Homoeopathy Indicators NABH
Homoeopathy Indicators NABH
Homoeopathy Indicators NABH
to Accreditation Standards
for Homoeopathy Hospitals
2nd Edition
July 2016
Annexure - 1
Fact sheet on End of Life care
End of life care is a person centered, personalized and family oriented perception
of “Good Death “ which encompasses all aspects of comprehensive care of an
individual at his or her end of life. End of Life Care constitutes:
Modalities of End of life care at ICU can be with de-escalation of life sustaining
measures, where as in the ward setting, it can be with symptomatic care. The
patients can also be transferred to hospice or home for provision of end of life
care
End of life care document shall be a policy statement that facilitates a dignified
dying process for those who are diagnosed to be at their end of life. It may
consists of:
making, symptom control , managing the dying process, death and after
death care including bereavement
Whenever, the treating physicians or group of physicians feel that the medical
care is FUTILE, then End of Life Care management can be discussed and
initiated. Medical futility is a clinical decision, which is defined as medical
interventions that are unlikely to provide any significant clinical benefit for the
patient. The reference is to clinical situations where in absence of brain death,
the physician believes that continuing life support is futile.
No. Any area within the hospital premises that offers a private conducible and
peaceful environment for the person to die and family members to be around can
offer End of Life Care process. It can be in ICU or in the ward. It will be preferable
to provide the scope of religious clerics to attend and practice any rituals.
6. How Code of Medical Ethics facilitates End of Life Care decision making?
i. Patient Autonomy
- Means the Right to Self-determination, where the informed patient has a
right to choose the manner of his treatment.
ii. Beneficence
- it implies acting in what is (or judged to be) in patient’s best interest.
iii. Non-malfeasance
- Means to do no harm, to impose no unnecessary or unacceptable
burden upon the patient
iv. Distributive Justice
10. How limitation of life sustaining treatment can take place in medically futile
condition?
Annexure - 2
Clinical Audit
A write-up for carrying out clinical audit is given below for comprehending the process of
auditing of the healthcare services. The text has been simplified in the format of FAQs
so as to explain all aspects of the subject without compromising the basic tenants of the
audit.
What is audit?
Evaluation of data, documents and resources to check if performance of systems meets
specified standards.
The aim of clinical audit is to measure the gap between ideal practice (determined from
evidence and guidelines) and actual practice. Audit does not seek to apportion blame
on individual practitioners, but aims to improve the systems in which individuals work.
Done correctly, audit can bring about change and improve practice and clinical
effectiveness.
For Patients
• Improves quality of care and service received
• Prompt changes in delivery of care
• Highlights precise patient needs
• Involves patients in decision-making
• Raises patients confidence in service and care levels
• Provides clear information about care and risks involved
For Organisation
• Improved care of patients
• Enhanced professionalism of staff
• Efficient use of resources
• Aids in continuing education
• Aids in administration
• Accountability to those outside the profession
asking the question ‘what is best practice?’ As a result of which a new service or new
practice may be developed. The methodology is designed so that it can be replicated
and so that the results can be generalised to other similar groups.
Research may involve a completely new treatment or practice, the use of control groups
or placebo treatment for purposes of comparison, or allocating service users randomly
to different treatment groups. Patients should be involved in the design, implementation
and analysis of the work.
Alternatively, clinical audit aims to improve the quality of local patient care and clinical
outcomes through the peer-led review of practice against evidence-based standards,
implementing change where necessary. It asks the questions ‘are we following best
practice?’ and ‘what is happening to patients as a result?’
• Structure
• Process
• Outcome
1. Audits of structure
This type of audit looks at environmental factors within which care is delivered.
Criteria that can be considered include the practice building (state of repair,
facilities offered, confidentiality offered during consultations, privacy, cleanliness),
the personnel (the receptionist, clinicians, other health care practitioners and
additional ancillary staff), equipment in the practice (is it always functioning, is it
regularly assessed for safety) and patient notes (are they kept securely to
maintain confidentiality, are they legible and complete, are they of a suitably high
standard). This provides an indirect assessment of a patient’s care, but the
environment in which a patient is treated is, nonetheless, an important aspect of
their care.
2. Audits of process
3. Audits of outcome
How to audit?
Measure baseline
Review standard
if required Set standards
Measure practice
Evaluate through data
change collection and
analysis
Assessment of
Implement performance against
change standard
Methodology
1. Selection of Topic
a) Should be common because it is common or high risk or bears high cost.
b) Should be having local clinical concern or known wide variance in clinical
practice.
c) Topic should be well defined, focused and amenable to standard setting.
Some topics
a) Long/short stay cases
b) Specific disease/specific operations
c) Vulnerable groups
d) Increase incidence of a disease
e) Post-operative infection/complications
2. Setting of standard
a. To be set prior to the study
b. Criteria to be based on objective measures
Criterion is an item of care or sure aspect of care that can be used to assess
quality. It is a written statement. For example,
i All patients requiring urgent appointment will be seen that day only.
ii All patients with epilepsy should be seen once a year.
c. Criteria should be well justified.
d. Target should be set at realistic level for defined patient groups and take into
account local circumstances.
A target describes the level of care to be achieved for any particular criteria.
For example,
i 98 per cent of patients requesting for urgent appointment will be seen on
that day.
ii 90 per cent of patients with epilepsy must be seen at least once a year.
Case Management
Criteria Staffing of IPD Case fatality
plan
Not < 1 per 5 Recorded 100% in all Not to exceed 0.1 per
Target
occupied beds case records cent for IPD cases
e. Objective criteria are explicit but clinical judgment can be used to answer the
question: “Was the management of this case satisfactory”? This is an implicit
criterion.
f. Use of explicit criteria should be preferred. The problem with implicit criteria
is that important deficiencies in care may be overlooked and rates may differ
in their assessments of the acceptability of management.
4. Tabulation of evaluation
5. Interpretations
a. Deficiency of care recognised
b. Specific solutions are proposed. They may not be possible every time.
E.g. a study of the way cervical screening is organised identified deficiencies
but concluded only that other schemes needed to be examined
c. Education impact is appreciated
d. Planned programme for change
e. All staff is involved
f. Active feedback
g. Audit is evaluated
Legal Motives
Checklist
Question Criteria
Few Examples
The setting and resources (what you need - staff, buildings and equipment
required to deliver a service), e.g.
2. Clinical process
• Post-operative pain management, Normal delivery v/s LSCS, Open v/s Lap
cases, communication with patients at first appointment in child and mental
health service, hand hygiene compliance, Health care associated infections,
single donor blood transfusion
• Organisational/administrative process, e.g. system for patient recall, discharge
practice, waiting times etc.
3. Outcome
• Risk register
• Activity information – e.g. throughput, re-admissions, waiting lists
Conclusion
Audit appears deceptively simple. Current care is observed so that it can be compared
with standards and the necessary charges in patient care are implemented.
In practice
• Topics for audit need to be chosen with care and refined to make them suitable.
• Standard setting requires clarity of thought and careful definition.
• Data collection to observe practice can consume endless time and money.
• Lasting change is notoriously difficult to achieve.
Notwithstanding the above, once audit is understood and planned, it is one of the best
ways to check quality of care being rendered, to bring about changes for improving
care, to improve patient and employee satisfaction and for professional development.
Annexure - 3
Introduction to Green Hospital
Green building refers to both a structure and the using of processes that are
environmentally responsible and resource efficient throughout building’s lifecycle.
A green building emphasises upon judicious use of its resources (water, power) and
creates less waste, and has efficient solid and water waste management treatment.
Green building which can also be called energy efficient building is the one which can
reduce energy consumption by atleast 40% as per few studies as compared to
conventional buildings.
Similarly green hospital building can be defined as one which enhances the patient well-
being, aids the curative process, while utilising natural resources in an efficient
environment-friendly manner.
There is empirical evidence linking the physical environment with patient, family and
staff leading to improved patient safety, improved clinical and psychosocial outcomes,
patient satisfaction, and increased staff effectiveness in providing care, staff satisfaction
and improvements in staff health.
The advantages of Green Hospitals are known to reduce patient recovery time, low
energy and water consumption, increase health and well being of the patients as well as
employees leading to better quality of care. It is also seen that it decreases long term
energy costs and leads to better patient outcomes and staff retention. It also reduces
stress levels amongst hospital workers and leads to better indoor air quality.
The focus areas for Green Hospital Design include day light, recycling of material and
resultant waste generation, better indoor air quality and increased fresh air ventilation,
CO2 monitoring, green house keeping, clean & green interior building materials, proper
waste disposal, etc.
Green hospital concepts will play an important part in the curative process in time to
come. Instead of being referred to as a place that houses healthcare amenities,
hospitals of tomorrow will now focus on wellness and be transformed into welcoming
spaces to get well.
• Minimum fresh air for all air conditioning area conditioning as per national or
international guidelines like ASHRAE, Less usage of VOC (volatile organic
compounds ) based paints/carpets to avoid bad environment quality, continuos
ventilation around 36 hours ( minimum of 12 hours) of all area before occupancy
so that foul air of construction material can be flushed out.
• The provision of ventilation ducts, exhaust hoods compliance of statutory &
manufacturers guidelines.
• The organisation having defined criteria, process and protocols for selection of
cleaning products, mops and wipers like on-hazardous cleaning agents,
environmental pollutants reduction , protection of the cleaning worker.
• The organisation having protocol for receiving, handling, storing and safe disposal
of all kinds of waste including recyclables, hazardous, bio medical and e-waste.
The organisation complies all bio-medical waste management rule and ensures
biological waste is disposed as recommended by national regulations.
• The organisation to have procurement plan include purchase of environment
friendly materials which can be reused or recycled as per manufacturer’s
recommendations. The organisation having purchase policy that reduces/avoids
purchase of mercury containing equipment. The organisation having sustainable
food purchasing policies and plan that support human and ecological health.
• The following strategy can be considered by organisation for optimisation of
energy saving & usage.
o Schedule of HVAC based on the requirement preferably using building
management system.
o Schedule for switching on & off of lights.
o Schedule of operation of exhaust fan.
o Flow restriction of water taps & showers.
o Sensor based urinal flushing.
o Operational control on hot water generation, chillers, lifts etc.
o Monthly audit of power & water consumption.
ECBC guidelines, bureau of energy efficiency, Govt. of India, Best practices across
various hospitals & AHPI checklist on green hospital
Annexure - 4
Communication in Healthcare
Introduction:
Delivery of healthcare is a complex process which involves lot of human interaction
between patients/families and healthcare workers and among healthcare workers as
well. It is has been proven that majority of the errors that happen in healthcare are
related to communication. Studies show that poor communication is the major cause
for patient dissatisfaction, litigation and financial loss. It is also proven that the patient
outcomes are better with good communication. Since good communication is not
addressed in any healthcare curriculum, organizations have to try hard to improve the
communication skills of its staff as communication plays a major role in quality.
An organisation has to train the staff to communicate effectively. Some areas like
Consenting, patient doctor interviews, and Nursing assessment need to be stressed
upon making the communication effective. The following is an indicative list which
needs to be addressed to make communication effective.
Safe communication:
Communication is one of the cornerstones of patient safety. Some areas where
communication leads to patient safety incidents are handing over, communication in
emergency situations, and lack of assertiveness among nurses. There are various
methods for doing the handing over. One of the easier examples is using ISBAR tool.
Another tool which helps in achieving patient safety is a tool called “Assertiveness
saves lives”. The steps are
Special situations:
Though the principles of communication remain same whatever the situation, some
special protocols need to be decided before hand and the concerned staff need to be
trained on those. Some examples of those situations are
• Who is the responsible person to handle it (the concerned treating consultant should
be the one to disclose and not the junior doctors)
• What preparation should he have before (The doctor should have enough time,
have a room where serious conversation can happen, know about the patient and
relevant investigations, have sufficient knowledge about further plan, have an
experienced nurse along to help the patient to deal with the emotions)
• Where to do the breaking bad news (Not on corridors, but in a comfortable
confidential room)
• How to break the bad news( Assessing patient knowledge about illness, knowing
the background information, and gently but unambiguously breaking the bad news
without medical jargon)
• Plan (Further plans, curative, palliation, support etc)
This is just a very sketchy example of breaking bad news protocol. Similarly
organisation should have protocols for different scenarios.
Communication barriers:
There are many barriers to effective communication. Many are internal barriers like
fatigue, lack of interest and motivation, type of patients etc which need to be identified
and handled by each healthcare professional. But one of the major communication
barriers in this vast country is language. So the organisation should identify staff who
can act as interpreters in case of need for a particular language, to help in the patient
interaction and counseling. It is also necessary to identify patients with speech and
hearing disability so that they can be appropriately counseled.
Unacceptable behaviour:
Unacceptable behaviour is the behaviour of a staff which is worse than the minimum
expectation a patient or management would have about the staff. These types of
behaviors will make the patient unhappy and the hospital to lose its patient base. So it is
the responsibility of the management to identify such unacceptable behaviors. The
management also should ensure a disciplinary action is taken against staff displaying
unacceptable behaviour. List of unacceptable behaviour is exhaustive, but at least the
common indicative list as below should be made public to the staff.
Training on communication:
Communication in spite of being an important determinant of patient safety and
satisfaction is not a part of healthcare curriculum. So the hospital aspiring for best
quality should make an effort to train its staff in healthcare communication. The training
requirements for each group of staff vary. As a first step, a group of internal trainers
should be identified who can develop some relevant resources and train the others.
The training can happen in the form of group discussions, role-plays, rolemodelling,
videos etc. Communication training for front office staff can be some good etiquette to
make the patient feel comfortable and welcome.
Annexure - 5
Revised Guidelines for Air Conditioning in Operation
Theatres
Air Conditioning in OT
A. The air conditioning requirements for Operation Theatre in a HCO have been
deliberated at length with manufacturers, engineers, technical committee members
and other stake holders and the following guidelines have been finalized.
B. For this purpose operation theatres have been divided into groups:
2. Air Velocity:
• The vertical down flow of air coming out of the diffusers should be able to
carry bacteria carrying particle load away from the operating table. The airflow
needs to be unidirectional and downwards on the OT table. The air face
velocity of 25-35 FPM (feet per minute) from non-aspirating
unidirectional laminar flow diffuser/ceiling array is recommended.
• Positive Pressure: There is a requirement to maintain positive pressure
differential between OT and adjoining areas to prevent outside air entry into
OT. Positive pressure will be maintained in OT at all times (operational &
non-operational hours)
• Laminar flow boxes/diffusers should be installed in the OT for supplying
majority air and also majority return air should be picked up 75-150 mm
above floor level.
4. Outdoor Air intakes: The location of outdoor air intake for an AHU must not be
located near potential contaminated sources like DG exhaust hoods, lab exhaust
vents, vehicle parking area.
5. Air handling in the OT including air Quality: Air is supplied through Terminal
HEPA (High-efficiency particulate arrestance) filters in the ceiling. The HEPA can
be at AHU level if it not feasible at terminal level inside OT. The minimum size of
the filtration area should extend one feet (i.e. 304.8 millimetres) on each side of
the OT table to cover the entire OT table and surgical team. The minimum supply
air volume to the OT (in cubic feet per minutes CFM) should be compliant with
the desired minimum air change. Air quality at the supply i.e. at grille level should
be Class 100/ ISO Class 5 (at rest condition).
Note: Class 100 means a cubic foot of air should not have more than 100
particles measuring more than 0.5 microns or larger.
6. Air Filtration: The AHU (i.e. air handling unit) must be an air purification unit and
air filtration unit. There must be two sets of washable flange type filters of
efficiency 90% down to 10 microns and 99% down to 5 microns with aluminium/
SS 304 frame within the AHU. The necessary service panels to be provided for
servicing the filters, motors & blowers. HEPA filters of efficiency 99.97% down to
0.3 microns or higher efficiency are to be provided .
REQUIREMENTS – General OT
1. Air Change Per Hour:
• Minimum total air changes should be 20 based on international guidelines
although the same will vary with biological load and the location.
• The fresh air component of the air change is required to be minimum 4 air
changes out of total minimum 20 air changes.
2. Air Velocity: should be same as per previous guide.
3. Positive Pressure: There is a requirement to maintain positive pressure differential
between OT and adjoining areas to prevent outside air entry into OT. The minimum
positive pressure recommended is 2.5 Pascal (0.01 inches of water).
4. Air handling/Filtration: It should be same as previous. When not possible, the
OTs should be well ventilated with 2 levels of filtrations with efficiencies as specified
previously (pre and micro vee filters should be in position at the AHU).
The air quality at the supply i.e. at grille level should be Class 1000/ ISO Class 6 (at
rest condition).
Note: Class 1000 means a cubic foot of air must have no more than 1000 particles
measuring 0.5 microns or larger.
5. Temperature and Humidity: The temperature should be maintained at 21C +/- 3
Deg C inside the OT all the time with corresponding relative humidity between 20 to
60%. Appropriate devices to monitor and display these conditions inside the OT
may be installed.
OT Construction:
a) The AHU of each OT should be dedicated one and should not be linked to air
conditioning of any other area for all OT constructed.
b) Window & split A/c should not be used in any type of OT because they are pure re
circulating units and have convenient pockets for microbial growth which cannot be
sealed.
c) Paint- antibacterial, anti-fungal
d) OT door – automatic/ Hermitically Sealed/Touch free (preferable)
References
1. American Society of Heating, Refrigerating and Air Conditioning Engineers
(ASHRAE) Standards. Ventilation for Indoor Air Quality. 2013
2. Previous NABH guidelines for air conditioning in operation theatre
3. Discussion by NABH TC & AC team on 25th April 2015.
Annexure - 6
Sentinel Events
Definition:
An unexpected incident, related to system or process deficiencies, which leads to death
or major and enduring loss of function* for a recipient of healthcare services.
use
• the failure or breakdown of a device or medical equipment
4. Environmental events
Patient death or serious disability while being cared for in a healthcare facility
associated with:
o wrong-patient error
• Patient death or serious disability associated with an avoidable delay in
treatment or response to abnormal test results
6. Criminal events
Annexure - 7
Patient Responsibilities (Indicative Guide)
– Treat hospital staff, other patients, and visitors with courtesy and respect.
• To be on time in case of appointments. To cancel or reschedule as far in advance as
possible in case of cancellation or rescheduling of the appointments.
• Not to give medication prescribed for him/her to others.
• Provide complete and accurate information for insurance claims and work with the
hospital and physician billing offices to make payment arrangements.
• To communicate with the healthcare provider if his/her condition worsens or does
not follow the expected course.
• To pay for services billed for in a timely manner as per the hospital policies.
• To respect that some other patients’ medical condition may be more urgent than
yours and accept that your doctor may need to attend them first.
• To respect that admitted patient and patients requiring emergency care take priority
for your doctor.
• To follow the prescribed treatment plan and carefully comply with the instructions
given.
• To accept, where applicable, adaptations to the environment to ensure a safe and
secure stay in hospital.
• To accept the measures taken by the hospital to ensure personal privacy and
confidentiality of medical records.
• To attend follow-up appointment as requested.
• Not to take any medications without the knowledge of doctor and healthcare
professionals.
• To provide correct and truthful history.
• To understand the charter of rights and seek clarification, if any.
Annexure - 8
Key Performance Indicators
In the last years, performance has become a well known term in the health services.
Performance represents the extent to which set objectives are accomplished. The
concept of performance in health services represents an instrument for bringing quality,
efficiency and efficacy together. Consequently, the concept of performance is a
multidimensional one, covering various aspects, such as: evidence-based practice
(EBD), continuity and integration in healthcare services, health promotion, orientation
towards the needs and expectation of patients.
Generally speaking, the mission of any hospital is to provide specific health services,
which can solve the patients’ health problems (efficacy) in the best manner (quality) and
in the most economic way possible (efficiency). Key Performance Indicators (KPIs) help
to systematically monitor, evaluate, and continuously improve service performance. In
and of themselves, KPIs cannot improve performance. However, they do provide
“signposts” that signal progress toward goals and objectives as well as opportunities for
improvement.
Well-designed KPIs should help health sector decision makers to do a number of things,
including:
Healthcare organizations are encouraged to capture all data which involves clinical and
support services. The data needs to be analyzed and risks, rates and trends for all the
indicators have to be demonstrated for appropriate action. The HCOs can gather data
based on the sample size (Guidance tool: Table 1) and mode of data collection can be
divided in three categories:
a) Continuous
b) Periodic (monthly)
c) Periodic (quarterly)
The intent of the NABH KPIs is to have comprehensive involvement of scope of services
for which an institution has applied for the accreditation program. Standardized
definitions (Annexure 9) for each indicator along with numerator and denominator have
been explained. Each HCO can have the data set, analyze the data and appropriate
correction, corrective and preventive action can be formulated. In the 4th edition, an
effort has been made to participate towards national programs and evolving databases.
Few essential health indicators like infant mortality, maternal mortality etc have been
included as KPIs for regular reporting.
Each institution can also design their own methodology of data collection but a broad
guidance note has been given to facilitate organization's compliance.
Suggested minimum sample size to be taken for various audits and KPIs as applicable.
(Table at the end).
Annexure - 9
The Key Performance Indicators Expected to be Monitored by
Healthcare Organisation
assessment is
completed by a
doctor.
2. CQI 3a Percentage of Number of in- Periodic- The indicator shall be
cases (in- patient case Atleast captured during the stay of
patients) records Monthly the patient and not from
wherein care wherein the (Refer to the medical record
plan with care plan with sample size department. It shall be
desired desired table / collated on a monthly
outcomes is outcomes has annexure) basis. The sampling base
documented been shall be patients who have
and counter- documented completed 24 hours of
signed by the X 100 stay in the hospital.
clinician. Total number of
patients However, immediate
correction is to be initiated,
when gaps are seen on a
real time basis.
3. CQI 3a Percentage of Number of in- Periodic- The indicator shall be
cases (in- patient case Atleast captured during the stay of
patients) records wherein Monthly the patient and not from
wherein the nutritional (Refer to the medical record
screening for assessment sample size department. It shall be
nutritional has been table / collated on a
needs has documented annexure) monthly basis. The
been done. X 100 sampling base shall be
Total number of patients who have
patients completed 24 hours of
stay in the hospital.
However, immediate
correction is to be
initiated, when gaps are
seen on a real time basis.
4. CQI 3a Percentage of Nursing care plan Number of in- Periodic - The indicator shall be
cases (in- shall be the patient case Atleast captured during the stay of
patients) outcome of the records wherein Monthly the patient and not from
wherein the nursing assessment the nursing (Refer to the medical record
nursing care done at the time of care plan has sample size department. It shall be
plan is admission. been table / collated on a monthly
documented. documented annexure) basis. The sampling base
X 100 shall be patients who have
Total number of completed 24 hours of
patients stay in the hospital.
However, immediate
correction is to be initiated,
when gaps are seen on a
real time basis.
5. CQI 3b Number of Reporting errors Number of Continuous This shall be captured in
reporting include those reporting errors the laboratory and
errors / picked up before X 1000 radiology.
1000investigat and after dispatch. Number of tests
ions It shall include performed Although the indicator is
transcription errors. capture don a monthly
basis, immediate
correction is to be initiated
when such instances
happen.
6. CQI 3b Rate of re- This shall also Number of re- Periodic - This shall be captured in
dos. include tests dos Atleast the laboratory and
repeated before X 1000 Monthly radiology.
release of the Number of tests (Refer to
Wrong patient
errors;
Wrong route of
administration
errors; and
Calculation or
preparation of
a) Prescription
Error
b) Dispensing
Error
Percentage of Refer to glossary Number of Continuous Separations means
10. CQI 3c admissions adverse discharges (includes
with adverse drug LAMA/DAMA and
drug reactions/ abscond) and deaths.
medications.
13. CQI 3d Percentage The anaesthesia Number of Continuous The modification is
of plan is the patients in anaesthesia plan could be
modification outcome of pre- whom the captured in a
of anaesthesia anaesthesia register/system before the
anaesthesia assessment. Any plan was patient is shifted out of the
plan, if changes done modified OT.
applicable after this shall be X 100
considered as Number of
modification of patients who
anaesthesia plan. underwent
anaesthesia
14. CQI 3d Percentage of Number of Continuous Every anaesthesia plan
unplanned patients shall invariably mention if
ventilation requiring there is a possibility of the
following unplanned patient requiring ventilation
anaesthesia, ventilation following anaesthesia.
if applicable following Every case wherein a
anaesthesia patient required ventilation
X 100 but this was not captured
Number of in the anaesthesia plan
patients who shall be a part of the
underwent numerator.
anaesthesia
15. CQI 3d Percentage Adverse Number of Continuous
of adverse anaesthesia event patients who
anaesthesia is any untoward developed
events, if medical adverse
applicable occurrence that anaesthesia
may present event
during treatment X 100
with an Number of
ely, if surgeries
applicable performed
22. CQI 3e Re- No. of re- Periodic Re-explorations should not
exploration explorations Monthly include two stage surgical
rate, if done during (Refer to procedures
applicable same sample size
admission table /
X 100 annexure)
Total number of
surgeries
23. CQI 3f Percentage of A systemic Number of Continuous Any adverse reaction to
transfusion response by the transfusion the transfusion of blood or
reactions body to the reactions blood components shall
recipient. The administration of X 100 be considered as
causes blood Number of transfusion reaction. It
include red incompatible with units may range from an mild
blood cell that of the transfused allergic reaction
incompatibilit (including chills/rigors) to
y allergic a life threatening
sensitivity to complication like TRALI
the and Graft Versus
leukocytes, Host Disease.
platelets,
plasma
protein
components
of the
transfused
blood; or
potassium or
citrate
preservatives
in the banked
blood, if
applicable.
24. CQI 3f Percentage a. Continuous This also includes blood
of wastage of Number of products found unfit for
blood and blood and use.
blood blood
components, components It is important that the
if applicable. units wasted organisation capture the
among those number of blood and blood
issued components used and not
X 100 just the number of
Number of transfusions carried out. At
blood and times more than one blood
blood bag or components may
components have been given in a
units issued single transfusion.
from the blood
bank In case the organisation
does not have a blood
b. bank of its own, the
Number of denominator shall be the
blood and total number of blood and
blood blood components
components collected / indented from
units wasted the blood bank.
at blood
bank/blood
storage
center
X 100
Number of
blood and
blood
components
units stored
in the blood
bank.
25. CQI 3f Percentage of Number of Continuous
blood components
component used
usage, if X 100
applicable Number of
blood and blood
products used
26. CQI 3f Turnaround The time shall um of time Continuous This will include blood
time for issue begin from the taken outsourced from other
of blood and time that the Blood Banks, for those
blood order is raised to Total number organisations not having
components, blood/blood of blood and in house Blood Banks.
if applicable component blood Refer to glossary
reaching the components
clinical unit. issued
27. CQI 3g Catheter As per the latest Number of Continuous
associated CDC/NHSN urinary
Urinary tract definition catheter
infection rate associated
UTIs in a
month
X 1000
Number of
urinary catheter
days in that
month
28. CQI 3g Ventilator As per the latest Number of Continuous
associated CDC/NHSN “Ventilator
Pneumonia definition Associated
rate, if Pneumonia” in
applicable a month
X1000
Number of
ventilator days
in that month
29. CQI 3g Central line As per the latest Number of Continuous
associated central line
Bloodstrea CDC/NHSN associated
m infection definition blood stream
rate, if infections in a
applicable month.
X1000
No. of central
line days in that
month
30. CQI 3g Surgical site As per the latest Number of Continuous Additionally the SSI rates
infection rate, surgical site for Inguinal Herniorraphy
if applicable CDC/NHSN infections in a with mesh, Caesarean
definition given month section, Laparoscopic
cholecystectomy and
X100
Number of Coronary artery bypass
surgeries grafting (CABG) shall be
performed in monitored separately as
that month applicable.
31. CQI 3h Mortality rate a. Continuous Additionally, Case fatality
Number of rate for 5 most frequent
b. Proportional
maternal Infant -Young baby from
mortality rate= birth to 12 month of age
Total no. Of
maternal
deaths
Total no. of X100
deaths
c. Proportional
infant mortality
rate=
Total No. of
infant deaths
X100
Total no. of
deaths
Number of X100
discharges/tran
sfers in the ICU
33. CQI 3h Return to the Number of Continuous To capture this indicator it
emergency returns to may be a good practice to
department emergency capture during the initial
within 72 within 72 assessment itself if the
hours with hours with patient had come within
similar similar 72 hours for similar
presenting presenting complaints.
complaints, complaints
if applicable X 100
Number of
patients who
have come to
the
emergency.
34. CQI 3h Re-intubation This shall include Number of Continuous
rate, if re- intubation re-
applicable within 48 hours of intubations
extubation. within 48
hours of
extubation
X 100
Number
intubations
35. CQI 3i Percentage Number of Continuous
of research research
activities activities
approved by approved by
Ethics ethics
committee committee
X 100
Number of
research
protocols
submitted to
ethics
committee
36. CQI 3i Percentage of Number of Continuous .
patients patients who
withdrawing have withdrawn
from the from all on-
study going studies
X 100
Number of
patients
enrolled in all
on-going
studies
37. CQI 3i Percentage of Number of Continuous Any protocol
protocol protocol violation/deviation that
violations/ violations/ gets reported based on an
deviations deviations internal/external
reported reported assessment finding shall
X 100 be considered as deemed
Number of to have happened but not
protocol reported. Hence, even
violations / though it gets reported it
deviations that shall be included to only
have occurred calculate the denominator
and shall not be included
in the numerator.
38. CQI 3i Percentage The timeframe for Number of Continuous
Number of X 100
drugs/items
procured in
hospital within
as well as
outside.
40. CQI 4a Percentage of A stock out is an Number of Continuous
stock outs event which occurs stock outs To capture this,
including when an item in a X 100 organisation should
emergency pharmacy or Number of maintain a register in the
drugs consumable store drugs listed in pharmacy and stores (and
is temporarily hospital also if necessary in the
unable to provide formulary and wards) wherein all such
for an intended hospital events are captured.
patient. consumables
list
41. CQI 4a Percentage All materials Total quantity Continuous Please note that the
of drugs and received not in rejected denominator is total
consumables conformity with X 100 quantity and not number.
rejected the specifications Total quantity For example, a single
before and requirements received before order may have 30 items
preparation ordered for in the GRN of “X” consumable. Of the
of Goods purchase order 30, 10 may be rejected. In
Receipt Note shall be rejected. this case the formula will
(GRN) be 10/30.
42. CQI 4a Percentage Variations from Total number of Continuous
of variations the written variations from
from the standardised the defined
procurement procurement procurement
process process of process
acquiring supplies X 100
from licensed, Total number of
actual bed
occupancy is the
sum of calculation
days and
occupancy days,
because every
patient occupies
one bed per
inpatient day in the
facility
49. CQI 4c Critical The term Sum of down Continuous Check list of all equipment
equipment downtime is used time for all should be updated in the
down time to refer to periods critical unit on daily basis to
when a system is equipment in monitor equipment
unavailable. hours in a utilisation and downtime.
Downtime or month.
outage duration
refers to a period
of time that a
system fails to
provide or
perform its
primary function
50. CQI 4c Nurse-patient Number of Continuous The HCOs should
ratio for nursing staff calculate the staffing
wards patterns separately for
(mandatory) Number of beds ICUs and for the wards.
and ICUs (if The in-charge/supervisor
applicable) To be of the area shall not be
calculated for included for calculating the
each shift number of staff.
It is preferable that in case
52. CQI 4d In patient Average Score Continuous Refer to remark for out
satisfaction achieved monitoring and patient satisfaction index.
index audits should
Maximum X 100 be done atleast
possible score quarterly
(Refer to
sample size
table /
annexure)
53. CQI 4d Waiting time A waiting time is a Sum (Patient- Periodic Waiting time for
for services length of time in Time for monitoring and diagnostics is applicable
including which one must Consultation/ audits should only for out- patients.
diagnostics wait in order for a Procedure - be done atleast
and out- specific action to Patient quarterly
patient occur, after that Reporting (Refer to
consultation action is requested Time in sample size
or mandated. OPD/Diagnosti table /
Waiting time for cs) annexure)
diagnostics is the
time from which Number of
the patient has patients
come to the reported in
diagnostic service OPD/
(requisition form Diagnostics
has been
presented to the
counter) till the
time that the test is
initiated.
Waiting time for
out- patient
consultation is the
time from which
the patient has
come to the
concerned out-
patient
department (it
may or may not be
the same time as
registration) till the
time that the
concerned
consultant (not the
junior
doctor/resident)
begins the
assessment
54. CQI 4d Time taken Discharge is the Sum of time Periodic – In case patients request
for discharge process by which a taken for Monthly AND additional time to leave
patient is shifted discharge audits should the clinical unit that shall
out from the be done not be added. The
hospital with all Number of atleast discharge is deemed to
concerned medical patients quarterly. have been complete when
summaries after discharged (Refer to the formalities for the
ensuring stability. sample size same have been
table / completed.
The discharge annexure)
process is deemed
to have started
when the consultant
formally approves
discharge
period.
58. Percentage of Employee Number of Periodic
CQI 4e employees awareness is the employees monitoring
who are state or condition who are AND audits
aware of of being aware; aware of should be done
employee having employee atleast
rights, knowledge; rights, quarterly
Responsibiliti consciousness responsibilitie (Refer to
es and about employee s and welfare sample size
welfare rights, schemes table /
schemes responsibilities X 100 annexure)
and welfare Number of
schemes. employees
interviewed
59. CQI 4f Number of Refer to glossary Number of Continuous If there is deviation in
sentinel sentinel events either reporting/
events analysed within collecting/analysis it shall
reported, the defined not be included in the
collected and timeframe numerator.
analysed X 100 Organisations should
within the Number of consider using a portfolio
defined sentinel events of tools-including incident
timeframe reported/collect reporting, medical record
ed review, and analysis of
patient claims-to gain a
comprehensive picture of
sentinel events.
60. CQI 4f Percentage A near miss is an Number of Continuous A key to any near miss
of near unplanned event near misses report is the "lesson
misses that did not result reported learned". Near miss
in injury, illness, or X 100 reporters can describe
damage – but had Number of what they observed of the
(Canadi an Centre
for Occupational
Health and Safety)
63 CQI 4g Percentage Documented Number of Periodic It will improve the
of individualised incomplete monitoring qualitative application of
incomplete patient-focused case AND audits record keeping and
case case management should be done documentation
manageme records atleast
management
nt records X 100 quarterly
plan includes
(IPD) Total number
case analysis
of case
and evaluation, management
miasmatic records
analysis, totality
formation,
repertorisation,
remedy
differentiation,
choice of remedy
and posology for
each patient.
63. CQI 4g Percentage of A discharge Number of Continuous Every medical record that
medical summary is the medical records comes to the MRD from
records not part of a patient not having the clinical unit following
having record that discharge the discharge of a patient
discharge summarizes the summary shall be immediately
summary reasons for X 100 checked for the presence
admission, Number of of discharge summary. If
significant clinical discharges and this is not present at this
findings, deaths stage it shall be captured
procedures as a part of the numerator.
performed,
treatment
rendered,
patient’s condition
on discharge and
any specific
instructions given
to the patient or
family (for
example follow-up
medications).
It is a summary of
the patient’s stay
in hospital written
by the attending
doctor.
64. CQI 4g Percentage of The ICD is the Number of Periodic ICD codification shall be
medical international medical records monthly done by the concerned
records not standard not having (Refer to staff within the specified
having diagnostic codification as sample size period following discharge.
codification classification for all per table / After completion of this
as per general International annexure) specified period an audit
International epidemiological, Classification of shall be done (using
Classification many health Diseases (ICD) sample size mentioned in
of Diseases management X 100 the previous column) by an
(ICD) purposes and Number of independent person to
clinical use. These discharges and capture this.
include deaths
the analysis of
the general health
situation of
population
groups and
monitoring of the
incidence and
prevalence of
diseases and
other health
problems in
relation to other
variables such as
the
characteristics
and
circumstances of
the individuals
affected,
reimbursement,
resource
allocation, quality
and guidelines
(WHO).
65. CQI 4g Percentage of Consent is the Number of Periodic -
medical willingness of a medical monthly
records patient to undergo records having (Refer to
having examination/ incomplete sample size
incomplete procedure/ and/ or table /
and/or treatment by a improper annexure)
improper health care consent
consent provider. Informed X 100
consent is a type of Number of
consent in which discharges and
the health care deaths
provider has a duty
to inform his/her
patient about the
procedure, its
potential risk and
benefits,
alternative
procedure with
their risk and
benefits so as to
enable the patient
to take an informed
decision of his/her
health care.
If any of the
essential
element/requirem
ent of consent is
missing it shall be
considered as
incomplete.
If any consent
obtained is
invalid/void
(consent obtained
from wrong
person/consent
obtained by
wrong person
etc.) it is
considered as
improper.
66. CQI 4g Percentage A medical record Number of Continuous Regular checks should be
of missing is considered as missing record in place to ensure that
records missing when the X 100 there are no missing
record could not Number of medical records or medical
be found out from records records are filed in the
the MRD after the wrong place.
72nd hour of
the record
request.
67. CQI 3j Appropriate Total no. of Periodic - Handover is an important
handovers handovers monthly communication tool used
during shift done (Refer to by the healthcare workers.
change (To appropriately sample size Handover documentation
be done X 100 table / by each shift can be used
separately for Total no. of annexure) as a guide to capture the
doctors and handover information.
nurses) - (per opportunities A good tool for hand over
patient per is ISBAR or SBAR
shift).
68. CQI 3j Incidence of No. of patient Periodic - Numerator can be
Patient identification monthly captured through
identification errors (Refer to observation of
errors X100 sample size doctors/nurses using two
No. of patients table / identification before
annexure) procedure/medication/inte
rvention
69. CQI 3j Compliance to Total no. of Periodic - Good reference is WHO
Hand hygiene hand hygiene monthly hand hygiene compliance
practice missed (Refer to monitoring tool
opportunities/ sample size
X100 table /
*For the recommended sample size, all the samples should be taken on continuous basis.
The following data has to be sent to NABH office at the end of each quarter in
prescribed format.
General information
1 Name of the Hospital
2 Total number of hospital operational beds
3 Total number of ICU beds, if applicable
4 Total number of non-ICU beds
5 Average number of Doctors on hospital rolls in specified period of time
6 Average number of Nurses on hospital rolls specified period of time
7 Total number of operation theatre tables, if applicable
8 Average number of admissions/day(excluding day care)
9 Average number of patients visiting OPD/day
10 Average number of patients visiting Emergency/day, if applicable
11 Average number of elective surgeries/day, if applicable
12 Average number of emergency surgeries/day, if applicable
13 Average number of day care surgeries/day, if applicable
14 Average units of water consumed/month (KL)
15 Average units of electricity consumed/month (Units)
16 Average Length of Stay
16.1 Average Length of Stay (excluding day care and obstetric cases)
17 Bed Occupancy
Annexure - 10
Minimum Standard Requirements for the Homoeopathy
Colleges and associated hospitals
The minimum standard requirements for the Homoeopathy colleges and associated
hospitals as published by The Gazette of India vide their notifications dated 8 th March
2013 or revised version can be followed.
The same are available from the website of Central Council for Homoeopathy at
www.cchindia.com
Annexure - 11
CASE RECORDING FORMAT
(Acute case)
PERSONAL DATA
3. Name of patient………………………
Referred by - …………………………………………………
1. INTERROGATION
1.1 Presenting complaint(s)
Complaints with Location & Sensations/ Modalities Concomitants/
duration extension Character & /Ailments Associated
Pathology from symptoms with
duration
1.2. History of Present Illness: (Origin, duration and progress of each symptom in
chronological order along with their mode of onset, probable cause (s), details of
treatment and their outcome)
2. PHYSICAL EXAMINATION:
2.1 General Examinations
• Conscious / unconscious…………….....
• General appearance (expression, look, decubitus, etc.)
…………………………
• Intelligence and education level……………………………..
• General built and nutrition…………………..
• Height ………. cm, Weight ………… kg & BMI…………………….
• Anaemia………….Jaundice…………… Cyanosis………….Oedema
…………
• Skin (Pigmentation, Hair distribution, Warts etc. ……………..…)
• Nails ………..……………
• Gait………………………..
• Lymphadenopathy (cervical, axillary, inguinal, etc.)……………………….
• Blood pressure… ….mm of Hg
• Pulse…………….
• Temperature……………..
• Respiration rate...… / min.
• Others………………..
System Findings
Respiratory system
Cardiovascular
system
Nervous system
Gastro-intestinal
system
Genito-urinary
system
Loco motor system
Others
4. PROVISIONAL DIAGNOSIS
5. DATA PROCESSING
5.1. Analysis of Case
8. PRESCRIPTION
FOLLOW UP
Date Change in symptomatology Further advise (regarding
prescription including
justification, general
management, investigations etc.)
Annexure - 12
CASE RECORDING FORMAT
(Chronic case)
PERSONAL DATA
3. Name of patient………………………
Email……………………………………………………………….
Referred by - …………………………………………………
1. INTERROGATION
1.1 Presenting complaint(s)
1.2. History of Present Illness: (Origin, duration and progress of each symptom in
chronological order along with their mode of onset, probable cause (s), details of treatment
and their outcome)
1.5.1. Accommodation
1.5.5. Hobbies
1.5.9.3. Education
1.5.9.7. Children
1.6.3. Climacteric
• Age of menopause
• Complaints associated with menopause
• Post menopausal complaints
1.6.4. Abnormal discharge(s) per vagina and Leucorrhoea
Particulars of discharge Modalities
Relation
Quantity & Colour Character including Concomitan
with
consisten & Odour (acrid/ precipitating ts
menses
cy Stains bland) factors
2nd
Appearance
Appetite
Taste
Thirst
Stool
Urine
Sweat
Sleep
Dreams
Thermal reactions
General modalities
Tendencies/Recurrent complaints
1.8.2. Mentals
Will
• Will & emotion including motivation
Cause
Modalities
State
Aversions and cravings (excluding for foods and drinks)
2. PHYSICAL EXAMINATIONS
2.1 General Examinations
• Conscious / unconscious…………….....
• General appearance (expression, look, decubitus, etc.)
…………………………
• General built and nutrition…………………..
• Height ………. cm, Weight ………… kg & BMI…………………….
• Anaemia………….Jaundice…………… Cyanosis………….Oedema
…………
• Skin (Pigmentation, Hair distribution, Warts……………………)
• Nails …………………………….………..
• Gait…………………………………
• Lymphadenopathy (cervical, axillary, inguinal, etc.)……………………….
• Blood pressure… ….mm of Hg Pulse……………. Temperature……………..
• Respiration rate...… / min.
• Others ………………
System Findings
Respiratory system
Cardiovascular
system
Nervous system
Gastro-intestinal
system
Genito-urinary
system
Locomotor system
Others
The physician may examine from scalp to foot, to observe any finding that patient had
forgotten to inform like warts, moles, abnormal growth of hair etc.
4. PROVISIONAL DIAGNOSIS
5. DATA PROCESSING
5.1. Analysis of Case
5.1.1. Classification of Symptoms
Body
6. SELECTION OF MEDICINE
6.1. Non Repertorial approach
6.2. Repertorial approach
• Selection of appropriate repertory
• Selection of symptoms for repertorisation
• Conversion of symptoms into corresponding rubrics for repertorisation
• Repertorisation proper
• Analysis of repertorial result
FOLLOW UP
Date Change in symptomatology Further advise (regarding
prescription including
justification, general
management, investigations etc.)