PRE Chapter

PRE 1: The Organisation Protects and Promotes Patient and Family Rights and Informs Them About Their Responsibilities During Care

PRE 1 is the foundational standard within the Patient Rights and Education (PRE) chapter of the NABH 6th Edition. It establishes the fundamental principle that a healthcare organization must actively safeguard and champion the rights of patients and their families throughout their care journey. Furthermore, it emphasizes the crucial role of informing patients about their responsibilities in this partnership. This standard sets the stage for a patient-centric approach where respect, dignity, and informed participation are paramount.

Let's break down PRE 1 into its objective elements, exploring each in extensive detail:

PRE 1a: Patient and family rights and responsibilities are documented, displayed and they are made aware of the same. * (C)

• Standard Statement: This objective element mandates that the hospital must have clearly documented patient and family rights and responsibilities, ensure these are visibly displayed, and actively communicate them to patients and families so they are fully aware. The asterisk (*) indicates mandatory system documentation, and (C) signifies a Commitment Level objective element.

• Rationale and Importance:

  • Clarity and Transparency: Documentation provides a clear and unambiguous articulation of rights and responsibilities, leaving no room for misinterpretation or ambiguity. This transparency builds trust and confidence in the healthcare system.

  • Empowerment: Making patients aware of their rights empowers them to actively participate in their care, ask questions, make informed decisions, and advocate for themselves or their loved ones.

  • Shared Responsibility: Outlining responsibilities alongside rights fosters a sense of partnership and shared accountability in the care process. Patients understand their role in contributing to positive health outcomes.

  • Standardization and Consistency: Documentation ensures consistent application of patient rights across the organization, preventing arbitrary or discriminatory practices.

  • Legal and Ethical Compliance: Documenting and displaying rights aligns with ethical principles of patient autonomy and dignity and often reflects legal requirements and national charters of patient rights.

  • NABH Accreditation Requirement: This is a fundamental requirement for NABH accreditation, demonstrating the organization's commitment to patient-centered care.

• Key Components and Actions:

  • Document Patient Rights:

    • Develop a comprehensive document: This document should meticulously list all the rights patients and their families are entitled to within the hospital setting.

    • Align with Charter of Patients' Rights: Crucially, this documentation must be in consonance with the "Charter of Patients' Rights" laid down by the statutory body or national health authority of the country. This ensures alignment with national standards and legal frameworks. Hospitals need to refer to the specific charter relevant to their jurisdiction.

    • Cover Key Areas: Rights typically include (but are not limited to): Right to information, right to consent, right to confidentiality and privacy, right to choose treatment options, right to seek a second opinion, right to refuse treatment, right to complain, right to access medical records, right to dignity and respect, right to religious and cultural beliefs, right to expected cost of treatment.

• • Inform Patient of Their Responsibilities:

    • Outline Patient Responsibilities: Document a clear list of responsibilities expected from patients and their families.

    • Focus on Partnership: Responsibilities should be framed in a positive light, emphasizing the patient's active role in their care and the partnership with the healthcare team.

    • Examples of Responsibilities: Providing accurate and complete medical history, following treatment plans and instructions, informing healthcare providers of any changes in their condition, respecting hospital rules and regulations, being considerate of other patients and staff, providing necessary information for insurance and billing, keeping appointments.

• • Display List of Rights and Responsibilities:

    • Prominent Locations: Display the documented rights and responsibilities in highly visible and accessible areas throughout the hospital.

    • Strategic Placement: Ideal locations include: Registration desks, waiting areas (OPD, IPD, Emergency), admission desks, patient rooms (if feasible), near payment counters, and on hospital websites/digital platforms.

    • Clear and Readable Format: Use clear, concise language, large enough font size for easy readability, and visually appealing layouts. Consider using bullet points or numbered lists for clarity.

• • Make Them Aware of the Same:

    • Multiple Communication Methods: Employ a variety of methods to ensure patients and families are actively made aware of their rights and responsibilities.

    • Verbal Communication: Staff (nurses, front desk staff, patient relations officers) should be trained to verbally explain key rights and responsibilities during admission or registration processes.

    • Pamphlets and Brochures: Develop informative pamphlets and brochures summarizing patient rights and responsibilities. Make these readily available in multiple locations (e.g., reception, patient rooms, OPD).

    • Bilingual Information: Provide information in languages commonly understood by the patient population served by the hospital. This often includes the local language and national languages like English and Hindi (in India).

    • Audio-Visual Aids: Consider using short videos or audio messages in waiting areas to explain patient rights and responsibilities in an engaging manner.

    • Website and Digital Platforms: Publish the documented rights and responsibilities prominently on the hospital's website and patient portals (if available).

    • Signage: Beyond the displayed list, use additional signage to highlight specific rights or responsibilities in relevant areas (e.g., signage about privacy in examination rooms, signage about complaint mechanism near feedback boxes).

• Points to Remember (as mentioned in the slides):

  • Document in consonance with Charter of Patients' Rights: This is paramount. Hospitals must ensure their documentation is aligned with the officially recognized charter.

  • Display in prominent locations: Visibility is key to awareness. Don't hide this information in obscure corners.

  • Use pamphlets: Pamphlets are a cost-effective and portable way to provide patients with information they can take with them and refer to later.

  • Provide bilingual information, education and communication materials: Language should not be a barrier to understanding fundamental rights and responsibilities.

• Challenges and Considerations:

  • Language Diversity: In multilingual settings, ensuring translation and provision of information in all relevant languages can be a logistical challenge.

  • Literacy Levels: Materials need to be designed considering varying literacy levels. Visual aids and simplified language can be helpful.

  • Dynamic Nature of Rights: Patient rights may evolve due to legal or policy changes. The hospital needs to have a system to regularly review and update their documentation and communication materials.

  • Staff Training and Awareness: Simply displaying rights is insufficient. Staff must be thoroughly trained to understand and uphold these rights in their daily interactions with patients.

  • Demonstrating Awareness: During audits, hospitals may need to demonstrate how they ensure patients are actually aware of their rights, not just that the information is displayed. This could involve patient surveys or staff interviews.

• Link to Patient Rights & Safety: PRE 1a is directly linked to protecting patient rights by ensuring they are clearly defined, communicated, and accessible. Awareness of rights is the first step towards safeguarding them. It also indirectly contributes to patient safety by promoting informed participation and a more collaborative care environment.

• Level and Implication: Being a Commitment Level (C) objective element, PRE 1a is a foundational requirement. Failure to meet this standard would significantly hinder the hospital's accreditation efforts. The mandatory system documentation (*) means the hospital must have documented procedures and evidence to demonstrate compliance.

PRE 1b: Patient and family rights and responsibilities are actively promoted. * (A)

• Standard Statement: This objective element moves beyond mere documentation and awareness to emphasize the proactive promotion of patient and family rights and responsibilities. It signifies a more active and ongoing effort to embed these principles into the hospital culture. The asterisk (*) again indicates mandatory system documentation, and (A) signifies an Achievement Level objective element, indicating a higher level of performance compared to Commitment Level.

• Rationale and Importance:

  • Beyond Passive Awareness: Active promotion ensures that rights are not just static information but are living principles actively upheld and reinforced within the hospital.

  • Cultural Shift: It fosters a culture where patient rights are deeply valued and consistently practiced by all staff members.

  • Empowerment in Practice: Active promotion translates awareness into tangible empowerment, encouraging patients and families to exercise their rights confidently.

  • Continuous Reinforcement: Promotion is an ongoing process, ensuring that the message about rights and responsibilities is constantly reinforced and remains top-of-mind for both patients and staff.

  • Higher Level of Commitment: Achievement Level (A) signifies a more robust commitment to patient rights compared to just basic compliance. It demonstrates a proactive approach to embedding these principles.

• Key Components and Actions:

  • Inpatient - Active Promotion:

    • Counsel Patient and/or Family:

      • Individualized Counseling: Provide individualized counseling sessions during admission or at appropriate times during the inpatient stay. This can be done by nurses, patient counselors, or patient relations staff.

      • Proactive Explanation: Don't just wait for patients to ask. Proactively explain key patient rights and responsibilities relevant to their inpatient experience.

      • Address Specific Concerns: Counseling should be tailored to address common concerns or questions patients may have about their rights in an inpatient setting.

• • • Use Format and Language They Can Understand:

      • Tailored Communication: Adapt the counseling approach and materials to suit the patient's understanding, language proficiency, and any special needs (e.g., visual or hearing impairments).

      • Simple and Clear Language: Avoid medical jargon and use plain, easily understandable language.

      • Visual Aids: Utilize visual aids, diagrams, or illustrations to enhance understanding, especially for complex rights or responsibilities.

• • Outpatient - Active Promotion:

    • Ensure Easy Access of Educational Material:

      • Variety of Materials: Provide a diverse range of educational materials promoting patient rights and responsibilities in outpatient areas.

      • Accessible Locations: Make materials easily accessible in waiting areas, consultation rooms, near registration desks, and discharge areas.

      • Material Types: This can include pamphlets, brochures, posters, standees, digital displays, and QR codes linking to online resources.

• • • Display (Use Television/Standee) in Prominent Locations:

      • Engaging Displays: Use more dynamic and attention-grabbing methods for displaying promotional messages.

      • Television/Digital Displays: Show short videos, animations, or scrolling text messages on televisions or digital displays in waiting areas. These can be more engaging than static posters.

      • Standees/Posters: Use visually appealing standees and posters with key messages about patient rights and responsibilities, placed in strategic locations with high patient traffic.

      • Regular Rotation: Rotate displays regularly to maintain patient interest and ensure the message remains fresh.

• Challenges and Considerations:

  • Resource Allocation: Active promotion, especially individualized counseling, requires dedicated staff time and resources. Hospitals need to allocate resources appropriately.

  • Staff Training and Buy-in: Staff needs to be trained not just on patient rights but also on how to actively promote them in their interactions. Buy-in from all staff levels is essential.

  • Measuring Effectiveness: Active promotion efforts need to be evaluated for effectiveness. Patient feedback surveys and observation of staff-patient interactions can be used.

  • Sustained Effort: Promotion is not a one-time activity. It requires sustained and ongoing effort to maintain a culture of respect for patient rights.

  • Balancing Promotion with Other Information: Ensure that the promotion of rights doesn't overshadow other important patient information or create information overload.

• Link to Patient Rights & Safety: PRE 1b takes patient rights protection a step further by actively embedding these principles into the daily practices and culture of the hospital. This proactive approach enhances patient empowerment and fosters a safer, more respectful, and patient-centered care environment.

• Level and Implication: As an Achievement Level (A) objective element, PRE 1b signifies a higher level of commitment to patient rights. Meeting this standard demonstrates a proactive and ongoing effort to promote these rights beyond just basic awareness. The mandatory system documentation (*) requires the hospital to have documented processes and evidence of active promotion activities.

PRE 1c: The organisation protects patient and family rights. (CO)

• Standard Statement: This objective element focuses on the active protection of patient and family rights by the organization itself. It emphasizes the responsibility of the hospital as a whole to safeguard these rights in practice. (CO) signifies a Commitment Level (Core OE) objective element, highlighting its crucial nature.

• Rationale and Importance:

  • Organizational Responsibility: This element clearly assigns the responsibility for protecting patient rights to the entire organization, not just individual staff members. It is a leadership-driven commitment.

  • Culture of Protection: It aims to create an organizational culture where protecting patient rights is a core value and a routine part of all operations.

  • Systemic Approach: Protection requires a systemic approach involving policies, procedures, training, monitoring, and accountability mechanisms within the hospital.

  • Core Commitment: Being a Core OE (CO) element, this is considered a fundamental commitment and is critically important for accreditation. Failure to adequately demonstrate this would be a significant concern.

• Key Components and Actions:

  • Make Staff Aware of Their Responsibility:

    • Comprehensive Training: Provide comprehensive training to all staff members (clinical and non-clinical) on patient rights and their specific responsibilities in upholding these rights.

    • Regular Reinforcement: Training should not be a one-time event but should be reinforced through regular updates, refreshers, and ongoing communication.

    • Role-Specific Training: Training should be tailored to different roles and responsibilities within the hospital, ensuring each staff member understands how patient rights apply to their specific job function.

• • Staff Conduct Should Convey Their Intent to Protect Patient and Family Rights:

    • Professional Conduct: Staff conduct in all interactions with patients and families should consistently demonstrate respect, empathy, and a commitment to upholding patient rights.

    • Observable Behavior: This goes beyond just knowing about rights; it's about demonstrating respect in actions, communication style, and decision-making processes.

    • Positive Patient Interactions: Staff should strive to create positive and supportive patient interactions that build trust and confidence in the hospital's commitment to patient rights.

    • Address Unacceptable Conduct: The organization must have mechanisms to address and correct any staff conduct that is not aligned with the principles of patient rights protection.

• Challenges and Considerations:

  • Changing Organizational Culture: Shifting organizational culture to be deeply rooted in patient rights protection can be a long-term and complex process.

  • Consistency Across Departments: Ensuring consistent application of patient rights protection across all departments and services within a hospital can be challenging.

  • Monitoring Staff Conduct: Monitoring staff conduct and ensuring it aligns with patient rights principles requires ongoing observation, feedback mechanisms, and performance management systems.

  • Addressing Violations: Having clear procedures to address and correct violations of patient rights and holding staff accountable is essential.

  • Leadership Commitment: Strong leadership commitment and role modeling are crucial to drive a culture of patient rights protection throughout the organization.

• Link to Patient Rights & Safety: PRE 1c is central to the entire PRE standard. It ensures that the organization as a whole takes ownership of protecting patient rights. This creates a supportive environment where patient rights are not merely acknowledged but actively defended, directly contributing to patient safety and well-being.

• Level and Implication: Being a Commitment Level (Core OE) (CO) objective element, PRE 1c is absolutely fundamental. It signifies a core commitment of the organization and is a critical aspect of NABH accreditation. Demonstrating this requires evidence of staff training, policies that support patient rights, and systems to monitor and address any deviations from expected conduct.

PRE 1d: The organisation has a mechanism to report a violation of patient and family rights. (CO)

• Standard Statement: This objective element mandates the existence of a readily accessible and functional mechanism within the hospital that allows patients, families, and even staff to report any perceived or actual violations of patient and family rights. (CO) again signifies a Commitment Level (Core OE) objective element.

• Rationale and Importance:

  • Accountability and Transparency: A reporting mechanism creates accountability by providing a formal channel to raise concerns about rights violations. It promotes transparency by encouraging open communication and addressing issues proactively.

  • Early Detection and Resolution: It enables the early detection of rights violations, allowing for prompt investigation and resolution before issues escalate or cause significant harm or dissatisfaction.

  • Patient Empowerment: It empowers patients and families to speak up if they feel their rights have been violated, fostering a sense of ownership and control over their care experience.

  • Continuous Improvement: Reported violations provide valuable data for identifying systemic issues and opportunities for improvement in patient rights protection practices.

  • Core Safety Component: A robust reporting mechanism is a crucial component of a patient safety culture, ensuring that concerns are heard and addressed.

  • Core Commitment: As a Core OE (CO) element, this is a non-negotiable requirement for NABH accreditation, emphasizing its fundamental importance.

• Key Components and Actions:

  • Develop a List of Violations:

    • Define Potential Violations: Create a comprehensive list of potential violations of patient and family rights that could occur within the hospital setting. This list should be derived from the documented patient rights and may include examples like:

      • Compromising privacy (e.g., discussing patient information in public areas).

      • Breaching confidentiality (e.g., unauthorized disclosure of medical information).

      • Disrespecting religious and cultural needs (e.g., failing to accommodate dietary restrictions or prayer requests).

      • Denying access to information about treatment or costs.

      • Lack of informed consent for procedures.

      • Discrimination or unfair treatment.

      • Abuse or neglect.

    • Guide for Reporting: This list can serve as a guide for patients, families, and staff to understand what constitutes a rights violation and what can be reported.

• • Train Staff - Provide Appropriate Training to Staff:

    • Training on Reporting Mechanism: Train all staff members on the existence and functionality of the patient rights violation reporting mechanism. They should know how to guide patients and families in reporting.

    • Training on Rights and Violations: Staff should be trained to recognize potential rights violations in their daily work and understand their responsibility to report them, whether they witness them or become aware of them.

• • Capture - Implement Reporting Mechanisms:

    • Multiple Reporting Channels: Establish multiple accessible channels for reporting violations to cater to different patient preferences and situations.

    • Incident Reporting Form:

      • Formal Documentation: Create a standardized "Incident Reporting Form" specifically designed for reporting patient rights violations. This form should be easily available in paper and ideally in electronic format.

      • Required Details: The form should include fields to capture essential details of the violation:

        • Details of Violation: A clear description of how the right was violated (what happened, what was said/done).

        • Who Violated the Right (if applicable): Identify the individual(s) involved in the violation, if known (e.g., staff member, doctor, visitor).

        • When and Where: Date, time, and location of the incident.

        • Impact on Patient/Family: Describe the impact of the violation on the patient or family (emotional distress, physical harm, etc.).

        • Reporter's Information (Optional): Space for the reporter's name and contact information (optional for anonymous reporting).

• • • Patient Feedback Form (Incorporating Patient Rights Wording Appropriately):

      • Integrate into Feedback: Incorporate questions or sections related to patient rights into the standard patient feedback forms used by the hospital.

      • Specific Prompts: Include prompts that specifically ask patients if they felt their rights were respected during their care experience.

      • Tool for Reporting Violations: Make it clear that the feedback form can also be used to report any perceived violation of their rights.

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    • Verbal Reporting Mechanism: Establish a process for patients and families to verbally report violations (e.g., to a designated patient relations officer, nurse in charge, or complaint desk).

    • Telephonic Reporting: Provide a dedicated phone number for reporting violations.

    • Online Reporting (If Applicable): If the hospital has a patient portal or website, consider adding an online reporting form.

    • Anonymous Reporting Option: Crucially, provide an option for anonymous reporting to encourage patients and staff to report concerns without fear of reprisal.

• Points to Remember (as mentioned in the slides):

  • The organisation should have a mechanism for the patient and /or family to report violation of their rights. This emphasizes the core requirement - a functional and accessible mechanism must exist.

  • Examples of violation of rights: These examples (Compromising privacy, Breaching confidentiality, Disrespecting religious and cultural needs) are provided as illustrative, not exhaustive. The hospital's list of potential violations should be more comprehensive.

• Challenges and Considerations:

  • Encouraging Reporting: Creating a culture where patients and staff feel comfortable reporting violations, especially anonymously, can be challenging. Fear of reprisal or disbelief can be barriers.

  • Handling Anonymous Reports: Organizations need to have a process for investigating and addressing anonymous reports effectively and fairly.

  • Confidentiality and Privacy of Reporters: Ensure the confidentiality of reporters (especially whistleblowers) and protect them from any negative consequences for reporting in good faith.

  • Timely Investigation and Redressal: The reporting mechanism is only effective if reported violations are investigated promptly and appropriate action is taken.

  • Promoting Awareness of Mechanism: Patients and staff need to be made aware of the existence and how to use the reporting mechanism.

• Link to Patient Rights & Safety: PRE 1d is vital for safeguarding patient rights. By providing a mechanism to report violations, the hospital creates a safety net, ensuring that any breaches of rights can be identified, addressed, and prevented in the future. This strengthens patient safety by promoting accountability and a culture of continuous improvement.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 1d is a critical requirement. NABH expects hospitals to have a demonstrably functional and accessible reporting mechanism in place. Failure to have this would be a major deficiency in terms of patient rights protection.

PRE 1e: Violation of patient and family rights are monitored, analysed, and corrective/preventive action taken by the top leadership of the organisation. (CO)

• Standard Statement: This objective element completes the cycle of rights protection by emphasizing the importance of what happens after a violation is reported. It mandates that the organization must monitor reported violations, analyze trends and root causes, and implement corrective and preventive actions, with oversight and accountability from top leadership. (CO) again signifies a Commitment Level (Core OE) objective element.

• Rationale and Importance:

  • Closing the Loop: This element ensures that the reporting mechanism (PRE 1d) is not just a formality but leads to tangible improvements in patient rights protection.

  • Continuous Improvement Cycle: Monitoring, analysis, and CAPA form a continuous improvement cycle, allowing the hospital to learn from past violations and prevent future occurrences.

  • Systemic Change: Analysis of trends can reveal systemic issues that need to be addressed through policy or process changes, rather than just individual corrective actions.

  • Leadership Accountability: Involvement of top leadership underscores the importance of patient rights protection at the highest organizational level and ensures accountability for addressing violations.

  • Enhanced Patient Safety and Trust: Effective monitoring and CAPA demonstrate the organization's commitment to patient rights and safety, building trust and confidence in patients and families.

  • Core Commitment: Being a Core OE (CO) element, this is essential for demonstrating a genuine and effective system for patient rights protection and is crucial for NABH accreditation.

• Key Components and Actions (Process Flow):

  • Document Violations:

    • Centralized Record Keeping: Establish a system for centrally documenting all reported violations of patient rights. This could be a dedicated logbook, database, or electronic system.

    • Maintain Records: Maintain accurate and detailed records of each reported violation, including the date, time, nature of violation, individuals involved, actions taken, and outcomes.

• • Investigate:

    • Prompt Investigation: Ensure that all reported violations are investigated promptly and thoroughly.

    • Designated Investigation Team/Person: Assign responsibility for investigation to a designated team or individual (e.g., Patient Relations Officer, Quality Improvement Team, or a designated committee).

    • Fair and Impartial Investigation: Conduct investigations in a fair, impartial, and objective manner, gathering all relevant information and perspectives.

• • Take CAPA (Corrective and Preventive Action):

    • Corrective Action: Take immediate corrective action to address the specific violation and mitigate any harm caused to the patient or family. This could involve:

      • Apology and explanation to the patient/family.

      • Counseling or support for the patient/family.

      • Disciplinary action for staff involved (if appropriate and warranted).

      • Rectification of the situation (e.g., correcting billing errors, providing missing information).

• • • Preventive Action: Implement preventive actions to address the root cause of the violation and prevent similar incidents from occurring in the future. This could involve:

      • Review and revision of policies and procedures.

      • Additional staff training and education.

      • Process improvements and system changes.

      • Enhanced communication strategies.

• • Maintain Record of Incident and its Outcomes:

    • Complete Documentation: Maintain a complete record of each incident, including:

      • The initial report.

      • Investigation findings.

      • Corrective actions taken.

      • Preventive actions implemented.

      • Outcome of the incident (resolution, patient satisfaction, etc.).

    • Trend Analysis: Use the documented records for trend analysis to identify recurring issues, patterns of violations, or systemic weaknesses in patient rights protection.

• Challenges and Considerations:

  • Data Analysis and Trend Identification: Effectively analyzing violation data to identify meaningful trends and root causes requires robust data management and analytical skills.

  • Implementing Effective CAPA: Developing and implementing effective corrective and preventive actions that truly address root causes and prevent recurrence can be complex.

  • Leadership Engagement: Ensuring consistent engagement and oversight from top leadership in monitoring, analysis, and CAPA implementation is crucial.

  • Resource Allocation for CAPA: Implementing CAPA may require resources (time, budget, personnel). Organizations need to allocate resources appropriately.

  • Measuring CAPA Effectiveness: Evaluate the effectiveness of CAPA implemented. Track whether the actions taken have reduced the incidence of similar violations over time.

• Link to Patient Rights & Safety: PRE 1e is the crucial element that transforms the reporting mechanism into a system for continuous improvement in patient rights protection. By ensuring monitoring, analysis, and CAPA, the organization demonstrates a commitment to learning from mistakes and proactively preventing future violations, thereby directly enhancing patient safety and trust.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 1e is of paramount importance. NABH expects hospitals to have a demonstrable and effective system for monitoring, analyzing, and acting upon reported patient rights violations, with clear leadership involvement. Failure to demonstrate this would be a significant deficiency and hinder accreditation.

In Summary of PRE 1:

PRE 1, in its entirety, establishes a comprehensive framework for protecting and promoting patient and family rights and responsibilities. It moves from documentation and awareness (PRE 1a), to active promotion (PRE 1b), organizational commitment (PRE 1c), establishing a reporting mechanism (PRE 1d), and finally to a continuous improvement cycle through monitoring, analysis, and CAPA (PRE 1e). Successfully implementing all sub-elements of PRE 1 is not just about achieving accreditation; it's about building a truly patient-centered healthcare organization where respect, dignity, and rights are at the core of patient care.

PRE 2: Patient and Family Rights Support Individual Beliefs, Values and Involve the Patient and Family in Decision-Making Processes

PRE 2 builds upon the foundation of PRE 1 by delving into the specifics of how a healthcare organization must respect the individuality of patients and families and actively involve them in the decision-making aspects of their care. It moves beyond simply acknowledging rights to ensuring that care is delivered in a manner that is sensitive to and supportive of each patient's unique beliefs, values, preferences, and needs. This standard is crucial for truly patient-centered care, recognizing that healthcare is not a one-size-fits-all approach.

Let's dissect each sub-element of PRE 2 in extensive detail:

PRE 2a: Patients and family rights include respecting values and beliefs, any special preferences, cultural needs, and responding to requests for spiritual needs. (C)

• Standard Statement: This objective element emphasizes the hospital's responsibility to respect and accommodate the diverse values, beliefs, preferences, cultural backgrounds, and spiritual needs of patients and their families. (C) signifies a Commitment Level objective element.

• Rationale and Importance:

  • Patient Dignity and Respect: Respecting individual beliefs and values is fundamental to upholding patient dignity and treating each person as a unique individual, not just a medical case.

  • Cultural Competence: In diverse populations, cultural sensitivity is essential for effective communication, building trust, and providing culturally appropriate care. Ignoring cultural needs can lead to misunderstandings, dissatisfaction, and even poorer health outcomes.

  • Spiritual Well-being: For many patients and families, spiritual beliefs are a vital source of comfort and strength, especially during illness. Addressing spiritual needs can significantly contribute to holistic well-being.

  • Personalized Care: Acknowledging special preferences and individual values allows for the delivery of care that is tailored to the patient's specific needs and desires, promoting patient satisfaction and engagement.

  • Ethical Imperative: Respecting autonomy and self-determination are core ethical principles in healthcare. Patients have the right to have their values and beliefs considered in their care.

  • Positive Healthcare Experience: When patients feel their values and beliefs are respected, they are more likely to have a positive healthcare experience and engage more actively in their treatment.

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• Key Components and Actions (Questions to Address - as suggested in the slides):

  • How Does a Patient Wish to be Addressed?

    • Preferred Name and Title: Train staff to always ask patients how they prefer to be addressed (e.g., formal title and surname, first name, preferred pronouns). Document this preference in the medical record and communicate it to all care team members.

    • Cultural Sensitivity in Address: Be mindful of cultural norms regarding addressing individuals. Some cultures place a strong emphasis on formal address, while others are more informal.

    • Respectful Communication: Using the patient's preferred name and title is a simple yet powerful way to show respect and build rapport.

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  • What are Their Dietary Preferences?

    • Dietary Assessment: Conduct a thorough dietary assessment for each patient, including:

      • Religious Dietary Restrictions: Inquire about religious dietary laws (e.g., Halal, Kosher, vegetarianism, veganism, fasting requirements).

      • Cultural Food Preferences: Understand cultural food preferences and avoidances.

      • Allergies and Intolerances: Document any food allergies or intolerances.

      • Personal Preferences: Inquire about any other dietary preferences or restrictions.

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    • Dietary Accommodation: Make reasonable efforts to accommodate documented dietary preferences within the hospital's food service capabilities. This may involve providing special menus, offering alternative food choices, or allowing families to bring in culturally appropriate food (while adhering to safety guidelines).

    • Communication with Dietary Services: Ensure clear communication between clinical staff and dietary services to accurately convey patient dietary needs and preferences.

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  • What are Their Worship Requirements?

    • Spiritual Needs Assessment: Assess patients' spiritual needs upon admission or during care. This can be done through a simple questionnaire or verbal inquiry.

    • Provision of Prayer Space: If feasible, provide a designated quiet space or prayer room within the hospital where patients and families can engage in worship or meditation.

    • Facilitation of Religious Practices: Within reasonable limits and without compromising patient safety or hospital operations, facilitate patients' religious practices. This might include:

      • Allowing patients to keep religious objects (rosaries, prayer beads, religious texts) with them.

      • Providing information on local religious services or leaders.

      • Facilitating visits from religious leaders or chaplains (if requested and permitted).

      • Respecting prayer times and rituals (where possible).

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    • Respect for Religious Symbols and Articles: Treat religious symbols and articles brought by patients with respect and care.

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  • Do They Have Any Specific Requirement After Death?

    • End-of-Life Care Planning: In end-of-life care discussions, proactively inquire about any specific religious or cultural requirements the patient or family may have regarding post-mortem care, funeral arrangements, or rituals after death.

    • Documentation of Wishes: Document these wishes clearly in the patient's medical record and end-of-life care plan.

    • Communication with Relevant Departments: Communicate these post-mortem requirements to relevant departments (nursing staff, mortuary services, etc.) to ensure they are respected and followed.

    • Cultural and Religious Sensitivity in Post-Mortem Care: Ensure staff are trained to handle post-mortem care with cultural and religious sensitivity, respecting rituals and practices related to death and bereavement.

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• Challenges and Considerations:

  • Balancing Accommodation with Practicality: While striving to accommodate diverse needs, hospitals must also consider practical limitations (resources, food service capacity, space constraints, infection control).

  • Diversity within Religions and Cultures: Recognize that there is diversity within religions and cultures. Patient preferences may vary even within the same religious or cultural group.

  • Respecting All Beliefs (and Non-Beliefs): Respect should extend to patients with no religious beliefs or specific cultural affiliations. Non-discrimination is key.

  • Staff Training and Cultural Competence: Staff training on cultural sensitivity, religious diversity, and effective communication is crucial for implementing this standard effectively.

  • Documentation and Communication: Clear documentation of patient preferences and effective communication across the care team are essential to ensure these preferences are consistently respected.

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• Link to Patient Rights & Safety: PRE 2a directly supports patient rights to dignity, respect, and self-determination. By respecting values, beliefs, and cultural/spiritual needs, hospitals create a more inclusive and comfortable environment, which can indirectly contribute to better patient outcomes and a safer, more trusting patient-provider relationship.

• Level and Implication: As a Commitment Level (C) objective element, PRE 2a is a foundational requirement. Demonstrating compliance involves having systems and processes in place to assess and respect these diverse patient needs, and staff trained to implement these processes.

PRE 2b: Patient and family rights include respect for personal dignity and privacy during examination, procedures and treatment. (C)

• Standard Statement: This objective element focuses specifically on respecting patient personal dignity and privacy throughout the entire care process, particularly during examinations, procedures, and treatments. (C) signifies a Commitment Level objective element.

• Rationale and Importance:

  • Fundamental Human Dignity: Respecting personal dignity is a basic human right and a core principle of ethical healthcare. Patients are often in vulnerable positions, and it is crucial to ensure they are treated with respect at all times.

  • Privacy as a Right: Patients have a right to privacy concerning their bodies, medical information, and personal space. Breaches of privacy can be deeply distressing and erode trust.

  • Reducing Anxiety and Embarrassment: Respect for dignity and privacy helps to minimize patient anxiety, embarrassment, and discomfort associated with healthcare procedures, especially those involving physical examinations or exposure.

  • Building Trust and Rapport: When patients feel their dignity and privacy are valued, it fosters trust in the healthcare providers and facilitates a more open and collaborative relationship.

  • Promoting Psychological Well-being: Respectful and private care contributes to the patient's psychological well-being and overall positive healthcare experience.

• 
  

• Key Components and Actions:

  • Staff - Actions for Dignity and Privacy:

    • All Stages of Patient Care: Maintain Patient's Privacy and Dignity:

      • Constant Vigilance: Privacy and dignity should be considered and maintained in every interaction with the patient, from admission to discharge, not just during specific procedures.

      • Respectful Language and Tone: Use respectful language, avoid demeaning or patronizing tones, and maintain a professional demeanor in all communication.

      • Knocking Before Entering Rooms: Always knock before entering patient rooms and wait for permission to enter.

      • Private Conversations: Conduct sensitive conversations (medical history, diagnosis, prognosis) in private settings, away from other patients and visitors.

      • Confidentiality: Maintain patient confidentiality in all verbal and written communication.

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    • Procedure: Ensure Patient is Exposed Just Before Actual Procedure:

      • Minimize Unnecessary Exposure: Avoid unnecessary exposure of the patient's body during examinations and procedures.

      • Appropriate Draping: Use appropriate draping and coverings to expose only the area of the body that needs to be examined or treated.

      • Preparation in Private: Provide a private space for patients to undress and prepare for procedures.

      • Timely Procedure Execution: Once the patient is prepared and exposed, ensure the procedure is performed promptly to minimize the duration of exposure.

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    • Photographs/Recording Procedure: Obtain Informed Consent. Do Not Reveal Patient's Identity:

      • Strict Informed Consent for Photography/Recording: Obtain explicit informed consent before taking any photographs or video/audio recordings of patients for medical purposes (documentation, teaching, research).

      • Explain Purpose and Use: Clearly explain the purpose of the photography/recording, how it will be used, who will have access, and how patient identity will be protected.

      • Written Consent Required: Informed consent for photography/recording should be documented in writing.

      • Anonymization and De-identification: Take strict measures to anonymize and de-identify photographs and recordings to protect patient privacy and prevent unauthorized disclosure of personal information. Avoid showing identifiable facial features or other unique identifiers unless absolutely necessary and with explicit consent.

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  • 
    

  • Organisation - Actions for Dignity and Privacy:

    • Develop Necessary Guidelines:

      • Privacy Policies and Procedures: Develop comprehensive policies and procedures outlining expectations for staff behavior regarding patient dignity and privacy.

      • Draping and Covering Protocols: Establish clear protocols for appropriate draping and covering during examinations and procedures.

      • Photography/Recording Guidelines: Create strict guidelines for medical photography and recording, emphasizing informed consent, anonymization, and data security.

      • Privacy in Physical Spaces: Design hospital spaces (examination rooms, consultation rooms, patient rooms, waiting areas) to maximize patient privacy and minimize unintentional exposure or observation.

      • Training Programs: Implement regular training programs for all staff on patient dignity, privacy, cultural sensitivity, and related policies and procedures.

      • Monitoring and Auditing: Establish mechanisms to monitor and audit compliance with privacy policies and procedures, and address any breaches effectively.

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  • 
    
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• Challenges and Considerations:

  • Balancing Privacy with Care Delivery: In some emergency or critical situations, the immediate need for care may sometimes necessitate a temporary compromise of absolute privacy. However, even in these situations, staff should strive to maintain as much dignity and privacy as possible.

  • Physical Space Limitations: Older hospital facilities may have limitations in terms of private examination rooms or waiting areas. Organizations need to be creative and resourceful in maximizing privacy within existing infrastructure.

  • Staff Awareness and Adherence: Ensuring that all staff members consistently adhere to privacy protocols requires ongoing training, reinforcement, and a strong organizational culture that prioritizes patient dignity and privacy.

  • Technological Advancements: The increasing use of digital technologies in healthcare (electronic records, telemedicine, etc.) presents new challenges for maintaining patient privacy and data security. Organizations must adapt their privacy policies and procedures to address these evolving technologies.

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• Link to Patient Rights & Safety: PRE 2b is directly linked to protecting patient rights to dignity and privacy. By ensuring respect for these aspects, hospitals create a safer and more comfortable environment for patients, fostering trust and encouraging open communication, which is essential for effective and safe care.

• Level and Implication: As a Commitment Level (C) objective element, PRE 2b is a foundational requirement. Demonstrating compliance involves having clear policies and procedures in place to protect patient dignity and privacy, staff training on these policies, and evidence of their implementation in practice.

PRE 2c: Patient and family rights include protection from neglect or abuse. (C)

• Standard Statement: This objective element underscores the hospital's fundamental responsibility to protect patients from any form of neglect or abuse during their care. (C) signifies a Commitment Level objective element.

• Rationale and Importance:

  • Patient Vulnerability: Patients, especially when ill or hospitalized, are often in a vulnerable position and dependent on healthcare providers. They are susceptible to neglect and abuse if safeguards are not in place.

  • Ethical and Legal Obligation: Protecting patients from harm is a fundamental ethical and legal obligation of healthcare organizations and professionals.

  • Patient Safety Imperative: Neglect and abuse are direct threats to patient safety and can have serious physical, psychological, and emotional consequences.

  • Maintaining Trust and Confidence: Patients and families must have confidence that the hospital is a safe and protective environment where they will not be subjected to neglect or abuse.

  • Promoting Healing and Well-being: A safe and abuse-free environment is essential for promoting patient healing and overall well-being.

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• Key Components and Actions:

  • Protect Patient from Falling from Bed/Trolley Due to Negligence:

    • Fall Prevention Protocols: Implement comprehensive fall prevention protocols, especially for patients at high risk of falls (elderly, confused, medicated, mobility impaired).

    • Risk Assessment: Conduct thorough fall risk assessments for all patients upon admission and regularly during their stay.

    • Safety Measures: Employ safety measures such as:

      • Bed rails (when appropriate and indicated).

      • Low beds.

      • Non-slip flooring.

      • Adequate lighting.

      • Call bells within easy reach.

      • Regular patient rounding and monitoring.

    • 
      

    • Staff Training on Fall Prevention: Train all staff members on fall prevention protocols, risk assessment, and proper patient handling techniques.

    • Incident Reporting and Analysis: Establish a system for reporting and analyzing all patient falls to identify contributing factors and implement corrective actions to prevent future falls.

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  • Avoid Repeated Internal Examinations (Unwarranted):

    • Justification for Examinations: Ensure that all internal examinations (e.g., pelvic, rectal) are clinically justified and necessary for diagnosis or treatment.

    • Appropriate Indications: Establish clear indications for internal examinations and ensure staff adhere to these guidelines.

    • Minimize Repetition: Avoid unnecessary repetition of internal examinations, especially by multiple providers, unless clinically indicated or for training purposes (with informed consent).

    • Respect Patient Comfort and Privacy: Even when warranted, perform internal examinations with utmost respect for patient comfort, privacy, and dignity.

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  • Prevent Manhandling:

    • Safe Patient Handling Techniques: Train staff in safe patient handling and transfer techniques to avoid manhandling, which can be physically harmful and disrespectful.

    • Use of Assistive Devices: Utilize assistive devices (lifts, transfer belts, sliding boards) when necessary to safely move and reposition patients, especially those with mobility limitations.

    • Respectful Physical Contact: Ensure all physical contact with patients is respectful, gentle, and for legitimate care purposes only. Avoid rough handling or unnecessary force.

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  • Take Special Precautions for Vulnerable Patients (as highlighted in "Points to Remember" in the slides):

    • Identify Vulnerable Patient Groups: Recognize and identify patient populations who are particularly vulnerable to neglect and abuse.

    • Examples of Vulnerable Patients:

      • Elderly: Due to age-related physical and cognitive decline.

      • Neonates: Completely dependent and unable to communicate.

      • Physically and Mentally Challenged Patients: May have communication difficulties or be unable to advocate for themselves.

      • Comatose Patients: Unconscious and entirely dependent on care providers.

      • Patients Under Anaesthesia: Unconscious and unable to protect themselves.

    • 
      

    • Enhanced Monitoring and Supervision: Implement enhanced monitoring and supervision for vulnerable patients, especially those who are unable to communicate or advocate for themselves.

    • Increased Staff Awareness: Raise staff awareness about the specific vulnerabilities of these patient groups and the importance of vigilance in protecting them.

    • Advocate for Vulnerable Patients: Designate staff members (e.g., nurses, social workers) to act as advocates for vulnerable patients, ensuring their needs are met and their safety is protected.

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• Points to Remember (Examples of Vulnerable Patients):

  • The slide explicitly lists examples of vulnerable patients, reinforcing the importance of special precautions for these groups.

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• Challenges and Considerations:

  • Defining Neglect and Abuse: Clearly define what constitutes neglect and abuse within the hospital context and communicate these definitions to all staff.

  • Reporting Mechanisms for Suspected Neglect/Abuse: Establish clear and confidential reporting mechanisms for staff, patients, and families to report suspected cases of neglect or abuse without fear of reprisal.

  • Investigation and Response to Reports: Have a clear procedure for investigating reported cases of neglect or abuse, ensuring a prompt, thorough, and impartial investigation.

  • Staff Background Checks and Screening: Implement appropriate background checks and screening processes for all staff members to minimize the risk of employing individuals with a history of abusive behavior.

  • Culture of Safety and Transparency: Foster a culture of safety, transparency, and accountability where staff feel empowered to speak up about concerns and where neglect and abuse are not tolerated.

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• Link to Patient Rights & Safety: PRE 2c is paramount for patient rights and safety. Protection from neglect and abuse is a fundamental right, and ensuring this protection is a core responsibility of any healthcare organization. Failing to protect patients from harm would be a severe breach of trust and a direct threat to patient well-being.

• Level and Implication: As a Commitment Level (C) objective element, PRE 2c is a foundational requirement. Demonstrating compliance involves having clear policies, procedures, and training programs in place to prevent neglect and abuse, reporting mechanisms for suspected cases, and evidence of their effective implementation and monitoring.

PRE 2d: Patient and family rights include treating patient information as confidential. (CO)

• Standard Statement: This objective element focuses on the crucial right of patients and families to have their personal and medical information treated with utmost confidentiality by the hospital and its staff. (CO) signifies a Commitment Level (Core OE) objective element, highlighting its critical nature.

• Rationale and Importance:

  • Patient Trust and Open Communication: Confidentiality is essential for building trust between patients and healthcare providers. Patients are more likely to be open and honest about their medical history and concerns if they trust that their information will be kept private.

  • Ethical and Legal Obligation: Maintaining patient confidentiality is a fundamental ethical principle in healthcare and is often legally mandated (e.g., HIPAA in the US, GDPR in Europe, national privacy laws).

  • Protecting Patient Privacy and Dignity: Confidentiality is a key aspect of protecting patient privacy and dignity. Unauthorized disclosure of personal medical information can be deeply embarrassing, stigmatizing, and damaging to patients.

  • Preventing Discrimination and Social Harm: Breaches of confidentiality can lead to discrimination, social stigma, and negative consequences for patients in their personal and professional lives.

  • Maintaining Professional Integrity: Upholding confidentiality is a cornerstone of professional integrity for healthcare professionals.

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• Key Components and Actions (Do's and Don'ts - as suggested in the slides):

  • Do's - Actions to Maintain Confidentiality:

    • Take Effective Measures to Maintain Patient's Confidentially:

      • Physical Security: Implement physical security measures to protect patient records (paper and electronic), such as secure storage, restricted access areas, and shredding of confidential documents.

      • Electronic Security: Implement robust electronic security measures to protect electronic health records (EHRs) and other digital patient information, including:

        • Access controls (role-based access, strong passwords).

        • Encryption of data in transit and at rest.

        • Audit trails of access and modifications.

        • Firewalls and intrusion detection systems.

        • Regular security updates and vulnerability assessments.

      • 
        

      • Verbal Confidentiality: Train staff to maintain verbal confidentiality by:

        • Avoiding discussing patient information in public areas (hallways, elevators, cafeterias).

        • Speaking privately with patients in consultation rooms or closed areas.

        • Using private phone lines or encrypted communication channels for sensitive discussions.

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      • Data Breach Response Plan: Develop and implement a comprehensive data breach response plan to handle any incidents of unauthorized disclosure of patient information.

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    • Follow Statutory Requirements Regarding Privileged Communication:

      • Understand Privileged Communication: Educate staff about the concept of "privileged communication" (as defined on Slide 16 - Confidential information furnished to facilitate diagnosis and treatment by the patient to an authorized professional).

      • Legal and Ethical Boundaries: Ensure staff understand the legal and ethical boundaries of privileged communication and when disclosure is permitted (e.g., with patient consent, legal exceptions).

      • Compliance with Laws: Strictly adhere to all relevant statutory requirements and laws regarding patient confidentiality and privileged communication in the jurisdiction.

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  • 
    

  • Don'ts - Actions to Avoid Breaching Confidentiality:

    • Do Not Discuss Patient-Related Information in Public Places: This is a fundamental rule. Avoid any discussion of patient details in areas where conversations can be overheard by unauthorized individuals (waiting rooms, cafeterias, hallways, elevators, public transport, social gatherings).

    • Do Not Reveal Confidential Information (Including HIV Status) Without Patient's Permission:

      • Strict Consent Required for Disclosure: Never disclose any confidential patient information to anyone without the patient's explicit informed consent, unless legally mandated (e.g., mandatory reporting of certain conditions).

      • HIV Status Example: Highlight HIV status as a particularly sensitive piece of information that requires strict confidentiality and cannot be disclosed without explicit patient consent or a very specific legal exception.

      • "Need to Know" Principle: Only share patient information with healthcare professionals who have a legitimate "need to know" for the purpose of providing care.

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    • Do Not Explicitly Write/Paste Confidential Information on the Cover of the Medical Record:

      • Cover Sheet Confidentiality: Avoid writing or pasting any confidential patient information (diagnosis, sensitive conditions, etc.) on the cover of the medical record where it could be easily visible to unauthorized individuals.

      • Internal Placement of Sensitive Information: Sensitive information should be placed inside the medical record, accessible only to authorized personnel.

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    • Do Not Display Confidential Information in a Manner That Can Be Understood by the Public:

      • Public Display Screens: Avoid displaying patient names, medical record numbers, diagnoses, or other confidential information on publicly visible screens or whiteboards in waiting areas or open spaces.

      • Call Systems: Use patient call systems that do not reveal confidential information publicly (e.g., use room numbers instead of patient names).

      • Chart Racks: Ensure patient charts are stored securely and not left in open areas where they can be viewed by unauthorized individuals.

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• Challenges and Considerations:

  • Balancing Information Sharing for Care Coordination: While maintaining confidentiality is paramount, healthcare often requires sharing patient information among care team members for effective coordination. Establish secure and appropriate channels for internal information sharing while respecting confidentiality boundaries.

  • Electronic Health Record Security: Maintaining the security of EHR systems and preventing unauthorized access or data breaches is a complex and ongoing challenge.

  • "Incidental Disclosure": Train staff to be mindful of "incidental disclosure" – unintentional breaches of confidentiality that can occur in busy healthcare settings (e.g., overheard conversations, accidentally leaving records visible).

  • Social Media and Technology: Address the risks of confidentiality breaches related to social media use by staff and patients, and the use of personal devices for work-related communication.

  • Data Security Training and Audits: Implement regular data security training for all staff and conduct periodic audits to assess compliance with confidentiality policies and procedures.

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• Link to Patient Rights & Safety: PRE 2d is fundamental to patient rights and safety. Breaches of confidentiality are not only unethical and often illegal but can also have serious negative consequences for patients' well-being, trust in the healthcare system, and willingness to seek care in the future. Robust confidentiality practices are essential for building a safe and trustworthy healthcare environment.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 2d is critically important. NABH expects hospitals to have comprehensive policies and procedures in place to ensure patient confidentiality, robust data security measures, and staff training to uphold these principles in all aspects of care. Failure to demonstrate a strong commitment to patient confidentiality would be a major deficiency.

In essence, PRE 2, through its various sub-elements, guides healthcare organizations towards a model of care that is deeply respectful of individual patient needs and preferences. It moves beyond a standardized approach to one that is personalized, culturally sensitive, and ethically grounded, recognizing the unique humanity of each patient and family served. Achieving full implementation of PRE 2 is a significant step towards creating a truly patient-centered and high-quality healthcare system.

PRE 3: The Patient and/or Family Members are Educated to Make Informed Decisions and are Involved in the Care Planning and Delivery Process

PRE 3 fundamentally shifts the paradigm of healthcare from a provider-centric model to a patient-centric one. It emphasizes that patients and their families are not passive recipients of care but active partners in their healthcare journey. This standard mandates that healthcare organizations must proactively educate patients to make informed decisions and actively involve them in the planning and delivery of their care. This collaborative approach recognizes the patient's right to autonomy and self-determination and leads to better patient outcomes and satisfaction.

Let's explore each sub-element of PRE 3 in extensive detail:

PRE 3a: The Patient and/or family members are explained about the proposed care, (including the risks, benefits alternatives)expected results and possible complications. (CO)

• Standard Statement: This core objective element (CO) requires that the attending doctor must thoroughly explain to the patient and/or family the proposed care plan. This explanation must be comprehensive and encompass not just the treatment itself but also the associated risks, potential benefits, available alternatives, expected results, and possible complications.

• Rationale and Importance:

  • Informed Decision-Making: The cornerstone of patient autonomy is informed consent. Patients cannot make truly informed decisions about their healthcare unless they have a clear understanding of what is being proposed, including the potential upsides and downsides.

  • Patient Empowerment: Providing this level of information empowers patients to actively participate in discussions about their care, ask questions, express concerns, and feel more in control of their healthcare journey.

  • Realistic Expectations: Explaining expected results and possible complications helps to set realistic expectations for patients and families, reducing anxiety and potential disappointment later on.

  • Shared Responsibility and Partnership: Open and honest communication about all aspects of care fosters a sense of shared responsibility and partnership between the healthcare team and the patient/family.

  • Improved Adherence and Outcomes: Patients who understand their treatment and its potential benefits are more likely to adhere to the care plan, leading to better health outcomes.

  • Ethical Obligation: Providing comprehensive information is a fundamental ethical obligation of healthcare providers, respecting the patient's right to make autonomous decisions about their body and health.

  • Core Commitment: As a Core OE (CO) element, this emphasizes the critical importance of comprehensive explanation as a foundational element of patient-centered care.

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• Key Components and Actions (Attending Doctor Actions - as suggested in the slides):

  • Discuss with Patient and/or Family:

    • Dedicated Discussion Time: Allocate sufficient time for a dedicated discussion with the patient and/or family to explain the proposed care plan. This should not be a rushed or cursory conversation.

    • Active Listening: Encourage patients and families to ask questions and actively listen to their concerns, perspectives, and values.

    • Respect for Patient Preferences: Consider patient preferences and values when discussing treatment options and tailor the explanation accordingly.

    • Family Involvement: Respect patient preferences regarding family involvement in these discussions. Some patients may want family members present, while others may prefer to make decisions independently.

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  • Explain in Language Patient/Attendant Can Understand:

    • Avoid Medical Jargon: Use plain, everyday language and avoid technical medical jargon that patients may not understand.

    • Language Proficiency: Communicate in a language that the patient and family are proficient in. Utilize interpreters when necessary to overcome language barriers.

    • Visual Aids and Analogies: Use visual aids (diagrams, charts, models) and analogies to simplify complex medical concepts and make them more understandable.

    • Check for Understanding: Periodically check for understanding by asking patients to summarize what has been explained or rephrase information in their own words.

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  • Document Relevant Information and Put Signature:

    • Documentation in Medical Record: Document in the patient's medical record that the proposed care, including risks, benefits, alternatives, expected results, and possible complications, has been explained to the patient and/or family.

    • Specific Details in Documentation: The documentation should be specific and include:

      • A summary of the proposed care plan.

      • Mention of the risks and benefits discussed.

      • Mention of alternatives considered and discussed (if any).

      • Expected results of the treatment.

      • Possible complications that were explained.

      • Patient's understanding and any questions or concerns raised.

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    • Attending Doctor Signature: The documentation should be signed and dated by the attending doctor who provided the explanation, signifying their responsibility for the informed consent process.

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• Further Elaboration (Slides 28 & 29):

  • Slide 28 - "The patient and/or family members are explained about the expected results."

    • Treating Physician or his/her team: Responsibility for explaining expected results lies with the treating physician or a designated member of their team.

    • Explain expected outcomes of treatment at periodic intervals: This emphasizes that explanation of expected results is not just a one-time event. It should be an ongoing process, with updates provided at periodic intervals throughout the treatment, especially if the care plan or patient condition changes.

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  • Slide 29 - "The patient and/or family members are explained about the possible complications."

    • Inform patient and/or family members: Directly states the need to inform patients and families about potential complications associated with the proposed care. This should be done in a balanced and honest manner, avoiding undue alarm while ensuring patients are aware of potential risks.

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• Challenges and Considerations:

  • Time Constraints: Doctors often face time constraints in busy clinical settings. Allocating sufficient time for comprehensive explanations can be challenging.

  • Complexity of Medical Information: Explaining complex medical information in a way that is understandable to non-medical individuals requires skill and patience.

  • Emotional Impact: Discussions about risks and complications can be emotionally challenging for both patients and doctors. Doctors need to be sensitive and empathetic in these conversations.

  • Cultural and Language Barriers: Overcoming cultural and language barriers to ensure effective communication and understanding is essential.

  • Documentation Burden: Thorough documentation of these discussions can add to the administrative burden. Streamlined and efficient documentation processes are needed.

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• Link to Patient Rights & Safety: PRE 3a is directly linked to patient rights to informed consent and self-determination. By ensuring comprehensive explanation, the hospital empowers patients to make informed choices, which is a cornerstone of ethical and safe healthcare practice. Informed patients are also better equipped to participate in their care and report any concerns, contributing to overall patient safety.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 3a is a critical requirement. NABH expects hospitals to demonstrate that they have systems and processes in place to ensure that patients and families receive comprehensive explanations of proposed care, and that this is consistently practiced by attending doctors.

PRE 3b: The care plan is prepared and modified in consultation with the patient and/or family members. (A)

• Standard Statement: This Achievement Level (A) objective element emphasizes that the care plan should not be developed in isolation by the healthcare team but should be prepared and modified in genuine consultation and collaboration with the patient and/or their family members.

• Rationale and Importance:

  • Patient-Centered Care in Practice: This standard puts the principle of patient-centered care into practice. It acknowledges that patients and families have valuable perspectives, preferences, and knowledge that should be incorporated into the care plan.

  • Shared Decision-Making: Consultation fosters shared decision-making, where patients and healthcare providers work together to determine the best course of action, considering both medical evidence and patient values.

  • Improved Patient Engagement and Ownership: When patients are involved in creating their care plan, they feel a sense of ownership and are more likely to be engaged in the treatment process and adhere to the plan.

  • Tailored and Personalized Care: Consultation allows for the care plan to be tailored to the patient's specific needs, goals, preferences, and circumstances, leading to more personalized and effective care.

  • Respect for Patient Autonomy and Values: Incorporating patient and family views, including religious, cultural, and spiritual beliefs, into the care plan respects their autonomy and values.

  • Enhanced Patient Satisfaction: Patients who feel heard and involved in their care planning are generally more satisfied with their healthcare experience.

  • Achievement Level: Being an Achievement Level (A) element signifies a higher level of performance and a more sophisticated approach to patient involvement compared to basic commitment.

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• Key Components and Actions (as suggested in the slides):

  • Prepare: Explain various treatment options, risks and benefits:

    • Foundation for Consultation: Before consultation, the healthcare team needs to prepare by thoroughly evaluating the patient's condition and identifying various viable treatment options.

    • Present Options Objectively: Explain the different treatment options, along with their respective risks and benefits, in a clear and unbiased manner.

    • Provide Evidence-Based Information: Base the explanation of options on current medical evidence and guidelines.

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  • Include: Patient and/or family concerns and requests:

    • Elicit Concerns and Requests: Actively solicit and encourage patients and families to express their concerns, questions, and requests related to the proposed care plan.

    • Value Patient Perspectives: Treat patient concerns and requests as valuable input and give them due consideration in the care planning process.

    • Address Concerns Openly: Address patient concerns and questions honestly and transparently, providing clear and understandable responses.

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  • Consider: Religious, cultural and spiritual views of patient and/or family during care delivery:

    • Cultural and Spiritual Sensitivity: Be sensitive to and proactively inquire about the patient's and family's religious, cultural, and spiritual views that may influence their healthcare decisions and preferences.

    • Integrate Beliefs into Care Plan: Where possible and appropriate, integrate these beliefs and values into the care plan. This might involve adjusting treatment approaches, considering dietary needs, respecting religious rituals, or providing spiritual support resources.

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• Points to Remember (as mentioned in the slides):

  • While incorporating patient's and/or family's requests, the organisation should:

    • Adhere to statutory requirements: Patient requests must be considered within the framework of legal and statutory requirements. Patient autonomy is not absolute and is limited by legal and ethical boundaries.

    • Develop structured mechanism to implement and capture them: The organization needs to have a structured mechanism to ensure that patient requests are effectively captured, documented, considered, and implemented when appropriate. This might involve:

      • Standardized documentation fields in care plans to record patient preferences and requests.

      • Protocols for care planning meetings that explicitly include patient and family input.

      • Checklists to ensure consideration of religious, cultural, and spiritual needs.

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• Challenges and Considerations:

  • Conflicting Preferences: Situations may arise where patient preferences conflict with medical recommendations or best practices. Navigating these situations ethically and effectively requires skilled communication and shared decision-making techniques.

  • Family Dynamics: Family dynamics can be complex, and it may be challenging to involve all relevant family members in a meaningful way while respecting patient autonomy and privacy.

  • Patient Capacity and Decision-Making Ability: For patients with impaired cognitive capacity, the process of consultation and shared decision-making may need to involve legal guardians or designated representatives while still respecting the patient's wishes to the extent possible.

  • Time and Resource Constraints: Meaningful consultation takes time and effort. Organizations need to allocate resources and adjust workflows to facilitate effective patient and family involvement in care planning.

  • Documentation of Consultation: Accurate and comprehensive documentation of the consultation process, including patient preferences, concerns, and the shared decisions made, is essential for continuity of care and accountability.

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• Link to Patient Rights & Safety: PRE 3b directly upholds patient rights to autonomy, self-determination, and respect for their values and beliefs. Involving patients in care planning leads to more personalized, acceptable, and effective care plans. It also reduces the risk of errors or misunderstandings because patients are active participants in the process, ultimately contributing to patient safety and better health outcomes.

• Level and Implication: As an Achievement Level (A) objective element, PRE 3b represents a significant step towards patient-centered care. NABH expects hospitals to demonstrate that they have implemented systems and processes to genuinely consult with patients and families in care planning, and that this is not just a theoretical ideal but a consistent practice.

PRE 3c: The patient and/or family members are informed about the results of diagnostic tests and the diagnosis. (C)

• Standard Statement: This Commitment Level (C) objective element mandates that patients and/or their families must be promptly and clearly informed about the results of diagnostic tests and their diagnosis once it is established.

• Rationale and Importance:

  • Right to Information: Patients have a fundamental right to know the results of tests and their diagnosis. This is essential for understanding their health condition and participating in treatment decisions.

  • Reducing Anxiety and Uncertainty: Waiting for test results and diagnosis can be a highly anxious time for patients and families. Timely communication of results reduces uncertainty and anxiety.

  • Basis for Shared Decision-Making: Diagnosis is the foundation upon which treatment plans are built. Patients need to know their diagnosis to engage in meaningful discussions about treatment options and make informed choices.

  • Timely Treatment Initiation: Prompt communication of diagnosis allows for timely initiation of appropriate treatment and interventions, improving patient outcomes.

  • Ethical Obligation: Withholding or delaying information about diagnosis is unethical and disrespectful of patient autonomy.

  • Commitment Level: As a Commitment Level (C) element, this emphasizes the basic yet crucial nature of informing patients about test results and diagnosis.

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• Key Components and Actions (Process Flow - as suggested in the slides):

  • Explain test results in broad terms:

    • Timely Communication: Establish a system to ensure that test results are communicated to patients and families in a timely manner, as soon as they are available and reviewed by the responsible physician.

    • Broad Terms and Understandable Language: Explain test results in broad terms, using plain language that patients can understand. Avoid technical jargon or overly detailed medical terminology.

    • Focus on Key Findings: Highlight the key findings of the tests and their implications for the patient's health.

    • Address Initial Questions: Be prepared to answer initial questions patients and families may have about the test results.

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  • Explain implications on progress and treatment:

    • Connect Results to Diagnosis: Clearly connect the test results to the establishment or confirmation of a diagnosis.

    • Explain Diagnosis in Understandable Terms: Explain the diagnosis in a way that patients can understand, including:

      • The nature of the condition.

      • The expected course of the condition (prognosis).

      • The potential impact on the patient's life.

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    • Link Diagnosis to Treatment Plan: Explain how the diagnosis informs the proposed treatment plan and why the recommended treatment is appropriate for their condition.

    • Opportunity for Further Discussion: Use the communication of diagnosis as an opportunity to initiate further discussion about treatment options, risks, benefits, and patient preferences (leading into PRE 3a and 3b).

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• Challenges and Considerations:

  • Managing Patient Anxiety: Communicating a serious diagnosis can be emotionally challenging for both patients and doctors. Doctors need to be sensitive and empathetic and provide appropriate support.

  • Breaking Bad News: When the diagnosis is unfavorable or serious, doctors need to be skilled in breaking bad news effectively and compassionately.

  • Cultural and Language Sensitivity: Communication about diagnosis needs to be culturally sensitive and in a language that the patient understands.

  • Coordination of Results and Communication: Ensuring timely receipt and review of test results and then coordinating communication with the patient requires efficient systems and teamwork.

  • Documentation of Communication: Documenting that the diagnosis and test results were communicated to the patient and/or family is important for record-keeping and accountability.

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• Link to Patient Rights & Safety: PRE 3c is directly linked to the patient's right to information and informed decision-making. Knowing their diagnosis is crucial for patients to understand their health status and participate in subsequent care decisions. Timely diagnosis and communication also enable prompt treatment, which is essential for patient safety and positive health outcomes.

• Level and Implication: As a Commitment Level (C) objective element, PRE 3c is a fundamental requirement. NABH expects hospitals to have systems in place to ensure that patients and families are routinely informed about test results and diagnoses in a timely and understandable manner.

PRE 3d: The patient and/or family members are explained about any change in the patient's condition in a timely manner. (C)

• Standard Statement: This Commitment Level (C) objective element emphasizes the need for timely communication to patients and/or families whenever there is a change in the patient's condition, whether it is an improvement, deterioration, or the occurrence of complications.

• Rationale and Importance:

  • Patient and Family Involvement in Ongoing Care: Keeping patients and families informed about changes in condition allows them to remain actively involved in the ongoing care process.

  • Managing Expectations and Anxiety: Changes in condition, especially deterioration or complications, can be concerning. Timely communication helps to manage patient and family expectations and anxieties.

  • Adjusting Care Plans: Changes in condition may necessitate adjustments to the care plan. Informed patients and families can participate in discussions about these adjustments.

  • Building Trust and Transparency: Prompt and honest communication about changes in condition builds trust and demonstrates transparency in the healthcare process.

  • Ethical Obligation: It is an ethical obligation to keep patients and families informed about significant changes in their health status.

  • Commitment Level: As a Commitment Level (C) element, this signifies the basic importance of timely communication about changes in patient condition.

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• Key Components and Actions (as suggested in the slides - Key Situations):

  • Improvement:

    • Celebrate Progress: When a patient's condition improves, promptly communicate this positive news to the patient and family.

    • Reinforce Treatment Plan: Explain how the improvement aligns with the treatment plan and reinforces its effectiveness.

    • Adjust Expectations (If Needed): While celebrating improvement, also manage expectations for continued progress and potential setbacks.

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  • Deterioration:

    • Timely and Sensitive Communication: When a patient's condition deteriorates, communicate this news to the patient and family as soon as possible, in a sensitive and compassionate manner.

    • Explain Nature of Deterioration: Explain the nature of the deterioration in understandable terms, including the potential causes and implications.

    • Discuss Plan of Action: Discuss the revised care plan to address the deterioration, including any changes in treatment, monitoring, or support.

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  • Occurrence of Complications:

    • Prompt Disclosure: If complications arise, disclose them to the patient and family promptly and transparently.

    • Explain Nature and Management of Complications: Explain the nature of the complication, its potential causes, and how it is being managed.

    • Address Concerns and Questions: Be prepared to address patient and family concerns and questions about the complication and its management.

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• Points to Remember (as mentioned in the slides):

  • Give explanation in a timely manner: Timeliness is crucial. Delays in communication can lead to increased anxiety, mistrust, and potentially missed opportunities for intervention.

  • Discuss withholding of resuscitation requests from relatives and family within ethical and legal parameters: This point specifically addresses a sensitive aspect of change in condition - end-of-life care.

    • End-of-Life Discussions: When a patient's condition deteriorates significantly and prognosis becomes poor, initiate timely and sensitive discussions about end-of-life care preferences, including resuscitation.

    • Respect Patient Wishes (Advance Directives): If the patient has advance directives (living will, DNR order), respect and adhere to their documented wishes regarding resuscitation.

    • Family Involvement in Decision-Making: Involve family members in discussions about withholding or withdrawing resuscitation, especially if the patient is unable to make decisions themselves.

    • Ethical and Legal Framework: Ensure all decisions about resuscitation are made within ethical and legal parameters, following hospital policy and relevant guidelines.

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• Challenges and Considerations:

  • Defining "Timely": "Timely" communication can be subjective. Hospitals need to establish reasonable timeframes for communicating different types of changes in condition, balancing urgency with the need for accurate information.

  • Emotional Impact of Negative Changes: Communicating negative changes in condition (deterioration, complications) can be emotionally taxing for both doctors and patients/families. Doctors need to be prepared to provide emotional support and resources.

  • Coordination of Communication: In complex cases with multiple care providers, ensuring coordinated and consistent communication about changes in condition can be challenging.

  • Documentation of Communication: Documenting the communication about changes in condition, including what was explained, when, and to whom, is important for record-keeping and continuity of care.

  • Cultural and Language Barriers: Effective communication about changes in condition must also overcome cultural and language barriers.

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• Link to Patient Rights & Safety: PRE 3d is crucial for upholding patient rights to information and participation in care decisions. Timely communication about changes in condition empowers patients and families to adapt to evolving situations, adjust expectations, and participate in decisions about further care. It also enhances patient safety by ensuring that everyone is aware of the current clinical status and any necessary adjustments to the care plan.

• Level and Implication: As a Commitment Level (C) objective element, PRE 3d is a fundamental expectation. NABH expects hospitals to have systems and processes in place to ensure timely communication of changes in patient condition, and that this is consistently practiced by healthcare providers.

PRE 3e: The patient and/or family members are provided multi-disciplinary counselling when appropriate. (A)

• Standard Statement: This Achievement Level (A) objective element focuses on providing multi-disciplinary counselling to patients and/or their families when appropriate, recognizing that certain situations require a coordinated and comprehensive approach to support patients and families.

• Rationale and Importance:

  • Complex Needs: Certain medical situations (critical illness, complex diagnoses, end-of-life care, organ donation) often involve complex medical, emotional, psychological, social, and ethical needs for patients and families.

  • Holistic Support: Multi-disciplinary counselling provides a holistic approach to address these complex needs, drawing upon the expertise of various healthcare professionals.

  • Improved Coping and Adjustment: Counselling can help patients and families cope with difficult situations, adjust to new diagnoses or prognoses, and make informed decisions during stressful times.

  • Enhanced Communication and Coordination: Multi-disciplinary counselling facilitates better communication and coordination among different healthcare professionals involved in the patient's care.

  • Family Support: Recognizes that families also need support during challenging times and extends counselling to family members.

  • Achievement Level: As an Achievement Level (A) element, this signifies a more advanced and comprehensive approach to patient and family support, going beyond basic information provision.

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• Key Components and Actions (as suggested in the slides - When and Who):

  • When should it be given? - The organisation should identify situations:

    • Proactive Identification: The organization needs to proactively identify situations where multi-disciplinary counselling is appropriate. This requires clear guidelines and criteria for triggering counselling referrals.

    • Examples of Situations (as given in slides):

      • Counselling family members of critically ill patients: Families of critically ill patients in the ICU or with life-threatening conditions often require significant emotional and informational support.

      • Potential organ donors: Families of potential organ donors require sensitive and specialized counselling regarding organ donation, ethical considerations, and bereavement support.

      • Other Situations: The list should be expanded to include other situations where multi-disciplinary counselling is beneficial, such as:

        • New diagnosis of serious or chronic illness (cancer, HIV, neurological conditions).

        • Complex treatment decisions (surgery, chemotherapy, palliative care).

        • End-of-life care and bereavement support.

        • Significant disability or functional impairment.

        • Psychological or emotional distress related to illness.

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  • Who should be part of counselling team? - Doctors from different specialities, nurses and physiotherapists:

    • Multi-disciplinary Team Composition: The counselling team should be multi-disciplinary, bringing together professionals with different expertise to address the diverse needs of patients and families.

    • Core Team Members (as suggested in slides):

      • Doctors from different specialties: Specialist physicians relevant to the patient's condition (e.g., oncologist, cardiologist, neurologist, intensivist).

      • Nurses: Nurses provide direct patient care, emotional support, and practical guidance.

      • Physiotherapists: Physiotherapists can address physical limitations, pain management, and rehabilitation needs.

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    • Other Potential Team Members (depending on situation):

      • Social workers: Address social, financial, and practical needs, and provide emotional support.

      • Psychologists/Psychiatrists: Address psychological and emotional distress, mental health issues, and coping strategies.

      • Chaplains/Spiritual care providers: Address spiritual needs and provide religious support.

      • Dieticians: Address nutritional needs and dietary modifications.

      • Pharmacists: Provide medication counseling and address drug-related concerns.

      • Patient advocates/Patient navigators: Help patients navigate the healthcare system and access resources.

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• Note (as mentioned in the slides):

  • Counselling could be led by clinician-in-charge of the patient: While multi-disciplinary, the counselling effort needs coordination. The clinician-in-charge (often the attending physician) can take a leadership role in coordinating the counselling team and ensuring a unified approach.

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• Challenges and Considerations:

  • Identifying Patients in Need: Developing effective systems to proactively identify patients and families who would benefit from multi-disciplinary counselling can be challenging.

  • Team Coordination and Communication: Effective multi-disciplinary counselling requires strong team coordination and communication among team members to ensure a cohesive and consistent approach.

  • Resource Availability: Providing multi-disciplinary counselling requires dedicated staff time and resources from various departments. Organizations need to allocate resources appropriately.

  • Patient Acceptance and Participation: Patients and families may not always be receptive to or understand the value of multi-disciplinary counselling. Education and clear communication about the benefits are important.

  • Documentation of Counselling Sessions: Documenting the content of counselling sessions, recommendations, and follow-up plans is important for continuity of care and communication within the team.

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• Link to Patient Rights & Safety: PRE 3e significantly enhances patient-centered care and indirectly contributes to patient safety. By providing comprehensive, multi-faceted support through counselling, hospitals address not just the medical aspects of illness but also the broader emotional, psychological, and social needs of patients and families. This holistic approach leads to better coping, improved decision-making, and potentially better health outcomes, all contributing to a safer and more supportive healthcare environment.

• Level and Implication: As an Achievement Level (A) objective element, PRE 3e represents a more advanced level of patient care. NABH expects hospitals to demonstrate that they have mechanisms in place to identify patients and families who would benefit from multi-disciplinary counselling and that they have the resources and team structure to provide this support effectively.

In Summary of PRE 3:

PRE 3 is a cornerstone of patient-centered care within the NABH standards. It moves beyond simply providing treatment to actively engaging patients and families in their healthcare journey. It emphasizes the importance of:

• Comprehensive Information: Ensuring patients and families are fully informed about all aspects of proposed care (PRE 3a).

• Collaborative Care Planning: Involving patients and families in the creation and modification of their care plans (PRE 3b).

• Timely Disclosure of Information: Promptly communicating test results, diagnosis, and changes in condition (PRE 3c and 3d).

• Holistic Support through Counselling: Providing multi-disciplinary counselling to address complex needs (PRE 3e).

By effectively implementing PRE 3, healthcare organizations can create a truly patient-centered environment where patients are empowered, respected, and actively involved in their care, leading to improved satisfaction, better outcomes, and enhanced patient safety.

PRE 4: Informed Consent is Obtained from the Patient or Family About Their Care

PRE 4 is entirely dedicated to the crucial concept of informed consent within the NABH 6th Edition standards. It underscores that obtaining valid informed consent from patients or their families is not merely a procedural formality but a fundamental ethical and legal requirement for all healthcare organizations. This standard emphasizes the patient's right to autonomy, self-determination, and to be an active participant in decisions about their care. PRE 4 is designed to ensure that consent is not just obtained, but that it is truly informed, voluntary, and respects the patient's rights and wishes.

Let's delve into each sub-element of PRE 4 in extensive detail:

PRE 4a: The organisation obtains informed consent from the patient or family for situations where informed consent is required. * (CO)

• Standard Statement: This core objective element (CO) mandates that the healthcare organization must have a robust system in place to identify situations requiring informed consent and to ensure that informed consent is indeed obtained from the patient or family in those situations. The asterisk (*) indicates mandatory system documentation.

• Rationale and Importance:

  • Ethical and Legal Foundation: Informed consent is a cornerstone of medical ethics and is legally mandated in most jurisdictions. It stems from the principles of patient autonomy and the right to self-determination.

  • Respect for Patient Autonomy: Informed consent respects the patient's right to make decisions about their own body and healthcare. It acknowledges that patients are capable of making choices that align with their values and preferences.

  • Shared Decision-Making: The informed consent process is a critical component of shared decision-making, where patients and healthcare providers collaborate to determine the best course of action.

  • Protection from Unwanted Procedures: Valid informed consent protects patients from undergoing medical procedures or treatments they do not understand or do not wish to receive.

  • Building Trust and Transparency: A strong informed consent process enhances transparency and builds trust between patients and healthcare providers.

  • Core Commitment: As a Core OE (CO) element, PRE 4a highlights the fundamental importance of having a system for obtaining informed consent and is critical for accreditation.

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• Key Components and Actions (as suggested in the slides):

  • Prepare a list - Make a list of procedures (Based on requirements of this standard and statutory requirements):

    • Identify Procedures Requiring Consent: The organization must proactively create a comprehensive list of all procedures and treatments for which informed consent is mandatory. This list should be based on:

      • NABH Standard Requirements: Review the entirety of the NABH standards to identify procedures specifically mentioned as requiring informed consent (e.g., blood transfusion, anesthesia, surgery, research protocols, invasive procedures).

      • Statutory Requirements: Consult relevant national and local laws, regulations, and guidelines pertaining to informed consent. These may specify procedures for which consent is legally required (e.g., specific surgeries, invasive diagnostic tests, participation in research).

      • Hospital Policy and Ethical Considerations: Supplement the list with procedures that, while not legally mandated, are considered ethically essential to obtain informed consent for due to their risks, invasiveness, or potential impact on the patient (e.g., certain medications, non-invasive procedures with significant risks).

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    • Dynamic List: The list should not be static but should be reviewed and updated regularly to reflect changes in medical practice, legal requirements, and ethical considerations.

    • Accessibility of List: The list should be readily accessible to all relevant staff members (doctors, nurses, administrative staff) so they are aware of which procedures require informed consent.

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  • Develop written guidance - Explain steps involved in obtained informed consent. Mention the person responsible for obtaining consent:

    • Standardized Informed Consent Process: Develop clear, written guidance and protocols outlining the standardized process for obtaining informed consent within the organization. This guidance should detail:

      • Steps in the Consent Process: Outline the sequential steps involved in obtaining valid informed consent (e.g., explanation of procedure, discussion of risks and benefits, answering patient questions, obtaining signature, documentation).

      • Content of Informed Consent Discussion: Specify the key information that must be included in the informed consent discussion (procedure details, risks, benefits, alternatives, who will perform the procedure - as elaborated in PRE 4c).

      • Documentation Requirements: Detail how informed consent should be documented in the patient's medical record (consent form, progress notes, etc.).

      • Process for Incapable Patients: Outline the process for obtaining consent when the patient lacks capacity to provide informed consent (as elaborated in PRE 4d).

      • Process for Refusal of Consent: Outline the procedure to follow when a patient refuses consent for a recommended treatment.

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    • Identify Responsible Person: Clearly define who is responsible for obtaining informed consent for different types of procedures. Typically, this is the person performing the procedure or a designated doctor member of the team (as elaborated in PRE 4e).

    • Accessibility of Guidance: The written guidance should be easily accessible to all relevant staff members, perhaps through hospital intranet, policy manuals, or training materials.

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  • Ensure staff awareness - The staff should be aware of the entire process:

    • Comprehensive Staff Training: Implement mandatory and comprehensive training programs for all relevant staff members (doctors, nurses, allied health professionals, administrative staff) on the organization's informed consent policy and procedures.

    • Training Content: Training should cover:

      • The importance of informed consent (ethical, legal, patient-centered care).

      • The organization's list of procedures requiring consent.

      • The standardized informed consent process and steps to follow.

      • The content that must be included in the informed consent discussion.

      • Proper documentation of informed consent.

      • Procedures for obtaining consent from incapable patients.

      • Procedures for handling refusal of consent.

      • Relevant statutory requirements and legal aspects of informed consent.

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    • Regular Refreshers and Updates: Provide regular refresher training and updates to staff on informed consent policies and procedures to reinforce knowledge and address any changes in guidelines or best practices.

    • Competency Assessment: Consider implementing competency assessments to ensure staff understand and can effectively implement the informed consent process.

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• Points to Remember (as mentioned in the slides - Examples of statutory requirements):

  • Examples of statutory requirements: The slides provide examples of relevant statutory acts, particularly in the Indian context:

    • MTP Act (Medical Termination of Pregnancy Act): Requires informed consent for termination of pregnancy.

    • PC-PNDT Act (Pre-Conception and Pre-Natal Diagnostic Techniques Act): Regulates prenatal diagnostic tests and often requires informed consent for specific procedures.

    • The Transplantation of Human Organs Act: Requires strict informed consent for organ donation and transplantation procedures.

    • Policy for HIV testing: Refers to national policy and guidelines for HIV testing, which often mandate specific informed consent procedures and pre-test counseling.

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• Challenges and Considerations:

  • Complexity of Legal and Ethical Landscape: The legal and ethical requirements for informed consent can be complex and vary across jurisdictions. Organizations need to stay updated and ensure compliance with all relevant regulations.

  • Defining "Required" Situations: Determining exactly which procedures should be on the mandatory informed consent list can be nuanced. Organizations need to err on the side of caution and include procedures where there is any significant risk or potential impact on the patient.

  • Ensuring Consistent Implementation: Ensuring that all staff members consistently follow the standardized informed consent process across all departments and services can be a challenge.

  • Documentation Burden: Balancing thorough documentation with efficiency and avoiding unnecessary administrative burden is important.

  • Cultural and Language Barriers: Addressing cultural and language barriers to ensure that informed consent is truly understood by diverse patient populations requires resources and training.

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• Link to Patient Rights & Safety: PRE 4a is fundamental to protecting patient rights and ensuring patient safety. By establishing a system to identify and act upon situations requiring informed consent, the organization prevents procedures from being performed without valid consent, upholding patient autonomy and reducing the risk of unwanted or misunderstood treatments.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 4a is a critical requirement for NABH accreditation. Hospitals must demonstrate that they have a documented system, list of procedures, written guidance, and staff training programs in place to ensure informed consent is obtained in all appropriate situations. The mandatory system documentation (*) means that the hospital must have documented policies and procedures and evidence of their implementation.

PRE 4b: Informed consent process adheres to statutory norms. (C)

• Standard Statement: This Commitment Level (C) objective element specifies that the process of obtaining informed consent must strictly adhere to all relevant statutory norms and legal requirements applicable in the jurisdiction.

• Rationale and Importance:

  • Legal Compliance: This standard directly emphasizes legal compliance. Failure to adhere to statutory norms for informed consent can have legal ramifications for the hospital and healthcare professionals.

  • Validity of Consent: Consent obtained in a manner that does not comply with statutory norms may be considered legally invalid, potentially exposing the hospital to legal liability.

  • Patient Protection: Statutory norms are often in place to protect patients and ensure that the informed consent process is robust, fair, and truly safeguards patient autonomy.

  • Ethical Consistency with Law: Ethical healthcare practice must be consistent with legal frameworks. Adhering to statutory norms ensures that the informed consent process is both ethically sound and legally compliant.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of legal compliance in the informed consent process.

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• Key Components and Actions (as suggested in the slides - Before a procedure, For repeat procedure, For change in treatment modality):

  • Before a procedure:

    • Take informed consent from patient: This reiterates the fundamental step of obtaining consent directly from the patient (if capable).

    • Get signature of at least one witness: Many statutory norms require the presence and signature of a witness during the informed consent process, especially for significant procedures. The witness typically attests that the patient signed the consent form voluntarily and appeared to understand the information provided.

    • Ensure the witness is present during entire communication between the doctor and the patient: In some jurisdictions, the statutory norms may specify that the witness should be present not just for the signature but during the entire communication between the doctor and patient regarding informed consent to ensure they can attest to the explanation and discussion that took place. Hospitals must verify if this is a requirement in their jurisdiction and comply accordingly.

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  • For repeat procedure (For example: Dialysis):

    • Take informed consent at first instance: For procedures that are repeated regularly (like dialysis, chemotherapy cycles, etc.), it is generally acceptable to obtain a comprehensive informed consent at the first instance of the procedure.

    • Define validity period (not more than six months.): Statutory norms may allow for a single informed consent to be valid for a defined period for repeat procedures. The slides suggest a validity period "not more than six months." Hospitals must verify the legally acceptable validity period in their jurisdiction and adhere to it. Beyond this period, fresh informed consent is generally required.

    • Ask patient to endorse consent at each repeat treatment: Even with a valid initial consent for repeat procedures, it is good practice to ask the patient to endorse or reaffirm their consent at each repeat treatment. This could be a brief verbal confirmation or a signature on a simplified form, indicating they still agree to proceed and have no new questions or concerns.

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  • For change in treatment modality/addition of another modality:

    • Obtain fresh consent: If there is a significant change in the treatment modality (e.g., switching from medical management to surgery, adding a new invasive procedure) or if another modality is added, then a fresh informed consent process is required for the new or changed treatment. The initial consent for the original plan does not automatically cover significant changes.

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• Challenges and Considerations:

  • Jurisdictional Variations: Statutory norms for informed consent can vary significantly across different countries, states, or regions. Hospitals must be fully aware of and compliant with the specific laws and regulations in their jurisdiction.

  • Keeping Up-to-Date: Laws and regulations related to informed consent can be amended or updated. Hospitals must have a system to stay informed of any changes and adapt their processes accordingly.

  • Witness Requirements: Understanding the specific requirements for witnesses (who can be a witness, what they need to attest to) in the local jurisdiction is crucial.

  • Validity Periods for Repeat Procedures: Accurately defining and tracking validity periods for consent for repeat procedures and ensuring fresh consent is obtained when needed requires robust systems.

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• Link to Patient Rights & Safety: PRE 4b is essential for ensuring that the informed consent process is legally sound and effectively protects patient rights. Adherence to statutory norms minimizes legal risks for the hospital and, more importantly, ensures that patients' rights to autonomy and informed decision-making are truly respected within the legal framework.

• Level and Implication: As a Commitment Level (C) objective element, PRE 4b is a fundamental requirement. NABH expects hospitals to demonstrate that their informed consent process is not just ethically guided but also fully compliant with all applicable statutory norms in their jurisdiction. This requires a thorough understanding of relevant laws, policies, and procedures that are demonstrably implemented.

PRE 4c: Informed consent includes information regarding the procedure; it's risks, benefits, alternatives and as to who will perform the procedure in a language that they can understand.

• Standard Statement: This Commitment Level (C) objective element details the essential content of the informed consent process. It specifies that the information provided to the patient must comprehensively cover key aspects of the proposed procedure, including its nature, risks, benefits, alternatives, and the identity of the person performing it. Crucially, this information must be communicated in a language the patient can understand.

• Rationale and Importance:

  • Truly Informed Consent: Consent is only truly "informed" when patients receive adequate and relevant information to make a reasoned decision. This standard outlines the minimum information required for valid informed consent.

  • Enabling Autonomous Choice: Providing information on risks, benefits, and alternatives empowers patients to weigh the options, consider their values, and make a choice that is consistent with their own preferences.

  • Transparency and Honesty: Openly discussing risks and potential complications, as well as benefits, demonstrates transparency and honesty from the healthcare provider, building patient trust.

  • Shared Understanding: Communicating in a language the patient understands is critical for ensuring shared understanding and preventing misunderstandings or misinterpretations of complex medical information.

  • Ethical Completeness: This element ensures that the informed consent process is ethically complete by covering the key elements of disclosure necessary for patient autonomy.

  • Commitment Level: As a Commitment Level (C) element, this emphasizes the basic yet essential nature of providing comprehensive and understandable information during the informed consent process.

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• Key Components and Actions (as suggested in the slides - Document in the consent form, Consent form considerations):

  • Document in the consent form: This emphasizes that the consent form itself should reflect that these key areas have been addressed.

    • Name of the doctor performing the procedure: Clearly document the name of the doctor who will be performing the procedure. This is essential for transparency and patient awareness.

    • Explain risks, benefits and alternatives: The consent form should document that risks, benefits, and alternatives to the proposed procedure have been explained to the patient. While the form itself doesn't need to detail all risks and benefits, it should acknowledge that these were discussed.

    • If multiple doctors are involved, enter names and roles of all principal surgeons. And, each doctor should explain separately to patient: If the procedure involves multiple surgeons or a team, the consent form should list the names and roles of all principal surgeons involved. Furthermore, the standard indicates that each doctor involved should explain their specific role and the aspects of the procedure they will be performing separately to the patient. This is particularly important for complex surgeries or procedures with multiple steps.

    • If 'doctor under training' is performing, both name of trainee doctor and qualified doctor supervising the procedure should be written: If a trainee doctor is performing the procedure (fully or partially), this must be disclosed to the patient. The consent form should clearly state the name of the trainee doctor and the name of the qualified doctor who will be supervising the trainee. This ensures transparency and allows patients to understand the level of experience of the person performing the procedure.

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  • Consent form considerations (Slide 38):

    • It should be bilingual: The consent form itself should ideally be bilingual, presented in both the local language understood by the patient and a widely used medical language (e.g., English, Hindi). This ensures accessibility and reduces language barriers.

    • It should be explained in a language patient understands: Crucially, the explanation of the procedure and consent information must be delivered in a language the patient understands. This may require the use of interpreters if the patient's primary language is different from that of the healthcare provider.

    • Mention language explained to the patient: The consent form should have a section to document the language in which the explanation was provided to the patient. This adds to transparency and accountability.

    • Write name of the interpreter used: If an interpreter was used during the informed consent process, the name of the interpreter should be documented on the consent form. This is important for record-keeping and verifying the process.

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• Challenges and Considerations:

  • Balancing Information Depth and Patient Comprehension: Providing comprehensive information while ensuring it is truly understandable to patients with varying levels of medical literacy is a delicate balance.

  • Managing Patient Anxiety about Risks: Discussing risks can understandably cause anxiety for patients. Doctors need to communicate risks honestly but also in a reassuring and supportive manner.

  • Cultural and Language Barriers: Overcoming cultural and language barriers to ensure effective communication of complex medical information requires resources and trained interpreters.

  • Documentation Efficiency: Ensuring that all required information is documented in the consent form and medical record without creating excessive administrative burden requires streamlined processes and user-friendly forms.

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• Link to Patient Rights & Safety: PRE 4c directly addresses the core of informed consent – ensuring that patients receive the necessary information to make autonomous decisions. By mandating comprehensive and understandable information, this standard empowers patients to make truly informed choices, which is fundamental to ethical healthcare and contributes to patient safety by promoting shared decision-making and reducing the risk of procedures being performed without adequate patient understanding.

• Level and Implication: As a Commitment Level (C) objective element, PRE 4c is a fundamental expectation. NABH expects hospitals to demonstrate that their informed consent process consistently includes the provision of comprehensive and understandable information to patients, covering all the key elements specified in the standard, and that this is reflected in their consent forms and documentation practices.

PRE 4d: The organisation describes who can give consent when a patient is incapable of independent decision making and implements the same. * (C)

• Standard Statement: This Commitment Level (C) objective element addresses the complex situation of patients who lack the capacity to provide informed consent for themselves. It mandates that the organization must have a clearly defined policy and process for determining who can provide consent on behalf of an incapable patient and must consistently implement this policy. The asterisk (*) indicates mandatory system documentation.

• Rationale and Importance:

  • Protecting Vulnerable Patients: Patients who are incapable of making their own decisions are particularly vulnerable. This standard aims to protect their rights and ensure that decisions about their care are made in their best interests.

  • Ethical and Legal Guidance: Provides ethical and legal guidance for decision-making for incapable patients, respecting their autonomy to the extent possible and ensuring surrogate decision-making is appropriate and ethical.

  • Clarity and Consistency: Having a clear policy ensures clarity and consistency in decision-making for incapable patients, preventing confusion or arbitrary practices.

  • Minimizing Conflict and Confusion: A well-defined process can help minimize potential conflicts among family members or between family and healthcare providers regarding decisions for incapable patients.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of having a clear policy and process for consent for incapable patients.

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• Key Components and Actions (as suggested in the slides - Who can give consent?, What if the patient is incapable to take an independent decision?, What is the order of preference to give consent?, Who can give consent during life-threatening situation?):

  • Who can give consent? - A patient who is capable and above legal age:

    • Capable Adult Patient: The standard reaffirms the primary principle that a patient who is legally an adult (age of majority as per local laws) and is deemed "capable" of making their own decisions is the one who should provide informed consent for their own care.

    • Note: No one can give consent on behalf of a competent adult: This is a crucial point. For a competent adult patient, even close family members cannot legally provide consent on their behalf. Consent must come from the patient themselves.

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  • What if the patient is incapable to take an independent decision? - The organisation should adhere to statutory norms. And, obtain consent from next of kin/legal guardian:

    • Assessment of Incapacity: The organization needs to have a process for assessing and determining when a patient lacks the capacity to make independent decisions. This assessment is usually done by a qualified physician and may involve considering cognitive function, understanding of information, and ability to communicate decisions.

    • Adherence to Statutory Norms: When a patient is deemed incapable, the organization must adhere to statutory norms and legal frameworks in their jurisdiction regarding surrogate decision-making. These laws typically specify who can legally act as a surrogate decision-maker.

    • Next of Kin/Legal Guardian: Statutory norms usually prioritize "next of kin" or a legally appointed "guardian" as surrogate decision-makers for incapable patients.

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  • What is the order of preference to give consent? - Next of kin/legal guardian is spouse, son/daughter/parents/brothers/sister:

    • Hierarchy of Surrogate Decision-Makers: Statutory norms often establish a hierarchy or order of preference for who can act as next of kin or surrogate decision-maker. The slides provide a common example hierarchy (though this can vary by jurisdiction):

      1. Spouse

      2. Adult Son or Daughter

      3. Parents

      4. Adult Brothers or Sisters

      5. Other close relatives (may be defined by law)

      6. Legal Guardian (if one has been appointed)

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    • Verify Local Hierarchy: Hospitals must verify the legally mandated order of preference in their specific jurisdiction and ensure their policy aligns with it.

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  • Who can give consent during life-threatening situation? - For life threatening situations, if the patient is incapable and next of kin is not available, then the treating doctor and another clinician can decide to safeguard patient's life:

    • Emergency Exception: In true life-threatening emergency situations where the patient is incapable of decision-making and next of kin or a legal guardian is not immediately available to provide consent, the standard recognizes an exception.

    • Implied Consent in Emergencies: In such extreme circumstances, the treating doctor (and often another senior clinician for second opinion/confirmation) can make decisions to provide life-saving treatment based on the principle of "implied consent" or "emergency exception." The ethical principle of beneficence (acting in the patient's best interest) takes precedence in these critical situations.

    • Limited to Life-Saving Measures: This emergency exception is generally limited to procedures or treatments that are immediately necessary to safeguard the patient's life. As soon as the emergency subsides or next of kin becomes available, the standard procedures for informed consent or surrogate decision-making should resume.

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• Challenges and Considerations:

  • Defining "Incapacity": Establishing clear and objective criteria for determining patient incapacity can be complex and requires careful medical assessment.

  • Legal Variations in Surrogate Decision-Making: Laws regarding surrogate decision-making vary significantly across jurisdictions. Hospitals must be thoroughly familiar with and compliant with the specific laws in their area.

  • Family Disputes and Conflicts: Disputes or conflicts may arise among family members about who should act as surrogate decision-maker or what decisions are in the patient's best interest. Hospitals need to have processes to manage such conflicts ethically and legally.

  • Best Interests Standard: When surrogate decision-making is necessary, decisions should ideally be guided by the "best interests" standard, considering what the patient would have wanted if they were capable and their current medical condition and prognosis.

  • Documentation of Incapacity and Surrogate Consent: Thorough documentation of the assessment of patient incapacity, the identification of the surrogate decision-maker, and the consent obtained from the surrogate is crucial for legal and ethical reasons.

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• Link to Patient Rights & Safety: PRE 4d is critical for protecting the rights of vulnerable, incapable patients. By establishing a clear and legally sound process for surrogate decision-making, the hospital ensures that even when patients cannot make decisions for themselves, their care is still guided by ethical principles and their best interests are protected. This safeguards patient autonomy to the greatest extent possible in complex situations and contributes to patient safety by ensuring appropriate care decisions are made.

• Level and Implication: As a Commitment Level (C) objective element, PRE 4d is a fundamental requirement. NABH expects hospitals to have a documented policy and process for surrogate decision-making that is compliant with statutory norms, clearly defines who can provide consent for incapable patients, and addresses emergency situations. The mandatory system documentation (*) requires the hospital to have documented policies and procedures and evidence of their implementation.

PRE 4e: Informed consent is taken by the person performing the procedure. (CO)

• Standard Statement: This core objective element (CO) specifies that the responsibility for obtaining informed consent should lie with the person who will actually be performing the procedure.

• Rationale and Importance:

  • Direct Responsibility and Expertise: The person performing the procedure is typically the most knowledgeable about the procedure itself, its specific risks and benefits, and the alternatives. They are best positioned to provide a comprehensive and accurate explanation to the patient.

  • Personalized Explanation: Having the person performing the procedure obtain consent allows for a more personalized explanation tailored to the specific patient and the nuances of the procedure as it will be performed by that individual.

  • Building Patient-Provider Relationship: The informed consent discussion is an important opportunity to build rapport and trust between the patient and the person who will be directly involved in their care during the procedure.

  • Accountability: Assigning responsibility to the performer of the procedure ensures clear accountability for the informed consent process.

  • Core Commitment: As a Core OE (CO) element, this underscores the importance of direct responsibility for informed consent by the proceduralist.

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• Key Components and Actions (as suggested in the slides - Responsibility of entire consent process, Point to Remember):

  • Responsibility of entire consent process: The responsibility for the entire informed consent process, from explanation to obtaining signature, should ideally rest with:

    • Person performing the procedure: This is the primary expectation - the doctor, surgeon, or other healthcare professional who will directly perform the procedure should be the one to obtain informed consent.

    • OR Doctor member of the team: In some situations, especially in larger teams or for complex procedures, a designated doctor member of the team who is thoroughly knowledgeable about the procedure may be delegated to obtain informed consent. However, this delegation should be clearly defined, and the ultimate responsibility still rests with the team and the proceduralist.

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  • Point to Remember (as mentioned in the slides):

    • Providing explanation and taking signature should be done by the same person: This reinforces the principle that the person who explains the procedure and answers the patient's questions should also be the one who takes the signature on the consent form. This ensures continuity and accountability.

    • For example: It is incorrect if the doctor explains the procedure and the written consent is taken by the nurse: This example explicitly states that it is generally not appropriate for a doctor to explain the procedure and then delegate the task of obtaining the written consent signature to a nurse. While nurses play a crucial role in patient education and support, the primary responsibility for the informed consent discussion and signature lies with the physician or proceduralist. Nurses can certainly witness the consent process and answer clarifying questions within their scope of practice, but they should not be the primary consent obtainers in place of the performing physician.

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• Challenges and Considerations:

  • Time Constraints for Physicians: Physicians, especially surgeons, often have very busy schedules. Allocating time for detailed informed consent discussions and documentation can be a challenge.

  • Delegation within Teams: In large healthcare teams, there may be a temptation to delegate consent to non-physician staff. This standard emphasizes that the responsibility should remain with the proceduralist or a knowledgeable doctor member of the team.

  • Training and Accountability: Ensuring that all physicians and proceduralists understand their responsibility for obtaining informed consent and are trained on best practices requires ongoing education and accountability mechanisms.

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• Link to Patient Rights & Safety: PRE 4e strengthens patient rights and safety by ensuring that the informed consent process is directly linked to the person who will be providing the care. This promotes better communication, personalized explanation, and accountability, ultimately contributing to a more robust and ethically sound informed consent process that truly protects patient autonomy.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 4e is a critical expectation. NABH expects hospitals to demonstrate that their policies and practices clearly assign responsibility for obtaining informed consent to the person performing the procedure or a designated doctor member of the team, and that this is consistently implemented in practice.

In Summary of PRE 4:

PRE 4 provides a comprehensive framework for informed consent, covering essential aspects from identifying when consent is required (PRE 4a) to ensuring legal compliance (PRE 4b), detailing the necessary information to be provided (PRE 4c), addressing consent for incapable patients (PRE 4d), and assigning responsibility for obtaining consent to the proceduralist (PRE 4e). By effectively implementing all sub-elements of PRE 4, healthcare organizations can build a robust and ethically sound informed consent process that truly respects patient autonomy, promotes shared decision-making, and enhances patient safety and trust. It is a fundamental standard for demonstrating a commitment to patient-centered care and ethical healthcare practice.

PRE 5: Patient and Families Have a Right to Information and Education About Their Healthcare Needs

PRE 5 shifts the focus to the patient's right to information and education, recognizing that knowledge is power in healthcare. This standard emphasizes that healthcare organizations have a responsibility to actively provide patients and families with the information and education they need to understand their health conditions, treatment options, and how to manage their health effectively. It moves beyond just consent, focusing on broader healthcare literacy and patient empowerment through education.

Let's explore each sub-element of PRE 5 in extensive detail:

PRE 5a: Patient and/or family are educated in a language and format that they can understand. (CO)

• Standard Statement: This core objective element (CO) highlights the fundamental principle that all patient and family education must be delivered in a language and format that is easily understandable to them.

• Rationale and Importance:

  • Effective Communication: Education is only effective if the recipient can comprehend the information being conveyed. Language and format accessibility are paramount for effective communication.

  • Patient Empowerment through Understanding: Patients cannot make informed decisions or actively participate in their care if they do not understand the information provided to them. Understandable education empowers them with knowledge.

  • Overcoming Barriers to Access: Language barriers, literacy levels, and sensory or cognitive limitations can all impede access to healthcare information. Addressing these barriers through appropriate language and format is crucial for equity and inclusivity.

  • Improved Adherence and Outcomes: Patients who understand their health conditions and treatment plans are more likely to adhere to recommendations, leading to better health outcomes and reduced readmissions.

  • Respect for Patient Diversity: Recognizes the diversity of patient populations and the need to tailor communication and education to individual needs.

  • Core Commitment: As a Core OE (CO) element, this emphasizes the critical importance of understandable communication as a foundation for patient education.

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• Key Components and Actions (as suggested in the slides - During patient's treatment):

  • During patient's treatment: This highlights that the assessment and adaptation of educational methods should be an ongoing part of the patient's treatment journey.

    • Screen (informally) patient and/or family:

      • Initial Assessment: Conduct an informal screening or assessment at the beginning of treatment (or at relevant points) to gauge the patient's and/or family's communication needs and potential barriers.

      • Methods for Screening: This screening can be informal and conversational. Staff can:

        • Observe patient interactions and communication style.

        • Ask direct questions about preferred language, literacy level, or any communication difficulties.

        • Use simple questionnaires or checklists to assess communication needs (e.g., language preference, reading ability, hearing or visual impairments).

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      • Sensitivity and Respect: Conduct screening sensitively and respectfully, avoiding any judgmental or patronizing approaches.

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    • Understand their abilities and language requirements:

      • Identify Specific Needs: Based on the screening, actively identify the patient's and/or family's specific abilities and language requirements. This includes:

        • Primary Language: Determine their preferred language for communication.

        • Literacy Level: Assess their reading and writing abilities in their preferred language.

        • Cognitive Abilities: Consider any cognitive impairments or learning disabilities that may affect their ability to process information.

        • Sensory Impairments: Identify any visual or hearing impairments that require adaptations in format.

        • Cultural Factors: Be aware of cultural communication norms and preferences.

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    • Provide counselling or use printed material/audio-visual aids:

      • Tailored Educational Methods: Based on the identified needs, select appropriate educational methods and materials that are tailored to the patient's and family's abilities and language requirements.

      • Counselling:

        • Verbal Explanation: Provide clear and concise verbal explanations in the patient's preferred language.

        • Interactive Discussion: Engage in interactive discussions, allowing patients and families to ask questions and clarify their understanding.

        • Individualized Approach: Adapt counselling style and pace to the patient's learning style and pace.

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      • Printed Material:

        • Translated Materials: Provide printed educational materials (pamphlets, brochures, handouts) translated into languages commonly spoken by the patient population.

        • Simplified Language: Use simplified language, avoiding medical jargon, and focusing on key messages.

        • Large Print: Offer materials in large print for patients with visual impairments.

        • Pictorial Aids: Incorporate pictures, diagrams, and illustrations to enhance understanding, especially for low-literacy patients.

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      • Audio-Visual Aids:

        • Videos and Animations: Utilize short, informative videos and animations with clear visuals and audio in relevant languages.

        • Audio Recordings: Provide audio recordings of educational content in different languages for patients with visual impairments or those who prefer auditory learning.

        • Multi-Sensory Approach: Combine visual, auditory, and tactile elements to cater to different learning styles.

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• Challenges and Considerations:

  • Language Diversity and Interpreter Resources: In diverse populations, providing materials and interpreters in all relevant languages can be resource-intensive and logistically challenging.

  • Assessing Literacy and Cognitive Abilities: Accurately assessing patient literacy levels and cognitive abilities requires sensitivity and appropriate tools.

  • Developing and Maintaining Diverse Materials: Developing and regularly updating educational materials in multiple languages and formats requires ongoing effort and resources.

  • Staff Training on Communication and Cultural Competence: Staff training on effective communication techniques, cultural sensitivity, and using diverse educational methods is crucial.

  • Balancing Information Detail and Understandability: Providing sufficient detail while keeping information understandable to patients with varying levels of medical knowledge is a delicate balance.

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• Link to Patient Rights & Safety: PRE 5a is fundamental to ensuring that the patient's right to information and education is truly realized. By making education accessible in understandable language and formats, hospitals empower patients to engage in informed decision-making, adhere to treatment plans, and manage their health effectively, all of which contribute to patient safety and better outcomes.

• Level and Implication: As a Core OE (CO) element, PRE 5a is a critical requirement. NABH expects hospitals to demonstrate that they have systems in place to assess patient communication needs and tailor educational methods and materials accordingly. This is a foundational element of patient-centered education.

PRE 5b: Patient and/or family are educated about the safe and effective use of medication and the potential side effects of the medication, when appropriate. (C)

• Standard Statement: This Commitment Level (C) objective element specifically focuses on medication education. It mandates that patients and/or families must be educated about the safe and effective use of their medications and the potential side effects, whenever medication is prescribed and education is appropriate.

• Rationale and Importance:

  • Medication Safety: Medication errors and adverse drug events are a significant patient safety concern. Proper medication education is crucial for minimizing these risks.

  • Effective Treatment: Patients who understand how to take their medications correctly are more likely to achieve the intended therapeutic benefits.

  • Adherence and Compliance: Education improves patient adherence to medication regimens, leading to better treatment outcomes.

  • Side Effect Management: Knowing about potential side effects allows patients to recognize them early, manage them effectively, and report them to their healthcare providers, preventing serious complications.

  • Patient Empowerment and Self-Management: Medication education empowers patients to take an active role in managing their medications and health.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of medication education for patient safety and effective treatment.

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• Key Components and Actions (as suggested in the slides - Patient and/or family education - three key areas):

  • Patient and/or family education - Key Areas: Medication education should encompass at least these three crucial areas:

    • Safe and effective use of a medication:

      • Dosage and Frequency: Explain the correct dosage, frequency (how often to take), and timing (when to take, e.g., morning, evening, with meals) of each medication.

      • Route of Administration: Clearly explain the route of administration (oral, topical, injection, inhalation, etc.) and provide instructions on how to administer the medication correctly for each route.

      • Duration of Therapy: Explain how long the patient needs to take the medication (duration of treatment).

      • Storage Instructions: Provide instructions on proper storage of the medication (temperature, light sensitivity, etc.).

      • Refills and Prescriptions: Explain how to obtain refills and the importance of adhering to the prescribed duration without self-discontinuation or alteration of dosage.

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    • Importance of taking a drug at specific time:

      • Timing with Meals: Explain if the medication needs to be taken with food, before food, or on an empty stomach, and the reason for this timing (e.g., to enhance absorption, reduce stomach upset).

      • Consistent Timing: Emphasize the importance of taking medication at consistent times each day to maintain therapeutic blood levels and effectiveness.

      • Missed Dose Instructions: Provide clear instructions on what to do if a dose is missed (e.g., take it as soon as remembered, skip the dose if it's almost time for the next dose, do not double dose).

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    • Potential side effects of medication:

      • Common and Serious Side Effects: Explain both common and potentially serious side effects that patients should be aware of.

      • Recognizing Side Effects: Describe how patients can recognize these side effects (symptoms, signs).

      • Management Strategies: Provide guidance on how to manage common side effects (e.g., dietary changes for nausea, hydration for dry mouth).

      • When to Seek Medical Attention: Clearly instruct patients when to seek immediate medical attention for side effects (e.g., allergic reactions, severe pain, unusual bleeding).

      • Reporting Side Effects: Explain how patients can report side effects to their healthcare provider and encourage them to do so.

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• Note (as mentioned in the slides):

  • The organisation should make a list of drugs. For example: Digoxin: The organization should proactively identify "high-risk" medications or medications with specific patient education needs and create a list of these drugs. Digoxin is given as an example, likely because it is a medication with a narrow therapeutic index and specific side effects that patients need to be aware of. This list should be tailored to the hospital's formulary and common prescribing patterns and could include drugs like:

    • Anticoagulants (Warfarin, Heparin, Novel Oral Anticoagulants).

    • Insulin and other diabetes medications.

    • Opioid pain medications.

    • Immunosuppressants.

    • Certain antibiotics with specific administration instructions or side effects.

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• Challenges and Considerations:

  • Complexity of Medication Regimens: Patients, especially those with multiple chronic conditions, may be on complex medication regimens. Providing clear and understandable education for multiple medications can be challenging.

  • Patient Memory and Retention: Patients may have difficulty remembering all the medication instructions provided. Using multiple educational methods (verbal, written, visual) and reinforcing education over time can help.

  • Low Literacy and Language Barriers: Medication education materials need to be adapted for patients with low literacy and provided in languages they understand.

  • Time Constraints in Consultations: Healthcare providers often face time constraints in consultations. Allocating sufficient time for comprehensive medication education requires planning and efficient workflows.

  • Documentation of Medication Education: Documenting the medication education provided to patients is important for record-keeping and continuity of care.

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• Link to Patient Rights & Safety: PRE 5b is directly linked to patient safety and the right to information. Effective medication education is a crucial patient safety intervention, reducing the risk of medication errors and adverse events. It also empowers patients to use medications safely and effectively, contributing to better health outcomes.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5b is a fundamental expectation. NABH expects hospitals to demonstrate that they have systems in place to provide medication education to patients and families, covering safe use, timing, and potential side effects, and that they have identified "high-risk" medications requiring specific patient education.

PRE 5c: Patient and/or family are educated about food-drug interaction. (C)

• Standard Statement: This Commitment Level (C) objective element focuses specifically on food-drug interactions. It mandates that patients and/or families must be educated about potential food-drug interactions relevant to their medications, when appropriate.

• Rationale and Importance:

  • Medication Effectiveness and Safety: Food-drug interactions can significantly alter the effectiveness of medications, either reducing their therapeutic effect or increasing the risk of adverse effects. Education about these interactions is crucial for both medication effectiveness and safety.

  • Preventing Adverse Events: Certain food-drug interactions can lead to serious adverse events or complications. Education can help patients avoid these potentially harmful interactions.

  • Optimizing Treatment Outcomes: Understanding food-drug interactions allows patients to adjust their diet appropriately to optimize medication effectiveness and achieve better treatment outcomes.

  • Patient Self-Management: Education empowers patients to make informed dietary choices while taking medications, promoting self-management of their health.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet important nature of food-drug interaction education for medication safety and efficacy.

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• Key Components and Actions (as suggested in the slides - Patient and/or family education, Note):

  • Patient and/or family education: Medication education should specifically include information about food-drug interactions.

    • Explain about diet during medication: Clearly explain any dietary restrictions or precautions that patients need to follow while taking specific medications.

    • Specific Examples: Provide specific examples of food-drug interactions relevant to the prescribed medications.

      • For example: Avoid alcohol intake when taking metronidazole: Metronidazole is given as a specific example because it is a common medication that has a well-known and significant interaction with alcohol (disulfiram-like reaction). This example illustrates the type of specific food-drug interaction education that should be provided.

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    • Other Examples of Food-Drug Interactions (beyond alcohol and metronidazole): The education should cover other common and clinically relevant food-drug interactions based on the patient's medication regimen. Examples include:

      • Warfarin and Vitamin K rich foods: Patients on Warfarin (an anticoagulant) need to be educated about maintaining consistent Vitamin K intake and avoiding drastic changes in their consumption of foods like leafy green vegetables, as Vitamin K can affect Warfarin's effectiveness.

      • MAOIs (Monoamine Oxidase Inhibitors) and Tyramine-containing foods: Patients on MAOIs (a class of antidepressants) need to avoid tyramine-rich foods (aged cheese, cured meats, fermented foods) to prevent hypertensive crisis.

      • Tetracycline antibiotics and dairy products/antacids: Dairy products and antacids can interfere with the absorption of tetracycline antibiotics, reducing their effectiveness.

      • Grapefruit juice and certain medications: Grapefruit juice can interact with various medications, including statins, calcium channel blockers, and some immunosuppressants, affecting their metabolism and potentially increasing side effects or reducing effectiveness.

      • Potassium-sparing diuretics and potassium-rich foods: Patients on potassium-sparing diuretics may need to be cautious about consuming excessive potassium-rich foods to avoid hyperkalemia (high potassium levels).

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• Note (as mentioned in the slides):

  • The organisation should make a list of drugs: Similar to PRE 5b, the organization should proactively identify medications that have clinically significant food-drug interactions and create a list of these drugs. This list will guide staff in providing appropriate food-drug interaction education. This list should be tailored to the hospital's formulary and common prescribing patterns.

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• Challenges and Considerations:

  • Complexity of Food-Drug Interactions: Food-drug interactions can be complex, and not all interactions are clinically significant. Education should focus on clinically relevant interactions that have a meaningful impact on medication effectiveness or safety.

  • Patient Dietary Habits: Understanding patients' dietary habits and cultural food preferences is important for providing relevant and practical food-drug interaction advice.

  • Providing Practical Dietary Guidance: Education should go beyond just listing foods to avoid and provide practical guidance on dietary modifications or substitutions.

  • Low Literacy and Language Barriers: Food-drug interaction education materials need to be adapted for patients with low literacy and provided in languages they understand.

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• Link to Patient Rights & Safety: PRE 5c is directly linked to patient safety and the right to information. Education about food-drug interactions is a crucial patient safety measure, preventing potentially harmful interactions and optimizing medication effectiveness. It empowers patients to make informed dietary choices while on medications, contributing to better health outcomes and medication safety.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5c is a fundamental expectation. NABH expects hospitals to demonstrate that they have systems in place to provide food-drug interaction education to patients and families when relevant, and that they have identified medications with significant food-drug interaction risks.

PRE 5d: Patient and/or family are educated about diet and nutrition. (C)

• Standard Statement: This Commitment Level (C) objective element broadens the scope to general diet and nutrition education. It mandates that patients and/or families must be educated about diet and nutrition, particularly in relation to their health conditions.

• Rationale and Importance:

  • Diet as a Cornerstone of Health: Diet and nutrition are fundamental determinants of health and well-being. Proper nutrition plays a crucial role in disease prevention, management, and recovery.

  • Disease Management and Prevention: For many chronic conditions (diabetes, heart disease, obesity, etc.), dietary modifications are a cornerstone of management and can significantly impact disease progression and outcomes. Nutrition education is also vital for promoting preventative health behaviors.

  • Recovery and Rehabilitation: Good nutrition is essential for recovery from illness, surgery, and injuries. Education can guide patients on nutritional strategies to support healing and rehabilitation.

  • Patient Empowerment and Self-Care: Nutrition education empowers patients to make informed food choices and take an active role in managing their health through diet.

  • Commitment Level: As a Commitment Level (C) element, this emphasizes the basic yet essential nature of diet and nutrition education as part of comprehensive patient care.

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• Key Components and Actions (as suggested in the slides - Patient and/or family education - two key areas):

  • Patient and/or family education - Key Areas: Diet and nutrition education should encompass at least these two key areas:

    • Inform about relationships between various foods or supplements and specific health conditions:

      • Disease-Specific Dietary Advice: Provide education on the relationship between specific foods or dietary patterns and the patient's particular health condition.

      • Examples:

        • Diabetes: Educate diabetic patients about carbohydrate counting, glycemic index, portion control, and appropriate food choices for blood sugar management.

        • Heart Disease: Educate patients with heart disease about low-fat, low-cholesterol, low-sodium diets, and the benefits of fiber-rich foods and healthy fats.

        • Chronic Kidney Disease: Educate patients with kidney disease about protein, potassium, phosphorus, and sodium restrictions.

        • Cancer: Provide nutrition guidance to cancer patients to manage side effects of treatment, maintain weight, and support overall nutritional status.

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      • Supplements: Discuss the role and potential risks/benefits of dietary supplements, advising patients to consult with their healthcare provider before taking any supplements, especially if they are on medications.

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    • Include general recommendations to follow a healthy diet:

      • Basic Healthy Eating Principles: Provide general recommendations for healthy eating that are applicable to most individuals, even beyond specific health conditions. This could include:

        • Emphasis on fruits, vegetables, and whole grains.

        • Lean protein sources.

        • Healthy fats (unsaturated fats).

        • Limiting processed foods, sugary drinks, and unhealthy fats (saturated and trans fats).

        • Portion control and calorie balance.

        • Adequate hydration.

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      • Age-Appropriate and Culturally Sensitive Guidance: Adapt general recommendations to be age-appropriate and culturally sensitive, considering dietary habits and preferences.

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• Challenges and Considerations:

  • Individualized Dietary Needs: Dietary needs are highly individualized and depend on various factors (age, activity level, health conditions, cultural preferences). Education needs to be tailored to each patient's specific situation.

  • Complexity of Nutrition Science: Nutrition science can be complex and sometimes conflicting information is available. Education should be based on evidence-based guidelines and avoid promoting fad diets or unsubstantiated claims.

  • Behavior Change and Long-Term Adherence: Changing dietary habits is challenging. Education should not just provide information but also strategies to support long-term behavior change and adherence to healthy eating patterns.

  • Low Literacy and Language Barriers: Nutrition education materials need to be adapted for patients with low literacy and provided in languages they understand.

  • Access to Healthy Foods and Resources: Consider patients' access to healthy foods and resources when providing dietary recommendations. Provide practical advice that is feasible within their socioeconomic context.

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• Link to Patient Rights & Safety: PRE 5d is linked to patient rights to information and the right to receive care that promotes their overall well-being. Nutrition education empowers patients to make healthier lifestyle choices and manage their health conditions through diet, contributing to better long-term health outcomes and potentially preventing or managing complications.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5d is a fundamental expectation. NABH expects hospitals to demonstrate that they provide diet and nutrition education to patients and families, particularly in relation to their health conditions, and that this education includes both disease-specific and general healthy eating recommendations.

PRE 5e: Patient and/or family are educated about immunisations. (C)

• Standard Statement: This Commitment Level (C) objective element focuses on immunization education. It mandates that patients and/or families must be educated about immunizations, both for themselves and their children, as a crucial preventive healthcare measure.

• Rationale and Importance:

  • Disease Prevention: Immunizations are one of the most effective public health interventions for preventing infectious diseases. Education promotes vaccine uptake and reduces the incidence of vaccine-preventable illnesses.

  • Individual and Community Health: Immunizations protect not only the individual receiving the vaccine but also contribute to herd immunity, protecting the broader community, especially vulnerable individuals who cannot be vaccinated.

  • Reducing Morbidity and Mortality: Vaccine-preventable diseases can cause significant morbidity (illness) and mortality (death). Immunization education helps to reduce the burden of these diseases.

  • Addressing Vaccine Hesitancy: Education can address vaccine hesitancy and misinformation by providing accurate information about vaccine safety and efficacy, promoting informed decision-making about vaccination.

  • Public Health Responsibility: Promoting immunization is a public health responsibility of healthcare organizations.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of immunization education as a core preventive healthcare service.

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• Key Components and Actions (as suggested in the slides - Patient and/or family education, Paediatric immunization):

  • Patient and/or family education - Inform adults about immunisation for: Education should specifically target adult immunizations and inform adults about vaccines recommended for them. The slides list examples of vaccines recommended for adults:

    • Influenza (Flu): Annual influenza vaccination is recommended for most adults, especially those at high risk of complications.

    • Streptococcus pneumonia (Pneumococcal pneumonia): Pneumococcal vaccines are recommended for adults over 65 and those with certain chronic conditions.

    • Typhoid: Typhoid vaccine is recommended for travelers to typhoid-endemic areas and certain high-risk groups.

    • Hepatitis B: Hepatitis B vaccine is recommended for adults at risk of Hepatitis B infection (healthcare workers, individuals with multiple sexual partners, etc.).

    • Neisseria meningitides (Meningococcal meningitis): Meningococcal vaccines are recommended for certain age groups (adolescents, young adults) and high-risk groups (travelers to meningitis-belt regions, individuals with certain medical conditions).

    • Other Adult Vaccines (Beyond the list in slides): Education should also cover other vaccines recommended for adults based on age, risk factors, and local guidelines, such as:

      • Tetanus, Diphtheria, Pertussis (Tdap/Td booster).

      • Measles, Mumps, Rubella (MMR) (for those not immune).

      • Varicella (Chickenpox) (for those not immune).

      • Human Papillomavirus (HPV) (for eligible adults).

      • Zoster (Shingles) vaccine (for adults over 50/60).

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  • Paediatric immunization shall follow universal immunization programme:

    • Universal Immunization Programme (UIP): For paediatric immunizations, the organization must adhere to the country's national Universal Immunization Programme (UIP) or equivalent national immunization schedule.

    • UIP Education: Educate parents and caregivers about the UIP schedule, recommended vaccines for children at different ages, and the importance of completing the full vaccination series.

    • Vaccine Information and Counseling: Provide parents with accurate information about vaccine benefits, risks, and common side effects. Address parental concerns and vaccine hesitancy with evidence-based information.

    • Tracking and Reminders: Implement systems to track paediatric vaccinations and provide reminders to parents for upcoming vaccinations.

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• Challenges and Considerations:

  • Vaccine Hesitancy and Misinformation: Vaccine hesitancy and misinformation are significant challenges. Education needs to address these concerns effectively with evidence-based information and empathetic communication.

  • Changing Vaccine Recommendations: Vaccine recommendations can change over time based on new research and evolving epidemiology. Education materials and staff training need to be regularly updated.

  • Adult Immunization Awareness: Awareness of recommended adult immunizations is often lower than awareness of childhood vaccines. Education efforts need to specifically target adult populations.

  • Access and Affordability: Ensure that patients have access to and can afford recommended vaccines. Provide information about vaccination programs and resources if needed.

  • Documentation of Immunization Education: Documenting that immunization education was provided to patients and families is important for record-keeping and tracking immunization status.

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• Link to Patient Rights & Safety: PRE 5e is strongly linked to patient rights to preventive care and the right to receive information that promotes their health. Immunization education is a vital preventive healthcare service, contributing to individual and public health safety by reducing the incidence of vaccine-preventable diseases.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5e is a fundamental expectation. NABH expects hospitals to demonstrate that they provide immunization education to patients and families, covering both adult and paediatric recommendations, and that they adhere to the national immunization programme for children.

PRE 5f: Patient and/or family are educated on various pain management techniques, when appropriate. (C)

• Standard Statement: This Commitment Level (C) objective element focuses on pain management education. It mandates that patients and/or families must be educated on various pain management techniques, especially when appropriate for their condition and needs.

• Rationale and Importance:

  • Pain as a Common Symptom: Pain is a common and often debilitating symptom in many medical conditions. Effective pain management is crucial for patient comfort, function, and quality of life.

  • Multi-modal Approach to Pain Management: Modern pain management often involves a multi-modal approach, combining pharmacological and non-pharmacological techniques. Education is needed to inform patients about these various options.

  • Patient Self-Management of Pain: Education empowers patients to actively participate in managing their pain, using self-management techniques and communicating effectively with their healthcare providers about their pain experience.

  • Reducing Reliance on Opioids: Education on non-opioid pain management techniques can help reduce reliance on opioid medications, which carry risks of addiction and side effects.

  • Improved Quality of Life: Effective pain management, facilitated by education, significantly improves patients' quality of life, allowing them to engage in daily activities and improve their overall well-being.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of pain management education as part of comprehensive patient care.

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• Key Components and Actions (as suggested in the slides - Educate patients having long-term pain, Points to Remember):

  • Educate patients having long-term pain due to underlying untreatable condition: The slides specifically emphasize educating patients with chronic or long-term pain, especially when the underlying condition may be untreatable or pain is a persistent symptom. This patient group often benefits most from comprehensive pain management education.

  • Various pain management techniques: Education should cover a variety of pain management techniques, including both pharmacological and non-pharmacological options.

    • Pharmacological Techniques:

      • Medications: Educate patients about different types of pain medications (analgesics, NSAIDs, opioids, adjuvants), their mechanisms of action, appropriate use, potential side effects, and safe medication practices.

      • Pain Medication Regimen: Explain their prescribed pain medication regimen in detail, including dosage, frequency, timing, and duration.

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    • Non-Pharmacological Techniques:

      • Physical Therapy/Exercise: Educate about the role of physical therapy, exercise, and movement in pain management, including specific exercises or stretches recommended for their condition.

      • Heat and Cold Therapy: Explain how to use heat and cold packs safely and effectively for pain relief.

      • Massage Therapy: Discuss the potential benefits of massage therapy and self-massage techniques.

      • Relaxation Techniques: Teach relaxation techniques such as deep breathing, meditation, progressive muscle relaxation, and guided imagery.

      • Cognitive Behavioral Therapy (CBT): Introduce CBT as a psychological approach to pain management, helping patients to change their thoughts and behaviors related to pain.

      • Transcutaneous Electrical Nerve Stimulation (TENS): Explain the use of TENS devices for pain relief, if appropriate.

      • Acupuncture/Acupressure: Discuss acupuncture or acupressure as potential complementary therapies for pain management.

      • Other Techniques: Depending on the patient's condition and needs, also educate about other techniques like yoga, tai chi, biofeedback, and mindfulness-based pain management.

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  • Points to Remember (as mentioned in the slides):

    • Provide information within framework of patient's beliefs: Pain perception and management are influenced by individual beliefs, cultural norms, and religious views. Education should be delivered in a culturally sensitive manner and consider the patient's framework of beliefs:

      • Personal Beliefs: Acknowledge and respect patient's personal beliefs about pain and pain management.

      • Cultural Beliefs: Be aware of cultural beliefs and practices related to pain and healthcare, and tailor education accordingly.

      • Religious Beliefs: Respect religious beliefs that may influence pain perception, pain management preferences, and acceptance of certain treatments.

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• Challenges and Considerations:

  • Subjectivity of Pain: Pain is a subjective experience, and patients' pain experiences can vary widely. Education needs to be personalized and address individual pain characteristics and needs.

  • Complexity of Pain Mechanisms: Pain mechanisms can be complex, and explaining them in understandable terms can be challenging.

  • Balancing Pharmacological and Non-Pharmacological Approaches: Education should emphasize a balanced approach to pain management, integrating both pharmacological and non-pharmacological techniques and avoiding over-reliance on medications alone.

  • Addressing Opioid Concerns: In the context of the opioid crisis, education should address responsible opioid use (if prescribed), risks of addiction, and alternative non-opioid pain management options.

  • Low Literacy and Language Barriers: Pain management education materials need to be adapted for patients with low literacy and provided in languages they understand.

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• Link to Patient Rights & Safety: PRE 5f is linked to patient rights to receive care that addresses their pain and improves their quality of life. Pain management education empowers patients to actively manage their pain, use various techniques effectively, and communicate their pain experience to healthcare providers, leading to better pain control, improved function, and enhanced well-being. Effective pain management also contributes to overall patient safety and satisfaction.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5f is a fundamental expectation. NABH expects hospitals to demonstrate that they provide pain management education to patients and families, particularly those with chronic pain, covering various pharmacological and non-pharmacological techniques, and that this education is culturally sensitive and considers patient beliefs.

PRE 5g: Patient and/or family are educated about their specific disease process, complications and prevention strategies. (C)

• Standard Statement: This Commitment Level (C) objective element focuses on disease-specific education. It mandates that patients and/or families must be educated about their specific disease process, potential complications, and strategies for prevention or risk reduction.

• Rationale and Importance:

  • Disease Understanding: Understanding their disease process empowers patients to cope with their condition, make informed decisions, and participate actively in their care.

  • Early Detection and Management of Complications: Education about potential complications allows patients to recognize early warning signs, seek timely medical attention, and prevent serious consequences.

  • Prevention and Risk Reduction: Education on prevention strategies empowers patients to adopt healthy lifestyle choices and behaviors that can reduce their risk of disease progression, recurrence, or complications.

  • Improved Self-Management and Outcomes: Patients who understand their disease and prevention strategies are better equipped to manage their condition effectively, leading to improved health outcomes and quality of life.

  • Patient Empowerment and Control: Knowledge about their disease empowers patients and gives them a sense of control over their health journey.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of disease-specific education as part of comprehensive patient care.

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• Key Components and Actions (as suggested in the slides - Patient and/or family education, Note):

  • Patient and/or family education - Key Areas: Disease-specific education should encompass at least these key areas:

    • Life style changes:

      • Tailored Lifestyle Recommendations: Provide specific lifestyle change recommendations relevant to the patient's disease process.

      • Examples (as given in slides):

        • Stress management: Educate about stress reduction techniques (relaxation exercises, mindfulness, time management) if stress is a contributing factor or exacerbating factor for their condition.

        • Physical exercise: Recommend appropriate types and levels of physical exercise based on their disease, functional limitations, and overall health status.

        • Cessation of smoking and substance abuse: Strongly advise and provide resources for smoking cessation and address substance abuse issues if relevant to the disease process.

      • 
        

      • Other Lifestyle Changes: Depending on the disease, also educate about other relevant lifestyle modifications such as:

        • Sleep hygiene.

        • Weight management.

        • Sun protection (for skin conditions or photosensitivity).

        • Safe sexual practices (for STIs).

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    • Diet changes:

      • Disease-Specific Dietary Modifications: Provide specific dietary recommendations tailored to the patient's disease process (as detailed in PRE 5d, but specifically linked to the disease).

      • Example: For patients with diabetes, provide detailed education on diabetes-specific dietary guidelines, carbohydrate counting, portion control, and appropriate food choices.

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    • Immunisations (where appropriate):

      • Disease-Related Immunization Recommendations: Educate about immunizations that are specifically recommended for patients with certain diseases or conditions to reduce their risk of infections or complications.

      • Examples:

        • Influenza and pneumococcal vaccines for patients with chronic respiratory conditions, heart disease, diabetes, or immunocompromising conditions.

        • Hepatitis B vaccine for patients with chronic liver disease.

        • HPV vaccine for individuals at risk of HPV-related cancers.

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• Note (as mentioned in the slides):

  • Booklets/video/leaflets can be used to educate a patient: The slides suggest using various educational materials to support disease-specific education.

    • Variety of Educational Resources: Utilize a variety of educational resources to enhance patient learning and cater to different learning styles.

    • Booklets, Brochures, Handouts: Provide printed materials with comprehensive information about the disease process, complications, prevention strategies, lifestyle modifications, and dietary recommendations.

    • Videos and Animations: Use videos and animations to explain complex disease processes in a visually engaging and understandable manner.

    • Leaflets and Quick Guides: Develop concise leaflets or quick reference guides summarizing key information and action steps for patients to take.

    • Website Resources: Direct patients to reliable and reputable websites or online resources for further information and support.

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• Challenges and Considerations:

  • Complexity of Disease Processes: Disease processes can be complex, and explaining them in understandable terms to patients with varying levels of medical literacy is challenging.

  • Information Overload: Providing too much information at once can overwhelm patients. Education should be delivered in manageable chunks and reinforced over time.

  • Individualized Education Needs: Disease-specific education needs to be tailored to each patient's specific diagnosis, stage of disease, prognosis, and individual circumstances.

  • Maintaining Accuracy and Up-to-Date Information: Medical knowledge and treatment guidelines are constantly evolving. Education materials and staff training need to be regularly updated to reflect current best practices.

  • Low Literacy and Language Barriers: Disease-specific education materials need to be adapted for patients with low literacy and provided in languages they understand.

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• Link to Patient Rights & Safety: PRE 5g is directly linked to patient rights to information and to receive care that promotes their long-term health and well-being. Disease-specific education empowers patients to understand their condition, manage it effectively, prevent complications, and make informed lifestyle choices, all of which contribute to better health outcomes and patient safety.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5g is a fundamental expectation. NABH expects hospitals to demonstrate that they provide disease-specific education to patients and families, covering the disease process, potential complications, and relevant prevention strategies, utilizing appropriate educational resources.

PRE 5h: Patient and/or family are educated about preventing healthcare associated infections. (C)

• Standard Statement: This Commitment Level (C) objective element focuses on infection prevention education. It mandates that patients and/or families must be educated about preventing healthcare-associated infections (HAIs), which are infections acquired during healthcare delivery.

• Rationale and Importance:

  • Patient Safety and HAI Reduction: Healthcare-associated infections are a significant patient safety concern. Education is a crucial component of HAI prevention strategies.

  • Patient Empowerment in Infection Control: Patients and families play an active role in infection prevention. Education empowers them to take steps to protect themselves and others from HAIs.

  • Reducing Healthcare Costs: HAIs increase healthcare costs due to prolonged hospital stays, increased treatment needs, and potential complications. Prevention through education can help reduce these costs.

  • Public Health Importance: Reducing HAIs is a public health priority, contributing to overall infection control and preventing the spread of antibiotic-resistant organisms.

  • Commitment Level: As a Commitment Level (C) element, this highlights the basic yet essential nature of HAI prevention education as a core patient safety measure.

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• Key Components and Actions (as suggested in the slides - Patient and/or family education, For example):

  • Patient and/or family education - Prevention of healthcare associated infection: Education should specifically focus on strategies patients and families can use to prevent HAIs.

    • For example (as given in slides):

      • Adopt proper hand washing techniques: Emphasize the importance of hand hygiene and teach proper hand washing techniques (using soap and water or alcohol-based hand rub). Explain when hand hygiene is critical (before meals, after using the restroom, after touching potentially contaminated surfaces, before and after contact with wounds or medical devices).

      • Avoid overcrowding near patient: Educate about avoiding overcrowding around the patient's bedside, especially if the patient is immunocompromised or at high risk of infection. Explain that limiting visitors and maintaining physical distance can help reduce the risk of infection transmission.

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    • Other Key HAI Prevention Measures to Educate Patients and Families About (beyond hand hygiene and overcrowding):

      • Cough Etiquette and Respiratory Hygiene: Teach proper cough and sneeze etiquette (covering mouth and nose with elbow or tissue, hand hygiene after coughing/sneezing). Educate about respiratory hygiene practices (wearing masks if appropriate, especially during respiratory illness).

      • Clean Environment: Encourage patients and families to keep the patient's immediate environment clean and tidy.

      • Catheter Care (if applicable): For patients with indwelling catheters (urinary, intravenous), educate about proper catheter care, including keeping the insertion site clean and dry, and avoiding pulling or kinking the catheter.

      • Wound Care (if applicable): For patients with wounds or surgical incisions, educate about proper wound care techniques, including hand hygiene before and after wound care, keeping the wound clean and dry, and recognizing signs of infection.

      • Infection Awareness: Educate patients and families to be aware of signs and symptoms of infection (fever, redness, swelling, pain, drainage) and to report any concerns to their healthcare provider promptly.

      • Vaccination (as appropriate): Encourage vaccination against vaccine-preventable infections like influenza and pneumococcal pneumonia, especially for high-risk patients.

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• Challenges and Considerations:

  • Patient Engagement and Compliance: Getting patients and families to actively engage in and consistently practice infection prevention measures can be challenging. Education needs to be motivating and emphasize the benefits of compliance.

  • Reinforcing Education: Infection prevention education should be reinforced repeatedly throughout the patient's hospital stay and at discharge.

  • Low Literacy and Language Barriers: HAI prevention education materials need to be adapted for patients with low literacy and provided in languages they understand.

  • Cultural Beliefs and Practices: Be sensitive to cultural beliefs and practices that may influence hygiene behaviors and tailor education accordingly.

  • Resource Availability for Infection Prevention: Ensure that patients and families have access to necessary resources for infection prevention, such as hand sanitizer, tissues, and clean environments.

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• Link to Patient Rights & Safety: PRE 5h is directly and fundamentally linked to patient safety. HAI prevention education is a critical patient safety intervention, empowering patients and families to actively participate in reducing the risk of infections acquired during healthcare. This directly protects patients from harm and contributes to a safer healthcare environment.

• Level and Implication: As a Commitment Level (C) objective element, PRE 5h is a core expectation for all healthcare organizations. NABH expects hospitals to demonstrate that they provide HAI prevention education to patients and families, covering key measures like hand hygiene and other relevant practices, and that this education is consistently delivered.

PRE 5i: The patients and/or family members' special educational needs are identified and addressed. (A)

• Standard Statement: This Achievement Level (A) objective element moves beyond general education to focus on special educational needs. It mandates that the organization must have systems to identify patients and/or family members who have special educational needs and to proactively address these needs appropriately.

• Rationale and Importance:

  • Equity and Inclusivity: Recognizes that not all patients learn or access information in the same way. Addressing special educational needs promotes equity and inclusivity in healthcare education.

  • Effective Education for All: Ensures that patients with diverse needs receive education that is tailored to their specific requirements, maximizing their understanding and benefit from the education.

  • Improved Outcomes for Vulnerable Populations: Addressing special educational needs is particularly important for vulnerable populations who may face additional barriers to accessing and understanding healthcare information (e.g., patients with disabilities, cognitive impairments, communication difficulties).

  • Patient-Centered and Personalized Care: Tailoring education to special needs is a key aspect of patient-centered and personalized care.

  • Achievement Level: As an Achievement Level (A) element, this signifies a higher level of sophistication and commitment to personalized education compared to basic compliance.

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• Key Components and Actions (as suggested in the slides - Identify during treatment, Educate patient and/or family, Special Needs (Example), Points to Remember):

  • Identify during treatment:

    • Ongoing Assessment: The identification of special educational needs should be an ongoing process, integrated into routine patient care and assessment.

    • Screening and Observation: Staff should be trained to be observant and proactively screen for potential special educational needs during patient interactions.

    • Methods for Identification: Methods for identification can include:

      • Direct questioning about learning preferences or any difficulties in understanding information.

      • Observation of patient communication style and comprehension during education sessions.

      • Review of patient medical history for pre-existing conditions that might indicate special needs (e.g., cognitive impairment, sensory deficits, learning disabilities).

      • Referral from other healthcare professionals or family members.

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  • Educate patient and/or family:

    • Tailored Educational Strategies: Once special educational needs are identified, implement tailored educational strategies to address those needs effectively.

    • Adaptations in Format and Delivery: Adapt the format and delivery of educational materials and sessions to suit the patient's specific needs.

    • Examples of Adaptations (based on Special Needs Examples given in slides):

      • Attention Deficit Hyperactivity Disorder (ADHD): For patients with ADHD, use shorter education sessions, break down information into smaller chunks, use visual aids, provide frequent breaks, and minimize distractions.

      • Autism support: For patients with autism, use visual aids, structured and predictable routines, clear and concise language, avoid figurative language or sarcasm, and provide a calm and quiet environment.

      • Physical disabilities needs: For patients with physical disabilities (mobility limitations, dexterity issues), ensure accessible educational settings, provide materials in accessible formats (large print, digital versions, audio recordings), and use assistive devices if needed.

      • Speech, language, communication needs: For patients with speech, language, or communication difficulties, use visual aids, written materials, picture cards, communication boards, interpreters (for sign language or other languages), and allow extra time for communication.

      • Social and emotional health needs: For patients with social and emotional health needs (anxiety, depression, emotional distress), provide a supportive and empathetic learning environment, address emotional barriers to learning, and offer counselling or support services.

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  • Special Needs (Example) (as given in slides): The slides provide a list of examples of special needs, illustrating the range of needs that should be considered:

    • Attention Deficit Hyperactivity Disorder (ADHD)

    • Autism support

    • Physical disabilities needs

    • Speech, language, communication needs

    • Social and emotional health needs

    • Other Examples of Special Educational Needs (beyond the list in slides):

      • Low literacy.

      • Learning disabilities.

      • Cognitive impairments (dementia, intellectual disability).

      • Sensory impairments (visual impairment, hearing impairment).

      • Cultural and linguistic diversity.

      • Age-related needs (elderly patients, paediatric patients).

      • Mental health conditions (anxiety, depression).

      • Serious illness or end-of-life situations.

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  • Points to Remember (as mentioned in the slides):

    • Information can be provided through: The slides reiterate the various methods for delivering education, emphasizing their applicability to addressing special needs:

      • Counselling: Individualized counselling sessions, adapted to the patient's specific needs and learning style.

      • Use of printed material: Printed materials in accessible formats (large print, simplified language, translated versions, pictorial aids).

      • Audio-visual aids: Audio-visual aids adapted for sensory impairments (videos with captions, audio descriptions, audio recordings).

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• Challenges and Considerations:

  • Diversity of Special Needs: The range of potential special educational needs is vast and diverse. Staff needs to be trained to recognize and address a wide spectrum of needs.

  • Individualized Approach: Addressing special needs requires a highly individualized and person-centered approach to education, which can be more time-consuming and resource-intensive.

  • Resource Availability for Adaptations: Developing and providing materials in diverse formats and languages and providing specialized support services may require additional resources.

  • Staff Training and Expertise: Staff needs to be trained to recognize and address special educational needs effectively and to utilize appropriate adaptation strategies.

  • Documentation of Special Needs and Adaptations: Documenting identified special educational needs and the adaptations implemented to address them is important for communication within the care team and for continuity of care.

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• Link to Patient Rights & Safety: PRE 5i is strongly linked to patient rights to equitable and accessible healthcare and to receive information and education that is truly meaningful and beneficial to them. By addressing special educational needs, hospitals ensure that all patients, regardless of their abilities or challenges, can access and benefit from healthcare education, leading to improved understanding, better self-management, and potentially better health outcomes and safety for all patients.

• Level and Implication: As an Achievement Level (A) objective element, PRE 5i signifies a higher level of commitment to patient-centered care and equitable access to education. NABH expects hospitals to demonstrate that they have systems in place to identify patients with special educational needs and that they proactively adapt their educational approaches to address these needs effectively, going beyond a one-size-fits-all approach to education.

PRE 5j: The organization has a mechanism to promote patient engagement to enhance clinical outcomes, safety and quality.(E) - NEW Objective Element in 6th Edition

• Standard Statement: This Excellence Level (E) objective element is new in the 6th Edition and emphasizes the organization's responsibility to actively promote patient engagement as a strategy to enhance clinical outcomes, safety, and overall quality of care.

• Rationale and Importance:

  • Patient Engagement as a Driver of Quality: Recognizes that active patient engagement is a powerful driver of improved healthcare quality, safety, and clinical outcomes.

  • Partnership and Collaboration: Promotes a shift towards a true partnership between patients, families, and healthcare providers, where patients are seen as active collaborators in their care.

  • Improved Patient Experience and Satisfaction: Patient engagement enhances patient experience and satisfaction by making care more patient-centered, responsive to patient needs, and empowering.

  • Enhanced Safety Culture: Engaged patients are more likely to report safety concerns, participate in safety initiatives, and contribute to a stronger safety culture within the organization.

  • Better Clinical Outcomes: Research shows that patient engagement can lead to better adherence to treatment plans, improved disease management, and better clinical outcomes.

  • Excellence Level: As an Excellence Level (E) element, this signifies that promoting patient engagement is considered a hallmark of a truly high-performing, patient-centered, and quality-focused healthcare organization.

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• Key Components and Actions (as suggested in the slides - Patient care engagement could involve, The organization):

  • Patient care engagement could involve disease-based patient support groups, involvement of patient in patient safety and quality improvement: The slides provide examples of patient engagement activities:

    • Disease-based patient support groups: Establish and support patient support groups focused on specific diseases or conditions. These groups provide peer support, education, and a platform for patients to share experiences and learn from each other.

    • Involvement of patient in patient safety and quality improvement: Actively involve patients in patient safety and quality improvement initiatives within the hospital. This could include:

      • Patient advisory councils (as mentioned in Slide 53).

      • Patient representatives on quality improvement committees.

      • Patient participation in root cause analyses of adverse events.

      • Patient feedback mechanisms to identify safety and quality concerns.

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  • The organization - Key Principles and Actions: The slides outline key principles and actions the organization should undertake to promote patient engagement:

    • Shall create an enabling environment for partnership between patient, families, communities and health care providers:

      • Culture of Partnership: Foster an organizational culture that values partnership and collaboration with patients and families at all levels.

      • Open Communication Channels: Establish open and accessible communication channels between patients, families, and healthcare providers.

      • Respectful and Collaborative Interactions: Train staff to interact with patients and families in a respectful, collaborative, and empowering manner.

      • Remove Barriers to Engagement: Identify and remove any barriers that may hinder patient and family engagement (e.g., complex processes, inaccessible information, lack of support).

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    • Has to recognize that patients are part of social groups, families and communities and that these broader networks can be a positive force to change:

      • Broader Perspective: Recognize that patients are not isolated individuals but are embedded in social networks, families, and communities.

      • Leverage Social Networks: Leverage these broader networks as a positive force for health improvement and patient engagement. This could involve:

        • Community outreach programs.

        • Family-centered care approaches.

        • Support for community-based patient groups.

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      • Recognize Social Determinants of Health: Acknowledge and address social determinants of health that may impact patient engagement and health outcomes.

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    • Has to designate and support patient safety champions or advocates, where appropriate, to help facilitate patient engagement:

      • Patient Safety Champions/Advocates: Designate and support patient safety champions or advocates within the organization. These individuals can act as:

        • Points of contact for patient engagement initiatives.

        • Liaisons between patients and the organization.

        • Facilitators of patient participation in safety and quality improvement activities.

        • Advocates for patient perspectives and needs within the organization.

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      • Empower Champions/Advocates: Provide patient safety champions/advocates with the necessary training, resources, and authority to effectively facilitate patient engagement.

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  • Slide 53 - Specific Recommendations for Patient Engagement:

    • Formation of patient advisory council in hospital is recommended as part of patient engagement: Establishing a Patient Advisory Council (PAC) is strongly recommended as a key mechanism for patient engagement. PACs provide a formal platform for patients and family representatives to advise the hospital on policies, programs, and service delivery, ensuring the patient voice is heard at the organizational level.

    • Patient shall be encouraged to become actively involved in reporting safety incidents, near misses and safety concerns: Actively encourage patients and families to report safety incidents, near misses, and safety concerns. Make it easy and safe for them to report concerns through user-friendly reporting mechanisms and a non-punitive culture.

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• Challenges and Considerations:

  • Defining and Measuring Patient Engagement: Patient engagement is a broad concept. Organizations need to clearly define what patient engagement means in their context and develop metrics to measure and track engagement efforts and their impact.

  • Sustaining Patient Engagement: Engaging patients is not a one-time initiative but requires sustained and ongoing effort to build a culture of partnership and maintain patient involvement over time.

  • Representativeness of Patient Engagement Initiatives: Ensure that patient engagement initiatives (like PACs) are truly representative of the diverse patient population served by the organization.

  • Resource Commitment: Implementing effective patient engagement strategies requires a commitment of resources (staff time, budget, infrastructure).

  • Integrating Patient Feedback into Action: Patient engagement efforts are only meaningful if patient feedback is actively listened to, analyzed, and translated into concrete actions and improvements in care delivery.

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• Link to Patient Rights & Safety: PRE 5j is at the forefront of patient-centered care and is deeply linked to patient rights and safety. By actively promoting patient engagement, hospitals empower patients to become true partners in their care, leading to a safer, more responsive, and higher-quality healthcare system. Engaged patients are safer patients, better informed patients, and more satisfied patients.

• Level and Implication: As an Excellence Level (E) objective element, PRE 5j signifies the highest level of commitment to patient-centered care and quality improvement. NABH recognizes that promoting patient engagement is a hallmark of excellence. Achieving this standard requires a fundamental shift in organizational culture towards partnership, a robust framework for patient engagement initiatives, and demonstrable evidence of the impact of patient engagement on clinical outcomes, safety, and quality.

In Summary of PRE 5:

PRE 5 comprehensively addresses the patient's right to information and education, encompassing a wide range of educational needs and approaches. It moves from foundational principles of understandable communication (PRE 5a) to specific areas like medication education (PRE 5b, 5c), nutrition (PRE 5d), immunizations (PRE 5e), pain management (PRE 5f), disease-specific education (PRE 5g), HAI prevention (PRE 5h), addressing special educational needs (PRE 5i), and culminating in the highest level of patient engagement for quality improvement (PRE 5j). Implementing PRE 5 effectively is essential for creating a truly patient-centered healthcare organization that empowers patients with knowledge, respects their autonomy, and promotes their health, safety, and well-being.

PRE 6: Patients and families have a right to information on expected costs

PRE 6 shifts the focus to the financial aspects of patient care, establishing the crucial right of patients and families to receive clear and understandable information about the expected costs of their treatment. This standard acknowledges that healthcare costs can be a significant concern for patients, and transparency in pricing is essential for building trust, enabling informed financial planning, and preventing unexpected financial burdens. PRE 6 aims to ensure that hospitals are upfront and transparent about their pricing policies and provide patients with the necessary information to understand the financial implications of their care.

Let's delve into each sub-element of PRE 6 in extensive detail:

PRE 6a: The patient and/or family members are made aware of the pricing policy in different settings (out-patient, emergency, ICU and inpatient). (CO)

• Standard Statement: This core objective element (CO) mandates that the hospital must ensure patients and/or their families are informed and aware of the hospital's pricing policy, and that this policy is differentiated and explained for various care settings within the hospital – specifically mentioning out-patient, emergency, ICU, and inpatient settings.

• Rationale and Importance:

  • Financial Transparency: Transparency in pricing is fundamental to ethical healthcare practice and builds trust between patients and the hospital. Patients have a right to understand how they will be billed for services.

  • Informed Financial Planning: Awareness of the pricing policy allows patients and families to plan financially for their healthcare expenses. This is particularly important for longer-term treatments or anticipated hospital stays.

  • Preventing Unexpected Financial Burdens: Lack of transparency can lead to unexpected and often substantial medical bills, causing financial distress and dissatisfaction. Knowing the pricing policy upfront helps avoid these surprises.

  • Fairness and Equity: A clear and accessible pricing policy promotes fairness and equity in billing practices across different patient groups and care settings.

  • Core Commitment: As a Core OE (CO) element, PRE 6a underscores the critical importance of pricing policy transparency as a fundamental aspect of patient rights and ethical financial practices.

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• Key Components and Actions (as suggested in the slides - Display, Based on):

  • Display: Near registration and/or admission desk:

    • Prominent Display: The hospital's pricing policy should be displayed prominently in areas where patients and families are likely to seek information about costs, primarily at registration desks and admission desks for all settings (OPD, Emergency, ICU, Inpatient).

    • Multiple Display Locations: Consider displaying the pricing policy in other relevant areas as well, such as:

      • Waiting areas in OPD, Emergency, and Inpatient departments.

      • Patient information kiosks or digital displays.

      • Hospital website (easily accessible section).

      • Patient information brochures or pamphlets.

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    • Clear and Understandable Display: The displayed policy should be presented in a clear, concise, and easily understandable format, avoiding technical jargon. Use clear headings, bullet points, and simple language.

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  • Based on: Billing policy which defines the charges to be levied for various healthcare activities in a given setting:

    • Formal Billing Policy: The displayed pricing policy should be derived from a formal, documented billing policy that the hospital has in place. This underlying billing policy should be comprehensive and detailed.

    • Setting-Specific Pricing: The billing policy and the displayed information should clearly differentiate pricing for different care settings (out-patient, emergency, ICU, inpatient). Charges often vary significantly between these settings due to different resource utilization and service intensity.

    • Defined Charges for Healthcare Activities: The billing policy should define the charges for various common healthcare activities performed in each setting. Examples include:

      • Consultation fees (OPD, Emergency, Specialist).

      • Room charges (different categories of inpatient rooms).

      • ICU bed charges.

      • Nursing charges (per day/shift).

      • Common procedures and investigations (basic lab tests, X-rays, etc.).

      • Emergency room visit charges.

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    • Accessibility of Full Billing Policy: While a summary or overview may be displayed prominently, the full and detailed billing policy document should be readily available to patients and families upon request (e.g., in patient relations department, on website).

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• Points to Remember (as mentioned in the slides - Points to Remember):

  • Pricing policy should include: The slides provide a list of common elements that should be covered in the pricing policy:

    • Consultation charges: Fees for consultations with doctors in different settings (OPD, Emergency, Specialist).

    • Bed charges: Daily or hourly charges for different categories of inpatient beds (general ward, semi-private, private, deluxe, etc.) and ICU beds.

    • Nursing charges: Charges for nursing care, often calculated on a per-day or per-shift basis.

    • Security deposit: Information about any security deposit required at the time of admission, the amount, and the refund policy.

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• Challenges and Considerations:

  • Complexity of Healthcare Pricing: Healthcare pricing is often complex and multi-layered. Simplifying it for patient understanding while maintaining accuracy can be challenging.

  • Dynamic Pricing: Pricing policies may change periodically due to various factors. Ensuring that displayed information and the underlying billing policy are always up-to-date requires a robust system for policy maintenance and dissemination.

  • Communication Skills of Front Desk Staff: Front desk staff, who are often the first point of contact for patients regarding pricing information, need to be trained to effectively explain the pricing policy in a clear and empathetic manner.

  • Addressing Patient Questions and Concerns: Patients may have specific questions or concerns about the pricing policy. Staff should be equipped to address these queries or direct patients to appropriate resources (patient relations, billing department).

  • Cultural Sensitivity in Communication: Communication about pricing should be culturally sensitive and consider potential anxieties or sensitivities patients may have regarding financial matters.

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• Link to Patient Rights & Safety: PRE 6a is directly linked to patient rights to information and financial transparency. By making the pricing policy readily available and understandable, hospitals empower patients to be informed consumers of healthcare services, reducing financial uncertainty and promoting trust in the system. While indirectly linked to direct patient safety, financial transparency contributes to a more positive and less stressful patient experience, which can have a positive impact on overall well-being.

• Level and Implication: As a Commitment Level (Core OE) (CO) objective element, PRE 6a is a critical requirement. NABH expects hospitals to demonstrate that they have a clear and documented pricing policy, that it is differentiated for various settings, that key aspects are prominently displayed, and that staff are aware of and can explain the policy to patients and families.

PRE 6b: The relevant tariff list is available to patients. (C)

• Standard Statement: This Commitment Level (C) objective element requires that a detailed and relevant tariff list, outlining the charges for various services and procedures, must be readily available to patients for their review.

• Rationale and Importance:

  • Detailed Pricing Information: While a pricing policy provides a general framework, a tariff list offers more granular and specific pricing information for individual services and procedures. This level of detail is essential for patients to understand potential costs more accurately.

  • Empowering Informed Choice: Access to a tariff list empowers patients to compare costs, understand the itemized charges, and make more informed choices about their care, especially for elective procedures or services.

  • Transparency and Accountability: Making the tariff list available enhances transparency and accountability in billing practices. It allows patients to verify charges against the published tariff.

  • Reducing Billing Disputes: Clear and accessible tariff lists can help reduce billing disputes by providing patients with a clear reference point for expected charges.

  • Commitment Level: As a Commitment Level (C) element, PRE 6b emphasizes the basic yet important nature of providing detailed tariff information for patient transparency.

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• Key Components and Actions (as suggested in the slides - Tariff list, Tariff rate):

  • Tariff list:

    • Detailed Itemized List: Develop a detailed tariff list that itemizes the charges for a wide range of services, procedures, investigations, medications, consumables, and other billable items offered by the hospital.

    • Categorization and Clarity: Organize the tariff list in a clear and logical manner, using categories and subcategories to make it easy for patients to navigate and find specific items. Use clear and descriptive names for each item.

    • Up-to-Date: The tariff list must be consistently maintained and kept up-to-date to reflect current pricing. Implement a system for regular review and updates of the list.

    • Relevant Tariff: Ensure that the tariff list available to patients is "relevant," meaning it includes the services and procedures commonly used by patients and is not outdated or incomplete.

    • Available for Patient's Review, at request: Make the tariff list readily available for patients to review upon request. This could be in various formats:

      • Printed Copies: Keep printed copies of the tariff list available at registration desks, patient information centers, and in patient rooms (if feasible).

      • Digital Access: Make the tariff list accessible in digital format on the hospital website, patient portal, or through QR codes that patients can scan.

      • Patient Relations Department: Ensure the patient relations department has access to and can provide the tariff list to patients upon request.

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  • Tariff rate:

    • Uniform (in a given setting) and transparent:

      • Uniformity: Tariff rates should be uniform for all patients receiving the same service in the same setting (e.g., same consultation fee for all OPD patients consulting a general physician).

      • Transparency: Tariff rates should be transparent and clearly stated in the list, without hidden charges or ambiguous pricing.

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    • Charge patient as per the tariff list: Billing practices must strictly adhere to the published tariff list. Patients should be charged exactly as per the listed rates for the services they receive.

    • Include additional charges: If there are any potential additional charges that are not explicitly itemized in the main tariff list (e.g., specific consumables for certain procedures, additional service charges), these should be clearly identified and explained, either within the tariff list or in a separate, clearly linked document.

    • Inform patient about additional charge (if any): If additional charges are applicable for a particular patient's case, ensure that the patient is proactively informed about these additional charges before the service is provided, if possible, or at the earliest opportunity.

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• Challenges and Considerations:

  • Volume and Complexity of Tariff List: Creating and maintaining a detailed and comprehensive tariff list for a large hospital with numerous services can be a significant undertaking.

  • Regular Updates and Version Control: Keeping the tariff list up-to-date with price changes and service additions requires a robust system for version control and dissemination of updated lists.

  • Accessibility in Different Formats: Providing the tariff list in multiple formats (printed, digital, etc.) to cater to diverse patient needs and preferences requires logistical planning.

  • Explaining Tariff List to Patients: While the tariff list provides detailed information, some patients may still find it complex to understand. Staff need to be available to explain specific items or charges and answer patient queries.

  • Balancing Transparency with Competitive Pricing: While transparency is crucial, hospitals also need to consider competitive pricing strategies and may need to balance the level of detail in the public tariff list with competitive considerations.

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• Link to Patient Rights & Safety: PRE 6b is directly linked to patient rights to information and financial transparency. Providing a detailed and accessible tariff list empowers patients with detailed pricing information, allowing them to make informed financial decisions about their care, verify charges, and reduce billing disputes. This transparency builds trust and contributes to a more positive patient financial experience.

• Level and Implication: As a Commitment Level (C) objective element, PRE 6b is a fundamental expectation. NABH expects hospitals to demonstrate that they have a detailed and up-to-date tariff list, that it is relevant to patients, that it is readily available for patient review upon request in multiple formats, and that billing practices adhere to the published tariff.

PRE 6c: The patient and/or family members are explained about the expected costs. (C)

• Standard Statement: This Commitment Level (C) objective element requires that patients and/or their families are provided with a clear explanation of the expected total costs of their treatment, based on their individual care plan.

• Rationale and Importance:

  • Personalized Cost Estimate: While a tariff list provides itemized pricing, this standard focuses on providing a personalized cost estimate that is specific to the patient's planned treatment. This is more directly relevant to the patient's individual financial planning.

  • Financial Preparedness: A clear estimate of expected costs allows patients and families to be financially prepared for their treatment. They can make arrangements for payment, explore insurance coverage, or seek financial assistance if needed.

  • Reducing Financial Anxiety: Uncertainty about costs can cause significant anxiety. Providing an estimate helps reduce this anxiety and allows patients to focus on their health and recovery.

  • Informed Consent in Financial Terms: Just as informed consent is needed for medical procedures, "financial informed consent" is also important. Patients should have a reasonable understanding of the financial implications of their treatment choices.

  • Commitment Level: As a Commitment Level (C) element, PRE 6c underscores the basic yet essential nature of providing expected cost estimates to patients.

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• Key Components and Actions (as suggested in the slides - Provide estimate of treatment, Discuss with patient):

  • Provide estimate of treatment:

    • In written form: The cost estimate should be provided to the patient or family in written form to ensure clarity and avoid misunderstandings. A written estimate serves as a record and reference point.

    • Based on treatment plan: The cost estimate must be based on the individualized treatment plan developed for the patient. This means it needs to consider the specific procedures, investigations, medications, length of stay, and other services anticipated for that particular patient's care. Generic estimates are not sufficient.

    • Itemized Estimate (If Possible): While a total estimate is essential, it is also helpful to provide a somewhat itemized breakdown of the major cost components (e.g., estimated cost for surgery, estimated cost for hospital stay per day, estimated cost for investigations). This provides greater transparency.

    • Validity Period of Estimate: The written estimate should specify a validity period. Treatment plans and costs can change, so the estimate should be valid for a reasonable timeframe (e.g., 7 days, 30 days).

    • Contact Person for Queries: Include contact information (phone number, department) for patients to reach out to if they have questions or need clarification about the estimate.

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  • Discuss with patient:

    • Personalized Discussion: Provide an opportunity for a personalized discussion with the patient and/or family to explain the cost estimate, answer their questions, and address any concerns.

    • Limitations of estimate, if any. For example: Emergency admissions:

      • Acknowledge Limitations: Be transparent about any limitations of the cost estimate. Explain that it is an estimate based on the current plan and that actual costs may vary depending on unforeseen circumstances, changes in the treatment plan, or complications.

      • Emergency Admission Example: Specifically mention that for emergency admissions, it may be difficult to provide a precise estimate upfront, as the full extent of treatment needs may not be immediately known. In emergency cases, provide an initial estimate as soon as practically possible and update it as the care plan becomes clearer.

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    • Payment Options and Financial Assistance: During the discussion, also provide information about payment options (cash, credit card, insurance, payment plans) and any available financial assistance programs or schemes that the patient may be eligible for.

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• Note (as mentioned in the slides):

  • The OPD, registration/admission staff in consultation with treating doctor should prepare the expected costs of treatment: This highlights the collaborative nature of preparing cost estimates. It is not solely the responsibility of the registration/admission staff. They should consult with the treating doctor or relevant clinical team to get an accurate understanding of the planned treatment and associated costs.

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• Challenges and Considerations:

  • Predicting Healthcare Costs: Healthcare costs can be inherently unpredictable, especially for complex conditions or prolonged hospital stays. Providing accurate estimates can be challenging.

  • Changes in Treatment Plan: Treatment plans can change during the course of care due to evolving patient conditions or new findings. Cost estimates may need to be revised if the plan changes significantly, requiring re-communication with the patient.

  • Coordination between Clinical and Administrative Staff: Effective preparation of cost estimates requires good communication and coordination between clinical teams (doctors, nurses) and administrative staff (registration, billing).

  • Time Constraints: Preparing personalized cost estimates, especially in busy outpatient or emergency settings, can be time-consuming. Efficient processes are needed.

  • Patient Understanding of Estimates: Even with written estimates and discussions, some patients may still find it difficult to fully understand the complexities of healthcare billing. Staff need to be patient and provide clear and simplified explanations.

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• Link to Patient Rights & Safety: PRE 6c is directly linked to patient rights to information and financial transparency. Providing expected cost estimates empowers patients to be financially prepared for their treatment, reduces financial anxiety, and promotes informed decision-making that extends beyond just medical aspects to include financial considerations. While not directly affecting clinical safety, financial transparency contributes to a more ethical and patient-centered healthcare experience.

• Level and Implication: As a Commitment Level (C) objective element, PRE 6c is a fundamental expectation. NABH expects hospitals to demonstrate that they have a system in place to provide written, personalized cost estimates to patients and families based on their treatment plan, that these estimates are discussed with patients, and that limitations of the estimates are explained.