ACCESS, ASSESSMENT & SUMMARY OF STANDARDS

CONTINUITY OF CARE (AAC)

AAC1
Scope & Display (3)
AAC7 AAC2
Discharge (6) Access, Registration & Admission (2)
assessment
and continuity
AAC6 of care (AAC) AAC3
Imaging services (4) Initial assessment (4)

AAC5 AAC4
Laboratory services (6) Reassessment (4)

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS

CAHO ENTRY LEVEL SERIES 1
AAC1: The organisation defines and displays the services
that it can provide.

AAC1a: The services being provided are

clearly defined.

AAC1b: The defined services are

prominently displayed.

AAC1c: The relevant staff is oriented to

these services.

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 How to implement
AAC1?
List all services Display Trainin
g
 Clinical.  All entrances.  Relevant staff.
 Diagnostic.  Registration.  Receptionist,
 Support  Waiting area. OPD staff,
Services.  Emergency emergency
department. department
staff, security
and clinical
team.

Note: The list and training must be up-to-date.

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 Hospital Display: Do’s and Don'ts

 Bilingual.
 Single language.
 Pictorial signage.
 Textual.
 Permanent structure.
 Temporary flex boards.
 List both services provided and
 List only services provided.
excluded.

Note: Display should be updated with the new services. Services can be listed
in the website of the hospital too.

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AAC2: The organisation has a documented registration,
admission and transfer process.

 AAC2a: Process addresses registering

and admitting outpatients, inpatients
and emergency patients.
 AAC2b: Process addresses mechanism
for transfer or referral of patients who do
not match the organisational resources.

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 How to implement
AAC2?
Registratio Safe transfer
n
 Provide first aid/stabilise.
 Document patient status
 Generate UHID. and treatment given.
 Document process.  Transfer after providing
prior information.

Note: All inpatient admissions need to be authorised by a doctor.

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 Best Practices for Registering a Patient

 Generate different number in case of

multiple visits.
 Link the number to UHID to provide
continuity of care.
 Define process for unknown patient or
medico-legal case.
 Register all foreign nationals after
verification.

Note: In the event of an admission, the organisation must be equipped to provide for
the required service both in terms of infrastructure as well as trained manpower.

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 Best Practices for Inter-facility Transfer of a Patient

 The organisation should have a list of

referring facilities.
 A patient can be transferred for
investigations/procedures.
 In absence of own ambulance service,
an ambulance should be available
within a defined time frame.

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AAC3: Patients cared for by the organisation undergo
an established initial assessment.

 AAC3a: The organisation defines the content

of the assessments for the outpatients,
inpatients and emergency patients.
 AAC3b: The organisation determines who can
perform the assessments.
 AAC3c: The initial assessment for inpatients is
documented within 24 hours or earlier.
 AAC3d: Initial assessment of inpatients
includes nursing assessment which is done at
the time of admission and documented.

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 How to implement
AAC3?
Standardise Designate Define
 Adopt  Doctors: OP, IP.  Define the
standardised  Nurses: Nursing IP time frame and
format for initial assessment and parameters for
assessment. dietary assessment. initial
 Modify  Doctor/nurse: assessment.
parameters Screening to  Document the
depending on identify nutritional actual time of
department. needs. initial
assessment.
Note: Initial assessment for an emergency patient can be performed by a doctor/nurse
based on the triage.

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 How to conduct initial
assessment?
Outpatient Inpatient
 Chief complaint.  Chief complaint.
 Provisional diagnosis.  History.
 Investigations with or without  Examination.
results .  Investigations.
 Treatment advised.  Plan of care including expected outcome, if
 Follow up or referral advice. relevant.
 Provisional diagnosis.
 Treatment to be given.
Emergency patients
Done based on a triage scale. (E.g. Day care
MEWS, Australian triage scale) Perform abridged documentation as
appropriate.

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 Best Practices for Performing Initial
Assessment

 Start at the time of admission.

 Complete within 24 hours.
 Monitor defined time frame using audit.
 Use checklist/templates.
Note: Templates can help in standardisation
of documentation and ensure completeness.

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 AAC4: Patient care is continuous and all patients
cared for by the organisation undergo a regular re-assessment.

 AAC4a: During all phases of care, there is a qualified individual responsible for
the patient’s care, who coordinates the care in all the settings within the
organisation.
 AAC4b: All patients are reassessed at appropriate intervals.
 AAC4c: Staff involved in direct clinical care document reassessments.
 AAC4d: Patients are reassessed to determine their response to treatment and to
plan further treatment or discharge.

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 Reassessment of the Patient

Who should reassess? Healthcare personnel.

What is the frequency? At least once daily.

Note: ICU patients should be reassessed more frequently than those in ward.

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 What to document?

Vital parameters Examination Medication orders

findings

Name:
Date:
Time:
Sign:

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 AAC5: Laboratory services are provided as per the
scope of the hospital’s services and laboratory safety requirements.

 AAC5a: Scope of laboratory services are commensurate to the services provided by the
organisation.
 AAC5b: Procedures guide collection, identification, handling, safe transportation,
processing and disposal of specimens.
 AAC5c: Laboratory results are available within a defined time frame and critical results are
intimated immediately to the concerned personnel.
 AAC5d: Adequately trained personnel perform , supervise and interpret the investigations.
 AAC5e: Laboratory personnel are trained in safe practices and are provided with
appropriate safety equipment/devices.
 AAC5f: Laboratory tests not available in the organisation are outsourced.

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 How to implement
AAC5?
Services offered Define
 Should complement
 Turnaround time.
clinical services.
 Include in TAT for both
 Can be outsourced.
in-house and outsourced
 Available 24/7.
tests: waiting time, time
 Available within
to perform the test and
premises for
time to prepare and
emergencies.
release report.
 Critical values.

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 How to implement
AAC5?
Documentation Collection and Transport
 Standardised test request forms
(TRF).  Wear appropriate PPE.
 Define mandatory fields.  Follow aseptic precautions.
 Instructions for doctors, nurses,  Transport: temperature, time
phlebotomists and patients. frame.
 Procedure for patient  Sample carrier with
identification and labelling. biohazard symbol.
 Informed consent (HIV, invasive  Discard in appropriate BMW
procedures). bins.
 Critical results information.

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 How to implement
AAC5?
Quality Assurance Outsourcing

 Validate sample processing methods.

 List all tests outsourced.
 Internal and external quality controls.
 Make list for inter laboratory
 Evaluate competency of lab
comparison (ILC).
technicians.
 Sign a MOU.
 Interpretation of test results by
 Periodically review
qualified personnel.
arrangements.
 Supervision by senior
 Evaluate performance of
technician/trained personnel.
referral lab.
 Regular calibration of
equipment.

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 Points to Remember: Evaluating
Referral Laboratory

The healthcare facility should evaluate the referral laboratory based on:
 Test parameters offered.
 Testing methodology is validated/ approved.
 TAT is agreeable with the clinicians.
 Quality of test performed and reported (preferably NABL accredited).
 Equipment and environment are safe and available.
 Laboratory is conveniently located.
 Sample pick up and reporting services are prompt.
 Cost effectiveness.

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 Points to Remember: Safety Measures

 Wear Personal Protective Equipment (PPE).

 Handle microbiological samples/ formalin in
bio-safety cabinets / chemical fume hoods.
 Ensure availability of safety data sheets
(SDS).
 Use spill kits for handling hazardous
material spill.
 Provide negative pressure room and N95
mask.
 Provide eye wash / showers when
chemical
/ biological material splash is expected.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 21

 Points to Remember: Staff Training

 Critical values and reporting.

 Common laboratory acquired infections.
 Safe handling of blood and body fluid spillage.
 Safe handling of chemicals and reagents.
 Safe disposal of biomedical waste.
 Protection from percutaneous and mucocutaneous exposure of blood and body
fluids.
 Fire safety.
 Hazardous material spill and management.

Note: Technicians should undergo training on performing new test parameters and
laboratory in charge should undergo training to interpret the parameters.

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 AAC6: Imaging services are provided as per the
scope of the hospital services and established
radiation
safety programme.
 AAC6a: Imaging services comply with legal and other requirements.
 AAC6b: Scope of the imaging services are commensurate to the services provided
by the organisation.
 AAC6c: Imaging results are available within a defined time frame and critical
results are intimated immediately to the concerned personnel.
 AAC6d: Imaging personnel are trained in safe practices and are provided with
appropriate safety equipment / devices.

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 How to implement
AAC6?
Services offered Define

 Should complement  Turnaround time.

clinical services.  Include in TAT: Waiting
 Available 24/7. time, time to perform
 List should be imaging, time to prepare
displayed at and release report.
prominent places.  Critical results.
 In-house and outsourced
tests.

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 How to implement
AAC6?
Documentation Outsourcing

 Consent for invasive

procedures, giving
contrast.  List all tests outsourced.
 Critical results  Sign a MOU.
information.  Periodically review
 Records of TLD badges arrangements.
sent for monitoring.  Evaluate performance of
 Records of screening referral facility.
lead aprons.

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 Points to Remember: Legal Requirements

 Display license for operating X-ray and scans.

 Display designated RSO with registration.
 Register ultrasound machines.
 Display PC-PNDT registration certificates.
 Display “Sex selection and detection is not
done in this centre and is punishable under
the PC-PNDT Act” in entrance.

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 AERB
Signages

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 Points to Remember: Safety Measures

 Place radiation safety display signs as per

AERB norms.
 Provide personal dosimeters.
 Monitor TLD badges for radiation
exposure.
 Provide lead shields and lead aprons.
 Verify lead aprons for cracks and
damages.
 Restrict entry at MRI.
 Ensure availability of MRI compatible life
saving devices and fire extinguishers.
 Ensure availability of crash cart.
CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 28
 AAC7: The organisation has a defined discharge process.

 AAC7a: Process addresses discharge of all patients including medico-legal cases and
patients leaving against medical advice.
 AAC7b: A discharge summary is given to all the patients leaving the organisation
(including patients leaving against medical advice.).
 AAC7c: Discharge summary contains the reason for admission, significant findings,
investigation results, diagnosis, procedure performed (if any), treatment given and
the patient’s condition at the time of discharge.
 AAC7d: Discharge summary contains follow up advice, medication and other
instructions in an understandable manner.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 29

AAC7: The organisation has a defined discharge process.

 AAC7e: Discharge summary incorporates instruction about when and how

to obtain urgent care.
 AAC7f: In case of death, the summary of the case also includes the cause of
death.

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 How to implement
AAC7?
Discharge process Discharge summary
 Doctor orders and  Standard template.
documents discharge.  Brief and contains
 Medicine returns and important information.
other clearances.  Signed by treating
 Issue of discharge doctor/team member.
summary.  Given to all patients.
 Bill payment.

Note: The hospital should monitor the discharge time for quality improvement.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 31

 How to implement
AAC7?
Follow up advice Urgent care

 Should not have unfamiliar

 List the urgent care advice
abbreviations/medical
related to the diagnosis.
terms.
 Provide details of service and
 Should be verbally
contact numbers.
explained to patient.

Note: Explain when and how to obtain urgent care in a language the patient/relatives
understands.

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 What should a discharge summary cover?

 Reasons for admission.

 Significant findings.
 Diagnosis.
 Procedures performed.
 Treatment given.
 Patient’s condition at the time of discharge.
 Follow up advice.
 Cause of death in line with diagnosis.
 Copy of postmortem report, if cause of death is unclear.
 Copy of death summary.

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 Do’s and Don'ts

List of modes of dying that should not be

mentioned as cause of death:
 Cardiac arrest.
 Cardiopulmonary arrest.
 Respiratory arrest.
 Respiratory failure.
 Failure to thrive.
 Multi organ/System failure.

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 What should be in a medical
record?

 Copy of the discharge summary.

 Consequences of patient leaving
against medical advice,
patient’s right and
patient’s/attendant’s
declaration.
 Police information for medico-legal
cases.

Note: A copy of death summary should be given to the patient’s relative.

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Desktop Assessment & Physical
Assessment – Documents to be submitted,
audit check points.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 36

 Signage & Training

 Scope of services
 Directional signage
 Departmental signage
 Scope of Obstetrics Service
 Scope of Pediatrics Service
 Uniform signage system in the Facility (Attach photos of the signage )
 Radiation Hazard
 Declaration under PCPNDT ACT
 Bio-hazard
 Patients’ rights & responsibility
 Fire exit signage
 Has a training on scope of services been conducted?

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 Location details of the Clinical
Services
Name of the building in
Services which the service is located Which floor of the building

Anaesthesia

Blood Bank

Blood Collection Centre

Cath Lab

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 38

 Location details of the Lab
Services
Located inside the If yes, Name of the Which floor of the
Services premises building in which the building
(Yes/No) service is located
Clinical Bio-Chemistry
Clinical Microbiology
and Serology
Clinical Pathology
Cytopathology

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 39

 Location details of the Imaging
Services
Located inside If yes, Name of the building
the premises in which the service is Which floor of
Services the building
(Yes/No) located

CT Scanning

DSA Lab

MRI

Mammography

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 40

 Protocols with Evidences for Implementations

Process addresses discharge of all patients including Medico-legal cases and patients
leaving against medical advice.

Documented procedure (s) address care of patients arriving in the emergency

including handling of medico-legal cases.

Procedure(s) guide collection, identification, handling, safe transportation,

processing and disposal of specimens.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 41

 Laborator
y
 Location details of the Laboratory services
 Upload scope of laboratory services.
 Is there any defined turnaround time for test?
 Upload a scanned copy of critical result reporting register pertaining to the
following:
 Time at which the test result was ready.
 Time at which the test result has been communicated.
 Name of the individual to whom the test result has been conveyed (preferably
treating doctor or duty doctor).
 Name and signature of the person who has conveyed the result.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 42

 Laborator
y
 Are the samples
 transported in a safe manner?
 identified properly?
 disposal of specimen done in safe manner?
 Are laboratory personnel using appropriate safety equipment/ devices?
 Training record:
 Safe practices in lab
 Spill Management
 Safety education program
 Upload Photo of Housekeeping staff and waste handlers using appropriate
PPE (industrial gloves, masks)

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 43

 Location details of the Lab
Services
Located inside the premises If yes, Name of the building in
Services (Yes/No) which the service is located Which floor of the building

Diagnostic Imaging
Clinical Bio-Chemistry X-Ray
 Bone Densitometry
Clinical Microbiology and Serology  CT Scanning Other Services -
Clinical Pathology  DSA Lab  2D Echo
Cytopathology  Gamma Camera  Audiometry
Genetics  Mammography  EEG
Hematology  MRI  EMG/EP
Histopathology  Nuclear Medicine  Holter Monitoring
 PET
Toxicology  Spirometry-PFT
 Ultrasound
Molecular Biology  Urodynamic Studies  Tread Mill Testing

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 44

 Imaging

 Upload scope of Imaging services.

 Upload a scanned copy of critical result reporting register pertaining to the
following:
 Time at which the test result was ready
 Time at which the test result has been communicated
 Name of the individual to whom the test result has been conveyed (preferably
treating doctor or duty doctor) *
 Name and signature of the person who has conveyed the result
 Has a training on Safe practices in Imaging been conducted? –Training records
 Has a training on Safety Education programme been conducted? –Training records

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 45

 Records - Upload

OPD
 Upload filled OPD Initial Assessment Form – Ensure hospital number is available*
 Are document for registration and admission of patient being maintained in OPD?

IPD
 Upload filled IP Initial Assessment Form – Please include the front sheet of admission
wherein the details of the patient, name of the treating doctor and time of admission
can be seen *
 Upload a filled Patient case sheet (of any 1 patient) from the ICU *
 Upload a filled Patient case sheet (of any 1 patient) from any 1 ward *
 Are document for registration and admission of patient being maintained in IPD?

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 46

 Records - Upload

Emergency Department
 Upload filled Initial Assessment Form or copy of Emergency Register – Ensure
hospital number is available*
 Are document for registration and admission of patient being maintained in
Emergency?
 Are admissions or discharge to home or transfer to another organization is
documented in emergency unit?
 Upload any 1 MLC form or Police intimation form or MLC register scanned
copy.

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 47

 Records - Upload

Discharge/ Transfer
 Upload filled ward discharge summary (all pages) of any one patient
 Upload filled discharge summary (all pages) of any one LAMA patient
 Upload register (or any other documentary evidence) of patients who were
referred/ transferred *

CONSORTIUM OF ACCREDITED HEALTHCARE ORGANIZATIONS 48