NATIONAL ACCREDITATION BOARD FOR HOSPITALS AND HEALTHCARE PROVIDERS (NABH) Accreditation Standards for Ayurveda Hospitals ---------------------------------------------------------------------- Categories of Ayurveda Hospitals Category –I   Ayurveda hospital norms for 10 to 49 beds Category –II Ayurveda hospital norms for 50 to 99 beds. Category-III  Ayurveda hospital norms for 100-200 beds. Category –IV Ayurveda hospital norms for 201 and above beds. ---------------------------------------------------------------------- Access, Assessment and continuity of Care (AAC) AAC.1. The organization defines and displays the services that it can provide. AAC.2. The organization has a well defined registration and admission process. AAC.3. There is an appropriate mechanism for transfer or referral of patients who do not match the organizational resources. AAC.4. During admission the patient and/or the family members are educated to make informed decisions. AAC.5. Patients cared for by the organization undergo an established initial assessment. AAC.6. All patients cared for by the organization undergo a regular reassessment. AAC.7. Laboratory services are provided as per the requirements of the patients . AAC.8. There is an established laboratory quality assurance programme. AAC.9. There is an established laboratory safety programme. AAC.10. Imaging services are provided as per the requirements of the patients. AAC.11. There is an established quality assurance programme for imaging services.                                                                                                      AAC.12. There is an established radiation safety programme. AAC.13. Patient care is continuous and multidisciplinary in nature. AAC.14. The organization has a documented discharge process. AAC.15. Organisation defines the content of the discharge summary. Care of Patients (COP) COP.1. Uniform care of patients is provided in all settings of the organization and is guided by the applicable laws, regulations and guidelines. COP.2. Emergency services are guided by policies, procedures and applicable laws and regulations. COP.3. The ambulance services are commensurate with the scope of the services provided by the organization. COP.4. Policies and procedures guide the care of patients requiring cardio-pulmonary resuscitation. COP.5. Policies and procedures guide the care of vulnerable patients (elderly, physically and/or mentally challenged and children). COP.6. Policies and procedures guide the care of obstetrical patients. COP.7. Policies and procedures guide the care of pediatric patients. COP.8. Policies and procedures guide the care of patients undergoing moderate sedation. COP.9. Policies and procedures guide the administration of anesthesia. COP.10. Policies and procedures guide the care of patients undergoing surgical/parasurgical procedures. COP.11. Policies and procedures guide the Panchkarma Therapy. COP.12. Policies and procedures guide the care of patients under restraints. COP.13. Policies and procedures guide appropriate pain management. COP.14. Policies and procedures guide appropriate rehabilitative services. COP.15. Policies and procedures guide all research activities. COP.16. Policies and procedures guide nutritional therapy. COP.17. Policies and procedures guide the end of life care.                 Management of Medication (MOM) MOM.1. Policies and procedures guide the organization of pharmacy services and usage of medication. MOM.2. There is a hospital formulary. MOM.3. Policies and procedures exist for storage of medication. MOM.4. Policies and procedures exist for prescription of medications. MOM.5. Policies and procedures guide the safe dispensing of medications. MOM.6. There are defined procedures for mediation administration. MOM.7. Patients and family members are educated about safe medication and food-drug interactions. MOM.8. Patients are monitored after medication administration. MOM.9. Policies and procedures guide the use of formulations containing toxic/narcotic drugs. MOM.10. Policies and procedures guide the use of medical gases. Patients Rights and Education (PRE) PRE.1. The organization protects patient and family rights and informs them about their responsibilities during care. PRE.2. Patient and family rights support individual beliefs, values and involve the patient and family in decision making processes. PRE.3. A documented process for obtaining patient and /or family’s consent exists for informed decision making about their care. PRE.4. Patient and families have a right to information and education about their healthcare needs. PRE.5. Patient and families have a right to information on expected costs.                     Hospital Infection Control (HIC) HIC.1. The organization has a well-designed, comprehensive and coordinated infection control programme aimed at reducing/ eliminating risks to patients, visitors and providers of care. HIC.2. The organization has an infection control manual, which is periodically updated. HIC.3. The infection control team is responsible for surveillance activities in the identified areas of the organization. HIC.4. The organization takes action to prevent or reduce the risk of Hospital Associated Infections (HAI) in patients and employees. HIC.5. Proper facilities and adequate resources are provided to support the infection control programme. HIC.6. The organization takes appropriate actions to control outbreaks of infections. HIC.7. There are documented procedures for sterilization activities in the organization. HIC.8. Statutory provisions with regard to Bio-medical Waste (BMW) management are complied with. HIC.9. The infection control programme is supported by the organization’s management and includes training of staff and employee health.              Continuous Quality Improvement (CQI) CQI.1. There is a structured quality improvement and continuous monitoring programme in the organization. CQI.2. The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools for continual improvement. CQI.3. The organization identifies key indicators to monitor the managerial structures, processes and outcomes which are used as tools for continual improvement. CQI.4. The quality improvement programme is supported by the management. CQI.5. There is an established system for audit of patient care services. CQI.6. Sentinel events are intensively analyzed. Responsibilities of Management (ROM) ROM.1. The responsibilities of the management are defined. ROM.2. The services provided by each department are documented. ROM.3. The organization is managed by the leaders in an ethical manner. ROM.4. A suitably qualified and experienced individual heads the organization. ROM.5. Leaders ensure that patient safety aspects and risk management issues are an integral part of patient care and hospital management. Facility Management and Safety (FMS) FMS.1. The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements. FMS.2. The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors. FMS.3. The organization has a program for clinical and support service equipment management. FMS.4. The organization has provisions for safe water, electricity, medical gases and vacuum systems. FMS.5. The organization has plans for fire and non-fire emergencies within the facilities. FMS.6. The organization has a smoking elimination policy. FMS.7. The organization has systems in place to provide a safe and secure environment.               Human Resource Management (HRM) HRM.1. The organization has a documented system of human resource planning. HRM.2. The staff joining the organization is socialized and oriented to the hospital environment. HRM.3. There is an ongoing programme for professional training and development of the staff. HRM.4. Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety. HRM.5. An appraisal system for evaluating the performance of an employee exists as an integral part of the human resource management process HRM.6. The organization has a well-documented disciplinary procedure. HRM.7. A grievance handling mechanism exists in the organization. HRM.8. The organization addresses the health needs of the employees. HRM.9. There is a documented personal record for each staff member. HRM.10. There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of medical professionals permitted to provide patient care without supervision. HRM.11. There is a process for authorizing all medical professionals to admit and treat patients and provide other clinical services commensurate with their qualifications. HRM.12. There is a process for collecting, verifying and evaluating the credentials (education, registration, training and experience) of nursing staff. HRM.13. There is a process to identify job responsibilities and make clinical work assignments to all nursing staff members commensurate with their qualifications and any other regulatory requirements. Information Management System (IMS) IM S.1. Policies and procedures exist to meet the information needs of the care providers, management of the organization as well as other agencies that require data and information from the organization. IMS.2. The organization has processes in place for effective management of data. IMS.3. The organization has a complete and accurate medical record for every patient. IMS.4. The medical record reflects continuity of care. IMS.5. Policies and procedures are in place for maintaining confidentiality, integrity and security of information. IMS.6. Policies and procedures exist for retention time of records, data and information. IMS.7. The organization regularly carries out review of medical records.