1. NABH PREACR –ENTRY LEVEL

2. CARE OF PATIENT IS GUIDED BY ACCEPTED NORMS AND PRACTICE

3.  CLINICIANS ARE ENCOURAGED TO CONSIDER THE USING EVIDENCE BASED MEDICINE FOR THE PROVISION OF OPTIMUM CARE TO THE PATIENTS :  INTERNATIONALLY ACCEPTED PROTOCOLS OF CARE ARE DOCUMENTED AND ACCEPTED AS THE PLAN OF CARE  SOPS AND WI ARE AVAILABLE FOR GUIDANCE AT WORKPLACE  DEPARTMENT MANUALS ARE PERUSED AND ACCEPTED AS RECOMMMENDATION BY HEADS OF DEPARTMENTS

4.  ALL ORDERS GIVEN BY THE DOCTOR DURING INTIAL ASSESSMENT OR CONSEQUENT REASSESSMENTS ARE TO BE SIGNED WITH DATE AND TIME BY DOCTOR  WITHIN 24 HOURS THE CONSULTANT HAS TO COUNTERSIGN THE ORDERS AND PLAN OF CARE

5.  EMERGENCY SERVICES INCLUDING AMBULANCE SERVICES ARE GUIDED BY DOCUMENTED PROCEDURES

6.  TO TRIAGE ALL INCOMING PATIENTS.  TO HAVE PATIENTS ASSESSED BY QUALIFIED INDIVIDUALS.  TO DIAGNOSE, TREAT, ADMIT AND PROVIDE APPROPRIATE REFERRAL AND FOLLOW UP.  TO ENSURE CRITICALLY ILL PATIENTS RECEIVE THE TOP PRIORITY CARE AS DETERMINED BY TRIAGE GUIDELINES.  TO INITIATE LIFESAVING TREATMENT.  TO PROVIDE END OF LIFE CARE.

7.  STAFF SHOULD BE WELL VERSED IN THE CARE OF EMERGENCY PATIENTS IN CONSONANCE WITH SCOPE OF SERVICES OF HOSPITAL

8.  ALS/BLS TRG AND DISASTER MANAGEMENT TRG  HOSPITAL CODES TRG  COMPETENCY EVELUATION DONE STAFF ARE TRAINED IN EMERGENCY CARE TO DEAL EFFECTIVELY WITH THE PATIENTS  ALS/BLS TRG AND DISASTER MANAGEMENT TRG  HOSPITAL CODES TRG  COMPETENCY EVELUATION DONE

9.  DEPENDING ON CLINICAL FINDINGS PATIENT IS ADMITTED TO WARD OR SENT TO HOME  IF PATIENT DESIRES OR TREATMENT IS OUT OF THE SCOPE OF HOSPITAL SERVICES THEN PATIENT IS TRANSFERRED IN SUITABLE FASHION WITH A TRANSFER NOTE AND MEDICAL ATTENDENT AS REQUIRED

10.  AMBULANCE MAYBE ALS/BLS  HAS TO BE EQUIPPED WITH BASIC OR ADVANCED LIFESAVING EQUIPMENT AND OXYGEN  EQUIPMENT HAS TO CHECKED REGULARLY AND ALL LICENSES SHOULD BE IN ORDER  DAILY FUNCTIONING CHECK  EMERGENCY MEDICATION STOCK HAS TO BE AVAILABLE ALWAYS

11.  DRIVER AND STAFF HAS TO BE TRAINED IN BLS/ALS DEPENDING ON TYPE OF AMBULANCE  TRAINING AND COMPETENCY HAS TO BE CHECKED

12.  COP3-DOCUMENTED PROCEDURES DEFINE RATIONAL USE OF BLOOD AND BLOOD PRODUCTS

13.  BLOOD / BLOOD COMPONENTS SHOULD NOT BE PRESCRIBED UNLESS THERE IS A REAL INDICATION.  REQUEST SHOULD BE MADE BY A CONSULTANT/DOCTOR WORKING IN THE HOSPITAL.  BLOOD TRANSFUSION REQUEST FORM SHOULD BE FILLED BY A DOCTOR  CONSENT FOR TRANSFUSION SHOULD BE TAKEN FROM PATIENT / GUARDIAN AFTER EXPLAINING THE TRANSFUSION REQUIREMENT OR DOCTOR CAN GIVE CONSENT IN CASE OF UNACCOMPANIED PATIENTS WHO ARE INCAPABLE OF GIVING CONSENT.

14.  REQUISITON FORM SIGNED BY DOCTOR  CONSENT TAKEN FROM PATIENT /ATTENDENT  CROSSMATCHED BLOOD TRANSFUSED UNDER CLOSE MONITORING  TRANSFUSION RECORD MAINTAINED AND ALSO ENDORSED IN FILE  DISPOSAL OF BLOOD BAG ACC BMW RULES

15.  PROTOCOLS TO BE FOLLOWED ACCORDING TO INSTRUCTIONS OF GOVT  ONLY AUTHORISED BLOOD BANK WILL PROVIDE SAFE BLOOD WHICH HAS TO BE TRANSFUSED FOLLOWING THE NATIONAL GUIDELINES  ALL BLOOD TRANSFUSION REACTIONS ARE REQUIRED TO BE REPORTED AND NECESSARY CA TAKEN

16.  PATIENT/ATTENDENT HAS TO BE INFORMED ABOUT ALL ASPECTS OF THE BLOOD TRANSFUSION AND CONSENT TAKEN BEFORE TRANSFUSION  EACH DAY OF TRANSFUSION REQUIRES FRESH CONSENT

17.  I. STEP 1 - STOP TRANSFUSION  II. STEP 2 - KEEP IV LINE OPEN WITH 0.9 % NACL  III. STEP 3 - NOTIFY PHYSICIAN AND TREAT SYMPTOMATICALLY  IV. IF TRANSFUSION IS TERMINATED  SEND FRESHLY COLLECTED POST – TRANSFUSION SAMPLE OF BLOOD (PREFERABLY FROM OPPOSITE ARM) AND SAMPLE OF URINE TO BLOOD BANK.  SEND THE RESIDUAL BLOOD COMPONENT UNIT ALONG WITH ADMINISTRATION SET TO BLOOD BANK.  FILL IN THE ADVERSE BLOOD TRANSFUSION FORM AND FORWARD THE SAME TO THE HEAD OF CLINICAL AUDIT COMMITTEE. 

18.  COP-4 DOCUMENTED PROCEDURES GUIDE THE CARE OF PATIENTS AS PER THE SCOPE OF SERVICES PROVIDED BY HOSPITAL IN ICU AND HDU

19.  ICU MANUAL HAS THE STANDARDISED PROTOCOLS TO BE FOLLOWED IN ICU  TRAINING AND FAMILIARISATION OF ICU STAFF REGARDING THE HOSPITAL PROTOCOLS IS DONE  ICU ADMISSION AND DISCHARGE CRITERIA DEPENDING ON SCOPE OF THE HOSPITAL SERVICES IS DOCUMENTED AND STAFF IS ORIENTED  INFECTION CONTROL PRACTICES ARE FOLLOWED AND STAFF IS TRAINED AND ORIENTED

20.  ICU IS EQUIPPED WITH CRITICAL LIFE SAVING EQUIPMENT MAINTAINED/CALIBRATED REGULARLY FOR OPTIMUM FUNCTIONING ACCORDING TO NO OF BEDS  STAFF IS ADEQUATE WITH RATIO 1;1ALS/BLS TRAINED AND TRAINED ON HANDLING PATIENTS REQUIRING CRITICAL CARE  EMERGENCY AND VITAL MEDICATION IS MADE AVAILABLE 24 HOURS  THERE IS BACK UP CRITICAL CARE EQUIPMENTS./SUPPLIES/ELECTRICITY/SUCTION/OXYGEN /STAFF FOR EMERGENT REQUIREMENTS  STAFF IS TRAINED IN EQUIPMENT MANGMENT AND EMERGENCY CASES MANGEMENT

21. COP-5 DOCUMENTED PROCEDURES GUIDE THE CARE OF OBSTRETICAL PATIENTS AS PER THE SCOPE OF SERVICES PROVIDED BY THE HOSPITAL

22.  THE ORGANISATION DEFINES AND DISPLAYS THE LEVEL OF OBSTETRIC CARE AVAILABLE IN THE HOSPITAL  IT DISPLAYS IF HIGH RISK CASES ARE ACCEPTED FOR CARE  EQUIPMENT,INFRASTRUCURE,MEDICINES,STAFF FOR OPTIMUM CARE ARE AVAILABLE  QUALIFIED AND TRAINED STAFF ARE AVAILABLE 24 HOURS  QUALIFIED GYNECOLOGIST AND OBSTRETRICIAN ARE AVAILABLE

23.  THE ORGANISATION DEFINES AND DISPLAYS OBSTETRIC CARE AS INCLUDING ANC CHECK UP,NUTRITIONAL CARE,INTRAPARTUM,POST PARTUM AND POST NATAL CARE AVAILABILITY  IMMUNISATION FACILITY,FAMILY PLANNING COUNSELLING  ‘REGISTRATION WITH GOVT FOR MTP AND TUBECTOMY IS DONE FOR ENSURING COMPLETE MATERNAL CARE  BIRTH INFORMATION IS FWD TO STATE CELL FOR REGISTRATION  ALL MTP AND TUBECTOMY AND CONTRACEPTIVE USE CARE INFO IS FORWARED ACC TO GOVT REGULATIONS TO GOVT DEPT RESPONSIBLE FOR FAM WELFARE

24.  THE ORGANISATION ENSURES AVAILABILITY OF CARE OF NEONATES ALONG WITH OBSTETRIC CARE IN ITS SCOPE  NEONATAL CARE INCLUDE IMMED RESUSCITAION CARE,NICU CARE AND EMERGENCY CARE  QUALIFIED AND SKILLED STAFF TRAINED FOR PEDIATRIC CARE UNDER PEDIATRIC COVER IS AVAILABLE  EQUIPMENT INFRASTRUCURE,MEDICINES FACILTIES FOR MANAGEMENT ARE AVAILABLE

25.  COP-6 DOCU PROCEDURES GUIDE THE CARE OF PAEDITRIC PATIENTS AS PER THE SCOPE OF SERVICES PROVIDED BY HOSPITAL

26.  DEPENDING ON STAFFING/INFRASTRUCTURE/EQUIPMENT AVAILABILITY THE ORGANISATION DECIDES ITS SCOPE OF SERVICES  SERVICES MAY INCLUDE SPL OR SUPERSPL NEONATOLOGY/PEDIATRIC CARDIOLOGY/PAED SURGERY ETC  THE SCOPE OF SERVICES IS DISPLAYED  STAFF IS ORIENTED

27.  PEDIATRIC PATIENTS HAVE SPECIAL NEEDS AND THEY ARE VULNERABLE PATEINTS  SPECIALISED TRAINED STAFF ALONG WITH PEDIATRICIANS CARE FOR THEM  PROTOCOLS OF CARE ARE DOCUMENTED AND FOLLOWED  SEPARATE WARD /ATTENDENT SPACE/FEEDING ROOM/PLAY AREA /SEPARATE TOILETS /EXTRA SECURITY  SEPARATE EQUIPMENT FOR PEDIATRIC PATIENTS IS MADE AVAILABLE FOR THEIR NEEDS  DIETARY SERVICES ARE ALSO AVAILABLE FOR SPECIAL NEEDS

28.  ALL PAED PATIENTS ARE ASSESSED FOR NUTRITIONAL STATUS AND IMMUNISATION STATUS  ALSO ASSESSED FOR MILESTONES,PSYCHOSOCIAL NEEDS  COUNSELLING OF PARENTS DONE FOR THE SAME

29.  CODE PINK  VULNERABLE PATIENTS  REQUIRE SPECIAL SECCURITY AND ATTENTION  STAFF ENGAGED IN CARE IS TRAINED IN SPECIAL CARE OF THE NEONATES AND CHILDREN  WRIST BANDS FOR VULNERABLE PATIENTS

30.  ASSESSMENT OF PEDIATRIC PATIETNS IN OPD OR IPD INCLUDES NUTRITIONAL STATUS EVALUATION/MILESTONES EVALUATION/BIRTH HISTORY AND IMMUNISATION STSTUS AS ROUTINE  IMMUNIZATION CARDS INCLUDE MILESTONES AND NUTRITIONSL STATUS REVIEW  STAFF IS TRAINED FOR BIRTH WEIGHT AND NUTRITIONAL STATUS ASSESSMENTS

31.  COP 7 DOCU PROCEDURES GUIDE THE ADMINISTRATION OF ANESTHESIA

32.  ANESTHESIA ADMINISTRAION POLICIES AND PROCEDURES ARE DOCUMENTED IN THE HOSPITAL PROCEDURE MANUAL FOR OT  INTERNATIONALLY ACCEPTED PROTOCOLS GUIDE ALL ASPECTS OF ANESTHESIA IN HOSPITAL

33.  NO PATIENT CAN BE TAKEN UP FOR ANY SURGICAL PROCEDURE WITHOUT A PAC BY QUALIFIED TRAINED ANESTHETIST  PAC FORM IS FILLED WITH ALL DETAILS AND SIGNED BY ANESTHETIST  CONSENT FOR ANESTHESIA IS ALSO TAKEN BY ANESTHETIST

34.  DEPENDING ON THE PAC A PLAN FOR ANESTHESIA IS DOCUMENTED ON PAC FORM  THE PREPARATION FOR PATIENT BY OT STAFF IS BASED ON THE PLAN OF ANESTHESIA SIGNED BY ANESTHETIST  IT IS ALSO DOCUMENTD IN THE OT LIST  ALL SPECIAL REQUIRMENTS ARE ALSO DOCUMENTED

35.  IMMED PREOP RE EVALUATION OF THE PATIENT IS MANDATORY  IT IS DOCUMENTED IN THE PREOP REEVAULATION FORM AND THE CHANGES IF ANY ARE DOCUMENTED ACCORDING TO LATEST STATUS OF THE PATIENT  SURGICAL SAFETY CHECKLIST IS USED

36.  THE PATIENT IS COUNSELLED AND INFORMED ABOUT HIS ANESTHESIA STATUS AND PLAN OF ANESTHESIA AND ALL SIDE EFFECTS  CONSENT IS TAKEN AND ALSO SIGNED BY ANESTHETISAND PATIENT

37.  THE MONITORING IS DOCUMENTED IN THE ANESTHESIA NOTES AND CHART  ALL PARAMETERS ARE MONITORED AND INTRAOPERATIVE MONITORING NOTES ARE DOCUMENTED

38.  ALL PARAMETERS ARE MONITORED AND DOCUMENTED IN PATIENT FILE BY AN ANESTHETIST AND DULY SIGNED  CRITERIA FOR SHIFTING FROM RECOVERY AREA ARE DOCUMENTED AND STAFF ORIENTED TO IT

39.  DOCUMENTED AND ACCEPTED GUIDELINES FOR TRANFER OF PATIENT FROM RECOVERY AREA ARE FOLLOWED  THE ANESTHETIST DOCUMENTS

40.  ALL ADVERSE ANESTHESIA EVENTS ARE TO BE RECORDED IN ADR FORM  ROOT CAUSE ANALYSIS TO BE DONE  CA AND PA TO BE DONE  ALL SUCH OCCURRENCES ARE THEN DISCUSSED FOR PREVENTION  EQUIPMENT/PROCEDURE/STAFF/MATERIAL ERROR TO BE RECTIFIED

41.  COP 8-DEFINED CRITERIA GUIDE THE CARE OF PATIENTS UNDERGOING SURGICAL PROCEDURES

42.  SURGEON SHOULD DOCUMENT PRE OP ASSESSMENT AND PROV DIAGNOSIS ALONG WITH PLAN OF CARE BEFOR TAKING FOR SURGERY  WARD AND OT STAFF TO BE INFORMED ABOUT THE REQUIRMENTS ACCORDINGLY

43.  THE PROCEDURE AND ITS IMPLCATIONS ARE EXPLAINED TO THE PATIENT BY THE SURGEO AND CONSENT FOR THE SURGERY PLANNED IS TO BE TAKEN BY SURGEON AND SIGNED BY PATIENT AND SURGEON  TIME AND DATE TO BE MENTIONED  ANY POSSIBLE COMPLIACTIONS AND DIAGNOSIS TO BE DOCCUMENTED IN CONSENT FORM IN LANGUAGE UNDERSTOOD BYBPATIENT

44.  USE OF WHO SURGICAL SAFETY CHECKLIST  TO AVOID SENTINAL EVENT LIKE  WRONG PATIENT  WRONG SITE  WRONG SURGERY  INTERNATIONALLY ACCEPTED AND USED CHECKLIST

45.  CREDENTIALLING IS DONE TO ENSURE ONLY QUALIFIED PERSONS PERFORM THE PROCEDURES THEY ARE COMPETENT TO PERFORM  CREDENTIALLING COMMITTEE ENSURES THIS  STAFF IS ALSO TRAINED AND ASSESSED FOR COMPETENCY PERIODICALLY

46.  THE OPERATING SURGEON DOCUMENTS THE OPERATIVE FFINDINGS,OPERATING NOTES  HE DOCUMENTS POST OPERATIVE PLAN OF CARE  FOLLOW UP IS DONE BY SURGEON  HE ALSO DOCUMENTS IF BIOPSY OR OTHER PROCEDURE WERE DONE

47.  INFECTION CONTROL PRACTICES ACCORDING TO THE INFEECTION CONTROL MANUAL ARE FOLOWED IN OP TH  PPE ARE USED,ZONING IN OT IS MAINTAINED  UNIVERSAL PREACUTIONS ARE FOLLOWED  REGULAR MICROBIOLOGICAL MONITORING IS DONE TO ENSURE INFECTION FREE ATMOSPHERE  INFECTION CONTROL OFFICER AND NURSE MONITOR THE INFECTION CONTROL PRACTICES  TRAINING IN ALL INFECTION CONTROL PRACTISE IS ENSURED  ALL PROTOCOLS ARE FOLLOWED AS ADVISED

48.  ZONING AND UNIDIRECTIONAL FLOW IN OT  STERILE AND UNSTERILE MATERIAL AND EQUIPMENT DO NOT MIX  UNSTERILE EQUIPMENT CLEANED -MOVE TO CSSD  LAUNDRY BAGGED MOVED TO UNSTERILE AREA  BIOMED WASTE BAGGED,SHIFTED IN COVERED CONTEINER FOR DISPOSAL

49.  CASE SHEET  CONSENT FORMS-ANESTH/SURGERY/PROCEDURE  PAC FORM/ PREOP EVALUATION FORM  BLOOD TRANSFUSION FORM  ADR FORM  TRANSFUSION REACTION FORM  PAC FORM  INTRAOP MONITORING FORM/POST OP MONITORING FORM/OT NOTES/NURSING OT NOTES/ANESTHESIA NOTES/  SURGICAL SAFETY CHECKLIST  INFECTION CONTROL RECORDS  TRANSFER SHEET

50.  ICU MANUAL  OT MANUAL  INFECTION CONTROL MANUAL