems by ensuring treatments are delivered to the intended individual.
- Reduces harm from misidentification, which can lead to severe consequences, including death.
2. *Improve Effective Communication*
- *Goal*: Ensure accurate and timely communication among healthcare providers to prevent errors.
- *Standards*: Implement standardized methods like SBAR (Situation, Background, Assessment, Recommendation) for handoffs, verify verbal or
telephone orders through read-back processes, and ensure critical test results are communicated promptly.
- *Importance*:
- Miscommunication is a leading cause of sentinel events (unexpected incidents causing harm).
- Clear communication ensures continuity of care, especially during shift changes or transfers.
- Reduces errors in medication administration, treatment plans, and surgical procedures.
Dr. J. L. Meena

3. *Improve the Safety of High-Alert Medications*
- *Goal*: Minimize risks associated with medications that have a high potential for harm if misused.
- *Standards*: Identify high-alert medications (e.g., insulin, opioids, anticoagulants), use special labeling, store them separately, and implement double-
check processes before administration.
- *Importance*:
- High-alert medications can cause life-threatening complications if given incorrectly.
- Standardized protocols reduce errors in dosage, administration, or patient selection.
- Protects vulnerable patients, such as those in critical care or with complex conditions.
4. *Ensure Safe Surgery*
- *Goal*: Prevent wrong-site, wrong-procedure, or wrong-patient surgeries.
- *Standards*: Follow the Universal Protocol, which includes pre-procedure verification, marking the surgical site, and conducting a time-out before
surgery to confirm details with the team.
- *Importance*:
- Wrong-site surgeries are rare but devastating, leading to physical and emotional harm.
- Enhances teamwork and accountability in the operating room.
- Builds patient confidence in surgical care by ensuring precision and safety.
5. *Reduce the Risk of Healthcare-Associated Infections*
- *Goal*: Prevent infections acquired during healthcare delivery.
- *Standards*: Adhere to evidence-based guidelines for hand hygiene, use proper sterilization techniques, implement catheter and ventilator care
bundles, and follow infection control protocols.
- *Importance*:
- Healthcare-associated infections (HAIs) like MRSA or CLABSI increase morbidity, mortality, and hospital stays.
- Protects patients, especially those with weakened immune systems, from preventable harm.
- Reduces healthcare costs and antibiotic resistance by preventing unnecessary infections.
(IPSG)
Dr. J. L. Meena

6. *Reduce the Risk of Patient Harm Resulting from Falls*
- *Goal*: Prevent injuries caused by patient falls in healthcare settings.
- *Standards*: Assess patients’ fall risk upon admission and periodically, implement preventive measures (e.g., non-slip footwear, bed alarms, low beds),
and educate patients and families.
- *Importance*:
- Falls are a leading cause of injury, particularly among elderly or mobility-impaired patients.
- Prevents fractures, head injuries, or prolonged recovery times.
- Improves patient outcomes and reduces liability for healthcare facilities.
7. *Prevent Pressure Ulcers (Bedsores)*
- *Goal*: Reduce the incidence of pressure ulcers in immobile or vulnerable patients.
- *Standards*: Conduct regular skin assessments, use pressure-relieving devices (e.g., specialized mattresses), reposition patients frequently, and ensure
proper nutrition and hydration.
- *Importance*:
- Pressure ulcers cause pain, infections, and extended hospital stays, particularly in bedridden patients.
- Prevention improves patient comfort and quality of life.
- Demonstrates a commitment to holistic care, addressing both treatment and prevention.
Overall Importance of the IPSG
- *Standardize Safety Practices*: Provide a global framework for hospitals to follow, ensuring consistency across diverse healthcare settings.
- *Reduce Preventable Harm*: Address common risks that lead to adverse events, protecting patients from avoidable injuries or complications.
- *Enhance Quality of Care*: Promote a culture of safety, accountability, and continuous improvement in healthcare organizations.
- *Build Trust*: Reassure patients and families that healthcare providers prioritize their safety and well-being.
- *Support Compliance*: Align with accreditation standards (e.g., JCI), helping facilities meet regulatory and quality requirements.
(IPSG)
Dr. J. L. Meena

WHO patient-safety solutions
✓ Look-alike, sound-alike medication names;
✓ Patient identification;
✓ Communication during patient hand-overs;
✓ Performance of correct procedure at correct body site;
✓ Control of concentrated electrolyte solutions;
✓ Assuring medication accuracy at transitions in care;
✓ Avoiding catheter and tubing misconnections;
✓ Single use of injection devices; and
✓ Improved hand hygiene to prevent health care- associated
infection.
Dr. J. L. Meena

Why Root Cause analysis ?
Root cause analysis (RCA) is a critical tool for monitoring and improving quality indicators in hospitals. It’s a structured method to
identify the underlying reasons for problems or adverse events, rather than just treating symptoms. In a hospital setting, where
patient safety and care quality are paramount, RCA helps ensure issues like medical errors, infections, or process inefficiencies
are addressed at their core, preventing recurrence and fostering continuous improvement. Here’s a breakdown of its importance:
1. *Enhances Patient Safety*
- Quality indicators, such as hospital-acquired infections (HAIs), medication errors, or patient falls, directly impact patient
outcomes. RCA digs into why these events occur—whether due to human error, faulty equipment, or flawed protocols.
- For example, if a hospital notes a spike in HAIs, RCA might reveal inadequate sterilization procedures or staff training gaps,
allowing targeted interventions rather than temporary fixes.
2. *Prevents Recurrence of Issues*
- RCA focuses on systemic issues rather than blaming individuals. By identifying root causes—like unclear communication during
shift changes leading to missed medications—hospitals can implement lasting solutions, such as standardized handoff protocols.
- This proactive approach reduces the likelihood of repeated errors, improving reliability in quality metrics like readmission
rates or surgical complications.
Dr. J. L. Meena

3. *Improves Process Efficiency*
- Many quality indicators, such as length of stay or wait times, reflect operational efficiency. RCA can uncover bottlenecks, like
delays in diagnostic testing due to scheduling issues, and guide process redesign.
- Streamlined workflows not only boost quality metrics but also enhance patient satisfaction and resource utilization.
4. *Supports Data-Driven Decision Making*
- Monitoring quality indicators requires robust data, and RCA complements this by linking data trends to actionable insights. For
instance, if mortality rates rise in a specific department, RCA can analyze contributing factors—say, delayed sepsis recognition—
and inform evidence-based protocols.
- This ensures interventions are grounded in reality, not assumptions, aligning with quality improvement frameworks like Plan-
Do-Study-Act (PDSA).
5. *Fosters a Culture of Accountability and Learning*
- RCA encourages a non-punitive approach, shifting focus from individual blame to system-level fixes. This builds trust among
staff, encouraging them to report incidents or near-misses, which are critical for monitoring quality indicators.
- Over time, this creates a learning environment where staff are empowered to contribute to solutions, enhancing metrics like
staff engagement and compliance with safety protocols.
Dr. J. L. Meena

6. *Meets Regulatory and Accreditation Requirements*
- Hospitals are often required by bodies like The Joint Commission or CMS to conduct RCAs for sentinel events (e.g.,
wrong-site surgeries). Demonstrating effective RCA processes ensures compliance while improving quality indicators tied
to accreditation, such as patient satisfaction scores or infection control measures.
7. *Prioritizes Resource Allocation*
- RCA helps hospitals allocate resources effectively by pinpointing high-impact problems. For example, if readmissions
are driven by poor discharge planning, RCA can justify investing in better case management rather than spreading
resources thinly across less critical areas.
- This focus optimizes quality indicators while managing costs—a key concern in healthcare.
Practical Example
Suppose a hospital tracks a quality indicator like post-surgical infection rates, which are above the benchmark. An RCA
might reveal:
- *Proximate cause*: Inconsistent wound care practices.
- *Root cause*: Lack of standardized training for new nurses and unclear documentation guidelines.
- *Solution*: Implement mandatory training, update protocols, and monitor compliance.
Dr. J. L. Meena

This targeted approach directly improves the indicator and prevents future issues.
Challenges to Consider
While RCA is powerful, it’s not without hurdles:
- *Time-Intensive*: Conducting thorough RCAs requires resources, which can strain busy hospital teams.
- *Bias Risk*: Teams may focus on obvious causes or avoid sensitive issues like leadership failures.
- *Follow-Through*: Identifying causes is only half the battle; hospitals must act on findings to impact quality indicators.
To overcome these, hospitals should train staff in RCA methodologies (e.g., fishbone diagrams, 5 Whys), involve
multidisciplinary teams, and integrate findings into quality improvement plans.
Conclusion
Root cause analysis is indispensable for monitoring hospital quality indicators because it transforms data into actionable
change. By addressing the "why" behind adverse events or performance gaps, RCA improves patient outcomes,
operational efficiency, and regulatory compliance. Hospitals that embed RCA into their quality monitoring systems not
only meet standards but also build safer, more reliable care environments. If you’d like, I can dig deeper into specific RCA
tools or examples tailored to a particular quality indicator—let me know!
Dr. J. L. Meena

Patient Safety and Quality Improvement (PSQ)
➢ The standards encourage an environment of patient safety and continual quality improvement.
The patient safety and quality programme should be documented and involve all areas of the
organisation and all staff members.
➢ The management creates a culture of safety in the organisation. Patient safety officer(s) shall be designated for
the implementation of patient safety programme.
➢ National/international patient-safety goals/solutions are implemented.
➢ The organisation should collect data on structures, processes and outcomes, especially in areas of high-risk
situations. The collected data should be collated, analysed and used for further improvements.
Appropriate quality tools shall be used for carrying out quality improvement activities. Clinical audits
shall be used as a tool to improve the quality of patient care. The improvements should be sustained.
Department leaders play an active role in patient safety and quality improvement.
➢ The organisation has a mechanism to capture patient reported outcome measures.
➢ The organisation shall have a robust incident reporting system. Sentinel events shall be defined. All
incidents are investigated, and appropriate action is taken.
➢ The management should support the patient safety and quality programme.
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Dr. J. L. Meena

PSQ.1. The organisation implements a structured patient-safety programme.
PSQ.2.
The organisation implements a structured quality improvement and continuous monitoring
programme.
PSQ.3.
The organisation identifies key indicators to monitor the structures, processes and outcomes,
which are used as tools for continual improvement.
PSQ.4. The organisation uses appropriate quality improvement tools for its quality improvement activities.
PSQ.5. There is an established system for clinical audit.
PSQ.6. The patient safety and quality improvement programme are supported by the management.
PSQ.7. Incidents are collected and analysed to ensure continual quality improvement.
46
Dr. J. L. Meena

Objective
Elements
PSQ 1 PSQ 2 PSQ 3 PSQ 4 PSQ 5 PSQ 6 PSQ 7
a CORE CORE Commitment CORE Commitment Achievement CORE
b Commitment Commitment CORE Achievement Commitment Commitment Commitment
c Commitment Excellence Commitment Commitment Achievement Commitment Commitment
d Commitment Excellence CORE Achievement Commitment Commitment Commitment
e Commitment Commitment Commitment Commitment Achievement Achievement
f Commitment Commitment Commitment Commitment Excellence Commitment
g CORE Commitment Commitment
h Commitment Achievement
i CORE
Summary Standards -7 OE-46 CORE -8 Commitment - 28 Achievement 7 Excellence - 3

PSQ 1 The organisation implements a structured
patient-safety programme.
Objective Elements
a) The patient-safety programme is developed, implemented and maintained by a multi-
disciplinary safety committee. *
b) The patient-safety programme is comprehensive and covers all the major elements related
to patient safety.
c) The programme covers incidents ranging from "no harm" to "sentinel events".
d) Designated patient safety officer(s) coordinates implementation of the patient- safety
programme.
e) The organisation performs proactive analysis of patient safety risks and makes
improvements accordingly.
f) The patient-safety programme is reviewed and updated at least once a year.
g) The organisation adapts and implements national/international patient-safety
goals/solutions/framework.
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Dr. J. L. Meena

PSQ 2 - The organisation implements a
structured quality improvement and continuous
monitoring programme.
Objective Elements
a) The quality improvement programme is developed, implemented and maintained by a multi-
disciplinary committee.*
b) The quality improvement programme is comprehensive and covers all the major elements related
to quality assurance.*
c) The quality improvement programme improves process efficiency and effectiveness.
d) The quality improvement programme focused on appropriateness of clinical care.
e) There is a designated individual for coordinating and implementing the quality improvement
programme.*
f) The quality improvement programme identifies opportunities for improvement based on the
review at pre-defined intervals.*
g) The quality improvement programme is reviewed and updated at least once a year.
h) Audits are conducted at regular intervals as a means of continuous monitoring.*
i) There is an established process in the organisation to monitor and improve the quality of nursing
care.*
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Dr. J. L. Meena

PSQ 3 - The organisation identifies key indicators to
monitor the structures, processes and outcomes,
which are used as tools for continual improvement.
Objective Elements
a) The organisation identifies and monitors key indicators to oversee the clinical structures,
processes and outcomes.
b) The organisation identifies and monitors the key indicators to oversee infection control activities.
c) The organisation identifies and monitors key indicators to oversee the managerial structures,
processes and outcomes.
d) The organisation identifies and monitors key indicators to oversee patient safety activities.
e) Verification of data is done regularly by the quality team.
f) There is a mechanism for analysis of data which results in identifying opportunities for
improvement.
g) The improvements are implemented and evaluated.
h) Feedback about care and service is communicated to staff.
50
Dr. J. L. Meena

PSQ 4 - The organisation uses appropriate
quality improvement tools for its quality
improvement activities.
Objective Elements
51
Dr. J. L. Meena
a) The organisation undertakes quality improvement
projects.
b) The Quality improvement projects shall include improvement in
patient care delivery and hospital operations which will have an
impact on cost and efficiency.
c) The organisation uses appropriate analytical tools for its
quality improvement activities.
d) The organisation has a mechanism to capture patient reported
outcome measures.

PSQ 5 - There is an established system for
clinical audit.
Objective Elements
a) Clinical audits are performed to improve the quality of
patient care.
b) The parameters to be audited are defined by the
organisation.
c) Medical and nursing staff participate in clinical audit.
d) Patient and staff anonymity are maintained.
e) Clinical audits are documented.
f) Remedial measures are implemented.
52
Dr. J. L. Meena

PSQ 6 - The patient safety and quality
improvement programme are supported by the
management.
Objective Elements
a) The management creates a culture of safety.
b) The leaders at all levels in the organisation are aware of the intent of the patient safety
and quality improvement programme and the approach to its implementation.
c) Departmental leaders are involved in patient safety and quality improvement.
d) Organisation earmarks adequate funds from its annual budget in this regard.
e) The management identifies organisational performance improvement targets.
f) The management uses the feedback obtained from the workforce to improve patient
safety and quality improvement programme.
53
Dr. J. L. Meena

PSQ 7 - Incidents are collected and analysed to
ensure continual quality improvement.
Objective Elements
a) The organisation implements an incident management system.*
b) The organisation has a mechanism to identify sentinel events.*
c) The organisation has established processes for analysis of incidents.
d) Corrective and preventive actions are taken based on the findings of such
analysis.
e) The organisation incorporates risks identified in the analysis of incidents
into the risk management system.
f) The organisation shall have a process for informing various stakeholders in
case of a near miss/adverse event/sentinel event.
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Dr. J. L. Meena

Important Quality Indicators
Dr. J. L. Meena

1. (PSQ 3a)- Time taken for initial assessment of indoor patient’s
2. (PSQ 3a)- Number of reporting errors /1000 investigations
3. (PSQ 3a)- Percentage of adherence to safety precautions by staff working in Diagnostics
4. (PSQ 3a)-Medication Errors Rate
5. (PSQ 3a)- Percentage of medication charts with error-prone abbreviations
6. (PSQ 3a )-Percentage of in-patients developing adverse drug reaction(s).
7. (PSQ 3a)- Percentage of unplanned return to OT
8. (PSQ 3a)- Percentage of surgeries where the organization's procedure to prevent adverse events like wrong site, wrong
patient and wrong surgery have been adhered to.
9. (PSQ 3a)- Percentage of Blood Transfusion Reactions
10. (PSQ 3a )- Standardised Mortality Ratio for ICU

11. (PSQ 3a)- Return to the emergency department within 72 hours with similar presenting complaints.
12. (PSQ 3a )-Incidence of hospital associated pressure ulcers after admission (Bed Sore per 1000
patient days)
13. (PSQ 3b )- Catheter associated urinary tract infection rate
14. (PSQ 3b )- Ventilator associated pneumonia rate
15. (PSQ 3b )- Central line associated blood stream infection rate
16. (PSQ 3b )- Surgical site infection rate
17. (PSQ 3b )- Hand Hygiene Compliance Rate
18. (PSQ 3b )- Percentage of cases who received appropriate prophylactic antibiotics within the
specified time frame
19. (PSQ 3c )- Percentage of re-scheduling of surgeries
20. (PSQ 3c )- Turnaround time for issue of blood and blood components
Dr. J. L. Meena

21. (PSQ 3c )- Nurse patient ratio for ICUs and wards
22. (PSQ 3c )- Waiting time for out-patient consultation.
23. (PSQ 3c )- Waiting time for diagnostics
24. (PSQ 3c )- Time taken for discharge
25. (PSQ 3c )- Percentage of medical records having incomplete and /or improper
consent
26. (PSQ 3c )- Stock out of Emergency medications
27. (PSQ 3d )- No. of variations observed in mock drills
28.(PSQ 3d )- Patient fall rate (falls per 1000 patient days)
29. (PSQ 3d )- Percentage of near misses
30. (PSQ 3d )- Incidence of needle stick injuries
31. (PSQ 3d )- Appropriate handovers during shift change(to be done separately for
doctors and nurses)-(per patient per shift)
32.(PSQ 3d )- Compliance to rate to Medication Prescription in capitals
Dr. J. L. Meena

1. (PSQ 3a)- Time taken for initial assessment of indoor
patient’s
Dr. J. L. Meena

Average time taken for initial assessment for
Emergency and Indoor Patients
Average time taken for initial assessment is: (Sum of time taken for initial assessment of all patients in a period) / (Total
number of patients assessed in that period).
Sum of time taken for initial assessment of all patients: This involves adding up the time it took to complete the initial
assessment for each individual patient within a specific timeframe (e.g., a month, a week, or a day).
Total number of patients assessed: This is the total number of patients who underwent an initial assessment during the
same timeframe.
Average time taken: Dividing the sum of time taken by the total number of patients provides the average time taken for an
initial assessment, according to a NABH.
Example:
If it took 30 minutes to assess patient A, 45 minutes to assess patient B, and 60 minutes to assess patient C, the sum of
time taken would be 30 + 45 + 60 = 135 minutes. If all three patients were assessed within the same period, the total
number of patients assessed would be 3. The average time taken would then be 135 minutes / 3 patients = 45 minutes per
patient.
Dr. J. L. Meena

ASSESSMENT Framework
While "ASSESSMENT" isn't a standard medical acronym, it can be adapted to represent key steps in patient evaluation,
especially in emergency and indoor (inpatient) settings. Here's a practical interpretation for initial assessment:
1. *A* - *Airway*: Ensure the airway is patent. Check for obstructions, respiratory distress, or need for airway support
(e.g., intubation, suction).
2. *S* - *SpO2 and Symptoms*: Assess oxygen saturation (SpO2) and primary symptoms (e.g., chest pain, shortness of
breath, altered mental status).
3. *S* - *Stabilize*: Stabilize critical conditions (e.g., administer oxygen, control bleeding, or manage arrhythmias).
4. *E* - *Examine*: Perform a rapid physical exam (primary survey for emergencies, focused exam for inpatients).
5. *S* - *Systems Review*: Evaluate key systems (cardiovascular, respiratory, neurological, etc.) for abnormalities.
6. *S* - *Support*: Provide immediate supportive care (e.g., IV fluids, medications, or monitoring).
7. *M* - *Monitor*: Continuously monitor vital signs (heart rate, BP, respiratory rate, temperature, SpO2).
8. *E* - *Environment*: Consider environmental factors (e.g., trauma scene safety for emergencies, infection control for
inpatients).
9. *N* - *Needs*: Identify urgent needs (e.g., imaging, labs, specialist consults).
10. *T* - *Triage/Time*: Prioritize care based on severity (triage in emergencies) and document time of assessment.
Dr. J. L. Meena

Application to Emergency and
Indoor Patients – Initial Assessment
Emergency Patients
- *Context*: Emergency patients require rapid assessment to identify life-threatening conditions (e.g., trauma, cardiac arrest, stroke).
- *Approach*:
- Follow *ABCDE* (Airway, Breathing, Circulation, Disability, Exposure) for primary survey.
- Use the *ASSESSMENT* framework to guide initial stabilization and prioritization.
- Example: For a patient with chest pain, ensure airway patency (A), check SpO2 and symptoms (S), stabilize with oxygen/nitroglycerin
(S), examine heart/lungs (E), and so on.
- *Tools*: ECG, pulse oximetry, blood glucose, portable imaging (if needed).
- *Time*: Immediate (within minutes).
Indoor (Inpatient) Patients
- *Context*: Inpatients may need initial assessment upon admission or during routine rounds to monitor progress or detect
deterioration.
- *Approach*:
- Conduct a *focused assessment* based on the patient’s condition (e.g., post-surgical, chronic illness).
- Use *ASSESSMENT* to ensure comprehensive evaluation, especially for changes in status (e.g., fever, confusion).
- Example: For a post-op patient, check airway (A), symptoms like pain/fever (S), stabilize with analgesics (S), examine surgical site (E),
and monitor vitals (M).
- *Tools*: Vital sign monitors, lab results, patient charts.
- *Time*: Within hours of admission or as per protocol (e.g., every 4-8 hours).
Dr. J. L. Meena

Key Considerations & Timing of
Initial Assessment
Key Consideration
- *Triage*: In emergencies, prioritize based on severity (e.g., red/yellow/green in triage systems).
For inpatients, escalate based on early warning scores (e.g., MEWS, NEWS).
- *Documentation*: Record findings clearly, including time, vitals, and interventions.
- *Teamwork*: Involve multidisciplinary teams (nurses, physicians, specialists) for comprehensive
care.
- *Infection Control*: Use PPE and follow protocols, especially for inpatients with infectious
diseases.
- *Patient Communication*: Explain procedures to reduce anxiety, if the patient is conscious.
Timing
- *Emergency*: Immediate assessment (within 1-5 minutes) to address life-threatening issues.
- *Indoor*: Initial assessment within 1-2 hours of admission, with ongoing assessments per
protocol (e.g., every shift).
Dr. J. L. Meena

Percentage of cases (in-patients) where in care
plan with desired outcomes is documented and
counter-signed by the clinician
Percentage of in-patient cases where a documented and counter-signed care plan with
desired outcomes is present is: (Number of case records with a documented and counter-
signed care plan / Total number of case records checked) x 100. This formula helps assess
how well hospitals are adhering to standards for patient care planning and
documentation.
Numerator: Total Number of patient care records where a comprehensive care plan has
been created, documented, and signed by the treating clinician.
Denominator: Total number of patient case records that were reviewed or checked within
a specific timeframe or sample.
Multiplication by 100: This converts the ratio into a percentage, making it easier to
understand and compare performance across different hospitals or departments.
Dr. J. L. Meena

Percentage of cases (in-patients) where in
screening for nutritional needs has been done
Percentage of in-patients screened for nutritional needs is: (Number of screened in-patients / Total number of in-patients) x
100.
Example: If 50 out of 200 in-patients were screened for nutritional needs, the percentage would be: (50 / 200) x 100 = 25%.
Nutritional screening is a process used to identify patients who may be at risk for malnutrition or who have nutritional
needs that require further assessment. The screening process helps clinicians determine if a more detailed nutritional
assessment is necessary.
Purpose: To identify patients who may be at risk for malnutrition or who have nutritional needs that require further
assessment.
Benefits: Can help prevent or mitigate malnutrition, improve patient outcomes, and reduce healthcare costs.
Common tools: Various screening tools are available, including the Malnutrition Screening Tool (MST), the Mini Nutritional
Assessment (MNA), and the Subjective Global Assessment (SGA).
Importance of screening: Studies have shown that only a small percentage of hospitalized patients receive nutritional
screening, highlighting the need for increased awareness and implementation of screening practices.
Dr. J. L. Meena

Percentage of cases (in-patients) wherein
the nursing care plan is documented.
The percentage of cases where nursing care plans are documented would be calculated as follows:
Numerator: The number of in-patient cases with a documented nursing care plan.
Denominator: The total number of in-patient cases.
Formula:
Percentage = (Number of cases with documented plan / Total number of cases) * 100
Example
If, out of 100 in-patient cases, 90 had a documented nursing care plan, the percentage would be:
(90 / 100) * 100 = 90%
Dr. J. L. Meena

2. (PSQ 3a)- Number of reporting errors /1000
investigations
Dr. J. L. Meena

Number of reporting errors / 1000
investigations
The formula for calculating reporting error rates per 1000 investigations is: (Number of lab or
radiology reports with errors detected / Number of lab or radiology reports checked) x 1000. This
metric is used to monitor and assess the quality of laboratory reporting and identify areas for
improvement.
Explanation:
Number of lab or radiology reports with errors detected: This refers to the count of reports where
errors or discrepancies were identified after review.
Number of lab or radiology reports checked: This represents the total number of reports that were
reviewed or audited during the period in question.
x 1000: The result is multiplied by 1000 to express the error rate per 1000 investigations, providing
a standardized metric for comparison.
Dr. J. L. Meena

Percentage of re-dos
Percentage of re-dos (or repeat tests) is: (Number of lab or radiology tests repeated /
Total lab or radiology tests conducted) * 100.
Explanation:
Number of lab or radiology tests repeated: This represents the count of tests that were
performed more than once due to errors, issues, or the need for confirmation.
Total lab or radiology tests conducted: This is the overall number of tests performed
during the specified period.
* 100: This multiplication converts the result into a percentage, making it easier to
understand and compare across different timeframes of laboratories or radiology.
Dr. J. L. Meena

Percentage of reports co-relating
with clinical diagnosis
Percentage of co-relating reports with clinical diagnosis is:
((Number of reports co-relating with clinical diagnosis) / (Total number of reports))
* 100.
Number of reports co-relating with clinical diagnosis: This refers to the count of
reports where the findings align with the clinical diagnosis made by the physician.
Total number of reports: This is the overall count of reports generated for a specific
period or dataset.
Calculation: Divide the number of co-relating reports by the total number of
reports, and then multiply the result by 100 to express it as a percentage.
Dr. J. L. Meena

3. (PSQ 3a)- Percentage of adherence to safety
precautions by staff working in Diagnostics
Dr. J. L. Meena

Percentage of adherence to safety precautions
by employees working in diagnostics
The percentage of adherence to safety precautions by employees in diagnostics can be
calculated by dividing the number of employees adhering to safety precautions by the total
number of employees and multiplying by 100.
Formula:
(Number of employees adhering to safety precautions / Total number of employees) * 100
Example:
If 80 out of 100 employees in a diagnostic lab adhere to all safety precautions, the
percentage of adherence would be:
(80 / 100) * 100 = 80%
Dr. J. L. Meena

Dr. J. L. Meena

Medication error
A medication error is any preventable event that may cause of lead
to inappropriate medication use or harm to a patient (US-FDA).
Examples include, but are not limited to:
• Errors in the prescribing, transcribing, dispensing,
administering, and monitoring of medications;
• Wrong drug, wrong strength, or wrong dose errors;
• Wrong patient errors;
• Wrong route of administration errors; and
• Calculation or preparation errors.
Dr. J. L. Meena

Incidence of medication errors
“Medication error rate” is determined by calculating
the percentage of medication errors observed during a
medication administration observation. The error rate
must be 5% or greater to cite F759. The equation for
calculation is as follows:
Medication Error Rate = Number of Errors Observed
divided by the Opportunities for Errors (doses given
plus doses ordered but not given) × 100.
Dr. J. L. Meena

5. (PSQ 3a)- Percentage of medication charts with
error-prone abbreviations
Dr. J. L. Meena

Error-prone abbreviations
Error-prone abbreviations in medication charts are a significant concern in healthcare due to their potential to cause misinterpretation,
leading to medication errors and patient harm.
Prevalence of Error-Prone Abbreviations
Several studies have quantified the occurrence of error-prone abbreviations in medication charts, with results varying by healthcare
setting, study design, and the specific abbreviations considered. Here’s a breakdown of key findings:
1. *Multi-Hospital Study in Australia (2019)*:
- *Source: Dooley MJ et al., published in the *Journal of Pharmacy Practice and Research.
- *Scope*: Conducted across six major hospitals in Victoria, Australia, analyzing 11,995 medication orders for 1,344 inpatients.
- *Findings*:
- *76.9% of patients* had at least one error-prone abbreviation in their medication charts.
- *8.4% of medication orders* (1,006 out of 11,995) contained error-prone abbreviations.
- *29.6% of these abbreviations* were classified as high-risk, meaning they had a significant potential to cause serious harm (e.g.,
abbreviations like "U" for units, which can be misread as "0," leading to a tenfold dosing error).
- Common abbreviations included those listed in hospital policies as error-prone, such as "IU" (international units), "QD" (once daily),
and "SC" (subcutaneous, potentially confused with other terms).
- *Implication*: The high prevalence underscores the widespread use of problematic abbreviations, even in settings with established
guidelines.
Dr. J. L. Meena

2. *Single-Hospital Audit in Australia (2016)*:
- *Source: Taylor SE et al., published in the *Australian Journal of Advanced Nursing.
- *Scope*: A point-prevalence audit of 784 medication orders in a metropolitan teaching hospital.
- *Findings*:
- *6% of medication orders* contained error-prone abbreviations.
- This rate was higher than previous audits at the same facility (5.1% in 2008 and 5.3% in 2012), suggesting persistent challenges
despite awareness efforts.
- The study noted specific abbreviations like "mg" written with a trailing zero (e.g., "5.0 mg") or "mL" abbreviated as "cc," both of
which are error-prone due to potential misinterpretation.
- *Implication*: Incremental increases over time indicate that passive interventions (e.g., education alone) may not suffice to eliminate
these errors.
3. *Emergency Department Study (2018)*:
- *Source*: Santamaria HH et al., evaluating an intervention to reduce unsafe abbreviations in an emergency department.
- *Scope*: Pre- and post-intervention analysis of medication charts in a U.S. emergency department.
- *Findings*:
- *Pre-intervention*: 19.69% of medication orders contained unsafe abbreviations.
- *Post-intervention*: This dropped to 3.31% after implementing targeted education and electronic prescribing alerts.
- Common issues included abbreviations like "QID" (four times daily) and "MSO4" (morphine sulfate, easily confused with magnesium
sulfate).
- *Implication*: The significant reduction post-intervention highlights the effectiveness of active measures like electronic health record
(EHR) prompts and staff training.
Dr. J. L. Meena

4. *Other Studies*:
- A 2007 study in a U.S. hospital found that *12–15% of medication orders* contained
error-prone abbreviations before interventions, with reductions to below 5% after
implementing strict policies.
- A pediatric hospital study reported that *10% of orders* in neonatal intensive care units
included abbreviations like "U" or "IU," which were linked to dosing errors in 3% of cases.
Dr. J. L. Meena

Factors Influencing Prevalence
The variation in reported percentages (ranging from ~6% to 76.9% of charts/orders) can be
attributed to several factors:
- *Definition of Error-Prone Abbreviations*: Studies differ in which abbreviations they classify as
error-prone. For example, the Institute for Safe Medication Practices (ISMP) and Joint
Commission provide lists of "do not use" abbreviations (e.g., "U," "QD," "MSO4"), but hospitals
may add local variations.
- *Setting*: Emergency departments, with their fast-paced environment, tend to have higher
rates (e.g., 19.69% pre-intervention) than inpatient wards (e.g., 6–8.4%).
- *Data Collection*: Point-prevalence audits (snapshot in time) may underestimate or
overestimate compared to longitudinal studies. Patient-level analysis (e.g., 76.9% of patients)
versus order-level analysis (e.g., 8.4% of orders) also affects reported figures.
- *Interventions in Place*: Facilities with electronic prescribing systems or strict policies report
lower rates, as seen in the emergency department study (3.31% post-intervention).
Dr. J. L. Meena

Implications of Error-Prone
Abbreviations
Error-prone abbreviations contribute to medication errors, which the World Health Organization estimates
affect 1 in 10 hospitalized patients globally. Specific risks include:
- *Dosing Errors*: "U" misread as "0" can lead to a tenfold overdose (e.g., 10 units of insulin becoming 100
units).
- *Drug Mix-Ups*: "MSO4" (morphine sulfate) confused with "MgSO4" (magnesium sulfate) has led to fatal
errors.
- *Communication Breakdowns*: Abbreviations like "QD" (once daily) versus "QID" (four times daily) can
confuse staff, especially in handwritten charts.
- *High-Risk Populations*: Neonates, elderly patients, and those on high-risk medications (e.g., opioids,
anticoagulants) are particularly vulnerable.
The 2019 multi-hospital study noted that 29.6% of error-prone abbreviations were high-risk, meaning they
could lead to severe harm or death. This aligns with ISMP reports that medication errors due to abbreviations
contribute to thousands of adverse events annually in the U.S. alone.
Dr. J. L. Meena

Strategies to Reduce Error-Prone
Abbreviations
Research highlights several effective interventions:
- *Electronic Health Records (EHRs)*: Systems that flag or block error-prone
abbreviations (e.g., rejecting "U" and requiring "units") reduced incidence
from 19.69% to 3.31% in the emergency department study.
- *Education and Training*: Regular staff training on ISMP/Joint Commission
"do not use" lists decreased rates in multiple studies.
- *Policy Enforcement*: Hospitals with strict auditing and feedback
mechanisms reported sustained reductions (e.g., from 15% to <5% in a 2007
study).
- *Standardized Order Sets*: Pre-populated templates in EHRs eliminate the
need for handwritten abbreviations.
Dr. J. L. Meena

Limitations of Existing Data
- *Geographic Bias*: Most detailed studies are from Australia
and the U.S., limiting generalizability to other healthcare
systems.
- *Study Design*: Small sample sizes (e.g., 784 orders in the 2016
audit) or single-center studies may not reflect broader trends.
- *Focus on Detection*: Many studies report prevalence but not
the actual harm (e.g., adverse events) caused by these
abbreviations, making it hard to quantify their clinical impact.
Dr. J. L. Meena

Conclusion
The percentage of medication charts with error-prone abbreviations
varies widely:
- *Patient-Level*: Up to 76.9% of patients may have at least one
such abbreviation in their charts.
- *Order-Level*: Between 6% and 19.69% of medication orders
typically contain error-prone abbreviations, with high-risk ones
comprising a significant subset (e.g., 29.6% in one study).
- *Post-Intervention*: Rates can drop to as low as 3–5% with robust
interventions.
Dr. J. L. Meena

The Error - Prone
abbreviations
The abbreviations found in this table have been reported to the Institute
for Safe Medical Practices (ISMP) through the ISMP Medication Error
Reporting Program as being frequently misinterpreted and involved in
harmful medication errors. These abbreviations should never be used
when communicating medical information. This includes internal
communications; verbal, handwritten, or electronic prescriptions;
handwritten and computer-generated medication labels; drug storage bin
labels; medication administration records; and screens associated with
pharmacy and prescriber computer order entry systems, automated
dispensing cabinets, smart infusion pumps, and other medication-related
technologies
Dr. J. L. Meena

The Error - Prone
abbreviations
Dr. J. L. Meena

Percentage of medication charts with
error-prone abbreviations
Percentage of Medication Charts with Error-Prone Abbreviations = Number of
Medication Charts with Error-Prone Abbreviations Total Number of Medication Charts
Reviewed* 100
- *Number of Medication Charts with Error-Prone Abbreviations*: The count of charts
(or patient records) that contain at least one error-prone abbreviation, as identified
based on a predefined list (e.g., ISMP or Joint Commission "do not use" abbreviations
like "U," "QD," or "MSO4").
- *Total Number of Medication Charts Reviewed*: The total number of medication charts
or patient records audited in the study or analysis.
- *Multiplication by 100*: Converts the fraction into a percentage.
Dr. J. L. Meena

6. (PSQ 3a )-Percentage of in-patients developing
adverse drug reaction(s).
Dr. J. L. Meena

Adverse drug event (ADE)
An *adverse drug event (ADE)* is defined as any harm or injury associated with the use of a medication, whether prescribed, over-the-counter, or herbal.
ADEs encompass a broad range of incidents, including side effects, allergic reactions, overdoses, drug interactions, and errors in prescribing, dispensing, or
administration. They are a major public health issue, contributing to significant morbidity, mortality, and healthcare costs globally. Below is a detailed
exploration of ADEs, including their types, causes, consequences, risk factors, prevention strategies, and real-world context.
Types of Adverse Drug Events
ADEs can be classified into two broad categories: *preventable* and *non-preventable*. They are further categorized based on their nature:
1. *Adverse Drug Reactions (ADRs):*
- Unintended, harmful effects of a drug at normal doses.
- Examples: Rash from antibiotics, gastrointestinal bleeding from NSAIDs, or QT prolongation from certain antipsychotics.
- Subtypes:
Type A (Augmented): Dose-dependent and predictable based on the drug’s pharmacology (e.g., hypoglycemia from insulin overdose).
Type B (Bizarre): Idiosyncratic, not dose-dependent, and less predictable (e.g., anaphylaxis from penicillin).
Type C (Chronic): Related to long-term use (e.g., osteoporosis from prolonged corticosteroid use).
Type D (Delayed): Effects appearing long after exposure (e.g., cancer from chemotherapeutic agents).
Type E (End-of-treatment): Withdrawal effects (e.g., rebound hypertension after stopping beta-blockers).
2. *Medication Errors:*
- Preventable mistakes in prescribing, dispensing, or administering a drug.
- Examples: Wrong drug, incorrect dose, or administration to the wrong patient.
- Common scenarios: Prescribing a drug contraindicated for a patient’s condition (e.g., metformin in severe kidney failure) or misinterpreting a prescription
due to poor handwriting.
Dr. J. L. Meena

Adverse drug event (ADE)
3. *Drug Interactions:*
- Harm caused by the interaction of two or more drugs, or a drug with food, alcohol, or supplements.
- Examples: Warfarin with NSAIDs increasing bleeding risk, or grapefruit juice inhibiting CYP3A4 enzymes,
altering drug metabolism.
4. *Overdoses/Toxicity:*
- Harm from excessive drug doses, intentional or accidental.
- Example: Hepatotoxicity from acetaminophen overdose.
5. *Allergic Reactions:*
- Immune-mediated responses to a drug, ranging from mild (hives) to life-threatening (anaphylaxis).
- Example: Penicillin-induced anaphylaxis.
6. *Therapeutic Failure:*
- Lack of efficacy, sometimes considered an ADE if it leads to harm (e.g., untreated infection due to
inappropriate antibiotic choice).
Dr. J. L. Meena

Causes of Adverse Drug Events
ADEs arise from a complex interplay of patient, drug, and system-related factors:
1. *Patient Factors:*
- *Age:* Elderly patients are more susceptible due to polypharmacy, reduced organ function, and altered drug metabolism. Pediatric
patients are at risk due to weight-based dosing errors.
- *Genetics:* Pharmacogenomic variations affect drug metabolism (e.g., CYP2C19 variants impacting clopidogrel efficacy).
- *Comorbidities:* Conditions like renal or liver impairment alter drug clearance.
- *Allergies:* Undocumented or unknown drug allergies increase risk.
2. *Drug Factors:*
- *High-risk medications:* Drugs with narrow therapeutic indices (e.g., warfarin, digoxin, insulin) are more likely to cause ADEs.
- *Complex regimens:* Multiple drugs or frequent dosing increase error risk.
- *Newly approved drugs:* Limited post-market data may reveal unforeseen risks.
3. *System Factors:*
- *Prescribing errors:* Inadequate knowledge, illegible handwriting, or lack of access to patient history.
- *Dispensing errors:* Pharmacy misfills or labeling mistakes.
- *Administration errors:* Incorrect route, timing, or patient identification.
- *Communication failures:* Poor handoffs between healthcare providers or inadequate patient counseling.
- *Technology issues:* Electronic health record (EHR) glitches or alert fatigue from clinical decision support systems.
Dr. J. L. Meena

Consequences of Adverse Drug
Events
ADEs have significant clinical, economic, and societal impacts:
- *Clinical:* Range from mild (nausea, rash) to severe (organ failure, death).
For example, opioid-related respiratory depression can be fatal.
- *Hospitalizations:* ADEs are responsible for 5-10% of hospital admissions in
developed countries, with higher rates in the elderly.
- *Economic:* In the U.S., ADEs cost an estimated $30-130 billion annually due
to hospitalizations, extended stays, and additional treatments.
- *Quality of Life:* Chronic side effects (e.g., fatigue from beta-blockers) or
fear of recurrence can reduce patient well-being.
- *Mortality:* ADEs contribute to thousands of deaths annually, with
estimates of 100,000+ deaths in the U.S. alone.
Dr. J. L. Meena

Risk Factors
Certain populations and scenarios increase the likelihood of ADEs:
- *Polypharmacy:* Taking multiple medications (common in the elderly)
increases interaction risks.
- *Transitions of Care:* Hospital discharges or transfers often lead to medication
discrepancies.
- *Low Health Literacy:* Patients may misunderstand dosing instructions or fail
to report side effects.
- *High-Risk Settings:* Intensive care units or emergency departments, where
rapid decisions and high-risk drugs are common.
- *Non-adherence:* Skipping doses or taking medications incorrectly can lead to
therapeutic failure or toxicity.
Dr. J. L. Meena

Prevention Strategies for ADEs
Preventing ADEs requires a multifaceted approach involving healthcare providers, patients, and systems:
1. *Healthcare Provider Interventions:*
- *Pharmacovigilance:* Monitor and report ADRs to databases like the FDA’s FAERS or WHO’s VigiBase.
- *Medication Reconciliation:* Verify medications during care transitions to avoid discrepancies.
- *Clinical Decision Support:* Use EHRs with alerts for drug interactions, allergies, or dosing errors.
- *Education:* Train providers on high-risk drugs and error-prone processes.
2. *Patient-Centered Approaches:*
- *Education:* Counsel patients on proper use, potential side effects, and when to seek help.
- *Shared Decision-Making:* Involve patients in treatment choices to improve adherence and satisfaction.
- *Medication Reviews:* Regular reviews by pharmacists or providers to simplify regimens or deprescribe unnecessary drugs.
3. *System-Level Interventions:*
- *Standardized Protocols:* Implement checklists or double-check systems for high-risk drugs.
- *Technology:* Use barcoding for drug administration, automated dispensing cabinets, and AI-driven risk prediction tools.
- *Regulatory Oversight:* Strengthen post-market surveillance to identify rare ADRs early.
- *Interdisciplinary Collaboration:* Involve pharmacists, nurses, and physicians in medication safety initiatives.
4. *Pharmacogenomics:* Tailor treatments based on genetic profiles to minimize ADRs (e.g., testing for HLA-B*5701 before prescribing
abacavir).
Dr. J. L. Meena

Real-World Context
- *Epidemiology:* Studies estimate that 6-10% of hospitalized patients experience an
ADE, with higher rates in intensive care settings. Outpatient ADEs are also common,
often underreported.
- *High-Profile Examples:*
- *Vioxx (rofecoxib):* Withdrawn in 2004 due to increased risk of heart attack and
stroke.
- *Thalidomide:* Caused birth defects in the 1950s, leading to stricter drug
regulations.
- *Opioid Crisis:* Overdoses and addiction linked to inappropriate prescribing
highlight ADE risks.
- *Global Efforts:* The WHO’s Global Patient Safety Challenge on Medication Safety
aims to reduce medication-related harm by 50% by 2027.
- *Technology Advances:* AI and machine learning are being used to predict ADEs by
analyzing EHRs, claims data, and social media for early signals of drug safety issues.
Dr. J. L. Meena

How to Respond to an ADE
If an ADE is suspected:
1. *Stop the Drug:* Discontinue the suspected medication if safe to do so.
2. *Assess Severity:* Determine if immediate medical attention is needed (e.g., anaphylaxis requires
epinephrine).
3. *Report:* Notify healthcare providers and report to pharmacovigilance systems.
4. *Document:* Record the event in the patient’s medical history to prevent recurrence.
5. *Alternative Therapy:* Identify safer treatment options, if needed.
*Additional Resources*
- *FDA Adverse Event Reporting System (FAERS):* For reporting and reviewing ADEs in the U.S.
(https://www.fda.gov/drugs/surveillance).
- *WHO VigiBase:* Global database for ADR monitoring (https://www.who-umc.org).
- *ISMP (Institute for Safe Medication Practices):* Resources on medication safety
(https://www.ismp.org).
Dr. J. L. Meena

Adverse drug event (ADE) rate
The adverse drug event (ADE) rate can be calculated in a few ways, typically focusing on the number of ADEs per a specific population or
time frame. Common formulas include ADEs per 100 admissions, ADEs per 1000 patient-days, or ADEs per 100 medication orders.
Formula 1: ADEs per 100 Admissions
Formula: (Total number of ADEs / Total number of admissions) and 100.
Formula 2: ADEs per 1000 Patient-Days
Formula: (Total number of ADEs / Total number of patient-days) and 1000.
Formula 3: ADEs per 100 Medication Orders
Formula: (Total number of ADEs / Sum of medications ordered) and 100.
Example Calculation (ADE per 100 admissions):
If there were 25 ADEs identified and 500 patients admitted, the ADE rate per 100 admissions would be: 5.5%
Dr. J. L. Meena

Percentage of patients receiving high risk
medications developing adverse drug event.
Percentage of patients receiving high-risk medications who develop an adverse drug event (ADE)
Percentage of patients with ADE = Number of patients on high-risk medications with ADETotal number of
patients on high-risk medications * 100
Example:
- If 50 patients are receiving high-risk medications and 10 of them develop an ADE:
10/50*100 = 20%
Notes:
- Ensure the numerator only includes patients who developed an ADE while on high-risk medications.
- The denominator should include all patients exposed to high-risk medications during the study period.
- Data accuracy depends on clear definitions of "high-risk medications" and "adverse drug events" (e.g., based
on clinical guidelines or coding systems like ICD-10).
Dr. J. L. Meena

Dr. J. L. Meena

Percentage of unplanned return
to OT
The percentage of unplanned returns to the operating theatre (OT) varies by surgical specialty and study context, based on available data:
➢ Orthopedic and Traumatologic Surgery: A study reported a 2.2% incidence of unplanned returns, with 3.2% for unscheduled
(traumatic) surgeries and 1.7% for scheduled ones. (https://pubmed.ncbi.nlm.nih.gov/25952709/)
➢ Gynaecology: A five-year retrospective review found a 0.03% incidence of unplanned returns, with over 80% of cases following
hysterectomy (2% risk post-hysterectomy). (https://www.sciencedirect.com/science/article/abs/pii/S0301211511001771)
➢ Emergency General Surgery: A study noted a 5.3% unplanned return rate over 25 months, with causes like haemorrhage and
inadequate abscess drainage. (https://academic.oup.com/bjs/article/110/Supplement_10/znad388.022/7455144)
➢ General Surgery: A prospective cohort study reported a 3.5% unplanned return rate across various
procedures.(https://pubmed.ncbi.nlm.nih.gov/11296110/)
➢ Neurosurgery: Rates are context-dependent but often tracked as a quality metric, with no specific percentage provided in the
data.(https://qualitysafety.bmj.com/content/21/5/432)
➢ Overall Hospital Data: One institution reported 16.1% (2017) and 15% (2018) total returns (planned and unplanned), with efforts to
reduce unplanned returns through quality initiatives.(https://www.facs.org/quality-programs/qi-resources/case-studies/reducing-
returns-to-the-operating-room-a-patient-quality-and-safety-initiative/)
These figures reflect specific studies and may not generalize across all hospitals or regions. Factors like patient complexity, surgical
technique, and emergency status influence rates. For a precise benchmark, national registries like the ACS NSQIP or hospital-specific data
are recommended. (https://thejns.org/view/journals/j-neurosurg/141/3/article-p804.xml)
Dr. J. L. Meena

Percentage of Unplanned Returns to OT = Number of Unplanned Returns to OT / Total Number of Surgical Procedures *100
Explanation:
➢ Number of Unplanned Returns to OT: The count of cases where patients required an unscheduled return to the operating theatre due
to complications or issues related to the initial surgery (e.g., bleeding, infection, technical errors).
➢ Total Number of Surgical Procedures: The total number of surgeries performed within the same period or context (e.g., a specific
department, hospital, or study timeframe).
➢ Multiplied by 100: Converts the ratio into a percentage.
Example:
If a hospital performed 10,000 surgeries and 224 patients had unplanned returns to the OT, the calculation would be: 224/10,000*100 =
2.24%
Notes:
- This formula is derived from studies and quality improvement initiatives that use unplanned return to OT as a quality metric, such as
those in general surgery, orthopedics, or gynecology.
(https://www.sciencedirect.com/science/article/pii/S1877056815001061)[](https://pubmed.ncbi.nlm.nih.gov/11296110/)
- The timeframe for counting unplanned returns (e.g., within 30 days, 90 days, or during the same admission) may vary depending on the
study or hospital policy. (https://thejns.org/view/journals/j-neurosurg/141/3/article-
p804.xml)[](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9104285/)
- Ensure accurate data collection, as misclassification of planned versus unplanned returns can skew results.
(https://www.sciencedirect.com/science/article/pii/S0002961016309564)
Percentage of unplanned return
to OT
Dr. J. L. Meena

8. (PSQ 3a)- Percentage of surgeries where the organization's
procedure to prevent adverse events like wrong site, wrong
Dr. J. L. Meena

Percentage of cases where the organization's procedure to
prevent adverse events like wrong site, wrong patient and
wrong surgery have been adhered t o
Percentage of cases where organizations’ procedures to prevent wrong-site, wrong-patient, and wrong-procedure surgeries (WSPEs) are adhered to across the
board.
Studies and reports indicate that adherence to protocols like The Joint Commission’s Universal Protocol (which includes pre-procedure verification, site marking,
and time-out) varies widely. A 2019 report from the Minnesota Department of Health noted that in wrong-site surgery cases requiring site marking, no
preoperative marking was done 20% of the time, and teams failed to visually confirm the site mark another 20% of the time.
A UK study from the same period found that only 36.1% of surgeons routinely marked all patients preoperatively, and even when marking occurred, it was
visible after draping in just 55.6% of cases. This points to inconsistent adherence, with less than half of cases following the full protocol correctly.
On the flip side, the Universal Protocol and WHO Surgical Safety Checklist have been widely adopted since 2004 and 2008, respectively, and are mandatory in
many accredited facilities. A 2014 systematic review of 33 studies on these checklists found they reduced complications and mortality, but no specific adherence
rates for WSPE prevention were given. Anecdotally, compliance is high in well-monitored hospital settings but drops in outpatient or less-regulated
environments like freestanding surgical centers. (https://pmc.ncbi.nlm.nih.gov/articles/PMC7104666/)
The catch is that even with protocols in place, errors persist. A 2006 study estimated that 38% of WSPEs wouldn’t be prevented by the Universal Protocol due to
errors occurring before the operating room, like incorrect documentation or radiology labeling. This implies that adherence to the protocol itself doesn’t catch
all issues, and full system compliance (beyond just the surgical team) is often lacking. (https://pmc.ncbi.nlm.nih.gov/articles/PMC7104666/)
So, while adherence to WSPE prevention procedures is likely over 50% in accredited hospitals (based on the push for checklists and time-outs), it’s probably
much lower in less-regulated settings, and specific failures (like skipping site marking or verification) can occur in 20-40% of cases depending on the context.
(https://www.ncbi.nlm.nih.gov/books/NBK2678/)[](https://blog.thesullivangroup.com/wrong-site-surgery-statistics)
(https://pmc.ncbi.nlm.nih.gov/articles/PMC7104666/)
Dr. J. L. Meena

To calculate the **percentage of cases** where an organization's procedure to prevent adverse events (e.g., wrong site, wrong patient,
or wrong surgery) has been adhered to, use the following formula:
Percentage Adherence = Number of Cases Where Procedure Was Adhered To / Total Number of Cases * 100
Steps:
1. Identify the numerator: Count the number of cases where the organization's procedure (e.g., surgical safety checklist, time-out
protocol) was fully followed.
2. Identify the denominator: Determine the total number of cases reviewed or performed within the relevant time period.
3. Calculate: Divide the number of adherent cases by the total number of cases, then multiply by 100 to express as a percentage.
Example:
- If 95 out of 100 surgical cases followed the procedure correctly: 95/100*100 = 95%
Notes:
- Ensure clear documentation of adherence (e.g., checklist completion, time-out verification) to accurately collect data.
- If specific procedures or adverse event types (e.g., wrong-site surgery) are targeted, define them clearly in the data collection process.
- If you have specific data or context (e.g., a dataset or case logs), I can help refine the calculation or analyze it further!
Percentage of cases where the organization's procedure to
prevent adverse events like wrong site, wrong patient and
wrong surgery have been adhered t o
Dr. J. L. Meena

Dr. J. L. Meena

Percentage of transfusion reactions
Transfusion reactions occur in approximately **1-3%** of blood transfusions, with rates varying based on the type of
reaction and blood component transfused. Here's a breakdown of common transfusion reactions and their approximate
percentages:
Febrile non-hemolytic reactions**: ~0.5-1% of transfusions, most common with red blood cell (RBC) or platelet
transfusions.
➢ Allergic reactions: ~0.1-0.5%, typically mild (e.g., hives) but can be severe (anaphylaxis in <0.01%).
➢ Acute hemolytic reactions: ~0.01-0.03%, often due to ABO incompatibility.
➢ Transfusion-related acute lung injury (TRALI): ~0.01-0.08%, more common with plasma or platelet transfusions.
➢ Transfusion-associated circulatory overload (TACO): ~0.1-1%, higher in elderly or cardiac patients.
➢ Delayed hemolytic reactions: ~0.02-0.05%, often in patients with prior alloimmunization.
➢ Infections: Extremely rare (<0.001% for most pathogens like HIV, hepatitis), due to stringent screening.
Data varies by region, blood bank practices, and patient population. Leukoreduction and improved testing have reduced
rates significantly. For precise figures, consult local transfusion registries or guidelines like those from AABB or WHO. If you
need more specific data or context (e.g., a particular country or blood product), let me know!
Dr. J. L. Meena

Percentage of transfusion reactions
The formula for calculating the percentage of transfusion reactions is:
Percentage of Transfusion Reactions = Number of Transfusion Reactions / Total Number of
Transfusions * 100
Explanation:
➢ Number of Transfusion Reactions: The count of adverse reactions observed during or
after transfusions.
➢ Total Number of Transfusions: The total number of transfusion procedures performed.
➢ Multiply by 100 to convert the fraction to a percentage.
For example, if there are 5 transfusion reactions out of 200 transfusions: 5/200*100 = 2.5%
Dr. J. L. Meena

Percentage of wastage of blood and
blood products
The percentage of wastage of blood and blood products varies across studies and regions, depending on factors like hospital type,
inventory management, and storage practices:
Global and Regional Estimates:
➢ In Iranian hospitals (Qazvin, 2010), wastage averaged **9.8%** of issued blood products (30,913 units), with 3,048 units discarded.
Packed red cell wastage ranged from **1.93% to 30.7%**, with 77.9% due to time
expiry.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC4102044/)
➢ At Georgetown Public Hospital, Guyana (2012–2014), **25%** of 16,426 issued blood units (4,167 units) were wasted, primarily due to
handling issues post-collection.[](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907253/)
➢ In a tertiary care hospital in India (2019–2020), the overall discard rate was **8.87%** of 9,308 donated units, with platelets most
frequently discarded due to their short shelf life.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC8760027/)
➢ In Taichung Tzu-Chi Hospital, Taiwan (2011–2023), the average annual wastage rate was **0.08%** of 424,197 units, with plasma
(0.14%), platelets (0.09%), and red blood cells (0.04%) showing low rates. Whole blood had a higher rate at
**1.95%**.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC11730163/)
➢ In the U.S. (2001, post-9/11), over 200,000 units of whole blood (~**40%** of 500,000 extra donations) were wasted due to expiry after
42 days.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC128413/)
➢ In Australia (2023–2024), red blood cell wastage was reported at 8,106 units, with a discard rate of ~**2–3%** of issued units, and
platelets at **12–18%**, depending on annual use.[](https://www.blood.gov.au/blood-products/blood-product-management/blood-
product-wastage)[](https://www.health.vic.gov.au/patient-care/blood-component-wastage)
Dr. J. L. Meena

Key Causes of Wastage:
➢ Time Expiry: The most common reason, especially for red cells (35–42 days shelf life) and platelets (5 days).
(https://pmc.ncbi.nlm.nih.gov/articles/PMC4102044/)[](https://pmc.ncbi.nlm.nih.gov/articles/PMC8760027/)
➢ Improper Storage/Handling: Includes temperature violations (e.g., red cells out of refrigeration >30 minutes) and transport issues.
(https://www.lifeblood.com.au/health-professionals/inventory-management/monitoring-
wastage)[](https://academic.oup.com/ajcp/article/143/3/329/1766348)
➢ Seropositivity: Blood testing positive for infections (e.g., HIV, Hepatitis) is discarded. (https://www.cureus.com/articles/77701-exploring-the-causes-of-
wastage-of-blood-and-its-components-in-a-tertiary-care-hospital-blood-bank)
➢ Non-Utilization: Blood ordered but not used, often due to over-ordering or changes in medical decisions.
(https://bmcresnotes.biomedcentral.com/articles/10.1186/s13104-016-2112-5)
➢ Physical Damage: Leakage, broken bags, or hemolysis. (https://pmc.ncbi.nlm.nih.gov/articles/PMC8760027/)
Context and Mitigation:
➢ Wastage rates are influenced by hospital size, with smaller inventories often facing higher expiry rates due to lower turnover.
(https://www.lifeblood.com.au/health-professionals/inventory-management/monitoring-wastage)
➢ Teaching hospitals tend to have higher wastage (e.g., 58.3% of total waste in Qazvin). (https://pmc.ncbi.nlm.nih.gov/articles/PMC4102044/)
➢ Interventions like better inventory management, staff education, and strict guidelines can reduce wastage significantly (e.g., Taiwan’s drop from 0.29% to
0.08%). (https://pmc.ncbi.nlm.nih.gov/articles/PMC11730163/)
➢ A certain level of wastage is considered inevitable to ensure emergency availability. (https://www.blood.gov.au/blood-products/blood-product-
management/blood-product-wastage)
Summary: Wastage rates typically range from **0.08% to 25%** globally, with red blood cells often below 3%, platelets up to 18%, and plasma around 0.14–
10%. Higher rates occur in resource-constrained settings or post-emergency donation surges. Effective management and education can lower these figures, but
zero wastage is impractical due to shelf-life constraints and unpredictable demand.
blood products
Dr. J. L. Meena

The formula for calculating the percentage of wastage of blood and blood products is:
Percentage of Wastage = Amount of Blood/Blood Products Wasted / Total Amount of
Blood/Blood Products * 100
Steps:
1. Determine the total amount of blood or blood products available (e.g., units collected or
stored).
2. Identify the amount wasted (e.g., units expired, contaminated, or discarded).
3. Divide the wasted amount by the total amount.
4. Multiply by 100 to get the percentage.
For example, if 50 units out of 500 units of blood are wasted: 50/500*100 = 10%
blood products
Dr. J. L. Meena

The formula for calculating the percentage of wastage of blood and blood products is:
Percentage of Wastage = Number of Wasted Units / Total Number of Units Available *100
Explanation:
➢ Number of Wasted Units: The quantity of blood or blood products (e.g., red blood cells, plasma, platelets) that are discarded due to
expiration, contamination, improper storage, or other reasons.
➢ Total Number of Units Available: The total number of blood or blood product units received or available for use (e.g., collected, stored,
or issued) during a specific period.
➢ The result is multiplied by 100 to express the wastage as a percentage.
Example:
If a blood bank had 500 units of blood available and 25 units were wasted: 25/500*100 = 5%
This indicates a 5% wastage rate.
blood products
Dr. J. L. Meena

Percentage of blood components
usage
Blood is composed of several key components, each with specific functions and approximate percentages by volume in healthy human blood:
➢Plasma: ~55% A yellowish liquid that carries water, electrolytes, proteins (like albumin and antibodies), nutrients, hormones, and waste
products.
➢Red Blood Cells (RBCs): ~40-45% Carry oxygen from the lungs to tissues and return carbon dioxide to the lungs for exhalation.
➢White Blood Cells (WBCs): ~1% Part of the immune system, fighting infections and foreign invaders.
➢Platelets: Less than 1% Essential for blood clotting and wound repair.
Use of Blood components:
➢Whole Blood: Used in cases of significant blood loss (e.g., trauma, surgery). Contains all components but is less common than specific component
transfusions.
➢Packed Red Blood Cells (PRBCs): Most frequently transfused (~80% of blood transfusions), used for anemia, surgery, or conditions like sickle cell
disease.
➢Plasma: Used in ~10-15% of transfusions, often for patients with clotting disorders, liver disease, or massive transfusions.
➢Platelets: Used in ~5-10% of transfusions, primarily for cancer patients, bone marrow disorders, or bleeding due to low platelet counts.
➢White Blood Cells: Rarely transfused due to risks like immune reactions; used in specific cases like severe infections unresponsive to antibiotics.
Exact "usage" percentages vary by region, hospital, and patient population. For example, trauma centers may use more PRBCs, while oncology units
may prioritize platelets.
Dr. J. L. Meena

Formula for Percentage of Blood Components - To calculate the percentage of a specific blood component: Percentage of Component = Volume of Component / Total Blood Volume *
100
Volume of Component is the volume of the specific component (e.g., plasma, RBCs).
Total Blood Volume is the total volume of blood (typically 4.5–5.5 liters in adults).
Alternatively, for **hematocrit** (the percentage of RBCs in blood): Hematocrit (%) = RBC Volume / Total Blood Volume * 100
Usage
1. **Medical Diagnostics**:
- **Hematocrit** is used to diagnose conditions like anemia (low RBCs) or polycythemia (high RBCs).
- Plasma percentage helps assess hydration status or conditions like dehydration or overhydration.
- WBC and platelet percentages are critical for diagnosing infections, immune disorders, or clotting issues.
2. **Blood Donation and Transfusion**:
- Blood is separated into components (e.g., plasma, RBCs, platelets) using centrifugation. Knowing their proportions ensures proper collection and transfusion.
- Example: Platelet concentrates are prepared when only platelets are needed.
3. **Research and Forensics**:
- Blood component analysis helps in toxicology, pathology, or forensic investigations to understand health status or cause of death.
4. **Clinical Monitoring**:
- Used in conditions like leukemia (abnormal WBC counts) or thrombocytopenia (low platelets) to monitor treatment efficacy.
Example Calculation: If a person has 5 liters of blood, with 2.2 liters of plasma: 2.2/5*100 = 44%
Percentage of blood components
usage
Dr. J. L. Meena

Dr. J. L. Meena

Hospital Mortality rate
Hospital mortality rates vary widely depending on the region, healthcare system, patient demographics, and specific
conditions treated.
General Rates: In high-income countries like the UK, the overall in-hospital mortality rate is roughly 1.5-3%. For example,
England reports just under 2% mortality for 15 million annual hospital admissions, with emergency admissions (35% of
cases) driving most deaths. In the US, crude mortality rates are estimated at 2-3% across hospitals, though specific
conditions like heart failure or pneumonia can have higher rates (e.g., 5.8% for heart attack in New Jersey).
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6297330/)
Condition-Specific Rates:
COVID-19: During the early pandemic (2020), US hospital mortality for COVID-19 patients was around 10-20%, dropping
to 1.5% by mid-2020 with better treatments. In England, it ranged from 23.6% to 31.4% across trusts.
Other Conditions: From 2000-2010, US hospital mortality for conditions like stroke dropped 27%, pneumonia 33%, and
heart disease 16%, but septicemia rose 17%. In California (2022), risk-adjusted mortality for conditions like acute stroke
or heart failure varied significantly across hospitals. (https://www.cdc.gov/nchs/products/databriefs/db118.htm)
Dr. J. L. Meena

Influencing Factors:
➢ Patient Factors: Age, comorbidities, and emergency vs. elective admission status heavily influence outcomes. Older,
sicker patients and emergency cases have higher mortality.
➢ Hospital Factors: Bed availability, staffing ratios (e.g., doctors per bed), and access to critical care units impact rates.
Hospitals with more resources often report lower mortality. (https://pmc.ncbi.nlm.nih.gov/articles/PMC27892/)
➢ Seasonality: Winter sees higher mortality due to increased admissions for conditions like pneumonia (e.g., 31.3%
higher mortality in US winters). (https://pmc.ncbi.nlm.nih.gov/articles/PMC7663007/)
Measurement Variations: Metrics like crude mortality rate (deaths/admissions) and risk-adjusted mortality (e.g., SHMI,
HSMR) account for patient risk profiles but aren't directly comparable across hospitals due to differences in case mix,
data quality, and reporting standards. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5949221/)
Regional Disparities: In low- and middle-income countries like Kenya, data gaps hinder accurate reporting, but mortality is
often higher due to resource constraints. High-income countries use standardized metrics like HSMR, showing declines
over time (e.g., 2.6% annual reduction in England, 1991-1995) (https://pmc.ncbi.nlm.nih.gov/articles/PMC27892/)
Dr. J. L. Meena

The formula for calculating Hospital Mortality Rate is:
Hospital Mortality Rate = (Number of deaths in hospital / Total number of discharges) x 100
Explanation
1. Number of deaths in hospital: The total number of patients who died in the hospital
during a specific period.
2. Total number of discharges: The total number of patients discharged from the hospital
during the same period, including deaths.
Purpose
The hospital mortality rate formula helps healthcare organizations track and monitor their
mortality rates, identify areas for improvement, and evaluate the quality of care provided.
Dr. J. L. Meena

11. (PSQ 3a)- Return to the emergency department
within 72 hours with similar presenting complaints
Dr. J. L. Meena

Return to the emergency department within
72 hours with similar presenting complaints
Return to the emergency department (ED) within 72 hours with similar presenting complaints is often used as a quality
metric to track:
Reasons for Return Visits
1. Incomplete diagnosis or treatment: Patients may return due to incomplete or inaccurate diagnosis or treatment during
the initial visit.
2. Worsening condition: Patients' conditions may worsen, requiring further evaluation or treatment.
3. New symptoms: Patients may develop new symptoms related to their initial presenting complaint.
Importance
Tracking return visits within 72 hours helps healthcare organizations:
1. Identify areas for improvement: Analyze reasons for return visits to identify potential issues with care delivery or
processes.
2. Improve patient outcomes: Implement changes to reduce the likelihood of return visits and improve patient outcomes.
3. Optimize resource utilization: Reduce unnecessary return visits and optimize resource utilization in the ED.
Dr. J. L. Meena

The formula for calculating Return to the Emergency Department (ED) within 72 hours with similar presenting
complaints is:
Return Rate = (Number of patients who returned to ED within 72 hours with similar complaints / Total number
of ED visits) x 100
Explanation
1. Number of patients who returned: Count the number of patients who returned to the ED within 72 hours
with similar presenting complaints.
2. Total number of ED visits: Calculate the total number of ED visits during the same period.
Purpose
This formula helps healthcare organizations track and monitor return visits to the ED, identify potential issues
with care delivery, and implement improvements to reduce unnecessary return visits.
Return to the emergency department within
72 hours with similar presenting complaints
Dr. J. L. Meena

12. (PSQ 3a )-Incidence of hospital associated pressure
ulcers after admission (Bed Sore per 1000 patient days)
Dr. J. L. Meena

Incidence of hospital associated pressure
ulcers after admission (Bed Sore per 1000
patient days)
Hospital-associated pressure ulcers (HAPUs), also known as bed sores or pressure sores, are a significant concern for
patient safety and quality of care.
1. Risk assessment: Identify patients at high risk for developing pressure ulcers.
2. Regular turning and repositioning: Turn and reposition patients regularly to reduce pressure on vulnerable areas.
3. Support surfaces: Use support surfaces, such as pressure-redistributing mattresses and cushions.
4. Skin assessment: Regularly assess patients' skin for early signs of pressure ulcers.
5. Nutrition and hydration: Ensure adequate nutrition and hydration to promote skin health.
Importance
Preventing HAPUs is crucial to:
1. Improve patient outcomes: Reduce pain, discomfort, and morbidity associated with pressure ulcers.
2. Reduce healthcare costs: Minimize costs associated with treating pressure ulcers.
3. Enhance quality of care: Demonstrate commitment to providing high-quality, patient-centered care.
Dr. J. L. Meena

The formula for calculating the incidence of hospital-associated pressure ulcers (HAPUs) is:
HAPU Incidence Rate = (Number of new HAPU cases / Total number of patient days) x 1,000
Explanation
1. Number of new HAPU cases: Count the number of patients who develop new pressure ulcers after
admission.
2. Total number of patient days: Calculate the total number of days patients were hospitalized during the
same period.
Purpose
This metric helps healthcare organizations track and monitor the incidence of HAPUs, identify areas for
improvement, and evaluate the effectiveness of their pressure ulcer prevention strategies.
Incidence of hospital associated pressure
ulcers after admission (Bed Sore per 1000
patient days)
Dr. J. L. Meena

13. (PSQ 3b )- Catheter associated urinary tract infection
rate
Dr. J. L. Meena

Urinary tract infection rate
Urinary tract infections (UTIs) are among the most common bacterial infections worldwide, with significant variation in incidence rates depending on population, sex, age, and socio-
demographic factors.
➢ Global Incidence: UTIs affect over 150 million people annually. From 1990 to 2021, global UTI cases increased by 66.45%, reaching approximately 4.49 billion cases in 2021, with an
age-standardized incidence rate (ASIR) of 5,531.88 per 100,000 population.
➢ Sex Differences: Women are significantly more likely to develop UTIs due to anatomical factors (shorter urethra, proximity to anus). The lifetime incidence for women is 50–60%,
with about 1 in 2 women experiencing a UTI. The ASIR for women is approximately 3.6–4 times higher than for men. Nearly 1 in 3 women will have a UTI requiring treatment by age
24. Men have lower rates, with 1 in 20 men affected in their lifetime.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC6502976/)
➢ Age Trends: UTI prevalence increases with age. In women over 65, the rate is roughly double that of the overall female population. The incidence peaks around ages 30–49 for
women and over 80 for men, with a significant rise in both sexes after age
65.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC6502976/)[](https://pmc.ncbi.nlm.nih.gov/articles/PMC9363895/)
➢ Recurrence: 20–30% of women experience a recurrent UTI within 6 months of an initial infection. Recurrent UTIs are defined as at least two infections in six months or three in a
year.[](https://www.ncbi.nlm.nih.gov/books/NBK470195/)
➢ Healthcare-Associated UTIs (HAUTIs): These account for over 30% of healthcare-associated infections, with catheter-associated UTIs (CAUTIs) being the most common. In 2002, US
hospitals reported over 560,000 HAUTIs, with a mortality rate of 2.3% (approximately 13,000 deaths). The CAUTI infection rate is about 2.25 per 1,000 urinary catheter-
days.[](https://www.cdc.gov/infection-control/hcp/cauti/background.html)
➢ Regional Variations: Higher socio-demographic index (SDI) regions, like high-income countries, have higher ASIRs (e.g., 64.24/1,000 in 2019), while low-SDI regions show declining
burden rates. Tropical Latin America reported the highest ASIR in 2021 (13,021.38 per 100,000).[](https://pmc.ncbi.nlm.nih.gov/articles/PMC9363895/)
Specific Populations:
➢ Immobile Inpatients: Prevalence is 1.64%, with an incidence of 0.69 per 1,000 patient-days.
➢ Children: Incidence is lower but significant, with febrile infants showing a prevalence of 17–23%.
➢ Pregnant Women: 2–10% have asymptomatic bacteriuria, increasing risks of complications like pyelonephritis.
➢ Elderly: UTIs are the second most common infection in noninstitutionalized elderly populations, accounting for nearly 25% of infections.
Sources of Data Gaps: Accurate incidence is hard to assess in some regions because UTIs are not reportable diseases, and diagnoses often rely on symptoms without confirmatory
cultures, especially in outpatient settings.
Dr. J. L. Meena

The formula for calculating the **urinary tract infection (UTI) rate** in a healthcare setting is typically expressed as the number of UTIs
per 1,000 catheter-days or patient-days, depending on the context (e.g., catheter-associated UTI or overall UTI rate).
UTI Rate = (Number of UTIs / Number of Catheter-Days or Patient-Days) × 1,000
Breakdown:
➢ Number of UTIs: The total number of diagnosed urinary tract infections within a specific time period.
➢ Number of Catheter-Days: The total number of days that patients had a urinary catheter in place during the same period (used for
catheter-associated UTI, or CAUTI).
➢ Number of Patient-Days: The total number of days patients were in the facility (used for overall UTI rate, not specific to catheters).
➢ Multiplied by 1,000: Standardizes the rate to "per 1,000 days" for easier comparison.
Example:
If a hospital has 10 UTIs in a month and 2,000 catheter-days, the CAUTI rate is: (10 / 2,000) × 1,000 = 5 UTIs per 1,000 catheter-days.
Notes:
➢ Ensure UTIs are defined consistently (e.g., using CDC/NHSN criteria for CAUTI).
➢ The formula may vary slightly based on institutional guidelines or specific study requirements.
➢ If you need a different context or formula (e.g., community-acquired UTI prevalence), please clarify!
Urinary tract infection rate
Dr. J. L. Meena

Dr. J. L. Meena

Ventilator associate
Pneumonia rate
Ventilator-associated pneumonia (VAP) is a lung infection that develops in patients on mechanical ventilation for at least 48 hours. It’s a serious healthcare-
associated infection, often caused by bacteria entering the lungs via the endotracheal tube.
Key Points
➢ Definition: Pneumonia occurring ≥48 hours after endotracheal intubation or within 48 hours of extubation.
➢ Incidence: Affects 5–40% of mechanically ventilated patients, with rates varying by ICU type and diagnostic criteria (1–2.5 cases per 1000 ventilator-days in
North America, higher in Europe). - Mortality**: Attributable mortality is ~10–13%, higher in surgical ICU patients or those with multidrug-resistant (MDR)
pathogens.
➢ Common Pathogens: Gram-negative bacilli (e.g., *Pseudomonas aeruginosa*, *Klebsiella pneumoniae*), *Staphylococcus aureus* (including MRSA). In
COVID-19 patients, Enterobacteriaceae and *P. aeruginosa* dominate.
Risk Factors
➢ Patient-related: Male sex, preexisting lung disease, multiple organ failure, smoking.
➢ Treatment-related: Prolonged intubation, enteral feeding, supine position, prior antibiotic use, nasogastric tubes.
(https://www.ncbi.nlm.nih.gov/books/NBK507711/)
➢ COVID-19 Context: Higher VAP incidence (up to 86% in ECMO patients), with frequent recurrence (79%) and Enterobacteriaceae predominance.
Diagnosis
Clinical Signs: Fever, leukocytosis/leukopenia, purulent secretions, worsening oxygenation, new/progressive chest X-ray infiltrates.
(https://www.ncbi.nlm.nih.gov/books/NBK507711/)
Diagnostic Methods:
➢ Noninvasive: Endotracheal aspirates (quantitative threshold: 1,000,000 CFUs).
➢ Invasive: Bronchoalveolar lavage (BAL) or protected specimen brush (PSB) for quantitative cultures. Debate exists on invasive vs. noninvasive approaches.
(https://pubmed.ncbi.nlm.nih.gov/38280768/)
➢ Emerging Tools: Multiplex PCR for rapid pathogen identification (24–36 hours vs. 48–72 hours for cultures).
Dr. J. L. Meena

Pneumonia rate
Challenges: No gold standard; clinical criteria alone have 69% sensitivity, 75% specificity. ARDS or poor-quality portable X-rays complicate
diagnosis.
Treatment
Empiric Antibiotics: Start broad-spectrum antibiotics based on local resistance patterns and patient risk factors (e.g., prior antibiotic use,
hospitalization ≥5 days). Cover *P. aeruginosa* and possibly MRSA. Examples: piperacillin-tazobactam, cefepime, or meropenem;
vancomycin/linezolid for MRSA if needed.[](https://www.ncbi.nlm.nih.gov/books/NBK507711/)
De-escalation: Narrow antibiotics within 2–3 days based on culture results and clinical response. Stop antibiotics if cultures are
negative.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC7095206/)
Duration: 7–8 days for uncomplicated VAP; 14 days for complicated cases (e.g., necrotizing pneumonia, *P. aeruginosa*, or MDR
pathogens).[](https://www.ncbi.nlm.nih.gov/books/NBK507711/)
Novel Therapies:
Inhaled antibiotics (e.g., amikacin, colistin) for MDR Gram-negatives; not routinely recommended due to limited evidence and bacteremia
concerns (10–20% of cases). A 2023 trial showed inhaled amikacin reduced VAP incidence by day
28.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC7095206/)
Cefiderocol: FDA-approved (2020) for VAP caused by resistant Gram-negatives (*Acinetobacter*, *E. coli*, *P. aeruginosa*).
Adjuncts: Probiotics (*Lactobacillus rhamnosus GG*) reduced VAP days and antibiotic use in one study.
Dr. J. L. Meena

Pneumonia rate
Prevention Core Strategies:
- Elevate head of bed (30–45°).
- Minimize intubation duration; use noninvasive ventilation when possible.
- Daily sedation vacations and weaning trials.
- Oral hygiene with chlorhexidine.
- Hand hygiene and infection control. (https://www.cdc.gov/ventilator-associated-pneumonia/about/index.html)
Bundles: ABCDEF bundle (awakening, breathing coordination, delirium management, early mobilization) improves outcomes but lacks large randomized trials
for mortality reduction. (https://pmc.ncbi.nlm.nih.gov/articles/PMC3951308/)
Prophylaxis: Inhaled antibiotics (e.g., amikacin) show promise but aren’t standard.
Challenges
Diagnostic Uncertainty: Misdiagnosis (e.g., tracheobronchitis, colonization) leads to overtreatment, increasing resistance.
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592694/) (https://pmc.ncbi.nlm.nih.gov/articles/PMC3951308/)
MDR Pathogens: Prior antibiotic use is a major risk for MDR infections, complicating therapy.
COVID-19: Higher VAP rates and recurrence; secondary bacterial pneumonia may drive mortality more than the virus itself.
Recent Insights
- A 2023 NEJM study found a 3-day course of inhaled amikacin reduced VAP incidence by day 28, with minimal adverse effects.
- Machine learning studies suggest secondary VAP, not cytokine storms, is a leading ICU killer in COVID-19 patients, emphasizing the need for better diagnostics
and treatment strategies.
Critical Perspective
The establishment narrative pushes aggressive antibiotic use and bundled prevention strategies, but evidence for mortality reduction is shaky. Overdiagnosis
inflates VAP rates, and broad-spectrum antibiotics fuel resistance. Focus on rapid diagnostics (e.g., PCR) and targeted therapies (e.g., cefiderocol, inhaled
antibiotics) could shift the paradigm, but cost and access remain barriers. Prevention bundles sound good but often lack rigorous outcome data—hospitals may
adopt them for optics over impact. Always question whether “standard” protocols are truly evidence-based or just entrenched dogma.
Dr. J. L. Meena

The formula for calculating Ventilator-Associated Pneumonia (VAP) rate is:
VAP rate = (Number of VAP cases / Number of ventilator days) x 1,000
Explanation
1. Number of VAP cases: The number of patients who developed VAP during a specific period.
2. Number of ventilator days: The total number of days patients were on mechanical ventilation
during the same period.
3. Multiplier: The rate is typically expressed per 1,000 ventilator days.
Purpose
The VAP rate formula helps healthcare organizations track and monitor the incidence of VAP in their
intensive care units (ICUs). By calculating the VAP rate, organizations can identify areas for
improvement and evaluate the effectiveness of their VAP prevention strategies.
Pneumonia rate
Dr. J. L. Meena

15. (PSQ 3b )- Central line associated blood stream
infection rate
Dr. J. L. Meena

Central line-associated bloodstream
infections (CLABSIs)
Central line-associated bloodstream infections (CLABSIs) are serious infections caused by pathogens entering the bloodstream through a
central venous catheter.
Definition: CLABSIs occur when bacteria, fungi, or other pathogens infect the bloodstream via a central line, often used for long-term IV
access in hospitals or outpatient settings.
Risk Factors:
- Prolonged catheter use.
- Improper insertion or maintenance.
- Immunocompromised patients.
- Contamination at the insertion site.
Symptoms: Fever, chills, hypotension, or signs of sepsis; may lack local signs at the catheter site.
Prevention (CDC and WHO guidelines):
- Strict hand hygiene and aseptic technique during insertion.
- Use of chlorhexidine for skin antisepsis.
- Daily review of catheter necessity and prompt removal when not needed.
- Use of antimicrobial-impregnated catheters in high-risk settings.
- Staff training and adherence to infection control protocols.
Diagnosis: Confirmed via blood cultures (drawn from the catheter and peripheral sites) showing the same organism, with no other
infection source.
Dr. J. L. Meena

Treatment:
- Catheter removal (if feasible, especially for severe infections or certain pathogens like *S. aureus* or fungi).
- Empiric antibiotics (e.g., vancomycin for gram-positive coverage) tailored to culture results.
- Duration: 7-14 days for uncomplicated cases; longer for complicated infections (e.g., endocarditis).
Impact: CLABSIs increase hospital stays, costs (estimated $7,000-$29,000 per case), and mortality (10-25% in severe cases).
Recent Data (2023-2025):
➢ CDC NHSN 2023 Report: CLABSI rates in U.S. hospitals rose slightly post-COVID due to staffing shortages and increased
patient acuity, with standardized infection ratios (SIR) around 0.8-1.2 depending on hospital type.
➢ Innovations: Antimicrobial coatings (e.g., chlorhexidine-silver sulfadiazine) and lock solutions (e.g., taurolidine) show
promise in reducing rates.
Recommendations:
- Follow evidence-based bundles (e.g., CDC’s CLABSI prevention checklist).
- Monitor local epidemiology for resistant pathogens (e.g., MRSA, Candida auris).
- Engage multidisciplinary teams for consistent protocol adherence.
For detailed protocols, check CDC’s CLABSI guidelines (cdc.gov) or WHO’s infection control resources.
Dr. J. L. Meena

The formula for calculating Central Line-Associated Bloodstream Infections (CLABSI) rate is:
CLABSI rate = (Number of CLABSI cases / Number of central line days) x 1,000
Explanation
1. Number of CLABSI cases: The number of patients who developed CLABSI during a specific period.
2. Number of central line days: The total number of days patients had a central line in place during
the same period.
3. Multiplier: The rate is typically expressed per 1,000 central line days.
Purpose
The CLABSI rate formula helps healthcare organizations track and monitor the incidence of CLABSI
in their facilities. By calculating the CLABSI rate, organizations can identify areas for improvement
and evaluate the effectiveness of their CLABSI prevention strategies.
Dr. J. L. Meena

Dr. J. L. Meena

Surgical site infection rate
Surgical site infection (SSI) rates vary depending on the type of surgery, geographical region, and healthcare setting.
➢ Global Incidence: A 2023 systematic review and meta-analysis estimated the worldwide incidence of SSIs in general surgical patients at 11%
(95% CI: 10%–13%) within 30 days post-surgery, based on 488,594 patients across six anatomical locations. Rates vary by surgical approach,
anatomical site, and whether the procedure is planned or emergency.
➢ United States: SSIs affect 2% to 5% of patients undergoing inpatient surgical procedures, with an estimated 160,000 to 300,000 cases annually.
They account for 20% of hospital-acquired infections, with an average hospital stay increase of 9.7 days and costs ranging from $3.5 billion to
$10 billion annually.
➢ Low- and Middle-Income Countries: In low- and middle-income countries, 11% of surgical patients develop SSIs. In Africa, up to 20% of women
undergoing cesarean sections contract SSIs. (https://www.who.int/teams/integrated-health-services/infection-prevention-control/surgical-site-
infection)
Specific Settings:
➢ In Ethiopia, a study at Jimma University Specialized Hospital (2009–2010) reported an SSI rate of 11.4% among 770 obstetric surgeries, with
higher rates in emergency procedures (11.9% vs. 5.9% for elective). (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275863/)
➢ In the UK, a 2017–2022 cohort study of 50,000 open surgery patients found an SSI rate of 11%, with 85% occurring post-discharge in the
community.
➢ In Australia, an estimated 16,541 SSI cases occurred in public hospitals in 2018–19, costing A$323.5 million directly.
➢ In the EU/EEA, nearly 20,000 SSIs were reported from 1.2 million surgeries across 13 countries (2018–2020), with rates varying by procedure
type.
Dr. J. L. Meena

By Procedure and Contamination Level:
- Clean wounds: ~2–5% SSI rate
- Clean-contaminated wounds: ~6–15%
- Contaminated/dirty wounds: Up to 30–40%[](https://ncbi.nlm.nih.gov/books/NBK560533/table/article-31404.table0/)
Recent Trends: In the US, SSI rates for abdominal hysterectomy increased by 8% from 2022 to 2023, while colon surgery
rates remained stable. Prevention efforts have reduced SSI rates by 7% between 2015 and
2019.[](https://www.jointcommissionjournal.com/article/S1553-7250%2824%2900259-9/fulltext)
(https://www.cdc.gov/healthcare-associated-infections/php/data/index.html)
Risk Factors: Include patient factors (age, diabetes, obesity, smoking), procedure-related factors (emergency surgery,
wound contamination), and hospital factors (length of stay, blood transfusion).[](https://psnet.ahrq.gov/primer/surgical-
site-infections) (https://pmc.ncbi.nlm.nih.gov/articles/PMC9661638/)
Prevention Impact: Evidence-based practices, such as preoperative antibiotic prophylaxis and adherence to surgical
safety checklists, can reduce SSIs by up to 50%. A US hospital system implementing a standardized antimicrobial
prophylaxis bundle saw SSI rates drop significantly (e.g., 32.8% reduction for hip arthroplasty).
Surgical site infection rate
Dr. J. L. Meena

Dr. J. L. Meena

Hand Hygiene Compliance Rate
Hand hygiene compliance in hospitals is critical for preventing healthcare-associated infections (HAIs), which affect 7% of patients in high-income countries and
15% in low- and middle-income countries. Despite its importance, global compliance rates remain suboptimal, averaging around 60% in intensive care units
and as low as 9.1% in low-income countries compared to 64.5% in high-income countries. (https://www.who.int/teams/integrated-health-services/infection-
prevention-control/hand-hygiene) (https://www.who.int/news/item/12-05-2023-first-ever-who-research-agenda-on-hand-hygiene-in-health-care-to-improve-
quality-and-safety-of-care)
Key Factors Influencing Compliance:
1. Training and Education: Ongoing education, including WHO’s “Five Moments for Hand Hygiene” (before patient contact, before aseptic procedures, after
body fluid exposure, after patient contact, and after touching patient surroundings), significantly improves adherence. Studies show targeted training can
boost compliance by up to 30%.
2. Availability of Resources: Easy access to alcohol-based hand rubs (ABHR) at the point of care and well-stocked soap and water facilities are essential.
Insufficient supplies, reported by 57.9% of healthcare workers in some studies, are a major barrier.
(https://www.journalofhospitalinfection.com/article/S0195-6701%2823%2900241-4/fulltext)
3. Institutional Culture and Leadership: Role modeling by senior staff and a strong safety climate improve compliance. Lack of leadership support or poor
peer accountability can hinder adherence.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC10213575/)
4. Monitoring and Feedback: Direct observation, the gold standard for measuring compliance, along with non-punitive feedback, fosters accountability.
Electronic monitoring and video recordings are emerging tools.
5. Workload and Staffing: High workloads, understaffing, and time constraints are frequently cited barriers, particularly in intensive care units where
compliance is often lower.
6. Individual Factors: Knowledge of guidelines, personal beliefs about efficacy, and skin reactions to ABHR (reported by 26.3% of nurses) influence
compliance.
Dr. J. L. Meena

Rates and Variations:
➢ Global Rates: Overall compliance is around 40% without interventions, rising to 60% in critical care settings with multimodal strategies.
(https://www.who.int/news/item/12-05-2023-first-ever-who-research-agenda-on-hand-hygiene-in-health-care-to-improve-quality-
and-safety-of-care)
➢ Regional Differences: In Bangladesh, compliance was 25.3%, with nurses at 28.5% and cleaning staff at 9.9%. In Ethiopia, rates were
37.4% among nurses. The Eastern Mediterranean region reported 32% compliance.
➢ By Role: Nurses often show higher compliance (e.g., 28.5% vs. 9.9% for cleaning staff), but physicians and allied staff vary widely.
➢ By Moment**: Compliance is highest after body fluid exposure (43.6%) and after patient contact (43.0%), but lower before patient
contact (17.1%).
Effective Interventions:
➢ WHO Multimodal Strategy: Includes system change (e.g., ABHR availability), training, observation, reminders, and a safety culture. This
approach can improve compliance by up to 83.3% in some settings and reduce HAIs by 35–70%.)
➢ Incentives and Competitions: Quarterly department competitions and public recognition increase engagement.
➢ Cues and Reminders**: Posters, signs, and strategic ABHR placement slightly improve adherence.
➢ Patient Empowerment: Encouraging patients to ask healthcare workers to clean their hands can reinforce compliance.
(https://www.hopkinsmedicine.org/patient-safety/infection-prevention/hand-hygiene)
Dr. J. L. Meena

Outcomes of Improved Compliance:
➢ Infection Reduction: Proper hand hygiene prevents up to 50% of HAIs, reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) by 21% and vancomycin-
resistant Enterococcus (VRE) by 41% in some studies. (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) (https://www.who.int/campaigns/world-
hand-hygiene-day/2021/key-facts-and-figures)
➢ Economic Benefits: Implementation yields savings 16 times the cost, with $1 invested saving up to $16.5 in healthcare costs. (https://www.who.int/campaigns/world-
hand-hygiene-day/2021/key-facts-and-figures)
➢ Antimicrobial Resistance: Enhanced compliance reduces the spread of multidrug-resistant organisms.
Challenges and Barriers:
➢ Infrastructure: Inadequate water, sanitation, and hygiene (WASH) services in 50% of global healthcare facilities, especially in low-income settings, limit compliance.
➢ Behavioral Resistance: Over-reliance on gloves, perceived low risk, and cultural attitudes can undermine adherence.
➢ Sustainability: Even during the COVID-19 pandemic, initial compliance peaks (e.g., 92.8% in March 2020) often declined to baseline (51.5% by August 2020) without
sustained efforts.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC10213575/)
Recommendations:
✓ Implement WHO’s multimodal strategy tailored to local needs.
✓ Ensure consistent ABHR and soap availability, especially in high-risk areas like ICUs.
✓ Foster a culture of accountability through leadership and peer support.
✓ Use direct observation and real-time feedback to monitor and sustain compliance.
✓ Educate patients to advocate for hand hygiene.
For further details on guidelines, see the WHO Hand Hygiene Guidelines (https://www.who.int) or CDC’s Clean Hands campaign
(https://www.cdc.gov).[](https://www.who.int/teams/integrated-health-services/infection-prevention-control/hand-hygiene)[](https://www.cdc.gov/clean-
hands/about/hand-hygiene-for-healthcare.html)
Dr. J. L. Meena

The Hand Hygiene Compliance Rate is calculated as:
Hand Hygiene Compliance Rate = (Number of observed hand hygiene opportunities met / Total
number of observed hand hygiene opportunities) x 100
Explanation
1. Observed hand hygiene opportunities: Count the number of times healthcare workers are
observed performing hand hygiene during critical moments (e.g., before patient contact).
2. Total observed opportunities: Calculate the total number of hand hygiene opportunities
observed.
Purpose
This metric helps healthcare organizations track and monitor hand hygiene compliance, identify
areas for improvement, and evaluate the effectiveness of their hand hygiene promotion
strategies.
Dr. J. L. Meena

18. (PSQ 3b )- Percentage of cases who received
appropriate prophylactic antibiotics within the specified
time frame
Dr. J. L. Meena

Percentage of cases who received appropriate
prophylactic antibiotics within the specified
time frame
Percentage of cases receiving appropriate prophylactic antibiotics within the specified time frame varies by study and context like:-
- A study in Pakistan reported 100% compliance with administering preoperative prophylactic antibiotics within 120 minutes before
surgical incision, as anesthesiologists administered the dose in the operating theater.
- In contrast, a study in Iran found only 8.75% of surgical prophylaxis cases used appropriate antibiotics according to guidelines, with
issues in dosage and duration, though timing compliance was not explicitly quantified.
- A U.S.-based study on "just-in-time" dosing showed 98% of case patients and 94% of control patients received antibiotics within the
recommended time frame (within 60 minutes prior to incision, or 120 minutes for vancomycin/fluoroquinolones).
- Studies highlight challenges in consistent adherence, with barriers like logistical issues or lack of guideline awareness affecting timely
administration. For instance, qualitative research in Canadian hospitals noted perceived failures in proper timing despite guideline
knowledge. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563990/)
Globally, compliance ranges widely, from less than 1% in some settings to 41.1% in others, influenced by hospital protocols and resources.
No universal percentage is consistently reported due to differences in guidelines, surgical settings, and data collection. For precise figures,
specific hospital or regional data would be needed, as compliance depends heavily on local practices. If you have a particular region or
surgery type in mind, I can try to narrow it down further. (https://pmc.ncbi.nlm.nih.gov/articles/PMC9661573/)
Dr. J. L. Meena

Percentage of cases who received appropriate prophylactic antibiotics within the specified time frame:
Percentage = Number of cases receiving appropriate prophylactic antibiotics within the specified time frame / Total
number of cases * 100
Explanation:
Numerator: Count the number of cases where patients received the correct prophylactic antibiotics within the designated
time frame (e.g., within 1 hour before surgical incision, as per guidelines).
Denominator: Count the total number of cases considered (e.g., all surgical cases requiring prophylactic antibiotics).
Multiply by 100 to convert the fraction to a percentage.
Example:
If 80 out of 100 surgical cases received appropriate prophylactic antibiotics within the specified time frame: 80/100 * 100 =
80%
Ensure the "appropriate" antibiotics and "specified time frame" align with relevant clinical guidelines (e.g., type, dose, and
timing as per hospital or national standards).
Percentage of cases who received appropriate
prophylactic antibiotics within the specified
time frame
Dr. J. L. Meena

Dr. J. L. Meena

Percentage of re-scheduling of
surgeries
Data on the exact percentage of surgery rescheduling varies by context, hospital, and time period, but available studies
provide some insights:
- A study from a major hospital found that 9.7% ± 0.5% of surgical cases were cancelled and later rescheduled to a
different date. Of the cases performed, 9.5% ± 0.5% had been previously cancelled and rescheduled.
(https://pubmed.ncbi.nlm.nih.gov/24023019/)
- During the COVID-19 pandemic, a Belgian study reported that of 366 cancelled elective surgeries, only 12% of patients
accepted immediate rescheduling, indicating a significant portion remained unscheduled in the short term.
- In a Canadian context post-COVID, the rescheduling of elective surgeries for older adults was complicated by backlogs,
with no specific percentage provided but noted as a significant issue due to prioritization by clinical urgency.
These figures suggest that rescheduling rates typically range from around 9-12% in normal conditions, with higher
disruptions during crises like the pandemic. Specific percentages depend on factors like hospital capacity, emergency case
volume, and patient willingness to reschedule. For precise data, hospital or regional health system records would be
needed.
Dr. J. L. Meena

Percentage of rescheduling of surgeries
Percentage of Rescheduling = Number of Rescheduled Surgeries / Total Number of Scheduled Surgeries *100
Steps:
1. Determine the **number of surgeries that were rescheduled** (e.g., postponed or canceled and reassigned
to a new date).
2. Determine the **total number of surgeries scheduled** (including both those that proceeded as planned
and those rescheduled).
3. Divide the number of rescheduled surgeries by the total number of scheduled surgeries.
4. Multiply the result by 100 to convert it to a percentage.
Example:
If 20 surgeries were rescheduled out of 200 total scheduled surgeries: 20/200*100 – 10%
This means 10% of the surgeries were rescheduled.
Percentage of re-scheduling of
surgeries
Dr. J. L. Meena

20. (PSQ 3c )- Turnaround time for issue of blood and
blood components
Dr. J. L. Meena

Turnaround time for issue of blood
and blood components
General TAT for Red Blood Cells (RBCs):
➢ Routine Hospital Setting: Studies report average TATs ranging from 30 to 135 minutes for RBC transfusions. For example, a study in an Indian hospital found a
median TAT of 135 minutes, with 47% of delays (about 63 minutes) due to blood bank processes like compatibility testing and 53% (72 minutes) from external
processes like ordering and transport.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC6311979/)
➢ Operating Room (OR): A U.S. study reported median TATs of 30–35 minutes from request to retrieval and 33–39 minutes to delivery in the OR, with most
delays occurring before blood bank release.[](https://pubmed.ncbi.nlm.nih.gov/12171488/)
➢ Intraoperative Requests: A South Korean study noted mean TATs of 37.1 minutes for delayed cases, with prolonged compatibility testing and courier delays as
key factors.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC5907900/)
Emergency Settings:
Emergency RBC issuance can take as little as 15 minutes if protocols prioritize speed, but delays may occur if antibody screening is positive, requiring 1–2 hours
or more for complex cases.[](https://journals.lww.com/gjtm/fulltext/2023/08020/improving_turnaround_time_for_the_issue_of_blood.14.aspx)
Electronic issuance (no crossmatch) for patients with negative antibody screens allows near-immediate
availability.[](https://www.barnsleyhospital.nhs.uk/pathology/blood-transfusion/test-turnaround)
Other Blood Components:
Platelets: Issued quickly (often <30 minutes) as they require no crossmatching and are stored at room temperature. TAT may increase if pooling is needed
(expires 4 hours post-pooling).[](https://www.cancer.org/cancer/managing-cancer/treatment-types/blood-transfusion-and-donation/how-blood-transfusions-
are-done.html)[](https://www.utmb.edu/bloodbank/handling-storage-and-returns)
Fresh Frozen Plasma (FFP): Thawing takes ~45 minutes, adding to TAT. Transfusion typically completes in <30
minutes.[](https://www.cancer.org/cancer/managing-cancer/treatment-types/blood-transfusion-and-donation/how-blood-transfusions-are-
done.html)[](https://www.utmb.edu/bloodbank/handling-storage-and-returns)
Cryoprecipitate: Thawing and pooling (if needed) take ~45 minutes. Must be kept at room temperature post-thaw, with a 6-hour
expiration.[](https://www.utmb.edu/bloodbank/handling-storage-and-returns)
Dr. J. L. Meena

Factors Affecting TAT:
➢ Pre-transfusion Testing: Compatibility testing, especially for patients with antibodies, can significantly extend TAT (hours to days for
complex cases). (https://www.utmb.edu/bloodbank/ordering-blood-components)
➢ Transport and Ordering: Delays in sample transport (e.g., 34 minutes) and order processing (e.g., 13 minutes) contribute significantly.
Systems like pneumatic chutes or electronic ordering can reduce these times. (https://pmc.ncbi.nlm.nih.gov/articles/PMC6311979/)
➢ Hospital Protocols: Pre-transfusion testing completion, access to patient data, and blood bank staffing impact efficiency.
(https://pubmed.ncbi.nlm.nih.gov/12171488/) (https://pmc.ncbi.nlm.nih.gov/articles/PMC5907900/)
Improving TAT:
➢ Implementing electronic blood ordering, pre-transfusion testing before surgery, and rapid transport systems (e.g., pneumatic tubes)
can reduce TAT. (https://pmc.ncbi.nlm.nih.gov/articles/PMC6311979/)[](https://www.sarstedt.com/en/products/laboratory-
automation/sample-transportation-system-tempus1800/)
➢ A study in Southwestern India reduced emergency RBC TAT from 17.1 to 14.9 minutes through process improvements.
(https://journals.lww.com/gjtm/fulltext/2023/08020/improving_turnaround_time_for_the_issue_of_blood.14.aspx)
For precise TATs, hospitals should monitor their processes and tailor protocols to minimize delays, especially for emergencies. If you need
specifics for a particular component or setting, let me know!
Turnaround time for issue of blood
and blood components
Dr. J. L. Meena

Percentage of modification of
anaesthesia plan
The percentage of modification of an anesthesia plan depends on various factors, such as
patient condition, surgical requirements, and clinical judgment. However, there isn't a
universal "anesthesia plan formula" with a fixed percentage of modification, as plans are
highly individualized and adjusted based on real-time data.
Studies suggest that anesthesia plans may be modified in *20-40% of cases*
intraoperatively due to factors like hemodynamic changes, unexpected surgical
complications, or patient response to anesthesia. For example:
- A 2018 study in Anesthesia & Analgesia reported that approximately *30% of cases*
required intraoperative adjustments to the anesthesia plan due to changes in patient status
or surgical needs.
- Modifications can include changes in drug dosage, type of anesthesia (e.g., general to
regional), or airway management strategies.
Dr. J. L. Meena

Percentage of Modification = Number of Modified Anesthesia Plans / Total Number of Anesthesia Plans *100
Steps to Apply:
1. Define "Modification": Clarify what constitutes a modification (e.g., change in anesthetic agent, dosage, technique, or
addition/removal of procedures).
2. Collect Data:
- Count the total number of anesthesia plans reviewed (denominator).
- Identify how many plans were modified (numerator).
3. Calculate:
- Divide the number of modified plans by the total number of plans.
- Multiply by 100 to express as a percentage.
Example:
If 20 out of 100 anesthesia plans were modified: 20/100*100 = 20%
Notes:
- Ensure the definition of "modification" is consistent to avoid bias.
- If you're referring to a specific clinical guideline, study, or protocol (e.g., from a hospital or research paper), please
provide more details, and I can tailor the formula or explanation.
Percentage of modification of
anaesthesia plan
Dr. J. L. Meena

Percentage of unplanned
ventilation following anaesthesia
The incidence of unplanned ventilation following anesthesia varies depending on the context,
patient population, and type of surgery. Studies generally report rates of *unplanned
postoperative ventilation* (requiring reintubation or prolonged mechanical ventilation) ranging
from *0.5% to 5%* in general surgical populations.
- A large retrospective study from the American College of Surgeons National Surgical Quality
Improvement Program (NSQIP) database found an incidence of *unplanned intubation* within
30 days post-surgery to be approximately *2-3%* for major surgeries.
- Risk factors like emergency surgery, advanced age, high ASA physical status, and prolonged
operative time increase the likelihood, with rates potentially exceeding *10%* in high-risk
groups (e.g., cardiac or neurosurgery patients).
- For specific procedures, such as abdominal or thoracic surgeries, rates of prolonged
ventilation may be higher, around *4-6%*, due to respiratory complications.
Dr. J. L. Meena

Percentage of unplanned ventilation following anesthesia is:
Percentage of Unplanned Ventilation = Number of Unplanned Ventilation Cases / Total Number of Anesthesia
Cases * 100
Explanation:
Numerator: The number of cases where unplanned ventilation (e.g., unexpected need for mechanical
ventilation post-anesthesia) occurred.
Denominator: The total number of anesthesia cases performed in the same period.
* Multiply by 100 to express the result as a percentage.
Notes:
* Ensure the data for unplanned ventilation cases is clearly defined (e.g., based on clinical records or specific
criteria like ICU admission for ventilation).
* The formula assumes accurate documentation of both unplanned ventilation events and total anesthesia
cases.
Percentage of unplanned
ventilation following anaesthesia
Dr. J. L. Meena

Percentage of adverse
anaesthesia events
The percentage of adverse anaesthesia events varies across studies:
General Incidence: Studies suggest adverse events in anaesthesia occur in approximately 0.0075% to 2.5% of cases, depending on the
context and criteria. For example, a study in Australia and New Zealand reported a serious incident rate of 2.5%, with half related to
airway issues and 40% to cardiovascular events.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC9391881/)
Specific Events:
✓ Medication Errors: These account for a significant portion, with one study noting a frequency of 0.0075% per anaesthetic case,
primarily due to incorrect doses or drug substitutions.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC6545954/)
✓ Awareness During Anaesthesia: This rare but serious event occurs in 0.1–0.2% of cases (1–2 per 1,000 patients), potentially leading to
psychological
distress.[](https://pmc.ncbi.nlm.nih.gov/articles/PMC2900098/)[](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900098/)
✓ Postoperative Nausea and Vomiting (PONV): A common issue, affecting 20–30% of patients post-anaesthesia, influenced by factors
like anaesthetic agents and surgical type.[](https://www.sciencedirect.com/science/article/abs/pii/S0140673603148003)
✓ Cardiovascular and Respiratory Events: In a Colombian study, these comprised 55.4% and 36.7% of adverse events, respectively, with
50.3% of cases resulting in death and 22.3% in cerebral insult.[](https://www.elsevier.es/es-revista-colombian-journal-
anesthesiology-342-articulo-characterization-analysis-adverse-events-in-S2256208716300268)
Dr. J. L. Meena

Context-Specific Data:
- In cesarean deliveries in New York State, 5.7% of cases used general anaesthesia without clinical indication, associated
with increased risks of complications like surgical site infections and venous thromboembolism.
[](https://pubs.asahq.org/anesthesiology/article/130/6/912/18336/Adverse-Events-and-Factors-Associated-with)
- In a Brazilian study, 87% of complications involved perioperative cardiac arrest, airway issues, or other events, with the
operating room being the most common site (78.1%).[](https://pmc.ncbi.nlm.nih.gov/articles/PMC9391881/)
Variability and Limitations: The reported percentages vary due to inconsistent definitions (e.g., “adverse event” vs.
“critical incident”), underreporting, and differences in study design. For instance, only 1 of 103 minor events observed in
one study was formally reported, suggesting underestimation. Additionally, time of day can influence rates, with higher
incidences (up to 4.2%) for cases starting around 4 PM compared to 1% at 9 AM.
[](https://academic.oup.com/bja/article/96/6/715/328199)[](https://pmc.ncbi.nlm.nih.gov/articles/PMC2564010/)
Conclusion: While anaesthesia is safer today than decades ago, adverse events still occur in a small but notable fraction of
cases, ranging from less than 0.01% for specific errors to 20–30% for common issues like PONV. Severe outcomes like
death or awareness are rare (0.0004% to 0.2%). For precise figures, more standardized reporting and context-specific data
are needed.
anaesthesia events
Dr. J. L. Meena

anaesthesia events
Percentage of adverse anaesthesia events
Percentage of adverse events = Number of adverse anaesthesia events / Total number of anaesthesia
procedures * 100
Explanation:
➢ Number of adverse anaesthesia events: The count of cases where an adverse event occurred during
anaesthesia (e.g., complications like allergic reactions, respiratory issues, etc.).
➢ Total number of anaesthesia procedures: The total number of anaesthesia administrations in the same
time period or study group.
➢ Multiply by 100 to convert the fraction into a percentage.
For example, if there were 5 adverse events out of 200 anaesthesia procedures: 5/200*100 = 2.5%
Dr. J. L. Meena

Anaesthesia related mortality rate
The anesthesia-related mortality rate is low but varies by context.
Global estimates suggest a rate of about 1-2 deaths per 100,000
procedures directly attributable to anesthesia. In high-income
countries with modern equipment and trained staff, it’s often lower,
around 0.1-0.4 per 100,000. Factors like patient health, procedure
complexity, and access to emergency care influence outcomes. In
low-resource settings, rates can be higher due to limited monitoring
and drug availability. Data from the American Society of
Anesthesiologists (ASA) indicates mortality within 48 hours of
anesthesia is roughly 1 in 200,000 for healthy patients (ASA I-II).
Dr. J. L. Meena

Anaesthesia related mortality rate
Anesthesia-related mortality rate is typically calculated as the number of deaths directly attributable to anesthesia divided by the total
number of anesthetic procedures performed, often expressed as a percentage or per 100,000 cases.
Anesthesia-Related Mortality Rate = Number of Anesthesia-Related Deaths / Total Number of Anesthetic Procedures * 100,000
Notes:
➢ Numerator: Includes deaths caused directly by anesthesia (e.g., complications like anaphylaxis, overdose, or airway mismanagement).
Deaths from surgical or patient-related factors are excluded unless anesthesia contributed.
➢ Denominator: Total number of procedures where anesthesia was administered (general, regional, or local).
➢ Time Frame: Usually calculated over a specific period (e.g., per year).
➢ Expression: Often reported per 100,000 cases for standardization, as anesthesia-related deaths are rare.
Example:
If 5 deaths are attributed to anesthesia in 500,000 procedures: 5/500000*100,000 = 1 death per 100,000 procedures
Considerations:
- Data accuracy depends on clear attribution of death to anesthesia, which can be complex.
- Rates vary by region, hospital, and anesthesia type. Modern rates are low (e.g., 0.5–2 per 100,000 in high-income countries) due to
improved safety.
Dr. J. L. Meena

Dr. J. L. Meena

Nurse patient ratio for ICUs and
wards
Intensive Care Units (ICUs)
➢ Ventilated patients: 1:1 nurse-to-patient ratio is recommended for patients on ventilators in ICUs and post-op recovery rooms.
➢ Non-ventilated patients: 1:2 nurse-to-patient ratio is suggested for patients not on ventilators in ICUs and post-op recovery
rooms.
➢ General ICU ratio: Some sources suggest a 1:2 ratio for ICUs, while others recommend 1:1 for each shift with a 30% leave
reserve .
General Wards
➢ General wards: 1:6 nurse-to-patient ratio is recommended for general wards.
➢ Super specialty wards: 1:4 nurse-to-patient ratio is suggested for super specialty wards.
➢ High dependency units: 1:3 nurse-to-patient ratio is recommended for high dependency units .
Other Units
➢ Pediatric ward: 1:5 nurse-to-patient ratio.
➢ Neonatal ICU: 1:1 nurse-to-patient ratio.
➢ Emergency and Trauma: 1:1 for ventilated patients and 1:2 for non-ventilated patients.
➢ Labor room: 2 nurses per labor table.
➢ Operation theaters: 2 nurses for each major OT table and 1 nurse for each minor OT table .
Dr. J. L. Meena

Dr. J. L. Meena

Waiting time for out-patient
consultation
Waiting times for outpatient consultations can vary significantly depending on several factors, including the type of clinic, patient load,
and efficiency of the healthcare system.
Average Waiting Times
➢ Registration to consultation: 41 minutes is the average waiting time from registration to seeing a physician.
➢ Total waiting time: 92% of patients wait 90 minutes or less to see a doctor, with an average total waiting time of 41 minutes.
➢ Consultation time: The average consultation time with a doctor is around 18.21 minutes, with most patients spending between 10-
20 minutes with the doctor.
Factors Affecting Waiting Times
➢ Patient arrival patterns: Scheduling appointments and managing patient arrivals can significantly impact waiting times.
➢ Consultation time variability: Variations in consultation times can lead to longer waiting times for individual patients.
➢ Resource alignment and operational efficiencies: Implementing strategies to optimize resource allocation and streamline processes
can help reduce waiting times.
Strategies to Reduce Waiting Times
➢ Online pre-registration: Implementing online pre-registration can help reduce waiting times for walk-in patients.
➢ Shared medical appointments: Innovative approaches like shared medical appointments and group office visits can increase capacity
and reduce waiting times.
➢ Phone, email, and video consultations: Alternative consultation methods can help reduce waiting times and improve patient
satisfaction.
Dr. J. L. Meena

The formula to calculate waiting time for outpatient consultation is:
Waiting Time = Time of Consultation - Time of Arrival
Explanation
1. Time of Consultation: Record the time when the patient is seen by the healthcare provider.
2. Time of Arrival: Record the time when the patient arrives at the outpatient department.
Calculation
Subtract the time of arrival from the time of consultation to get the waiting time.
Example
If a patient arrives at 9:00 AM and is seen by the healthcare provider at 9:30 AM, the waiting time would be
30 minutes.
Waiting time for out-patient
consultation
Dr. J. L. Meena

Dr. J. L. Meena

Waiting time for diagnostics
Diagnostic test waiting times vary depending on the type of test and location.
Median Waiting Time
The median waiting time for diagnostic tests was around 2.6 weeks in January 2024, down from 2.9 weeks in January 2023. However,
waiting times increased significantly during the COVID-19 pandemic, peaking at 8.6 weeks in May 2020 ¹.
Waiting Times by Test Type
➢ Common tests with relatively low waiting times:
- CT scans: 16% of people waited over six weeks
- Non-obstetric ultrasounds: 21.3% of people waited over six weeks
➢ Less common tests with longer waiting times:
- Audiology assessments: 31-41% of people waited over six weeks
- Echocardiographies: 31-41% of people waited over six weeks
- Gastroscopies: 31-41% of people waited over six weeks
- Colonoscopies: 31-41% of people waited over six weeks
Variations in Waiting Times
Waiting times can vary significantly depending on the location and specific healthcare provider. Some reports suggest that radiology
tests account for most waits between 26-52 weeks, while endoscopy tests account for most waits over 52 weeks.
Dr. J. L. Meena

The formula to calculate waiting time for diagnostics is:
Waiting Time = Time of Test Completion - Time of Test Order
Explanation
1. Time of Test Completion: Record the time when the diagnostic test is completed.
2. Time of Test Order: Record the time when the diagnostic test is ordered.
Calculation
Subtract the time of test order from the time of test completion to get the waiting time.
Example
If a test is ordered at 9:00 AM on Monday and completed at 2:00 PM on Wednesday, the waiting time would
be 2 days and 5 hours.
Waiting time for diagnostics
Dr. J. L. Meena

Dr. J. L. Meena

Time taken for discharge
The time taken for discharge from a hospital can vary depending on several factors, including the complexity
of the patient's condition, the efficiency of the hospital's discharge process, and the availability of necessary
documentation and transportation.
Factors Affecting Discharge Time
1. Documentation and paperwork: Completing necessary paperwork and documentation can take time.
2. Medication and treatment instructions: Providing patients with clear instructions on medication and
follow-up care can add to discharge time.
3. Transportation arrangements: Coordinating transportation for patients can also impact discharge time.
Strategies to Reduce Discharge Time
1. Streamlined discharge processes: Implementing efficient discharge processes can help reduce delays.
2. Early planning: Starting discharge planning early in the patient's stay can help identify potential issues and
reduce delays.
3. Clear communication: Ensuring clear communication among healthcare providers, patients, and families
can also help facilitate a smoother discharge process.
Dr. J. L. Meena

The formula to calculate the time taken for discharge is:
Discharge Time = Time of Discharge Order - Time of Discharge Completion
Alternatively, it can be calculated as:
Discharge Time = Time Patient Leaves Hospital - Time Discharge Process Starts
Explanation
1. Time of Discharge Order: Record the time when the discharge order is written.
2. Time of Discharge Completion: Record the time when the patient is actually discharged.
3. Time Patient Leaves Hospital: Record the time when the patient leaves the hospital.
4. Time Discharge Process Starts: Record the time when the discharge process begins.
Calculation
Subtract the start time from the completion time to get the discharge time.
Example
If the discharge process starts at 10:00 AM and the patient leaves the hospital at 12:00 PM, the discharge time would be 2 hours.
Time taken for discharge
Dr. J. L. Meena

25. (PSQ 3c )- Percentage of medical records having
incomplete and /or improper consent
Dr. J. L. Meena

Percentage of medical records having
Medical records with incomplete and/or improper consent can lead to:
Risks and Consequences
1. Legal issues: Incomplete or improper consent can lead to legal disputes and potential lawsuits.
2. Patient safety: Lack of informed consent can compromise patient safety and autonomy.
3. Regulatory non-compliance: Failure to obtain proper consent can result in regulatory non-compliance and potential penalties.
Best Practices
1. Clear documentation: Ensure that consent is clearly documented in the medical record.
2. Patient education: Provide patients with adequate information about their treatment options and risks.
3. Informed consent process: Follow a standardized informed consent process to ensure that patients understand the risks and
benefits of treatment.
Importance
Proper consent is essential for:
1. Patient autonomy: Respecting patients' rights to make informed decisions about their care.
2. Trust and transparency: Building trust between healthcare providers and patients.
3. Quality care: Ensuring that patients receive high-quality care that meets their needs and expectations.
Dr. J. L. Meena

Calculating the percentage of medical records with incomplete or improper consent involves tracking the number
of records with consent issues and dividing it by the total number of medical records, then multiplying by 100.
Percentage = (Number of medical records with incomplete/improper consent / Total number of medical records) x
100
Importance
Monitoring this metric helps hospitals identify areas for improvement in their consent processes, ensuring patients
are adequately informed and empowered to make decisions about their care .
Best Practices
- Clear documentation: Ensure consent forms are thoroughly completed and signed.
- Patient education: Provide patients with comprehensive information about treatments and risks.
- Standardized consent process: Implement a consistent process for obtaining informed consent .
Percentage of medical records having
Dr. J. L. Meena

Dr. J. L. Meena

Stock out of Emergency
medications
Stockouts of emergency medications can be critical, especially when it comes to life-saving treatments. Here are some key points to
consider:
Essential Emergency Medications like:
- Epinephrine: For anaphylaxis and other severe allergic reactions
- Naloxone: For opioid overdoses
- Amiodarone: For cardiac arrhythmias
- Aspirin: For suspected myocardial infarction
- Nitroglycerin: For severe angina symptoms
- Glucose: For diabetic or hypoglycemic emergencies
- Antidotes and reversal agents: Such as naloxone for opioid overdoses
- Vasoactive agents: Like dopamine, norepinephrine, and vasopressin for critical care situations
Consequences of Stockouts:
- Delayed treatment can lead to increased morbidity and mortality
- Increased burden on healthcare systems
- Potential for adverse outcomes due to lack of timely intervention
Dr. J. L. Meena

Strategies to Mitigate Stockouts:
- Automated dispensing cabinets: Can provide quick access to emergency medications
- Regular inventory management: Ensures medications are not expired or near expiration
- 24-hour pharmacies: Can provide access to emergency medications outside regular hours
- Emergency kits: Pre-assembled kits with essential medications can help in crisis situations
Best Practices:
- Regularly review and update emergency medication lists
- Ensure proper storage and maintenance of emergency medications
- Train staff on emergency medication administration and storage
- Consider emergency preparedness kits with essential medications
Stock out of Emergency
medications
Dr. J. L. Meena

The formula to calculate the stockout rate of emergency medications is:
Stockout Rate = (Number of Emergency Medications Out of Stock / Total Number of Emergency Medications) x 100
Explanation
1. Number of Emergency Medications Out of Stock: Count the number of emergency medications that are currently out of
stock.
2. Total Number of Emergency Medications: Determine the total number of emergency medications that should be
stocked.
Calculation
Divide the number of emergency medications out of stock by the total number of emergency medications, and then
multiply by 100 to get the stockout rate as a percentage.
Example
If 5 out of 20 emergency medications are out of stock, the stockout rate would be (5/20) x 100 = 25%.
Stock out of Emergency medications
Dr. J. L. Meena

Dr. J. L. Meena

No. of variations observed in mock
drills
The number of variations observed in mock drills in hospitals can vary depending on several factors, including:
Types of Variations
1. Response time: Variations in response time to emergency situations.
2. Communication: Differences in communication among team members.
3. Procedure adherence: Variations in adherence to established protocols and procedures.
4. Equipment usage: Differences in equipment usage and handling.
5. Teamwork and coordination: Variations in teamwork and coordination among team members.
Importance of Mock Drills
1. Identifying areas for improvement: Mock drills help identify areas for improvement in emergency response.
2. Enhancing preparedness: Regular mock drills enhance hospital preparedness for emergency situations.
3. Improving patient safety: Mock drills help improve patient safety by identifying and addressing potential issues.
Benefits of Analyzing Variations
1. Targeted training: Analyzing variations helps identify areas for targeted training.
2. Process improvement: Identifying variations can lead to process improvements.
3. Enhanced patient care: By addressing variations, hospitals can enhance patient care and safety.
Dr. J. L. Meena

The formula to calculate the number of variations observed in mock drills in hospitals can be:
Number of Variations = Total Number of Observed Actions - Number of Actions Performed According to Protocol
Explanation
1. Total Number of Observed Actions: Count the total number of actions observed during the mock drill.
2. Number of Actions Performed According to Protocol: Count the number of actions that were performed according to
established protocols.
Calculation
Subtract the number of actions performed according to protocol from the total number of observed actions to get the
number of variations.
Example
If 100 actions were observed during a mock drill and 80 were performed according to protocol, the number of variations
would be 100 - 80 = 20.
No. of variations observed in mock
drills
Dr. J. L. Meena

28.(PSQ 3d )- Patient fall rate (falls per 1000 patient
days)
Dr. J. L. Meena

Patient fall rate (falls per 1000
patient days)
Patient fall rates in hospitals vary depending on several factors, including hospital type, patient demographics and ward type.
- Overall fall rates:
- 0.85 falls per 1000 patient days in a study of 86 hospitals
- 3.4% of patients experiencing a fall in a Swiss study, translating to varying fall rates across hospital types
- Fall rates by hospital type:
- Tertiary hospitals: 0.48 falls per 1000 patient days
- General hospitals: 1.04 falls per 1000 patient days
- Semi-hospitals: 0.63 falls per 1000 patient days
- University hospitals: 3.8% (highest among hospital types)
- Fall rates by ward type:
- Intensive Care Unit: 1.30 falls/1000 patient days
- Surgical: 2.79 falls/1000 patient days
- Medical: 4.54 falls/1000 patient days
- Rehabilitation: 7.15 falls/1000 patient days
- Other findings:
- A study in a multi-specialty hospital reported an incidence rate of 3.8 falls per 1000 patient days
- Another study found fall rates of 5.51 and 15.83 per 1000 patient bed days in multi-bedded wards and single rooms, respectively
Dr. J. L. Meena

The patient fall rate is a key metric used to measure the safety and quality of care in healthcare settings.
Patient Fall Rate = (Number of Falls / Total Patient Days) x 1000
Explanation
1. Number of Falls: Count the total number of patient falls during a specified period.
2. Total Patient Days: Calculate the total number of patient days during the same period.
Calculation
Divide the number of falls by the total patient days, and then multiply by 1000 to get the fall rate per 1000 patient days.
Example
If there were 10 falls during a month with 3000 patient days, the patient fall rate would be (10 / 3000) x 1000 = 3.33 falls
per 1000 patient days.
Importance
Monitoring patient fall rates helps healthcare providers identify areas for improvement and implement strategies to
reduce falls and enhance patient safety.
Patient fall rate (falls per 1000
patient days)
Dr. J. L. Meena

Dr. J. L. Meena

Percentage of near misses
Near misses in hospitals refer to errors or incidents that occur during patient care but do not result in harm or injury.
These incidents can provide valuable insights into potential safety risks and areas for improvement.
Types of Near Misses:
- Medication errors: Wrong medication or dosage administered but caught before harming the patient
- Equipment malfunctions: Medical equipment fails but is replaced or fixed before use
- Communication breakdowns: Miscommunication between healthcare providers that could have led to errors
- Patient falls: Patients nearly fall but are caught or supported by staff
Importance of Reporting Near Misses:
- Prevents future harm: Analyzing near misses helps identify potential safety risks and implement corrective actions
- Improves patient safety: Reporting near misses promotes a culture of safety and transparency
- Enhances staff awareness: Educates staff on potential hazards and encourages vigilance
Dr. J. L. Meena

Challenges in Reporting Near Misses:
- Fear of repercussions: Staff may hesitate to report near misses due to fear of blame or punishment
- Lack of understanding: Staff may not recognize what constitutes a near miss or understand its significance
- Underreporting: Studies suggest that up to 86% of patient safety incidents, including near misses, go
unreported
Benefits of a Strong Near Miss Reporting System:
- Increased employee relationships and teamwork
- Improved safety culture
- Reduced risk of adverse events
- Lessons learned: Analyzing near misses provides valuable insights for improving patient care and safety
Dr. J. L. Meena

The formula to calculate the rate of near misses in hospitals can be:
Near Miss Rate = (Number of Near Misses / Total Number of Opportunities) x 100
Explanation
1. Number of Near Misses: Count the number of near misses reported during a specified period.
2. Total Number of Opportunities: Determine the total number of opportunities for near misses to occur (e.g., total
number of patient interactions, procedures, or medications administered).
Calculation
Divide the number of near misses by the total number of opportunities, and then multiply by 100 to get the near miss
rate as a percentage.
Example
If there were 50 near misses and 10,000 patient interactions during a month, the near miss rate would be (50 / 10,000) x
100 = 0.5%.
Dr. J. L. Meena

Dr. J. L. Meena

Incidence of needle stick injuries
Needle stick injuries (NSIs) are a significant concern in healthcare settings.
Causes of NSI
1. Recapping needles: Recapping needles is a common cause of NSIs.
2. Improper disposal: Improper disposal of sharps can lead to NSIs.
3. Patient movement: Unexpected patient movement during procedures can increase the risk of NSIs.
1. Use safety-engineered devices: Devices with built-in safety features can reduce NSI risk.
2. No-touch technique: Using a no-touch technique when handling sharps can minimize risk.
3. Proper training: Regular training on safe needle handling and disposal is essential.
4. Personal protective equipment: Wearing personal protective equipment, such as gloves, can reduce exposure risk.
Consequences of NSI
1. Bloodborne pathogen transmission: NSIs can transmit bloodborne pathogens, such as HIV, hepatitis B, and hepatitis C.
2. Emotional distress: NSIs can cause significant emotional distress and anxiety.
3. Post-exposure prophylaxis: Healthcare workers may require post-exposure prophylaxis (PEP) after an NSI.
Importance of Reporting NSIs
1. Timely treatment: Reporting NSIs ensures timely treatment and reduces the risk of infection.
2. Safety protocol evaluation: Analyzing NSI data helps evaluate safety protocols and identify areas for improvement.
3. Protecting healthcare workers: Reporting NSIs prioritizes the health and safety of healthcare workers.
Dr. J. L. Meena

The incidence of needle stick injuries (NSIs) can vary depending on several factors, including:
Factors Affecting NSI Incidence
1. Occupation: Healthcare workers, particularly nurses and physicians, are at higher risk.
2. Work environment: Busy or high-stress environments can increase the risk of NSIs.
3. Safety protocols: Adherence to safety protocols and use of safety-engineered devices can reduce NSI incidence.
Consequences of NSIs
1. Infection risk: NSIs can transmit bloodborne pathogens, such as HIV, hepatitis B, and hepatitis C.
2. Emotional distress: NSIs can cause significant emotional distress and anxiety.
1. Safety-engineered devices: Use devices with built-in safety features, such as retractable needles.
2. Proper training: Provide regular training on safe needle handling and disposal.
3. Personal protective equipment: Use personal protective equipment, such as gloves, to reduce exposure risk.
Importance of Reporting NSIs
1. Tracking incidence: Reporting NSIs helps track incidence and identify areas for improvement.
2. Improving safety: Analyzing NSI data can inform safety protocols and reduce future risk.
3. Protecting healthcare workers: Reporting NSIs ensures that healthcare workers receive timely and appropriate care.
Dr. J. L. Meena

The formula to calculate the incidence of needle stick injuries (NSIs) is:
Incidence Rate = (Number of NSIs / Total Number of Person-Hours Worked) x 100 or x 1,000 or x 10,000
Explanation
1. Number of NSIs: Count the number of needle stick injuries reported during a specified period.
2. Total Number of Person-Hours Worked: Calculate the total number of person-hours worked by healthcare workers
during the same period.
Calculation
Divide the number of NSIs by the total number of person-hours worked, and then multiply by a standard unit (e.g., 100,
1,000, or 10,000) to express the incidence rate.
Example
If there were 10 NSIs and 100,000 person-hours worked during a year, the incidence rate would be (10 / 100,000) x 1,000
= 0.1 NSIs per 1,000 person-hours worked.
Dr. J. L. Meena

31. (PSQ 3d )- Appropriate handovers during shift
change(to be done separately for doctors and nurses)-
(per patient per shift)
Dr. J. L. Meena

Appropriate handovers during shift change(to
be done separately for doctors and nurses)-
Effective handovers during shift changes are crucial for ensuring continuity of care and patient safety. Here's a structured
approach for doctors and nurses:
Key Elements of Handovers
1. Patient identification: Clearly identify the patient and their location.
2. Current status: Provide an update on the patient's current condition, including any changes or concerns.
3. Treatment plan: Review the patient's treatment plan, including medications, tests, and procedures.
4. Pending tasks: Identify any pending tasks or actions that need to be completed during the upcoming shift.
5. Concerns and questions: Address any concerns or questions the incoming team may have.
Best Practices for Handovers
1. Standardized format: Use a standardized format for handovers to ensure consistency and completeness.
2. Face-to-face communication: Conduct handovers in person to facilitate clear communication and questions.
3. Minimize distractions: Minimize distractions during handovers to ensure focus on the patient information.
4. Documentation: Document the handover process and any agreed-upon actions.
Dr. J. L. Meena

Handover Tools
1. SBAR (Situation, Background, Assessment, Recommendation): A structured framework for communicating patient
information.
2. ISBAR (Identification, Situation, Background, Assessment, Recommendation): An extension of SBAR that includes
patient identification.
Benefits of Effective Handovers
1. Improved patient safety: Reduces errors and ensures continuity of care.
2. Enhanced teamwork: Fosters collaboration and communication among healthcare teams.
3. Reduced adverse events: Helps prevent adverse events and near misses.
Challenges and Solutions
1. Time constraints: Allocate sufficient time for handovers and prioritize patient information.
2. Communication barriers: Use clear and concise language, and encourage questions and clarification.
3. Electronic health records: Leverage electronic health records to support handovers and ensure accurate information.
Dr. J. L. Meena

The formula to calculate the appropriateness of handovers during shift changes can be:
Handover Appropriateness Rate = (Number of Handovers Meeting Criteria / Total Number of Handovers) x 100
Explanation
1. Number of Handovers Meeting Criteria: Count the number of handovers that meet established criteria for appropriateness (e.g.,
completeness, accuracy, and timeliness).
2. Total Number of Handovers: Determine the total number of handovers observed or audited during a specified period.
Calculation
Divide the number of handovers meeting criteria by the total number of handovers, and then multiply by 100 to get the handover
appropriateness rate as a percentage.
Example
If 80 out of 100 handovers met the established criteria, the handover appropriateness rate would be (80 / 100) x 100 = 80%.
Separate Calculation for Doctors and Nurses
Calculate the handover appropriateness rate separately for doctors and nurses to identify areas for improvement specific to each
profession.
Dr. J. L. Meena

32.(PSQ 3d )- Compliance to rate to Medication
Prescription in capitals
Dr. J. L. Meena

Compliance to rate to Medication
Medication prescription in hospitals is crucial for several reasons:
Patient Safety
1. Accurate treatment: Ensures patients receive the correct medication and dosage.
2. Reduced adverse events: Minimizes the risk of medication errors and adverse reactions.
Effective Care
1. Targeted therapy: Enables healthcare providers to tailor treatment to individual patient needs.
2. Improved outcomes: Enhances patient outcomes by ensuring timely and appropriate medication administration.
Quality Assurance
1. Standardized protocols: Promotes adherence to established guidelines and protocols.
2. Continuous improvement: Allows for ongoing evaluation and improvement of medication use practices.
Regulatory Compliance
1. Accreditation standards: Meets regulatory requirements and accreditation standards.
2. Risk management: Helps mitigate risks associated with medication errors and adverse events.
Patient Trust
1. Confidence in care: Fosters trust between patients and healthcare providers.
2. Informed decision-making: Enables patients to make informed decisions about their care.
Overall Benefits
1. Enhanced patient care: Supports high-quality patient care and improves health outcomes.
2. Reduced healthcare costs: Minimizes costs associated with medication errors and adverse events.
3. Improved healthcare system: Contributes to a safer and more effective healthcare system.
Dr. J. L. Meena

Medication prescription compliance in capitals can be measured using various metrics. Here are some possible ways to calculate compliance:
Compliance Rate = (Number of Prescriptions Meeting Criteria / Total Number of Prescriptions) x 100
Explanation
1. Number of Prescriptions Meeting Criteria: Count the number of prescriptions that meet established criteria (e.g., accuracy, completeness, and adherence to
guidelines).
2. Total Number of Prescriptions: Determine the total number of prescriptions audited or reviewed during a specified period.
Calculation
Divide the number of prescriptions meeting criteria by the total number of prescriptions, and then multiply by 100 to get the compliance rate as a percentage.
Example
If 90 out of 100 prescriptions met the established criteria, the compliance rate would be (90 / 100) x 100 = 90%.
Key Performance Indicators (KPIs)
1. Accuracy rate: Percentage of prescriptions with accurate medication orders.
2. Completeness rate: Percentage of prescriptions with complete information (e.g., dosage, frequency, and duration).
3. Adherence rate: Percentage of prescriptions adhering to established guidelines or protocols.
Benefits of Measuring Compliance
1. Improved patient safety: Enhances medication safety and reduces adverse events.
2. Quality improvement: Identifies areas for improvement and informs quality initiatives.
3. Optimized medication use: Promotes evidence-based prescribing practices.
Compliance to rate to Medication
Dr. J. L. Meena

Summary
The National Accreditation Board for Hospitals and Healthcare Providers (NABH) emphasizes
Patient Safety and Quality Improvement (PSQ) to ensure high-quality care. Key aspects include:
Key Aspects of PSQ
1. Patient-centered care: Focus on patient needs and preferences.
2. Safety protocols: Implementation of safety protocols to prevent adverse events.
3. Quality improvement: Continuous monitoring and improvement of care processes.
4. Risk management: Identification and mitigation of risks to patient safety.
5. Staff training: Education and training for staff on safety and quality.
Goals
1. Improve patient outcomes: Enhance patient safety and quality of care.
2. Reduce adverse events: Minimize errors and adverse events.
3. Enhance patient satisfaction: Foster a culture of safety and quality.
Dr. J. L. Meena

Quality is a Team
Work, Never Achieve
by a Single Person
Quality Never
Improve without
Truth
Jo Aap Ko
Chahiye, Bo
Dusron Ko Do
Quality Coming
from your Heart
Self Assessment
is the Best
Assessment for
Quality
Dr. J. L. Meena
Total 639 Objective Elements
v 100 are in core category which will be
mandatorily assessed during each
assessment,
v 457 are in commitment category which
will be assessed during final
assessment,
v 60 are in achievement category which
will be assessed during surveillance
assessment
v 17 are in excellence category which will
be assessed during re- accreditation.
This will help the healthcare organisation
in step wise progression to mature quality
system covering the full accreditation cycle.

Key for Quality
"Improving safety and quality of care should be a
central concern for all those in the healthcare
system: policy makers, managers and health
practitioners alike."
Dr. J. L. Meena

The Framework for Managing the
Quality of Health Services
Focuses on the quality of care.
Ø Provides clear accountability for the quality of health are with a systemic orientation.
Ø Provides the principles for managing the quality of health services.
Ø Provides an organizational focus for quality activities and reporting, while recognizing the
essential role played by health care professionals in quality improvement.
Ø Is aimed at the top level but is applicable also, at the facility or service level.
Ø Describes the infrastructure needed to facilitate the statewide coordination, monitoring,
evaluation, reporting and feedback on health care quality and which builds on and supports local
health service quality processes.
Ø Establishes a means by which lessons learned can be shared with other parts of the health
system.
Ø Provides a stable framework for the necessary ongoing development and maturing of quality
indicators and processes .
Ø Recognizes the essential cultural requirement of continuous quality improvement.
Dr. J. L. Meena

Management Responsibility
A. Top level Management Commitment: - ultimately responsible for Quality System, roles and responsibilities and
authorities are in place and communicated by:-
Ø Involvement in Quality System lifecycle: - Design, implementation, monitoring and maintenance.
Ø Active support for Quality System: - walk and talk.
Ø Communication: - timely and effective, known communication process .
Ø Roles and Responsibilities.
Ø Management Reviews: - Assessment of Quality healthcare System.
Ø Continual Improvement: - don't accept status.
Ø Resource Management:- Set & allocate resources according to priorities.
B. Quality Policy:- Overall intention and direction
C. Quality Planning:- Make straight objectives with strategy.
D. Resource Management:- Determine and provide adequate resources .
E. Internal Communication:- Appropriate and timely communication at all levels.
F. Management Review:- Continued review of suitability & effectiveness of Quality System.
G. Management of Outsourced Activities and Purchased Materials:- Responsibility lies with company for outsourced
activities and material.
H. Management of Change in Product Ownership:- Establish clear roles and responsibilities.
Dr. J. L. Meena

Top level management
Top-level management embodies a blend of strategic vision, emotional intelligence, and
operational excellence.
1. Visionary Leadership: Sets a clear, inspiring long-term vision while aligning the
organization’s goals. Communicates purpose effectively to motivate teams.
2. Decision-Making: Balances data-driven insights with intuition. Decisive yet open to
feedback, ensuring informed choices under pressure.
3. Emotional Intelligence: Builds trust through empathy, active listening, and
adaptability. Manages conflicts constructively and fosters a positive culture.
4. Strategic Delegation: Empowers teams by assigning responsibilities based on
strengths, while maintaining accountability without micromanaging.
5. Adaptability: Navigates change and uncertainty with agility, pivoting strategies as
market or internal dynamics shift.
Dr. J. L. Meena

6. Communication: Transparent and consistent in sharing goals, expectations, and feedback.
Encourages open dialogue across levels.
7. Results-Oriented: Drives performance by setting measurable objectives, tracking progress, and
celebrating achievements.
8. Ethical Integrity: Models honesty, fairness, and social responsibility, ensuring decisions align with
organizational values.
Structure for Success:
Ø Diverse Team: Builds a complementary leadership team with varied skills and perspectives.
Ø Continuous Learning: Invests in personal growth and encourages team development.
Ø Stakeholder Engagement: Balances needs of employees, customers, investors, and communities.
Effective top-level management aligns people, processes, and purpose to achieve sustainable
growth while fostering an inclusive, innovative environment.
Top level management
Dr. J. L. Meena

Key responsibility of the
management
The management of a hospital has several key responsibilities:
Strategic Planning
1. Developing a clear vision and mission: Defining the hospital's purpose, goals, and
values.
2. Creating a strategic plan: Outlining the hospital's objectives, strategies, and tactics to
achieve its mission.
Operational Management
1. Overseeing daily operations: Ensuring the hospital runs smoothly and efficiently.
2. Managing resources: Allocating resources, such as staff, equipment, and supplies, to
meet patient needs.
3. Maintaining facilities: Ensuring the hospital's facilities are safe, clean, and well-
maintained.
Dr. J. L. Meena

Quality Improvement
1. Ensuring high-quality patient care: Implementing quality improvement initiatives to enhance patient
outcomes.
2. Monitoring patient satisfaction: Collecting feedback and data to identify areas for improvement.
3. Implementing evidence-based practices: Promoting the use of best practices and guidelines to improve patient
care.
Financial Management
1. Managing budgets: Developing and managing budgets to ensure the hospital's financial sustainability.
2. Controlling costs: Identifying opportunities to reduce costs without compromising patient care.
3. Investing in technology and infrastructure: Investing in technology and infrastructure to improve patient care
and operational efficiency.
Human Resources
1. Recruiting and retaining staff: Attracting and retaining qualified staff to meet patient needs.
2. Developing staff: Providing training and development opportunities to enhance staff skills and knowledge.
3. Fostering a positive work environment: Promoting a culture of safety, respect, and teamwork.
management
Dr. J. L. Meena

Patient Safety and Risk Management
1. Ensuring patient safety: Implementing policies and procedures to prevent adverse events.
2. Managing risk: Identifying and mitigating risks to patient safety and the hospital's reputation.
3. Responding to incidents: Investigating and responding to incidents, such as medical errors or patient
complaints.
Community Engagement
1. Building relationships: Developing relationships with the community, including patients, families, and
local organizations.
2. Promoting health and wellness: Providing education and resources to promote health and wellness in the
community.
3. Responding to community needs: Identifying and responding to the healthcare needs of the community.
By fulfilling these responsibilities, hospital management can ensure the delivery of high-quality patient
care, promote a positive work environment, and maintain the hospital's financial sustainability.
management
Dr. J. L. Meena

Responsible for governance manage the
organisation in ethical manner.
Those responsible for governance in an organization, such as hospital boards or trustees, play a critical role in ensuring that the
organization is managed in an ethical manner.
Setting the Tone
1. Establishing a strong ethical culture: Governance leaders set the tone for the organization's ethical culture, promoting a culture of
integrity, transparency, and accountability.
2. Defining values and principles: They define and promote the organization's values and principles, ensuring that they align with ethical
standards and best practices.
Oversight and Accountability
1. Providing oversight: Governance leaders provide oversight of the organization's operations, ensuring that they are managed in an ethical
and responsible manner.
2. Holding leaders accountable: They hold senior leaders accountable for promoting an ethical culture and ensuring that the organization
operates with integrity.
Decision-Making
1. Making informed decisions: Governance leaders make informed decisions that balance competing interests and prioritize the well-being
of patients, staff, and the community.
2. Considering ethical implications: They consider the ethical implications of their decisions, ensuring that they align with the organization's
values and principles.
Dr. J. L. Meena

Transparency and Communication
1. Promoting transparency: Governance leaders promote transparency in decision-making and operations,
ensuring that stakeholders have access to accurate and timely information.
2. Communicating effectively: They communicate effectively with stakeholders, including patients, staff, and
the community, to build trust and credibility.
Continuous Improvement
1. Monitoring and evaluating: Governance leaders monitor and evaluate the organization's ethical
performance, identifying areas for improvement and implementing changes as needed.
2. Fostering a culture of learning: They foster a culture of learning and continuous improvement, encouraging
staff to speak up and report concerns without fear of reprisal.
By managing the organization in an ethical manner, governance leaders can promote a culture of integrity,
transparency, and accountability, ultimately enhancing the quality of care and services provided to patients and
the community.
Responsible for governance manage the
organisation in ethical manner.
Dr. J. L. Meena

Those responsible for governance in a hospital
play a crucial role in ensuring sustainability
Those responsible for governance in a hospital play a crucial role in ensuring sustainability by addressing environmental, social, and
economic factors that impact the long-term well-being of the healthcare system and community.
Environmental Sustainability
1. Reducing environmental impact: Governance leaders prioritize reducing the hospital's environmental impact, such as energy
consumption, water usage, and waste management.
2. Promoting eco-friendly practices: They promote eco-friendly practices, such as sustainable procurement, green building design, and
reducing carbon footprint.
Social Sustainability
1. Fostering a positive work environment: Governance leaders prioritize creating a positive work environment, promoting staff well-
being, diversity, and inclusion.
2. Engaging with the community: They engage with the community, understanding their needs and priorities, and developing programs
that promote health and well-being.
Economic Sustainability
1. Ensuring financial viability: Governance leaders ensure the hospital's financial viability, making strategic decisions that balance
financial constraints with quality care and services.
2. Investing in infrastructure and technology: They invest in infrastructure and technology that supports high-quality care, improves
efficiency, and reduces costs.
Dr. J. L. Meena

Long-term Well-being
1. Prioritizing population health: Governance leaders prioritize population health, developing strategies that
promote health and well-being, and reduce health inequities.
2. Building partnerships: They build partnerships with other healthcare organizations, community groups, and
stakeholders to leverage resources, expertise, and knowledge.
Community Engagement
1. Understanding community needs: Governance leaders understand the needs and priorities of the
community, developing programs and services that meet those needs.
2. Fostering collaboration: They foster collaboration between healthcare organizations, community groups,
and stakeholders to promote health and well-being.
By addressing environmental, social, and economic factors, governance leaders can ensure the long-term
sustainability of the hospital and the well-being of the healthcare system and community.
Those responsible for governance in a hospital
play a crucial role in ensuring sustainability
Dr. J. L. Meena

The organisation displays
professionalism in its functioning.
The organization's display of professionalism in its functioning is reflected in several key aspects:
Ethical Conduct
1. Adhering to codes of conduct: The organization adheres to established codes of conduct, ensuring
that all employees understand and uphold the expected standards of behavior.
2. Promoting integrity: Professionalism is demonstrated through integrity in all interactions,
including transparency, honesty, and accountability.
Competence and Expertise
1. Employing qualified staff: The organization employs qualified and competent staff who possess
the necessary skills and expertise to perform their roles effectively.
2. Providing ongoing training: Professional development opportunities are provided to ensure that
staff stay updated with the latest knowledge and best practices.
Dr. J. L. Meena

Respect and Empathy
1. Treating others with respect: The organization promotes a culture of respect, where all individuals are treated with dignity and
courtesy.
2. Demonstrating empathy: Staff are trained to demonstrate empathy and compassion in their interactions with patients, families, and
colleagues.
Accountability and Responsibility
1. Taking ownership: Employees take ownership of their actions and decisions, acknowledging their role in achieving organizational goals.
2. Being accountable: The organization holds itself accountable for its actions, decisions, and outcomes, ensuring that it meets its
obligations to stakeholders.
Continuous Improvement
1. Seeking feedback: The organization actively seeks feedback from patients, staff, and other stakeholders to identify areas for
improvement.
2. Implementing changes: It implements changes based on feedback and best practices, demonstrating a commitment to continuous
quality improvement.
By displaying professionalism in its functioning, the organization builds trust with its stakeholders, enhances its reputation, and
ultimately improves the quality of care and services it provides.
The organisation displays
Dr. J. L. Meena

To ensure patient safety and
effective risk management
Patient Safety Initiatives
1. Implementing safety protocols: Develop and implement safety protocols to prevent adverse events and minimize risks.
2. Conducting regular audits: Conduct regular audits to identify potential safety risks and implement corrective actions.
Risk Management Strategies
1. Identifying potential risks: Identify potential risks and develop strategies to mitigate them.
2. Developing contingency plans: Develop contingency plans to address potential risks and ensure business continuity.
Staff Training and Education
1. Providing ongoing training: Provide ongoing training and education to staff on patient safety and risk management.
2. Encouraging a safety culture: Encourage a culture of safety and transparency, where staff feel empowered to report incidents and near misses.
Continuous Quality Improvement
1. Monitoring and evaluating: Continuously monitor and evaluate patient safety and risk management processes.
2. Implementing changes: Implement changes and improvements based on lessons learned and best practices.
Patient Engagement
1. Involving patients: Involve patients and their families in care decisions and safety protocols.
2. Providing education: Provide education to patients and their families on safety protocols and risk management.
By prioritizing patient safety and risk management, management can ensure that patients receive high-quality care and minimize the risk of adverse events.
Dr. J. L. Meena

If management is not proper in a hospital, it can have several negative effects:
Operational Issues
1. Inefficient decision-making: Poor leadership can lead to delayed or ineffective decision-making, impacting patient care
and hospital operations.
2. Lack of direction: Without clear leadership, staff may feel uncertain about priorities and goals, leading to confusion and
inefficiency.
3. Inadequate resource allocation: Poor management can result in misallocated resources, leading to waste and
inefficiency.
Patient Care Consequences
1. Decreased patient satisfaction: Poor leadership can lead to decreased patient satisfaction due to inadequate care, long
wait times, or poor communication.
2. Increased medical errors: Ineffective management can contribute to medical errors, compromising patient safety.
3. Decreased quality of care: Without strong leadership, quality improvement initiatives may not be prioritized, leading to
decreased quality of care.
If management can’t take
proper responsibility
Dr. J. L. Meena

Staff-Related Issues
1. Low staff morale: Poor management can lead to low staff morale, high turnover rates, and decreased job satisfaction.
2. Increased staff burnout: Ineffective leadership can contribute to staff burnout, impacting their well-being and ability to provide
quality care.
3. Difficulty attracting and retaining talent: A hospital with poor management may struggle to attract and retain top talent, impacting
the quality of care.
Financial Consequences
1. Financial losses: Poor management can lead to financial losses due to inefficient operations, decreased patient volume, or increased
costs.
2. Decreased funding: A hospital with poor management may struggle to secure funding or investment, impacting its ability to provide
quality care.
3. Reputation damage: A hospital with poor management may suffer reputational damage, impacting its ability to attract patients and
staff.
Other Consequences
1. Regulatory issues: Poor management can lead to regulatory issues, such as non-compliance with accreditation standards or laws.
2. Litigation: Ineffective management can increase the risk of litigation due to medical errors, patient safety issues, or other concerns.
3. Decreased community trust: A hospital with poor management may lose the trust of the community, impacting its ability to provide
care and services.
If management can’t take
proper responsibility
Dr. J. L. Meena

If top-level management is not
approachable to all
If top-level management is not approachable to all, it can lead to:
Communication Breakdown
1. Lack of feedback: Employees may feel hesitant to provide feedback or suggestions, leading to missed opportunities for
improvement.
2. Unclear expectations: Without open communication, employees may not understand expectations, goals, or priorities.
Decreased Employee Engagement
1. Low morale: Employees may feel undervalued, unheard, or unappreciated, leading to low morale and decreased job
satisfaction.
2. Decreased productivity: Without approachable management, employees may feel less motivated to perform at their
best.
Poor Decision-Making
1. Limited perspectives: Management may not receive diverse perspectives or ideas, leading to poor decision-making.
2. Uninformed decisions: Without input from employees, management may make uninformed decisions that don't
address real issues.
Dr. J. L. Meena

Increased Turnover
1. Employee dissatisfaction: Employees may feel frustrated or unsupported, leading to increased
turnover rates.
2. Loss of talent: Top performers may seek opportunities elsewhere, leading to a loss of talent and
expertise.
Negative Impact on Patient Care
1. Decreased quality of care: Without open communication and feedback, patient care may suffer
due to unaddressed issues or concerns.
2. Patient dissatisfaction: Patients may notice a lack of communication or empathy from staff,
leading to decreased satisfaction.
To mitigate these issues, top-level management should prioritize being approachable, fostering
open communication, and encouraging feedback from all employees.
If top-level management is not
approachable to all
Dr. J. L. Meena

Regular committee meetings are
essential
Regular committee meetings are essential for effective collaboration, decision-making, and organizational success.
Ø Alignment and Coordination: Meetings ensure all members are on the same page, aligning goals, priorities, and actions across teams or
departments.
Ø Decision-Making: They provide a structured forum for discussing issues, evaluating options, and making informed decisions collectively.
Ø Accountability: Regular check-ins track progress on tasks, hold members accountable, and address delays or challenges promptly.
Ø Communication: Meetings foster open dialogue, allowing members to share updates, ideas, and feedback, reducing misunderstandings.
Ø Problem-Solving: They offer a platform to identify challenges early and brainstorm solutions collaboratively.
Ø Team Building: Consistent interaction builds trust, strengthens relationships, and enhances team cohesion.
Ø Strategic Planning: Meetings help review progress toward long-term goals and adjust strategies as needed.
Ø Documentation: They create a record of discussions, decisions, and action items, ensuring clarity and continuity.
Without regular meetings, committees risk miscommunication, inefficiency, and missed opportunities. However, meetings should be well-planned
with clear agendas to maximize productivity and avoid wasting time.
Dr. J. L. Meena

Some of the Practical reality in field
Meeting minutes are prepared by one person without a committee meeting, it can lead to:
Potential Issues
1. Inaccurate representation: The minutes may not accurately reflect the discussions or decisions made.
2. Lack of input: Other committee members may not have the opportunity to provide input or corrections.
3. Miscommunication: Important information may be miscommunicated or omitted.
4. Lack of transparency: The process may lack transparency, leading to mistrust among committee members.
Consequences
1. Poor decision-making: Decisions may be made based on inaccurate or incomplete information.
2. Conflicts: Conflicts may arise due to misunderstandings or miscommunication.
3. Ineffective actions: Actions may not be effective due to a lack of input and discussion.
4. Erosion of trust: Trust among committee members may be eroded due to a lack of transparency and accountability.
Best Practice
1. Collaborative minute-taking: Involve multiple people in the minute-taking process.
2. Review and approval: Have committee members review and approve the minutes.
3. Regular meetings: Hold regular meetings to ensure open discussion and collaboration.
Dr. J. L. Meena

Responsibilities of Management (ROM)
Ø The management of the healthcare organisation is aware of and manages all the key components of governance.
Ø Those responsible for governance are identified and their roles defined.
Ø The standards encourage the governance of the organisation professionally and ethically.
Ø Clinically governance framework is established, that includes clinical audits, clinical pathways, education and research. The responsibilities of management are defined.
Ø The responsibilities of the leaders at all levels are defined.
Ø The management executes its responsibility for compliance with all applicable regulations. Those responsible for governance address the organisations social
responsibility.
Ø Leaders ensure that patient-safety and risk-management issues are an integral part of patient care and hospital management. The organisation has a written
guidance in place for change management and services continuity plan.
Note 1: "Responsible for Governance' refers to the governing entity of the healthcare organisation and can exist in many configurations. For example, the
owner(s), the board of directors, or in the case of public hospitals, the respective Ministry (Health/Railways/Labour).
Note 2: “Leadership” refers to appointment leader for example CEO, COO, Managing Director, Dean, Director, Medical Director / Medical Superintendent.
In case of single owner / partners all the standards and objective elements shall be applicable.
27
Dr. J. L. Meena

ROM.1.
The organisation identifies those responsible for governance and their roles
are defined.
ROM.2. Those responsible for governance manage the organisation in ethical manner.
ROM.3.
Those responsible for governance ensure sustainable in hospital by
addressing environment, social and economic factors from long well being of
healthcare system and community.
ROM.4. The organisation is headed by a leader who shall be responsible for
operating the organisation on a day-to-day basis.
ROM.5.
The organisation displays professionalism in its functioning.
ROM.6.
Management ensures that patient-safety aspects and risk-
management issues are an integral part of patient care and hospital
management.
28
Dr. J. L. Meena

Objective Elements ROM 1 ROM 2 ROM 3 ROM 4 ROM 5 ROM 6
a CORE CORE Commitment Commitment Commitment CORE
b Commitment Commitment Commitment CORE Commitment Commitment
c Commitment Commitment Commitment Commitment Commitment Commitment
d Commitment Commitment Commitment Achievement Achievement Achievement
e Commitment Commitment Achievement Commitment Commitment
f Commitment Commitment
Excellence
Achievement
g Commitment Achievement
h Achievement
i Commitment
Summary Standards -6 OE-37 CORE -4 Commitment - 23 Achievement - 8 Excellence - 2

ROM 1 The organisation identifies those
responsible for governance and their roles are
defined.
Objective Elements
a) Those responsible for governance are identified, and their roles and responsibilities are defined and
documented. *
b) Those responsible for governance lay down the organisation's vision, mission and values.*
c) Those responsible for governance approve the strategic and operational plans and the
organisation's annual budget.
d) Those responsible for governance monitor and measure the performance of the organisation against the
stated mission.
e) Those responsible for governance appoint the senior leaders in the organisation.
f) Those responsible for governance support safety initiatives, clinical governance framework and quality
improvement plans.*
g) Those responsible for governance shall develop clinical governance framework.
h) Those responsible for governance support the ethical management framework of the organisation.
i) Those responsible for governance inform the public of the quality and performance of services.
30
Dr. J. L. Meena

Mission
The overall function of an organization.
The mission answers the question, "What is this
organization attempting to achieve?" The mission
might define patients, stakeholders, or markets
served, distinctive or core competencies, or
technologies used.
Dr. J. L. Meena

Vision
An overarching statement of the way an
organization wants to be, an ideals state of being
at a future point. This refers to the desired future
state of an organization. The vision describes
where the organization is headed, what it intends
to be, or how it wishes to be perceived in the
future.
Dr. J. L. Meena

Values
The fundamental beliefs that drive organizational
behavior and decision-making. This refers to the
guiding principles and behaviors that embody
how an organization and its people are expected
to operate. Values reflect and reinforce the
desired culture of an organization.
Dr. J. L. Meena

"Strategic plans".
Strategic planning is an organization's process of defining its strategy or
direction and making decisions on allocating its resources to pursue this
strategy, including its capital and people. Various business analysis techniques
can be used in strategic planning, including SWOT analysis (Strengths,
Weaknesses, Opportunities and Threats) e.g. Organization can have a strategic
plan to become market leader in provision of cardiothoracic and vascular
services. The resource allocation will have to follow the pattern to achieve the
target. The process by which an organization envisions its future and
develops strategies, goals, objectives and action plans to
achieve that future. (ASQ)
Dr. J. L. Meena

"Operational plans".
Operational plan is the part of your strategic plan. It
define how you will operate in practice to implement
your action and monitoring plans-what your capacity
needs are, how you will engage resources, how you
will deal with risks, and how you will ensure
sustainability of the organization's achievements.
Dr. J. L. Meena

Objective Elements
a)The leaders establish the organisation's ethical management
framework. *
b)The ethical management framework includes processes for
managing issues with ethical implications, dilemmas and concerns.
c) The organisation discloses its ownership.
d)The organisation honestly portrays its affiliations and
accreditations.
36
Dr. J. L. Meena
ROM – 2 Those responsible for
governance manage the organisation in
an ethical manner.

ROM 3 - Those responsible for governance ensure sustainable in
hospital by addressing environment, social and economic factors
from long well being of healthcare system and community.
Objective Elements
a) Those responsible for governance address the organisation's sustainability programme in
terms of Environment Social and Governance (ESG) responsibility.
b) The organisation takes initiatives towards an energy – efficient and environmentally
friendly hospital. *
c) Those responsible for governance address the organisation social responsibility.
d) Staff well-being is promoted.
e) The organisation follows sustainable procurement practices.
f) Hospital shall encourage employees to use common / public transportation to reduce the
environment impact of commuting and carbon footprint.
g) The organisation ensures financial sustainability of the hoaspital by balancing the
financial aspects of healthcare delivery.
37
Dr. J. L. Meena

ROM 4 - The organisation is headed by a leader
who shall be responsible for operating the
organisation on a day-to-day basis.
Objective Elements
a) The person heading the organisation has requisite and appropriate administrative
qualifications and experience.
b) The leader is responsible for and complies with the laid-down and applicable legislations,
regulations and notifications.
c) The leader appoints/participates in the recruitment of senior leadership of the
organisation who will assist in the day-to-day functioning of the organisation.
d) The leader ensures that each organisational programme, service, site or department has
effective leadership.
e) The performance of the organisation's leader is reviewed for effectiveness.
38
Dr. J. L. Meena

List of Legal Licenses Required for
Hospitals as per NABH
The following licenses are critical for NABH accreditation, as they align with statutory requirements and NABH’s focus on legal and operational
compliance:
Core Registrations
1. Registration under the Clinical Establishments (Registration and Regulation) Act, 2010
- Purpose: Mandatory in states where the Act is adopted to regulate clinical establishments. Ensures minimum standards for facilities, staff, and
services.
- NABH Relevance: Required under AAC to prove the hospital is legally recognized.
- Authority: State Health Department.
- Requirement: One-time registration with periodic inspections. Display the certificate prominently.
2. Registration under Companies Act, 2013 or Societies Registration Act, 1860 (if applicable)
- Purpose: For hospitals established as private companies, trusts, or societies.
- NABH Relevance: Ensures the hospital operates under a legal entity, aligning with governance standards.
- Authority: Ministry of Corporate Affairs (for companies) or State Registrar of Societies (for societies/trusts).
- Requirement: Memorandum and Articles of Association, Director Identification Number (DIN) for directors, or society registration documents.
3. Municipal Registration
- Purpose: To register the hospital premises with local authorities for legal operation.
- NABH Relevance: Verifies compliance with local zoning and building regulations.
- Authority: Local Municipal Corporation or Panchayat.
- Requirement: Certificate of registration or trade license.
Dr. J. L. Meena

Infrastructure and Safety Licenses
4. Building Plan Approval and Occupancy Certificate
- Purpose: Ensures the hospital building complies with local building codes, zoning laws, and safety standards.
- NABH Relevance: Required under Facility Management and Safety (FMS) standards for safe infrastructure.
- Authority: Local Municipal Corporation or Development Authority.
- Requirement: Approved building plans and an occupancy certificate post-construction.
5. Fire Safety Clearance (No Objection Certificate)
- Purpose: Ensures fire safety measures like extinguishers, alarms, sprinklers, and evacuation plans are in place.
- NABH Relevance: Mandatory under FMS for patient and staff safety.
- Authority: Local Fire Department.
- Requirement: Fire NOC, renewed periodically after inspections. Display compliance records.
6. Pollution Control Board Approvals
- Purpose: To manage biomedical waste and ensure environmental compliance.
- NABH Relevance: Required under FMS and Hospital Infection Control (HIC) for waste management.
- Licenses:
- Consent to Establish (CTE): Pre-construction approval.
- Consent to Operate (CTO): For ongoing operations.
- Biomedical Waste Management Authorization: Under Bio-Medical Waste Management Rules, 1998, for segregation, treatment, and disposal.
- Authority: State Pollution Control Board.
- Requirement: Valid authorizations and contracts with authorized waste disposal agencies.
Dr. J. L. Meena

7. Atomic Energy Regulatory Board (AERB) Approval
- Purpose: For hospitals using radiation equipment (e.g., X-ray, CT scan, radiotherapy).
- NABH Relevance: Required under FMS for radiation safety in diagnostic and treatment areas.
- Authority: Atomic Energy Regulatory Board.
- Requirement: License for equipment installation and operation, ensuring radiation safety compliance.
8. Lift Operating License (if applicable)
- Purpose: For hospitals with elevators to ensure safety.
- NABH Relevance: Aligns with FMS for safe patient and staff movement.
- Authority: Local Municipal Authority or Lift Safety Department.
- Requirement: Annual inspection and certification.
Medical and Operational Licenses
9. Indian Medical Council (IMC) / State Medical Council Registration
- Purpose: All doctors must be registered with the National Medical Commission (NMC) or State Medical Council.
- NABH Relevance: Required under Human Resource Management (HRM) to ensure qualified staff.
- Authority: National Medical Commission or State Medical Council.
- Requirement: Display registration certificates and comply with IMC Regulations, 2002 (e.g., patient records, ethical practices).
10. Indian Nursing Council / State Nursing Council Registration
- Purpose: All nurses must be registered with the Indian Nursing Council or State Nursing Council.
- NABH Relevance: Ensures qualified nursing staff under HRM.
- Authority: Indian Nursing Council or State Nursing Council.
- Requirement: Verify and display registration certificates.
Dr. J. L. Meena

11. Drug Sale License for Pharmacy
- Purpose: For in-house pharmacies dispensing medicines to OPD, IPD, or external patients.
- NABH Relevance: Mandatory under MOM for safe medication management.
- Authority: State Drug Standard Control Organization or Office of the Drug Controller.
- Requirement: License under Drugs and Cosmetics Act, 1940, ensuring proper storage, qualified pharmacists, and compliance with shop size and refrigeration standards.
12. Narcotic Drugs and Psychotropic Substances (NDPS) License
- Purpose: For hospitals using or storing narcotic drugs (e.g., morphine, pethidine).
- NABH Relevance: Required under MOM for controlled substance management.
- Authority: State Food and Drug Administration.
- Requirement: License specifying drug type and quantity, with periodic renewals and record-keeping.
13. Food Safety and Standards Authority of India (FSSAI) License
- Purpose: For hospitals operating in-house kitchens for patients or staff.
- NABH Relevance: Aligns with FMS for safe food handling.
- Authority: FSSAI, Ministry of Health and Family Welfare.
- Requirement: License ensuring compliance with food safety and hygiene standards.
14. Blood Bank License (if applicable)
- Purpose: For hospitals operating blood banks.
- NABH Relevance: Required under AAC for blood transfusion services.
- Authority: Drug Standard Control Organization.
- Requirement: License ensuring infrastructure, staff, and storage compliance.
15. Transplantation of Human Organs Act, 1994 Registration (if applicable)
- Purpose: For hospitals conducting organ transplants or harvesting.
- NABH Relevance: Required under AAC for specialized services.
- Authority: State Health Department or Designated Authority.
- Requirement: Registration with infrastructure and expertise compliance.
Dr. J. L. Meena

16. Pre-Natal Diagnostic Techniques (PNDT) Act, 1994 Registration (if applicable)
- Purpose: For hospitals conducting prenatal diagnostic tests (e.g., ultrasound).
- NABH Relevance: Required under AAC for diagnostic compliance.
- Requirement: Registration and display of compliance in radiology or relevant departments.
17. Medical Termination of Pregnancy (MTP) Act, 1971 Registration (if applicable)
- Purpose: For hospitals offering abortion services.
- NABH Relevance: Required under AAC for gynecological services.
- Requirement: Registration and compliance display in relevant departments.
18. Mental Health Act Registration (if applicable)
- Purpose: For hospitals providing psychiatric or de-addiction services.
- NABH Relevance: Required under AAC for mental health services.
- Requirement: Registration ensuring compliance with mental health regulations.
19. Excise Permit for Spirit Storage
- Purpose: For storing spirit (alcohol) for medical purposes beyond permissible limits.
- NABH Relevance: Aligns with MOM for medical supply management.
- Authority: State Excise Department.
- Requirement: Permit specifying storage limits.
Dr. J. L. Meena

20. Petroleum Act, 1934 Permit (if applicable)
- Purpose: For storing large quantities of LPG cylinders (e.g., for kitchens).
- NABH Relevance: Required under FMS for safety.
- Authority: Petroleum and Explosives Safety Organization (PESO).
- Requirement: Permit for safe storage.
Additional Permits
21. Ambulance Registration
- Purpose: For ambulances operated by the hospital.
- NABH Relevance: Required under AAC for emergency services.
- Authority: Regional Transport Office (RTO).
- Requirement: Registration as commercial vehicles with emergency equipment compliance.
22. Electricity and Water Supply Permissions
- Purpose: To ensure adequate power and water for hospital operations.
- NABH Relevance: Aligns with FMS for operational continuity.
- Authority: Local Municipal Corporation or Utility Boards.
- Requirement: Permissions for high-capacity connections and sewage systems.
23. Arms License (if applicable)
- Purpose: For security guards carrying firearms.
- NABH Relevance: Aligns with FMS for hospital security.
- Authority: Local Police Department or District Magistrate.
- Requirement: License under Arms Act, 1959.
Dr. J. L. Meena

NABH-Specific Compliance Requirements
- Documentation: Maintain a comprehensive record of all licenses, renewals, and compliance certificates in a designated file for NABH audits.
- Display: Prominently display key licenses (e.g., Clinical Establishments Act certificate, doctor/nurse registrations, PNDT compliance) in relevant areas.
- Staff Qualifications: Ensure all medical and non-medical staff (e.g., pharmacists, radiologists) are registered with respective councils (e.g., Pharmacy Council, NMC).
- Periodic Renewals: Licenses like Fire NOC, CTO, NDPS, and lift certifications require timely renewals to avoid lapses during NABH inspections.
- Scope of Services: The hospital must define its scope (e.g., OPD, IPD, ICU, diagnostics, surgery) and ensure all relevant licenses align with services offered. For example, a
hospital with a cath lab needs AERB approval, while one with a blood bank needs a specific license.
- Patient Safety and Ethics: Comply with IMC Regulations, 2002, for patient records, consent forms, and ethical practices, as emphasized in NABH’s Care of Patient (COP)
standards.
State-Specific Variations
- Since healthcare is a state subject, some states may have additional requirements or different procedures for licenses like the Clinical Establishments Act or biomedical
waste management. For NABH accreditation, hospitals must comply with both central and state regulations.
- Example: States like Karnataka and Maharashtra have stricter biomedical waste management rules, requiring additional documentation for NABH compliance.
Optional but Recommended for NABH
- NABH Accreditation: While not a license, obtaining NABH accreditation itself enhances credibility and is often required for empanelment with insurance providers.
- NABL Accreditation: For hospital laboratories to ensure diagnostic accuracy, aligning with NABH’s quality standards.
- Trademark Registration: To protect the hospital’s brand, recommended for long-term operations.
Procedural Notes for NABH Compliance
1. Pre-Assessment: Before applying for NABH, conduct an internal audit to ensure all licenses are valid and documented.
2. Application: Submit the NABH application with copies of all licenses, scope of services, and infrastructure details.
3. Inspection: NABH assessors verify licenses, staff qualifications, and compliance with safety and quality standards during on-site audits.
4. Renewals: Maintain a calendar for license renewals to avoid non-compliance during NABH surveillance audits (conducted every 18 months post-accreditation).
Dr. J. L. Meena

ROM 5 - The organisation displays
Objective Elements
a) The organisation has 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.
b) The organisation coordinates the functioning with departments and external agencies
and monitors the progress in achieving the defined goals and objectives.
c) The organisation plans and budgets for its activities annually.
d) The functioning of committees is reviewed for their effectiveness.
e) The organisation documents the service standards that are measurable and monitors
them.*
f) Systems and processes are in place for change management.
46
Dr. J. L. Meena

Commonly Required Committees for NABH
Accreditation
The following committees are typically required to meet NABH standards, particularly for hospitals seeking full accreditation:
1. Hospital Quality Committee (Quality Assurance Committee)
Ø Purpose: Oversees the hospital’s quality management system, monitors key performance indicators, and ensures continuous quality
improvement.
Ø Reference: NABH Standard on Patient Safety & Quality Improvement (PSQ)
2. Patient Safety Committee
Ø Purpose: Focuses on patient safety protocols, incident reporting, root cause analysis, and preventive actions to reduce medical errors.
Ø Reference: NABH Standard on Patient Safety and Risk Management.
3. Infection Control Committee
Ø Purpose: Develops and monitors infection prevention and control policies, including surveillance of hospital-acquired infections.
Ø Reference: NABH Standard on Infection Prevention & Control (IPC).
4. Medical Audit Committee
Ø Purpose: Reviews clinical outcomes, medical records, and adherence to clinical protocols to ensure high-quality care.
Ø Reference: NABH Standard on Care of Patients (COP).
Dr. J. L. Meena

5. Ethics Committee
Ø Purpose: Addresses ethical issues in patient care, including informed consent, end-of-life decisions, and research ethics
(mandatory for hospitals conducting clinical trials).
Ø Reference: NABH Standard on Patient Rights and Education (PRE).
6. Pharmaco-Therapeutics Committee (Pharmacy and Therapeutics Committee)
Ø Purpose: Manages medication safety, formulary development, and monitors adverse drug reactions.
Ø Reference: NABH Standard on Management of Medication (MOM).
7. Safety Committee (Facility Safety Committee)
Ø Purpose: Ensures safety of the hospital environment, including fire safety, equipment maintenance, and disaster preparedness.
Ø Reference: NABH Standard on Facility Management and Safety (FMS).
8. Blood Transfusion Committee
Ø Purpose: Oversees blood bank operations, transfusion practices, and monitors transfusion reactions (mandatory for hospitals
with blood banks).
Ø Reference: NABH Standards for Blood Banks/Transfusion Services.
Accreditation
Dr. J. L. Meena

9. Credentialing and Privileging Committee
Purpose: Evaluates and grants privileges to medical staff based on qualifications and competency.
Reference: NABH Standard on Human Resource Management (HRM).
10. Grievance Redressal Committee
Purpose: Handles patient complaints and ensures timely resolution to enhance patient satisfaction.
Reference: NABH Standard on Patient Rights and Education (PRE).
11. Internal Complaints Committee (ICC)
Purpose: plays a crucial role in addressing and resolving complaints related to sexual harassment and other forms of harassment in the workplace.
12. Mortality and Morbidity Review Committee
Purpose: Reviews deaths and adverse events to identify preventable causes and improve care processes.
Reference: NABH Standard on Care of Patients (COP).
13. Disaster Management Committee (optional, depending on hospital size)
Purpose: Plans and prepares for disaster response, including emergency preparedness drills.
Reference: NABH Standard on Facility Management and Safety (FMS).
Note: Smaller hospitals (e.g., Small Healthcare Organizations with ≤50 beds) may combine some of these functions into fewer committees to meet
NABH’s Pre-Accreditation Entry-Level Certification standards,
Accreditation
Dr. J. L. Meena

1. Hospital Quality Committee (Quality Assurance Committee)
ØPurpose: Oversees the hospital’s quality management system, monitors key
performance indicators, and ensures continuous quality improvement.
ØReference: NABH Standard on Continuous Quality Improvement (CQI).
Accreditation
Dr. J. L. Meena

Hospital Quality Committee (Quality
Assurance Committee)
The Hospital Quality Committee (Quality Assurance Committee) plays a crucial role in ensuring the delivery of high-quality patient care.
Roles
1. Oversight of quality improvement initiatives: Ensures that quality improvement initiatives are implemented and monitored across the hospital.
2. Policy development and review: Develops, reviews, and updates policies related to quality of care, patient safety, and risk management.
3. Monitoring and evaluation: Monitors and evaluates the effectiveness of quality improvement initiatives and identifies areas for improvement.
Responsibilities
1. Setting quality goals and objectives: Establishes quality goals and objectives for the hospital and monitors progress towards achieving them.
2. Reviewing incident reports: Reviews incident reports, identifies trends, and implements corrective actions to prevent future incidents.
3. Analyzing quality metrics: Analyzes quality metrics, such as patient satisfaction, readmission rates, and infection rates, to identify areas for
improvement.
4. Implementing evidence-based practices: Promotes the implementation of evidence-based practices and guidelines to improve patient care.
5. Ensuring compliance with regulatory requirements: Ensures that the hospital complies with regulatory requirements and standards related to
quality of care.
Benefits
1. Improved patient outcomes: Enhances patient safety and quality of care.
2. Reduced risk: Identifies and mitigates risks to patient safety and quality of care.
3. Increased accountability: Promotes accountability among healthcare professionals and departments.
4. Continuous quality improvement: Fosters a culture of continuous quality improvement.
By fulfilling these roles and responsibilities, the Hospital Quality Committee plays a vital role in ensuring that the hospital delivers high-quality
patient care and maintains a safe and effective environment for patients, staff, and visitors.
Dr. J. L. Meena

Committee Members:
v Senior Leadership:
- Hospital Director or CEO
- Medical Director or Chief Medical Officer
v Clinical Representatives:
- Physicians from various departments (e.g., surgery, medicine, pediatrics)
- Nurses and other healthcare professionals
v Quality Improvement Experts:
- Quality assurance specialists
- Patient safety officers
v Administrative Support:
- Hospital administrators
- Quality committee coordinators
v Patient Representatives:
- Patient advocates
- Family members or caregivers
Dr. J. L. Meena

v Ideal Committee Size:
A typical quality committee can range from 8 to 15 members, depending on the hospital's size and complexity ¹.
v Key Roles:
- Chair: A senior leader or quality expert who facilitates meetings and ensures the committee's objectives are met.
- Vice-Chair: A clinical representative who supports the chair and provides clinical expertise.
- Secretary: An administrative support staff who records minutes and maintains committee documents.
v Meeting Frequency:
The committee should meet regularly, ideally :
- Bi-monthly: Every other month, aligning with hospital board meetings.
- Quarterly: Every three months, focusing on specific quality initiatives.
- As Needed: Additional meetings can be called to address urgent quality concerns.
By including representatives from various departments and levels of expertise, the Hospital Quality Committee can
effectively oversee quality improvement initiatives, ensure patient safety, and promote a culture of excellence.
Dr. J. L. Meena

2. Patient Safety Committee
ØPurpose: Focuses on patient safety protocols, incident reporting, root cause
analysis, and preventive actions to reduce medical errors.
ØReference: NABH Standard on Patient Safety and Risk Management.
Accreditation
Dr. J. L. Meena

Patient Safety Committee
The Patient Safety Committee plays a crucial role in ensuring patient safety and promoting a culture of safety within a healthcare
organization.
Roles
1. Oversight and governance: The committee provides oversight and governance for patient safety initiatives and policies.
2. Strategic planning: The committee develops and implements strategic plans to improve patient safety and reduce adverse
events.
Responsibilities
1. Identifying safety risks: The committee identifies potential safety risks and develops strategies to mitigate them.
2. Developing policies and procedures: The committee develops and reviews policies and procedures related to patient safety.
3. Monitoring and evaluating: The committee monitors and evaluates patient safety initiatives and outcomes.
4. Providing education and training: The committee provides education and training to staff on patient safety protocols and
procedures.
5. Investigating incidents: The committee investigates incidents and near misses, and implements corrective actions to prevent
future occurrences.
6. Promoting a safety culture: The committee promotes a culture of safety and transparency, encouraging staff to report incidents
and near misses without fear of reprisal.
Dr. J. L. Meena

Key Activities
1. Reviewing incident reports: The committee reviews incident reports and near misses to identify
trends and areas for improvement.
2. Conducting root cause analyses: The committee conducts root cause analyses to identify
underlying causes of adverse events.
3. Developing safety initiatives: The committee develops and implements safety initiatives, such as
fall prevention and medication safety programs.
4. Collaborating with other committees: The committee collaborates with other committees, such
as quality improvement and infection control, to ensure a comprehensive approach to patient
safety.
By fulfilling these roles and responsibilities, the Patient Safety Committee can help ensure that
patients receive safe and high-quality care, and that the healthcare organization maintains a strong
culture of safety.
Dr. J. L. Meena

The Patient Safety Committee typically consists of a multidisciplinary team of healthcare professionals, including:
Members
1. Physicians: Representatives from various medical specialties.
2. Nurses: Representatives from various nursing departments.
3. Quality improvement specialists: Experts in quality improvement and patient safety.
4. Risk management specialists: Experts in risk management and liability.
5. Pharmacists: Representatives from pharmacy services.
6. Administrators: Senior leaders and administrators.
7. Other stakeholders: Representatives from relevant departments, such as infection control, patient advocacy, and biomedical
engineering.
Frequency of Meetings
1. Regular meetings: The committee typically meets regularly, such as quarterly or bimonthly.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific patient safety concerns or incidents.
3. Minutes and follow-up: Meeting minutes are documented, and follow-up actions are assigned and tracked to ensure implementation
of patient safety initiatives.
The frequency of meetings may vary depending on the organization's size, complexity, and patient safety priorities.
Dr. J. L. Meena

3. Infection Control Committee
ØPurpose: Develops and monitors infection prevention and control policies,
including surveillance of hospital-acquired infections.
ØReference: NABH Standard on Infection Prevention & Control (IPC).
Accreditation
Dr. J. L. Meena

Infection Control Committee
The *Infection Control Committee (ICC)* plays a critical role in healthcare settings by overseeing policies and practices to prevent and
control infections. Its primary goal is to ensure patient, staff, and visitor safety by minimizing the risk of healthcare-associated infections
(HAIs).
Roles
1. Policy Development and Implementation: Develop, review, and update infection control policies and protocols based on evidence-
based practices, regulatory guidelines, and emerging threats (e.g., pandemics, antibiotic-resistant pathogens).
2. Surveillance and Monitoring: Oversee the systematic collection, analysis, and reporting of infection data to identify trends, outbreaks,
or areas for improvement.
3. Education and Training: Promote awareness and ensure training for healthcare staff on infection prevention practices, such as hand
hygiene, sterilization, and personal protective equipment (PPE) use.
4. Risk Assessment and Management: Identify infection risks within the facility and implement strategies to mitigate them, including
environmental controls and equipment sterilization.
5. Regulatory Compliance: Ensure adherence to local, national, and international infection control standards (e.g., WHO, CDC, or country-
specific health regulations).
6. Outbreak Investigation and Response: Lead investigations into infection outbreaks, coordinate containment measures, and recommend
corrective actions.
7. Collaboration and Communication: Act as a liaison between departments, administration, and external agencies (e.g., public health
authorities) to align infection control efforts.
8. Quality Improvement: Integrate infection control into the organization’s quality assurance programs, evaluating the effectiveness of
interventions and updating practices as needed.
Dr. J. L. Meena

Responsibilities
1. Establishing Guidelines: Create and enforce protocols for infection prevention, such as handwashing, isolation procedures, and
waste management.
2. Data Analysis: Regularly review surveillance data to detect patterns of HAIs and assess the effectiveness of control measures.
3. Training Programs: Organize and evaluate training sessions to ensure all staff are competent in infection control practices.
4. Facility Audits: Conduct regular inspections of hospital environments, equipment, and procedures to ensure compliance with
infection control standards.
5. Antimicrobial Stewardship: Promote the appropriate use of antibiotics to combat resistance, often in collaboration with
pharmacy and medical teams.
6. Incident Reporting: Maintain a system for reporting and investigating infection control breaches or HAIs, ensuring lessons are
learned and shared.
7. Emergency Preparedness: Develop contingency plans for infectious disease outbreaks, including resource allocation and
communication strategies.
8. Advisory Role: Provide expert guidance to hospital leadership and staff on infection control matters, including new technologies
or practices.
9. Documentation: Maintain accurate records of policies, training, audits, and infection data for accountability and regulatory
purposes.
Dr. J. L. Meena

The Infection Control Committee typically consists of a multidisciplinary team of healthcare professionals, including:
Members
1. Infection control specialists: Experts in infection control and epidemiology.
2. Physicians: Representatives from various medical specialties, such as infectious diseases and microbiology.
3. Nurses: Representatives from various nursing departments, including infection control nurses.
4. Microbiologists: Experts in microbiology and laboratory testing.
6. Administrators: Senior leaders and administrators.
7. Other stakeholders: Representatives from relevant departments, such as environmental services, pharmacy, and occupational health.
1. Regular meetings: The committee typically meets regularly, such as quarterly or bimonthly.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific infection control concerns or outbreaks.
3. Minutes and follow-up: Meeting minutes are documented, and follow-up actions are assigned and tracked to ensure implementation of
infection control initiatives.
The frequency of meetings may vary depending on the organization's size, complexity, and infection control priorities. The committee's
composition and meeting frequency should be tailored to meet the specific needs of the organization.
Dr. J. L. Meena

4. Medical Audit Committee
ØPurpose: Reviews clinical outcomes, medical records, and adherence to
clinical protocols to ensure high-quality care.
ØReference: NABH Standard on Care of Patients (COP).
Accreditation
Dr. J. L. Meena

Medical Audit Committee
The *Medical Audit Committee* in a healthcare organization is responsible for overseeing and improving the= the quality of medical care
through systematic review and evaluation of clinical practices, patient outcomes, and adherence to standards. Its roles and
responsibilities typically include:
1. Quality Assurance: Monitor and evaluate the quality of patient care by reviewing clinical practices, patient records, and outcomes to
ensure compliance with regulatory standards and best practices.
2. Policy and Guideline Development: Develop, review, and update clinical protocols, guidelines, and policies to align with current
medical standards, evidence-based practices, and regulatory requirements.
3. Case Review: Conduct audits of patient cases, including adverse events, sentinel events, or near-misses, to identify root causes and
recommend corrective actions to prevent recurrence.
4. Compliance Monitoring: Ensure adherence to healthcare regulations, accreditation standards (e.g., Joint Commission, CMS), and
internal policies through audits and assessments.
5. Data Analysis: Analyze clinical data, such as infection rates, readmission rates, mortality rates, and other key performance indicators,
to identify trends and areas for improvement.
Dr. J. L. Meena

6. Education and Training: Recommend or facilitate training programs for healthcare staff to address identified gaps in knowledge or
practice and promote continuous improvement.
7. Risk Management: Identify potential risks in clinical processes and recommend strategies to mitigate them, reducing medical errors
and improving patient safety.
8. Reporting and Accountability: Prepare reports on audit findings, present them to hospital leadership or governing bodies, and ensure
follow-up on recommended actions.
9. Interdisciplinary Collaboration: Work with other departments, such as nursing, pharmacy, and administration, to implement quality
improvement initiatives and ensure a multidisciplinary approach.
10. Continuous Improvement: Foster a culture of continuous quality improvement by promoting evidence-based practices and
encouraging staff to participate in audit activities.
The committee typically includes physicians, nurses, administrators, quality assurance professionals, and other relevant stakeholders to
ensure a comprehensive approach to improving healthcare delivery. Specific responsibilities may vary depending on the organization's
size, structure, and regulatory environment.
Dr. J. L. Meena

Composition of the Medical Audit Committee
The composition of a Medical Audit Committee (MAC) varies by healthcare organization but typically includes a multidisciplinary team
to ensure comprehensive oversight of clinical quality and patient care.
1. Physicians: Senior doctors or department heads (e.g., from surgery, internal medicine, or pediatrics) to provide clinical expertise.
2. Nursing Representatives: Senior nurses or nurse managers to address nursing care standards and patient safety.
3. Quality Assurance/Improvement Officer: A professional responsible for coordinating audits and ensuring compliance with standards.
4. Hospital Administrator: A management representative to align committee activities with organizational goals and resource
allocation.
5. Pharmacist: To review medication-related issues, such as prescribing errors or drug administration protocols.
6. Medical Records Officer: To facilitate access to patient records and ensure accurate documentation for audits.
7. Infection Control Specialist: To monitor and address hospital-acquired infections and related protocols.
8. Other Specialists (as needed): Depending on the organization, additional members may include radiologists, pathologists, or
representatives from specific departments like oncology or emergency care.
9. External Consultants (optional): In some cases, external auditors or regulatory body representatives may participate for independent
oversight.
The committee is typically chaired by a senior physician or quality assurance director to ensure leadership and accountability. The size
of the committee depends on the organization but usually ranges from 5 to 15 members to balance expertise and efficiency.
Dr. J. L. Meena

1. Regular Meetings:
- Monthly: Common in larger hospitals or those with high patient volumes to address ongoing audits, review cases, and track quality metrics.
- Quarterly: Suitable for smaller facilities or those with fewer issues, focusing on periodic reviews and updates.
2. Ad Hoc Meetings:
- Convened as needed to address urgent issues, such as sentinel events (e.g., unexpected patient deaths), regulatory inspections, or significant audit findings.
3. Annual Reviews:
- At least once a year, the committee conducts a comprehensive review of audit outcomes, quality improvement initiatives, and compliance with
accreditation standards.
Additional Notes
- Subcommittees: In larger organizations, subcommittees may focus on specific areas (e.g., surgical audits, infection control) and meet more frequently,
reporting to the main committee.
- Documentation: Meetings are documented with minutes, audit reports, and action plans to ensure accountability and track progress.
- Regulatory Requirements: Frequency and composition may be influenced by local healthcare regulations or accreditation bodies (e.g., Joint Commission,
CMS, or country-specific standards).
For precise details, the organization’s bylaws, accreditation requirements, or local healthcare regulations should be consulted, as these may dictate specific
compositions or meeting schedules.
Dr. J. L. Meena

5. Ethics Committee
ØPurpose: Addresses ethical issues in patient care, including informed
consent, end-of-life decisions, and research ethics (mandatory for hospitals
conducting clinical trials).
ØReference: NABH Standard on Patient Rights and Education (PRE).
Accreditation
Dr. J. L. Meena

Ethics Committee
The Ethics Committee in a hospital plays a critical role in addressing ethical issues related to patient care, hospital policies, and professional conduct. Its primary
purpose is to provide guidance, ensure ethical decision-making, and promote the well-being of patients, families, and healthcare staff.
Roles of the Ethics Committee
1. Advisory Role:
- Provide recommendations on ethical dilemmas in patient care, such as end-of-life decisions, informed consent, or conflicts between patients, families, and
healthcare providers.
- Offer non-binding guidance to clinicians, patients, and families to resolve ethical conflicts.
2. Educational Role:
- Educate hospital staff, patients, and families about ethical principles, such as autonomy, beneficence, non-maleficence, and justice.
- Conduct training sessions or workshops on topics like advance directives, cultural competence, or ethical decision-making.
3. Policy Development Role:
- Assist in developing and reviewing hospital policies to ensure they align with ethical standards, legal requirements, and best practices.
- Address issues like organ donation, patient privacy, or resource allocation.
4. Consultative Role:
- Serve as a resource for case consultations when ethical uncertainties arise, such as withholding or withdrawing treatment or managing patient refusals of
care.
- Facilitate discussions among stakeholders to reach a consensus.
5. Conflict Resolution Role:
- Mediate disputes between patients, families, and healthcare providers when values or goals of care conflict.
- Ensure all perspectives are considered in a fair and respectful manner. Dr. J. L. Meena

Responsibilities of the Ethics Committee
1. Case Review and Consultation:
- Analyze specific patient cases referred to the committee, gathering input from relevant parties (e.g., physicians, nurses, patients, or families).
- Provide recommendations to support ethical decision-making while respecting patient rights and medical standards.
2. Ensuring Patient Rights:
- Uphold patient autonomy by ensuring informed consent and the right to refuse treatment are respected.
- Protect vulnerable patients, such as minors, those with diminished capacity, or those in critical care.
3. Promoting Fair Resource Allocation:
- Address ethical issues related to the allocation of scarce resources, such as ICU beds, ventilators, or organ transplants, especially during crises like pandemics.
- Ensure decisions are transparent, equitable, and based on ethical principles.
4. Maintaining Confidentiality:
- Handle sensitive information with strict confidentiality during case reviews and discussions.
- Ensure compliance with privacy laws, such as HIPAA (in the U.S.) or similar regulations in other countries.
5. Monitoring and Evaluating Ethical Practices:
- Regularly assess hospital practices to identify potential ethical issues, such as disparities in care or lapses in informed consent processes.
- Recommend improvements to enhance ethical standards.
6. Interdisciplinary Collaboration:
- Work with diverse stakeholders, including physicians, nurses, social workers, chaplains, and legal advisors, to ensure a holistic approach to ethical challenges.
- Include community representatives or patient advocates in some cases to reflect broader perspectives.
7. Documentation and Reporting:
- Maintain records of consultations, decisions, and recommendations for accountability and future reference.
- Provide periodic reports to hospital leadership on ethical trends or recurring issues.
Ethics Committee
Dr. J. L. Meena

Examples of Issues Addressed
- End-of-life care decisions (e.g., withdrawing life support).
- Conflicts over treatment plans (e.g., patient refusal of life-saving treatment).
- Ethical implications of experimental treatments or research.
- Balancing family wishes with patient autonomy.
- Equitable access to limited medical resources.
Conclusion
The Ethics Committee serves as a vital resource in hospitals, fostering ethical integrity,
supporting patient-centered care, and resolving complex moral dilemmas. By providing
guidance, education, and policy recommendations, it ensures that healthcare delivery
aligns with ethical principles and respects the dignity of all involved.
Ethics Committee
Dr. J. L. Meena

The Ethics Committee in a hospital typically consists of a multidisciplinary team of healthcare professionals, including:
2. Nurses: Representatives from various nursing departments.
3. Bioethicists: Experts in bioethics and healthcare ethics.
4. Social workers: Representatives from social work departments.
5. Chaplains or spiritual care providers: Representatives from spiritual care departments.
6. Patient advocates: Representatives from patient advocacy groups.
7. Community representatives: Representatives from the community served by the hospital.
8. Other stakeholders: Representatives from relevant departments, such as law, philosophy, or ethics.
1. Regular meetings: The committee typically meets regularly, such as monthly or quarterly.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific ethics concerns or cases.
ethics initiatives.
The frequency of meetings may vary depending on the organization's size, complexity, and ethics priorities. The committee's composition
and meeting frequency should be tailored to meet the specific needs of the organization.
Ethics Committee
Dr. J. L. Meena

6. Pharmaco-Therapeutics Committee (Pharmacy and Therapeutics
Committee)
ØPurpose: Manages medication safety, formulary development, and monitors
adverse drug reactions.
ØReference: NABH Standard on Management of Medication (MOM).
Accreditation
Dr. J. L. Meena

Pharmaco-Therapeutics Committee
(Pharmacy and Therapeutics Committee)
The Pharmacy and Therapeutics Committee (PTC), also known as the Pharmaco-Therapeutics Committee, is a multidisciplinary group responsible for
overseeing medication-related policies and practices within a healthcare organization. Its primary role is to ensure safe, effective, and cost-efficient use of
medications.
1. Formulary Management
- Develop, maintain, and update the organization's drug formulary (a list of approved medications).
- Evaluate new medications for inclusion based on efficacy, safety, cost, and therapeutic need.
- Remove or restrict medications that are outdated, less effective, or pose safety risks.
- Establish criteria for the use of non-formulary drugs.
2. Policy and Guideline Development
- Create and implement policies for medication use, including prescribing, dispensing, and administration.
- Develop clinical guidelines and protocols to standardize treatment and improve patient outcomes.
- Establish procedures for handling high-risk medications, controlled substances, and investigational drugs.
3. Medication Safety and Quality Assurance
- Monitor adverse drug reactions (ADRs) and medication errors to enhance patient safety.
- Review and analyze medication use data to identify trends or issues.
- Recommend strategies to prevent medication-related harm, such as staff education or system improvements.
4. Drug Utilization Review (DUR)
- Conduct evaluations of medication use to ensure appropriateness, efficacy, and cost-effectiveness.
- Identify overuse, underuse, or misuse of medications and recommend corrective actions.
- Promote adherence to evidence-based prescribing practices.
Dr. J. L. Meena

5. Education and Training
- Provide education to healthcare providers on formulary changes, new medications, and best practices.
- Disseminate information on medication safety, therapeutic guidelines, and policy updates.
- Support continuing education programs for pharmacists, physicians, and nurses.
6. Cost Management
- Evaluate the cost-effectiveness of medications and therapeutic alternatives.
- Recommend strategies to optimize medication budgets, such as generic substitution or therapeutic interchange.
- Collaborate with purchasing departments to negotiate favorable drug pricing.
7. Regulatory Compliance
- Ensure compliance with national and local regulations, accreditation standards, and institutional policies.
- Align medication practices with guidelines from organizations like the FDA, WHO, or Joint Commission.
8. Interdisciplinary Collaboration
- Facilitate communication among physicians, pharmacists, nurses, and administrators to align medication practices with organizational goals.
- Serve as an advisory body to hospital leadership on medication-related issues.
9. Research and Innovation
- Support the use of investigational drugs in clinical trials by reviewing protocols and ensuring ethical standards.
- Stay updated on emerging therapies and pharmacotherapeutic advancements to guide formulary decisions.
Dr. J. L. Meena

The Pharmaco-Therapeutics Committee (also known as the Pharmacy and Therapeutics Committee) is a multidisciplinary group designed to oversee
medication-related policies. Its composition typically includes representatives from various healthcare disciplines to ensure diverse perspectives.
- Pharmacists: Often lead the committee, providing expertise on drug therapy, formulary management, and medication safety.
- Physicians: Represent various specialties (e.g., internal medicine, surgery, pediatrics) to offer clinical insights and prescribing perspectives.
- Nurses: Contribute knowledge on medication administration, patient care, and practical implementation of policies.
- Administrators: Represent hospital or healthcare system leadership to align PTC decisions with organizational goals and budgets.
- Other Healthcare Professionals: May include dietitians, infection control specialists, or quality assurance officers, depending on the organization's needs.
- Patient Representatives (optional): Occasionally included to provide a patient-centered perspective.
- External Consultants (optional): Experts in pharmacology, economics, or specific therapeutic areas may be invited for specialized input.
- Liaisons: Representatives from departments like purchasing, risk management, or regulatory affairs may participate.
The committee is often chaired by a physician or pharmacist, with a pharmacist typically serving as the secretary to manage documentation and
communication.
The PTC typically meets regularly, with the frequency depending on the organization's size, needs, and workload.
- Common Frequency: Monthly or quarterly meetings are standard for most healthcare institutions.
- Larger Institutions: May meet monthly due to higher volumes of formulary changes, medication reviews, or policy updates.
- Smaller Institutions: May meet quarterly or biannually if fewer issues arise.
- Ad Hoc Meetings: Special meetings may be called for urgent issues, such as evaluating a new high-cost drug, addressing a medication shortage, or
responding to a safety concern.
- Meetings are often supplemented by subcommittees or working groups that handle specific tasks (e.g., formulary review, drug utilization evaluation) and
report back to the main committee.
Dr. J. L. Meena

7. Safety Committee (Facility Safety Committee)
ØPurpose: Ensures safety of the hospital environment, including fire safety,
equipment maintenance, and disaster preparedness.
ØReference: NABH Standard on Facility Management and Safety (FMS).
Accreditation
Dr. J. L. Meena

Safety Committee (Facility Safety
Committee)
A **Hospital Facility Safety Committee** plays a critical role in ensuring a safe environment for patients, staff, visitors, and contractors. Its primary purpose is
to oversee, promote, and maintain safety standards within the hospital facility.
Roles of the Hospital Safety Committee
1. Policy Development and Implementation:
- Develop, review, and update safety policies and procedures to comply with regulatory standards (e.g., OSHA, Joint Commission, local health authorities).
- Ensure policies address workplace hazards, infection control, emergency preparedness, and patient safety.
2. Risk Assessment and Hazard Identification:
- Conduct regular safety audits and inspections to identify potential hazards (e.g., fire risks, chemical exposures, ergonomic issues, or unsafe equipment).
- Assess risks specific to hospital operations, such as radiation safety, sharps injuries, or patient handling.
3. Incident Investigation and Reporting:
- Review and investigate safety incidents, accidents, or near-misses (e.g., staff injuries, patient falls, or equipment failures).
- Analyze root causes and recommend corrective actions to prevent recurrence.
- Ensure proper documentation and reporting to regulatory bodies as required.
4. Training and Education:
- Coordinate safety training programs for hospital staff on topics like fire safety, infection control, hazardous material handling, and emergency response.
- Promote a culture of safety awareness through regular communication and campaigns.
Dr. J. L. Meena

5. Emergency Preparedness:
- Develop and maintain emergency response plans for events like fires, natural disasters, or mass casualty incidents.
- Organize drills and simulations to test preparedness and improve response capabilities.
6. Regulatory Compliance:
- Ensure the hospital adheres to safety regulations and standards set by agencies like OSHA, CDC, NFPA, and state/local health departments.
- Prepare for and participate in accreditation surveys and inspections.
7. Interdepartmental Coordination:
- Collaborate with departments like infection control, facilities management, and human resources to address safety concerns.
- Act as a liaison between hospital leadership and staff to communicate safety priorities.
8. Monitoring and Evaluation:
- Track safety performance metrics (e.g., injury rates, compliance rates) and evaluate the effectiveness of safety programs.
- Recommend improvements based on data analysis and feedback from staff.
Responsibilities of Committee Members
- Chairperson: Lead meetings, set agendas, and ensure follow-through on action items.
- Members: Represent various departments (e.g., nursing, facilities, administration) to provide diverse perspectives and ensure comprehensive safety
coverage.
- Safety Officer/Coordinator: Serve as the primary point of contact for safety issues, conduct inspections, and maintain records.
- Regular Meetings: Convene periodically (e.g., monthly or quarterly) to review safety data, discuss incidents, and plan initiatives.
- Communication: Disseminate safety updates, policies, and training opportunities to all hospital staff.
- Advocacy: Promote a proactive safety culture and encourage staff to report hazards or concerns without fear of reprisal.
Committee)
Dr. J. L. Meena

Key Focus Areas in a Hospital Setting
- Patient Safety: Prevent medical errors, falls, and hospital-acquired infections.
- Staff Safety: Protect against workplace injuries (e.g., needlesticks, back injuries from lifting patients).
- Environmental Safety: Ensure proper waste disposal, air quality, and equipment maintenance.
- Fire and Life Safety: Maintain fire alarms, sprinklers, and evacuation plans.
- Infection Control: Enforce hand hygiene, sterilization protocols, and PPE usage.
Regulatory Context
Hospitals must comply with standards from:
- OSHA: Workplace safety and hazard communication.
- NABH/ Joint Commission: Accreditation standards for safety and emergency management.
- CDC/NIOSH: Guidelines for infection control and occupational health.
- NFPA: Fire safety codes (e.g., NFPA 101 Life Safety Code).
- Local and state health departments.
By fulfilling these roles and responsibilities, the Hospital Safety Committee ensures a safe, compliant, and resilient
healthcare environment, protecting all stakeholders while supporting high-quality patient care.
Committee)
Dr. J. L. Meena

The Safety Committee (Facility Safety Committee) typically consists of a multidisciplinary team of healthcare professionals, including:
Members
1. Safety officer: A designated safety officer or risk manager.
2. Department representatives: Representatives from various departments, such as nursing, medicine, facilities, and security.
3. Staff representatives: Representatives from different staff groups, such as frontline staff and management.
4. Environmental services: Representatives from environmental services or housekeeping.
5. Engineering and maintenance: Representatives from engineering and maintenance departments.
6. Other stakeholders: Representatives from relevant departments, such as quality improvement, infection control, or emergency
preparedness.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific safety concerns or incidents.
safety initiatives.
The frequency of meetings may vary depending on the organization's size, complexity, and safety priorities. The committee's composition
Committee)
Dr. J. L. Meena

8. Blood Transfusion Committee
ØPurpose: Oversees blood bank operations, transfusion practices, and
monitors transfusion reactions (mandatory for hospitals with blood banks).
ØReference: NABH Standards for Blood Banks/Transfusion Services.
Accreditation
Dr. J. L. Meena

Blood Transfusion Committee
The **Blood Transfusion Committee (BTC)**, also known as the Hospital Transfusion Committee (HTC) or Blood Management Committee, is a multidisciplinary group responsible for
overseeing and ensuring safe, effective, and appropriate blood transfusion practices within a healthcare institution. Below is a detailed outline of its **roles and responsibilities**,
based on established guidelines and practices:
Roles and Responsibilities of the Blood Transfusion Committee
1. Development and Implementation of Policies and Guidelines
- Develop and enforce local policies and standard operating procedures (SOPs) for all aspects of the transfusion process, including blood ordering, handling, administration, and
monitoring. - Ensure alignment with national and international guidelines (e.g., WHO, ISBT, or regional transfusion standards) to promote evidence-based practices.
(https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-committees.html)
- Draft transfusion protocols and decision trees to guide clinical staff in appropriate blood use. (https://www.isbtweb.org/resources/educational-modules-on-clinical-use-of-
blood/principles-of-appropriate-use-of-blood.html)
2. Promotion of Patient Blood Management (PBM)
- Implement PBM initiatives to optimize patient outcomes by minimizing unnecessary transfusions, reducing blood loss, and enhancing alternatives like autologous transfusion or
erythropoietin. (https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-committees.html)
- Encourage the use of transfusion alternatives when appropriate, such as tranexamic acid or iron supplementation, to reduce reliance on allogeneic blood.
(https://www.britishjournalofnursing.com/content/clinical/blood-transfusions-in-adults-ensuring-patient-safety/)
3. Ensuring Safe Transfusion Practices
- Oversee the entire transfusion chain, from blood collection (if applicable) to patient administration, to ensure safety and compliance with regulations.
(https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-committees.html)
- Monitor and enforce positive patient identification (PPI) protocols to prevent errors like ABO-incompatible transfusions.
(https://www.britishjournalofnursing.com/content/clinical/blood-transfusions-in-adults-ensuring-patient-safety/)
- Ensure proper storage, handling, and transportation of blood components to minimize contamination or degradation. (https://www.isbtweb.org/resources/educational-modules-
on-clinical-use-of-blood/principles-of-appropriate-use-of-blood.html)
Dr. J. L. Meena

4. Education and Training
- Provide ongoing education and training for healthcare staff (clinicians, nurses, laboratory personnel) on transfusion indications, risks,
and best practices. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258981/)
- Develop and disseminate local educational materials to improve awareness of safe transfusion practices and PBM.
(https://www.lifeblood.com.au/health-professionals/clinical-practice/patient-blood-management/transfusion-committees)
- Train staff on obtaining informed consent for transfusions, ensuring patients are aware of benefits, risks, and alternatives.
(https://www.isbtweb.org/resources/educational-modules-on-clinical-use-of-blood/principles-of-appropriate-use-of-blood.html)
5. Auditing and Monitoring Transfusion Practices
- Conduct regular audits of blood ordering, usage, and wastage to ensure appropriateness and efficiency.
- Monitor transfusion practices against institutional, national, or international benchmarks to identify areas for improvement.
- Review randomly selected medical records of transfused patients to assess compliance with protocols.
6. Management of Adverse Events and Haemovigilance
- Investigate and analyze adverse transfusion reactions or errors, implementing corrective and preventive actions.
(https://www.isbtweb.org/resources/educational-modules-on-clinical-use-of-blood/principles-of-appropriate-use-of-blood.html)
- Report adverse events through the hospital’s haemovigilance system to national or regional committees for continuous quality
improvement. (https://www.isbtweb.org/resources/educational-modules-on-clinical-use-of-blood/principles-of-appropriate-use-of-
blood.html)
- Follow up on serious transfusion-related incidents, such as fatalities, and notify blood suppliers if donor-related issues are suspected.
Dr. J. L. Meena

7. Blood Utilization and Conservation
- Monitor blood usage patterns to reduce inappropriate transfusions and conserve blood resources, especially given the limited and costly nature of blood products.
- Implement tools like Maximum Surgical Blood Order Schedules (MSBOS) to optimize blood ordering and reduce wastage.
- Promote techniques like cell salvage and autologous transfusion in surgical settings.
8. Facilitation of Communication and Collaboration
- Serve as a forum for multidisciplinary collaboration among clinicians (e.g., surgeons, hematologists, anesthesiologists), laboratory staff, and hospital management to address
transfusion-related challenges. (https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-
committees.html)
- Liaise with blood transfusion services or blood establishments to ensure a consistent supply of safe blood components. (https://www.isbtweb.org/resources/educational-modules-
on-clinical-use-of-blood/principles-of-appropriate-use-of-blood.html)
- Share knowledge, feedback, and solutions to improve transfusion practices across departments. (https://www.isbtweb.org/isbt-working-parties/clinical-
transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-committees.html)
9. Quality Assurance and Regulatory Compliance
- Ensure compliance with accreditation standards (e.g., JCAHO, CAP) and national regulations (https://pubmed.ncbi.nlm.nih.gov/16304424/)
- Maintain a data-driven quality assessment and performance improvement program to enhance transfusion safety and efficacy.
- Regularly review and update the committee’s Terms of Reference and membership to reflect current needs and staff changes. (https://www.isbtweb.org/isbt-working-
parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-committees.html)
10. Clinical Governance and Risk Management
- Contribute to clinical governance by overseeing the safety and appropriateness of transfusion practices, reducing risks like transfusion-transmitted infections or
complications.[](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258981/)
- Work with hospital executive management to secure resources and authority for effective committee functioning.[](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258981/)
Dr. J. L. Meena

Structure and Operations
- Membership: Includes multidisciplinary professionals such as hematologists, surgeons, anesthesiologists, nurses, transfusion practitioners, and laboratory
staff. The chair is ideally a healthcare professional involved in transfusion support, excluding the consultant hematologist in charge, to encourage diverse
perspectives. (https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-
transfusion-committees.html)
- Meetings: Typically held quarterly, though larger institutions may meet more frequently. Meetings require a minimum attendance (e.g., 65% of members)
to be valid. (https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-
committees.html)[](https://www.srmhospital.co.in/srm_committee/blood-transfusion-committee/)
- Reporting Lines: The BTC reports to hospital management and, in some countries, to regional or national transfusion committees.
(https://www.isbtweb.org/isbt-working-parties/clinical-transfusion/resources/patient-blood-management-resources/12-the-role-of-transfusion-
committees.html)[](https://nationalbloodtransfusion.co.uk/)
Challenges
- Lack of universal criteria for appropriate blood use can complicate policy development. (https://pubmed.ncbi.nlm.nih.gov/15067589/)
- Inadequate resources, authority, or infrastructure may limit the committee’s effectiveness, as seen in some regions.
- Continuous education is needed to keep staff updated on evolving transfusion practices and technologies.
Impact
A functional BTC can significantly reduce inappropriate transfusions, improve patient safety, conserve blood resources, and enhance clinical outcomes. By
fostering collaboration, education, and adherence to best practices, the committee ensures that blood transfusions are safe, effective, and reserved for cases
where no alternatives exist. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3258981/)
Dr. J. L. Meena

The Blood Transfusion Committee typically consists of a multidisciplinary team of healthcare professionals, including:
Members
1. Transfusion medicine specialists: Experts in transfusion medicine, such as hematologists or transfusion medicine physicians.
2. Blood bank medical director: The medical director of the blood bank or transfusion service.
3. Clinicians: Representatives from various clinical departments, such as surgery, anesthesia, and hematology/oncology.
4. Nurses: Representatives from nursing services, including those involved in transfusion administration.
5. Laboratory representatives: Representatives from the laboratory or blood bank.
1. Regular meetings: The committee typically meets regularly, such as quarterly or semiannually.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific transfusion-related issues or concerns.
transfusion-related initiatives.
The frequency of meetings may vary depending on the organization's size, complexity, and transfusion volume. The committee's
composition and meeting frequency should be tailored to meet the specific needs of the organization.
Dr. J. L. Meena

9. Credentialing and Privileging Committee
Purpose: Evaluates and grants privileges to medical staff based on
qualifications and competency.
Reference: NABH Standard on Human Resource Management (HRM).
Accreditation
Dr. J. L. Meena

Credentialing and Privileging
Committee
The **Credentialing and Privileging Committee** in a hospital is responsible for ensuring that healthcare providers are qualified, competent, and authorized to deliver
patient care. Its primary role is to oversee the credentialing and privileging processes to maintain high standards of care, patient safety, and regulatory compliance.
1. Credentialing
- Verify Qualifications: Review and verify the education, training, licensure, certifications, and professional experience of healthcare providers (physicians, nurses,
allied health professionals, etc.).
- Background Checks: Ensure providers have no history of malpractice, disciplinary actions, or criminal issues by checking references, National Practitioner Data Bank
(NPDB), and other databases.
- Licensure Compliance: Confirm that providers maintain active, valid licenses and certifications required for their roles.
- Primary Source Verification: Directly validate credentials from issuing institutions (e.g., medical schools, licensing boards) to ensure authenticity.
2. Privileging
- Grant Clinical Privileges: Determine the specific procedures, treatments, or services a provider is authorized to perform based on their training, experience, and
competency.
- Evaluate Competency: Assess providers’ skills through peer reviews, performance evaluations, and outcomes data to ensure they meet hospital standards.
- Scope of Practice: Define and approve the scope of practice for each provider, aligning with hospital policies, specialty requirements, and regulatory standards.
- Temporary or Emergency Privileges: Review and approve temporary privileges for locum tenens or emergency situations, ensuring proper vetting.
3. Ongoing Monitoring and Re-credentialing
- Periodic Review: Conduct re-credentialing (typically every 1-2 years) to ensure providers maintain qualifications, licensure, and competency.
- Performance Monitoring: Review quality metrics, patient outcomes, incident reports, and peer evaluations to identify areas for improvement or concerns.
- Continuing Education: Verify that providers meet continuing medical education (CME) or professional development requirements.
Dr. J. L. Meena

4. Policy Development and Compliance
- Develop Guidelines: Establish and update credentialing and privileging policies in line with hospital bylaws, accreditation standards (e.g., Joint Commission, CMS),
and state/federal regulations.
- Ensure Fairness: Maintain a standardized, transparent, and unbiased process for credentialing and privileging decisions.
- Regulatory Compliance: Ensure adherence to laws, accreditation requirements, and industry standards to mitigate legal and financial risks.
5. Risk Management
- Identify Red Flags: Address issues such as lapses in licensure, malpractice claims, or behavioral concerns that could impact patient safety.
- Disciplinary Actions: Recommend suspension, restriction, or revocation of privileges if a provider fails to meet standards or engages in misconduct.
- Appeal Process: Oversee fair hearings or appeals for providers who contest credentialing or privileging decisions.
6. Collaboration and Communication
- Work with Medical Staff: Collaborate with medical staff leadership, department chairs, and hospital administration to align credentialing with organizational needs.
- Advise Leadership: Provide recommendations to the hospital’s governing board or medical executive committee on credentialing and privileging matters.
- Maintain Records: Ensure accurate, confidential documentation of credentialing and privileging activities for audits and legal purposes.
Composition of the Committee
The committee typically includes experienced physicians, hospital administrators, and representatives from nursing or allied health. Members are chosen for their
expertise and impartiality to ensure objective decision-making.
Importance
The Credentialing and Privileging Committee plays a critical role in safeguarding patient safety, upholding the hospital’s reputation, and ensuring high-quality care by
ensuring only qualified and competent providers are allowed to practice.
Committee
Dr. J. L. Meena

The Credentialing and Privileging Committee typically consists of a multidisciplinary team of healthcare professionals:
Members
1. Medical staff leaders: Representatives from the medical staff, such as the chief medical officer or department chairs.
4. Credentialing office representatives: Representatives from the credentialing office, who are responsible for verifying credentials.
5. Other stakeholders: Representatives from relevant departments, such as nursing or hospital administration.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific credentialing or privileging issues.
3. Minutes and follow-up: Meeting minutes are documented, and follow-up actions are assigned and tracked to ensure that
credentialing and privileging activities are completed in a timely manner.
The frequency of meetings may vary depending on the organization's size, complexity, and volume of credentialing and privileging
activities. The committee's composition and meeting frequency should be tailored to meet the specific needs of the organization.
Committee
Dr. J. L. Meena

10. Grievance Redressal Committee
Purpose: Handles patient complaints and ensures timely resolution to enhance
patient satisfaction.
Accreditation
Dr. J. L. Meena

Grievance Redressal Committee
The **Grievance Redressal Committee (GRC)** in a hospital is responsible for addressing and resolving complaints or concerns raised by patients, their
families, or staff, ensuring a fair, transparent, and efficient process. Its primary goal is to enhance patient satisfaction, maintain trust, and improve the
quality of healthcare services.
Roles and Responsibilities of the Grievance Redressal Committee in a Hospital:
1. Receiving Complaints:
- Serve as a point of contact for grievances related to medical care, staff behavior, billing, facilities, or other hospital services.
- Ensure accessibility through multiple channels (e.g., complaint boxes, online portals, or direct submissions).
2. Investigation and Fact-Finding:
- Conduct impartial and thorough investigations into complaints.
- Gather relevant information, including statements from complainants, staff, and witnesses, and review medical records or other documents.
3. Resolution of Grievances:
- Facilitate timely resolution of complaints through mediation, dialogue, or corrective actions.
- Recommend appropriate measures, such as apologies, refunds, staff counseling, or policy changes, based on findings.
4. Ensuring Fairness and Transparency:
- Maintain neutrality and avoid bias during the redressal process.
- Provide clear communication to complainants about the progress and outcome of their grievances.
Dr. J. L. Meena

5. Compliance with Regulations:
- Ensure adherence to national and local healthcare regulations, such as guidelines from the Ministry of Health, NABH (National Accreditation Board for
Hospitals), or other regulatory bodies.
- Protect patient rights as per legal and ethical standards.
6. Documentation and Reporting:
- Maintain records of all complaints, investigations, and resolutions for accountability and future reference.
- Prepare periodic reports on grievance trends to identify systemic issues and recommend improvements.
7. Improving Hospital Services:
- Analyze recurring complaints to identify gaps in service delivery or operational inefficiencies.
- Provide feedback to hospital management for quality improvement and staff training.
8. Educating Stakeholders:
- Raise awareness among patients and staff about the grievance redressal process.
- Train hospital staff to handle complaints sensitively and professionally.
9. Escalation Handling:
- Address escalated or unresolved grievances and, if necessary, guide complainants to higher authorities or external bodies (e.g., consumer courts or health
ombudsman).
10. Confidentiality and Sensitivity:
- Protect the privacy of complainants and ensure sensitive handling of issues, especially those involving medical errors or ethical concerns.
Dr. J. L. Meena

The Grievance Redressal Committee (GRC) typically consists of a multidisciplinary team of healthcare professionals,
including:
Members
1. Chairperson: A senior healthcare professional or administrator.
2. Medical representatives: Representatives from various medical departments.
3. Nursing representatives: Representatives from nursing services.
4. Patient advocate: A patient advocate or representative from patient relations.
5. Quality improvement specialist: An expert in quality improvement and patient safety.
6. Other stakeholders: Representatives from relevant departments, such as customer service or hospital administration.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific grievances or concerns.
3. Timely review: The committee reviews grievances in a timely manner, ensuring that concerns are addressed promptly.
The frequency of meetings may vary depending on the organization's size, complexity, and volume of grievances. The
committee's composition and meeting frequency should be tailored to meet the specific needs of the organization.
Dr. J. L. Meena

11. Internal Complaints Committee (ICC)
Purpose: plays a crucial role in addressing and resolving complaints related to
sexual harassment and other forms of harassment in the workplace.
Accreditation
Dr. J. L. Meena

Internal Complaints Committee (ICC)
The **Internal Complaints Committee (ICC)** is a mandatory body in workplaces, particularly in India, established under the **Sexual
Harassment of Women at Workplace (Prevention, Prohibition, and Redressal) Act, 2013 (POSH Act)**. Its primary role is to address
complaints of sexual harassment and ensure a safe working environment.
Roles of the ICC
1. Grievance Redressal Body: Act as a dedicated committee to receive, investigate, and resolve complaints of sexual harassment in the
workplace.
2. Policy Implementation: Ensure compliance with the POSH Act and organizational policies on preventing sexual harassment.
3. Awareness and Sensitization: Promote a workplace culture free from harassment by conducting awareness programs and training.
4. Neutral Mediator: Facilitate fair and unbiased resolution of complaints while protecting the rights of both complainant and respondent.
Responsibilities of the ICC
1. Receiving Complaints:
- Accept written complaints of sexual harassment from employees (within 3 months of the incident, extendable by 3 more months in
exceptional cases).
- Ensure accessibility and confidentiality for complainants.
2. Investigation:
- Conduct a fair, impartial, and time-bound inquiry into complaints (to be completed within 90 days of receiving the complaint).
- Follow principles of natural justice, allowing both parties to present their case and evidence.
- Summon witnesses, review documents, and gather relevant information.
Dr. J. L. Meena

3. Interim Measures:
- Recommend interim relief, such as leave, transfer, or restraining the respondent from contacting the complainant, to protect the
complainant during the inquiry.
4. Recommendations:
- Submit a report with findings and recommendations to the employer within 10 days of completing the inquiry.
- Suggest actions, such as disciplinary measures (e.g., warning, termination), compensation to the complainant, or counseling, based on
the inquiry outcome.
5. Confidentiality:
- Maintain strict confidentiality of the complaint, identities of the parties involved, and inquiry proceedings, except as required by law.
6. Awareness and Training:
- Organize workshops, training sessions, and awareness programs to educate employees about their rights and the organization’s POSH
policy.
7. Annual Reporting:
- Prepare and submit an annual report to the employer and the district officer, detailing the number of complaints received, resolved,
and pending, as required under the POSH Act.
Dr. J. L. Meena

8. Policy Advisory:
- Advise the employer on strengthening workplace policies to prevent sexual harassment and ensure a safe environment.
Composition of ICC
- Presiding Officer: A senior-level woman employee.
- Members: At least two employees, preferably with experience in social work or legal knowledge.
- External Member: A person from an NGO or association familiar with sexual harassment issues.
- At least 50% of the members** must be women.
Key Notes
- The ICC must adhere to the POSH Act guidelines and ensure a transparent, time-bound process.
- Failure to constitute an ICC or comply with its recommendations can result in penalties for the employer, including fines up to ₹50,000 or
cancellation of business licenses.
- The ICC’s scope is limited to workplace sexual harassment as defined under the POSH Act, but it may also address related concerns based on
organizational policies.
Ø As needed: The ICC meets as needed to investigate and address complaints.
Ø Regular meetings: The ICC may hold regular meetings to discuss ongoing investigations, review policies, and provide updates.
Ø Timely response: The ICC responds to complaints in a timely manner, ensuring that investigations are conducted promptly and efficiently.
The composition and frequency of meetings may vary depending on the organization's size, complexity, and specific needs. The ICC's primary focus is
on addressing and resolving complaints related to sexual harassment and creating a safe and respectful work environment.
Dr. J. L. Meena

12. Mortality and Morbidity Review Committee
Purpose: Reviews deaths and adverse events to identify preventable causes
and improve care processes.
Reference: NABH Standard on Care of Patients (COP).
Accreditation
Dr. J. L. Meena

Mortality and Morbidity Review
Committee
A **Mortality and Morbidity Review Committee (MMRC)** is typically established in healthcare settings to improve patient safety, quality of care, and clinical
outcomes by systematically reviewing deaths and complications.
Role
The MMRC serves as a multidisciplinary team responsible for analyzing adverse patient outcomes, including deaths (mortality) and serious complications
(morbidity), to identify trends, systemic issues, and opportunities for improvement in healthcare delivery.
Responsibilities
1. Case Review and Analysis:
- Conduct thorough reviews of patient cases involving deaths or significant complications.
- Assess clinical care, decision-making, and adherence to protocols to determine contributing factors.
- Identify whether outcomes were preventable or linked to errors, system failures, or other issues.
2. Quality Improvement:
- Recommend changes to clinical practices, policies, or procedures to prevent future adverse events.
- Develop action plans to address identified deficiencies in care delivery or systems.
3. Education and Training:
- Share lessons learned from reviews with healthcare staff to enhance knowledge and skills.
- Promote a culture of continuous learning and improvement through feedback and training initiatives.
4. Data Collection and Reporting:
- Maintain records of reviewed cases, including causes, contributing factors, and outcomes.
- Generate reports on trends, patterns, or recurring issues to inform hospital leadership and regulatory bodies.
- Ensure compliance with legal, ethical, and regulatory reporting requirements. Dr. J. L. Meena

5. Promoting a Non-Punitive Culture:
- Foster an environment where staff feel safe to report errors or near-misses without fear of blame.
- Focus on system-level improvements rather than individual fault, unless gross negligence is evident.
6. Interdisciplinary Collaboration:
- Engage diverse stakeholders (e.g., physicians, nurses, administrators, pharmacists) to ensure comprehensive reviews.
- Facilitate communication across departments to address cross-cutting issues.
7. Risk Management:
- Identify potential risks to patient safety and recommend strategies to mitigate them.
- Collaborate with risk management teams to address legal or liability concerns arising from adverse events.
8. Monitoring and Follow-Up:
- Track the implementation and effectiveness of recommended changes.
- Re-evaluate cases or systems periodically to ensure sustained improvements.
Key Principles
- Confidentiality: Protect patient and staff privacy during reviews, adhering to regulations like HIPAA.
- Objectivity: Conduct impartial assessments based on evidence and clinical standards.
- System Focus: Emphasize systemic issues over individual blame to drive meaningful change.
Examples of Outcomes
- Revising hospital protocols (e.g., sepsis management).
- Implementing new training programs (e.g., on early warning signs).
- Upgrading equipment or technology to enhance patient safety.
Committee
Dr. J. L. Meena

The Mortality and Morbidity Review Committee typically consists of a multidisciplinary team of healthcare professionals,
including:
Members
1. Chairperson: A senior healthcare professional or department chair.
3. Nurses: Representatives from nursing services.
5. Other stakeholders: Representatives from relevant departments, such as risk management or patient safety.
2. Ad hoc meetings: Additional meetings may be called as needed to review specific cases or address urgent issues.
3. Timely review: The committee reviews mortality and morbidity cases in a timely manner, ensuring that lessons are learned and
improvements are implemented promptly.
The frequency of meetings may vary depending on the organization's size, complexity, and volume of mortality and morbidity
cases. The committee's composition and meeting frequency should be tailored to meet the specific needs of the organization.
Committee
Dr. J. L. Meena

13. Disaster Management Committee (optional, depending on hospital size)
Purpose: Plans and prepares for disaster response, including emergency
preparedness drills.
Reference: NABH Standard on Facility Management and Safety (FMS).
Accreditation
Dr. J. L. Meena

Disaster Management Committee
(depending on hospital size)
The **Disaster Management Committee** in a hospital plays a critical role in preparing for, responding to, and recovering from disasters,
whether natural (e.g., earthquakes, floods) or man-made (e.g., terrorist attacks, chemical spills). The establishment of such a committee is
often optional and depends on the hospital's size, location, resources, and risk profile. Larger hospitals or those in high-risk areas are more
likely to have a dedicated committee, while smaller facilities may integrate these responsibilities into other administrative or safety
committees.
Roles of the Disaster Management Committee
1. Leadership and Coordination: Provide strategic oversight and coordination for disaster preparedness, response, and recovery efforts.
2. Policy Development: Formulate and update the hospital’s disaster management plan (DMP) in alignment with national, state, and local
regulations.
3. Risk Assessment: Identify potential hazards specific to the hospital’s location and infrastructure (e.g., proximity to fault lines, flood
zones, or industrial areas).
4. Resource Management: Ensure availability and maintenance of resources, including emergency supplies, equipment, and trained
personnel.
5. Training and Awareness: Educate hospital staff, patients, and visitors about disaster preparedness and response protocols.
6. Liaison with External Agencies: Collaborate with local government, emergency services (fire, police, EMS), and other healthcare facilities
for coordinated disaster response.
7. Monitoring and Evaluation: Regularly assess the effectiveness of the disaster management plan through drills, simulations, and post-
incident reviews.
Dr. J. L. Meena

Key Responsibilities
1. Developing the Disaster Management Plan (DMP):
- Create a comprehensive plan outlining procedures for various disaster scenarios (e.g., evacuation, triage, communication).
- Ensure the plan addresses surge capacity, patient care continuity, and staff safety.
- Include protocols for mass casualty incidents, power outages, water shortages, and communication failures.
2. Risk and Vulnerability Assessment:
- Conduct periodic hazard vulnerability analyses (HVAs) to identify risks like earthquakes, floods, or pandemics.
- Assess the hospital’s structural and non-structural safety (e.g., building integrity, equipment anchoring).
3. Training and Drills:
- Organize regular training sessions for staff on disaster response, including triage, evacuation, and use of emergency equipment.
- Conduct simulation exercises (e.g., tabletop drills, full-scale mock disasters) to test preparedness and identify gaps.
4. Resource and Logistics Management:
- Maintain an inventory of emergency supplies (e.g., medical kits, food, water, generators).
- Establish agreements with vendors for rapid supply replenishment during disasters.
- Ensure backup systems (e.g., power, communication) are functional.
5. Communication Systems:
- Develop and maintain robust internal and external communication plans for disasters.
- Ensure redundancy in communication tools (e.g., radios, satellite phones) in case of network failures.
- Designate a public information officer to manage media and public communications.
Dr. J. L. Meena

6. Incident Response Coordination:
- Activate the hospital’s incident command system (ICS) during a disaster to streamline decision-making.
- Coordinate triage, patient transfer, and resource allocation during a crisis.
- Ensure clear roles for staff (e.g., medical, administrative, security) during response.
7. Collaboration with External Stakeholders:
- Work with local disaster management authorities, fire departments, and other hospitals for mutual aid.
- Participate in community-wide disaster preparedness initiatives and regional healthcare coalitions.
8. Post-Disaster Recovery:
- Oversee the restoration of normal hospital operations after a disaster.
- Conduct debriefings and after-action reviews to evaluate response effectiveness.
- Update the DMP based on lessons learned.
9. Compliance and Accreditation:
- Ensure the hospital’s disaster management practices comply with regulations (e.g., Joint Commission, WHO guidelines, or
national health standards).
- Prepare documentation and reports for audits or accreditation reviews.
Dr. J. L. Meena

Optional Nature and Hospital Size
- Large Hospitals: Typically have a dedicated Disaster Management Committee with specialized sub-teams (e.g., logistics, medical response, communications).
These hospitals often serve as regional hubs during disasters, requiring robust planning and resources.
- Medium Hospitals: May have a smaller committee or integrate disaster management into a broader safety or emergency preparedness team. Responsibilities
are often shared among existing staff.
- Small Hospitals/Clinics: May not have a formal committee due to limited resources. Disaster management duties may be assigned to a single administrator or
safety officer, with reliance on external support (e.g., local government or larger hospitals).
Factors Influencing Committee Formation:
- Geographic Risk: Hospitals in disaster-prone areas (e.g., hurricane zones, seismic regions) are more likely to prioritize a dedicated committee.
- Regulatory Requirements: Some countries or accreditation bodies mandate disaster preparedness committees for certain hospital sizes.
- Resource Availability: Larger budgets and staff pools enable more formalized committees.
Challenges
- Limited funding or resources in smaller hospitals.
- Staff turnover affecting training continuity.
- Balancing disaster preparedness with daily operations.
- Ensuring community-wide coordination in rural or underserved areas.
Conclusion
The Disaster Management Committee is vital for ensuring a hospital’s resilience and ability to function during crises. Dependent on hospital size, its core
responsibilities—planning, training, resource management, and coordination—are critical for patient and staff safety. Even in smaller facilities without a formal
committee, these functions should be integrated into existing safety frameworks to meet preparedness goals.
Dr. J. L. Meena

The Disaster Management Committee typically consists of a multidisciplinary team of healthcare professionals, including:
Members
1. Chairperson: A senior healthcare administrator or emergency management expert.
2. Department representatives: Representatives from various departments, such as emergency medicine, nursing, facilities, and security.
3. Safety officer: A designated safety officer or risk manager.
4. Communication specialist: A specialist in communication and public relations.
5. External partners: Representatives from external agencies, such as emergency services, public health departments, and local
authorities.
6. Other stakeholders: Representatives from relevant departments, such as logistics, supply chain, and information technology.
1. Regular meetings: The committee typically meets regularly, such as quarterly or biannually.
2. Ad hoc meetings: Additional meetings may be called as needed to address specific disaster-related issues or concerns.
3. Drills and exercises: The committee participates in regular drills and exercises to test disaster preparedness and response plans.
The frequency of meetings may vary depending on the organization's size, complexity, and disaster risk. The committee's composition
Dr. J. L. Meena

ROM 6 – Leadership ensures that patient-safety aspects
and risk-management issues are an integral part of patient
care and hospital management.
Objective Elements
a) Leadership ensures proactive risk management across the organisation.*
b) Leadership provides resources for proactive risk assessment and risk- reduction
activities.
c) Leadership ensures integration between quality improvement, risk management and
strategic planning within the organisation.
d) Leadership ensures implementation of systems for internal and external reporting of
system and process failures.*
e) Leadership ensures that it has a documented agreement for all outsourced services
that include service parameters.
f) Leadership monitors the quality of the outsourced services and improvements
are made as required.
109
Dr. J. L. Meena

Progress of Clinical Indicators
Top-level management in hospitals must continuously monitor key clinical indicators to ensure quality care, patient safety, and operational
efficiency.
1. Patient Mortality Rates
- Tracks in-hospital mortality rates, including condition-specific mortality (e.g., cardiac, stroke).
- Indicates quality of care and effectiveness of interventions.
2. Hospital-Acquired Infections (HAIs)
- Monitors rates of infections like MRSA, CLABSI, CAUTI, and SSI.
- Reflects infection control practices and patient safety.
3. Readmission Rates
- Measures patients readmitted within 30 days for the same or related conditions.
- Indicates care quality, discharge planning, and follow-up effectiveness.
4. Adverse Event Rates
- Tracks incidents like medication errors, falls, or pressure ulcers.
- Highlights patient safety and risk management issues.
5. Patient Satisfaction Scores
- Derived from surveys (e.g., HCAHPS) on care experience, communication, and responsiveness.
- Reflects patient-centered care and hospital reputation.
Dr. J. L. Meena

6. Average Length of Stay (ALOS)
- Measures the average duration of inpatient stays, overall and by department.
- Indicates efficiency in care delivery and resource utilization.
7. Emergency Department (ED) Wait Times
- Tracks time from arrival to treatment or admission in the ED.
- Reflects operational efficiency and patient access to care.
8. Surgical Complication Rates
- Monitors postoperative complications like infections, bleeding, or organ failure.
- Indicates surgical care quality and provider performance.
9. Medication Error Rates
- Tracks errors in prescribing, dispensing, or administering medications.
- Highlights pharmacy and clinical process safety.
10. Compliance with Clinical Guidelines
- Measures adherence to evidence-based protocols (e.g., sepsis, stroke, or MI care).
- Ensures standardized, high-quality care delivery.
11. Staff-to-Patient Ratios
- Monitors nurse, physician, and support staff ratios per patient.
- Impacts care quality, staff burnout, and patient outcomes.
Dr. J. L. Meena

12. Code Blue/ Rapid Response Activations
- Tracks frequency of emergency responses for cardiac arrest or critical deterioration.
- Indicates early warning system effectiveness and patient stability.
13. Diagnostic Error Rates
- Measures missed, delayed, or incorrect diagnoses.
- Reflects clinical decision-making accuracy and testing quality.
14. Utilization of Preventive Care Measures
- Tracks adherence to screenings, vaccinations, and prophylaxis (e.g., DVT prevention).
- Promotes long-term patient health and reduces complications.
15. Patient Flow and Bed Occupancy Rates
- Monitors bed turnover, occupancy, and discharge efficiency.
- Indicates capacity management and resource allocation.
Monitoring Approach
Ø Dashboards and Real-Time Analytics: Use digital tools to track indicators in real time.
Ø Benchmarking: Compare metrics against national standards (e.g., CMS, WHO) or peer hospitals.
Ø Regular Audits: Conduct periodic reviews to identify trends and address gaps.
Ø Multidisciplinary Oversight: Involve clinical, administrative, and quality teams in monitoring and action planning.
These indicators provide a comprehensive view of clinical performance, enabling management to make data-driven decisions to improve patient outcomes
and operational excellence.
Dr. J. L. Meena

Progress of Important Quality
Indicators
1. (PSQ 3a)- Time taken for initial assessment of indoor patient’s
2. (PSQ 3a)- Number of reporting errors /1000 investigations
3. (PSQ 3a)- Percentage of adherence to safety precautions by staff working in Diagnostics
5. (PSQ 3a)- Percentage of medication charts with error-prone abbreviations
6. (PSQ 3a )-Percentage of in-patients developing adverse drug reaction(s).
8. (PSQ 3a)- Percentage of surgeries where the organization's procedure to prevent adverse events like wrong site, wrong
Dr. J. L. Meena

11. (PSQ 3a)- Return to the emergency department within 72 hours with similar presenting complaints.
12. (PSQ 3a )-Incidence of hospital associated pressure ulcers after admission (Bed Sore per 1000
patient days)
13. (PSQ 3b )- Catheter associated urinary tract infection rate
15. (PSQ 3b )- Central line associated blood stream infection rate
18. (PSQ 3b )- Percentage of cases who received appropriate prophylactic antibiotics within the
specified time frame
20. (PSQ 3c )- Turnaround time for issue of blood and blood components
Dr. J. L. Meena
Indicators

25. (PSQ 3c )- Percentage of medical records having incomplete and /or improper
consent
28.(PSQ 3d )- Patient fall rate (falls per 1000 patient days)
31. (PSQ 3d )- Appropriate handovers during shift change(to be done separately for
doctors and nurses)-(per patient per shift)
32.(PSQ 3d )- Compliance to rate to Medication Prescription in capitals
Dr. J. L. Meena
Indicators

Regular Monitoring
of the NABH Progress (Quarterly / Monthly)
Chapters Standards
Objective
Elements
Not applicable
Non-
Compliance
Partial
Compliance
Fully
Compliance
AAC 13 87
COP 20 135
MOM 11 68
PRE 8 52
IPC 8 49
PSQ 7 46
ROM 6 37
FMS 7 43
HRM 13 76
IMS 7 45
Total 100 639 Dr. J. L. Meena

Summary
The Responsibility of Management (ROM) is a critical standards that outlines
the roles and responsibilities of hospital management in ensuring quality
patient care and safety. It defines the authority, accountability, and
responsibilities of hospital leaders, including the governing body, CEO, and
department heads. The ROM typically covers areas such as strategic planning,
quality improvement, risk management, patient safety, and compliance with
regulatory requirements. By clearly defining roles and responsibilities, the
ROM helps ensure effective leadership, decision-making, and oversight,
ultimately contributing to the delivery of high-quality patient care and a safe
environment for patients, staff, and visitors.
Dr. J. L. Meena

THANKS
“Want your support for Continues Improvement”
Dr. J. L. Meena

Key for Facility Management and
Safety for Quality Healthcare Service
Facility management and safety are critical for delivering quality healthcare services.
Key Aspects of Facility Management for Quality Healthcare
1. Compliance with Regulations: Healthcare facilities must adhere to standards set by bodies like The Joint Commission,
CMS, and NFPA. This includes maintaining certifications, meeting ADA requirements, and ensuring fire and life safety
protocols (e.g., regular fire drills, ILSM compliance).
2. Cleanliness and Infection Control: Proper custodial management, adequate training, and supplies ensure high cleanliness
standards, reducing healthcare-associated infections (HAIs). Facility managers collaborate with infection prevention teams
to monitor and mitigate risks like improper ventilation or pressurization.
3. Maintenance of Critical Systems: Regular upkeep of HVAC, medical gas, vacuum systems, and life-saving equipment
ensures operational reliability and patient safety. Facility management software can track inspections and maintenance
efficiently.
4. Sustainability Initiatives: Implementing energy-efficient technologies (e.g., LED lighting, smart HVAC) and waste
management programs reduces costs and supports community health, aligning with long-term healthcare goals.
5. Technology Integration: Adopting cybersecurity measures and advanced facility management systems (e.g., ISO
41001:2018) enhances efficiency, safety, and data-driven decision-making.
Dr. J. L. Meena

Key Aspects of Safety for Quality Healthcare
1. Patient Safety Standards: Facilities must implement evidence-based interventions to reduce harm, such as
robust medication management, precise protocols for external providers, and comprehensive discharge
programs to improve care coordination.
2. Safe Infrastructure: Compliance with accessibility standards, proper room management for specialized areas
(e.g., surgical centers), and functional safety equipment (e.g., fire extinguishers, emergency lighting) are
essential.
3. Workforce Safety: Training staff in occupational safety, providing mental health support, and fostering a
positive organizational climate reduce burnout and errors, directly impacting patient
outcomes.[](https://www.iso.org/healthcare/quality-management-health)
4. Risk Management and Audits: Regular safety audits, accurate record-keeping, and proactive risk
assessments (e.g., ICRA for infection control) ensure compliance and operational efficiency.
(https://www.ihs.gov/office-of-quality/quality-assurance-patient-safety-and-clinicial-risk-management/)
5. Quality Improvement Systems: Tools like the PDCA cycle, Six Sigma, and Total Quality Management (TQM)
drive continuous improvement. Patient safety indicators (PSIs) measure adverse events, enabling data-driven
enhancements. (https://pmc.ncbi.nlm.nih.gov/articles/PMC6561897/)
Dr. J. L. Meena

Integration for Quality Healthcare
- Holistic Approach: Facility managers collaborate with clinical staff, administrators, and external contractors to create a
safe, efficient, and patient-centered environment.
- Patient-Centered Care: A well-maintained, safe facility enhances patient satisfaction, reduces stress, and supports positive
health outcomes, aligning with WHO’s quality care principles (safe, effective, people-centered).
(https://www.who.int/health-topics/quality-of-care) (https://www.iso.org/healthcare/quality-management-health)
- Data-Driven Management: Using software like Clear Point Strategy to track KPIs (e.g., occupancy rates, patient
satisfaction scores) ensures continuous improvement and accountability.
Conclusion
Effective facility management and safety in healthcare require regulatory compliance, robust maintenance, infection
control, and a culture of safety. By integrating sustainable practices, technology, and quality improvement systems,
healthcare facilities can enhance patient and staff well-being, reduce costs, and deliver high-quality care. For further details
on compliance or quality management systems, refer to resources from The Joint Commission (QualityCheck.org) or CMS
(cms.gov). (https://www.cms.gov/medicare/quality-initiatives-patient-assessment-
instruments/qualityinitiativesgeninfo/aca-mqi/patient-safety/mqi-patient-safety)
Dr. J. L. Meena

➢ Patient safety is a fundamental principle of
health care. Every point in the process of care-
giving contains a certain degree of inherent
unsafety.
➢ Adverse events may result from problems in
practice, products, procedures or systems.
Patient safety improvements demand a
complex system-wide effort, involving a wide
range of actions in performance improvement,
environmental safety a n d risk management,
including infection control, safe use of
medicines, equipment safety, safe clinical
practice and safe environment of care.
Facility Management in Patient
Safety
Dr. J. L. Meena

Patient Safety is a culture, it's a revolution and
every revolution needs conjoint efforts
Dr. J. L. Meena

Expectations of the
Patients
Patients’ expectations for facility management in healthcare settings revolve around comfort, safety,
accessibility, and efficiency.
1. Cleanliness and Hygiene: Patients prioritize spotless environments, especially in hospitals and clinics. Regular
cleaning, sanitized restrooms, and odor-free spaces are non-negotiable. For instance, a 2023 study highlighted
that 78% of patients associate cleanliness with quality of care.
2. Safety and Security: Patients expect secure facilities with clear emergency protocols, fire safety measures,
and well-maintained equipment. This includes safe parking areas and protection against theft or violence.
3. Comfort and Ambiance: A welcoming environment with comfortable waiting areas, adequate seating, proper
lighting, and temperature control enhances patient satisfaction. Noise reduction and calming aesthetics (e.g.,
artwork or plants) are also valued.
4. Accessibility: Easy navigation with clear signage, wheelchair access, and well-maintained elevators or ramps is
critical. Patients expect facilities to cater to diverse needs, including those with disabilities.
Dr. J. L. Meena

5. Efficient Systems: Well-managed facilities minimize wait times through streamlined operations,
such as functional HVAC systems, reliable power supply, and maintained medical equipment.
Downtime or delays due to facility issues frustrate patients.
6. Technology Integration: Patients increasingly expect smart facility management, like digital
check-ins, real-time updates on wait times, and Wi-Fi access. A 2024 healthcare survey noted 65%
of patients value tech-driven convenience.
7. Sustainability: Eco-friendly practices, such as waste management and energy-efficient systems,
are gaining traction. Patients appreciate facilities that align with environmental consciousness.
Facility management directly impacts patient experience, with 85% of patients in a 2023 survey
stating that poor facility conditions would deter them from returning. Effective management
ensures trust and loyalty, while lapses can erode confidence in care quality.
Expectations of the
Patients
Dr. J. L. Meena

Expectations of the Doctors /
Nurses / Technicians
Doctors, nurses, and technicians have several key expectations from facility management to ensure a safe, efficient, and effective
healthcare environment.
1. Clean and Safe Environment:
- Hygiene: Regular cleaning and disinfection of patient rooms, operating theaters, and common areas to prevent infections.
- Safety Compliance: Adherence to health and safety regulations, including proper waste disposal (e.g., biohazardous materials) and fire
safety measures.
- Maintenance: Prompt repair of broken equipment, fixtures, or infrastructure to avoid disruptions or hazards.
2. Reliable Infrastructure:
- Utilities: Uninterrupted power supply, water, and HVAC systems to maintain optimal conditions for patient care and equipment
functionality.
- Equipment Maintenance: Regular servicing and calibration of medical devices (e.g., MRI machines, ventilators) to ensure accuracy and
reliability.
- Space Management: Adequate space for patient care, staff workstations, and storage of medical supplies.
3. Efficient Operations:
- Accessibility: Well-maintained elevators, ramps, and signage to facilitate movement for staff and patients.
- Inventory Support: Timely restocking of essential supplies (e.g., PPE, medications, linens) to avoid shortages.
- Communication Systems: Reliable intercoms, paging systems, and IT infrastructure for seamless coordination.
Dr. J. L. Meena

Expectations of the Doctors /
Nurses / Technicians
4. Technology and Innovation:
- IT Support: Fast and secure Wi-Fi, electronic health record (EHR) systems, and technical support for troubleshooting.
- Upgrades: Integration of modern facility technologies (e.g., automated lighting, energy-efficient systems) to enhance workflow.
5. Staff Support:
- Comfort: Well-maintained break rooms, rest areas, and ergonomic workstations to support staff well-being.
- Response Time: Quick resolution of reported issues (e.g., plumbing leaks, equipment failures) to minimize workflow
disruptions.
- Training: Facility management should provide training on new systems or protocols (e.g., emergency evacuation plans).
6. Sustainability:
- Eco-Friendly Practices: Energy-efficient systems and waste reduction initiatives to align with modern healthcare standards.
- Cost Efficiency: Balancing quality with cost-effective solutions to support the facility’s financial health.
Sources of Expectations
These expectations stem from the need to maintain patient care quality, comply with regulations (e.g., Joint Commission
standards), and support staff productivity. Facility management teams are expected to collaborate closely with healthcare
professionals to understand their specific needs, which may vary by department (e.g., surgical vs. emergency).
Dr. J. L. Meena

Expectations of the
Management
Management expects facility management to ensure a safe, efficient, and comfortable
workplace while aligning with organizational goals. Key expectations include:
1. Operational Efficiency: Maintain and optimize building systems (HVAC, electrical,
plumbing) to minimize downtime and reduce costs.
2. Safety and Compliance: Ensure compliance with health, safety, and environmental
regulations, including fire safety, accessibility, and workplace standards.
3. Cost Management: Control budgets, optimize resource use, and negotiate vendor
contracts to deliver cost-effective services.
4. Sustainability: Implement eco-friendly practices, such as energy-efficient systems and
waste reduction, to support corporate sustainability goals.
5. Space Utilization: Plan and manage workspace layouts to maximize productivity and
adapt to changing organizational needs.
Dr. J. L. Meena

6. Maintenance and Upkeep: Perform regular maintenance, repairs, and cleaning to keep facilities in
top condition and enhance employee satisfaction.
7. Technology Integration: Use facility management software and IoT solutions for real-time
monitoring, predictive maintenance, and data-driven decisions.
8. Customer Service: Respond promptly to employee and stakeholder requests, ensuring a positive
experience and addressing concerns effectively.
9. Risk Management: Mitigate risks like security threats, natural disasters, or equipment failures
through proactive planning and emergency preparedness.
10. Strategic Alignment: Support business objectives by aligning facility operations with
organizational growth, culture, and employee well-being.
Management also expects clear communication, regular reporting on KPIs (e.g., energy usage,
maintenance costs), and adaptability to evolving workplace trends, such as hybrid work models.
Expectations of the
Management
Dr. J. L. Meena

Regulatory authorities expect facility management to ensure compliance with laws and regulations to maintain safe,
efficient, and sustainable operations. Their key expectations include:
1. Compliance with Statutory and Regulatory Requirements: Facility managers must adhere to government-enacted
statutory laws (e.g., Health and Safety at Work Act 1974 in the UK) and industry-specific regulatory standards enforced by
delegated bodies. This includes fire safety (Regulatory Reform Order 2005), gas safety (Gas Safety Regulations 1998), and
health and safety standards (EU and national regulations).
2. Health and Safety: Facility managers are responsible for creating safe environments for employees, visitors, and
contractors. This involves conducting risk assessments, implementing emergency procedures (e.g., fire evacuation plans,
first aid provisions), and ensuring regular maintenance of critical systems like fire alarms, emergency lighting, and HVAC.
Authorities expect documented evidence of compliance through audits and records.
3. Environmental and Sustainability Standards: Facility management must align with environmental regulations, such as
waste management (Environment Agency guidelines), energy efficiency, and water conservation. Compliance with net-
zero goals (e.g., UK’s 2050 target) and sustainable practices like recycling and pollution control is increasingly emphasized.
Expectations of the Regulatory
authorities
Dr. J. L. Meena

4. Documentation and Record-Keeping: Authorities require comprehensive, up-to-date records of inspections, maintenance schedules,
and compliance activities. Digital systems or facility management software are often recommended to streamline documentation and
ensure traceability during audits.
5. Staff Training and Competency: Facility managers must ensure that staff and contractors are trained in safety protocols, emergency
procedures, and industry-specific regulations. Regulatory bodies expect evidence of competency, such as certifications for gas-safe
engineers or fire safety officers.
6. Proactive Risk Management: Authorities expect facility managers to conduct regular audits, assessments, and preventive maintenance
to identify and mitigate risks before they escalate. This includes addressing hazards like asbestos, electrical faults, or structural issues.
7. Adoption of Technology: Regulatory bodies encourage the use of facility management software, IoT sensors, and data analytics to
monitor compliance in real-time, automate tasks, and generate audit-ready reports. Cloud-based platforms are favored for multi-site
operations.
8. Collaboration and Communication: Facility managers must cooperate with regulatory inspectors, provide access to records, and
address non-compliance issues promptly. Clear communication with stakeholders, including vendors and employees, is critical to
maintaining compliance across the supply chain.
Failure to meet these expectations can result in fines, reputational damage, increased liability, or operational disruptions. Regulatory
authorities prioritize proactive compliance to protect public safety, ensure operational efficiency, and uphold legal and ethical standards.
Expectations of the Regulatory
authorities
Dr. J. L. Meena

The **National Accreditation Board for Hospitals & Healthcare Providers (NABH)** sets comprehensive standards for facility management and safety (FMS)
to ensure healthcare organizations provide a safe, efficient, and patient-centric environment. Below are the key expectations of NABH from facility
management, based on the Facility Management and Safety (FMS) standards, which are part of the NABH accreditation framework:
1. Infrastructure and Maintenance
- Safe and Functional Infrastructure: Facilities must be designed and maintained to ensure patient and staff safety, with adequate space, ventilation, and
accessibility. This includes non-slippery floors, safe staircases (with marked first and last steps), and obstacle-free corridors.
- Legal Compliances: Hospitals must maintain valid legal clearances, such as Fire No Objection Certificate (NOC), building occupancy certificates, lift
inspections, electrical safety reports, and Atomic Energy Regulatory Board (AERB) approvals for radiation areas (e.g., X-ray, CT).
- Signage and Navigation: Clear signage for services, emergency exits, toilets, and waste disposal areas must be displayed to enhance accessibility and
patient experience. NABH emphasizes hybrid or symbol-based signage for clarity.
- Space Standards: Specific areas like blood banks (minimum 100 sq.m for operations), CSSD, and patient wards (inter-bed distance of ~6 feet) must adhere
to defined spatial requirements to support operations and infection control.
2. Safety and Emergency Preparedness
- Fire Safety: Hospitals must have an updated Fire NOC, a multidisciplinary safety committee (meeting at least quarterly), and a designated Fire Safety
Officer aware of fire prevention protocols. Fire exits must be clearly marked and accessible.
- Emergency and Disaster Management: Facilities must have plans for emergencies like fires, floods, or mob attacks, including accessible emergency exits
and flexible patient care zones that can be repurposed during disasters. Regular training and drills for staff are required.
- Electrical Safety: No dangling or exposed wires, and rubber mats must be placed under electrical panels to prevent shocks. Regular electrical inspections
are mandatory.
- Facility Inspections: Regular safety inspections must be conducted to identify and mitigate hazards, ensuring a safe environment for patients and staff.
Expectations of NABH
Dr. J. L. Meena

3. Infection Control
- Design for Infection Prevention: Facility design must minimize cross-infection risks. This includes maintaining a 6-foot
inter-bed distance in wards, providing accessible handwashing basins or hand rubs near patient beds, and zoning in areas
like CSSD (clean, sterile, and general zones) and Operation Theatres.
- Biomedical Waste Management: Compliance with statutory provisions for biomedical waste (BMW) management is
critical. This includes proper segregation, collection, storage, and transportation of BMW in covered vehicles to
authorized treatment facilities.
- Sterilization: Adequate space for sterilization activities, regular validation tests, and a documented recall procedure for
sterilization failures are required.
4. Environmental and Operational Efficiency
- Waste Management: Effective waste management systems must be in place to handle medical and general waste
safely, reducing infection risks and ensuring a hygienic environment.
- Building Maintenance: Regular maintenance of infrastructure, including air-conditioning, water testing for potability,
and equipment calibration, is expected to support safe and efficient operations.
- Energy and Resource Management: Facilities should optimize resource use, such as through automation and green
building practices, to enhance efficiency and reduce costs while maintaining compliance.
Dr. J. L. Meena

5. Patient-Centric Design
- Accessibility: Hospitals must be located in areas with good transportation access and designed to be
patient-friendly, with clear layouts displayed at entrances and information on services, visiting hours, and
policies.
- Comfort and Privacy: Patient rooms should provide comfort, privacy, and adequate medical equipment,
contributing to a positive care experience.
- Patient Safety: Infrastructure must support patient safety through features like clean utility areas in
wards/ICUs for secure medicine storage and adherence to national/international standards for clinical
services.
6. Continuous Quality Improvement
- Regular Audits and Feedback: Facility management must undergo regular audits to ensure ongoing
compliance with NABH standards. Feedback from patients and staff should be used to drive improvements.
- Documentation: Accurate records of maintenance, safety inspections, and compliance with legal and
NABH requirements must be maintained and reviewed during audits.
Dr. J. L. Meena

6. Continuous Quality Improvement
- Regular Audits and Feedback: Facility management must undergo regular audits to ensure ongoing compliance with
NABH standards. Feedback from patients and staff should be used to drive improvements.
- Documentation: Accurate records of maintenance, safety inspections, and compliance with legal and NABH
requirements must be maintained and reviewed during audits.
7. Staff Training and Management
- Training for Safety: Staff must be trained on facility safety protocols, emergency response, and infection control
practices to ensure compliance and preparedness.
- Safety Committee: A multidisciplinary safety committee, chaired by a senior official, must oversee facility
management and safety, with documented minutes submitted to senior management.
Summary
NABH expects facility management to prioritize **patient safety**, **infection control**, **legal compliance**, and
**operational efficiency** through well-maintained infrastructure, robust safety protocols, and patient-centric design.
Compliance involves adhering to specific spatial and operational standards, maintaining legal clearances, conducting
regular audits, and fostering a culture of continuous improvement. Hospitals must integrate these expectations into their
design and operations from the planning stage to achieve and maintain accreditation.
Dr. J. L. Meena

List of proactive risk analysis strategies for
facility safety management in a hospital.
These strategies focus on identifying, assessing, and mitigating risks to ensure the safety of patients, staff, visitors, and infrastructure.
Each strategy is tailored to the unique environment of a hospital, where safety is critical due to the presence of vulnerable populations,
complex equipment, and high-stakes operations.
Proactive Risk Analysis Strategies for Hospital Facility Safety Management
1. Hazard Identification and Mapping:
- Conduct a comprehensive walkthrough to identify physical, environmental, and operational hazards (e.g., slippery floors, exposed
wiring, or inadequate lighting in corridors).
- Create a **hazard map** of the facility, highlighting high-risk areas like emergency rooms, operating theaters, and storage rooms for
hazardous materials (e.g., medical gases, chemicals).
- Engage multidisciplinary teams (e.g., clinicians, maintenance staff, infection control specialists) to identify department-specific risks.
2. Environmental Risk Assessments:
- Assess risks related to natural disasters (e.g., earthquakes, floods, hurricanes) based on the hospital’s geographic location, using tools
like FEMA’s flood maps or seismic risk data.
- Evaluate indoor environmental risks, such as poor air quality, mold growth, or ventilation issues, particularly in areas like ICUs or
sterile processing units.
- Monitor noise levels in patient care areas to prevent disruptions to recovery or staff concentration.
Dr. J. L. Meena

Detailed list of proactive risk analysis
strategies for facility safety management in a
hospital.
3. Equipment and Infrastructure Risk Analysis:
- Perform regular audits of critical equipment (e.g., ventilators, defibrillators, MRI machines) to identify risks of malfunction or
obsolescence.
- Assess the reliability of power systems, including backup generators and uninterruptible power supplies (UPS), to prevent outages
during emergencies.
- Inspect structural integrity, such as walls, ceilings, and fireproofing, to ensure compliance with building codes and resilience against
disasters.
4. Fire and Life Safety Risk Assessment:
- Evaluate fire hazards, such as improper storage of flammable materials (e.g., oxygen tanks, alcohol-based sanitizers) or overloaded
electrical circuits.
- Assess the adequacy of fire detection and suppression systems (e.g., smoke alarms, sprinklers) and ensure clear access to fire exits.
- Conduct **fire risk modeling** to simulate fire spread scenarios and identify vulnerabilities in evacuation routes or
compartmentation.
5. Infection Control Risk Analysis:
- Identify risks of healthcare-associated infections (HAIs) due to inadequate sterilization, poor hand hygiene, or contaminated surfaces.
- Assess airflow and pressure differentials in isolation rooms to prevent the spread of airborne pathogens (e.g., tuberculosis, COVID-19).
- Evaluate waste management processes to ensure safe disposal of biohazardous materials, reducing risks of exposure or environmental
contamination.
Dr. J. L. Meena

hospital.
6. Security and Violence Risk Assessment:
- Analyze risks of workplace violence, particularly in high-stress areas like emergency departments or psychiatric units, using incident
reports and staff feedback.
- Assess physical security measures, such as access controls, surveillance cameras, and panic buttons, to prevent unauthorized entry or
theft of controlled substances.
- Evaluate risks of external threats, such as active shooters or terrorism, and develop lockdown protocols.
7. Human Factors Risk Analysis:
- Identify risks stemming from human error, such as medication administration mistakes or miscommunication during patient handoffs,
using tools like **Root Cause Analysis (RCA)**.
- Assess staff fatigue risks due to long shifts or inadequate staffing, which can lead to lapses in safety protocol adherence.
- Evaluate training gaps that could hinder staff’s ability to respond to emergencies, such as operating fire extinguishers or performing
CPR.
8. Cybersecurity Risk Assessment:
- Analyze vulnerabilities in hospital IT systems, including electronic health records (EHRs), medical devices, and networked equipment,
to prevent data breaches or ransomware attacks.
- Assess risks of disruptions to critical systems (e.g., radiology or laboratory systems) due to cyberattacks or software failures.
- Conduct penetration testing and phishing simulations to identify weaknesses in cybersecurity defenses.
Dr. J. L. Meena

hospital.
9. Supply Chain and Resource Risk Analysis:
- Evaluate risks of supply shortages (e.g., PPE, medications, or IV fluids) due to vendor disruptions, global shortages, or pandemics.
- Assess storage conditions for critical supplies, such as temperature controls for vaccines or sterile conditions for surgical instruments.
- Develop contingency plans for alternative suppliers or resource allocation during crises.
10. Emergency Preparedness Risk Analysis:
- Conduct scenario-based risk assessments for disasters like mass casualty incidents, power outages, or chemical spills, identifying gaps in
response plans.
- Evaluate the hospital’s surge capacity, including bed availability, staffing, and equipment, to handle sudden increases in patient volume.
- Assess communication systems (e.g., radios, paging systems) to ensure reliability during emergencies when standard networks may fail.
11. Regulatory and Compliance Risk Assessment:
- Review compliance with safety regulations, such as OSHA, Joint Commission standards, and local fire codes, to identify areas at risk of penalties
or accreditation loss.
- Assess documentation practices for safety-related activities (e.g., equipment maintenance logs, staff training records) to ensure audit
readiness.
- Evaluate risks of non-compliance with patient safety standards, such as fall prevention protocols or pressure ulcer prevention measures.
12. Patient Safety Risk Analysis:
- Identify risks of patient falls, particularly for elderly or mobility-impaired patients, by assessing bed heights, handrails, and floor conditions.
- Evaluate risks of medical errors, such as wrong-site surgeries or incorrect dosages, using tools like **Failure Modes and Effects Analysis (FMEA).
- Assess risks of adverse events during patient transport, such as delays or equipment failures in elevators.
Dr. J. L. Meena

hospital.
13. Utility Systems Risk Assessment:
- Evaluate risks of water system failures, such as contamination or low pressure, which could disrupt dialysis, sterilization, or sanitation.
- Assess HVAC system reliability to maintain temperature and humidity controls critical for patient care and equipment operation.
- Conduct risk analyses for medical gas systems (e.g., oxygen, nitrogen) to prevent leaks, cross-connections, or supply interruptions.
14. Climate and Sustainability Risk Analysis:
- Assess risks of climate-related events, such as extreme heat or flooding, that could strain hospital infrastructure or disrupt access.
- Evaluate energy efficiency and backup power systems to reduce reliance on fossil fuels and ensure sustainability during prolonged
outages.
- Identify risks of resource overuse (e.g., water, disposable supplies) that could exacerbate shortages during crises.
15. Continuous Monitoring and Data-Driven Risk Analysis:
- Implement real-time monitoring systems, such as IoT sensors, to detect risks like temperature excursions in medication storage or
pressure drops in medical gas lines.
- Use predictive analytics to identify emerging risks based on historical incident data, staff reports, or external trends (e.g., rising cyber
threats).
- Regularly review near-miss reports and incident data to refine risk priorities and mitigation strategies.
Dr. J. L. Meena

hospital.
Implementation Best Practices
- Multidisciplinary Approach: Involve clinicians, facility managers, safety officers, and IT specialists in risk analysis to ensure
comprehensive coverage.
- Prioritization: Use a **risk matrix** (likelihood vs. impact) to focus resources on high-priority risks, such as power failures or infection
outbreaks.
- **Documentation**: Maintain detailed records of risk analyses, including identified hazards, assessments, and mitigation plans, for
regulatory compliance and audits.
- Regular Updates: Revisit risk analyses annually or after significant changes (e.g., new equipment, facility expansions, or emerging
threats like pandemics).
- Technology Integration: Leverage software like risk management platforms (e.g., RLDatix, Riskonnect) or building management systems
to streamline data collection and analysis.
- Stakeholder Engagement: Communicate findings to staff and leadership, fostering a culture of safety and shared responsibility.
Example Application
A hospital conducting proactive risk analysis might:
- Identify a high risk of power outages due to an aging generator. They upgrade the system, install redundant power sources, and train
staff on outage protocols.
- Detect inadequate signage for fire exits during a risk assessment. They install illuminated signs and conduct evacuation drills to ensure
compliance.
- Use predictive analytics to flag a rising trend in HAIs, prompting enhanced cleaning protocols and staff retraining on hand hygiene.
Dr. J. L. Meena

Risk Matrix
A **risk matrix** is a tool used to assess and prioritize risks by evaluating their **likelihood** (probability of occurrence) and
**impact** (severity of consequences). Below, I’ll provide a detailed explanation of how to create and use a risk matrix for proactive risk
analysis in the context of **facility safety management in a hospital**, followed by a sample risk matrix tailored to hospital-specific risks.
How to Create and Use a Risk Matrix for Hospital Facility Safety Management
1. Define the Axes
- Likelihood: How probable is it that the risk will occur? Typically rated on a scale (e.g., 1–5, from Rare to Almost Certain).
- Impact: What would be the consequences if the risk occurs? Also rated on a scale (e.g., 1–5, from Negligible to Catastrophic).
- These scales can be customized to the hospital’s needs, but a common 5x5 matrix is widely used for clarity and granularity.
2. Assign Risk Ratings
- Combine likelihood and impact scores to determine the overall risk level (e.g., Low, Moderate, High, Critical).
- Use a color-coded system (e.g., Green for Low, Red for Critical) to visually prioritize risks.
3. Identify Hospital-Specific Risks
- Based on the proactive risk analysis strategies previously discussed, list relevant risks (e.g., power outages, healthcare-associated
infections, fire hazards).
- Assess each risk’s likelihood and impact using data from incident reports, safety rounds, staff feedback, or external benchmarks.
Dr. J. L. Meena

4. Prioritize and Mitigate
- Focus mitigation efforts on **High** and **Critical** risks first, allocating resources to reduce likelihood or impact.
- Develop action plans, such as upgrading equipment, enhancing training, or revising protocols, and monitor progress.
5. Review and Update
- Regularly revisit the risk matrix (e.g., quarterly or after incidents) to reflect new risks, changes in operations, or mitigation outcomes.
- Use the matrix to communicate priorities to leadership and staff, ensuring alignment on safety goals.
Sample Risk Matrix for Hospital Facility Safety Management
Below is a **5x5 risk matrix** with definitions for likelihood and impact, followed by examples of hospital-specific risks plotted on the
matrix.
Likelihood Scale
1. Rare: May occur only in exceptional circumstances (<5% chance).
2. Unlikely: Could occur but is not expected (5–25% chance).
3. Possible: Might occur at some point (25–50% chance).
4. Likely: Will probably occur in most circumstances (50–75% chance).
5. Almost Certain: Expected to occur in most cases (>75% chance).
Risk Matrix
Dr. J. L. Meena

Impact Scale
1. Negligible: Minimal harm or disruption (e.g., minor inconvenience, no injuries).
2. Minor: Limited harm or disruption (e.g., minor injuries, short-term delays).
3. Moderate: Noticeable harm or disruption (e.g., treatable injuries, operational downtime).
4. Major: Significant harm or disruption (e.g., serious injuries, prolonged outages).
5. Catastrophic: Severe harm or disruption (e.g., fatalities, permanent closure, widespread harm).
Risk Matrix
| **Likelihood / Impact** | **Negligible (1)** | **Minor (2)** | **Moderate (3)** | **Major (4)** | **Catastrophic (5)** |
|--------------------------|--------------------|---------------|------------------|---------------|----------------------|
| **Almost Certain (5)** | Low (5) | Moderate (10) | High (15) | Critical (20) | Critical (25) |
| **Likely (4)** | Low (4) | Moderate (8) | High (12) | High (16) | Critical (20) |
| **Possible (3)** | Low (3) | Low (6) | Moderate (9) | High (12) | High (15) |
| **Unlikely (2)** | Low (2) | Low (4) | Low (6) | Moderate (8) | Moderate (10) |
| **Rare (1)** | Low (1) | Low (2) | Low (3) | Low (4) | Low (5) |
Risk Levels
- Low (1–6): Monitor but no immediate action required.
- Moderate (7–10): Plan mitigation to reduce likelihood or impact.
- High (12–15): Prioritize mitigation and implement controls promptly.
- Critical (16–25): Immediate action required to eliminate or significantly reduce risk.
Risk Matrix
Dr. J. L. Meena

Likelihood Scale
1. Negligible: Minimal
harm or disruption (e.g.,
minor inconvenience, no
injuries).
2. Minor:
Limited harm or
disruption (e.g.,
minor injuries,
short-term
delays).
3. Moderate: Noticeable
harm or disruption (e.g.,
treatable injuries,
operational downtime).
4. Major:
Significant harm
or disruption
(e.g., serious
injuries,
prolonged
outages).
5. Catastrophic:
Severe harm or
disruption (e.g.,
fatalities,
permanent closure,
widespread harm).
Impact Scale
1. Rare: May occur only in
exceptional circumstances
(<5% chance).
Rare & Negligible (1)
Rare & Minor
(2)
Rare & Moderate (3) Rare & Major (4)
Rare & Catastrohic
(5)
2. Unlikely: Could occur
but is not expected (5–
25% chance).
Unlikely & Negligible (2)
Unlikely &
Minor (4)
Unlikely & Moderate (6)
Unlikely & Major
(8)
Unlikely &
Catastrohic (10)
3. Possible: Might occur at
some point (25–50%
chance).
Possible & Negligible (3)
Possible &
Minor (6)
Possible & Moderate (9)
Possible & Major
(12)
Possible &
Catastrohic (15)
4. Likely: Will probably
occur in most
circumstances (50–75%
chance).
Likely & Negligible (4)
Likely & Minor
(8)
Likely & Moderate (12)
Likely & Major
(16)
Likely & Catastrohic
(20)
5. Almost Certain:
Expected to occur in most
cases (>75% chance).
Almost Certain &
Negligible (5)
Almost Certain
& Minor (10)
Almost Certain & Moderate
(15)
Almost Certain &
Major (20)
Almost Certain &
Catastrohic (25)
Risk Levels
- Low (1–6): Monitor but no
immediate action required.
- Moderate (7–10): Plan
mitigation to reduce likelihood
or impact.
- High (12–15): Prioritize
mitigation and implement
controls promptly.
- Critical (16–25): Immediate
action required to eliminate or
significantly reduce risk.
Risk Matrix
Dr. J. L. Meena

Example Risks Plotted on the Matrix
1. Power Outage Due to Generator Failure
- Likelihood: Possible (3) – Aging generators may fail during storms.
- Impact: Major (4) – Disrupts critical care (e.g., ventilators, surgeries).
- Score: High (12)
- Mitigation: Upgrade generators, install redundant power sources, conduct regular maintenance, and train staff on outage protocols.
2. Healthcare-Associated Infection (HAI) Outbreak
- Likelihood: Likely (4) – High patient turnover and invasive procedures increase risk.
- Impact: Major (4) – Can cause serious illness or death, especially in immunocompromised patients.
- Score: High (16)
- Mitigation: Enhance cleaning protocols, monitor hand hygiene compliance, improve ventilation in isolation rooms, and train staff on
infection control.
3. Fire Hazard from Oxygen Tank Storage
- Likelihood: Unlikely (2) – Strict storage protocols reduce risk, but human error is possible.
- Impact: Catastrophic (5) – Fire in a hospital could lead to fatalities and evacuations.
- Score: Moderate (10)
- Mitigation: Install additional fire suppression systems, conduct regular storage audits, and train staff on fire safety.
Risk Matrix
Dr. J. L. Meena

4. Cyberattack on Electronic Health Records (EHRs)
- Likelihood: Possible (3) – Rising cyber threats target healthcare systems.
- Impact: Major (4) – Data breaches compromise patient privacy and disrupt care delivery.
- Score: High (12)
- Mitigation: Implement multi-factor authentication, conduct penetration testing, and train staff on phishing awareness.
5. Patient Fall in General Ward
- Likelihood: Almost Certain (5) – Elderly patients and busy wards increase fall risks.
- Impact: Moderate (3) – Falls may cause treatable injuries but disrupt care.
- Score: High (15)
- Mitigation: Install bed alarms, improve lighting, use non-slip flooring, and train staff on fall prevention protocols.
6. Flooding from Severe Weather
- Likelihood: Rare (1) – Depends on geographic location and flood defenses.
- Impact: Catastrophic (5) – Flooding could shut down the hospital and endanger patients.
- Score: Low (5)
- Mitigation: Elevate critical equipment, install flood barriers, and develop evacuation plans for flood scenarios.
Risk Matrix
Dr. J. L. Meena

Visual Representation of the Matrix
To visualize, imagine the matrix color-coded:
- Green (Low, 1–6): Flooding (5), minor equipment malfunctions.
- Yellow (Moderate, 7–10): Fire hazard (10), supply shortages.
- Orange (High, 12–15): Power outage (12), cyberattack (12), patient fall (15).
- Red (Critical, 16–25): HAI outbreak (16).
This prioritization helps hospital leadership allocate resources effectively, focusing on **Critical** and **High** risks like HAIs and
patient falls first.
Practical Application in a Hospital
1. Data Collection: Gather input from safety rounds, incident reports, and staff surveys to assess likelihood and impact. For example,
recent near-misses with oxygen tanks might increase the likelihood score for fire hazards.
2. Plotting Risks: Use the matrix to plot identified risks during a risk analysis meeting with facility managers, infection control specialists,
and clinical leaders.
3. Action Planning: Assign mitigation tasks based on risk scores. For instance, a High score for patient falls (15) might prompt immediate
installation of handrails and staff retraining.
4. Monitoring: Track mitigation progress in a risk register and update the matrix after implementing controls (e.g., a new generator might
lower the power outage score from 12 to 6).
Risk Matrix
Dr. J. L. Meena

Tools and Templates
➢ Software: Use risk management platforms like RLDatix or
Excel/Google Sheets to create dynamic risk matrices with
automated scoring.
➢ Checklists: Develop checklists for each risk category (e.g.,
infection control, fire safety) to standardize likelihood and impact
assessments.
➢ Training: Educate staff on the risk matrix during safety training to
ensure they understand how risks are prioritized and mitigated.
Risk Matrix
Dr. J. L. Meena

Salient Features of National Building
Code for Hospital
The National Building Code of India (NBC) 2016, published by the Bureau of Indian Standards (BIS), provides comprehensive
guidelines for the design, construction, and maintenance of buildings, including hospitals. Below are the salient features of the
NBC 2016 specific to hospital design and construction, focusing on safety, accessibility, functionality, and compliance:
1. Fire and Life Safety (Part 4 of NBC)
➢ Compartmentation: Hospitals must incorporate compartmentation to contain fires and facilitate safe evacuation to an
assembly point outside the building.
➢ Fire Safety Provisions: Hospitals are classified as **hazardous occupancy** due to the presence of vulnerable patients,
requiring stringent fire safety measures.
➢ Use of Class A materials (fire-resistant) for construction, especially in basements.
➢ Installation of **automatic sprinkler systems** in basements used for parking.
➢ Appointment of a **qualified fire officer** and trained staff for significant occupancies.
➢ Fire Drills and Evacuation: Guidelines mandate regular fire drills and evacuation plans, particularly for high-rise hospital
buildings.
➢ Access for Firefighting:
✓ Minimum **4.5 m wide entrance** with a **5 m clear headroom** for fire-fighting vehicles.
✓ Access roads must be at least **6 m wide** with a **9 m turning radius** for fire tenders.
✓ Main street abutting the hospital must be at least **12 m wide**, with no dead-end roads.
Dr. J. L. Meena

Code for Hospital
2. Structural Safety and Integrity
➢ Hospitals must adhere to standards for structural design to ensure robustness and safety against natural disasters like earthquakes
and cyclones.
➢ Foundation and Materials: Guidelines specify the use of safe, durable materials and construction practices to ensure long-term
structural integrity.
3. Accessibility Standards
➢ The NBC 2016 integrates accessibility standards to ensure hospitals are inclusive for persons with disabilities. This includes ramps,
tactile paving, accessible restrooms, and signage.
➢ These standards significantly influence the design and construction process to promote universal accessibility.
4. Open Space and Circulation
➢ Open Spaces: Hospitals must provide sufficient open space around the building for patient movement and emergency vehicle access.
These spaces must remain free of obstructions and be motorable.
➢ Setback Requirements: A minimum **4.5 m setback** is required to ensure ventilation, lighting, and fire safety.
➢ No Parking in Open Spaces: The open space around the hospital cannot be used for parking or other purposes to maintain
accessibility.
5. Ventilation and Basements
➢ Basement Ventilation: Basements, if used (e.g., for parking), must be separately ventilated with a cross-sectional vent area of at least
**2.5% of the floor area**. Air inlets and smoke outlets must be clearly marked.
➢ Clear Headroom**: A minimum **2.4 m clear headroom** is required in basements for safety and accessibility.
Dr. J. L. Meena

Code for Hospital
6. Zoning and Land Use
➢ Hospitals must comply with **zoning regulations** to ensure proper land use, balancing urban development with safety and
accessibility.
➢ Guidelines specify permissible building heights, setbacks, and density controls to promote a safe and functional environment.
7. Health, Comfort, and Sustainability
➢ Ventilation and Lighting: Adequate natural ventilation and lighting are mandated to enhance patient comfort and recovery.
➢ Environmental Sustainability**: The NBC emphasizes eco-friendly construction practices, such as minimizing hazardous materials
and promoting energy-efficient designs.
➢ Cleanliness and Hygiene: Hospitals must incorporate design features that ensure high standards of cleanliness to prevent
infections.
8. Compliance and Standardization
➢ The NBC serves as a **Model Code** for adoption by public and private agencies, including Public Works Departments, local
bodies, and government construction departments.
➢ Compliance with NBC guidelines ensures **standardization** in construction processes, enhancing safety, quality, and
consistency across hospital projects.
➢ Hospitals must also refer to additional standards like **BIS codes** (e.g., IS 12433-1 for hospitals up to 30 beds) and **NFPA
(National Fire Protection Association)** guidelines for clean room standards and fire safety.
Dr. J. L. Meena

Code for Hospital
9. Additional Guidelines for Institutional Buildings
➢ Hospitals fall under Group C: Institutional Buildings** as per NBC occupancy classification.
➢ Specific requirements include:
✓ Multiple Exits: Buildings with a floor area exceeding **150 m²** and housing over **20 people**
must have at least two doorways for evacuation, placed as far apart as possible.
✓ Fire Staircase: At least one staircase must serve as a fire staircase unless two sides of the staircase
are exposed to open space.
Notes:
✓ The NBC is recommendatory but widely adopted by state and local authorities. Non-compliance may
lead to legal and safety issues.
✓ The code was first published in **1970**, revised in **1983**, and the latest edition is **2016**,
reflecting contemporary international practices.
✓ For detailed planning of hospitals, additional resources like **IS 12433-1** (for hospitals up to 30
beds).
Dr. J. L. Meena

Legal Framework and
Enforcement
The National Building Code (NBC) of India, established by the Bureau of Indian Standards,
provides guidelines for regulating building construction activities, including hospitals, to
ensure safety, accessibility, and compliance. However, the NBC is a recommendatory
document, not a statutory law, and its enforcement depends on its incorporation into state or
local building bylaws. Non-compliance with the NBC, when adopted as mandatory by local
authorities, can lead to legal consequences under various laws and regulations.
Legal Framework and Enforcement
1. NBC as a Recommendatory Document:
- The NBC is not directly enforceable unless adopted by state governments or local bodies
(e.g., municipal corporations) into their bylaws. States are encouraged to integrate NBC
provisions, particularly for fire safety, accessibility, and structural integrity, into local
regulations.
- Hospitals are classified as institutional buildings under the NBC, and specific guidelines
cover fire safety, accessibility, structural design, and waste management. Non-compliance with
these guidelines, when mandated locally, can trigger penalties under relevant state laws.
Dr. J. L. Meena

Legal Framework and
Enforcement
2. Relevant Laws and Regulations:
- Clinical Establishments (Registration and Regulation) Act, 2010: This act regulates healthcare facilities, including
hospitals, and requires compliance with infrastructure standards, which may include NBC guidelines if adopted by the
state. Non-compliance can lead to penalties or cancellation of registration.
- State Building Bylaws: Many states have incorporated NBC provisions into their municipal or development authority
bylaws. Violations of these bylaws can result in fines, demolition orders, or suspension of construction permits.
- Fire Safety Regulations: The NBC’s Part 4 (Fire and Life Safety) is often enforced through state fire safety laws,
such as the Delhi Fire Prevention and Fire Safety Act, 1986. Non-compliance, especially in hospitals (classified as
hazardous due to high occupancy), can lead to penalties or closure.
- Environmental and Waste Management Laws: Hospitals must comply with biomedical waste management rules and
environmental regulations (e.g., Environment Protection Act, 1986). Non-compliance with NBC guidelines on waste
disposal infrastructure can result in fines or legal action.
- Criminal Liability: If non-compliance with NBC standards (e.g., inadequate fire exits or structural safety) leads to
harm, such as death or injury, criminal charges may be filed under the Indian Penal Code (IPC):
- Section 304A (Causing Death by Negligence): Punishable with imprisonment up to 2 years, a fine, or both, if
negligence results in death. (https://pmc.ncbi.nlm.nih.gov/articles/PMC5109761/)
- Section 337 (Causing Grievous Hurt by Negligence): Punishable with imprisonment up to 2 years, a fine up to
₹1,000, or both, if negligence endangers human life or safety. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109761/)
Dr. J. L. Meena

Legal Framework and
Enforcement
3. Local Authority Actions:
- Fines and Penalties: Municipal authorities or development bodies may impose fines for violations of
building bylaws, such as inadequate setbacks, fire safety provisions, or accessibility standards. For
example, the NBC requires a minimum setback of 4.5 meters and access roads of 6 meters for fire
tenders, and non-compliance may lead to monetary penalties.
- Demolition Orders: If a hospital building violates structural or safety norms, authorities may order
partial or complete demolition.
- Closure or Suspension: Non-compliant hospitals may face suspension of operations or cancellation of
licenses until compliance is achieved. For instance, failure to obtain a Fire No Objection Certificate (NOC)
can halt operations.
- Sealing of Premises: Local authorities may seal non-compliant hospital premises, as seen in cases
where hospitals were closed for violating fire safety norms.
4. Consumer Protection and Civil Liability:
- Patients or affected parties can file complaints under the **Consumer Protection Act, 2019**, if hospital
infrastructure deficiencies lead to substandard care or harm. Compensation may be awarded through
consumer courts.
- Civil lawsuits for negligence can be pursued in courts, seeking monetary damages for harm caused by
non-compliance with safety standards.
Dr. J. L. Meena

Legal Framework and
Enforcement
5. Specific Examples and Precedents:
- Hospital Closures: According to a Times of India survey, 25 hospitals in Bangalore were closed in 2020 due to non-
compliance with various regulations, including infrastructure and safety norms.
- Fire Safety Violations: Frequent hospital fires have highlighted lax enforcement of NBC’s fire safety provisions. States
have been criticized for ignoring NBC guidelines, leading to stricter enforcement in some regions.
- Medical Negligence Cases: If non-compliance with NBC standards (e.g., inadequate exits or ventilation) contributes to
patient harm, hospitals may face liability under cases like *Spring Meadows Hospital v. Harjol Ahluwalia* (1998), where
negligence led to compensation orders.[](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109761/)
Specific Punishments
The exact punishment depends on the nature of the violation, the state’s legal framework, and the consequences of non-
compliance. Common penalties include:
- Monetary Fines: Fines vary by state and violation type, ranging from thousands to lakhs of rupees. For example,
environmental violations may incur hefty fines under pollution control board regulations.
- Imprisonment: Criminal negligence leading to death or injury (e.g., fire or structural collapse) can result in imprisonment
under IPC sections, typically up to 2 years.
- License Cancellation: Hospitals may lose their registration under the Clinical Establishments Act or other state laws,
halting operations.
- Closure or Sealing: Non-compliant hospitals may be shut down, as seen in cases of fire safety violations or unauthorized
constructions.
- Compensation: Courts or consumer forums may order hospitals to pay compensation to affected parties, ranging from
lakhs to crores, depending on the harm caused. Dr. J. L. Meena

Legal Framework and
Enforcement
Challenges and Gaps
➢ Lack of Uniform Enforcement: Since NBC is recommendatory, enforcement varies across states.
Some states have robust bylaws, while others lag in adoption, leading to inconsistent penalties.
➢ Awareness and Compliance: Many hospital administrators may not be fully aware of NBC
requirements or local bylaws, increasing the risk of violations.
➢ Corruption and Oversight: In practice, mandatory certifications (e.g., fire NOCs) may be issued
without proper compliance, undermining NBC’s effectiveness.
Recommendations for Compliance
➢ To avoid legal repercussions, hospitals should:
➢ Ensure building plans adhere to NBC guidelines, particularly for fire safety (e.g., 4.5-meter
entrances, 6-meter access roads, sprinkler systems) and accessibility.
➢ Obtain necessary licenses, including Fire NOC, Consent to Establish/Operate from pollution boards,
and registration under the Clinical Establishments Act. - Conduct regular compliance audits and
maintenance to meet structural, fire, and environmental standards.
➢ Consult legal and architectural experts to align with state-specific bylaws and NBC provisions.
Dr. J. L. Meena

Legal Framework and
Enforcement
Conclusion
Failing to follow the National Building Code for hospitals in India,
when incorporated into local bylaws, can result in fines,
imprisonment (in cases of negligence causing harm), license
cancellation, or closure of the facility. The severity of punishment
depends on the violation’s impact, such as endangering lives or
causing environmental harm. Since enforcement varies by state,
hospitals must align with both NBC guidelines and local regulations
to avoid legal consequences. For specific penalties, one would need
to refer to the relevant state’s building bylaws or consult a legal
expert familiar with local laws.
Dr. J. L. Meena

Some vital aspects of facility management
which leads to patient safety
Compliance to Laws applicable to healthcare facilities.
➢ Equipment Management.
➢ Engineering Service.
➢ Environmental Safety.
➢ Safety of Support Services.
➢ Fire & Non fire emergency.
➢ Hazardous Material Handling.
➢ Hospital Infection Control.
➢ Technology Application.
➢ Preventing Patient Falls.
➢ Internal & external disasters.
Dr. J. L. Meena

Compliance to Laws applicable
to healthcare facilities
❖Compliance to rules, regulations, laws and byelaws, licenses, certifications &
registrations.
❖Laws are checks that limit the risk associated with a professional activity,
❖Compliance reduces the chances of potential damage that ignorance can
cause.
❖Building safety codes, fire safety rules, drug license, radiation protection
rules, AERB guidelines, laws applicable for medical gases, electrical safety,
lifts and patient and human rights some aspects without which any HCF
cannot be declared safe.
"Compliance should be for the safety of patient and not just for a
legal formality"
Dr. J. L. Meena

Equipment Management
❖ A well documented a n d operational breakdown plan for
corrective a n d preventive maintenance of all equipment
particularly life saving equipment.
❖ Ensuring back up for power, medical gases, spare supply a n d
methodic equipment management planning ensures patient
safety. Calibration of machines saves the patient from
misdiagnosis.
❖ Logbooks are not mere sheets, but horoscope of your machines.
❖ Adequate training of staff in using the equipment - saves the
patient and saves the equipment.
"Equipment failure is inevitable but having a safe failure is
achievable." Dr. J. L. Meena

Engineering Service
❖ Renovations in a healthcare facility invariably compromises patient safety. Plans to
put special precautions during renovations helps in maintaining patient safety.
❖ Heating, Ventilating and Air Conditioning (HVAC) systems to be installed
considering the possibility of spread of infection through HVAC due to faulty design
and incomplete planning.
❖ Building materials used for the facility to be non-toxic, tire resistant and meeting
safety levels of material constituents.
❖ Protocols should be in place for accidental exposure to any such material.
❖ Equipment functioning forms an integral part of surgical safety checklist. Thus
patient safety derived out of usage of standard checklists depends upon error free
equipment management and subsequent engineering support both of which are
elements of facility management.
Dr. J. L. Meena

Environmental Safety
❖ Hygiene plan for the facility and disinfection protocol for critical, semi-critical
and non-critical items.
❖ Layout, floor plans, fire escape routes- they are not just pictures that we put on
the walls but lifeline in emergencies.
❖ Space allocation for various activities in a healthcare facility should be as per
international or national standards. They help us in making our environment risk
free and safe.
❖ Inspection of waste disposal methods, water storage systems, ignition
machinery, duct and pipeline maintenance are some areas which get low priority
but have highest importance because cables and pipelines are arteries and veins
of a hospital.
"Signage tell our patients. "where to go and where not to go"
Dr. J. L. Meena

Safety of Support Services
❖ Safe water - free from spores and colonies of infectious agents ensures safe
treatment and correct values of fluoride, heavy metals and salts protects
the machines from corrosion.
❖ Electrical back up with correct load estimation.
❖ LT (Low-tension) and HT (High-tension) supply disintegration keeps
connections safe and protects patients who are on support of bio-medical
equipment.
❖ Back up "Gas Bank" to provide medical gases when main supply fails.
❖ Auto alarm systems and output detectors for all medical gases, vacuum
and compressed air supplies.
"Sound alerts for things that eyes cannot see"
Dr. J. L. Meena

Fire & Non fire emergency
❖ Key principles- prevention, protection and life safety.
❖ Detection system with adequate technology application – auto sprinkler
systems, i-buildings fire calls, exit plans, bomb threat management, terrorist
attack neutralizing plan.
❖ Training of staff, drills and application of hospital emergency codes forms
the most crucial aspect of handling any emergency.
❖ Chemical, Biological, Radiological and Nuclear (CBRN) disaster protocols-
with separate triage areas so as to keep other patients safe.
"Test of preparedness tells you how safe are your patients in
your hospital."
Dr. J. L. Meena

Hazardous Material Handling
❖ Healthcare institutions handle a lot of hazardous material for a
number of diagnostic and therapeutic activities. Their usage
demands strict protocols, alertness and post-usage containment.
❖ Small activity like biomedical waste management can actually,
enhance patient safety.
❖ Patient safety cycle constitutes right usage, right way of usage and
right disposal after use. It also includes right disposal of human
waste after exposure to radiological matter.
"How well you throw decides how well you grow."
Dr. J. L. Meena

Hospital Infection Control
❖ Facility management has direct impact on hospital infection rate.
❖ Housekeeping and hygiene have greatest impact on HAI
(Healthcare associated infection) rates.
❖ Surveillance of facility shows whether the infection is under
permissible limits or not.
❖ Infection control protocols needs to be an integral part of patient
safety.
❖ Patient safety is incomplete without fool proof planning &
functioning of CSSD.
Dr. J. L. Meena

Technology Application
❖ Technology brings in the possibility of hand-hygiene sensors and laser
particle counters which could be installed at the entrances of the critical
areas, thus helping a healthcare worker, know whether he or she is safe to
entre and deliver care.
❖ Patient identification using finger printing assures that the unique
identification of patient is tallied with the various processes that a patient
becomes a part of. Similarly, safety of high alert medications could be
achieved if the medications and dozes are bar coded as per prescription
and radiofrequency ID or magnetic bar coding is incorporated with
medication management.
❖ Green hospitals are safer hospitals due to high degree of patient
environment protection that they provide. Dr. J. L. Meena

Preventing Patient Falls
❖ How many hospitals have railing in hospitals toilets, how many
hospitals have beds with railing and how many wards have
patient alarm call systems?
❖ It's time that we decide to give our patients a risk-free stay.
❖ Provision of belts is one of the most inexpensive facility that could
be provided to stretcher, trolleys, patient transport systems.
❖ Detectors could be helpful in letting care givers know if the
patient is crossing the physical limits of stretchers, beds, trolleys
and can greatly reduce patient falls.
"Patient safety - a road and a cross road"
Dr. J. L. Meena

Internal & external disasters
❖ Internal & external disasters bring in an increased work load and
a crunch of existing resources.
❖ Disease outbreak management plan and external disaster
management plans not only helps in providing care to the victims
of such disasters but also protects the other patients from unsafe
situations.
❖ Earmarking of treatment areas with well planned air circulation
systems, storages space, human resources planning and
sanitation system planning for internal & external disasters are
scientific steps to enhance patient safety.
Dr. J. L. Meena

Facility Management and Safety (FMS)
➢ The standards guide the provision of a safe and secure environment for patients, their families,
staff and visitors.
➢ The organisation attends to the facility, equipment, and internal physical environment for
improving patient safety and quality of services by consistently addressing issues that may arise
out of the same.
➢ The organisation does this through proactive risk analysis, safety rounds, training of staff on the
enhancement of safety and management of disasters.
➢ To ensure this, the organisation conducts regular facility inspection rounds and takes the
appropriate action to ensure safety.
➢ The organisation provides for safe water, electricity, medical gases and vacuum systems.
➢ The organisation has a programme for medical and utility equipment management.
➢ The organisation plans for fire and non-fire emergencies within the facilities.
The organisation is a no-smoking area.
➢ The organisation safely manages hazardous materials.
The organisation works towards measures on being energy efficient.
59
Dr. J. L. Meena

FMS.1. The organisation has a system in place to provide a safe and secure environment.
FMS.2.
The organisation's environment and facilities operate in a planned manner and
promotes environment-friendly measures.
FMS.3.
The organisation's environment and facilities operate to ensure the safety of patients,
their families, staff and visitors.
FMS.4.
The organisation has a programme for the facility, engineering support services and
utility system.
FMS.5. The organisation has a programme for medical equipment management.
FMS.6. The organisation has a programme for medical gases, vacuum and compressed air.
FMS.7. The organisation has plans for fire and non-fire emergencies within the facilities.
60
Dr. J. L. Meena

Objective
Elements
FMS 1 FMS 2 FMS 3 FMS 4 FMS 5 FMS 6 FMS 7
a CORE Commitment Commitment Commitment Commitment Commitment CORE
b Commitment Commitment Excellence Commitment Commitment CORE CORE
c CORE CORE Commitment CORE CORE Commitment Commitment
d Commitment CORE Commitment Commitment Commitment CORE Commitment
e Commitment Commitment CORE Commitment Commitment Commitment Commitment
f Commitment Commitment Commitment Commitment
g Achievement Commitment
h Commitment Achievement

FMS 1 - The organisation has a system in place
to provide a safe and secure environment.
Objective Elements
a) Patient-safety devices and infrastructure are installed across the
organisation and inspected periodically.
b) The organisation has facilities for the differently-abled.
c) Facility inspection rounds to ensure safety are conducted at least
once a month.
d) Inspection reports of facility rounds are documented, and
corrective and preventive measures are undertaken.
e) Before construction, renovation and expansion of existing
hospital, risk assessment are carried out.
62
Dr. J. L. Meena

FMS 2 - The organisation's environment and
facilities operate in a planned manner and
promotes environment-friendly measures.
Objective Elements
a) Facilities and space provisions are appropriate to the scope of services.
b) As-built and updated drawings are maintained as per statutory requirements.
c) There are internal and external sign postings in the organisation in a manner
understood by the patient, families and community.
d) Potable water and electricity are available round the clock.
e) Alternate sources for electricity and water are provided as a backup for any
failure/shortage.
f) The organisation tests the functioning of these alternate sources at a predefined
frequency.
63
Dr. J. L. Meena

FMS 3 - The organisation's environment and
facilities operate to ensure the safety of patients,
their families, staff and visitors.
Objective Elements
a) Operational planning identifies areas which need to have extra security and
describes access to different areas in the hospital by staff, patients, and visitors.
b) Patient safety aspects in terms of structural safety of hospitals especially of critical
areas are considered while planning, design and construction of new hospitals
and re-planning, assessment, and retrofitting of existing hospitals.
c) The organisation conducts electrical safety audits for the facility.
d) There is a procedure which addresses the identification and disposal of material(s)
not in use in the organisation. *
e) Hazardous materials are identified and used safely within the organisation.*
f) The plan for managing spills of hazardous materials is implemented. *
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Dr. J. L. Meena

FMS 4 - The organisation has a programme for the facility,
engineering support services and utility system.
Objective Elements
a) The organisation plans for utility and engineering equipment in accordance with its services and
strategic plan.
b) Equipment is inventoried, and proper logs are maintained as required.
c) The documented operational and maintenance (preventive and breakdown) plan is implemented. *
d) Utility equipment, are periodically inspected and calibrated (wherever applicable) for their proper
functioning.
e) Competent personnel operate, inspect, test and maintain equipment and utility systems.
f) Maintenance staff is contactable round the clock for emergency repairs.
g) Downtime for critical equipment breakdowns is monitored from reporting to inspection and
implementation of corrective actions.
h) Written guidance supports equipment replacement, identification of unwanted material and
disposal. *
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Dr. J. L. Meena

FMS 5 - The organisation has a programme for
medical equipment management.
Objective Elements
a) The organisation plans for medical equipment in accordance with its services and
strategic plan.
b) Medical equipment is inventoried, and proper logs are maintained as required.
c) The documented operational and maintenance (preventive and breakdown) plan for
medical equipment is implemented. *
d) Medical equipment is periodically inspected and calibrated for their proper functioning.
e) Qualified and trained personnel operate and maintain medical equipment.
f) Written guidance supports medical equipment replacement and disposal. *
g) There is a monitoring of medical equipment and medical devices related to adverse
events, and compliance hazard notices on recalls. *
h) Downtime for critical equipment breakdown is monitored from reporting to inspection
and implementation of corrective actions.
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Dr. J. L. Meena

FMS 6 - The organisation has a programme for
medical gases, vacuum and compressed air.
Objective Elements
67
Dr. J. L. Meena
a) Written guidance governs the implementation of procurement, handling,
storage, distribution, usage and replenishment of medical gases. *
b)Medical gases are handled, stored, distributed and used in a safe manner.
c) There is an operational, inspection, testing and maintenance plan for piped
medical gas, compressed air and vacuum installation. *
d)Alternate sources for medical gases, vacuum and compressed air are
provided for, in case of failure.
e) The organisation regularly tests the functioning of these alternate sources.

Ensuring the safe handling, storage,
distribution, and use of medical gases
Ensuring the safe handling, storage, distribution, and use of medical gases is critical in healthcare settings to protect
patients, staff, and facilities. Below is a detailed breakdown of each aspect, incorporating best practices, regulatory
considerations, and safety protocols:
1. Handling of Medical Gases:- Medical gases, such as oxygen, nitrous oxide, medical air, and carbon dioxide, are often
stored in high-pressure cylinders or cryogenic containers, requiring careful handling to prevent accidents, injuries, or
damage to equipment.
➢ Trained Personnel: Only trained staff should handle medical gases. Training should cover gas identification, cylinder
safety, and emergency procedures. Staff must understand the hazards associated with each gas (e.g., oxygen supports
combustion, nitrous oxide is an anesthetic).
➢ Proper Equipment: Use specialized carts or trolleys designed for cylinder transport to prevent tipping or falling. Avoid
dragging, rolling, or dropping cylinders, as this can damage valves or cause ruptures.
➢ Personal Protective Equipment (PPE): Wear appropriate PPE, such as gloves and safety shoes, to protect against
cryogenic burns (for liquid gases like nitrogen) or physical injuries.
➢ Valve and Regulator Care: Never lubricate valves with oil or grease, especially for oxygen cylinders, as this can ignite
under pressure. Ensure regulators are compatible with the specific gas and cylinder type.
➢ Label Verification: Always check cylinder labels and color-coding before handling to confirm the gas type and avoid
mix-ups (e.g., oxygen cylinders are typically green in the U.S., per FDA standards).
Dr. J. L. Meena

2. Storage of Medical Gases:- Proper storage minimizes risks of fire, explosion, or gas leaks and ensures the gases remain
uncontaminated and ready for use.
Storage Environment:
- Store cylinders in a clean, dry, well-ventilated area to prevent corrosion or accumulation of hazardous gases.
- Keep storage areas away from heat sources (e.g., radiators, open flames) and electrical equipment that could spark.
- Maintain temperatures within manufacturer-recommended ranges (e.g., below 125°F/52°C for most gases).
Cylinder Security:
- Secure cylinders upright with chains, straps, or racks to prevent them from falling.
- Store full and empty cylinders separately, clearly marked, to avoid confusion.
Segregation by Gas Type:
- Separate oxidizing gases (e.g., oxygen, nitrous oxide) from flammable gases (e.g., hydrogen) by at least 20 feet or a fire-resistant
barrier to reduce fire risks, per NFPA 99 (National Fire Protection Association) standards.
- Store toxic or corrosive gases in designated areas with restricted access.
Signage and Access Control:
- Post clear signage indicating “Medical Gas Storage” and “No Smoking” or “No Open Flames.”
- Restrict access to authorized personnel to prevent tampering or theft.
Inventory Management:
- Rotate stock using a first-in, first-out system to ensure older cylinders are used first.
- Regularly inspect cylinders for damage, leaks, or expired hydrostatic test dates (typically every 5-10 years, depending on cylinder
type).
Dr. J. L. Meena

3. Distribution of Medical Gases:- Medical gases are distributed through pipelines, manifolds, or portable cylinders to points of
use (e.g., operating rooms, patient wards). Safe distribution prevents leaks, contamination, or incorrect gas delivery.
Pipeline Systems:
- Install pipelines according to standards like NFPA 99 or ISO 7396, with materials compatible with specific gases (e.g., copper
for oxygen).
- Use color-coded pipes and outlet valves (e.g., green for oxygen, yellow for medical air in the U.S.) to prevent errors.
- Label all pipelines and outlets clearly with the gas name and flow direction.
Maintenance and Testing:
- Conduct regular inspections for leaks, corrosion, or blockages using pressure tests or gas analyzers.
- Verify gas purity at the point of delivery to ensure no cross-contamination (e.g., nitrogen in oxygen lines).
- Maintain records of maintenance and testing for regulatory compliance.
Manifold Systems:
- Use automatic changeover manifolds to switch between primary and reserve cylinders seamlessly, ensuring uninterrupted
supply.
- Equip manifolds with alarms to alert staff of low pressure or system failures.
Transport Safety:
- When distributing cylinders within a facility, secure them on carts and avoid overcrowding elevators or corridors.
- Use designated routes to minimize exposure to patients or visitors.
Dr. J. L. Meena

4. Use of Medical Gases:- Safe use of medical gases ensures patient safety, prevents equipment misuse, and maintains therapeutic
efficacy.
Gas Verification:
- Before connecting a cylinder or pipeline to a patient or device, verify the gas type by checking labels, color codes, and pin-index safety
systems (a standardized system preventing incorrect cylinder connections).
- Use gas-specific regulators and flowmeters to control delivery accurately.
Equipment Compatibility:
- Ensure all delivery devices (e.g., ventilators, anesthesia machines) are compatible with the gas and maintained per manufacturer
guidelines.
- Calibrate flowmeters and pressure gauges regularly to deliver precise dosages.
Patient Safety:
- Administer gases only under the supervision of trained healthcare providers (e.g., respiratory therapists, anesthesiologists).
- Monitor patients for adverse reactions, such as oxygen toxicity or nitrous oxide-related neurological effects.
- Avoid high oxygen concentrations near ignition sources, as oxygen-enriched environments increase fire risk.
Infection Control:
- Sterilize or disinfect reusable equipment (e.g., masks, tubing) to prevent cross-infection.
- Use single-use accessories, when possible, to reduce contamination risks.
Emergency Preparedness:
- Train staff on emergency procedures, such as shutting off gas supply in case of leaks or fires.
- Maintain backup cylinders and portable oxygen units for critical care areas.
Dr. J. L. Meena

Regulatory and Safety Considerations:- Compliance with local and international regulations is essential for safe medical gas management
United States:
- FDA: Regulates medical gases as drugs, requiring proper labeling, purity, and quality control.
- OSHA: Enforces workplace safety standards, including hazard communication and PPE requirements.
- NFPA 99: Provides guidelines for healthcare facility gas systems, including storage and fire safety.
International:
- ISO 7396: Specifies requirements for medical gas pipeline systems.
- WHO Guidelines: Offer recommendations for safe gas use in low-resource settings.
Training and Audits:
- Conduct regular staff training on gas safety, including hands-on practice with cylinders and pipelines.
- Perform audits to ensure compliance with regulations and identify areas for improvement.
Emergency Protocols
- Leaks: Evacuate the area, shut off the gas supply if safe, and ventilate the space. Notify facility management and follow spill response
protocols.
- Fires: Use appropriate extinguishers (e.g., water or CO2 for non-oxygen fires) and shut off oxygen supply to reduce fire intensity.
- Cylinder Failures: If a cylinder is damaged or valve fails, isolate it in a safe area and contact the supplier or emergency services.
Dr. J. L. Meena

Additional Best Practices
- Alarm Systems: Install pressure alarms and gas detection systems in storage and
distribution areas to alert staff of anomalies.
- Documentation: Maintain detailed records of gas deliveries, cylinder inspections, and
system maintenance for traceability and audits.
- Supplier Coordination: Work with reputable suppliers who comply with Good
Manufacturing Practices (GMP) to ensure gas quality and reliable delivery.
“By adhering to these detailed protocols, healthcare facilities can ensure the
safe and effective management of medical gases, minimizing risks and
maintaining high standards of patient care”
Dr. J. L. Meena

The color coding for medical gas
cylinders follows the Indian Standard IS
3933:1966
In India, the color coding for medical gas cylinders follows the **Indian Standard IS 3933:1966** (reaffirmed and
updated periodically) and aligns with safety protocols for identification in healthcare settings. The color codes are
applied to the shoulder or top part of the cylinder, while the body is typically painted a neutral color like silver, white,
or grey for visibility. Below is the standard color coding for medical gases in India:
Color Codes for Medical Gases in India:
1. Oxygen (O₂):
- Color: **White shoulder** with the body often black or silver.
- Use: Respiratory support, oxygen therapy.
2. Nitrous Oxide (N₂O):
- Color: **French Blue shoulder** (a specific shade of blue).
- Use: Anesthetic, analgesia (e.g., in dental or surgical procedures).
3. Medical Air:
- Color: **Yellow shoulder** with black and white checkered bands.
- Use: Respiratory therapy, powering ventilators, or medical equipment.
4. Carbon Dioxide (CO₂):
- Color: **Grey shoulder**.
- Use: Laparoscopic surgeries, cryotherapy, or respiratory stimulation.
Dr. J. L. Meena

The color coding for medical gas
cylinders follows the Indian Standard IS
3933:1966
5. Helium/Oxygen Mixture (Heliox):
- Color: **Brown and white shoulder** (brown for helium, white for oxygen).
- Use: Treatment of airway obstruction or respiratory conditions.
6. Nitrogen (N₂):
- Color: **Black shoulder**.
- Use: Powering surgical tools, cryosurgery, or as a carrier gas.
7. Entonox (50% Oxygen + 50% Nitrous Oxide):
- Color: **White and French Blue shoulder** (combining oxygen and nitrous oxide colors).
- Use: Pain relief, especially in labor or trauma care.
Key Notes:
- Labeling: In addition to color coding, cylinders must have clear labels indicating the gas name, chemical formula, and hazard
warnings, as per Indian standards. Color alone is not sufficient for identification.
- Pin Index System: India uses the pin index system to prevent incorrect connections of cylinders to medical equipment,
complementing the color coding.
- Storage and Safety: Cylinders must be stored upright, away from heat sources, and handled per safety guidelines to avoid
accidents.
- Regional Compliance: The Indian Standard IS 3933 is widely followed, but hospitals must also comply with guidelines from the
**Drugs and Cosmetics Act** and regulations by the **Gas Cylinder Rules, 2016** for safe handling and transport.
- Verification: Always verify the gas type with the label and pin index, especially in critical care settings, to avoid errors.
Dr. J. L. Meena

FMS 7 - The organisation has plans for fire and
non-fire emergencies within the facilities.
Objective Elements
a)The organisation has plans and provisions for early detection,
abatement and containment of the fire and evacuation in the event
of the fire emergencies. *
b)The organisation has plans and provisions for identification, and
management of non-fire emergencies. *
c) The organisation has a documented and displayed exit plan in case of
fire and non-fire emergencies.
d)Mock drills are held at least twice a year.
e)There is a maintenance plan for fire-related equipment and
infrastructure *
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Dr. J. L. Meena

Disaster Plan
Disaster plan for a hospital should be comprehensive, adaptable, and focused on ensuring patient safety, continuity of
care, and effective response to emergencies.
1. Risk Assessment and Preparedness:
- Conduct a thorough hazard vulnerability analysis (HVA) to identify potential disasters (e.g., natural disasters, pandemics,
power outages, cyberattacks, etc).
- Develop specific response protocols for each identified risk, tailored to the hospital’s location and resources.
2. Clear Command Structure:
- Establish an Incident Command System (ICS) with defined roles and responsibilities for leadership and staff during a
disaster.
- Designate a clear chain of command and backup personnel to ensure continuity.
3. Communication Plan:
- Implement redundant communication systems (e.g., satellite phones, radios) to maintain internal and external
communication during power or network failures.
- Develop protocols for coordinating with local emergency services, government agencies, and other healthcare facilities.
Dr. J. L. Meena

Disaster Plan
4. Staff Training and Drills:
- Conduct regular training for all staff on disaster response protocols, including evacuation, triage, and infection control.
- Perform routine drills and simulations to test the plan and identify gaps.
5. Patient Safety and Continuity of Care:
- Prioritize patient triage and evacuation plans, ensuring vulnerable populations (e.g., ICU patients, neonates) are addressed.
- Maintain backup systems for critical medical equipment (e.g., ventilators, dialysis machines) and ensure adequate supplies of
medications and essentials.
6. Resource Management:
- Stockpile essential supplies (e.g., food, water, medical supplies, PPE) for at least 96 hours of self-sufficiency.
- Establish agreements with vendors and neighboring facilities for emergency resupply.
7. Infrastructure Resilience:
- Ensure backup power sources (e.g., generators) with sufficient fuel reserves and regular maintenance.
- Harden critical infrastructure (e.g., HVAC, water systems) against disasters like floods or earthquakes.
8. Surge Capacity Planning:
- Develop protocols to expand bed capacity, repurpose non-clinical spaces, and manage an influx of patients.
- Plan for rapid staff augmentation, including volunteers and cross-trained personnel.
Dr. J. L. Meena

Disaster Plan
9. Infection Control and Public Health:
- Include measures to prevent disease spread during disasters, such as isolation protocols and vaccination plans.
- Coordinate with public health agencies for outbreak management and community support.
10. Recovery and Post-Disaster Evaluation:
- Create a recovery plan to restore normal operations, including mental health support for staff and patients.
- Conduct a post-event debrief to evaluate the plan’s effectiveness and update it based on lessons learned.
11. Community Integration:
- Collaborate with local emergency management, fire, police, and other hospitals to ensure a coordinated regional response.
- Educate the community on the hospital’s role during disasters to manage expectations and reduce panic.
12. Compliance and Accreditation:
- Align the plan with regulatory requirements (e.g., Joint Commission, CMS) and local/state guidelines.
- Regularly review and update the plan to meet evolving standards and best practices.
“By focusing on these key points, a hospital can create a robust disaster plan that minimizes risks, ensures
patient care, and supports staff and community resilience during crises”
Dr. J. L. Meena

Summary
The National Accreditation Board for Hospitals and Healthcare Providers (NABH) outlines specific standards for
Facility Management and Safety (FMS) to ensure a safe, efficient, and compliant hospital environment. Below is a final
summary of the key points for facility management as per NABH standards, based on the provided context and
general NABH guidelines:
1. Infrastructure Compliance:
- Ensure legal clearances (e.g., Fire NOC, building occupancy certificate, AERB licenses for radiation equipment,
electrical inspections) are in place and up-to-date.
- Maintain physical infrastructure to meet safety and accessibility standards, including transportation access and
adequate space for clinical services (e.g., blood bank, imaging areas).
2. Safety and Emergency Preparedness:
- Implement fire safety protocols, including updated Fire NOC, a multidisciplinary safety committee meeting
quarterly, and a designated Fire Safety Officer.
- Ensure firefighting equipment, emergency illumination, and evacuation plans (e.g., separate staircases, safe areas
for patient collection) are available for emergencies like fire, flood, or mob attacks.
- Conduct regular emergency drills and maintain equipment for transporting bedridden patients during evacuations.
Dr. J. L. Meena

Summary
3. Infection Control:
- Design facilities to prevent cross-infection, with inter-bed distances of ~6 feet in wards, accessible handwashing
basins or hand rubs near beds, and zoning in CSSD and operation theatres.
- Maintain strict protocols for sterilization, hand hygiene, and isolation of infectious patients.
4. Maintenance and Equipment Management:
- Regularly inspect and maintain hospital equipment to ensure operational readiness and extend equipment lifespan.
- Implement preventive maintenance schedules and manage work orders to address minor issues before they
escalate.
5. Environmental Safety and Cleanliness:
- Ensure a safe and clean hospital environment by regularly monitoring and addressing potential hazards.
- Promote sustainability through energy-efficient practices (e.g., proper ventilation, reduced energy consumption)
and waste management systems.
6. Signage and Accessibility:
- Provide clear, standardized signage (preferably symbols or hybrid text-symbol) for services, toilets, and waste
disposal to guide patients and visitors effectively.
- Ensure facilities are accessible, with adequate circulation areas for outpatients, inpatients, staff, and services to
prevent congestion.
Dr. J. L. Meena

Summary
7. Disaster Management:
- Prepare for external disasters (e.g., mass casualties from accidents) by ensuring surge
capacity and the ability to manage bulk patient influx.
- Address region-specific disaster risks (e.g., floods, earthquakes) with tailored facility plans.
8. Continuous Quality Improvement:
- Regularly audit facility management processes and use data to drive improvements in
safety and efficiency.
- Maintain compliance with NABH’s FMS standards through ongoing staff training and
internal assessments.
“These points align with NABH’s Facility Management and Safety (FMS) standards,
emphasizing patient and staff safety, regulatory compliance, and operational efficiency.
Hospitals must integrate these elements into their disaster preparedness plans to ensure
resilience and quality care during crises”
Dr. J. L. Meena

Effective Human Resource
Management

Key for Human Recourse
Management
✓ Human Resource Planning
✓ Recruitment and selection
✓ Performance management
✓ Learning and development
✓ Career planning
✓ Function evaluation
✓ Rewards
✓ Industrial relations
✓ Employee participation &
communication
✓ Health & safety
✓ Well- being
✓ Administrative responsibilities
Dr. J. L. Meena

Human Resource Management
(HRM) for a hospital
Human Resource Management (HRM) for a hospital requires tailored strategies to address the unique demands of
healthcare, ensuring high-quality patient care, employee satisfaction, and operational efficiency.
1. Specialized Recruitment & Selection:
- Hire skilled professionals (doctors, nurses, technicians, administrative staff) with relevant qualifications and
certifications.
- Use targeted job descriptions and competency-based interviews to assess clinical and interpersonal skills.
- Maintain a talent pipeline for critical roles to address shortages, especially for specialists and emergency staff.
2. Comprehensive Training & Development:
- Provide ongoing training on medical advancements, patient safety, and technology (e.g., electronic health records).
- Offer leadership development for senior staff and soft skills training (empathy, communication) for patient-facing
roles.
- Support continuous professional development (CPD) to meet licensing requirements and enhance expertise.
3. Employee Well-being & Support:
- Implement wellness programs to address burnout, stress, and mental health, given the high-pressure environment.
- Offer flexible scheduling and adequate rest periods to manage long shifts and work-life balance.
- Provide access to counseling and peer support for staff dealing with emotional or traumatic cases.
Dr. J. L. Meena

4. Performance Management:
- Set clear performance metrics for clinical outcomes, patient satisfaction, and teamwork.
- Conduct regular evaluations with constructive feedback to improve care quality and efficiency.
- Recognize and reward exceptional performance to boost morale and retention.
5. Competitive Compensation & Benefits:
- Offer competitive salaries, overtime pay, and shift differentials to attract and retain talent.
- Provide comprehensive benefits, including health insurance, retirement plans, and childcare support.
- Include incentives like loan repayment programs for medical staff or bonuses for critical roles.
6. Compliance & Safety:
- Ensure strict adherence to healthcare regulations (e.g., HIPAA, OSHA) and labor laws.
- Maintain rigorous workplace safety protocols, including infection control and handling of hazardous materials.
- Regularly update policies to align with evolving healthcare standards and legal requirements.
7. Diversity, Equity & Inclusion (DEI):
- Foster a diverse workforce to reflect the patient population and improve cultural competence in care delivery.
- Promote inclusivity through training on unconscious bias and equitable hiring practices.
- Ensure equal opportunities for career advancement across all staff levels.
Dr. J. L. Meena

8. Employee Relations & Conflict Resolution:
- Address workplace conflicts promptly, especially in high-stress multidisciplinary teams.
- Establish clear grievance procedures and maintain open communication channels.
- Encourage collaboration between departments (e.g., nursing, administration, physicians) to enhance teamwork.
9. Strategic Workforce Planning:
- Align HR strategies with hospital goals, such as improving patient outcomes or expanding services.
- Forecast staffing needs based on patient volume, seasonal trends, and service demands.
- Develop succession plans for leadership roles to ensure continuity in critical positions.
10. Technology & Data-Driven HRM:
- Use HR information systems (HRIS) to streamline scheduling, payroll, and compliance tracking.
- Leverage data analytics to monitor staff turnover, engagement, and performance trends.
- Implement telehealth training and digital tools to prepare staff for evolving healthcare delivery models.
11. Crisis Management & Resilience:
- Prepare for emergencies (e.g., pandemics, natural disasters) with contingency staffing plans.
- Train staff in crisis response protocols to maintain care continuity under pressure.
- Build a resilient workforce through regular drills and adaptive HR policies.
Dr. J. L. Meena

12. Patient-Centered Culture:
- Align HR practices with a patient-first mission, emphasizing empathy and quality care in employee training and
evaluations.
- Involve staff in decision-making to enhance commitment to hospital values and patient satisfaction.
- Foster interdisciplinary collaboration to ensure seamless care delivery.
Implementation Tips:
- Leadership Support: Engage hospital leadership to champion HR initiatives and allocate resources for staff
development.
- Feedback Mechanisms: Use employee surveys and patient feedback to assess HR effectiveness and identify
improvement areas.
- Partnerships: Collaborate with medical schools, nursing programs, and professional associations to build a robust talent
pipeline.
- Retention Focus: Prioritize retention strategies, as replacing healthcare professionals is costly and disruptive to care.
“By focusing on these areas, hospital HRM can create a supportive, efficient, and resilient workforce that enhances
patient care, staff satisfaction, and organizational success”
Dr. J. L. Meena

Human Resource Planning
Human resource planning (HRP) in hospitals ensures a skilled, adequate workforce to deliver quality patient care while meeting
operational and strategic goals. It involves forecasting staffing needs, recruiting, training, and retaining healthcare professionals in
a dynamic, high-stakes environment.
1. Workforce Assessment:
- Evaluate current staff (doctors, nurses, technicians, admin) for skills, roles, and numbers.
- Identify gaps, such as shortages in specialists (e.g., ICU nurses, radiologists).
- Consider patient load, shift requirements, and staff turnover.
2. Forecasting Needs:
- Demand: Project future staffing based on patient volume, new services (e.g., cardiology wing), technology adoption, or
seasonal surges (e.g., epidemics).
- Supply: Analyze internal resources (promotions, cross-training) and external talent pools (medical graduates, local market).
- Account for retirements, resignations, and regulatory changes.
3. Recruitment:
- Target critical roles through partnerships with medical/nursing schools, job fairs, or online platforms.
- Ensure compliance with certifications, licenses, and background checks.
- Attract talent with competitive benefits and clear career paths.
Dr. J. L. Meena

4. Training and Development:
- Provide ongoing education on medical advancements, equipment (e.g., MRI machines), and protocols.
- Support certifications and leadership training for career progression.
- Address skill gaps through in-house or external programs.
5. Retention Strategies:
- Combat burnout with fair pay, flexible schedules, and wellness programs.
- Foster a supportive culture through recognition and growth opportunities.
- Enhance workplace safety, especially in high-risk areas like ER or infectious disease units.
6. Succession Planning:
- Identify and prepare staff for leadership roles (e.g., department heads).
- Ensure continuity in critical positions to avoid disruptions in care.
Challenges in Hospital HRP
- Staff Shortages: Global demand for healthcare workers often outstrips supply.
- Burnout: High-stress roles lead to turnover, requiring robust retention plans.
- Regulatory Compliance: Adhering to healthcare laws, certifications, and accreditation standards.
- Budget Constraints: Balancing staffing needs with financial resources.
Dr. J. L. Meena

Best Practices
- Use data analytics to predict staffing needs based on patient
trends and historical data.
- Engage staff in planning to align individual goals with hospital
objectives.
- Leverage technology (e.g., HR software) for scheduling,
recruitment, and performance tracking.
- Regularly review and update the HRP to adapt to changing
healthcare demands.
Dr. J. L. Meena

A defined process for staff recruitment in a hospital ensures the hiring of qualified, competent professionals
to deliver quality patient care while meeting regulatory and operational needs.
Defined Recruitment Process for Hospital Staff
1. Identify Staffing Needs:
- Collaborate with department heads (e.g., nursing, surgery, radiology) to assess vacancies or new roles
based on patient volume, service expansion, or staff turnover.
- Define job roles, required qualifications (e.g., RN license, board certification), skills, and experience levels.
- Consider shift requirements (e.g., night shifts, on-call) and workload demands.
2. Develop Job Descriptions:
- Create detailed job postings outlining responsibilities, qualifications, certifications (e.g., BLS, ACLS), and
competencies.
- Specify hospital-specific requirements, such as familiarity with electronic health records (EHR) or
specialized equipment.
- Highlight benefits (e.g., competitive pay, health insurance, professional development) to attract
candidates.
Process for Staff
recruitment
Dr. J. L. Meena

3. Source Candidates:
- Internal Recruitment: Promote from within or reassign existing staff to fill roles, fostering career growth.
- External Recruitment:
- Post openings on hospital websites, job boards (e.g., Indeed, Health eCareers), and professional networks
(e.g., LinkedIn).
- Partner with medical and nursing schools, residency programs, or professional associations (e.g., AMA,
ANA).
- Attend job fairs or host recruitment events to attract local talent.
- Engage staffing agencies for temporary or specialized roles (e.g., locum tenens physicians).
4. Screen Applications:
- Review resumes and applications to shortlist candidates meeting minimum qualifications.
- Verify credentials, including licenses, certifications, and education, through primary source verification
(e.g., state medical boards).
- Use applicant tracking systems (ATS) to streamline screening and ensure compliance with hiring policies.
Process for Staff
recruitment
Dr. J. L. Meena

5. Conduct Interviews:
- Initial Interviews: HR conducts phone or video screenings to assess basic fit, availability, and motivation.
- Panel Interviews: Involve department leaders, clinical supervisors, or peers to evaluate technical skills, cultural fit, and
teamwork.
- Use competency-based questions (e.g., “How have you handled a critical patient emergency?”) and scenario-based
assessments for clinical roles.
- Assess soft skills like communication, empathy, and stress management, critical for patient-facing roles.
6. Skills and Background Checks:
- Administer practical assessments for clinical roles (e.g., simulation-based tests for nurses or technicians).
- Conduct thorough background checks, including criminal history, reference checks, and drug screenings.
- Verify work history and any disciplinary actions through regulatory bodies.
7. Selection and Offer:
- Convene a hiring committee (HR, department heads) to select the best candidate based on interviews, assessments,
and alignment with hospital values.
- Extend a formal job offer, detailing salary, benefits, work hours, and onboarding details.
- Negotiate terms if needed, ensuring transparency and competitiveness.
Process for Staff
recruitment
Dr. J. L. Meena

8. Onboarding:
- Provide a structured orientation program covering hospital policies, safety protocols, and EHR training.
- Assign mentors or preceptors for clinical staff to ease integration into patient care workflows.
- Ensure compliance with mandatory training (e.g., infection control, HIPAA) and credentialing processes.
9. Evaluation and Feedback:
- Monitor new hires during probationary periods to assess performance and fit.
- Collect feedback from recruits on the hiring process to identify areas for improvement.
- Adjust recruitment strategies based on hiring outcomes, retention rates, and department needs.
Best Practices for Hospital Recruitment
- Compliance: Adhere to healthcare regulations (e.g., NABH standards, local labor laws) and maintain documentation for
audits.
- Diversity and Inclusion: Promote equitable hiring practices to build a diverse workforce reflective of the community
served.
- Employer Branding: Highlight the hospital’s mission, work culture, and growth opportunities to attract top talent.
- Efficiency: Streamline processes to reduce time-to-hire, especially for critical roles like ER staff.
- Data-Driven Decisions: Use recruitment metrics (e.g., cost-per-hire, applicant-to-hire ratio) to optimize the process.
Process for Staff
recruitment
Dr. J. L. Meena

➢ Challenge: Shortage of specialized staff (e.g., anesthesiologists,
ICU nurses).
➢ Solution: Offer sign-on bonuses, relocation assistance, or student
loan repayment programs.
➢ Challenge: High competition for talent.
➢ Solution: Build a strong employer brand and engage passive
candidates through networking.
➢ Challenge: Lengthy credentialing processes.
➢ Solution: Start verification early and use technology to expedite
checks.
Process for Staff
recruitment
Dr. J. L. Meena

Effective human resource
management (HRM)
Effective human resource management (HRM) involves strategically managing an organization’s workforce to
maximize productivity, engagement, and alignment with business goals.
1. Strategic Alignment
- Link HR to Business Goals: Align HR strategies with the organization’s mission, vision, and objectives. For
example, if a company prioritizes innovation, HR should focus on recruiting creative talent and fostering a
culture of experimentation.
- Workforce Planning: Anticipate future staffing needs by analyzing trends, skills gaps, and business growth.
Use data analytics to forecast hiring needs and succession planning.
2. Recruitment and Selection
- Attract Top Talent: Use targeted job descriptions, employer branding, and diverse sourcing channels (e.g.,
job boards, social media, employee referrals). Highlight company culture and growth opportunities.
- Fair and Efficient Selection: Implement structured interviews, skills assessments, and behavioral
evaluations to ensure unbiased hiring. Leverage AI tools for resume screening but maintain human oversight
to avoid bias.
- Diversity and Inclusion: Prioritize diverse hiring to enhance creativity and decision-making. Ensure inclusive
job ads and equitable selection processes. Dr. J. L. Meena

management (HRM)
3. Employee Engagement and Retention
- Foster a Positive Culture: Build a workplace that values trust, collaboration, and recognition. Regular
employee feedback (e.g., surveys, pulse checks) helps gauge satisfaction and address concerns.
- Recognition and Rewards: Implement fair compensation, bonuses, and non-monetary rewards (e.g.,
flexible work, public acknowledgment) to motivate employees.
- Work-Life Balance: Offer flexible schedules, remote work options, and wellness programs to reduce
burnout and improve retention.
4. Training and Development
- Continuous Learning: Provide ongoing training, mentorship, and upskilling programs to keep employees
competitive. Focus on both technical skills (e.g., software proficiency) and soft skills (e.g., leadership,
communication).
- Career Pathing: Create clear career progression plans to retain ambitious employees. Use performance
reviews to identify development opportunities.
- Leadership Development: Invest in programs to groom future leaders, ensuring a pipeline for critical roles.
Dr. J. L. Meena

management (HRM)
5. Performance Management
- Set Clear Expectations: Use SMART goals (Specific, Measurable, Achievable, Relevant, Time-bound) to
define employee objectives.
- Regular Feedback: Conduct frequent performance reviews, combining formal appraisals with informal
check-ins to provide constructive feedback.
- Data-Driven Evaluations: Use key performance indicators (KPIs) and 360-degree feedback to assess
performance objectively.
6. Compliance and Fairness
- Adhere to Labor Laws: Stay updated on local and international regulations (e.g., wage laws, anti-
discrimination policies) to ensure compliance.
- Promote Equity: Implement policies to prevent harassment, discrimination, and bias. Train managers on
equitable treatment and conflict resolution.
- Transparent Policies: Maintain clear, accessible HR policies on hiring, promotions, and disciplinary actions
to build trust.
Dr. J. L. Meena

management (HRM)
7. Technology and Innovation
- Leverage HR Tech: Use HR management systems (e.g., Workday, BambooHR) for payroll, attendance, and employee
data management. AI tools can streamline recruitment and performance tracking.
- Data Analytics: Analyze HR metrics (e.g., turnover rates, engagement scores) to make informed decisions and predict
trends.
- Remote Work Tools: Support hybrid or remote teams with collaboration platforms (e.g., Slack, Microsoft Teams) and
cybersecurity measures.
8. Employee Well-Being
- Mental Health Support: Offer employee assistance programs (EAPs), counseling, and stress management workshops.
- Health Benefits: Provide comprehensive health insurance and wellness initiatives (e.g., gym memberships, health
screenings).
- Safe Work Environment: Ensure physical and psychological safety through workplace policies and regular safety audits.
9. Change Management
- Adapt to Change: Prepare employees for organizational changes (e.g., mergers, tech adoption) through clear
communication and training.
- Involve Employees: Engage staff in decision-making during transitions to reduce resistance and build buy-in.
Dr. J. L. Meena

management (HRM)
10. Global and Cultural Considerations
- Cross-Cultural Competence: For global organizations, train HR teams to understand cultural nuances and manage diverse
teams effectively.
- Localized Strategies: Adapt HR practices (e.g., benefits, holidays) to regional norms while maintaining global consistency.
Practical Tips for Implementation
- Start Small: Focus on high-impact areas like employee engagement or performance reviews before scaling up.
- Communicate Clearly: Ensure HR policies and changes are transparent and well-communicated to avoid confusion.
- Measure Success: Track HR metrics (e.g., retention rates, time-to-hire) to evaluate effectiveness and refine strategies.
- Stay Updated: Monitor HR trends (e.g., remote work, AI in recruitment) via industry reports or platforms like SHRM or
LinkedIn.
- High Turnover: Address with better onboarding, career development, and exit interviews to understand root causes.
- Resistance to HR Tech: Train employees on new tools and highlight benefits to gain acceptance.
- Budget Constraints: Prioritize cost-effective solutions like internal training or open-source HR software.
Dr. J. L. Meena

Induction training for new hospital
employees
Induction training for new hospital employees is critical to ensure they are well-equipped to perform their roles effectively,
integrate into the organizational culture, and contribute to patient safety and operational efficiency.
List of Induction Training Topics for New Hospital Employees
1. Organizational Overview
- Topics Covered: History, mission, vision, values, organizational structure, and key departments of the hospital.
- Importance: Helps employees understand the hospital’s goals, culture, and their role within the broader organization. It
fosters a sense of belonging and alignment with the hospital’s ethos.
2. Health and Safety Training
- Topics Covered: Fire safety, emergency evacuation procedures, infection control, handling hazardous materials, personal
protective equipment (PPE), and workplace risk assessments.
- Importance: Ensures employee and patient safety by familiarizing staff with protocols to prevent accidents, infections,
and injuries. Compliance with regulatory requirements (e.g. NABH, Joint Commission) is also maintained.
3. Hospital Policies and Procedures
- Topics Covered: Code of conduct, attendance policies, leave procedures, patient confidentiality (e.g., HIPAA/GDPR),
grievance procedures, and anti-harassment policies.
- Importance: Clarifies expectations and legal obligations, reducing the risk of policy violations and fostering a
professional work environment.
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employees
4. Job-Specific Training
- Topics Covered: Role responsibilities, use of medical equipment, electronic health record (EHR) systems, clinical
protocols, and department-specific workflows.
- Importance: Equips employees with the skills and knowledge needed to perform their duties efficiently, reducing errors
and improving patient care quality.
5. Patient Safety and Quality Standards
- Topics Covered: Clinical quality benchmarks, patient-centered care, incident reporting, and medico-legal considerations.
- Importance: Enhances patient outcomes by ensuring employees understand how to maintain high standards of care and
report adverse events promptly. (https://pmc.ncbi.nlm.nih.gov/articles/PMC10887481/)
6. Infection Control Practices
- Topics Covered: Hand hygiene, sterilization techniques, isolation protocols, and management of hospital-acquired
infections.
- Importance: Critical for preventing the spread of infections, protecting patients, staff, and visitors, and complying with
accreditation standards (e.g., NABH, JCI). (https://pmc.ncbi.nlm.nih.gov/articles/PMC11844963/)
7. Introduction to Team and Key Personnel
- Topics Covered: Meet-and-greet with colleagues, supervisors, and interdisciplinary teams, including roles and
responsibilities of team members.
- Importance: Builds relationships, fosters collaboration, and helps new employees feel welcomed, reducing anxiety and
improving team cohesion.
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employees
8. Administrative and HR Processes
- Topics Covered: Payroll setup, benefits enrollment, contract signing, ID badge issuance, and workstation setup.
- Importance: Streamlines onboarding by addressing logistical needs, allowing employees to focus on their roles without
administrative delays.
9. Technology and Systems Training
- Topics Covered: Use of hospital management information systems (HMIS), EHR platforms, and other role-specific software or
equipment.
- Importance: Enables employees to navigate critical systems efficiently, reducing errors and improving productivity.
10. Compliance and Legal Training
- Topics Covered: Regulatory requirements (e.g., HIPAA, GDPR, local healthcare laws), ethical standards, and anti-bribery
policies.
- Importance: Ensures adherence to legal and ethical standards, protecting the hospital from liabilities and maintaining trust
with patients.
11. Emergency Preparedness
- Topics Covered: Response to medical emergencies, disaster management, and location of medical kits and evacuation routes.
- Importance: Prepares staff to act swiftly and effectively during crises, ensuring patient and staff safety.
12. Cultural and Diversity Training
- Topics Covered: Respecting patient and staff diversity, inclusivity, and sensitivity to cultural differences.
- Importance: Promotes a respectful and inclusive environment, improving patient satisfaction and team dynamics.
Dr. J. L. Meena

employees
13. Feedback and Follow-Up Mechanisms
- Topics Covered: How to provide feedback on the induction process, expectations for probation reviews, and ongoing
support channels.
- Importance: Allows employees to voice concerns, clarifies performance expectations, and identifies areas for additional
training, enhancing retention.
Importance of Induction Training in Hospitals
1. Improves Employee Performance and Productivity
- Well-structured induction training equips employees with the knowledge and skills to perform their roles effectively
from the start, reducing the learning curve and enabling faster contribution to hospital operations.
2. Enhances Patient Safety and Care Quality
- Training on infection control, patient safety protocols, and clinical standards ensures employees deliver high-quality
care, minimizing errors and adverse events. (https://pmc.ncbi.nlm.nih.gov/articles/PMC11844963/)
3. Reduces Employee Turnover
- A comprehensive induction makes employees feel valued and supported, fostering a sense of belonging and reducing
the likelihood of early attrition. Studies show strong onboarding can improve retention by 82%.
Dr. J. L. Meena

employees
4. Ensures Compliance with Regulations
- Training on legal, ethical, and safety standards ensures compliance with healthcare regulations, reducing the risk of
penalties and maintaining accreditation.
5. Fosters a Positive Organizational Culture
- Induction introduces employees to the hospital’s values and culture, promoting inclusivity, teamwork, and alignment
with organizational goals.
6. Boosts Employee Confidence and Engagement
- Clear role expectations and support during induction reduce anxiety, increase confidence, and enhance job satisfaction,
leading to higher engagement.
7. Cost-Effectiveness
- Investing in induction training is more cost-effective than managing high turnover or correcting errors due to inadequate
training. It saves resources in the long term by building a competent workforce.
8. Facilitates Seamless Integration
- By familiarizing employees with their work environment, colleagues, and processes, induction ensures a smoother
transition, reducing stress and improving team dynamics.
Dr. J. L. Meena

employees
Best Practices for Effective Induction Training
- Tailor the Program: Customize training to the employee’s role (e.g., nurses, doctors, administrative staff) to ensure
relevance.
- Spread Over Time: Deliver training over several days or weeks to avoid overwhelming new hires.
- Use Multiple Formats: Combine presentations, hands-on training, e-learning, and shadowing to cater to different learning
styles.
- Engage Trainers: Involve competent trainers, including HR, supervisors, and senior staff, to deliver clear and engaging
sessions.
- Evaluate Effectiveness: Use pre- and post-tests, feedback forms, and follow-up reviews to assess the program’s impact
and identify areas for improvement. (https://pmc.ncbi.nlm.nih.gov/articles/PMC10887481/)
- Incorporate Technology: Use learning management systems (LMS) or immersive simulations for scalable, engaging
training.
Conclusion
Induction training for new hospital employees is a vital investment that enhances performance, ensures patient safety, and
promotes a positive workplace culture. By covering essential topics like health and safety, job-specific skills, and
organizational policies, hospitals can set new hires up for success while meeting regulatory and operational goals. A well-
executed induction program not only benefits employees but also strengthens the hospital’s reputation, reduces turnover,
and improves patient care outcomes. (https://pmc.ncbi.nlm.nih.gov/articles/PMC10887481/)
Dr. J. L. Meena

Professional training and
development of hospital staff
Professional training and development of hospital staff are critical for ensuring high-quality patient care,
operational efficiency, and adaptability to evolving healthcare demands.
1. Enhanced Patient Care: Ongoing training ensures staff are skilled in the latest medical techniques,
technologies, and evidence-based practices, leading to better patient outcomes, reduced errors, and
improved safety.
2. Compliance with Standards: Regular training keeps staff updated on regulatory requirements, accreditation
standards, and hospital policies, minimizing legal and ethical risks.
3. Staff Competence and Confidence: Development programs build expertise, boost confidence, and improve
decision-making, enabling staff to handle complex cases effectively.
4. Adaptability to Innovation: Training equips staff to use new technologies, such as electronic health records
or advanced diagnostic tools, ensuring hospitals remain competitive and efficient.
Dr. J. L. Meena

Professional training and
development of hospital staff
5. Employee Retention and Morale: Investing in development shows staff they are valued,
increasing job satisfaction, reducing turnover, and fostering a culture of continuous improvement.
6. Team Collaboration: Training programs often include interdisciplinary exercises, improving
communication and teamwork, which are essential for coordinated patient care.
7. Emergency Preparedness: Regular drills and training ensure staff can respond effectively to crises,
such as pandemics or mass casualty events.
8. Cost Efficiency: Well-trained staff are more efficient, reducing errors, rework, and unnecessary
procedures, which lowers operational costs.
“Hospitals that prioritize training create a skilled, motivated workforce capable of delivering
exceptional care while adapting to healthcare challenges. “
Dr. J. L. Meena

Job description
Definition
A job description is a written statement that clearly defines the scope, responsibilities, qualifications, and expectations
associated with a particular position. It acts as a blueprint for the role, ensuring alignment between the organization’s
needs and the employee’s contributions. It is used by employers, recruiters, and employees to understand the role’s
purpose, requirements, and place within the organizational structure.
Key Components of a Job Description
A well-crafted job description typically includes the following elements, though the structure may vary depending on the
organization’s size, industry, or specific needs:
1. Job Title:
- A concise, accurate title that reflects the role’s function and level (e.g., "Senior Software Engineer," "Marketing
Coordinator").
- Should align with industry standards to attract the right candidates and avoid confusion.
2. Job Summary:
- A brief overview (2–4 sentences) of the role’s purpose and its contribution to the organization’s goals.
Dr. J. L. Meena

Job description
3. Duties and Responsibilities:
- A detailed list of the primary tasks and responsibilities the employee will perform.
- Often presented in bullet points for clarity, prioritizing the most critical duties.
- Should be specific and measurable
- May include frequency (e.g., daily, weekly) or scope (e.g., managing a team of 5).
4. Qualifications and Requirements:
- Education: Minimum academic qualifications (e.g., bachelor’s degree in a relevant field).
- Experience: Specific years or types of professional experience (e.g., "3+ years in project management").
- Skills: Technical skills (e.g., proficiency in Python, CRM software) and soft skills (e.g., communication, leadership).
- Certifications: Any required or preferred certifications (e.g., PMP, CPA).
- May include "preferred" versus "required" qualifications to attract a broader candidate pool.
5. Reporting Structure:
- Clarifies who the employee reports to (e.g., "Reports to the Director of Operations") and, if applicable, who reports to
them.
- May include interactions with other teams or departments.
Dr. J. L. Meena

Job description
6. Work Environment and Conditions:
- Details about the workplace, such as whether the role is remote, hybrid, or on-site.
- May include physical demands (e.g., lifting, standing) or environmental factors (e.g., outdoor work, travel
requirements).
- Example: "This role requires 25% travel for client meetings."
7. Salary and Benefits (Optional):
- Some organizations include a salary range to promote transparency, though this is not universal.
- May list benefits like health insurance, retirement plans, or professional development opportunities.
- Example: "Competitive salary range of $60,000–$80,000 based on experience, plus comprehensive health benefits."
8. Company Overview (Optional):
- A brief description of the organization’s mission, values, or culture to attract candidates who align with its goals.
- Example: "Join our innovative tech startup dedicated to revolutionizing sustainable energy solutions."
9. Equal Opportunity Statement (Optional):
- A statement affirming the organization’s commitment to diversity and non-discrimination.
- Example: "We are an equal opportunity employer and value diversity in our workforce."
Dr. J. L. Meena

Purposes of a Job Description
1. Recruitment and Hiring:
- Attracts qualified candidates by clearly outlining expectations and requirements.
- Guides the creation of job postings and interview questions.
- Helps screen applicants by comparing their qualifications to the role’s needs.
2. Employee Onboarding and Training:
- Provides new hires with a clear understanding of their role and responsibilities.
- Serves as a reference for setting initial goals and training plans.
3. Performance Management:
- Establishes measurable criteria for evaluating employee performance.
- Aligns individual contributions with organizational objectives.
- Supports feedback sessions and performance reviews.
Dr. J. L. Meena

4. Organizational Clarity:
- Defines roles to prevent overlap or confusion among team members.
- Supports workforce planning by identifying staffing needs and skill gaps.
5. Legal and Compliance:
- Ensures compliance with labor laws, such as the Americans with Disabilities Act (ADA),
by documenting essential job functions.
- Protects organizations in disputes by clarifying expectations upfront.
6. Career Development:
- Helps employees understand pathways for growth by outlining skills and qualifications
for their current and potential future roles.
Dr. J. L. Meena

Best Practices for Writing a Job
Description
To create an effective job description, consider the following guidelines:
1. Be Clear and Concise:
- Use simple, direct language to avoid ambiguity.
- Avoid jargon unless it’s industry-standard and relevant to the role.
2. Focus on Essential Functions:
- Prioritize core responsibilities and avoid listing every possible task.
- Highlight what makes the role unique or critical to the organization.
3. Use Action Verbs:
- Start bullet points with strong verbs like "manage," "design," "analyze," or "coordinate" to convey accountability.
- Example: "Develop quarterly financial reports" is better than "Responsible for financial reports."
4. Be Inclusive:
- Use gender-neutral language and avoid overly rigid requirements that may deter diverse applicants.
- Example: Instead of "must have 5 years of experience," consider "3–5 years of experience or equivalent skills."
Dr. J. L. Meena

5. Align with Organizational Goals:
- Ensure the role’s responsibilities support the company’s mission and strategic objectives.
- Reflect the organization’s culture and values in the tone and content.
6. Update Regularly:
- Review and revise job descriptions periodically to reflect changes in the role, technology, or organizational
needs.
- Outdated descriptions can lead to misalignment or ineffective hiring.
7. Comply with Legal Standards:
- Ensure the description adheres to labor laws, such as specifying essential functions for ADA compliance.
- Avoid discriminatory language or requirements unrelated to job performance.
8. Tailor to the Audience:
- Consider the candidate pool and industry norms when crafting the tone and level of detail.
- For technical roles, emphasize specific tools or certifications; for creative roles, highlight innovation and
collaboration.
Best Practices for Writing a Job
Description
Dr. J. L. Meena

Job description
Challenges and Considerations
- Overloading Responsibilities: Listing too many duties can overwhelm candidates or set unrealistic
expectations.
- Vagueness: Broad or unclear descriptions may attract unqualified applicants or confuse employees.
- Bias: Unconscious bias in language (e.g., "rockstar" or "ninja") may alienate certain groups or imply a specific
demographic.
- Static Nature: Roles evolve, and failure to update descriptions can lead to misalignment between the job and
its execution.
Conclusion
“A job description is a foundational tool that bridges organizational needs with employee performance. By
clearly defining a role’s purpose, responsibilities, and requirements, it supports effective hiring, employee
development, and operational success. Crafting a detailed, inclusive, and up-to-date job description requires
careful consideration of the role’s scope, the organization’s goals, and the needs of potential candidates.
When done well, it serves as a roadmap for both the employer and employee, fostering clarity and
alignment.”
Dr. J. L. Meena

Training in safety and quality-
related
Training in safety and quality-related aspects is critical across industries to ensure employee well-being,
regulatory compliance, and high-quality outputs.
1. Workplace Safety Training
- Description: Covers hazard identification, safe work practices, personal protective equipment (PPE) use,
and emergency procedures.
- Importance: Prevents workplace injuries, reduces accidents, and ensures compliance with regulations.
2. Fire Safety and Evacuation Training
- Description: Teaches fire prevention, proper use of fire extinguishers, and evacuation protocols.
- Importance: Prepares employees to respond effectively to fire emergencies, minimizing harm and
property damage.
3. First Aid and CPR Training
- Description: Equips employees with skills to provide immediate medical assistance in emergencies.
- Importance: Saves lives during critical situations before professional medical help arrives.
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related
4. Chemical and Hazardous Materials Handling
- Description: Focuses on safe storage, handling, and disposal of hazardous substances, including understanding
Material Safety Data Sheets (MSDS).
- Importance: Prevents chemical spills, exposures, and environmental contamination.
5. Ergonomics Training
- Description: Educates on proper workstation setup and body mechanics to prevent musculoskeletal injuries.
- Importance: Reduces repetitive strain injuries and improves long-term employee health.
6. Machine and Equipment Safety
- Description: Covers safe operation, lockout/tagout procedures, and maintenance of machinery.
- Importance: Prevents equipment-related accidents and ensures operational efficiency.
7. Workplace Violence Prevention
- Description: Trains employees to recognize and de-escalate potential violent situations.
- Importance: Enhances workplace security and fosters a safe working environment.
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related
Training in Quality-Related Aspects
1. Quality Management Systems (e.g., NABH, ISO 9001)
- Description: Introduces standards for process documentation, continuous improvement, and customer satisfaction.
- Importance: Ensures consistent product/service quality and boosts organizational credibility.
2. Lean and Six Sigma Training
- Description: Focuses on reducing waste, improving processes, and minimizing defects through data-driven
methodologies.
- Importance: Enhances efficiency, reduces costs, and improves customer satisfaction.
3. Statistical Process Control (SPC)
- Description: Teaches monitoring and controlling processes using statistical methods to maintain quality.
- Importance: Identifies process variations early, ensuring consistent quality output.
4. Root Cause Analysis (RCA)
- Description: Trains employees to identify underlying causes of quality issues using tools like Fishbone diagrams or 5
Whys.
- Importance: Prevents recurring defects and drives long-term process improvements.
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5. Customer Service Quality Training
- Description: Focuses on meeting customer expectations through effective communication and
problem-solving.
- Importance: Enhances customer loyalty and strengthens brand reputation.
6. Good Manufacturing Practices (GMP)
- Description: Covers hygiene, documentation, and process controls.
- Importance: Ensures product safety and regulatory compliance, protecting consumers.
7. Total Quality Management (TQM)
- Description: Promotes a culture of continuous improvement involving all employees in quality
initiatives.
- Importance: Aligns organizational goals with quality outcomes, fostering accountability.
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related
Overall Importance of Safety and Quality Training
✓ Employee Well-Being: Safety training reduces workplace injuries, while quality training
empowers employees to perform effectively.
✓ Regulatory Compliance: Ensures adherence to industry standards (e.g., OSHA, ISO, FDA),
avoiding fines and legal issues.
✓ Operational Efficiency: Minimizes errors, rework, and accidents, leading to cost savings
and productivity gains.
✓ Customer Satisfaction: High-quality products/services build trust and loyalty, enhancing
market competitiveness.
✓ Risk Mitigation: Proactively addresses hazards and quality issues, reducing liability and
reputational risks.
✓ Organizational Culture: Fosters a culture of safety, accountability, and excellence,
improving employee morale.
Dr. J. L. Meena

Staff performance is a critical component
of human resource management (HRM)
It directly influences organizational success, productivity, and employee development. Here's a concise
overview of its role within the HRM process:
1. Performance Appraisal: HRM uses performance evaluations to assess employees' job performance against
set goals, competencies, and expectations. This process identifies strengths, areas for improvement, and
informs decisions on promotions, rewards, or corrective actions.
2. Goal Setting and Alignment: Performance management ensures individual, and team objectives align with
organizational goals. HRM facilitates this through frameworks like SMART goals (Specific, Measurable,
Achievable, Relevant, Time-bound).
3. Employee Development: Performance data guides training, mentoring, and career development initiatives.
HRM identifies skill gaps and provides resources to enhance employee capabilities, fostering growth and
engagement.
4. Motivation and Engagement: Recognizing high performers through rewards, feedback, or incentives is a key
HRM function. Effective performance management boosts morale, reduces turnover, and enhances workplace
culture. Dr. J. L. Meena

Staff performance is a critical component
of human resource management (HRM)
5. Feedback and Communication: Continuous feedback loops, facilitated by HRM, ensure
employees receive constructive input and clarity on expectations, improving performance
and accountability.
6. Decision-Making Support: Performance metrics inform HRM decisions on recruitment,
succession planning, compensation, and workforce planning, ensuring resources are
allocated effectively.
7. Compliance and Fairness: HRM ensures performance evaluations are fair, transparent,
and compliant with labor laws, reducing bias and promoting equity.
“By integrating performance management into HRM, organizations create a structured
approach to monitor, develop, and optimize employee contributions, driving overall
success.”
Dr. J. L. Meena

The process for disciplinary and grievance handling in hospitals in India is shaped by a combination of labor laws,
organizational policies, and industry-specific guidelines. While there is no single, universally mandated process for all
hospitals, the framework is generally guided by the principles of fairness, transparency, and compliance with legal
standards such as the Industrial Disputes Act, 1947, and guidelines from bodies like the Medical Council of India (MCI) or
hospital-specific policies.
Disciplinary Process in Hospitals
The disciplinary process addresses employee misconduct, poor performance, or violations of hospital policies (e.g.,
negligence, unethical behavior, or breach of patient care standards). Hospitals, as critical healthcare institutions, emphasize
strict adherence to ethical and professional standards, making disciplinary actions particularly significant.
1. Identification of Issue:
- Misconduct or performance issues are identified through direct observation, patient complaints, peer reports, or audits.
Common issues include negligence, violation of medical protocols, absenteeism, or workplace harassment.
- For example, negligence by a doctor or nurse that harms a patient may trigger a disciplinary investigation.
2. Preliminary Inquiry:
- A preliminary investigation is conducted to gather initial facts. This may involve interviewing the employee, witnesses,
or reviewing records (e.g., patient charts, attendance logs).
- The hospital’s HR department or a designated committee (e.g., Disciplinary Committee) typically oversees this step to
ensure impartiality.
Process for disciplinary
Dr. J. L. Meena

3. Show Cause Notice:
- If the inquiry finds prima facie evidence, the employee is issued a formal show cause notice, detailing the allegations
and giving them an opportunity to respond (usually within 7-15 days).
- The notice must specify the charges clearly, referencing hospital policies or codes of conduct (e.g., MCI’s Code of
Medical Ethics).
4. Formal Investigation:
- A formal investigation is initiated if the employee’s response is unsatisfactory or further clarity is needed. This may
involve:
- Forming an inquiry committee with impartial members (e.g., senior doctors, HR representatives).
- Collecting evidence, such as witness statements, medical records, or CCTV footage.
- Conducting hearings where the employee can present their case, often with a representative (e.g., union member or
colleague).
5. Disciplinary Hearing:
- A formal hearing is held where the employee is given a chance to defend themselves. They have the right to be
accompanied by a colleague or union representative, as per standard labor practices in India.
- The committee evaluates evidence and ensures the process aligns with principles of natural justice (e.g., right to be
heard, unbiased decision-making).
Dr. J. L. Meena

6. Decision and Action:
- Based on the investigation and hearing, the committee recommends disciplinary action, which may include:
- Warning (verbal or written).
- Suspension (with or without pay).
- Demotion or transfer.
- Termination, in cases of gross misconduct (e.g., patient endangerment, fraud).
- The decision is communicated in writing, detailing the reasons and evidence.
7. Appeal Process:
- The employee can appeal the decision to a higher authority (e.g., Hospital Director, Medical Superintendent, or
Appellate Committee) within a specified period (typically 15-30 days).
- The appeal is reviewed, and a final decision is made, which may uphold, modify, or reverse the original action.
8. Documentation:
- All steps, including notices, evidence, hearing minutes, and decisions, are documented to ensure transparency
and compliance with legal scrutiny, especially if the case escalates to a labor court or tribunal.
Dr. J. L. Meena

Grievance Handling Process in Hospitals
Grievance handling addresses employee concerns or dissatisfaction arising from workplace issues, such as unfair treatment,
harassment, pay disputes, or workload concerns. In hospitals, grievances can significantly impact staff morale and patient care
quality, necessitating a robust process.
1. Informal Resolution:
- Employees are encouraged to resolve grievances informally by discussing the issue with their immediate supervisor (e.g., Head of
Department, Nursing Superintendent).
- For example, a nurse facing scheduling conflicts may first approach their ward supervisor for resolution.
2. Formal Grievance Filing:
- If informal resolution fails, the employee submits a written grievance to the HR department or a designated Grievance
Committee. The complaint should include:
- Details of the issue (e.g., dates, incidents, individuals involved).
- Desired resolution (e.g., policy change, apology).
3. Acknowledgment and Initial Review:
- The hospital acknowledges the grievance in writing (within 3-7 days) and assigns it to the Grievance Committee or a responsible
officer (e.g., HR Manager, Medical Superintendent).
- The committee reviews the grievance to determine its validity and whether it falls under the grievance policy (e.g., it excludes
matters covered by separate appeal processes, like disciplinary actions).
Process for grievance handling
Dr. J. L. Meena

4. Investigation:
- The committee conducts a thorough investigation, which may involve:
- Interviewing the grievant, witnesses, and relevant parties (e.g., supervisors, co-workers).
- Reviewing documents (e.g., HR policies, employee contracts).
- Maintaining confidentiality to protect all parties.
- In some cases, mediation is offered, involving an impartial internal or external mediator to facilitate dialogue and
resolution.
5. Grievance Meeting:
- A formal meeting is held with the employee, who may be accompanied by a colleague or union representative. The
committee discusses the grievance, hears the employee’s perspective, and explores solutions.
- For group grievances (e.g., pay disparities affecting multiple nurses), the hospital may hold a single meeting or separate
meetings, ensuring fairness.
6. Decision and Communication:
- The committee makes a decision based on the investigation and meeting outcomes. Possible resolutions include policy
changes, mediation agreements, or disciplinary action against other employees.
- The decision is communicated in writing, explaining the rationale and any actions to be taken.
Process for grievance handling
Dr. J. L. Meena

7. Appeal:
- If the employee is dissatisfied with the outcome, they can appeal to a higher authority (e.g., Hospital Director or a separate Appellate
Committee) within a specified period (e.g., 15 days).
- The appeal process involves a review of the grievance handling procedure and may include a fresh hearing.
8. Follow-Up:
- The hospital follows up to ensure the resolution is implemented and the employee is satisfied. This step helps prevent recurring issues
and builds trust.
Key Considerations in Indian Hospitals
- Legal Compliance: Hospitals must align with Indian labor laws, such as the Industrial Disputes Act, 1947, and the Shops and
Establishments Act (state-specific).
- MCI Guidelines: The Medical Council of India (now National Medical Commission) sets ethical standards for medical professionals.
Disciplinary actions involving doctors often reference the MCI’s Code of Medical Ethics, especially for issues like negligence or malpractice.
- Confidentiality: Given the sensitive nature of hospital work, both disciplinary and grievance processes emphasize confidentiality to
protect patient and employee privacy.
- Training: Supervisors and managers are often trained to handle grievances and disciplinary issues professionally, focusing on conflict
resolution and bias elimination.
- Union Involvement: In unionized hospitals (common in public sector hospitals like those under the National Health Mission), union
representatives play a significant role in grievance and disciplinary hearings, advocating for employee rights.
- Cultural Factors: Studies highlight that supervisor attitudes, trust, and communication significantly influence grievance resolution in
Indian healthcare settings. A supportive supervisor can prevent escalation.
Process for disciplinary and
grievance handling
Dr. J. L. Meena

Challenges and Best Practices
Challenges:
- High workload in hospitals can delay grievance resolution, impacting staff morale and patient care.
- Defensive employee behaviors (e.g., filing counter-grievances during disciplinary processes) can
complicate matters.
- Lack of awareness among employees about formal procedures, especially in smaller hospitals.
- Best Practices:
- Develop clear, written policies for disciplinary and grievance handling, included in employee
handbooks.
- Train managers and HR staff on fair investigation techniques and legal compliance.
- Encourage informal resolution to prevent escalation, fostering a positive work culture.
- Use technology (e.g., HR software like NotchHR) to streamline documentation and ensure compliance.
- Regularly review policies to address emerging issues like workplace harassment or mental health
concerns.
Process for disciplinary and
grievance handling
Dr. J. L. Meena

Hospitals, maintaining documented personal
information for each staff member
In Indian hospitals, maintaining documented personal information for each staff member is a critical aspect of human resource
management. The specific details collected and documented depend on hospital policies, whether the institution is public or
private, and legal requirements under Indian regulations such as the Employees’ Provident Fund and Miscellaneous Provisions Act,
1952, and the Shops and Establishments Act (state-specific).
Categories of Personal Information Documented
Hospitals in India, whether public or private maintain a structured employee database, often in physical files and increasingly in
digital HR systems. The following categories of personal information are commonly documented for each staff member, including
doctors, nurses, administrative staff, and support personnel:
1. Basic Personal Details
- Full Name: Legal name as per government-issued identification.
- Date of Birth: Verified through documents like birth certificates or Aadhaar cards.
- Gender: For record-keeping and compliance with policies like maternity benefits.
- Marital Status: Relevant for benefits like family health insurance or leave entitlements.
- Contact Information:
- Permanent and current address (with proof, e.g., Aadhaar, voter ID).
- Phone number(s) and email address for communication.
- Emergency Contact: Name, relationship, and contact details of a designated person.
- Photograph: Passport-sized photo for identification and employee ID cards.
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2. Identification Documents
- Aadhaar Number: Used for KYC (Know Your Customer) compliance and linking to benefits like provident fund accounts.
- PAN (Permanent Account Number): Required for tax deductions and salary processing.
- Passport Details (if applicable): For employees who may travel for work or training.
- Voter ID or Driving License: Additional ID proof, often collected for verification.
- Professional Registration Numbers: For medical staff, e.g., National Medical Commission (NMC) registration for doctors,
or Indian Nursing Council (INC) registration for nurses.
3. Employment Details
- Employee ID: Unique identifier assigned by the hospital.
- Date of Joining: Start date of employment.
- Department and Designation: E.g., Cardiology (department), Consultant Cardiologist (designation).
- Employment Type: Permanent, contractual, temporary, or part-time.
- Salary Details:
- Basic pay, allowances (e.g., dearness allowance, house rent allowance), and deductions (e.g., provident fund, income
tax).
- Bank account details for salary transfers.
- Work Schedule: Shift details, especially for staff like nurses or technicians working in 24/7 hospital environments.
- Contract/Agreement: Copy of the employment contract or appointment letter outlining terms and conditions.
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4. Educational and Professional Qualifications
- Academic Certificates: Degrees, diplomas, or certificates (e.g., MBBS, MD, B.Sc. Nursing), attested or verified.
- Professional Licenses/Certifications: For medical staff, proof of valid registration with regulatory bodies like NMC or INC.
- Training Records: Certificates from in-house or external training programs (e.g., BLS/ACLS certification, infection control
training).
- Work Experience: Letters or certificates from previous employers, detailing roles and tenure.
- Specializations: For doctors or nurses, details of specialized training or expertise (e.g., oncology, critical care).
5. Statutory and Compliance Records
- Provident Fund (PF) Details: Employee’s PF account number and Universal Account Number (UAN) for contributions
under the Employees’ Provident Fund Organisation (EPFO).
- Employees’ State Insurance (ESI): ESI number for employees eligible under the Employees’ State Insurance Act, 1948,
typically for lower-wage staff.
- Tax Details: Form 16 (for income tax), TDS deductions, and declarations for tax-saving investments.
- Gratuity Nomination: Details of nominee(s) for gratuity benefits under the Payment of Gratuity Act, 1972.
- Health Records:
- Pre-employment medical check-up reports to ensure fitness for hospital work.
- Vaccination records (e.g., Hepatitis B, COVID-19), critical for healthcare workers.
- Background Verification: Results of criminal background checks or reference checks, especially for sensitive roles.
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6. Performance and Disciplinary Records
- Performance Appraisals: Annual or periodic reviews documenting performance ratings, feedback, and promotion
eligibility.
- Training and Development: Records of completed training programs or continuing medical education (CME) credits.
- Disciplinary Actions: Documentation of warnings, suspensions, or inquiries related to misconduct or policy violations.
- Grievance Records: Details of any grievances filed by or against the employee, including outcomes.
7. Leave and Attendance Records
- Leave Entitlements: Records of earned leave, casual leave, sick leave, maternity/paternity leave, or other applicable
leave types.
- Attendance Logs: Daily or monthly attendance data, often tracked via biometric systems or HR software.
- Absenteeism or Lateness: Records of unauthorized absences or tardiness, which may feed into disciplinary processes.
8. Benefits and Insurance
- Health Insurance: Details of group health insurance plans provided by the hospital, including coverage for dependents.
- Life Insurance: If offered, details of policies or accidental death benefits.
- Other Benefits: Records of perks like housing, transport allowances, or subsidized meals.
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9. Termination or Resignation Details
- Resignation Letter: If applicable, a copy of the employee’s resignation and acceptance by the hospital.
- Exit Interview: Notes or forms from exit interviews, capturing reasons for leaving.
- Clearance Records: Confirmation of return of hospital property (e.g., ID cards, equipment) and settlement
of dues (e.g., pending salary, gratuity).
- Relieving Letter: Issued upon termination or resignation, confirming the employee’s tenure and conduct.
10. Miscellaneous
- Nominee Details: For benefits like PF, gratuity, or insurance, including name, relationship, and contact
information.
- Language Proficiency: Useful for patient-facing roles, especially in multilingual regions.
- Confidentiality Agreements: Signed agreements to protect patient data and hospital information, critical
under laws like the Information Technology Act, 2000.
- Union Membership: If applicable, details of membership in employee unions, common in public hospitals.
Dr. J. L. Meena

Storage and Management of Personal Information
- Physical Records: Traditionally, hospitals maintain physical files for each employee, stored securely
in HR departments. These include hard copies of documents like certificates, contracts, and notices.
- Digital Records: Modern hospitals, especially private chains, use HR management systems (e.g.,
SAP SuccessFactors, NotchHR, or custom software) to digitize records. These systems ensure easy
access, updates, and compliance with data protection requirements.
- Data Privacy: Hospitals must comply with the **Digital Personal Data Protection Act, 2023 (DPDP
Act)**, which mandates secure storage, consent for data collection, and protection against
breaches. Employee data is considered sensitive, especially medical records or financial details.
- Access Control: Only authorized personnel (e.g., HR staff, department heads) can access employee
records. Access is restricted to protect confidentiality and prevent misuse.
- Retention Period: Records are retained as per legal requirements (e.g., PF records for the
employee’s service duration, tax records for 7 years) or hospital policy, even after an employee
leaves.
Dr. J. L. Meena

Legal and Regulatory Compliance
Hospitals in India must ensure that their documentation practices align with:
- Labor Laws: Including the Industrial Disputes Act, 1947, Minimum Wages Act, 1948, and
state-specific Shops and Establishments Acts, which mandate maintaining records like
employment contracts and wage registers.
- Statutory Benefits: Compliance with EPFO, ESI, and gratuity laws requires accurate
documentation of PF/ESI contributions and nominee details.
- Professional Regulations: For medical staff, hospitals verify and document NMC/INC
registrations to ensure compliance with the National Medical Commission Act, 2019, or
Indian Nursing Council guidelines.
- Data Protection: The DPDP Act, 2023, requires hospitals to obtain employee consent for
data collection, secure storage, and notify employees of data usage purposes.
Dr. J. L. Meena

Challenges and Best Practices
Challenges:
- Incomplete documentation, especially in smaller hospitals, can lead to legal disputes or
compliance issues.
- Data breaches or mismanagement of sensitive information (e.g., Aadhaar, medical records) pose
risks under the DPDP Act.
- High staff turnover in hospitals complicates record updates and retention.
Best Practices:
- Implement robust HR software for centralized, secure data management.
- Conduct regular audits to ensure compliance with labor and data protection laws.
- Train HR staff on data privacy and legal requirements.
- Use standardized templates for collecting and storing employee information to ensure
consistency.
- Communicate data usage policies to employees, ensuring transparency and consent.
Dr. J. L. Meena

The process for credentialing and
privileging
Credentialing Process
Credentialing is the process of verifying a healthcare provider’s qualifications, education, training, licensure, and
professional background to ensure they meet the standards required to practice in a hospital.
Steps in Credentialing:
1. Application Submission:
- The healthcare provider (e.g., physician, surgeon, or allied health professional) submits a formal application to the
hospital’s Medical Staff Office (MSO) or Credentialing Verification Office (CVO).
- Required documents typically include:
- Medical degree certificates (MBBS, MD, MS, or equivalent).
- Postgraduate qualifications (if applicable).
- Valid registration with the Medical Council of India (MCI) or State Medical Council (SMC).
- Current medical license.
- Curriculum Vitae (CV) detailing education, training, and work experience.
- Certificates of residency, fellowships, or specialized training.
- Professional liability insurance (if applicable).
- Government-issued identification (e.g., Aadhaar, PAN card).
- Letters of recommendation or references from peers or previous employers.
- Disclosure of any past or pending malpractice claims, disciplinary actions, or license suspensions.
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privileging
2. Primary Source Verification (PSV):
- The hospital or a designated Credentials Verification Organization (CVO) verifies the authenticity of the submitted
documents by contacting primary sources, such as:
- Medical schools and universities for educational qualifications.
- NMC/SMC for licensure and registration status.
- Previous employers or hospitals for work history and performance.
- Specialty boards for certifications (e.g., National Board of Examinations for DNB).
- Background checks are conducted to screen for criminal records, professional misconduct, or sanctions by regulatory
bodies like the National Medical Commission (NMC, which replaced MCI in 2020).
- The hospital may also check the National Practitioner Data Bank (if applicable) or equivalent systems for any adverse
reports.
3. Review by Credentialing Committee:
- A credentialing committee, typically comprising senior medical staff, department heads, and administrative
representatives, reviews the verified application.
- The committee assesses the provider’s qualifications, experience, and competence to ensure they meet the hospital’s
standards and bylaws.
- If the application is incomplete or discrepancies are found, the committee may request additional information or
clarification within a specified timeframe. Failure to provide this may result in the application being withdrawn.
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privileging
4. Approval or Denial:
- Upon satisfactory review, the credentialing committee recommends the provider for medical
staff membership to the hospital’s governing body (e.g., Board of Trustees or Governing Board).
- The governing body makes the final decision to approve or deny the application.
- Denials may occur due to incomplete documentation, failure to meet eligibility criteria, or
concerns about past performance or conduct. Denials at this stage may be reportable events
and could impact the provider’s professional record.
5. Ongoing Monitoring and Recredentialing:
- Credentialing is not a one-time process. Providers undergo recredentialing every 1–2 years
(as per hospital policy or NABH guidelines) to ensure continued competence and compliance.
- Recredentialing involves updating documentation, verifying current licensure, and reviewing
performance metrics, such as patient outcomes and peer reviews.
Dr. J. L. Meena

privileging
Privileging Process
Privileging authorizes a credentialed healthcare provider to perform specific clinical procedures or services within the hospital
based on their training, experience, and demonstrated competence. It defines the scope of practice for the provider within the
facility.
Steps in Privileging:
1. Privilege Delineation Request:
- After credentialing, the provider submits a privilege delineation form, specifying the clinical procedures or services they seek to
perform (e.g., general surgery, cardiac catheterization, or endoscopy).
- The request is tailored to the provider’s specialty and the hospital’s capabilities (e.g., availability of equipment, support staff, or
ICU facilities).
2. Evaluation of Competence:
- The hospital’s medical staff or a privileging committee evaluates the provider’s qualifications and competence for the
requested privileges. This may involve:
- Reviewing training certificates or fellowship records.
- Assessing prior experience (e.g., case logs or procedure volumes).
- Conducting peer reviews or obtaining references from colleagues familiar with the provider’s clinical skills.
- Proctoring or shadowing for new or high-risk procedures, especially for providers trained abroad or those seeking specialized
privileges.
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privileging
3. Types of Privileges:
- Active/Admitting Privileges: Allow providers to admit and manage patients in the hospital as primary caregivers (e.g.,
internists, pediatricians).
- Courtesy Privileges: Permit limited patient admissions or consultations, often for providers who primarily practice
elsewhere.
- Surgical Privileges: Authorize specific surgical procedures, such as laparoscopic surgery or neurosurgery, based on
training and expertise.
- Temporary Privileges: Granted in emergencies or for locum tenens providers, subject to abbreviated verification
processes.
- Telemedicine Privileges: For providers offering remote services, often facilitated through credentialing by proxy, where
a distant site’s credentialing decisions are accepted under a formal agreement.
4. Approval Process:
- The privileging committee reviews the request and recommends approval, modification, or denial of specific privileges.
- The hospital’s governing body grants final approval, ensuring alignment with medical staff bylaws and NABH standards.
- Privileges are granted for a defined period (typically 1–2 years) and are subject to renewal through re-privileging.
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privileging
5. Focused Professional Practice Evaluation (FPPE):
- Initial privileges are often subject to a probationary period during which the provider’s performance is
monitored through:
- Direct observation or proctoring by senior staff.
- Review of patient outcomes, complication rates, or procedure success.
- Feedback from peers and support staff.
- FPPE ensures that the provider demonstrates competence in the granted privileges.
6. Ongoing Professional Practice Evaluation (OPPE):
- Hospitals conduct regular evaluations (e.g., every 6–12 months) to monitor the provider’s performance,
including:
- Clinical outcomes (e.g., mortality rates, infection rates).
- Adherence to hospital protocols and quality standards.
- Participation in continuing medical education (CME).
- OPPE data informs decisions about privilege renewal or modification.
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privileging
Regulatory and Accreditation Framework in India
- National Medical Commission (NMC): The NMC regulates medical education and licensure in India,
ensuring that providers maintain valid registration and adhere to ethical standards.
- NABH Standards: NABH accreditation, mandatory for many hospitals, outlines specific
requirements for credentialing and privileging, including:
- Standardized processes for verifying qualifications and competence.
- Clear delineation of privileges based on training and hospital resources.
- Regular monitoring through FPPE and OPPE.
- Compliance with medical staff bylaws.
- Hospital Bylaws: Each hospital has medical staff bylaws that define eligibility criteria, credentialing
procedures, privileging categories, and due process for disputes or denials.
- Legal Compliance: Hospitals must comply with state health regulations, labor laws, and insurance
requirements (e.g., for professional indemnity). Failure to properly credential or privilege providers
can lead to negligent credentialing lawsuits or loss of accreditation.
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privileging
Challenges and Considerations
- Time-Consuming Process: Credentialing and privileging can take 2–6 months due to extensive
verification and committee reviews, causing delays in onboarding providers.
- Incomplete Applications: Missing or outdated documents are a common cause of delays. Providers
are advised to maintain updated records with platforms like the Council for Affordable Quality
Healthcare (CAQH) or NMC portals.
- State Variations: Licensing and privileging requirements may differ across states, requiring
providers to comply with local regulations.
- Telemedicine: Credentialing by proxy is increasingly used for telehealth providers, but it requires
formal agreements and oversight to ensure compliance with CMS or NABH standards.
- Foreign-Trained Providers: Providers trained abroad may require additional verification by the
NMC and proctoring to align with Indian standards.
- Disputes: Privilege denials or revocations can lead to legal challenges. Hospitals must ensure fair,
transparent processes and provide due process as per bylaws.
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privileging
Best Practices for Providers
- Prepare Documentation: Maintain a comprehensive portfolio of qualifications, licenses, and certifications,
and ensure they are up-to-date.
- Understand Bylaws: Review the hospital’s medical staff bylaws to confirm eligibility and required privileges
before applying.
- Engage Early: Contact the hospital’s MSO or CVO early to understand specific requirements and timelines.
- Consult Legal Experts: If there are concerns about past malpractice claims, disciplinary actions, or application
complexities, seek advice from a healthcare attorney.
- Participate in Committees: Serving on hospital credentialing or privileging committees can help providers
advocate for fair processes and stay informed about standards.
Role of Technology
- Many Indian hospitals use electronic credentialing systems (e.g., NABH-compliant software or platforms like
Credential Stream) to streamline document management, verification, and monitoring.
- Automation reduces errors, speeds up processing, and ensures compliance with regulatory standards.
- Telemedicine platforms may integrate credentialing by proxy to facilitate faster onboarding of remote
providers.
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privileging
Conclusion
The credentialing and privileging process in Indian hospitals is a rigorous,
multi-step procedure designed to safeguard patient safety and ensure high-
quality care. It involves thorough verification of qualifications (credentialing)
and authorization of specific clinical roles (privileging), guided by hospital
bylaws, NABH standards, and NMC regulations. While the process can be
complex and time-intensive, adherence to standardized protocols, use of
technology, and proactive preparation by providers can enhance efficiency and
compliance. For detailed guidance, providers should refer to hospital-specific
bylaws or consult with the hospital’s MSO or a healthcare attorney familiar
with Indian regulations.
Dr. J. L. Meena

Human Resource Management (HRM)
➢ The most important resource of the organisation is its human resource. Human resources are an asset for the effective and efficient
functioning of the organisation.
➢ The management plans on identifying the right number and skill mix of staff required to render safe care to the
patients.
➢ Recruitment of staff is accomplished by having a uniform and standardised system.
➢ The organisation must orient the staff including outsourced staff, volunteers, students and trainees to its environment and also orient them
to specific duties and responsibilities related to their position.
➢ The organisation should plan to have an ongoing professional training/in-service education to enhance the
competencies and skills of the staff continually.
➢ A systematic and structured appraisal system must be used for staff development.
➢ The organisation uses this as an opportunity to discuss, motivate, identify gaps in the performance of the staff.
➢ The organisation promotes the physical and mental well-being of staff. A grievance handling mechanism and disciplinary
procedure should be in place.
➢ Credentialing and privileging of health-care professionals (medical, nursing and other para-clinical professional) are done to ensure patient
safety.
➢ A document containing all such personal information has to be maintained for all staff.
Note:- The term “employee” refers to all salaried personnel working in the organisation. The term “staff’ refers to all personnel working in the
organisation including employees, “fee for services” medical professionals, part time works, contractual personnel and volunteers.
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Summary of standards
HRM.1. The organisation has a documented system of human resource planning.
HRM.2. The organisation implements a defined process for staff recruitment.
HRM.3. Staff are provided induction training at the time of joining the organisation.
HRM.4. There is an on-going programme for professional training and development of the staff.
HRM.5. Staff are appropriately trained based on their specific job description.
HRM.6. Staff are trained in safety and quality-related aspects.
HRM.7. An appraisal system for evaluating the performance of staff exists as an integral part of the human resource management process.
HRM.8. Process for disciplinary and grievance handling is defined and implemented in the organisation.
HRM.9. The organisation addresses their health and safety needs of staff.
HRM.10. There is documented personal information for each staff member.
HRM.11. There is a process for credentialing and privileging of medical professionals, permitted to provide patient care without supervision.
HRM.12. There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision.
HRM.13.
There is a process for credentialing and privileging of para-clinical professionals, permitted to provide patient care without
supervision.
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Objective
Elements
HRM 1 HRM 2 HRM 3 HRM 4 HRM 5 HRM 6 HRM 7 HRM 8 HRM 9 HRM 10 HRM 11 HRM 12 HRM 13
a Commitment CORE CORE CORE Commitment Commitment Commitment Commitment Commitment Commitment CORE CORE CORE
b CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment
c Achievement CORE Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment Commitment CORE
d Commitment Commitment Commitment Commitment Commitment Commitment Commitment CORE CORE Commitment CORE CORE Commitment
e Commitment Commitment Achievement CORE CORE Commitment Commitment Commitment Commitment Commitment
f Commitment Commitment Achievement Commitment CORE Commitment Commitment Commitment
g Achievement Commitment Commitment
h Commitment
i Commitment
j Commitment
Summary Standards 13 OE 76 CORE 16
Commitment
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Achievement
4 Excellence 0

HRM 1 - The organisation has a documented
system of human resource planning.
Objective Elements
d) Human resource planning supports the organisation's current and future ability to
meet the care, treatment and service needs of the patient.
e) The organisation maintains an adequate number and mix of staff to meet the care,
treatment and service needs of the patient.
f) The organisation has contingency plans to manage long- and short-term workforce
shortages, including unplanned shortages.
d) The job specification and job description are defined for each category of staff. *
e) The organisation performs a background check of new staff.
f) Reporting relationships are defined for each category of staff. *
g) Exit interviews are conducted and used as a tool to improve human resource
practices.
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HRM 2 The organisation implements a defined
process for staff recruitment.
Objective Elements
a) Written guidance governs the process of recruitment. *
b) A pre-employment medical examination is conducted on
the staff.
c) The organisation defines and implements a code of
conduct for its staff.
d) Administrative procedures for human resource
management are documented .*
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HRM 3 - Staff are provided induction training at
the time of joining the organisation.
Objective Elements
a) Staff are provided with induction training.
b) The induction training includes orientation to the organisation's vision, mission and values.
c) The induction training includes awareness on staff rights and responsibilities and patient rights and
responsibilities.
d) The induction training includes training on safety.
e) The induction training includes training on cardio-pulmonary resuscitation for staff.
f) The induction training includes training in hospital infection prevention and control.
g) The induction training includes orientation to the service standards of the organisation.
h) The induction training includes an orientation on administrative procedures.
i) The induction training includes an orientation on relevant department/unit/
service/programme's policies and procedures.
j) Staff is trained on information systems, information security, information use and management.
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HRM 4 - There is an on-going programme for
professional training and development of the staff.
Objective Elements
a) Written guidance governs training and development policy for the
staff.*
b) The organisation maintains the training record.
c) Training also occurs when job responsibilities change/new equipment
is introduced.
d) Feedback mechanisms are in place for improvement of training and
development programme.
e) Evaluation of training effectiveness is done by the organisation.
f) The organisation supports continuing professional development and
learning.
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HRM 5 - Staff are appropriately trained based on
their specific job description.
Objective Elements
a) Staff involved in blood transfusion services are trained on the
handling of blood and blood products.
b) Staff are trained in handling vulnerable patients.
c) Staff are trained in control and restraint techniques.
d) Staff are trained in healthcare communication techniques.
e) Staff involved in direct patient care are provided training on
cardiopulmonary resuscitation periodically.
f) Staff are provided training on infection prevention and control.
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HRM 6 - Staff are trained in safety and quality-
related aspects.
Objective Elements
a) Staff are trained on the organisation's safety programme.
b)Staff are provided training on the detection, handling, minimisation and
elimination of identified risks within the organisation's environment.
c) Staff members are made aware of procedures to follow in the event of an
incident.
d)Staff are trained in occupational safety aspects.
e) Staff are trained in the organisation's disaster management plan.
f) Staff are trained in handling fire and non-fire emergencies.
g) Staff are trained on the organisation's quality improvement programme
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HRM 7 An appraisal system for evaluating the
performance of staff exists as an integral part of the
human resource management process.
Objective Elements
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a) Performance appraisal is done for staff within the organisation.*
b) The staff are made aware of the system of appraisal at the time
of induction.
c) Performance is evaluated based on the pre-determined criteria.
d) The appraisal system is used as a tool for further development.
e) Performance appraisal is carried out at defined intervals and
is documented.

HRM 8 - Process for disciplinary and grievance
handling is defined and implemented in the
organisation.
Objective Elements
a) Written guidance governs disciplinary and grievance handling mechanisms.*
b) The disciplinary and grievance handling mechanism is known to all
categories of staff of the organisation.
c) The disciplinary policy and procedure are based on the principles of natural
justice.
d) The disciplinary and grievance procedure is in consonance with the
prevailing laws.
e) There is a provision for appeals in all disciplinary cases.
f) Actions are taken to redress the grievance.
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HRM 9 - The organisation addresses their health
and safety needs of the staff.
Objective Elements
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a) Health problems of the staff, including occupational health hazards, are
taken care of in accordance with the organisation's policy.*
b) Health checks of staff dealing with direct patient care are done at least
once a year and the findings/results are documented.
c) Organisation provides treatment to staff who sustain
workplace-related injuries.
d) The organisation has measures in place for prevention and handling
e) workplace violence.*

HRM 10 - There is documented personal
information for each staff member.
Objective Elements
a)Personal files are maintained with respect to all staff, and their
confidentiality is ensured
b)The personal files contain personal information regarding the
staff's qualification, job description, verification of credentials and
health status.
c)Records of in-service training and education are maintained.
d)Personal files contain results of all evaluations and remarks.
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HRM 11 - There is a process for credentialing and
privileging of medical professionals, permitted to
provide patient care without supervision.
Objective Elements
a) Medical professionals permitted by law, regulation and the organisation to provide
patient care without supervision are identified.
b) The education, registration, training and experience of the identified medical
professionals are documented and updated periodically.
c) The information about medical professionals is appropriately verified when possible.
d) Medical professionals are granted privileges to admit and care for patients in consonance
with their qualification, training, experience and registration.
e) The requisite services to be provided by the medical professionals are known to them as
well as the various departments/units of the organisation.
f) Medical professionals admit and care for patients as per their privileging.
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privileging of nursing professionals, permitted to provide
patient care without supervision
Objective Elements
a) Nursing staff permitted by law, regulation and the organisation to provide patient care
without supervision are identified.
b) The education, registration, training and experience of nursing staff are appropriately
verified, documented and updated periodically.
c) The information about the nursing staff is appropriately verified when possible.
d) Nursing staff are granted privileges in consonance with their qualification, training,
experience and registration.
e) The requisite services to be provided by the nursing staff are known to them as well as
the various departments/units of the organisation.
f) Nursing professionals care for patients as per their privileging.
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privileging of para-clinical professionals, permitted
to provide patient care without supervision.
Objective Elements
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a) Para-clinical professionals permitted by law, regulation and the organisation to
provide patient care without supervision are identified.
b) The education, registration, training and experience of para clinical
professionals are appropriately verified, documented and updated periodically.
c) Para-clinical professionals are granted privileges in consonance with their
qualification, training, experience and registration.
d) The requisite services to be provided by the para-clinical professionals are
known to them as well as the various departments/units of the organisation.
e) Para-clinical professionals care for patients as per their privileging.

Summary
Human Resource Management (HRM) is critical for delivering quality healthcare services.
Effective HRM ensures a skilled, motivated, and patient-focused workforce, directly
impacting care quality and safety. Strategic HR planning aligns staffing with patient needs,
while rigorous recruitment and credentialing guarantee competent professionals.
Continuous training, including job-specific and safety programs, keeps staff updated on
best practices, enhancing clinical outcomes. Performance appraisals identify skill gaps,
fostering professional growth and accountability. Well-defined disciplinary and grievance
processes maintain a fair work environment, boosting morale. Prioritizing staff well-being
reduces burnout, ensuring consistent care delivery. Comprehensive documentation and
training on information systems support operational efficiency and data-driven care. By
fostering a culture of quality and safety, HRM enables healthcare organizations to meet
patient expectations, comply with global standards, and achieve accreditation, ultimately
improving patient satisfaction, trust, and health outcomes.
Dr. J. L. Meena

Healthcare facilities in India must address the
diverse information needs of patients, visitors,
staff, management, and external agencies
1. Patients:- Patients require clear, accessible, and timely information to make informed decisions about their care and navigate healthcare
facilities.
Information Needs:
- Medical Information: Diagnosis, treatment options, procedures, costs, and expected outcomes.
- Logistical Information: Appointment scheduling, hospital navigation, visiting hours, and accommodation options (especially for medical
tourists or rural patients).
- Cultural and Linguistic Needs: Information in regional languages or through interpreters for non-English/Hindi speakers.
- Financial Transparency: Cost estimates, insurance coverage, and government scheme details (e.g., Ayushman Bharat).
How Needs Are Met:
- Digital Tools: Many hospitals, provide patient portals and mobile apps for appointment booking, accessing medical records, and
teleconsultations. Government hospitals are increasingly adopting eHospital Management Software for patient registration and records.
- Multilingual Support: JCI- and NABH-accredited hospitals offer interpreters for languages like Arabic, Russian, and regional Indian
languages to cater to international and diverse domestic patients.
- Financial Counseling: Hospitals provide detailed cost estimates and assist with insurance or government scheme navigation. Ayushman
Bharat’s PM-JAY offers cashless treatment information at empaneled hospitals.
- Navigation Aids: Indoor navigation apps and signage in larger hospitals help patients locate departments, though rural facilities often lack
such systems.
Challenges: Public hospitals face resource constraints, leading to limited digital infrastructure and long wait times for information. Rural
patients may struggle with low digital literacy or language barriers.
Dr. J. L. Meena

2. Visitors:- Visitors, including family members and attendants, need information to support patients and comply with
hospital protocols.
Information Needs:
- Visiting Policies: Hours, restrictions, and badge requirements.
- Patient Updates: Status updates on patient condition or surgery progress.
- Facility Navigation: Directions to wards, cafeterias, or pharmacies.
- Safety Protocols: Infection control measures, especially post-COVID.
How Needs Are Met:
- Visitor Management Systems (VMS): Digital VMS in some hospitals use QR codes, e-passes, and contactless check-ins
to streamline entry, issue badges, and track visitor movements. These systems also screen for health risks like fever.
- Information Desks: Most hospitals have help desks to guide visitors, though staffing shortages in public facilities can
limit effectiveness.
- Real-Time Notifications: Advanced VMS notify staff of visitor arrivals, reducing wait times and ensuring compliance
with restricted areas.
Challenges: Adoption of digital VMS is low in rural and smaller hospitals, where paper-based logs persist, compromising
security and efficiency. Visitors in public hospitals often face unclear signage and overcrowding, increasing stress.
Dr. J. L. Meena

3. Staff:- Doctors, nurses, and support staff need accurate, real-time information to deliver care and manage operations.
Information Needs:
- Clinical Data: Access to patient records, test results, and treatment plans.
- Operational Data: Staff schedules, equipment availability, and patient flow.
- Safety and Compliance: Infection control protocols, emergency procedures, and visitor management data.
- Training and Updates: Continuous medical education (CME) and policy changes.
How Needs Are Met:
- Hospital Information Systems (HIS): Hospitals use HIS like eHospital or custom software to centralize patient data, staff
schedules, and asset tracking. Tele-ICU software aids remote patient monitoring.
- Asset Tracking: Real-time location systems (RTLS) in advanced facilities track equipment, saving time for staff.
- Training Programs: National Medical Commission mandates CME for doctors, and NABH accreditation ensures staff
training on infection control and safety.
- Visitor Management Integration: VMS provide staff with visitor data, flagging restricted individuals or overcrowding in
patient rooms.
Challenges: Public hospitals often lack integrated HIS, relying on manual records, which delays care. Staff in rural areas
may have limited access to digital tools or training.
Dr. J. L. Meena

4. Management:- Hospital administrators and management require data to optimize operations, ensure compliance, and
enhance patient satisfaction.
Information Needs:
- Operational Metrics: Bed occupancy, patient throughput, and resource utilization.
- Financial Data: Billing, insurance claims, and cost management.
- Compliance and Accreditation: Adherence to NABH, JCI, and government regulations.
- Security and Risk Management: Visitor logs, incident reports, and emergency preparedness.
How Needs Are Met:
- Centralized Dashboards: HIS and VMS provide real-time analytics on patient flow, visitor traffic, and resource use. For
example, geospatial intelligence software optimizes ambulance routing.
- Accreditation Support: NABH and JCI-accredited hospitals use standardized data systems to meet quality and safety
benchmarks.
- Government Initiatives: The 2017 district hospital performance tracking system ranks public hospitals based on resource
availability and patient satisfaction, aiding management decisions.
- Security Systems: Advanced VMS with CCTV integration and blacklisting features help manage risks, as seen in facilities.
Challenges: Smaller hospitals lack funds for advanced analytics tools, and public facilities struggle with bureaucratic delays
in implementing centralized systems.
Dr. J. L. Meena

5. External Agencies:- External agencies, such as government bodies, insurance providers, and accreditation organizations,
require data for oversight, funding, and quality assurance.
Information Needs:
- Regulatory Compliance: Data on patient safety, infection rates, and infrastructure (e.g., WASH facilities).
- Financial Accountability: Billing transparency and insurance claim validation.
- Public Health Monitoring: Disease surveillance and hospital performance metrics.
- Accreditation Standards: Evidence of quality care and staff qualifications.
How Needs Are Met:
- Government Reporting: Public hospitals submit data to the Ministry of Health and Family Welfare via centralized systems.
Initiatives like KAYAKALP and Swachh Swasth Sarvatra assess cleanliness and WASH compliance.
- Accreditation Bodies: NABH and JCI require hospitals to maintain detailed records on patient care, safety, and staff
training, accessible during audits.
- Insurance Integration: Private hospitals provide digital billing and claim data to insurers, supported by Ayushman Bharat’s
cashless treatment framework.
- Public Health Data: Hospitals report infectious disease cases to state health departments, though manual reporting in
rural areas can cause delays.
Challenges: Inconsistent data standards across hospitals hinder national-level monitoring. Rural facilities often lack the
infrastructure to provide timely data to external agencies. Dr. J. L. Meena

Hospital data management and
control processes in India
Hospital data management and control processes in India are critical for ensuring efficient healthcare delivery, regulatory
compliance, and patient data security. Below is an overview of typical processes and systems hospitals in India employ,
based on industry practices and available information:
1. Hospital Management Systems (HMS)
Hospitals in India widely adopt Hospital Management Systems (HMS) or Hospital Information Systems (HIS) to streamline
data management. These systems integrate various hospital functions, including:
- Patient Data Management: Centralized storage of electronic medical records (EMRs) or electronic health records (EHRs)
for patient demographics, medical history, diagnoses, treatments, and test results. Modules manage patient registration,
appointment scheduling, and billing.
- Administrative Processes: Automation of billing, invoicing, claims processing, and financial analytics to reduce errors and
optimize revenue cycles.
- Clinical Operations: Support for laboratory management, pharmacy, radiology, and operation theater scheduling to
ensure seamless data flow across departments.
- Inventory Management: Tracking medical supplies, equipment, and medications to prevent shortages or overstocking,
often using barcode or RFID technologies.
Examples: Software like TiaNuMR, MocDoc, Healthray, and Docpulse are popular in India, offering cloud-based, HIPAA-
compliant solutions with features like telemedicine integration and mobile access.
Dr. J. L. Meena

2. Data Security and Privacy
Hospitals handle sensitive personal data, including health and financial information, necessitating robust security
measures:
- Regulatory Compliance: Adherence to the **Information Technology Act 2000**, **IT (Reasonable Security Practices and
Procedures and Sensitive Personal Data or Information) Rules 2011**, and the proposed **Digital Information Security in
Healthcare Act (DISHA)**. These laws mandate encryption, access controls, and anonymization of health data.
- HIPAA and GDPR Compliance: Many HMS platforms (e.g., TiaNuMR, MediSoft+) comply with international standards like
HIPAA for secure data storage and transfer.
- Access Controls: Role-based access controls (RBAC) ensure only authorized personnel access specific data. Audit trails and
logs track data usage to prevent breaches.
- Cloud-Based Solutions: Increasing adoption of cloud storage with replicated data centers for backup, recovery, and
scalability, ensuring data protection against breaches or loss.
3. Data Quality and Standardization
- Metadata Management: Hospitals standardize terminology for diagnoses, procedures, and clinical data to enhance data
transparency and interoperability.
- Data Validation: Multi-step processes to detect and correct errors in data entry, ensuring accuracy for clinical decisions.
- Interoperability: Integration with third-party systems (e.g., EHRs, laboratory information systems) to eliminate duplicate
data and create a single source of truth.
Dr. J. L. Meena

4. Analytics and Reporting
- Business Intelligence: HMS modules generate comprehensive reports on hospital performance,
patient outcomes, and financial metrics, enabling data-driven decisions.
- Predictive Analytics: AI and machine learning tools analyze patient data to predict health
conditions, optimize treatment plans, and reduce readmissions.
- Real-Time Data Access: Dashboards and MIS reports provide instant insights into patient traffic,
resource utilization, and operational efficiency.
5. Patient-Centric Processes
- Patient Portals: Mobile apps and web platforms allow patients to access their records, book
appointments, and make payments, reducing manual processes.
- Telemedicine Integration: HMS platforms like Docpulse support virtual consultations, e-
prescriptions, and remote patient monitoring via IoT devices.
- Reduced Wait Times: Automation of appointment scheduling, billing, and report delivery
minimizes patient wait times and enhances satisfaction.
Dr. J. L. Meena

6. Challenges and Considerations
- Resource Constraints: Limited storage space and skilled personnel for data management can hinder scalability.
- Data Breaches: Rising cyber threats necessitate regular penetration testing and vulnerability assessments.
- Regulatory Gaps: While DISHA and the Health Data Management Policy are in development, India lacks a comprehensive
data protection law, relying on IT Act provisions.
- Manual Processes: Smaller hospitals may still rely on periodic inventory systems or paper-based records, leading to
inefficiencies and errors.
7. Case Studies
- Manipal Hospitals: Implemented LeadSquared’s HMS to centralize patient data across 27 multispecialty hospitals,
improving lead management and reporting.
- Vivekananda Kendra Bina Refinery Hospital: Uses Docpulse for seamless online booking, queue management, and
vaccine reminders, enhancing patient experience.
8. Emerging Trends
- AI and IoT: Adoption of AI for predictive modeling and IoT for remote monitoring to enhance proactive care.
- Blockchain: Emerging use for secure, transparent health data management to ensure traceability and privacy.
- Digital Twins: Virtual simulations of hospital processes for training and AI validation without disrupting EMR systems.
Dr. J. L. Meena

Conclusion
Hospitals in India leverage HMS platforms to manage and control
data, focusing on automation, security, and analytics to improve
patient care and operational efficiency. However, challenges like
regulatory gaps and resource limitations persist, particularly for
smaller facilities. Adopting scalable, cloud-based solutions and
adhering to evolving data protection laws are critical for robust data
management. For specific hospital processes, further details on the
organization’s size, software, or compliance needs would help tailor
the response.
Dr. J. L. Meena

Checklist to ensure a medical record provides a
complete, chronological account of patient care
1. Patient Identification:
- Full name, date of birth, medical record number, and contact information.
- Emergency contact details.
2. Demographic Information:
- Age, gender, ethnicity, and occupation.
- Insurance information (if applicable).
3. Medical History:
- Past medical conditions, surgeries, and hospitalizations.
- Family medical history.
- Allergies (medications, food, environmental).
- Immunization records.
4. Medication History:
- Current and past medications (name, dosage, frequency, duration).
- Any adverse reactions or side effects.
Dr. J. L. Meena

5. Chronological Visit Documentation:
- Date and time of each visit or encounter.
- Reason for visit (chief complaint).
- Vital signs (e.g., blood pressure, heart rate, temperature).
- Physical examination findings.
- Diagnostic test results (e.g., labs, imaging, EKGs).
6. Diagnosis and Treatment Plan:
- Primary and secondary diagnoses.
- Treatment plans, including medications, therapies, or procedures.
- Referrals to specialists or other healthcare providers.
7. Progress Notes:
- Detailed notes from each encounter (e.g., SOAP notes: Subjective, Objective, Assessment, Plan).
- Updates on patient condition, response to treatment, and changes in plan.
8. Procedures and Surgeries:
- Date, type, and outcome of procedures or surgeries.
- Operative reports, anesthesia records, and post-procedure notes.
Dr. J. L. Meena

9. Correspondence and Consultations:
- Letters or reports from consulting physicians or specialists.
- Communication with other healthcare providers (e.g., discharge summaries, transfer notes).
10. Patient Education and Consent:
- Documentation of informed consent for treatments or procedures.
- Instructions provided to the patient (e.g., discharge instructions, lifestyle recommendations).
11. Follow-Up and Continuity of Care:
- Scheduled follow-up appointments.
- Care coordination notes (e.g., home health, rehabilitation).
- Documentation of missed or canceled appointments.
12. Legal and Administrative Documentation:
- Advance directives, power of attorney, or living will.
- Incident reports (e.g., falls, medication errors).
- Privacy and confidentiality compliance (e.g., HIPAA acknowledgment).
Dr. J. L. Meena

13. Timeliness and Accuracy:
- Entries are dated, signed, and timed by the provider.
- Corrections are clearly marked (no overwriting or deleting).
- Use of standardized terminology and abbreviations.
14. Accessibility and Organization:
- Records are stored securely and accessible to authorized personnel.
- Chronological order is maintained (e.g., most recent entries are easily identifiable).
- Electronic health records (EHRs) are backed up and interoperable if applicable.
15. Compliance with Regulations:
- Adheres to local, state, and federal regulations (e.g., HIPAA, CMS).
- Meets standards set by accrediting bodies (e.g., Joint Commission).
“This checklist ensures the medical record is comprehensive, organized, and compliant, providing a clear
timeline of patient care.”
Dr. J. L. Meena

Key Points of Health Information
Management Systems (HIMS)
1. Data Management and Organization:
- HIMS centralizes patient data, including medical histories, diagnoses, treatments, and test results, in electronic health
records (EHRs) or electronic medical records (EMRs). This streamlines data collection, storage, and retrieval, reducing
reliance on paper-based records.
- It supports various data types, such as clinical, financial, demographic, and epidemiological, enabling comprehensive
management across hospital operations.
2. Operational Efficiency:
- Automates administrative tasks like appointment scheduling, billing, and inventory management, minimizing manual
errors and saving time for healthcare staff.
- Facilitates real-time communication and coordination among departments, improving workflow and resource allocation.
3. Data Security and Compliance:
- Ensures patient data privacy through encryption, access controls, and compliance with regulations like HIPAA and GDPR.
- Maintains audit trails and standardized coding (e.g., ICD-10, CPT) for accurate billing and regulatory adherence.
4. Enhanced Patient Care:
- Provides quick access to accurate patient information, enabling informed clinical decisions and reducing medical errors.
- Supports features like e-prescribing and patient engagement tools, improving medication safety and patient experience.
Dr. J. L. Meena

5. Analytics and Decision Support:
- Generates actionable insights through data analytics, tracking key performance indicators (KPIs) like patient
outcomes and resource utilization.
- Supports population health management, disease surveillance, and evidence-based research by analyzing
trends and patterns.
6. Interoperability:
- Integrates with other healthcare systems (e.g., laboratory, pharmacy, and billing systems), ensuring
seamless data sharing across providers and facilities.
- Enhances care continuity, especially in telemedicine and multi-facility settings.
Importance of HIMS
1. Improved Patient Outcomes:
- HIMS ensures timely access to complete and accurate patient data, reducing miscommunication and errors
(e.g., medication errors reduced by 50-80%). This leads to better diagnoses, treatments, and patient safety.
Dr. J. L. Meena

2. Cost and Time Efficiency:
- By automating processes, HIMS reduces administrative costs, paper usage, and operational inefficiencies. It
also optimizes revenue cycle management by minimizing billing errors and claim denials.
- Studies show HIMS can improve staff performance by up to 81.85% when strategically implemented.
3. Regulatory Compliance and Data Security:
- HIMS helps healthcare facilities adhere to strict data privacy laws, avoiding penalties and building patient
trust. Robust security measures protect against cyber threats, critical in an era where healthcare data breaches
are common.
4. Support for Evidence-Based Practice:
- Aggregated data from HIMS enables research, trend analysis, and policy development, contributing to
advancements in treatments and public health strategies.
5. Scalability and Adaptability:
- HIMS supports hospitals of all sizes, from small clinics to large networks, and integrates emerging
technologies like AI, machine learning, and blockchain to enhance functionality (e.g., reducing readmission
rates by 20%). Dr. J. L. Meena

6. Global Health Transformation:
- HIMS fosters interoperability and digital transformation, aligning with
initiatives like India’s Ayushman Bharat Digital Mission. It supports
telemedicine and unified EMR systems, improving access to care in
underserved areas.
Conclusion
HIMS is a cornerstone of modern healthcare, integrating technology to enhance
patient care, operational efficiency, and data security. Its ability to streamline
processes, ensure compliance, and provide data-driven insights makes it
indispensable for healthcare facilities aiming to deliver high-quality, equitable
care while staying competitive in a rapidly evolving industry.
Dr. J. L. Meena

Importance of the complete and
accurate medical record.
1. Improved Patient Safety and Care Quality: Accurate records ensure healthcare providers have full visibility
into a patient’s medical history, allergies, medications, and prior treatments, reducing errors like misdiagnoses
or harmful drug interactions. For example, knowing a patient’s penicillin allergy prevents prescribing errors.
2. Effective Care Coordination: Comprehensive records enable seamless communication among providers,
especially in multidisciplinary or referral-based care. This ensures continuity, prevents redundant tests, and
supports informed decision-making.
3. Legal and Regulatory Compliance: Accurate records are essential for meeting standards set by bodies like
HIPAA (U.S.), GDPR (EU), or local health authorities. Incomplete or erroneous records risk legal penalties,
audits, or loss of accreditation.
4. Billing and Reimbursement Accuracy: Precise documentation supports correct coding and billing, reducing
claim denials and ensuring financial sustainability for the organization.
5. Data-Driven Insights: Complete records fuel analytics for population health management, research, and
quality improvement initiatives, helping organizations identify trends and optimize care delivery.
Dr. J. L. Meena

Importance of the complete and
accurate medical record.
6. Patient Trust and Engagement: Reliable records foster trust, as patients feel confident
their health information is handled responsibly. This encourages active participation in
their care.
7. Risk Management: Thorough documentation protects against malpractice claims by
providing evidence of care provided, decisions made, and patient interactions.
Challenges to Address: Maintaining accuracy requires robust systems (e.g., EHRs), staff
training, and regular audits to catch errors like incomplete entries or outdated data.
“In summary, complete and accurate medical records are the backbone of safe, efficient,
and compliant healthcare delivery, benefiting patients, providers, and the organization.”
Dr. J. L. Meena

The medical record reflects the
continuity of care
1. Role of Medical Records in Continuity of Care
Medical records are the primary tool for documenting and sharing critical information about a patient’s health journey. They ensure that
healthcare providers have the necessary data to deliver consistent, informed, and personalized care. Keyways in which medical records
reflect, and support continuity of care include:
- Comprehensive Health History: Medical records compile a patient’s medical history, including diagnoses, treatments, medications,
allergies, surgeries, and immunizations. This longitudinal view allows providers to understand the patient’s health context, track disease
progression, and make informed decisions.
- Coordination Across Providers: Patients often interact with multiple healthcare professionals (e.g., primary care physicians, specialists,
pharmacists, therapists). Medical records enable these providers to share information, align treatment plans, and avoid duplication of
tests or conflicting interventions.
- Tracking Progress and Outcomes: By documenting clinical encounters, test results, and treatment responses, medical records allow
providers to monitor a patient’s progress over time. This is especially critical for chronic conditions like diabetes or hypertension, where
long-term management is essential.
- Facilitating Transitions of Care: When patients move between healthcare settings (e.g., from hospital to outpatient care or from pediatric
to adult care), medical records ensure that the receiving provider has access to relevant information, reducing the risk of gaps in care.
- Patient Empowerment and Engagement: Medical records, especially when accessible via patient portals, enable patients to review their
health information, adhere to treatment plans, and communicate effectively with providers, fostering shared decision-making.
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continuity of care
2. Key Components of Medical Records Supporting Continuity
A well-maintained medical record contains several standardized components that collectively support continuity of
care:
- Demographic Information: Basic details like name, date of birth, and contact information ensure accurate patient
identification across systems.
- Problem List: A summary of active and past medical conditions provides a quick reference for providers.
- Medication List: A record of current and past medications, including dosages and durations, helps prevent adverse
drug interactions and ensures appropriate prescribing.
- Allergy Information: Documenting allergies, especially to medications, is critical for patient safety.
- Clinical Notes: Detailed notes from each encounter (e.g., SOAP notes: Subjective, Objective, Assessment, Plan) capture
the provider’s observations, diagnoses, and treatment plans.
- Diagnostic Test Results: Lab reports, imaging studies, and other test results provide objective data to guide treatment.
- Immunization Records: A history of vaccinations ensures patients receive timely preventive care.
- Care Plans: Instructions for ongoing management, including follow-up appointments and lifestyle recommendations,
help maintain continuity.
- Correspondence: Letters or summaries from specialists or other providers ensure all parties are informed of the
patient’s care.
Dr. J. L. Meena

continuity of care
3. Types of Medical Records and Their Role
The format and accessibility of medical records have evolved significantly, impacting their ability to support
continuity of care:
- Paper Records: Traditional paper charts, while still used in some settings, are limited by accessibility and
portability. They can hinder continuity when records are not easily shared between providers.
- Electronic Health Records (EHRs): EHRs have revolutionized continuity of care by digitizing and centralizing
patient information. EHRs allow real-time access, interoperability between systems (when standardized), and
integration of decision-support tools like drug interaction alerts.
- Personal Health Records (PHRs): Maintained by patients, PHRs complement provider-managed records by
allowing patients to track their health data and share it with providers, enhancing engagement.
- Health Information Exchanges (HIEs): HIEs enable secure sharing of medical records across organizations,
ensuring that providers in different systems can access a patient’s history, which is vital for continuity in
fragmented healthcare systems.
Dr. J. L. Meena

continuity of care
4. Challenges in Using Medical Records for Continuity of Care
Despite their importance, medical records face several challenges that can disrupt continuity:
- Incomplete or Inaccurate Documentation: Missing or erroneous information (e.g., outdated
medication lists) can lead to misinformed decisions and errors.
- Interoperability Issues: Not all EHR systems are compatible, which can prevent seamless data
sharing between providers or facilities.
- Data Overload: Providers may struggle to extract relevant information from voluminous records,
especially in complex cases.
- Privacy and Security Concerns: Strict regulations like HIPAA (in the U.S.) or GDPR (in Europe) govern
medical record access, and breaches or misuse can undermine trust.
- Patient Access Barriers: Some patients, particularly in underserved populations, may lack access to
digital tools like patient portals, limiting their ability to engage with their records.
- Fragmentation: In systems without centralized records, patients seeing multiple providers may
have scattered records, complicating coordination.
Dr. J. L. Meena

continuity of care
5. Legal and Ethical Considerations
Medical records are subject to stringent legal and ethical standards to protect
patient privacy and ensure quality care:
- Confidentiality: Laws like HIPAA mandate that patient information be safeguarded,
with access limited to authorized individuals.
- Accuracy and Timeliness: Providers are ethically and legally obligated to maintain
accurate and up-to-date records to support safe care.
- Patient Rights: Patients have the right to access their records, request
amendments, and control who can view their information (with some exceptions).
- Retention: Regulations often require records to be retained for a minimum period
(e.g., 7 years in the U.S.), ensuring availability for future care.
Dr. J. L. Meena

continuity of care
6. Impact of Technology on Continuity of Care
Advancements in technology are enhancing the role of medical records in continuity of care:
- Artificial Intelligence (AI): AI tools can analyze medical records to identify patterns, predict risks, and suggest treatment
options, aiding providers in decision-making.
- Telemedicine Integration: Telehealth platforms integrate with EHRs, ensuring that virtual visits are documented and
accessible for future care.
- Wearable Devices: Data from wearables (e.g., glucose monitors, fitness trackers) can be incorporated into medical
records, providing real-time insights for chronic disease management.
- Blockchain: Emerging blockchain technologies aim to improve record security and interoperability, enabling secure,
decentralized access to patient data.
7. Real-World Example
Consider a patient with Type 2 diabetes managed by a primary care physician, an endocrinologist, and a dietitian. The
patient’s EHR documents their blood glucose levels, insulin regimen, dietary plan, and recent hospitalization for
hypoglycemia. When the patient visits the endocrinologist, the specialist can access the primary care physician’s notes, the
dietitian’s recommendations, and hospital discharge summary. This comprehensive view allows the endocrinologist to
adjust the insulin dose, coordinate with the dietitian, and schedule a follow-up, ensuring consistent care. If the patient uses
a patient portal, they can also review their care plan and communicate concerns, further enhancing continuity.
Dr. J. L. Meena

continuity of care
8. Conclusion
The medical record is far more than a static document; it is a
dynamic tool that reflects and enables continuity of care by
capturing a patient’s health journey, facilitating communication
among providers, and empowering patients. While challenges like
interoperability and data accuracy persist, advancements in EHRs, AI,
and health information exchanges are strengthening the ability of
medical records to support seamless care. Ensuring that records are
complete, accessible, and secure is essential for delivering high-
quality, coordinated healthcare.
Dr. J. L. Meena

Maintenance of medical records, along with
ensuring their confidentiality, integrity and
security
In India, the organization and maintenance of medical records, along with ensuring their **confidentiality**,
**integrity**, and **security**, are critical for supporting continuity of care while complying with legal,
ethical, and regulatory frameworks.
1. Overview of Confidentiality, Integrity, and Security in India
- Confidentiality: Ensures that patient information is accessible only to authorized individuals (e.g., healthcare
providers, patients, or legal entities) and protected from unauthorized disclosure.
- Integrity: Guarantees that medical records and data remain accurate, complete, and unaltered, except by
authorized changes, to support reliable clinical decision-making.
- Security: Involves safeguards (physical, technical, and administrative) to protect records and data from
breaches, loss, or unauthorized access.
In India, these principles are governed by a combination of laws, regulations, and guidelines tailored to the
healthcare sector, with additional considerations for the growing adoption of digital health technologies.
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security
2. Legal and Regulatory Framework in India
Several laws and guidelines regulate the management of medical records and health data in India to ensure confidentiality,
integrity, and security:
Indian Medical Council (Professional Conduct, Etiquette, and Ethics) Regulations, 2002:
- Mandates that registered medical practitioners maintain confidentiality of patient information, except when required by law or
with patient consent.
- Requires maintenance of medical records for at least **3 years** and provision of records to patients upon request.
Information Technology Act, 2000 (IT Act):
- Section 43A and the **IT (Reasonable Security Practices and Procedures and Sensitive Personal Data or Information) Rules,
2011** classify health data as **sensitive personal data or information (SPDI)**.
- Organizations handling SPDI must implement reasonable security practices, including encryption, access controls, and audits, to
protect data confidentiality and security.
Digital Personal Data Protection Act, 2023 (DPDP Act):
- A comprehensive data protection law that governs the processing of personal data, including health data.
- Requires organizations to obtain explicit consent for processing health data, ensure data accuracy (integrity), and implement
robust security measures.
- Mandates data breach notifications and grants individuals rights to access, correct, or erase their data.
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National Digital Health Mission (NDHM) / Ayushman Bharat Digital Mission (ABDM):
- Introduced the **Health Data Management Policy** to regulate electronic health records (EHRs) and ensure
interoperability, confidentiality, and security.
- Establishes the **Health ID** system, allowing patients to control access to their health records via consent-based
sharing.
- Requires compliance with security standards like **ISO 27001** (Information Security Management) and encryption
protocols.
Clinical Establishments (Registration and Regulation) Act, 2010:
- Mandates healthcare facilities to maintain and securely store medical records as per prescribed standards.
- Emphasizes accurate documentation to ensure continuity of care.
Drugs and Cosmetics Act, 1940 and Pharmacy Practice Regulations, 2015:
- Require pharmacies and healthcare providers to maintain records of prescriptions and drug dispensing, ensuring
traceability and integrity.
3. Mechanisms to Ensure Confidentiality, Integrity, and Security
Healthcare organizations in India adopt various practices and technologies to uphold these principles:
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A. Confidentiality
Access Controls:
- Role-based access ensures that only authorized personnel (e.g., treating physicians, nurses) can view patient records.
- User authentication (e.g., passwords, biometrics) prevents unauthorized access to EHR systems.
Patient Consent:
- Under the DPDP Act and ABDM, explicit consent is required before sharing health data with third parties (e.g., specialists, insurance
companies).
- Patients can manage data sharing via Health IDs in the ABDM ecosystem.
Confidentiality Agreements: Healthcare staff are bound by non-disclosure agreements and ethical codes to prevent unauthorized
disclosure.
De-identification: Health data used for research or analytics is anonymized to protect patient identity.
B. Integrity
Standardized Documentation:
- Records follow formats prescribed by the National Medical Commission (NMC) or ABDM, ensuring completeness and consistency.
- Use of structured templates (e.g., SOAP notes) minimizes errors.
Audit Trails:
- EHR systems log all access and modifications to records, ensuring traceability of changes.
- Version control prevents unauthorized or accidental alterations.
Data Validation: Automated checks in EHRs flag inconsistencies (e.g., incorrect medication doses) to maintain accuracy.
Regular Updates: Providers are required to update records promptly after each patient encounter to reflect current health status.
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C. Security
Technical Safeguards:
- Encryption: Data is encrypted during storage and transmission (e.g., using AES-256 standards) to prevent
interception.
- Firewalls and Antivirus: Protect against cyber threats like malware or hacking.
- Secure Cloud Storage: Many hospitals use cloud-based EHRs with compliance to Indian security standards.
Physical Safeguards:
- Paper records and servers are stored in locked, access-controlled areas.
- Surveillance systems and restricted entry protect data centers.
Administrative Safeguards:
- Regular staff training on data protection laws and cybersecurity.
- Periodic security audits and risk assessments to identify vulnerabilities.
- Incident response plans for data breaches, including mandatory reporting under the DPDP Act.
Disaster Recovery: Backup systems ensure data availability in case of system failures or natural disasters.
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4. Role of Electronic Health Records (EHRs) and ABDM
The shift from paper-based to electronic records has significantly enhanced the ability to maintain confidentiality, integrity, and security:
- EHR Systems: Platforms like **e-Hospital**, **OpenMRS**, or proprietary systems used by private hospitals (e.g., Apollo, Fortis) enable
secure storage, real-time updates, and controlled access.
ABDM Ecosystem:
- Facilitates interoperability through the **Unified Health Interface (UHI)**, allowing secure data exchange between providers.
- Uses **Health Information Provider (HIP)** and **Health Information User (HIU)** frameworks to regulate data access.
- Employs blockchain-like technologies for secure, decentralized data management.
- Patient Portals: Patients can access their records via ABDM’s Health ID or hospital portals, ensuring transparency while maintaining
security through authentication.
5. Challenges in Maintaining Confidentiality, Integrity, and Security
Despite robust frameworks, challenges persist:
- Fragmented Healthcare System: India’s mix of public, private, and informal healthcare providers leads to inconsistent record-keeping
practices.
- Interoperability Issues: Not all EHR systems are ABDM-compliant, hindering seamless data sharing.
- Cybersecurity Threats: Increasing digitization exposes health data to risks like ransomware or phishing attacks.
- Resource Constraints: Smaller clinics and rural facilities may lack funds for advanced EHR systems or cybersecurity measures.
- Low Digital Literacy: Patients and staff may not fully understand data protection practices, leading to unintentional breaches.
- Compliance Gaps: Some organizations fail to fully adhere to DPDP Act or IT Rules due to lack of awareness or enforcement.
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6. Best Practices by Healthcare Organizations
Leading hospitals and organizations in India adopt global standards to enhance record management:
- NABH Accreditation: The National Accreditation Board for Hospitals (NABH) mandates strict protocols for record
maintenance, access control, and data security.
- ISO 27001 Certification: Many hospitals and IT vendors adopt this standard for information security management.
- Regular Training: Staff are trained on data privacy laws, ethical handling of records, and cybersecurity protocols.
- Patient Education: Hospitals provide guidance on using patient portals and understanding data rights under the DPDP Act.
- Collaboration with ABDM: Large healthcare chains integrate with ABDM to ensure standardized, secure record-keeping.
7. Real-World Example
A patient with chronic kidney disease visits a hospital in Delhi. Their EHR, integrated with ABDM, contains their dialysis
history, lab reports, and medication list. The hospital uses:
- Confidentiality: Role-based access ensures only the nephrologist and dialysis team view the records. The patient consents
to share data with a consulting urologist via their Health ID.
- Integrity: The EHR system logs all updates (e.g., new lab results) with timestamps and provider IDs, ensuring no
unauthorized changes.
- Security: Data is encrypted, stored on a secure cloud, and protected by multi-factor authentication. The hospital conducts
regular cybersecurity audits to prevent breaches.
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8. Conclusion
In India, healthcare organizations maintain confidentiality, integrity,
and security of medical records, data, and information through a
combination of legal compliance (e.g., DPDP Act, IT Act),
technological advancements (e.g., EHRs, ABDM), and operational
safeguards. While challenges like interoperability and cybersecurity
risks remain, initiatives like ABDM and increasing adoption of global
standards are strengthening data management practices. These
efforts ensure that medical records effectively support continuity of
care while protecting patient privacy and trust.
Dr. J. L. Meena

Hospitals are required to ensure the availability, maintenance,
and retention of current and relevant documents, records, data,
and information as per various legal and regulatory frameworks.
1. Regulatory Requirements:
- Clinical Establishments (Registration and Regulation) Act, 2010: Mandates hospitals to maintain and provide
access to medical records, ensuring they are current, accurate, and relevant.
- Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002: Requires doctors and
hospitals to maintain patient records for a minimum of **3 years** from the last date of treatment or consultation.
- Drugs and Cosmetics Act, 1940: Ensures proper documentation of drug procurement, storage, and dispensing.
- National Accreditation Board for Hospitals & Healthcare Providers (NABH): For accredited hospitals, NABH
standards require robust systems for document control, data management, and record retention, including
electronic health records (EHRs).
2. Types of Records:
- Patient Records: Medical history, diagnosis, treatment plans, prescriptions, and discharge summaries.
- Administrative Records: Licenses, staff credentials, and hospital registration documents.
- Financial Records: Billing, insurance claims, and audit reports.
- Statutory Records: Compliance with labor laws, biomedical waste management, and radiation safety (if
applicable).
Dr. J. L. Meena

3. Retention Periods:
- Patient Records: Minimum 3 years (MCI guidelines); NABH recommends **5–10 years** for
medico-legal cases.
- Medico-Legal Cases (MLCs): Records should be retained longer (up to 7 years or as per state
laws) due to potential legal proceedings.
- Financial and Tax Records: As per the Income Tax Act, 1961, retain for **7 years**.
- Biomedical Waste Records: As per Biomedical Waste Management Rules, 2016, maintain for **5
years**.
4. Data Protection and Privacy:
- Digital Information Security in Healthcare Act (DISHA) (proposed): Ensures confidentiality,
security, and accessibility of digital health data.
- Personal Data Protection Bill (under consideration): Hospitals must comply with data localization
and patient consent requirements.
- IT Act, 2000: Mandates secure storage of electronic records with safeguards against
unauthorized access. Dr. J. L. Meena

5. Implementation in Hospitals:
- Electronic Medical Records (EMRs): Many hospitals use EMR systems for real-time data
access and compliance with MoHFW’s EHR Standards, 2016.
- Document Management Systems: Ensure version control and accessibility of policies,
SOPs, and clinical guidelines.
- Archival Systems: Physical and digital archives for long-term retention, with regular
audits to ensure compliance.
6. Challenges and Best Practices:
- Challenges: Inadequate infrastructure in rural hospitals, lack of trained staff, and
cybersecurity risks.
- Best Practices: Regular staff training, adoption of cloud-based EHRs with encryption, and
periodic audits to ensure compliance with NABH and legal standards.
Dr. J. L. Meena

Retention periods for death records and
medico-legal case (MLC) files
In India, the retention periods for death records and medico-legal case (MLC) files are governed by a combination of
national laws, state regulations, institutional policies, and guidelines from medical bodies like the Indian Medical
Council (IMC).
Death Records
Death records in India are primarily managed under the **Registration of Births and Deaths Act, 1969**, which
mandates the registration of all births and deaths. The retention of these records varies depending on the entity
maintaining them (government registrars, hospitals, etc.).
1. Government Records (Registrar of Births and Deaths):
- Death records maintained by the Registrar of Births and Deaths are typically kept “permanently”. This is because
these records are part of vital statistics used for legal, administrative, and statistical purposes.
- The Office of the Registrar General, India (ORGI), oversees the system, and records are often digitized for long-
term preservation. For instance, the Civil Registration System (CRS) portal ensures digital archiving of these records.
- Physical copies, if maintained, are usually stored for a minimum of “30 years” before being archived, though this
can vary by state. For example, states like Maharashtra and Tamil Nadu have robust systems for permanent
retention, often transferring older records to state archives.
Dr. J. L. Meena

2. Hospital Records of Death:
- Hospitals maintain their own records of deaths, especially in cases where a patient dies during
treatment. These records include death summaries, autopsy reports (if applicable), and certificates issued
by the hospital.
- The “National Accreditation Board for Hospitals & Healthcare Providers (NABH)”, which sets standards
for hospitals, recommends retaining death records for at least “5 years”. However, many hospitals,
especially government ones, may keep them for “10 years” or more to comply with legal or audit
requirements.
- State-specific health policies may extend this period. For example, in Kerala, hospital death records
are often retained for up to “10 years” as per the Kerala Health Services guidelines.
- If the death is medico-legal (e.g., unnatural death, accident, or suspected foul play), the retention
period aligns with MLC guidelines (15-20 years).
3. Legal Considerations:
- If a death leads to legal proceedings (e.g., a court case or insurance claim), hospitals and registrars are
required to retain records until the case is resolved, which could extend beyond the standard retention
period. Dr. J. L. Meena

Medico-Legal Case (MLC) Files
Medico-legal cases involve incidents where medical records may be required for legal proceedings, such as accidents,
assaults, suicides, homicides, or unnatural deaths. MLC files typically include injury reports, post-mortem reports,
treatment records, and police correspondence.
1. General Retention Period:
- The **Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002**, under Section 1.3.1,
mandates that medical records, including MLC files, be maintained for a minimum of **3 years** from the last date of
treatment. However, for medico-legal cases, this period is often extended due to their legal sensitivity.
- Most government hospitals and forensic departments retain MLC files for a minimum of **10 years**. This is a standard
practice to ensure records are available for potential legal proceedings, as the statute of limitations for certain criminal
cases (e.g., under the Indian Penal Code) can extend up to 10 years or more for serious offenses like murder, which has no
limitation period.
- Some states and institutions extend this to **20 years** or more, especially for cases involving unnatural deaths or
ongoing investigations. For example:
- In **Maharashtra**, the Directorate of Health Services recommends retaining MLC files for **20 years** if the case
involves a suspicious death.
- In **Delhi**, the Delhi Medical Council advises hospitals to keep MLC records for at least **15 years**.
Dr. J. L. Meena

2. Post-Mortem Reports (Part of MLC Files):
- Post-mortem reports, often prepared in unnatural death cases, are typically retained by forensic departments or
hospitals for **10 to 20 years**, depending on state guidelines.
- For example, the **Tamil Nadu Medico-Legal Manual** suggests a minimum retention period of **20 years** for post-
mortem reports to accommodate potential legal inquiries.
3. Police and Court Requirements:
- If an MLC case is under active investigation or legal proceedings, records must be retained until the case is resolved,
regardless of the standard retention period. Courts can issue orders to preserve records indefinitely in such cases.
- Police stations often keep copies of MLC reports as part of their case files, and these are retained as per police record
retention policies, which can also extend to **20 years** for serious crimes.
4. NABH and Other Standards:
- NABH-accredited hospitals are required to have a clear policy on record retention. For MLC files, NABH guidelines
suggest a minimum of **10 years**, but hospitals often adopt longer periods (e.g., 15–20 years) to mitigate legal risks.
- The **National Health Mission (NHM)** and state health departments may also provide specific guidelines. For
instance, in Uttar Pradesh, NHM guidelines recommend retaining MLC records for at least **15 years**.
Dr. J. L. Meena

5. Digital Records:
- With the digitization of health records under initiatives like the **Ayushman Bharat Digital Mission
(ABDM)**, many hospitals and forensic departments are transitioning to digital storage. Digital MLC records
are often kept indefinitely, though physical copies may still follow the 10–20-year retention period before
being destroyed.
State-Specific Variations
Retention periods can vary across states due to differences in health policies, forensic practices, and legal
requirements:
- Karnataka: The Karnataka Medical Registration Act and state health policies recommend retaining MLC files
for **15 years**, while death records in hospitals are kept for **10 years**.
- West Bengal: The West Bengal Clinical Establishments Act suggests a minimum of **10 years** for MLC files,
but post-mortem reports are often retained for **20 years**.
- Rajasthan: Government hospitals typically retain MLC files for **10 years**, but this can extend to **20
years** for unresolved cases.
Dr. J. L. Meena

Challenges and Practical Considerations
- Storage Constraints: Many government hospitals and forensic departments face storage issues, leading to
premature destruction of records in some cases, despite guidelines.
- Legal Awareness: Smaller hospitals may not strictly adhere to retention policies due to lack of awareness or
resources, which can lead to legal complications if records are requested later.
- Destruction Process: After the retention period, records are typically destroyed following a formal process
(e.g., shredding or incineration), often with approval from a hospital committee or legal authority to ensure no
pending cases are affected.
Conclusion
- Death Records: Permanent retention by registrars; hospitals typically retain for 5–10 years unless medico-
legal.
- MLC Files: Minimum 10 years, often extended to 20 years or more, depending on state guidelines, legal
proceedings, and institutional policies.
Dr. J. L. Meena

Patient medical records typically
contain the following components
Patient medical records typically contain the following components, though specific contents may vary depending on the
healthcare provider, system, or legal requirements:
1. Patient Demographics:
- Full name
- Date of birth
- Gender
- Contact information (address, phone, email)
- Emergency contact details
- Insurance information
2. Medical History:
- Past and current medical conditions
- Surgical history
- Allergies (medications, food, environmental)
- Immunization records
- Family medical history
- Social history (e.g., smoking, alcohol use, occupation)
Dr. J. L. Meena

3. Medications:
- Current and past medications (prescription and over-the-counter)
- Dosage and frequency
- Prescribing physician
- Medication allergies or adverse reactions
4. Vital Signs and Measurements:
- Blood pressure
- Heart rate
- Respiratory rate
- Temperature
- Height, weight, BMI
5. Clinical Notes:
- Physician, nurse, or specialist notes
- Chief complaint or reason for visit
- Physical exam findings
- Assessment and plan
- Progress notes Dr. J. L. Meena

6. Diagnostic Test Results:
- Laboratory results (blood tests, urinalysis, etc.)
- Imaging reports (X-rays, MRIs, CT scans)
- Pathology reports (biopsies, cultures)
- Other diagnostic procedures (e.g., ECG, EEG)
7. Treatment Plans:
- Prescribed treatments or therapies
- Referrals to specialists
- Follow-up appointments
- Patient instructions
8. Encounter Records:
- Dates and details of visits (inpatient, outpatient, or telehealth)
- Hospitalization records (admission/discharge summaries)
- Emergency room visits
9. Consent Forms and Legal Documents:
- Informed consent for procedures or treatments
- Advance directives (e.g., living will, power of attorney)
- Privacy acknowledgments (e.g., HIPAA forms) Dr. J. L. Meena

10. Billing and Insurance Information:
- Billing codes (ICD, CPT)
- Insurance claims and approvals
- Payment history
11. Correspondence:
- Letters or communications between healthcare providers
- Referrals or consultation reports
- Patient-provider communication (e.g., secure messaging)
12. Miscellaneous:
- Dietary or lifestyle recommendations
- Rehabilitation or physical therapy records
- Mental health notes (if applicable)
- Research participation records (if enrolled in clinical trials)
Note: The exact contents depend on the healthcare system, country-specific regulations (e.g., HIPAA in the US), and
whether the record is electronic (EHR) or paper-based.
Dr. J. L. Meena

Conducting a medical record
review in India
Conducting a medical record review in India, whether for legal, insurance, healthcare, or research purposes,
requires a systematic approach to ensure accuracy, compliance, and usability.
Steps for Medical Record Review in India
1. Define the Purpose and Scope
- Action: Clearly identify the objective of the review (e.g., litigation support for personal injury, medical
malpractice, insurance claims, clinical research, or quality audits).
- Details:
- Determine the type of records needed (e.g., patient history, diagnostic reports, treatment plans, billing
records).
- Specify case types (e.g., personal injury, mass torts, workers’ compensation) and required outputs (e.g.,
chronology, summary, error detection).
- Establish timelines and budget constraints.
- Specific Note: Ensure the purpose aligns with legal requirements under the Indian Evidence Act, 1872,
which recognizes signed medical records as admissible evidence.
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2. Identify and Collect Relevant Medical Records
- Action: Request and gather all pertinent medical records from healthcare providers, hospitals, or
clinics.
- Details:
- Obtain patient consent or legal authorization (e.g., court order, attorney request) to access records.
- Request records in both physical and electronic formats, if available, as per the Clinical
Establishments Act, 2010, which mandates hospitals to provide records within 72 hours.
- Collect comprehensive records, including:
- Admission and discharge summaries
- Physician notes, nursing notes, and progress reports
- Diagnostic tests (e.g., X-rays, MRIs, lab reports)
- Medication and treatment records
- Billing and insurance documents
- Specific Note: Verify that records are signed by authorized personnel, as unsigned records lack legal
validity. Be aware of potential issues like incomplete or fabricated records, especially in smaller facilities.
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3. Organize and Index Records
- Action: Sort and categorize records to facilitate efficient review.
- Details:
- Digitize physical records (if not already in electronic format) using scanning and OCR (Optical
Character Recognition) tools.
- Index records by key categories, such as:
- Patient demographics
- Dates of service
- Type of document (e.g., lab report, prescription)
- Medical events (e.g., surgeries, consultations)
- Use software or AI-powered tools (e.g., NLP-based platforms) to automate indexing and ensure
accuracy.
- Specific Note: Indian hospitals may use inconsistent formats or handwritten notes. Engage
providers with expertise in deciphering illegible shorthand or regional medical terminology.
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4. Conduct Initial Review and Quality Check
- Action: Perform a preliminary review to ensure completeness and authenticity.
- Details:
- Check for missing pages, incomplete entries, or discrepancies in dates and signatures.
- Verify that records are from credible sources (e.g., registered hospitals or clinics).
- Flag any signs of tampering or fabrication, such as inconsistent handwriting or altered
dates, which can be a concern in India.
- Ensure compliance with data privacy laws, including the Digital Personal Data Protection
Act, 2023, and HIPAA (if serving international clients).
Specific Note: Cross-reference records with hospital logs or electronic medical record (EMR)
systems, if available, to confirm authenticity.
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5. Analyze and Summarize Medical Records
- Action: Review records in detail to extract relevant information and create actionable outputs.
- Details:
- Assign trained professionals (e.g., doctors, nurses, legal nurse consultants) to analyze records for:
- Medical history and pre-existing conditions
- Treatment timelines and outcomes
- Errors, negligence, or deviations from standard care
- Causation and liability (for legal cases)
- Produce deliverables, such as:
- Medical Chronology: A timeline of medical events.
- Narrative Summary: A concise overview of key findings.
- Deposition Summary: Highlights for legal proceedings.
- Error Reports: Identification of gaps or inconsistencies.
- Use AI tools (e.g., NLP, machine learning) to accelerate analysis and highlight critical details, such as missed diagnoses
or medication errors.
Specific Note: Ensure summaries address local medical practices and terminology, as Indian healthcare systems may differ
from Western standards.
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6. Ensure Compliance and Security
- Action: Adhere to legal and regulatory standards for data handling and confidentiality.
- Details:
- Follow HIPAA, ISO, and HITECH standards for international clients, and India’s Digital Personal Data Protection Act for
domestic cases.
- Use secure platforms (e.g., encrypted servers, VPNs) for data storage and transfer.
- Implement access controls to limit record handling to authorized personnel only.
- Maintain audit trails to track who accessed or modified records.
Specific Note: Indian providers must comply with the Indian Medical Council (Professional Conduct, Etiquette, and Ethics)
Regulations, 2002, for ethical record management.
7. Quality Assurance and Peer Review
- Action: Conduct a multi-tier quality check to ensure accuracy and reliability.
- Details:
- Perform a secondary review by a different team member to catch errors or omissions.
- Use standardized checklists to verify that all required elements (e.g., chronology, causation analysis) are included.
- Validate findings against original records to ensure no misinterpretations.
- For legal cases, have a medico-legal expert review outputs to ensure court admissibility.
Specific Note: Engage professionals familiar with Indian medico-legal frameworks to ensure summaries meet judicial
standards. Dr. J. L. Meena

review in India
8. Deliver Outputs and Obtain Feedback
- Action: Provide the finalized deliverables to the client and address any follow-up needs.
- Details:
- Share outputs in the client’s preferred format (e.g., PDF, Word, or proprietary software).
- Ensure deliverables are concise, clear, and tailored to the case (e.g., highlighting negligence for malpractice cases).
- Offer revisions or additional analysis based on client feedback.
- Maintain records of the review process for future reference or audits.
Specific Note: For legal cases, ensure deliverables include references to relevant Indian laws or precedents, if applicable.
9. Maintain Records for Future Use
- Action: Archive records securely for potential future reviews or audits.
- Details:
- Store records in compliance with retention policies (e.g., 3 years for adult patients, 7 years for minors under Indian
law).
- Use cloud-based or encrypted storage systems to ensure accessibility and security.
- Document the review process for transparency in case of disputes or legal scrutiny.
Specific Note: Follow guidelines from the Ministry of Health and Family Welfare for record retention and disposal.
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review in India
Additional:-
- Leverage Technology: Use AI-powered tools (e.g., from providers like LezDo TechMed or PreludeSys) to handle large
volumes of records efficiently, especially for complex cases like mass torts.
- Engage Local Expertise: Work with Indian providers who understand local medical practices, regional terminology, and
legal nuances, as healthcare delivery varies across states.
- Address Fabrication Risks: Verify records against multiple sources (e.g., hospital EMRs, pharmacy logs) to mitigate risks of
falsified documents.
- Outsource Strategically: Consider reputable Indian providers like Flatworld Solutions, MOS, or SunTec India for cost-
effective, high-quality reviews, especially if handling international cases.
Tools and Resources
- Software: Use tools like Adobe Acrobat for digitization, CaseMap for legal case management, or AI platforms like those
offered by PreludeSys for automated analysis.
- Regulatory References: Refer to the Indian Evidence Act, 1872, Clinical Establishments Act, 2010, and Digital Personal Data
Protection Act, 2023, for compliance.
- Professional Support: Engage certified medical record reviewers or legal nurse consultants with experience in Indian
healthcare systems.
Dr. J. L. Meena

False medical record audits
lead to significant harm
False medical record audits in India—where records are inaccurately assessed, manipulated, or
misrepresented—can lead to significant harm across clinical, legal, financial, and ethical domains.
1. Clinical Harms: Compromised Patient Care
- Misdiagnosis and Inappropriate Treatment: False audits may fail to identify errors in medical records, such
as incorrect diagnoses, incomplete patient histories, or missing treatment details. This can perpetuate flawed
care plans, leading to adverse patient outcomes. For instance, a study highlighted that poor record-keeping in
Indian hospitals often omits critical details like patient history or operation notes, which audits should catch
but may overlook if falsified. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4627207/)
- Delayed or Denied Care: If audits falsely deem records compliant, patients may face delays in receiving
necessary interventions, especially in insurance-driven systems where claims depend on accurate
documentation. Conversely, falsified audits may wrongly deny care by misrepresenting a patient’s condition
or treatment history.
- Medical Identity Theft Risks: False entries from medical identity theft, if undetected by audits, can introduce
erroneous data into records (e.g., diseases or treatments not belonging to the patient). This can lead to
inappropriate treatments or even life-threatening errors. Victims may face long-term consequences, such as
incorrect medical histories affecting future care.
Dr. J. L. Meena

2. Legal and Ethical Harms
- Malpractice and Negligence Lawsuits: Inaccurate audits can obscure evidence of negligence, making it harder for patients
to seek justice. For example, courts in India have ruled that failure to produce or tampering with medical records can lead
to adverse inferences, implying negligence. Falsified audits may hide such tampering, denying patients legal recourse.
- Fraud and Criminal Liability: If audits falsely certify manipulated records, healthcare providers may face allegations of
fraud, especially under laws like the False Claims Act (applied in similar contexts globally) or India’s Medical Council
regulations. Falsifying records is a misdemeanor in some jurisdictions, with penalties including fines or imprisonment.
- Erosion of Trust: False audits undermine trust between patients and healthcare providers. Ethical breaches, such as
altering records to hide errors or inflate bills, damage the integrity of the medical profession and deter patients from
seeking care.
3. Financial Harms
- Insurance Claim Denials: Poor or falsified audits can lead to improper record-keeping, resulting in denied insurance
claims. In India, where medical insurance is growing, incomplete or inaccurate records often lead to claim rejections,
burdening patients with out-of-pocket costs. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779965/)
- Fraudulent Billing: False audits may fail to detect deliberate overbilling or billing for services not rendered, costing
insurers and patients. Healthcare fraud, including falsified records, is a global issue, with the U.S. estimating $68–105
billion in annual losses, suggesting a similar risk in India’s less-regulated system.
- Penalties for Providers: If false audits are later exposed, providers may face fines or repayment demands from insurers or
government programs, alongside reputational damage.
Dr. J. L. Meena

3. Financial Harms
- Insurance Claim Denials: Poor or falsified audits can lead to improper record-keeping, resulting in denied insurance claims. In
India, where medical insurance is growing, incomplete or inaccurate records often lead to claim rejections, burdening patients with
out-of-pocket costs. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2779965/)
- Fraudulent Billing: False audits may fail to detect deliberate overbilling or billing for services not rendered, costing insurers and
patients. Healthcare fraud, including falsified records, is a global issue, with the U.S. estimating $68–105 billion in annual losses,
suggesting a similar risk in India’s less-regulated system.
- Penalties for Providers: If false audits are later exposed, providers may face fines or repayment demands from insurers or
government programs, alongside reputational damage.
4. Systemic Harms
- Ineffective Quality Control: Clinical audits are meant to improve care by identifying gaps in processes, but false audits obscure
these gaps, preventing systemic improvements. In India, the lack of a legislative framework for standardized data collection
hampers meaningful audits, and falsified audits exacerbate this issue.
- Resource Misallocation: False audits may misrepresent hospital performance metrics (e.g., bed occupancy or infection rates),
leading to misinformed policy decisions or resource allocation. This can strain an already overburdened healthcare system.
- Barriers to Research: Inaccurate records and audits hinder medical research, as reliable data is critical for studying treatment
outcomes or public health trends. Ethical concerns also arise when patient data is used without proper oversight, a practice not
uniformly regulated in India.
Dr. J. L. Meena

Critical Perspective
While the sources highlight the dangers of poor record-keeping and falsification, they often reflect an establishment view
that assumes audits are inherently beneficial if done correctly. This overlooks deeper systemic issues in India, such as
underfunded healthcare infrastructure, overworked staff, and cultural attitudes toward documentation. For example, one
doctor’s query about the need for operation notes reflects a broader lack of training or incentive for meticulous record-
keeping. False audits may also stem from institutional pressures to meet insurance or regulatory targets, which sources
rarely address. Moreover, the focus on legal penalties (e.g., fines or jail time) may disproportionately affect smaller clinics
while larger hospitals with better legal resources evade scrutiny.
Recommendations to Mitigate Harm
- Strengthen Legislative Frameworks: India needs laws mandating standardized, computer-readable medical records and
regular, independent audits to ensure compliance. Maharashtra’s initiative with structured data collection is a promising
model.
- Enhance Training: Regular training for medical and paramedical staff on proper documentation and audit processes can
reduce errors and intentional falsification.
- Implement Digital Systems: Electronic health records (EHRs) with audit trails can deter tampering by logging all changes.
However, these must be paired with robust cybersecurity to prevent unauthorized access.
- Patient Empowerment: Encouraging patients to review their records regularly can help detect discrepancies early, reducing
the impact of false audits.
- Independent Oversight: External audits by third-party bodies, as opposed to internal audits prone to bias, can improve
accountability. Dr. J. L. Meena

Conclusion
False medical record audits in India can cause profound harm by jeopardizing
patient safety, enabling fraud, obstructing justice, and undermining
healthcare quality. The absence of a robust legislative framework and
standardized practices exacerbates these risks. While initiatives like
Maharashtra’s data collection efforts show promise, systemic reforms—
combining technology, training, and independent oversight—are critical to
ensuring audits serve their purpose of improving care rather than concealing
failures.
Dr. J. L. Meena

Intent of the Chapter
Information Management System (IMS)
➢ The goal of information management in the organisation is to ensure that the right information is available to
the right person at the right time.
➢ Information management includes management of hospital information system as well as all modalities of
information communicated to staff, patients, visitors and community in general.
➢ Data and information management must be directed to meet the organisation's needs and support the
delivery of quality patient care. The information needs are provided in an authenticated, secure and accurate
manner at the right time and place.
➢ Confidentiality, integrity and security of records, data and information is maintained. Confidentiality of
protected health information is paramount and is safeguarded across all information processing, storing and
disseminating platforms.
➢ Information management also includes periodic review, revision and withdrawal of obsolete information to
avoid confusion among staff, patients and visitors.
➢ The organisation maintains a complete and accurate medical record for every patient. Various aspects of the
medical record like contents, staff authorised to make entries and retention of records are addressed
effectively by the organisation. The medical record is available for appropriate care providers. The medical
records are reviewed at regular intervals.
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Dr. J. L. Meena

IMS.1.
Information needs of the patients, visitors, staff, management and external agencies are
met.
IMS.2.
The organisation has processes in place for management and control of data and
information.
IMS.3. The patients cared for by the organisation have a complete and accurate medical record.
IMS.4. The medical record reflects the continuity of care.
IMS.5.
The organisation maintains confidentiality, integrity and security of records, data and
information.
IMS.6.
The organisation ensures availability of current and relevant documents, records, data
and information and provides for retention of the same.
IMS.7. The organisation carries out a review of medical records.
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Objective
Elements
IMS 1 IMS 2 IMS 3 IMS 4 IMS 5 IMS 6 IMS 7
a CORE Commitment CORE Commitment CORE CORE CORE
b Commitment Commitment Commitment Commitment CORE CORE Commitment
c Commitment Commitment CORE Commitment CORE Commitment Commitment
d Commitment Commitment Commitment Commitment Achievement Commitment Commitment
e Achievement Commitment Commitment Commitment Commitment Commitment
f Commitment Commitment Commitment Commitment Commitment
g Commitment Commitment Commitment Commitment
h Excellence Commitment

IMS 1 - Information needs of the patients,
visitors, staff, management and external
agencies are met.
Objective Elements
a) The organisation identifies the information needs of the patients, visitors, staff, management external
agencies and community. *
b) Identified information needs are captured and/or disseminated.
c) Information management and technology acquisitions are commensurate with the identified information
needs.
d) A maintenance plan for information technology and communication network is
implemented.
e) Contingency plan ensures continuity of information capture, integration and dissemination.
f) The organisation ensures that information resources are accurate and meet stakeholder requirements.
g) The organisation contributes to external databases in accordance with the law and
regulations.
h) The organisation shall make efforts to use digital health technology to improve operational efficiency,
patient safety and patient experience.
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Dr. J. L. Meena

IMS 2 - The organisation has processes in place
for management and control of data and
information.
Objective Elements
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Dr. J. L. Meena
a) Processes for data collection are standardised.
b) Data is analysed to meet the information needs.
c) The organisation disseminates the information in a timely and
accurate manner.
d) The organisation stores and retrieves data according to its
information needs. *
e) Clinical and managerial staff participate in selecting, integrating
and using data for meeting the information needs.

IMS 3 - The patients cared for by the
organisation have a complete and accurate
medical record.
Objective Elements
a) A unique identifier is assigned to the medical record.
b) The contents of the medical record are identified and
documented. *
c) The medical record provides a complete, up-to-date and
chronological account of patient care.
d) Authorised staff make the entry in the medical record. *
e) Entry in the medical record is signed, dated and timed.
f) The author of the entry can be identified.
g) The medical record has only authorised abbreviations.
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Dr. J. L. Meena

IMS 4 - The medical record reflects the
continuity of care.
Objective Elements
a) The medical record contains information regarding reasons for admission, diagnosis and
care plan.
b) The medical record contains the details of assessments, re-assessments and
consultations.
c) The medical record contains the results of investigations and the details of the care
provided.
d) Operative and other procedures performed are incorporated in the medical record.
e) When a patient is transferred to another organisation, the medical record contains the
details of the transfer.
f) The medical record contains a signed copy of the discharge summary.
g) In case of death, the medical record contains a copy of the medical certificate of the
cause of death.
h) Care providers have access to current and past medical record.
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Dr. J. L. Meena

IMS 5 - The organisation maintains
confidentiality, integrity and security of records,
data and information.
Objective Elements
a) The organisation maintains the confidentiality of records, data and
information.*
b) The organisation maintains the integrity of records, data and information. *
c) The organisation maintains the security of records, data and information.*
d) The organisation uses developments in appropriate technology for
improving confidentiality, integrity and security.
e) The organisation discloses privileged health information as authorised by
the patient and/or as required by law.
f) Request for access to information in the medical records by
patients/physicians and other public agencies are addressed consistently.*
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Dr. J. L. Meena

IMS 6 - The organisation ensures availability of
current and relevant documents, records, data and
information and provides for retention of the same.
Objective Elements
a) The organisation has an effective process for document
control. *
b) The organisation retains patient's clinical records, data and
information according to its requirements. *
c) The retention process provides expected confidentiality and
security.
d) The destruction of medical records, data and information are
in accordance with the written guidance.*
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Dr. J. L. Meena

IMS 7 - The organisation carries out a
review of medical records.
Objective Elements
a)The medical records are reviewed periodically.
b)The review uses a representative sample based on statistical
principles.
c)The review is conducted by identified individuals.
d)The review of records is based on identified parameters.
e)The review process includes records of both active and discharged
patients.
f) The review points out and documents any deficiencies in records.
g)Appropriate corrective and preventive measures are undertaken
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Summary
An Information Management System (IMS) promotes patient safety by
reducing medical errors, streamlining communication among healthcare
providers, and enabling data-driven decisions. Key features include automated
alerts for potential risks, compliance tracking, and secure data sharing. By
fostering transparency and accountability, IMS improves care quality,
minimizes adverse events, and supports regulatory compliance, ultimately
safeguarding patient well-being in healthcare settings. IMS for patient safety is
a digital framework designed to enhance healthcare delivery by organizing,
storing, and analyzing patient data. It integrates electronic health records,
incident reporting, and risk management tools to ensure accurate, real-time
information access.
Dr. J. L. Meena

Building a quality culture in India through NABH 6th STD.pdf

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