1. Changes in Clinical Standards - NABH
4th Edition 2016
Dr. A. L. Basile MS
Co Chair Technical Committee, NABH.
Medical Director, Star Hospitals.
Consultant Ophthalmolgist

2. Section I: Patient-Centered Standards
Access, Assessment and Continuity of Care (AAC)
3rd edition
4th edition
14/86
14/96

3. 3rd Edition AAC 4th Edition AAC
Standard NUMBER OE
SCOPE 1 3
REGISTRATION & ADMISSION 2 6
TRANSFER & REFERRAL 5
INITIAL ASSESSMENT 4 10
REASSESSMENT
LAB 8
LAB QA 7
LAB SAFETY
IMAGING 9
IMAGING QA
IMAGING SAFETY 11
CONTINUOUS/MULTIDISCIPLINARY CARE 12
DISCHARGE PROCESS 13
DISCHARGE SUMMARY 14
TOTAL 86
4th Edition
AAC
Standard NUMBER OE
SCOPE 1 4
REGISTRATION & ADMISSION 2 7
TRANSFER & REFERRAL 3 5
INITIAL ASSESSMENT 9
REASSESSMENT 6
LAB 10
LAB QA
LAB SAFETY 8
IMAGING
IMAGING QA
IMAGING SAFETY 11
CONTINUOUS/MULTIDISCIPLINARY CARE 12
DISCHARGE PROCESS 13
DISCHARGE SUMMARY 14
TOTAL 96

4. Overall Impact of improvements: AAC
Each Service in the scope should be justifiable
appropriate diagnostics and treatment facilities
suitably qualified personnel
out-patient, in-patient and emergency cover
Display ‘not in scope’
Imaging services
Screening of Patients
Peer review
Surveillance methodology

5. Overall Impact of improvements: AAC
Equipment and Manpower of pathology & radiology depts
Adequacy
Actions on critical results
Lab and Imaging
Focus on response
Critical results of outsourced services
Addressing of reporting errors
Amend or recall
Structured handovers
Transitions of care

6. Overall Impact of improvements: AAC
Care Plan to reflect the desired outcome.
Coordination of care: timelines
Monitoring
Acting on delays
Informing stakeholders
Access is prioritized
More sick patients are seen earlier.
Early warning system
Time taken for discharge
Monitor timelines

7. Section I: Patient-Centered Standards
3rd edition
4th edition
Care of Patients (COP)
20/136
22/149

8. 4th Edition 3rd Edition COP COP Standard NUMBER OE
UNIFORM CARE, LAWS, REGULATIONS & GUIDELINES 1 4
EMERGENCY SERVICES 2 10
AMBULANCE SERVICES 3 9
HANDLING COMMUNITY EMERGENCIES, EPIDEMICS AND OTHER DISASTERS 5
CARDIO PULMONARY RESUSCITATION
DOCUMENTED POLICIES and PROCEDURES GUIDE NURSING CARE 6 7
Documented procedures guide the performance of various procedures.
RATIONAL USE OF BLOOD & BLOOD PRODUCTS 8
INTENSIVE CARE & HIGH DEPENDENCY UNITS
VULNERABLE PATIENTS
HIGH RISK OBSTETRIC CARE 11
3rd Edition
COP
Standard NUMBER OE
UNIFORM CARE 1 4
EMERGENCY SERVICES 2 7
AMBULANCE SERVICES 3 8
CARDIO PULMONARY RESUSCITATION 5
NURSING CARE
VARIOUS PROCEDURES 6
RATIONAL USE OF BLOOD & BLOOD PRODUCTS
INTENSIVE CARE & HIGH DEPENDENCY UNITS
VULNERABLE PATIENTS 9
OBSTETRIC CARE 10
PAEDIATRIC SERVICES 11
MODERATE SEDATION 12
ADMINISTRTAION OF ANESTHESIA 13

9. 4th Edition 3rd Edition COP COP Standard NUMBER OE PAEDIATRIC SERVICES12 8
MODERATE SEDATION 13
ADMINISTRTAION OF ANESTHESIA 14 11
SURGICAL PROCEDURES 15
ORGAN TRANSPLANT PROGRAM 16 4
RESTRAINTS 17 5
PAIN MANAGEMENT 18
REHABILITATIVE SERVICES 19 6
RESEARCH ACTIVITIES 20
NUTRITIONAL THERAPY 21
END OF LIFE CARE 22
TOTAL
149
3rd Edition
COP
Standard NUMBER OE
SURGICAL PROCEDURES 14 11
RESTRAINTS 15 5
PAIN MANAGEMENT 16
REHABILITATIVE SERVICES 17 6
RESEARCH ACTIVITIES 18
NUTRITIONAL THERAPY 19
END OF LIFE CARE 20
TOTAL
136

10. Overall Impact of improvements: COP
Emergency Department
Access QA
Brought in dead
Communication with ambulance during transit
Organ transplant
Full standard
Monitoring of patients after procedures
Disaster Management
Focus on role of Emergency services
Patient care

11. Overall Impact of improvements: COP
Counseling of patients on progress
ICU setting
Clarity on informed consent when needed repeatedly for Blood Transfusions
Single consent with endorsements on repeat
Consent for Moderate sedation
Reason for restraint
Functional assessment (rehab)
Reassessment
Pain alleviation
Initiate and Titrate based on need

12. Section I: Patient-Centered Standards
3rd edition
4th edition
Management of Medication (MOM)
13/73
13/76

13. 3rd Edition MOM 4th Edition MOM
Standard NUMBER OE
ORGANIZATION & USAGE OF PHARMACY 1 4
HOSPITAL FORMULARY 2 5
STORAGE OF MEDICATION 3 7
PRESCRIPTIONS OF MEDICATIONS 12
SAFE DISPENSING OF MEDICATIONS 6
MEDICATION ADMINISTRATION 10
PATIENT MONITORING
NEAR MISSES, MEDICATION ERRORS, ADR’s 8
NARCOTIC DRUGS & PSYCHOTROPIC SUBSTANCES 9
CHEMOTHERAPEUTIC AGENTS
RADIOACTIVE DRUGS 11
IMPLANTABLE PROSTHESIS & MEDICAL DEVICES
MEDICAL SUPPLIES & CONSUMABLES 13
TOTAL 73
4th Edition
MOM
Standard NUMBER OE
ORGANIZATION & USAGE OF PHARMACY 1 4
HOSPITAL FORMULARY 2 5
STORAGE OF MEDICATION 3 7
PRESCRIPTIONS OF MEDICATIONS 13
SAFE DISPENSING OF MEDICATIONS 6
MEDICATION ADMNISTRATION 10
PATIENTS ARE MONITORED AFTER MEDICATION ADMINISTRATION
NEAR MISSES, MEDICATION ERRORS ,ADVERSE DRUG EVENTS ARE REPORTED & ANALYSED 8
NARCOTIC DRUGS & PSYCHOTROPIC SUBSTANCES 9
CHEMOTHERAPEUTIC AGENTS
RADIOACTIVE DRUGS 11
IMPLANTABLE PROSTHESIS 12
MEDICAL GASES
TOTAL 76

14. Overall Impact of improvements: MOM
Strengthening of Inventory management
All areas in HCO
Stock outs
Physician samples tracking and management
Address safety in storage, usage and prevent medication errors.
Prescriptions have to be in Capital letters
LASA drug list to be formed from formulary
Reconciliation of medications/orders at transitions of care

15. Overall Impact of improvements: MOM
Special training for chemo therapeutic drugs and bio safety cabinets
Patient education for chemo drugs
Strengthen medication administration
Strengthen medical supplies

16. Section I: Patient-Centered Standards
3rd edition
4th edition
Patients Rights And Education (PRE)
7/46
8/54

17. 4th Edition PRE 3rd Edition PRE
Standard NUMBER OE
PROTECTION OF RIGHTS & INFORMATION ABOUT RESPONSIBILITY OF CARE 1 5
SUPPORTING INDIVIDUAL BELIEFS & VALUES 2 11
INFORMED CONSENT 3 7
PATIENT AND/OR FAMILY’S CONSENT EXISTS FOR MAKING INFORMED DECISION ABOUT THEIR CARE 4 8
RIGHT TO INFORMATION & EDUCATION ABOUT HEALTHCARE NEEDS
RIGHT TO INFORMATION ON EXPECTED COSTS 6
PATIENT’S FEEDBACK AND REDRESSAL OF COMPLAINTS.
EFFECTIVE COMMUNICATION WITH PATIENTS AND /OR FAMILIES
TOTAL 54
3rd Edition
PRE
Standard NUMBER OE
PROTECTION OF RIGHTS & INFORMATION ABOUT RESPONSIBILITY OF CARE 1 5
SUPPORTING INDIVIDUAL BELIEFS & VALUES 2 10
EDUCATING PATIENT/ FAMILY MEMBERS TO MAKE INFORMED DECISIONS 3 7
INFORMED CONSENT 4 8
RIGHT TO INFORMATION & EDUCATION ABOUT HEALTHCARE NEEDS
RIGHT TO INFORMATION ON EXPECTED COSTS 6
COMPLAINT REDRESSAL PROCESS
TOTAL 46

18. Overall Impact of improvements: PRE
Patient right to get another opinion
Respect and facilitate the right
New standard on communication
Acceptable and effective communication
Communication in specific situation
Avoiding and identifying unacceptable communication
Stress on capturing patient experience in addition to feedback
Patient educational need identification and addressing it

19. Section I: Patient-Centered Standards
3rd edition
4th edition
Hospital Infection control (HIC)
9/51
9/54

20. 3rd Edition HIC 4th Edition HIC
Standard NUMBER OE
HOSPITAL INFECTION CONTROL PROGRAMME 1 6
INFECTION CONTROL MANUAL 2 11
SURVEILLANCE ACTIVTIES 3 8
HOSPITAL ASSOCIATED INFECTIONS 4
PREVENTION & CONTROL OF HEALTHCARE ASSOCIATED INFECTIONS 5
CONTROL OUTBREAKS OF INFECTION
STERILIZATION ACTIVITIES 7
BIOMEDICAL WASTE MEASURES (BMW)
TRAINING OF STAFF TO SUPPORT HIC PROGRAMME 9
TOTAL 51
4th Edition
HIC
Standard NUMBER OE
HOSPITAL INFECTION CONTROL PROGRAMME 1 6
INFECTION CONTROL MANUAL 2 12
SURVEILLANCE ACTIVTIES 3 9
HOSPITAL ASSOCIATED INFECTIONS 4
SUPPORT TO INFECTION CONTROL PROGRAMME 5
CONTROL OUTBREAKS OF INFECTION
STERILIZATION ACTIVITIES 7
BIOMEDICAL WASTE MEASURES (BMW) 8
TRAINING OF STAFF TO SUPPORT HIC PROGRAMME
TOTAL 54

21. Overall Impact of improvements: HIC
Clinical privileging of ICN – empowerment of ICNs
Rational and safe use of disinfectants
Enhanced participation of stakeholders by sharing of HIC data
Promote rational use of antimicrobials and monitor its usage
Monitoring of MDROs & infection containment due to MDROs
Improved patient safety due to pre-defined informed reuse of devices