Checklist of Blood Bank and Quality Indicators for NABH accreditation preparation

Blood Bank has a unique importance in a healthcare facility. It provides the life-saving resource, blood and blood components, which is collected from donors and has limited availability. It is of high importance that this precious resource is used rationally and is not wasted. Blood bank is also considered a high risk area for patient safety as any error or infection in blood can be potentially lethal for the patient. Hence policies and procedures in blood bank should be aimed at achieving the highest level of safety, rational use of blood and blood products and reduction of wastage. The checklist given below which takes into account NABH standards for blood bank can be used as a framework to achieve these objectives. This checklist may not be sufficient for a separate accreditation of Blood Bank, under NABH accreditation for Blood Banks’.

Patient’s Fall Risk Assessment

One of the common risk to safety of patients in hospital is the risk of fall. Several epidemiological studies has found that on an average 3 to 5 patient fall incidence occur in every 1000 bed-days. It is also estimated that a third of fall results into injuries which could be severe such as fracture. Due to the widespread prevalence and resulting harm, prevention of patient fall is included as one of the International Patient Safety Goals (IPSG) of JCI standards for hospitals.

The first step to prevention of fall is identifying patient who is at a risk of fall. Most accreditation bodies, including NABH and JCI expects hospital to undertake a fall risk assessment of all admitted patient and take preventive measures for those who are at a higher risk of fall.

The table below describes the points that should be used for assessing risk of fall, and classifies features into very high, high, moderate and low risk categories.

Checklist of Quality Indicators for NABH accreditation preparation

Quality Indicators are the backbone on which quality assurance programme of a hospital relies. NABH accreditation expects hospitals to calculate several quality indicators and use it for monitoring the quality of care. These are the list of quality indicators, which a hospital preparing for accreditation must necessarily monitor. (Also check - Performance measures for hospital business)

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

Checklist of documents for NABH accreditation preparation

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)

A.   Documents related to Access, Assessment and Continuity of Care

1.       Registration and admission of patients (OPD, IPD and Emergency)

2.       Managing patients during non-availability of beds

Licenses, permits and other legal documents required to open and operate a hospital

There are many regulatory clearances required to establish and operate a hospital. The management of hospital must be aware about all such legal documents, requirements and process to obtain the same. Here is a comprehensive list of applicable legal documents with their brief description and relevant links. Some of these may not be applicable to specific hospitals, depending upon the scope of service, type of infrastructure, location etc.

1. Legal documents required for establishing the business of hospital

Infection control checklist for NABH accreditation preparation

Healthcare Associated Infections (HAI) can easily qualify as the most important patient safety concerns in hospitals. To address the menace of HAI, infection control is kept as one of the main objectives, while designing any healthcare delivery structure, policies and processes. Almost all activities that are done within hospital has a bearing on infection control and there are a large number of studies that has resulted in various good practices for controlling infections. NABH has also dedicated a full chapter on Infection Control, while standards and objective elements under various other chapters also incorporates infection control aspects in it. A list of all infection control measures, grouped under appropriate heading is given below for hospitals to keep a check on.

Checklist of housekeeping services for NABH accreditation

Perhaps the most pervasive service across the hospital is the housekeeping. This is also one of the most important services for prevention of healthcare associated infections and for compliance to Biomedical Waste Management rules. While housekeeping maintains the ambience clean, they must adhere to certain work practices that are recommended by accreditation bodies and  regulatory bodies. Below is the list of all such requirements which housekeeping must ensure.

A. Housekeeping procedures

1.         Standard housekeeping procedures should be used across the organization. The documented procedures should be available with the supervisor/housekeeping manager. For staff these procedures should be documented in a simplified manner and in a language that the housekeeping staff can understand. These procedures must include following

Checklist of Purchase department for NABH accreditation preparation

The purchase department helps in steady supply of materials required in hospital for daily functioning. This requires a good deal of planning and management, as any disruption in functioning of purchase may cause disruption in supply of essential items, which can adversely affect various functions of hospital including healthcare. Also, as purchase function involves a large amount of money, an inefficient management can significantly add to the cost burden of running a hospital. Following practices are recommended for purchase, which if implemented appropriately can tremendously boost its efficiency.

As most of the work in purchase in a hospital is related to medicines and pharmaceuticals, it is highly recommended that this checklist must be used along with the checklist of Pharmacy.

Purchase:

1.       A documented purchase policy should be available that specifies who has the authority for taking purchase decision, according to the amount of purchase

2.       Purchase of capital items (beyond a defined cost) should always be done through a multi-disciplinary committee. The committee must consist of representative from the user department (where the purchased item is going to be used), representative from finance, management and purchase department

Checklist of Anaesthesia department for NABH accreditation preparation

Anaesthesia services plays a crucial role in patients’ safety, especially for patients undergoing surgery or under critical care. As it is closely linked to patient safety, NABH has focussed on anaesthesia services and has given certain requirements to be fulfilled by it. These requirements are largely to ensure safety of patients from adverse and sentinel events related to Anaesthesia. The list of requirements is as given below.

Note: These requirements are applicable to all types of anaesthesia (general, regional, spinal) except local anaesthesia

1. Anaesthesia services should be given by qualified anaesthetist only. The hospital’s credentialing and privileging policy must specify the names of doctors, who has the privilege of providing different types of anaesthesia. Technician shall not administer anaesthesia.

Checklist of Bio-medical engineering department for NABH accreditation preparation

Bio-medical engineering department in a hospital serves a very important purpose of ensuring that medical equipment in various departments are in their best functional condition and are being effectively utilized. The performance of the department is reflected from how well the patient care staff are able to use medical equipment. To be able to effectively manage medical equipment there are several standards and practices that the department must follow. The NABH has also outlined these standards, largely in its FMS chapter. The complete checklist of all requirements that bio-medical engineering department must fulfil is given below.

1. There should a documented equipment plan for the hospital. An equipment plan should typically have speciality wise list of equipment required, with brief specification and their quantity. The plan should be based on clinical need and workload. Such plan should be developed in consonance with the doctors of the clinical departments. A reference for minimum equipment requirement should followed, such as IPHS standards.

Checklist of Admissions Department for NABH accreditation preparation

A patients’ actual experience with hospital begins from the admission department. The department in addition to admitting a patient, also serves as a key point where all important information is shared between hospital and patient. The key performance expected from admissions department is time efficiency in admitting patient and achieving a positive first impression of the patient.

The admission department can help in addressing many NABH standards under AAC, PRE and ROM chapters. Here is the list of things that admission department staff must be prepared with for facing accreditation assessment.

1. Admission staff should be aware of hospital's policy of a patient's admission. S/he should know who has the authority to admit patients (i.e. list of doctors who can admit patients in the hospital)

Checklist of Hospital’s Food services (Kitchen) for NABH accreditation preparation

The Food services department of hospital is responsible for fulfilling the food and diet requirements patients. In addition to patient, it can also cater to employees, patients’ family members and visitors. The food services for patients plays important role in aiding to treatment and faster recovery of patient. The quality objectives of food services in hospital should be to provide right food to right patient at right time, provide food that is safe to consume and palatable and to avoid wastages of food. To meet these objectives there are certain practices that must be followed which are also given under NABH standards. Here is the list of what a hospital’s food services department must do to provide quality services and also to meet NABH accreditation norms. Note that these standards are applicable even if the kitchen is outsourced

A. Infrastructure

1. The kitchen of the hospital should have an identified area and its location should be segregated from patient areas and traffic flows.

Checklist for CSSD for NABH preparation and its quality indicators

Central Sterilization and Supplies Department (CSSD), has its importance in prevention of cross infection in hospitals. An effective functioning of CSSD will reduce the HAI traceable to use of instruments on patients’ care. For this CSSD must follow standard practices in its sterilization and supplies operations. NABH recommends following standards to be implemented in CSSD.

Infrastructure

     ·         The CSSD should be located in a delineated area where there is less or no external traffic movement.

   ·         Location of CSSD should be either close to OT or should be connected to OT with safe & quick  transfer mechanism, like dumbwaiters.

Checklist of Pathology Laboratory and its quality indicators for NABH accreditation preparation

Pathology lab is expected to provide as accurate diagnosis as possible, within reasonable time frame and without compromising the safety of patient or its staff. To be able to do so, the lab is required to follow certain policies and processes. The NABH standards outlines following requirements for a medical laboratory in a hospital.

Checklist of Radiology and Imaging department and its quality indicators for NABH accreditation preparation

Imaging department is one of the pivotal department for diagnosis of diseases. It includes both radiation based and non-radiation based imaging modalities. The key result areas (KRAs) for imaging departments are availability of required tests, accuracy of diagnosis, safety of patients and staff, maintenance of turn-around time and optimal utilization of equipment. NABH standards for imaging revolves around these KRAs. 

Below is the compilation of all requirements that is applicable to an imaging department for NABH accreditation fulfillment

Checklist for Pharmacy and its quality indicators

A significant number of standards and objective elements of NABH are applicable to Pharmacy of a hospital. Most of these requirements are given under the chapter of ‘Management of Medication’, but there are objective elements under other chapters also, which are applicable to pharmacy. The checklist below has been prepared after taking in consideration all such requirements. Objective of this checklist is that the hospital should be able to prepare and quickly evaluate everything that is applicable to pharmacy under NABH accreditation preparation.

A. Legal requirements
1. The person dispensing the medicine in pharmacy is a qualified pharmacist (B. Pharm or D. Pharm). The qualification certificate should preferably be displayed in pharmacy.

Checklist of facility safety inspection for NABH accreditation preparation

NABH puts high importance to safety in hospitals and ask the preparing hospitals to ensure that the facility is safe for patients, staff and visitors. As per one of the objective elements (FMS.1 e. of NABH 4^th edition), the preparing hospital is required to conduct facility inspection rounds to ensure safety. Further, it also states that the round should be conducted at-least twice in patient care areas and once in non-patient care areas. In-order for these rounds to be effective, it is important that a comprehensive checklist be used so that common safety hazards and potential risks could be checked and necessary remedial measures be taken. Below, I have prepared a checklist of points that could be used for such rounds. The checklist also addresses various other safety parameters that has been asked in different standards and objective elements of NABH standards book.

This checklist would be of much more value if used along-with the Infrastructure checklist for NABH accreditation preparation.

Checklist of Hospital’s Human Resources Department for NABH accreditation preparation

In NABH standards there is a complete chapter devoted for HR management in hospitals. It is expected that the hospital follows all good HR practices which ultimately makes the hospital a better organization for delivering healthcare services. From NABH standards and various assessment observation, following are the important points with which an HR department of a hospital must be prepared.

Other checklists available for NABH accreditation preparation: 

Infrastructure, IPD-Wards, ICU, Medical Records, Operation Theatre, Ambulance,

All checklists

Checklist for HR department
1. Having a documented HR plan for the hospital. The plan must mention the categories of employees, quantity required under each category, quantity available and future quantity requirements.

Checklist of Ambulance for NABH accreditation preparation

Ambulance plays a vital role in emergency medical care. In-order to be able to provide best ambulance services to emergency cases, NABH has specified certain requirements to be met. As functionally ambulance is related to emergency care, it is suggested that this checklist be used in combination with checklist of emergency department.

Specific points that needs to be taken care of for ambulance are