The documented procedures address OP, IP and ER patients.*  | preferably separately addressed.

The documented policies and procedures also address managing patients during non-availability of beds.*  

The staff are aware of these policies and processes.

Documented policies and procedures guide the transfer-in of patients to the organisation.* | both planned and unplanned transfer-in.

Documented policies and procedures guide the transfer-out/referral of unstable patients to another facility in an appropriate manner.* | (1) for patients cae to ED but to be transferred to other organization, admitted but required to move to another organization and pts being shifted for diagnostic tests. Address Stable/unstable/Ventilated  patients.

Documented policies and procedures guide the transfer-out/referral of stable patients to another facility in an appropriate manner.*

The documented procedure identify staff responsible during transfer / referral.*

The organisation gives a summary of patients condition and the treatment given.

The organisation defines and documents the content of initial assessment for the OP, IP and ER patients.*

The organisation determines who can perform the initial assessment.*

Transfer between departments/ units are done in a safe manner.

There shall be an identified area in the organisation which is easily accessible to receive and manage emergency patients.

Policies and procedures for emergency care are documented and are in consonance with statutory requirements.*

This also addresses the handling of medico-legal cases.*

The patients receive care in consonance with the policies.

Documented policies and procedures guide the triage of patients for initiation of appropriate care.*

Staff are familiar with the policies and trained on the procedures for care of emergency patients.*

Admission or discharge to home or transfer to another organisation is also documented.

In case of discharge to home or transfer to another organisation, a discharge note shall be given to the patient.

Quality assurance programmes are documented and implemented.*

The documented policies and procedures guide management of patients found dead on arrival to the hospital.*

Equipments are checked on a daily basis using a checklist.*

Emergency medications are checked daily and prior to dispatch using a checklist.

The organisation identifies potential emergencies.*

The organisation has a documented disaster management plan.*

Documented policies and procedures guide the uniform use of resuscitation throughout the organisation.*

Staff providing direct patient care are trained and periodically updated in CPR.

The events during a CPR  are recorded.

A post-event analysis of all CPR is done by multidisciplinary committee.

Corrective and preventive measures are taken based on the post-event analysis.

Documented policies and procedures guide the management of pain.*

All patients are screened for pain.

Patients with pain undergo detailed assessment and periodic reassessment.

The organisation respects and supports management of pain for such patients.

Patient and family are educated on various pain management techniques, where appropriate.

Sound inventory control practices guide storage of the medications in all areas throughout the organisation.

Look-alike and Sound-alike medications are identified and stored physically apart from each other.*

The list of emergency medications are defined and are stored in an uniform manner.*

Known drug allergies are ascertained before prescribing.

The organisation determines who can write orders.*

Orders are written in a uniform location in the medical records which also reflects patients name and unique identification number.

Medication orders are clear, legible, dated, timed, named and signed.

Medication orders contain the name of the medicine, route of administration, dose to be administered and frequency / time of administration.

Documented policy and procedure on verbal orders are implemented.*

Expiry date are checked prior to dispensing.

Medications are administered by those who are permitted by law to do so / legally authorised person.

Prepared medication is labelled prior to preparation of a second drug.

Patient is identified prior to administration.

Medication is verified from the order and physically inspected prior to administration.

Dosage is verified from the order prior to administration.

Route is verified from the order prior to administration.

Timing is verified from the order prior to administration.

Medication administration is documented.

Documented policies and procedures govern patients self-administration of medications.*

Documented policies and procedures govern patients own medications brought from outside the organisation.*

Documented policies and procedures guide the monitoring of patients after medication administration.*

The organisation defines those situations where close monitoring is required.*

Monitoring is done in collaborative manner.

Medications are changed where appropriate based on the monitoring.

Documented procedures guide the use of narcotic drugs and psychotropic substances which are in consonance with local and national regulations.*

These drugs are stored in a secure manner.

A proper record is kept of the usage, administration and disposal of these drugs.

These drugs are handled by appropriate personnel in accordance with the documented procedures.

Patient-safety devices & infrastructure are installed across the organisation and inspected periodically.

Equipments are periodically inspected and calibrated for their proper functioning.

Monitoring includes patient safety goals (identifier)

Every medical record has a unique identifier.

Entry in the medical record is named, signed, dated and timed.

The author of the entry can be identified.

Adequate and appropriate personal protective equipment, soap solutions and disinfectants are available and used correctly.

Adequate and appropriate facilities for hand hygiene in all patient-care areas are accessible to healthcare providers.

Proper segregation and collection of biomedical waste from all patient-care areas of the hospital is implemented and monitored..

There is adequate access and space for the ambulance(s).

The ambulance adheres to statutory requirements.

The ambulance(s) is appropriately equipped.

The ambulance(s) is manned by trained personnel (ACLS / BLS).

The ambulance(s) is checked on a daily basis.

Equipment's are checked on a daily basis using a checklist.*

Emergency medications are checked daily and prior to dispatch using a checklist.

The ambulance(s) has a proper communication system.

Statutory requirements (RC book, License of drivers, insurance, Emission check).