NABH Hospital Accreditation Standards 6th E

Elements

Chapter1:ACCESS,
ASSESSMENT AND
CONTINUITY OF
CARE(AAC)
AAC.1:The organisation
defines and displays the
healthcare services that it
provides.
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response from the drop down menu
The healthcare services being provided are
AAC.1. a. defined and are in consonance with
the needs of the community.
Each defined healthcare service shall have
diagnostic and treatment services
AAC.1.b. with suitably qualified personnel who provide
out-patient, in-patient, daycare and
emergency cover.
Scope of the healthcare services of each
AAC.1.c.
department is defined. *
d. The organisation's defined healthcare
AAC.1.d.
services are prominently displayed.
AAC.2:The organisation has
a well-defined registration
and admission process.
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response from the drop down menu

The organisation uses written guidance for

AAC.2.a.
registering and admitting patients. *
A unique identification number is generated
AAC.2.b.
at the end of the registration.
Patients are accepted only if the
AAC.2.c. organisation can provide the required
service.
The written guidance also addresses
AAC.2.d. managing patients during non-availability
of beds. *
Access to the healthcare services in the
AAC.2.e. organisation is prioritised according to
the clinical needs of the patient. *
AAC.3:There is an
appropriate mechanism for
transfer (in and out) or
referral of patients.
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response from the drop down menu
Transfer-in of patients to the organisation is
AAC.3.a.
done appropriately. *
Transfer- out/referral of patients to another
AAC.3.b.
facility is done appropriately. *
During transfer or referral, accompanying
AAC.3.c. staff are appropriate to the clinical
condition of the patient.
The organisation gives a summary of the
AAC.3.d. patient's condition and the
treatment given.
AAC.4:Patients cared for by
the organisation undergo an
established initial
assessment.
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response from the drop down menu
 The initial assessment of the outpatients,
AAC.4.a. day-care, in-patients and emergency
patients is done in a standardised manner. *
The initial assessment is performed by
AAC.4.b
qualified personnel. *
The initial assessment is performed within a
AAC.4.c. time frame based on the needs of
the patient. *
Initial assessment of day-care and in-
patients includes nursing assessment,
AAC.4.d.
which is done at the time of admission and
documented.
The initial assessment for in-patients results
AAC.4.e.
in a documented care plan.
The care plan is countersigned by the
AAC.4.f. clinician-in-charge of the patient within 24
hours.
The care plan includes the identification of
AAC.4.g. special needs regarding care following
discharge.

AAC.5:Patients cared for by

the organization undergo a
regular reassessment
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response from the drop down menu

Patients are reassessed at appropriate

intervals to determine their response to
AAC.5.a.
treatment and to plan further treatment or
discharge.
Out-patients are informed of their next follow-
AAC.5.b.
up, where appropriate.
For in-patients during reassessment, the
AAC.5.c. care plan is monitored and modified,
where found necessary.
Staff involved in direct clinical care
AAC.5.d.
document reassessments.
The organisation lays down guidelines and
implements processes to identify
AAC.5.e. early warning signs of change or
deterioration in clinical conditions for
initiating prompt intervention.
AAC.6:Laboratory services
are provided as per the
scope of services of the
organisation.
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response from the drop down menu
Scope of the laboratory services is
AAC.6.a. commensurate to the services provided by
the organisation.
The infrastructure (physical and equipment)
AAC.6.b. is adequate to provide the defined scope of
services.
Human resource is adequate to provide the
AAC.6.c.
defined scope of services.
Qualified and trained personnel perform and
AAC.6.d. supervise the investigations and
report the results.
Requisition for tests, collection,
identification, handling, safe transportation,
AAC.6.e. processing and disposal of a specimen is
performed according to written
guidance. *
Laboratory results are available within a
AAC.6.f.
defined time frame. *
Critical results are intimated to the person
AAC.6.g.
concerned at the earliest. *
Results are reported in a standardised
AAC.6.h.
manner.
There is a mechanism to address the recall /
AAC.6.i. amendment of reports whenever
applicable. *
Laboratory tests not available in the
organisation are outsourced to the
AAC.6.j.
organisation(s) based on their quality
assurance system. *
AAC.7:There is an
established laboratory
quality assurance and safety
programme.
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response from the drop down menu
The laboratory quality assurance
AAC.7.a.
programme is implemented. *
 The programme ensures the quality of test
AAC.7.b.
results through internal quality control. *
Laboratory participates in proficiency
AAC.7.c.
testing/external quality assurance scheme.
The programme addresses
AAC.7.d.
clinicopathological meeting(s).
The laboratory safety programme is
AAC.7.e.
implemented. *
Laboratory personnel are appropriately
AAC.7.f.
trained in safe practices.
Laboratory personnel are provided with
AAC 7.g.
appropriate safety measures.

AAC.8:Imaging services are

provided as per the scope of
services of the organisation.
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response from the drop down menu

Imaging services comply with legal and other

AAC.8.a.
requirements.
Scope of the imaging services is
AAC.8.b. commensurate to the services provided by
the organisation.
The infrastructure (physical and equipment)
AAC.8.c. and human resources are adequate to
provide for its defined scope of services.
Qualified and trained personnel perform,
AAC.8.d.
supervise and interpret the investigations.
Imaging results are available within a
AAC.8.e.
defined time frame. *
Critical results are intimated immediately to
AAC.8.f.
the personnel concerned. *
Results are reported in a standardised
AAC.8.g.
manner.
There is a mechanism to address the recall /
AAC.8.h. amendment of reports whenever
applicable. *
Imaging tests not available in the
organisation are outsourced to the
AAC.8.i.
organisation(s) based on their quality
assurance system. *
AAC.9:There is an
established quality
assurance and safety
programme for imaging
services.
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response from the drop down menu
The quality assurance programme for
AAC.9.a.
imaging services is implemented. *
A system is in place to ensure the
AAC.9.b. appropriateness of the investigations and
procedures for the clinical indication.
The programme addresses periodic
AAC.9.c. internal/external peer review of imaging
results using appropriate sampling.
The programme addresses the clinico-
AAC.9.d.
radiological meeting(s).
The programme includes the documentation
AAC.9.e.
of corrective and preventive actions. *
The radiation-safety programme is
AAC 9.f.
implemented. *
Patients are appropriately screened for
AAC 9.g.
safety/risk before imaging.
Imaging personnel and patients use
AAC 9.h. appropriate radiation safety and monitoring
devices where applicable.
Radiation-safety and monitoring devices are
AAC 9.i. periodically tested, and results are
documented. *
Imaging and ancillary personnel are trained
AAC 9.j. in imaging safety practices and
radiation-safety measures.
Imaging signage is prominently displayed in
AAC. 9.k.
all appropriate locations.
AAC.10:Patient care is
continuous and
multidisciplinary.
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response from the drop down menu
 During all phases of care, there is a qualified
AAC.10.a. individual identified as responsible
for the patient's care.
Patient care is co-ordinated in all care
AAC.10.b.
settings within the organisation.
Information about the patient's care and
AAC.10.c. response to treatment is shared among
medical, nursing and other care -providers.
The Organisation implements standardiszed
hand-over communication during each
AAC.10.d. staffing shift, between shifts and during
transfers between units/
departments.
Patient transfer within the organisation is
AAC.10.e.
done safely in a safe manner.
Referral of patients to other departments/
AAC.10.f.
specialities follow written guidance.
The organisation ensures predictable
service delivery by adhering to defined
AAC.10.g. timelines and informs the patient/family and/
or caregiver whenever there is a
change in schedule.
The organisation has a mechanism in place
to monitor whether adequate clinical
AAC.10.h.
intervention has taken place in response to a
critical value alert.

AAC 11: The preventive and

promotive health services are
provided in a safe, collaborative
and consistent manner. * Please
select the appropriate response
from the drop down menu

Written guidance governs the

AAC 11.a. implementation of preventive and promotive
care as per the scope of services. *

Organization shall define evidenced based

AAC 11.b. and contextual age-appropriate screening
for non-communicable diseases.
Mental Health screening and appropriate
AAC. 11.c. intervention is advised for patients wherever
applicable
 Evidence based and contextual paediatric
AAC. 11.d. and adult immunization shall be advised
whereever applicable
A multidisciplinary approach is adopted in
AAC 11.e. imparting health education on life-style
modifications.
AAC.12:The organisation
has an established
discharge process.
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response from the drop down menu

The patient's discharge process is planned

AAC.12.a.
in consultation with the patient and/or family.

The discharge process is coordinated

among various departments and agencies
AAC.12.b.
involved (including medico-legal and
absconded cases). *

Written guidance governs the discharge of

AAC.12.c.
patients leaving against medical advice. *

A discharge summary is given to all the

AAC.12.d. patients leaving the organisation (including
patients leaving against medical advice).
The organisation adheres to planned
AAC.12.e.
discharge.
The care shall be provided by expanding
AAC.12.f. access to health practices through
domiciliary visits, wherever applicable.
The organization monitors the discharge
AAC. 12.g. time, sets appropriate benchmarks and
make continual improvement.
AAC.13:The organisation
defines the content of the
discharge summary.
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response from the drop down menu
A discharge summary is provided to the
AAC.13.a.
patients at the time of discharge.
Discharge summary has a standarised
AAC.13.b.
content.
 Discharge summary contains follow-up
AAC.13.c. advice, medication and other instructions
in an understandable manner.
Discharge summary incorporates
AAC.13.d. instructions about when and how to obtain
urgent care.
In case of death, the summary of the case
AAC.13.e.
also includes the cause of death.
Chapter2:CARE OF PATIENTS(COP)

COP.1:Uniform care to
patients is provided in all
settings of the organisation
and is guided by written
guidance, and the applicable
laws and regulations.
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response from the drop down menu

Uniform care is provided to patients

COP.1.a.
following written guidance. *
The organisation has a uniform process for
COP.1.b. identification of patients and at a
minimum, uses two identifiers.
The organization implements evidence-
based clinical practice guidelines and/or
COP 1.c.
clinical protocols to guide uniform patient
care.
Clinical care pathways are developed,
COP.1.d. consistently followed across all settings of
care, and reviewed periodically.
Multi-disciplinary and multi-speciality care,
where appropriate, is planned based
COP.1.e. on best clinical practices/clinical practice
guidelines and delivered in a uniform
manner across the organisation.
Telemedicine facility is provided safely and
COP.1.f.
securely based on written guidance. *
COP.2:Emergency services
are provided in accordance
with written guidance,
applicable laws and
regulations.
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response from the drop down menu
There shall be an identified area in the
organisation which is easily accessible to
COP.2.a. receive and manage emergency patients,
with adequate and appropriate
resources.
Prevention of patient over-crowding is
COP.2.b. planned, and crowd management
measures are implemented.
Emergency care is provided in consonance
with statutory requirements including
COP.2.c.
medicolegal cases and as per written
guidance. *
Initiation of appropriate care is guided by a
COP.2.d.
system of triage. *
Patients waiting in the emergency are
COP.2.e. reassessed as appropriate for change in
status.
Admission, discharge to home, or transfer to
COP.2.f. another organisation is
documented.
In case of discharge to home or transfer to
COP.2.g. another organisation, a discharge/
transfer note shall be given to the patient.
The organisation shall implement a quality
COP.2.h.
assurance programme. *
The organisation has systems in place for
the management of patients found
COP.2.i.
dead on arrival and patients who die within a
few minutes of arrival *
COP.3:Ambulance services
ensure safe patient
transportation with
appropriate care
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response from the drop down menu
 The organisation has access to ambulance
COP.3.a. services commensurate with the
scope of the services provided by it.
There are adequate access and space for
COP.3.b.
the ambulance(s).
The ambulance(s) is fit for purpose and is
COP.3.c.
appropriately equipped.
The ambulance(s) is operated by trained
COP.3.d.
personnel.
The ambulance(s) is checked daily for
COP.3.e. functioning status, medical equipment,
emergency medications and consumables.
The ambulance(s) has a proper
COP.3.f.
communication system.*
The emergency department identifies
opportunities to initiate treatment at the
COP.3.g.
earliest when the patient is in transit to the
organisation.
COP.4:The organisation
plans and implements
mechanisms for the care of
patients during community
emergencies, epidemics and
other disasters.
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response from the drop down menu
The organisation identifies potential
COP.4.a. community emergencies, epidemics and
other disasters.*
The organisation manages community
COP.4.b. emergencies, epidemics and other
disasters as per a documented plan.*
Provision is made for availability of medical
COP.4.c. supplies, equipment and materials
during such emergencies.
COP.4.d. The plan is tested at least twice a year.
COP.5:Cardio-pulmonary
resuscitation services are
provided uniformly across
the organisation.
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response from the drop down menu
Cardio-pulmonary resuscitation services are
COP.5.a.
available to patients at all times.
During cardio-pulmonary resuscitation,
COP.5.b. assigned roles and responsibilities are
complied with.

Medical equipment and medications for use

COP.5.c. during cardio-pulmonary resuscitation are
available in various areas of the organisation.

The events during cardio-pulmonary

COP.5.d.
resuscitation are recorded.
A multidisciplinary committee does a post-
COP.5.e. event analysis of cardiopulmonary
resuscitations.
Corrective and preventive measures are
COP.5.f.
taken based on the post-event analysis.

COP.6: Nursing care is

provided to patients in the
organisation in consonance
with clinical protocols.
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response from the drop down menu

Nursing care is provided to patients in

COP.6.a.
accordance with written guidance. *
Assignment of patient care is done as per
COP 6.b. current good clinical/ nursing practice
guidelines.
The organization implements acquity-based
COP.6.c.
staffing to improve patient outcomes.

Nursing care is aligned and integrated with

COP.6.d.
overall patient care which is documented.*
Nurses are provided with appropriate and
COP.6.e. adequate equipment for providing safe
and efficient nursing care.
 Nurses are empowered to make patient care
COP.6.f.
decisions within their scope of practice.

COP.7:Clinical procedures
are performed in a safe
manner.
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response from the drop down menu
Clinical procedures are performed based on
COP.7.a.
the clinical needs of the patient.
Performance of various clinical procedures
COP.7.b. is based on written guidance and done in
safe manner. *
Qualified personnel order, plan, perform and
COP.7.c.
assist in performing procedures.
Care is taken to prevent adverse events like
COP.7.d. a wrong patient, wrong procedure
and wrong site. *
Informed consent is taken by the personnel
COP.7.e. performing the procedure, where
applicable.
Patients are appropriately monitored during
COP.7.f.
and after the procedure.
Procedures are documented accurately in
COP.7.g.
the patient record.
COP.8:Transfusion services
are provided as per the
scope of services of the
organisation, safely.
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response from the drop down menu
Scope of transfusion services is
COP.8.a. commensurate with the services provided by
the organisation.
The organization shall establish and
implement processes for blood/component
COP 8.b.
collection, testing, storage and distribution
under written guidance.*
Blood and components are stored safely
COP.8.c.
from the time of collection till transfusion.
 The organization ensures safe and rational
COP.8.d.
use of blood and blood components.
Blood/blood components are available for
COP.8.e. use in emergency and routine situations
within a defined time-frame. *
The organization shall ensure that post
transfusion form is collected, reactions if any
COP.8.f.
identified and are analyzed for preventive
and corrective actions.*
The organisation shall implement a quality
COP.8.g.
assurance programme. *
COP.9:The organisation
provides care in intensive
care and high dependency
units in a systematic
manner.
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response from the drop down menu

Care of patients in intensive care and high

COP.9.a. dependency units is provided based on
written guidance. *
The defined admission and discharge
COP.9.b. criteria for intensive care and high
dependency units are implemented. *
COP.9.c. Adequate staff and equipment are available.
Defined procedures for the situation of bed
COP.9.d.
shortages are followed. *
Infection prevetion and control practices are
COP.9.e.
followed. *
The organisation shall implement a quality
COP.9.f.
assurance programme. *
The organisation has a mechanism to
COP.9.g.
counsel the patient and/or family periodically.

COP.10:Organisation
provides safe obstetric care.
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response from the drop down menu

Obstetric services are organised and

COP.10.a.
provided safely. *
 The organisation identifies and, provides
care to high-risk obstetric cases, and
COP.10.b.
where needed, refers them to another
appropriate centre.
Persons caring for high-risk obstetric cases
COP.10.c.
are competent.
COP.10.d. Ante-natal services are provided. *
Organization encourages and welcome the
COP 10.e.
presence of a birth companion during labour
Organization treats pregnant women and her
companion cordially and respectfully,
COP.10.f.
ensures privacy and confidentiality for
pregnant woman and her companion.
The treating doctor explains danger signs
COP.10.g. and important care activities to pregnant
woman and her companion.
Obstetric patient's assessment also includes
COP.10.h.
maternal nutrition
Appropriate perinatal and post natal
COP 10.i.
monitoring is performed.
The organization caring for high-risk
COP 10.j. obstetric cases have the facilities to take
care of neonates of such cases.
Organization shall adhere to legal and
COP 10.k. defined Assisted Reproductive Technology
(ART) practices.
COP.11:Organisation
provides safe paediatric
services.
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response from the drop down menu
Paediatric services are organised and
COP.11.a.
provided safely. *
Neonatal care is in consonance with the
COP.11.b.
national/ international guidelines. *
Those who care for children have age-
COP.11.c.
specific competency.
Provisions are made for special care of
COP.11.d.
children.
Paediatric assessment includes growth,
COP.11.e. developmental and immunisation
assessment.
 The organisation has measures in place to
COP.11.f. prevent child/neonate abduction
and abuse. *
The child's family members are educated
COP.11.g. about nutrition, immunisation and safe
parenting.
The organization provides for adolescent
COP 11.h.
friendly health care services.

COP.12:Procedural sedation
is provided in a consistent
and safe manner.
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response from the drop down menu
Procedural sedation is administered in a
COP.12.a.
consistent manner *
Informed consent for administration of
COP.12.b.
procedural sedation is obtained.
Competent and trained persons administer
COP.12.c.
sedation.
The person monitoring sedation is different
COP.12.d. from the person performing the
procedure.
Intra-procedure monitoring includes at a
minimum the heart rate, cardiac rhythm,
COP.12.e.
respiratory rate, blood pressure, oxygen
saturation, and level of sedation.
Patients are monitored after sedation, and
COP.12.f.
the same is documented.
Criteria are used to determine the
COP.12.g. appropriateness of discharge from the
observation/recovery area. *
Equipment and workforce are available to
manage patients who have gone into a
COP.12.h.
deeper level of sedation than initially
intended.

COP.13:Anaesthesia
services are provided in a
consistent and safe manner.
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response from the drop down menu

Anaesthesia services are provided in a

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

COP.14:Surgical services
are provided in a consistent
and safe manner.
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response from the drop down menu

Surgical services are provided in a

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

COP.15:The organ
transplant programme is
carried out safely.
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response from the drop down menu
The organ transplant program shall be in
COP.15.a. consonance with the legal requirements
and shall be conducted ethically.
Care of transplant patients is guided by
COP.15.b.
clinical practice guidelines. *
The organisation ensures education and
counselling of recipient and donor
COP.15.c.
through trained/qualified counsellors before
organ transplantation.
The organisation shall take measures to
COP.15.d. create awareness regarding organ
donation.
COP.16:The organisation
identifies and manages
patients who are at higher
risk of morbidity/ mortality.
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response from the drop down menu
The organisation identifies and manages
COP.16.a.
vulnerable patients. *
The organisation identifies and manages
COP.16.b.
patients who are at a risk of fall.*
 The organisation identifies and manages
COP.16.c. patients who are at risk of
developing/worsening of pressure ulcers.*
The organisation identifies and manages
COP.16.d. patients who are at risk of developing
deep vein thrombosis.*
The organisation identifies and manages
COP.16.e.
patients who need restraints. *
COP.17:Pain management
for patients is done in a
consistent manner.
* Please select the appropriate
response from the drop down menu

COP.17.a. Patients in pain are effectively managed. *

COP.17.b. Patients are screened for pain.
Patients with pain undergo detailed
COP.17.c.
assessment and periodic reassessment.
Pain alleviation measures or medications
COP.17.d. 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.
* Please select the appropriate
response from the drop down menu

Scope of the rehabilitation services at a

COP.18.a. minimum is commensurate to the services
provided by the organisation.
Rehabilitation services are provided in a
COP.18.b.
consistent manner.
Care providers collaboratively plan
COP.18.c.
rehabilitation services.
There are adequate space and equipment to
COP.18.d.
provide rehabilitation.
Care is guided by functional assessment
COP.18.e. and periodic re-assessments which are
done and documented.
Care is provided adhering to infection control
COP.18.f.
and safety practices.
 Care pathways are developed, implemented,
COP.18.g.
and reviewed periodically.
COP.19:Nutritional therapy
is provided to patients
consistently and
collaboratively.
* Please select the appropriate
response from the drop down menu
Patients admitted to the organisation are
COP.19.a.
screened for nutritional risk. *
Nutritional assessment is done for patients
COP.19.b.
found at risk during nutritional screening.
The therapeutic diet is planned and provided
COP.19.c.
collaboratively.
Patients receive food according to the
COP.19.d.
written order for the diet.
When family provides food, they are
COP.19.e.
educated about the patient's diet limitations.

COP.20:End-of-life-care is
provided in a
compassionate and
considerate manner.
* Please select the appropriate
response from the drop down menu
End-of-life care is provided in a consistent
COP.20.a.
manner in the organisation. *
A multi-professional approach is used to
COP.20.b.
provide end-of-life care.
End-of-life care is in consonance with the
COP.20.c.
legal requirements.
End of life care also addresses the
COP.20.d. identification of the unique needs of such
patient and family.
Symptomatic treatment is provided and
COP.20.e. where appropriate measures are taken
for the alleviation of pain.
Chapter3:Management of Medication(MOM)
MOM.1:Pharmacy services
and medication
management is done safely.
* Please select the appropriate
response from the drop down menu

Pharmacy services and medication

MOM.1.a. management are implemented following
written guidance. *
A multidisciplinary committee guides the
formulation and implementation of
MOM.1.b.
pharmacy services and medication
management.
The multidisciplinary committee updates
MOM.1.c.
medication management processes.
There is a procedure to obtain medication
MOM.1.d. when the pharmacy is closed or in case of
stock-outs. *
The organisation has a mechanism to inform
relevant staff of key changes in
MOM.1.e. pharmacy services and medication
management to ensure uninterrupted and
safe care.
MOM.2.The organisation
develops, updates and
implements a hospital
formulary.
* Please select the appropriate
response from the drop down menu
A list of medications appropriate for the
patients and as per the scope of the
MOM.2.a. organisation's clinical services is developed
collaboratively by the multidisciplinary
committee.
The list is reviewed and updated
MOM.2.b. collaboratively by the multidisciplinary
committee at least annually.
The current formulary is available for
MOM.2.c.
clinicians to refer to.
The clinicians adhere to the current
MOM.2.d.
formulary.
The organisation adheres to the procedure
MOM.2.e. for the acquisition of formulary
medications. *
 The organisation adheres to the procedure
MOM.2.f. to obtain medications not listed in the
formulary. *

MOM.3:Medications are
stored appropriately and are
available where required.
* Please select the appropriate
response from the drop down menu

Medications are stored in a clean, safe and

secure environment; and while
MOM.3.a.
incorporating the manufacturer's
recommendation(s).
Sound inventory control practices guide
MOM.3.b. storage of the medications throughout
the organisation.
The organisation defines and updates its list
MOM.3.c.
of high-risk medication(s). *
High-risk medications are stored in areas of
MOM.3.d. the organisation where it is clinically
necessary.
High-risk medications including look-alike,
sound-alike medications and
MOM.3.e. different concentrations of the same
medication are stored physically apart
from each other. *
The list of emergency medications is defined
MOM.3.f.
and is stored uniformly. *
Emergency medications are available all the
MOM.3.g. time and are replenished promptly
when used.
MOM.4:Medications are
prescribed safely and
rationally.
* Please select the appropriate
response from the drop down menu
Medication prescription is in consonance
MOM.4.a. with good practices/guidelines for the
rational prescription of medications. *
The organisation adheres to the determined
MOM.4.b. minimum requirements of a
prescription. *
 Drug allergies and previous adverse drug
MOM.4.c. reactions are ascertained before
prescribing.
The organisation has a mechanism to assist
MOM.4.d. the clinician in prescribing
appropriate medication.
Reconciliation of medications occurs at
MOM. 4.e.
transition points of patient care.
Verbal orders are implemented by ensuring
MOM.4.f.
safe medication management practices. *
Audit of medication orders/prescription is
MOM.4.g. carried out to check for safe and
rational prescription of medications.
Corrective and/or preventive action(s) is
MOM.4.h. taken based on the audit, where
appropriate.
MOM.5:Medications orders
are written in a uniform
manner.
* Please select the appropriate
response from the drop down menu
The organisation ensures that only
MOM.5.a.
authorised personnel write orders. *
Medication orders are written in a uniform
location in the medical records, which
MOM.5.b.
also include the patient's name and unique
identification number.
Medication orders are legible, dated, timed
MOM.5.c.
and signed.
Medication orders contain the name of the
medicine, route of administration,
MOM.5.d.
strength to be administered and
frequency/time of administration.

MOM.6:Medications are
dispensed in a safe manner.
* Please select the appropriate
response from the drop down menu

MOM.6.a. Dispensing of medications is done safely. *

MOM.6.b. Medication recalls are handled effectively. *

 Near-expiry medications are handled
MOM.6.c.
effectively. *
MOM.6.d. Dispensed medications are labelled. *
High-risk medication orders are verified
MOM.6.e.
before dispensing.
Return of medications to the pharmacy is
MOM.6.f.
addressed. *
MOM.7:Medications are
administered safely.
* Please select the appropriate
response from the drop down menu
Medications are administered by those who
MOM.7.a.
are permitted by law to do so.
Prepared medication is labelled before
MOM.7.b.
preparation of a second drug.
The patient is identified before
MOM.7.c.
administration.
Medication is verified from the medication
MOM.7.d. order and physically inspected before
administration.
Strength is verified from the order before
MOM.7.e.
administration.
The route is verified from the order before
MOM.7.f.
administration.
Timing is verified from the order before
MOM.7.g.
administration.
Measures to avoid catheter and tubing mis-
MOM.7.h. connections during medication
administration are implemented. *
MOM.7.i. Medication administration is documented.
Measures to govern patient's self-
MOM.7.j. administration of medications are
implemented. *
Measures to govern patient's medications
MOM.7.k. brought from outside the organisation
are implemented. *
MOM.8:Patients are
monitored after medication
administration.
* Please select the appropriate
response from the drop down menu
Patients shall be monitored after medication
MOM.8.a.
administration. *
 Medications shall be changed where
MOM.8.b.
appropriate based on the monitoring.
The organisation shall captures near misses,
MOM.8.c. medication errors and adverse drug
reactions. *
Near misses, medication errors and adverse
MOM.8.d. drug reactions shall be reported within a
specified time frame. *
Near misses, medication errors and adverse
MOM.8.e.
drug reactions are collected and analysed.
Corrective and/or preventive action(s) are
MOM.8.f.
taken based on the analysis.
MOM.9:Narcotic drugs and
psychotropic substances,
chemotherapeutic agents
and radioactive agents are
used in a safe manner.
* Please select the appropriate
response from the drop down menu

Narcotic drugs and psychotropic

MOM.9.a. substances, chemotherapeutic agents and
radioactive agents are used safely. *

Narcotic drugs and psychotropic

substances, chemotherapeutic agents and
MOM.9.b.
radioactive agents are prescribed by
appropriate caregivers.

Narcotic drugs and psychotropic

substances, chemotherapeutic agents and
MOM.9.c.
radioactive agents drugs shall be stored
securely.
Chemotherapy and radioactive agents are
MOM.9.d. prepared properly and safely and
administered by qualified personnel.
A proper record shall be kept of the usage,
administration and disposal of narcotic drugs
MOM.9.e. and psychotropic substances,
chemotherapeutic agents and radioactive
agents.
MOM.10:Implantable
prosthesis and medical
devices are used in
accordance with laid down
criteria.
* Please select the appropriate
response from the drop down menu

Usage of the implantable prosthesis and

medical devices is guided by scientific
MOM.10.a. criteria for each item and
national/international recognised guidelines/
approvals for such specific item(s).

The organisation implements a mechanism

MOM.10.b. for the usage of the implantable
prosthesis and medical devices. *
Patient and his/her family are counselled for
the usage of the implantable
MOM.10.c.
prosthesis and medical device, including
precautions if any.
The batch and the serial number of the
implantable prosthesis and medical
MOM.10.d. devices are recorded in the patient's medical
record, the master logbook and the
discharge summary.
Process of recall of implantable prosthesis
MOM.10.e. and medical devices are handled effectively.
*

MOM.11:Medical supplies
and consumables are stored
appropriately and are
available where required.
* Please select the appropriate
response from the drop down menu

The organisation adheres to the defined

MOM.11.a. process for the acquisition of medical
supplies and consumables. *
Medical supplies and consumables are used
MOM.11.b.
in a safe manner, where appropriate.
 Medical supplies and consumables are
stored in a clean, safe and secure
MOM.11.c.
environment; and incorporating the
manufacturer's recommendation(s).
Sound inventory control practices guide
MOM.11.d. storage of medical supplies and
consumables
There is a mechanism in place to verify the
MOM.11.e. condition of medical supplies and
consumables
Chapter4:Patient Rights and Education(PRE)

PRE.1.The organisation
protects and promotes
patient and family rights and
informs them about their
responsibilities during care.
* Please select the appropriate
response from the drop down menu

Patient and family rights and responsibilities

PRE.1.a. are documented, displayed and they are
made aware of the same. *
Patient and family rights and responsibilities
PRE.1.b.
are actively promoted. *
The organisation protects patient and family
PRE.1.c.
rights.
The organisation has a mechanism to report
PRE.1.d.
a violation of patient and family rights.
Violation of patient and family rights are
monitored, analysed, and
PRE.1.e.
corrective/preventive action taken by the top
leadership of the organisation.

PRE.2:Patient and family

rights support individual
beliefs, values and involve
the patient and family in
decision-making processes.
* Please select the appropriate
response from the drop down menu
 Patients and family rights include respecting
values and beliefs, any special
PRE.2.a.
preferences, cultural needs, and responding
to requests for spiritual needs.
Patient and family rights include respect for
PRE.2.b. personal dignity and privacy during
examination, procedures and treatment.
Patient and family rights include protection
PRE.2.c.
from neglect or abuse.
Patient and family rights include treating
PRE.2.d.
patient information as confidential.
Patient and family rights include the refusal
PRE.2.e.
of treatment.
Patient and family rights include a right to
PRE.2.f. seek an additional opinion regarding
clinical care.
Patient and family rights include informed
consent before the transfusion of blood
and blood components, anaesthesia,
PRE.2.g.
surgery, initiation of any research protocol
and any other invasive/high-risk
procedures/treatment.
Patient and family rights include a right to
PRE.2.h. complain and information on how to
voice a complaint.
Patient and family rights include information
PRE.2.i. on the expected cost of the
treatment.
Patient and family rights include access to
PRE.2.j.
their clinical records.
Patient and family rights include information
on the name of the treating doctor,care plan,
PRE.2.k.
progress and information on their health
care needs.
Patient rights include determining what
PRE.2.l. information regarding their care would be
provided to self and family.
PRE.3:The patient and/or
family members are
educated to make informed
decisions and are involved
in the care planning and
delivery process.
* Please select the appropriate
response from the drop down menu
The Patient and/or family members are
explained about the proposed care,
PRE.3.a. (including the risks, alternatives and
benefits), expected rresults and possible
complications.
The care plan is prepared and modified in
PRE.3.b. consultation with the patient and/or
family members.
The patient and/or family members are
PRE.3.c. informed about the results of diagnostic
tests and the diagnosis.
The patient and/or family members are
PRE.3.d. explained about any change in the
patient's condition in a timely manner.
The patient and/or family members are
PRE.3.g. provided multi-disciplinary counselling
when appropriate.
PRE.4:Informed consent is
obtained from the patient or
family about their care.
* Please select the appropriate
response from the drop down menu

The organisation obtains informed consent

PRE.4.a. from the patient or family for situations
where informed consent is required. *
Informed consent process adheres to
PRE.4.b.
statutory norms.
Informed consent includes information
regarding the procedure; it's risks,
PRE.4.c. benefits, alternatives and as to who will
perform the procedure in a language that
they can understand.
 The organisation describes who can give
consent when a patient is incapable of
PRE.4.d.
independent decision making and
implements the same. *
Informed consent is taken by the person
PRE.4.e.
performing the procedure.
PRE.5:Patient and families
have a right to information
and education about their
healthcare needs.
* Please select the appropriate
response from the drop down menu
Patient and/or family are educated in a
PRE.5.a. language and format that they can
understand.
Patient and/or family are educated about the
safe and effective use of medication
PRE.5.b.
and the potential side effects of the
medication, when appropriate.
Patient and/or family are educated about
PRE.5.c.
food-drug interaction.
Patient and/or family are educated about
PRE.5.d.
diet and nutrition.
Patient and/or family are educated about
PRE.5.e.
immunisations.
Patient and/or family are educated on
PRE.5.f. various pain management techniques,
when appropriate.
Patient and/or family are educated about
PRE.5.g. their specific disease process,
complications and prevention strategies.
Patient and/or family are educated about
PRE.5.h. preventing healthcare associated
infections.
The patients and/or family members' special
PRE.5.i. educational needs are identified and
addressed.
The organization has a mechanism to
PRE. 5j. promote patient engagement to enhance
clinical outcomes, safety and quality.
PRE.6:Patients and families
have a right to information
on expected costs.
* Please select the appropriate
response from the drop down menu
The patient and/or family members are
made aware of the pricing policy in
PRE.6.a.
different settings (out-patient, emergency,
ICU and inpatient).
PRE.6.b. The relevant tariff list is available to patients.
The patient and/or family members are
PRE.6.c.
explained about the expected costs.
Patient and/or family are informed about the
PRE.6.d. 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.
* Please select the appropriate
response from the drop down menu
The organisation has a mechanism to
PRE.7.a. capture feedback from patients, which
includes patient satisfaction.
The organisation has a mechanism to
PRE.7.b.
capture patient experience.
The organisation redress patient complaints
PRE.7.c.
as per the defined mechanism. *
Patient and/or family members are made
PRE.7.d. aware of the procedure for giving
feedback and/or lodging complaints.
Feedback and complaints are reviewed
PRE.7.e. and/or analysed within a defined
time frame.
Corrective and/or preventive action(s) are
PRE.7.f. taken based on the analysis where
appropriate.
PRE.8:The organisation has
a system for effective
communication with
patients and/or families.
* Please select the appropriate
response from the drop down menu
Communication with the patients and/or
PRE.8.a.
families is done effectively. *
The organisation shall identify special
situations where enhanced communication
PRE.8.b.
with patients and/or families would be
required. *

Enhanced communication with the patients

PRE.8.c.
and/or families is done effectively. *
The organisation ensures that there is no
PRE.8.d.
unacceptable communication.
The organisation has a system to monitor
PRE.8.e. and review the implementation of
effective communication.
Chapter5:INFECTION PREVENTION AND CONTROL (IPC)
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.
* Please select the appropriate
response from the drop down menu
The infection prevention and control
programme is documented, which
IPC.1.a. aims at preventing and reducing the risk of
healthcare associated infections in the
hospital. *
The infection prevention and control
programme identifies high-risk
IPC.1.b. activities, and has written guidance to
prevent and manage infections for these
activities.*
 The infection prevention and control
IPC.1.c. programme is reviewed and updated at least
once a year.
The infection prevention and control
IPC.1.d. programme is reviewed based on infection
control assessment tool.
The organisation has a multi-disciplinary
infection control committee, which
IPC.1.e.
coordinates all infection prevention and
control activities. *
The organisation has an infection control
team, which coordinates the
IPC.1.f.
implementation of all infection prevention
and control activities. *
The organisation has designated infection
IPC.1.g. control officer as part of the infection
control team. *
The organisation has designated infection
IPC.1.h. control nurse(s) as part of the infection
control team. *
The organisation implements information,
education and communication
IPC.1.i.
programme for infection prevention and
control activities for the community.
The organisation participates in managing
IPC.1.j.
community outbreaks.
IPC.2:The organisation
provides adequate and
appropriate resources for
infection prevention and
control.
* Please select the appropriate
response from the drop down menu
The management makes available
resources required for the infection
IPC.2.a. prevention and control
programme including allocation of adequate
funds from its annual budget.
Adequate and appropriate personal
protective equipment, soaps, and
IPC.2.b.
disinfectants are available and used
correctly.
 Adequate and appropriate facilities for hand
IPC.2.c. hygiene in all patient-care areas are
accessible to healthcare providers.
Isolation/barrier nursing facilities are
IPC.2.e.
available.

IPC.3:The organisation
implements the infection
prevention and control
programme in clinical areas.
* Please select the appropriate
response from the drop down menu

The organisation adheres to standard

IPC.3.a.
precautions at all times. *
The organisation adheres to hand-hygiene
IPC.3.b.
guidelines. *
The organisation adheres to transmission-
IPC.3.c.
based precautions. *
The organisation adheres to safe injection
IPC.3.d.
and infusion practices. *
Appropriate antimicrobial usage policy is
IPC.3.e.
established and documented *
The organisation implements the
antimicrobial stewardship programme and
IPC.3.f.
monitors the rational use of antimicrobial
agents.
IPC.4:The organisation
implements the infection
prevention and control
programme in support
services.
* Please select the appropriate
response from the drop down menu

The organisation has appropriate

IPC.4.a.
engineering controls to prevent infections. *
The organisation designs and implements a
IPC.4.b. plan to reduce the risk of infection
during construction and renovation. *
The organisation adheres to housekeeping
IPC.4.c.
procedures. *
Biomedical waste (BMW) is handled
IPC.4.d.
appropriately and safely.
 The organisation adheres to laundry and
IPC.4.e.
linen management processes. *
The organisation adheres to kitchen
IPC.4.f.
sanitation and food-handling issues. *
HIC.5:The organisation
takes actions to prevent
healthcare associated
infections (HAI) in patients.
* Please select the appropriate
response from the drop down menu
The organisation takes action to prevent
IPC.5.a. catheter-associated urinary tract
Infections.
The organisation takes action to prevent
IPC.5.b.
ventilator-associated pneumonia.
The organisation takes action to prevent
IPC.5.c.
central line blood stream infections.
The organisation takes action to prevent
IPC.5.d.
surgical site infections.
IPC.6:The organisation
performs surveillance to
capture and monitor
infection prevention and
control data.
* Please select the appropriate
response from the drop down menu
The scope of surveillance incorporates
IPC.6.a. tracking and analysing of infection risks,
rates and trends.
Verification of data is done regularly by the
IPC.6.b.
infection control team.
Surveillance is directed towards the
IPC.6.c
identified high-risk activities.
Surveillance includes monitoring compliance
IPC.6.d.
with hand-hygiene guidelines.
Surveillance includes mechanisms to
IPC.6.e. capture the occurrence of multi-drug
resistant organisms.
Surveillance includes monitoring the
IPC.6.f.
effectiveness of housekeeping services.
Feedback regarding surveillance data is
IPC.6.g. provided regularly to the appropriate
health care provider.
 The organisation identifies and takes
IPC.6.h. appropriate action to control outbreaks of
infections.
Surveillance data is analysed, and
IPC.6.I. appropriate corrective and preventive
actions are taken.
IPC.7:Infection prevention
measures include
sterilisation and/or
disinfection of instruments,
equipment and devices.
* Please select the appropriate
response from the drop down menu
The organisation provides adequate space
IPC.7.a. and appropriate zoning for sterilisation
activities.
Cleaning, packing, disinfection and/or
IPC.7.b. sterilisation, storing and the issue of items
is done as per the written guidance. *
Reprocessing of single-use instruments,
IPC.7.c. equipment and devices are done as per
written guidance. *
Regular validation tests for sterilisation are
IPC.7.d.
carried out and documented. *
The established recall procedure is
IPC.7.e. implemented when a breakdown in the
sterilisation system is identified. *
IPC.8:The organisation
takes action to prevent or
reduce healthcare
associated infections in its
staff.
* Please select the appropriate
response from the drop down menu
The organisation implements occupational
health and safety practices as per written
IPC.8.a. guidance to reduce the risk of transmitting
microorganisms among health care
providers.*
The organisation implements an
IPC.8.b.
immunisation policy for its staff. *
The organisation implements work
IPC.8.c. restrictions for health care providers with
transmissible infections.
 The organisation implements measures for
IPC.8.d.
blood and body fluid exposure prevention.

Appropriate post-exposure prophylaxis is

IPC.8.e.
provided to all staff members concerned. *

Chapter6: Patient Safety

and Quality Improvement
(PSQ)
PSQ.1. The organisation
implements a structured
patient-safety programme.
* Please select the appropriate
response from the drop down menu
The patient-safety programme is developed,
PSQ.1.a. implemented and maintained by a multi-
disciplinary safety committee. *
The patient-safety programme is
PSQ.1.b. comprehensive and covers all the major
elements related to patient safety.
The programme covers incidents ranging
PSQ.1.c.
from "no harm" to "sentinel events".
Designated patient safety officer(s)
PSQ.1.d. coordinates implementation of the patient
safety programme.
The organisation performs proactive
PSQ.1.e. analysis of patient safety risks and makes
improvements accordingly.
The patient-safety programme is reviewed
PSQ.1.f.
and updated at least once a year.
The organisation adapts and implements
PSQ.1g. national/international patient-safety
goals/solutions/framework.
PSQ.2.The organisation
implements a structured
quality improvement and
continuous monitoring
programme.
* Please select the appropriate
response from the drop down menu
 The quality improvement programme is
PSQ.2.a. developed, implemented and maintained
by a multi-disciplinary committee.*
The quality improvement programme is
PSQ.2.b. comprehensive and covers all the major
elements related to quality assurance.*
The quality improvement programme
PSQ.2.c. improves process efficiency and
effectiveness.
The quality improvement programme
PSQ. 2.d.
focuses on appropriateness of clinical care.
There is a designated individual for
PSQ.2.e. coordinating and implementing the quality
improvement programme.*
The quality improvement programme
PSQ.2.f. identifies opportunities for improvement
based on the review at pre-defined intervals.*

The quality improvement programme is

PSQ.2.g.
reviewed and updated at least once a year.
Audits are conducted at regular intervals as
PSQ.2.h.
a means of continuous monitoring.*
There is an established process in the
PSQ.2.i. organisation to monitor and improve the
quality of nursing care.*
PSQ.3.The organisation
identifies key indicators to
monitor the structures,
processes and outcomes,
which are used as tools for
continual improvement.
* Please select the appropriate
response from the drop down menu
The organisation identifies and monitors key
PSQ.3.a. indicators to oversee the clinical
structures, processes and outcomes.
The organisation identifies and monitors the
PSQ.3.b. key indicators to oversee infection
control activities.
The organisation identifies and monitors key
PSQ.3.c. indicators to oversee the managerial
structures, processes and outcomes.
 The organisation identifies and monitors key
PSQ.3.d. indicators to oversee patient safety
activities.
Verification of data is done regularly by the
PSQ.3.e.
quality team.
There is a mechanism for analysis of data
PSQ.3.f. which results in identifying opportunities for
improvement.
The improvements are implemented and
PSQ.3.g.
evaluated.
Feedback about care and service is
PSQ.3.h.
communicated to staff.
PSQ.4.The organisation
uses appropriate quality
improvement tools for its
quality improvement
activities.
* Please select the appropriate
response from the drop down menu
The organisation undertakes quality
PSQ.4.a.
improvement projects.
The Quality Improvement Projects shall
include improvements in patient care
PSQ. 4.b.
delivery and hospital operations which will
have an impact on cost and efficiency.
The organisation uses appropriate analytical
PSQ.4.c. managerial and statistical tools for its quality
improvement activities.
The organization has a mechanism to
PSQ.4.d.
capture patient reported outcome measures.

PSQ.5.There is an
established system for
clinical audit.
* Please select the appropriate
response from the drop down menu
Clinical audits are performed to improve the
PSQ.5.a.
quality of patient care.
The parameters to be audited are defined by
PSQ.5.b.
the organisation.
Medical and nursing staff participate in
PSQ.5.c.
clinical audit.
PSQ.5.d. Patient and staff anonymity are maintained.
PSQ.5.e. Clinical audits are documented.
PSQ.5.f. Remedial measures are implemented.
PSQ.6.The patient safety
and quality improvement
programme are supported
by the management.
* Please select the appropriate
response from the drop down menu

PSQ.6.a. The management creates a culture of safety.

The leaders at all levels in the organisation

are aware of the intent of the patient safety
PSQ.6.b.
and quality improvement programme and
the approach to its implementation.
Departmental leaders are involved in patient
PSQ.6.c.
safety and quality improvement.
Organisation earmarks adequate funds from
PSQ. 6.d.
its annual budget in this regard.
The management identifies organisational
PSQ.6.e.
performance improvement targets.
The management uses the feedback
obtained from the workforce to improve
PSQ.6.f.
patient safety and quality improvement
programme.
PSQ.7.Incidents are
collected and analysed to
ensure continual quality
improvement.
* Please select the appropriate
response from the drop down menu
The organisation implements an incident
PSQ.7.a.
management system.*
The organisation has a mechanism to
PSQ.7.b.
identify sentinel events.*
The organisation has established processes
PSQ.7.c.
for analysis of incidents.
Corrective and preventive actions are taken
PSQ.7.d.
based on the findings of such analysis.
 The organisation incorporates risks identified
PSQ.7.e. in the analysis of incidents into the
risk management system.

The organisation shall have a process for

PSQ.7.f. informing various stakeholders in case
of a near miss/adverse event/sentinel event.
Chapter7:Responsibilities of Management(ROM)
ROM.1:The organisation
identifies those responsible
for governance and their
roles are defined.
* Please select the appropriate
response from the drop down menu

Those responsible for governance are

ROM.1.a. identified, and their roles and responsibilities
are defined and documented. *
Those responsible for governance lay down
ROM.1.b. the organisation's vision, mission and
values.*
Those responsible for governance approve
ROM.1.c. the strategic and operational plans
and the organisation's annual budget.*

Those responsible for governance monitor

ROM.1.d. and measure the performance of the
organisation against the stated mission.

Those responsible for governance appoint

ROM.1.e.
the senior leaders in the organisation.

Those responsible for governance support

ROM.1.f. safety initiatives, clinical governance
framework and quality improvement plans.*
Those responsible for governance shall
ROM. 1.g.
develop clinical governance framework.
Those responsible for governance support
ROM.1.h. the ethical management framework of the
organisation.
Those responsible for governance inform
ROM.1.h. the public of the quality and performance of
services.
ROM.2:The leaders manage
the organisation in an
ethical manner.
* Please select the appropriate
response from the drop down menu
The leaders establish the organisation's
ROM.2.a.
ethical management framework. *
The ethical management framework
includes processes for managing issues
ROM.2.b.
with ethical implications, dilemmas and
concerns.
ROM.2.c. The organisation discloses its ownership.
The organisation honestly portrays its
ROM.2.d.
affiliations and accreditations.
ROM.3:Those responsible for
governance ensures
sustainability in hospitals by
addressing environmental,
social and economic factors
from long term well-being of
healthcare system and
community.
* Please select the appropriate
response from the drop down
menu
Those responsible for governance address
the organization's sustainability programme
ROM.3.a
in terms of Environmebtal Social and
Governance (ESG) responsibility.
The organization takes initiatives towards an
ROM 3b. energy-efficient and environmentally friendly
hospital.*
Those responsible for governance address
ROM. 3.c.
the organization's social responsibiltiy.
ROM. 3.d. Staff well-being is promoted.
The organization follows sustainable
ROM. 3.e.
procurement practices.
Hospitals shall encourage employees to use
common / public transportation to reduce the
ROM. 3.f.
environmental impact of commuting and
carbon footprint.
 The organization ensures financial
ROM. 3.g. sustainability of the hospital by balancing the
financial aspects of healthcare delivery.

ROM.4:The organisation is
headed by a leader who
shall be responsible for
operating the organisation
on a day-to-day basis.
* Please select the appropriate
response from the drop down menu
The person heading the organisation has
ROM.4.a. requisite and appropriate administrative
qualifications and experience.
The leader is responsible for and complies
ROM.4.b. with the laid-down and applicable
legislations, regulations and notifications.
The leader appoints/participates in the
recruitment of department leaders of the
ROM.4.c.
organisation who will assist in the day-to-day
functioning of the organisation.
The leader ensures that each organisational
ROM.4.d. programme, service, site or
department has effective leadership.
The performance of the organisation's
ROM.4.e.
leader is reviewed for effectiveness.
ROM.5:The organisation
displays professionalism in
its functioning.
* Please select the appropriate
response from the drop down menu

The organisation has strategic and

operational plans, including long-term and
ROM.5.a. short-term goals commensurate to the
organisation's vision, mission and values
in consultation with the various stakeholders.

The organisation coordinates the functioning

with departments and external agencies and
ROM.4.b.
monitors the progress in achieving the
defined goals and objectives.
 The organisation plans and budgets for its
ROM.4.c.
activities annually.
The functioning of committees is reviewed
ROM.4.d.
for their effectiveness.
The organisation documents the service
ROM.4.e. standards that are measurable and
monitors them.*
Systems and processes are in place for
ROM.4.f.
change management.
ROM.6:Leadership ensures
that patient-safety aspects
and risk-management
issues are an integral part of
patient care and hospital
management.
* Please select the appropriate
response from the drop down menu
Leadership ensures proactive risk
ROM.6.a.
management across the organisation.*
Leadership provides resources for proactive
ROM.6.b.
risk assessment and risk reduction activities.

Leadership ensures integration between

ROM.6.c. quality improvement, risk management and
strategic planning within the organisation.
Leadership ensures implementation of
ROM.6.d. systems for internal and external
reporting of system and process failures.*
Leadership ensures that it has a
ROM.6.e. documented agreement for all outsourced
services that include service parameters.
Leadership monitors the quality of the
ROM.6.f. outsourced services and improvements
are made as required.
Chapter8:Facility Management and Safety(FMS)
FMS.1:The organisation has
a system in place to provide
a safe and secure
environment.
* Please select the appropriate
response from the drop down menu
 Patient-safety devices and infrastructure are
FMS.1.a. installed across the organisation and
inspected periodically.
The organisation has facilities for the
FMS.1.b.
differently-abled.
Facility inspection rounds to ensure safety
FMS.1.c.
are conducted at least once a month.
Inspection reports of facility rounds are
FMS.1.d. documented, and corrective and
preventive measures are undertaken.
Before construction, renovation and
FMS.1.e. expansion of existing hospital, risk
assessment are carried out.

FMS.2:The organisation's
environment and facilities
operate in a planned manner
and promotes environment-
friendly measures.
* Please select the appropriate
response from the drop down menu

Facilities and space provisions are

FMS.2.a.
appropriate to the scope of services.
As-built and updated drawings are
FMS.2.b.
maintained as per statutory requirements.
There are internal and external sign postings
in the organisation in a manner
FMS.2.c.
understood by the patient, families and
community.
Potable water and electricity are available
FMS.2.d.
round the clock.
Alternate sources for electricity and water
FMS.2.e. are provided as a backup for any
failure/shortage.
The organisation tests the functioning of
FMS.2.f. these alternate sources at a predefined
frequency.
FMS.3:The organisation's
environment and facilities
operate to ensure the safety
of patients, their families,
staff and visitors.
* Please select the appropriate
response from the drop down menu
 Operational planning identifies areas which need to
FMS. 3a. have extra security and describes access to different
areas in the hospital by staff, patients, and visitors.*
Patient safety aspects in terms of structural
safety of hospitals especially of critical areas
are considered while planning, design and
FMS.3.b.
construction of new hospitals
and re-planning, assessment, and retrofitting
of existing hospitals.
The organisation conducts electrical safety
FMS.3.c.
audits for the facility.
There is a procedure which addresses the
FMS.3.d. identification and disposal of material(s) not
in use in the organisation. *
Hazardous materials are identified and used
FMS.3.e.
safely within the organisation.*
The plan for managing spills of hazardous
FMS.3.f.
materials is implemented. *

FMS.4:The organisation has

a programme for the facility,
engineering support
services and utility system.
* Please select the appropriate
response from the drop down menu

The organisation plans for utility and

FMS.4.a. engineering equipment in accordance with
its services and strategic plan.
Equipment is inventoried, and proper logs
FMS.4.b.
are maintained as required.
The documented operational and
FMS.4.c. maintenance (preventive and breakdown)
plan is implemented. *
Utility equipment, are periodically inspected
FMS.4.d. and calibrated (wherever applicable) for their
proper functioning.
Competent personnel operate, inspect, test
FMS.4.e.
and maintain equipment and utility systems.
Maintenance staff is contactable round the
FMS.4.f.
clock for emergency repairs.
 Downtime for critical equipment breakdowns
is monitored from reporting to
FMS.4.g.
inspection and implementation of corrective
actions.
Written guidance supports equipment
FMS.4.h. replacement, identification of unwanted
material and disposal. *
FMS.5:The organisation has
a programme for medical
equipment management.
* Please select the appropriate
response from the drop down menu

The organisation plans for medical

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

FMS.6:The organisation has

a programme for medical
gases, vacuum and
compressed air.
* Please select the appropriate
response from the drop down menu
 Written guidance governs the
implementation of procurement, handling,
FMS.6.a.
storage, distribution, usage and
replenishment of medical gases. *
Medical gases are handled, stored,
FMS.6.b.
distributed and used in a safe manner.
There is an operational, inspection, testing
and maintenance plan for piped medical
FMS.6.c.
gas, compressed air and vacuum
installation. *
Alternate sources for medical gases,
FMS.6.d. vacuum and compressed air are provided
for, in case of failure.
The organisation regularly tests the
FMS.6.e.
functioning of these alternate sources.
FMS.7:The organisation has
plans for fire and non-fire
emergencies within the
facilities.
* Please select the appropriate
response from the drop down menu
The organisation has plans and provisions
for early detection, abatement, containment
FMS.7.a.
of the fire, and evacuation in the event of fire
emergencies. *
The organization has plans and provisions
FMS. 7.b. for identification, and management of non-
fire emergencies.
The organisation has a documented and
FMS.7.c. displayed exit plan in case of fire and
non-fire emergencies.
FMS.7.d. Mock drills are held at least twice a year.
There is a maintenance plan for fire-related
FMS.7.e.
equipment and infrastructure *
Chapter9:Human Resource Management(HRM)

HRM.1. The organisation

has a documented system
of human resource planning.
* Please select the appropriate
response from the drop down menu
 Human resource planning supports the
organisation's current and future ability to
HRM.1.a.
meet the care, treatment and service needs
of the patient.
The organisation maintains an adequate
HRM.1.b. number and mix of staff to meet the care,
treatment and service needs of the patient.

The organisation has contingency plans to

HRM.1.c. manage long- and short-term workforce
shortages, including unplanned shortages.
The job specification and job description are
HRM.1.d.
defined for each category of staff.
The organisation performs a background
HRM.1.e.
check of new staff.
Reporting relationships are defined for each
HRM.1.f.
category of staff. *
Exit interviews are conducted and used as a
HRM.1.g.
tool to improve human resource practices.

HRM.2.The organisation
implements a defined
process for staff recruitment.
* Please select the appropriate
response from the drop down menu

Written guidance governs the process of

HRM.2.a.
recruitment. *
A pre-employment medical examination is
HRM.2.b.
conducted on the staff.
The organisation defines and implements a
HRM.2.c.
code of conduct for its staff.
Administrative procedures for human
HRM.2.d.
resource management are documented .*
HRM.3.Staff are provided
induction training at the
time of joining the
organisation.
* Please select the appropriate
response from the drop down menu
HRM.3.a. Staff are provided with induction training.
 The induction training includes orientation to
HRM.3.b.
the organisation's vision, mission and values.
The induction training includes awareness
HRM.3.c. on staff rights and responsibilities and
patient rights and responsibilities.
The induction training includes training on
HRM.3.d.
safety.
The induction training includes training on
HRM.3.e. cardio-pulmonary resuscitation for
staff.
The induction training includes training in
HRM.3.f.
hospital infection prevention and control.
The induction training includes orientation to
HRM.3.g.
the service standards of the organisation.
The induction training includes an orientation
HRM.3.h.
on administrative procedures.
The induction training includes an orientation
on relevant department/unit/
HRM. 3.i.
service/programme's policies and
procedures.
Staff is trained on information systems,
HRM.3.j. information security, information use and
management.
HRM.4.There is an on-going
programme for professional
training and development of
the staff.
* Please select the appropriate
response from the drop down menu
Written guidance governs training and
HRM.4.a.
development policy for the staff.*
The organisation maintains the training
HRM.4.b.
record.
Training also occurs when job
HRM.4.c. responsibilities change/new equipment is
introduced.
Feedback mechanisms are in place for
HRM.4.d. improvement of training and development
programme.
Evaluation of training effectiveness is done
HRM.4.e.
by the organisation.
The organisation supports continuing
HRM.4.f.
professional development and learning.
HRM.5.Staff are
appropriately trained based
on their specific job
description.
* Please select the appropriate
response from the drop down menu
Staff involved in blood transfusion services
HRM.5.a. are trained on the handling of blood and
blood products.
Staff are trained in handling vulnerable
HRM.5.b.
patients.
Staff are trained in control and restraint
HRM.5.c
techniques.
Staff are trained in healthcare
HRM.5.d.
communication techniques.
Staff involved in direct patient care are
HRM.5.e. provided training on cardiopulmonary
resuscitation periodically.
Staff are provided training on infection
HRM.5.f.
prevention and control.
HRM.6.Staff are trained in
safety and quality-related
aspects.
* Please select the appropriate
response from the drop down menu
Staff are trained on the organisation's safety
HRM.6.a.
programme.
Staff are provided training on the detection,
handling, minimisation and elimination of
HRM.6.b.
identified risks within the organisation's
environment.
Staff members are made aware of
HRM.6.c. procedures to follow in the event of an
incident.
Staff are trained in occupational safety
HRM.6.d.
aspects.
Staff are trained in the organisation's
HRM.6.e.
disaster management plan.
Staff are trained in handling fire and non-fire
HRM.6.f.
emergencies.
Staff are trained on the organisation's quality
HRM.6.g.
improvement programme
HRM.7.An appraisal system
for evaluating the
performance of staff exists
as an integral part of the
human resource
management process.
* Please select the appropriate
response from the drop down menu
Performance appraisal is done for staff
HRM.7.a.
within the organisation.*
The staff are made aware of the system of
HRM.7.b.
appraisal at the time of induction.
Performance is evaluated based on the pre-
HRM.7.c.
determined criteria.
The appraisal system is used as a tool for
HRM.7.d.
further development.
Performance appraisal is carried out at
HRM.7.e.
defined intervals and is documented.
HRM.8.Process for
disciplinary and grievance
handling is defined and
implemented in the
organisation.
* Please select the appropriate
response from the drop down menu
Written guidance governs disciplinary and
HRM.8.a.
grievance handling mechanisms.*
The disciplinary and grievance handling
HRM.8.b. mechanism is known to all categories
of staff of the organisation.
The disciplinary policy and procedure are
HRM.8.c.
based on the principles of natural justice.
The disciplinary and grievance procedure is
HRM.8.d.
in consonance with the prevailing laws.
There is a provision for appeals in all
HRM.8.e.
disciplinary cases.
HRM.8.f. Actions are taken to redress the grievance.
HRM.9.The organisation
promotes staff well-being
and addresses their health
and safety needs.
* Please select the appropriate
response from the drop down menu
Health problems of the staff, including
occupational health hazards, are taken
HRM.9.a.
care of in accordance with the organisation's
policy.
Health checks of staff dealing with direct
HRM.9.b. patient care are done at least once a year
and the findings/results are documented.
Organisation provides treatment to staff who
HRM.9.c.
sustain workplace-related injuries.
The organisation has measures in place for
HRM.9.d. prevention and handling workplace
violence.
HRM.10.There is
documented personal
information for each staff
member.
* Please select the appropriate
response from the drop down menu
Personal files are maintained with respect to
HRM.10.a. all staff, and their confidentiality is
ensured
The personal files contain personal
information regarding the staff's qualification,
HRM.10.b.
job description, verification of credentials
and health status.
Records of in-service training and education
HRM.10.c.
are maintained.
Personal files contain results of all
HRM.10.d.
evaluations and remarks.
HRM.11.There is a process
for credentialing and
privileging of medical
professionals, permitted to
provide patient care without
supervision.
* Please select the appropriate
response from the drop down menu
 Medical professionals permitted by law,
regulation and the organisation to
HRM.11.a.
provide patient care without supervision are
identified.
The education, registration, training and
experience of the identified medical
HRM.11.b.
professionals are documented and updated
periodically.
The information about medical professionals
HRM.11.c. is appropriately verified when
possible.
Medical professionals are granted privileges
to admit and care for patients in
HRM.11.d.
consonance with their qualification, training,
experience and registration.
The requisite services to be provided by the
medical professionals are known to
HRM.11.e.
them as well as the various
departments/units of the organisation.
Medical professionals admit and care for
HRM.11.f.
patients as per their privileging.
HRM.12.There is a process
for credentialing and
privileging of nursing
professionals, permitted to
provide patient care without
supervision
* Please select the appropriate
response from the drop down menu
Nursing staff permitted by law, regulation
HRM.12.a. and the organisation to provide patient
care without supervision are identified.
The education, registration, training and
experience of nursing staff are
HRM.12.b.
appropriately verified, documented and
updated periodically.
The information about the nursing staff is
HRM.12.c.
appropriately verified when possible.
Nursing staff are granted privileges in
HRM.12.d. consonance with their qualification,
training, experience and registration.
 The requisite services to be provided by the
nursing staff are known to them as
HRM.12.e.
well as the various departments/units of the
organisation.
Nursing professionals care for patients as
HRM.12.f.
per their privileging.
HRM.13.There is a process
for credentialing and
privileging of para-clinical
professionals, permitted to
provide patient care without
supervision.
* Please select the appropriate
response from the drop down menu
Para-clinical professionals permitted by law,
regulation and the organisation to
HRM.13.a.
provide patient care without supervision are
identified.
The education, registration, training and
experience of para clinical professionals
HRM.13.b.
are appropriately verified, documented and
updated periodically.
Para-clinical professionals are granted
privileges in consonance with their
HRM.13.c.
qualification, training, experience and
registration.
The requisite services to be provided by the
para-clinical professionals are known
HRM.13.d.
to them as well as the various
departments/units of the organisation.
Para-clinical professionals care for patients
HRM.13.e.
as per their privileging.
Chapter10:Information Management System(IMS)
IMS.1.Information needs of
the patients, visitors, staff,
management and external
agencies are met.
* Please select the appropriate
response from the drop down menu
The organisation identifies the information
needs of the patients, visitors, staff,
IMS.1.a.
management external agencies and
community. *
 Identified information needs are captured
IMS.1.b.
and/or disseminated.*
Information management and technology
IMS.1.c. acquisitions are commensurate with
the identified information needs.
A maintenance plan for information
IMS.1.d. technology and communication network is
implemented.
Contingency plan ensures continuity of
IMS.1.e. information capture, integration and
dissemination.
The organisation ensures that information
IMS.1.f. resources are accurate and meet
stakeholder requirements.
The organisation contributes to external
IMS.1.g. databases in accordance with the law
and regulations.
The organization shall make efforts to use
digital health technology to improve
IMS. 1.h.
operational efficiency, patient safety and
patient experience.
IMS.2.The organisation has
processes in place for
management and control of
data and information.
* Please select the appropriate
response from the drop down menu
Processes for data collection are
IMS.2.a.
standardised.
Data is analysed to meet the information
IMS.2.b.
needs.
The organisation disseminates the
IMS.2.c.
information in a timely and accurate manner.
The organisation stores and retrieves data
IMS.2.d.
according to its information needs. *
Clinical and managerial staff participate in
IMS.2.e. 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.
* Please select the appropriate
response from the drop down menu
The unique identifier is assigned to the
IMS.3.a.
medical record.
The contents of the medical record are
IMS.3.b.
identified and documented. *
The medical record provides a complete, up-
IMS.3.c. to-date and chronological account
of patient care.
Authorised staff make the entry in the
IMS.3.d.
medical record. *
Entry in the medical record is signed, dated
IMS.3.e.
and timed.
IMS.3.f. The author of the entry can be identified.
The medical record has only authorised
IMS.3.g.
abbreviations.
IMS.4.The medical record
reflects the continuity of
care.
* Please select the appropriate
response from the drop down menu
The medical record contains information
IMS.4.a. regarding reasons for admission,
diagnosis and care plan.
The medical record contains the details of
IMS.4.b. assessments, re-assessments and
consultations.
The medical record contains the results of
IMS.4.c. investigations and the details of the
care provided.
Operative and other procedures performed
IMS.4.d.
are incorporated in the medical record.
When a patient is transferred to another
IMS.4.e. organisation, the medical record
contains the details of the transfer.
The medical record contains a signed copy
IMS.4.f.
of the discharge summary.
 In case of death, the medical record
IMS.4.g. contains a copy of the medical certificate of
the cause of death.
Care providers have access to current and
IMS.4.h.
past medical record.
IMS.5.The organisation
maintains confidentiality,
integrity and security of
records, data and
information.
* Please select the appropriate
response from the drop down menu
The organisation maintains the
IMS.5.a. confidentiality of records, data and
information.*
The organisation maintains the integrity of
IMS.5.b.
records, data and information. *
The organisation maintains the security of
IMS.5.c.
records, data and information.*
The organisation uses developments in
IMS.5.d. appropriate technology for improving
confidentiality, integrity and security.
The organisation discloses privileged health
IMS.5.e. information as authorised by the
patient and/or as required by law.
Request for access to information in the
medical records by patients/physicians
IMS.5.f.
and other public agencies are addressed
consistently.*
IMS.6.The organisation
ensures availability of
current and relevant
documents, records, data
and information and
provides for retention of the
same.
* Please select the appropriate
response from the drop down menu
The organisation has an effective process
IMS.6.a.
for document control. *
The organisation retains patient's clinical
IMS.6.b. records, data and information according
to its requirements. *
 The retention process provides expected
IMS.6.c.
confidentiality and security.
The destruction of medical records, data and
IMS.6.d. information are in accordance with
the written guidance.*
IMS.7.The organisation
carries out a review of
medical records.
* Please select the appropriate
response from the drop down menu
The medical records are reviewed
IMS.7.a.
periodically.
The review uses a representative sample
IMS.7.b.
based on statistical principles.
The review is conducted by identified
IMS.7.c.
individuals.
The review of records is based on identified
IMS.7.d.
parameters.
The review process includes records of both
IMS.7.e.
active and discharged patients.
The review points out and documents any
IMS.7.f.
deficiencies in records.
Appropriate corrective and preventive
IMS.7.g.
measures are undertaken.
ation Standards 6th Edition Self Assessment Toolkit
Scores
Systems Implementation
(Rate from 1-5)
No evidence of working
No systems in place 1 (≤ 20% compliance)
towards implementation

Some evidence of
Elementary Systems are in
working towards 2 (21-40% compliance)
place
implementation
There is evidence of
Systems are partially in place working towards 3 (41-60% compliance)
implementation
There is evidence of
Systems are in place working towards 4 (61-80% compliance)
implementation
There is evidence of
Systems are in place working towards 5 (81-100% complaince)
implementation
Toolkit
Remarks