Checklist For NABH

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tx9194 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \
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100 Page 5 of 53

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3d\tab \up0 \expndtw-3\charscalex100 Check list of Ambulance\ul0\nosupersub\cf1
6\f17\fs24 ,\ul0\nosupersub\cf4\f5\fs24 drugs and equipment\par\pard\li1584\sb1
63\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 COP 3e\tab \up0 \expn
dtw-3\charscalex100 Ambulance: adequate equipment in working order\par\pard\ql \
li3471\sb151\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Training of personnel
on BLS/ACLS \par\pard\li1584\sb161\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\cha
rscalex100 FMS a,b,c,d\tab \dn3 \expndtw-3\charscalex100 Statutory requirements\
par\pard\ql \li3831\sb7\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupe
rsub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
RC book \par\pard\ql \li3831\
sb4\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o
\ul0\nosupersub\cf4\f5\fs24
License of driver (s) \par\pard\ql \li3831\sb4\sl
-276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\n
osupersub\cf4\f5\fs24
Insurance \par\pard\ql \li3831\sb1\sl-256\slmult0 \up0
\expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\f
s24
Emission check \par\pard\qj \li1584\ri7018\sb160\sl-600\slmult0 \up0 \exp
ndtw-2\charscalex100 \ul0\nosupersub\cf1\f2\fs24 2. Out Patient Department \up
0 \expndtw-2\charscalex100 Primary \par\pard\li1584\sb95\sl-276\slmult0\fi0\tx34
71 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 AAC 5a-g\tab \dn2 \
expndtw-3\charscalex100 Predefined initial assessment and re-assessment\par\pard
\ql \li3471\sb157\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Time frame for do
ing and documenting initial assessment \par\pard\ql \li3471\sb164\sl-276\slmult0
\up0 \expndtw-3\charscalex100 Initial assessment to include screening for nutri
tional needs. \par\pard\qj \li3471\ri1450\sb26\sl-420\slmult0 \up0 \expndtw0\cha
rscalex103 Documented plan of care including preventive aspects of the \line \up
0 \expndtw-3\charscalex100 care \par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1
584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl
-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmul
t0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\par
d\li1584\sb69\sl-253\slmult0\fi0\tx4585\tx9194 \up0 \expndtw-3\charscalex100 \ul
0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date:
17/05/11\tab \up0 \expndtw-3\charscalex100 Page 6 of 53
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arscalex101 Time frame for doing and documenting initial assessment -\par\pard\l
i1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex101 finished within 2
4 hours\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\pa
584\sb168\sl-253\slmult0\fi0\tx4585\tx9194 \up0 \expndtw-3\charscalex100 \ul0\no
supersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/
05/11\tab \up0 \expndtw-3\charscalex100 Page 7 of 53
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ds\par\pard\qj \li3471\ri1450\sb44\sl-420\slmult0 \up0 \expndtw0\charscalex103 D
ocumented plan of care including preventive aspects of the \line \up0 \expndtw-3
\charscalex100 care \par\pard\li1584\sb128\sl-276\slmult0\fi0\tx3471 \up0 \expnd
tw-1\charscalex100 AAC 6a\tab \dn2 \expndtw-1\charscalex100 Reassessment - frequ
ency of reassessment, documentation of\par\pard\ql \li3471\sb135\sl-276\slmult0
\up0 \expndtw-3\charscalex100 response to treatment, plan for further treatment
or discharge \par\pard\ql \li1584\sb164\sl-276\slmult0\tx3471 \up0 \expndtw-3\ch
arscalex100 AAC 13a-f \tab \up0 \expndtw-3\charscalex100 Multidisciplinary nat
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slmult0 \up0 \expndtw-3\charscalex100 various departments/ staff / shift \par\pa
rd\qj \li3471\ri2701\sb37\sl-430\slmult0 \up0 \expndtw-3\charscalex100 Qualified
individual identified as responsible for care \up0 \expndtw-3\charscalex100 Ref
erral of patients to other departments/specialties \up0 \expndtw-3\charscalex100
Handing and taking over \par\pard\li1584\sb125\sl-276\slmult0\fi0\tx3471 \up0 \
expndtw-2\charscalex100 AAC 14a-d\tab \dn2 \expndtw-2\charscalex100 Discharge pl
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mult0\fi1886 \up0 \expndtw-2\charscalex100 including medico-legal cases / LAMA,
discharge summary to all\par\pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \up0 \e
xpndtw-2\charscalex100 AAC 15a-f\tab \up0 \expndtw-2\charscalex100 Content of di
scharge summary\par\pard\li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\
charscalex100 COP 1a-d\tab \up0 \expndtw-2\charscalex100 Care and treatment orde
rs are signed, named, timed and dated\par\pard\ql \li3471\sb144\sl-276\slmult0 \
up0 \expndtw-3\charscalex100 by the doctor \par\pard\qj \li3471\ri1451\sb62\sl-4
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li3471\sb143\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Evidence based medicin
e and clinical practice guidelines \par\pard\li1584\sb154\sl-276\slmult0\fi0\tx3
471 \up0 \expndtw0\charscalex102 COP 4a-e\tab \dn2 \expndtw0\charscalex102 CPR
- Policy and procedure, staff trained in BLS/ALS,\par\pard\li1584\sb153\s
l-276\slmult0\fi1886 \up0 \expndtw0\charscalex102 Documentation of events dur
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l-276\slmult0\fi0\tx3471\tx8766 \up0 \expndtw0\charscalex102 COP\tab \dn3 \expnd
tw0\charscalex102 Rational use of blood and blood products\tab \dn3 \expnd
tw0\charscalex102 - Policy and\par\pard\li1584\sb139\sl-276\slmult0\fi0\tx3471
\up0 \expndtw0\charscalex102 5a,c,d,e\tab \dn2 \expndtw0\charscalex102 procedur
e, informed consent, patient and family education\par\pard\li1584\sb154\sl-276\
slmult0\fi1886 \up0 \expndtw0\charscalex102 about donation, monitoring transfusi
on reactions\par\pard\li1584\sb148\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\char
scalex102 COP 7a-e\tab \dn2 \expndtw0\charscalex102 Care of vulnerable patients
- Policy and procedure, safe and\par\pard\li1584\sb155\sl-276\slmult0\fi1886 \up
0 \expndtw0\charscalex102 secure environment, informed consent from the appropri

ate\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex102 leg
al representative\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\
584\sb0\sl-253\slmult0\par\pard\li1584\sb117\sl-253\slmult0\fi0\tx4585\tx9194 \u
p0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expn
dtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page
8 of 53
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\slmult0\tx3471 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 COP 12
a-c \tab \up0 \expndtw0\charscalex102 Care of patients undergoing surgical proce
dures - Policy and \par\pard\qj \li3471\ri1443\sb31\sl-413\slmult0 \up0 \expndtw
-1\charscalex100 procedure, preoperative assessment and provisional diagnosis \u
p0 \expndtw0\charscalex102 documented prior to surgery, informed consent obtaine
d by a \up0 \expndtw0\charscalex102 surgeon, documented policies and procedu
res to prevent \up0 \expndtw-3\charscalex100 adverse events. \par\pard\li1584\
sb141\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 COP 14a-c\tab \up0
\expndtw-3\charscalex100 Pain assessment\par\pard\li1584\sb170\sl-276\slmult0\f
i1886 \up0 \expndtw-3\charscalex100 Education of family\par\pard\li1584\sb147\sl
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0\tx3471 \up0 \expndtw-3\charscalex100 COP 8c\tab \dn3 \expndtw-3\charscalex100
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71 \up0 \expndtw-1\charscalex100 MOM 3g,h\tab \dn2 \expndtw-1\charscalex100 Emer
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dtw-1\charscalex100 MOM 4a-g\tab \dn2 \expndtw-1\charscalex100 Medicine orders a
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sl-440\slmult0 \up0 \expndtw-3\charscalex100 dated, timed, named, signed \up0 \e
xpndtw-3\charscalex100 Verbal orders \par\pard\ql \li3471\sb116\sl-276\slmult0 \
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1584\sb164\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 6a-j\tab
\up0 \expndtw-3\charscalex100 Medication administration\par\pard\ql \li3471\ri27
28\sb41\sl-426\slmult0 \up0 \expndtw-3\charscalex100 Staff interview on the meth
odology of administration \line \up0 \expndtw-3\charscalex100 Medication adminis
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dministration of medicines \line \up0 \expndtw-3\charscalex100 Management of med
ications got from outside \par\pard\li1584\sb138\sl-276\slmult0\fi0\tx3471 \up0
\expndtw-1\charscalex100 MOM 8a,c\tab \up0 \expndtw-1\charscalex100 Patient moni
toring after medication administration\par\pard\li1584\sb170\sl-276\slmult0\fi18
86 \up0 \expndtw-1\charscalex100 Knowledge to pick adverse drug events and repor
ting of the\par\pard\li1584\sb140\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscal
ex100 same\par\pard\li1584\sb147\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\chars
calex100 MOM 9a-d\tab \dn2 \expndtw-1\charscalex100 Narcotic drug procedure\par\
pard\li1584\sb170\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Handling\p
ar\pard\li1584\sb156\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Documen
tation\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par
tx9194 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \
up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex
100 Page 9 of 53

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\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 Medication storage uni
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7\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 high risk medications\par\
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1 \up0 \expndtw-1\charscalex100 FMS 5a,b\tab \dn2 \expndtw-1\charscalex100 Signa
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arscalex100 FMS 3c,e\tab \dn3 \expndtw-1\charscalex100 All equipment are invento
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b \up0 \expndtw-1\charscalex100 on\par\pard\ql \li3471\sb122\sl-276\slmult0 \up0
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i1584\sb164\sl-276\slmult0\fi0\tx3471\tx7293\tx7723 \up0 \expndtw0\charscalex100
FMS 4d\tab \up0 \expndtw0\charscalex100 Gas
and
vacuum
supply\tab \up0
\expndtw0\charscalex100 /\tab \up0 \expndtw0\charscalex100 Storage
of
oxy
gen\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex100 cyl
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\up0 \expndtw0\charscalex100 IMS 3a,c,d\tab \dn3 \expndtw0\charscalex100 Medical
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atient interview\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw0\char
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4\sb138\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\charscalex100 \ul0\nosu
persub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05
/11\tab \up0 \expndtw-3\charscalex100 Page 10 of 53
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76\slmult0 \par\pard\ql\li1584\sb220\sl-276\slmult0 \up0 \expndtw-2\charscalex10
0 \ul0\nosupersub\cf1\f2\fs24 4. Specialized Wards \par\pard\ql \li1584\sb0\sl

-276\slmult0 \par\pard\ql\li1584\sb188\sl-276\slmult0 \up0 \expndtw-3\charscalex
100 Paediatric \par\pard\ql \li1584\sb244\sl-276\slmult0 \up0 \expndtw-3\charsca
lex100 Primary \par\pard\ql \li1584\sb144\sl-276\slmult0\tx3471 \up0 \expndtw-3\
charscalex100 \ul0\nosupersub\cf4\f5\fs24 COP 9a-g \tab \up0 \expndtw0\charscale
x105 Care of paediatric patients - display the scope, age specific \par\pard\ql
\li3471\ri1439\sb26\sl-420\slmult0 \up0 \expndtw0\charscalex104 competency, prov
isions for special care of children, detailed \up0 \expndtw-3\charscalex100 nutr
itional, growth, psychosocial and immunization assessment, \up0 \expndtw-3\chars
calex100 provision for preventing child/neonate abduction and abuse \line \up0 \
expndtw-1\charscalex100 Parent education on nutrition, immunization and safe par
enting \up0 \expndtw-3\charscalex100 and documentation of the same \par\pard\ql
\li1584\ri6922\sb38\sl-520\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub
\cf1\f2\fs24 Secondary:\ul0\nosupersub\cf4\f5\fs24 Checklist of ward \line \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 OBG and Labour Room \line
\up0 \expndtw-3\charscalex100 Primary \par\pard\li1584\sb107\sl-276\slmult0\fi0\
tx3471 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf4\f5\fs24 COP 8a-d\tab \d
n2 \expndtw-2\charscalex100 Care of high risk obstetrical patients -\par\pard\ql
\li3831\ri1450\sb21\sl-420\slmult0\tx4191 \up0 \expndtw-3\charscalex100 \ul0\no
supersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Display of whether high r
isk obstetric cases can be cared \line\tab \up0 \expndtw-3\charscalex100 for or
not \par\pard\ql \li3831\sb119\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0
\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Assessment of maternal
nutrition \par\pard\ql \li3831\ri1448\sb6\sl-420\slmult0\tx4191 \up0 \expndtw-2
\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Com
petence of staff handling high risk obstetrical \line\tab \up0 \expn
dtw-2\charscalex100 patients \par\pard\ql \li3831\ri1443\sb9\sl-410\slmult0\tx41
91\tx4191 \up0 \expndtw0\charscalex101 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosup
ersub\cf4\f5\fs24
Facilities to take care of neonates of high
risk \line\tab \up0 \expndtw0\charscalex100 pregnancies, NICU/PICU with prop
er equipment and \line\tab \up0 \expndtw-3\charscalex100 staff to take care of
neonates of high risk obstetric cases \par\pard\ql \li1584\sb241\sl-276\slmult0
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Secondary:\ul0\nosupe
rsub\cf4\f5\fs24 Checklist of ward \par\pard\ql \li1584\sb264\sl-276\slmult0 \u
p0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Chemotherapy Unit \par\p
ard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584
\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-25
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par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\l
i1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\
sl-253\slmult0\par\pard\li1584\sb82\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expnd
tw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\cha
rscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 11 of 53
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n,\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 ver
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\fi0\tx3471 \up0 \expndtw-1\charscalex100 MOM 9a-d\tab \up0 \expndtw-1\charscale
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\sb153\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 usage/ disposal/ hand
led by competent staff\par\pard\li1584\sb166\sl-276\slmult0\fi1886 \up0 \expndtw
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scalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex10
0 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 12 of 53
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0 \ul0\nosupersub\cf1\f2\fs24 6. Dialysis Unit \par\pard\ql \li1584\sb0\sl-276
Primary \par\pard\li1584\sb139\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charsca
lex100 \ul0\nosupersub\cf4\f5\fs24 HIC 2d\tab \dn3 \expndtw-3\charscalex100 Over
all adherence to infection control\par\pard\ql \li3471\ri1441\sb56\sl-413\slmult
0 \up0 \expndtw-1\charscalex100 Re-use policy of tubes, how safely it was kept a
nd the labelling \line \up0 \expndtw-3\charscalex100 requirement to prevent exch
ange/ensure patient\u8217?s safety\ul0\nosupersub\cf16\f17\fs24 . \line \up0 \ex
pndtw0\charscalex105 \ul0\nosupersub\cf4\f5\fs24 Check Adequate soap, masks, glo
ves and disinfectants are \line \up0 \expndtw-3\charscalex100 available \par\par
d\ql \li3471\sb141\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Quality of RO wa
ter \par\pard\li1584\sb158\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex10
1 PRE 3e\tab \dn3 \expndtw0\charscalex101 Policy on consent. Who can give consen
t when patient is\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw0\cha
rscalex101 incapable\par\pard\li1584\sb148\sl-276\slmult0\fi0\tx3471 \up0 \expnd
tw0\charscalex101 FMS 3c,e\tab \dn2 \expndtw0\charscalex101 All equipment are in
ventoried and log maintained / calibrated\par\pard\li1584\sb171\sl-276\slmult0\f
i1886\tx5457\tx8513\tx9995 \up0 \expndtw0\charscalex101 Preventive\tab \up0 \exp
ndtw0\charscalex101 maintenance/service\tab \up0 \expndtw0\charscalex101 labels\
tab \up0 \expndtw0\charscalex101 on\par\pard\ql \li3471\sb129\sl-276\slmult0 \up
0 \expndtw-3\charscalex100 Equipment/calibration records \par\pard\ql \li1584\sb
264\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Sec
ondary \par\pard\qj \li3471\ri6477\sb9\sl-440\slmult0 \up0 \expndtw-3\charscalex
100 \ul0\nosupersub\cf4\f5\fs24 Patient interview \line \up0 \expndtw-3\charscal
ex100 Staff interview \par\pard\li1584\sb123\sl-276\slmult0\fi0\tx3471 \up0 \exp
ndtw0\charscalex100 COP 4b\tab \dn2 \expndtw0\charscalex100 Training in CPR - BL
S/ ALS\par\pard\li1584\sb166\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex
100 MOM 3g,h\tab \dn2 \expndtw0\charscalex100 Emergency drug management\par\pard
\li1584\sb173\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex100 HIC 2d\tab
\dn2 \expndtw0\charscalex100 Sterilized sets: expiry dates, storage conditions\p
ar\pard\li1584\sb156\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex100 HIC
5a-e\tab \dn2 \expndtw0\charscalex100 Check hand washing facilities for sta
ff in all care area,\par\pard\li1584\sb153\sl-276\slmult0\fi1886 \up0 \expnd
tw0\charscalex100 instructions for proper hand washing\par\pard\li1584\sb154\sl276\slmult0\fi1886 \up0 \expndtw0\charscalex100 Check Adequate soap, masks, glov
es and disinfectants are\par\pard\li1584\sb139\sl-276\slmult0\fi1886 \up0 \expnd
tw0\charscalex100 available\par\pard\li1584\sb146\sl-276\slmult0\fi0\tx3471 \up0
\expndtw0\charscalex100 HIC 8b\tab \dn2 \expndtw0\charscalex100 Segregation of
bio-medical waste\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\
584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl
t0\par\pard\li1584\sb249\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\charsc
alex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100
Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 13 of 53
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0 \ul0\nosupersub\cf1\f2\fs24 7. Intensive Care, Neonatal/ Paediatric ICU and
High Dependency Units \par\pard\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li158
4\sb108\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Primary \par\pard\li1584\sb
137\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf4\
f5\fs24 COP 6a-f\tab \dn3 \expndtw-2\charscalex100 Admission and discharge crite
ria\par\pard\li1584\sb173\sl-276\slmult0\fi1886 \up0 \expndtw-2\charscalex100 Qu
ality assurance program\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndt
w-2\charscalex100 Adherence to infection control practices\par\pard\li1584\sb153
\sl-276\slmult0\fi1886 \up0 \expndtw-2\charscalex100 Adequacy of staff and equip
ment\par\pard\li1584\sb147\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex1
00 COP 13c,d\tab \dn2 \expndtw-2\charscalex100 Documented policies and proced
ures on use of restraints,\par\pard\li1584\sb156\sl-276\slmult0\fi1886 \up0
\expndtw-2\charscalex100 reason for restraints, monitoring requirements\par\pard
\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw-2\charscalex100 Staff awarenes
s on control and restraint technique\par\pard\li1584\sb149\sl-276\slmult0\fi0\tx
3471 \up0 \expndtw-2\charscalex100 COP 18a-e\tab \dn2 \expndtw-2\charscalex100 E
nd of life care - Documented policies and procedures, unique\par\pard\li1584\sb1
53\sl-276\slmult0\fi1886 \up0 \expndtw-2\charscalex100 needs identification, aut
opsy/ organ donation process\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \e
xpndtw-2\charscalex100 Staff awareness on end of life care\par\pard\li1584\sb149
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w-2\charscalex100 Policy for Bed shortage in ICU\par\pard\li1584\sb163\sl-276\sl
mult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 AAC 5a,c,d\tab \dn3 \expndtw-2\ch
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t0 \up0 \expndtw-3\charscalex100 Time frame for doing and documenting initial as
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i1584\sb156\sl-276\slmult0\fi0\tx3471\tx8766 \up0 \expndtw0\charscalex103 COP 5a
-f\tab \dn2 \expndtw0\charscalex103 Rational use of blood and blood produc
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expndtw-1\charscalex100 COP 9c\tab \up0 \expndtw-1\charscalex100 Age specific co
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fi1886 \up0 \expndtw-1\charscalex100 population\par\pard\li1584\sb149\sl-276\slm
ult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 COP 17a-f\tab \dn3 \expndtw-1\char
scalex100 Nutritional assessment\par\pard\li1584\sb171\sl-276\slmult0\fi1886 \up
0 \expndtw-1\charscalex100 Order for diet\par\pard\li1584\sb154\sl-276\slmult0\f
i1886 \up0 \expndtw-1\charscalex100 Planning of nutritional therapy in a collabo
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arscalex100 MOM 3g,h\tab \dn3 \expndtw-1\charscalex100 Emergency drug management
\sl-253\slmult0\par\pard\li1584\sb218\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \exp
ndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\c
harscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 14 of 5
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ul0\nosupersub\cf3\f4\fs22 NABH Assessment Checklist \par\pard\li1584\sb0\sl-276
\slmult0\par\pard\li1584\sb0\sl-276\slmult0\par\pard\li1584\sb0\sl-276\slmult0\p
ar\pard\li1584\sb0\sl-276\slmult0\par\pard\li1584\sb266\sl-276\slmult0\fi0\tx347
1 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs24 MOM 4a-g\tab \up0 \e
xpndtw-1\charscalex100 Medicine orders are written in a uniform location clear,
legible,\par\pard\li1584\sb156\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex1
00 dated, timed, named, signed\par\pard\ql \li3471\sb150\sl-276\slmult0 \up0 \ex

pndtw-3\charscalex100 Written order for high risk medication \par\pard\li1584\sb
153\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 6a-j\tab \dn2 \e
xpndtw-3\charscalex100 Medication administration\par\pard\ql \li3471\sb155\sl-27
6\slmult0 \up0 \expndtw-3\charscalex100 Medication administration documentation
\par\pard\ql \li3471\sb164\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Manageme
nt of medications got from outside \par\pard\li1584\sb151\sl-276\slmult0\fi0\tx3
471 \up0 \expndtw-1\charscalex100 MOM 8a,c\tab \dn2 \expndtw-1\charscalex100 Pat
ient monitoring after medication administration\par\pard\li1584\sb173\sl-276\slm
ult0\fi1886 \up0 \expndtw-1\charscalex100 Knowledge to pick adverse drug events
and reporting of the\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw-1
\charscalex100 same\par\pard\li1584\sb147\sl-276\slmult0\fi0\tx3471 \up0 \expndt
w-1\charscalex100 MOM 9a-d\tab \dn2 \expndtw-1\charscalex100 Narcotic drug proce
dure\par\pard\li1584\sb172\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 H
andling\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex10
0 Documentation\par\pard\li1584\sb146\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\
charscalex100 HIC 2e\tab \dn2 \expndtw-1\charscalex100 Adherence to antibiotic p
olicy\par\pard\li1584\sb166\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex
100 HIC 4a-e\tab \dn3 \expndtw-1\charscalex100 Collection of Infection control d
ata\par\pard\li1584\sb170\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Av
ailability of various HAI rates of that area and action taken\par\pard\li1584\sb
137\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 based on this\par\pard\l
i1584\sb150\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 FMS 2c,d\tab
\dn3 \expndtw-1\charscalex100 Layout of beds, spacing, visual privacy\par\pard\
li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 FMS 3c,e\ta
b \dn3 \expndtw-1\charscalex100 All equipment are inventoried and log maintained
/ calibrated\par\pard\li1584\sb170\sl-276\slmult0\fi1886\tx5457\tx8516\tx9998 \
up0 \expndtw-1\charscalex100 Preventive\tab \up0 \expndtw-1\charscalex100 mainte
nance/service\tab \up0 \expndtw-1\charscalex100 labels\tab \up0 \expndtw-1\chars
calex100 on\par\pard\li1584\sb139\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscal
ex100 Equipment/calibration records/Refrigerator\par\pard\li1584\sb147\sl-276\sl
mult0\fi0\tx3471\tx7293\tx7723 \up0 \expndtw-1\charscalex100 FMS 4d\tab \up0 \ex
pndtw-1\charscalex100 Gas
and
vacuum
supply\tab \up0 \expndtw-1\charsca
lex100 /\tab \up0 \expndtw-1\charscalex100 Storage
of
oxygen\par\pard\li15
84\sb139\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 MOM 13a\tab \dn
3 \expndtw-1\charscalex100 cylinders/Condition of Humidifiers\par\pard\li1584\sb
163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 PRE 5d\tab \dn3 \exp
ndtw-1\charscalex100 Patient interview\par\pard\li1584\sb154\sl-276\slmult0\fi22
46 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\
cf4\f5\fs24
Explanation of cost when change in treatment setting\par\pard\li1
584\sb266\sl-276\slmult0\fi0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf1\f
2\fs24 Secondary\par\pard\li1584\sb133\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1
\charscalex100 \ul0\nosupersub\cf4\f5\fs24 AAC 5e,g\tab \dn3 \expndtw-1\charscal
ex100 Initial assessment to include screening for nutritional needs\par\pard\li1
584\sb170\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Documented plan of
care including preventive aspects of the\par\pard\li1584\sb139\sl-276\slmult0\f
i1886 \up0 \expndtw-1\charscalex100 care (where applicable)\par\pard\li1584\sb0\
ult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb248\sl-253\slmult0\fi0
\tx4585\tx9071 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version
1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\ch
arscalex100 Page 15 of 53
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1 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf4\f5\fs24 AAC 13a-f\tab \up0 \
expndtw-2\charscalex100 Multidisciplinary nature of care and co-ordina
tion among\par\pard\li1584\sb156\sl-276\slmult0\fi1886 \up0 \expndtw-2\charsca
lex100 various departments/ staff /shift\par\pard\li1584\sb154\sl-276\slmult0\fi
1886 \up0 \expndtw-2\charscalex100 Qualified individual identified as responsibl
e for care\par\pard\li1584\sb153\sl-276\slmult0\fi1886 \up0 \expndtw-2\charscale
x100 Referral of patients to other departments/specialties\par\pard\li1584\sb156
\sl-276\slmult0\fi1886 \up0 \expndtw-2\charscalex100 Handing and taking over\par
\pard\li1584\sb147\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 AAC 1
4a-d\tab \dn2 \expndtw-2\charscalex100 Discharge planning in coordination with v
arious departments,\par\pard\li1584\sb153\sl-276\slmult0\fi1886 \up0 \expndtw-2\
charscalex100 including medico-legal cases / LAMA, discharge summary to all\par\
pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 AAC 15
a-f\tab \up0 \expndtw-2\charscalex100 Content of discharge summary\par\pard\li15
84\sb164\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 COP 1a-d\tab \u
p0 \expndtw-2\charscalex100 Care and treatment orders are signed, named, timed a
nd dated\par\pard\ql \li3471\sb142\sl-276\slmult0 \up0 \expndtw-3\charscalex100
by the doctor \par\pard\qj \li3471\ri1451\sb62\sl-400\slmult0 \up0 \expndtw0\cha
rscalex100 Plan of care countersigned by the clinician in charge within 24 \line
\up0 \expndtw-3\charscalex100 hours \par\pard\ql \li3471\sb143\sl-276\slmult0 \
up0 \expndtw-3\charscalex100 Evidence based medicine and clinical practice guide
lines \par\pard\ql \li1584\sb144\sl-276\slmult0\tx3471 \up0 \expndtw-3\charscale
x100 COP 7a-e \tab \dn2 \expndtw0\charscalex103 Care of vulnerable patients - Po
licy and procedure, safe and \par\pard\qj \li3471\ri1449\sb62\sl-400\slmult0 \up
0 \expndtw0\charscalex105 secure environment, informed consent from the appropri
ate \up0 \expndtw-3\charscalex100 legal representative \par\pard\ql \li1584\sb12
3\sl-276\slmult0\tx3471 \up0 \expndtw-3\charscalex100 COP 12 a-c \tab \dn3 \expn
dtw0\charscalex102 Care of patients undergoing surgical procedures - Policy and
\par\pard\qj \li3471\ri1444\sb51\sl-413\slmult0 \up0 \expndtw-1\charscalex100 pr
ocedure, preoperative assessment and provisional diagnosis \up0 \expndtw0\charsc
alex102 documented prior to surgery, informed consent obtained by a \up0 \expndt
w0\charscalex102 surgeon, documented policies and procedures to prevent \u
p0 \expndtw-3\charscalex100 adverse events. \par\pard\li1584\sb137\sl-276\slmult
0\fi0\tx3471 \up0 \expndtw-3\charscalex100 HIC 5a,c,d\tab \dn3 \expndtw0\charsca
lex106 Check hand washing facilities for staff in all care area\par\par
d\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 instructions
for proper hand washing\par\pard\li1584\sb153\sl-276\slmult0\fi1886 \up0 \expndt
w-3\charscalex100 Check Isolation /Barrier nursing facility available\par\pard\l
i1584\sb156\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex102 Check if adequate
soap, masks, gloves and disinfectants are\par\pard\li1584\sb138\sl-276\slmult0\

fi1886 \up0 \expndtw-3\charscalex100 available Hand washing\par\pard\li1584\sb14
8\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 HIC 8b-f\tab \dn2 \exp
ndtw-3\charscalex100 Bio-medical waste\par\pard\li1584\sb164\sl-276\slmult0\fi0\
tx3471 \up0 \expndtw-3\charscalex100 PRE 3c,d\tab \dn2 \expndtw0\charscalex109 P
olicy on consent. Who can give consent when patient is\par\pard\li1584\sb153\sl276\slmult0\fi1886 \up0 \expndtw0\charscalex100 incapable/ Informed consent s
ituations/ performing doctor\u8217?s\par\pard\li1584\sb139\sl-276\slmult0\fi18
86 \up0 \expndtw-3\charscalex100 name\par\pard\li1584\sb0\sl-253\slmult0\par\par
d\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb123\sl-253\slmult0\fi0\tx4585\tx90
71 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0
\expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100
Page 16 of 53
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rscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 17 of 53
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1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 MOM 12a,c\tab \up0 \
expndtw-3\charscalex100 Procedure for procuring and using implants\par\pard\qj \
li3471\ri1442\sb44\sl-420\slmult0 \up0 \expndtw0\charscalex108 Entry of batch an
d serial number in patient\u8217?s case file and \up0 \expndtw-3\charscalex100 m
aster log book \par\pard\li1584\sb128\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\
charscalex100 PRE 3c,d\tab \dn2 \expndtw-3\charscalex100 Consent\par\pard\ql \li
3831\sb135\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18
\fs24 o\ul0\nosupersub\cf4\f5\fs24
Name of procedure \par\pard\ql \li3831\sb1
44\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\
ul0\nosupersub\cf4\f5\fs24
Name of doctor \par\pard\ql \li3831\sb144\sl-276\s
lmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosuper
sub\cf4\f5\fs24
Explanation of risks, benefits and alternatives if any \par\p
ard\ql \li3831\ri1442\sb6\sl-420\slmult0\tx4191 \up0 \expndtw0\charscalex100 \ul
0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Language (that the pa
tient understands) used for taking \line\tab \up0 \expndtw-3\charscalex100 conse
nt \par\pard\qj \li3471\ri2408\sb0\sl-440\slmult0\fi360 \up0 \expndtw-3\charscal
ex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Completeness
of the consent form in all aspects \up0 \expndtw-3\charscalex100 Equipment clea
ning (if any) \par\pard\ql \li1584\sb0\sl-216\slmult0 \up0 \expndtw-3\charscalex
100 HIC 2d \par\pard\ql \li3471\sb0\sl-216\slmult0 \up0 \expndtw-3\charscalex100
Sterilized sets: expiry dates, storage conditions \par\pard\li1584\sb110\sl-276
\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 HIC 2e,h\tab \up0 \expndtw-1\c
harscalex100 Antibiotic policy\par\pard\li1584\sb173\sl-276\slmult0\fi1886\tx602
2 \up0 \expndtw-1\charscalex100 Engineering controls\tab \up0 \expndtw-1\charsc
alex100 (AC requirements as mentioned in\par\pard\li1584\sb137\sl-276\sl
mult0\fi1886 \up0 \expndtw-1\charscalex100 guidebook), change of HEPA filters\pa
r\pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 HIC
2f\tab \dn2 \expndtw-1\charscalex100 Linen disinfection (if any) in OT\par\pard\
li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 HIC 5a-e\ta
b \dn2 \expndtw-1\charscalex100 Check hand washing facilities for staff in
all care area,\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw-1\c
harscalex100 instructions for proper hand washing\par\pard\li1584\sb156\sl-276\s
lmult0\fi1886 \up0 \expndtw-1\charscalex100 Check Adequate soap, masks, gloves a
nd disinfectants are\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw-1
\charscalex100 available\par\pard\li1584\sb146\sl-276\slmult0\fi0\tx3471 \up0 \e

xpndtw-1\charscalex100 HIC 7a\tab \dn2 \expndtw-1\charscalex100 Sterilization/di
sinfection activities being performed\par\pard\li1584\sb166\sl-276\slmult0\fi0\t
x3471 \up0 \expndtw-1\charscalex100 FMS 2d\tab \dn2 \expndtw-1\charscalex100 Lay
out of OT (no mix of sterile and un sterile)\par\pard\li1584\sb163\sl-276\slmult
0\fi0\tx3471 \up0 \expndtw-1\charscalex100 FMS 3c,e\tab \dn2 \expndtw-1\charscal
ex100 All equipment are inventoried and log maintained / calibrated\par\pard\li1
584\sb170\sl-276\slmult0\fi1886\tx5457\tx8513\tx9995 \up0 \expndtw-1\charscalex1
00 Preventive\tab \up0 \expndtw-1\charscalex100 maintenance/service\tab \up0 \ex
pndtw-1\charscalex100 labels\tab \up0 \expndtw-1\charscalex100 on\par\pard\li158
4\sb139\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Equipment/calibratio
n records/Refrigerator\par\pard\li1584\sb148\sl-276\slmult0\fi0\tx3471\tx7294\tx
7723 \up0 \expndtw-1\charscalex100 FMS 4d\tab \dn2 \expndtw-1\charscalex100 Gas
and
vacuum
supply\tab \dn2 \expndtw-1\charscalex100 /\tab \dn2 \expndtw
-1\charscalex100 Storage
of
oxygen\par\pard\li1584\sb155\sl-276\slmult0\fi
1886 \up0 \expndtw-1\charscalex100 cylinders/Condition of Humidifiers\par\pard\l
i1584\sb147\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 HRM 11a\tab
\dn2 \expndtw-1\charscalex100 Credentialing of doctors\par\pard\li1584\sb165\sl276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 HRM 13a\tab \dn2 \expndtw-1
\charscalex100 Credentialing of nurses\par\pard\li1584\sb0\sl-253\slmult0\par\pa
rd\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\
sb0\sl-253\slmult0\par\pard\li1584\sb1\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \ex
pndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\
charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 18 of
53
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z61\shplid265
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tx3471 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf4\f5\fs24 COP 4a-e\tab \dn
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\par\pard\ql\li1584\sb12\sl-276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosu
persub\cf1\f2\fs24 10. Endoscopy \par\pard\ql \li1584\sb0\sl-276\slmult0 \par\pa
rd\ql\li1584\sb108\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Primary \par\par
d\li1584\sb137\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 \ul0\nosu
persub\cf4\f5\fs24 COP 10a-f\tab \dn3 \expndtw-3\charscalex100 Sedation policy i
mplementation\par\pard\li1584\sb171\sl-276\slmult0\fi1886 \up0 \expndtw-3\charsc
alex100 Check who gives sedation and who monitors patient\par\pard\li1584\sb153\
sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 Documentation of monitoring
activities\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscale
x100 Availability of equipment and manpower\par\pard\li1584\sb149\sl-276\slmult0
\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 3g,h\tab \dn2 \expndtw-3\charscale
x100 Emergency drug management\par\pard\li1584\sb163\sl-276\slmult0\fi0\tx3471 \
up0 \expndtw-3\charscalex100 PRE 3c,d\tab \dn2 \expndtw-3\charscalex100 Consent\
par\pard\ql \li3831\sb141\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosu
persub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Name of procedure \par\pard
\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\c
f17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Name of doctor \par\pard\ql \li3831
\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs2
4 o\ul0\nosupersub\cf4\f5\fs24
Explanation of risks, benefits and alternative
s if any \par\pard\ql \li3831\ri1449\sb6\sl-420\slmult0\tx4191 \up0 \expndtw0\ch
arscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Langua
ge (that the patient understands) used for taking \line\tab \up0 \expndtw-3\char
scalex100 consent \par\pard\qj \li3471\ri2408\sb0\sl-440\slmult0\fi360 \up0 \exp
ndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Completeness of the consent form in all aspects \up0 \expndtw-3\charscalex100
Equipment cleaning (if any) \par\pard\ql \li1584\sb0\sl-216\slmult0 \up0 \expnd
tw-3\charscalex100 HIC 2d \par\pard\ql \li3471\sb0\sl-216\slmult0 \up0 \expndtw3\charscalex100 Sterilized sets: expiry dates, storage conditions \par\pard\li15
84\sb107\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex102 HIC 5a-e\tab \dn
3 \expndtw0\charscalex102 Check hand washing facilities for staff in all
care area,\par\pard\li1584\sb153\sl-276\slmult0\fi1886 \up0 \expndtw0\charscal
ex102 instructions for proper hand washing\par\pard\li1584\sb157\sl-276\slmult0\
fi1886 \up0 \expndtw0\charscalex102 Check Adequate soap, masks, gloves and disin
fectants are\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw0\charscal
ex102 available\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\sl
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x4585\tx9071 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1
\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\char
scalex100 Page 21 of 53
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f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up
0 \expndtw-3\charscalex100 Page 22 of 53
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sl-420\slmult0 \up0 \expndtw0\charscalex101 Staff trained in safe practice; staf
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fi0\tx3471 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs24 MOM 3g,h\ta
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tw-1\charscalex100 Policy on consent. Who can give consent when patient is\par\p
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calex100 labels\tab \up0 \expndtw-1\charscalex100 on\par\pard\li1584\sb137\sl-27
6\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Equipment/calibration records/Ref
rigerator\par\pard\li1584\sb166\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex

100 Patient interview\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw1\charscalex100 Staff interview\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li15
0\par\pard\li1584\sb14\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\charscal
ex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Is
sue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 23 of 53
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0 \ul0\nosupersub\cf1\f2\fs24 13. Nuclear Medicine \par\pard\ql \li1584\sb0\sl-2
0 Primary \par\pard\li1584\sb137\sl-276\slmult0\fi0\tx3428 \up0 \expndtw-3\chars
calex100 \ul0\nosupersub\cf4\f5\fs24 AAC 10a-g\tab \dn3 \expndtw-3\charscalex100
Comply with BARC/AERB legal requirements\par\pard\ql \li3428\sb171\sl-276\slmul
t0 \up0 \expndtw-3\charscalex100 Scope of imaging services \par\pard\qj \li3428\
ri4705\sb9\sl-440\slmult0 \up0 \expndtw-3\charscalex100 Performing and reporting
of tests \line \up0 \expndtw-3\charscalex100 Technician qualified as per AERB \
par\pard\ql \li3428\ri1444\sb0\sl-420\slmult0 \up0 \expndtw-1\charscalex100 Docu
mented policies and procedures for identification and safe \line \up0 \expndtw-3
\charscalex100 transportation of patients to the imaging services \line \up0 \ex
pndtw0\charscalex102 Turnaround time - Check results are available in defined ti
me \line \up0 \expndtw-3\charscalex100 frame \par\pard\ql \li3428\sb136\sl-276\s
lmult0 \up0 \expndtw-3\charscalex100 Critical results intimation \par\pard\ql \l
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up0 \expndtw0\charscalex101 TLD badges\par\pard\ql \li3471\sb147\sl-276\slmult0
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6\sb20\sl-420\slmult0 \up0 \expndtw-3\charscalex100 Safety devices periodically
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y\par\pard\li1584\sb132\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex100 \
ul0\nosupersub\cf4\f5\fs24 MOM 3g,h\tab \dn2 \expndtw0\charscalex100 Emergency d

rug management\par\pard\li1584\sb166\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\ch
arscalex100 PRE 3c,d\tab \dn2 \expndtw0\charscalex100 Policy on consent. Who can
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expndtw0\charscalex100 incapable/ Informed consent situations/ performing d
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lex100 name\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\slmult
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4585\tx9071 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\
tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\chars
calex100 Page 24 of 53
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1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 FMS 3c,e\tab \up0 \e
xpndtw-3\charscalex100 All equipment are inventoried and log maintained / calibr
ated\par\pard\qj \li3471\ri3725\sb35\sl-430\slmult0 \up0 \expndtw-3\charscalex10
0 Preventive maintenance/service labels on \up0 \expndtw-3\charscalex100 Equipme
nt/calibration records/Refrigerator \up0 \expndtw-3\charscalex100 Patient interv
iew \par\pard\ql \li3471\sb118\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Staf
f interview \par\pard\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb0\sl-2
\ul0\nosupersub\cf1\f2\fs24 14. Cardiac Catheterization lab \par\pard\ql \li158
4\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb108\sl-276\slmult0 \up0 \expndtw-3\ch
arscalex100 Primary \par\pard\li1584\sb145\sl-276\slmult0\fi0\tx3428 \up0 \expnd
tw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 AAC 10c-e\tab \up0 \expndtw-3\cha
rscalex100 Comply with BARC/AERB legal requirements\par\pard\ql \li3428\sb163\sl
-276\slmult0 \up0 \expndtw-3\charscalex100 Performing and reporting of tests \pa
r\pard\ql \li3428\ri1441\sb51\sl-413\slmult0 \up0 \expndtw-1\charscalex100 Docum
ented policies and procedures for identification and safe \line \up0 \expndtw-3\
charscalex100 transportation of patients to the imaging services \line \up0 \exp
ndtw0\charscalex102 Turnaround time - Check results are available in defined tim
e \line \up0 \expndtw-3\charscalex100 frame \par\pard\ql \li3428\sb141\sl-276\sl
mult0 \up0 \expndtw-3\charscalex100 Critical results intimation \par\pard\li1584
\sb156\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex102 AAC 12a-g\tab \dn2
\expndtw0\charscalex102 Safety programme including usage of safety equipment an
d\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex102 TLD b
adges\par\pard\ql \li3471\sb142\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Adh

erence to standard precautions and safe practices \par\pard\qj \li3471\ri1444\sb
62\sl-400\slmult0 \up0 \expndtw0\charscalex104 Staff trained in safe practice; s
taff has safety equipment/ fire \up0 \expndtw-3\charscalex100 extinguisher/ dres
sing materials/ etc. \par\pard\ql \li3471\sb143\sl-276\slmult0 \up0 \expndtw-3\c
harscalex100 Imaging signage - Radiation hazard \par\pard\li1584\sb154\sl-276\sl
mult0\fi0\tx3471 \up0 \expndtw0\charscalex103 MOM 12a,c\tab \dn2 \expndtw0\chars
calex103 Procedure for procuring and using implants\par\pard\li1584\sb171\sl-276
\slmult0\fi1886 \up0 \expndtw0\charscalex103 Entry of batch and serial number in
patient\u8217?s case file and\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0
\expndtw0\charscalex103 master log book\par\pard\li1584\sb149\sl-276\slmult0\fi0
\tx3471 \up0 \expndtw0\charscalex103 PRE 3c,d\tab \dn3 \expndtw0\charscalex103 P
olicy on consent. Who can give consent when patient is\par\pard\li1584\sb154\sl
-276\slmult0\fi1886\tx7934 \up0 \expndtw0\charscalex103 incapable/ Informed cons
ent situations\tab \up0 \expndtw0\charscalex103 / performing doctor\u8217?s\par\
pard\li1584\sb139\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex103 name\par\pa
rd\li1584\sb146\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex103 HIC 2d\ta
b \up0 \expndtw0\charscalex103 Re-use policy\par\pard\li1584\sb0\sl-253\slmult0\
i1584\sb0\sl-253\slmult0\par\pard\li1584\sb224\sl-253\slmult0\fi0\tx4585\tx9071
\up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \ex
pndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Pag
e 25 of 53
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Secondary \par\pard\li1584\sb134\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charsc
alex100 \ul0\nosupersub\cf4\f5\fs24 COP 4a-e\tab \dn2 \expndtw0\charscalex100 CP
R - Policy and procedure, staff trained in BLS/ALS,\par\pard\li1584\sb15
4\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex100 Documentation of events
during CPR, Communication of\par\pard\li1584\sb139\sl-276\slmult0\fi1886 \up0
\expndtw0\charscalex100 corrective and preventive measures\par\pard\li1584\sb14
6\sl-276\slmult0\fi0\tx3471 \up0 \expndtw0\charscalex100 MOM 3g,h\tab \dn3 \expn
dtw0\charscalex100 Emergency drug management\par\pard\li1584\sb166\sl-276\slmult
0\fi0\tx3471 \up0 \expndtw0\charscalex100 FMS 3c,e\tab \dn3 \expndtw0\charscalex
100 All equipment are inventoried and log maintained / calibrated\par\pard\qj \l
i3471\ri3725\sb51\sl-420\slmult0 \up0 \expndtw-3\charscalex100 Preventive mainte
nance/service labels on \up0 \expndtw-3\charscalex100 Equipment/calibration reco
rds/Refrigerator \up0 \expndtw-3\charscalex100 Patient interview \par\pard\ql \l
i3471\sb139\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Staff interview \par\pa
rd\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb0\sl-276\slmult0 \par\par
d\ql\li1584\sb12\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf
1\f2\fs24 15. Laboratory: Haematology/ Biochemistry/ Pathology/ Microbiology \pa
r\pard\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb108\sl-276\slmult0 \u
p0 \expndtw-3\charscalex100 Primary \par\pard\li1584\sb138\sl-276\slmult0\fi0\tx
3471 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf4\f5\fs24 AAC 7a-f\tab \dn3
\expndtw0\charscalex100 Standard operating procedures\par\pard\li1584\sb170\sl-2
76\slmult0\fi1886\tx6599 \up0 \expndtw0\charscalex100 Appropriate use of logo
s\tab \up0 \expndtw0\charscalex100 (e.g. NABL) and scope of lab\par\pard\li
1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw0\charscalex100 accreditation (if
accredited)\par\pard\ql \li3471\sb151\sl-276\slmult0 \up0 \expndtw-3\charscalex1
00 Technician qualified \par\pard\ql \li3471\ri1442\sb26\sl-420\slmult0 \up0 \ex

pndtw-3\charscalex100 Turn-around time - Results are available in defined time f
rame \line \up0 \expndtw0\charscalex100 Policies and Procedures for collection,
identification, handling, \line \up0 \expndtw-3\charscalex100 safe transportatio
n, processing and disposal of specimens \line \up0 \expndtw0\charscalex102 Alert
and Panic levels - Critical results intimated immediately, \line \up0 \expndtw0
\charscalex100 documented procedures of out sourcing test Measurement \lin
e \up0 \expndtw-3\charscalex100 uncertainties \par\pard\ql \li3471\sb139\sl-276\
slmult0 \up0 \expndtw-3\charscalex100 Signatures \par\pard\ql \li3471\sb144\sl-2
76\slmult0 \up0 \expndtw-3\charscalex100 Outsourcing and controls \par\pard\li15
181\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\charscalex100 \ul0\nosupers
ub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\
tab \up0 \expndtw-3\charscalex100 Page 26 of 53
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xpndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3
\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 28 of
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0 \ul0\nosupersub\cf1\f2\fs24 19. Research Activities \par\pard\ql \li1584\sb0\s
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e to standard precautions, equipment cleaning and \up0 \expndtw-1\charscalex100
sterilization practices, antibiotic policy, laundry and linen \up0 \
expndtw-2\charscalex100 management, kitchen sanitation and food handling, engine
ering \up0 \expndtw-2\charscalex100 controls and mortuary practices \par\pard\ql
\li3471\sb121\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Periodicity of updat
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2 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \exp
ndtw-3\charscalex100 Page 30 of 53
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1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 CQI 2a-k\tab \up0 \e
xpndtw-3\charscalex100 Data for all indicators mentioned in the guidebook\par\pa

rd\li1584\sb139\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 CQI 3a-i
\tab \dn3 \expndtw-3\charscalex100 Check raw data\par\pard\qj \li3471\ri4315\sb6
9\sl-420\slmult0 \up0 \expndtw-3\charscalex100 Verify collection methodology of
data \up0 \expndtw-3\charscalex100 Data analysis \par\pard\ql \li3471\sb139\sl-2
76\slmult0\tx9868 \up0 \expndtw0\charscalex101 Improvement activities carried
out based on analysis \tab \up0 \expndtw-3\charscalex100 and \par\pard\ql \l
i3471\sb124\sl-276\slmult0 \up0 \expndtw-3\charscalex100 results of the improvem
ent activity \par\pard\li1584\sb161\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\ch
arscalex100 CQI 5a-e\tab \dn3 \expndtw-3\charscalex100 Members who perform clini
cal audits\par\pard\qj \li3471\ri2994\sb49\sl-420\slmult0 \up0 \expndtw-3\charsc
alex100 Selection of topic and identification of parameters \up0 \expndtw-3\char
scalex100 Performance of audit \par\pard\qj \li3471\ri3608\sb20\sl-420\slmult0 \
up0 \expndtw-3\charscalex100 Audit report highlighting remedial measures \line \
up0 \expndtw-3\charscalex100 Maintenance of patient and staff anonymity \par\par
d\li1584\sb137\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 CQI 6a-d\
tab \dn3 \expndtw-3\charscalex100 Identification of sentinel events\par\pard\qj
\li3471\ri4368\sb48\sl-420\slmult0 \up0 \expndtw-3\charscalex100 Procedure for r
eporting and analysis \line \up0 \expndtw-3\charscalex100 Corrective and prevent
ive action \par\pard\ql \li1584\sb239\sl-276\slmult0 \up0 \expndtw-3\charscalex1
00 \ul0\nosupersub\cf1\f2\fs24 Secondary \par\pard\ql \li3471\sb164\sl-276\slmul
t0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 Staff interview \pa
p0 \expndtw-2\charscalex100 \ul0\nosupersub\cf1\f2\fs24 3. Management/Administ
ration \par\pard\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb128\sl-276\
slmult0 \up0 \expndtw-3\charscalex100 Primary \par\pard\li1584\sb134\sl-276\slmu
lt0\fi0\tx3447 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs24 ROM 1ai\tab \dn2 \expndtw-1\charscalex100 Mission statement and monitoring of activiti
es taken to achieve\par\pard\li1584\sb153\sl-276\slmult0\fi1886 \up0 \expndtw-1\
charscalex100 mission statement\par\pard\qj \li3447\ri1446\sb27\sl-420\slmult0 \
up0 \expndtw0\charscalex101 Operation and strategic plans in consultation
with various \up0 \expndtw-3\charscalex100 stakeholders \par\pard\ql \li3447\sb
119\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Budget \par\pard\ql \li3447\sb1
64\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Organogram and appointment of se
nior leaders \par\pard\ql \li3447\sb144\sl-276\slmult0 \up0 \expndtw-3\charscale
x100 Support for research and quality improvement activities \par\pard\ql \li344
7\ri1450\sb46\sl-420\slmult0 \up0 \expndtw0\charscalex104 Adherence to statutory
requirements, mechanism to update \up0 \expndtw-3\charscalex100 amendments and
adherence to same; renewal of licenses \line \up0 \expndtw-3\charscalex100 Soci
al responsibility \par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253
\slmult0\par\pard\li1584\sb127\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\
charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscal
ex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 33 of 53
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1 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs24 ROM 2a-d\tab \up0 \e
xpndtw-1\charscalex100 Scope of services of various departments including design
ated\par\pard\li1584\sb156\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 h
eads\par\pard\ql \li3471\sb150\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Admi
nistrative policies \par\pard\ql \li3471\sb144\sl-276\slmult0 \up0 \expndtw-3\ch
arscalex100 Involvement of department heads in quality initiatives \par\pard\li1
584\sb162\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 ROM 3a-f\tab \
dn3 \expndtw-3\charscalex100 Ethical management\par\pard\ql \li3471\ri6010\sb48\
sl-420\slmult0 \up0 \expndtw-3\charscalex100 Displaying mission \line \up0 \expn
dtw-3\charscalex100 Revealing ownership \par\pard\qj \li3471\ri5009\sb20\sl-420\
slmult0 \up0 \expndtw-3\charscalex100 Affiliations and accreditations \line \up0
\expndtw-3\charscalex100 Billing based on standard tariff \par\pard\li1584\sb13
8\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 ROM 4a-b\tab \dn3 \exp
ndtw-3\charscalex100 Qualification and experience of person heading the organiza
tion\par\pard\li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex1
00 ROM 5c,d\tab \dn3 \expndtw-3\charscalex100 Internal and external reporting of
process and system failures\par\pard\li1584\sb173\sl-276\slmult0\fi1886 \up0 \e
xpndtw-3\charscalex100 Resources for proactive risk assessment and risk reductio
n\par\pard\li1584\sb146\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100
PRE 1c,e\tab \dn2 \expndtw-3\charscalex100 Protection of patient rights by addre
ssing grievance\par\pard\li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\
charscalex100 CQI 4a-c\tab \dn2 \expndtw-3\charscalex100 Availability of resourc
es\par\pard\li1584\sb173\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 Qua
lity improvement budget\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndt
w-3\charscalex100 Usage of statistical and management tools\par\pard\li1584\sb26
4\sl-276\slmult0\fi0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 S
econdary\par\pard\li1584\sb132\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charsca
lex100 \ul0\nosupersub\cf4\f5\fs24 HIC 1\tab \dn3 \expndtw-3\charscalex100 HIC p
rogramme\par\pard\li1584\sb166\sl-276\slmult0\fi0\tx3428 \up0 \expndtw-3\charsca
lex100 CQI 4b\tab \dn3 \expndtw-3\charscalex100 Budget - research / quality impr
ovement/ HIC\par\pard\li1584\sb137\sl-276\slmult0\fi0 \up0 \expndtw-3\charscalex
100 HIC 9b\par\pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\chars
calex100 HRM 2,3,4\tab \dn3 \expndtw-3\charscalex100 Training and Development pr
ogram\par\pard\li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex
100 HRM 7\tab \dn3 \expndtw-3\charscalex100 Grievance handling\par\pard\li1584\s
b165\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 HRM 8\tab \dn3 \exp
ndtw-3\charscalex100 Staff health programme\par\pard\li1584\sb0\sl-253\slmult0\p
sb0\sl-253\slmult0\par\pard\li1584\sb74\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \e
xpndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3
\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 34 of
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0 \ul0\nosupersub\cf1\f2\fs24 4. Committees \par\pard\ql \li1584\sb0\sl-276\sl
mult0 \par\pard\ql\li1584\sb108\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Pri
mary \par\pard\li1584\sb137\sl-276\slmult0\fi0\tx3447 \up0 \expndtw-3\charscalex
100 \ul0\nosupersub\cf4\f5\fs24 COP 4d,e\tab \dn3 \expndtw-3\charscalex100 Compo
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slmult0\fi1862 \up0 \expndtw-3\charscalex100 Analysis of all cardiac arrests\par
\pard\li1584\sb154\sl-276\slmult0\fi1862 \up0 \expndtw-3\charscalex100 Correctiv
e and preventive measures taken based on analysis\par\pard\li1584\sb146\sl-276\s
lmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 1a\tab \dn3 \expndtw-3\chars
calex100 Pharmaco-therapeutic committee or anything similar\par\pard\li1584\sb13
9\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 2a\tab \dn2 \expnd
tw-3\charscalex100 Development of hospital formulary\par\pard\li1584\sb137\sl-27
6\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 8b,c\tab \dn3 \expndtw-3\
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-3\charscalex100 FMS 9a,b\tab \dn2 \expndtw-3\charscalex100 Safety committee com
position and functioning\par\pard\li1584\sb139\sl-276\slmult0\fi0\tx3471 \up0 \e
xpndtw-3\charscalex100 ROM 5a,b\tab \dn3 \expndtw-3\charscalex100 Scope of progr
amme\par\pard\li1584\sb188\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 D
evelopment, implementation and monitoring of safety plans\par\pard\li1584\sb264\
sl-276\slmult0\fi0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Sec
ondary\par\pard\li1584\sb132\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscale
x100 \ul0\nosupersub\cf4\f5\fs24 COP 16b,c\tab \dn2 \expndtw-3\charscalex100 Eth
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alex100 Composition as per guidelines\par\pard\li1584\sb156\sl-276\slmult0\fi188
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\dn2 \expndtw-3\charscalex100 Quality improvement committee composition and fun
ctioning\par\pard\li1584\sb166\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charsca
lex100 ROM 1h\tab \dn3 \expndtw-3\charscalex100 Prevention of sexual harassment
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100 Any other committee as required by state/local regulations\par\pard\li1584\s
b0\sl-276\slmult0\par\pard\li1584\sb0\sl-276\slmult0\par\pard\li1584\sb9\sl-276\
slmult0\fi0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 5. Human
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11\sl-276\slmult0\fi0 \up0 \expndtw-3\charscalex100 Primary\par\pard\li1584\sb13
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\sb171\sl-276\slmult0\fi1862 \up0 \expndtw-3\charscalex100 Job specification/Job
description\par\pard\li1584\sb153\sl-276\slmult0\fi1862 \up0 \expndtw-3\charsca
lex100 Criminal antecedents verification\par\pard\li1584\sb0\sl-253\slmult0\par\
53\slmult0\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb173\sl-253\slmul
t0\fi0\tx4585\tx9071 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 V
ersion 1\tab \up0 \expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndt
w-3\charscalex100 Page 35 of 53
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1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 HRM 2a-e\tab \up0 \e
xpndtw-3\charscalex100 Induction training\par\pard\ql \li3831\sb142\sl-276\slmul
t0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\
cf4\f5\fs24
Orientation to mission and goals \par\pard\ql \li3831\sb144\sl-27
6\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosu
persub\cf4\f5\fs24
Policies and procedures (hospital and department) \par\par
d\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\
cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Rights and responsibilities-patien
t and employee \par\pard\ql \li3831\sb124\sl-276\slmult0 \up0 \expndtw-2\charsca
lex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Service sta
ndards \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \
ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Performance apprais
al (HRM 5b) \par\pard\li1584\sb157\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\cha
rscalex100 HRM 3a-c\tab \dn2 \expndtw-3\charscalex100 Training policy\par\pard\q
l \li3471\ri5902\sb16\sl-440\slmult0 \up0 \expndtw-3\charscalex100 Training iden
tification \line \up0 \expndtw-3\charscalex100 Training calendar \line \up0 \exp
ndtw-3\charscalex100 Training effectiveness \par\pard\ql \li3471\sb116\sl-276\sl
mult0 \up0 \expndtw-3\charscalex100 Training requirements as per the standard \p
ar\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosup
ersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Blood and blood products (CO
P 5e) \par\pard\ql \li3831\sb124\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \u
l0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Vulnerable patients
(COP 7e) \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100
\ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Restraint techniq
ues (COP 13e) \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-2\charscal
ex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
End of life
care (COP 18e) \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-2\charsca
Infection c
ontrol (HIC 9c,d) \par\pard\ql \li3831\sb124\sl-276\slmult0 \up0 \expndtw-3\char
scalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Quality
improvement (CQI 1e) \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\c
harscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Fire
and non-fire emergencies (FMC 5c) \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\
fs24
Disaster management (FMS 5c) \par\pard\ql \li3831\sb124\sl-276\slmult0 \
up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\
f5\fs24
Hazardous materials (FMC 8c) \par\pard\ql \li3831\sb144\sl-276\slmult
0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\c
f4\f5\fs24
Safety (FMS 9e) \par\pard\li1584\sb158\sl-276\slmult0\fi0\tx3471 \
up0 \expndtw-3\charscalex100 HRM 4a,c,d\tab \dn3 \expndtw-3\charscalex100 Traini
ng on risks\par\pard\ql \li3471\sb170\sl-276\slmult0 \up0 \expndtw-3\charscalex1
00 Reporting format \par\pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \up0 \expnd
tw-3\charscalex100 HRM 5a-e\tab \dn2 \expndtw-3\charscalex100 Documented perform
ance appraisal system\par\pard\li1584\sb170\sl-276\slmult0\fi1886 \up0 \expndtw-
3\charscalex100 Parameters based on job description\par\pard\li1584\sb154\sl-276

\slmult0\fi1886 \up0 \expndtw-3\charscalex100 Frequency of appraisal\par\pard\li
1584\sb157\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 Used as tool for
further development\par\pard\li1584\sb146\sl-276\slmult0\fi0\tx3471\tx8875\tx100
60 \up0 \expndtw-3\charscalex100 HRM 6a-e\tab \dn3 \expndtw-3\charscalex100 Docu
mented disciplinary procedure based on\tab \dn3 \expndtw-3\charscalex100 pri
nciples\tab \dn3 \expndtw-3\charscalex100 of\par\pard\li1584\sb153\sl-276\slmult
0\fi1886 \up0 \expndtw-3\charscalex100 natural justice and in consonance with la
ws\par\pard\li1584\sb156\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 Pro
vision of appeal\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0\sl-253\s
lmult0\par\pard\li1584\sb195\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\ch
arscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex
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1 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs24 HRM 7a-c\tab \up0 \e
xpndtw-1\charscalex100 Documented grievance handling mechanism\par\pard\li1584\s
b166\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 HRM 8a-d\tab \dn2 \
expndtw-1\charscalex100 Pre-employment medical examination\par\pard\li1584\sb170
\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Medical benefits for employ
ees\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 Re
gular health check (at least once a year) of staff involved in\par\pard\li1584\s
b137\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100 patient care\par\pard\l
i1584\sb156\sl-276\slmult0\fi1886\tx9916 \up0 \expndtw-1\charscalex100 Health c
heck of employees exposed to radiation as\tab \up0 \expndtw-1\charscalex10
0 per\par\pard\li1584\sb136\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100
statutory requirements\par\pard\ql \li3471\sb147\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 Occupational health hazards \par\pard\li1584\sb156\sl-276\slmult0\
fi0\tx3471 \up0 \expndtw-3\charscalex100 HRM 9a-d\tab \dn2 \expndtw-3\charscalex
100 Personal file for every employee containing information on\par\pard\ql \li38
31\sb152\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\f

s24 o\ul0\nosupersub\cf4\f5\fs24
Educational qualification \par\pard\ql \li38
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4 o\ul0\nosupersub\cf4\f5\fs24
Health status \par\pard\ql \li3831\sb144\sl-27
6\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosu
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t0 \up0 \expndtw-3\charscalex100 Verification where appropriate \par\pard\li1584
\sb168\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 HRM 11a-c\tab \dn
2 \expndtw-3\charscalex100 Privileging of doctors\par\pard\ql \li3471\sb160\sl-2
76\slmult0 \up0 \expndtw-3\charscalex100 Communication of same \par\pard\li1584\
sb157\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 HRM 12a-b\tab \dn3
\expndtw-3\charscalex100 Credentialing of nurses\par\pard\ql \li3471\sb171\sl-2
76\slmult0 \up0 \expndtw-3\charscalex100 Updating of credentials \par\pard\ql \l
i3471\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Verification where appr
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lex100 HRM 13a-c\tab \dn3 \expndtw-3\charscalex100 Privileging of nurses\par\par
d\li1584\sb170\sl-276\slmult0\fi1886 \up0 \expndtw-3\charscalex100 Communication
of same\par\pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charsca
lex100 ROM 1h\tab \dn2 \expndtw-3\charscalex100 Policy on prevention of sexual h
arassment (committee)\par\pard\li1584\sb180\sl-276\slmult0\fi1886 \up0 \expndtw3\charscalex100 Staff interview\par\pard\li1584\sb0\sl-253\slmult0\par\pard\li15
\li1584\sb213\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\charscalex100 \ul
0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Date:
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ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue Dat
e: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 38 of 53
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1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 IMS 5a-g\tab \up0 \e
xpndtw-3\charscalex100 Security, integrity and confidentiality of data\par\pard\
qj \li3471\ri1442\sb44\sl-420\slmult0 \up0 \expndtw-1\charscalex100 Safeguarding
data/ record against loss, destruction and \up0 \expndtw-3\charscal
ex100 tampering \par\pard\qj \li3471\ri1443\sb0\sl-420\slmult0 \up0 \expndtw-2\c
harscalex100 Technology used for improving/maintaining confidentiality,
\up0 \expndtw-3\charscalex100 security and integrity \par\pard\ql \li3471\sb119\
sl-276\slmult0 \up0 \expndtw-3\charscalex100 Usage of privileged health informat
ion \par\pard\li1584\sb172\sl-276\slmult0\fi1886\tx9893 \up0 \expndtw0\charscale
x101 Documented policies and procedures on how to handle\tab \up0 \expndtw0\char
scalex101 MR\par\pard\li1584\sb137\sl-276\slmult0\fi1886 \up0 \expndtw0\charscal
ex101 information requirement\par\pard\li1584\sb149\sl-276\slmult0\fi0\tx3471 \u
p0 \expndtw0\charscalex101 IMS 6a-d\tab \dn2 \expndtw0\charscalex101 Retention P
olicy\par\pard\qj \li3471\ri2367\sb23\sl-440\slmult0 \up0 \expndtw-3\charscalex1
00 Maintenance of confidentiality and security at all stages \up0 \expndtw-3\cha
rscalex100 Method for destruction of medical records \par\pard\li1584\sb123\sl-2
76\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 IMS 7a-g\tab \dn2 \expndtw-3
\charscalex100 Medical record audit\par\pard\ql \li3831\sb137\sl-276\slmult0 \up
0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5
\fs24
Frequency \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-2\cha
rscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Sample
size \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-2\charscalex100 \ul
0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Person (s) authorized
\par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\no
supersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Timeliness, legibility an
d completeness \par\pard\ql \li3831\sb124\sl-276\slmult0 \up0 \expndtw-3\charsca
Active and
discharged patients \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\ch
arscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Defici
encies identified and documentation of same \par\pard\ql \li3831\sb144\sl-276\sl
mult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupers
ub\cf4\f5\fs24
Corrective and preventive actions \par\pard\li1584\sb150\sl-27
6\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 AAC 15b-f\tab \dn2 \expndtw-3
\charscalex100 Discharge summary\par\pard\ql \li3831\ri1442\sb20\sl-420\slmult0\
tx4191 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupers
ub\cf4\f5\fs24
reason for admission, findings, diagnosis, condition at \line\
tab \up0 \expndtw-3\charscalex100 the time of discharge \par\pard\ql \li3831\ri1
437\sb17\sl-400\slmult0\tx4191 \up0 \expndtw0\charscalex102 \ul0\nosupersub\cf17
\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
investigation results, procedure perfo
rmed, medication \line\tab \up0 \expndtw-3\charscalex100 and other treatment giv
en \par\pard\ql \li3831\sb123\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\
nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
follow up advice and me
dication instructions \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
when
and how to obtain urgent care \par\pard\li1584\sb0\sl-253\slmult0\par\pard\li15
\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb161\sl-253\slmult0\fi0\tx4585\tx907
1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \
expndtw-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 P
age 39 of 53
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1 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf4\f5\fs24 COP 5c,\tab \up0 \ex
pndtw-2\charscalex100 Check for completeness of consent documents\par\pard\li158
4\sb139\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 11e, 12c,\tab \d
n3 \expndtw-2\charscalex100 Consent for anaesthesia, blood transfusion, res
earch and\par\pard\li1584\sb137\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\chars
calex100 16 d, 7d,\tab \dn2 \expndtw-2\charscalex100 surgical procedures\par\par
d\li1584\sb139\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 PRE 3d\ta
b \dn3 \expndtw-2\charscalex100 Authorized legal representative\par\pard\ql \li3
471\sb199\sl-276\slmult0 \up0 \expndtw-3\charscalex100 General consent \par\pard
\ql \li3471\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Language of conse
nt \par\pard\li1584\sb161\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex10
0 COP 1d\tab \dn3 \expndtw-1\charscalex100 Care plan is countersigned by the cli
nician in-charge of the\par\pard\li1584\sb154\sl-276\slmult0\fi1886 \up0 \expndt
w-1\charscalex100 patient within 24 hours\par\pard\li1584\sb149\sl-276\slmult0\f
i0\tx3471 \up0 \expndtw-1\charscalex100 AAC 14b,c\tab \dn2 \expndtw-1\charscalex
100 Medico legal case documentation\par\pard\li1584\sb171\sl-276\slmult0\fi1886
\up0 \expndtw-1\charscalex100 LAMA case file has discharge summary and risks exp
lained\par\pard\li1584\sb149\sl-276\slmult0\fi1886 \up0 \expndtw-1\charscalex100
\ul0\nosupersub\cf18\f19\fs24 Paediatric cases:\par\pard\li1584\sb136\sl-276\sl
mult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf4\f5\fs24 PRE 3
a,\tab \dn3 \expndtw-1\charscalex100 Authorized legal representative\par\pard\li
1584\sb140\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\charscalex100 COP 9 e,g\tab
\dn2 \expndtw-1\charscalex100 Patient assessment includes detailed nutr

itional, growth,\par\pard\ql \li3471\sb152\sl-276\slmult0 \up0 \expndtw-3\char
scalex100 psychosocial and immunization assessment \par\pard\qj \li3471\ri1450\s
b54\sl-410\slmult0 \up0 \expndtw0\charscalex103 The children\u8217?s family memb
ers are educated about nutrition, \up0 \expndtw-2\charscalex100 immunization and
safe parenting and this is documented in the \up0 \expndtw-2\charscalex100 med
ical record \par\pard\li1584\sb140\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-1\cha
rscalex100 COP 7 a,b\tab \dn3 \expndtw-1\charscalex100 Assessment and care plans
for vulnerable patients\par\pard\li1584\sb165\sl-276\slmult0\fi0\tx3471 \up0 \e
xpndtw-1\charscalex100 COP 12\tab \up0 \expndtw-1\charscalex100 Surgical safety
checklist, Operation Notes, recovery criteria,\par\pard\li1584\sb137\sl-276\slmu
lt0\fi0\tx3471 \up0 \expndtw-1\charscalex100 b,d,f,g\tab \dn3 \expndtw-1\charsca
lex100 post-operative plan of care\par\pard\li1584\sb166\sl-276\slmult0\fi0\tx34
71 \up0 \expndtw-1\charscalex100 FMS 1c\tab \up0 \expndtw-1\charscalex100 \ul0\n
osupersub\cf18\f19\fs24 Random check for statutory documents\par\pard\ql \li3538
MTP register \par\pard\ql \li3471\sb144\sl-276\slmult0 \up0 \expndtw-3\charscale
x100 Birth and death registration \par\pard\qj \li3471\ri4434\sb37\sl-430\slmult
0 \up0 \expndtw-3\charscalex100 Consent document under MTP act \line \up0 \expnd
tw-3\charscalex100 Consent document under PNDT act \line \up0 \expndtw-3\charsca
lex100 Completeness of death certificates \par\pard\ql \li1584\sb238\sl-276\slmu
lt0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Secondary \par\par
d\li1584\sb140\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 \ul0\nosu
persub\cf4\f5\fs24 HIC 3d\tab \dn3 \expndtw-3\charscalex100 Communication of not
ifiable diseases to concerned authorities\par\pard\li1584\sb180\sl-276\slmult0\f
i1886 \up0 \expndtw-3\charscalex100 Staff interview\par\pard\li1584\sb0\sl-253\s
\pard\li1584\sb107\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\charscalex10
0 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100 Issue
Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 40 of 53
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0 \ul0\nosupersub\cf1\f2\fs24 7. Hospital Information System (HIS) \par\pard\q
l \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb188\sl-276\slmult0 \up0 \expn
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51\sl-420\slmult0 \up0 \expndtw-3\charscalex100 License for software \line \up0
\expndtw-3\charscalex100 Validation of software \par\pard\ql \li3471\sb139\sl-27
6\slmult0 \up0 \expndtw-3\charscalex100 Documented policies and procedures \par\
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71 \up0 \expndtw-3\charscalex100 IMS 2a-e\tab \dn3 \expndtw-3\charscalex100 Stan
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up0 \expndtw-3\charscalex100 Documented procedures for data dissemination and st
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43\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Resources for analysing data \pa
r\pard\ql \li3471\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Participati
on of staff in selecting, integrating and using data \par\pard\li1584\sb165\sl-2
76\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 IMS 5a-g\tab \up0 \expndtw-3
\charscalex100 Security, integrity and confidentiality of data\par\pard\qj \li34
71\ri1442\sb45\sl-420\slmult0 \up0 \expndtw-1\charscalex100 Safeguarding data/
record against loss, destruction and \up0 \expndtw-3\charscalex100 ta
mpering \par\pard\qj \li3471\ri1444\sb0\sl-420\slmult0 \up0 \expndtw-2\charscale
x100 Technology used for improving/maintaining confidentiality, \up0 \ex
pndtw-3\charscalex100 security and integrity \par\pard\ql \li3471\sb119\sl-276\s
lmult0 \up0 \expndtw-3\charscalex100 Usage of privileged health information \par
\pard\qj \li3471\ri1446\sb46\sl-420\slmult0 \up0 \expndtw0\charscalex105 Documen
ted policies and procedures on how to handle MR \up0 \expndtw-3\charscalex100 in
formation requirement \par\pard\ql \li1584\sb239\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 \ul0\nosupersub\cf1\f2\fs24 Secondary \par\pard\ql \li3471\sb144\s
l-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 Digital
signatures \par\pard\ql \li3471\sb144\sl-276\slmult0 \up0 \expndtw-3\charscalex1
00 Interface with equipment \par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\
lt0\par\pard\li1584\sb189\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\chars

calex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex100
Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 41 of 53
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ql \li3471\sb157\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Scope of general c
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0 \ul0\nosupersub\cf1\f2\fs24 10. Medication Management: Pharmacy and Pharmacy S
tore \par\pard\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb108\sl-276\sl
mult0 \up0 \expndtw-3\charscalex100 Primary \par\pard\ql \li1584\sb124\sl-276\sl
mult0\tx3471 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 MOM 1a,b
\tab \dn3 \expndtw0\charscalex101 Documented
policies
and
procedures
on
medication \par\pard\qj \li3471\ri1447\sb62\sl-400\slmult0 \up0 \expndtw1\charscalex100 procurement, storage, formulary, prescription, dispensin
g, \up0 \expndtw-3\charscalex100 administration, monitoring etc. \par\pard\ql \l
i3471\sb143\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Separate license for ea
ch of the pharmacies. \par\pard\ql \li3471\sb164\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 Adherence to terms and conditions mentioned in the license. \par\p
ard\qj \li3471\ri1449\sb26\sl-420\slmult0 \up0 \expndtw0\charscalex101 Duty rost

er to ensure that there is a qualified pharmacist at all \up0 \expndtw-3\charsca
lex100 times (his/her name being mentioned in the license). \par\pard\li1584\sb1
27\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 2a,c,d\tab \dn2 \
expndtw-3\charscalex100 Hospital formulary\par\pard\qj \li3471\ri1449\sb38\sl-42
0\slmult0 \up0 \expndtw-2\charscalex100 Defined process of procurement of medici
ne and to obtain non \up0 \expndtw-3\charscalex100 listed medicines \par\pard\l
i1584\sb131\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 3a-g\tab
\dn2 \expndtw-3\charscalex100 Documented policies and procedures for storage\pa
r\pard\ql \li3471\ri1442\sb25\sl-430\slmult0 \up0 \expndtw0\charscalex101 Storag
e of medicines in clean, well lit and ventilated \up0 \expndtw-3
\charscalex100 environment and/or as per manufacture\u8217?s requirement \line \
up0 \expndtw-3\charscalex100 Inventory control practices like FIFO \par\pard\ql
\li3471\sb118\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Stock of medicines \p
ar\pard\ql \li3471\sb164\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Precaution
s against theft \par\pard\ql \li3471\ri1804\sb17\sl-430\slmult0 \up0 \expndtw-3\
charscalex100 Identification and storage of sound alike and look alike drugs \up
0 \expndtw-3\charscalex100 Procedure to obtain medications when pharmacy is clos
ed \up0 \expndtw-3\charscalex100 Availability of emergency medicines \par\pard\l
i1584\sb134\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-2\charscalex100 MOM 4a\tab \
dn3 \expndtw-2\charscalex100 Prescription adheres to statutory requirements and
the Code of\par\pard\ql \li3471\sb148\sl-276\slmult0 \up0 \expndtw-3\charscalex1
00 Medical Ethics \par\pard\li1584\sb154\sl-276\slmult0\fi0\tx3471 \up0 \expndtw
-3\charscalex100 MOM 5a-d\tab \dn2 \expndtw-3\charscalex100 Procedures for dispe
nsing\par\pard\ql \li3471\sb154\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Med
ication recall policy \par\pard\ql \li3471\sb164\sl-276\slmult0 \up0 \expndtw-3\
charscalex100 Expiry date check before dispensing \par\pard\qj \li3471\ri1439\sb
26\sl-420\slmult0 \up0 \expndtw0\charscalex105 Proper labelling on medicines (es
pecially ones prepared in-\line \up0 \expndtw-3\charscalex100 house) \par\pard\l
ult0\par\pard\li1584\sb248\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \expndtw-3\char
scalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw-3\charscalex10
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1 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 MOM 7a,b\tab \up0 \e

xpndtw-3\charscalex100 Patient and family educated on\par\pard\li1584\sb156\sl-2
76\slmult0\fi2246 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\
ul0\nosupersub\cf4\f5\fs24
safe and effective use of medication\par\pard\li15
84\sb137\sl-276\slmult0\fi2246 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf1
7\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
food drug interactions\par\pard\li158
4\sb149\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM\tab \dn2 \ex
pndtw-3\charscalex100 Procedure for narcotic drugs\par\pard\li1584\sb137\sl-276\
slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 9a,b,d\tab \dn3 \expndtw-3\char
scalex100 Proper record\par\pard\li1584\sb187\sl-276\slmult0\fi1886 \up0 \expndt
w-3\charscalex100 Handling\par\pard\li1584\sb266\sl-276\slmult0\fi0 \up0 \expndt
w-3\charscalex100 \ul0\nosupersub\cf1\f2\fs24 Secondary\par\pard\li1584\sb133\sl
-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs2
4 MOM 1c\tab \dn3 \expndtw-3\charscalex100 Multidisciplinary committee\par\pard\
li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 MOM 4f,g\ta
b \dn3 \expndtw-3\charscalex100 Identified high risk medicines\par\pard\ql \li34
71\sb166\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Procedure for dispensing t
hese medicines \par\pard\qj \li3471\ri1858\sb62\sl-400\slmult0 \up0 \expndtw-3\c
harscalex100 Patient interview on safe and effective use of medicines and \up0 \
expndtw-3\charscalex100 food-drug interaction \par\pard\ql \li1584\sb0\sl-276\sl
0\nosupersub\cf1\f2\fs24 11. Purchase \par\pard\ql \li1584\sb0\sl-276\slmult0 \p
ar\pard\ql\li1584\sb108\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Primary \pa
r\pard\li1584\sb151\sl-276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 \ul0
\nosupersub\cf4\f5\fs24 MOM 12a\tab \dn2 \expndtw-3\charscalex100 Procedures for
procuring implants\par\pard\li1584\sb163\sl-276\slmult0\fi0\tx3471 \up0 \expndt
w-3\charscalex100 FMS 3a,b\tab \dn2 \expndtw-3\charscalex100 Equipment planning\
par\pard\ql \li3471\sb158\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Equipment
selection \par\pard\ql \li1584\sb264\sl-276\slmult0 \up0 \expndtw-3\charscalex1
00 \ul0\nosupersub\cf1\f2\fs24 Secondary \par\pard\qj \li3471\ri6009\sb46\sl-420
\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 Scope of depa
rtment \up0 \expndtw-3\charscalex100 Staff interview \par\pard\li1584\sb0\sl-253
sb0\sl-253\slmult0\par\pard\li1584\sb138\sl-253\slmult0\fi0\tx4585\tx9071 \up0 \
expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 45 o
f 53
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0 \ul0\nosupersub\cf1\f2\fs24 12. Facility Management: Engineering and Maintenan
ce \par\pard\ql \li1584\sb0\sl-276\slmult0 \par\pard\ql\li1584\sb108\sl-276\slmu
lt0 \up0 \expndtw-3\charscalex100 Primary \par\pard\li1584\sb137\sl-276\slmult0\
fi0\tx3471 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf4\f5\fs24 FMS 1a,c\ta
b \dn3 \expndtw-3\charscalex100 Various statutory requirements\par\pard\ql \li38
Fire \par\pard\ql \li3831\sb124\sl-276\slmul
t0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\
cf4\f5\fs24
Diesel storage \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \ex
pndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
Liquid oxygen and storage of medical cylinders. \par\pard\ql \li3831\sb144\s
l-276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\
nosupersub\cf4\f5\fs24
Boiler \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\f
s24
Electrical inspectorate reports. \par\pard\ql \li3831\sb124\sl-276\slmult
0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\c
f4\f5\fs24
ETP \par\pard\ql \li3831\sb144\sl-276\slmult0 \up0 \expndtw-2\char
scalex100 \ul0\nosupersub\cf17\f18\fs24 o\ul0\nosupersub\cf4\f5\fs24
DG sets
\par\pard\ql \li3471\sb164\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Mechanis
m for renewing licenses \par\pard\li1584\sb146\sl-276\slmult0\fi0\tx3471 \up0 \e
xpndtw-3\charscalex100 FMS 2a-g\tab \up0 \expndtw-3\charscalex100 Preventive and
break down maintenance plan\par\pard\ql \li3471\sb162\sl-276\slmult0 \up0 \expn
dtw-3\charscalex100 Response time \par\pard\qj \li3471\ri3928\sb46\sl-420\slmult
0 \up0 \expndtw-3\charscalex100 Up to date drawing, layout, escape route \up0 \e
xpndtw-3\charscalex100 Signage \par\pard\ql \li3471\sb139\sl-276\slmult0 \up0 \e
xpndtw-3\charscalex100 Provision of space \par\pard\ql \li3471\sb144\sl-276\slmu
lt0 \up0 \expndtw-3\charscalex100 Designated individual for maintenance \par\par
d\ql \li3471\sb164\sl-276\slmult0 \up0 \expndtw-3\charscalex100 Presence of staf
f round the clock for emergency repairs \par\pard\li1584\sb148\sl-276\slmult0\fi
0\tx3471 \up0 \expndtw-3\charscalex100 FMS 4a-c\tab \dn2 \expndtw-3\charscalex10
0 Availability of potable water and electricity\par\pard\qj \li3471\ri4355\sb25\
sl-440\slmult0 \up0 \expndtw-3\charscalex100 Alternate sources and their checkin
g \up0 \expndtw-3\charscalex100 Water quality reports \par\pard\li1584\sb121\sl276\slmult0\fi0\tx3471 \up0 \expndtw-3\charscalex100 FMS 9c-f\tab \dn2 \expndtw3\charscalex100 Safety devices\par\pard\qj \li3471\ri1448\sb41\sl-420\slmult0 \u
p0 \expndtw-2\charscalex100 Facility inspection rounds twice a year in patient c
are areas and \up0 \expndtw-2\charscalex100 once in non-patient care areas \par\
pard\qj \li3471\ri3779\sb0\sl-440\slmult0 \up0 \expndtw-3\charscalex100 Document
ation of facility inspection report \up0 \expndtw-3\charscalex100 Safety educati
on program for all staff \par\pard\li1584\sb0\sl-253\slmult0\par\pard\li1584\sb0
4\sb0\sl-253\slmult0\par\pard\li1584\sb97\sl-253\slmult0\fi0\tx4585\tx9071 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs22 Version 1\tab \up0 \expndtw
-3\charscalex100 Issue Date: 17/05/11\tab \up0 \expndtw-3\charscalex100 Page 46
of 53
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z61\shplid789

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