SAFE-ITSM STANDARDS

Standards & Objective element A standard is a statement that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care Objective element is measurable component of a standard Acceptable compliance with objective elements determines the overall compliance with a standard,

NABH & SAFE-ITSM NABH SAFE-I 102 Standards 9 Standards 10 Chapters 102 Standards 636 Objective Elements SAFE-I 1 Chapters 9 Standards 51 Objective Elements

Standards-1 The organization has a well defined ,comprehensive and coordinated Hospital Infection Prevention & Control (HIC) programme aimed at reducing and eliminating risks to patients,visitors and health care workers a.HIC program is documented which aims at preventing and reducing risk of hospital associated infections. b.HIC program is a continuous process and updated at least once a year. c.The hospital has multi-disciplinary infection control committee which coordinates all infection prevention and control activities. d. The hospital has infection control team. e. The hospital has infection control officer as part of ICT f . The hospital has a infection control nurse as part of ICT

Standards-2 The organization implement the policies and procedures laid down in the Infection Control Manual a. The organization identifies the various high risk areas and procedures and implement policies and procedures to prevent infection in theses areas. Area ICU/NICU OT Post Operative ward Blood Bank CSSD Lab/Endoscopy Procedures -Cardiac Catheterization -Endoscopy -Surgery -IV infusion -Central line insertion

Standards-2 b. The organization adheres to standard precautions at all times ( Standard precautions include a group of infection prevention practices that apply to all patients regardless of suspected or confirmed infection status in any setting in which healthcare is delivered) - Hand Hygiene - Use of gloves - Gown - Mask - Eye protection/Face shield - Safe injection practices Standard precaution are also intended to protect patients by ensuring that HCW do not carry infectious agents to patients on their hands or via equipments used during patient care

Standards-2 c. The organization adheres to hand hygiene guideline. d. The organization adhere to safe injection and infusion practices. e. The Organization adheres to transmission based precautions at all times. f. The organization adheres to cleaning, disinfection and sterilization practices. g. The organization adhere to laundry and linen management. h. The organization adhere to kitchen sanitation and food handling issues. i. An appropriate antibiotic policy is established and implemented j. The organization has appropriate engineering control to prevent infection (Air conditioning of OT/ICU) k. The organization adhere to housekeeping procedures

Standards-3 Organization performs surveillance activities to capture and monitor infection prevention and control data. a. Surveillance activities are appropriately directed towards the high risk area. b. Collection of surveillance data is ongoing process. c. Verification of data is done on regular basis. d. Scope of surveillance activities incorporates tracking and analyzing of infection rate, risks and trend . e. Surveillance activities including monitoring the compliance with hand hygiene guideline . f. Surveillance activities include monitoring the effectiveness of housekeeping services. g. Feedback on HAIs are provided on regular basis to appropriate personnel.

Standards-3 h. In case of notifiable disease information is sent to appropriate authorities HAI indicators -UTI rate -VAP rate -SSI rate -CRBSI rate -Incidence of Phlebitis HCW safety indicator -Incidence of NSI Nursing care indicator -Incidence of bed sore after admission

Standards-4 The organization takes actions to prevent and control Healthcare Associated Infections in patients a. The organization takes action to prevent urinary tract infection. b. The organization takes action to prevent respiratory tract infection. c. The organization takes action to prevent intra vascular device infection. d. The organization takes action to prevent SSI. e. The organization takes action to prevent phlebitis.

Standards-5 The organization provides adequate and appropriate resources for prevention and control of Healthcare Associated Infections a. Adequate and appropriate PPE,soaps and disinfection are available and used correctly. b. Adequate and appropriate facilities for hand hygiene in all patient care area accessible to HCW . c. Isolation and barriers nursing facilities are available. d. Appropriate pre and post exposure prophylaxis is provided to all concerned staff members .

Standards-6 The organization identifies and takes appropriate action to control outbreak of infections a. Organization has a documented procedure for identifying an outbreak. b. Organization has a documented procedure for handling outbreak . c. The procedure is implemented during outbreak. d. After the outbreak is over appropriate corrective actions are taken to prevent recurrence.

Standards-7 There are documented policies and procedures for sterilization activities in the organization. a. Organization provide adequate space and appropriate zoning for sterilization activities. b. Documented procedure guides the cleaning packing disinfection sterilization, storing and issue of items . c. Reprocessing of equipment and instruments are covered. d. Regular validation test for sterilization are carried out. e. There is an established recall procedure when outbreak in the sterilization system is identified.

Performance/Validation test Bowie Dick test (daily) Leak rate test (weekly) Temperature and process control test (weekly) Air detector performance test (weekly) Biological indicator test (weekly) - Bacillus stearothermophillus: steam - Bacillus subtillis:ETO and Dry heat Quarterly test (using thermocouples) (Usually done by company once in six months) Yearly commissioning and re-commissioning test (using thermocouples)

Standards-8 Biomedical waste (BMW) is handled in an appropriate and safe manner. a. Organization adhere to statutory provision with regards to waste. b. Proper segregation and collection of BMW from all patient care area of the hospital is implemented and monitored. c. The organization ensures that Biomedical Waste is stored and transported to the site of treatment and disposal in proper vehicle within stipulated time limits in a secure manner. d. Bio medical waste treatment facility is managed as per statutory provision( if in house) or outsourced to authorized contractors . e. Personal protective measure are used by staff handling BMW

Standards-9 Infection control program is supported by management and includes training of staffs. a. Management makes available resources required for the infection control program. b. The organization earmarks adequate funds from its annual budget in this regards. c. The organization conducts induction training for all staff. d. The organization conducts appropriate in service training session for all staff at least once in 6 month for nursing staff and once in a year for doctors