Wards

Chapter AAC - Assessment of Patients

1. Initial Assessment (AAC 4a, 4c, 4d):

   • A standardized format for initial assessment must be used for In-patients (IPs).

   • For IPs, the assessment must cover history, examination, vital signs, drug allergies, and provisional diagnosis.

   • The assessment must link to any earlier assessment (if applicable).

   • The initial assessment for IPs must be completed within 24 hours of admission.

   • Initial assessment for IPs must include a nursing assessment.

   • The nursing assessment should identify nursing needs and be completed within a defined time frame (at admission). A checklist or template can be used.

2. Qualified Personnel (AAC 4b):

   • The hospital must define which qualified personnel are authorized to perform the initial assessment in wards.

3. Care Plan (AAC 4e, 4f, 4g, 5c):

   • The initial assessment for IPs must result in a documented care plan.

   • The care plan should be documented by the treating doctor.

   • It should include the provisional diagnosis, investigations, initial treatment, and specific instructions.

   • The care plan should reflect the desired results of treatment and care.

   • The care plan must be countersigned by the clinician-in-charge (treating doctor) within 24 hours.

   • The care plan must include identification of special needs (e.g., for extremes of age, restricted mobility, specific nursing/rehabilitation needs, assistance with daily living).

   • The process of identifying special discharge needs should begin early in the assessment process and be included in the care plan.

   • The care plan for IPs must be monitored and modified during reassessment as necessary, according to the patient's condition. This dynamic nature of the care plan should be documented in medical records (progress notes, doctor's orders, medication charts can show evidence).

4. Reassessment (AAC 5a, 5d, 10):

   • Patients in wards must be reassessed at appropriate intervals to determine their response to treatment and plan further care or discharge.

   • The frequency of reassessment may differ for different areas (wards typically less frequent than ICU).

   • Every patient in the ward should be reassessed at least once every day by the treating doctor.

   • Reassessments must be documented in the case sheet by staff involved in direct clinical care (treating doctor or nurses).

   • Documentation must include vitals, systemic examinations, findings, and medication orders. Vague terms like "patient well" are not acceptable.

5. Early Warning Signs (AAC 5e, 11):

   • Guidelines and processes must be in place to identify early warning signs of clinical condition change or deterioration for prompt intervention.

   • Defined parameters for identifying deterioration (e.g., vital parameters, airway, circulation, neurological status, other staff/patient concerns) must be specified.

   • This information must be made available to appropriate medical personnel to initiate prompt action.

6. Continuum of Care - Responsibility & Coordination (AAC 12a, 12b, 12c, 12d, 12e):

   • During all phases of care in the ward, a qualified individual (primary physician) must be identified in the hospital record as responsible for the patient's care.

   • Patient care must be coordinated among all care providers in the ward setting (medical, nursing, etc.).

   • There must be effective communication of patient requirements among care providers in the ward.

   • Information about patient care and response to treatment must be shared among medical, nursing, and other care-providers in the ward (e.g., through case sheet entries, team meetings, grand rounds).

   • Standardized hand-over communication must be implemented during staffing shifts in the ward and during transfers of patients to/from the ward.

   • Patient transfers within the organisation (to/from wards) must be done safely. Proper handover and takeover must be documented during such transfers.

7. Referrals & Service Timelines (AAC 12f, 12g):

   • Referral of patients from the ward to other departments/specialties must follow written guidance (reason, urgency, seen within a defined frame).

   • The organisation must ensure predictable service delivery timelines in the ward (e.g., lab/radiology report turnaround time, waiting time for consultations).

   • Patient/family/caregiver must be informed if there is any deviation from defined timelines.

8. Critical Value Alerts (AAC 12h):

   • A mechanism must be in place in the ward to monitor whether adequate clinical intervention has taken place in response to critical value alerts.

   • Evidence of the clinical intervention in response to critical value alerts must be documented in the progress note or medication orders.

9. Discharge Process (AAC 13a, 13b, 13c, 13d, 13e, 14a, 14b, 14c, 14d, 14e, 14f):

   • The patient discharge process must be planned in consultation with the patient and/or family.

   • The discharge process must be coordinated among various departments/agencies involved (including handling of medico-legal and absconded cases).

   • Written guidance must govern the discharge of patients leaving against medical advice (LAMA), including addressing the reasons and taking Consent Against Medical Advice (CAPA) if possible.

   • A discharge summary must be given to all patients leaving the ward (including LAMA patients), and a copy retained in the medical record.

   • The hospital must adhere to the planned discharge process, which should be planned at least 24 hours in advance.

   • Discharge planning should include preparation of the draft summary, refund of medications, and patient education on continued care.

   • A discharge summary must be provided to patients in the ward at the time of discharge, signed by the treating doctor or a member of the treating team. Receipt should be acknowledged.

   • The discharge summary must contain:

     • Patient's name, unique identification number, name of the treating doctor (and other consultants involved), date of admission/discharge.

     • Reasons for admission, significant findings, diagnosis, and the patient's condition at discharge.

     • Investigation results, any procedure performed, medication administered, and other treatment given.

     • Follow-up advice, medication, and other instructions in an understandable manner (avoid medical terms like BD, TDS).

     • Instructions about when and how to obtain urgent care (in understandable language).

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   • In case of death in the ward, the summary of the case must include the cause of death (document post-mortem if performed).

Chapter COP - Care of Patients

1. Uniform Care (COP 1a, 1c, 1f):

   • Uniform care must be provided in the ward following written guidance (SOPs).

   • Care must be provided in the ward in consonance with applicable laws and regulations (e.g., consent before surgery, first aid to emergency patients - implies initial care that may happen in ward, police intimation for MLC cases - which are often admitted to wards).

   • Care delivery must be uniform for a given clinical condition when similar care is provided in the ward compared to other settings, based on clinical needs, not patient category.

2. Guidelines and Pathways (COP 1d, 1e):

   • Evidence-based clinical practice guidelines/protocols must be adapted to guide uniform patient care in the ward.

   • Clinical care pathways must be developed, consistently followed across all settings including wards, and reviewed periodically (should be multidisciplinary).

3. Multi-disciplinary Care (COP 1g):

   • Multi-disciplinary and multi-specialty care, where appropriate in the ward, must be planned based on best clinical practices/guidelines and delivered uniformly (integrated care plan including professional, nursing, nutritional, supportive care).

4. Resuscitation Services (COP 5a, 5b, 5c):

   • Resuscitation services must be available to patients in the ward at all times.

   • During CPR in the ward, assigned roles and responsibilities must be complied with.

   • Equipment and medications for use during CPR (crash cart, defibrillator) must be available in various areas of the organisation, including ward areas. Emergency medication on crash carts should be standardized.

5. Nursing Care (COP 6a, 6b, 6c, 6e, 6f):

   • Nursing care must be provided to patients in the ward in accordance with written guidance (Nursing manual covering basic practices like vital signs, medication administration, basic hygiene).

   • The organisation must develop and implement nursing clinical practice guidelines relevant to ward care (e.g., fall prevention, pressure ulcer prevention, DVT risk assessment/prevention), reflecting current standards of practice, and reviewed/revised annually.

   • Assignment of patient care in the ward must be done as per current good clinical/nursing practice guidelines (based on patient's clinical requirements and nursing staff competence).

   • Nursing care in the ward must be aligned and integrated with overall patient care (nursing care plan includes assessment, plan, implementation, evaluation, modification).

   • Care provided by nurses in the ward must be documented in the patient record (nursing progress notes).

6. Nursing Equipment & Empowerment (COP 6g, 6h):

   • Nurses in the ward must be provided with appropriate and adequate equipment for safe and efficient nursing care (e.g., sphygmomanometers, thermometers, weighing scales - ensuring appropriate size like paediatric cuffs). This equipment should be documented in an inventory register.

   • Nurses in the ward must be empowered to make patient care decisions within their scope of practice (scope defined and nurses aware).

7. Procedure Management (COP 7a, 7b, 7c, 7d, 7e, 7f, 7g, 7h):

   • Procedures performed in the ward must be based on the clinical needs of the patient.

   • Performance of clinical procedures in the ward must be based on written guidance (SOPs covering who does it, pre/post care).

   • Qualified personnel (privileged) must order, plan, perform, and assist in performing procedures in the ward.

   • Care must be taken to prevent adverse events like wrong patient, wrong procedure, and wrong site during procedures in the ward, using a documented checklist (elements from WHO safe surgery), 2 identifiers, site marking, and patient/relative involvement.

   • Informed consent must be taken by the personnel performing the procedure in the ward, where applicable.

   • Procedures in the ward must be done adhering to standard precautions (hand hygiene, PPE, sterile instruments).

   • Patients must be appropriately monitored during and after procedures in the ward (vitals, clinical parameters).

   • Procedures must be documented accurately in the patient record in the ward (procedure name, performer, steps, findings, post-care, date/time/signature).

8. Blood Transfusion Safety (COP 8b, 8d):

   • Transfusion of blood and blood components in the ward must be done safely (SOP covering storage, transport, verification, monitoring). Verification before transfusion (identifying patient/monitoring) is key in the ward.

   • Informed consent must be obtained for transfusion of blood and blood components in the ward (valid for multiple transfusions, specific timeframe for transfusion-dependent patients, include risks/benefits/complications).

9. Surgical Patient Care (COP 14a, 14b, 14c, 14d):

   • For patients in the ward who are pre or post-surgical:

     • They must have a preoperative assessment, a documented preoperative diagnosis, and pre-operative instructions provided before surgery.

     • Informed consent must be obtained by a surgeon before the procedure.

     • Care must be taken to prevent adverse events like the wrong site, wrong patient, and wrong surgery (SOP, surgical safety checklist, site marking).

10. Care for Vulnerable Patients (COP 16a, 16b, 16f):

    • The organisation must identify and manage vulnerable patients in the ward (elderly, children, disabled, sedated, comatose, critically ill, pregnant, dialysis, chemo patients, mentally ill).

    • Responsibility for identifying, risk management, and monitoring (at least twice daily) of vulnerable patients in the ward must be defined. Informed consent process for these patients should be included.

    • Care for vulnerable patients in the ward must be organised and delivered in accordance with written guidance.

    • The organisation must provide for a safe and secure environment for vulnerable patients in the ward (fall prevention measures, ramps with railings, grab-bars in patient washrooms, care of differently-abled).

    • The organisation must identify and manage patients in the ward who need restraints (SOP for appropriate use and control).

11. Risk Identification & Management (COP 16c, 16d, 16e):

    • The organisation must identify and manage patients in the ward who are at risk of fall (use a validated tool like Morse Fall scale, Paediatric assessment scale, Humpty Dumpty; manage according to written guidance like Universal precautions).

    • The organisation must identify and manage patients in the ward who are at risk of developing/worsening of pressure ulcers (use a validated tool like Braden scale; manage according to written guidance).

    • The organisation must identify and manage patients in the ward who are at risk of developing deep vein thrombosis (use a validated tool; manage according to written guidance).

12. Pain Management (COP 17a, 17b, 17c, 17d):

    • Patients in the ward experiencing pain must be effectively managed.

    • Patients admitted to the ward must be screened for pain (on admission, consider as 5th vital sign, incorporate a yes/no question in initial assessment).

    • Patients in the ward with pain must undergo detailed and periodic reassessment (intensity using a validated pain rating scale, character, frequency, location, duration, referral/radiation).

    • Pain alleviation measures or medications must be initiated and titrated in the ward according to the patient's need and response (includes medical, surgical, anesthetic techniques).

13. Nutritional Care (COP 19a, 19d, 19e):

    • Patients admitted to the ward must be screened for nutritional risk (by caregiver/nurse using a validated tool like NRS 2002, Mini Nutritional Assessment, etc.).

    • Patients in the ward must receive food according to the written order for their diet (therapeutic or normal diet), prepared as per a diet sheet if therapeutic.

    • When family provides food for a patient in the ward, they must be educated about the patient's diet limitations and monitored for compliance.

Chapter MOM - Management of Medication

1. Medication Storage (MOM 3a, 3b, 3d, 3e, 3f, 3g):

   • Medications in the ward must be stored in a clean, safe, and secure environment. Access to medication storage areas should be limited.

   • Temperature monitoring must be done at least once a day for medication storage areas in the ward.

   • Beyond expiry date drugs in the ward must be stored separately before disposal.

   • Sound inventory control practices must guide storage in the ward (defined pattern like ABC, VED, FSN, FEFO; alphabetical order by generic name).

   • High-risk medications (defined list: low therapeutic window, controlled substances, psychotherapeutics, LASA, concentrated electrolytes) must be stored in predetermined areas where clinically necessary, such as certain wards. Safeguards should be in place.

   • High-risk medications, including look-alike, sound-alike (LASA) medications, and different concentrations of the same medication in the ward, must be stored physically apart.

   • A list of emergency medications must be defined and stored uniformly in the ward (on crash carts with defined contents by rows/drawers, no other drugs).

   • Emergency medications must be available in the ward all the time and replenished promptly when used (at least daily inventory check of crash carts).

2. Medication Prescription (MOM 4a, 4b, 4c, 4d, 4e):

   • Medication prescription should be in consonance with good practices/rational guidelines. Clinicians should be trained on rational prescription.

   • Prescriptions in the ward must adhere to minimum requirements: patient name/UHID, drug details (generic composition mandatory), strength, dosage, instructions, duration, total quantity, prescribing doctor's name/signature/registration number.

   • Error-prone abbreviations must not be used. Prescriptions should be written in capital letters. Prescription errors or illegible prescriptions must be initialled after a single strikethrough and rewritten.

   • Drug allergies and previous adverse drug reactions must be ascertained before prescribing in the ward and documented prominently in medical records (e.g., using a yellow sticker).

   • A mechanism must be in place to assist clinicians in the ward in prescribing appropriate medication (e.g., standard online drug reference) to identify drug reactions, food-drug interactions, therapeutic duplication, and dose adjustments.

   • Implementation of verbal orders in the ward must ensure safe medication management practices (SOP defining who can give/when, authentication process, approved formulary list, repeat back/read back, countersigned by ordering doctor within 24 hours).

3. Medication Reconciliation (MOM 4h):

   • Reconciliation of medications must occur at transition points of patient care involving the ward (admission, transfer between wards, discharge), and documented.

4. Medication Handling & Administration (MOM 6b, 6c, 7a, 7b, 7c, 7d, 7e, 7f, 7g, 7h):

   • Medication recalls in the ward must be handled effectively based on communication (regulatory, manufacturer, internal feedback).

   • Near-expiry medications in the ward must be handled effectively following defined procedures (e.g., define near expiry as 3 months before date).

   • Medications must be administered in the ward by those permitted by law (registered nurse or doctor).

   • Prepared medication in the ward must be labelled before preparation of a second drug (SOP applies).

   • The patient must be identified (using UHID/Name) before medication administration in the ward.

   • Medication must be verified from the medication order and physically inspected (appearance, expiry date) before administration in the ward. High-risk meds require verification by at least 2 staff (nurse-nurse or nurse-doctor), documented. Nurses must be knowledgeable and empowered to highlight errors.

   • Strength must be verified from the order before administration in the ward.

   • The route must be verified from the order before administration in the ward (site of administration also verified).

   • Timing must be verified from the order before administration in the ward (documentation for meds without explicit time).

   • Measures must be implemented to avoid catheter and tubing misconnections during medication administration in the ward (using design features, tracing lines, verifying attachments).

5. Medication Documentation (MOM 7i):

   • Medication administration must be documented accurately and in a uniform location in the patient record in the ward. Documentation should include medication name, strength, route, timing, and the name/employee ID and signature of the person administering.

   • Documentation should be done for each time/dose. For infusions, start time, rate, and end time must be captured. Patient refusal to take medication must also be documented.

6. Self-Administration & Outside Meds (MOM 7j, 7k):

   • Measures must govern patients' self-administration of medications in the ward (define list of permitted meds, reminder mechanism, documentation).

   • Measures must govern patient's medications brought from outside the organisation in the ward (SOP).

7. Medication Monitoring & Errors (MOM 8a, 8b, 8c, 8d):

   • Patients must be monitored after medication administration in the ward (monitor beneficial or adverse effects, e.g., via lab results).

   • Medications must be changed in the ward where appropriate based on the monitoring (clinical response, adverse drug reactions).

   • The organisation must capture near miss, medication error, and adverse drug reaction events occurring in the ward (define terms, SOP for identifying, documenting, reporting, analysing, acting).

   • Near miss, medication error, and adverse drug reaction events occurring in the ward must be reported within a specified time frame.

8. Special Categories of Medications (MOM 9a, 9b, 9c, 9d, 9e):

   • Narcotic drugs and psychotropic substances, chemotherapeutic agents, and radioactive agents must be used safely in the ward (SOP, follow relevant acts/guidelines).

   • These medications must be prescribed by appropriate caregivers (narcotics by designated medical officer, chemo by medical oncologist, radioactive agents by caregiver authorised by statutory body).

   • These medications must be stored securely in the ward (narcotics in a double lock cabinet, chemo access limited to authorised personnel, radioactive agents as per guidelines, stored separately from other meds).

   • Chemotherapy agents administered in the ward must be prepared properly and safely (training received, use biosafety cabinet with appropriate PPE). Radioactive agents also prepared/administered by appropriate caregiver.

   • A proper record must be kept in the ward of the usage, administration, and disposal of narcotic drugs, psychotropic substances, chemotherapeutic agents, and radioactive agents (strict inventory control, follow statutory requirements/BMW rules/manufacturer recommendations).

Chapter PRE - Patient and Family Rights

1. Patient/Family Rights & Awareness (PRE 1a, 1b, 2h, 2i, 2j, 2k, 2l):

   • Patient and family rights and responsibilities must be documented, displayed visibly (bilingual), and they must be made aware of the same (using pamphlets).

   • Patient and family rights and responsibilities must be actively promoted in the ward (counseling for IPs in understandable format/language, educational material/display).

   • Staff in the ward must conduct themselves in a manner that conveys a positive attitude towards protecting patient and family rights.

   • The organisation must have a mechanism to report violations of patient and family rights related to ward care (feedback form, OVR, train staff on infringements).

   • The ward must respect patient/family values and beliefs, special preferences, cultural needs, and respond to requests for spiritual needs (ask how they wish to be addressed, dietary preferences, worship requirements).

   • The patient/family in the ward must have the right to complain, and information on how to voice a complaint must be known to them (displayed).

   • Patient and families must be informed about the expected costs of treatment.

   • Patient and family must have access to their clinical records maintained in the ward (in consonance with the code of medical ethics).

   • Patient and family must be informed about the name of the treating doctor, care plan, patient's progress, and healthcare needs (discussed in the ward).

   • Patient rights determining what information regarding their care would be provided to self and family must be respected (mechanism to provide sensitive information).

2. Privacy & Safety (PRE 2b, 2c, 2d):

   • Respect for personal dignity and privacy must be maintained during examination, procedures, and treatment in the ward. Necessary guidelines should be developed.

   • Patient and family must be protected from neglect or abuse in the ward (special precautions for vulnerable patients).

   • Patient information handled in the ward must be treated as confidential (effective measures to maintain confidentiality).

3. Treatment Decisions & Information (PRE 2e, 2f, 13a, 13b, 13c, 13d, 13e, 13f, 13g):

   • Patient and family in the ward have the right to refuse treatment (treating doctor discusses options, consequences of refusal explained/documented).

   • Patient and family in the ward have the right to seek an additional opinion (respect decision, facilitate access to info/evaluation).

   • Patient and/or family members in the ward must be explained about the proposed care, including risks, alternatives, and benefits (by the treating doctor in understandable language, documented/signed).

   • Patient and/or family members must be explained about the expected results of care in the ward (in detail by doctor periodically).

   • Patient and/or family members must be explained about the possible complications of care in the ward.

   • The care plan for patients in the ward must be prepared and modified in consultation with the patient and/or family members (structured mechanism).

   • Patient and/or family members must be informed about the results of diagnostic tests and the diagnosis (implication on progress/treatment explained).

   • Patient and/or family members must be explained about any change in the patient's condition in the ward in a timely manner.

   • Patient and/or family members must be provided multi-disciplinary counselling in the ward when appropriate (identify situations, team involves different specialities/nurse/physio).

4. Informed Consent (PRE 2g, 4a, 4b, 4c, 4d, 4e):

   • Informed consent must be obtained in the ward before blood transfusion, anaesthesia, surgery, initiation of any research protocol, and any other invasive/high-risk procedures/treatment (by the treating doctor or a member of the treating team).

   • The organisation must obtain informed consent for specified procedures by the patient or family in the ward following written guidance (list procedures requiring consent, consonance with statutory requirements like MTP, PC-PNDT, Transplantation of organs, HIV testing policy). The process should involve written guidance, awareness of staff, and identification of the responsible person.

   • Informed consent process must adhere to statutory norms (consent before procedure, at least one witness signing, witness present for entire duration, handling repeated procedures, fresh consent for changes in treatment modality).

   • Informed consent must include information regarding the procedure, its risks, benefits, and alternatives, and specify who will perform the procedure (language they can understand, bilingual if possible, mention doctor-under-training and supervisor if applicable).

   • The organisation must describe who can give consent in the ward when a patient is incapable of independent decision making and implement the same (statutory norms, next of kin/legal guardian, provisions for life-threatening situations).

   • Informed consent must be taken by the person performing the procedure (responsible for explanation and signature).

5. Patient Education (PRE 5a, 5b, 5c, 5d, 5e, 5f, 5g, 5h, 5i, 6d):

   • Patient and/or family in the ward must be educated in a language and format that they can understand (counseling, printed/audio-visual materials).

   • Patient and/or family must be educated about the safe and effective use of medication and potential side effects in the ward, when appropriate (list drugs, importance of timing).

   • Patient and/or family must be educated about food-drug interaction related to their care in the ward (list drugs, diet during medication).

   • Patient and/or family must be educated about diet and nutrition (healthy diet).

   • Patient and/family must be educated about immunisations relevant to their condition/stay.

   • Patient and/or family must be educated on various pain management techniques when appropriate (within personal/cultural/religious beliefs).

   • Patient and/or family must be educated about their specific disease process, complications, and prevention strategies in the ward (stress management, exercise, smoking cessation, substance abuse, diet changes, immunisations), using booklets/videos/leaflets.

   • Patient and/or family must be educated about preventing healthcare associated infections in the ward (hand washing, avoiding overcrowding near the patient).

   • The patients and/family members' special educational needs must be identified and addressed in the ward (counseling, printed/audio-visual material).

   • Patient and/family must be informed about the financial implications when there is a change in the care plan in the ward (shifting units, surgery vs medical, expensive investigations).

6. Patient Experience & Communication (PRE 7b, 8b, 8c, 8d):

   • The organisation must have a mechanism to capture patient experience related to their stay in the ward (communication with doctors/nurses, pain management, environment, responsiveness, discharge info, med communication, overall rating).

   • The organisation must identify special situations in the ward where enhanced communication with patients and/families would be required (breaking bad news, handling adverse events, aggressive patients, talking to family of deceased, counselling for complicated interventions).

   • Enhanced communication with patients and families in the ward must be done effectively (detail nature required).

   • The organisation must ensure that there is no unacceptable communication in the ward (abusing patients, hurting religious/cultural sentiments).

Chapter HIC - Hospital Infection Control

1. Resources & Facilities (HIC 2a, 2c, 2d, 2e):

   • The management must make available adequate resources (personnel, materials) required for the infection control programme relevant to ward activities.

   • Adequate and appropriate personal protective equipment (PPE), soaps, and disinfectants must be available and used correctly in the ward (monitoring disinfectants used).

   • Adequate and appropriate facilities for hand hygiene must be accessible to healthcare providers in all patient-care areas, including wards (washbasin, hands-free tap, soap, facility for drying hands, handrub).

   • Isolation/barrier nursing facilities must be available in the ward area (define conditions for use, resources, isolation rooms including negative pressure for airborne cases, signage).

2. HIC Practices (HIC 3a, 3b, 3c, 3d, 4c, 4d, 4e):

   • The organisation must adhere to standard precautions at all times in the ward (across the organisation, documentation).

   • The organisation must adhere to hand-hygiene guidelines in the ward (WHO guidelines, instructions displayed near hand washing areas).

   • The organisation must adhere to transmission-based precautions in the ward (appropriate usage of PPE in identified situations).

   • The organisation must adhere to safe injection and infusion practices in the ward (one needle/syringe, one time).

   • The organisation must adhere to housekeeping procedures in the ward (cleaning frequency, disinfectants, terminal cleaning, blood/body fluid clean up).

   • Biomedical waste (BMW) generated in the ward must be handled appropriately and safely (segregation, collection, storage, hand over, color coded bags).

   • The organisation must adhere to laundry and linen management processes relevant to the ward (handling in patient care units, transport, storage, distribution, separation of clean/dirty linen).

3. Healthcare Associated Infection (HAI) Prevention (HIC 5a, 5b, 5c, 5d):

   • The organisation must take action to prevent catheter-associated urinary tract infections (CAUTI) in the ward (implement care bundles).

   • The organisation must take action to prevent infection-related ventilator associated complication/ventilator-associated pneumonia (VAP) in the ward, if applicable (implement care bundles).

   • The organisation must take action to prevent catheter linked bloodstream infections (CLABSI) in the ward (implement care bundles).

   • The organisation must take action to prevent surgical site infections (SSI) for patients in the ward (implement care bundles).

4. Instrument Reprocessing (HIC 7b, 7c, 7e):

   • Cleaning, packing, disinfection and/or sterilisation, storing and the issue of items used in the ward must be done as per written guidance (SOP, expiry date guidance).

   • Reprocessing of single-use instruments, equipment, and devices used in the ward must be done as per written guidance (define number of reuses, monitored).

   • The established recall procedure must be implemented in the ward when a breakdown in the sterilisation system is identified.

Chapter FMS - Facility Management & Safety

1. Patient Safety Infrastructure (FMS 1a):

   • Patient-safety devices and infrastructure must be installed across the organisation, including wards, and inspected periodically (grab bars, bed rails, signage, alarms, call bells, fire safety devices).

2. Signage (FMS 2c):

   • There must be internal and external sign postings in the organisation, including wards, in a manner understood by the patient, families, and community (bilingual/pictorial, as per regulatory requirements).

3. Utilities (FMS 2d, 2e):

   • Adequate potable water and electricity must be available round the clock in the ward area. Water quality must be monitored.

   • Alternate sources for electricity and water must be provided as a backup for any failure/shortage in the ward area.

4. Security (FMS 3b):

   • Operational planning must identify areas in the ward which need to have extra security and describe access to different areas for staff, patients, and visitors (mechanism to identify, defined access categories, CCTV).

5. Waste Management (FMS 3d):

   • There must be a procedure which addresses the identification and disposal of material(s) not in use in the organisation, including the ward (condemnation).

6. Hazardous Materials (FMS 3e, 3f):

   • Hazardous materials used in the ward must be identified and used safely (documentation, procedure for sorting/storage/handling/transport/disposal, availability of MSDS).

   • The plan for managing spills of hazardous materials in the ward must be implemented (MSDS-based plan, staff trained, HAZMAT kit).

7. Equipment Management (FMS 4b, 4d, 4h, 5b, 5d):

   • Equipment used in the ward must be inventoried, and proper logs maintained as required (unique ID, quality certs, test certs, installation report).

   • Utility equipment (relevant to wards) must be periodically inspected and calibrated (wherever applicable) for their proper functioning (calibration schedule, traceability).

   • Written guidance must support equipment replacement, identification of unwanted material, and disposal in the ward area.

   • Medical equipment used in the ward must be inventoried, and proper logs maintained (unique ID, classification by risk, quality certs, test certs, installation report).

   • Medical equipment used in the ward must be periodically inspected and calibrated for their proper functioning (schedule, traceability, commissioning check, recalibration after repair).

8. Medical Gases (FMS 6a, 6b, 6c, 6d):

   • Written guidance must govern the procurement, handling, storage, distribution, usage, and replenishment of medical gases used in the ward (SOP, uniform color coding, signage, statutory requirements).

   • Medical gases in the ward must be handled, stored, distributed, and used in a safe manner (standardized color coding, air purity check if applicable).

   • The procedures for medical gases must address safety issues at all levels (storage, supply lines, end-user area), including installation of alarm units, valve boxes, and 24x7 monitoring of plant alarms.

   • Alternate sources for medical gases, vacuum, and compressed air must be provided for use in the ward, in case of failure (stand by units/cylinders).

9. Emergency Exit Plan (FMS 7b):

   • The organisation must have a documented and displayed exit plan in case of fire and non-fire emergencies on each floor/close to exits in the ward area.

Chapter HRM - Human Resource Management

1. Staff Training (HRM 3a, 4c, 5a, 5b, 5c, 5d, 5e, 5f, 6a, 6b, 6c, 6d, 6e, 6f, 6g):

   • Staff working in the ward must be provided with induction training (attendance, schedule, topics, records).

   • Training must also occur when job responsibilities change or new equipment is introduced in the ward.

   • Staff involved in blood transfusion services in the ward must be trained on the handling of blood and blood products.

   • Staff in the ward must be trained in handling vulnerable patients (identifying, care as per SOP).

   • Staff in the ward must be trained in control and restraint techniques (appropriate use as per SOP).

   • Staff in the ward must be trained in healthcare communication techniques (during challenging situations, good practices).

   • Staff involved in direct patient care in the ward must be provided training on cardiopulmonary resuscitation periodically (BLS yearly for doctors/nurses/rehab, advanced training for critical care staff, based on evidence).

   • Staff in the ward must be trained in infection prevention and control (at least once a year inservice training).

   • Staff must be trained on the organisation's safety programme.

   • Staff must be trained on the detection, handling, minimisation, and elimination of identified risks within the organisation's environment (physical, chemical, environmental, process), including management of spills/hazardous materials.

   • Staff members in the ward must be made aware of procedures to follow in the event of an incident (intimate sequence of events).

   • Staff in the ward must be trained in occupational safety aspects (Risk & PA, NSI, Spill, Radiation, Chemo, Noise).

   • Staff in the ward must be trained in the organisation's disaster management plan (Code Yellow).

   • Staff in the ward must be trained in handling fire and non-fire emergencies (specific role defined).

   • Staff in the ward must be trained on the organisation's quality improvement programme (structure, role).

2. Staff Welfare & Rights (HRM 7b, 8b, 9c, 9d):

   • Staff in the ward must be made aware of the system of appraisal at the time of induction (objectively described).

   • The disciplinary and grievance handling mechanism must be known to all categories of staff in the ward.

   • Health checks of staff dealing with direct patient care in the ward must be done at least once a year (defined parameters, free, freq increase if required), and findings/results documented.

   • The organisation must provide treatment for staff working in the ward who sustain workplace-related injuries (needle stick, sound pollution etc.).

3. Nursing Staff Competence & Privileging (HRM 12a, 12b, 12d, 12e, 12f):

   • Nursing staff in the ward must be permitted by law, regulation, and the organisation to provide patient care without supervision (identified, minimum qualification based on council act).

   • The education, registration, training, and experience of nursing staff in the ward must be appropriately verified, documented, and updated periodically.

   • Nursing staff in the ward must be granted privileges in consonance with their qualification, training, experience, and registration.

   • The requisite services to be provided by the nursing staff in the ward must be known to them and the various departments/units of the organisation (internal communication).

   • Nursing professionals in the ward must care for patients as per their privileging (audit use/misuse of privileges).

Chapter IMS - Information Management System

1. Medical Record (IMS 3a, 3c, 3d, 4b):

   • A unique identifier must be assigned to the medical record used in the ward (on every sheet). For electronic records, all entries for one ID must be in one place.

   • The medical record for patients in the ward must provide a complete, up-to-date, and chronological account of patient care (sheets filed in sequential/chronological order, mandatory MLC info included, pages preferably numbered).

   • Authorised staff must make entries in the medical record in the ward (SOP defining who can make entries and content - e.g., doctor orders, nurse administration, dietician assessment).

   • The medical record in the ward must contain the details of assessments, re-assessments, and consultations (medical, nursing, rehabilitation, physiotherapy, nutrition etc.).