NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS (NABH)         ACCREDITATION STANDARDS                                 FOR                SMALL HEALTH CARE                     ORGANIZATIONS --------------------------------------------------- Small Health Care Organizations (SHCO) Those healthcare organizations having bed strength between 20 to 50 beds and are in possession of supportive and utility facilities that are appropriate and relevant to the services being provided by organization. Exclusions _ Polyclinics _ Diagnostic Centres _ Superspeciality* centres (single/multiple) Exceptions Specialty **Day Care centres (minimum bed strength not mandatory) *     Super Specialty centres are the centres which reflect requirement of DM/MCh or equivalent qualified personnel. **    Specialty centres are the centres which reflect requirement of MD/MS or equivalent qualified personnel. ---------------------------------------------------      Access, Assessment and Continuity of Care (AAC) AAC.1. The organization defines and displays the services that it can provide AAC.2. The organization has a documented registration, admission and transfer process AAC.3. Patients cared for by the organization undergo an established initial assessment AAC.4. Patient care is continuous and all patients cared for by the organization undergo a regular reassessment AAC.5. Laboratory services are provided as per the scope of the hospital’s services and adhering to best practices AAC.6. Imaging services are provided as per the scope of the hospital’s services and adhering to best practices AAC.7. The organization has a defined discharge process                           Care of Patients (COP) COP.1. Care of patients is uniform and is guided by the laws and regulations COP.2. Emergency services including ambulance are guided by documented procedure and applicable laws and regulations COP.3. Documented procedures guide the care of patients requiring cardio-pulmonary resuscitation COP.4. Documented procedures define rational use of blood and blood products COP.5. Documented procedures guide the care of patients in the intensive care and high dependency units COP.6. Documented procedures guide the care of obstetrical patients COP.7. Documented procedures guide the care of paediatric patients Management of Medication (MOM) MOM.1. Documented procedures guide the organization of pharmacy services and usage of medication MOM.2. Documented procedures guide the prescription of medications MOM.3. Documented procedures guide the safe dispensing of medications MOM.4. There are defined procedures for medication administration MOM.5. Patients are monitored for adverse drug events after medication  Administration MOM.6. Documented procedures guide the use of medical gases Patient rights and Education (PRE) PRE.1 The organization protects patient and family rights during care and informs them about their responsibilities PRE.2 Patient rights support individuals beliefs, values and involve the patient and family in decision making processes PRE.3 A document policy for obtaining patient and/or families consent exists for informed decision making about their care PRE.4 Patient and families have a right to information and education about their healthcare needs PRE.5 Patient and families have a right to information on expected costs Hospital Infection Control (HIC) HIC.1 The organization has a well-designed, comprehensive and coordinated Hospital Infection Control (HIC) programme aimed at reducing /eliminating risks to patients, visitors and providers of care. HIC.2 The hospital has an infection control manual, which is periodically updated and conducts surveillance activities HIC.3 The hospital takes actions to prevent or reduce the risks of Hospital Associated Infections (HAI) in patients and employees HIC.4 There are documented procedures for sterilization activities in the hospital HIC.5 Statutory provisions with regard to Bio-Medical Waste (BMW) management are complied with HIC.6 The infection control program is supported by hospital management and includes training of staff and employee health Continuous Quality Improvement (CQI) CQI.1 There is a structured quality improvement and continuous monitoring programme in the organization. CQI.2 The organization identifies key indicators to monitor the structures, processes and outcomes which are used as tools for continual improvement. CQI.3. The quality improvement programme is supported by the management. CQI.4 There is an established system for clinical audits CQI 5. Sentinel events are intensively analyzed. Responsibilities of Management (ROM) ROM.1 The responsibilities of the management are defined ROM.2 The organization is managed by the leaders in an ethical manner ROM.3 Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management. Facility Management and Safety (FMS) FMS.1 The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements. FMS.2 The organisation’s environment and facilities operate to ensure safety of patients, their families, staff and visitors. FMS.3 The organization has a program for clinical and support service equipment management FMS.4 The organization has provisions for safe water, electricity, medical gases and vacuum systems FMS.5 The organization has plans for fire and non-fire emergencies within the facilities Human Resource Management (HRM) HRM.1 The organization has a documented system of human resource planning. HRM.2 The staff joining the organization is socialized and oriented to the hospital environment HRM.3 There is an ongoing programme for professional training and development of the staff. HRM.4 An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process HRM.5 The organization has a well-documented disciplinary and grievance handling procedure HRM.6 The organization addresses the health needs of the employees HRM.7 There is a documented personal record for each staff member HRM.8 There is a process for authorizing all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications HRM.9 There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members commensurate with their qualifications and any other regulatory requirements Information Management Systems (IMS) IMS.1 Documented procedures exist to meet the information needs of the care providers, management of the organization as well as external agencies that require data and information from the organization. IMS.2 The organization has processes in place for effective management of data IMS.3 The organization has a complete and accurate medical record for every patient IMS.4 The medical record reflects continuity of care IMS.5 Documented procedures are in place for maintaining confidentiality, integrity and security of information IMS.6 Documented procedures exist for retention time of records, data and information IMS.7 The organization regularly carries out medical record audits