Cqi Kpi Booklet

Annexures
2nd Edition
April 2016
© National Accreditation Board for Hospitals and Healthcare Providers i

© All Rights Reserved
No part of this book may be reproduced or transmitted in any form without permission in
writing from the author.
2nd Edition April 2016
© National Accreditation Board for Hospitals and Healthcare Providers ii

Table of Contents
Sr. No. Particulars Page No.
01. Annexure-1 : Introduction to Green Hospital 01-04
02. Annexure-2 : Communication in Healthcare 05-10
03. Annexure-3 : Clinical Audit 11-15
Annexure-4: Revised Guidelines for Air Conditioning in

04. 16-21
Operation Theatres
05. Annexure-5 : Sentinel Events 22-24
06. Annexure-6 : Patient Responsibilities (Indicative Guide) 25-26
07. Annexure-7 : Key Performance Indicators 27-29
Annexure-8: The Key Performance Indicators Expected to

08. 30-64
be Monitored by Healthcare Organisation
Annexure-9: Minimum Standards Requirement for the

9. 66
Ayurveda colleges and associated hospitals
© National Accreditation Board for Hospitals and Healthcare Providers iii

© National Accreditation Board for Hospitals and Healthcare Providers iv
Annexure - 1 : Introduction to Green Hospital
Annexure - 1
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 at least 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 wellbeing 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 housekeeping, 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,
© National Accreditation Board for Hospitals and Healthcare Providers 1

hospitals of tomorrow will now focus on wellness and be transformed into welcoming
spaces to get well.
The following are the suggestive measures to be adopted by organisation to move

towards energy efficient Green Hospital concept.
 Efficient usage periphery area & terrace of organisation by creation of

landscape gardening including planting suitable boundary, roadside &
ornamental trees.
 The arriving at right water balance chart for both intake & reuse for newly
constructed hospital using NBC (National Building Code) guidelines.
 The due consideration is to be given towards high energy efficient equipment
(including medical equipment) during purchase of equipment.
 Step towards energy efficiency can be achieved by providing of more natural
lights inside the organisation including patient care area ,usage of low power
consumption lights, solar photo voltaic energy, usage of alternate energy source
like wind energy. The dynamic harmonic filtration with Power Factor
improvement system can considered as part of design. The installation of
electrical energy meters across various locations and possible integration to
building management system with energy meters is suggested.
 Water efficiency includes rain water harvesting, rain water recharge pits, high
efficiency faucets, sterilisation of aerators used for water conservations once in
six months, sewage treatment & reusage of waste water, usage of solar plant
towards generation of 20% of hot water generation. Usage of water Level
controllers in pumping systems, variable frequency drives usage. The installation
of water meter across hospital and provision of water consumption monitoring is
another suggested measured.
 Creation of building envelop for air reduction leakage & infiltration of air may
cause bad air quality, energy efficiency in HVAC, lighting, electrical power and
water heating. Areas under central air conditioning can be planned with individual
controls using Variable Air Volume system. All Air Handling Units are planned
with VFD’s (Variable Frequency Drives) for fan speed modulations.

 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, continuous
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.

o The organisation to have indicators for measuring the waste generation as

per the category (hazardous, recyclable, bio-medical, e-waste etc.) through
waste audit.
References:
ECBC guidelines, bureau of energy efficiency, Govt. of India, Best practices across
various hospitals & AHPI checklist on green hospital

Annexure - 2 : Communication in Healthcare
Annexure - 2
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.
What is effective communication?

By definition, “communication is a transactional process to create meaning”. There are
3 components of communication. Those are sender, receiver and message. In a typical
doctor –patient interview, doctor assumes the role of sender as well as receiver. The
meaning which needs to be communicated is not in the “message” as the doctor may
have a different meaning and the patient may have a different one. So the purpose of
effective communication is to share a common meaning.
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.

 Greeting, establishing the rapport

 Listening patiently
 Having a favourable body language which includes the way we dress up, sitting
posture, eye contact etc.
 Showing empathy ( Putting ourselves in patient/family’s position)
 Not using unnecessary medical jargon
 Not being judgmental
 Clearing the doubts and confirming whether they have any questions
 Greeting, thanking
Though apparently it appears that good communication demands more time, the
literature has proven that on an average it takes only a minute more to communicate
well once the skill is mastered.
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.
I: Identification (of the staff, patient)

S: situation (current problem)
B: Background (past problems, comorbidities, treatment given so far etc)
A: Assessment (Vitals, pain, drains etc)
R: Recommendation (Investigations to be done, medication to be given, consults to be
taken , pending things, planning for discharge or move out etc).
The same tool can be used by doctors also for handing over during shifts, telephone
conversations about a patient or for communications among different specialties.
Another tool which helps in achieving patient safety is a tool called “Assertiveness
saves lives”. The steps are
1. Get Person’s attention (Doctor, I am …calling from ward…, I have a serious

problem now)

2. Express concern (I am really concerned about Mr…….)

3. State problem (His pulse is 130, BP is 90/60, and he is looking pale…)
4. Propose Action (Doc, I would like you to come and see the patient immediately)
5. Reach decision (Doctor, So… you are busy in theatre, can I inform the Consultant,
as I think a doctor is needed urgently to make a decision).
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
 Breaking Bad news

 Disclosing Death
 Handling an aggressive patient/family
 Communication in case of emergency/disasters
 Disclosure of an adverse event
 Managing an angry employee
 Handling patient-staff argument etc.
The protocols for these situations should include the following points though can be
customized according to situations. Below is an example of Breaking Bad news.
 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 counselling. It is also necessary to identify patients with speech and
hearing disability so that they can be appropriately counselled.
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
behaviours 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 behaviours. 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.
 Alcohol and smoking at workplace

 Abusing a patient
 Inappropriate behaviour with women
 Employees fighting in the corridors
 Disrespect to any religion
 Any behaviour violating the patient right
 Talking bad about professional colleagues of same or different specialty
 Talking bad about alternate approved system of medicine
 Corruption etc.

Monitoring effective communication:

With the help of patient feedbacks, complaints and analysis of incidents the issues
which are communication related should be identified as this forms the major portion of
root cause. Then appropriate dissemination of information in the form of training to
concerned personnel should be given as a preventive action. Other ways of capturing
information about communication are direct observations by peers and getting
communication specific feedbacks from stakeholders.
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, role modelling,
videos etc. Communication training for front office staff can be some good etiquette to
make the patient feel comfortable and welcome.
Communication is the back bone of healthcare communication and strategically the

organisation has to plan regarding educating, monitoring and learning constantly the
“good communication practices”.
Material for further reading:

1. Alexander Thomas. Communicate. care. cure - A guide to healthcare
communication. 2nd ed. Wolters Kluwer and Bangalore Baptist Hospital;2015
2. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP.SPIKES: a six-
step protocol for delivering bad news: application to the patient with cancer. The
Oncologist 2000 Aug;5(4):302-11
3. British Medical Association, National Patient Safety Agency, NHS Modernisation
Agency. Safe handover for clinicians and manager [cited 2011 Jan 21]. Available
from: 2005
http://www.saferhealthcare.org.uk/IHI/Products/Publications/safehandoversafepatie
nts.htm2005.

4. Communicating with patients, Australian Government.2004 Available

from:http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/e58.pdf
5. Communicating with patients about surgical errors and adverse outcomes.
American College of Surgeons Division of Education: Chicago;2007. [Video DVD].
[Cited 2012 Oct 17]. Available from:
URL:https://web4.facs.org/ebusiness/productCatalog/product.aspx?ID=229.
6. Haig K, Sutton S, Whittington J. SBAR: a shared mental model for improving
communication between clinicians. Jt Comm J Qual Patient Saf 2006
Mar;32(3):167-75.

Annexure - 3 : Clinical Audit
Annexure - 3
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 so as to explain all
aspects of the subject without compromising the basic tenants of the audit.
What is audit?
It is the process of reviewing of delivery of care to identify deficiencies so that they may
be remedied.
What is clinical audit (CA)?

It may be defined as peer review for evaluation of medical care through retrospective
and concurrent analysis of medical record.
What is the primary aim of CA?

To improve the quality of healthcare services rendered to the patients.
Who will carry out CA?

Clinical Audit Committee
 MS/Coordinator/Hospital Administrator
 Representatives of all disciplines
What are the prerequisites?

 Good record-keeping system
 Should be carried out by fair and impartial professionals
 Clinicians, nursing and other staff as well as patient anonymity to be maintained
 Purpose should be simple and clearly stated
 Intention should be to effect change for the better

How to audit?
The Audit Cycle
Measure baseline
Review standard
if required Set standards
Measure practice
Evaluate through data
change collection and
analysis
Assessment of
Implement performance against
change standard
Suggest change Identify opportunity

for improvement
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. Specific disease/specific operations
b. Increase incidence of a disease
c. Post Panchakarma therapy/treatment procedure or 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, all patients requiring urgent
appointment will be seen that day only.
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.
Example of Criteria and Target Applicable to Structure, Process and Outcome Variables
Structure Process Outcome
Criteria Staffing of Monitoring during Vyapaths
Panchakarma Panchakarma
Theatre procedure
Target Not < 2 therapists Not < 90 per cent of the Not to exceed 0.1 per
per treatment procedures done cent for specified
room procedures
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.
3. Worksheet preparation and methodology of administration
a. Simplest for the purpose
b. Only essential data is collected
c. Suitable sample size is to be selected
d. Probability of bias is to be considered
i. Non-response to a survey
ii. Unavailability of certain type of case note
iii. Selective referral of certain types of patients

iv. Failure of patient to turn up for follow up

4. Tabulation of evaluation
5. Interpretations
a. Deficiency of care recognised
b. Specific solutions are proposed. They may not be possible every time.
c. Education impact is appreciated
d. Planned programme for change
e. All staff is involved
f. Active feedback
g. Audit is evaluated
Q) What are the motives for doing audit?

They can be broadly categorised as under:
 Professional
 Social
 Pragmatic
 Legal
A diagrammatic representation of the motives is given below
Professional Motives Social Motives Pragmatic Motives
a) To identify a) To ensure safety of To reduce patients

deficiencies public suffering
b) Educational need b) To prevent
c) Self-correction & patient from
self-regulation inappropriate or
suboptimal care
Legal Motives
CPA Negligence Malpractice

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.
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 - 4 : Revised Guidelines for Air Conditioning in Operation Theatres
Annexure - 4
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:
1. Super specialty OT: Super specialty OT means operation theatres for

Neurosciences, Orthopaedics (Joint Replacement), Cardiothoracic and
Transplant Surgery (Renal, Liver etc.).
2. General OT: This includes operation theatres for Ophthalmology, District
hospital OTs, FRU OT and all other basic surgical disciplines.
3. Day care centre: Day surgery is the admission of selected patients to
hospital for a planned surgical procedure, returning home on the same day,
would fall under the category of general OT.
C. The following basic assumptions have been kept in view:
 Occupancy: Standard occupancy of 5-8 persons at any given point of time

inside the OT is considered.
 Equipment Load: Standard equipment load of 5-7 kW and lighting load of 1
kW to be considered per OT. For super speciality OT the equipment load can
be taken as 7 – 9KW.
 Ambient temperature & humidity at each location to be considered while
designing the system.

REQUIREMENTS – Super Specialty OT

1. Air Changes 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.
 100 % outdoor ventilation air systems are not mandatory. If HCO chooses to
have 100% fresh air system than appropriate energy saving devices like heat
recovery wheel, run around pipes etc. should be installed.
 The supply & return air ducts must be of non-corrosive material.
 No internal insulation or acoustic lining must be done on ducts as they can
become breeding grounds.
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.

3. The minimum positive pressure recommended is 2.5 Pascal (0.01 inches of

water)
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.
7. Temp & RH for Super-specialty OT: It should be maintained 21 C +/- 3 C

(except for Ortho for Joints replacement as 18 C +/-2 C) with corresponding
relative humidity between 20 to 60% though the ideal RH is considered to be
55%. Appropriate devices to monitor and display these conditions inside the OT
may be installed.

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.
Design considerations for Planning New Operation Theatres
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)

e) General Lights – Clean room lights

f) Provision of safety against static charge.
g) Separate power circuit for equipment like Laser.
h) The anti-static flooring, walls and ceiling should be non-porous, smooth, seamless
without corners (coving) and should be easily cleanable repeatedly. The material
should be chosen accordingly. Anti-static Flooring – seamless, including skirting,
should not be of porous stone as it absorbs moisture and could be a source of bio-
burden.
Maintenance of the system

 During the non-functional hours AHU blower will be operational round the clock (may
be without temperature control). Variable frequency devices (VFD) may be used to
conserve energy. Air changes can be reduced to 25% during non-operating hours
thru VFD provided positive pressure relationship is not disturbed during such period.
 Validation of system to be done as per ISO 14644 standards and should include:
 Temperature and Humidity check
 Air particulate count
 Air Change Rate Calculation
 Air velocity at outlet of terminal filtration unit /filters
 Pressure Differential levels of the OT wrto ambient / adjoining areas
 Validation of HEPA Filters by appropriate tests like DOP (Dispersed Oil
Particulate) /POA (Poly Alpha Olefin) etc.; repeat after 6 month in case HEPA
found healthy.
 Preventive Maintenance of the system: It is recommended that periodic

preventive maintenance be carried out in terms of cleaning of pre filters, micro vee
at the interval of 15 days. Preventive maintenance of all the parts of AHU is
carried out as per manufacturer recommendations.

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.
ASSESSORS CHECKLIST DURING NABH AUDIT

1. To check the temperature, humidity inside OT.
2. The differential pressure inside & outside OT.
3. Maintenance record of AHU & filter cleaning frequency.
4. Last HEPA filtration report & HEPA validation report.
5. Is Air-conditioning done through split AC or AHU?

Annexure - 5 : Sentinel Events
Annexure - 5
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.
Major and enduring loss of function refers to sensory, motor, physiological, or

psychological impairment not present at the time services were sought or begun. The
impairment lasts for a minimum period of two weeks and is not related to an underlying
condition.
Event type description

1. Surgical events
 Surgery performed on the wrong body part

 Surgery performed on the wrong patient
 Wrong surgical procedure performed on the wrong patient
 Retained instruments in patient discovered after surgery/procedure
 Patient death during or immediately post-surgical procedure
 Anesthesia-related event
2. Device or product events Patient death or serious disability associated with:
 the use of contaminated drugs, devices, products supplied by the

organisation
 the use or function of a device in a manner other than the device’s intended
use
 the failure or breakdown of a device or medical equipment
 intravascular air embolism
3. Patient protection events
 Discharge of an infant to the wrong person

 Patient death or serious disability associated with elopement from the

healthcare facility
 Patient suicide, attempted suicide, or deliberate self-harm resulting in serious
disability
 Intentional injury to a patient by a staff member, another patient, visitor, or
other
 Any incident in which a line designated for oxygen or other came to be
delivered to a patient and contains the wrong gas or is contaminated by toxic
substances
 Nosocomial infection or disease causing patient death or serious disability
4. Environmental events
Patient death or serious disability while being cared for in a healthcare facility
associated with:
 a burn incurred from any source

 a slip, trip, or fall
 an electric shock
 the use of restraints or bedrails
5. Care management events
 Patient death or serious disability associated with a hemolytic reaction due to

the administration of ABO-incompatible blood or blood products
 Maternal death or serious disability associated with labour or delivery in a low-
risk pregnancy
 Medication error leading to the death or serious disability of patient due to
incorrect administration of drugs, for example:
o omission error
o dosage error
o dose-preparation error
o wrong-time error
o wrong rate of administration error
o wrong administrative technique error

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
 Any instance of care ordered by or provided by an individual impersonating a

clinical member of staff
 Abduction of a patient
 Sexual assault on a patient within or on the grounds of the healthcare facility
 Death or significant injury of a patient or staff member resulting from a
physical assault or other crime that occurs within or on the grounds of the
healthcare facility.

Annexure - 6 : Patient Responsibilities (Indicative Guide)
Annexure - 6
Patient Responsibilities (Indicative Guide)
Patient Responsibilities (Indicative Guide)

 Provide complete and accurate information about his/her health, including present
condition, past illnesses, hospitalisations, medications, natural products and
vitamins, and any other matters that pertain to his/her health.
 Provide complete and accurate information including full name, address and other
information.
 To ask questions when he/she does not understand what the doctor or other
member of the healthcare team tells about diagnosis or treatment. He/she should
also inform the doctor if he/she anticipates problems in following prescribed
treatment or considering alternative therapies.
 Abide by all hospital rules and regulations.
– Comply with the no-smoking policy.
– Comply with the visitor policies to ensure the rights and comfort of all patients. Be
considerate of noise levels, privacy, and safety. Weapons are prohibited on
premises.
– 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 patient’s medical condition may be more urgent than
yours and accept that your doctor may need to attend them first.

Annexure - 6 : Patient Responsibilities (Indicative Guide)
 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 - 7 : NABH Key Performance Indicators
Annexure - 7
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 economical 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:
 Establish baseline information (i.e., the current state of performance)

 Set performance standards and targets to motivate continuous improvement
 Measure and report improvements over time
 Compare performance across geographic locations
 Benchmark performance against regional and international peers or norms
 Allow stakeholders to independently judge health sector performance.
There are several main dimensions most frequently used to measure hospitals’
performance viz Clinical efficiency (Clinical quality, evidence-based practices, health
improvement and outcomes for individual and patients), Operational efficiency
(Resource utilisation of services like reduction in waiting time or improvement in non-

productive OT time and provision of state-of-the-art medical equipment and technique),

Personnel (Satisfying the human resources needs, providing proper conditions to keep
the health of the hospital personnel safe and also to improve it, ensuring fair
opportunities for continuous medical education), Social accountability and reactivity
(Orientation towards community- response to needs and requirements, health
promotion with abilities to adapt to increasing demands of the population) , Safety (for
Patients, Healthcare worker and facility) and Focus on patient (Availability of services in
accordance to scope towards patients, focusing on the patient and attendants, patient`s
satisfaction and patient’s experience involving dignity, confidentiality, autonomy,
communication).
Donabedian et al introduced a concept of key performance indicators being seen as

structure, process and outcome based. NABH in its 2nd edition has 62 key performance
indicators. Most of the indicators in hospitals are process based indicators with an intent
that quality delivery and outcome improves.
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 - 8 : The Key Performance Indicators
Annexure - 8
The Key Performance Indicators Expected to be Monitored by
Healthcare Organisation
The Key performance indicators expected to be monitored by healthcare organisation
Sl. Standard Indicator Definition Formula Frequency Remarks**

No of Data
Collection /
Monitoring*
1. CQI 3a Time for The time shall begin Sum of time taken for the The average time
initial from the time that the assessment should be reviewed by
assessment patient has arrived at the hospital, to see if
of in-patient the bed of the ward till Total number of in-patients and this has impacted
and the time that the initial emergency patients clinical care, outcome,
emergency assessment has been or has reduced the
patients completed by a doctor. efficiency.
In case of emergency The outliers: those
the time shall begin taking more than 20% of
from the time the the average time shall
patient has come to the be audited.
door of the emergency
The hospital will make
till the time that the
efforts to keep this
initial assessment is
measure at low levels,
completed by a doctor.
and track trends in times
of increased patient
flows.

2. Percentage Desired outcome Number of in-patient The indicator shall be

of cases (in- includes curative, case records wherein captured during the stay
patients) preventive, the care plan with of the patient and not
wherein care rehabilitative etc. desired outcomes from the medical record
plan with has been department. It shall be
desired documented collated on a monthly
outcomes is basis. The sampling
documented Total number of X 100 base shall be patients
and counter- patients who have completed 24
signed by the hours of stay in the
clinician. hospital.
However, immediate
correction is to be
initiated, when gaps are
seen on a real time
basis.
3. Percentage Treatment outcomes Number of in-patient The indicator shall be

of cases (in- include that of case records wherein captured during the stay
patients) Panchakarma treatment outcome is of the patient and not
wherein the treatments, Treatment documented from the medical record
treatment procedures, X 100 department. It shall be
plan is Parasurgical Total number of collated on a monthly
documented. procedures etc patients basis. The sampling
base shall be patients
who have 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 3b Number of Reporting errors Number of reporting continuous This shall be captured in
reporting include those picked up errors the laboratory and
X
errors/1000 before and after radiology.
1000
investigation dispatch. It shall Number of tests
Although the indicator is
s include transcription performed
capture don a monthly
errors.
basis, immediate
correction is to be
initiated when such
instances happen.
5. Percentage This shall also include Number of re-dos continuous This shall be captured in
of re-dos. tests repeated before the laboratory and
X 100
release of the result (to Number of tests radiology
confirm the finding). performed
6. Percentage Co-relation means that Number of reports Refer to This shall be captured in
of reports co- the test results should co-relating with sample size the laboratory (at least
X 100
relating with match either the clinical diagnosis table/Annexu histo-pathology) and
clinical diagnosis or differential re radiology (at least CT
diagnosis. diagnosis written in the Number of tests and MRI).
requisition form. performed
7. Percentage Number of Refer to This shall be captured in

of adherence employees adhering sample size the laboratory and
X 100
to safety to safety precautions table/Annexu radiology.

precautions re This shall be captured

Number of
by by doing an audit on a
employees sampled
employees monthly basis.
working in
Even if the employee is
diagnostics.
not adhering with any
one of the
organisation’s/statutory
safety precautions it
shall be considered as
non-adherence.
8. CQI 3c Incidence of A medication error is Total number of X 100 Refer to In addition to incident
medication any preventable event medication errors sample size reporting, to detect

errors that may cause or lead table/Annexu medication errors the

Number of patient
to inappropriate re organisation shall either
(Medication days
medication use or harm adopt medical record
errors per
to a patient (US-FDA). review or direct
patient days)
observation. The
Examples include, but
sample size for this shall
are not limited to:
be as per the preceding
 Errors in the column. The average
prescribing, occupancy shall be of
transcribing, the preceding 3 months.
dispensing, Medication Error is to be
administering, and calculated only in IP. OP
monitoring of calculations are beyond
medications; the scope.
 Wrong drug, wrong

strength, or wrong
dose errors;
 Wrong patient
errors;
 Wrong route of
administration
errors; and
 Calculation or
preparation errors.
9. Percentage Refer to glossary Number of adverse X 100 Continuous

of drug reactions
admissions

with adverse
Number of
drug reaction
discharges and
(s)
deaths
10. Percentage Medication chart with Number of Refer to This could be clubbed
of medication illegible handwriting medication charts sample size with the activity for
X 100
charts with and un accepted error with error prone table/Annexu capturing medication
error prone prone abbreviations abbreviations re errors.
abbreviations
Number of
medication charts
reviewed
11. Percentage High risk medications Number of patients Continuous The denominator can be
of patients are medications receiving high alert captured from the
receiving involved in a high medications who pharmacy by having a
high alert percentage of have an adverse drug X 100 master list of in-patients
medications medication errors or event who have been
developing sentinel events and dispensed high-alert
adverse drug medications that carry Number of patients medications.
event. a high risk for abuse, receiving high alert
error, or other adverse medications
outcomes.
12. CQI 3 e Urinary tract Number of urinary X 100 continuous

infection rate catheter associated
UTIs in a month
Number of urinary
catheter days in that
month
13. Basti Number of Basti continuous

infection rate Associated infections
in a month

X 100
Number of basti days
in that month
14. Para-surgical Number of Para- continuous Para-surgical site

site infection surgical site infection are those
rate infections in a month infection which are
X 100 detected within 30 days
Number of of the procedure.
Parasurgeries in that
month
15. CQI 3 f Percentage Re-scheduling of Number of cases re- continuous

of re- patients includes scheduled
X 100
scheduling of cancellation and
parasurgical postponement (beyond Number of surgeries
procedure 4 hours) of the performed in that
procedure. month
16. Percentage Number of cases Not This could be checked

of cases where the procedure applicable in the post-op/recovery
X 100
where the was followed room and documented

organisation’ in a register/system.
Number of procedure
s procedure
performed in that
to prevent
month
adverse
events like
wrong site,
wrong patient
and wrong
procedure
have been
adhered to
17. CQI 3 g Percentage Re-scheduling of Number of cases re- Not

of re- patients includes scheduled applicable
X 100
Panchakarm postponement (beyond Number of
a therapies/ 4 hours) of the Panchakarma/
Treatment Panchakarma therapy/ treatment procedure
procedure Treatment procedure. performed

of cases where the procedure applicable in the Panchakarma
X 100
where the was not followed treatment record/
organisation’ treatment procedure
s procedure Number of record and documented
to prevent Panchakarma in the register/system.
adverse therapies and
events like treatment procedures
wrong site, performed

wrong patient
and wrong
procedure
have been
adhered to
19. CQI 3 h Percentage Number of research Continuous This indicator shall be

of research activities approved by captured on a quarterly
activities ethics committee basis.
approved by X 100
Ethics Number of research
committee protocols submitted
to ethics committee
20. Percentage Number of patients Continuous This indicator shall be

of patients who have withdrawn captured on a quarterly
withdrawing from all on-going basis.
from the studies
study X 100
Number of patients
enrolled in all on-
going studies
21. Percentage Number of protocol Continuous This indicator shall be

of protocol violations/ deviations captured on a quarterly
violations/ reported basis.

deviations X 100 Any protocol violation/

Number of protocol
reported deviation that gets
violations/ deviations
reported based on an
that have occurred
internal/external
assessment finding shall
be considered as
deemed to have
happened but not
reported. Hence, even
though it gets reported it
shall be included to only
calculate the
denominator and shall
not be included in the
numerator.
22. Percentage The timeframe for Number of serious Continuous This indicator shall be
of serious reporting shall be as adverse events captured on a quarterly
adverse per ICMR guidelines or reported within the basis.
events as laid down by the defined timeframe
(which have sponsor. X 100
occurred in Number of serious
As per ICMR
the adverse events
guidelines, within the
organisation) reported within and
defined timeframe is
reported to outside the defined
the most essential
the ethics timeframe
which is 24hrs and
committee
sponsored trial
within the
expresses timeframe
defined
as 3 days.
timeframe.
23. CQI 4a Percentage These include drugs Number of items Continuous This includes medicines
of drugs and and consumables purchased by local or consumables which
consumables which are not included purchase were used by the

procured by in the hospital X 100 patients before

Number of drugs
local formulary at the time of admission and need to
listed in hospital
purchase prescription, but are continue but it is not
formulary and
then arranged by the included in the hospital
hospital consumables
hospital pharmacy itself list (generic).
list
for the patient with in a
To capture this,
short time.
organisation should
maintain a register in
the pharmacy and
stores (and also if
necessary in the wards)
wherein all such events
are captured.
24. Percentage A stock out is an event Number of stock outs X 100 Continuous To capture this,
of stock outs which occurs when an organisation should
including item in a pharmacy or Number of drugs maintain a register in
emergency consumable store is listed in hospital the pharmacy and
drugs temporarily unable to formulary and stores (and also if
provide for an intended hospital consumables necessary in the wards)
patient. list wherein all such events
are captured.
25. Percentage All materials received Total quantity X 100 Continuous Please note that the
of drugs and not in conformity with rejected denominator is total
consumables the specifications and quantity and not
rejected requirements ordered Total quantity number. For example, a
before for in the purchase received before GRN single order may have
preparation order shall be rejected. 30 items of “X”
of Goods consumable. Of the 30,
Receipt Note 10 may be rejected. In
this case the formula will
be 10/30.

26. Percentage Variations from the Total number of Continuous

of variations written standardised variations from the
X 100
from the procurement process of defined procurement
procurement acquiring supplies from process
process licensed, authorized,
agencies, wholesalers/ Total number of items
distributors. procured
27. CQI 4b Number of Mock drill is a Total number of variations in a Continuous To capture the variation
variations simulation exercise of mock drill it is suggested that
observed in preparedness for any every organisation
mock drills type of event. It could develop a checklist to
be event or disaster. capture the events
This is basically a dry during a mock drill.
run or preparedness
drill.
For example, fire mock
drill, disaster drill, Code
Blue Drill.
28. Incidence of The US Department of Number of falls X 100 Continuous Falls may be:

falls Veteran Affairs National • at different levels –

Total number of
Centre for Patient i.e., from one level to
patient days
Safety defines fall as ground level e.g.
from beds,
“Loss of upright
wheelchairs or down
position that results in
stairs
landing on the floor,
ground or an object or • on the same level as
furniture or a sudden, a result of slipping,
uncontrolled, tripping, or
unintentional, non- stumbling, or from a
purposeful, downward collision, pushing, or
displacement of the shoving, by or with
body to the floor/ground another person
or hitting another object
• below ground level,
like a chair or stair.”
i.e. into a hole or
It is an event that other opening in
results in a person surface
coming to rest
All types of falls are to
inadvertently on the
be included whether
ground or floor or other
they result from
lower level.
physiological reasons
(fainting) or
environmental reasons.
Assisted falls (when
another person attempts
to minimize the impact
of the fall by assisting
the patient’s descent to
the floor) should be
included. (NDNQI, 2005)
29. Incidence of A pressure ulcer is Number of patients Continuous The organisation shall
bed sores localized injury to the who develop new use The European and
after skin and/or underlying /worsening of US National Pressure
admission tissue usually over a pressure ulcer Ulcer Advisory panels

(Bed sores bony prominence, as a X (EPUAP and NPUAP)

Total no. of patient
per 1000 result of pressure, or 1000 staging system to look
days
patient days) pressure in for worsening pressure
combination with shear ulcers.
and/or friction.
30. Incidence of Number of patients Continuous

burn injury with burn injury
during
treatment X100
Number of patients
procedures
receiving treatment
procedures that
include heat
application
31. Percentage Pre-exposure Number of Continuous This shall include at a

of employees prophylaxis is any employees who were minimum prophylaxis
provided pre- medical or public health provided pre- against Hepatitis B.
exposure procedure used before exposure prophylaxis
The denominator shall
prophylaxis exposure to the
include new employees
disease causing agent, Number of
X 100 (working in patient care
its purpose is to employees who were
areas) and existing
prevent, rather than due to be provided
employees whose
treat or cure a disease. pre- exposure
booster dose is due in
(Wikipedia) prophylaxis
that month.
32. CQI 4 d Bed The bed occupancy Number of inpatient X 100 Continuous For a bed to be included
occupancy rate is the percentage days in a given in the official count, it
rate and of official beds month must be set up, staffed,

average occupied by hospital equipped and available

Number of available
length of stay inpatients for a given for patient care.
bed days in that
period of time. – (Basic Inpatient Days: A patient
month
statistics for health day is the unit of
information measure denoting
management lodging provided and
technology By Carol E. services rendered to
Osborn) inpatients between the
The occupancy rate is census taking hours
a calculation used to (usually at midnight) of
show the actual two successive days. A
utilisation of an patient formally admitted
inpatient health facility who is discharged or
for a given time period. dies on the same day is
counted as one patient
day, regardless of the
number of hours the
patient occupies a
hospital bed. For
patients switched from
observation to inpatient
status, the patient day
count should begin on
the day the patient was
officially admitted as an
inpatient.
Length of stay (LOS) is Number of inpatient Continuous Available bed days- It is

a term used to measure days in a given the product of number of
the duration of a single month inpatient beds and
episode of number of days in that
hospitalization. Number of month.
Inpatient days are discharges and
Number of inpatient
calculated by deaths in that month

subtracting day of days-It is a sum of daily

admission from day of inpatient census.
discharge. However,
While calculating the
persons entering and
overall length of stay
leaving a hospital on
and available number of
the same day have a
inpatient beds,
length of stay of one
emergency,
rehabilitation and day
care beds should not be
considered.
33. Panchakarm Utilisation is defined as Utilisation rate = Total Resource hours - total
a theatre, the quotient of hours of population number of hours
treatment OT time actually used scheduled to be
procedure during elective Utilisation time in available for
room and OT resource hours and the hours performance of
X 100
utilisation total number of elective procedures
rate resource hours Resource hours
available for use. Equipment days
available = Number of
The degree of equipment X 30 days
utilisation depicts the
average utilisation of Equipment utilisation
beds in per cent. The =
actual bed occupancy
is set in relation to the Number of equipment
maximum bed utilized days
occupancy. The
Equipment days X 100
maximum bed capacity
is the result of the available
product of installed
beds and the number of
Bed utilisation =
calendar days in the
reporting year. The
Number of bed
actual bed occupancy
utilized days

is the sum of X 100

Bed days available
calculation days and
occupancy days,
because every patient
occupies one bed per
inpatient day in the
facility
34. Critical The term downtime is Sum of down time for Continuous Check list of all
equipment used to refer to periods all critical equipment in equipment should be
down time when a system is hours updated in the unit on
unavailable. Downtime X 1000 daily basis to monitor
or outage duration Patient days equipment utilisation
refers to a period of and downtime.
time that a system fails
to provide or perform its
primary function
35. Paricharaka- Number of staff Continuous The HCOs should

patient ratio calculate the staffing
for wards Number of beds patterns separately for
the wards.
The in-
To be calucalted for every shift charge/supervisor of the

area shall not be

included for calculating
the number of staff.
For example, if in the
wards there are a total
of 15 Paricharakas who
work in 3 shifts the
numerator will 5 (15/3)
and if there are 15 beds
the ratio is 1:3. Similarly
for wards.
36. CQI 4 e Out patient Patient Satisfaction is Average Score Refer to The sample shall be
satisfaction defined in terms of the achieved sample size derived from repeat

index degree to which the X 100 table/Annexu patients. It is preferable

Maximum possible
patient’s expectations re that patients who are
score
are fulfilled. It is an coming to the hospital
expression of the gap for the first time not be
between the expected included as it is possible
and perceived that they would not be in
characteristics of a a position to give
service (Lochoro, feedback on some
2004). aspects.
The organisation could
also capture satisfaction
for various individual
parameters (as laid
down in its feedback
form). In case the
organisation is not
capturing an overall
feedback but instead
only for various
parameters, the index
shall be calculated by
averaging the
satisfaction of various
parameters.
37. In patient Average Score Refer to Refer to remark for out

satisfaction achieved sample size patient satisfaction
X 100
index table/Annexu index.
Maximum possible re
score
38. Waiting time A waiting time is a Sum (Patient-in Time Continuous Waiting time for
for services length of time which for Consultation/ diagnostics is applicable
including one must wait in order Procedure - Patient only for out-patients.
diagnostics for a specific action to Reporting Time in
and out- occur, after that action OPD/Diagnostics)

patient is requested or
Number of patients
consultation mandated.
reported in OPD/
Waiting time for Diagnostics
diagnostics is the time
from which the patient
has come to the
diagnostic service
(requisition form 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.
39. Time taken Discharge is the Sum of time taken for Continuous In case patients request
for discharge process by which a discharge additional time to leave

patient is shifted out the clinical unit that shall

Number of patients discharged
from the hospital with not be added. The
all concerned medical discharge is deemed to
summaries after have been complete
ensuring stability. when the formalities for
the same have been
The discharge process
completed.
is deemed to have
started when the
consultant formally
approves discharge
and ends with the
patient leaving the
clinical unit.
40. CQI 4 f Employee Employee satisfaction Average Score Refer to Refer to remark for out-
satisfaction index is an index to achieved sample size patient satisfaction
X 100
index measure satisfaction of table/Annexu index. The satisfaction
employee in an Maximum possible re shall be captured from
organisation score all categories of staff
and at least once in six
months.
41. Employee Attrition rate is the Number of Continuous

attrition rate percentage of people employees who have
leaving the left in the month
organisation.
Number of
X 100
employees at the
beginning of month +
newly joined staff
42. Employee Absenteeism in Number of Continuous

absenteeism employment law is the employees who are
X 100
rate state of not being on unauthorised
present that occurs absence

when an employee is
Number of
absent or not present at
employees
work during a normally
scheduled work period.
43. Percentage Employee awareness is Number of Refer to

of employees the state or condition of employees who are sample size
who are being aware; having aware of employee table/Annexu
aware of knowledge; rights, responsibilities re
employee consciousness about and welfare schemes
rights, employee rights,
responsibiliti responsibilities and Number of X 100
es and welfare schemes. employees
welfare interviewed
schemes
44. CQI 4 g Number of Refer to glossary Number of sentinel Continuous If there is deviation in
sentinel events analysed either reporting/
events within the defined collecting/analysis it
reported, timeframe shall not be included in
collected and X 100 the numerator.
analysed Number of sentinel
Organisations should
within the events reported,
consider using a
defined
portfolio of tools-
timeframe
including incident
reporting, medical
record review, and
analysis of patient
claims-to gain a
comprehensive picture
of sentinel events.
45. Percentage A near miss is an Number of near X 100 Continuous A key to any near miss
of near unplanned event that misses reported report is the "lesson

misses did not result in injury, learned". Near miss

Number of incident
illness, or damage – reporters can describe
reports
but had the potential to what they observed of
do so. the beginning of the
event, and the factors
Errors that did not
that prevented loss from
result in patient harm,
occurring.
but could have, can be
categorized as near
misses.
A. In IPD Areas:
46. Incidence of An exposure is when Continuous All exposures to
blood body blood, blood Number of blood blood/body fluids should
fluid components or other body fluid exposures be assessed on a case-
exposures potentially infectious by-case basis. Like:
materials come in Number of in-patient
days X Vamna Fluids
contact with a staff’s 1000
eyes, mucous Basti Fluids
membranes, non-intact Bleeding procedures
skin or mouth. B. In OPD Areas
Number of blood etc.
(Adopted from Joan
Viteri Memorial Clinic body fluid exposures
“PEP” Post Exposure Number of OPD
Prophylaxis) patient visits
47. Incidence of Needle stick injury is a Number of parenteral Continuous Parenteral exposure
needle stick penetrating stab wound exposures means injury due to any

injuries from a needle (or other sharp.

Number of in-patient
sharp object) that may
days X 100 All incidences of needle
result in exposure to
stick injuries should be
blood or other body
assessed on a case-by-
fluids.
case basis.
Needle stick injuries
Analyze needle stick
are wounds caused by
and other sharps related
needles that
injuries in the workplace
accidentally puncture
to identify hazards and
the skin.
injury trends.
Needle stick injuries Data from injury
are a hazard for people reporting should be
who work with compiled and assessed
hypodermic syringes to identify:
and other needle (1) where, how, with
equipment. These what devices, and when
injuries can occur at injuries are occurring
any time when people and
use, disassemble, or (2) the groups of health
dispose of needles. care workers being
When not disposed of injured.
properly, needles can
become concealed in
linen or garbage and
injure other workers
who encounter them
unexpectedly.(Canadia
n Centre for
Occupational Health
and Safety)
48. CQI 4 h Percentage A discharge summary Number of medical X 100 Continuous Every medical record
of medical is the part of a patient records not having that comes to the MRD
records not record that summarizes discharge summary from the clinical unit

having the reasons for following the discharge

Number of
discharge admission, significant of a patient shall be
discharges and
summary clinical findings, immediately checked for
deaths
procedures performed, the presence of
treatment rendered, discharge summary. If
patient’s condition on this is not present at this
discharge and any stage it shall be
specific instructions captured as a part of the
given to the patient or numerator.
family (for example
follow-up medications).
It is a summary of the
patient’s stay in
hospital written by the
attending doctor.
49. Percentage Consent is the Number of medical Refer to

of medical willingness of a patient records having sample size
X 100
records to undergo incomplete and/ or table/Annexu
having examination/ improper consent re

incomplete procedure/ treatment

Number of
and/or by a health care
discharges and
improper provider. Informed
deaths
consent consent is a type of
consent in which the
health care 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/requirement 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.
50. Percentage A medical record is Number of missing X 100 Continuous Regular checks should
of missing considered as missing record be in place to ensure

records when the record could that there are no

Number of records
not be found out from missing medical records
the MRD after the 72nd or medical records are
hour of the record filed in the wrong place.
request.
51. CQI 3 k Percentage The anaesthesia plan is Number of patients in Continuous The modification is
of the outcome of pre- whom the anaesthesia plan could
X 100
modification anaesthesia anaesthesia plan was be captured in a
of assessment. Any modified register/system before
anaesthesia changes done after this the patient is shifted out
plan shall be considered as Number of patients of the OT.
modification of who underwent
anaesthesia plan. anaesthesia
52. Percentage Number of patients Continuous Every anaesthesia plan

of unplanned requiring unplanned shall invariably mention
X 100
ventilation ventilation following if there is a possibility of
following anaesthesia the patient requiring
anaesthesia ventilation following
Number of patients anaesthesia. Every case
who underwent wherein a patient
anaesthesia required ventilation but
this was not captured in
the anaesthesia plan
shall be a part of the
numerator.
53. Percentage Adverse anaesthesia Number of patients Continuous

of adverse event is any untoward who developed
X 100
anaesthesia medical occurrence adverse anaesthesia
events that may present during event

treatment with an
Number of patients
anaesthetic product but
who underwent
which does not
anaesthesia
necessarily have a
causal relationship with
this treatment.
54. Anaesthesia Any death where the Number of patients Continuous

related cause is possible, who died due to
X 100
mortality rate probable (likely) or anaesthesia
certain to be due to
anaesthesia shall be Number of patients
included. who underwent
anaesthesia
55. CQI 3e Percentage Number of unplanned X 100 Continuous

of unplanned return to OT
return to OT
Number of patients
operated
56. Percentage Re-scheduling of Number of cases re- Continuous

of re- patients includes scheduled
X 100
surgeries postponement (beyond Number of surgeries
4 hours) of the surgery. planned

of cases where the procedure applicable in the post-op/recovery
X 100
where the was followed room and documented

organisation’ in a register/system.
Number of surgeries
s procedure
performed
to prevent
adverse
events like
wrong site,
wrong patient
and wrong
surgery have
been
adhered to
58. Percentage Number of patients Continuous It is equally important

of cases who who did receive that the antibiotic should
X 100
received appropriate have been given not
appropriate prophylactic antibiotic more than two hours
prophylactic (s) prior to the incision.
antibiotics
This indicator could be
within the Number of surgeries
captured in a
specified performed
register/system before
time frame
the patient enters the
OT.
Appropriate prophylactic
antibiotic should be
according to hospital
policy.
59. CQI 3 m Percentage A systemic response by Number of X 100 Continuous Any adverse reaction to
of transfusion the body to the transfusion reactions the transfusion of blood

reactions administration of blood or blood components

Number of units
incompatible with that shall be considered as
transferred
of the recipient. The transfusion reaction. It
causes include red may range from an
blood cell allergic reaction to a life
incompatibility; allergic threatening complication
sensitivity to the like TRALI and Graft
leukocytes, platelets, Versus Host Disease.
plasma protein
components of the
transfused blood; or
potassium or citrate
preservatives in the
banked blood.
60. Percentage Number of blood and X 100 Continuous This also includes blood
of wastage of blood products products found unfit for
blood and wasted use.

blood In case the organisation

Number of blood and
products does not have a blood
blood products
bank of its own, the
issued from the blood
denominator shall be
bank
the total number of
blood and blood
products
collected/indented from
the blood bank.
It is important that the
organisation capture the
number of blood and
blood products used
and not just the number
of transfusions carried
out. At times more than
one blood bag or
components may have
been given in a single
transfusion.
61. Percentage Number of X 100 Continuous

of blood components used
component
usage Number of blood and
blood products used
62. Turnaround The time shall begin Sum of time taken Continuous This will include blood
time for issue from the time that the outsourced from other
of blood and order is raised to Total number of Blood Banks, for those
blood blood/blood component blood and blood organisations not having
components reaching the clinical components issued in house Blood Banks.
unit.

The indicators shall be indicated in both rates/percentages/ratios and absolute numbers

A. Indicator frequency has been described under:
Continuous: implies data/reports needs to be monitored on daily basis for all events/episodes/activities and analysed
atleast on monthly basis followed by corrective and prevention actions.
Periodic monthly basis: The data needs to be compiled and analysed atleast on monthly basis followed by
corrective and preventive actions based on sample size.
Periodic with audits been done atleast quarterly: This type of indicators can be reviewed on periodic basis using
well designed audits with a goal to improve the patient care and patient safety. The audits can be done through open
and/or closed files using a suggestive sample size as tabulated in sample size annexure below.
B. Indicator results/data presentation:

The presentation of indicators shall be helpful for easy understanding of the data to all relevant stakeholders. Thus
data can be presented as:
1. Indicator results presented in a bar graph: Here, the results can be presented in the form of bar graph with
periodicity monthly/quarterly etc. on x-axis and magnitude of the indicator on y-axis. The graph shall depict
change in results over period of time.
2. Indicator results presented in a statistical process control chart: In such charts, results can be depicted in more
dynamic fashion and comparison with the control line graphs. Action points can be easily identified and impact
post interventions can be assessed in easier manner.
3. Indicator mix graphs can be used to understand impact of intervention/or one indicator over the other. E.g.
Hand hygiene compliance of particular surgical unit can be plotted along with surgical site infection rates or
hand hygiene compliance can be plotted along with ventilator associated pneumonia rates in a graph.

C. Sample size annexure
Screening Population Sample Size*

50 44
100 79
150 108
200 132
500 217
1000 278
2000 322
5000 357
10000 370
20000 377
*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
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
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
11 Average number of elective surgeries/day
12 Average number of emergency surgeries/day
13 Average number of day care surgeries/day
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

Key performance indicators
S. No. Indicator Name

1.1 Incidence of medication errors (Medication errors per patient days)
1.2 Prescription Errors

1.3 Dispensing Errors
2. Percentage of cases who received appropriate prophylactic antibiotics
within the specified time frame
3. Percentage of transfusion reactions
4. Catheter Associated Urinary tract infection rate (CAUTI)

5. Para Surgical site infection rate (SSI)
6. Compliance to Hand Hygiene
7. Incidence of fall
8. Incidence of bed sores after admission
9. Incidence of needle stick injuries
10. In IPD Areas
11 In OPD Areas

Annexure - 10 : Minimum Standard requirements for the Ayurveda colleges and associated hospitals
Annexure - 9
Minimum Standard Requirements for the Ayurveda
Colleges and associated hospitals
Refer the minimum standard requirements for the Ayurveda colleges and associated
hospitals as published by The Gazette of India vide their notifications dated 18 th July
2012 and 22nd April 2013.

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Annexures

© National Accreditation Board for Hospitals and Healthcare Providers i

2nd Edition April 2016

© National Accreditation Board for Hospitals and Healthcare Providers ii

Sr. No. Particulars Page No.

01. Annexure-1 : Introduction to Green Hospital 01-04

02. Annexure-2 : Communication in Healthcare 05-10

03. Annexure-3 : Clinical Audit 11-15

Annexure-4: Revised Guidelines for Air Conditioning in

05. Annexure-5 : Sentinel Events 22-24

06. Annexure-6 : Patient Responsibilities (Indicative Guide) 25-26

07. Annexure-7 : Key Performance Indicators 27-29

Annexure-8: The Key Performance Indicators Expected to

Annexure-9: Minimum Standards Requirement for the

© National Accreditation Board for Hospitals and Healthcare Providers iii

© National Accreditation Board for Hospitals and Healthcare Providers 1

The following are the suggestive measures to be adopted by organisation to move

 Efficient usage periphery area & terrace of organisation by creation of

© National Accreditation Board for Hospitals and Healthcare Providers 2

© National Accreditation Board for Hospitals and Healthcare Providers 3

o The organisation to have indicators for measuring the waste generation as

© National Accreditation Board for Hospitals and Healthcare Providers 4

What is effective communication?

© National Accreditation Board for Hospitals and Healthcare Providers 5

 Greeting, establishing the rapport

I: Identification (of the staff, patient)

1. Get Person’s attention (Doctor, I am …calling from ward…, I have a serious

© National Accreditation Board for Hospitals and Healthcare Providers 6

2. Express concern (I am really concerned about Mr…….)

 Breaking Bad news

© National Accreditation Board for Hospitals and Healthcare Providers 7

 Alcohol and smoking at workplace

© National Accreditation Board for Hospitals and Healthcare Providers 8

Monitoring effective communication:

Communication is the back bone of healthcare communication and strategically the

Material for further reading:

© National Accreditation Board for Hospitals and Healthcare Providers 9

4. Communicating with patients, Australian Government.2004 Available

© National Accreditation Board for Hospitals and Healthcare Providers 10

What is clinical audit (CA)?

What is the primary aim of CA?

Who will carry out CA?

What are the prerequisites?

© National Accreditation Board for Hospitals and Healthcare Providers 11

Suggest change Identify opportunity

© National Accreditation Board for Hospitals and Healthcare Providers 12

© National Accreditation Board for Hospitals and Healthcare Providers 13

iv. Failure of patient to turn up for follow up

Q) What are the motives for doing audit?

A diagrammatic representation of the motives is given below

Professional Motives Social Motives Pragmatic Motives

a) To identify a) To ensure safety of To reduce patients

CPA Negligence Malpractice

© National Accreditation Board for Hospitals and Healthcare Providers 14

© National Accreditation Board for Hospitals and Healthcare Providers 15

1. Super specialty OT: Super specialty OT means operation theatres for

C. The following basic assumptions have been kept in view:

 Occupancy: Standard occupancy of 5-8 persons at any given point of time

© National Accreditation Board for Hospitals and Healthcare Providers 16

REQUIREMENTS – Super Specialty OT