Changes in Clinical

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

Section I:
Patient-Centered Standards

Access, Assessment and

Continuity of Care (AAC)

3rd
4th
edition edition
14/86

14/96

4th Edition

3rd Edition

Stand
ard
NUMB
ER

OE

SCOPE
REGISTRATION &
ADMISSION

TRANSFER & REFERRAL

Standard
NUMBER

OE

SCOPE
REGISTRATION &
ADMISSION

TRANSFER & REFERRAL

INITIAL ASSESSMENT

10

REASSESSMENT

INITIAL ASSESSMENT

LAB

REASSESSMENT

LAB QA

LAB

10

LAB SAFETY

LAB QA

IMAGING

LAB SAFETY

IMAGING QA

10

IMAGING

10

IMAGING SAFETY
CONTINUOUS/MULTIDIS
CIPLINARY CARE

11

IMAGING QA

10

11

12

DISCHARGE PROCESS

13

IMAGING SAFETY
CONTINUOUS/MULTIDISCIP
LINARY CARE

12

DISCHARGE SUMMARY

14

DISCHARGE PROCESS

13

TOTAL

14

86

DISCHARGE SUMMARY

14

TOTAL

14

963

AAC

AAC

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

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

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

Section I:
Patient-Centered Standards

Care of Patients (COP)

3rd
edition

4th
edition

20/136

22/149

3rd Edition
Standa
COP

OE

rd
NUMBE
R
1

EMERGENCY SERVICES

AMBULANCE SERVICES

CARDIO PULMONARY
RESUSCITATION

NURSING CARE

VARIOUS PROCEDURES

RATIONAL USE OF
BLOOD & BLOOD
PRODUCTS
INTENSIVE CARE & HIGH
DEPENDENCY UNITS

VULNERABLE PATIENTS

OBSTETRIC CARE

10

PAEDIATRIC SERVICES

11

MODERATE SEDATION

12

ADMINISTRTAION OF
ANESTHESIA

13

11

UNIFORM CARE

4th Edition
Stand
COP

UNIFORM CARE, LAWS,

REGULATIONS &
GUIDELINES
EMERGENCY SERVICES
AMBULANCE SERVICES
HANDLING COMMUNITY
EMERGENCIES, EPIDEMICS
AND OTHER DISASTERS
CARDIO PULMONARY
RESUSCITATION
DOCUMENTED POLICIES
and PROCEDURES GUIDE
NURSING CARE
Documented procedures
guide the performance of
various procedures.
RATIONAL USE OF BLOOD
& BLOOD PRODUCTS
INTENSIVE CARE & HIGH
DEPENDENCY UNITS
VULNERABLE PATIENTS
HIGH RISK OBSTETRIC
CARE

OE

ard
NUMB
ER
1

2
3
4

10
9
5

10
11

5
7

4th Edition
Standa
COP

3rd Edition
Standa
rd
NUMBE
COP
R
OE
SURGICAL PROCEDURES
14
11
RESTRAINTS
15
5
PAIN MANAGEMENT
16
5
REHABILITATIVE
17
6
SERVICES
RESEARCH ACTIVITIES
18
6
NUTRITIONAL THERAPY
19
6
END OF LIFE CARE
20
5
TOTAL
20
136

OE

rd
NUMBE
R
12

MODERATE SEDATION
ADMINISTRTAION OF
ANESTHESIA
SURGICAL PROCEDURES

13
14

8
11

15

11

ORGAN TRANSPLANT
PROGRAM
RESTRAINTS
PAIN MANAGEMENT

16

17
18

5
4

REHABILITATIVE SERVICES

19

RESEARCH ACTIVITIES

20

NUTRITIONAL THERAPY

21

END OF LIFE CARE

22

TOTAL

22

149

PAEDIATRIC SERVICES

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

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

Section I:
Patient-Centered Standards

Management of Medication
(MOM)

3rd
edition

4th
edition

13/73

13/76

12

3rd Edition
MOM
ORGANIZATION & USAGE
OF PHARMACY
HOSPITAL FORMULARY
STORAGE OF MEDICATION
PRESCRIPTIONS OF
MEDICATIONS
SAFE DISPENSING OF
MEDICATIONS
MEDICATION
ADMINISTRATION
PATIENT MONITORING
NEAR MISSES,
MEDICATION ERRORS,
ADRs
NARCOTIC DRUGS &
PSYCHOTROPIC
SUBSTANCES
CHEMOTHERAPEUTIC
AGENTS
RADIOACTIVE DRUGS
IMPLANTABLE
PROSTHESIS & MEDICAL
DEVICES
MEDICAL SUPPLIES &

4th Edition

Standar
d
NUMBER

OE

1
2
3

4
5
7

12

6
7

10
4

10
11

4
4

12

MOM
ORGANIZATION & USAGE
OF PHARMACY
HOSPITAL FORMULARY
STORAGE OF MEDICATION
PRESCRIPTIONS OF
MEDICATIONS
SAFE DISPENSING OF
MEDICATIONS
MEDICATION
ADMNISTRATION
PATIENTS ARE MONITORED
AFTER MEDICATION
ADMINISTRATION
NEAR MISSES, MEDICATION
ERRORS ,ADVERSE DRUG
EVENTS ARE REPORTED &
ANALYSED
NARCOTIC DRUGS &
PSYCHOTROPIC
SUBSTANCES
CHEMOTHERAPEUTIC
AGENTS

Standa
rd
NUMB
ER

OE

1
2
3

4
5
7

13

10

10

513

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

All areas in HCO

LASA

drug list to be formed from formulary

Reconciliation

of care

of medications/orders at transitions

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

Section I:
Patient-Centered Standards

Patients Rights And

Education (PRE)

3rd
edition

4th
edition

7/46

8/54

16

4th Edition
3rd Edition

PRE
PROTECTION OF RIGHTS
& INFORMATION ABOUT
RESPONSIBILITY OF
CARE
SUPPORTING INDIVIDUAL
BELIEFS & VALUES
EDUCATING PATIENT/
FAMILY MEMBERS TO
MAKE INFORMED
DECISIONS

PRE

Standar
d
NUMBE
R

OE

10

INFORMED CONSENT
RIGHT TO INFORMATION
& EDUCATION ABOUT
HEALTHCARE NEEDS
RIGHT TO INFORMATION
ON EXPECTED COSTS
COMPLAINT REDRESSAL
PROCESS

TOTAL

46

PROTECTION OF RIGHTS &

INFORMATION ABOUT
RESPONSIBILITY OF CARE
SUPPORTING INDIVIDUAL
BELIEFS & VALUES
INFORMED CONSENT
PATIENT AND/OR FAMILYS
CONSENT EXISTS FOR
MAKING INFORMED
DECISION ABOUT THEIR
CARE
RIGHT TO INFORMATION &
EDUCATION ABOUT
HEALTHCARE NEEDS
RIGHT TO INFORMATION ON
EXPECTED COSTS
PATIENTS FEEDBACK AND
REDRESSAL OF
COMPLAINTS.
EFFECTIVE
COMMUNICATION WITH
PATIENTS AND /OR FAMILIES

Standa
rd
NUMBE
R

OE

11

6
17

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

Section I:
Patient-Centered Standards

Hospital Infection control

(HIC)

3rd
edition

4th
edition

9/51

9/54

19

3rd Edition

HIC
HOSPITAL INFECTION
CONTROL PROGRAMME
INFECTION CONTROL
MANUAL
SURVEILLANCE
ACTIVTIES
HOSPITAL ASSOCIATED
INFECTIONS
PREVENTION &
CONTROL OF
HEALTHCARE
ASSOCIATED INFECTIONS
CONTROL OUTBREAKS
OF INFECTION
STERILIZATION
ACTIVITIES
BIOMEDICAL WASTE
MEASURES (BMW)
TRAINING OF STAFF TO
SUPPORT HIC
PROGRAMME
TOTAL

4th Edition

Standar
d
NUMBE
R

OE

11

9
9

4
51

HIC
HOSPITAL INFECTION
CONTROL PROGRAMME
INFECTION CONTROL
MANUAL
SURVEILLANCE ACTIVTIES
HOSPITAL ASSOCIATED
INFECTIONS
SUPPORT TO INFECTION
CONTROL PROGRAMME
CONTROL OUTBREAKS OF
INFECTION
STERILIZATION ACTIVITIES
BIOMEDICAL WASTE
MEASURES (BMW)
TRAINING OF STAFF TO
SUPPORT HIC
PROGRAMME
TOTAL

Stand
ard
NUMB
ER

OE

2
3

12
9

6
7

4
6

9
9

4
54

20

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