NABH 6th Edition - Chapter 7: Responsibilities of Management (ROM)

Introduction: Understanding the Intent of ROM (Slide 2)

Chapter 7 of the NABH 6th Edition Accreditation Standards for Hospitals, focusing on the Responsibilities of Management (ROM), is foundational for establishing effective hospital governance and operations. The intent of ROM is multifaceted and crucial for achieving accreditation and, more importantly, ensuring high-quality and safe patient care.

Key Training Points on the Intent of ROM:

• Ensuring Management Governance Awareness and Action:

  • Training Note: ROM emphasizes that hospital management must possess a comprehensive understanding of all critical components of good governance. This goes beyond simply being aware; it requires active management and implementation of these components.

  • Professional Language: This standard aims to ensure a proactive and informed management team capable of effectively steering the organization through robust governance practices.

• Defining Governance Roles and Responsibilities:

  • Training Note: Clarity in roles is paramount. ROM mandates the explicit identification of individuals or bodies responsible for governance and the precise definition of their respective roles and accountabilities. This eliminates ambiguity and fosters ownership.

  • Professional Language: This aspect is designed to create a clear governance structure, preventing overlaps, gaps in responsibility, and ensuring accountability at all levels of decision-making.

• Promoting Ethical and Professional Governance Culture:

  • Training Note: Governance isn't just about processes; it's deeply rooted in ethical conduct and professional standards. ROM encourages a governance framework that operates both ethically and professionally, fostering trust and integrity within the organization.

  • Professional Language: This standard emphasizes the cultivation of an organizational culture where governance decisions are guided by ethical principles and professional best practices, ensuring patient-centric and responsible operations.

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• Establishing a Robust Clinical Governance Framework:

  • Training Note: Clinical Governance is a core element of modern healthcare. ROM mandates the establishment of a formal framework encompassing key pillars:

    • Clinical Audit: Systematic review of clinical care against defined standards to identify areas for improvement.

    • Clinical Pathways: Standardized, evidence-based approaches to patient care to ensure consistency and optimal outcomes.

    • Education and Research: Continuous professional development and engagement in research to advance clinical practice and knowledge.

  • Professional Language: This framework is designed to continuously improve the quality and safety of clinical services, integrating evidence-based practices and promoting a culture of learning and innovation within the clinical domain.

• Clarifying Management and Leadership Responsibilities at All Levels:

  • Training Note: Responsibility for effective management is not confined to top leadership. ROM clearly defines the responsibilities of management and leadership across all levels of the hospital hierarchy, ensuring accountability and effective functioning at every operational tier.

  • Professional Language: This standard promotes a distributed leadership model, empowering individuals at various levels to contribute to effective management and ensuring a cohesive approach to operational excellence.

• Ensuring Regulatory Compliance in Management Practices:

  • Training Note: Hospitals operate within a complex regulatory environment. ROM mandates that management executes its responsibilities in strict compliance with all applicable laws, regulations, and statutory requirements.

  • Professional Language: This is critical for legal adherence, risk mitigation, and maintaining the integrity and reputation of the healthcare organization. It underscores the importance of a robust compliance framework embedded within management operations.

• Integrating Patient Safety and Risk Management:

  • Training Note: Patient safety and risk management are not separate entities but integral aspects of patient care and hospital management. ROM ensures that leaders consider these issues as fundamentally interwoven into all operational and clinical processes.

  • Professional Language: This holistic approach ensures a proactive and preventative safety culture, minimizing risks to patients and enhancing the overall quality of care through integrated risk management strategies.

ROM - Summary of Standards & Changes (Slides 3, 5-7, 18, 35, 43, 52)

Understanding the Evolution from 5th to 6th Edition:

The NABH 6th Edition ROM chapter has evolved to incorporate contemporary best practices in hospital management and governance. Understanding the key changes from the 5th Edition is essential for effective implementation and compliance.

Key Training Points on Summary of Standards & Changes:

• Increased Focus and Scope: The total number of Objective Elements (OEs) in the ROM chapter has increased from 32 in the 5th Edition to 37 in the 6th Edition. This expansion signifies a more detailed and comprehensive approach to management responsibilities.

  • Training Note: This increase reflects the growing complexity of hospital management and the enhanced emphasis on specific areas like sustainability and clinical governance.

• Key Intent Modifications in the 6th Edition:

  • Inclusion of Clinical Governance: Reflects the increasing importance of structured clinical governance frameworks within healthcare organizations.

  • Introduction of Service Continuity Plan: Highlights the critical need for hospitals to plan for and maintain essential services during disruptions and emergencies.

  • Emphasis on Level of Leadership: Acknowledges the distributed nature of leadership and management responsibilities across the organization.

• Specific Standard-Wise Changes – A Comparative Overview:

Standard (ROM #)

6th Edition Change Summary

Training Significance

ROM 1

Standard Title: No Change - "The organization identifies those responsible for governance and their roles are defined." <br> Objective Elements: Modified, including new elements and interpretation changes.

Training Note: While the core standard remains, the nuances within its objective elements have been refined and expanded. Training should focus on understanding these updated OEs and their implications for implementation.

ROM 2

Standard Title: Modified - "Those responsible for governance manage the organisation by ethical manner." (Previously focused on 'leaders'). <br> Objective Elements: Interpretation of objective elements modified.

Training Note: The shift in standard title emphasizes collective governance responsibility for ethical management, rather than solely relying on 'leaders'. Training should highlight this shift and the updated interpretations of related OEs.

ROM 3

NEW Standard - "Responsibility for Organisations sustainability." <br> Objective Elements: Multiple new OEs introduced focusing on Environmental, Social, and Governance (ESG) aspects.

Training Note: This is a significant addition reflecting the growing global emphasis on sustainability. Training must comprehensively cover the new OEs under ROM 3 and guide participants on developing and implementing sustainability programs within the hospital.

ROM 4

Standard Title: Moved from ROM 3 in 5th Edition to ROM 4 in 6th - "Day-to-day operation by Leader." <br> Objective Elements: Objective elements merged and interpretations modified.

Training Note: While the standard title remains, the merging and modified interpretations of OEs require careful attention during training. Participants need to understand how the scope of this standard has been adjusted in the 6th Edition.

ROM 5

Standard Title: Moved from ROM 4 in 5th Edition to ROM 5 in 6th - "Professionalism in functioning." <br> Objective Elements: Objective element changed from achievement to commitment, and interpretation modified.

Training Note: The shift from 'achievement' to 'commitment' in OEs signifies a change in emphasis. Training should clarify this nuanced change and the modified interpretations, focusing on continuous improvement and embedding professionalism as a core organizational value.

ROM 6

Standard Title: Moved from ROM 5 in 5th Edition to ROM 6 in 6th - "Patient safety and risk management." <br> Objective Elements: Interpretations modified.

Training Note: Despite no change in standard title, the modified interpretations within the OEs are crucial. Training should delve into these updated interpretations to ensure a contemporary and comprehensive approach to patient safety and risk management aligned with the 6th Edition.

Colour Coding & Level of Standards (Slide 4)

Understanding the NABH Accreditation Levels:

The NABH accreditation process utilizes a colour-coding system and different levels of standards to categorize and prioritize the objective elements within each chapter. This system helps hospitals understand the relative importance and implementation expectations for each standard.

Key Training Points on Colour Coding & Levels:

• Commitment Level (Blue): Foundational Requirements

  • Colour Code: Blue

  • Icon: C - General Commitment: These OEs represent fundamental commitments required for accreditation. They are essential building blocks for a robust quality management system.

  • Icon: CO - Core OE (Mandatory System Documentation): These are critical commitment-level OEs that mandate formal system documentation as evidence of compliance.

  • Training Note: Commitment level standards, particularly Core OEs (CO), are non-negotiable for accreditation. Hospitals must demonstrate compliance and provide documented evidence for these elements. These form the base of the accreditation framework.

• Achievement Level (Burgundy): Demonstrating Performance

  • Colour Code: Burgundy

  • Icon: A

  • Training Note: Achievement level standards indicate areas where the hospital needs to demonstrate effective performance and outcomes. Meeting these standards signifies a move beyond basic commitment towards tangible results and quality improvement.

• Excellence Level (Green): Striving for Best Practices

  • Colour Code: Green

  • Icon: E

  • Training Note: Excellence level standards represent aspirational goals and best practices in hospital management. Achieving these standards demonstrates a commitment to continuous excellence and sets the hospital apart as a leader in quality care. While not always mandatory for initial accreditation, striving for excellence is encouraged and reflects a mature quality culture.

By understanding the intent, changes, and the level-based approach of the ROM chapter, hospital staff can effectively prepare for NABH accreditation and, more importantly, contribute to building a safer, more efficient, and ethically sound healthcare environment.

Standard ROM 1: The organisation identifies those responsible for governance and their roles are defined.

Introduction to ROM 1:

ROM 1 is the cornerstone of effective hospital governance within the NABH framework. It establishes the fundamental principle that for any organization, especially a complex entity like a hospital, to function effectively and ethically, there must be clearly identified individuals or bodies responsible for governance. Furthermore, their roles, responsibilities, and accountabilities must be explicitly defined and understood across the organization. This standard sets the stage for all subsequent ROM standards and is crucial for achieving and maintaining NABH accreditation.

Rationale and Importance of ROM 1:

• Foundation of Good Governance: ROM 1 lays the bedrock for robust governance. Without clear identification and defined roles, governance becomes ambiguous, leading to diffused responsibility, potential conflicts, and ultimately, ineffective oversight.

• Accountability and Transparency: Defining governance responsibilities ensures accountability. When roles are clear, it becomes easier to track performance, identify areas for improvement, and hold individuals or groups responsible for governance functions. This also fosters transparency within the organization.

• Effective Decision-Making: Clearly defined roles streamline decision-making processes. Knowing who is responsible for what aspect of governance prevents delays, duplication of effort, and ensures that decisions are made by the appropriate authority.

• Organizational Alignment: ROM 1 facilitates alignment between governance functions and the overall strategic objectives of the hospital. When governance bodies and their roles are defined, they can effectively guide the organization towards its vision, mission, and values.

• Compliance and Regulatory Adherence: In the highly regulated healthcare environment, clear governance structures are essential for ensuring compliance with legal and regulatory requirements. Defined roles help ensure that responsibilities for compliance are appropriately assigned and managed.

• Patient Safety and Quality of Care: Ultimately, effective governance directly impacts patient safety and the quality of care provided. By ensuring robust oversight and direction, ROM 1 contributes to a safer and more patient-centric hospital environment.

Key Elements of ROM 1 (Detailed Breakdown for Training):

To effectively implement ROM 1, hospitals must focus on several key elements, which are further elaborated in the objective elements (ROM 1a through ROM 1i). Let's break down the core components:

1. Identification of Those Responsible for Governance:

• Explanation: This involves formally recognizing and documenting the individuals or bodies within the hospital structure that are entrusted with governance responsibilities. This is typically the Governing Body of the hospital, which could be a Board of Directors, a Board of Trustees, a Management Committee, or similar entity depending on the hospital's legal structure and ownership.

• NABH Perspective: NABH expects hospitals to clearly articulate who constitutes their governing body and how this body is formally recognized within the organizational structure. This identification should be documented and readily available.

• Practical Implementation Guidance:

  • Formal Documentation: Create a formal document (e.g., organizational chart, governance charter) that explicitly names the governing body and its members.

  • Legal Basis: Reference the legal documents that establish the governing body (e.g., trust deed, articles of association, company registration).

  • Communication: Ensure that all staff members are aware of who the governing body is and their overall role in the hospital.

2. Definition of Governance Roles and Responsibilities:

• Explanation: Simply identifying the governing body is insufficient. ROM 1 requires a detailed definition of the specific roles and responsibilities that the governing body and its individual members undertake. This includes outlining the scope of their authority, decision-making powers, and areas of oversight.

• NABH Perspective: NABH looks for clear, written documentation that specifies the responsibilities of the governing body. This documentation should cover a comprehensive range of governance functions, including strategic direction, financial oversight, quality and safety monitoring, ethical conduct, and regulatory compliance.

• Practical Implementation Guidance:

  • Terms of Reference (TOR): Develop a comprehensive Terms of Reference (TOR) document for the governing body. This is a crucial piece of documentation for ROM 1a (CO - Core Objective Element). The TOR should clearly define:

    • Purpose and Mandate: The overall reason for the governing body's existence and its legal or organizational mandate.

    • Scope of Authority: The areas over which the governing body has authority and decision-making power.

    • Key Responsibilities: A detailed list of specific responsibilities, such as:

      • Setting strategic direction and approving strategic plans.

      • Approving annual budgets and overseeing financial performance.

      • Monitoring quality and patient safety indicators.

      • Ensuring ethical conduct and addressing ethical dilemmas.

      • Overseeing regulatory compliance.

      • Appointing and evaluating senior leadership (e.g., CEO, Medical Director).

      • Reviewing and approving organizational policies.

      • Managing organizational risk.

    • Membership: Define the composition of the governing body, including the roles and types of members (e.g., independent directors, executive directors, community representatives).

    • Meeting Procedures: Outline the frequency of meetings, quorum requirements, decision-making processes, and minutes recording procedures.

    • Reporting Relationships: Clarify to whom the governing body reports (if applicable) and who reports to the governing body

  • By-laws/Governance Policies: Develop by-laws or governance policies that further elaborate on the operational aspects of the governing body, supplementing the TOR.

  • Role Descriptions for Members: Consider developing individual role descriptions for key positions within the governing body (e.g., Chairperson, Committee Chairs) to further clarify specific responsibilities.

3. Orientation and Ongoing Education:

• Explanation: Once governance roles are defined, it's essential to ensure that individuals appointed to these roles are adequately oriented and equipped to fulfill their responsibilities. This is not a one-time event but requires ongoing education to keep governance members informed and effective.

• NABH Perspective: NABH expects hospitals to have a formal orientation program for new governance members and demonstrate a commitment to ongoing education on relevant governance topics.

• Practical Implementation Guidance:

  • Formal Orientation Program: Develop a structured orientation program for new governing body members. This program should cover:

    • Hospital Overview: Vision, mission, values, services, organizational structure.

    • Governance Structure and TOR: Detailed explanation of the hospital's governance framework, the governing body's TOR, and individual member roles.

    • Key Policies and Procedures: Relevant hospital policies, particularly those related to governance, ethics, quality, and safety.

    • Regulatory Environment: Overview of relevant healthcare regulations and accreditation standards.

    • Financial Information: Basic understanding of hospital finances and budget processes.

    • Quality and Safety Data: Introduction to key quality and patient safety indicators.

  • Ongoing Education Plan: Establish a plan for continuous education of governance members. This could include:

    • Regular Updates: Providing updates on changes in regulations, accreditation standards, best practices in governance, and relevant healthcare trends.

    • Training Sessions: Conducting focused training sessions on specific governance topics (e.g., risk management, financial oversight, ethical decision-making, quality improvement).

    • External Resources: Encouraging members to attend external conferences, workshops, or access relevant publications to enhance their governance knowledge.

    • Performance Reviews and Feedback: Providing feedback to governance members on their performance and identifying areas for development.

4. Regular Meetings and Documentation (Minutes):

• Explanation: Effective governance requires regular interaction and deliberation among governance members. Meetings provide a forum for discussion, decision-making, and monitoring of hospital performance. Accurate and detailed minutes of these meetings are essential for documenting decisions, tracking action items, and ensuring accountability.

• NABH Perspective: NABH expects governing bodies to meet at regular intervals (as defined in their TOR) and to maintain comprehensive minutes of their meetings. These minutes serve as evidence of governance activities and decision-making.

• Practical Implementation Guidance:

  • Schedule Regular Meetings: Establish a schedule for regular governing body meetings, adhering to the frequency outlined in the TOR (e.g., quarterly, bi-monthly, monthly).

  • Agenda Setting: Develop a clear agenda for each meeting, focusing on key governance matters, performance review, strategic updates, and emerging issues.

  • Minute Taking: Assign a designated person (e.g., secretary, administrative staff) to take detailed and accurate minutes of each meeting. Minutes should include:

    • Date, Time, and Location of Meeting.

    • List of Attendees and Absentees.

    • Agenda Items Discussed.

    • Key Decisions Made.

    • Action Items Assigned (with responsible individuals and deadlines).

    • Dissenting Opinions (if any).

  • Review and Approval of Minutes: Minutes should be reviewed and approved by the governing body (typically at the subsequent meeting) to ensure accuracy and agreement.

  • Action Item Tracking: Implement a system for tracking action items arising from meetings, ensuring that they are followed up on and completed by the designated individuals within the agreed timeframes.

Detailed Breakdown of ROM 1 Objective Elements (ROM 1a - ROM 1i) for Training:

Now, let's delve into each Objective Element (OE) of ROM 1 to understand the specific requirements:

ROM 1a: Those responsible for governance are identified, and their roles and responsibilities are defined and documented. * (CO)

• Standard Statement: This OE emphasizes the formal identification, defined roles and responsibilities, and documentation of the governing body. The asterisk and (CO) designation highlights its Core Objective Element status, meaning it requires mandatory system documentation and is critical for accreditation.

• Detailed Explanation: This is the cornerstone OE of ROM 1. It mandates that hospitals must have written evidence clearly stating who the governing body is and what they are responsible for. This goes beyond simply knowing informally; it requires formalization and written articulation.

• Implementation Strategies & Best Practices:

  • Develop a Governance Charter/TOR: A comprehensive Terms of Reference (TOR) document is the primary means of demonstrating compliance. As discussed earlier, this document should cover all aspects mentioned in the "Definition of Governance Roles and Responsibilities" section.

  • Organizational Chart: Include the governing body in the hospital's organizational chart, clearly showing its position in the hierarchy and reporting lines (if any).

  • By-laws and Policies: Develop supporting by-laws or governance policies that further detail the functioning of the governing body.

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• Documentation Examples:

  • Terms of Reference (TOR) of the Governing Body.

  • Hospital Organizational Chart.

  • By-laws/Governance Policies.

  • Membership List of the Governing Body.

  • Meeting Minutes as evidence of activity and decision-making.

ROM 1b: Those responsible for governance lay down the organisation's vision, mission and values. (C)*

• Standard Statement: This OE focuses on the governing body's responsibility in establishing the vision, mission, and values of the hospital. The asterisk (*) and (C) indicate it is a Commitment Level OE.

• Detailed Explanation: Vision, mission, and values are the guiding principles for the hospital. This OE emphasizes that the governing body is responsible for defining and articulating these fundamental statements, ensuring they are aligned with the organization's purpose and ethical framework. It also emphasizes the prominent display of these statements.

• Implementation Strategies & Best Practices:

  • Governance-Led Development: The governing body should actively participate in the development or review of the vision, mission, and values. This might involve workshops, discussions, and consultations with stakeholders.

  • Stakeholder Consultation: While the governing body leads, consider involving other stakeholders (senior management, clinicians, staff representatives, and potentially even patient representatives) in the process to ensure broad ownership and relevance.

  • Prominent Display: Display the vision, mission, and values prominently throughout the hospital in locations accessible to patients, staff, and visitors. This includes waiting areas, reception, corridors, departments, and staff areas.

  • Bilingual Display: Ensure bilingual display (local language and English, or other relevant languages) to cater to diverse patient and staff populations.

  • Avoid Website-Only Display: Note the important point: It is not appropriate to display vision, mission, and values only on the website. Physical display within the hospital premises is crucial to reinforce these principles within the organizational culture.

• Documentation Examples:

  • Documented Vision, Mission, and Values statements.

  • Photographic evidence of prominent display in various hospital locations.

  • Minutes of governing body meetings where vision, mission, and values were discussed and approved.

ROM 1c: Those responsible for governance approve the documented strategic and operational plans and the organisation's annual budget. (C)

• Standard Statement: This OE highlights the governing body's role in approving the hospital's strategic plan, operational plan, and annual budget. It is a Commitment Level OE (C).

• Detailed Explanation: This OE underscores the governing body's financial and strategic oversight responsibilities. Approving these key documents ensures that the hospital's direction, operational activities, and financial resources are aligned and strategically guided by governance.

• Implementation Strategies & Best Practices:

  • Strategic Plan Development: While management develops the plans, the governing body must actively review, provide input, and ultimately approve the strategic plan. This ensures strategic alignment with the hospital's vision and mission. The plan should:

    • Be documented.

    • Choose methodology and frequency of preparation based on hospital size and type.

    • Identify responsibilities for implementation.

    • Define possible timeframes for achievement.

  • Operational Plan Development: Similarly, the governing body approves the operational plan, ensuring it is linked to the strategic plan and outlines annual operational objectives. The plan should:

    • Be documented.

    • Link with the strategic plan.

    • Be approved annually.

    • Identify responsibilities for implementation.

    • Define possible timeframes for achievement.

  • Annual Budget Approval: The governing body has the crucial responsibility of approving the annual budget. This ensures financial accountability and resource allocation aligned with strategic and operational plans. The budget should:

    • Be approved annually.

    • Include both capital expenditure and operating expenditure.

    • Be documented.

    • Identify responsibilities for budget management.

    • Define possible timeframes for budget cycles.

• Documentation Examples:

  • Documented Strategic Plan (approved version with governing body approval noted).

  • Documented Operational Plan (approved version with governing body approval noted).

  • Documented Annual Budget (approved version with governing body approval noted).

  • Minutes of governing body meetings where strategic plan, operational plan, and budget were discussed and approved.

ROM 1d: Those responsible for governance monitor and measure the performance of the organisation against the stated mission. (C)

• Standard Statement: This OE emphasizes the governing body's responsibility to monitor and measure the hospital's performance against its stated mission. It is a Commitment Level OE (C).

• Detailed Explanation: Governance is not just about setting direction and approving plans; it's also about ongoing oversight. This OE mandates that the governing body actively monitors the hospital's progress and performance, ensuring it is aligned with its mission and strategic goals.

• Implementation Strategies & Best Practices:

  • Performance Reporting: Establish a system for regular performance reporting to the governing body. This should be based on strategic and operational plans and should include:

    • Quarterly (at least) Performance Reports: Develop regular reports that track key performance indicators (KPIs) related to strategic and operational objectives.

    • Head of Organization Presentation: The head of the organization (e.g., CEO, Hospital Director) should present these performance reports to the governing body.

  • Performance Discussion at Meetings: Performance reports should be a standing agenda item at governing body meetings. Discussions should focus on:

    • Progress against Objectives: Review progress towards strategic and operational goals.

    • Quality and Patient Safety Parameters: Monitor key quality and patient safety indicators.

    • Financial Performance: Review financial performance against budget and targets.

  • Action Follow-up: Regularly follow up on action items arising from performance discussions to ensure that corrective actions are taken and improvements are implemented.

• Documentation Examples:

  • Quarterly Performance Reports presented to the governing body.

  • Minutes of governing body meetings showing discussions on performance reports and action items.

  • Action tracking logs or systems demonstrating follow-up on performance issues.

ROM 1e: Those responsible for governance appoint the senior leaders in the organisation. (C)

• Standard Statement: This OE highlights the governing body's role in appointing senior leaders, specifically the person responsible for managing the day-to-day functioning of the hospital. It is a Commitment Level OE (C).

• Detailed Explanation: Senior leadership is crucial for the effective operation of the hospital. This OE emphasizes that the governing body has the ultimate responsibility for selecting and appointing these key individuals, particularly the leader responsible for daily operations (often the CEO or Hospital Director).

• Implementation Strategies & Best Practices:

  • Governance-Led Appointment Process: Establish a formal process for appointing senior leaders that is led or significantly involved by the governing body. This process should include:

    • Defining the Role and Responsibilities: Clearly define the role, responsibilities, and required qualifications for the senior leadership position.

    • Selection Criteria: Establish clear criteria for evaluating candidates, focusing on:

      • Qualification: Appropriate administrative qualifications (e.g., MBA in Healthcare Management, Hospital Administration).

      • Training: Relevant training and professional development.

      • Experience: Significant experience in hospital management/administration.

      • Skills: Leadership, strategic thinking, communication, financial management, etc.

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    • Interview and Selection Panel: Form an interview and selection panel that includes governing body members and potentially other relevant stakeholders (e.g., senior clinicians).

    • Formal Appointment: The governing body should formally approve and document the appointment of the senior leader.

• Documentation Examples:

  • Documented process for senior leader appointment (policy or procedure).

  • Job description for the senior leadership position.

  • Minutes of governing body meetings documenting the appointment process and final approval.

  • Records of candidate evaluation and selection process.

ROM 1f: Those responsible for governance support safety initiatives, Clinical Governance framework and quality improvement plans. (C)

• Standard Statement: This OE highlights the governing body's responsibility to support safety initiatives, the Clinical Governance framework, and quality improvement plans. It is a Commitment Level OE (C).

• Detailed Explanation: Governance responsibility extends to actively supporting and enabling the hospital's efforts in patient safety, clinical governance, and quality improvement. This is not just passive approval but active engagement and resource allocation.

• Implementation Strategies & Best Practices:

  • Information Sharing: Ensure that relevant information related to safety, clinical governance, and quality improvement is regularly shared with the governing body. This includes:

    • Reports of Safety and Quality Improvement Committee Minutes: Share minutes of relevant committee meetings to keep the governing body informed of activities and issues.

    • Salient Points of Risk Management: Provide summaries of risk management activities, including:

      • Process of reporting risk.

      • Sentinel events (serious adverse events).

      • Quality improvement activities arising from risk management.

  • Resource Allocation: The governing body should actively allocate funds and resources to support safety initiatives, clinical governance framework implementation, and quality improvement activities. This includes:

    • Funds for CAPA (Corrective and Preventive Actions): Allocate budget for implementing CAPA arising from safety incidents, audits, and improvement initiatives.

    • Resources for Clinical Audit, Research, Education: Provide resources to support clinical audit activities, education and training programs related to quality and safety, and research initiatives within the clinical governance framework.

• Documentation Examples:

  • Minutes of governing body meetings showing discussions on safety, clinical governance, and quality improvement initiatives.

  • Budget documents demonstrating allocation of funds to support safety and quality initiatives.

  • Reports shared with the governing body on safety and quality committee activities.

ROM 1g: Those responsible for Governance shall develop clinical governance framework (C) - NEW OE in 6th Edition

• Standard Statement: This is a new Objective Element in the 6th Edition, specifically mandating that the governing body develop a clinical governance framework. It is a Commitment Level OE (C).

• Detailed Explanation: This new OE emphasizes the increased importance of a structured Clinical Governance framework. It requires the governing body to take ownership in developing and establishing this framework, which is essential for systematic quality and safety improvement in clinical services.

• Implementation Strategies & Best Practices:

  • Framework Development: The governing body should oversee the development of a formal Clinical Governance framework document. This framework should clearly outline:

    • Components of the Framework: Include the key components as listed in the slide:

      • Patient Safety

      • Medication Safety

      • Clinical Audit

      • Clinical Pathway Development and Implementation

      • Clinical Indicators Monitoring

      • Education and Research in clinical practice

    • Roles and Responsibilities: Define the roles and responsibilities of various individuals and committees in implementing and overseeing the framework.

    • Implementation Plan: Outline a plan for implementing the framework components, including timelines and resource allocation.

    • Clinical Department Leaders Role: Recognize the crucial role of clinical department leaders in selecting and implementing:

      • Clinical Practice Guidelines

      • Care Pathways

      • Clinical Protocols

  • Clinical Leader Encouragement: The framework should emphasize that clinical leaders are responsible for encouraging clinical audit, education, and research within their departments.

• Documentation Examples:

  • Documented Clinical Governance Framework document (approved by the governing body).

  • Implementation plan for the Clinical Governance Framework.

  • Minutes of governing body meetings showing discussions and approval of the Clinical Governance Framework.

ROM 1h: Those responsible for governance support the ethical management framework of the organisation. (A) - Interpretation Modified & Achievement Level

• Standard Statement: This OE focuses on the governing body's responsibility to support the ethical management framework of the hospital. It is an Achievement Level OE (A), indicating a higher level of performance expectation compared to Commitment Level OEs. Interpretation is modified in the 6th edition.

• Detailed Explanation: Ethical conduct is paramount in healthcare. This OE requires the governing body to actively support and promote a robust ethical management framework within the organization. The shift to Achievement Level and interpretation modification emphasizes a deeper commitment to ethical practices beyond just basic compliance.

• Implementation Strategies & Best Practices:

  • Ethical Management Framework Support: The governing body should actively demonstrate support for the ethical management framework by:

    • Promoting Ethical Culture: Fostering an organizational culture that values ethical behavior and integrity.

    • Resource Allocation: Providing resources for ethics training, ethical consultation services, and ethics committees.

    • Addressing Ethical Issues: Actively engaging in addressing ethical issues and dilemmas that arise within the hospital.

  • Resolve Ethical Issues: Establish mechanisms for identifying, reporting, and resolving ethical issues.

  • Address Conflicts of Interest: Implement policies and procedures to identify and manage conflicts of interest among governance members, staff, and other stakeholders.

  • Define Time Frame for Resolution: Establish timeframes for addressing and resolving ethical issues to ensure timely action.

  • Support Ethical Conduct of Research: Ensure that research activities are conducted ethically, with appropriate ethical review processes in place (e.g., Ethics Committee/Institutional Review Board).

• Documentation Examples:

  • Documented Ethical Management Framework policy or guidelines.

  • Minutes of governing body meetings showing discussions on ethical issues and support for the ethical framework.

  • Policies and procedures for managing conflicts of interest.

  • Records of ethical issue resolution and timeframes.

  • Documentation of ethical review processes for research.

ROM 1i: Those responsible for governance inform the public of the quality and performance of services. (C)

• Standard Statement: This OE requires the governing body to ensure that the hospital informs the public about the quality and performance of its services. It is a Commitment Level OE (C).

• Detailed Explanation: Transparency and accountability to the community are essential. This OE mandates that the governing body takes responsibility for making information about the hospital's quality and performance publicly available.

• Implementation Strategies & Best Practices:

  • Provide Feedback to the Public: Establish channels for providing feedback to the public on service quality and performance. This can be done through:

    • Use of Displays: Publicly display information within the hospital premises (e.g., in waiting areas, reception).

    • Provide Brochures: Make brochures or leaflets available to the public with key quality and performance information.

    • Post on Website: Publish quality and performance data on the hospital's website (important, but not sufficient as per ROM 1b note).

  • Points to Remember - Content of Public Information: The information provided to the public should include:

    • Feedback on Quality and Performance:

      • Positive and negative feedback received from stakeholders (patients, families, community).

      • Results of surveys conducted by independent third parties (e.g., patient satisfaction surveys).

      • Results of benchmarking exercises done by professional bodies (if applicable).

• Documentation Examples:

  • Examples of public displays of quality and performance information within the hospital.

  • Samples of brochures or leaflets providing quality and performance data.

  • Screenshots of website sections displaying quality and performance information.

  • Policies or procedures related to public information and transparency.

Common Challenges and Pitfalls in Implementing ROM 1:

• Lack of Clarity in Governing Body Structure: Hospitals may have unclear or informal governance structures, making it difficult to identify "those responsible for governance."

• Inadequate Documentation: Insufficient or incomplete documentation of governance roles, responsibilities, TOR, and meeting minutes is a common pitfall.

• Lack of Governing Body Engagement: Governing bodies may be passive or not actively engaged in key governance functions like strategic planning, performance monitoring, or ethical oversight.

• Orientation and Education Gaps: Inadequate orientation and ongoing education for governance members can hinder their effectiveness.

• Website-Only Approach for Vision/Mission/Values: Relying solely on website display and neglecting physical display within the hospital premises.

• Treating ROM 1 as a "Paper Exercise": Implementing ROM 1 solely for accreditation purposes without genuinely embedding the principles of good governance into the hospital culture and operations.

Key Takeaways and Actionable Steps for ROM 1 Training:

• ROM 1 is Foundational: Emphasize that ROM 1 is the bedrock for effective hospital governance and all subsequent ROM standards.

• Documentation is Key: Stress the importance of comprehensive and readily available documentation, particularly the Terms of Reference (TOR) for the governing body.

• Active Governance Engagement: Promote the concept of an active and engaged governing body that takes ownership of its responsibilities.

• Orientation and Continuous Learning: Highlight the need for robust orientation programs and ongoing education for governance members.

• Practical Implementation: Focus on providing practical, actionable guidance on how to implement each objective element of ROM 1.

• Integrate, Don't Just Comply: Encourage hospitals to view ROM 1 not just as an accreditation requirement but as an opportunity to strengthen their governance and improve organizational effectiveness, ultimately benefiting patient care.

By providing this detailed and structured training on ROM 1, hospital staff and governance members will be better equipped to understand, implement, and demonstrate compliance with this crucial NABH standard, contributing to a stronger and more effective hospital governance framework.

ROM 2: Those responsible for governance manage the organisation by ethical manner.

Introduction to ROM 2:

Building upon the foundation laid by ROM 1 (identifying governance and defining roles), ROM 2 delves into the how of governance. It emphasizes that effective governance is not merely about structure and processes, but fundamentally about ethical conduct and management. This standard underscores that those entrusted with governance responsibilities must manage the organization in a manner that is demonstrably ethical, fostering trust, integrity, and responsible operations.

Rationale and Importance of ROM 2:

• Ethical Foundation of Healthcare: Healthcare, by its very nature, is an ethical endeavor. Patient well-being, trust, confidentiality, and fairness are paramount. ROM 2 ensures that ethical principles are not just aspirational but are actively embedded in the management and governance of the hospital.

• Building Trust and Reputation: Ethical management is crucial for building and maintaining trust with patients, staff, the community, and other stakeholders. A reputation for ethical conduct enhances the hospital's credibility and strengthens its relationships.

• Patient-Centric Care: Ethical management directly supports patient-centric care. By prioritizing ethical considerations in decision-making and operations, hospitals ensure that patient needs and best interests are always at the forefront.

• Legal and Regulatory Compliance (Beyond the Letter of the Law): While ROM 4 focuses on legal compliance, ROM 2 goes beyond simply adhering to regulations. It emphasizes the spirit of ethical conduct, ensuring that the hospital operates with integrity even in areas where regulations may be less explicit.

• Mitigating Ethical Risks: Proactive ethical management helps identify and mitigate potential ethical risks, such as conflicts of interest, breaches of confidentiality, unethical research practices, and unfair treatment of patients or staff.

• Promoting a Positive Organizational Culture: A commitment to ethical management fosters a positive and values-driven organizational culture. This, in turn, improves staff morale, attracts talent, and enhances the overall working environment.

Key Elements of ROM 2 (Detailed Breakdown for Training):

ROM 2 emphasizes several key elements that contribute to ethical management within a hospital. These elements are further elaborated in the objective elements (ROM 2a through ROM 2d). Let's break down the core components:

1. Establishing an Ethical Management Framework:

• Explanation: This involves creating a formal, documented framework that outlines the hospital's approach to ethical management. It's not enough to simply intend to be ethical; the hospital needs a structured system to guide ethical decision-making and behavior.

• NABH Perspective: NABH expects hospitals to have a documented ethical management framework that is actively implemented and understood throughout the organization. This framework should articulate guiding principles and address key areas of ethical concern within a hospital setting.

• Practical Implementation Guidance:

  • Develop a Written Ethical Management Framework Document: This document is crucial for ROM 2a (CO - Core Objective Element). It should include:

    • Guiding Principles: Articulate the core ethical principles that underpin the hospital's operations. The slide highlights Transparency in Actions as a key guiding principle. Other relevant principles might include:

      • Beneficence: Acting in the best interests of patients.

      • Non-maleficence: Avoiding harm to patients and staff.

      • Autonomy: Respecting patient rights and choices.

      • Justice: Ensuring fairness and equitable access to care.

      • Integrity: Maintaining honesty and ethical conduct in all operations.

      • Confidentiality: Protecting patient privacy and sensitive information.

    • Areas to Address: Identify specific areas within hospital operations that require particular ethical attention. The slide outlines key areas:

      • Handling of Complaints: Establish fair and transparent processes for receiving, investigating, and resolving patient and stakeholder complaints.

      • Handling Grievances: Develop mechanisms for addressing staff grievances in a just and equitable manner.

      • Clinical Care Delivery: Ensure ethical considerations are integrated into clinical decision-making, treatment planning, and patient care processes (e.g., informed consent, end-of-life care, resource allocation).

      • Research: Establish ethical guidelines for research activities, including patient consent, data privacy, and scientific integrity.

      • Codes of Conduct: Develop codes of conduct for all staff members, outlining expected ethical behavior and professional standards. These codes should align with professional ethics guidelines (e.g., for doctors, nurses, administrators). Reference to external codes like the "Code of Medical Ethics - 2002" by MCI (Medical Council of India) is valuable (as noted on Slide 19).

  • Dissemination and Communication: Ensure that the ethical management framework is effectively communicated to all staff members, governance members, and relevant stakeholders. Training and awareness programs are essential.

  • Regular Review and Updates: The ethical management framework should be reviewed and updated periodically to reflect evolving ethical standards, legal requirements, and organizational needs.

2. Processes for Managing Ethical Issues, Dilemmas, and Concerns:

• Explanation: An ethical management framework is not just a document; it needs to be operationalized through clear processes for managing ethical issues that inevitably arise in a hospital setting. This includes having mechanisms for identifying, analyzing, and resolving ethical dilemmas and concerns.

• NABH Perspective: NABH expects hospitals to have established processes for managing ethical issues, demonstrating a proactive and systematic approach to ethical problem-solving. These processes should ensure timely action, documentation, and continuous improvement.

• Practical Implementation Guidance:

  • Establish a Defined Process for Ethical Issue Management: Develop a step-by-step process for handling ethical issues, dilemmas, and concerns. The slides for ROM 2b outline a useful flow:

    • Collect, Collate, and Analyze Ethical Dilemmas: Establish mechanisms for individuals to report ethical concerns (e.g., reporting channels, ethics hotline, designated ethics officer/committee). Ensure that reported issues are systematically collected, documented, and analyzed to understand the nature and scope of ethical challenges.

    • Take CAPA (Corrective and Preventive Action) within a Defined Timeframe: Develop a process for responding to ethical issues promptly and effectively. This includes:

      • Investigation: Conducting appropriate investigations to understand the facts and circumstances of the ethical issue.

      • Decision-Making: Establishing a clear process for ethical decision-making. This might involve an ethics committee, consultation with relevant experts, or using established ethical guidelines. Note the importance of a "consistent approach to ethical decision-making based on guiding principle(s)" as highlighted in the note on Slide 20.

      • Action Implementation: Taking corrective and preventive actions to address the ethical issue and prevent recurrence.

      • Defined Timeframes: Establish reasonable timeframes for each stage of the process (investigation, decision, action) to ensure timely resolution.

    • Document Decisions Taken: Maintain thorough documentation of all ethical issues reported, investigations conducted, decisions made, and actions taken. This documentation is crucial for accountability, transparency, and learning.

    • Identify Opportunities for Improvement: Regularly review the ethical issue management process to identify areas for improvement. Analyze trends in ethical issues to proactively address systemic ethical challenges within the hospital.

  • Ethics Committee (Optional but Recommended): Consider establishing an Ethics Committee to provide expert guidance on ethical issues, facilitate ethical consultations, and oversee the ethical management framework.

  • Training on Ethical Issue Management: Train staff on the ethical issue management process, how to identify ethical dilemmas, how to report concerns, and how to participate in ethical decision-making.

3. Disclosure of Ownership:

• Explanation: Transparency about hospital ownership is a fundamental ethical requirement. Patients and stakeholders have a right to know who owns and operates the hospital. This transparency builds trust and allows for informed decision-making.

• NABH Perspective: NABH expects hospitals to clearly and publicly disclose their ownership structure. This disclosure should be easily accessible and understandable to patients and the public.

• Practical Implementation Guidance:

  • Disclose Ownership Name and Type: Clearly state the name of the owning entity and the type of ownership (e.g., Trust, Private Limited Company, Public Sector, Government).

  • Display Hospital's Registration Certificate: Display the hospital's registration certificate in a prominent location where it is visible to patients and visitors. This certificate often contains ownership information.

  • Information on Website and Public Materials: Include ownership information on the hospital website, brochures, and other public-facing materials.

  • Points to Remember - Types of Hospital Ownership: Be aware of the different legal structures under which hospitals can be governed in India (as mentioned on Slide 21):

    • Trust

    • Private (Companies Act, Limited Liability Partnership Act, Sole Proprietorship)

    • Public (Government of India/State Government, Societies Registration Act)

  • Rationale for Disclosure: Explain why ownership disclosure is ethically important:

    • Transparency and Accountability: Allows stakeholders to understand the governance structure and potential accountabilities.

    • Potential Conflicts of Interest: Helps identify potential conflicts of interest related to ownership (e.g., related party transactions).

    • Informed Decision-Making: Enables patients and stakeholders to make informed decisions about seeking care at the hospital.

4. Honest Portrayal of Affiliations and Accreditations:

• Explanation: Hospitals often have affiliations with other institutions (e.g., universities, medical groups) and may hold accreditations from various bodies (e.g., NABH, JCI, NABL). It is crucial to honestly and accurately portray these affiliations and accreditations, avoiding any misleading or exaggerated claims.

• NABH Perspective: NABH expects hospitals to present their affiliations and accreditations truthfully and without misrepresentation. Any claims of affiliation or accreditation must be verifiable and accurate.

• Practical Implementation Guidance:

  • Display Affiliations and Accreditations Honestly: Display information about affiliations and accreditations in a clear and honest manner.

  • Specify Scope: Clearly indicate whether the affiliation or accreditation applies to the entire hospital or specific departments or services.

  • Verifiable Information: Ensure that any claims of affiliation or accreditation are supported by valid certificates or documentation.

  • Avoid Misleading Language: Refrain from using ambiguous or exaggerated language that could mislead patients about the nature or extent of affiliations or accreditations.

  • Wherever Such Exist: Only portray affiliations and accreditations that genuinely exist. Do not fabricate or imply affiliations that are not in place.

  • Rationale for Honest Portrayal: Explain why honest portrayal is ethically important:

    • Trust and Credibility: Misleading claims erode trust and damage the hospital's credibility.

    • Patient Choice: Patients rely on accurate information about affiliations and accreditations when making choices about their healthcare.

    • Professional Integrity: Honest portrayal reflects professional integrity and ethical marketing practices.

Detailed Breakdown of ROM 2 Objective Elements (ROM 2a - ROM 2d) for Training:

Let's delve into each Objective Element (OE) of ROM 2 to understand the specific requirements:

ROM 2a: The leaders establish the organisation's ethical management framework. * (CO)

• Standard Statement: This OE mandates that hospital leaders are responsible for establishing the organization's ethical management framework. The asterisk (*) and (CO) designation highlight its Core Objective Element status, requiring mandatory system documentation.

• Detailed Explanation: This OE places the onus on hospital leadership to take the initiative in creating and implementing the ethical management framework. "Leaders" in this context generally refers to senior management and governance bodies. "Establish" implies a proactive and formal process of developing and putting the framework in place.

• Implementation Strategies & Best Practices:

  • Leadership Ownership: Senior leaders must take ownership of the ethical management framework. This includes championing its development, allocating resources, and ensuring its effective implementation.

  • Develop a Written Framework Document: As discussed earlier, creating a comprehensive written document outlining the framework is essential. This document should include guiding principles and address the key areas of ethical concern.

  • Transparency as a Guiding Principle: The framework should explicitly emphasize "Transparency in Actions" as a core guiding principle, as highlighted on Slide 19.

  • Address Key Areas: The framework must specifically address the areas listed on Slide 19: handling complaints, grievances, clinical care delivery, research, and codes of conduct.

  • Reference External Codes: Consider referencing relevant external ethical codes, such as the "Code of Medical Ethics - 2002" by MCI, to provide a foundation for the hospital's ethical standards.

• Documentation Examples:

  • Documented Ethical Management Framework Policy.

  • Minutes of leadership meetings demonstrating the process of developing and approving the framework.

  • Communication materials used to disseminate the framework to staff.

ROM 2b: The ethical management framework includes processes for managing issues with ethical implications, dilemmas and concerns. (C)

• Standard Statement: This OE requires that the ethical management framework must include processes for managing ethical issues, dilemmas, and concerns. It is a Commitment Level OE (C).

• Detailed Explanation: This OE emphasizes the operationalization of the ethical framework. It's not enough to have principles; there must be concrete processes in place for dealing with ethical challenges in practice.

• Implementation Strategies & Best Practices:

  • Develop a Defined Process Flow: Create a clear process flow diagram or written procedure outlining the steps for managing ethical issues. The process should include:

    • Reporting Mechanisms: Establish clear and accessible channels for reporting ethical concerns.

    • Investigation Procedures: Outline how ethical issues will be investigated.

    • Decision-Making Process: Define how ethical decisions will be made (e.g., by whom, using what criteria).

    • CAPA and Follow-up: Ensure a process for implementing corrective and preventive actions and monitoring their effectiveness.

    • Documentation: Mandate documentation at each stage of the process.

  • 
    

  • Examples of Ethical Issues: Use the "Examples of ethical issues" listed on Slide 20 (conflict of interest, breach of confidentiality, ethical behavior, informed consent, withdrawing life-sustaining treatment) during training to illustrate the types of issues the process should address.

  • Consistent Approach: Emphasize the need for a "consistent approach to ethical decision-making based on guiding principle(s)" as highlighted in the Note on Slide 20. This ensures fairness and predictability.

• Documentation Examples:

  • Documented procedure for managing ethical issues.

  • Records of ethical issues reported, investigated, and resolved (anonymized for training purposes).

  • Minutes of Ethics Committee meetings (if applicable) discussing ethical issue management processes.

ROM 2c: The organisation discloses its ownership. (C)

• Standard Statement: This OE directly states the requirement for the organization to disclose its ownership. It is a Commitment Level OE (C).

• Detailed Explanation: This is a straightforward requirement emphasizing transparency of ownership. Patients and stakeholders have a right to know who owns the hospital.

• Implementation Strategies & Best Practices:

  • Prominent Display of Ownership Information: Display ownership information in prominent locations, such as:

    • Reception areas

    • Waiting areas

    • Hospital website ("About Us" section)

    • Brochures and public materials

• • Display Registration Certificate: Display the hospital's registration certificate in a visible location.

  • Clearly State Ownership Type and Name: Ensure the disclosed information clearly states the type of ownership (Trust, Private, Public) and the name of the owning entity.

• Documentation Examples:

  • Photographic evidence of displayed ownership information in various locations.

  • Screenshot of website section displaying ownership information.

  • Sample of brochures containing ownership details.

ROM 2d: The organisation honestly portrays its affiliations and accreditations. (C)

• Standard Statement: This OE mandates that the organization honestly portrays its affiliations and accreditations. It is a Commitment Level OE (C).

• Detailed Explanation: Honesty and accuracy are key. Hospitals must avoid misleading or exaggerated claims about affiliations and accreditations.

• Implementation Strategies & Best Practices:

  • Truthful and Accurate Representation: Ensure that all claims of affiliation and accreditation are truthful, accurate, and verifiable.

  • Specify Scope: Clearly indicate the scope of affiliations and accreditations (e.g., entire hospital, specific department).

  • Display Valid Certificates: If displaying accreditation logos or certifications, ensure they are valid and current.

  • Avoid Ambiguity: Use clear and unambiguous language when describing affiliations and accreditations.

  • Wherever Such Exist: Only portray affiliations and accreditations that genuinely exist and are currently valid.

• Documentation Examples:

  • Examples of how affiliations and accreditations are portrayed in hospital materials (website, brochures, displays).

  • Copies of valid accreditation certificates (NABH, etc.).

  • Agreements or documentation supporting claims of affiliations.

Common Challenges and Pitfalls in Implementing ROM 2:

• Lack of a Formal Ethical Management Framework: Hospitals may operate without a documented ethical framework, relying on informal or ad-hoc approaches to ethical issues.

• Inconsistent Application of Ethical Principles: Even with a framework, ethical principles may not be consistently applied across different departments or situations.

• Insufficient Training on Ethics: Staff may not receive adequate training on ethical principles, the ethical framework, or processes for managing ethical issues.

• Poor Documentation of Ethical Issues: Hospitals may fail to adequately document ethical issues, investigations, decisions, and actions taken.

• "Tick-Box" Approach to Ethics: Treating ethical management as a mere compliance exercise rather than embedding ethical values into the organizational culture.

• Misleading Marketing and Communication: Overstating affiliations or accreditations in marketing materials to gain a competitive advantage, which is unethical.

• Resistance to Transparency: Reluctance to fully disclose ownership or honestly portray affiliations due to concerns about reputational impact or competitive disadvantage.

Key Takeaways and Actionable Steps for ROM 2 Training:

• Ethics is Core to Good Governance: Emphasize that ethical management is not a separate add-on but an integral part of good governance and effective hospital operations.

• Establish a Formal Ethical Framework: Stress the importance of developing and documenting a comprehensive ethical management framework.

• Operationalize Ethics through Processes: Highlight the need for clear and well-defined processes for managing ethical issues, dilemmas, and concerns.

• Transparency and Honesty are Non-Negotiable: Underscore the ethical imperatives of ownership disclosure and honest portrayal of affiliations and accreditations.

• Training and Culture are Essential: Promote the importance of ongoing ethics training for all staff and fostering an organizational culture that values ethical conduct and integrity.

• Ethical Management Benefits the Hospital: Frame ethical management not just as a compliance requirement, but as a strategic advantage that builds trust, enhances reputation, improves patient care, and creates a more positive working environment.

By providing this detailed and structured training on ROM 2, hospitals can move beyond simply aiming to be ethical and develop robust systems and a strong ethical culture, ultimately enhancing patient care and organizational integrity.

Standard ROM 3: Responsibility for Organisations sustainability.

Introduction to ROM 3:

ROM 3 is a new and highly significant addition in the NABH 6th Edition, reflecting the growing global awareness and urgency surrounding organisational sustainability. This standard shifts the focus of hospital management beyond immediate operational concerns to encompass a broader responsibility for the long-term well-being of the healthcare system, the community it serves, and the planet as a whole. ROM 3 mandates that those responsible for governance must actively address sustainability across environmental, social, and economic dimensions.

Rationale and Importance of ROM 3:

• Contemporary Relevance and Global Imperative: Sustainability is no longer a niche concept but a mainstream imperative. Healthcare, as a significant consumer of resources and generator of waste, has a crucial role to play in contributing to a sustainable future. ROM 3 aligns NABH standards with this global movement.

• Ethical Responsibility to Future Generations: Hospitals, as institutions dedicated to health and well-being, have an ethical obligation to operate in a manner that does not compromise the health and well-being of future generations. Sustainability is about responsible resource management and minimizing negative impacts on the environment and society.

• Resource Efficiency and Cost Savings: Sustainable practices often lead to increased resource efficiency (energy, water, materials), which translates into long-term cost savings for the hospital. This economic benefit directly contributes to the financial sustainability component of ROM 3.

• Mitigation of Environmental and Social Risks: Hospitals are vulnerable to environmental and social risks, such as climate change impacts, resource scarcity, and social inequalities. Proactive sustainability measures can mitigate these risks and enhance the hospital's resilience.

• Enhanced Reputation and Stakeholder Trust: A commitment to sustainability enhances the hospital's reputation and builds trust with patients, staff, the community, and other stakeholders. Patients are increasingly conscious of environmental and social responsibility and may prefer hospitals that demonstrate such commitment.

• Long-Term Viability and Resilience of the Healthcare System: By embracing sustainability, hospitals contribute to the long-term viability and resilience of the entire healthcare system. A sustainable healthcare system is better equipped to address future challenges and ensure continued access to quality care.

• Direct Link to Patient and Community Health: Environmental and social factors directly impact health outcomes. For example, air and water pollution, climate change, and social determinants of health all influence population health. By addressing sustainability, hospitals contribute to creating healthier communities and preventing illness in the long run.

Key Elements of ROM 3 (Detailed Breakdown for Training):

ROM 3 is structured around the three pillars of sustainability: Environment, Social, and Governance (ESG). The objective elements (ROM 3a through ROM 3g) are organized within this ESG framework. Let's break down each pillar and its key components:

1. Environmental Sustainability:

• Explanation: This pillar focuses on minimizing the hospital's negative impact on the natural environment and promoting environmentally responsible practices. It encompasses resource consumption, waste generation, pollution, and contribution to climate change.

• NABH Perspective: NABH expects hospitals to demonstrate a commitment to environmental sustainability through concrete actions and policies across various operational areas.

• Key Areas within Environmental Sustainability (as per Slide 24):

  • Energy Usage and Efficiency:

    • Training Note: Hospitals are energy-intensive facilities. Reducing energy consumption not only lowers operational costs but also reduces greenhouse gas emissions and reliance on fossil fuels.

    • Examples: Implementing energy-efficient lighting (LEDs), optimizing HVAC systems, using renewable energy sources (solar panels), conducting energy audits, promoting energy conservation awareness among staff.

  • Climate Change Strategy:

    • Training Note: Hospitals need to acknowledge and address the risks posed by climate change (extreme weather events, heat waves, changing disease patterns). A climate change strategy involves both mitigation (reducing emissions) and adaptation (preparing for impacts).

    • Examples: Carbon footprint assessment, setting emission reduction targets, developing climate resilience plans, participating in climate action initiatives.

  • Waste Reduction:

    • Training Note: Hospitals generate significant amounts of waste, including biomedical waste, general waste, and hazardous waste. Waste reduction strategies minimize environmental pollution, conserve resources, and reduce disposal costs.

    • Examples: Implementing waste segregation and recycling programs, reducing single-use plastics, promoting reusable medical supplies where safe and feasible, optimizing waste disposal processes, minimizing food waste.

  • Biodiversity Laws:

    • Training Note: Hospitals should be aware of and comply with biodiversity laws and regulations, especially if located in or near ecologically sensitive areas. Protecting biodiversity is crucial for ecosystem health and human well-being.

    • Examples: Avoiding habitat destruction during construction, promoting green spaces and landscaping with native plants, minimizing pesticide use, supporting biodiversity conservation initiatives in the community.

  • Greenhouse Gas Emission:

    • Training Note: Hospitals contribute to greenhouse gas emissions through energy consumption, transportation, and other operations. Reducing these emissions is essential for mitigating climate change.

    • Examples: Transitioning to cleaner energy sources, promoting sustainable transportation options for staff and patients, optimizing supply chains to reduce transportation emissions, using less carbon-intensive materials

  • Carbon Footprint Reduction:

    • Training Note: Carbon footprint is a measure of the total greenhouse gas emissions caused by an organization. Reducing the carbon footprint is a comprehensive goal encompassing all aspects of environmental sustainability.

    • Examples: Implementing all the strategies mentioned above (energy efficiency, renewable energy, waste reduction, sustainable transportation, etc.), tracking and reporting carbon emissions, setting carbon reduction targets.

2. Social Sustainability:

• Explanation: This pillar focuses on the hospital's impact on people and society. It encompasses fair labor practices, employee well-being, community engagement, ethical sourcing, and addressing social determinants of health.

• NABH Perspective: NABH expects hospitals to demonstrate social responsibility by promoting fair and ethical practices within their operations and contributing to the well-being of their staff and the community.

• Key Areas within Social Sustainability (as per Slide 24):

  • Fair Pay and Leaving Wages:

    • Training Note: Hospitals should ensure fair wages and benefits for all employees, including minimum wage compliance and providing adequate compensation for all roles. "Leaving wages" refers to fair severance and benefits upon termination, ensuring dignified treatment of departing employees.

    • Examples: Regular salary reviews, fair wage policies, competitive benefits packages, transparent pay scales, ethical severance practices.

  • Equal Employment Opportunities:

    • Training Note: Hospitals should promote equal opportunities for all individuals, regardless of gender, race, religion, disability, or other protected characteristics. This includes fair hiring practices, promotion opportunities, and a diverse and inclusive workforce.

    • Examples: Non-discriminatory hiring policies, diversity and inclusion initiatives, equal pay for equal work, accessibility for employees with disabilities, promoting women in leadership roles.

  • Employee Benefits:

    • Training Note: Providing comprehensive employee benefits is essential for attracting and retaining talent and promoting employee well-being. Benefits go beyond just salary and can include health insurance, retirement plans, paid leave, childcare support, and wellness programs.

    • Examples: Health insurance coverage for employees and dependents, retirement savings plans, paid sick leave and vacation, employee assistance programs, wellness initiatives, childcare facilities or support.

  • Workplace Health and Safety:

    • Training Note: Ensuring a safe and healthy working environment is a fundamental social responsibility. This includes preventing workplace injuries, promoting occupational health, and addressing workplace hazards.

    • Examples: Implementing robust occupational safety protocols, providing safety training, conducting risk assessments, providing personal protective equipment, promoting ergonomics, addressing workplace stress, ensuring infection prevention and control measures for staff.

  • Community Engagement:

    • Training Note: Hospitals are integral parts of their communities. Community engagement involves actively interacting with and contributing to the well-being of the local community beyond just providing healthcare services.

    • Examples: Free health camps, community health education programs, outreach programs for vulnerable populations, partnerships with local organizations, supporting local economic development, addressing social determinants of health in the community.

  • Responsible Supply Chain Partnership:

    • Training Note: Hospitals should ensure ethical and sustainable practices throughout their supply chain. This involves selecting suppliers who adhere to fair labor standards, environmental regulations, and ethical business practices.

    • Examples: Supplier code of conduct, supplier audits for ethical and environmental compliance, prioritizing local and sustainable suppliers, promoting fair trade practices, avoiding suppliers with known human rights violations or environmental damage.

  • Adhering to Labour Laws:

    • Training Note: Compliance with all applicable labor laws is a fundamental social responsibility. This includes laws related to wages, working hours, working conditions, employee rights, and industrial relations.

    • Examples: Compliance with minimum wage laws, overtime regulations, working hour limits, employee leave policies, ensuring freedom of association and collective bargaining, preventing child labor and forced labor.

3. Governance Sustainability:

• Explanation: This pillar focuses on the hospital's internal governance structures and practices that ensure ethical, transparent, and accountable operations. It encompasses corporate governance, risk management, compliance, ethical business practices, and financial integrity.

• NABH Perspective: NABH expects hospitals to demonstrate sound governance practices that promote transparency, accountability, ethical conduct, and effective risk management.

• Key Areas within Governance Sustainability (as per Slide 25):

  • Corporate Governance:

    • Training Note: This refers to the overall system of rules, practices, and processes by which a hospital is directed and controlled. Good corporate governance ensures accountability to stakeholders, ethical decision-making, and effective oversight.

    • Examples: Clearly defined roles and responsibilities for the governing body (as per ROM 1), independent board members, ethical codes of conduct for governance members, transparent reporting practices, stakeholder engagement.

  • Risk Management:

    • Training Note: Effective risk management is crucial for organizational sustainability. This involves identifying, assessing, mitigating, and monitoring risks across all areas of hospital operations, including financial, clinical, operational, and reputational risks (as further detailed in ROM 6).

    • Examples: Developing a comprehensive risk management framework, conducting regular risk assessments, implementing risk mitigation strategies, monitoring risk indicators, establishing business continuity plans (as touched upon in ROM 6d).

  • Compliance:

    • Training Note: Hospitals operate in a highly regulated environment. Compliance with all applicable laws, regulations, and ethical standards is essential for legal and operational sustainability (as emphasized in ROM 4b).

    • Examples: Establishing a compliance program, conducting regular compliance audits, implementing policies and procedures to ensure regulatory adherence, providing compliance training to staff, having mechanisms for reporting and addressing compliance violations.

  • Ethical Business Practices:

    • Training Note: Beyond legal compliance, hospitals should adhere to high ethical standards in all business practices, including procurement, marketing, financial management, and interactions with stakeholders (as emphasized in ROM 2).

    • Examples: Ethical procurement policies, transparent financial reporting, avoiding conflicts of interest, fair marketing practices, ethical interactions with patients, staff, and suppliers, promoting a culture of integrity.

  • Avoiding Conflicts of Interests:

    • Training Note: Conflicts of interest can undermine ethical decision-making and organizational integrity. Hospitals must have mechanisms to identify, disclose, and manage conflicts of interest involving governance members, staff, and other stakeholders (as mentioned in ROM 2h).

    • Examples: Conflict of interest policies, disclosure forms for governance members and senior staff, processes for reviewing and managing potential conflicts, ensuring transparency in decision-making when conflicts may arise.

  • Accounting Integrity and Transparency:

    • Training Note: Accurate and transparent financial accounting is crucial for financial sustainability and stakeholder trust. Hospitals should maintain high standards of accounting integrity and ensure that financial information is reported truthfully and transparently.

    • Examples: Following accounting standards, independent financial audits, transparent financial reporting, robust internal financial controls, ethical financial management practices

Detailed Breakdown of ROM 3 Objective Elements (ROM 3a - ROM 3g) for Training:

Let's now examine each objective element of ROM 3 to understand the specific requirements and implementation guidance:

ROM 3a: Those responsible for Governance address the Organisation's sustainability programme in terms of Environment, Social and Governance (ESG) responsibility. (C)

• Standard Statement: This foundational OE mandates that the governing body addresses the hospital's sustainability program across all three ESG dimensions. It is a Commitment Level OE (C).

• Detailed Explanation: This OE sets the overarching requirement for ROM 3. It emphasizes that sustainability is not just an operational issue but a governance responsibility. The governing body must take ownership of developing, implementing, and overseeing a comprehensive sustainability program. "Address" implies proactive engagement and action.

• Implementation Strategies & Best Practices:

  • Establish a Sustainability Committee (Recommended): While the governing body is ultimately responsible, consider establishing a dedicated Sustainability Committee (or integrating sustainability into an existing committee) to oversee the development and implementation of the sustainability program. This committee should include representatives from various departments and levels of the hospital.

  • Conduct a Sustainability Assessment/Gap Analysis: Start by assessing the hospital's current sustainability performance across ESG areas. Identify strengths, weaknesses, and areas for improvement. This assessment can serve as a baseline for setting targets and tracking progress.

  • Develop a Sustainability Policy and Strategy: Based on the assessment, develop a comprehensive sustainability policy and strategy document. This document should:

    • Articulate the hospital's commitment to sustainability and its vision for a sustainable future.

    • Define specific goals and targets for each ESG pillar (Environmental, Social, and Governance).

    • Outline action plans and initiatives to achieve these goals.

    • Assign responsibilities for implementation and monitoring.

    • Establish a timeline for implementation and review.

  • Integrate Sustainability into Strategic Planning: Ensure that sustainability considerations are integrated into the hospital's overall strategic planning process. Sustainability should be a core element of the hospital's long-term vision and operational strategy.

• Documentation Examples:

  • Documented Sustainability Policy and Strategy.

  • Sustainability Assessment Report/Gap Analysis.

  • Terms of Reference for the Sustainability Committee (if established).

  • Minutes of governing body meetings showing discussions on sustainability program development and oversight.

ROM 3b: The organisation takes initiatives towards an energy-efficient and environmentally friendly hospital. (C)

• Standard Statement: This OE focuses specifically on initiatives towards making the hospital energy-efficient and environmentally friendly. It is a Commitment Level OE (C).

• Detailed Explanation: This OE translates the broader environmental sustainability pillar into concrete actions focused on resource efficiency and minimizing environmental impact within the hospital's daily operations. It promotes the concept of a "Green Hospital."

• Implementation Strategies & Best Practices:

  • Implement "Reduce, Recycle, Reuse" Strategies (as per Slide 26):

    • Reduce: Focus on reducing consumption of resources and generation of waste at the source. Example: Reduce plastic usage (plastic bags, single-use items).

    • Recycle: Implement comprehensive recycling programs for various waste streams. Example: Recycle STP/ETP water for gardening and flushing.

    • Reuse: Promote reuse of materials and resources wherever feasible. Example: Reuse rainwater through rainwater harvesting.

• • Focus on Efficient and Sustainable Use of Energy, Water, and Other Utilities (as per Slide 26): Implement measures to optimize the use of energy, water, and other utilities (e.g., natural gas, medical gases).

  • Suggested Measures for Green Hospital (as per Slide 28): Adopt a range of green hospital measures, including:

    • Energy Efficient Lighting (LEDs)

    • Water Efficiency and Rainwater Harvesting

    • Increased Usage of Solar Power

    • Wind Energy (where feasible)

    • Use of Battery Operated/E-vehicles for internal transport

    • Recycling of STP/ETP Water

    • Reduction of Plastic Usage

    • Use of Green Building Materials in Construction

    • Volatile Organic Compound (VOC) Free Paints

  • Awareness Campaigns (as per Slide 29): Conduct awareness campaigns among staff and patients to promote energy and water conservation

• Documentation Examples:

  • Green Hospital initiatives implementation plan.

  • Data on energy and water consumption reduction.

  • Records of waste recycling and reuse programs.

  • Photographic evidence of green hospital initiatives (solar panels, rainwater harvesting systems, etc.).

  • Awareness campaign materials and records of staff/patient engagement.

ROM 3c: Those responsible for Governance address the organisations social responsibility. (C)

• Standard Statement: This OE focuses on the governing body addressing the hospital's social responsibility. It is a Commitment Level OE (C).

• Detailed Explanation: This OE translates the broader social sustainability pillar into concrete actions that demonstrate the hospital's commitment to the well-being of its staff and the wider community.

• Implementation Strategies & Best Practices:

  • Develop Social Responsibility Policy and Implement it (as per Slide 30): Create a formal social responsibility policy outlining the hospital's commitments and strategies.

  • Implement Community Outreach Programs (as per Slide 30):

    • Free Camps: Organize free health camps for underserved populations.

    • Outreach Programs for Below Poverty Line Population: Develop targeted outreach programs to provide healthcare access to those living below the poverty line.

    • Consider other Community Engagement Activities: Go beyond free camps and explore other community engagement initiatives relevant to the local context (e.g., health education, support for local schools, partnerships with community organizations).

  • Comply with Regulatory Requirements (as per Slide 30): Ensure compliance with all regulatory requirements related to corporate social responsibility (CSR) if applicable in your jurisdiction.

• Documentation Examples:

  • Documented Social Responsibility Policy.

  • Implementation plan for social responsibility programs.

  • Records of free health camps and outreach programs conducted.

  • Reports on community engagement activities and their impact.

  • Compliance documentation for relevant CSR regulations.

ROM 3d: Staff well-being is promoted. (C)

• Standard Statement: This OE specifically emphasizes the promotion of staff well-being. It is a Commitment Level OE (C).

• Detailed Explanation: Recognizing that staff are the backbone of any hospital, this OE highlights the social responsibility of promoting their physical, mental, and emotional well-being. Staff well-being is not just a social concern but also directly impacts patient care quality and organizational sustainability.

• Implementation Strategies & Best Practices:

  • Promote Healthy Lifestyle Programs (as per Slide 31): Implement programs that encourage healthy lifestyles among staff, such as:

    • Wellness programs, health screenings, fitness initiatives, smoking cessation programs, healthy eating campaigns.

  • Ensure Defined Work Hours and Manage Workloads (as per Slide 31): Establish reasonable work hours, manage workloads effectively to prevent burnout, and provide adequate staffing levels.

  • Provide Scheduled Breaks (as per Slide 31): Ensure staff receive scheduled breaks during their shifts to prevent fatigue and maintain focus.

  • Stress Management Programs (as per Slide 31): Offer stress management training, counseling services, and other resources to support staff mental health.

  • Rewards and Recognitions (as per Slide 31): Implement systems for recognizing and rewarding staff contributions and achievements to boost morale and motivation.

  • Track Performance Indicators Related to Staff Well-being (as per Slide 31):

    • Track Absenteeism/Overtime: Monitor absenteeism and overtime rates as indicators of potential stress and fatigue.

    • Staff Satisfaction Surveys: Conduct regular staff satisfaction surveys to gauge employee morale and identify areas for improvement in well-being initiatives.

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  • Assess Facilities for Staff (as per Slide 31): Evaluate and improve facilities that contribute to staff well-being, such as:

    • Dining facilities, staff engagement and recreational areas.

    • Seek Feedback and Advice from Staff: Regularly solicit feedback from staff on well-being initiatives and seek their advice on improvements.

• Documentation Examples:

  • Staff well-being policy and program documentation.

  • Records of healthy lifestyle programs and staff participation.

  • Workload management policies and staffing plans.

  • Staff satisfaction survey results and action plans based on feedback.

  • Data on absenteeism and overtime trends.

ROM 3e: The Organisation follows sustainable procurement practices (E)

• Standard Statement: This OE focuses on sustainable procurement practices. It is an Excellence Level OE (E), indicating a higher level of aspiration and best practice.

• Detailed Explanation: Sustainable procurement goes beyond just cost and quality; it considers the environmental and social impacts of purchased goods and services throughout their lifecycle. This OE encourages hospitals to adopt procurement practices that minimize negative impacts and promote positive social and environmental outcomes.

• Implementation Strategies & Best Practices:

  • Sourcing Products and Services with Lower Environmental Impact (as per Slide 32): Prioritize products and services that have a reduced environmental footprint throughout their lifecycle, considering factors like:

    • Energy consumption in production and use.

    • Water consumption.

    • Waste generation.

    • Pollution potential.

    • Use of renewable or recycled materials.

• • Prioritize Environmentally Friendly and Socially Responsible Products (as per Slide 32): Specifically favor products and services that are certified or recognized as environmentally friendly (e.g., eco-labels, energy efficiency ratings) and socially responsible (e.g., fair trade, ethical sourcing certifications).

  • Develop a Sustainable Procurement Policy: Create a formal sustainable procurement policy that outlines the hospital's commitment, principles, and procedures for sustainable sourcing.

  • Supplier Engagement: Engage with suppliers to promote sustainable practices in their operations and encourage them to offer more sustainable products and services.

  • Life Cycle Assessment (LCA): Consider using Life Cycle Assessment (LCA) principles to evaluate the environmental impact of different products and services.

• Documentation Examples:

  • Documented Sustainable Procurement Policy.

  • Supplier code of conduct emphasizing sustainability criteria.

  • Examples of procurement decisions favoring sustainable products and services.

  • Records of supplier engagement and promotion of sustainable practices.

ROM 3f: Hospitals shall encourage employees to use common/public transportation to reduce the environmental impact of commuting and carbon footprint (A)

• Standard Statement: This OE focuses on encouraging employees to use common/public transportation to reduce commuting-related environmental impacts. It is an Achievement Level OE (A).

• Detailed Explanation: Employee commuting contributes significantly to a hospital's carbon footprint and local traffic congestion. This OE encourages hospitals to actively promote sustainable commuting options for their staff.

• Implementation Strategies & Best Practices:

  • Promote Carpooling (as per Slide 33): Encourage carpooling among employees by facilitating ride-sharing platforms, providing preferential parking for carpoolers, or organizing carpool matching programs.

  • Promote Cycling (as per Slide 33): Support cycling as a commuting option by providing bike racks, showers, changing facilities, and cycle-to-work schemes.

  • Promote Use of Public Transport (as per Slide 33): Encourage the use of public transport by providing information on public transport routes, offering subsidized public transport passes, or advocating for improved public transport access to the hospital.

  • Efficient Environmentally Friendly Logistic and Transportation Management within the Hospital (as per Slide 33): Optimize internal logistics and transportation to be environmentally friendly, considering options like electric vehicles for internal transport, optimized routing, and reduced unnecessary movement.

  • Awareness Campaigns: Conduct awareness campaigns to educate staff about the environmental benefits of sustainable commuting and promote available options.

• Documentation Examples:

  • Employee commuting survey data.

  • Documentation of carpooling, cycling, and public transport promotion initiatives.

  • Examples of communication materials promoting sustainable commuting.

  • Data on employee participation in sustainable commuting programs.

ROM 3g: The Organisation ensures financial sustainability of the hospital by balancing the financial aspect of healthcare delivery (A)

• Standard Statement: This OE focuses on financial sustainability and the need to balance financial aspects with healthcare delivery. It is an Achievement Level OE (A).

• Detailed Explanation: Financial sustainability is crucial for any organization, including hospitals. However, in healthcare, financial sustainability cannot be pursued at the expense of quality patient care and ethical service delivery. This OE emphasizes the need to strike a balance between financial viability and the hospital's core mission of providing healthcare.

• Implementation Strategies & Best Practices:

  • Long Term Sustainability through Balancing Financial Aspect of Healthcare Delivery (as per Slide 34): Develop strategies for achieving long-term financial sustainability while maintaining quality healthcare services.

  • Efficient Resource Allocation (as per Slide 34): Optimize resource allocation to ensure efficient use of financial resources across all departments and services, avoiding waste and unnecessary expenditure.

  • Cost Management (as per Slide 34): Implement cost management strategies to control operational expenses, improve efficiency, and reduce unnecessary costs without compromising patient care quality.

  • Revenue Generation Strategies (as per Slide 34): Develop ethical and sustainable revenue generation strategies to ensure financial viability and support the hospital's mission. This might include optimizing service offerings, exploring new revenue streams, and improving billing and collection processes, while ensuring ethical billing practices and avoiding over-charging patients.

  • Financial Planning and Budgeting: Implement robust financial planning and budgeting processes to ensure financial stability and long-term sustainability.

• Documentation Examples:

  • Financial sustainability plan or strategy document.

  • Financial performance reports demonstrating financial stability and sustainability.

  • Examples of cost management and efficient resource allocation initiatives.

  • Revenue generation strategies and their ethical considerations.

  • Long-term financial projections and plans.

Common Challenges and Pitfalls in Implementing ROM 3:

• Perception of Sustainability as an "Extra Cost": Initial investment in sustainable practices may be perceived as costly, overlooking the long-term cost savings and benefits.

• Lack of Expertise and Resources: Hospitals may lack internal expertise and resources to develop and implement comprehensive sustainability programs.

• Resistance to Change: Implementing sustainable practices may require changes in existing processes and behaviors, leading to resistance from staff or departments.

• Measurement and Tracking Challenges: Measuring the impact of sustainability initiatives and tracking progress can be complex.

• Balancing Sustainability with Immediate Operational Pressures: Hospitals may prioritize immediate operational needs over long-term sustainability goals, especially in resource-constrained environments.

• "Greenwashing" vs. Genuine Commitment: Hospitals may engage in superficial "greenwashing" efforts without genuine commitment to deep and systemic sustainability changes.

• Integrating ESG holistically: Treating Environment, Social, and Governance as separate silos rather than interconnected elements of a holistic sustainability strategy.

Key Takeaways and Actionable Steps for ROM 3 Training:

• Sustainability is a Strategic Imperative: Emphasize that sustainability is not just an ethical add-on but a strategic imperative for long-term hospital viability and success.

• ESG Framework is Comprehensive: Highlight the importance of addressing sustainability across all three ESG pillars (Environment, Social, and Governance) for a holistic approach.

• Long-Term Benefits Outweigh Initial Costs: Educate on the long-term cost savings, risk mitigation, and reputational benefits of sustainable practices that outweigh initial investments.

• Start Small and Scale Up: Encourage hospitals to start with achievable sustainability initiatives and gradually scale up their efforts over time.

• Collaboration and Partnerships: Promote collaboration with external experts, consultants, and other organizations to gain expertise and resources for sustainability initiatives.

• Measure and Track Progress: Emphasize the importance of establishing metrics, tracking progress, and regularly reporting on sustainability performance.

• Embed Sustainability into Organizational Culture: Promote a culture of sustainability throughout the hospital, engaging all staff members and fostering a sense of shared responsibility for environmental and social stewardship.

• Sustainability Enhances Healthcare Quality: Connect sustainability directly to improved patient care, staff well-being, and community health, reinforcing its value beyond just environmental concerns.

By providing this detailed and structured training on ROM 3, hospitals can understand the importance of organizational sustainability, develop comprehensive programs across ESG pillars, and take concrete steps towards becoming more environmentally friendly, socially responsible, and financially resilient healthcare providers. This will not only contribute to NABH accreditation but, more importantly, to a healthier future for the hospital, its community, and the planet.

Standard ROM 4: The organisation is headed by a leader who shall be responsible for operating the organisation on a day-to-day basis.

Introduction to ROM 4:

ROM 4 directly addresses the critical aspect of leadership and operational management within a hospital. It establishes the fundamental requirement that every hospital, regardless of size or complexity, must be headed by a designated leader who is ultimately accountable for the organization's daily functioning. This standard ensures clear lines of responsibility and authority for the smooth and effective operation of the hospital on a continuous basis.

Rationale and Importance of ROM 4:

• Essential for Organizational Functioning: Every organization, especially a complex and dynamic entity like a hospital, needs a central point of leadership for day-to-day operations. Without a designated leader, responsibilities become diffused, decision-making is hampered, and operational efficiency suffers.

• Accountability for Daily Operations: ROM 4 ensures clear accountability for the hospital's daily performance. The designated leader is ultimately responsible for ensuring that all aspects of the hospital's operations function effectively and efficiently, contributing to overall organizational success and patient care quality.

• Coordination and Integration of Services: Hospitals are composed of diverse departments and services that must work in a coordinated and integrated manner. The designated leader plays a crucial role in ensuring this coordination, breaking down silos, and fostering a cohesive operational approach.

• Responsiveness and Adaptability: The healthcare environment is constantly evolving and often requires rapid responses to changing needs and challenges. A designated leader is essential for ensuring the hospital can quickly adapt to new situations, address urgent issues, and maintain operational continuity.

• Strategic Implementation and Execution: While the governing body sets the strategic direction (as covered in ROM 1), the leader responsible for day-to-day operations is crucial for translating strategy into action and ensuring effective execution at the operational level.

• Maintaining Quality and Safety in Daily Operations: Ultimately, the effectiveness of daily operations directly impacts patient safety and the quality of care provided. A capable leader ensures that operational processes are designed and implemented to prioritize patient safety and quality at every level.

Key Elements of ROM 4 (Detailed Breakdown for Training):

ROM 4 focuses on the characteristics, responsibilities, and accountability of the leader heading the organization. The objective elements (ROM 4a through ROM 4e) elaborate on these critical aspects. Let's break down the core components:

1. Designation of a Leader:

• Explanation: ROM 4 mandates that the hospital must formally designate a specific individual as the leader responsible for day-to-day operations. This designation should be clear, documented, and communicated throughout the organization.

• NABH Perspective: NABH expects hospitals to clearly identify and document who this leader is. The title of this leader may vary depending on the hospital's structure (e.g., CEO, Hospital Director, Medical Superintendent, Administrator), but the key is that there is a single, identifiable individual with overall operational responsibility.

• Practical Implementation Guidance:

  • Formal Designation in Organizational Structure: The designated leader's position and reporting lines should be clearly depicted in the hospital's organizational chart.

  • Job Description and Responsibilities: A detailed job description should be in place for this leadership role, clearly outlining the responsibilities for day-to-day operations.

  • Communication of Designation: Communicate the designation of this leader to all staff members, governance bodies, and relevant stakeholders to ensure clarity and awareness of accountability.

2. Responsibility for Day-to-Day Operations:

• Explanation: The core responsibility of this leader is to oversee and manage the "day-to-day operation" of the hospital. This encompasses a broad range of functions, including clinical services, administrative functions, support services, and overall organizational performance on a daily basis.

• NABH Perspective: NABH expects the designated leader to have the authority and responsibility to manage all aspects of daily operations, ensuring efficiency, effectiveness, quality, and safety across the hospital.

• Scope of Day-to-Day Operations: "Day-to-day operation" is a broad term. Training should clarify the scope, which typically includes:

  • Clinical Operations: Ensuring smooth functioning of all clinical departments (e.g., OPD, IPD, ICUs, specialty departments), patient flow, resource allocation for clinical services, clinical staff management, and adherence to clinical protocols and standards.

  • Administrative Operations: Overseeing administrative departments (e.g., finance, HR, administration, IT, marketing), ensuring efficient administrative processes, resource management, and compliance with administrative policies and regulations.

  • Support Services Operations: Managing support services (e.g., housekeeping, security, engineering, food services, laundry, pharmacy), ensuring these services effectively support clinical and administrative functions and maintain a safe and functional hospital environment.

  • Overall Organizational Performance: Monitoring key performance indicators (KPIs) related to operations (e.g., patient satisfaction, bed occupancy, waiting times, infection rates, financial performance), identifying areas for improvement, and implementing corrective actions.

  • Crisis Management and Emergency Response: Leading the hospital's response to day-to-day operational challenges, emergencies, and unexpected events, ensuring business continuity and patient safety.

  • Implementation of Strategic and Operational Plans: Translating strategic and operational plans (approved by governance) into daily operational actions and ensuring effective execution and achievement of objectives.

3. Requisite Qualifications and Experience:

• Explanation: To effectively manage the complex day-to-day operations of a hospital, the designated leader must possess the necessary qualifications, experience, and competencies. ROM 4 emphasizes that this individual should have "requisite and appropriate administrative qualifications and experience."

• NABH Perspective: NABH expects hospitals to appoint leaders with qualifications and experience that are relevant and appropriate for the scope and complexity of the hospital's operations. This demonstrates a commitment to professional leadership and effective management.

• Types of Requisite Qualifications and Experience (as per Slide 37):

  • Administrative Qualifications: Appropriate formal qualifications in hospital management or administration are highly desirable. Examples include:

    • MBA in Healthcare Management

    • Master's in Hospital Administration (MHA)

    • Master's in Public Health (MPH) with a focus on healthcare management

    • Other relevant management degrees with specialized healthcare focus.

  • Experience in Hospital Management/Administration: Significant and progressive experience in managing hospital operations is crucial. This experience should demonstrate:

    • Operational leadership in a hospital setting.

    • Experience in managing diverse hospital departments and services.

    • Financial management skills relevant to hospital operations.

    • Knowledge of healthcare regulations and accreditation standards.

    • Experience in quality improvement and patient safety initiatives.

    • Leadership and people management skills in a healthcare environment.

  • "Appropriate" Denotes Context: The "appropriateness" of qualifications and experience should be evaluated in the context of the specific hospital's size, complexity, ownership structure, and service offerings. A larger, multi-specialty hospital will likely require a leader with more extensive qualifications and experience than a smaller, single-specialty facility.

4. Compliance with Legislations, Regulations, and Notifications:

• Explanation: Hospitals operate within a complex legal and regulatory framework. The designated leader has a fundamental responsibility to ensure that the hospital's day-to-day operations are conducted in compliance with all applicable legislations, regulations, and notifications issued by relevant authorities.

• NABH Perspective: NABH expects the leader to demonstrate a thorough understanding of relevant legal and regulatory requirements and to implement systems and processes to ensure ongoing compliance across all operational areas.

• Scope of Compliance Responsibility (as per Slide 38):

  • Familiarity with Statutory Requirements: The leader must be thoroughly familiar with all statutory requirements relevant to the hospital's scope of services. This requires continuous updating and staying abreast of changes in legislation and regulations.

  • Mechanism to Implement Statutory Requirements: The leader must establish and maintain mechanisms to effectively implement statutory requirements within the hospital. This includes:

    • Developing policies and procedures to ensure compliance.

    • Assigning responsibilities for compliance to relevant departments and individuals.

    • Providing training to staff on compliance requirements.

    • Monitoring compliance levels and taking corrective actions when necessary.

    • Regularly reviewing and updating compliance mechanisms to reflect changes in regulations.

  • Organization Functioning as Permitted Legal Entity: Ensure the hospital functions as a legally permitted entity under relevant registering authority(s). This includes maintaining necessary licenses, registrations, and permits.

  • Conduct Research as per Statutory Norms: If the hospital conducts research (including clinical trials), ensure that all research activities are conducted in accordance with relevant statutory norms and ethical guidelines.

  • Mechanism to Update Amendments in Laws: Use a mechanism (such as a tracker sheet or legal compliance software) to regularly update and track amendments in existing laws and regulations.

  • Continuity of Statutory Compliance: Ensure continuity of statutory compliance by submitting timely applications to update statutory documents (licenses, registrations, etc.) and maintain their validity.

• Timeline for Submitting Applications (Points to Remember on Slide 38): Emphasize that timelines for submitting applications for licenses, registrations, and renewals are crucial and must be adhered to as per relevant laws and registration authority requirements.

5. Appointment/Participation in Recruitment of Department Leaders:

• Explanation: The designated leader cannot manage the entire hospital alone. Effective day-to-day operation relies on a strong team of department leaders who are responsible for their respective areas. ROM 4 highlights the leader's role in appointing or actively participating in the recruitment of these department leaders.

• NABH Perspective: NABH expects the designated leader to play a key role in building a competent and effective leadership team by being involved in the selection and appointment of department heads. This ensures alignment with the leader's vision and operational priorities.

• Leader's Role in Department Leader Recruitment (as per Slide 39 & 40):

  • Appoint/Participate in Recruitment: The leader may directly appoint department leaders or actively participate in the recruitment process (e.g., as part of the interview panel, by providing final approval). The level of involvement may vary depending on the organizational structure and size.

  • Ensure Competent Department Leadership: The leader's involvement in recruitment aims to ensure that department leaders are competent, qualified, and aligned with the hospital's goals and values.

  • Department Leaders Assist in Day-to-Day Functioning: Department leaders are crucial for assisting the overall leader in managing the day-to-day functioning of their respective departments.

  • Document Services Provided by Departments: Each department leader should document the services provided by their department, ensuring clarity of scope and responsibilities.

  • Integrated Approach: Department leaders should adopt an integrated approach, ensuring alignment of their departmental services with the services of other departments to promote seamless patient care and operational efficiency.

  • Participation in Patient Safety and Quality Improvement: Department leaders should actively participate in patient safety and quality improvement activities within their departments and across the hospital, contributing to a culture of continuous improvement.

6. Ensuring Effective Department Leadership:

• Explanation: Beyond just appointing department leaders, ROM 4 emphasizes that the designated leader is responsible for ensuring that each organizational programme, service, site, or department has effective leadership. This goes beyond just filling positions; it's about ensuring leadership is competent and impactful at all levels.

• NABH Perspective: NABH expects the designated leader to actively ensure that department leaders are not only qualified but also effective in their roles, contributing to the overall success of their departments and the hospital.

• Characteristics of Effective Department Leadership (as per Slide 41):

  • Minimum Essential Qualification and/or Relevant Experience: Department leaders should possess the minimum essential qualifications and/or relevant experience required for their specific roles. This ensures competence and expertise in their respective areas.

  • Domain Knowledge of the Department: Department leaders should have in-depth domain knowledge of their department's functions, services, and operational requirements.

  • Develop Metrics for Measuring Effectiveness of Leaders: The organization (led by the designated leader) should develop metrics and systems for measuring the effectiveness of department leaders. This allows for performance evaluation, identification of areas for improvement, and leadership development. Metrics could include:

    • Departmental performance indicators (KPIs).

    • Staff satisfaction within the department.

    • Patient satisfaction with departmental services.

    • Quality and safety outcomes within the department.

    • Compliance with departmental policies and procedures.

    • Leadership skills and competencies (assessed through 360-degree feedback, performance appraisals).

7. Performance Review of the Organisation's Leader:

• Explanation: Accountability applies at all levels, including the top leadership. ROM 4 mandates that the performance of the organization's leader responsible for day-to-day operations must be reviewed for effectiveness. This ensures accountability at the highest operational level and promotes continuous improvement in leadership performance.

• NABH Perspective: NABH expects hospitals to have a mechanism for regularly reviewing the performance of the designated leader. This review should be structured, objective, and focused on effectiveness in fulfilling leadership responsibilities.

• Methods for Performance Review (as per Slide 42):

  • Establish Key Result Areas (KRAs): Define Key Result Areas (KRAs) for the leader's role. These KRAs should be aligned with the hospital's strategic and operational objectives and should cover key areas of responsibility (e.g., operational efficiency, financial performance, quality and safety outcomes, staff satisfaction, stakeholder relations). Performance can be reviewed against these KRAs.

  • Conduct Performance Appraisal: Conduct a formal performance appraisal process for the leader. This appraisal can be conducted by:

    • Responsible for Governance: The governing body (or a designated committee of the governing body) is typically responsible for conducting the performance appraisal of the top operational leader.

    • 360-Degree Feedback: Consider incorporating 360-degree feedback, gathering input from subordinates, peers, and superiors (governance members) to provide a comprehensive view of leadership effectiveness.

  • Self-Evaluation (Note on Slide 42): In instances where the person responsible for governance and the organization's leader are the same individual (e.g., in a smaller hospital where the owner is also the operational head), self-evaluation should be conducted. However, it's still recommended to have some form of external input or peer review to ensure objectivity.

Detailed Breakdown of ROM 4 Objective Elements (ROM 4a - ROM 4e) for Training:

Let's examine each Objective Element (OE) of ROM 4 to understand the specific requirements:

ROM 4a: The person heading the organisation has requisite and appropriate administrative qualifications and experience. (C)

• Standard Statement: This OE focuses on the qualifications and experience of the leader. It is a Commitment Level OE (C).

• Detailed Explanation: This OE reinforces the need for a professionally qualified and experienced individual to lead the hospital's day-to-day operations. It ensures that leadership is based on competence and expertise.

• Implementation Strategies & Best Practices:

  • Define Job Description with Qualification Requirements: Develop a detailed job description for the top operational leader role that clearly outlines the required administrative qualifications and experience.

  • Recruitment and Selection Process: Incorporate qualification and experience criteria into the recruitment and selection process for this position.

  • Verification of Credentials: Verify the qualifications and experience of candidates during the recruitment process.

  • Succession Planning: Consider succession planning to ensure that future leaders are developed and possess the requisite qualifications and experience.

• Documentation Examples:

  • Job description for the top operational leader role outlining qualification and experience requirements.

  • Resume/CV of the designated leader demonstrating relevant qualifications and experience.

  • Minutes of governing body meetings documenting the appointment of the leader and consideration of their qualifications.

ROM 4b: The leader is responsible for and complies with the laid-down and applicable legislations, regulations and notifications. (CO)

• Standard Statement: This OE emphasizes the leader's responsibility for legal and regulatory compliance. The asterisk (*) and (CO) designation highlight its Core Objective Element status, requiring mandatory system documentation.

• Detailed Explanation: This is a critical OE, underscoring that legal and regulatory compliance is a fundamental responsibility of the operational leader. It's not just about knowing the rules but actively ensuring compliance in daily operations.

• Implementation Strategies & Best Practices:

  • Establish a Compliance Management System: Implement a formal compliance management system that includes:

    • Identification of applicable laws and regulations.

    • Development of compliance policies and procedures.

    • Compliance training for staff.

    • Compliance monitoring and auditing.

    • Mechanism for reporting and addressing compliance breaches.

• • Designate a Compliance Officer/Function (Optional but Recommended): Consider designating a specific individual or department responsible for overseeing compliance management, reporting to the leader.

  • Legal Updates and Awareness: Establish a process for regularly updating the leader and relevant staff on changes in laws, regulations, and notifications.

  • Compliance Audits: Conduct periodic compliance audits to assess adherence to regulatory requirements and identify areas for improvement.

• Documentation Examples:

  • Documented Compliance Management System policy and procedures.

  • Legal and regulatory compliance tracker sheet or system.

  • Records of compliance training conducted for staff.

  • Compliance audit reports and corrective action plans.

  • Examples of mechanisms used to update on legal and regulatory changes.

ROM 4c: The leader appoints/participates in the recruitment of department leaders of the organisation who will assist in the day to day functioning of the organisation (C)

• Standard Statement: This OE focuses on the leader's role in department leader recruitment. It is a Commitment Level OE (C).

• Detailed Explanation: This OE highlights the importance of the leader building a strong leadership team and taking ownership of the selection process for department heads, recognizing their critical role in day-to-day operations.

• Implementation Strategies & Best Practices:

  • Define Leader's Role in Recruitment Process: Clearly define the leader's role in the department leader recruitment process (e.g., final approval, interview panel member, shortlisting, etc.). This should be documented in recruitment policies.

  • Standardized Recruitment Process: Use a standardized and documented recruitment process for department leader positions to ensure fairness and consistency.

  • Leader Involvement in Interviews: Ensure the leader is actively involved in the interview process for key department leader positions.

  • Focus on Competence and Alignment: During recruitment, focus on selecting candidates who are not only qualified but also competent and aligned with the hospital's vision, mission, and operational goals.

• Documentation Examples:

  • Documented recruitment policy and procedure outlining the leader's role in department leader recruitment.

  • Job descriptions for department leader positions.

  • Interview records and selection documentation for department leader appointments showing leader's involvement.

ROM 4d: The leader ensures that each organisational programme, service, site or department has effective leadership. (A)

• Standard Statement: This OE focuses on ensuring effective leadership at all levels. It is an Achievement Level OE (A), indicating a higher level of performance expectation.

• Detailed Explanation: This OE goes beyond just appointing department leaders; it emphasizes the ongoing responsibility of the top leader to ensure that leadership at every organizational level is effective and contributes to overall organizational success.

• Implementation Strategies & Best Practices:

  • Define Expectations for Department Leadership: Clearly define the expectations for effective leadership at the department level. This can be done through:

    • Department leader job descriptions with performance expectations.

    • Leadership competency frameworks outlining desired skills and behaviors.

    • Performance agreements or goal setting for department leaders.

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  • Leadership Development Programs: Implement leadership development programs to enhance the skills and effectiveness of department leaders.

  • Performance Monitoring and Feedback: Establish systems for monitoring the performance of department leaders and providing regular feedback. This can include performance reviews, 360-degree feedback, and mentoring.

  • Metrics for Measuring Effectiveness (as per Slide 41): Develop and utilize metrics to assess the effectiveness of department leaders (as discussed earlier), using these metrics for performance evaluation and leadership development.

• Documentation Examples:

  • Department leader job descriptions with performance expectations.

  • Leadership competency framework (if developed).

  • Performance appraisal records for department leaders.

  • Documentation of leadership development programs and participation.

  • Metrics used to measure department leader effectiveness and reports based on these metrics.

ROM 4e: The performance of the organisation's leader is reviewed for effectiveness. (A)

• Standard Statement: This OE mandates performance review of the top leader. It is an Achievement Level OE (A).

• Detailed Explanation: This OE ensures accountability at the highest operational level. Regular performance review of the leader promotes continuous improvement, identifies areas for development, and ensures that leadership is effective in achieving organizational goals.

• Implementation Strategies & Best Practices:

  • Establish a Formal Performance Review Process: Develop a formal and documented process for reviewing the performance of the top operational leader.

  • Define Review Frequency: Conduct performance reviews at regular intervals (e.g., annually, bi-annually).

  • Use Key Result Areas (KRAs) or Performance Appraisal Methods (as per Slide 42): Utilize KRAs or a formal performance appraisal system to assess leader effectiveness (as discussed earlier).

  • Governing Body Involvement: The governing body (or a designated committee) should be primarily responsible for conducting the leader's performance review.

  • Feedback and Development Plan: Provide constructive feedback to the leader based on the performance review and develop a personal development plan to address any identified areas for improvement.

  • Self-Evaluation When Applicable (as per Note on Slide 42): In situations where the leader and governance are the same, self-evaluation is necessary, but consider incorporating external input for objectivity.

• Documentation Examples:

  • Documented performance review process for the top operational leader.

  • Key Result Areas (KRAs) or performance appraisal forms used for leader review.

  • Performance review reports for the leader, including feedback and development plans.

  • Minutes of governing body meetings documenting the performance review process and outcomes.

Common Challenges and Pitfalls in Implementing ROM 4:

• Lack of Clarity in Leadership Roles: In some hospitals, the roles and responsibilities of the top operational leader may not be clearly defined or understood.

• Insufficient Leader Qualifications and Experience: Appointing leaders without the requisite qualifications or experience can hinder operational effectiveness and compliance.

• Weak Compliance Mechanisms: Failure to establish robust compliance mechanisms and ensure leader accountability for regulatory adherence.

• Ineffective Department Leadership: Weak or underperforming department leadership can undermine overall operational effectiveness, despite a capable top leader.

• Lack of Leader Performance Evaluation: Failure to implement a formal and regular performance review process for the top leader, hindering accountability and continuous improvement.

• Overemphasis on Clinical vs. Administrative Leadership: Hospitals may sometimes overemphasize clinical leadership while neglecting the importance of strong administrative and managerial leadership for overall operational effectiveness.

Key Takeaways and Actionable Steps for ROM 4 Training:

• Leadership is Paramount: Emphasize that strong and effective leadership is absolutely critical for the successful operation and sustainability of any hospital.

• Designate a Clear Operational Leader: Ensure that every hospital has a clearly designated leader who is accountable for day-to-day operations.

• Focus on Qualifications and Experience: Stress the importance of appointing leaders with the requisite administrative qualifications, experience, and competencies.

• Compliance is a Core Leadership Responsibility: Highlight that legal and regulatory compliance is a fundamental responsibility of the operational leader and requires proactive management.

• Build a Strong Leadership Team: Emphasize the leader's role in building a competent and effective team of department leaders and ensuring leadership effectiveness at all levels.

• Regular Performance Review is Essential: Promote the importance of regular and objective performance review for the top leader to ensure accountability and continuous improvement.

• Leadership Drives Organizational Success: Frame ROM 4 not just as an accreditation requirement but as an opportunity to strengthen hospital leadership, improve operational effectiveness, and ultimately enhance patient care and organizational performance.

By providing this detailed and structured training on ROM 4, hospitals can ensure they have strong and accountable leadership at the helm, driving effective day-to-day operations, ensuring compliance, and contributing to the overall success and sustainability of the organization.

Standard ROM 5: The organisation displays professionalism in its functioning.

Introduction to ROM 5:

ROM 5 shifts the focus from specific governance structures and leadership roles (ROM 1-4) to the overall operational culture and functioning of the hospital. It emphasizes that to achieve accreditation and deliver high-quality care, a hospital must demonstrate professionalism in all aspects of its operations. This standard is about ensuring a structured, planned, coordinated, and continuously improving organizational approach to healthcare delivery.

Rationale and Importance of ROM 5:

• Ensuring Consistent Quality and Safety: Professionalism in functioning translates to consistent and reliable processes, leading to predictable quality of care and enhanced patient safety. Standardized procedures, clear communication, and proactive planning minimize errors and variations in service delivery.

• Optimizing Efficiency and Resource Utilization: A professional organization operates efficiently, minimizing waste, optimizing resource allocation, and improving productivity. This is crucial for financial sustainability and effective use of limited healthcare resources.

• Enhancing Stakeholder Confidence: Patients, staff, referring physicians, and the community gain confidence in a hospital that demonstrates professionalism in its functioning. This builds trust, strengthens relationships, and enhances the hospital's reputation.

• Promoting a Culture of Excellence: Professionalism fosters a culture of excellence within the hospital. It encourages staff to adhere to high standards, continuously improve processes, and take pride in their work.

• Facilitating Strategic Goals Achievement: A professionally run organization is better positioned to achieve its strategic goals and objectives. Structured planning, coordinated efforts, and performance monitoring ensure that the hospital is moving in the right direction and effectively implementing its strategy.

• Adaptability and Resilience in a Dynamic Environment: Professionalism includes the ability to adapt to change and respond effectively to challenges. A well-functioning organization has systems in place for change management, risk mitigation, and business continuity, making it more resilient in a dynamic healthcare landscape.

Key Elements of ROM 5 (Detailed Breakdown for Training):

ROM 5 encompasses several key elements that contribute to demonstrating professionalism in hospital functioning. These elements are further elaborated in the objective elements (ROM 5a through ROM 5f). Let's break down the core components:

1. Strategic and Operational Planning:

• Explanation: Professionalism starts with planning. ROM 5 emphasizes the importance of having well-defined strategic and operational plans that guide the hospital's direction and activities. These plans should be aligned with the hospital's vision, mission, and values and developed in consultation with stakeholders.

• NABH Perspective: NABH expects hospitals to have documented strategic and operational plans that are comprehensive, regularly reviewed, and actively used to manage the organization. These plans should demonstrate a structured and forward-looking approach to hospital management.

• Key Aspects of Strategic and Operational Plans (as per Slide 45 & 46):

  • Strategic Plan (Long-Term Focus):

    • Focus: Aligned with Vision and Mission, Organization-level goals, Internal and External Scan.

    • Time Frame: Typically Three to Five Years.

    • Developed By: Organization Leader (with input from senior management and governance).

    • Budget: Strategic Budget (allocating resources for strategic initiatives).

    • Timeframe for Reporting: Annually and Quarterly (to track progress against strategic goals).

    • Report To: Strategic Planning Committee or Executive Team (for review and oversight).

  • Operational Plan (Annual Focus):

    • Focus: Department-level goals, translating strategic goals into annual operational objectives.

    • Time Frame: Annually (reviewed and updated each year).

    • Developed By: Department Leader (aligned with overall operational plan and strategic direction).

    • Budget: Annual Budget (departmental budget aligned with operational plan).

    • Timeframe for Reporting: Monthly (to monitor progress against operational targets).

    • Report To: Department Leader's Supervisor or relevant operational review committee.

  • Consultation with Stakeholders: Both strategic and operational plans should be developed in consultation with various stakeholders (as highlighted on Slide 45). Stakeholders (Points to Remember on Slide 46) are defined as the community the organization serves, and inputs to be considered in planning include:

    • Findings of risk management plan.

    • Patient safety goals.

    • Results of facility rounds.

  • Note on Strategic Plans (Slide 45): Strategic plans can be used to maintain the current level of operations, not just for growth or expansion. This highlights that planning is essential even for stability and continuous improvement.

2. Coordination and Monitoring of Progress:

• Explanation: Professional functioning requires effective coordination between different departments and external agencies involved in hospital operations. Furthermore, it necessitates monitoring the progress in achieving defined goals and objectives outlined in the strategic and operational plans.

• NABH Perspective: NABH expects hospitals to demonstrate mechanisms for coordination and monitoring to ensure that plans are being implemented effectively and that organizational goals are being achieved.

• Key Aspects of Coordination and Monitoring (as per Slide 47):

  • Goals and Objectives should be:

    • Drawn from Strategic and Operational Plans: Coordination and monitoring efforts should be focused on achieving the goals and objectives outlined in the hospital's plans.

    • Consistent with Mission and Values: Goals and objectives should align with the hospital's overarching mission and values, ensuring ethical and patient-centered direction.

    • Have Measurable Outcomes: Goals and objectives must be measurable to allow for effective monitoring of progress and performance evaluation.

  • What if a Goal is Not Achieved? (as per Slide 47): Professionalism includes a process for addressing situations where goals are not met:

    • Analyse Reason for Not Achieving the Goal: Conduct a thorough analysis to understand the root causes of why a goal was not achieved. This might involve reviewing processes, identifying barriers, and assessing resource allocation.

    • Conduct Periodic Review and/or Formal Management Review Meetings: Regularly review progress towards goals and objectives. This can be done through periodic performance reviews at departmental and organizational levels, and through formal management review meetings (as also mentioned in ROM 5d related to committees).

    • Take Appropriate Action: Based on the analysis and review, take appropriate corrective actions to address the reasons for not achieving the goal and implement preventive actions to avoid recurrence.

3. Planning and Budgeting for Activities:

• Explanation: Professional functioning requires a structured approach to planning and budgeting for all hospital activities. This ensures that activities are aligned with strategic and operational plans and that resources are allocated effectively to support these activities.

• NABH Perspective: NABH expects hospitals to demonstrate a systematic approach to annual planning and budgeting, aligning financial resources with planned activities and ensuring financial accountability.

• Key Aspects of Planning and Budgeting (as per Slide 48):

  • Plan Activities:

    • Based on Strategic and Operational Plans: Annual planning of activities should be directly derived from the hospital's strategic and operational plans, ensuring alignment with organizational goals.

  • Budget:

    • Include Review of Budgeted Expenditure against Actual Expenditure: The budgeting process should include a mechanism for reviewing and comparing budgeted expenditure with actual expenditure, allowing for variance analysis and financial control.

    • Allocate Funds for Infection Control and Quality Improvement Activities: Budgeting should specifically allocate funds for essential functions like infection control and quality improvement activities, demonstrating a commitment to patient safety and quality.

    • Calendar or Financial Year Basis: Planning and budgeting can be done on a calendar year basis (January-December) or a financial year basis (April-March), depending on organizational preference and regulatory requirements.

  • Organization Responsibilities:

    • Define and Follow Responsibilities for Planning and Budgeting: Clearly define and document the responsibilities of individuals and departments involved in the planning and budgeting process. This ensures accountability and a structured approach to financial management.

4. Review of Committee Functioning:

• Explanation: Hospitals rely heavily on committees for various functions (e.g., quality improvement, infection control, ethics, pharmacy and therapeutics). Professionalism includes regularly reviewing the functioning of these committees to ensure their effectiveness and contribution to organizational goals.

• NABH Perspective: NABH expects hospitals to demonstrate a system for monitoring and evaluating the effectiveness of committees, ensuring they are fulfilling their purpose and contributing to quality and safety improvement.

• Key Aspects of Committee Functioning Review (as per Slide 49):

  • Management Review: Committee functioning review is considered a part of overall management review.

  • Questions to Consider in Review: The review process should address key questions to assess committee effectiveness:

    • Is the purpose of having a committee being met? Evaluate if the committee is achieving its intended objectives and mandate.

    • Does the committee meet at the prescribed frequency? Check if the committee is meeting as per its established schedule and terms of reference.

    • Are remedial measures suggested in the meeting? Assess if committee meetings are action-oriented, identifying issues and suggesting remedial measures.

    • Is there adequate monitoring of CAPA taken? Evaluate if the committee effectively monitors the implementation of Corrective and Preventive Actions (CAPA) arising from its discussions and recommendations.

  • Points to Remember - Ensuring Effective Management Review (Slide 49): Organizations can ensure effective management review of committees by documenting:

    • Scope of Every Committee: Clearly define and document the scope and mandate of each committee in its terms of reference.

    • Roles and Responsibilities of Committee Members: Define the roles and responsibilities of committee members to ensure accountability and effective participation.

    • Frequency of Meetings: Establish and document the planned frequency of committee meetings in the terms of reference.

    • Minutes of Meeting: Maintain detailed and accurate minutes of committee meetings to document discussions, decisions, action items, and recommendations.

5. Documentation of Service Standards:

• Explanation: Professionalism in service delivery includes defining and documenting service standards that are measurable and reflect the organization's commitment to quality patient care. These standards provide benchmarks for performance and help ensure consistent service delivery.

• NABH Perspective: NABH expects hospitals to have documented service standards that are measurable, communicated to staff, and monitored for performance. This demonstrates a commitment to defined quality levels and continuous improvement.

• Key Aspects of Service Standards (as per Slide 50):

  • Based on Organisation's Values: Service standards should be aligned with the hospital's core values, reflecting its commitment to patient-centered care, ethical practices, and quality.

  • Develop Benchmark for Services Provided: Establish benchmarks or targets for key service parameters to define expected levels of performance. These benchmarks should be realistic, measurable, and aligned with best practices.

  • Measurable Service Standards: Service standards must be defined in measurable terms to allow for objective monitoring and performance assessment. Examples of measurable aspects include:

    • Waiting times (e.g., OPD waiting time, emergency room response time).

    • Turnaround times (e.g., lab test turnaround time, report generation time).

    • Patient satisfaction scores.

    • Response times (e.g., call answering time, bed allocation time).

    • Process completion rates (e.g., medication reconciliation completion rate).

  • 
    

  • Monitoring Service Standards: Implement a system for regularly monitoring performance against documented service standards. This involves data collection, analysis, and reporting.

  • Note on Responsibility and Frequency (Slide 50): The organization should decide and document the responsibility for monitoring service standards and the frequency of monitoring (e.g., daily, weekly, monthly, quarterly).

6. Systems and Processes for Change Management:

• Explanation: Hospitals operate in a constantly changing environment (technological advancements, evolving regulations, changing patient needs). Professional functioning requires having systems and processes in place for effective change management. This ensures that changes are implemented smoothly, minimizing disruption and maximizing positive outcomes.

• NABH Perspective: NABH expects hospitals to demonstrate a proactive and structured approach to managing change, ensuring that changes are well-planned, communicated, and effectively implemented.

• Key Aspects of Change Management (as per Slide 51):

  • Types of Changes to Manage: Change management systems should be designed to address various types of changes within the hospital, including:

    • Operational Changes: Changes in processes, workflows, service delivery models.

    • Financial Changes: Changes in budgets, financial systems, revenue models.

    • Departmental Changes: Restructuring, merging, or creating new departments.

    • Succession Planning: Leadership changes, promotions, retirements.

    • Change in Leadership: Changes at the top leadership level (CEO, Director, etc.).

  • Key Elements of Change Management Process: Effective change management processes typically involve:

    • Communication: Clear and timely communication about the need for change, the nature of the change, and its impact on stakeholders.

    • Ownership: Establishing clear ownership and accountability for managing the change process.

    • Organisation Culture: Considering the organizational culture and adapting change management strategies to fit the culture. A culture that is resistant to change will require a different approach compared to a culture that is more adaptable.

  • Phases of Change Management: A structured change management process often follows phases like:

    • Planning: Defining the change, setting goals, identifying stakeholders, developing a communication plan.

    • Implementation: Executing the change plan, providing training and support, addressing resistance.

    • Monitoring and Evaluation: Tracking progress, measuring the impact of the change, making adjustments as needed.

    • Sustaining Change: Ensuring that the change is embedded in the organization and becomes part of the new normal.

Detailed Breakdown of ROM 5 Objective Elements (ROM 5a - ROM 5f) for Training:

Let's examine each Objective Element (OE) of ROM 5 to understand the specific requirements:

ROM 5a: The organisation has strategic and operational plans, including long-term and short-term goals commensurate to the organisation's vision, mission and values in consultation with the various stakeholders. (C)

• Standard Statement: This OE emphasizes the existence of strategic and operational plans that are aligned with vision, mission, values and developed in consultation with stakeholders. It is a Commitment Level OE (C).

• Detailed Explanation: This OE reinforces the planning aspect of professionalism. It's not just about having plans, but ensuring they are strategic, operational, aligned with core organizational principles, and developed inclusively.

• Implementation Strategies & Best Practices:

  • Develop Formal Strategic and Operational Plans: Create documented strategic and operational plans, as outlined in the "Strategic and Operational Planning" section above.

  • Alignment with Vision, Mission, Values: Explicitly link the goals and objectives in both plans to the hospital's vision, mission, and values. Demonstrate how the plans support the organization's core purpose and ethical framework.

  • Stakeholder Consultation Process: Document the process used for stakeholder consultation during plan development. This could include:

    • Surveys

    • Focus groups

    • Workshops

    • Meetings with stakeholder representative

  • Note on Strategic Plan Usage (Slide 45): Emphasize that strategic plans can be used to maintain current operations, not just for growth. Planning is valuable even for stability and continuous improvement.

• Documentation Examples:

  • Documented Strategic Plan (showing alignment with vision, mission, values and evidence of stakeholder consultation).

  • Documented Operational Plan (showing alignment with strategic plan and stakeholder input).

  • Records of stakeholder consultation activities (meeting minutes, survey reports).

ROM 5b: The organisation coordinates the functioning with departments and external agencies and monitors the progress in achieving the defined goals and objectives. (C)

• Standard Statement: This OE focuses on coordination and monitoring of progress. It is a Commitment Level OE (C), however, note that the slide mentions "Objective element changed from achievement to commitment." This might indicate a change in emphasis or interpretation between editions.

• Detailed Explanation: This OE highlights the operational effectiveness aspect of professionalism. It's about ensuring smooth functioning through coordination and actively tracking progress towards organizational goals.

• Implementation Strategies & Best Practices:

  • Establish Coordination Mechanisms: Implement mechanisms to facilitate coordination between departments and with external agencies. This could include:

    • Regular interdepartmental meetings

    • Cross-functional teams for specific projects

    • Defined communication channels and protocols

    • Service Level Agreements (SLAs) with external agencies (for outsourced services, etc.)

  • Implement Performance Monitoring System: Set up a system for monitoring progress against defined goals and objectives. This should include:

    • Key Performance Indicators (KPIs) tracking

    • Regular performance reports

    • Performance review meetings at departmental and organizational levels

  • Address Goal Achievement Issues (as per Slide 47): Establish a process for analyzing reasons for not achieving goals, conducting reviews, and taking appropriate action (as discussed in "Coordination and Monitoring of Progress" section above).

• Documentation Examples:

  • Examples of coordination mechanisms (meeting schedules, communication protocols).

  • Performance monitoring reports showing progress against goals and objectives.

  • Minutes of performance review meetings and action plans arising from these reviews.

  • Service Level Agreements (SLAs) with key external agencies (if applicable).

ROM 5c: The organisation plans and budgets for its activities annually. (C)

• Standard Statement: This OE focuses on annual planning and budgeting. It is a Commitment Level OE (C).

• Detailed Explanation: This OE emphasizes the financial management aspect of professionalism. It ensures that activities are planned and resourced through a structured annual budgeting process.

• Implementation Strategies & Best Practices:

  • Develop Annual Activity Plan: Create a documented annual activity plan that outlines the key activities planned for the upcoming year, aligned with strategic and operational plans.

  • Annual Budgeting Process: Implement a formal annual budgeting process that includes:

    • Budget preparation by departments

    • Consolidation of departmental budgets into an organizational budget

    • Review and approval of the budget by governance or senior management

    • Budget allocation and management

    • Variance analysis and budget monitoring throughout the year

  • Allocate Funds for Key Areas: Ensure budget allocation includes specific funds for essential areas like infection control and quality improvement activities (as highlighted on Slide 48).

  • Define Planning and Budgeting Responsibilities (as per Slide 48): Clearly define and document the responsibilities of individuals and departments involved in the planning and budgeting process.

• Documentation Examples:

  • Documented Annual Activity Plan.

  • Documented Annual Budget (approved version).

  • Budgeting process documentation (policy or procedure).

  • Variance analysis reports comparing budgeted and actual expenditure.

ROM 5d: The functioning of committees is reviewed for their effectiveness. (A)

• Standard Statement: This OE focuses on reviewing committee effectiveness. It is an Achievement Level OE (A), indicating a higher level of performance expectation.

• Detailed Explanation: This OE emphasizes the performance measurement and improvement aspect of professionalism, specifically applied to the crucial function of hospital committees. It's not enough to just have committees; their effectiveness must be actively assessed and improved.

• Implementation Strategies & Best Practices:

  • Establish a Committee Review Process: Develop a documented process for regularly reviewing the functioning and effectiveness of hospital committees. This process should include:

    • Defined review frequency (e.g., annually).

    • Criteria for evaluating effectiveness (aligned with questions on Slide 49: purpose met, meeting frequency, remedial measures, CAPA monitoring).

    • Responsibility for conducting reviews (e.g., designated committee, senior management).

  • Use Points to Remember Checklist (Slide 49): Utilize the "Points to Remember" checklist on Slide 49 (Scope, Roles, Frequency, Minutes) as a framework for evaluating committee effectiveness. Ensure these elements are well-defined and documented for each committee.

  • Action Plan for Improvement: Based on the committee review, develop action plans to address any identified weaknesses and improve committee effectiveness.

  • Management Review Integration (Slide 49): Integrate committee effectiveness review into the overall management review system of the hospital.

• Documentation Examples:

  • Documented process for reviewing committee effectiveness.

  • Terms of Reference for key hospital committees (clearly defining scope, roles, frequency).

  • Minutes of committee meetings (demonstrating meeting frequency, discussions, action items).

  • Committee effectiveness review reports and action plans for improvement.

ROM 5e: The organisation documents the service standards that are measurable and monitors them. (C)*

• Standard Statement: This OE focuses on documented and monitored service standards. The asterisk (*) and (C) designation highlight its Core Objective Element status, requiring mandatory system documentation.

• Detailed Explanation: This is a critical OE emphasizing the service quality aspect of professionalism. It mandates the formal documentation and active monitoring of measurable service standards to ensure consistent and defined levels of service delivery.

• Implementation Strategies & Best Practices:

  • Identify Key Services: Identify key services provided by the hospital that are critical for patient care and have a significant impact on patient experience.

  • Develop Measurable Service Standards: For each key service, develop specific, measurable, achievable, relevant, and time-bound (SMART) service standards. Examples of measurable parameters were provided in the "Documentation of Service Standards" section above.

  • Document Service Standards: Formally document the defined service standards in a policy or procedure document.

  • Implement Monitoring System: Establish a system for regularly monitoring performance against the documented service standards. This system should include:

    • Data collection methods (e.g., audits, patient feedback, process tracking).

    • Data analysis and reporting mechanisms.

    • Responsibility for monitoring and reporting.

    • Defined frequency of monitoring.

  • Note on Responsibility and Frequency (Slide 50): Document the responsibility for monitoring service standards and the frequency of monitoring.

• Documentation Examples:

  • Documented Service Standards (policy or procedure document).

  • Service standard monitoring reports showing performance data against benchmarks.

  • Responsibility and frequency of monitoring documented.

ROM 5 f: Systems and processes are in place for change management. (E)

• Standard Statement: This OE focuses on change management systems and processes. It is an Excellence Level OE (E), indicating a higher level of aspiration and best practice.

• Detailed Explanation: This OE emphasizes the adaptability and resilience aspect of professionalism. It encourages hospitals to go beyond reactive responses to change and proactively establish systems for managing change effectively and strategically.

• Implementation Strategies & Best Practices:

  • Develop a Change Management Framework: Create a formal change management framework or policy document that outlines the hospital's approach to managing change. This framework should include:

    • Principles of change management.

    • Phases of change management (planning, implementation, monitoring, sustaining).

    • Roles and responsibilities for change management.

    • Communication strategies for change initiatives.

  • Establish Change Management Processes: Develop specific processes and procedures for managing different types of changes (operational, financial, departmental, leadership). These processes should be aligned with the change management framework.

  • Consider Key Elements of Change Management (Slide 51): Ensure that change management systems and processes incorporate key elements like communication, ownership, and consideration of organizational culture.

  • Training on Change Management: Provide training to staff and leaders on change management principles and processes to build organizational capacity for managing change effectively.

• Documentation Examples:

  • Documented Change Management Framework or Policy.

  • Change management processes and procedures for different types of changes.

  • Examples of change management plans for specific change initiatives.

  • Records of change management training conducted.

Common Challenges and Pitfalls in Implementing ROM 5:

• Lack of Strategic and Operational Planning: Hospitals may operate without well-defined strategic and operational plans, leading to reactive management and lack of direction.

• Weak Coordination and Communication: Poor coordination between departments and ineffective communication can hinder smooth functioning and goal achievement.

• Inadequate Budgeting Processes: Lack of structured annual budgeting processes and insufficient financial control can lead to financial instability and inefficient resource allocation.

• Ineffective Committee Functioning: Committees may be ineffective due to unclear mandates, lack of member engagement, poor meeting management, or failure to follow up on action items.

• Undefined or Unmonitored Service Standards: Hospitals may not have documented service standards or may fail to actively monitor performance against these standards, resulting in inconsistent service delivery.

• Resistance to Change and Lack of Change Management Systems: Organizations may resist change or lack formal systems for managing change, leading to disruptions and ineffective implementation of new initiatives.

• "Siloed" Approach: Departments may operate in silos, hindering coordination and integrated planning across the organization.

• Lack of Data-Driven Decision Making: Decisions may be made based on intuition or past practices rather than on data and performance monitoring, limiting the ability to improve and optimize processes.

Key Takeaways and Actionable Steps for ROM 5 Training:

• Professionalism is a Culture: Emphasize that professionalism is not just about individual actions but about building an organizational culture that values structure, planning, coordination, measurement, and continuous improvement.

• Planning is Foundational: Highlight the critical importance of strategic and operational planning as the foundation for professional functioning.

• Measure Performance and Drive Improvement: Stress the need for robust performance monitoring systems, including service standards monitoring and committee effectiveness reviews, to drive continuous improvement.

• Coordination and Communication are Essential: Promote effective coordination mechanisms and clear communication channels to ensure smooth functioning across departments and with external agencies.

• Budgeting Aligns Resources with Plans: Emphasize the importance of structured annual budgeting to align financial resources with planned activities and ensure financial responsibility.

• Change Management for Adaptability: Highlight the need for change management systems to enable the hospital to adapt to a dynamic environment and implement changes effectively.

• Documentation Demonstrates Professionalism: Reinforce that documentation is crucial to demonstrate professionalism and compliance with ROM 5 requirements.

• Professional Functioning Benefits Everyone: Frame ROM 5 not just as an accreditation requirement but as a pathway to a more efficient, effective, safer, and higher-quality hospital environment that benefits patients, staff, and the community.

By providing this detailed and structured training on ROM 5, hospitals can move beyond basic operational compliance towards building a truly professional organization, characterized by structured processes, data-driven decision-making, continuous improvement, and a commitment to excellence in all aspects of healthcare delivery.

Standard ROM 6: Leadership ensures that patient safety aspect and risk management issues are an integral part of patient care and hospital management.

Introduction to ROM 6:

ROM 6 culminates the ROM chapter by focusing on the pinnacle of effective hospital management: integrating patient safety and risk management into the very fabric of patient care and overall hospital operations. This standard emphasizes that patient safety and risk management are not separate initiatives or add-on programs, but rather fundamental perspectives that must be embedded in all leadership decisions, operational processes, and clinical practices. ROM 6 underscores that leadership is ultimately accountable for creating and maintaining a culture of safety and proactively managing risks to protect patients and the organization.

Rationale and Importance of ROM 6:

• Patient Safety as the Prime Directive: Patient safety is the paramount ethical and operational imperative for any healthcare organization. ROM 6 reinforces that leadership's primary responsibility is to ensure patient safety and minimize the risk of harm to patients throughout their care journey.

• Proactive Risk Prevention and Mitigation: ROM 6 promotes a proactive approach to risk management, shifting from reactive responses to adverse events to actively identifying, assessing, and mitigating risks before they impact patients. This preventative mindset is crucial for creating a safer environment.

• Holistic Integration, Not Siloed Approach: ROM 6 stresses the integration of patient safety and risk management. This means these considerations should not be confined to dedicated departments or committees but must be woven into the daily work of every department, service, and individual within the hospital.

• Leadership Accountability for Safety Culture: Leadership sets the tone for organizational culture. ROM 6 places direct accountability on leadership to cultivate a culture of safety, where patient safety is prioritized, risks are openly discussed, errors are learned from, and continuous improvement is embraced.

• Improving Quality of Care: Effective risk management and a focus on patient safety directly contribute to improved quality of care. By minimizing errors, preventing adverse events, and optimizing processes, hospitals can enhance patient outcomes and overall service delivery.

• Protecting the Organization: Beyond patient well-being, proactive risk management also protects the hospital itself. It mitigates financial risks (legal liabilities, insurance costs), reputational risks (loss of trust, negative publicity), and operational risks (service disruptions, staff morale issues).

• Meeting Ethical and Regulatory Expectations: Patients and regulatory bodies increasingly expect hospitals to prioritize patient safety and demonstrate robust risk management systems. ROM 6 ensures that NABH standards align with these evolving expectations.

Key Elements of ROM 6 (Detailed Breakdown for Training):

ROM 6 focuses on how leadership ensures the integration of patient safety and risk management. The objective elements (ROM 6a through ROM 6f) elaborate on the key actions and systems required. Let's break down the core components:

1. Proactive Risk Management Across the Organisation:

• Explanation: ROM 6 emphasizes proactive risk management as a fundamental leadership responsibility. This means going beyond reactive incident reporting and establishing a system for continuously identifying, assessing, and managing risks across all areas of the hospital, both clinical and non-clinical.

• NABH Perspective: NABH expects hospitals to demonstrate a comprehensive and proactive risk management plan that is actively implemented, regularly reviewed, and drives continuous improvement in safety and risk mitigation.

• Key Components of Proactive Risk Management (as per Slide 54):

  • Identify Risks:

    • Clinical Risks: Risks directly related to patient care processes, medical treatments, and clinical interventions. Examples from Slide 55: Medication errors, infections, surgical complications, diagnostic errors, equipment malfunctions, risks related to specific procedures or patient conditions.

    • Non-Clinical Risks: Risks that are not directly clinical but can impact patient safety, organizational operations, and financial stability. Examples from Slide 54: Strategic risks (market changes, competition), financial risks (revenue loss, budget overruns), operational risks (supply chain disruptions, IT system failures), hazard risks (fire, natural disasters, security breaches).

    • Systematic Identification: Risk identification should be systematic and ongoing, not ad-hoc. Methods include:

      • Brainstorming sessions with staff from different departments.

      • Review of incident reports and near misses.

      • Analysis of patient safety data and quality indicators.

      • Environmental scans to identify emerging risks.

• • Assess Risks:

    • Determine Likelihood of Occurrence: Evaluate the probability or frequency of each identified risk occurring. This can be qualitative (e.g., low, medium, high likelihood) or quantitative (e.g., probability percentage).

    • Analyse Potential Severity of Impact or Consequence: Assess the potential harm or negative impact if the risk materializes. This can also be qualitative (e.g., minor, moderate, severe impact) or quantitative (e.g., financial loss, number of patients affected).

    • Risk Assessment Matrix: Use a risk assessment matrix (likelihood vs. severity) to prioritize risks based on their overall risk level (e.g., high-risk, medium-risk, low-risk). This helps focus resources on managing the most significant risks.

• • Manage Risks:

    • Prioritise Risks: Focus on managing high-priority risks first, based on the risk assessment.

    • Take Actions to Alleviate These Risks: Implement risk mitigation strategies and controls to reduce the likelihood or severity of prioritized risks. These actions can include:

      • Preventive Controls: Actions taken to prevent the risk from occurring in the first place (e.g., implementing standardized protocols, staff training, equipment maintenance).

      • Detective Controls: Actions taken to detect if a risk has occurred or is about to occur (e.g., monitoring systems, audits, incident reporting).

      • Corrective Controls: Actions taken to correct the situation after a risk has materialized and to mitigate its consequences (e.g., incident investigation, root cause analysis, corrective action implementation).

    • Develop Contingency Plans: For significant risks, develop contingency plans to manage the situation effectively if the risk does occur, minimizing negative impact and ensuring business continuity. Example from Slide 62: Service Continuity Plan.

    • Educate and Train Staff: Provide training to staff on risk management principles, identified risks relevant to their areas, and risk mitigation strategies. Promote a culture of risk awareness and proactive risk management among all staff.

  • Risk Register (Note on Slide 54): Maintain a Risk Register to document all identified risks, their assessments, mitigation strategies, responsible individuals, and monitoring status. The Risk Register is a crucial documentation tool for ROM 6a (Core OE). It should be regularly updated (at regular intervals) to reflect changes in risks and mitigation efforts.

2. Providing Resources for Proactive Risk Assessment and Risk Reduction:

• Explanation: Proactive risk management requires resources. ROM 6 emphasizes that leadership must provide adequate resources to support risk assessment and risk reduction activities. This demonstrates a commitment to safety and enables effective risk management implementation.

• NABH Perspective: NABH expects hospitals to allocate sufficient resources (financial, human, technological) to support their risk management program. This resource allocation should be demonstrable and aligned with the identified risk priorities.

• Types of Resources to Provide (as per Slide 59):

  • Financial Resources: Budget allocation for:

    • Risk assessment tools and technologies.

    • Risk management training programs.

    • Implementation of risk mitigation measures (e.g., equipment upgrades, process improvements).

    • Contingency planning and emergency preparedness.

  • Human Resources:

    • Designating a Risk Management Officer or team to oversee and coordinate risk management activities.

    • Allocating staff time for risk assessments, training, and implementation of mitigation strategies.

    • Establishing risk management committees or working groups.

  • Technological Resources:

    • Risk management software and tools for risk register management, incident reporting, data analysis, and risk assessment.

    • Technology to support risk mitigation measures (e.g., medication safety systems, infection control monitoring systems).

  • Keep Sufficient Resources as Contingency (Slide 59): Emphasize the importance of setting aside resources as contingency for unexpected risks and potential adverse events.

  • Note on Preventive Actions (Slide 59): Resources should be primarily used to take preventive actions whenever feasible, as prevention is always more effective and cost-efficient than reactive responses.

3. Ensuring Integration Between Quality Improvement, Risk Management, and Strategic Planning:

• Explanation: ROM 6 emphasizes the integration of risk management with other key organizational functions, particularly quality improvement and strategic planning. This integration ensures a holistic and coordinated approach to organizational performance and safety.

• NABH Perspective: NABH expects hospitals to demonstrate that risk management is not a standalone function but is actively linked to and informs quality improvement initiatives and strategic decision-making.

• Integration Points (as per Slide 60):

  • Risk Management informs Strategic Planning:

    • Risk assessment findings should be considered during strategic planning to identify potential risks and opportunities related to strategic goals.

    • Strategic plans should incorporate risk mitigation strategies and contingency plans to address identified strategic risks.

  • Risk Management informs Quality Improvement:

    • Risk assessment findings should be used to identify areas for quality improvement initiatives.

    • Quality improvement activities should aim to reduce identified risks and improve patient safety outcomes.

    • Incident reports, sentinel events, and near misses (risk management data) should be used to identify areas for quality improvement and process redesign.

  • Visual Representation (Slide 60): The slide visually depicts the interconnectedness of Strategic Plan, Risk Management Aspects, and Quality Improvement, highlighting the need for these functions to work in synergy.

4. Ensuring Implementation of Systems for Internal and External Reporting of System and Process Failures:

• Explanation: Open and effective reporting systems are crucial for learning from errors, identifying systemic issues, and driving improvement. ROM 6 mandates the implementation of systems for both internal and external reporting of system and process failures that could impact patient safety.

• NABH Perspective: NABH expects hospitals to have well-defined and accessible reporting systems that encourage staff to report errors, near misses, and system failures without fear of reprisal. These systems should facilitate both internal learning and, where appropriate, external reporting to relevant authorities.

• Reporting Systems for System and Process Failures (as per Slide 61 & 62):

  • When System and Process Fails:

    • Perform Internal Reporting: Establish a clear process for internal reporting of system and process failures. Example from Slide 61: MRI machine breakdown - internal reporting to head of department.

    • Perform External Reporting: Define situations where external reporting is required to regulatory bodies, patients, or other stakeholders. Example from Slide 61: Radiation source incident - external reporting to AERB (Atomic Energy Regulatory Board).

    • Document System for Reporting: Document the internal and external reporting systems, including reporting channels, timelines, responsible individuals, and escalation pathways.

  • When Failure is Anticipated:

    • Develop Contingency Plan to Deal with the Situation: For critical systems and processes, develop contingency plans to address anticipated failures and maintain service continuity. Example: Service Continuity Plan (Slide 62).

  • Service Continuity Plan (Slide 62): The Service Continuity Plan (SCP) is a key element of ROM 6d and is designed to:

    • Maintain Service Continuity of Critical Operations: Ensure essential services continue to be delivered during disruptions.

    • Improve Organisation's Ability to Respond During Fire and Non-Fire Emergencies: Enhance preparedness for and response to various emergencies.

    • Ensure Non-Failure of Critical Systems and Services: Implement measures to prevent failures of critical systems and services.

    • Ensure Recovery of Failed System/Service within Minimum Timeframe: Establish procedures for rapid recovery and restoration of failed systems and services.

    • Testing of Service Continuity Plan (Slide 62): The SCP must be regularly tested (at regular intervals) through drills and simulations to validate its effectiveness and identify areas for improvement.

  • Points to Remember - Examples of Reporting (Slide 61): Use the examples on Slide 61 (MRI breakdown, Radiation Source) during training to illustrate the difference between internal and external reporting requirements.

5. Ensuring Documented Agreements for All Outsourced Services:

• Explanation: Hospitals increasingly rely on outsourced services for various functions. ROM 6 emphasizes the importance of managing risks associated with outsourcing by ensuring that documented agreements are in place for all outsourced services. These agreements should clearly define service parameters and responsibilities.

• NABH Perspective: NABH expects hospitals to have formal agreements with all outsourced service providers, demonstrating due diligence in managing risks associated with external dependencies.

• Key Aspects of Outsourced Service Agreements (as per Slide 63):

  • Agreement for All Outsourced Services: Ensure that documented agreements are in place for all outsourced services, including clinical and non-clinical services. This includes agreements with group or affiliate concerns providing services.

  • Include Service Parameters: Agreements must clearly define key service parameters to ensure quality and accountability. These parameters should include:

    • Quality: Expected quality standards for the outsourced service (e.g., performance metrics, quality indicators).

    • Numbers: Volume or quantity of service to be provided (e.g., number of tests, staffing levels).

    • Reports: Reporting requirements from the outsourced provider (e.g., performance reports, incident reports).

    • Timelines: Agreed timelines for service delivery, response times, and reporting.

  • Include Agreed Dispute Resolution Mechanisms: Agreements should include mechanisms for resolving disputes that may arise between the hospital and the outsourced service provider.

  • Note on Management Agreement (Slide 63): The management should have an agreement with all outsourced units, even those within the same group or affiliate concern, to ensure formalization and accountability.

6. Monitoring the Quality of Outsourced Services and Making Improvements:

• Explanation: Simply having agreements is not enough. ROM 6 requires leadership to actively monitor the quality of outsourced services and ensure that improvements are made as required. This ongoing monitoring and improvement cycle is essential for managing risks associated with outsourcing and ensuring consistent service quality.

• NABH Perspective: NABH expects hospitals to demonstrate a system for monitoring the quality of outsourced services and taking action to address any performance issues or areas for improvement.

• Key Aspects of Monitoring Outsourced Service Quality (as per Slide 64):

  • Determine Frequency of Monitoring: Establish a frequency for monitoring outsourced service quality. The frequency should be based on:

    • Criticality of Service in Providing Patient Care: Services that are more critical to patient care (e.g., lab services, radiology services) should be monitored more frequently.

  • Monitor Quality of Service Provided: Implement a system for monitoring the quality of outsourced services based on:

    • Service Standards Laid Down by Organisation: Use the service standards defined in the outsourced service agreement as benchmarks for monitoring performance.

  • Improve Quality of Service Provided:

    • Work with Vendor to Achieve Agreed Service Parameters: If monitoring reveals performance issues, work collaboratively with the vendor to identify root causes, implement corrective actions, and improve service quality to meet agreed-upon parameters.

  • Points to Remember - Frequency and Statutory Basis (Slide 64):

    • Frequency of Monitoring should not be less than a year: At a minimum, outsourced service quality should be monitored annually, but more frequent monitoring may be needed for critical services.

    • Outsourcing Based on Statutory Norms (Exception): If outsourcing is done strictly based on statutory norms and regulations (and the hospital has limited control over the vendor selection or service parameters), then it may not be mandatory to monitor the quality of these services. However, this is a narrow exception and generally, monitoring is expected for all outsourced services that directly or indirectly impact patient care.

Detailed Breakdown of ROM 6 Objective Elements (ROM 6a - ROM 6f) for Training:

Let's examine each Objective Element (OE) of ROM 6 to understand the specific requirements:

ROM 6a: Leadership ensures proactive risk management across the organisation. (CO)*

• Standard Statement: This OE emphasizes proactive risk management and its organization-wide scope. The asterisk (*) and (CO) designation highlight its Core Objective Element status, requiring mandatory system documentation.

• Detailed Explanation: This is the foundational OE of ROM 6, mandating the implementation of a comprehensive and proactive risk management program across the entire hospital, overseen and ensured by leadership.

• Implementation Strategies & Best Practices: Implement all the key components of proactive risk management outlined in the "Proactive Risk Management Across the Organization" section above (Identify, Assess, Manage risks, Risk Register, Monitor and Review, Communicate).

• Documentation Examples:

  • Documented Risk Management Plan (comprehensive and organization-wide).

  • Risk Register (regularly updated and maintained).

  • Risk assessment reports and matrices.

  • Risk mitigation action plans.

  • Minutes of risk management committee meetings (if applicable).

  • Reports on annual review of risk management plan effectiveness.

  • Communication matrix and examples of risk communication to stakeholders.

ROM 6b: Leadership provides resources for proactive risk assessment and risk reduction activities. (C)

• Standard Statement: This OE focuses on resource provision for risk management. It is a Commitment Level OE (C).

• Detailed Explanation: This OE ensures that the proactive risk management program is not just a paper exercise but is supported by adequate resources to be effective.

• Implementation Strategies & Best Practices: Allocate and provide the different types of resources mentioned in the "Providing Resources for Proactive Risk Assessment and Risk Reduction" section above (financial, human, technological). Demonstrate this resource allocation in budget documents and resource allocation plans.

• Documentation Examples:

  • Budget documents showing allocation of funds for risk management activities.

  • Organizational chart showing designated Risk Management Officer/team.

  • Examples of resources allocated (e.g., software licenses, training budgets).

ROM 6c: Leadership ensures integration between quality improvement, risk management and strategic planning within the organisation. (C)

• Standard Statement: This OE emphasizes integration of risk management with quality improvement and strategic planning. It is a Commitment Level OE (C).

• Detailed Explanation: This OE reinforces the holistic and interconnected approach to organizational performance, ensuring that risk management is not isolated but works in synergy with quality and strategy.

• Implementation Strategies & Best Practices: Implement mechanisms to ensure integration, as outlined in the "Ensuring Integration Between Quality Improvement, Risk Management, and Strategic Planning" section above. This could involve:
  * Cross-functional committees or teams.
  * Integrated reporting and data sharing between departments.
  * Joint planning sessions and reviews.
  * Incorporating risk assessment findings into strategic and quality improvement plans.

• Documentation Examples:

  • Terms of Reference for committees or teams that integrate risk management, quality, and strategy.

  • Minutes of meetings demonstrating joint planning and discussions across these functions.

  • Examples of how risk assessment findings have informed strategic and quality improvement plans (e.g., documented linkages in plan documents).

ROM 6d: Leadership ensures implementation of systems for internal and external reporting of system and process failures. (A)*

• Standard Statement: This OE focuses on implementation of reporting systems. The asterisk (*) and (A) designation highlight its Achievement Level and mandatory system documentation.

• Detailed Explanation: This OE mandates the establishment and operationalization of robust reporting systems for both internal learning and external compliance, demonstrating a commitment to transparency and accountability.

• Implementation Strategies & Best Practices: Implement comprehensive internal and external reporting systems and a Service Continuity Plan, as outlined in the "Ensuring Implementation of Systems for Internal and External Reporting of System and Process Failures" section above. Regular testing of the SCP is crucial.

• Documentation Examples:

  • Documented internal reporting system procedure.

  • Documented external reporting system procedure (including criteria for external reporting).

  • Documented Service Continuity Plan (SCP).

  • Records of SCP testing (drill reports, simulation results).

  • Examples of internal and external reports generated (anonymized for training).

ROM 6e: Leadership ensures that it has a documented agreement for all outsourced services that include service parameters. (C)

• Standard Statement: This OE focuses on documented agreements for outsourced services. It is a Commitment Level OE (C).

• Detailed Explanation: This OE ensures that risks associated with outsourcing are managed through formal agreements that clearly define expectations and responsibilities.

• Implementation Strategies & Best Practices: Ensure documented agreements are in place for all outsourced services, including the service parameters and dispute resolution mechanisms, as outlined in the "Ensuring Documented Agreements for All Outsourced Services" section above.

• Documentation Examples:

  • Sample templates of outsourced service agreements.

  • List or inventory of all outsourced services with corresponding documented agreements.

  • Examples of service parameters included in agreements (quality metrics, reporting requirements).

ROM 6f: Leadership monitors the quality of the outsourced services and improvements are made as required. (A)

• Standard Statement: This OE focuses on monitoring and improving outsourced service quality. It is an Achievement Level OE (A), indicating a higher level of performance expectation.

• Detailed Explanation: This OE goes beyond just agreements and mandates active monitoring and continuous improvement of outsourced service quality, demonstrating ongoing management of outsourcing risks.

• Implementation Strategies & Best Practices: Implement a system for monitoring outsourced service quality and making improvements, as outlined in the "Monitoring the Quality of Outsourced Services and Making Improvements" section above. Define monitoring frequency based on criticality, monitor against service standards, and work with vendors for improvement.

• Documentation Examples:

  • Procedure for monitoring outsourced service quality.

  • Monitoring reports for key outsourced services (showing performance data against service standards).

  • Records of actions taken to improve outsourced service quality based on monitoring findings.

  • Documentation of frequency of monitoring for different outsourced services.

Common Challenges and Pitfalls in Implementing ROM 6:

• Reactive vs. Proactive Risk Management: Hospitals may focus primarily on reactive incident reporting rather than proactive risk identification and mitigation.

• Siloed Risk Management: Risk management may be treated as a separate function, not integrated into daily operations, quality improvement, or strategic planning.

• Insufficient Resources for Risk Management: Lack of dedicated resources (staff, budget, technology) can hinder effective risk management implementation.

• Weak Reporting Culture: Staff may be hesitant to report errors or near misses due to fear of blame or reprisal, undermining the effectiveness of reporting systems.

• Inadequate Service Continuity Planning: Hospitals may lack comprehensive Service Continuity Plans or may fail to regularly test and update these plans.

• Lax Management of Outsourced Services: Insufficient attention to managing risks associated with outsourced services, including inadequate agreements and lack of quality monitoring.

• Lack of Leadership Engagement: If leadership does not actively champion and support patient safety and risk management, these initiatives will likely be less effective.

Key Takeaways and Actionable Steps for ROM 6 Training:

• Patient Safety and Risk Management are Leadership's Core Responsibility: Emphasize that leadership is ultimately accountable for ensuring patient safety and proactively managing risks across the hospital.

• Proactive Risk Management is Essential: Shift from reactive to proactive risk management, focusing on prevention and early mitigation.

• Integration is Key to Effectiveness: Integrate risk management with quality improvement and strategic planning for a holistic and synergistic approach.

• Resources Enable Action: Allocate sufficient resources (financial, human, technological) to support a robust risk management program.

• Reporting Drives Improvement: Foster a culture of open reporting and utilize reporting systems for continuous learning and improvement.

• Outsourced Services Require Diligent Management: Pay close attention to managing risks associated with outsourced services through formal agreements, quality monitoring, and ongoing vendor management.

• Documentation is Crucial for Accountability: Maintain thorough documentation of all aspects of the risk management program, including plans, risk registers, policies, procedures, and monitoring reports, to demonstrate compliance and effectiveness.

• ROM 6 is About Culture Change: Frame ROM 6 not just as a set of requirements but as a framework for fostering a fundamental culture change within the hospital – a culture where patient safety and risk awareness are deeply ingrained in every aspect of operations.

By providing this detailed and structured training on ROM 6, hospitals can develop and implement robust systems for patient safety and risk management, ensuring a safer environment for patients, protecting the organization, and achieving NABH accreditation standards. Remember that continuous effort, leadership commitment, and a culture of safety are essential for long-term success in this critical domain.

Comprehensive list of policies and procedures that are explicitly mentioned or strongly implied as being required for compliance:

ROM 1: The organisation identifies those responsible for governance and their roles are defined.

• Governance Structure Policy/Procedure: (Implied by ROM 1a and general intent of ROM 1)

  • This policy should outline the overall governance structure of the hospital, including the governing body, its committees (if any), and reporting lines.

• Terms of Reference (TOR) for the Governing Body: (Explicitly mentioned in ROM 1a - Core OE)

  • This document is crucial and functions as a procedural document defining the purpose, scope, responsibilities, membership, meeting procedures, and reporting relationships of the governing body.

• By-laws of the Governing Body: (Explicitly mentioned in ROM 1a - Core OE)

  • These by-laws should detail the rules and regulations governing the operation of the governing body, supplementing the TOR and providing more specific procedural guidance.

• Senior Leader Appointment Policy/Procedure: (Implied by ROM 1e)

  • This policy should outline the process for appointing senior leaders in the organization, including defining roles, responsibilities, required qualifications, selection criteria, interview process, and approval mechanisms.

• Clinical Governance Framework Document: (Explicitly mentioned in ROM 1g - NEW OE)

  • This is a framework document, but functions like a policy, outlining the components of the hospital's clinical governance system, including patient safety, medication safety, clinical audit, clinical pathways, clinical indicators, education, and research.

• Ethical Management Framework Policy: (Implied by ROM 1h)

  • This policy should articulate the hospital's guiding ethical principles, areas of ethical concern, and commitment to ethical conduct in all operations.

ROM 2: Those responsible for governance manage the organisation by ethical manner.

• (Reiterated) Ethical Management Framework Policy: (Explicitly mentioned in ROM 2a - Core OE)

  • This is the same policy as mentioned in ROM 1h, but its importance is re-emphasized in ROM 2, especially regarding its establishment by leaders.

• Ethical Issue Management Procedure: (Implied by ROM 2b)

  • This procedure should detail the process for reporting, collecting, collating, analyzing, investigating, and resolving ethical issues, dilemmas, and concerns within the hospital. It should include timelines for CAPA and documentation requirements.

• Conflict of Interest Policy: (Implied by ROM 2h - "Address conflicts of interest")

  • This policy should outline how the hospital identifies, manages, and mitigates potential conflicts of interest for governance members, staff, and other relevant stakeholders.

ROM 3: Responsibility for Organisations sustainability.

• Sustainability Policy and Strategy: (Implied by ROM 3a)

  • This overarching policy should document the hospital's commitment to sustainability across Environmental, Social, and Governance (ESG) aspects. It should include strategic goals, targets, and action plans for each pillar.

• Energy Efficiency and Environmental Initiatives Policy/Procedure: (Implied by ROM 3b)

  • This policy can be part of the broader Sustainability Policy or a standalone document outlining specific initiatives for energy conservation, renewable energy adoption, water efficiency, waste reduction, pollution prevention, and other environmental measures.

• Social Responsibility Policy: (Implied by ROM 3c)

  • This policy can be part of the broader Sustainability Policy or a standalone document outlining the hospital's commitment to social responsibility, including community outreach programs, fair labor practices, ethical supply chains, and staff well-being.

• Sustainable Procurement Policy: (Implied by ROM 3e - Excellence Level)

  • This policy should guide the hospital's procurement practices towards sourcing products and services that have lower environmental and social impacts, prioritizing environmentally friendly and socially responsible options.

• Staff Well-being Program Policies/Procedures: (Implied by ROM 3d)

  • While not a single policy, this refers to a set of policies and procedures that support staff well-being, including policies on work hours, workload management, break schedules, stress management programs, healthy lifestyle initiatives, and recognition/reward systems.

• Sustainable Commuting Initiatives Policy/Procedure: (Implied by ROM 3f - Achievement Level)

  • This policy should outline initiatives to encourage employees to use sustainable commuting options like carpooling, cycling, and public transport, aiming to reduce the hospital's carbon footprint from commuting.

ROM 4: The organisation is headed by a leader who shall be responsible for operating the organisation on a day-to-day basis.

• Job Description for the Top Operational Leader: (Implied by ROM 4a)

  • While not strictly a "policy," a documented job description for the CEO, Hospital Director, or equivalent role is essential to define responsibilities, required qualifications, and reporting relationships.

• Compliance Management System Policy and Procedures: (Implied by ROM 4b - Core OE)

  • This comprehensive system should include policies and procedures for identifying, monitoring, and ensuring compliance with all applicable legislations, regulations, and notifications. It should cover areas like legal updates, compliance training, audits, and reporting mechanisms.

• Recruitment Policy and Procedure (covering Department Leaders): (Implied by ROM 4c)

  • This policy should outline the standardized recruitment process for all staff, including specific procedures for recruiting department leaders, highlighting the leader's role in this process.

• Performance Review Policy and Procedure for Top Operational Leader: (Implied by ROM 4e - Achievement Level)

  • This policy should document the process for conducting regular performance reviews of the top operational leader, including the review frequency, methodology (KRAs, appraisals), responsible parties, and feedback mechanisms.

• Leadership Development Program Policy: (Implied by ROM 4d - "Develop metrics for measuring effectiveness of leaders")

  • This policy should outline the hospital's commitment to leadership development at all levels, potentially including programs for department leaders to enhance their effectiveness.

ROM 5: The organisation displays professionalism in its functioning.

• Strategic Plan Document: (Implied by ROM 5a)

  • While not a "policy," a comprehensive and documented Strategic Plan is essential to guide the hospital's long-term direction.

• Operational Plan Document: (Implied by ROM 5a)

  • Similarly, a documented Operational Plan translates the strategic plan into annual operational objectives and activities.

• Procedure for Interdepartmental Coordination: (Implied by ROM 5b)

  • This procedure should outline mechanisms for fostering coordination and communication between different departments to ensure smooth functioning and integrated services.

• Procedure for Performance Monitoring: (Implied by ROM 5b)

  • This procedure should detail how the hospital monitors progress towards defined goals and objectives, including the use of KPIs, reporting frequency, and review processes.

• Budgeting Policy and Procedure: (Implied by ROM 5c)

  • This policy should outline the hospital's annual budgeting process, including budget preparation, approval, allocation, monitoring, and variance analysis.

• Procedure for Committee Effectiveness Review: (Implied by ROM 5d - Achievement Level)

  • This procedure should document how the hospital regularly reviews the functioning and effectiveness of its committees, using defined criteria and processes.

• Service Standards Document: (Explicitly mentioned in ROM 5e - Core OE)

  • This document outlines the hospital's documented service standards, specifying measurable benchmarks for key service parameters across different departments and services.

• Change Management Policy and Procedures: (Implied by ROM 5f - Excellence Level)

  • This policy should outline the hospital's framework and processes for managing organizational change effectively, including planning, communication, implementation, and evaluation of change initiatives.

ROM 6: Leadership ensures that patient safety aspect and risk management issues are an integral part of patient care and hospital management.

• Risk Management Plan: (Implied by ROM 6a - Core OE)

  • This comprehensive plan should outline the hospital's approach to risk management, including processes for risk identification, assessment, analysis, mitigation, monitoring, and communication.

• Service Continuity Plan: (Implied by ROM 6d)

  • This plan should detail how the hospital will maintain essential services during disruptions, emergencies, and system/process failures. It should include contingency plans, recovery procedures, testing protocols, and communication strategies.

• Outsourced Services Agreement Procedure: (Implied by ROM 6e)

  • While not strictly a "policy", this procedure should ensure that documented agreements are in place for all outsourced services, including service parameters, quality standards, and dispute resolution mechanisms.

Important Notes:

• Core Objective Elements (CO): Policies/Procedures marked as relating to Core Objective Elements are particularly critical and require mandatory system documentation for NABH accreditation.

• Integration: Some policies and procedures can be integrated. For example, the Sustainable Procurement Policy might be a section within the broader Sustainability Policy.

• Customization: This list is based on the training notes. The specific policies and procedures needed may vary slightly depending on the individual hospital's size, scope of services, organizational structure, and local regulatory requirements.

• Beyond Policies: While this list focuses on policies and procedures, remember that implementation, training, monitoring, and review are equally crucial for demonstrating compliance with the ROM Chapter.

This expanded list provides a robust foundation for hospitals to develop the necessary documentation to meet the requirements of the ROM Chapter in the NABH 6th Edition. Remember to tailor these policies and procedures to your specific organizational context and ensure they are actively implemented and regularly reviewed.