The staff are oriented to these services. ? Scope of service known to staff ? Trained on SOC

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

Managing patients during non-availability of beds - The staff are aware of these processes.

Documented policies and procedures guide the transfer-in of patients to the organisation.*

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

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

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 the initial assessment for the out-patients, in-patients and emergency patients.*

The organisation determines who can perform the initial assessment.*

 The organisation defines the time frame within which the initial assessment is completed based on patients needs.*

The initial assessment for in-patients is documented within 24 hours or earlier as per the patients condition, as defined in the organisations policy.*

Initial assessment of in-patients includes nursing assessment which is done at the time of admission and documented. *

Initial assessment includes screening for nutritional needs.

The initial assessment results in a documented care plan. *

The Care plan reflects desired results of the treatment, care or service.

The Care plan is countersigned by the clinician in-charge of the patient within 24 hours.

Patients are reassessed at appropriate intervals.

Out-patients are informed of their next follow-up, where appropriate.

For in-patients during reassessment the Care plan is monitored and modified,where found necessary.

Staff involved in direct clinical care document reassessments. *

Patients are reassessed to determine their response to treatment and to plan further treatment or discharge.

During all phases of care, there is a qualified individual identified as responsible for the patient’s care.

Care of patients is coordinated in all care settings within the organisation.

Information about the patient’s care and response to treatment is shared among medical, nursing and other care-providers.

Information is exchanged and documented during each staffing shift, between shifts, and during transfers between units/departments.

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

The patient’s record(s) is available to the authorised care-providers to facilitate the exchange of information.

Documented procedures guide the referral of patients to other departments/specialities. *

The patient’s discharge process is planned in consultation with the patient and/or family.

Documented procedures exist for coordination of various departments and agencies involved in the discharge process (including medico-legal and absconded cases). *

Documented policies and procedures are in place for patients leaving against medical advice and patients being discharged on request. *

A discharge summary is given to all the patients leaving the organisation(including patients leaving against medical advice and on request).

The organisation defines the time taken for discharge and monitors the same.

Discharge summary is provided to the patients at the time of discharge.

Discharge summary contains the patient’s name, unique identification number,date of admission and date of discharge.

Discharge summary contains the reasons for admission, significant findings and diagnosis and the patient’s condition at the time of discharge.

Discharge summary contains information regarding investigation results, any procedure performed, medication administered and other treatment given.

Discharge summary contains follow-up advice, medication and other instructions in an understandable manner.

Discharge summary incorporates instructions about when and how to obtain urgent care.

In case of death, the summary of the case also includes the cause of death.

Care delivery is uniform for a given health problem when similar care is provided in more than one setting. *

The organisation adapts evidence-based medicine and clinical practice guidelines to guide uniform patient care.

There are documented policies and procedures for all activities of the nursing services. *

Assignment of patient care is done as per current good practice guidelines.

Nursing care is aligned and integrated with overall patient care.

Care provided by nurses is documented in the patient record. *

Nurses are provided with adequate equipment for providing safe and efficient nursing services.

Documented procedures are used to guide the performance of various clinical procedures. *

Only qualified personnel order, plan, perform and assist in performing procedures.

Documented procedures exist to prevent adverse events like a wrong site, wrong patient and wrong procedure. *

Informed consent is taken by the personnel performing the procedure, where applicable.

Adherence to standard precautions and asepsis is adhered to during the conduct of the procedure.

Patients are appropriately monitored during and after the procedure.

Procedures are documented accurately in the patient record. *

Informed consent is obtained for donation and transfusion of blood and blood components.

Informed consent also includes patient and family education about the donation.

The organisation defines the process for availability and transfusion of blood/blood components for use in emergency situations.*

Post-transfusion form is collected, reactions if any identified and are analysed for preventive and corrective actions.

Staff are trained to implement the policies.

Care of vulnerable patients - Policies and procedures are documented and are in accordance with the prevailing laws and the national and international guidelines. *

Care of vulnerable patients - Care is organised and delivered in accordance with the policies and procedures.

Care of vulnerable patients - The organisation provides for a safe and secure environment for the vulnerable group.

Care of vulnerable patients - A documented procedure exists for obtaining informed consent from the appropriate legal representative. *

Staff are trained to care for the vulnerable group.

Pain management - Documented policies and procedures guide the management of pain. *

All patients are screened for pain.

Patients with pain undergo detailed assessment and periodic reassessment.

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

Documented policies and procedures guide nutritional therapy including assessment and reassessment. *

Nutritional therapy is planned and provided in a collaborative manner.

There is a written order for the diet.

Patients receive food according to their clinical needs.

Food is prepared, handled, stored and distributed in a safe manner.

When families provide food, they are educated about the patient’s diet limitations.

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 is defined and is stored in a 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 patient’s 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 is implemented.*

Expiry dates are checked prior to dispensing.

Medications are administered by those who are permitted by law to do so.

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 patient’s self-administration ofmedications. *

Documented policies and procedures govern patient’s 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 a 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 procedure.

Patients and family rights include respecting any special preferences, spiritual and cultural needs.

Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment.

Patient and family rights include protection from neglect or abuse.

Patient and family rights include treating patient information as confidential.

Patient and family rights include refusal of treatment.

Patient and family have a right to seek an additional opinion regarding clinical care.

Patient and family rights include informed consent before transfusion of blood and blood components, anaesthesia, surgery, initiation of any research protocol and any other invasive / high risk procedures / treatment.

Patient and family rights include right to complain and information on how to voice a complaint

Patient and family rights include information on the expected cost of the treatment.

Patient and family rights include access to his / her clinical records.

Patient and family rights include information on Care plan, progress and information on their health care needs.

The patient and/or family members are explained about the proposed care including the risks, alternatives and benefits.

The patient and/or family members are explained about the expected results.

The patient and/or family members are explained about the possible complications.

The care plan is prepared and modified in consultation with patient and/or family members.

The care plan respects and where possible incorporates patient and/or family concerns and requests.

The patient and/or family members are informed about the results of diagnostic tests and the diagnosis.

The patient and/or family members are explained about any change in the patient’s condition in a timely manner.

Policy on consent and the procedure describing who can give consent when patient is incapable of independent decision making.*

Informed consent is taken by the person performing the procedure.

The organisation adheres to cleaning, disinfection and sterilization practices.*

Adequate and appropriate personal protective equipment, soaps, 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.

The patient-safety programme is comprehensive and covers all the major elements related to patient safety and risk management.

Percentage of cases (IP) wherein - Care plan with desired outcomes are documented and counter signed by the clinician, Screening for nutritional needs has been done, Nursing care plan is documented.

Equipment are periodically inspected and calibrated for their proper functioning.

The organisation has plans and provisions for early detection, abatement and containment of fire, and non-fire emergencies. *

The organisation has a documented safe-exit plan in case of fire and non-fire emergencies.

Staff is trained for its role in case of such emergencies.

Mock drills are held at least twice a year.

There is a maintenance plan for fire-related equipment & infrastructure *

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.

Patient interview.

Staff interview.