A large number of activities takes place in a hospital. Accreditation requires that hospital has standardized its systems and process for carrying out all those functions. One of the important requirement for standardization is to document the policies and processes for each function. Accordingly, a hospital requires a large number of documented systems, policies, processes, protocols, criteria etc. Here is a list of all such topics on which a written document must be there,
(Also check - How to organize policy and procedure documents)
(Also check - How to organize policy and procedure documents)
A. Documents related to Access, Assessment and Continuity of Care
3. Transfer-in of the patient to the hospital
5. Transfer out/referral of stable patients to another facility
6. Initial assessment of patients (Out-patients, in-patients and emergency patients)
7. Laboratory scope of tests
8. Ordering of lab tests, collection, identification, handling, transportation, processing and disposal of specimen
9. Time-frame for the availability of lab test results
11. Outsourcing of lab tests
12. Laboratory quality assurance programme
13. Laboratory safety programme
14. Imaging scope of tests
15. Identification and safe transportation of patients to and from the imaging department
16. Time-frame for the availability of imaging results
17. Critical findings of imaging and its timely intimation
18. Outsourcing of imaging tests
19. Imaging quality assurance programme
20. Radiation safety programme
21. Discharge process (including MLC discharge and absconding cases)
22. Discharge against medical advice
23. Death discharge
B. Documents related to Care of Patients
25. Handling of medico-legal cases
26. Triage of patients in emergency
27. Managing dead on arrival cases
28. Identification of likely community emergencies, epidemics and disasters likely
31. Clinical protocols of managing various emergency cases (for adults and children)
32. Quality assurance programme of emergency services
33. Checklist of equipment and emergency medicine in Ambulance
35. Rational use of blood and blood products
36. Transfusion of blood and blood products
37. Availability and transfusion of blood/blood components in an emergency situation
38. Care of patients in ICU and HDU
39. Admission and discharge criteria for ICU and HDU
40. Managing situation of bed shortage in ICU
41. Quality assurance programme of ICU
43. Provision of obstetric care services
44. Care of Paediatric patients
45. Administration of moderate Anaesthesia
46. Monitoring of patients under anaesthesia
48. Care of surgical patients
49. Surgical safety policies and practices
50. Quality assurance programme of surgical services
51. Organ transplant policy and process
52. Standard treatment protocols
54. Pain management
55. Provision of rehabilitative services
56. Conduction of clinical research activities
C. Documents related to Management of Medication
59. Hospital formulary
60. Process of acquisition of medicine in the formulary
61. Process of acquisition of medicine not listed in the formulary
62. Storage of medication
63. Safe storage and handling of look-alike and sound-alike medication
64. List of emergency medicine and its storage
65. Prescription of medicine
66. Policy and process on verbal orders of medication
67. List of high risk medicines
68. Safe dispensing of medicines
69. Medication recall
70. Procedure for near expiry medicine
71. Labelling requirements of medicine
72. Safe administration of medication
73. Policy on patient’s self-administration of medicine
74. Monitoring of patients after medication administration
75. Recording and reporting of medication errors, adverse events and near misses
76. Procedure for usage of narcotic drugs and psychotropic medications
77. Usage of chemotherapeutic medications
78. Disposal of waste medication (cytotoxic)
79. Usage of radio-active drugs (safe storage, preparation, handling, distribution and disposal)
80. Use of implantable prosthesis (procurement, storage, issuance, and record keeping)
81. Acquisition of medical supplies and consumables
D. Documents related to Patients’ Rights and Education
84. List of procedures for which informed consent is required
85. Uniform pricing policy
86. Effective communication with patient and family
87. Patients complaint obtaining and handling system
E. Documents related to Hospital Infection Control
88. Infection control programme
89. Infection surveillance
90. Identification of high risk areas
91. Standard Precaution/Universal Precaution for Infection Control
92. Safe injection and infusion practices
92. Safe injection and infusion practices
93. Cleaning, disinfection and sterilization practices
95. Laundry and linen management processes
96. Kitchen sanitation and food handling
97. Housekeeping procedures
99. Handling outbreak of infections
100. Sterilization process
101. Biomedical waste handling process
F. Documents related to Continual Quality Improvement
102. Organization wide quality improvement programme
104. Patient safety programme
105. Clinical audit system
106. Incident reporting, analysis and corrective preventive action system
107. Definition and lists of sentinel events
108. Analysis of sentinel events
G. Documents related to Responsibilities of Management
109. Vision, mission and values of the organization
110. Strategic and operational plan of the organization
111. Organogram
112. Managing compliance to laws, regulations, licenses and permits
113. Scope of services of each department
114. Administrative policies and procedures (attendance, leave, conduct, replacement etc.)
116. Service standards of the organizations
H. Documents related to Facility Management and Safety
117. Disposal of non-functioning items and scrap materials
119. Up-to-date drawings and site layout
120. Maintenance plan for the facility
121. Preventive and breakdown maintenance plan
122. Maintenance plan for water management
123. Maintenance plan for electrical systems
124. Maintenance plan for HVAC systems
125. Maintenance plan for IT and communication network
126. Equipment replacement and disposal
127. Managing medical gases (procurement, handling, storage, distribution, usage and replenishment
129. List of hazardous materials in the organization
130. Handling of hazardous materials (sorting, labelling, handling, storage, transporting and disposal)
131. Managing spills of hazardous materials (including blood)
I. Documents related to Human Resources Management
132. Human resources plan of the organization
133. Job specification and job description of each category of staff
134. Recruitment and selection procedure
135. Induction programme of new staff
136. Training and development policy
137. Employee appraisal system
138. Disciplinary and grievance handling system
139. Addressing health needs of employee
141. Credentialing and privileging of nursing professionals
J. Documents related to Information Management System
142. Managing information needs of the organization
143. Document control process
144. Data management (dissemination, storage, retrieval)
145. Policy on who is authorized to make entries in the medical record
147. Maintaining confidentiality, security and integrity of records, data and information
148. Retention of patient’s clinical record, data and information
149. Destruction of medical records
150. Medical record review
