Changes in Clinical

Standards -
NABH
4th Edition 2016

Dr. A. L. Basile MS
Co Chair Technical Committee, NABH.
Medical Director, Star Hospitals.
Consultant Ophthalmolgist
Section I:
Patient-Centered Standards

3rd 4th
Access, Assessment and edition edition
Continuity of Care (AAC) 14/86 14/96

2
 3rd Edition 4th Edition
Stand
Standard ard
AAC NUMBER OE NUMB
SCOPE 1 3 AAC ER OE
REGISTRATION & SCOPE 1 4
ADMISSION 2 6 REGISTRATION &
ADMISSION 2 7
TRANSFER & REFERRAL 3 5
TRANSFER & REFERRAL 3 5
INITIAL ASSESSMENT 4 10 INITIAL ASSESSMENT 4 9
REASSESSMENT 5 5 REASSESSMENT 5 6
LAB 6 8 LAB 6 10
LAB QA 7 5
LAB QA 7 5 LAB SAFETY 8 5
LAB SAFETY 8 5 IMAGING 9 10
IMAGING 9 9 IMAGING QA 10 6
IMAGING SAFETY 11 8
IMAGING QA 10 5
CONTINUOUS/MULTIDISCIP
IMAGING SAFETY 11 7 LINARY CARE 12 9
CONTINUOUS/MULTIDIS DISCHARGE PROCESS 13 5
CIPLINARY CARE 12 7 DISCHARGE SUMMARY 14 7
DISCHARGE PROCESS 13 4 TOTAL 14 96
DISCHARGE SUMMARY 14 7
TOTAL 14 86
3
Overall Impact of improvements:
AAC
Each Service in the scope should be justifiable
appropriate diagnostics and treatment facilities
suitably qualified personnel
out-patient, in-patient and emergency cover
Display not in scope
Imaging services
Screening of Patients
Peer review
Surveillance methodology
Overall Impact of improvements:
AAC
Equipment and Manpower of pathology & radiology
depts
Adequacy
Actions on critical results
Lab and Imaging
Focus on response
Critical results of outsourced services
Addressing of reporting errors
Amend or recall
Structured handovers
Transitions of care
Overall Impact of improvements:
AAC
Care Plan to reflect the desired outcome.
Coordination of care: timelines
Monitoring
Acting on delays
Informing stakeholders
Access is prioritized
More sick patients are seen earlier.
Early warning system
Time taken for discharge
Monitor timelines
Section I:
Patient-Centered Standards

3rd 4th
edition edition
Care of Patients (COP) 20/136 22/149

7
 3rd Edition 4th Edition
COP Stand OE
COP Standard OE
ard
NUMBER
NUMB
UNIFORM CARE 1 4 ER
UNIFORM CARE, LAWS, 1 4
EMERGENCY SERVICES 2 7
REGULATIONS &
AMBULANCE SERVICES 3 8 GUIDELINES
EMERGENCY SERVICES 2 10
CARDIO PULMONARY 4 5 AMBULANCE SERVICES 3 9
RESUSCITATION HANDLING COMMUNITY 4 5
EMERGENCIES, EPIDEMICS
NURSING CARE 5 7
AND OTHER DISASTERS
VARIOUS PROCEDURES 6 7 CARDIO PULMONARY 5 5
RATIONAL USE OF BLOOD & 7 8 RESUSCITATION
BLOOD PRODUCTS DOCUMENTED POLICIES 6 7
and PROCEDURES GUIDE
INTENSIVE CARE & HIGH 8 7 NURSING CARE
DEPENDENCY UNITS Documented procedures 7 7
guide the performance of
VULNERABLE PATIENTS 9 5
various procedures.
OBSTETRIC CARE 10 7 RATIONAL USE OF BLOOD 8 8
PAEDIATRIC SERVICES 11 8 & BLOOD PRODUCTS
INTENSIVE CARE & HIGH 9 8
MODERATE SEDATION 12 8 DEPENDENCY UNITS
VULNERABLE PATIENTS 10 5
ADMINISTRTAION OF 13 11 HIGH RISK OBSTETRIC CARE 11 7
ANESTHESIA
8
 4th Edition
COP Standa OE
3rd Edition rd
NUMBE
Standard R
COP NUMBER OE PAEDIATRIC SERVICES 12 8
SURGICAL PROCEDURES 14 11 MODERATE SEDATION 13 8
ADMINISTRTAION OF 14 11
RESTRAINTS 15 5 ANESTHESIA
SURGICAL PROCEDURES 15 11
PAIN MANAGEMENT 16 5 ORGAN TRANSPLANT 16 4
PROGRAM
REHABILITATIVE SERVICES 17 6 RESTRAINTS 17 5
PAIN MANAGEMENT 18 4
RESEARCH ACTIVITIES 18 6 REHABILITATIVE SERVICES 19 6
RESEARCH ACTIVITIES 20 6
NUTRITIONAL THERAPY 19 6 NUTRITIONAL THERAPY 21 6
END OF LIFE CARE 22 5
END OF LIFE CARE 20 5
TOTAL 22 149
TOTAL 20 136

9
Overall Impact of improvements:
COP

Emergency Department
- Access
- QA
- Brought in dead
- Communication with ambulance during
transit
Organ transplant
- Full standard
Monitoring of patients after procedures
Disaster Management
- Focus on role of Emergency services
- Patient care
Overall Impact of improvements:
COP
Counseling of patients on progress
- ICU setting
Clarity on informed consent when needed
repeatedly for Blood Transfusions
- Single consent with endorsements on repeat
Consent for Moderate sedation
Reason for restraint
Functional assessment (rehab)
- Reassessment
Pain alleviation
- Initiate and Titrate based on need
Section I:
Patient-Centered Standards

3rd 4th
edition edition
Management of Medication
13/73 13/76
(MOM)

12
 3rd Edition 4th Edition
Standar Standa
d
MOM rd
NUMBER OE
NUMB
ORGANIZATION & USAGE
OF PHARMACY 1 4
MOM ER OE
ORGANIZATION & USAGE
HOSPITAL FORMULARY 2 5 OF PHARMACY 1 4
STORAGE OF MEDICATION 3 7 HOSPITAL FORMULARY 2 5
PRESCRIPTIONS OF STORAGE OF MEDICATION 3 7
MEDICATIONS 4 12 PRESCRIPTIONS OF MEDICATIONS 4 13
SAFE DISPENSING OF SAFE DISPENSING OF
MEDICATIONS 5 6 MEDICATIONS 5 6
MEDICATION ADMNISTRATION 6 10
MEDICATION ADMINISTRATION 6 10 PATIENTS ARE MONITORED
PATIENT MONITORING 7 4 AFTER MEDICATION
NEAR MISSES, MEDICATION ADMINISTRATION 7 4
ERRORS, ADRs 8 5 NEAR MISSES, MEDICATION
NARCOTIC DRUGS & ERRORS ,ADVERSE DRUG
PSYCHOTROPIC SUBSTANCES 9 4 EVENTS ARE REPORTED &
CHEMOTHERAPEUTIC AGENTS 10 4 ANALYSED 8 5
RADIOACTIVE DRUGS 11 4 NARCOTIC DRUGS &
PSYCHOTROPIC SUBSTANCES 9 4
IMPLANTABLE PROSTHESIS &
MEDICAL DEVICES 12 4 CHEMOTHERAPEUTIC AGENTS 10 5
RADIOACTIVE DRUGS 11 4
MEDICAL SUPPLIES &
CONSUMABLES 13 4 IMPLANTABLE PROSTHESIS 12 4
TOTAL 13 73 MEDICAL GASES 13 5
TOTAL 13 76
13
Overall Impact of improvements:
MOM
Strengthening of Inventory management
- All areas in HCO
- Stock outs
Physician samples tracking and management
- Address safety in storage, usage and prevent
medication errors.
Prescriptions have to be in Capital letters
All areas in HCO

LASA drug list to be formed from formulary

Reconciliation of medications/orders at transitions
of care
Overall Impact of improvements:
MOM

Special training for chemo therapeutic drugs and

bio safety cabinets
Patient education for chemo drugs
Strengthen medication administration
Strengthen medical supplies
Section I:
Patient-Centered Standards

3rd 4th
edition edition
Patients Rights And
7/46 8/54
Education (PRE)

16
 4th Edition
Standa
3rd Edition rd
Standar PRE NUMBE
OE
d
NUMBE R
PRE R OE PROTECTION OF RIGHTS &
INFORMATION ABOUT 1 5
PROTECTION OF RIGHTS & RESPONSIBILITY OF CARE
INFORMATION ABOUT SUPPORTING INDIVIDUAL BELIEFS
2 11
RESPONSIBILITY OF CARE 1 5 & VALUES
INFORMED CONSENT 3 7
SUPPORTING INDIVIDUAL PATIENT AND/OR FAMILYS
BELIEFS & VALUES 2 10 CONSENT EXISTS FOR
MAKING INFORMED 4 8
EDUCATING PATIENT/ FAMILY
MEMBERS TO MAKE DECISION ABOUT THEIR
INFORMED DECISIONS 3 7 CARE
RIGHT TO INFORMATION &
INFORMED CONSENT 4 8 EDUCATION ABOUT HEALTHCARE 5 8
NEEDS
RIGHT TO INFORMATION & RIGHT TO INFORMATION ON
EXPECTED COSTS 6 4
EDUCATION ABOUT
HEALTHCARE NEEDS 5 8 PATIENTS FEEDBACK AND
RIGHT TO INFORMATION ON REDRESSAL OF 7 5
EXPECTED COSTS 6 4 COMPLAINTS.
EFFECTIVE
COMPLAINT REDRESSAL COMMUNICATION WITH 8 6
PROCESS 7 4
PATIENTS AND /OR FAMILIES
TOTAL 7 46 TOTAL 8 54
17
Overall Impact of improvements:
PRE
Patient right to get another opinion
- Respect and facilitate the right
New standard on communication
Acceptable and effective communication
Communication in specific situation
Avoiding and identifying unacceptable
communication
Stress on capturing patient experience in addition
to feedback
Patient educational need identification and
addressing it
Section I:
Patient-Centered Standards

3rd 4th
edition edition
Hospital Infection control
9/51 9/54
(HIC)

19
 3rd Edition 4th Edition
Standar Stand
d
ard
NUMBE
HIC R OE NUMB
HIC ER OE
HOSPITAL INFECTION HOSPITAL INFECTION CONTROL
CONTROL PROGRAMME 1 6 PROGRAMME 1 6
INFECTION CONTROL MANUAL 2 11 INFECTION CONTROL MANUAL 2 12
SURVEILLANCE ACTIVTIES 3 8
SURVEILLANCE ACTIVTIES 3 9
HOSPITAL ASSOCIATED
INFECTIONS 4 4 HOSPITAL ASSOCIATED
PREVENTION & CONTROL OF INFECTIONS 4 4
HEALTHCARE ASSOCIATED SUPPORT TO INFECTION
INFECTIONS 5 4 CONTROL PROGRAMME 5 4
CONTROL OUTBREAKS OF CONTROL OUTBREAKS OF
INFECTION 6 4 INFECTION 6 4
STERILIZATION ACTIVITIES 7 5 STERILIZATION ACTIVITIES 7 6
BIOMEDICAL WASTE BIOMEDICAL WASTE MEASURES
MEASURES (BMW) 8 5 (BMW) 8 5
TRAINING OF STAFF TO TRAINING OF STAFF TO SUPPORT
SUPPORT HIC PROGRAMME 9 4 HIC PROGRAMME 9 4
TOTAL 9 51 TOTAL 9 54
20
Overall Impact of improvements:
HIC

Clinical privileging of ICN empowerment of ICNs

Rational and safe use of disinfectants
Enhanced participation of stakeholders by sharing
of HIC data
Promote rational use of antimicrobials and monitor
its usage
Monitoring of MDROs & infection containment due
to MDROs
Improved patient safety due to pre-defined
informed reuse of devices