The healthcare services being provided are clearly defined and are inconsonance with the needs of the community.(The services provided are clearly defined, Consonance with the requirements of the community, Need of the community is addressed when new services are added, Captured through various feedback mechanisms).

Each defined service should have appropriate diagnostics and treatment facilities with suitably qualified personnel who provide out-patient, in-patient and emergency cover. (The organisation shall ensure that before starting a service, suitably qualified medical and nursing staff are available to take care of patient‘s clinical needs. The said service shall have outpatient facility and inpatient facility and the consultant shall provide emergency cover. Appropriate infrastructure for diagnostics and treatment facilities should be available for regular functioning).

The defined healthcare services are prominently displayed.  (The services so defined should be displayed prominently in an area visible to all patients entering the organisation. The display could be in the form of boards, citizen's charter, etc. They should be of permanent nature. Care should be taken to ensure that these are displayed in the language(s) the patient understands. Healthcare services routinely associated with standard of care within the defined scope of healthcare services, but not offered in the organisation should be clearly displayed as not available. Display in the form of brochures only is NOT acceptable. Display should be at least bi-lingual (English and the state language/language spoken by the majority of people in that area).

The staff are oriented to these services.(All the staff in the hospital mainly in the reception/registration,OPD, IPD are oriented to these facts through regular training programme or through manuals. Records of all such training shall be available).

Documented policies and procedures are used for registering and admitting patients. * (Organisation shall prepare document(s) detailing the policies and procedures for registration and admission of patients which should also include unidentified patients. All patients who are assessed in the hospital shall be registered. All admissions must be authorised by a doctor. Additional documentation as required shall be included for foreign nationals).

The documented procedures address out-patients, in-patients and emergency patients. *  

A unique identification number is generated at the end of registration.

Patients are accepted only if the organisation can provide the required service. (The staff handling admission and registration needs to be aware of the services that the organisation can provide. It is also advisable to have a system wherein the staff is aware as to whom to contact if they need any clarification on the services provided. In case of emergency, life-saving treatment shall be initiated before any decision is taken regarding acceptance).

The documented policies and procedures also address managing patients during non-availability of beds. * (The organisation is aware of the availability of alternate organisations where the patients may be directed in case of non-availability of beds. In case the organisation admits these patients in a temporary holding area it shall ensure that there is adequate infrastructure to take care of these patients. Further, the organisation shall define as to how long patients are kept on temporary beds before a decision to transfer out is taken. The documented procedure also addresses managing patients when bed space is not available in the desired bed category or unit and the financial implications explained to the patient of the same).

Access to the healthcare services in the organisation is prioritised according to the clinical needs of the patient. (Patients with clinical problem which warrant an earlier response are identified and prioritised in all care settings. For eg. A patient waiting in the OPD who complains of giddiness, is seen as soon as possible).

The staff are aware of these processes. (All the staff handling these activities should be oriented to the applicable policies and procedures).

Patient and family rights and responsibilities are documented and displayed. * (Organisation should respect patient‘s rights and inform them of their responsibilities. The rights and responsibilities of the patients should be displayed (bilingually) in strategic location like the entrance/Lobby of the hospital, registration, billing, outpatient areas etc.. Pamphlets may also be provided regarding the same).

Patients and families are informed of their rights and responsibilities in a format and language that they can understand.(Display, information material, communication or counselling should at least be bi-lingual (English and the state language/language spoken by the majority of people in that area/region).

Documented procedure incorporates the list of situations where informed consent is required and the process for taking informed consent. * (The process for taking informed consent shall specify the various steps involved with the responsibility. A list of procedures should be made for which informed consent should be taken. This shall be prepared keeping in mind the requirements of this standard and statutory requirement. For example, some statutory requirements are MTP Act, PC-PNDT Act and Organ Transplantation Act. The policy for HIV testing should follow the national policy on HIV testing(NACO).

General consent for treatment is obtained when the patient enters the organisation.

Patient and/or his family members are informed of the scope of such general consent. (The organisation shall define as to what is the scope of the general consent and the same shall be communicated to the patient and/or his family members. This cannot include consent for invasive procedures or other procedures for which a specific consent is required as per this standard).

There is a uniform pricing policy in a given setting (out-patient and ward category). (There should be a billing policy which defines the charges to believed for various activities).

The relevant tariff list is available to patients. (The organisation shall ensure that there is an updated tariff list and that the relevant tariff is available for reviewing to patients when required. The organisation shall charge as per the tariff list. Any additional charge should also be enumerated in the tariff and the same communicated to the patients. The tariff rates should be uniform (in a given setting) and transparent).

The organisation has a mechanism to capture feedbacks from patients which includes patient satisfaction and patient experience.(Patient experience goes beyond patient satisfaction and making patient happy. In addition to collecting patient feedback the organisation shall also capture patient experience which may include communication with doctors and nurses, pain management, hospital environment (cleanliness and quietness), responsiveness of hospital staff, discharge information, communication about medications and overall rating of the hospitals. Eg: There may be a negative outcome but still have a positive patient experience).

The organisation has a documented complaint redressal procedure. * (This shall incorporate the mechanism for lodging complaints(including verbal or telephonic complaints), method of compiling them, analysing complaints including the time frame, the person(s) responsible and documenting the action taken. It is for the organisation to decide if it wants to give credence to anonymous complaints).

Patient and/or family members are made aware of the procedure for giving feedback and /or lodging complaints. (This shall be either by display or providing written information. It is important that the organisation creates an environment of trust wherein the patient would be comfortable to air his/her views).

All feedback and complaints are reviewed and/or analysed within a defined time frame. (The entire process shall be documented. Where appropriate the patient and/or family could be involved in the discussions and also informed regarding the outcome).

Corrective and/or preventive action(s) are taken based on the analysis where appropriate.

Display of vision, mission and values of the organisation.  (This shall be done by displaying the same prominently. For definition of "mission", ―vision‖ and ―values‖ refer to glossary. Only a display on its website would not be appropriate. It is preferable that the same be translated and displayed in the local language also).

The organisation has established processes for analysis of incidents. (The quality improvement committee (refer to CQI 1a) shall be responsible for this activity. This could preferably be done by identifying the root cause. Where possible, it is preferable that patients and other stakeholders be included in analysing the feedback and complaint).

The organisation has established processes for analysis of incidents. (The quality improvement committee (refer to CQI 1a) shall be responsible for this activity. This could preferably be done by identifying the root cause. Where possible, it is preferable that patients and other stakeholders be included in analysing the feedback and complaint).

The organisation defines and displays whether high-risk obstetric cases can be cared for or not. (The organisation shall define as to what constitutes high-risk obstetric case in consonance with best clinical practices. The display should be in a prominent location (either near the entrance or registration counter or near the OPD). This is applicable only if it cares for such patients. The organisation caring for high-risk obstetric cases has the facilities to take care of such mothers).

Scope of services of each department is defined. *(Each department's activity is to be predefined. This could be documented either at individual department level or the organisation could have a brochure detailing the scope of each department. This includes clinical and non-clinical departments. For example, nephrology department could do all activities like biopsy, shunts, fistulas, dialysis (hemodialysis and CAPD), etc.

The organisation defines and displays the scope of its paediatric services. (The scope shall include various paediatric sub specialities and special clinics. for eg. Well baby clinics, different levels of NICUs, PICU etc. The display should be in a prominent location (either near the entrance or registration counter or near the OPD).

The defined healthcare services are prominently displayed. Display should be at least bi-lingual (English and the state language/language spoken by the majority of people in that area).

There is internal and external sign postings in the organisation in a language understood by the patient, families and community. (Fire signage should follow the norms laid down by National Building Code and/or respective statutory body (for example, fire service). These signage shall guide patients and visitors. It is preferable that signage are bilingual. Statutory requirements shall be met).

Patient and family rights and responsibilities are documented and displayed. *

Patient Interview.

Staff Interview.