22
Changes in Clinical Standards - NABH 4 th Edition 2016 Dr. Mahboob ali khan Phd Renowned Healthcare Quality Consultant

Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Embed Size (px)

Citation preview

Page 1: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Changes in Clinical Standards -NABH 4th Edition 2016

Dr. Mahboob ali khan Phd Renowned Healthcare Quality Consultant

Page 2: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Section I:Patient-Centered Standards

Access, Assessment and Continuity of Care (AAC)

3rd edition

4th edition

14/86 14/96

2

Page 3: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

3

3rd Edition

AACStandard NUMBER OE

SCOPE 1 3REGISTRATION & ADMISSION 2 6TRANSFER & REFERRAL 3 5INITIAL ASSESSMENT 4 10REASSESSMENT 5 5LAB 6 8LAB QA 7 5LAB SAFETY 8 5IMAGING 9 9IMAGING QA 10 5IMAGING SAFETY 11 7CONTINUOUS/MULTIDISCIPLINARY CARE 12 7DISCHARGE PROCESS 13 4DISCHARGE SUMMARY 14 7TOTAL 14 86

4th Edition

AAC

Standard

NUMBER OE

SCOPE 1 4 REGISTRATION & ADMISSION 2 7

TRANSFER & REFERRAL 3 5

INITIAL ASSESSMENT 4 9

REASSESSMENT 5 6

LAB 6 10

LAB QA 7 5

LAB SAFETY 8 5

IMAGING 9 10

IMAGING QA 10 6

IMAGING SAFETY 11 8 CONTINUOUS/MULTIDISCIPLINARY CARE 12 9

DISCHARGE PROCESS 13 5

DISCHARGE SUMMARY 14 7

TOTAL 14 96

Page 4: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

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

Page 5: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

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 servicesAddressing of reporting errors

◦ Amend or recall Structured handovers

◦ Transitions of care

Page 6: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

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 systemTime taken for discharge

◦ Monitor timelines

Page 7: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Section I:Patient-Centered Standards

3rd edition

4th edition

Care of Patients (COP) 20/136 22/149

7

Page 8: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

8

3rd Edition COP Standard

NUMBEROE

UNIFORM CARE 1 4

EMERGENCY SERVICES 2 7

AMBULANCE SERVICES 3 8

CARDIO PULMONARY RESUSCITATION

4 5

NURSING CARE 5 7

VARIOUS PROCEDURES 6 7

RATIONAL USE OF BLOOD & BLOOD PRODUCTS

7 8

INTENSIVE CARE & HIGH DEPENDENCY UNITS

8 7

VULNERABLE PATIENTS 9 5

OBSTETRIC CARE 10 7

PAEDIATRIC SERVICES 11 8

MODERATE SEDATION 12 8

ADMINISTRTAION OF ANESTHESIA

13 11

4th Edition COP Stand

ard NUMB

ER

OE

UNIFORM CARE, LAWS, REGULATIONS & GUIDELINES

1 4

EMERGENCY SERVICES 2 10AMBULANCE SERVICES 3 9HANDLING COMMUNITY EMERGENCIES, EPIDEMICS AND OTHER DISASTERS

4 5

CARDIO PULMONARY RESUSCITATION

5 5

DOCUMENTED POLICIES and PROCEDURES GUIDE NURSING CARE

6 7

Documented procedures guide the performance of various procedures.

7 7

RATIONAL USE OF BLOOD & BLOOD PRODUCTS

8 8

INTENSIVE CARE & HIGH DEPENDENCY UNITS

9 8

VULNERABLE PATIENTS 10 5HIGH RISK OBSTETRIC CARE 11 7

Page 9: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

9

3rd Edition

COPStandard NUMBER OE

SURGICAL PROCEDURES 14 11

RESTRAINTS 15 5

PAIN MANAGEMENT 16 5

REHABILITATIVE SERVICES 17 6

RESEARCH ACTIVITIES 18 6

NUTRITIONAL THERAPY 19 6

END OF LIFE CARE 20 5

TOTAL 20 136

4th Edition COP Standa

rd NUMBE

R

OE

PAEDIATRIC SERVICES 12 8

MODERATE SEDATION 13 8ADMINISTRTAION OF ANESTHESIA

14 11

SURGICAL PROCEDURES 15 11

ORGAN TRANSPLANT PROGRAM

16 4

RESTRAINTS 17 5PAIN MANAGEMENT 18 4

REHABILITATIVE SERVICES 19 6

RESEARCH ACTIVITIES 20 6

NUTRITIONAL THERAPY 21 6

END OF LIFE CARE 22 5

TOTAL 22 149

Page 10: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

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

Page 11: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

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

Page 12: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Section I:Patient-Centered Standards

3rd edition

4th edition

Management of Medication (MOM) 13/73 13/76

12

Page 13: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

13

3rd Edition

MOMStandar

d NUMBER OE

ORGANIZATION & USAGE OF PHARMACY 1 4HOSPITAL FORMULARY 2 5STORAGE OF MEDICATION 3 7PRESCRIPTIONS OF MEDICATIONS 4 12SAFE DISPENSING OF MEDICATIONS 5 6

MEDICATION ADMINISTRATION 6 10PATIENT MONITORING 7 4NEAR MISSES, MEDICATION ERRORS, ADR’s 8 5NARCOTIC DRUGS & PSYCHOTROPIC SUBSTANCES 9 4CHEMOTHERAPEUTIC AGENTS 10 4RADIOACTIVE DRUGS 11 4IMPLANTABLE PROSTHESIS & MEDICAL DEVICES 12 4MEDICAL SUPPLIES & CONSUMABLES 13 4TOTAL 13 73

4th Edition

MOM

Standard

NUMBER OE

ORGANIZATION & USAGE OF PHARMACY 1 4HOSPITAL FORMULARY 2 5STORAGE OF MEDICATION 3 7PRESCRIPTIONS OF MEDICATIONS 4 13SAFE DISPENSING OF MEDICATIONS 5 6MEDICATION ADMNISTRATION 6 10PATIENTS ARE MONITORED AFTER MEDICATION ADMINISTRATION 7 4NEAR MISSES, MEDICATION ERRORS ,ADVERSE DRUG EVENTS ARE REPORTED & ANALYSED 8 5NARCOTIC DRUGS & PSYCHOTROPIC SUBSTANCES 9 4CHEMOTHERAPEUTIC AGENTS 10 5RADIOACTIVE DRUGS 11 4IMPLANTABLE PROSTHESIS 12 4MEDICAL GASES 13 5TOTAL 13 76

Page 14: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Overall Impact of improvements: MOMStrengthening 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 formularyReconciliation of medications/orders at transitions

of care

Page 15: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Overall Impact of improvements: MOM

Special training for chemo therapeutic drugs and bio safety cabinets

Patient education for chemo drugsStrengthen medication administration Strengthen medical supplies

Page 16: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Section I:Patient-Centered Standards

3rd edition

4th edition

Patients Rights And Education (PRE) 7/46 8/54

16

Page 17: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

17

3rd Edition

PRE

Standard

NUMBER OE

PROTECTION OF RIGHTS & INFORMATION ABOUT RESPONSIBILITY OF CARE 1 5

SUPPORTING INDIVIDUAL BELIEFS & VALUES 2 10

EDUCATING PATIENT/ FAMILY MEMBERS TO MAKE INFORMED DECISIONS 3 7

INFORMED CONSENT 4 8

RIGHT TO INFORMATION & EDUCATION ABOUT HEALTHCARE NEEDS 5 8

RIGHT TO INFORMATION ON EXPECTED COSTS 6 4

COMPLAINT REDRESSAL PROCESS 7 4

TOTAL 7 46

4th Edition

PREStanda

rd NUMBE

ROE

PROTECTION OF RIGHTS & INFORMATION ABOUT RESPONSIBILITY OF CARE

1 5

SUPPORTING INDIVIDUAL BELIEFS & VALUES 2 11

INFORMED CONSENT 3 7PATIENT AND/OR FAMILY’S CONSENT EXISTS FOR MAKING INFORMED DECISION ABOUT THEIR CARE

4 8

RIGHT TO INFORMATION & EDUCATION ABOUT HEALTHCARE NEEDS

5 8

RIGHT TO INFORMATION ON EXPECTED COSTS 6 4

PATIENT’S FEEDBACK AND REDRESSAL OF COMPLAINTS.

7 5

EFFECTIVE COMMUNICATION WITH PATIENTS AND /OR FAMILIES

8 6

TOTAL 8 54

Page 18: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

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

Page 19: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Section I:Patient-Centered Standards

3rd edition

4th edition

Hospital Infection control (HIC) 9/51 9/54

19

Page 20: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

20

3rd Edition

HIC

Standard

NUMBER OE

HOSPITAL INFECTION CONTROL PROGRAMME 1 6

INFECTION CONTROL MANUAL 2 11SURVEILLANCE ACTIVTIES 3 8HOSPITAL ASSOCIATED INFECTIONS 4 4

PREVENTION & CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS 5 4

CONTROL OUTBREAKS OF INFECTION 6 4

STERILIZATION ACTIVITIES 7 5

BIOMEDICAL WASTE MEASURES (BMW) 8 5

TRAINING OF STAFF TO SUPPORT HIC PROGRAMME 9 4

TOTAL 9 51

4th Edition

HIC

Standard

NUMBER OE

HOSPITAL INFECTION CONTROL PROGRAMME 1 6

INFECTION CONTROL MANUAL 2 12

SURVEILLANCE ACTIVTIES 3 9

HOSPITAL ASSOCIATED INFECTIONS 4 4

SUPPORT TO INFECTION CONTROL PROGRAMME 5 4

CONTROL OUTBREAKS OF INFECTION 6 4

STERILIZATION ACTIVITIES 7 6

BIOMEDICAL WASTE MEASURES (BMW) 8 5

TRAINING OF STAFF TO SUPPORT HIC PROGRAMME 9 4

TOTAL 9 54

Page 21: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd

Overall Impact of improvements: HICClinical privileging of ICN – empowerment of ICNsRational and safe use of disinfectantsEnhanced participation of stakeholders by sharing

of HIC dataPromote rational use of antimicrobials and monitor

its usageMonitoring of MDROs & infection containment due

to MDROs Improved patient safety due to pre-defined

informed reuse of devices

Page 22: Changes in Clinical Standards -NABH by Dr.Mahboob ali khan Phd