Self Assessment Toolkit
Self Assessment Toolkit
Self Assessment Toolkit
Organisation is required to provide self assessment report in the format 'Self Assessment Toolkit' given below. All the entries are to be properly filled
up. Regarding scoring following criteria would be applicable.
d Patients are accepted only if the organisation can provide the required service.
e The documented policies and procedures also address managing patients during
non-availability of beds. *
f Access to the healthcare services in the organisation is prioritised according to
the clinical needs of the patient.
g The staff are aware of these processes.
AAC.3: There is an appropriate mechanism for transfer (in and out) or referral
of patients.
a Documented policies and procedures guide the transfer-in of patients to the
organisation. *
b Documented policies and procedures guide the transfer-out/referral of unstable
patients to another facility in an appropriate manner. *
c Documented policies and procedures guide the transfer- out/referral of stable
patients to another facility in an appropriate manner. *
d The documented procedures identify staff responsible during transfer/referral.*
e The organisation gives a summary of patient’s condition and the treatment given.
c The organisation defines the time frame within which the initial assessment is
completed based on patient’s needs. *
d The initial assessment for in-patients is documented within 24 hours or earlier as
per the patient’s condition, as defined in the organisation’s policy. *
e Initial assessment of in-patients includes nursing assessment which is done at the
time of admission and documented.
f Initial assessment includes screening for nutritional needs.
h The care plan reflects desired results of the treatment, care or service.
i The care plan is countersigned by the clinician in-charge of the patient within 24
hours.
AAC.5: Patients cared for by the organisation undergo a regular
reassessment.
a Patients are reassessed at appropriate intervals.
c For in-patients during reassessment the care plan is monitored and modified,
where found necessary.
d Staff involved in direct clinical care document reassessments.*
c Written procedures guide the handling and disposal of infectious and hazardous
materials. *
d Laboratory personnel are appropriately trained in safe practices.
c Information about the patient’s care and response to treatment is shared among
medical, nursing and other care-providers.
d Information is exchanged and documented during each staffing shift, between
shifts, and during transfers between units/departments.
e Transfers between departments/units are done in a safe manner.
c Documented policies and procedures are in place for patients leaving against
medical advice and patients being discharged on request. *
d A discharge summary is given to all the patients leaving the organisation
(including patients leaving against medical advice and on request).
e The organisation defines the time taken for discharge and monitors the same.
e Documented policies and procedures guide the triage of patients for initiation of
appropriate care. *
f Staff are familiar with the policies and trained on the procedures for care of
emergency patients.
g Admission or discharge to home or transfer to another organisation is also
documented.
h In case of discharge to home or transfer to another organisation, a discharge note
shall be given to the patient.
i Quality assurance programmes are documented and implemented.
COP.3: The ambulance services are commensurate with the scope of the
services provided by the organisation.
a There is adequate access and space for the ambulance(s).
b The ambulance adheres to statutory requirements.
g Emergency medications are checked daily and prior to dispatch using a checklist.
f Nurses are provided with adequate equipment for providing safe and efficient
nursing services.
g Nurses are empowered to take nursing-related decisions to ensure the timely care
of patients.
COP.7:Documented procedures guide the performance of various
procedures.
a Documented procedures are used to guide the performance of various clinical
procedures. *
b Only qualified personnel order, plan, perform and assist in performing procedures.
c Documented procedures exist to prevent adverse events like a wrong site, wrong
patient and wrong procedure. *
d Informed consent is taken by the personnel performing the procedure, where
applicable.
e Adherence to standard precautions and asepsis is adhered to during the conduct
of the procedure.
f Patients are appropriately monitored during and after the procedure.
g Procedures are documented accurately in the patient record.*
COP.8: Documented policies and procedures define rational use of blood and
blood components.
a Documented policies and procedures are used to guide the rational use of blood
and blood components. *
b Documented procedures govern transfusion of blood and blood components. *
c The transfusion services are governed by the applicable laws and regulations.
d Informed consent is obtained for donation and transfusion of blood and blood
components.
e Informed consent also includes patient and family education about the donation.
COP.9: Documented policies and procedures guide the care of patients in the
intensive care and high dependency units.
a Documented policies and procedures are used to guide the care of patients in the
intensive care and high dependency units. *
b The organisation has documented admission and discharge criteria for its
intensive care and high dependency units. *
c Staff are trained to apply these criteria.
c The organisation provides for a safe and secure environment for the vulnerable
group.
d A documented procedure exists for obtaining informed consent from the
appropriate legal representative. *
e Staff are trained to care for this vulnerable group.
b The organisation defines and displays whether high-risk obstetric cases can be
cared for or not.
c Persons caring for high-risk obstetric cases are competent.
b The organisation defines and displays the scope of its paediatric services.
c The policy for care of neonatal patients is in consonance with the national/
international guidelines. *
d Those who care for children have age-specific competency.
d The person administering and monitoring sedation is different from the person
performing the procedure.
e Intra-procedure monitoring includes at a minimum the heart rate, cardiac rhythm,
respiratory rate, blood pressure, oxygen saturation, and level of sedation.
h The anaesthesiologist applies defined criteria to transfer the patient from the
recovery area. *
i The type of anaesthesia and anaesthetic medications used are documented in
the patient record.*
j Procedures shall comply with infection control guidelines to prevent cross-
infection between patients.
k Adverse anaesthesia events are recorded and monitored.
d Documented policies and procedures exist to prevent adverse events like wrong
site, wrong patient and wrong surgery. *
e Persons qualified by law are permitted to perform the procedures that they are
entitled to perform.
f A brief operative note is documented prior to transfer out of patient from recovery
area.
g The operating surgeon documents the postoperative care plan.
b The policies and procedures include both physical and chemical restraint measures.
e Staff receives training and periodic updating in control and restraint techniques.
f Patient and family are educated on various pain management techniques, where
appropriate.
c The committee has the powers to discontinue a research trial when risks outweigh
the potential benefits.
d Patient’s informed consent is obtained before entering them in research protocols.
e Patients are informed of their right to withdraw from the research at any stage and
also of the consequences (if any) of such withdrawal.
f Patients are assured that their refusal to participate or withdrawal from
participation will not compromise their access to the organisation’s services.
f When families provide food, they are educated about the patient’s diet limitations.
COP.22: Documented policies and procedures guide the end of life care.
a Documented policies and procedures guide the end of life care. *
b These policies and procedures are in consonance with the legal requirements.
c These also address the identification of the unique needs of such patient and
family.
d Symptomatic treatment is provided and where appropriate measures are taken for
the alleviation of pain.
e Staff are educated and trained in end of life care.
Chapter 3: Management of Medication (MOM)
MOM.1: Documented policies and procedures guide the organisation of
pharmacy services and usage of medication.
a There is a documented policy and procedure for pharmacy services and
medication usage.*
b Policies and procedures comply with the applicable laws and regulations.
MOM.4: Documented policies and procedures guide the safe and rational
prescription of medications.
a Documented policies and procedures exist for prescription of medications.*
f Orders are written in a uniform location in the medical records which also reflects
patient’s name and unique identification number.
g Medication orders are clear, legible, dated, timed, named and signed.
h Medication orders contain the name of the medicine, route of administration, dose
to be administered and frequency/time of administration.
i Documented policy and procedure on verbal orders is implemented.*
j The organisation defines a list of high-risk medication(s).*
k Audit of medication orders/prescription is carried out to check for safe and rational
prescription of medications.
l Reconciliation of medications occur at transition points of patient care.
MOM.8: Near misses, medication errors and adverse drug events are reported
and analysed.
a Documented procedure exists to capture near miss, medication error and adverse
drug event.*
b Near miss, medication error and adverse drug event are defined.*
c These are reported within a specified time frame. *
e Corrective and/or preventive action(s) are taken based on the analysis where
appropriate.
c A proper record is kept of the usage, administration and disposal of these drugs.
b These policies and procedures are in consonance with laws and regulations.
c The policies and procedures include the safe storage, preparation, handling,
distribution and disposal of radioactive drugs.
d Staff, patients and visitors are educated on safety precautions.
b Medical supplies and consumables are used in a safe manner, where appropriate.
c Medical supplies and consumables are stored in a clean, safe and secure
environment; and incorporating manufacturer’s recommendation(s).
d Sound inventory control practices guide storage of medical supplies and
consumables.
e There is a mechanism in place to verify the condition of medical supplies and
consumables.
Chapter 4: Patient Rights and Education (PRE)
PRE.1. The organisation protects patient and family rights and informs them
about their responsibilities during care.
a Patient and family rights and responsibilities are documented and displayed.*
b Patients and families are informed of their rights and responsibilities in a format
and language that they can understand.
c The organisation’s leaders protect patient and family rights.
d Staff are aware of their responsibility in protecting patient and family rights.
e Violation of patient and family rights is recorded, reviewed and
corrective/preventive measures taken.
PRE.2: Patient and family rights support individual beliefs, values and involve
the patient and family in decision making processes.
a Patients and family rights include respecting any special preferences, spiritual and
cultural needs.
b Patient and family rights include respect for personal dignity and privacy during
examination, procedures and treatment.
c Patient and family rights include protection from neglect or abuse.
f Patient and family have a right to seek an additional opinion regarding clinical
care.
g Patient and family rights include informed consent before transfusion of blood
and blood components, anaesthesia, surgery, initiation of any research protocol
and any other invasive / high risk procedures / treatment.
h Patient and family rights include right to complain and information on how to voice
a complaint
i Patient and family rights include information on the expected cost of the
treatment.
j Patient and family rights include access to his / her clinical records.
k Patient and family rights include information on Care plan, progress and
information on their health care needs.
PRE.3: The patient and/or family members are educated to make informed
decisions and are involved in the care planning and delivery process.
a The patient and/or family members are explained about the proposed care
including the risks, alternatives and benefits.
b The patient and/or family members are explained about the expected results.
c The patient and/or family members are explained about the possible
complications.
d The care plan is prepared and modified in consultation with patient and/or family
members.
e The care plan respects and where possible incorporates patient and/or family
concerns and requests.
f The patient and/or family members are informed about the results of diagnostic
tests and the diagnosis.
g The patient and/or family members are explained about any change in the
patient’s condition in a timely manner.
e The procedure describes who can give consent when patient is incapable of
independent decision making.*
f Informed consent is taken by the person performing the procedure.
PRE.5: Patient and families have a right to information and education about
their healthcare needs.
a Patient and/or family are educated about the safe and effective use of medication
and the potential side effects of the medication, when appropriate.
b Patient and/or family are educated about food-drug interaction
e Patient and/or family are educated about their specific disease process,
complications and prevention strategies.
f Patient and/or family are educated about preventing healthcare associated
infections
g The patients and/or family members’ special educational needs are identified
and addressed
h Patient and/or family are educated in a language and format that they can
understand.
d Patient and/or family are informed about the financial implications when there is a change
in the patient condition or treatment setting.
c Patient and/or family members are made aware of the procedure for giving
feedback and /or lodging complaints.
d All feedback and complaints are reviewed and/or analysed within a defined time
frame.
e Corrective and/or preventive action(s) are taken based on the analysis where
appropriate.
PRE.8: The organisation has a system for effective communication with
patients and /or families.
a Documented policies and procedures guide the effective communication with the
patients and/or families.*
b The organisation shall identify special situations where enhanced communication
would be required.*
c The organisation lays down an approach for effective communication in these
identified situations.
d The organisation also defines what constitutes an unacceptable communication
and sensitizes the staff about the same.*
e The organisation has a system to monitor and review the implementation of
effective communication
f The staff are trained in healthcare communication techniques periodically.
e The hospital has designated infection control officer as part of the infection control
team.*
f The hospital has designated infection control nurse(s) as part of the infection
control team.*
HIC.2: The organisation implements the policies and procedures laid down in
the Infection Control Manual in all areas of the hospital.
a The organisation identifies the various high-risk areas and procedures and
implements policies and/or procedures to prevent infection in these areas. *
b The organisation adheres to standard precautions at all times.*
h The organisation implements the antibiotic policy and monitors rational use of
antimicrobial agents.
i The organisation adheres to laundry and linen management processes.*
c The organisation takes action to prevent catheter linked blood stream infections.
d After the outbreak is over appropriate corrective actions are taken to prevent
recurrence.
HIC.7: There are documented policies and procedures for sterilization
activities in the organisation.
a The organisation provides adequate space and appropriate zoning for sterilization
activities.
b Documented procedure guides the cleaning, packing, disinfection and/or
sterilization, storing and issue of items.*
c Reprocessing of instruments and equipment are covered.*
d The organisation shall have a documented policy and procedure for reprocessing
of devices whenever applicable.*
e Regular validation tests for sterilization are carried out and documented.*
b Proper segregation and collection of biomedical waste from all patient-care areas
of the hospital is implemented and monitored.
c The organisation ensures that biomedical waste is stored and transported to the
site of treatment and disposal in properly covered vehicles within stipulated time
limits in a secure manner.
d The biomedical waste treatment facility is managed as per statutory provisions (if
in- house) or outsourced to authorized contractor(s).
e Appropriate personal protective measures are used by all categories of staff
handling biomedical waste.
d The organisation conducts appropriate “in-service” training sessions for all staff at
least once in a year.
Chapter 6: Continual Quality Improvement (CQI)
c The patient safety programme is comprehensive and covers all the major
elements related to patient safety and risk management.
d The scope of the programme is defined to include adverse events ranging from
“no harm” to “sentinel events”.
d Monitoring includes patient satisfaction which also incorporates waiting time for
services.
a The leaders at all levels in the organisation are aware of the intent of the quality
improvement program and the approach to its implementation.
c Corrective and preventive actions are taken based on the findings of such
analysis.
d The organisation shall have a process for informing various stakeholders in case
of a near miss / adverse event.
b The organisation has established processes for intense analysis of such events.
d Corrective and preventive actions are taken based on the findings of such
analysis.
a Those responsible for governance lay down the organisation’s vision, mission and
values.*
b Those responsible for governance approve the strategic and operational plans
and organisation’s annual budget.
c Those responsible for governance monitor and measure the performance of the
organisation against the stated mission.
i Those responsible for governance inform the public of the quality and
performance of services.
ROM.2: The organisation is responsible for and complies with the laid down
and applicable legislations, regulations and notifications.
a The management is conversant with the applicable laws and regulations and
undertakes the responsibility to adhere to the same.
b b. The management ensures that the policies and procedures pertaining to patient
care are in compliance with the prevailing laws, regulations and notifications.
d The organisation honestly portrays the services which it can and cannot provide.
f The organisation accurately bills for its services based upon a standard billing
tariff.
a The person heading the organisation has requisite and appropriate administrative
qualifications.
b The person heading the organisation has requisite and appropriate administrative
experience.
c The organisation prepares the strategic and operational plans including long-term
and short-term goals commensurate to the organisation’s vision, mission and
values in consultation with the various stakeholders.
d The organisation coordinates the functioning with departments and external
agencies, and monitors the progress in achieving the defined goals and
objectives.
j The organisation has a formal documented agreement for all outsourced services.
b Patient-safety devices & infrastructure are installed across the organisation and
inspected periodically.
c The organisation is a non-smoking area.
e Facility inspection rounds to ensure safety are conducted at least twice in a year
in patient-care areas and at least once in a year in non-patient-care areas.
f Inspection reports are documented and corrective and preventive measures are
undertaken.
b Up-to-date drawings are maintained which detail the site layout, floor plans and
fire-escape routes.
d The provision of space shall be in accordance with the available literature on good
practices (Indian or International Standards) and directives from government
agencies.
i There are designated individuals (with appropriate equipment) responsible for the
maintenance of all the facilities.
d Qualified and trained personnel operate, inspect, test and maintain equipment
and utility systems.
e Utility equipment are periodically inspected and calibrated (wherever applicable)
for their proper functioning.
d Qualified and trained personnel operate and maintain the medical equipment.
e Equipment are periodically inspected and calibrated for their proper functioning.
FMS.5: The organisation has a programme for medical gases, vacuum and
compressed air.
a Documented procedures govern procurement, handling, storage, distribution,
usage and replenishment of medical gases.*
b Medical gases are handled, stored, distributed and used in a safe manner.
c The procedures for medical gases address the safety issues at all levels.
d Alternate sources for medical gases, vacuum and compressed air are provided
for, in case of failure.
FMS.6: The organisation has plans for fire and non-fire emergencies within
the facilities.
a The organisation has plans and provisions for early detection, abatement and
containment of fire, and non-fire emergencies.*
b The organisation has a documented safe-exit plan in case of fire and non-fire
emergencies.
b The organisation maintains an adequate number and mix of staff to meet the
care, treatment and service needs of the patient.
c The required job specification and job description are well defined for each
category of staff.*
d The organisation verifies the antecedents of the potential employee with regards
to criminal/negligence background.
HRM.2. The organisation has a documented procedure for recruiting staff and
orienting them to the organisation’s environment.
h Every staff member is made aware of organisation's wide policies and procedures
as well as relevant department / unit / service / programme’s policies and
procedures.
HRM.3. There is an on-going programme for professional training and
development of the staff.
a A documented training and development policy exists for the staff.*
b Staff members can demonstrate and take actions to report, eliminate, or minimize
risks.
c Staff members are made aware of procedures to follow in the event of an incident.
b The employees are made aware of the system of appraisal at the time of
induction.
c Performance is evaluated based on the pre-determined criteria.
b The policies and procedures are known to all categories of staff of the
organisation.
c The disciplinary policy and procedure is based on the principles of natural justice.
b Health problems of the employees are taken care of in accordance with the
organisation’s policy.
c Regular health checks of staff dealing with direct patient care are done at least
once a year and the findings/ results are documented.
b The personal files contain personal information regarding the staff’s qualification,
disciplinary background and health status.
c All records of in-service training and education are contained in the personal files.
d Medical professionals are granted privileges to admit and care for patients in
consonance with their qualification, training, experience and registration.
e The requisite services to be provided by the medical professionals are known to
them as well as the various departments / units of the organisation.
f Medical professionals admit and care for patients as per their privileging.
c All such information pertaining to the nursing staff is appropriately verified when
possible.
d Nursing staff are granted privileges in consonance with their qualification, training,
experience and registration.
e The requisite services to be provided by the nursing staff are known to them as
well as the various departments / units of the organisation.
a The information needs of the organisation are identified and are appropriate to the
scope of the services being provided by the organisation.*
b Documented policies and procedures to meet the information needs exist.*
IMS.2. The organisation has processes in place for effective control and
management of data.
a
The organisation has an effective process for document control.*
d Documented procedures are laid down for timely and accurate dissemination of
data.*
IMS.3. The organisation has a complete and accurate medical record for
every patient.
a Every medical record has a unique identifier.
b The medical record contains the results of tests carried out and the care provided.
d When patient is transferred to another hospital, the medical record contains the
date of transfer, the reason for the transfer and the name of the receiving hospital.
e The medical record contains a copy of the discharge summary duly signed by
appropriate and qualified personnel.
f In case of death, the medical record contains a copy of the cause of death
certificate.
g Whenever a clinical autopsy is carried out, the medical record contains a copy of
the report of the same.
c The policies and procedure (s) incorporate safeguarding of data/ record against
loss, destruction and tampering.
b The policies and procedures are in consonance with the local and national laws
and regulations.
c The retention process provides expected confidentiality and security.
d The destruction of medical records, data and information is in accordance with the
laid-down policy.
IMS.7. The organisation regularly carries out review of medical records.
d The review focuses on the timeliness, legibility and completeness of the medical
records.
e The review process includes records of both active and discharged patients.