Checklist of training topics for NABH accreditation preparation

Amongst various preparation that is required for preparing a hospital for accreditation, training of staff is perhaps the most important for implementation. Staff needs to be trained on various policies and procedures documented by the hospital to address NABH standards. Some of the topics require only an orientation while for some a detailed training may be required along with practical demonstration or drills. Here is a list of various training topics that are relevant for accreditation 

Quality Indicators for NABH accreditation preparation

S.N.	Training topic	Coverage	Relevant to
A.      Training topics related to Access, Assessment and Continuity of Care
1.	Scope of hospital services	Clinical services offered by the hospital Services not in scope	All staff, especially staff of front office and admission
2.	Registration and admission of patient	Admission policies Managing during non-availability of beds Handling un-identified patients	Staff of reception, registration and admission (including staff handling emergency admissions)
3.	Safe transfer of patient	Internal and External transfers Transfer of stable and unstable patients	Nurses and duty doctors Hospital attendants (for safety measures to be taken while transferring)
4.	Standard operating procedures of various lab tests		Lab technicians
5.	Collection of samples	Aseptic sample collection, patient safety, labelling or samples, safe transportation and storage	Phlebotomist, Lab technician
6.	Intimation of critical lab results	Panic values, identification, confirmation and communication of critical results	Lab technicians
7.	Quality control in laboratory	Calibration, verification, validation, surveillance, Internal quality assurance, external quality assurance	Technical supervisors, Lab technicians and pathologists
8.	Laboratory safety	Lab waste disposal, infection control, chemical safety, Use of PPE	All laboratory staff (technical and non-technical)
9.	Standard operating procedures of various imaging tests		Imaging technicians
10.	Safety of patient undergoing imaging	Safe transportation and shifting of patient, patient screening, safety in MRI	All lab technicians and supervisors
11.	Intimation of critical imaging findings	Panic findings, Identification, confirmation and communication of critical results	Imaging technicians
12.	Quality control in Imaging	Calibration, verification, validation, surveillance, clinical correlation, clinician’s feedback	Technical supervisors, imaging technicians and radiologists
13.	Radiation safety	AERB regulations, Use and upkeep of radiation safety devices	All staff in imaging (technical and non-technical)
14.	Safe disposal of radio-active waste	Types of radio-active waste, health and environmental effect, disposal	Technical supervisors, imaging technicians and radiologists
15.	Discharge process	Normal discharge, Discharge on request, DAMA, Death	Nurses, Duty doctors, Customer care executives, Admission and discharge staff, staff from pharmacy, billing and insurance
16.	Discharge summary	Contents to be included in discharge summary	Duty doctor, Consultants to be oriented
B.      Training topics related to Care of Patient
17.	Uniform care to patients	Policies of Evidence based medicine, clinical practice guideline, provision of emergency care, applicable laws such as PCPNDT, MTP, organ transplant etc., informed consent	Consultants, duty doctor and nurses
18.	Triaging of patients	Triage in routine cases and triaging during mass casualty situation	Triage nurse
19.	Handling of medico-legal cases		Doctor in-charge of emergency, Nurse in-charge or admin in-charge of emergency dept.
20.	Maintenance of ambulance	Equipment, medicines, maintenance, communication	Ambulance staff and nurse-in-charge of emergency
21.	Handling of emergency patient on-site	Road traffic accidents, trauma, unconscious patients, patient in cardiac arrest etc.	Ambulance staff and emergency medical technicians
22.	Handling of disaster situations, community emergencies and mass casualty situations	Entire plan of managing epidemic and disaster situation. Mock drills must be conducted for this	All staff for their role, and specifically to all staff of emergency.
23.	Basic Life support	CPR, use of crash cart, other life support measures	All nurses and doctors, other staff involved in healthcare such as technicians and therapists
24.	Code blue system	Code blue process, CPR Mock drills must be conducted for this	All nurses and doctors, All other staff for understanding of code blue process
25.	Safe blood transfusion	Rational use of blood, blood storage, prevention of error while transfusion, transfusion monitoring	Blood bank technicians, duty doctors and nurses. Consultants to be oriented on rational use of blood
26.	Disposal of blood		Blood bank staff
27.	Admission and discharge criteria		Orientation to all consultants
28.	Care of vulnerable patients	Vulnerability assessment, identification and care	All nurses and duty doctors. Other healthcare staff
29.	Care of paediatric patients	Paediatric assessment, safety of children, dealing with children	Staff in paediatric ward/ICU
30.	Prevention of child abduction and abuse	Code pink procedure, safety measures, action in case of such events	Staff in paediatric ward/ICU, Security staff, All other staff
31.	Surgical safety	Pre-surgery, during surgery and post-surgery safety measures. These include things like site and side marking, time out and sign out process, infection control etc. WHO surgical safety checklist would be a good reference material.	Operation theatre nurses, surgery resident doctors, surgeons
32.	Care of patients under restraint	Physical and chemical restraints	Nurses, nursing in-charges, resident doctors, consultants
33.	Nutritional screening and assessment		Dietician, Nurses
34.	End of life care		Nurses and doctors in ICU
C.      Training topics related to Management of Medication
35.	Procedure to obtain medicine when pharmacy is closed		Nurses and duty doctors
36.	Safe storage of medication		Store in-charge, pharmacy in-charge, nurse in-charge (for storing in wards)
37.	Safe and rational prescription of medicines		Consultants, Duty doctors
38.	Inventory analysis and control		Store and pharmacy in-charge
39.	Look-alike and sound alike medication	Storage, issue and administration of LASA medicines	Store and pharmacy staff, nurses and duty doctors
40.	High-risk medicine safety		Nurses and duty doctors
41.	Verbal orders for medicines		Nurses, duty doctors and consultants
42.	Safe dispensing of medicine		Pharmacy staff
43.	Medication recall		Store and pharmacy in-charge and nurse in-charges
44.	Safe administration of medicines	Patient identification, checks during administration, post administration monitoring	Nurses and duty doctors
45.	Reporting of medication errors		Nurses and duty doctors
46.	Safe usage of chemotherapeutic medication	Preparation, administration and disposal	Staff involved in chemotherapeutic medicines
47.	Safe usage of radio-active drugs	Safe usage and disposal	Staff involved in radioactive drugs usage
D.      Training topics related to Patients’ Rights and Education
48.	Rights of a patient and how to protect the same		All staff specially front office, nurses, duty doctors, consultants and managers of patient care departments
49.	Taking consent from patients	General consent and informed consent	Consultants, duty doctors and nurses
50.	Patient feedback and complaints	Feedback mechanism and complaint processes	Customer care executives, nurses, nursing in-charges
E.       Training topics related to Hospital Infection Control
51.	Standard precautions	Hand hygiene, use of PPE	Nurses and duty doctors
52.	Safe injection and infusion practices		Nurses and duty doctors
53.	Antibiotic policy		Consultants and duty doctors
54.	Laundry and linen management process		Nurses and laundry staff
55.	Safe handling of food		Kitchen staff and dietician
56.	Housekeeping procedures		Housekeeping staff and supervisors
57.	Bio-medical waste safety	Segregation, storage, transportation, disposal	Nurses, doctors, housekeeping staff. Other staff such as lab and blood bank technicians, OT technicians, therapists etc.
58.	Needlestick injury protocol		All patient care staff
59.	Infection control surveillance		Infection control team
60.	Prevention of HAI in patients	Care bundles for CA-UTI, VAP, SSI and CA-BSI	Nurses, especially ICU nurses
61.	Isolation/barrier nursing		Nurses and duty doctors
62.	Infection outbreak handling	Identification and action	Infection control team, Nursing in-charges
63.	Sterilization activities	Sterilization process and quality control	CSSD staff
F.       Training topics related to Continual Quality Improvement
64.	Quality indicators of each department		In-charge and staff of each department
65.	Patient safety practices		All staff involved in patient care activities
66.	Reporting of patient safety events		All staff involved in patient care activities
67.	Medical audit		Consultants and clinical committee
68.	Sentinel events		All staff involved in patient care activities
G.      Training topics related to Responsibilities of Management
69.	Vision, Mission and Values of the organization		Top management personnel and heads of departments
70.	Scope of services in each department	Services in scope and not in scope	In-charge and staff of each department, especially of obstetric and paediatric departments
H.      Training topics related to Facility Management and Safety
71.	Preventive and breakdown maintenance of equipment		Maintenance staff
72.	Calibration of equipment		Maintenance staff
73.	Handling of fire emergency	Code red alert system Mock drills must be conducted for this	All staff specifically security and maintenance
74.	Use of fire extinguisher		All staff
I.        Training topics related to Human Resources Management
75.	Induction training	Vision, mission, values, patients’ rights, infection control, safety, service standards	All staff upon recruitment
76.	Employee rights and responsibilities		All staff
77.	Training and development policy		All staff
78.	Performance appraisal system		All staff
79.	Disciplinary and grievance handling process		All staff
80.	Prevention of sexual harassment		All staff
81.	Credentialing and privileging of medical professionals		Consultants to be oriented. Duty doctors and nursing in-charges to be informed
82.	Credentialing and privileging of nursing professionals		All nurses and nursing in-charge to be oriented
J.        Training topics related to Information Management System
83.	Safety and security of patient’s data	Data in medical records, registers and computers. Access to medical records	All nurses, nursing in-charges, duty doctors, patient care executives and MRD staff
84.	Medical record documentation	Contents, legibility, use of abbreviation, endorsements	Consultants, duty doctors, nurses, therapists and MRD staff
85.	Medical record maintenance	Screening, completion, storage, retrieval	MRD staff
86.	Hospital statistics from medical record	Various stats and reports	MRD in-charge
87.	Retention time of medical record		MRD in-charge and staff
88.	Process of condemnation of records		MRD in-charge and staff