NABH 6th Edition Hospital Quality Management Certificate

        Course Introduction

1. NABH 6th Edition

2. NABH 6th Edition Besic Details

3. NABH 6th, Chapter, Standard, Objective Elements

4. Objective Elements, Core, Commitment, Achivement,
   Excellence.

5. NABH Standards

6. Scoring System

7. NABH Fees

8. Quality Indicator (KPI)

9. How to apply for NABH Assessments

10. NC Closure

    
    

    Quality Management Department

11. Culture Reports,

12. Patient file form and format

13. Consent List

14. Department Manual

    
    

    Auditing

15. Internal Audit

16. Committee

17. Mock Drill

18. Quality Assurance Programe

19. Clinical Audit

20. Quality 7 Tools

21. PDCA

    
    

    Patients Safety

22. Incident Reporting, RCA, CAPA

23. MSDS

24. IPSG Goal

25. HIRM, FEMA

    
    

    Training

26. Training Scheduling

27. Documents Preparation

28. Pre and Post Test

29. How to make Training PPT

    
    

    Services Management

30. Patients Feedback

31. Scope of services

32. Patients Right and Responsibility

33. Staff Right and Responsibility

34. Discharge Management

35. Biomedical waste Management

    
    

    Job Selection

36. NABH Question and answer

37. Interview Question and answer

• NABH Full Form: National Accreditation Board for Hospitals

• Starting Date: January 1, 2025

• Duration: 4 Years

• Chapters: 10

• Standard: 100

• Objective Elements: 639

NABH 6th Chapter

1. Access, Assessment, and Continuity of Care (AAC)

2. Care Of Patients (COP)

3. Medication of Management (MOM)

4. Patient Rights and Education (PRE)

5. Infection Prevention and Control (IPC)

6. Patient Safety and Quality Improvement (PSQ)

7. Responsibilities of Management (ROM)

8. Facility Management and Safety (FMS)

9. Information Management System (IMS)

10. Human Resource Management (HRM)

NABH6th Edition: Objective Elements, Core, Commitment, Achivement

NABH Accreditation Fees Details, NABH Full Accreditation, NABH Entry Level, NABH Ayush Hospital, NABL Lab, NABH Nursing Excellence, Eye Accreditation, SHCO, HCO Accreditation Fees

• Scope of Services Display       

• Registration and admission of patients (OPD, IPD and Emergency)

• Managing patients during non-availability of beds

• Transfer-in of the patient to the hospital

• Transfer out/referral of unstable patients to another facility

• Transfer out/referral of stable patients to another facility

• Initial assessment of patients (Out-patients, in-patients and emergency patients)

• Laboratory scope of tests

• Ordering of lab tests, collection, identification, handling, transportation, processing and disposal of specimen

• Time-frame for the availability of lab test results

• Critical results of lab and its timely intimation

• Outsourcing of lab tests

• Laboratory quality assurance programme

• Laboratory safety programme

• Imaging scope of tests

• Identification and safe transportation of patients to and from the imaging department

• Time-frame for the availability of imaging results

• Critical findings of imaging and its timely intimation

• Outsourcing of imaging tests

• Imaging quality assurance programme

• Radiation safety programme

• Discharge process (including MLC discharge and absconding cases)

• Discharge against medical advice

• Death discharge

COP: Standard List

COP.1. Uniform care to patients is provided in all settings of the organisation and is guided by written guidance.*

COP.2. Emergency services are provided in accordance with written guidance, applicable laws and regulations.

COP.3. Ambulance services ensure safe patient transportation with appropriate care.

COP.4. The organisation plans and implements mechanisms for the care of patients during community emergencies, epidemics and other disasters.

COP.5. Cardio-pulmonary resuscitation services are provided uniformly across the organisation.

COP.6. Nursing care is provided to patients in the organisation in consonance with clinical protocols.

COP.7. Clinical procedures are performed safely.

COP.8. Transfusion services are provided as per the scope of services of the organisation, safely.

COP.9. The organisation provides care in intensive care and high dependency units in a systematic manner.

COP.10. Organisation provides safe obstetric care.

COP.11. Organisation provides safe paediatric services.

COP.12. Procedural sedation is provided consistently and safely.

COP.13. Anaesthesia services are provided in a consistent and safe manner.

COP.14. Surgical services are provided in a consistent and safe manner.

COP.15. The organ transplant programme is carried out safely.

COP.16. The organisation identifies and manages patients who are at high risk of morbidity / mortality.

COP.17. Pain management for patients is done in a consistent manner.

COP.18. Rehabilitation services are provided to the patients in a safe, collaborative and consistent manner.

COP.19. Nutritional therapy is provided to patients consistently and collaboratively.

COP.20. End-of-life care is provided in a compassionate and considerate manner.

MOM Documents List

• Medication Management Policy

• Pharmacy Manual

• Standard Operating Procedures (SOPs) for:

• Procurement of medications

• Storage of medications

• Dispensing of medications

• Administration of medications

• Medication Error Report and Log

• Incident Reports for Medication Errors

• Pharmacy Audit Reports

• Training Records for Pharmacy and Clinical Staff

• Medication Reconciliation Logs

• Inventory Management Records

• Temperature and Humidity Monitoring Logs for Storage Areas

• List of Approved Vendors and Supplier Agreements

• Adverse Drug Reaction (ADR) Monitoring Records

• Emergency Drug Stock Checklist

• High-Alert Medication List and Handling Guidelines

• Look-Alike, Sound-Alike (LASA) Drug List and Mitigation Strategies

• Medication Usage Data Analysis Reports

• Pharmacy Inspection Checklists

• PTC Committee

• Hospital Formulary

• Refrigerator Temperature Logs for Cold Chain Maintenance

• Medication Storage Audit Reports

• Inventory and Stock Registers

• Emergency Drug Availability Checklist

• List of Expired, Damaged, or Returned Medications

• Drug Expiry Monitoring Records

• Pest Control Records for Storage Areas

• Stock Replenishment and Reordering Records

• Storage Area Cleaning and Maintenance Records

• Standard Operating Procedures (SOPs) for Prescription Writing

• Uniform Prescription Template (Including mandatory fields such as patient details, drug name, dose, frequency, duration, and prescriber signature)

• List of Approved Abbreviations

• Audit Reports on Prescription Practices

• Adverse Drug Reaction (ADR) Monitoring and Reporting Records

• Documentation of High-Alert Medication Prescribing Protocols

• Standard Operating Procedures (SOPs) for Medication Dispensing

• Dispensing Checklist (Including verification of medication, dose, patient details, and proper labeling)

• Medication Dispensing Record Logs

• Audit Reports on Medication Dispensing Practices

• List of High-Alert Medications and Special Dispensing Protocols

• Training Records for Pharmacy Staff on Safe Dispensing Practices

• Medication Dispensing Error Log and Incident Reports

• Corrective Action Plans for Dispensing Errors

• Documentation of Pharmacist Double-Check System (If implemented for dispensing)

• Patient Education Materials for Dispensed Medications

• Patient Counseling Records on Medication Usage

• Stock Replenishment and Expiry Date Monitoring Records

• Inventory Management and Stock Control Records

• Personal Protective Equipment (PPE) Usage Guidelines for Dispensing

• Reports of Adverse Drug Reactions (ADRs) Related to Dispensed Medications

• Documentation of Continuous Improvement Initiatives in Medication Dispensing

• Incident Reports for Medication Administration Errors

• Corrective Action Plans for Medication Administration Errors

• Audit Reports on Medication Administration Practices

• Patient Education Materials on Medication Administration (Including proper techniques, side effects, and what to do in case of a missed dose)

• Records of Double-Check Systems for High-Risk Medications

• Patient Consent Forms for Medication Administration (if applicable)

• Documentation of Medication Administration in Emergency Situations

• Medication Administration Time Logs (e.g., within the prescribed window)

• Monitoring Records for Adverse Drug Reactions (ADRs) Post-Administration

• Reports of Medication Errors and Near Misses During Administration

• Protocols for Medication Administration in Special Populations (e.g., pediatric, geriatric, pregnant patients)

• Documentation of Compliance with Five Rights of Medication Administration (Right patient, right drug, right dose, right route, right time)

• Compliance Reports for Medication Administration Safety Protocols

• Reports of Medication-Related Incidents Post-Administration (Including ADRs, side effects, or other complications)

• Post-Medication Monitoring and Assessment of Efficacy Records

• Records of Escalation Procedures for Abnormal Post-Administration Findings

• Patient Education Materials on Monitoring After Medication (Including instructions on signs and symptoms to watch for after medication)

• Incident Reports Related to Insufficient Post-Administration Monitoring

• Daily Medication Monitoring Reports (For patients receiving regular medications)

• Standard Operating Procedures (SOPs) for Handling Narcotics and Psychotropic Substances

• Storage and Dispensing Guidelines for Controlled Substances

• Monitoring and Documentation of Narcotic Drug Usage

• Records of Controlled Drug Purchases, Prescriptions, and Administration

• Chemotherapeutic Agent Handling and Disposal Protocols

• Radio-Pharmaceutical Usage Protocols (Including patient safety and radiation safety guidelines)

• Staff Training Records on Safe Handling of High-Risk Medications

• Security Protocols for Controlled Drugs (Including locked storage areas and inventory checks)

• Incident Reports Related to Controlled Substance Errors or Misuse

• Compliance Reports for Controlled Substance Management

• Pharmacy Records for Controlled Substances (Including usage logs and waste documentation)

• Adverse Drug Reaction (ADR) Reports Related to High-Risk Medications

• Safety Data Sheets (SDS) for Chemotherapeutic Agents and Radio-Pharmaceuticals

• Radiation Safety Protocols and Monitoring Reports

• Audit Logs of Narcotic and Psychotropic Substance Inventory

• Patient Education Materials for Chemotherapy and Psychotropic Medications

• Record of Regulatory Compliance for Controlled Drug Handling

• Waste Disposal and Decontamination Protocols for Chemotherapeutic Agents and Radio-Pharmaceuticals

• Documentation of Safety Checks Before Administration of High-Risk Medications

• Patient Consent Forms for Implantable Devices and Prosthesis

• Training Records for Staff on Device Insertion and Handling

• Surgical and Insertion Protocols for Implantable Devices

• Device Monitoring and Follow-up Records Post-Implantation

• Incident Reports Related to Implantable Devices

• Device Failure and Recall Logs

• Audit and Inspection Reports for Implanted Devices and Prosthesis

• Patient Education Materials on Implantable Devices and Prosthesis

• Documentation of Compliance with Regulatory Standards for Implantable Devices

• Clinical Decision Support for Implantable Device Usage

• Infection Control Protocols for Implanted Devices

• Stock and Inventory Management Records for Prosthetics and Medical Devices

• Post-Operative Monitoring Protocols for Implantable Devices

• Documentation of Implant Removal or Replacement Procedures

• Surgeon and Specialist Reports on Implantation Outcomes

• Maintenance and Sterilization Protocols for Reusable Medical Devices

• Audit Reports on Medical Supplies Storage

• Stock Rotation and First-In-First-Out (FIFO) Policy Implementation Records

• Storage Guidelines for Hazardous Medical Supplies (e.g., chemicals, radioactive materials)

• Records of Special Handling Requirements for Medical Supplies (e.g., sterile items, cold-chain products)

• Pest Control Records for Storage Areas

• Emergency Stock Requisition and Availability Logs

• Stock Take and Reconciliation Reports

• Training Records for Staff Handling Medical Supplies

• Incident Reports for Stock-Outs or Mismanagement of Medical Supplies

• Records of Delivery and Receipt of Medical Supplies

• Documentation of Compliance with Legal and Regulatory Requirements for Medical Supplies

• Cleaning and Maintenance Protocols for Storage Areas

Document List for Infection Prevention and Control (IPC) as per NABH Accreditation

• Infection Prevention and Control Policy

• Hand Hygiene Policy and Guidelines

• SOP for Infection Prevention in Clinical Areas

• SOP for Infection Prevention in Support Services (e.g., housekeeping, laundry, waste management)

• SOP for Surveillance of Healthcare-Associated Infections (HAI)

• Sterilization and Disinfection Policy

• Biomedical Waste Management Policy

• Antimicrobial Stewardship Policy

• Policy for Occupational Health and Safety of Staff

• Post-Exposure Prophylaxis (PEP) Protocol

• Registers and Logs

• HAI Surveillance Register

• Infection Outbreak Investigation Register

• Sterilization and Disinfection Logbook

• Biomedical Waste Disposal Register

• Hand Hygiene Audit Register

• Cleaning and Disinfection Log for Equipment and Instruments

• Needle Stick Injury Incident Register

• Employee Vaccination Register

• Forms and Templates

• Infection Reporting Form

• HAI Data Collection Form

• Sterilization Monitoring Form

• Cleaning Schedule Form for Clinical and Support Areas

• Incident Reporting Form (e.g., for needle stick injuries)

• Occupational Exposure Incident Form

• Training Materials

• Training Schedule and Attendance Logs for IPC Training

• Training Material for Hand Hygiene and PPE Usage

• Evaluation Forms for Staff Training on IPC

• Reports and Analysis

• Monthly HAI Surveillance Reports

• Infection Trend Analysis Reports

• Compliance Reports on Hand Hygiene and PPE Usage

• Audit Reports for Sterilization and Disinfection Processes

• Audit Reports for Biomedical Waste Management

• Display Materials

Document List for Patient Safety and Quality (PSQ) as per NABH Accreditation

• Patient Safety Policy

• Quality Improvement Policy

• Clinical Audit Policy

• Incident Reporting and Management Policy

• Root Cause Analysis (RCA) Policy

• Incident Reporting Register

• Root Cause Analysis (RCA) Register

• Patient Safety Indicator Monitoring Register

• Quality Improvement Indicator Monitoring Register

• Clinical Audit Register

• Corrective and Preventive Action (CAPA) Log

• Incident Reporting Form

• Root Cause Analysis Form

• Clinical Audit Checklist and Report Template

• Patient Safety Indicator Data Collection Form

• Quality Improvement Project Proposal Form

• Corrective and Preventive Action (CAPA) Form

• Risk Assessment Template

• Monthly Patient Safety Programme Report

• Quality Improvement Programme Reports

• Key Indicator Monitoring Reports

• Clinical Audit Reports

• Incident Trend Analysis Reports

• Root Cause Analysis Summary Reports

• Patient Safety Training Programme Material

• Quality Improvement Tools Training Material

• Incident Reporting and Investigation Training Logs

• Clinical Audit Training Programme Records

• Evaluation Forms for Training Effectiveness

Document List for Responsibility of Management (ROM) as per NABH Accreditation

• SOP for Defining Roles and Responsibilities of Governance Members

• SOP for Ethical Decision-Making

• SOP for Environmental Sustainability Practices

• SOP for Social Responsibility Initiatives

• SOP for Economic Sustainability and Financial Planning

• SOP for Risk Assessment and Management

• Governance Meeting Attendance Register

• Ethical Issue Reporting Register

• Sustainability Activity Log

• Risk Management and Mitigation Register

• Patient Safety Incident Register

• Governance Role Definition Template

• Ethical Concern Reporting Form

• Risk Assessment Form

• Patient Safety Audit Checklist

• Sustainability Project Proposal Form

• Professional Conduct Monitoring Checklist

• Governance Committee Meeting Minutes

• Patient Safety and Risk Management Reports

• Sustainability Initiative Reports

• Ethical Practices Compliance Reports

• Professionalism and Behavioral Audit Reports

• Management's Annual Report on Governance and Sustainability

• Governance Training Material for Leadership and Management

• Ethics and Professionalism Training Materials

• Sustainability Awareness Training Materials

• Risk Management Training Programme Logs

• Patient Safety Leadership Training Records

• Organizational Leadership Structure Chart

• Mission, Vision, and Values Posters

• Code of Ethics Display Material

• Sustainability Policy Display

• Compliance Reports for Governance and Ethical Practices

• Audit Reports on Patient Safety and Risk Management

• Checklists for Monitoring Environmental Sustainability Efforts

• Records of Social Responsibility Projects and Outcomes

• Performance Evaluation Reports for Governance Members

Chapter 9: HRM

NABH Chapter 10