1. SAFE-ITSM
STANDARDS

2. 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,

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. 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.

11. 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 .

12. 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.

13. 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.

14. 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)

15. 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

16. 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