FINAL PROJECT OF JCI DOCUMENTATION

IMPLEMENTATION OF
JOINT COMMISSION
INTERNATIONAL
STANDARDS IN TERTIARY
CARE HEART HOSPITAL
WITH SPECIAL FOCUS
ON DOCUMENTATION
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INDIAN INSTITUTE OF SOCIAL WELFARE AND
BUSINESS MANAGEMENTCOLLEGE SQUARE
WEST, KOLKATA 700 073
IMPLEMENTATION OF JOINT COMMISSION INTERNATIONAL
STANDARDS IN TERTIARY CARE HEART HOSPITAL WITH
SPECIAL FOCUS ON DOCUMENTATION
Project Report Submitted to the University of Calcutta
in Partial Fulfillment for the Award of Master of Public Systems
Management (With Specialization in Environment Management)
By
KAUSTAV DEB
ROLL NO.: 107/MPS/130049
SESSION: 2013-2015
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INDIAN INSTITUTE OF SOCIAL WELFARE AND
BUSINESS MANAGEMENT
COLLEGE SQUARE WEST, KOLKATA 700 073
May, 2012
DECLARATION
I, Mr. Kaustav Deb
Hereby declare that this project report is the record of
authentic work carried out by me during the period
from 6th
March to 22nd
May and has not been
subjected to any other University or
Institute for the award of any degree /
diploma etc.
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Signature:
Name of the student: Kaustav Deb
Date:
CERTIFICATE FROM THE COMPANY / ORGANISATION
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CERTIFICATE
This is to certify that Mr KAUSTAV DEB of INDIAN
INSTITUTE OF SOCIAL WELFARE AND BUSINESS
MANAGEMENT has successfully completed the project work
titled IMPLEMENTATION OF JOINT COMMISSION
INTERNATIONAL STANDARDS IN TERTIARY CARE
HEART HOSPITAL WITH SPECIAL FOCUS ON
DOCUMENTATION in partial fulfillment of requirement for the
completion of PGP course as prescribed by the College of
Management COLLEGE NAME.
This project report is the record of authentic work carried out
by him/her during the period from March to May He has
worked under my guidance.
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Signature
Name
Project Guide (Internal)
Date:
Counter signed by
Signature
Name
Director
Date:
ACKNOWLEDGEMENT
I would like to owe a great debt of gratitude to Dr. Aninda Chatterjee
(Chief Operating Officer), and Mr. Kaushik Kuthe (Assistant Manger -
Human Resource) for selecting, accepting and inducting me as a
Management Trainee in B.M BIRLA HEART RESEARCH CENTRE
and for motivating me to be better. Also I am obliged to Mr. Sukanta
Kumar Das (HOD of Quality Assurance Department ) & to the whole
Quality Assurance Department for sharing their knowledge with me
and for guiding me constantly. I express my extreme thanks as they
provided me with all possible help and support in spite of their busy
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schedule. Special thanks and gratitude to Dr. Tushar PalChoudhury
(Astron Quality Consultant )
I also want to convey my gratefulness to Prof. (Dr.) B.K. Chowdhury
(HOD of Masters in Public System Management) Dr. Sanghamitra
Sen. (Hospital and Healthcare Batch Coordinator) & Mr.
Sandip Ghosh (Project Guide) of our College for sharing
their experience with me, keeping faith on me & for making me what I
am today.
LIST OF ABBREVIATIONS
Section I: Accreditation Participation Requirements
• Accreditation Participation Requirements - APR
Section II: Patient-Centered Standards
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• International Patient Safety Goals - IPSG
• Access to Care and Continuity of Care - ACC
• Patient and Family Rights - PFR
• Assessment of Patients - AOP
• Care of Patients - COP
• Anesthesia and Surgical Care - ASC
• Medication Management and Use - MMU
• Patient and Family Education - PFE
Section III: Health Care Organization Management Standards
• Quality Improvement and Patient Safety - QPS
• Prevention and Control of Infections - PCI
• Governance, Leadership, and Direction - GLD
• Facility Management and Safety - FMS
• Staff Qualifications and Education - SQE
• Management of Information - MOI
Section IV: Academic Medical Center Hospital Standards
• Medical Professional Education - MPE
• Human Subjects Research Programs - HRP
EXECUTIVE SUMMARY
This is the report of the JCI on Quality Care in Hospitals B.M BIRLA HEART
RESEARCH CENTRE. It aims to provide information on the of quality, quality
management and quality challenges in health care. The challenge of quality is
founded on the basic principle of reducing the number of errors, which is still a
great challenge for health care. Latest research demonstrates that almost every
tenth patient suffers from preventable harm and adverse effects related to their
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care and that variation among health care providers is large and cannot be
explained by patient characteristics.
The JOINT COMMISSION INTERNATIONAL, 5th Edition started its work 2014,
1st of April. A survey was carried out which demonstrated that the concepts and
principles relating to quality management in health care differ from one country
and culture to another. The same was true for quality system audits and the
principles for their credibility and authorization (accreditation and certification).
Since then many projects in health care have demonstrated that the general
management and quality assurance principles apply well for health care. Projects
like the 'Expert' demonstrated that health care should learn from all the different
quality management programs.
This report provides an analysis, evaluation and comparison study of the JCI and
NABH. Results of standards comparison show that some of the policies are not
there and most of them needed to improve. In particular, comparative
performance is poor in the areas of Patient care, Nursing care, Hospital leadership
procedure, and biomedical waste management.
The report finds the prospects of the company in its current position are not
positive. The major areas of weakness require further investigation and remedial
action by management.
CONTENT
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SL NO CHAPTERS PAGE NO
1 Introduction
1.1 Background of the study 10
1.2 Company profile 11
1.3 Background of the topic 13
1.4 ORGANOGRAM 17
1.5 Need of the study 18
1.6 Objectives of the study 18
2 Research Methodology – Comparative
Study
20
3 Findings 52
4 Conclusions 53
5 Bibliography 54
INTRODUCTION
Hospitals play an important role in the health care system. They are health care
institutions that have an organized medical and other professional staff, and inpatient
facilities, and deliver medical, nursing and related services 24 hours per day, 7 days per
week.
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Hospitals offer a varying range of acute, convalescent and terminal care using diagnostic
and curative services in response to acute and chronic conditions arising from diseases
as well as injuries and genetic anomalies. In doing so they generate essential information
for research, education and management.
Traditionally oriented on individual care,
hospitals are increasingly forging closer links
with other parts of the health sector and
communities in an effort to optimize the use of
resources for the promotion and protection of individual and collective health status.
QUALITYhealth care has a wide variety of meanings. To some people,
sitting in the waiting room a short time to see a doctor means “QUALITY” health care.
To others, being treated politely by the doctor's staff means “QUALITY” health care.
There are those who define “QUALITY” health care by how much time the doctor
devotes to examining you.
By examining the number of times a hospital has
provided care that has been scientifically proven to
improve a medical condition and looking at the
outcome after a patient has received the
recommended care, you can get a picture of how
well a hospital is providing quality of care. Using
definitions of care that can be measured with
numbers is one way to gauge the success or failure of a treatment.
The BM Birla Heart Research Centre is acknowledged
for providing quality patient care, diagnosis and treatment; and research of
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cardiovascular diseases. A commitment to the art and science of healing
forms the core of its ethos:
• Leadership and excellence in delivering quality healthcare services
• Expanding the horizons of medical knowledge through biomedical
research
• Educating and training physicians and other healthcare professionals
• Improving the health of our society
Apart from providing quality cardiac care to its patients, the BM Birla Heart
Research Centre has several breakthroughs in angioplasty to its credit. To
name a few:
• Performing a less-invasive alternative to cardiac bypass surgery
• Earning worldwide recognition for innovative developments in the
diagnosis and treatment of heart diseases
The BM Birla Heart Research Centre caters to the entire spectrum of
cardiac ailments for children as well as adults. The Centre focuses on the
advanced field of cardiac surgery, with added attention to reconstructive
operations on children. BMBHRC researchers put their findings into
practice, thereby improving the health of society.
Vision
To be the leading super-specialty healthcare & research institute in Eastern
India, with world-class standards in quality.
Mission
• To offer the highest standards of medical treatment.
• To treat patients with care, compassion & commitment.
• To touch every section of society, and offer them the best in medical
care.
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HIGH LEVEL ORGANIZATION CHART
Joint Commission International Accreditationis
a voluntary process in which an entity separate and distinct
from the health care organization which assesses the health
care organization to determine if
it meets a set of requirement (standards) designed to provide
a visible commitment by an organization to improve the
safety and quality of care which is optimal and achievable.
It is an effective quality evaluation and management tool for
ensuring a safe care environment which helps continuous
improvement process to reduce risk to patient and staffs.
Joint Commission International is a U.S. based not for profit
accreditation body which sets and designs
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Standards and processes to create a culture of ethics, safety
and quality within an organization that
Strive to continually improve patient care processes and
results..
Benefits of JCI
Joint Commission International teaches and leads us to:
 Improve patient trust by improving patient safety, quality and care.
 Provide a safe and efficient work environment that contributes to
staff satisfaction
 Listen to patients and their families, respect their
rights, and involve them in the care process as
partners; and
 Helps establish collaborative leadership that sets
priority for and continuous leadership for quality and
patient safety at all levels.
Purpose and Goal of JCI Accreditation Initiatives
The Purpose is to give BM BIRLA HEART RESEARCH
CENTRE fame by setting Goals which stimulate demonstration of
continuous, sustained improvement in healthcare organization by
applying international consensus standard, International Patient Safety
Goals and Data Measurement Support.
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JCI addresses the following issues very intensively:
1. International Patient Safety Goals
2. Patient & Family Education
3. Patient & Family Rights & Responsibilities
4. Pain Management
5. Quality Indicators & Monitoring
6. Hand Wash & Prevention and Control of Infection
7. Fire Safety and Emergency Codes
8. Removal of Barriers to Care
9. Patient Identifiers
10. Care of High Risk Patients (Vulnerable patients)
11. Restraint Order
12. Rights of Drug administration
13. Discharge Planning & Components of Discharge Summary
14. Time Out
15. Biomedical Waste Disposal
16. Personal Protective Equipments (PPE)
17. HAZMAT, Lab, Radiation, Facility Safety
18. DNR (Do Not Resuscitate)
19. End of Life Care
20. Hospital Mandatory Trainings
JCI Standards (5th Edition)
Accreditation Participation Requirements (APR): 12
Chapters Total Number: 16
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 Patient Centered Chapters: 8
 Organization Management Chapters: 6
 Academic Medical Center Hospital Chapters: 2
Standards: Total Number: 304
Standards are set around the important functions; they are
common to all
healthcare organizations.
Intent statement: Easy explanation of the standards
Measurable Elements: Total number: 1218
Measurable elements are those requirements of standards
which are
reviewed and assigned a score during survey.
Survey: Assesses the hospitals compliance on JCI standards
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Chapter Details
I. Accreditation Participation Requirements
Accreditation Participation Requirements (APR)-Introductory
II. The Patient Centered Standards are:
1. International Patient Safety Goals (IPSG)
2. Access to Care and Continuity of Care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care (ASC)
7. Medication Management and Use (MMU)
8. Patient and Family Education (PFE)
III. The Organization Management Standards are:
9. Quality Improvement and Patient Safety (QPS)
10. Prevention and Control of Infections (PCI)
11. Governance, Leadership, and Direction (GLD)
12. Facility Management and Safety (FMS)
13. Staff Qualifications and Education (SQE)
14. Management of Information (MOI)
IV. The Academic Medical Center Hospital Standards are:
15. Medical Professional Education (MPE)
16. Human Subjects Research Programs (HRP)
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JCI ORGANOGRAM
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COO
GM / HS
SECTION
COORDINATOR
SECTION COORDINATOR
SECTION COORDINATOR
SECTION COORDINATOR
SECTION COORDINATOR

NEED OF THE STUDY
Implementation of JCI to improve quality service in Patient centered
areas and Hospital Centered areas. This study shows the comparison,
equivalent policies and elements of JCI and NABH. It will also helps to
find out what are the remaining policies and what are polices needed
to change and what are the polices need to create.
OBJECTIVES OF THE STYDY
Comparative Study of JCI and NABH policy
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RESEARCH METHODOLOGY
Comparative Study between JCI
and NABH for Patient Centered
and Hospital Centered Standards.
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CARE OF PATIENTS
STANDARD MEASURABLE ELEMENTS NABH 3rd Edition Standard
Standard COP.1
Uniform care of all
patients is provided and
follows applicable laws
and regulations. ℗
Measurable Elements of COP.1
ME 1. The hospital’s department/service
leaders collaborate to provide uniform care
processes.
ME 2. The provision of uniform care
reflects local and regional laws and
regulations.
ME 3. Uniform care is provided that meets
requirements a) through e) in the intent
COP.1.a.b
COP 1.c
COP.1.a
Standard COP.3
The care of high-risk
patients and the
provision of high-risk
services are guided by
professional practice
guidelines, laws, and
regulations. ℗
ME 1. Hospital leadership has identified
the high-risk patients and services.
ME 2. When high-risk services are
provided by the hospital, leadership
establishes and implements guidelines
and procedures for those services and
for the care of high-risk patients, for at
least a) through i) of the
intent. (Also see MOI.10.1, ME 4)
ME 3. Staff have been trained and use
the guidelines and procedures for care.
ME 4. Hospital leadership identifies
additional risks that may affect high-risk
patients and services.
COP.8.a
COP.9.a
COP.8.a
COP.8.b
COP.8.c
COP.9.e
N/A
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ME 5. Evaluation of the high-risk
services is included in the hospital’s
quality improvement program
COP.8.g
Standard COP.3.3
Clinical guidelines and
procedures are
established and
implemented for the
handling, use, and
administration of
blood and blood
products. ℗
ME 1. An individual with education,
knowledge, and expertise oversees the
administration of blood and blood
products. (Also see AOP.5.11, ME 1)
ME 2. Clinical guidelines and
procedures are established and
implemented for the handling, use, and
administration of blood and blood
products. (Also see AOP.5.11, ME 2)
ME 3. Clinical guidelines and
procedures address the processes for
a) through e) in the intent.
N/A
COP.7.a
COP.7.b
COP.7.b
Standard COP.6
Patients are supported in
managing pain
effectively. ℗
ME 1. Based on the scope of services
provided, the hospital has processes to
identify patients in pain.
ME 2. When pain is an expected result
of planned treatments, procedures, or
examinations, patients are
informed about the likelihood of pain
and options for pain management.
ME 3. Patients in pain receive care
according to pain management
guidelines and according to patient
COP.16.a.b
N/A
COP.16.d
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goals
for pain management.
communicate with and to
educate patients and families about
pain.
educate staff about pain.
COP.16.e
N/A
ACCESS TO CARE AND CONTINUITY OF CARE
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Standard ACC.1
Patients who may be
admitted to the hospital
or who seek outpatient
services are screened to
identify if their
health care needs match
the hospital’s mission
and resources. ℗
Measurable Elements of ACC.1
ME 1. Based on the results of screening, it
is determined if the needs of the patient
match the hospital’s
mission and resources. (Also see GLD.3.1,
ME 1)
ME 2. Patients are accepted only if the
hospital can provide the necessary
services and the appropriate
outpatient or inpatient setting for care.
ME 3. There is a process to provide the
results of diagnostic tests to those
responsible for determining if the patient is
to be admitted, transferred, or referred.
ME 4. Specific screening tests or
evaluations are identified when the hospital
requires them prior to admission or
registration.
ME 5. Patients are not admitted,
transferred, or referred before the test
results required for these decisions are
available.
NA
AAC.2.d
NA
NA
NA
Standard ACC.1.2
The hospital considers
the clinical needs of
patients and informs
patients when there are
waiting periods or
delays for diagnostic
and/or treatment
services. ℗
Measurable Elements of ACC.1.2
ME 1. Inpatients and outpatients are
informed when there will be a delay in
care and/or treatment.
ME 2. Patients are informed of the
reasons for the delay or wait and
provided with information on available
alternatives consistent with their
clinical needs.
ME 3. The information is documented in
the patient record.
NA
NA
NA
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Standard ACC.2.3
Admission to units
providing intensive or
specialized services is
determined by
established criteria.℗
ME 1. The hospital has established
entry and/or transfer criteria for
admission to intensive and specialized
services or units, including research
and other programs to meet special
patient needs.
ME 2. The criteria utilize prioritization,
diagnostic, and/or objective parameters,
including physiologic-based
criteria.
ME 3. Individuals from
intensive/specialty units are involved in
developing the criteria.
ME 4. Staff are trained to apply the
criteria.
ME 5. The records of patients who are
admitted to units providing
intensive/specialized services contain
evidence that they meet the criteria for
services.
COP.8.b
AAC.3.b
COP.8.b
NA
COP.8.c
NA
Standard ACC.2.3.1
Discharge from units
providing intensive or
specialized services is
determined by
established criteria. ℗
Measurable Elements of ACC.2.3.1
ME 1. The hospital has established
discharge and/or transfer criteria from
intensive and specialized services
or units to a different level of care,
including research and other programs.
ME 2. The criteria used for discharge or
transfer should include the criteria used
for admission to the next
level of care.
ME 3. Individuals from intensive or
specialty units are involved in
developing the criteria.
ME 4. Staff are trained to apply the
criteria.
ME 5. The records of patients who are
transferred or discharged from units
providing intensive or specialized
services contain evidence that they no
longer meet the criteria for services.
COP.8.b
NA
NA
COP.8.c
NA
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Standard ACC.4.3.2
The clinical records of
inpatients contain a copy
of the discharge
summary. ℗
Measurable Elements of ACC.4.3.2
ME 1. A discharge summary is prepared
by a qualified individual.
ME 2. A copy of the discharge summary
is provided to the practitioner
responsible for the patient’s continuing
or follow-up care.
ME 3. A copy of the discharge summary
is provided to the patient in cases in
which information regarding the
practitioner responsible for the patient’s
continuing or follow-up care is
unknown.
ME 4. A copy of the completed
discharge summary is placed in the
patient's record in a time frame
identified
by the hospital.
AAC.13.a
NA
AAC.14.a
NA
Standard ACC.4.4
The records of
outpatients requiring
complex care or with
complex diagnoses
contain profiles of the
medical
care and are made
available to health care
practitioners providing
care to those patients. ℗
ME 1. The hospital identifies the types
of outpatients receiving complex care
and/or with complex diagnoses
who require an outpatient profile.
ME 2. The information to be included in
the outpatient profile is identified by the
clinicians who treat those
patients.
ME 3. The hospital uses a process that
will ensure the outpatient profile is
available in an easy to retrieve and
review format.
ME 4. The process is evaluated to see if
it meets the needs of the clinicians and
improves the quality and safety of
outpatient clinical visits.
NA
NA
NA
NA
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ASSESSMENT OF PATIENT
Standard AOP.1
All patients cared for by
the hospital have their
health care needs
identified through an
assessment process that
has been defined by the
hospital ℗
Measurable Elements of AOP.1
ME 1. The minimum content of
assessments for inpatients is defined for
each clinical discipline that performs
assessments and specifies the required
elements of the history and physical
examination.
ME 2. The minimum content of
assessments for outpatients is defined for
each clinical discipline that
performs assessments and specifies the
required elements of the history and
physical examination.
ME 3. Only qualified individuals permitted
by licensure, applicable laws and
regulations, or certification
perform the assessment. (Also see
SQE.10)
ME 4. The hospital identifies the
information to be documented for the
assessments
AAC.4.a
AAC.4.a
AAC.4.b
AAC.4.a.e.f.g.h.j
Standard AOP.1.1
Each patient’s initial
assessment includes an
evaluation of physical,
psychological, social,
and economic factors,
including a physical
examination and health
history ℗
Measurable Elements of AOP.1.1
ME1. All inpatients and outpatients have
an initial assessment that includes a health
history and physical
examination consistent with the
requirements defined in hospital policy.
ME 2. Each patient receives an initial
psychological assessment as indicated by
his or her needs.
ME 3. Each patient receives an initial
social and economic assessment as
indicated by his or her needs.
ME 4. The initial assessment results in an
initial diagnosis.
AAC.4.a
NA
NA
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AAC.4.d
Standard AOP.1.2
The patient’s medical
and nursing needs are
identified from the initial
assessments, which are
completed and
documented in the
clinical record within the
first 24 hours after
admission as an
inpatient or earlier as
indicated
by the patient’s
condition.℗
Measurable Elements of AOP.1.2
ME 1. The initial medical assessment,
including health history, physical exam,
and other assessments required
by the patient’s condition, is performed
and documented within the first 24
hours of admission as an
inpatient or sooner as required by
patient condition.
ME 2. The initial medical assessment
results in a list of specific medical
diagnoses that includes primary and
associated conditions requiring
treatment and monitoring.
ME 3. The initial nursing assessment is
performed and documented within the
first 24 hours of admission as
an inpatient or sooner as required by
patient condition.
ME 4. The initial nursing assessment
results in a list of specific patient
nursing needs or conditions that
require
AAC.4.c.d
AAC.4.d
AAC.4.d.e
AAC.4.e.j
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nursing care, interventions, or
monitoring
Standard AOP.1.2.1
The initial medical and
nursing assessments of
emergency patients are
based on their needs and
conditions.℗
Measurable Elements of AOP.1.2.1
ME1. The medical assessment of
emergency patients is based on their
needs and condition and documented
in the patient record.
ME2. The nursing assessment of
emergency patients is based on their
needs and condition and documented
in the patient record.
ME 3. Before surgery is performed,
there is a brief note and preoperative
diagnosis documented for
emergency patients requiring
emergency surgery. (Also see ASC.7)
AAC.4.a.c.d.g
AAC.4.a.c.d.e
COP.14.b.
Standard AOP.2
All patients are
reassessed at intervals
based on their condition
and treatment to
determine their response
to
treatment and to plan for
continued treatment or
discharge. ℗
ME 1. Patients are reassessed to
determine their response to treatment
and plan for continued treatment
and/or discharge. (Also see COP.5, ME
3; ASC.6.1; and MMU.7, ME 1)
ME 2. Patients are reassessed at
intervals based on their condition and
when there has been a significant
change in their condition, plan of care,
or individual needs. (Also see AOP.1.7,
ME 2)
ME 3. A physician reassesses patients
at least daily, including weekends,
during the acute phase of their care
and treatment.
ME 4. For non-acute patients, the
hospital defines, in writing, the
circumstances in which, and the types
of
patients or patient populations for
which, a physician’s assessment may
AAC.5.a.e
AAC 5.a.c
NA
NA
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be less than daily and identifies
the minimum reassessment interval for
these patients.
ME 5. Reassessments are documented
in the patient record. AAC 5.c.d
Standard AOP.3
Qualified individuals
conduct the
assessments and
reassessments ℗
ME 1. Individuals qualified to conduct
patient assessments and
reassessments are identified and have
their
responsibilities defined in writing. (Also
see SQE.1.1, ME 2)
ME 2. Only those individuals permitted
by licensure, applicable laws and
regulations, or certification perform
patient assessments.
ME 3. Emergency assessments are
conducted by individuals qualified to do
so.
ME 4. Nursing assessments are
conducted by individuals qualified to do
so.
AAC.4.b
HRM.8.b
HRM.9.a
AAC.4.b.e
HRM.10.a
HRM.10.a
MEDICATION MANAGEMENT AND
USE
Standard MMU.2
Medications for
prescribing or ordering
are stocked, and there is
a process for
medications not stocked
or
normally available to the
hospital or for times
when the pharmacy is
closed. ℗
Measurable Elements of MMU.2
ME 1. There is a list of medications
stocked in the hospital or readily
available from outside sources.
ME 2. The process used to develop the
list (unless determined by regulation or
an authority outside the
hospital) includes representation from
all those who prescribe and manage
medications in the hospital.
ME 3. There is a process for obtaining
medications during the night or when
the pharmacy is closed.
MOM 2.a
MOM 2.b
MOM 1.d
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Standard MMU.3
Medications are properly
and safely stored. ℗
ME 1. Medications are stored under
conditions suitable for product stability,
including medications stored on
individual patient care units.
ME 2. Controlled substances are
accurately accounted for according to
applicable laws and regulations.
ME 3. Medications and chemicals used
to prepare medications are accurately
labeled with contents, expiration dates,
and warnings.
ME 4. All medication storage areas,
including medication storage areas on
patient care units, are periodically
inspected to ensure that medications
are stored properly.
ME 5. Medications are protected from
loss or theft throughout the hospital.
MOM 3.a.b.d.e
MOM 3.c
MOM 5.e
MOM 3.c
NA
Standard MMU.3.1
There is a process for
storage of medications
and nutrition products
that require special
consideration. ℗
Measurable Elements of MMU.3.1
ME 1. The hospital establishes and
implements a process for how nutrition
products requiring special
considerations are stored.
implements a process for how
radioactive, investigational, and similar
medications are stored. (Also see
FMS.5) ME 3. The hospital establishes
and implements a process for how
sample medications are stored and
controlled.
medications brought in by the patient
are identified and stored.
NA
MOM 11 a.c
NA
NA
Standard MMU.3.2
Emergency medications
are available, monitored,
and safe when stored out
of the pharmacy. ℗
ME 1. Emergency medications are
available in the units where they will be
needed or are readily accessible within
the hospital to meet emergency needs.
(Also see MMU.2)
emergency medications are
stored,maintained, and protected from
loss or theft.
ME 3. Emergency medications are
monitored and replaced in a timely
manner after use or when expired or
damaged.
MOM 3 - e, f, g
MOM 3.b.e,
NA
Standard MMU.3.3
The hospital has a
ME 1. There is a medication recall MOM 5 b
31 | P a g e

medication recall
system. ℗
system in place.
implements a process for use of
medications known to be expired or
outdated.
implements a process for the
destruction of medications known to be
expired or outdated.
NA
NA
Standard MMU.4
Prescribing, ordering,
and transcribing are
guided by policies and
procedures. ℗
implements a process for the safe
prescribing, ordering, and transcribing
of medications in the hospital.
implements a process for managing
illegible prescriptions and orders,
including measures to prevent
continued occurrence.
ME 3. Staff are trained in correct
prescribing, ordering, and transcribing
processes.
ME 4. Patient records contain a list of
current medications taken prior to
admission, and this information is made
available to the pharmacy and the
patient’s health care practitioners.
ME 5. Initial medication orders are
compared to the list of medications
taken prior to admission, according to
the hospital’s established process.
MOM 4 - a, b,h
NA
NA
NA
NA
PATIENT AND FAMILY RIGHTS
32 | P a g e

Standard PFR.1
The hospital is
responsible for
providing processes that
support patients’ and
families’ rights during
care. ℗
Measurable Elements of PFR.1
ME 1. Hospital leadership works to protect
and to advance patient and family rights.
ME 2. Hospital leadership understands
patient and family rights as identified in
laws and regulations and in
relation to the cultural practices of the
community or individual patients served.
ME 3. The hospital respects the right of
patients, and in some circumstances the
right of the patient’s family,
to have the prerogative to determine what
information regarding their care would be
provided to family
or others, and under what circumstances.
ME 4. All staff are knowledgeable about
patient rights and can explain their
responsibilities in protecting
patient rights.
PRE.1.A
N/A
PRE 3.a.b.c
PRE.1.d
Standard PFR.1.3
The patient’s rights to
privacy and confidentiality
of care and information are
respected.
Measurable Elements of PFR.1.3
ME 1. Staff members identify patient
expectations and needs for privacy
during care and treatment.
ME 2. A patient’s expressed need for
privacy is respected for all clinical
interviews, examinations,
procedures/treatments, and transport.
ME 3. Confidentiality of patient
information is maintained according to
laws and regulations. (Also see MOI.2
and MOI.7)
ME 4. Patients are requested to grant
permission for the release of
information not covered by laws and
regulations.
PRE.2.b
PRE.2.b
PRE.2.d
N/A
33 | P a g e

Standard PFR.3
The hospital informs
patients and families
about its process to
receive and to act on
complaints, conflicts,
and
differences of opinion
about patient care and
the patient’s right to
participate in these
processes. ℗
Measurable Elements of PFR.3
ME 1. Patients are informed about the
process for voicing complaints,
conflicts, and differences of opinion.
ME 2. Complaints, conflicts, and
differences of opinion are investigated
by the hospital.
ME 3. Complaints, conflicts, and
differences of opinion that arise during
the care process are resolved.
ME 4. Patients and families participate
in the resolution process.
PRE 7.b
PRE 7.c
PRE 7.d
NA
Standard PFR.5.1
Patient informed consent
is obtained through a
process defined by the
hospital and carried out
by trained staff in
a manner and language
the patient can
understand. ℗
Measurable Elements of PFR.5.1
ME 1. The hospital develops and
implements a clearly defined informed
consent process.
ME 2. Designated staff are trained in the
process
ME 3. Patients learn about the process
for granting informed consent in a
manner and language that the
patient understands.
ME 4. Patients give informed consent
consistent with the process.
ME 5. There is a uniform recording of
informed consent.
PRE 4.a
NA
PRE 4.d
PRE 4.d
PRE 4.a
34 | P a g e

ANESTHESIA AND SURGICAL
CARE
Standard ASC.3
The administration of
procedural sedation is
standardized throughout
the hospital. ℗
Measurable Elements of ASC.3
ME 1. The administration of procedural
sedation is standardized throughout the
hospital.
ME 2. Standardization of procedural
COP 12.a
35 | P a g e

sedation includes identifying and
addressing at least a) through e) in the
intent.
ME 3. Emergency medical technology
and supplies are readily available and
customized to the type of sedation
being performed and the age and
medical condition of the patient.
ME 4. An individual with advanced life-
support training must be immediately
available when procedural
sedation is being performed. (Also see
COP.3.2)
COP 12.a
NA
NA
Standard ASC.3.1
Practitioners responsible
for procedural sedation
and individuals
responsible for
monitoring patients
receiving
sedation are qualified. ℗
Measurable Elements of ASC.3.1
ME 1. Health care practitioners
responsible for providing procedural
sedation are competent in at least a)
through d) of the intent.
ME 2. The individual responsible for
patient monitoring during procedural
sedation is competent in at least
elements e) through h) in the intent.
ME 3. Procedural sedation
competencies for all staff involved in
sedation are documented in the
personnel files.
COP 12.c
COP 12.c
HRM 8.b
HRM 9.d
Standard ASC.3.2
Procedural sedation is
administered and
monitored according to
professional practice
guidelines. ℗
Measurable Elements of ASC.3.2
ME 1. There is a presedation
assessment performed and
documented that includes at least a)
through e) to
evaluate risk and appropriateness of
procedural sedation for the patient.
(Also see AOP.1, MEs 1 and 2)
ME 2. A qualified individual monitors
the patient during the period of sedation
and documents the
monitoring.
ME 3 Established criteria are used and
documented for the recovery and
discharge from procedural sedation.
COP 12.a
COP 12.d
COP 12.g
International Patient Safety Goals
Standard IPSG.1
The hospital develops
and implements a
process to improve
Measurable Elements of IPSG.1
ME 1. Patients are identified using two
patient identifiers, not including the use NA
36 | P a g e

accuracy of patient
identifications. ℗
of the patient’s room number
or location.
ME 2. Patients are identified before
providing treatments and procedures.
ME 3. Patients are identified before any
diagnostic procedures. (Also see
AOP.5.7, ME 2)
NA
NA
Standard IPSG.2
and implements a
process to improve the
effectiveness of verbal
and/or telephone
communication among
caregivers. ℗
ME 1. The complete verbal order is
documented and read back by the
receiver and confirmed by the
individual giving the order.
ME 2. The complete telephone order is
receiver and confirmed by the
individual giving the order.
ME 3. The complete test result is
receiver and confirmed by the individual
giving the result.
MOM.4.i
MOM.4.i
MOM.4.i
Standard IPSG.3
and implements a
process to improve the
safety of high-alert
medications. ℗
ME 1. The hospital has a list of all high-
alert medications, including look-
alike/sound-alike medications, that is
developed from hospital-specific data.
ME 2. The hospital implements
strategies to improve the safety of high-
alert medications, which may include
specific storage, prescribing,
preparation, administration, or
monitoring processes.
ME 3. The location, labeling, and
storage of high-alert medications,
including look-alike/sound-alike
medications, is uniform throughout the
hospital.
MOM.4.j
MOM 3.b
MOM 3.d
MOM 3.b
MOM 3.d
Standard IPSG.4
and implements a
process for ensuring
correct-site, correct-
ME 1. The hospital uses an instantly
recognizable mark for surgical- and
invasive procedure–site identification
COP.6.c
37 | P a g e

procedure, and
correct-patient surgery.
℗
that is consistent throughout the
hospital.
ME 2. Surgical- and invasive procedure–
site marking is done by the person
performing the procedure.
ME 3. The hospital uses a checklist or
other process to document, before the
procedure, that the informed
consent is appropriate to the
procedure; that the correct site, correct
procedure, and correct patient are
identified; and that all documents and
medical technology needed are on
hand, correct, and functional.
COP 14.d
NA
NA
Standard IPSG.5
The hospital adopts and
implements evidence-
based hand-hygiene
guidelines to reduce the
risk of health
care–associated
infections. ℗
ME 1. The hospital has adopted
currently published, evidence-based
hand-hygiene guidelines.
ME 2. The hospital implements an
effective hand-hygiene program
throughout the hospital.
ME 3. Hand-washing and hand-
disinfection procedures are used in
accordance with hand-hygiene
guidelines throughout the hospital.
HIC 2.c.
HIC.2.c
HIC.2.c.
Standard IPSG.6
and implements a
process to reduce the
risk of patient harm
resulting from falls. ℗
ME 1. The hospital implements a
process for assessing all inpatients and
those outpatients whose condition,
diagnosis, situation, or location
identifies them as at high risk for falls.
ME 2. The hospital implements a
process for the initial and ongoing
assessment, reassessment, and
intervention of inpatients and
outpatients identified as at risk for falls
based on documented criteria.
ME 3. Measures are implemented to
reduce fall risk for those identified
patients, situations, and locations
assessed to be at risk.
COP.9.a
COP.9.c
COP.9.a
COP.9.c
COP.9.e
STAFF QUALIFICATION AND EDUCATION
38 | P a g e

Standard SQE.1.1
Each staff member’s
responsibilities are
defined in a current job
description.℗
Measurable Elements of SQE.1.1
ME 1. Each staff member not permitted
to practice independently has a job
description.
ME 2. Those individuals identified in a)
through d) in the intent, when present in
the hospital, have job
descriptions appropriate to their
activities and responsibilities or have
been privileged if noted as an
alternative. (Also see AOP.3, ME 1)
ME 3. Job descriptions are current
according to hospital policy
HRM 1.C ,
HMB 1.C
HRM 1.c
Standard SQE.5
There is documented
personnel information
for each staff member.℗
Measurable Elements of SQE.5
ME 1. Personnel files for each staff
member are standardized and current
and maintained according to
hospital policy.
ME 2. Personnel files contain the
qualifications of the staff member.
ME 3. Personnel files contain the job
description of the staff member when
applicable.
ME 4. Personnel files contain the work
history of the staff member.
results of evaluations.
ME 6. Personnel files contain a record
of in-service education attended by the
staff member.
HRM.8.a,
HRM 8.b,
NA
NA
HRM 8.d
HRM 8.6
39 | P a g e

Standard SQE.5
There is documented
personnel information
for each staff member.℗
ME 1. Personnel files for each staff
member are standardized and current
and maintained according to
hospital policy.
qualifications of the staff member.
ME 3. Personnel files contain the job
description of the staff member when
applicable.
ME 4. Personnel files contain the work
history of the staff member.
results of evaluations.
ME 6. Personnel files contain a record
of in-service education attended by the
staff member.
HRM.8.a,
HRM 8.b
NA
NA,
HRM 8.d
HRM 8.6
Standard SQE.6
A staffing strategy for
the hospital, developed
by the leaders of
hospital departments
and services, identifies
the
number, types, and
desired qualifications of
staff. ℗
ME 1. The hospital’s department/service
leaders develop a written strategy for
staffing the hospital in a
manner that complies with local laws
and regulations.
ME 2. The number, types, and desired
qualifications of staff are identified in
the strategy using a recognized
staffing method. (Also see AOP.6.2, ME
5)
ME 3. The strategy addresses the
assignment and reassignment of staff.
NA
NA
NA
40 | P a g e

Standard SQE.8.2
The hospital provides a
staff health and safety
program. ℗
Measurable Elements of SQE.8.2
ME 1. The hospital provides, and
incorporates into the hospital quality
and safety program, a staff health and
safety program that is responsive to
urgent and nonurgent staff needs
through direct treatment and
referral.
ME 2. The hospital identifies
epidemiologically significant infections,
as well as staff that are at high risk for
exposure to and transmission of
infections, and implements a staff
vaccination and immunization
program.
ME 3. The hospital provides evaluation,
counseling, and follow-up of staff
exposed to infectious diseases that
is coordinated with the infection
prevention and control program.
result of workplace violence.
HRM.7.b,
HIC 5.d
HIC 5.d
ME 4. The hospital identifies areas for
potential workplace violence and
implements measures to reduce the
risk.
ME 5. The hospital provides evaluation,
counseling, and follow-up treatment of
staff who are injured as a
NA
NA
41 | P a g e

FACILITY MANAGEMENT AND SAFETY
Standard FMS.2
and maintains a written
program(s) describing
the processes to manage
risks to patients,
families, visitors, and
staff. ℗
Measurable Elements of FMS.2
ME 1. There are written programs that
address the risk areas a) through f) in
the intent.
ME 2. The programs are current and are
fully implemented.
ME 3. The hospital has a process to
review and to update the program(s)
when changes in the hospital’s
environment occur or at a minimum, on
an annual basis.
ME 4. When independent entities are
present within the patient care facilities
to be surveyed, the hospital
ensures that the entities comply with all
aspects of the facility management
programs identified in a)
through d) of the intent.
FMS 3. a to e
FMS 3. a to e
NA
NA
Standard FMS.4
The hospital plans and
implements a program to
provide a safe physical
facility through
inspection and planning
to reduce risks. ℗
ME 1. The hospital has a program to
provide a safe physical facility.
ME 2. The hospital has a documented,
current, accurate inspection of its
physical facilities.
ME 3. The program includes assessing
safety and security during times of
construction and renovation and
implementing strategies to reduce risks.
(Also see PCI.7.5)
FMS.1.a
FMS.1.d
N.A.
Standard FMS.4.1
The hospital plans and
implements a program to
provide a secure
environment for patients,
families, staff, and
visitors. ℗
Measurable Elements of FMS.4.1
ME 1. The hospital has a program to
provide a secure environment,
including monitoring and securing
areas identified as security risks. (Also
see AOP.5.3 and AOP.6.3)
ME 2. The program ensures that all
staff, contract workers, and vendors are
identified.
ME 3. All security risk areas and
restricted areas are identified,
documented, monitored, and kept
secure.
N.A.
N.A
N.A.
42 | P a g e

Standard FMS.6
The hospital develops,
maintains, and tests an
emergency management
program to respond to
emergencies,
epidemics, and natural
or other disasters that
have the potential of
occurring within their
community. ℗
ME 1. The hospital has identified the
major internal and external disasters,
such as community emergencies,
epidemics, and natural or other
disasters, as well as major epidemic
events that pose significant risks of
occurring, taking into consideration the
hospital’s geographic location.
ME 2. The hospital identifies the
probable impact that each type of
disaster will have on all aspects of care
and
services.
implements a disaster program that
identifies its response to likely
disasters, including items a) through g)
in the intent.
ME 4. The entire program, or at least
critical elements c) through g) of the
program, is tested annually.
ME 5. At the conclusion of every test,
debriefing of the test is conducted.
FMS 7.a
FMS.7.a
FMS.7.b
F.M.S.7.e. (*)
FMS 7. e
Standard FMS.7
The hospital establishes
and implements a
program for the
prevention, early
detection, suppression,
abatement,
and safe exit from the
facility in response to
fires and nonfire
emergencies. ℗
implements a program to ensure that all
occupants of the hospital’s
facilities are safe from fire, smoke, or
other nonfire emergencies.
ME 2. The program includes the
documented assessment of fire risks,
including when construction is present
in or adjacent to the facility.
ME 3. The program includes the early
detection of fire and smoke.
ME 4. The program includes the
abatement of fire and containment of
smoke.
ME 5. The program includes the safe
exit from the facility when fire and
nonfire emergencies occur.
F.M.S.6.a
FMS 6.a
FMS.6.a
FMS.6.b
FMS.6.b
43 | P a g e

PREVENTION AND CONTROL OF INFECTIONS
Standard PCI.5
The hospital designs and
implements a
comprehensive program
to reduce the risks of
health care–associated
infections in patients
and health care workers.
℗
Measurable Elements of PCI.5
ME 1. There is a comprehensive
program that crosses all levels of the
hospital, to reduce the risk of health
care–associated infections in patients.
ME 2. There is a comprehensive
program that crosses all levels of the
hospital to reduce the risk of health
care–associated infections in health
care workers. (Also see SQE.8.2)
ME 3. The program incorporates a range
of strategies that includes systematic
and proactive surveillance
activities to determine usual (endemic)
rates of infection.
HIC 4.a.b.c.d.
HIC 5. a.b.c.d
HIC 3.a.b.c.d.e.f.h
ME 4. The program includes systems to
investigate outbreaks of infectious
diseases.
ME 5. Risk-reduction goals and
measurable objectives are established
and reviewed.
HIC 6.a.b.c.d
NA
Standard PCI.6
The hospital uses a risk-
based approach in
establishing the focus of
the health care–
associated infection
prevention and reduction
program. ℗
ME 1. The hospital has established the
focus of the program through the
collection of data related to a)
through f) in the intent.
ME 2. The data collected in a) through
f) are analyzed to identify priorities for
reducing rates of infection.
HIC 3.b
HIC 3.d
44 | P a g e

ME 3. Infection control strategies are
implemented to reduce the rates of
infection for the identified priorities.
HIC 2.a
HIC 3.e.f.
Standard PCI.7
The hospital identifies
the procedures and
processes associated
with the risk of infection
and implements
strategies to reduce
infection risk. ℗
ME 1. The hospital has identified those
processes associated with infection
risk. (Also see MMU.5, ME 1)
ME 2. The hospital has implemented
strategies, education, and evidence-
based activities to reduce infection
risk in those processes.
ME 3. The hospital identifies which risks
require policies and/or procedures, staff
education, practice
changes, and other activities to support
risk reduction.
HIC 3.a
NA
NA
Standard PCI.7.3
The hospital implements
practices for safe
handling and disposal of
sharps and needles. ℗
Measurable Elements of PCI.7.3
ME 1. The hospital identifies and
implements practices to reduce the risk
of injury and infection from the
handling and management of sharps
and needles.
ME 2. Sharps and needles are collected
in dedicated, closable, puncture-proof,
leakproof containers that are
not reused.
ME 3. The hospital disposes of sharps
and needles safely or contracts with
sources that ensure the proper
disposal of sharps containers in
dedicated hazardous waste sites or as
determined by national laws and
regulations.
HIC 5.d.
HIC 8.c
HIC 8.b.c
HIC 8.a.b.c.d
45 | P a g e

Standard PCI.8
The hospital provides
barrier precautions and
isolation procedures that
protect patients, visitors,
and staff from
communicable diseases
and protects
immunosuppressed
patients from acquiring
infections to which they
are uniquely prone. ℗
ME 1. Patients with known or suspected
contagious diseases are isolated in
accordance with recommended
guidelines. (Also see ACC.6)
ME 2. Patients with communicable
diseases are separated from patients
and staff who are at greater risk due to
immunosuppression or other reasons.
ME 3. Negative-pressure rooms are
monitored routinely and available for
infectious patients who require
isolation for airborne infections; when
negative-pressure rooms are not
immediately available, rooms
with HEPA filtration systems with a
minimum of 12 air changes per hour
may be used.
ME 4. Cleaning of infectious rooms
during the patient’s hospitalization and
after discharge follow infection
control guidelines.
HIC 2.e
HIC 5.c
HIC 2.e
HIC 5.c
NA
Standard PCI.8.1
and implements a
process to manage a
sudden influx of patients
with airborne infections
and when negative-
pressure rooms are not
available. ℗
Measurable Elements of PCI.8.1
implements a process to address
managing patients with airborne
infections
for short periods of time when negative-
pressure rooms are not available.
implements a process for managing an
influx of patients with contagious
diseases.
ME 3. Staff are educated in the
management of infectious patients
when there is a sudden influx or when
negative-pressure rooms are not
HIC 5.c
NA
HIC 9.d
46 | P a g e

available.
MANAGEMENT OF
INFORMATION
STANDARD MEASURABLE ELEMENTS NABH 3rd Edition standard
Standard MOI.2
Information privacy,
confidentiality, and
security including data
integrity are maintained.
℗
Measurable Elements of MOI.2
ME 1. The hospital has a written
process that protects the
confidentiality, security, and integrity of
data and
information.
ME 2. The process is based on and
consistent with laws and regulations.
ME 3. The process identifies the level of
confidentiality maintained for different
categories of data and
information.
ME 4. Those persons who need or have
a job position permitting access to each
category of data and information are
identified.
ME 5. Compliance with the process is
monitored.
IMS 5.a
IMS 5.b
IMS 5.a.c
IMS 3.b
NA
Standard MOI.3
The hospital determines
47 | P a g e

the retention time of
records, data, and
information. ℗
ME 1. The hospital determines the
retention time of patient clinical records
and other data and information.
ME 2. The retention process provides
expected confidentiality and security.
ME 3. Records, data, and information
are destroyed in a manner that does not
compromise confidentiality and
security.
IMS 6.a
IMS 6.c
IMS 6.d
Standard MOI.5
The data and information
needs of those in and
outside the hospital are
met on a timely basis in a
format that
meets user expectations
and with the desired
frequency.
ME 1. Data and information
dissemination meet user needs.
ME 2. Users receive data and
information on a timely basis.
ME 3. Users receive data and
information in a format that aids its
intended use.
IMS 1.b
IMS 1.b
IMS 2.a
STANDARD MEASURABLE ELEMENTS NABH 3rd Edition standard
Standard MOI.10
The hospital initiates and
maintains a standardized
clinical record for every
patient assessed or
treated and
determines the record’s
content, format, and
location of entries. ℗
ME 1. A clinical record is initiated for
every patient assessed or treated by the
hospital.
ME 2. Patient clinical records are
maintained through the use of an
identifier unique to the patient or some
other effective method.
ME 3. The specific content, format, and
location of entries for patient clinical
records is standardized and
determined by the hospital.
IMS 3.a
CQI 2.j
IMS 3.e
Standard MOI.10.1
The clinical record
contains sufficient
information to identify
the patient, to support
the diagnosis, to justify
the
treatment, and to
document the course
and results of treatment.
Measurable Elements of MOI.10.1
ME 1. Patient clinical records contain
adequate information to identify the
patient.
adequate information to support the
diagnosis. (Also see AOP.1.1)
ME 3. Patient clinical records contain n
adequate information to justify the care
and treatment. (Also see
AOP.1.2)
CQI 2.j
IMS 3.a
NA
NA
48 | P a g e

adequate information to document the
course and results of treatment.
(Also see COP.2.1, ME 6; COP.3, ME 2;
ASC.5; and ASC.7)
NA
QUALITY IMPROVEMENT AND PATIENT SAFETY
STANDARD MEASURABLE ELEMENTS
NABH STANDARDS 3RD
EDITION
49 | P a g e

Standard QPS.1
A qualified individual guides
the implementation of the
hospital’s program for quality
improvement and patient
safety and manages the
activities needed to carry out
an effective program of
continuous quality
improvement
and patient safety within the
hospital. ℗
Measurable Elements of QPS.1
ME 1. An individual(s) who is
experienced in the methods and
processes of improvement is
selected to guide the implementation
of the hospital’s quality and patient
safety program.
ME 2. The individual(s) with
oversight for the quality program
selects and supports qualified staff
for the
program and supports those staff
with quality and patient safety
responsibilities throughout the
hospital. (Also see SQE.1)
ME 3. The quality program provides
supp ort and coordination to
department/service leaders for like
measures across the hospital and for
the hospital’s priorities for
improvement. (Also see GLD.11)
CQI 1.c
CQI 2.e
CQI 1.c
CQI 2.e
CQI 1.d
ME 4. The quality program
implements a training program for all
staff that is consistent with staff’s
roles in
the quality improvement and patient
safety program. (Also see SQE.14.1,
ME 1 and SQE.16.1, ME 1)
ME 5. The quality program is
responsible for the regular
communication of quality issues to
all staff
CQI 1.e
CQI 2.f
CQI 1.e
CQI 2.f
NABH STANDARDS 3RD
EDITION
50 | P a g e

Standard QPS.6
The hospital uses an internal
process to validate data. ℗
ME 1. Data validation is used by
the quality program as a
component of the improvement
process selected by
leadership.
ME 2. Data are validated when any
of the conditions noted in a)
through f) in the intent are met.
ME 3. An established
methodology for data validation is
used.
ME 4. Hospital leadership
assumes accountability for the
validity of the quality and
outcome data made public.
(Also see GLD.3.1, ME 3)
NA
NA
NA
NA
Standard QPS.7
The hospital uses a defined
process for identifying and
managing sentinel events ℗
ME 1. Hospital leadership has
established a definition of a
sentinel event that at least
includes a) through f)
found in the intent.
ME 2. The hospital completes a
root cause analysis of all sentinel
events in a time period specified
by hospital
leadership that does not exceed
45 days from the date of the event
or when made aware of the event.
ME 3. Hospital leadership takes
action on the results of the root
cause analysis.
CQI 8.a
CQI 8.c
CQI 8.d
Standard QPS.8
Data are always analyzed when
undesirable trends and
variation are evident from the
data. ℗
ME 1. Intense analysis of data
takes place when adverse levels,
patterns, or trends occur.
ME 2. All confirmed transfusion
reactions, if applicable to the
hospital, are analyzed. (Also see
COP.3.3)
ME 3. All serious adverse drug
events, if applicable and as
CQI 7 - c
CQI 3.k
MOM 8.d
51 | P a g e

defined by the hospital, are
analyzed. (Also see
MMU.7)
ME 4. All significant medication
errors, if applicable and as
defined by the hospital, are
analyzed. (Also see
MMU.7.1)
ME 5. All major discrepancies
between preoperative and
postoperative diagnoses are
analyzed. (Also see
ASC.7.2)
MOM 8.d
NA
ME 6. Adverse events or patterns
of adverse events during
moderate or deep sedation and
anesthesia use are
analyzed. (Also see ASC.3.2 and
ASC.5)
ME 7. Other adverse events
defined by the hospital are
analyzed
CQI 3.k
CQI 7.c
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GOVERNANCE, LEADERSHIP AND DIRECTION
NABH STANDARDS 3RD
EDITION
Standard GLD.1
Governance structure and
authority are described in
bylaws, policies and
procedures, or similar
documents. ℗
Measurable Elements of GLD.1
ME 1. The hospital’s governance
structure is described in a written
document(s), and those
responsible for governance of the
hospital are identified by name
and governance function.
ME 2. Governance responsibilities
and accountabilities are described
in the document(s).
ME 3. The document(s) describes
how the governing entity will be
evaluated and the criteria
approved for the
evaluation process.
ME 4. There is an annual
evaluation conducted of the
governing entity, and the results
are documente
ME 5. The document(s) describes
when and how governance and
senior management authority can
be delegated.
NA
ROMA 1. A to I
NA
NA
NA
Standard GLD.1.2
Those responsible for
governance approve the
hospital’s program for quality
and patient safety and regularly
receive and act on reports of
the quality and patient safety
program. ℗
Measurable Elements of GLD.1.2
ME 1. Those responsible for
governance annually approve the
hospital’s program for quality and
patient
safety.
ME 2. Those responsible for
governance at least quarterly
receive and act on reports of the
quality and patient
safety program, including reports
of adverse and sentinel events.
(Also see QPS.4.1, ME 5)
ME 3. Minutes reflect actions
taken and any follow-up on those
actions.
ROM 1.f
NA
NA
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NABH STANDARDS 3RD
EDITION
Standard GLD.2
A chief executive(s) is
responsible for operating the
hospital and complying with
applicable laws
and regulations. ℗
ME 1. The education and
experience of the chief
executive(s) match the
requirements in the position
description.
ME 2. The chief executive(s)
manages the hospital’s day-to-day
operations, including those
responsibilities
described in the position
description.
recommends policies, strategic
plans, and budgets to the
governing body.
ensures compliance with
approved policies.
ensures compliance with
applicable laws and regulations.
responds to any reports from
inspecting and regulatory
agencies.
NA
NA
NA
NA
ROM 2.a
NA
Standard GLD.3.2
Hospital leadership ensures
effective communication
throughout the hospital. ℗
ME 1. Hospital leadership ensures
that processes are in place for
communicating relevant
information
throughout the hospital in a timely
manner.
ME 2. Hospital leadership ensures
effective communication among
clinical and nonclinical
departments,
services, and individual staff
members.
NA
NA
ROM 4.a
54 | P a g e

communicates the hospital’s
vision, mission, goals, policies,
and plans to staff.
NABH STANDARDS 3RD
EDITION
Standard GLD.6
Hospital leadership is
accountable for the review,
selection, and monitoring of
clinical or nonclinical
contracts. ℗
ME 1. Hospital leadership is
accountable for contracts to meet
patient and management needs.
ME 2. The hospital has a written
description of the nature and
scope of those services to be
provided through contractual
agreements.
ME 3. Health professional staff
contracts require credential
review comparable to the
hospital’s review process.
ME 4. Department/service leaders
share accountability for the
review, selection, and monitoring
of clinical
and nonclinical contracts. (Also
see AOP.5.1, ME 5 and AOP.6.1,
ME 5)
ME 5. When contracts are
renegotiated or terminated, the
hospital maintains the continuity
of patient services.
NA
NA
NA
ROM 5.k
NA
Standard GLD.10
Each department/service leader
identifies, in writing, the
services to be provided by the
department, and
integrates or coordinates those
services with the services of
other departments. ℗
ME 1. Department/service leaders
have selected and use a uniform
format and content for planning
documents.
ME 2. The departmental or service
documents describe the current
and planned services provided by
each
department or service.
NA
ROM 3.a.
ROM 3.a.b
55 | P a g e

documents guide the provision of
identified services.
documents address the staff
knowledge and skills needed to
assess and to
meet patient needs.
ME 5. There is coordination and/or
integration of services within and
with other departments and
services.
ROM 3.a.b
NA
NABH STANDARDS 3RD
EDITION
Standard GLD.12
The hospital’s framework for
ethical management addresses
operational and business
issues, including
marketing, admissions,
transfer, discharge, and
disclosure of ownership and
any business and professional
conflicts that may not be in
patients’ best interests. ℗
establishes a framework for the
hospital’s ethical management
that promotes a
culture of ethical practices and
decision making to ensure the
protection of patients and their
rights.
ME 2. The ethical framework
ensures that patient care is
provided within business,
financial, ethical, and legal
norms.
ME 3. The hospital ensures
nondiscrimination in employment
practices and provision of patient
care in the
context of the cultural and
regulatory norms of the country.
examines national and
international ethical norms for
incorporation when
developing the hospital’s
framework for ethical conduct
ROM 4.b
ROM 4.b
NA
ROM 4.b
Standard GLD.12.1
Hospital leadership establishes
a framework for ethical
management that promotes a
culture of ethical practices
and decision making to ensure
that patient care is provided
within business, financial,
ME 1. The hospital discloses its
ownership and any conflicts of
interest. (Also see AOP.5, ME 5
and AOP.6,
ME 5)
ME 2. The hospital honestly
portrays its services to patients.
NA
ROM 4.d
56 | P a g e

ethical, and legal norms
and protects patients and their
rights. ℗
ME 3. The hospital accurately bills
for services and ensures that
financial incentives and payment
arrangements do not compromise
patient care.
ROM 4.f
FINDINGS
This report provides an analysis, evaluation and comparison study of the JCI and
NABH. Results of standards comparison show that some of the policies are not
there and most of them needed to improve. In particular, comparative
performance is poor in the areas of Patient care, Nursing care, Hospital leadership
procedure, and biomedical waste management.
The report finds the prospects of the company in its current position are not
positive. The major areas of weakness require further investigation and remedial
action by management.
1. There are some existing policies which are equivalent to JCI as
this hospital is already accredited by NABH.
2. There are some policies which are needed to improve to reach
and complete the JCI criteria.
3. There are policies which are not yet implemented or exist. Those
policies needed to create.
4. There are some policies which are NOT APPLICABLE for the
prior hospital.
57 | P a g e

CONCLUSIONS
Not all the documents and policies are available in the
hospital. Improvements in every area of the company are
needed if the company is, in the first instance, to survive and
then grow. The key areas of reform are the liquidity of the
company and the quantity and quality of patient service
areas. Management must address these areas simultaneously
if the company is to overcome its present poor record.
Limitations
It must be remembered that this analysis is limited: a
greater depth of understanding and evaluation can only occur
with utilization of other resource. Only after this process can
a full appreciation of the company’s current situation and
possible future occur.
58 | P a g e

Prospects
At this point the company does not have strong future
prospects in the areas improvement if it continues on its
current path.
BIBLIOGRAPHY
Www. Google.com
www.jointcommissioninternational.org
www.slideshare.com
www.nabh.co
59 | P a g e

FINAL PROJECT OF JCI DOCUMENTATION

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