NABH Chapters

NABH accreditation standards will lead us to improved patient care, patient and employee safety and onto a path of continuous quality improvement.

• Access, Assessment and continuity of care (AAC):
  • The organization defines and displays the services that it can provide The organization has a well-defined registration and admission process and proper mechanism for transfer or referral of patients.
• Care of Patients (COP):
  • Uniform care of patients is guided by the applicable laws and regulations.
• Management of Medication (MOM):
  • The organization has proper pharmacy services and usage of medication and Policies and procedures exist for storage of medication.
• Patient Rights and Education (PRE):
  • The organization protects patient and family right during care. Patient and family rights support individual beliefs, values and involve the patient and family in decision-making process.
• Hospital Infection Control (HIC):
  • The organization has a well-designed, comprehensive and coordinated infection control program aimed at reducing/eliminating risks to patients, visitors and providers of care.
• Patient Safety and Quality Improvement (PSQ):
  • The Organization has a structured patient safety and quality assurance system and continuous monitoring program in the organization.
• Responsibility of Management (ROM):
  • The responsibilities of the management are defined and the services provided by each department are documented.
• Facility Management and Safety (FMS):
  • The organization is aware of and complies with the relevant rules and regulations, laws and byelaws and requisite facility inspection requirements and the organization has provisions for safe water, electricity, medical gases and vacuum systems.
• Human Resource Management (HRM):
  • The organization has a documented system of human resource planning and the staff joining the organization is socialized and oriented to the hospital environment.
• Information Management System (IMS):
  • The organization has policies and procedures in place 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.

Green and Clean Policy:

Yashoda super specialty hospital is a tertiary care hospital with focus on enhancing patient well being, aids in curative process while utilizing natural resources in an efficient environment friendly manner with an aim to mitigate adverse effects of environment of patients and staff by providing infection free ambience while cutting down carbon footprint along with appropriate and optimized uses of resources chemicals, energy, water, transportation, food, pharmaceuticals with adherence to all applicable statutory and regulatory requirement.

Responsibilities

• To follow Green and Clean Hospital Policy.
• The staff immunization is a mandatory programme for the welfare of the employees which is done annually as per the work profile.
• The staff will use PPE’S which includes lead apron, gloves, TLD, Mask etc as provided by the organization for the safety of the employees.
• Encourage sustainable consumption and waste reduction.
• Co-ordinate with various departments to improve efficiency and effectiveness in day to day lifestyle and work practice.

NABH 5th edition manual has 10 chapters consist of 100 standards. Every standard has their Objective elements. A total of 651 Objectives Elements. The name of chapter-6 was “Continuous Quality Improvement “as it is renamed as “Patient Safety and Quality Improvement” after the NABH 5th edition launched.
 

The Objective Elements are further categorized which will be assessed in Assessment.