AAC

AAC AAC.1: THE ORGANIZATION DEFINES AND DISPLAYS

THE SERVICES THAT IT CAN PROVIDE.. THE SERVICES ARE DISPLAYED PROMINENTLY IN AN

AREA VISIBLE TO PATIENTS BILINGUAL DISPLAY

THE SERVICES BEING PROVIDED ARE CLEARLY DEFINED

THE SCOPE OF SERVICES IS DEFINED AND DISPLAYED

SIGNAGES,PAMPHLETS AND SIGNBOARDS DISPLAY THE INFO ABOUT THE SERVICES PROVIDED

THE SCOPE IS DEPENDENT ON THE FACILITIES ,STAFF AND INFRASTRUCTURE

THE DEFINED SERVICES ARE PROMINENTLY DISPLAYED. THE STAFF IS ORIENTED TO THESE SERVICES.

THE SERVICES PROVIDED ARE DISPLAYED AND SHOULD BE ACTUALLY AVAILABLE

PERMANENT DISPLAY BOARD RECEPTION STAFF AND OPD AND IPD STAFF ARE

ORIENTED THROUGH TRAINING RECORDS OF TRAINING

. A.       AAC.2: THE ORGANIZATION HAS A

DOCUMENTED REGISTRATION, ADMISSION AND TRANSFER PROCESS

PROCESS ADDRESSES REGISTERING AND ADMITTING OUT-PATIENTS, IN-PATIENTS AND EMERGENCY PATIENTS.

HOSPITAL POLICIES ARE DOCUMENTED WITH PROCEDURE TO BE FOLLOWED FOR REGISTRATION,ADMISSION IPD PATIENTS AND EMERGENCY PATIENTS

PROCESS ADDRESSES MECHANISM FOR TRANSFER OR REFERRAL OF PATIENTS WHO DO NOT MATCH THE ORGANIZATIONAL RESOURCES

THE STAFF IS ORIENTED TO THE SCOPE OF SERVICES SAFE TRANSFER OR REFERRRAL OF PATIENTS POLICIES

AND PROCEDURES GUIDE THE PROCESS IF THE PATIENT REQUIRES SERVICES NOT AVAILABLE .   

AMBULANCE SERVICES ARE MADE AVAILABLE IF REQUIRED  .

TRANSFER SUMMARY IS GIVEN INVESTIGATION AT ANOTHER CENTRE ALSO SHOULD

BE MANAGED IN SAFE MANNER

AAC.3 PATIENTS CARED FOR BY THE ORGANIZATION UNDERGO AN ESTABLISHED INITIAL ASSESSMENT. A.   

  THE ORGANIZATION DEFINES THE CONTENT OF THE ASSESSMENTS FOR THE OUT-PATIENTS, INPATIENTS AND EMERGENCY PATIENTS.            

A STANDARD FORMAT IS USED FOR INITIAL ASSESSMENT IS DONE IN OPD AND IPD AND EMERGENCY PATIENTS

ALL ASPECTS OF ASSESSMENT NEED TO BE MENTIONED

THE ORGANISATION DETERMINES WHO CAN PERFORM THE ASSESSMENTS

ASSESSMENT IS PERFORMED BY STAFF ACCORDING TO THEIR QUALIFICATIONS AND AUTHORIZATION BY HOSPITAL

HR DEPT GIVES JOB DESCRIPTION TO STAFF OUTLINING THEIR DUTIES AND AUTHORIZATION

THE INITIAL ASSESSMENET IS DOCUMENTED WITHIN 24 HOURS OR EARLIER

DEPENDING ON THE CONDITION OF THE PATIENT INITIAL ASSESSMENT IN IPD HAS TO BE DONE AT THE EARLIEST AND DOCUMENTED WITHIN 24 HOURS

EMERGENCY PATIENTS REQUIRE EARLY ASSESSMENT

  INITIAL ASSESSMENT OF INPATIENTS INCLUDES NURSING ASSESSMENT WHICH IS DONE AT THE TIME OF ADMISSION AND DOCUMENTED

   NURSING ASSESSMENT IS DONE AT TIME OF ADMISSION AND WILL IDENTIFY NURSING NEEDS OF THE PATIENT

NUTRITIONAL ASSESSMENT IS ALSO INCLUDED

PATIENT CARE IS CONTINUOUS AND ALL PATIENTS CARED FOR BY THE

ORGANIZATION UNDERGO A REGULAR REASSESSMENT   

PATIENT IS REASSESSED AT REGULAR INTERVELS AND IS DOCUMENTED

PLAN OF CARE IS DOCUMENTED

DURING ALL PHASES OF CARE, THERE IS A QUALIFIED INDIVIDUAL IDENTIFIED AS RESPONSIBLE FOR THE PATIENT’S CARE WHO

COORDINATES THE CARE IN ALL SETTINGS IN THE ORGANISATION

 ALL ASPECTS OF CARE ARE TAKEN CARE OF AND THE TREATING CONSULTANT AND WARD MO COORDINATE CARE OF THE PATIENT

   .      PATIENTS ARE REASSESSED TO DETERMINE THEIR RESPONSE TO TREATMENT AND TO PLAN FURTHER TREATMENT OR DISCHARGE.

PATIENTS ARE REASSESSED AT REGULAR INTERVELS DISCHARGE PLANNING IS DONE AT THE TIME OF

ADMISSION ALONG WITH THE PLAN OF CARE

AAC.5 Laboratory services are provided as per the scope of the hospital’s services and laboratory safety requirements. a.

     

SCOPE OF THE LABORATORY SERVICES ARE COMMENSURATE TO THE SERVICES PROVIDED BY THE ORGANIZATION.

THE LAB SERVICES MAY BE OUTSOURCED OR IN HOUSE AVAILABILITY ROUND THE CLOCK IS ENSURED EMERGENCY TEST AVAILABILTY ROUND THE CLOCK

SHOULD BE ENSURED

PROCEDURES GUIDE COLLECTION, IDENTIFICATION, HANDLING, SAFE TRANSPORTATION, PROCESSING AND DISPOSAL OF SPECIMENS.

   .DOCUMENTED PROCEDURES GUIDE THE ORDERING ,COLLECTION,IDENTIFICATION,HANDLING,TRANSPORTATION ,PROCESSING AND DISPOSAL OF SPECIMANS

SAMPLE COLLECTION MANUAL AND LAB MANUAL SOPS AND WI ARE THE GUIDLELINES VALIDATION AND VERIFICATION AND EXTERNAL AND

INTERNAL QUALITY ASSURANCE IS ENSURED

    LABORATORY RESULTS ARE AVAILABLE WITHIN A DEFINED TIME FRAME AND CRITICAL RESULTS ARE INTIMATED IMMEDIATELY TO THE CONCERNED PERSONNEL. D.     

   TAT IS MAINTAINED CRITICAL RESULTS ARE MADE AVAILABLE ON

URGENT BASIS VERBAL REQUEST POLICY IS FOLLOWED ACCORDING

TO PROTOCOL

LABORATORY PERSONNEL ARE TRAINED IN SAFE PRACTICES AND ARE PROVIDED WITH APPROPRIATE SAFETY EQUIPMENT/ DEVICES. .   

.       PPE ARE MADE AVAILABLE AND USED STANDARD PRECAUTIONS ARE FOLLOWED BMW DISPOSAL IS ACCORDING TO REGULATIONS SAFETY TRAINING IS GIVEN TO STAFF INCLUDING

EQUIPMENT HANDLING

AAC.6 Imaging services are provided as per the scope of the hospital’s services and established

radiation safety programme.

A.      SCOPE OF THE IMAGING SERVICES ARE COMMENSURATE TO THE SERVICES PROVIDED BY THE ORGANIZATIONIMAGING SIGNAGES ARE DISPLAYED AT ALL APPROPRIATE LOCATIONS

. .     THE AVAILABILITY OF RADIOLOGY SERVICES IS COMMESURATE WITH THE SCOPE OF SERVICES

OUTSOURCING OF TEST IS TO CENTRES WITH QUALITY ASSURANCE METHODS FOR CREDIBILITY

RELEVANT IMAGING SIGNAGES ESP FOR RADIATION HAZARDS ACCORDING TO AERB GUIDELINES IS ENSURED

.      IMAGING RESULTS ARE AVAILABLE WITHIN A DEFINED TIME FRAME AND CRITICAL RESULTS

TURNAROUND TIME IS DECIDED BY MANAGEMENT DEPENDING ON URGENCY,TYPE OF TEST AND AVAILABILITY

ADEQUATE AND TRAINED STAFFF AND EQUIPMENT IS ENSURED TO KEEP MAINTAINRESULTS IN TAT

CRITICAL RESULTS ARE AVAILABLE ON URGENT BASIS

IMAGING PERSONNAL ARE TRAINED IN SAFE PRACTICES AND PROVIDED WIH APPROPRIATE SAFETY EQUIPMENT /DEVICES

RADIATION SAFETY MEASURES ARE TAKEN ACCCORDING TO AERB

STAFF IS TRAINED IN RADIATION SAFETY PROTECTION DEVICES ARE MADE AVAILABLE DOSIMETERS ARE MADE AVAILABLE RSO IS APPOINTED QA TESTS ARE DONE

.THE ORGANSIATION HAS A DEFINED DISCHARGE PROCESS

PROCESS ADDRESSES DISCHARGE OF ALL PATIENTS INCLUDING MEDICO-LEGAL CASES AND PATIENTS LEAVING AGAINST MEDICAL ADVICE. B.   

DISCHARGE POLICY AND PROCEDURES ARE DOCUMENTED

THEY INCLUDE MLC CASES,LAMA,DEATH CASES      

A DISCHARGE SUMMARY IS GIVEN TO ALL THE PATIENTS LEAVING THE ORGANIZATION (INCLUDING PATIENTS LEAVING AGAINST MEDICAL ADVICE). C.   

 DISCHARGE SUMMARY CONTAINING ALL RELEVANT DETAILS OF IPD STAY IS GIVEN TO ALL PATIENTS

ALL PATIENTS INCLUDING LAMA,TRANSFER ARE GIVEN A SUMMARY

DISCHARGE SUMMARY CONTAINS THE REASONS FOR ADMISSION, SIGNIFICANT FINDINGS, INVESTIGATION RESULTS, DIAGNOSIS, PROCEDURE PERFORMED (IF ANY), TREATMENT GIVEN AND THE PATIENT’S CONDITION AT THE TIME OF DISCHARGE.

 DISCHARGE SUMMARY IS GIVEN IN STANDARD FORMAT WITH ALL DETAILS OF ADMISSION,IMP FINDINGS,INV RESULTS,DIAGNOSIS,PROCEDURE NOTES,TREATMENT GIVEN,AND COURSE OF TREATMENT IN HOSPITAL

.      DISCHARGE SUMMARY CONTAINS FOLLOW UP ADVICE, MEDICATION AND OTHER INSTRUCTIONS IN AN UNDERSTANDABLE MANNER DISCHARGE SUMMARY INCORPORATES INSTRUCTIONS ABOUT WHEN AND HOW TO OBTAIN URGENT CARE

.  DISCHARGE SUMMARY CONTAINS FOLLOW UP ADVICE MEDICATION DIET WHEN TO OBTAIN URGENT CARE

IN CASE OF DEATH THE SUMMARY ALSO INCLUDES CAUSE OF DEATH

FOR DEATH CASES A DEATH SUMMARY IS WRITTEN AND FORM FOR INTIMATION OF DEATH IS FILLED

HANDDING TAKING OVER OF BODY ID PROOF AND ATTENDENTS RECORDS ARE KEPT COPY OF DEATH CERTIFCATE IS KEPT