1. NABH AND NURSES CONTRIBUTION TO QUALITY
Mrs. Justina Nancy Mendonca
Chief of Nursing Services
Columbia Asia Referral Hospital
Bangalore

2. ISQUA ACCREDITATION
India has become the 12th country in the world to be accredited by the International Society for Quality in Health Care (ISQua) for four years. The accreditation follows the submission of the hospital standards set by NABH to ISQua.

3. STANDARDS Patient Centered M O C
Access Assessment & Continuity of care P R E H I C
Care of Patients A C
Management of medication
Patients Rights and Education
Hospital Infection control
Patient Centered

4. ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC). 15 standards
Services display
Patient registration.
Transfer / Referral of patients.
Admission of patients – Informed Consent.
and Relative education.
Initial assessment / Regular reassessment.
Laboratory services to patient need – safety /QI.
Imaging services – safety /QI.
Patient care continuous /multidisciplinary in nature
Discharge process - documents and discharge summary.

5. 2. CARE OF PATIENTS (COP). 18 standards
Uniform care of Patients in all settings.
Emergency/Ambulance services – CPR guidelines /Blood product usage.
ICU standards –Care of Vulnerable patients
P&P on High risk pregnancy, Pediatrics, Anesthesia, Surgical, Pain management, Restrains, Rehabilitation, research activities, nutritional and end of life care.

6. 4. MANAGEMENT OF MEDICATION (MOM) . 13 standards
P&P - pharmacy services/usage of medication - hospital formulary - storage - prescription - safe dispensing - administration - patient and family educated on safe medication.
Monitoring after medication – food drug interaction - policies in narcotic drugs and psychotropic - chemotherapy - radioactive drugs - prosthesis implantation and use of medical gases.

7. 4. PATIENT RIGHT AND EDUCATION (PRE). 5 standards
Organization protection to patient and family rights during care.
Support to patient's family for decision making process.
Documented - consent - for informed decision making.
Information on health needs to patient's family.
Cost of care

8. 5. HOSPITAL INFECTION AND CONTROL (HIC). 9 standards
Well designed comprehensive infection control programme – manual- surveillance activities.
Prevention of Hospital Associated infection (patients & employees).
Adequate resources for IC programme.
Control of out break of infection.
Sterilization activities - biomedical waste management.
Training of employees on IC

9. STANDARDS Management Centered F M S H R M
Continuous Quality Improvement
R O M C Q I
Responsibility of management I M S
Facility Management & Safety
Human resource Management
Management Centered
Information Management System

10. 6. CONTINUOUS QUALITY IMPROVEMENT (CQI). 6 standards
Quality improvement programme
QI indicators and Monitoring – patient care areas
QI indicators and Monitoring – Management areas
QI programme supported by the management.
Audit of patient care services.
Sentinel events analysis.

11. 7.RESPONSIBILITIES OF MANAGEMENT (ROM). 5 standards
Defined management responsibilities.
Documented service provided.
Leaders manage in ethical manner.
Qualified/Experienced person heads the organization.
Ensures pt safety and knows the risk management issues.

12. 8. FACILITY MANAGEMENT AND SAFETY (FMS). 9 standards
Organization is aware of rules and regulations complies.
Safe environment for patients/families/employees.
Clinical and support service equipment management.
Plan for Fire and Non fire emergencies.
No smoking policy.
Plan for community emergencies - Epidemics - disasters - hazardous material management.

13. 9.HUMAN RESOURCE MANAGEMENT (HRM). 13 standards
Human resource planning documented.
Orientation of newly joined.
Ongoing training.
Job responsibilities.
Appraisal documented.
Disciplinary procedure.
Grievance handling.
Health needs of the employees.
Personal records.
Medical professional - Nursing staff – credentials.

14. 10. INFORMATION MANAGEMENT SYSTEM (IMS). 7 standards
Data information to all patient care providers.
Process of management of data.
Medical record keeping.
EMRD reflects continuity of care.
Records confidentiality - integrity – security of information.
Policy and procedures for retention time of records, data and information.
Medical audits.

15. Nurses Contribution Patient care related- Assessment and reassessment.
Patient rights
Management of medications.
Infection control
Medical records.
Patient safety
Emergency and disaster.
Patient care related-
Code Blue
ICU protocols
Restraint
Vulnerable
Pain.
All Infection Control Policies.
Adverse drug events and reactions
Adverse events.
Patient Identification
Staff Hazards.

16. Nurses Contribution Admission and discharge. Prescription standards.
Inter and intra hospital transfers.
Assessment and reassessment
Informed consent.
Confidentiality and privacy.
Patients rights.
Complaint handling.
Prescription standards.
Medication administrations.
Verbal orders.
High risk medication
Labeling and storage.
Narcotics.
Sound alike look alike medicines.

17. Sentinel Events Sentinel Events Being No Sentinel Event.
PARA AESTHESIA FOLLOWING SPINAL ANESTHESIA.
SURGERY ON WRONG SIDE AND
WRONG PATIENT
WRONG SURGICAL PROCEDURE
ADVERSE DRUG REACTION
DEATH DURING A PLANNED SURGERY
No Sentinel Event.
Time out practice .
Pre op Checklist.
Identification bands.
Theater Record.
Surgical Site Marking.
Surgical safety checklist.
Allergy Bands also started.
Regular trainings.
Regular audits.

18. INFECTION CONTROL Quality Indicators. Steps of Hand hygiene.
BMW act and segregation of waste.
Cleaning protocol.
Staff vaccination.
Spill kits.
Isolation protocols.
Needle stick injury.

19. NURSING QUALITY INDICATORS
Call bell response.
Patient Fall.
Medication error.
Bedsore.
Completion of crash cart checklist.
Completion of nursing initial assessment.

20. DISASTER MANAGEMENT
Code Blue.
Code yellow.
Code Red.
Code Pink.

21. HOW TO FACE AN AUDIT Know your hospital procedure and policies.
Know your infection control manual.
Awareness on hospital set up and your unit orientation.
Awareness of emergency management.
Departmental flow chart.
Legal issues.
Job description and HR policies.

22. THANK YOU