Download CAHOCON16-Dr-Basile-NABH-4th

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