All NABH NCs

Session 1: Understanding NABH and Our Performance – The Foundation for Excellence

(Approximate Duration: 1.5 - 2 hours – This is more realistic given the "extensive detail" requirement. If strictly 1 hour, some sections would need to be significantly condensed or made pre-reading material.)

Session Goal:
To provide all staff with a comprehensive understanding of NABH, its importance in enhancing patient safety and quality of care, and to transparently share an analysis of our hospital's past NABH audit performances, highlighting common themes and areas for focused improvement.

Learning Objectives:
Upon completion of this session, participants will be able to:

1. Define NABH and articulate its significance for patients, staff, and the hospital.

2. List at least three key benefits of NABH accreditation.

3. Name the two broad categories of NABH standards (Patient Centered and Organization Centered) and recall key chapter areas.

4. Understand the importance of analyzing past audit Non-Compliances (NCs).

5. Identify the "hotspot" chapters where our hospital has faced the most NCs.

6. Describe at least four common themes (e.g., "not uniformly done," documentation issues) recurring in our NCs.

7. Recognize that NCs can be systemic (affecting "all wards & ICU") or department-specific.

Materials Needed:

• Projector and screen

• Presentation slides (PowerPoint/Google Slides)

• Handouts (optional):

  • Summary of NABH benefits

  • List of NABH Chapters (5th Edition)

  • Key themes of NCs observed in our hospital (anonymized examples)

• Whiteboard or flip chart (for interactive discussions)

• Markers

• List of actual NCs (for trainer's reference to pull specific examples)

Session Plan & Detailed Content:

(0:00 – 0:05) Welcome and Introduction (5 minutes)

• Trainer: Welcome participants.

• Icebreaker (Optional, if time permits and group size is manageable): "In one word, what does 'quality healthcare' mean to you?" (Quick round-robin or a few volunteers).

• Session Overview:

  • "Today, we're laying the groundwork for our journey towards enhanced NABH compliance and, more importantly, even better patient care."

  • "We'll cover two main parts: First, a deep dive into what NABH is all about. Second, an honest look at our own performance based on past audits. This isn't about blame; it's about learning and improving together."

• State Learning Objectives: Clearly present the learning objectives for the session.

(0:05 – 0:35) Part 1: Understanding NABH – The "What, Why, and How" (30 minutes)

• A. What is NABH? (5 minutes)

  • Full Form: National Accreditation Board for Hospitals & Healthcare Providers.

  • Parent Body: A constituent board of the Quality Council of India (QCI), set up to establish and operate accreditation programs for healthcare organizations.

  • Purpose: To drive a quality culture in healthcare, focusing on patient safety and the quality of care provided.

  • Voluntary but Increasingly Essential: Explain that while accreditation is voluntary, it's becoming a benchmark for quality and is often required for empanelment with insurance companies, government schemes, etc.

  • Not Just a Certificate: Emphasize that NABH is a process of continuous improvement, not just an award to be hung on the wall.

• B. Why is NABH Important? The Benefits. (10 minutes)

  • For Patients:

    • Enhanced Patient Safety: Reduced errors, safer practices, focus on infection control.

    • High Quality of Care: Standardized processes leading to consistent and improved clinical outcomes.

    • Respect for Patient Rights: Clear policies on patient rights, consent, information, and confidentiality.

    • Increased Confidence: Assurance that the hospital meets recognized standards of care.

    • Trainer Note: Use relatable examples. "Imagine you're a patient; wouldn't you want to know the hospital has systems to prevent medication errors or hospital-acquired infections?"

  • For Staff:

    • Clear Roles & Responsibilities: Defined processes and protocols reduce ambiguity.

    • Improved Work Environment: Focus on staff safety, training, and competency.

    • Professional Development: Encourages learning and adherence to best practices.

    • Increased Morale & Job Satisfaction: Working in a system that values quality and safety.

  • For the Hospital/Organization:

    • Improved Reputation & Community Trust: NABH accreditation is a mark of quality.

    • Benchmarking: Provides a framework to compare with national/international standards.

    • Enhanced Efficiency & Reduced Waste: Streamlined processes can lead to better resource utilization.

    • Risk Mitigation: Proactive identification and management of risks.

    • Better Empanelment Opportunities: With insurance, TPAs, and government schemes.

    • Continuous Improvement Culture: Embeds quality into the hospital's DNA.

  • For the Community:

    • Access to quality healthcare services.

    • Increased public confidence in the healthcare system.

• C. Overview of NABH Standards (5th Edition Recommended) (10 minutes)

  • Structure: Explain that standards are organized into chapters, and each standard has "Objective Elements" (OEs). NCs are raised against these OEs.

  • Two Main Categories of Chapters:

    • Patient-Centered Standards (Chapters 1-5):

      • Chapter 1: Access, Assessment and Continuity of Care (AAC)

      • Chapter 2: Care of Patients (COP)

      • Chapter 3: Management of Medication (MOM)

      • Chapter 4: Patient Rights and Education (PRE)

      • Chapter 5: Hospital Infection Control (HIC)

      • Trainer Note: Briefly explain the core focus of each chapter. E.g., "AAC covers everything from patient registration, initial assessment, lab/imaging, to discharge."

    • Organization-Centered Standards (Chapters 6-10):

      • Chapter 6: Continuous Quality Improvement (CQI)

      • Chapter 7: Responsibilities of Management (ROM)

      • Chapter 8: Facility Management and Safety (FMS)

      • Chapter 9: Human Resource Management (HRM)

      • Chapter 10: Information Management System (IMS)

      • Trainer Note: Briefly explain the core focus. E.g., "HRM deals with staff recruitment, training, credentialing, and well-being."

  • The Objective Elements (OEs):

    • Explain that each standard is broken down into specific, measurable, and auditable OEs.

    • "When an auditor finds something not meeting a requirement, the NC is written against a specific OE, like 'AAC 4d' or 'MOM 3c'." This helps participants understand the codes in the NC list.

• D. The Accreditation Process (Brief Overview) (5 minutes)

  • Application submission.

  • Self-Assessment Toolkit (SAT).

  • Pre-assessment visit by NABH assessors (identifies gaps).

  • Corrective actions by the hospital.

  • Final Assessment visit.

  • Accreditation decision.

  • Surveillance audits (to ensure continued compliance).

  • "This is a cyclical process, emphasizing that quality is an ongoing journey."

(0:35 – 1:15) Part 2: Insights from Our Audits – Learning from Our Experience (40 minutes)

• A. Setting the Context: Why Analyze Our NCs? (5 minutes)

  • "Now, let's look inwards. We've undergone several NABH assessments (mention the years: 2019-S, 2016-F/P, 2020-R, 2021-DS, 2023-R from your list)."

  • "Analyzing these NCs is crucial. It helps us understand:

    • Where our systems are strong and where they are weak.

    • Recurring problems that need systemic solutions.

    • Areas where targeted training and resources are most needed.

    • How we can proactively prevent future NCs."

  • Reinforce Non-Blame Culture: "This is not about pointing fingers. It's about collective learning and shared responsibility for improvement."

• B. Overview of Audit Findings (Using the provided NC list) (5 minutes)

  • Data Source: "The following analysis is based directly on the Non-Compliance reports from our audits in 2019, 2016, 2020, 2021, and 2023." (Show a slide with the audit years listed).

  • General Trend (If discernible from the NC list or if known): Briefly comment if there's an overall trend (e.g., "While we've made progress in some areas, certain types of NCs continue to appear").

  • Volume of NCs: "The sheer number of NCs across these audits, as you'll see, indicates significant opportunities for us to strengthen our processes and practices."

• C. NC Hotspots – Chapters Most Affected (10 minutes)

  • Methodology: "We've analyzed all the NCs from these audits and tallied them by NABH chapter to identify our 'hotspots' – the chapters where we received the most Non-Compliances."

  • Present Data Visually (Highly Recommended):

    • Show a simple bar chart or table with the top 5-7 chapters having the highest NC counts. (e.g., Based on your list, COP, AAC, MOM, HIC, FMS, HRM, ROM, PRE will likely feature).

    • Trainer Example from NC List: "For instance, in the 2019-S audit alone, there were over 30 NCs related to the 'Care of Patients (COP)' chapter."

  • Briefly Revisit Hotspot Chapter Purpose: For each identified hotspot chapter, quickly remind the audience of its main focus.

    • "For example, if COP is a hotspot, it means we need to look closely at our direct patient care processes like assessments, care planning, surgical safety, medication administration at the bedside, etc."

    • "If HIC is a hotspot, our infection control practices, BMW management, and staff adherence to protocols need attention."

  • Implication: "Focusing on these hotspot chapters will give us the biggest impact in improving our overall compliance and patient safety."

• D. Common Themes in Our Non-Compliances (15 minutes)

  • "Beyond just chapter numbers, we've identified some recurring themes or patterns in the NCs. Understanding these themes is key to finding systemic solutions."

  • Theme 1: "Not Uniformly Done/Implemented/Identified/Aware/Displayed"

    • Explanation: "This phrase appears very frequently in our NCs. It means that while a process might exist, or be done correctly by some staff or in some areas, it's not consistent across all departments, all shifts, or by all relevant staff."

    • Examples from Your NC List (Crucial for relatability):

      • "2019-S-2 (AAC 4d): The initial assessment for in-patients is not uniformly documented within 24 hours."

      • "2019-S-8 (AAC 7d): Periodic maintenance of all equipment is not uniformly done (Lab)."

      • "2019-S-14 (AAC 11h): Imaging signage are not uniformly prominently displayed..."

      • "2023-R-7 (AAC 8.c): Laboratory personnel were not uniformly and appropriately trained in relevant MSDS."

    • Impact: Inconsistent care quality, potential patient safety risks depending on where the lapse occurs, unpredictability.

  • Theme 2: Documentation Deficiencies – "If it's not documented, it's not done."

    • Explanation: "Many NCs relate to missing, incomplete, or improper documentation. In NABH (and legally), if a care activity isn't documented, it's considered not done."

    • Common Issues Found in Our NCs:

      • Programmes/Policies not documented (e.g., "2019-S-11 (AAC 10a): The quality assurance programme for imaging services is not documented").

      • Activities not documented (e.g., "2020-R-3 (AAC 4c,f): The initial assessment does not uniformly include nutritional screening" - implying lack of documentation).

      • Records not named, signed, dated, timed (e.g., "2019-S-88 (IMS 3c,d): Entry in the medical record is not uniformly named, signed, dated and timed").

      • Author of entry not identified.

      • Training records not maintained or incomplete.

    • Impact: Breaks in continuity of care, medico-legal vulnerabilities, difficulty in auditing or reviewing care, failure to demonstrate compliance.

  • Theme 3: Implementation Gaps (Policy vs. Practice)

    • Explanation: "This means we might have a good policy or procedure written down, but it's not being followed consistently in practice."

    • Examples from Your NC List:

      • "2019-S-19 (COP 2i): Quality assurance programmes are not documented and not implemented."

      • "2019-S-63 (HIC 2h): The organisation does not uniformly implement the antibiotic policy..."

      • "2023-R-17 (COP 1.e): HCO has not developed clinical care pathways" (could also be lack of policy).

    • Impact: Policies become ineffective, desired patient safety outcomes are not achieved, wasted effort in creating policies.

  • Theme 4: Lack of or Inadequate Policies & Procedures (P&Ps)

    • Explanation: "Sometimes, the NC points to a missing policy or procedure that NABH requires, or an existing one is not comprehensive enough."

    • Examples from Your NC List:

      • "2019-S-7 (AAC 5f): The organisation has no processes to identify early warning signs..."

      • "2019-S-10 (AAC 9i): There is no mechanism to address recall / amendment of reports whenever applicable (Radiology)."

      • "2020-R-2 (AAC 2a): There is no policy or procedure for registering and admitting foreign nationals."

    • Impact: Leads to ad-hoc practices, increased risk of errors, inconsistency, and inefficiency.

  • Theme 5: Staff Awareness, Training & Education Deficits

    • Explanation: "This theme highlights gaps in staff knowledge, skills, or understanding of required practices, or a lack of patient/family education."

    • Examples from Your NC List:

      • "2019-S-30 (COP 12h): The children's family members are not uniformly educated about nutrition, immunization and safe parenting..."

      • "2019-S-38 (COP 22e): Staff are not uniformly aware in end of life care."

      • "2023-R-1 (AAC 2.e): Staffs were not aware regarding prioritization of the care available in OPDs."

      • "2023-R-101 (HRM 5.d): All staff are not trained in healthcare communication techniques."

    • Impact: Increased risk of errors, poor patient experience, non-compliance with standards.

  • Theme 6: System and Process Weaknesses (Monitoring, Analysis, Feedback, CAPA)

    • Explanation: "These NCs point to weaknesses in our overarching quality management systems – how we monitor our performance, analyze data, provide feedback, and take corrective/preventive actions."

    • Examples from Your NC List:

      • "2019-S-69 (CQI 5a,b,c,d,e): There is no mechanism for validation, analysis, improvement and feedback of data."

      • "2020-R-12 (AAC 12i): There is no evidence that the organisation has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to a critical value alert."

      • "2023-R-6 (AAC 6.i): CAPA for recall and amendment of reports was not evidenced."

    • Impact: Problems recur, missed opportunities for improvement, quality initiatives may not be data-driven or effective.

• E. NCs by Key Hospital Areas (5 minutes)

  • Systemic Issues: "A significant number of NCs, especially those using the term 'uniformly,' apply to 'all wards & ICU' or 'across the HCO.' This tells us that many of our challenges require hospital-wide solutions, not just isolated departmental fixes."

  • Department-Specific Mentions:

    • "While many issues are systemic, some departments were frequently highlighted with specific NCs. This doesn't mean other departments are perfect, but it gives us areas to focus on in later, more detailed sessions."

    • Briefly list 3-4 departments that had many specific NCs (without detailing the NCs themselves here):

      • E.g., "Radiology had several NCs around documentation, safety, and QA."

      • "The Laboratory faced NCs related to safety, TAT, and equipment maintenance."

      • "Operating Theatres had observations on checklists and pre-op protocols."

      • "Pharmacy NCs often related to medication storage and prescription practices."

      • "MRD regarding record completeness and retrieval."

    • "Staff from these areas, and indeed all areas, will find the upcoming sessions particularly relevant as we delve into specific standards."

(1:15 – 1:25) Session Recap and Key Takeaways (10 minutes)

• Recap Learning Objectives: Briefly go over them and ask if participants feel they have a better understanding.

• Key Takeaways:

  • "NABH is a framework for patient safety and continuous quality improvement."

  • "Accreditation benefits everyone: patients, staff, and the hospital."

  • "Our past audits show clear patterns: lack of uniformity, documentation gaps, and sometimes, policies not being fully implemented are major themes."

  • "These challenges are often systemic, requiring a hospital-wide, collaborative approach."

  • "This understanding is the first step. The next sessions will focus on how we address these NCs within specific NABH chapters."

• Positive Reinforcement: "Identifying these areas is not a failure, but an opportunity. We have the collective expertise and commitment to make significant improvements."

(1:25 – 1:30) Q&A and Preview of Next Session (5 minutes)

• Open the floor for questions regarding this session's content.

• Briefly introduce the topic of the next training session (e.g., "In our next session, we'll start a deep dive into the Access, Assessment, and Continuity of Care (AAC) chapter and the Care of Patients (COP) chapter, looking at specific NCs and how to address them.").

• Thank participants for their attention and engagement.

Trainer Notes for Session 1:

• Tone: Maintain a positive, encouraging, and non-judgmental tone, especially when discussing past NCs. Emphasize learning and improvement.

• Engagement: Use questions to engage the audience (e.g., "Why do you think consistent documentation is important?").

• Visuals: Use clear, concise slides. Incorporate visuals like the NABH logo, QCI logo, simple diagrams for processes, and especially charts/graphs for the NC analysis.

• Real Examples: When discussing NC themes, pull 2-3 specific, anonymized examples directly from the provided NC list for each theme. This makes the information tangible and relatable to this hospital. Have the full NC list handy for reference.

• Time Management: This is a content-heavy session. Be mindful of time. If running short, prioritize the analysis of your hospital's NCs, as this is often the most impactful part.

• Tailor to Audience: While this is a general session, if the audience is primarily from one department, you can subtly emphasize themes most relevant to them.

• Link to "Why": Constantly link NABH requirements back to the "why" – patient safety and quality of care. This increases buy-in. 

Session 2: Deep Dive into Critical NABH Chapters & NCs (Part 1) – Mastering Access, Assessment, Continuity of Care (AAC) & Care of Patients (COP)

(Approximate Duration: 2 - 2.5 hours – This is a very content-rich session, and breaking it further or allowing more time might be beneficial if possible.)

Session Goal:
To provide staff with an in-depth understanding of common Non-Compliances (NCs) related to the NABH chapters on Access, Assessment, and Continuity of Care (AAC) and Care of Patients (COP), and to collaboratively explore practical solutions, best practices, and documentation requirements to ensure compliance and enhance patient outcomes.

Learning Objectives:
Upon completion of this session, participants will be able to:

1. Identify at least 5 common NCs related to the AAC chapter based on our hospital's audit findings.

2. Describe the correct procedures for initial assessment, reassessment, and information exchange as per NABH standards.

3. Outline the requirements for safe laboratory and imaging services, including QA and radiation safety.

4. Explain the key components of a NABH-compliant discharge process.

5. Identify at least 7 common NCs related to the COP chapter based on our hospital's audit findings.

6. Discuss the NABH requirements for care planning, including nursing care plan alignment.

7. Describe the specific care considerations and documentation for vulnerable patients (obstetric, pediatric).

8. Articulate the critical elements of surgical safety, anesthesia care, and CPR as per NABH.

9. Explain the principles and process of obtaining valid informed consent for various procedures.

10. Detail the requirements for effective pain management and end-of-life care.

11. Understand the importance of uniform documentation for all processes within AAC and COP.

Materials Needed:

• Projector and screen

• Presentation slides (PowerPoint/Google Slides)

• Handouts (strongly recommended for this session):

  • Checklist for Initial Assessment (AAC 4)

  • Key elements of a Reassessment Plan (AAC 5)

  • SBAR Handover Tool template

  • Key elements of a Discharge Summary (AAC 14)

  • Surgical Safety Checklist (WHO or hospital-adapted)

  • Vulnerable Patient Care Checklist (highlights for OBG/Peds)

  • Informed Consent Checklist (key elements)

• Anonymized copies of relevant hospital SOPs (e.g., Initial Assessment, Consent, Discharge).

• Case studies (short scenarios based on actual NCs from the provided list).

• Whiteboard or flip chart

• Markers

• The full list of hospital NCs (trainer's reference to pull specific, anonymized examples).

Session Plan & Detailed Content:

(0:00 – 0:05) Welcome and Recap of Session 1 (5 minutes)

• Trainer: Welcome participants.

• Quick Recap: "In our last session, we understood NABH and saw the common themes in our hospital's NCs, such as lack of uniformity and documentation gaps. Today, we're diving deep into two critical patient-centered chapters: AAC and COP, which were significant hotspots for us."

• Session Overview & Learning Objectives: Briefly outline the session structure and present the learning objectives.

(0:05 – 1:05) Part 1: Access, Assessment, and Continuity of Care (AAC) (60 minutes)

• Introduction to AAC:

  • "The AAC chapter guides the patient's entire journey from their first contact with the hospital until their discharge or transfer. It's about ensuring the right care, at the right time, in the right way, with smooth transitions."

  • "Many of our NCs in this chapter revolve around uniformity and documentation."

• A. Display of Services (AAC 1c) & Registration/Admission (AAC 2a) (5 minutes)

  • NC Examples from Your List:

    • "2019-S-1 (AAC 1c, ROM 4d): The services not available are not displayed (OPD, front office)."

    • "2020-R-1 (AAC 1c): The healthcare services not available are not prominently displayed."

    • "2020-R-2 (AAC 2a): There is no policy or procedure for registering and admitting foreign nationals."

  • NABH Requirement:

    • Clearly display available services, scope, and those not available. Bilingual where appropriate.

    • Defined process for registration, admission, and transfer, including for foreign nationals if applicable.

  • Why it Matters: Manages patient expectations, directs them appropriately, ensures legal/ethical handling of diverse patient populations.

  • Solutions & Best Practices:

    • Regular audit of display boards by OPR/Front Office Manager.

    • Standardized SOP for registration, including specific instructions for unique patient groups.

    • Training for front office staff.

• B. Initial Assessment (AAC 4d, 4f, 4g,h,i) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-2 (AAC 4d): The initial assessment for in-patients is not uniformly documented within 24 hours."

    • "2019-S (AAC 4f - unnumbered): Initial assessment does not uniformly include screening for nutritional needs."

    • "2019-S-3 (AAC 4g,h): The initial assessment does not uniformly result in a documented care plan and the same does not uniformly reflect desired results of the treatment, care or service."

    • "2019-S-4 (AAC 4i, CQI 3a(ii)): The care plan is not uniformly countersigned by the clinician in-charge of the patient within 24 hours."

    • "2016-F-1 (AAC 4f & COP 11e): Though initial assessment includes screening for nutritional needs in most patients, the same was not evidenced uniformly in outpatient records of the obstetric patients."

    • "2023-R-2 (AAC 4.a): Initial assessment of OPD and daycare patients was not uniformly done using the defined structured format."

  • NABH Requirement:

    • Timeliness: Within defined timeframe (e.g., 24 hours for inpatients; hospital to define for OPD/Daycare).

    • Scope: By qualified individuals, covering medical, nursing, nutritional, psychosocial (as applicable) needs. Specific focus on uniform nutritional screening.

    • Documentation: Uniformly documented using a structured format.

    • Care Plan: Must result in a documented care plan that reflects desired outcomes and is countersigned by the clinician-in-charge within 24 hours.

  • Why it Matters: Forms the basis for all subsequent care, identifies risks early, ensures patient needs are comprehensively addressed.

  • Solutions & Best Practices:

    • Standardized Assessment Forms: For different patient types (Inpatient, OPD, Daycare, specialties). Include mandatory fields for nutritional screening.

    • Training: For all doctors and nurses on comprehensive assessment and correct documentation.

    • Checklists: To ensure all components are covered.

    • Audits: Regular medical record audits focusing on timeliness, completeness, and care plan documentation/countersignatures.

    • Clear Responsibility: Defining who performs which part of the assessment and who countersigns.

    • Activity: Review an anonymized (but real) initial assessment form from the hospital. Identify strengths and areas for improvement based on the NCs.

• C. Reassessment and Monitoring (AAC 5d,e,f) (10 minutes)

  • NC Examples from Your List:

    • "2019-S-6 (AAC 5d,e): Staff involved in direct clinical care does not uniformly document reassessments. Response to treatment and to plan further treatment or discharge."

    • "2019-S-7 (AAC 5f): The organisation has no processes to identify early warning signs of change or deterioration in clinical conditions for initiating prompt intervention."

    • "2020-R-5 (AAC 5a,f): Patients in ICU are assessed only once in 24 hrs... staff are not aware of how and when to take action to escalate the same (for early warning signs)."

    • "2023-R-5 (AAC 5.e): Early warning signs for paediatric and neonatal patients was not uniformly implemented across patient care areas."

  • NABH Requirement:

    • Regular reassessment based on patient condition and hospital policy.

    • Documentation of reassessments, patient's response to treatment, and plans for further treatment or discharge.

    • Established processes (and staff awareness) for identifying and responding to early warning signs of deterioration (e.g., MEWS, PEWS).

  • Why it Matters: Allows for timely intervention, adjustment of care plan, and prevents adverse events.

  • Solutions & Best Practices:

    • Define Reassessment Triggers: E.g., post-procedure, change in condition, transfer, daily for stable patients.

    • Standardized Reassessment Tools: E.g., MEWS/PEWS charts, progress note formats.

    • Escalation Protocols: Clear pathways for staff to escalate concerns when a patient deteriorates.

    • Training: On recognizing early warning signs and using escalation protocols.

    • Mock Drills: For rapid response team activation.

• D. Laboratory and Imaging Services (AAC 6, 7, 9, 10, 11) (15 minutes)

  • NC Examples from Your List (many Radiology-specific from 2019-S, 2016-F/P, 2020-R, 2023-R):

    • "2019-S-8 (AAC 7d): Periodic maintenance of all equipment is not uniformly done (Lab)."

    • "2019-S-9 (AAC 9e): Documented policies and procedures do not exist to ensure correct identification and safe and timely transportation of patients to and from the imaging services."

    • "2019-S-10 (AAC 9i): There is no mechanism to address recall / amendment of reports whenever applicable (Radiology)."

    • "2019-S-11 (AAC 10a): The quality assurance programme for imaging services is not documented."

    • "2019-S-12 (AAC 10b): The programme does not address periodic internal / external peer review of imaging protocols and results using appropriate sampling."

    • "2019-S-13 (AAC 10d): A system to ensure the appropriateness of the investigations... is lacking."

    • "2019-S-14 (AAC 11h): Imaging signage are not uniformly prominently displayed... e.g. OT when radiation procedure is on."

    • "2016-F-4 (AAC 11e): Imaging personnel did not have appropriate radiation safety monitoring devices. TLD badges were not evidenced..."

    • "2023-R-12 (AAC 11.d): All staff nurses working in Orthopedic OT during surgeries requiring C arm did not have TLD badges."

    • "2023-R-13 (AAC 11.g): The display of radiation signage outside OT and Cath lab was not as per requirement of AERB."

  • NABH Requirement:

    • Safety & Quality: Established procedures for sample collection, patient identification, transport, processing, reporting.

    • Equipment: Calibration and maintenance program.

    • TAT: Defined and monitored Turnaround Times.

    • Critical Alerts: Process for communicating critical results immediately.

    • QA Programs: Documented and implemented for both Lab and Imaging (including peer review, proficiency testing for lab, appropriate sampling for imaging review).

    • Radiation Safety: Program in place as per AERB guidelines (signage, TLD badges, MRI compatible equipment, staff training).

    • Appropriateness: System to ensure investigations are clinically indicated.

    • Report Recall/Amendment: Mechanism to address this.

  • Why it Matters: Accurate and timely diagnostics are crucial for patient care; safety of patients and staff from radiation and other hazards.

  • Solutions & Best Practices:

    • SOPs: For all key processes in Lab and Imaging.

    • QA Calendars: Documented schedule for all QA activities.

    • RSO (Radiation Safety Officer): Clearly designated and trained.

    • AERB Compliance: Regular review of AERB guidelines.

    • Staff Training: On safety protocols, QA procedures, critical value communication.

    • Audits: Internal audits focusing on compliance with SOPs and safety.

    • Logbooks: For maintenance, calibration, TLD badge usage.

• E. Information Exchange & Handovers (AAC 12d, 12i, 12f, 12h) (10 minutes)

  • NC Examples from Your List:

    • "2019-S-15 (AAC 12d): Information exchanged and documented during each staffing shift...is not uniform.e.g. doctors."

    • "2016-P-4 (AAC 12d): Structured clinical hand-over between shifts by doctors was not documented in the intensive care unit."

    • "2020-R-11 (AAC 12d,g): There is no structured handover between doctors and nurses..."

    • "2020-R-12 (AAC 12i): There is no evidence that the organisation has a mechanism in place to monitor whether adequate clinical intervention has taken place in response to a critical value alert."

    • "2023-R-15 (AAC 12.f): Sampled cross referrals did not uniformly have mention of urgency of referral."

    • "2023-R-16 (AAC 12.h): Mechanism to monitor appropriate clinical intervention in response to critical alert was not uniformly evidenced."

  • NABH Requirement:

    • Standardized process for handovers (shift-to-shift, unit-to-unit, doctor-to-doctor, nurse-to-nurse).

    • Uniform documentation of exchanged information.

    • Mechanism to monitor clinical intervention post-critical value alert.

    • Clear process for referrals, including urgency.

  • Why it Matters: Prevents communication errors, ensures continuity of care, timely response to critical situations.

  • Solutions & Best Practices:

    • SBAR (Situation, Background, Assessment, Recommendation) Tool: Implement and train staff.

    • Dedicated Handover Time: And location, free from interruptions.

    • Bedside Handovers: Where appropriate.

    • Checklists: For information to be exchanged.

    • Critical Value Alert System: With closed-loop communication (confirmation of receipt and action taken).

    • Referral Forms: Standardized, including urgency.

• F. Discharge Process (AAC 13e, 14f) & Police Intimation (AAC 13b,d) (5 minutes)

  • NC Examples from Your List:

    • "2019-S-16 (AAC 13e, CQI 4d): The organisation does not uniformly monitor the discharge time."

    • "2019-S-17 (AAC 14f): Discharge summary does not uniformly incorporate instructions about when to obtain urgent care."

    • "2020-R-13 (AAC 13b,d): Police intimation is not given at the time of discharge of MLC cases. A discharge summary is not given to patients LAMA from the ER."

  • NABH Requirement:

    • Planned discharge process, monitoring of discharge timelines.

    • Comprehensive discharge summary including follow-up instructions, medication reconciliation, and when to seek urgent care.

    • Process for LAMA (Leave Against Medical Advice) including documentation.

    • Defined process for police intimation in MLC cases (including at discharge if applicable).

  • Why it Matters: Ensures safe transition home, patient understanding of follow-up, medico-legal compliance.

  • Solutions & Best Practices:

    • Discharge Planning: Starts at admission.

    • Standardized Discharge Summary Template: Ensure all required elements are included.

    • Patient Education: At discharge, by nurse/doctor.

    • MLC Register & SOP: For handling medico-legal cases.

    • LAMA Form & Counseling: Documented.

(1:05 – 2:05) Part 2: Care of Patients (COP) (60 minutes)

• Introduction to COP:

  • "The COP chapter is the heart of direct patient care. It covers how we plan and deliver care, manage specific patient populations, handle procedures, and ensure patient comfort and safety."

  • "This was a major hotspot for us, with many NCs related to uniformity of care, documentation, and adherence to protocols."

• A. Clinical Care Pathways & Care Planning (COP 1e, 6b, 6d, 6e) (10 minutes)

  • NC Examples from Your List:

    • "2023-R-17 (COP 1.e): HCO has not developed clinical care pathways."

    • "2019-S-22 (COP 6d): Nursing care plan is not uniformly aligned with care plan of patient."

    • "2023-R-19 (COP 6.b): Deep venous thrombosis risk assessment was not uniformly evidenced in all sampled case files." (Care planning component)

    • "2023-R-21 (COP 6.e): In nursing care plan, evaluation and modification were not uniformly evidenced and documented."

  • NABH Requirement:

    • Development and implementation of clinical care pathways for common conditions (where feasible).

    • Documented care plan for all patients, individualized.

    • Nursing care plan aligned with the overall multidisciplinary care plan.

    • Uniform documentation of risk assessments (e.g., DVT, falls, pressure sores) and integration into care plan.

    • Regular evaluation and modification of the care plan based on patient progress.

  • Why it Matters: Standardizes care for common conditions, ensures holistic and coordinated care, proactive risk management.

  • Solutions & Best Practices:

    • Multidisciplinary Team: For developing care pathways.

    • Integrated Care Plan Format: That allows for input from all disciplines.

    • Standardized Risk Assessment Tools: Integrated into nursing assessment.

    • Training: On care planning, pathway utilization, and risk assessment.

    • Audits: Reviewing alignment and completeness of care plans.

• B. Care of Vulnerable Patients (COP 10a, 11b, 12b, 11e, 11f, 12f, 12g, 12h) (15 minutes)

  • Focus: Obstetric & Pediatric Care NCs from Your List:

    • "2019-S-25 (COP 10a): Vulnerable patients are not uniformly identified."

    • "2019-S-26 (COP 11b, 12b): Although the organization defines and displays high risk obstetric cases and pediatrics, the same is not bilingual."

    • "2019-S-27 (COP 11e): Obstetric patient's assessment does not uniformly include maternal nutrition."

    • "2016-F-9 (COP 11f): Appropriate intensive monitoring for post natal mothers was not evidenced during the first 2 hours after delivery (4th stage of delivery)."

    • "2019-S-28 (COP 12f): Patient assessment does not uniformly include detailed nutritional, growth, developmental and immunization assessment (Pediatric)."

    • "2019-S-29 (COP 12g): During assessment Code Pink was not satisfactory (Pediatric)."

    • "2019-S-30 (COP 12h): The children's family members are not uniformly educated about nutrition, immunization and safe parenting and this is not uniformly documented."

    • "2023-R-25 (COP10.e): Nutritional assessment of all obstetric patients were not uniformly evidenced."

    • "2023-R-26 (COP 11.c): All staff providing care to children did not have age specific competency eg some Nursing staff working in PICU."

  • NABH Requirement:

    • Define and uniformly identify vulnerable patients (elderly, pediatric, obstetric, differently-abled, etc.).

    • Specific protocols for care of high-risk obstetric and pediatric patients, including bilingual signage where needed.

    • Comprehensive maternal nutritional assessment.

    • Intensive post-natal monitoring.

    • Detailed pediatric assessment (nutrition, growth, development, immunization).

    • Effective child abduction prevention systems (Code Pink).

    • Education of family members on pediatric care aspects.

    • Age-specific competencies for staff caring for children.

  • Why it Matters: These patient groups have unique needs and risks requiring specialized care and attention.

  • Solutions & Best Practices:

    • Clear Definition & Identification: Mechanism to flag vulnerable patients in HMS.

    • Specialized Protocols & Checklists: For OBG and Pediatric care.

    • Competency-Based Training: For staff in these areas, including Code Pink drills.

    • Patient & Family Education Materials: Standardized and documented.

    • Multilingual Signage: As required.

    • Activity (Group Discussion): How can we ensure uniform identification and consistent application of special protocols for vulnerable patients across all shifts and staff?

• C. Surgical and Procedural Safety (COP 7c,d,g, 15d,k) & Anesthesia Care (COP 14c,d,f) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-32 (COP 15d): Though surgical safety check list exists...the same is not uniformly signed."

    • "2016-F-7 (COP 7c & 15d): Surgical safety checklists were not complete. The ones seen in the OR did not bear the signatures of the surgeon or the anaesthetist."

    • "2020-R-17 (COP 7c,d,g): For procedures done outside the OT, there are no documented procedures to prevent adverse events... consent form does not specify the name of the doctor in training... Procedures are not documented accurately..."

    • "2020-R-21 (COP 15d,k): The timings of time in, time out and sign out in the WHO surgical safety checklist are not uniformly documented. The HCO is not monitoring the pressure differential, humidity and air changes in the CT OT." (CT OT monitoring falls under FMS but checklist part is COP)

    • "2019-S-31 (COP 14c): The pre-anaesthesia assessment does not uniformly results in formulation of an anaesthesia plan."

    • "2016-F-11 (COP 14d): Immediate preoperative anaesthetic re- evaluation was not uniformly observed."

    • "2020-R-20 (COP 14d,f): There is no evidence that an immediate preoperative re-evaluation is performed... Intra operative anaesthesia monitoring does not uniformly include end tidal CO2."

  • NABH Requirement:

    • Surgical Safety: Mandatory use of a comprehensive surgical safety checklist (Sign In, Time Out, Sign Out), uniformly completed and signed. Monitoring of OT environment.

    • Procedures Outside OT: Documented procedures to prevent adverse events. Accurate documentation.

    • Anesthesia: Pre-anesthesia assessment resulting in a documented plan. Immediate pre-operative re-evaluation. Uniform intra-operative monitoring (including ETCO2).

  • Why it Matters: Critical for preventing wrong-site/patient/procedure errors, anesthesia-related complications, and ensuring overall surgical safety.

  • Solutions & Best Practices:

    • Mandatory Checklist Implementation: Training, champions, audits with feedback.

    • Standardized Pre-anesthesia Forms & Protocols: Including re-evaluation checklist.

    • SOPs for Procedures Outside OT: Including safety checks.

    • Team Briefings & Debriefings: In OT.

    • Training: On checklist use, crisis management.

• D. Cardiopulmonary Resuscitation (CPR) (COP 5a,b,c,d,e) (5 minutes)

  • NC Examples from Your List:

    • "2019-S-20 (COP 5a): Protocol of CPR is not uniformly displayed across the HCO."

    • "2019-S-21 (COP 5e): Corrective and preventive measures are not uniformly taken based on the post-event analysis."

    • "2020-R-16 (COP 5a,b,c,d): Staff training on the sequence to be followed in a CPR needs strengthening. There is no evidence that pediatric and neonatal CPRs are documented or analysed. The events...are not uniformly recorded."

  • NABH Requirement:

    • Readily available CPR equipment and protocols displayed.

    • Staff training (BLS/ACLS) and competency.

    • Documentation and analysis of all CPR events (including pediatric/neonatal).

    • Post-event analysis and CAPA.

  • Why it Matters: Timely and effective CPR is life-saving.

  • Solutions & Best Practices:

    • Code Blue Team & Protocol: Clearly defined.

    • Regular Mock Drills: Documented and debriefed.

    • CPR Training Schedule: Ensure all clinical staff are certified.

    • Standardized CPR Record Form: For documenting events.

    • Display of CPR Algorithm: In all patient care areas.

• E. Informed Consent (PRE 4 is the main chapter, but COP NCs sometimes refer to consent for procedures e.g. COP 7, COP 8b for transfusion) (Covered in more detail in PRE session, brief touch here) (5 minutes)

  • NC Examples (linking to COP where applicable):

    • "2020-R-17 (COP 7c,d,g)" - consent form issues for procedures.

    • "2016-F-8 (COP 8b): Transfusion request forms seen in the blood bank...did not have specifics if the request was urgent or routine; doctor's name was not identifiable." (While not direct consent, related to process for transfusion which requires consent).

    • Trainer Note: Cross-reference to PRE session for detailed consent discussion. Here, focus on consent for specific procedures mentioned in COP.

  • NABH Requirement (as it relates to procedures in COP):

    • Specific informed consent taken by the person performing the procedure (or qualified designee) before any invasive procedure/transfusion/anesthesia.

    • Documentation includes procedure, risks, benefits, alternatives.

  • Why it Matters: Upholds patient autonomy, legal requirement.

  • Solutions & Best Practices:

    • Standardized Procedure-Specific Consent Forms.

    • Counseling and ensuring patient understanding.

    • Documentation of the consent discussion.

• F. Pain Management (COP 18c,f,g), Palliative/End-of-Life Care (COP 19c, 22e), Other COP (10 minutes)

  • Pain Management (COP 18c,f,g):

    • NCs: "2019-S-34 (COP 18c): Patients with pain do not uniformly undergo periodic re-assessment." "2019-S-35 (COP 18f): Patient and family are not uniformly aware on various pain management techniques..." "2023-R-38 (COP 17.d): Titration of pain management after assessment and reassessment was not uniformly evidenced."

    • Requirement: Uniform assessment, reassessment, documentation, patient/family education on techniques, titration of management.

    • Solutions: Pain as 5th vital, standardized pain scales, multimodal approach, education.

  • Rehabilitative Services (COP 18g):

    • NC: "2023-R-39 (COP 18.g): Care pathways are not developed, implemented, and reviewed periodically for rehabilitative services."

    • Requirement: Developed, implemented, and reviewed care pathways.

  • Nutritional Screening & Care (COP 19a):

    • NC: "2023-R-40 (COP 19.a): All admitted patients did not uniformly undergo nutritional screening."

    • Requirement: Uniform nutritional screening for all admitted patients. (Overlaps with AAC 4f).

  • End-of-Life Care (COP 22e):

    • NC: "2019-S-38 (COP 22e): Staff are not uniformly aware in end of life care."

    • Requirement: Policies, protocols, and staff sensitization/training.

  • Research (COP 20e,f):

    • NC: "2019-S-37 (COP 20e,f): Patients are not uniformly informed of their right to withdraw from the research..."

    • Requirement: Ensuring patient rights in research, including right to withdraw.

  • Sedation (COP 13e,f,g):

    • NCs: "2020-R-19 (COP 13e,f): The level of sedation is not being monitored." "2016-P-10 (COP 13g): There are no well defined criteria used to determine appropriateness of discharge from observation / recovery area after moderate sedation."

    • Requirement: Monitoring level of sedation, defined discharge criteria post-sedation.

  • Organ Donation Awareness (COP 16d):

    • NCs: "2019-S-33 (COP 16d): The organisation does not take measures to create awareness regarding organ donation." "2020-R-22 (COP 16d): There is no evidence that the organisation has taken measures to create awareness..."

    • Requirement: Measures to create awareness.

  • Solutions for these areas:

    • Specific SOPs, staff training, patient education materials, inter-departmental collaboration (e.g., with dietetics, physiotherapy, ethics committee).

(2:05 – 2:15) Session Recap, Key Takeaways, and Action Planning Intro (10 minutes)

• Recap Learning Objectives: Briefly go over them.

• Key Takeaways for AAC & COP:

  • "Uniformity in assessment, care planning, and documentation is PARAMOUNT."

  • "Special attention to vulnerable populations is non-negotiable."

  • "Safety protocols (surgical, anesthesia, CPR, imaging) must be robustly implemented and audited."

  • "Informed consent is a critical right and a protective process."

  • "Effective communication (handover, critical alerts) prevents errors."

• Small Group Activity Introduction (if time permits or as homework):

  • "Based on the NCs we discussed today in AAC and COP that are relevant to your area:

    1. Identify ONE specific NC.

    2. List 2-3 potential root causes for why this NC occurred in our hospital.

    3. Suggest ONE practical corrective action."

  • (Provide a simple template if doing as homework).

(2:15 – 2:20) Q&A and Preview of Next Session (5 minutes)

• Open the floor for questions.

• "In our next session, we'll continue our deep dive into Management of Medication (MOM), Hospital Infection Control (HIC), and Facility Management & Safety (FMS)."

• Thank participants.

Trainer Notes for Session 2:

• Pacing is Critical: This session is packed. Keep a brisk pace but allow time for questions on complex topics. Use the "Parking Lot" for questions that might derail the session or are too niche.

• Use the NC List: Constantly refer back to your hospital's specific NCs to make the content real. State the NC code and the finding.

• Interactive Elements: Break up lectures with:

  • Quick questions to the audience.

  • Reviewing sample forms/checklists.

  • Short case studies (1-2 minutes) based on NCs, asking "What went wrong here according to NABH?" or "What should have been done?"

• Focus on "How To": Don't just state the requirement; discuss how to achieve it (e.g., "For uniform initial assessment, we need standardized forms AND regular training AND audits.").

• Link to Patient Safety: Always connect the standard/NC back to its impact on patient safety and quality of care.

• Visuals: Use flowcharts for processes (e.g., discharge, handover), images of correctly filled forms (anonymized), and bullet points for key requirements.

• Manageable Chunks: Break down each standard into its core components. 

Session 3: Deep Dive into Critical NABH Chapters & NCs (Part 2) – Ensuring Safety in Medication Management (MOM), Infection Control (HIC), & Facility Operations (FMS)

(Approximate Duration: 2 - 2.5 hours – Similar to Session 2, this is very content-rich. Consider breaking it or allowing more time if feasible.)

Session Goal:
To provide staff with an in-depth understanding of common Non-Compliances (NCs) related to the NABH chapters on Management of Medication (MOM), Hospital Infection Control (HIC), and Facility Management and Safety (FMS), and to collaboratively explore practical solutions, best practices, and documentation requirements to ensure compliance, patient safety, and a safe working environment.

Learning Objectives:
Upon completion of this session, participants will be able to:

1. Identify at least 5 common NCs related to the MOM chapter based on our hospital's audit findings.

2. Describe NABH requirements for safe medication storage, prescription, dispensing, and administration.

3. Explain the importance of managing high-risk medications, LASA drugs, and emergency medications.

4. Identify at least 5 common NCs related to the HIC chapter based on our hospital's audit findings.

5. Outline the key components of an effective hospital infection control program, including surveillance and antibiotic stewardship.

6. Describe the correct procedures for biomedical waste management, spill management, and PPE usage.

7. Identify at least 5 common NCs related to the FMS chapter based on our hospital's audit findings.

8. Explain NABH requirements for facility safety inspections, equipment management (medical and utility), fire safety, and hazardous material management.

9. Understand the importance of uniform documentation and staff training for all processes within MOM, HIC, and FMS.

Materials Needed:

• Projector and screen

• Presentation slides (PowerPoint/Google Slides)

• Handouts (strongly recommended):

  • Checklist for Safe Medication Storage (MOM)

  • Elements of a "Good" Prescription (MOM)

  • Steps for BMW Segregation (HIC)

  • Key Elements of a Fire Safety Plan (FMS)

  • Sample MSDS (FMS)

• Anonymized copies of relevant hospital SOPs (e.g., Medication Administration, BMW Management, Fire Safety Plan).

• LASA drug list, High-Risk medication list, Emergency drug list (hospital-specific).

• Case studies (short scenarios based on actual NCs from the provided list).

• Whiteboard or flip chart

• Markers

• The full list of hospital NCs (trainer's reference to pull specific, anonymized examples).

Session Plan & Detailed Content:

(0:00 – 0:05) Welcome and Recap of Session 2 (5 minutes)

• Trainer: Welcome participants.

• Quick Recap: "In our last session, we covered AAC and COP, focusing on patient journey, assessments, care planning, and procedural safety. Today, we tackle three more crucial chapters: MOM – ensuring medication safety; HIC – preventing and controlling infections; and FMS – maintaining a safe and functional facility."

• Session Overview & Learning Objectives: Briefly outline the session structure and present the learning objectives.

(0:05 – 0:50) Part 1: Management of Medication (MOM) (45 minutes)

• Introduction to MOM:

  • "Medication management is a high-risk area in any hospital. The MOM chapter provides a framework to ensure medications are used safely and effectively from procurement to administration and monitoring."

  • "Our audits highlighted several areas needing improvement, particularly in storage, prescription practices, and handling of specific medication categories."

• A. Medication Availability, Storage, and Formulary (MOM 2a,f, 3b,c,d,e,g) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-39 (MOM 2b): The list (formulary) is not reviewed and updated collaboratively by the multidisciplinary committee."

    • "2023-R-41 (MOM 2.a): Implants and devices not included in the hospital drug formulary."

    • "2023-R-42 (MOM 2.f): Whenever there is local purchase of medication that is not listed in formulary, the organisation do not have a process of evaluation, authorization and ratification."

    • "2019-S-40 (MOM 3c): Sound inventory control practices of the medications in all areas is not uniform across the organisation."

    • "2019-S-41 (MOM 3d): Look-alike and Sound-alike medications are not uniformly identified and not uniformly stored physically apart from each other."

    • "2020-R-23 (MOM 3b,d): Medicines not required to be stored between 2-8oC were seen in the refrigerator. The list of Look-alike and Sound-alike medications is not updated periodically... not stored separately."

    • "2019-S-42 (MOM 3e): The list of emergency medications is not uniformly defined and not uniformly stored in a uniform manner."

    • "2020-R-24 (MOM 3e,g): The list of emergency medicines does not include Inj Potassium Chloride and emergency medicines are not replenished in a timely manner..."

    • "2023-R-43 (MOM 3.d): The HCO does not store the high risk medications in predetermined areas as in pharmacy stores."

    • "2023-R-44 (MOM 3.e): High risk medications including LASA... not stored physically apart... LASA list not available/updated... LASA drugs not stored physically apart..." (Extensive detail here)

    • "2023-R-45 (MOM 3.g): Emergency medications were not replenished promptly when used. Example Dopamine was not available in crash cart in Physiotherapy."

  • NABH Requirement:

    • Formulary: A regularly updated list of medications available, developed by a multidisciplinary committee. Process for non-formulary drug procurement. Implants/devices to be part of this or a similar controlled list.

    • Inventory Control: Sound practices to ensure availability and prevent stockouts/expiry.

    • Storage: Safe, secure, and appropriate storage conditions (temperature, light).

    • LASA (Look-Alike Sound-Alike): Identified, list maintained, stored separately or with clear visual cues (e.g., Tall Man lettering).

    • High-Risk Medications: Identified, list maintained, stored securely, possibly with double checks before administration.

    • Emergency Medications: Standardized list, readily available in patient care areas, regularly checked for expiry and replenishment.

  • Why it Matters: Prevents medication errors due to confusion, unavailability, improper storage leading to degradation, or delayed access in emergencies.

  • Solutions & Best Practices:

    • Pharmacy & Therapeutics (P&T) Committee: Active role in formulary management, LASA/High-Risk list development.

    • Regular Audits/Inspections: Of all medication storage areas (pharmacy, nursing stations, crash carts) by pharmacy staff/ICN.

    • Clear Labeling: For shelves, bins, and individual LASA/High-Risk medications.

    • Standardized Crash Cart Checklist: Including expiry dates and par levels.

    • Temperature Monitoring Logs: For refrigerators/areas storing temperature-sensitive drugs.

    • Activity: Show pictures of good vs. poor medication storage (e.g., cluttered shelves, unlabeled LASA drugs next to each other vs. organized, clearly labeled areas).

• B. Prescription Practices (MOM 4c,d,g,i,j,k,m) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-43 (MOM 4d): Known drug allergies are not uniformly ascertained before prescribing."

    • "2023-R-46 (MOM 4.c): Drug allergies and previous adverse drug reactions were not ascertained before prescribing. Example orthopedics OPD."

    • "2019-S-44 (MOM 4g): Medication orders are not uniformly clear, legible, dated, timed, named and signed."

    • "2016-F-12 (MOM 4g): Medication orders are not always clearly dated, timed, named and signed."

    • "2020-R-25 (MOM 4c,g, CQI 3j(iv)): All hand written prescriptions are not written in capitals. Compliance to use of capitals is only checked from the medication card and not from the case notes."

    • "2019-S-45 (MOM 4i): The list of medication for verbal orders is not defined." (Should be: Policy for verbal orders, including who can give/receive, read-back, documentation).

    • "2020-R-26 (MOM 4i,j): The Organisation does not have an approved list of drugs which can be ordered verbally and staff awareness... needs to be strengthened. ...list of high-risk medication(s) but drugs Inj Polybion were found labelled as high risk in the pharmacy."

    • "2019-S-46 (MOM 4j): The list of high risk medication is not uniform across the HCO."

    • "2019-S-47 (MOM 4k,m): Audit of medication orders/prescription is not carried out and CAPA not done."

    • "2023-R-48 (MOM 4.f): Audit of medication orders/prescription to check for safe and rational prescription... does not include all the parameters. Example Drug interaction."

    • "2023-R-47 (MOM 4.d): There is no mechanism for clinicians which helps to identify drug interactions, food-drug interactions, therapeutic duplication, dose adjustments."

  • NABH Requirement:

    • Allergies: Ascertain and document drug allergies before prescribing.

    • Prescription Elements: Legible, in capital letters (for drug name at least), patient identifiers, drug name (generic preferred), dose, route, frequency, prescriber's name, signature, date, and time.

    • Verbal Orders: Discouraged, but if used, a clear policy must exist (limited situations, read-back, documentation by receiver, countersign by prescriber). List of drugs that cannot be given verbally.

    • High-Risk Medications: List defined and available to prescribers.

    • Prescription Audits: Regular audits for completeness, appropriateness, and rationality. CAPA for deviations. Mechanism to check for drug interactions.

  • Why it Matters: Prevents errors due to illegibility, ambiguity, wrong drug/dose/route, missed allergies, or inappropriate prescriptions.

  • Solutions & Best Practices:

    • "Do Not Use" Abbreviation List: Displayed and enforced.

    • Prescription Audit Checklist.

    • Training for Prescribers: On good prescription practices.

    • Clinical Pharmacist Role: Reviewing prescriptions, especially for high-risk drugs and polypharmacy.

    • Software Support: CPOE with allergy alerts, interaction checkers.

    • CAPITAL LETTERS for drug names.

• C. Dispensing, Administration, and Monitoring (MOM 5c,d,e, 8e, 9a, 10c, 12d) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-49 (MOM 5e): Labelling requirements are not uniformly implemented e.g. cut strips."

    • "2020-R-27 (MOM 5d,e): Near expiry drugs seen in the crash carts... Cut strips policy is not implemented in the wards and IP Pharmacy."

    • "2023-R-50 (MOM 5.c): All sampled medication orders were not legible, signed." (Should be picked up at dispensing/administration).

    • "2019-S-50 (MOM 8e): Corrective and/or preventive action (s) is not uniformly taken based on the analysis (of medication errors/ADRs)."

    • "2020-R-28 (MOM 9a): Patients' signature is not taken on Form 3 E for narcotic prescriptions."

    • "2023-R-52 (MOM 9.a): Use of Form 3E for narcotics was not evidenced across the HCO."

    • "2016-F-14 (MOM 10c): A bio-safety cabinet for preparation and mixing of chemotherapeutic drugs has not yet been installed." (Relates to safe handling/preparation).

    • "2020-R-30 (MOM 12d): The batch and serial number of the implantable prosthesis and medical devices are not recorded in the discharge summary." (Tracking for recall).

  • NABH Requirement:

    • Dispensing: Correct labeling of dispensed medications (including cut strips, multi-dose vials). Checking near-expiry dates.

    • Administration: Adherence to "Rights of Medication Administration" (Right patient, drug, dose, route, time, documentation, reason, response).

    • Monitoring: System for monitoring adverse drug reactions (ADRs) and medication errors, analysis, and CAPA.

    • Narcotics: Secure storage, proper documentation (e.g., Form 3E or equivalent), and control.

    • Chemotherapy/Hazardous Drugs: Safe handling, preparation (e.g., in biosafety cabinet), administration, and disposal.

    • Implants/Medical Devices: Tracking of batch/serial numbers.

  • Why it Matters: Ensures correct medication reaches the patient, prevents administration errors, manages risks associated with specific drug types, allows for recall if needed.

  • Solutions & Best Practices:

    • "Rights of Medication Administration" Posters & Training.

    • Bedside Barcode Scanning (if available).

    • ADR & Medication Error Reporting System: Non-punitive, with clear analysis and feedback loop.

    • SOP for Narcotic Management.

    • SOP for Chemotherapy Handling & Spill Management.

    • Designated area and equipment for chemotherapy preparation.

  • 
    

(0:50 – 1:35) Part 2: Hospital Infection Control (HIC) (45 minutes)

• Introduction to HIC:

  • "Hospital-Acquired Infections (HAIs) are a major threat to patient safety. The HIC chapter provides a comprehensive framework for preventing, identifying, and managing infections within the hospital."

  • "Our audits show consistent challenges in areas like BMW management, adherence to protocols, and surveillance."

• A. Infection Control Program & Leadership (HIC 1b,e,f) (5 minutes)

  • NC Examples from Your List:

    • "2019-S-61 (HIC 1e,f): There is no designated infection control officer and infection control nurse."

    • "2020-R-34 (HIC 1b): The infection prevention and control programme is not updated at annually. Documents dated both 2018 & 2019 were seen in circulation."

  • NABH Requirement:

    • A documented, comprehensive, and annually updated infection control program.

    • Designated and qualified Infection Control Officer (ICO) and Infection Control Nurse(s) (ICN).

    • Active Hospital Infection Control Committee (HICC)

  • Why it Matters: Provides structure, leadership, and resources for all IC activities.

  • Solutions & Best Practices:

    • Ensure qualified personnel are in place with defined roles.

    • Schedule annual review and update of the IC manual by HICC.

• B. Identification of High-Risk Areas/Procedures & Practices (HIC 2a,h,i,j,k,l) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-62 (HIC 2a): The organization does not uniformly identify the various high-risk procedures."

    • "2019-S-63 (HIC 2h): The organisation does not uniformly implement the antibiotic policy and monitors rational use of antimicrobial agents." (Antibiotic Stewardship)

    • "2016-F-16 (HIC 2h): The HCO has an updated antibiotic policy document; however, the monitoring of rational application...was not uniformly evidenced."

    • "2020-R-35 (HIC 2i): The organisation does not adhere to laundry and linen management processes. There is no protocol for washing of different categories of linen eg, blankets."

    • "2020-R-36 (HIC 2j): Periodic screening of kitchen workers and food handlers for carriage of parasites and S.Typhi is not evidenced."

    • "2020-R-37 (HIC 2k): Renovation work in hospital patient-care areas (OPD waiting area) has not been planned with infection control team."

    • "2020-R-38 (HIC 2l): There is no cleaning protocols for isolation rooms and other high risk areas. Disinfectants and Dilution protocols are not documented."

    • "2016-F-17 (HIC 2l): Knowledge of appropriate handling of blood spills was not demonstrated by the technician..." (Spill mgt part of practices).

    • "2023-R-66 (HIC 4.c): Procedures for housekeeping in BMTU rooms, IVF lab are not defined and not complied with."

  • NABH Requirement:

    • Identification of high-risk areas (ICU, OT, CSSD, etc.) and procedures (invasive procedures).

    • Specific IC protocols for these areas/procedures.

    • Antibiotic Stewardship Program: Policy, monitoring of use, promoting rational use.

    • Protocols for laundry/linen management, kitchen hygiene (including staff screening), environmental cleaning & disinfection (including dilutions), spill management.

    • IC team involvement in planning renovations/new constructions.

  • Why it Matters: Targets IC efforts where risk is highest, prevents spread of infection through environment/food/linen, combats antimicrobial resistance.

  • Solutions & Best Practices:

    • Risk Assessment: To identify high-risk areas/procedures.

    • SOPs: For all key IC practices, including dilutions for disinfectants, spill management steps.

    • Antibiotic Stewardship Committee/Team.

    • Training: For all staff on standard precautions, hand hygiene, specific protocols relevant to their area.

    • Regular Audits: Of cleaning practices, antibiotic use, laundry processes.

    • Activity: Role-play or demonstrate correct spill management for a blood spill.

• C. Surveillance Activities & Outbreak Management (HIC 3a,e,f) (10 minutes)

  • NC Examples from Your List:

    • "2020-R-39 (HIC 3a,e): Surveillance activities are not appropriately directed towards the identified high-risk procedures. Surveillance activities include monitoring the compliance with hand-hygiene guidelines but does not include appropriate sample size and all categories of staff...are not monitored."

    • "2023-R-65 (HIC 3.f): Prophylactic antibiotics were not uniformly prescribed as per the defined antibiotic policy..." (Monitoring part of surveillance).

  • NABH Requirement:

    • A documented surveillance program, directed towards identified risks (e.g., HAIs like CAUTI, CLABSI, VAP, SSI).

    • Monitoring compliance with IC practices (e.g., hand hygiene, antibiotic prophylaxis).

    • Data collection, analysis, interpretation, and dissemination of surveillance findings.

    • A plan for managing outbreaks of infection.

  • Why it Matters: Identifies trends, outbreaks, and areas for improvement in IC practices. Data-driven decision making.

  • Solutions & Best Practices:

    • Define Surveillance Indicators: Based on hospital risk assessment.

    • Standardized Data Collection Tools.

    • Regular Analysis & Reporting: To HICC and relevant departments.

    • Hand Hygiene Audits: "5 Moments of Hand Hygiene."

    • Outbreak Investigation Protocol.

• D. Sterilization (CSSD), Biomedical Waste (BMW) Management & PPE (HIC 4d, 5a, 7c,d,e, 8b,d) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-64 (HIC 4d): The organisation does not uniformly take action to prevent surgical site infections." (Sterilization is a key part).

    • "2016-F-18 (HIC 5a, HRM 4d): Correct use and removal of PPE was not demonstrated by the outsourced employee observed and interviewed in the laboratory."

    • "2020-R-22 (HIC 7c,d - 2016-P): There is no documented procedure to address reprocessing of single use devices and equipments." (Old NC, 5th Ed HIC 7d focuses on informing patient if reprocessed single use device is used).

    • "2020-R-40 (HIC 7d): The patient is not informed about the reprocessing of single use devices."

    • "2019-S-65 (HIC 7e): Reports for biological indicator not evidenced. Color indicator not inserted for all cycles (CSSD)."

    • "2019-S-66 (HIC 8b): Proper collection of biomedical waste from all patient care areas...is not uniformly implemented and not uniformly monitored. The bags are in shortage. Sharp containers not in point of generation."

    • "2020-R-41 (HIC 8b,d): Wastes are not segregated and collected in different colour coded bags and containers as per statutory provisions... The outsourced facility has not been visited..."

    • "2021-DS-02 (HIC 8.d): Evidence that the HCO has visited the outsourced facility to verify that the BMW is being disposed as per the guidelines is not submitted."

    • "2023-R-67 (HIC 4.d): Sharps and vials were noted to be kept in open in BMW collection area due to dearth of storage space." (BMW NC)

  • NABH Requirement:

    • Sterilization (CSSD): Validated sterilization processes, monitoring with physical, chemical, and biological indicators. Proper documentation.

    • Reprocessing of Single-Use Devices (SUDs): If done, a stringent policy must exist, including validation, tracking, and informing the patient. (Generally discouraged).

    • PPE: Availability, appropriate selection, and correct usage by all staff. Training on donning/doffing.

    • BMW Management: Segregation at point of generation, collection, transportation, treatment, and disposal as per statutory BMW Management Rules. Training for all staff. Monitoring of outsourced agency if applicable.

    • Needle Stick Injury/Sharps Management: Policy for prevention and post-exposure prophylaxis.

  • Why it Matters: Prevents SSIs, protects staff and community from infectious waste and sharps injuries.

  • Solutions & Best Practices:

    • CSSD SOPs: Covering all aspects of sterilization. Regular validation.

    • Strict Policy on SUD Reprocessing (if any).

    • PPE Availability & Training: Based on risk assessment for different tasks.

    • BMW Color Coding Charts: Displayed prominently.

    • Puncture-Proof Sharps Containers: Available at point of use, not overfilled.

    • Regular BMW Audits.

    • Due Diligence & Agreement with BMW Vendor.

    • Needle Stick Injury Protocol & Reporting.

(1:35 – 2:20) Part 3: Facility Management and Safety (FMS) (45 minutes)

• Introduction to FMS:

  • "The FMS chapter focuses on providing a safe, secure, and functional physical environment for patients, staff, and visitors. This includes the building itself, equipment, utilities, and emergency preparedness."

  • "Our audits have pointed to needs in safety inspections, equipment maintenance, and fire safety preparedness."

• A. Facility Safety, Inspections, and Infrastructure (FMS 1b,e,f, 3j) (10 minutes)

  • NC Examples from Your List:

    • "2019-S-75 (FMS 1b): Patient-safety devices & infrastructure are not uniformly installed... e.g. call bell, grab bars."

    • "2020-R-50 (FMS 1b): Grab bars were not seen in the toilets in Paediatric and General wards. A large amount of scrap material was seen on the 4th floor which can pose a fire hazard."

    • "2019-S-76 (FMS 1e,1f): Facility inspection rounds to ensure safety are not uniformly conducted..."

    • "2016-F-21 (FMS 1e): Facility inspection rounds...were not documented. Checklists incorporating some of the common safety hazards were not evidenced."

    • "2020-R-51 (FMS 3j): There is no maintenance plan for IT and communication network."

    • "2023-R-87 (FMS 1.c): Potential safety risks are not identified with an appropriate check list. Example rubber mats, smoke detectors, grab bars etc."

  • NABH Requirement:

    • Safe physical environment, including patient safety devices (call bells, grab bars, non-slip floors, etc.).

    • Regular, documented facility safety inspection rounds using checklists to identify and mitigate hazards (structural, environmental, security).

    • Maintenance plans for critical infrastructure, including IT and communication systems.

  • Why it Matters: Prevents falls, injuries, ensures operational continuity of essential services.

  • Solutions & Best Practices:

    • Facility Safety Committee.

    • Scheduled Safety Rounds: With multidisciplinary team, documented findings, and CAPA.

    • Preventive Maintenance Schedule: For all critical infrastructure.

    • Checklists: For safety rounds, identifying potential hazards.

• B. Equipment Management (Medical & Utilities) (FMS 4a,e,f,h,g) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-78 (FMS 4a): There are only 2 defibrillators in the OT Complex having 10 theatres..." (Availability issue).

    • "2019-S-79 (FMS 4e,f): Equipment are not uniformly periodically inspected and calibrated... There is no operational and maintenance (preventive and breakdown) plan."

    • "2019-S-80 (FMS 4h): The procedures do not uniformly address medical equipment recalls."

    • "2023-R-92 (FMS 4.g): Though HCO captures downtime of all utility equipment, it does not monitor the downtime of critical utility equipment which have not been identified separately."

  • NABH Requirement:

    • Inventory of all medical and utility equipment.

    • Program for planned preventive maintenance (PPM) and calibration for all equipment, especially life-support and critical equipment.

    • Documented breakdown maintenance procedures.

    • Procedure for handling medical equipment recalls.

    • Monitoring downtime of critical utility equipment.

  • Why it Matters: Ensures equipment is safe, functional, and available when needed. Prevents patient harm due to equipment malfunction.

  • Solutions & Best Practices:

    • Biomedical Engineering Department: With adequate resources and SOPs.

    • Comprehensive Equipment Inventory: With unique identification numbers.

    • PPM Schedule & Records: Maintained for all equipment. Calibration certificates.

    • User Training: On correct equipment operation.

    • Medical Equipment Recall SOP.

    • Logbooks for critical utilities downtime.

• C. Fire Safety and Emergency Preparedness (FMS 6a,b,c, 7a,e) (10 minutes)

  • NC Examples from Your List:

    • "2019-S-81 (FMS 6c): During assessment, Code Red was not satisfactory."

    • "2016-P-28 (FMS 1b): Bio hazard warning signs...is not displayed." (FMS 1b for safety devices but also relates to general safety signage which FMS 6 covers for emergencies). Re-evaluate FMS 1b for specific emergency signage.

    • "2020-R-52 (FMS 6a,b): The HCO does not have a dedicated emergency illumination system... All fire exit signs are at a level of above 6 ft... Fire-exit plans are not displayed on 5th & & 6th floors. Signage warning against using the lifts in case of fire was not seen..."

    • "2023-R-93 (FMS 6.a): Though HCO has a fire safety plan, availability of appropriate fire extinguisher near LMO was not evidenced. Jockey pump was on manual mode... Staff are not well aware of roles and responsibilities during fire emergencies..."

    • "2023-R-96 (FMS 7.e): HCO did not have a defined service continuity plan in case of fire and non fire emergencies." (Business continuity).

  • NABH Requirement:

    • A documented fire safety plan, including prevention, detection, abatement, and evacuation.

    • Adequate fire safety equipment (extinguishers, hydrants, alarms, sprinklers, smoke detectors, emergency illumination, clear exit routes/signage), regularly inspected and maintained.

    • Regular fire drills (Code Red) involving staff from all areas and shifts, with documented debriefing.

    • Staff training on their roles and responsibilities during a fire, use of fire extinguishers.

    • Plans for managing other emergencies (e.g., natural disasters, utility failures) and ensuring service continuity.

  • Why it Matters: Protects lives and property in case of fire or other emergencies.

  • Solutions & Best Practices:

    • Fire Safety Officer & Committee.

    • Regular Fire Safety Audits & Inspections.

    • Clear Evacuation Plans: Displayed in all areas.

    • Hands-on Fire Extinguisher Training (P.A.S.S. method).

    • Mock Drills: Varied scenarios, documented, and lessons learned implemented.

    • Disaster Management Plan.

• D. Hazardous Material and Medical Gas Safety (FMS 7b, 2c) (5 minutes)

  • NC Examples from Your List:

    • "2019-S-82 (FMS 7b): MSDS display is not uniform across the HCO."

    • "2020-R-53 (FMS 7b): Chemicals like Sodium Hypochlorite and Bleach were seen in unlabeled cans in the laundry. No MSDS was evidenced..."

    • "2019-S-77 (FMS 2c): The signages are not uniformly bilingual across the HCO." (Relates to general safety signage, including for hazardous areas/materials).

    • "2023-R-90 (FMS 3.e): Hazardous materials are not uniformly identified and used safely within the organisation." (Could be FMS 7b instead of 3e depending on context).

    • "2023-R-93 (FMS 6.a): Uniform colour coding of medical gas pipeline was not uniformly evidenced... PESo approval for 6KLD LMO was not evidenced." (Medical gas is a utility but also hazardous).

  • NABH Requirement:

    • Identification of hazardous materials used in the hospital.

    • Availability of Material Safety Data Sheets (MSDS) for all hazardous chemicals.

    • Safe handling, storage, use, and disposal of hazardous materials.

    • Staff training on handling hazardous materials and spill management.

    • Safe management of medical gas systems (storage, pipelines, alarms).

    • Appropriate safety signage, bilingual where needed.

  • Why it Matters: Prevents chemical burns, exposures, and environmental contamination. Ensures safe use of medical gases.

  • Solutions & Best Practices:

    • Inventory of Hazardous Materials.

    • MSDS Binder/System: Readily accessible to staff.

    • SOPs for Handling Specific Hazardous Materials & Spills.

    • Appropriate PPE for handling hazardous materials.

    • Regular Inspection & Maintenance of Medical Gas Systems.

    • Clear and Uniform Signage.

(2:20 – 2:25) Session Recap and Key Takeaways (5 minutes)

• Recap Learning Objectives: Briefly.

• Key Takeaways for MOM, HIC, FMS:

  • "Medication safety requires vigilance at every step – from storage to administration."

  • "A robust infection control program is multi-faceted, involving everyone from clinicians to support staff."

  • "A safe facility relies on proactive maintenance, regular inspections, and preparedness for emergencies."

  • "Uniformity in practice, clear documentation, and ongoing staff training are common threads for compliance in all these chapters."

(2:25 – 2:30) Q&A and Preview of Next Session (5 minutes)

• Open the floor for questions.

• "Our final deep-dive session will cover HRM, IMS, CQI, ROM, PRE and PSQ, focusing on the systems and processes that support all our clinical and operational activities. We'll also discuss action planning."

• Thank participants.

Trainer Notes for Session 3:

• Practical Demonstrations: If possible, for HIC, demonstrate hand hygiene steps or donning/doffing PPE. For FMS, show how to use a fire extinguisher (P.A.S.S.).

• Visuals are Key: Pictures of correct BMW segregation, MSDS sheets, fire safety equipment, well-organized medication storage areas, etc., will be very helpful.

• Real-Life Scenarios: Use short scenarios based on your hospital's NCs. E.g., "A nurse finds an unlabeled syringe in the medication trolley. What are the MOM and HIC implications?"

• Statutory Compliance: Emphasize that HIC (BMW rules) and FMS (fire safety, PESO for medical gases) have significant statutory/legal compliance aspects beyond just NABH.

• Cross-Departmental Importance: Highlight how these chapters require collaboration (e.g., Pharmacy working with Nursing for MOM, Engineering with all departments for FMS, everyone for HIC).

• Engage with Examples: When discussing LASA drugs or high-risk medications, ask the audience to name some examples relevant to their work area. 

Session 4: Strengthening Systems for Sustained Compliance – People, Information, Quality, Management, Rights & Safety

(Approximate Duration: 2.5 - 3 hours – This session covers many chapters, each with significant depth. It's crucial not to rush. Breaking it into two parts might be ideal if feasible.)

Session Goal:
To equip staff, particularly HODs, managers, and quality champions, with an in-depth understanding of common Non-Compliances (NCs) related to NABH chapters on Human Resource Management (HRM), Information Management System (IMS), Continuous Quality Improvement (CQI), Responsibilities of Management (ROM), Patient Rights and Education (PRE), and Patient Safety (PSQ). The session will focus on establishing and strengthening the systems, policies, and practices necessary for sustained compliance and a culture of continuous improvement.

Learning Objectives:
Upon completion of this session, participants will be able to:

1. Identify at least 3 common NCs for each chapter (HRM, IMS, CQI, ROM, PRE, PSQ) based on our hospital's audit findings.

2. Describe NABH requirements for effective human resource management, including recruitment, training, credentialing, and staff well-being.

3. Explain the principles of a robust information management system, focusing on medical record management, data security, and confidentiality.

4. Outline the key components of a continuous quality improvement program, including quality assurance, monitoring, data analysis, and CAPA.

5. Discuss the critical responsibilities of management in driving the quality agenda, ensuring legal compliance, and managing risk.

6. Articulate NABH standards related to upholding patient rights, providing effective patient education, and managing patient feedback.

7. Describe how to integrate patient safety goals and practices (PSQ) across all hospital functions.

8. Understand the importance of documentation, policy implementation, and leadership commitment for all these organizational chapters.

Materials Needed:

• Projector and screen

• Presentation slides (PowerPoint/Google Slides)

• Handouts (strongly recommended):

  • Checklist for Employee File Contents (HRM)

  • Key Elements of a Medical Record Audit (IMS)

  • Simple CQI Project Template (e.g., PDCA cycle) (CQI)

  • List of Key Statutory Compliances (ROM)

  • Patient Rights & Responsibilities Charter (PRE) (Hospital's version)

  • Patient Grievance Redressal Flowchart (PRE)

• Anonymized copies of relevant hospital SOPs (e.g., Recruitment Policy, Training Policy, Medical Record Policy, CQI Plan, Risk Management Policy, Patient Grievance Policy).

• Sample committee minutes, audit reports (anonymized).

• Case studies (short scenarios based on actual NCs from the provided list).

• Whiteboard or flip chart

• Markers

• The full list of hospital NCs (trainer's reference to pull specific, anonymized examples).

Session Plan & Detailed Content:

(0:00 – 0:05) Welcome and Recap of Session 3 (5 minutes)

• Trainer: Welcome participants.

• Quick Recap: "In our previous sessions, we've deep-dived into patient-centered care (AAC, COP) and critical operational areas (MOM, HIC, FMS). Today, we focus on the organizational backbone – the systems and management practices that enable and sustain quality and safety across the entire hospital. We'll cover HRM, IMS, CQI, ROM, PRE, and PSQ."

• Session Overview & Learning Objectives: Briefly outline the session structure and present the learning objectives.

(0:05 – 0:40) Part 1: Human Resource Management (HRM) (35 minutes)

• Introduction to HRM:

  • "Our staff are our most valuable asset. The HRM chapter ensures that we recruit the right people, train them effectively, ensure their competency, look after their well-being, and manage their performance to deliver high-quality patient care."

  • "NCs in this area often relate to documentation of training, credentialing, and staff awareness of their rights and responsibilities."

• A. Planning, Recruitment, and Onboarding (HRM 1e, 3a) (10 minutes)

  • NC Examples from Your List:

    • "2023-R-97 (HRM 1.e): Background check of new staff was not evidenced."

    • "2023-R-98 (HRM 3.a): Induction training of all consultants was not uniformly evidenced."

  • NABH Requirement:

    • Defined process for human resource planning based on hospital needs.

    • Well-documented recruitment process, including verification of credentials and background checks.

    • Structured induction training for all new staff (including consultants, part-time, outsourced) covering hospital mission, policies, patient rights, safety protocols, and job-specific roles.

  • Why it Matters: Ensures competent and suitable staff are hired and are well-prepared from day one.

  • Solutions & Best Practices:

    • Standardized Job Descriptions and Person Specifications.

    • SOP for Recruitment, including mandatory background/credential checks.

    • Comprehensive Induction Program with checklist, feedback, and documented attendance.

• B. Training and Development (HRM 3c, 4c,e, 5d,e,f, 6d, 7c, 8c,d) (15 minutes)

  • NC Examples from Your List (Extensive list here):

    • "2019-S-85 (HRM 3c): Training does not uniformly occur when job responsibilities change."

    • "2023-R-99 (HRM 4.c): Training when job responsibilities change was not uniformly evidenced."

    • "2023-R-100 (HRM 4.e): Evaluation of training effectiveness by the organisation was not evidenced."

    • "2023-R-101 (HRM 5.d): All staff are not trained in healthcare communication techniques."

    • "2019-S-60 (PRE 8f - linked to HRM 5d): The staff are not uniformly aware in healthcare communication techniques periodically."

    • "2023-R-102 (HRM 5.e): Staff (doctors) involved in direct patient care were not uniformly provided training on cardiopulmonary resuscitation periodically."

    • "2023-R-103 (HRM 5.f): All staff (doctors) were not uniformly provided training on infection prevention and control at least once a year."

    • "2023-R-104 (HRM 6.d): Staff working in areas with potential occupational hazards were not uniformly trained in occupational safety aspects."

    • "2019-S-86 (HRM 7c): Regular health checks of staff dealing with direct patient care are not uniformly done at-least once a year and the findings/ results are not uniformly documented. E.g. doctors."

    • "2019-S-87 (HRM 8c): All records of in-service training are not uniformly contained in the personal files."

    • "2020-R-55 (HRM 8c,d): All records of in-service training and education and evaluations are not contained in the personal files."

    • "2023-R-108 (HRM 10.c): Personal files did not uniformly have records of in-service training and education."

    • "2023-R-109 (HRM 10.d): Personal files did not uniformly contain results of all evaluations and remarks."

  • NABH Requirement:

    • Ongoing training programs based on identified needs (including job changes, new equipment/processes).

    • Mandatory training on patient safety, CPR, infection control, fire safety, communication skills, occupational hazards.

    • Evaluation of training effectiveness.

    • Maintenance of comprehensive training records for all staff in their personal files, including evaluations and remarks on performance.

    • Regular health checks for staff, especially those in direct patient care, with documented findings.

  • Why it Matters: Ensures staff competency, safety, and continuous professional development. Meets regulatory requirements.

  • Solutions & Best Practices:

    • Annual Training Calendar: Based on training needs analysis.

    • Competency Mapping & Assessment.

    • Varied Training Methodologies: (Classroom, e-learning, drills, on-the-job).

    • Post-Training Evaluation: (Tests, observations, feedback).

    • Standardized Employee Files: With checklist for mandatory documents including all training records.

    • System for tracking staff health checks.

    • Activity (Small Group): Review a sample (anonymized) employee file checklist. Does it cover all NABH requirements for training documentation?

• C. Staff Rights, Responsibilities, Well-being & Credentialing (HRM 2e,f, 6b, 9b,c,d,e, 10d, 11d) (10 minutes)

  • NC Examples from Your List:

    • "2019-S-83 (HRM 2e): The staff are not uniformly aware of employee rights and responsibilities."

    • "2020-R-54 (HRM 2e,f, HRM 6b): On interviewing the staff, awareness on employee and patient rights and responsibilities and Anti sexual harassment policy was found lacking."

    • "2023-R-105 (HRM 9.b): Staff working in high noise level areas were not using ear muffs during assessment." (Occupational health).

    • "2023-R-106 (HRM 9.c): Annual health check of all staff was not uniformly evidenced eg doctors." (Duplicate of 7c).

    • "2023-R-107 (HRM 9.e): Measures for prevention and handling workplace violence was not evidenced."

    • "2020-R-56 (HRM 9d): Medical professionals are not granted privileges to admit and care for patients in consonance with their qualification... The ICO (a microbiologist) has not been granted privileges..."

    • "2020-R-57 (HRM 10d): Nursing staff do not have privileges documented, only a competency matrix is evidenced."

    • "2023-R-110 (HRM 11.d): All medical professionals are not uniformly granted privileges as per their qualification, training, experience and registration."

  • NABH Requirement:

    • Staff are aware of their rights (e.g., grievance redressal, safe workplace) and responsibilities.

    • Policies for occupational health & safety (e.g., noise protection, handling workplace violence, anti-sexual harassment).

    • Credentialing & Privileging (C&P): A well-defined, documented process to verify qualifications, training, experience, and registration of all medical, nursing, and other professional staff. Privileges granted must be commensurate with their credentials and periodically reviewed.

  • Why it Matters: Promotes a fair and safe work environment, ensures patient care is provided by qualified and competent professionals.

  • Solutions & Best Practices:

    • Employee Handbook: Outlining rights, responsibilities, policies.

    • Internal Complaints Committee (ICC) for sexual harassment.

    • Clear C&P Policy & Procedure: Involving relevant HODs and a C&P committee.

    • Privilege Delineation Forms: Specific to profession and specialty.

    • Regular review of C&P files.

(0:40 – 1:10) Part 2: Information Management System (IMS) (30 minutes)

• Introduction to IMS:

  • "Effective healthcare relies on accurate, timely, and secure information. The IMS chapter covers the management of all patient-related and organizational information, with a strong focus on medical records."

  • "Documentation quality, record completeness, and maintaining confidentiality are key areas where NCs often arise."

• A. Medical Record Management (IMS 2a, 3c,d,e,f) (15 minutes)

  • NC Examples from Your List:

    • "2020-R-58 (IMS 2a): Obsolete documents were found in the PICU and the HIC manual has not been updated annually." (Relates to document control, part of IMS).

    • "2019-S-88 (IMS 3c,d): Entry in the medical record is not uniformly named, signed, dated and timed. The author of the entry is not uniformly identified."

    • "2020-R-59 (IMS 3c,d): All entries in the medical record are not named, signed, dated and timed. The author of each entry cannot always be identified."

    • "2016-F-27 (IMS 3c): Entries in some of the medical records reviewed were not uniformly named, dated and timed..."

    • "2016-F-28 (IMS 3d): The author in the case of entries in medical records cannot always be identified."

    • "2023-R-111 (IMS 3.e): All entries in medical record were not named, signed and timed."

    • "2023-R-112 (IMS 3.f): All entries in case records were not signed, hence author of each entry could not Br uniformly identified."

  • NABH Requirement:

    • Unique identifier for each patient record.

    • Standardized format and content for medical records.

    • All entries must be legible, timed, dated, named, and signed by the author. Author must be clearly identifiable.

    • Process for correcting errors in records.

    • Secure storage, timely retrieval, and defined retention period for records.

    • Policy on document control (versioning, managing obsolete documents).

  • Why it Matters: Essential for continuity of care, communication between providers, medico-legal defense, research, and quality audits.

  • Solutions & Best Practices:

    • Medical Record Policy & SOPs: Covering all aspects from creation to destruction.

    • Standardized Forms & Templates.

    • Regular Training on Good Documentation Practices (GDP).

    • Medical Record Audits: Focusing on completeness, legibility, timeliness, and author identification.

    • Secure MRD with controlled access.

    • Use of Hospital Information System (HIS) with audit trails.

• B. Data Security, Confidentiality, and Review (IMS 5f, 7d,e,g) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-89 (IMS 5f): Privileged health information is disclosed without the patient's authorization."

    • "2020-R-60 (IMS 5f): Privileged health information is disclosed without the patient's authorization."

    • "2019-S-90 (IMS 7e): The review process does not uniformly include records of active patients."

    • "2023-R-113 (IMS 7.d): The review of medical records is not based on all the parameters." (Implies incomplete review process).

    • "2019-S-91 (IMS 7g): Appropriate corrective and preventive measures are not uniformly undertaken within a defined period of time and are documented (for medical record deficiencies)."

    • "2023-R-114 (IMS 7g): Appropriate corrective and preventive measures are not evidenced."

  • NABH Requirement:

    • Policies and procedures to ensure confidentiality, security, and integrity of patient information (both paper and electronic).

    • Restricted access to patient records based on roles.

    • Regular review of medical records (active and discharged) for completeness and quality.

    • Documented CAPA for deficiencies found during record reviews.

  • Why it Matters: Protects patient privacy, ensures data integrity, meets legal obligations, drives improvement in documentation.

  • Solutions & Best Practices:

    • Confidentiality Agreements for staff.

    • Access Controls in HIS.

    • Secure storage of paper records.

    • SOP for medical record review, including sampling methodology and parameters.

    • Documented CAPA process for record deficiencies.

    • Training on data privacy and security.

(1:10 – 1:50) Part 3: Continuous Quality Improvement (CQI) (40 minutes)

• Introduction to CQI:

  • "CQI is not a one-time project; it's a continuous cycle of planning, doing, checking, and acting (PDCA) to improve processes and outcomes. It's about embedding quality into everything we do."

  • "Our audits show a need to strengthen our systems for identifying improvement opportunities, validating data, and implementing and monitoring quality projects."

• A. Quality Assurance (QA) Programs & Monitoring (CQI 1h,i, 3a,b,d,e, 4d,h) (20 minutes)

  • NC Examples from Your List (Extensive list, indicates a major systemic gap):

    • "2016-P-23 (CQI 1h): Though there are regular audits done in the HCO, the same are not done by multi disciplinary audit teams independent of their area of work..."

    • "2016-P-24 (CQI 1i): There are no clinical nursing audits done; hence there is no established process in the organization to monitor and improve quality of nursing care."

    • "2016-F-19 (CQI 3a & ROM 3d): The organization did not capture and document key performance indicators regarding time for initial assessment by doctors and percentage of cases where care plan with desired outcomes were documented..."

    • "2020-R-42 (CQI 3b(iii),(iv)): Monitoring does not include percentage of all CT & MRI reports co-relating with clinical diagnosis and percentage of adherence to safety precautions by employees working in the radiological services."

    • "2020-R-43 (CQI 3d(ii)): Monitoring of percentage of unplanned ventilation following anaesthesia only mentions the reasons as 'major surgery'/ 'sick patient'."

    • "2020-R-44 (CQI 3e(ii),(iv)): Re-scheduling of patients only includes postponement... Percentage of cases who received appropriate prophylactic antibiotics... is shown to be 100%, whereas on verification it was found that time of administration is not being captured..." (Data validation issue).

    • "2020-R-45 (CQI 4d(iii)): Waiting time for out-patient consultation is not monitored. The waiting time for diagnostics is not monitored appropriately."

    • "2019-S-68 (CQI 4h): The organisation does not uniformly identify and does not uniformly monitor priority managerial activities in the organisation."

  • NABH Requirement:

    • A structured quality assurance program, including identification of key performance indicators (KPIs) for clinical and managerial activities.

    • Regular monitoring of these KPIs. Data collected must be accurate and validated.

    • Audits (clinical, nursing, departmental) conducted by multidisciplinary teams, independent where possible.

    • Defined processes for how the organization identifies and monitors priority activities.

  • Why it Matters: Provides data-driven insights into performance, identifies areas needing improvement, ensures accountability.

  • Solutions & Best Practices:

    • Hospital-wide CQI Plan: Outlining goals, indicators, responsibilities, audit schedules.

    • Dashboard of KPIs: Regularly reviewed by management and HODs.

    • Data Validation Process: Before analysis and reporting.

    • Standardized Audit Tools and Checklists.

    • Training for Internal Auditors.

    • Clear definition of "priority managerial activities" and their monitoring.

    • Activity: Brainstorm 3-4 key clinical indicators and 2-3 managerial indicators that our hospital should be tracking.

• B. Data Analysis, Improvement, Feedback & CAPA (CQI 5a-e, 7b,d,e, 8c) (20 minutes)

  • NC Examples from Your List:

    • "2019-S-69 (CQI 5a,b,c,d,e): There is no mechanism for validation, analysis, improvement and feedback of data."

    • "2020-R-46 (CQI 5a-e): There is no mechanism for validation of data or for analysis of data which results in identifying opportunities for improvement."

    • "2016-P-26 (CQI 7b): There is no established system for clinical audits in the HCO on a regular basis encompassing all aspects of clinical care."

    • "2020-R-47 (CQI 7b,d,e): For clinical audits, the parameters to be audited are not defined... All audits do not have a checklist with the predefined parameters. Remedial measures are not implemented."

    • "2019-S-70 (CQI 8c): Corrective and Preventive Actions are not uniformly taken based on the findings of such analysis."

    • "2020-R-48 (CQI 8c): No CAPA was evidenced for the incidents reported."

  • NABH Requirement:

    • Systematic process for data validation, analysis, and identification of improvement opportunities.

    • Feedback mechanisms for data and audit findings.

    • Structured approach to clinical audits (defined parameters, checklists).

    • Robust Corrective and Preventive Action (CAPA) process for all identified non-conformities, incidents, and audit findings. CAPA must be documented and its effectiveness monitored.

  • Why it Matters: Turns data into actionable insights, ensures problems are fixed and don't recur, drives a culture of learning and improvement.

  • Solutions & Best Practices:

    • Quality Department/Team: To facilitate data analysis, CQI projects, and CAPA tracking.

    • Use of Quality Tools: (e.g., Fishbone diagrams, Pareto charts, PDCA cycle).

    • Regular Quality Review Meetings: At departmental and hospital levels.

    • Standardized CAPA Form & Process: Including root cause analysis.

    • Training on CQI methodologies and tools.

    • Sharing of "Lessons Learned" from incidents and audits.

(1:50 – 2:20) Part 4: Responsibilities of Management (ROM) (30 minutes)

• Introduction to ROM:

  • "The ROM chapter emphasizes the crucial role of the hospital's leadership in defining the mission, vision, and values, ensuring ethical practices, managing resources, complying with legal requirements, and driving the quality and patient safety agenda."

  • "NCs here often point to gaps in statutory compliance, committee functioning, or proactive risk management."

• A. Leadership, Governance, and Ethical Conduct (ROM 2b, 5e,f,g,k) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-71 (ROM 2b): PCB license expired... Wireless license expired... Pharmacy stocks Food products but lacks FSSAI license... OT pharmacy not licensed. Psychiatry ward present but not registered under Mental Health Act. The building... occupied 5th and 6th floor... completion and occupation certificate and fire NOC for the same is yet pending..." (Multiple statutory/legal lapses).

    • "2020-R-49 (ROM 2b): The HCO does not have a fire NOC for the 5th and 6th floors... Details of patients undergoing MTP were not kept confidential."

    • "2021-DS-03": Multiple statutory license issues (PCB, MoU with BMW, Fire NOC).

    • "2023-R-84 (ROM 3.c): Multiple statutory license issues (PCB, Fire NOC, ART clinic, Mental Health Act)."

    • "2023-R-85 (ROM 5.e): MOU with outsourced hospital for irradiation of cellular product and total body irradiation for BMTU was not evidenced."

    • "2016-P-27 (ROM 5f): Performance evaluation of senior leaders by those responsible for governance is not evidenced."

    • "2019-S-72 (ROM 5g): The roles and responsibilities of members (committees) are not defined and minutes not structured. The functioning of committees is not reviewed for their effectiveness."

    • "2019-S-73 (ROM 5k): The organization does not monitor the quality of the outsourced services."

    • "2023-R-86 (ROM 5.f): Monitoring of Services of all outsourced agencies including Teleradiology was not evidenced."

  • NABH Requirement:

    • Defined hospital mission, vision, and strategic plan.

    • Compliance with all applicable statutory and regulatory requirements. Maintenance of valid licenses.

    • Ethical framework for hospital operations (including confidentiality, MTP).

    • Effective functioning of various hospital committees (defined roles, structured minutes, review of effectiveness).

    • Monitoring quality of outsourced services, including MOUs.

    • Performance evaluation of senior leaders.

  • Why it Matters: Ensures legal operation, ethical practice, effective governance, and accountability from leadership.

  • Solutions & Best Practices:

    • Designated Person/Department: To track all licenses and ensure timely renewals.

    • Legal Compliance Audit: Periodically.

    • Code of Conduct for all staff.

    • SOP for Committee Functioning: Including TOR, agenda, minutes format, action tracking.

    • Vendor Management Policy: Including quality monitoring of outsourced services.

    • Formal process for senior leader performance appraisal.

• B. Risk Management & Patient Safety Program (ROM 6a, CQI 2e) (15 minutes)

  • NC Examples from Your List:

    • "2019-S-74 (ROM 6a): Management does not ensure proactive risk management across the organization."

    • "2016-F-20 (ROM 6a&b, FMS 1a): Documentation of proactive risk management plan including risk assessment and risk reduction activities were not comprehensively evidenced."

    • "2019-S-67 (CQI 2e): There is no designated individual for coordinating and implementing the patient safety programme."

  • NABH Requirement:

    • A proactive, hospital-wide risk management program, including identification, assessment, and mitigation of risks.

    • Integration of risk management with the patient safety program.

    • Designated individual responsible for coordinating the patient safety program.

  • Why it Matters: Helps prevent adverse events, reduces liability, improves patient and staff safety.

  • Solutions & Best Practices:

    • Risk Management Policy & Plan.

    • Hospital Risk Register: Regularly updated.

    • Tools like FMEA (Failure Mode and Effects Analysis) for high-risk processes.

    • Patient Safety Officer/Committee: With clear roles.

    • Integration of incident reporting data into risk management.

    • Training on risk identification and reporting.

(2:20 – 2:45) Part 5: Patient Rights and Education (PRE) & Patient Safety (PSQ) (25 minutes)

• Introduction to PRE & PSQ:

  • "PRE ensures that patients are treated with dignity, their rights are respected, they are well-informed, and can participate in their care. PSQ (from 5th Edition) is about proactively identifying and mitigating patient safety risks and promoting a culture of safety."

  • "NCs in PRE often relate to communication, consent (though covered in COP too), and grievance redressal. PSQ often integrates with CQI and ROM."

• A. Patient Rights, Information, and Consent (PRE 1b,d,e, 2b,j, 4a,c,d,f,g) (15 minutes)

  • NC Examples from Your List (Many consent issues overlap with COP, highlight PRE aspects here):

    • "2019-S-84 (HRM 2f, PRE 1d): The employees are not uniformly aware on patient's rights and responsibilities."

    • "2023-R-54 (PRE 1.e): Corrective/preventive action taken by the top leadership of the organisation for violation of patient and family rights was not evidenced."

    • "2019-S-51 (PRE 2b): Patient and family rights do not include respect for privacy."

    • "2020-R-31 (PRE 2b,j): The changing rooms for X rays are just a partition with a curtain which violates the patient's right for respect of personal dignity and privacy. OP patients are not granted access to their records..."

    • "2023-R-56 (PRE2.j): Patient and family rights did not include access of patients to their clinical records."

    • "2019-S-53 (PRE 4b): General consent for treatment is not structured accordingly."

    • "2020-R-32 (PRE 4a,d, COP 8d): The list of situations where informed consent is required was not evidenced. Informed consent does not include information regarding the surgery or anesthesia and the risks, benefits or alternatives..."

    • "2016-F-15 (PRE 4f&g): Informed consent prior to TMT testing was not evidenced."

    • "2023-R-58 (PRE 4.c): The consent form does not explain the procedure as seen in Labour room, gynec surgeries, Dermatology, dental departments."

    • "2023-R-55 (PRE2.g): Informed consent is not being taken uniformly for all patients as seen in TMT department, Dermatology Skin biopsy, Ophthalmology departments for Laser."

  • NABH Requirement:

    • Display of patient rights and responsibilities. Staff awareness.

    • Ensuring patient privacy, dignity, and access to their clinical records (as per policy).

    • Process for taking informed consent: structured general consent, specific informed consent for procedures/anesthesia/transfusion/research, covering risks, benefits, alternatives, by the performing person, in understandable language. List of situations requiring consent.

    • Leadership action on violation of patient rights.

  • Why it Matters: Empowers patients, ensures ethical practice, legal compliance.

  • Solutions & Best Practices:

    • Patient Rights Charter: Displayed, available in local language.

    • Staff Training on Patient Rights & Communication.

    • Standardized Consent Forms (general and specific).

    • Process for patients to access their records.

    • Dedicated Counselors for complex consents.

    • Audits of consent documentation and process.

• B. Patient Education, Communication, and Feedback (PRE 6c, 7b,c,d,f, 8a-f) (10 minutes)

  • NC Examples from Your List:

    • "2016-P-19 (PRE 6c): Patients and family members interviewed during the audit were not aware of the expected costs."

    • "2023-R-59 (PRE 7.b): Patient experience is not captured."

    • "2019-S-57 (PRE 7c): Patient and/or family members are not uniformly made aware of the procedure for lodging complaints."

    • "2019-S-58 (PRE 7d): All feedback and complaints are not uniformly reviewed and/or analysed within a defined time frame and CAPA not done."

    • "2023-R-62 (PRE 7.f): Corrective and/or preventive action(s) are not evident for those patient complaints which are captured by QR code based on the analysis where appropriate."

    • "2020-R-33 (PRE 8a-f): There is no evidence that the organisation has a system for effective communication with patients and /or families."

    • "2019-S-59 (PRE 8b): The organisation does not uniformly identify special situations where enhanced communication would be required..."

  • NABH Requirement:

    • Providing patients/families with information about their condition, treatment plan, expected costs, and how to lodge complaints/provide feedback.

    • System for capturing and analyzing patient experience and feedback. CAPA for complaints.

    • Effective communication strategies, especially for patients with special needs (language barriers, disabilities).

  • Why it Matters: Improves patient satisfaction, adherence to treatment, identifies areas for service improvement.

  • Solutions & Best Practices:

    • Patient Information Leaflets/Brochures.

    • Financial Counseling.

    • Clear Grievance Redressal Mechanism (with timelines).

    • Patient Satisfaction Surveys.

    • Staff Training on Communication Skills (including empathetic communication).

    • Availability of interpreters or language aids.

• C. Patient Safety (PSQ) (Integrated throughout, but highlight key PSQ specific NCs if available from list, e.g., 2023-R PSQ NCs 75-83) (Briefly, as much is covered in CQI/ROM) (This section will be more prominent if you have explicit PSQ chapter NCs from 5th Ed audits)

  • NC Examples from Your List (2023-R):

    • "2023-R-75 (PSQ 3.b): Key indicators for HIC are defined but are not monitored appropriately..."

    • "2023-R-76 (PSQ 3.e): HCO has not initiated capture of patient reported outcome measures."

    • "2023-R-77 (PSQ 3.f): Verification of data by quality team was not evidenced."

    • "2023-R-78 (PSQ 3.g): Analysis of data and CAPA was not evidenced."

    • "2023-R-79 (PSQ 3.h): Implementation of Improvement activities based on CAPA was not evidenced..."

    • "2023-R-80 (PSQ 4.a): HCO has not under taken two quality improvement projects per year."

    • "2023-R-81 (PSQ 5.a): HCO has not conducted one clinical audit per department per year."

    • "2023-R-83 (PSQ 7.e): Risk identified in incident analysis was not incorporated in the risk management plan."

  • NABH Requirement (5th Edition focus):

    • Establishment of patient safety goals and indicators.

    • Monitoring of patient safety indicators (including HIC indicators, PROMs).

    • Data verification, analysis, and CAPA for patient safety issues.

    • Defined number of QIPs and clinical audits.

    • Integration of incident analysis into the risk management plan.

  • Why it Matters: Drives a proactive approach to preventing patient harm.

  • Solutions & Best Practices:

    • Define hospital-specific patient safety goals (aligned with National/International goals).

    • System for collecting and analyzing PROMs.

    • Robust incident reporting and analysis system.

    • Ensure QIPs and clinical audits are meaningful and lead to improvements.

    • Regularly update risk management plan with insights from incidents.

(2:45 – 2:55) Session Recap and Key Takeaways (10 minutes)

• Recap Learning Objectives: Briefly.

• Key Takeaways for HRM, IMS, CQI, ROM, PRE, PSQ:

  • "Strong HRM practices ensure we have competent, well-trained, and motivated staff."

  • "Reliable IMS is vital for quality care, legal compliance, and data-driven decisions."

  • "CQI is an ongoing journey, not a destination, requiring commitment from everyone."

  • "Effective ROM means leadership actively drives quality, ensures compliance, and manages risks."

  • "Respecting PRE and actively engaging patients improves experience and outcomes."

  • "PSQ aims to create a culture where patient safety is paramount."

  • "These organizational chapters are interconnected and provide the foundation for excellence in patient-centered care."

(2:55 – 3:00) Q&A and Introduction to Final Session/Action Planning (5 minutes)

• Open the floor for questions.

• "In our final session, we will focus on consolidating our learning, developing department-specific action plans to address these NCs, and discussing how to build and sustain a strong culture of quality and safety in our hospital."

• Thank participants.

Trainer Notes for Session 4:

• Audience Relevance: This session is particularly crucial for HODs, managers, Quality team, and NABH coordinators. Tailor examples and discussions to their roles in implementing and overseeing these systems.

• Link to Previous Sessions: Continuously show how these organizational chapters support the clinical and operational chapters discussed earlier (e.g., "Effective HRM training (HRM) directly impacts medication administration safety (MOM) and infection control practices (HIC)").

• Policy Focus: Many NCs in these chapters relate to missing or unimplemented policies. Have key (anonymized) hospital policies available for reference or brief review if time permits.

• Systemic Thinking: Encourage participants to think systemically. An NC in IMS (e.g., poor documentation) might have root causes in HRM (inadequate training) or CQI (lack of audits).

• Leadership Role: Emphasize the critical role of leadership (ROM) in championing and resourcing all these initiatives.

• Engagement: Use case studies where a failure in one of these organizational systems leads to a patient care issue. For example, "A new nurse wasn't properly inducted (HRM) and made a medication error (MOM) because she wasn't aware of the LASA drug policy (MOM/IMS)." 

Session 5: Moving Forward – Departmental Action Planning, Culture Building, and Sustained Excellence

(Approximate Duration: 2.5 - 3 hours – This session is highly interactive and requires significant time for group work and discussion.)

Session Goal:
To empower participants to translate the knowledge gained from previous sessions into concrete, department-specific action plans for addressing identified Non-Compliances (NCs). The session will also focus on strategies for fostering a sustainable culture of patient safety, continuous quality improvement, and NABH compliance throughout the hospital.

Learning Objectives:
Upon completion of this session, participants will be able to:

1. Apply root cause analysis techniques to identify underlying reasons for common NCs relevant to their department.

2. Develop SMART (Specific, Measurable, Achievable, Relevant, Time-bound) action plans to address at least two key NCs for their department.

3. Identify key elements and strategies for building a strong culture of patient safety and quality.

4. Understand the role of leadership, teamwork, open communication, and non-punitive reporting in sustaining quality initiatives.

5. Recognize available resources and support systems within the hospital for NABH compliance and continuous improvement.

6. Commit to their role in driving and sustaining NABH compliance and quality improvement efforts.

Materials Needed:

• Projector and screen

• Presentation slides (PowerPoint/Google Slides)

• Handouts:

  • List of common NC themes (from Session 1)

  • Abridged list of top 5-10 NCs relevant to major departments/groups present (derived from the full NC list)

  • Root Cause Analysis Tool Template (e.g., Fishbone Diagram, 5 Whys)

  • SMART Action Plan Template

  • Key characteristics of a "Culture of Safety"

• Flip charts or large sheets of paper for each group

• Different colored markers for group work

• Sticky notes (optional)

• Completed NC analysis from previous sessions (for trainer reference).

Session Plan & Detailed Content:

(0:00 – 0:10) Welcome and Recap of Entire Training Program (10 minutes)

• Trainer: Welcome participants to the final session.

• Comprehensive Recap:

  • "Over the past few sessions, we've journeyed through the landscape of NABH. We started by understanding NABH and our hospital's performance (Session 1). We then did deep dives into patient-centered chapters like AAC and COP (Session 2), critical operational chapters like MOM, HIC, and FMS (Session 3), and the organizational backbone chapters like HRM, IMS, CQI, ROM, PRE, and PSQ (Session 4)."

  • "We've identified common themes in our NCs: lack of uniformity, documentation gaps, implementation challenges, policy weaknesses, training needs, and system-level issues in monitoring and CAPA."

  • "Today, it's about taking all that learning and turning it into concrete action and a lasting commitment."

• Session Overview & Learning Objectives: Briefly outline the session structure and present the learning objectives. Emphasize that this session is highly interactive and relies on their active participation.

(0:10 – 1:10) Part 1: Department-Specific NC Analysis & Root Cause Analysis (RCA) (60 minutes)

• A. Introduction to Action Planning and RCA (10 minutes)

  • Why Action Planning? "Simply knowing our NCs isn't enough. We need a structured plan to address them effectively and prevent recurrence."

  • Why Root Cause Analysis?

    • "Often, an NC is just a symptom of a deeper problem. If we only treat the symptom, the problem will likely return."

    • "RCA helps us dig deeper to find the fundamental reasons why an NC occurred."

    • Introduce simple RCA tools:

      1. 5 Whys: Keep asking "Why?" until the root cause is identified. (Provide a simple example unrelated to healthcare first, then a healthcare one).

      2. Fishbone Diagram (Ishikawa Diagram): Briefly explain categories (e.g., People, Process, Equipment, Materials, Environment, Management) and how they help brainstorm potential causes.

• • Focus: "We'll be using these tools to analyze a few key NCs relevant to your areas."

• B. Group Formation and NC Selection (10 minutes)

  • Group Formation: Divide participants into small groups, ideally based on their departments or functional areas (e.g., Nursing (Wards), ICU, OT, Lab, Radiology, Pharmacy, MRD, Admin/HR, Support Services). Aim for 4-6 people per group.

  • NC Selection:

    • Provide each group with an abridged list of 3-5 high-impact or frequently recurring NCs from the hospital's audit reports that are most relevant to their department/functional area. (Trainer should pre-select these based on the master NC list provided earlier).

    • Instruct each group to select TWO NCs from their provided list that they feel are most critical or representative of challenges in their area.

• C. Group Work: Root Cause Analysis (30 minutes)

  • Instructions:

    • "For each of the two NCs your group selected, conduct a Root Cause Analysis using either the '5 Whys' or a simple Fishbone Diagram."

    • "Discuss openly and honestly. Think about systems, processes, resources, training, communication, etc."

    • "Document your RCA findings on the flip chart provided."

  • Facilitation: Trainer(s) circulate among groups, guiding them, clarifying doubts, and ensuring they are digging deep enough.

    • Prompting Questions: "Why was the documentation not uniform? Was it lack of training? Unclear forms? Time pressure? Lack of awareness of the policy?"

    • Encourage them to look beyond individual blame and focus on system/process issues.

  • Example NC for a Nursing Group to Analyze: "2019-S-2 (AAC 4d): The initial assessment for in-patients is not uniformly documented within 24 hours."

    • Potential "5 Whys" path:

      1. Why? Nurses are busy with immediate patient needs.

      2. Why? High patient-to-nurse ratio during admission peak.

      3. Why? Staffing patterns don't match admission flow.

      4. Why? The form is too lengthy and not user-friendly.

      5. Why? Lack of clear expectation/audit on completion time.

    • (This reveals multiple root causes: staffing, form design, clarity of expectation).

• D. Group Presentations of RCA Findings (Brief – if time is short, skip and go to action planning) (10 minutes)

  • Each group briefly shares ONE of their NCs and the key root cause(s) they identified.

  • This helps in cross-learning and seeing commonalities across departments.

(1:10 – 2:10) Part 2: Developing SMART Action Plans (60 minutes)

• A. Introduction to SMART Action Planning (10 minutes)

  • "Now that we have a better understanding of the root causes, let's develop action plans to address them."

  • "A good action plan is SMART:"

    • Specific: What exactly will be done? Who will do it?

    • Measurable: How will we know if it's successful? What are the indicators?

    • Achievable: Is it realistic with available resources and constraints?

    • Relevant: Does it directly address the root cause and the NC?

    • Time-bound: What is the deadline for completion

  • Provide the SMART Action Plan Template. (Columns: NC, Root Cause(s), Specific Action, Responsible Person/Dept, Resources Needed, Timeline, Measurable Outcome/Indicator).

  • Example:

    • NC: Initial assessment not uniformly documented within 24 hrs.

    • Root Cause (from RCA): Form is too lengthy and not user-friendly; lack of consistent reminders.

    • Specific Action: Revise initial assessment form to be more concise and user-friendly; implement daily audit checklist by ward in-charge for 24-hr completion.

    • Responsible: Nursing Superintendent, MRD Head, IT (for HIS changes if any).

    • Resources: Time for committee work, printing new forms.

    • Timeline: Form revision – 1 month; Audit implementation – 2 weeks post form finalization.

    • Measurable Outcome: 95% of initial assessments documented within 24 hrs within 3 months of implementation.

• B. Group Work: Developing Departmental Action Plans (40 minutes)

  • Instructions:

    • "Using your RCA findings for the two selected NCs, develop a SMART action plan for each."

    • "Focus on practical, implementable solutions."

    • "Assign responsibilities and realistic timelines."

    • "Think about how you will measure success."

    • Document the action plans on the template/flip chart.

  • Facilitation: Trainer(s) actively engage with groups, helping them refine their actions to be SMART, ensuring they are addressing the identified root causes, and prompting them to think about resources and measurement.

• C. Group Presentations of Action Plans (10 minutes)

  • Each group presents ONE of their action plans.

  • Focus on clarity of actions, responsibilities, and timelines.

  • Allow for brief peer feedback or suggestions (constructive).

(2:10 – 2:40) Part 3: Fostering a Culture of Safety and Continuous Quality Improvement (30 minutes)

• A. What is a Culture of Safety & Quality? (10 minutes)

  • Definition: "A culture where patient safety and quality are core values, openly discussed, and constantly pursued by everyone in the organization, from top leadership to frontline staff."

  • Key Characteristics (Interactive Discussion – ask participants for ideas first):

    • Leadership Commitment: Leaders visibly champion safety and quality, allocate resources, and hold people accountable.

    • Teamwork and Collaboration: Across departments and disciplines.

    • Open Communication: Staff feel safe to speak up about concerns, errors, and near misses without fear of blame.

    • Non-Punitive Reporting: Focus on learning from errors, not punishing individuals (distinguish from reckless behavior).

    • Just Culture: Balances accountability with learning.

    • Data-Driven Decision Making: Using data from audits, incidents, feedback to guide improvements.

    • Continuous Learning & Improvement: Seeing quality as an ongoing journey.

    • Patient-Centeredness: Keeping the patient at the heart of all decisions.

    • Empowerment of Staff: Staff at all levels are encouraged to contribute to quality improvement.

  • Contrast with a Blame Culture: Discuss the negative impacts of a blame culture (hiding errors, fear, lack of improvement).

• B. Strategies for Building and Sustaining the Culture (15 minutes)

  • Leadership Walk-Rounds: Leaders regularly visit clinical areas to discuss safety and quality with frontline staff.

  • Regular Safety Briefings/Huddles: Short, focused discussions at shift changes or departmental meetings.

  • Robust Incident Reporting System: Easy to use, confidential, with timely feedback to reporters.

  • Multidisciplinary Quality & Safety Committees: Actively involved in reviewing data and driving initiatives.

  • Celebrating Successes & Recognizing Champions: Acknowledge efforts and achievements in quality and safety.

  • Investing in Training & Education: Continuously building staff competency.

  • Standardization of Processes: Where appropriate, to reduce variability and risk.

  • Patient and Family Engagement: Involving them in safety initiatives and feedback.

  • "Safety Champions" Program: Designating and training staff in each department to promote safety.

  • Transparent Data Sharing (Appropriate Level): Sharing performance data (anonymized trends) to foster awareness and motivation.

  • Discussion: "Which of these strategies do we already do well? Which ones could we strengthen or implement in our hospital?"

• C. Overcoming Barriers to Culture Change (5 minutes)

  • Briefly discuss common barriers:

    • Resistance to change.

    • Fear of blame.

    • Lack of time or resources.

    • Communication breakdowns.

    • Hierarchical structures.

  • Emphasize that culture change takes time, persistence, and commitment from everyone.

(2:40 – 2:50) Part 4: Resources, Support, and Next Steps (10 minutes)

• Internal Resources:

  • Quality Department / NABH Cell: "Your primary resource for guidance, support, SOPs, audit schedules, and training materials."

  • Department Heads / NABH Coordinators: "Responsible for driving compliance within your departments."

  • Hospital Policies & Procedures Manuals: "Ensure you know where to find them and are familiar with relevant SOPs."

  • Internal Audit System: "View internal audits as a learning opportunity, not a test."

• Commitment and Accountability:

  • "The action plans you developed today are a starting point. They need to be implemented, monitored, and reviewed."

  • "Each of us has a role to play. HODs in leading and monitoring, frontline staff in implementing correctly and providing feedback."

• Next Steps Post-Training:

  • Submission of departmental action plans to the Quality Department.

  • Quality Department to compile and track progress.

  • Regular review meetings (departmental and hospital-level) to discuss progress on action plans and new initiatives.

  • Schedule for follow-up audits/checks.

(2:50 – 3:00) Q&A, Program Evaluation, and Closing (10 minutes)

• Open Q&A: Address any remaining questions about the entire training program.

• Program Evaluation: Distribute a short feedback form for the training program.

• Closing Remarks by Senior Leadership (Highly Recommended):

  • Reinforce commitment to NABH and quality.

  • Acknowledge staff efforts.

  • Encourage continued participation and vigilance.

• Trainer's Closing:

  • Thank participants for their active engagement throughout the program.

  • Reiterate that NABH is an ongoing journey, and continuous effort is key.

  • End on a positive and motivational note, emphasizing the collective ability to achieve excellence in patient care and safety.

Trainer Notes for Session 5:

• Highly Interactive: This session's success depends on participation. Create a comfortable and open environment for discussion and group work.

• Facilitation Skills: The trainer needs strong facilitation skills to guide group work, manage time, and keep discussions focused and productive.

• Pre-Work for Trainer: Before this session, review all NCs and pre-select relevant ones for each department/group to save time during the session. Prepare clear templates.

• Focus on Practicality: Ensure action plans are realistic and implementable. Discourage overly ambitious or vague plans.

• Empowerment: Frame the session as empowering staff to take ownership of quality in their areas.

• Leadership Presence: Having senior leadership present, especially for the closing, adds significant weight and demonstrates commitment.

• Follow-Up is Key: Emphasize that this training is not the end but the beginning of a renewed focus. The action plans must be followed up. 

Methodology:

1. Identify Repetition: Look for NCs with similar wording or addressing the same objective element across different audits or even within the same audit for different areas.

2. Categorize by Theme: Group similar NCs under broad themes (e.g., Documentation, Uniformity, Implementation, Training, Policy Gaps, System Weaknesses).

3. Cross-Reference to NABH Chapters: Where a theme strongly relates to a specific chapter's requirements, I'll note it.

4. Provide Specific Examples: List the Audit Code, SLNO/CODE, Obj Element, and the NC description for each instance.

Detailed Analysis of Repeated Non-Compliances (NCs)

I. Overarching Theme: Lack of Uniformity & Consistency
(This is the most pervasive theme, cutting across almost all chapters and processes)

• NC: Processes/Documentation/Practices Not Uniformly Done/Implemented/Identified/Displayed/Aware

  • AAC Chapter Related:

    • Initial Assessment Documentation:

      • 2019-S, 2, 2019-S-2, AAC 4d: "The initial assessment for in-patients is not uniformly documented within 24 hours."

      • 2019-S, (unnumbered), AAC 4f: "Initial assessment does not uniformly include screening for nutritional needs."

      • 2019-S, 3, 2019-S-3, AAC 4g,h: "The initial assessment does not uniformly result in a documented care plan..."

      • 2023-R, 2, 2023-R-2, AAC 4.a: "Initial assessment of OPD and daycare patients was not uniformly done using the defined structured format."

    • Care Plan Countersignatures:

      • 2019-S, 4, 2019-S-4, AAC 4i, CQI 3a(ii): "The care plan is not uniformly countersigned by the clinician in-charge... within 24 hours."

    • Reassessment Documentation:

      • 2019-S, 6, 2019-S-6, AAC 5d,e: "Staff involved in direct clinical care does not uniformly document reassessments."

    • Equipment Maintenance (Lab):

      • 2019-S, 8, 2019-S-8, AAC 7d: "Periodic maintenance of all equipment is not uniformly done (Lab)."

    • Imaging Signage:

      • 2019-S, 14, 2019-S-14, AAC 11h: "Imaging signage are not uniformly prominently displayed in all appropriate locations."

      • 2023-R, 13, 2023-R-13, AAC 11.g: "The display of radiation signage outside OT and Cath lab was not as per requirement of AERB." (Implicit uniformity issue if not consistently per requirement).

    • Information Exchange (Handovers):

      • 2019-S, 15, 2019-S-15, AAC 12d: "Information exchanged and documented during each staffing shift... is not uniform.e.g. doctors."

    • Discharge Time Monitoring & Summary Content:

      • 2019-S, 16, 2019-S-16, AAC 13e, CQI 4d: "The organisation does not uniformly monitor the discharge time."

      • 2019-S, 17, 2019-S-17, AAC 14f: "Discharge summary does not uniformly incorporate instructions about when to obtain urgent care."

      • 2020-R, 14, 2020-R-14, AAC 14f: "While how to obtain urgent care is mentioned, the discharge summary does not uniformly incorporate instructions about when to obtain urgent care."

    • Lab/Radiology Training:

      • 2023-R, 7, 2023-R-7, AAC 8.c: "Laboratory personnel were not uniformly and appropriately trained in relevant MSDS."

    • Echocardiography Report Signing:

      • 2023-R, 10, 2023-R-10, AAC 9.h: "All sampled echocardiography reports performed by echocardiography technicians were not uniformly signed."

    • Mechanism for Critical Alert Intervention Monitoring:

      • 2023-R, 16, 2023-R-16, AAC 12.h: "Mechanism to monitor appropriate clinical intervention in response to critical alert was not uniformly evidenced."

• • COP Chapter Related:

    • Nursing Care Plan Alignment:

      • 2019-S, 22, 2019-S-22, COP 6d: "Nursing care plan is not uniformly aligned with care plan of patient."

    • Awareness of Patient Condition Changes:

      • 2019-S, 24, 2019-S-24, COP 9h: "Patients and families are not uniformly aware about change in the condition of the patient, and same is not uniformly documented."

    • Vulnerable Patient Identification & Care:

      • 2019-S, 25, 2019-S-25, COP 10a: "Vulnerable patients are not uniformly identified."

      • 2019-S, 27, 2019-S-27, COP 11e: "Obstetric patient's assessment does not uniformly include maternal nutrition."

      • 2023-R, 25, 2023-R-25, COP10.e: "Nutritional assessment of all obstetric patients were not uniformly evidenced."

      • 2019-S, 28, 2019-S-28, COP 12f: "Patient assessment does not uniformly include detailed nutritional, growth, developmental and immunization assessment."

      • 2019-S, 30, 2019-S-30, COP 12h: "The children's family members are not uniformly educated about nutrition, immunization and safe parenting and this is not uniformly documented."

      • 2023-R, 35, 2023-R-35, COP 16.a: "Identification of vulnerable patients was not uniformly implemented across the HCO."

    • Anesthesia/Surgical Safety:

      • 2019-S, 31, 2019-S-31, COP 14c: "The pre-anaesthesia assessment does not uniformly results in formulation of an anaesthesia plan."

      • 2019-S, 32, 2019-S-32, COP 15d: "...surgical safety check list... the same is not uniformly signed."

      • 2020-R, 21, 2020-R-21, COP 15d,k: "The timings of time in, time out and sign out in the WHO surgical safety checklist are not uniformly documented."

      • 2016-F-11, 11, 2016-F-11, COP 14d: "Immediate preoperative anaesthetic re- evaluation was not uniformly observed."

      • 2020-R, 20, 2020-R-20, COP 14d,f: "...Intra operative anaesthesia monitoring does not uniformly include end tidal CO2."

    • Pain Reassessment:

      • 2019-S, 34, 2019-S-34, COP 18c: "Patients with pain do not uniformly undergo periodic re-assessment."

      • 2023-R, 37, 2023-R-37, COP 17.c: "Periodic pain reassessment was not uniformly evidenced in all live files audited."

    • Pain Management Awareness/Titration:

      • 2019-S, 35, 2019-S-35, COP 18f: "Patient and family are not uniformly aware on various pain management techniques..."

      • 2023-R, 38, 2023-R-38, COP 17.d: "Titration of pain management after assessment and reassessment was not uniformly evidenced."

    • Functional Assessment & Reassessment for Care Guidance:

      • 2019-S, 36, 2019-S-36, COP 19c: "Care is not uniformly guided by functional assessment and periodic re-assessment which is not uniformly documented."

    • Research Patient Rights Awareness:

      • 2019-S, 37, 2019-S-37, COP 20e,f: "Patients are not uniformly informed of their right to withdraw from the research..."

    • End-of-Life Care Awareness:

      • 2019-S, 38, 2019-S-38, COP 22e: "Staff are not uniformly aware in end of life care."

    • DVT Risk Assessment:

      • 2023-R, 19, 2023-R-19, COP 6.b: "Deep venous thrombosis risk assessment was not uniformly evidenced in all sampled case files."

    • Nursing Care Plan Evaluation/Modification:

      • 2023-R, 21, 2023-R-21, COP 6.e: "In nursing care plan, evaluation and modification were not uniformly evidenced and documented."

    • Post-Procedure Endoscopy Monitoring:

      • 2023-R, 23, 2023-R-23, COP 7.g: "Post procedure Monitoring of Endoscopy patients was not uniformly evidenced."

    • Adverse Anesthesia Event Monitoring:

      • 2023-R, 30, 2023-R-30, COP 13.j: "Monitoring of adverse anaesthesia events was not uniformly evidenced in all Operation theatres."

    • Operation Notes in Post-Op Files:

      • 2023-R, 31, 2023-R-31, COP 14.e: "All sampled post operative active case files did not uniformly have the operation notes."

• • MOM Chapter Related:

    • Inventory Control:

      • 2019-S, 40, 2019-S-40, MOM 3c: "Sound inventory control practices of the medications in all areas is not uniform across the organisation."

    • LASA Medication Identification & Storage:

      • 2019-S, 41, 2019-S-41, MOM 3d: "Look-alike and Sound-alike medications are not uniformly identified and not uniformly stored physically apart from each other."

    • Emergency Medication Definition & Storage:

      • 2019-S, 42, 2019-S-42, MOM 3e: "The list of emergency medications is not uniformly defined and not uniformly stored in a uniform manner."

    • Allergy Ascertainment:

      • 2019-S, 43, 2019-S-43, MOM 4d: "Known drug allergies are not uniformly ascertained before prescribing."

    • Medication Order Clarity:

      • 2019-S, 44, 2019-S-44, MOM 4g: "Medication orders are not uniformly clear, legible, dated, timed, named and signed."

    • High-Risk Medication List:

      • 2019-S, 46, 2019-S-46, MOM 4j: "The list of high risk medication is not uniform across the HCO."

    • Medication Reconciliation:

      • 2019-S, 48, 2019-S-48, MOM 4l: "Reconciliation of medications does not uniformly occur at transition points of patient care."

    • Labeling of Cut Strips:

      • 2019-S, 49, 2019-S-49, MOM 5e: "Labelling requirements are not uniformly implemented e.g. cut strips."

• • PRE Chapter Related:

    • Awareness of Complaint Lodging Procedure:

      • 2019-S, 57, 2019-S-57, PRE 7c: "Patient and/or family members are not uniformly made aware of the procedure for lodging complaints."

      • 2023-R, 61, 2023-R-61, PRE 7.d: (Similar to above)

    • Analysis of Feedback/Complaints:

      • 2019-S, 58, 2019-S-58, PRE 7d: "All feedback and complaints are not uniformly reviewed and/or analysed..."

    • Awareness of Communication Techniques:

      • 2019-S, 60, 2019-S-60, PRE 8f: "The staff are not uniformly aware in healthcare communication techniques periodically."

    • Informed Consent Process:

      • 2019-S, 54, 2019-S-54, PRE 4d: "Informed consent does not uniformly include information regarding the procedure, risks, benefits, alternatives..."

      • 2019-S, 55, 2019-S-55, PRE 4f: "Informed consent is not uniformly taken by the person performing the procedure."

      • 2023-R, 55, 2023-R-55, PRE2.g: "Informed consent is not being taken uniformly for all patients as seen in TMT department, Dermatology..."

• • HIC Chapter Related:

    • Antibiotic Policy Implementation:

      • 2019-S, 63, 2019-S-63, HIC 2h: "The organisation does not uniformly implement the antibiotic policy..."

      • 2016-F-16, 16, 2016-F-16, HIC 2h: "...monitoring of rational application of the same was not uniformly evidenced."

      • 2023-R, 65, 2023-R-65, HIC 3.f: "Prophylactic antibiotics were not uniformly prescribed as per the defined antibiotic policy..."

    • Action to Prevent SSIs:

      • 2019-S, 64, 2019-S-64, HIC 4d: "The organisation does not uniformly take action to prevent surgical site infections."

    • BMW Collection & Monitoring:

      • 2019-S, 66, 2019-S-66, HIC 8b: "Proper collection of biomedical waste... is not uniformly implemented and not uniformly monitored."

• • FMS Chapter Related:

    • Patient Safety Device Installation/Inspection:

      • 2019-S, 75, 2019-S-75, FMS 1b: "Patient-safety devices & infrastructure are not uniformly installed across the organisation and inspected periodically."

    • Facility Safety Inspection Rounds:

      • 2019-S, 76, 2019-S-76, FMS 1e,1f: "Facility inspection rounds to ensure safety are not uniformly conducted..."

    • Bilingual Signages:

      • 2019-S, 77, 2019-S-77, FMS 2c: "The signages are not uniformly bilingual across the HCO."

    • Equipment Inspection/Calibration & Maintenance Plan:

      • 2019-S, 79, 2019-S-79, FMS 4e,f: "Equipment are not uniformly periodically inspected and calibrated... There is no operational and maintenance...plan."

    • Medical Equipment Recall Procedures:

      • 2019-S, 80, 2019-S-80, FMS 4h: "The procedures do not uniformly address medical equipment recalls."

    • MSDS Display:

      • 2019-S, 82, 2019-S-82, FMS 7b: "MSDS display is not uniform across the HCO."

      • 2016-F-23, 23, 2016-F-23, FMS 7a,b & HIC 2f: "Material safety data sheets (MSDS)... were not uniformly displayed."

    • Hazardous Material Identification/Use:

      • 2023-R, 90, 2023-R-90, FMS 3.e: "Hazardous materials are not uniformly identified and used safely within the organisation."

    • Medical Gas Pipeline Color Coding:

      • 2023-R, 93, 2023-R-93, FMS 6.a: "Uniform colour coding of medical gas pipeline was not uniformly evidenced across the HCO..."

• • HRM Chapter Related:

    • Staff Awareness of Rights/Responsibilities:

      • 2019-S, 83, 2019-S-83, HRM 2e: "The staff are not uniformly aware of employee rights and responsibilities."

      • 2019-S, 84, 2019-S-84, HRM 2f, PRE 1d: "The employees are not uniformly aware on patient's rights and responsibilities."

    • Training on Job Responsibility Changes:

      • 2019-S, 85, 2019-S-85, HRM 3c: "Training does not uniformly occur when job responsibilities change."

      • 2023-R, 99, 2023-R-99, HRM 4.c: "Training when job responsibilities change was not uniformly evidenced."

    • Health Checks for Staff:

      • 2019-S, 86, 2019-S-86, HRM 7c: "Regular health checks of staff... are not uniformly done at-least once a year and the findings/ results are not uniformly documented."

      • 2023-R, 106, 2023-R-106, HRM 9.c: "Annual health check of all staff was not uniformly evidenced eg doctors."

    • Training Records in Personal Files:

      • 2019-S, 87, 2019-S-87, HRM 8c: "All records of in-service training are not uniformly contained in the personal files."

      • 2023-R, 108, 2023-R-108, HRM 10.c: "Personal files did not uniformly have records of in-service training and education."

    • Training on CPR/Infection Control/Occupational Safety:

      • 2023-R, 102, 2023-R-102, HRM 5.e: "Staff (doctors)... were not uniformly provided training on cardiopulmonary resuscitation periodically."

      • 2023-R, 103, 2023-R-103, HRM 5.f: "All staff (doctors) were not uniformly provided training on infection prevention and control at least once a year."

      • 2023-R, 104, 2023-R-104, HRM 6.d: "Staff working in areas with potential occupational hazards were not uniformly trained in occupational safety aspects."

    • Granting of Privileges:

      • 2023-R, 110, 2023-R-110, HRM 11.d: "All medical professionals are not uniformly granted privileges as per their qualification, training, experience and registration."

• • IMS Chapter Related:

    • Medical Record Entries (Named, Signed, Dated, Timed):

      • 2019-S, 88, 2019-S-88, IMS 3c,d: "Entry in the medical record is not uniformly named, signed, dated and timed. The author... is not uniformly identified."

      • 2023-R, 111, 2023-R-111, IMS 3.e: "All entries in medical record were not named, signed and timed."

    • Medical Record Review Process:

      • 2019-S, 90, 2019-S-90, IMS 7e: "The review process does not uniformly include records of active patients."

    • CAPA for Medical Record Deficiencies:

      • 2019-S, 91, 2019-S-91, IMS 7g: "Appropriate corrective and preventive measures are not uniformly undertaken..."

• • CQI Chapter Related:

    • Monitoring of Priority Managerial Activities:

      • 2019-S, 68, 2019-S-68, CQI 4h: "The organisation does not uniformly identify and does not uniformly monitor priority managerial activities..."

    • CAPA for Audit Findings:

      • 2019-S, 70, 2019-S-70, CQI 8c: "Corrective and Preventive Actions are not uniformly taken based on the findings of such analysis."

II. Theme: Documentation Deficiencies
(Many overlap with "Uniformity" if the NC implies lack of uniform documentation. This focuses on cases where documentation is explicitly stated as missing or incomplete.)

• NC: Program/Process/Activity Not Documented or Incompletely Documented

  • AAC/COP/MOM/HIC/FMS/CQI Related:

    • QA Program for Imaging Not Documented:

      • 2019-S, 11, 2019-S-11, AAC 10a: "The quality assurance programme for imaging services is not documented."

    • QA Programs (General ED/ICU) Not Documented/Implemented:

      • 2019-S, 19, 2019-S-19, COP 2i: "Quality assurance programmes are not documented and not implemented (ED)."

      • 2019-S, 23, 2019-S-23, COP 9g: "A quality assurance programme is not documented and not implemented (All ICU & ICU manual)."

    • Documentation of Triage Lacking:

      • 2019-S, 18, 2019-S-18, COP 2e: "Documention of the triage of patients is lacking."

    • Care Plan Not Resulting from Initial Assessment:

      • 2016-F, 2, 2016-F-2, AAC 4g: "Initial assessment did not result in a documented care plan in the medical records..."

    • Medical Supplies for Disasters Not Adequate (Implies check/documentation lacking):

      • 2016-F, 6, 2016-F-6, COP 4c: "Medical supplies kept in readiness for external disasters / emergencies were not adequate..."

    • Surgical Safety Checklist Incomplete/Not Signed:

      • 2016-F, 7, 2016-F-7, COP 7c & 15d: "Surgical safety checklists were not complete. The ones seen in the OR did not bear the signatures..."

    • Post Natal Monitoring Not Evidenced:

      • 2016-F, 9, 2016-F-9, COP 11f: "Appropriate intensive monitoring for post natal mothers was not evidenced..."

      • 2016-P, 9, 2016-P-9, COP 11f: "Appropriate post natal maternal monitoring is not evidenced."

    • Pre-op Re-evaluation Not Documented/Observed:

      • 2016-P, 11, 2016-P-11, COP 14d: "Immediate pre operative re evaluation was not documented in patients going in for surgeries."

    • MOM Reorder Levels Not Uniformly Documented:

      • 2016-P, 12, 2016-P-12, MOM 2d: "...reorder levels to initiate purchase procedures were not uniformly documented."

    • Proactive Risk Management Plan Not Comprehensively Evidenced:

      • 2016-F, 20, 2016-F-20, ROM 6a&b, FMS 1a: "Documentation of proactive risk management plan... were not comprehensively evidenced."

    • Facility Inspection Rounds Not Documented / Checklists Not Evidenced:

      • 2016-F, 21, 2016-F-21, FMS 1e: "Facility inspection rounds... were not documented. Checklists... were not evidenced."

    • Disinfectant/Dilution Protocols Not Documented (HIC):

      • 2020-R, 38, 2020-R-38, HIC 2l: "...Disinfectants and Dilution protocols are not documented."

    • MRI Compatible Fire Extinguisher Evidence Not Submitted:

      • 2021-DS, 1, 2021-DS-01, AAC 11b: "Evidence regarding MRI compatible fire extinguisher is not submitted."

    • CAPA for Lab Discrepancies Not Evident:

      • 2016-P, 1, 2016-P-1, AAC 7c,e: "...Documentation of CAPA is not evident in case of discrepancies observed in EQAS."

    • MSDS Not in Evidence (Lab):

      • 2016-P, 2, 2016-P-2, AAC 8c: "...MSDS... were not in evidence for laboratory chemicals..."

    • Structured Clinical Handover Not Documented (ICU/HCO):

      • 2016-P, 4, 2016-P-4, AAC 12d: "Structured clinical hand-over between shifts by doctors was not documented in the intensive care unit."

      • 2023-R, 14, 2023-R-14, AAC 12.d: "Structured handover for doctors was not evidenced across the HCO."

    • CPR Events Not Uniformly Recorded/Analysed:

      • 2020-R, 16, 2020-R-16, COP 5a,b,c,d: "...no evidence that pediatric and neonatal CPRs are documented or analysed. The events...are not uniformly recorded."

    • CAPA for Recall/Amendment of Reports Not Evidenced:

      • 2023-R, 6, 2023-R-6, AAC 6.i: "CAPA for recall and amendment of reports was not evidenced.

    • PCPNDT Registration for CT/MRI Not Evidenced:

      • 2023-R, 8, 2023-R-8, AAC 9.a: "PCPNDT registration for CT and MRI was not evidenced."

    • MOU for Teleradiology Not Including Critical Results List:

      • 2023-R, 9, 2023-R-9, AAC 9.g: "MOU with outsourced teleradiology services did not include list of critical results..."

    • Evaluation of Training Effectiveness Not Evidenced:

      • 2016-P, 32, 2016-P-32, HRM 3d: "Evaluation of effectiveness of training... is not evidenced uniformly."

      • 2023-R, 100, 2023-R-100, HRM 4.e: "Evaluation of training effectiveness by the organisation was not evidenced."

    • Background Check of New Staff Not Evidenced:

      • 2023-R, 97, 2023-R-97, HRM 1.e: "Background check of new staff was not evidenced."

    • Induction Training Not Evidenced:

      • 2023-R, 98, 2023-R-98, HRM 3.a: "Induction training of all consultants was not uniformly evidenced."

    • CAPA for Prescription Audit Not Evidenced:

      • 2023-R, 49, 2023-R-49, MOM 4.g: "The Corrective and/or preventive action records is not evidenced for prescription audit conducted."

    • Use of Form 3E for Narcotics Not Evidenced:

      • 2023-R, 52, 2023-R-52, MOM 9.a: "Use of Form 3E for narcotics was not evidenced across the HCO."

    • Patient Experience Not Captured:

      • 2023-R, 59, 2023-R-59, PRE 7.b: "Patient experience is not captured."

    • Redressal of Patient Complaint Not Evidenced:

      • 2023-R, 60, 2023-R-60, PRE 7.c: "Redressal of patient complaint was not evidenced for all complaints."

    • CAPA for QR Code Complaints Not Evident:

      • 2023-R, 62, 2023-R-62, PRE 7.f: "Corrective and/or preventive action(s) are not evident for those patient complaints which are captured by QR code..."

    • Mechanism for Unacceptable Communication Not Evidenced:

      • 2023-R, 63, 2023-R-63, PRE 8.d: "Mechanism to ensure no unacceptable communication was not evidenced."

    • Monitoring of Effective Communication Not Evidenced:

      • 2023-R, 64, 2023-R-64, PRE 8.e: "System to monitor and review the implementation of effective communication was not evidenced."

    • MOU for BMTU Irradiation Not Evidenced:

      • 2023-R, 85, 2023-R-85, ROM 5.e: "MOU with outsourced hospital for irradiation of cellular product and total body irradiation for BMTU was not evidenced."

    • Validation Tests for Flash Autoclave Not Evidenced:

      • 2023-R, 73, 2023-R-73, HIC 7.d: "Validation tests including biological indicators were not evidenced for flash autoclave in Cardiac OT."

    • Verification of Data by Quality Team Not Evidenced:

      • 2023-R, 77, 2023-R-77, PSQ 3.f: "Verification of data by quality team was not evidenced."

    • Analysis of Data and CAPA Not Evidenced (PSQ):

      • 2023-R, 78, 2023-R-78, PSQ 3.g: "Analysis of data and CAPA was not evidenced."

    • Implementation of Improvement Activities Based on CAPA Not Evidenced (PSQ):

      • 2023-R, 79, 2023-R-79, PSQ 3.h: "Implementation of Improvement activities based on CAPA was not evidenced, hence evaluation of same was not captured."

    • Risk from Incident Analysis Not Incorporated in Risk Mgt Plan:

      • 2023-R, 83, 2023-R-83, PSQ 7.e: "Risk identified in incident analysis was not incorporated in the risk management plan."

    • Medical Record Entries Not Named/Signed/Timed/Author Identified (IMS - multiple entries):

      • 2019-S, 88; 2020-R, 59; 2016-F, 27; 2016-F, 28; 2023-R, 111; 2023-R, 112 (all point to these core documentation failures)

III. Theme: Policy & Procedure Gaps
(NCs indicating that a required policy, procedure, or system does not exist or is inadequate)

• NC: Lack of or Inadequate Policies/Procedures/Systems/Mechanisms

  • AAC/COP Related:

    • No Process for Early Warning Signs:

      • 2019-S, 7, 2019-S-7, AAC 5f: "The organisation has no processes to identify early warning signs..."

    • No Mechanism for Report Recall/Amendment (Radiology):

      • 2019-S, 10, 2019-S-10, AAC 9i: "There is no mechanism to address recall / amendment of reports whenever applicable."

      • 2023-R, 6, 2023-R-6, AAC 6.i: (Implies no robust mechanism if CAPA not evidenced).

    • System for Appropriateness of Investigations Lacking:

      • 2019-S, 13, 2019-S-13, AAC 10d: "A system to ensure the appropriateness of the investigations... is lacking."

    • Policies for Patient Identification & Transport for Imaging Not Existing:

      • 2019-S, 9, 2019-S-9, AAC 9e: "Documented policies and procedures do not exist to ensure correct identification and safe and timely transportation of patients..."

    • No Documented Policies for Death on Arrival:

      • 2020-R, 15, 2020-R-15, COP 2j: "There are no documented policies and procedures to guide management of death on arrival patients."

    • No Documented Procedures for Preventing Adverse Events Outside OT:

      • 2020-R, 17, 2020-R-17, COP 7c,d,g: "For procedures done outside the OT, there are no documented procedures to prevent adverse events..."

    • Clinical Care Pathways Not Developed:

      • 2023-R, 17, 2023-R-17, COP 1.e: "HCO has not developed clinical care pathways."

  • MOM Related:

    • No Defined List for Verbal Orders / Staff Awareness Lacking:

      • 2019-S, 45, 2019-S-45, MOM 4i: "The list of medication for verbal orders is not defined."

      • 2020-R, 26, 2020-R-26, MOM 4i,j: "The Organisation does not have an approved list of drugs which can be ordered verbally and staff awareness..."

    • No Mechanism for Clinicians to Identify Drug Interactions, etc.:

      • 2023-R, 47, 2023-R-47, MOM 4.d: "There is no mechanism for clinicians which helps to identify drug interactions, food-drug interactions, therapeutic duplication, dose adjustments."

  • HIC Related:

    • No Cleaning Protocols for Isolation Rooms/High-Risk Areas:

      • 2020-R, 38, 2020-R-38, HIC 2l: "There is no cleaning protocols for isolation rooms and other high risk areas."

    • No Protocol for Washing Different Linen Categories:

      • 2020-R, 35, 2020-R-35, HIC 2i: "...There is no protocol for washing of different categories of linen eg, blankets."

    • No Documented Procedure for Reprocessing Single-Use Devices:

      • 2016-P, 22, 2016-P-22, HIC 7c,d: "There is no documented procedure to address reprocessing of single use devices and equipments."

• • CQI Related:

    • No Mechanism for Validation/Analysis/Improvement/Feedback of Data:

      • 2019-S, 69, 2019-S-69, CQI 5a,b,c,d,e: "There is no mechanism for validation, analysis, improvement and feedback of data."

      • 2020-R, 46, 2020-R-46, CQI 5a-e: "There is no mechanism for validation of data or for analysis of data..."

    • No Established System for Clinical Audits:

      • 2016-P, 26, 2016-P-26, CQI 7b: "There is no established system for clinical audits in the HCO on a regular basis..."

    • No Established Process for Clinical Nursing Audits:

      • 2016-P, 24, 2016-P-24, CQI 1i: "...hence there is no established process in the organization to monitor and improve quality of nursing care."

  • FMS Related:

    • No Maintenance Plan for IT/Communication Network:

      • 2020-R, 51, 2020-R-51, FMS 3j: "There is no maintenance plan for IT and communication network."

    • No Defined Service Continuity Plan for Fire/Non-Fire Emergencies:

      • 2023-R, 96, 2023-R-96, FMS 7.e: "HCO did not have a defined service continuity plan in case of fire and non fire emergencies."

  • ROM Related:

    • No Designated Infection Control Officer/Nurse:

      • 2019-S, 61, 2019-S-61, HIC 1e,f: "There is no designated infection control officer and infection control nurse." (Responsibility of Management to ensure this)

    • No Designated Individual for Patient Safety Programme:

      • 2019-S, 67, 2019-S-67, CQI 2e: "There is no designated individual for coordinating and implementing the patient safety programme."

  • PRE Related:

    • No System for Effective Communication with Patients/Families:

      • 2020-R, 33, 2020-R-33, PRE 8a-f: "There is no evidence that the organisation has a system for effective communication with patients and /or families."

IV. Theme: Implementation Gaps (Policy vs. Practice)
(NCs where a policy/procedure might exist, but it's not being followed or implemented effectively)

• NC: Policy/Procedure/Program Not Implemented or Ineffectively Implemented

  • This theme often overlaps with "Not Uniformly Done." Specific examples where "implementation" is explicitly mentioned:

    • 2019-S, 19, 2019-S-19, COP 2i: "Quality assurance programmes are not documented and not implemented (ED)."

    • 2019-S, 23, 2019-S-23, COP 9g: "A quality assurance programme is not documented and not implemented (All ICU & ICU manual)."

    • 2019-S, 63, 2019-S-63, HIC 2h: "The organisation does not uniformly implement the antibiotic policy..."

    • 2019-S, 66, 2019-S-66, HIC 8b: "Proper collection of biomedical waste... is not uniformly implemented..."

    • 2023-R, 65, 2023-R-65, HIC 3.f: "Prophylactic antibiotics were not uniformly prescribed as per the defined antibiotic policy..." (Implementation failure).

    • 2023-R, 39, 2023-R-39, COP 18.g: "Care pathways are not developed, implemented, and reviewed periodically for rehabilitative services."

    • 2023-R, 79, 2023-R-79, PSQ 3.h: "Implementation of Improvement activities based on CAPA was not evidenced..."

    • 2023-R, 82, 2023-R-82, PSQ 5.f: "Remedial measures were not uniformly implemented after clinical audit."

V. Theme: Staff Awareness, Training & Competency Deficiencies
(NCs directly pointing to lack of staff knowledge, training, or skills)

• NC: Staff Not Aware / Not Trained / Competency Not Ensured

  • This is extensively covered under the "Uniformity" theme for HRM. Key repeats:

    • Staff awareness of rights/responsibilities (Employee & Patient).

    • Training on specific procedures/protocols (CPR, Infection Control, Communication, Occupational Safety).

    • Training when job responsibilities change.

    • Evaluation of training effectiveness.

    • Specific: "2016-F-17 (HIC 2l): Knowledge of appropriate handling of blood spills was not demonstrated by the technician..."

    • Specific: "2020-R-54 (HRM 2e,f,6b): On interviewing the staff, awareness on employee and patient rights... Anti sexual harassment policy was found lacking."

    • Specific: "2023-R, 26 (COP 11.c): All staff providing care to children did not have age specific competency eg some Nursing staff working in PICU."

VI. Theme: System & Process Weaknesses (Monitoring, Analysis, Feedback, CAPA)
(NCs indicating failures in the overarching quality management and oversight systems)

• NC: Lack of Monitoring / Inadequate Analysis / No CAPA / No Feedback

  • This is extensively covered under "Uniformity" for CQI and relevant chapters. Key repeats:

    • No mechanism for validation, analysis, improvement, and feedback of data (CQI 5).

    • CAPA not evidenced for incidents/audit findings/report amendments (CQI 8c, AAC 6i, MOM 4k,m, MOM 8e, PRE 7d, PSQ 3g).

    • Monitoring of specific parameters lacking (Discharge time, waiting times, managerial activities, sedation levels, outsourced services quality, effectiveness of committees, etc.).

    • Clinical audit parameters not defined / checklists not used / remedial measures not implemented (CQI 7).

VII. Theme: Statutory & Legal Compliance Issues
(NCs specifically related to non-adherence to laws, regulations, and licensing requirements)

• NC: Expired Licenses / Lack of Required Registrations / Non-Compliance with Legal Mandates

  • ROM 2b / ROM 3.c is the prime Obj Element here. Multiple instances:

    • 2019-S, 71, 2019-S-71, ROM 2b: (PCB, Wireless, FSSAI, OT Pharmacy, Mental Health Act, Building Occupancy/Fire NOC for new floors).

    • 2020-R, 49, 2020-R-49, ROM 2b: (Fire NOC for 5th/6th floors, MTP confidentiality).

    • 2021-DS, 3, 2021-DS-03: (PCB, BMW MoU, Fire NOC).

    • 2023-R, 84, 2023-R-84, ROM 3.c: (PCB, Fire NOC, ART Clinic Reg, Mental Health Act Reg, PESO for LMO).

  • AAC 9a / AAC 11b,h (PNDT related):

    • 2020-R, 10, 2020-R-10, AAC 11b,h: "PNDT licence was not displayed on the Echo machine and portable USG machines."

    • 2023-R, 8, 2023-R-8, AAC 9.a: "PCPNDT registration for CT and MRI was not evidenced."

  • AAC 11g (AERB related):

    • 2023-R, 13, 2023-R-13, AAC 11.g: "The display of radiation signage outside OT and Cath lab was not as per requirement of AERB."

Key Observations from Repeated NCs:

1. Systemic Nature: The sheer volume of "not uniformly" NCs indicates that many issues are not isolated incidents but rather systemic weaknesses in process implementation, monitoring, and standardization across the hospital.

2. Documentation is a Major Hurdle: From initial assessments to training records to QA programs, the failure to document adequately is a persistent problem.

3. Policy vs. Practice Gap: Even when policies might exist, their consistent implementation is lacking.

4. Training Effectiveness & Record Keeping: There are significant gaps in ensuring all staff are uniformly trained on critical aspects and that these trainings are documented effectively.

5. QA and CQI Framework Needs Strengthening: The hospital struggles with consistently documenting, implementing, and monitoring its quality assurance programs and acting upon the findings through a robust CAPA process.

6. Statutory Compliance Oversight: Repeated lapses in maintaining valid licenses and adhering to legal mandates suggest a need for a more robust tracking and oversight system.

7. Specific Departmental Focus Areas: While systemic issues are prevalent, Radiology, Laboratory, OT, and areas dealing with vulnerable patients (OBG, Peds) frequently appear with specific NCs that also tie into the broader themes.

This detailed categorization of repeated NCs should serve as a strong foundation for targeted interventions, training, and system improvements.

Important Considerations:

• Overlap: Many NCs involve inter-professional collaboration (e.g., care planning). I will try to assign it to the profession with the primary execution or documentation responsibility for that specific element.

• Systemic Issues: Some NCs are due to system failures (e.g., lack of a policy, resource issues) which are management's responsibility, but the impact is seen in the practice of a profession.

• "Uniformly": NCs stating "not uniformly" often point to inconsistent practice across many individuals within a profession or across departments.

Profession-Wise Details of Non-Compliances (NCs)

I. Doctors / Clinicians / Physicians

• Initial Assessment & Care Planning (AAC & COP):

  • 2019-S, 2, 2019-S-2, AAC 4d: (If doctors are primarily responsible for the 24-hr inpatient assessment documentation).

  • 2019-S, 3, 2019-S-3, AAC 4g,h: "The initial assessment does not uniformly result in a documented care plan and the same does not uniformly reflect desired results of the treatment, care or service." (Primary responsibility for formulating care plan reflecting desired results).

  • 2019-S, 4, 2019-S-4, AAC 4i, CQI 3a(ii): "The care plan is not uniformly countersigned by the clinician in-charge of the patient within 24 hours."

  • 2016-F, 2, 2016-F-2, AAC 4g: "Initial assessment did not result in a documented care plan in the medical records..."

  • 2023-R, 2, 2023-R-2, AAC 4.a: "Initial assessment of OPD and daycare patients was not uniformly done using the defined structured format." (If doctor-led).

• Reassessment & Response to Treatment (AAC):

  • 2019-S, 6, 2019-S-6, AAC 5d,e: "Staff involved in direct clinical care (including doctors) does not uniformly document reassessments. Response to treatment and to plan further treatment or discharge."

• Prescription Practices (MOM):

  • 2019-S, 43, 2019-S-43, MOM 4d: "Known drug allergies are not uniformly ascertained before prescribing."

  • 2023-R, 46, 2023-R-46, MOM 4.c: "Drug allergies and previous adverse drug reactions were not ascertained before prescribing. Example orthopedics OPD."

  • 2019-S, 44, 2019-S-44, MOM 4g: "Medication orders are not uniformly clear, legible, dated, timed, named and signed." (Primarily prescriber).

  • 2016-F-12, 12, 2016-F-12, MOM 4g: (Similar to above).

  • 2020-R-25, 25, 2020-R-25, MOM 4c,g,CQI3j(iv): "All hand written prescriptions are not written in capitals."

  • 2023-R, 50, 2023-R-50, MOM 5.c: "All sampled medication orders were not legible, signed."

• Informed Consent (PRE & COP):

  • 2019-S, 55, 2019-S-55, PRE 4f: "Informed consent is not uniformly taken by the person performing the procedure."

  • 2020-R, 17, 2020-R-17, COP 7c,d,g: "...consent form does not specify the name of the doctor in training when he/she is performing the procedure."

  • 2023-R, 55, 2023-R-55, PRE2.g: "Informed consent is not being taken uniformly for all patients as seen in TMT department, Dermatology Skin biopsy, Ophthalmology departments for Laser." (Performed by doctors).

• Surgical & Anesthesia Care (COP):

  • 2019-S, 31, 2019-S-31, COP 14c: "The pre-anaesthesia assessment does not uniformly results in formulation of an anaesthesia plan." (Anesthetist).

  • 2016-F-11, 11, 2016-F-11, COP 14d: "Immediate preoperative anaesthetic re- evaluation was not uniformly observed." (Anesthetist).

  • 2020-R, 20, 2020-R-20, COP 14d,f: "...Intra operative anaesthesia monitoring does not uniformly include end tidal CO2." (Anesthetist).

  • 2016-F, 7, 2016-F-7, COP 7c & 15d: "...Surgical safety checklists... did not bear the signatures of the surgeon or the anaesthetist."

• Medical Record Documentation (IMS):

  • 2019-S, 88, 2019-S-88, IMS 3c,d: "Entry in the medical record is not uniformly named, signed, dated and timed. The author of the entry is not uniformly identified." (Doctors contribute significantly to medical records).

  • (Similar: 2020-R, 59; 2016-F, 27; 2016-F, 28; 2023-R, 111; 2023-R, 112)

• Training & Awareness (HRM):

  • 2023-R, 102, 2023-R-102, HRM 5.e: "Staff (doctors) involved in direct patient care were not uniformly provided training on cardiopulmonary resuscitation periodically."

  • 2023-R, 103, 2023-R-103, HRM 5.f: "All staff (doctors) were not uniformly provided training on infection prevention and control at least once a year."

  • 2019-S, 86, 2019-S-86, HRM 7c: "Regular health checks of staff dealing with direct patient care are not uniformly done... E.g. doctors."

  • 2023-R, 106, 2023-R-106, HRM 9.c: "Annual health check of all staff was not uniformly evidenced eg doctors."

• Handovers (AAC):

  • 2019-S, 15, 2019-S-15, AAC 12d: "Information exchanged and documented during each staffing shift... is not uniform.e.g. doctors."

  • 2016-P, 4, 2016-P-4, AAC 12d: "Structured clinical hand-over between shifts by doctors was not documented..."

  • 2023-R, 14, 2023-R-14, AAC 12.d: "Structured handover for doctors was not evidenced across the HCO."

• Specific Clinical Area Issues:

  • 2023-R, 30, 2023-R-30, COP 13.j: "Monitoring of adverse anaesthesia events was not uniformly evidenced in all Operation theatres." (Anesthetist/Surgeon).

  • 2023-R, 31, 2023-R-31, COP 14.e: "All sampled post operative active case files did not uniformly have the operation notes." (Surgeon).

II. Nurses

• Initial Assessment & Care Planning (AAC & COP):

  • 2019-S, 2, 2019-S-2, AAC 4d: (Nurses often perform initial nursing assessment, contributing to the 24-hr documentation).

  • 2019-S, (unnumbered), AAC 4f: "Initial assessment does not uniformly include screening for nutritional needs." (Often a nursing responsibility).

  • 2016-F-1, 1, 2016-F-1, AAC4f&COP11e: "Though initial assessment includes screening for nutritional needs... same was not evidenced uniformly in outpatient records of the obstetric patients." (Nursing in OPD).

  • 2019-S, 22, 2019-S-22, COP 6d: "Nursing care plan is not uniformly aligned with care plan of patient."

  • 2023-R, 19, 2023-R-19, COP 6.b: "Deep venous thrombosis risk assessment was not uniformly evidenced..." (Often part of nursing assessment).

  • 2023-R, 20, 2023-R-20, COP 6.d: "Acuity based nursing staffing and assignment was not evidenced." (Nursing Admin/Management).

  • 2023-R, 21, 2023-R-21, COP 6.e: "In nursing care plan, evaluation and modification were not uniformly evidenced and documented."

• Reassessment & Monitoring (AAC & COP):

  • 2019-S, 6, 2019-S-6, AAC 5d,e: "Staff involved in direct clinical care (including nurses) does not uniformly document reassessments."

  • 2020-R-5, 5, 2020-R-5, AAC5a,f: "Patients in ICU are assessed only once in 24 hrs... staff are not aware of how and when to take action to escalate the same (for early warning signs)." (Primarily nursing assessment and escalation).

  • 2023-R, 5, 2023-R-5, AAC 5.e: "Early warning signs for paediatric and neonatal patients was not uniformly implemented..." (Nursing responsibility).

• Medication Administration & Management (MOM):

  • 2019-S, 49, 2019-S-49, MOM 5e: "Labelling requirements are not uniformly implemented e.g. cut strips." (Often dispensed/prepared at ward level by nurses).

  • 2020-R-27, 27, 2020-R-27, MOM5d,e: "Near expiry drugs seen in the crash carts... Cut strips policy is not implemented in the wards..." (Ward stock mgt by nurses).

• Vulnerable Patient Care (COP):

  • 2016-F-9, 9, 2016-F-9, COP 11f: "Appropriate intensive monitoring for post natal mothers was not evidenced during the first 2 hours after delivery..." (Nursing).

  • 2023-R, 26, 2023-R-26, COP 11.c: "All staff providing care to children did not have age specific competency eg some Nursing staff working in PICU."

• Patient Education & Communication (PRE & COP):

  • 2019-S, 30, 2019-S-30, COP 12h: "The children's family members are not uniformly educated about nutrition, immunization and safe parenting..." (Often a nursing role).

  • 2019-S, 57, 2019-S-57, PRE 7c: "Patient and/or family members are not uniformly made aware of the procedure for lodging complaints." (All patient-facing staff, including nurses).

• Medical Record Documentation (IMS):

  • (Similar to Doctors, nurses are major contributors to medical records, so NCs on incomplete/unsigned entries apply).

• Handovers (AAC):

  • 2020-R, 11, 2020-R-11, AAC 12d,g: "There is no structured handover between doctors and nurses." (Nursing involvement critical).

• Radiation Safety (AAC):

  • 2023-R, 12, 2023-R-12, AAC 11.d: "All staff nurses working in Orthopedic OT during surgeries requiring C arm did not have TLD badges."

• Infection Control Practices (HIC):

  • Nurses are frontline for many HIC practices (hand hygiene, PPE, BMW segregation at ward level). NCs like 2019-S, 66 (HIC 8b) on BMW collection have a strong nursing component.

III. Laboratory Technicians / Pathologists

• Equipment Maintenance & Safety (AAC):

  • 2019-S, 8, 2019-S-8, AAC 7d: "Periodic maintenance of all equipment is not uniformly done (Lab)."

  • 2016-P, 3, 2016-P-3, AAC 8e, HIC 5a: "Though the laboratory is well equipped, certain safety devices were not provided to the lab personnel. Eye wash facilities were not available... Appropriate PPE was not used by all the lab personnel."

  • 2016-P, 2, 2016-P-2, AAC 8c: "...MSDS... were not in evidence for laboratory chemicals... These were not stored in a safe and secure manner."

  • 2023-R, 7, 2023-R-7, AAC 8.c: "Laboratory personnel were not uniformly and appropriately trained in relevant MSDS."

• Quality Assurance & Reporting (AAC):

  • 2020-R, 6, 2020-R-6, AAC 6f,i: "The time of sample collection is not documented, hence the TAT is not appropriately monitored. The mechanism to address recall/amendment of reports in the lab is not appropriate..."

  • 2016-P, 1, 2016-P-1, AAC 7c,e: "Surveillance of laboratory results like controls, external and internal quality assurance procedures are in place; however, non conformances are not assessed... CAPA is not evident..."

• Infection Control & PPE (HIC):

  • 2016-F, 18, 2016-F-18, HIC 5a, HRM 4d: "Correct use and removal of PPE was not demonstrated by the outsourced employee observed and interviewed in the laboratory."

  • 2016-F, 17, 2016-F-17, HIC 2l: "Knowledge of appropriate handling of blood spills was not demonstrated by the technician interviewed in the sample collection area."

IV. Radiology Technicians / Radiologists

• Quality Assurance & Reporting (AAC):

  • 2019-S, 10, 2019-S-10, AAC 9i: "There is no mechanism to address recall / amendment of reports whenever applicable (Radiology)."

  • 2019-S, 11, 2019-S-11, AAC 10a: "The quality assurance programme for imaging services is not documented."

  • 2019-S, 12, 2019-S-12, AAC 10b: "The programme does not address periodic internal / external peer review of imaging protocols and results..."

  • 2016-F, 3, 2016-F-3, AAC 10b: "Periodic internal and external peer reviews of imaging protocols, reviews using appropriate sampling was not evidenced."

  • 2020-R, 9, 2020-R-9, AAC 10b: "The internal and external peer review for radiology reports is not done in a structured manner." (Repeated for 2020-R, 7)

  • 2023-R, 10, 2023-R-10, AAC 9.h: "All sampled echocardiography reports performed by echocardiography technicians were not uniformly signed."

  • 2023-R, 11, 2023-R-11, AAC 10.e: "Peer review program is not structured with sampling not as per sampling techniques..."

• Radiation Safety & Signage (AAC):

  • 2019-S, 14, 2019-S-14, AAC 11h: "Imaging signage are not uniformly prominently displayed..."

  • 2016-F, 4, 2016-F-4, AAC 11e: "Imaging personnel did not have appropriate radiation safety monitoring devices. TLD badges were not evidenced..."

  • 2020-R, 10, 2020-R-10, AAC 11b,h: "There are no MRI compatible fire extinguishers in the Radiology department. The PNDT licence was not displayed..." (Repeated for 2020-R, 5 and 2020-R, 8)

  • 2023-R, 13, 2023-R-13, AAC 11.g: "The display of radiation signage outside OT and Cath lab was not as per requirement of AERB."

• Patient Privacy (PRE):

  • 2020-R, 31, 2020-R-31, PRE 2b,j: "The changing rooms for X rays are just a partition with a curtain which violates the patient's right for respect of personal dignity and privacy."

V. Pharmacists / Pharmacy Staff

• Medication Storage & Inventory (MOM):

  • 2019-S, 40, 2019-S-40, MOM 3c: "Sound inventory control practices of the medications in all areas is not uniform across the organisation."

  • 2019-S, 41, 2019-S-41, MOM 3d: "Look-alike and Sound-alike medications are not uniformly identified and not uniformly stored physically apart..."

  • 2020-R-23 (MOM 3b,d): (Similar to above, refrigerator storage, LASA list not updated).

  • 2019-S, 42, 2019-S-42, MOM 3e: "The list of emergency medications is not uniformly defined and not uniformly stored..."

  • 2020-R-24 (MOM 3e,g): (Similar, emergency meds not replenished, Inj KCL missing).

  • 2023-R-43 (MOM 3.d): "The HCO does not store the high risk medications in predetermined areas as in pharmacy stores."

  • 2023-R-44 (MOM 3.e): (Extensive NC on LASA/High-Risk storage, list availability).

• Dispensing & Labeling (MOM):

  • 2019-S, 49, 2019-S-49, MOM 5e: "Labelling requirements are not uniformly implemented e.g. cut strips."

  • 2020-R-27 (MOM 5d,e): "...Cut strips policy is not implemented in the wards and IP Pharmacy."

• Formulary Management (MOM):

  • 2019-S, 39, 2019-S-39, MOM 2b: "The list is not reviewed and updated collaboratively by the multidisciplinary committee." (P&T committee usually involves Chief Pharmacist).

• Statutory Compliance (ROM):

  • 2019-S, 71, 2019-S-71, ROM 2b: "...OT pharmacy not licensed. Pharmacy stocks Food products but lacks FSSAI license." (Responsibility of Pharmacy In-charge/Management).

VI. Medical Records Department (MRD) Staff

• Record Content & Completeness (IMS):

  • MRD ensures all records are complete before final filing. They are often the ones auditing for missing signatures, dates, etc., as highlighted in IMS 3c,d,e,f NCs (2019-S, 88 etc.).

• Record Review Process (IMS):

  • 2019-S, 90, 2019-S-90, IMS 7e: "The review process does not uniformly include records of active patients." (MRD usually coordinates this review).

  • 2019-S, 91, 2019-S-91, IMS 7g: "Appropriate corrective and preventive measures are not uniformly undertaken..." (Following up on deficiencies found in MRD audits).

• Discharge Summary (AAC):

  • 2019-S, 17, 2019-S-17, AAC 14f: (MRD might be involved in checking discharge summary completeness before filing).

  • 2020-R, 14, 2020-R-14, AAC 14f: (Similar).

VII. Biomedical Engineers / Maintenance Staff

• Equipment Maintenance & Calibration (AAC, FMS):

  • 2019-S, 8, 2019-S-8, AAC 7d: "Periodic maintenance of all equipment is not uniformly done (Lab)." (If biomedical handles lab equipment).

  • 2019-S, 79, 2019-S-79, FMS 4e,f: "Equipment are not uniformly periodically inspected and calibrated... There is no operational and maintenance...plan."

  • 2019-S, 80, 2019-S-80, FMS 4h: "The procedures do not uniformly address medical equipment recalls."

• Facility Safety & Utilities (FMS):

  • 2020-R, 52, 2020-R-52, FMS 6a,b: (Emergency illumination system, fire exit signs - maintenance dept).

  • 2023-R, 93, 2023-R-93, FMS 6.a: (Fire extinguisher availability near LMO, jockey pump, medical gas pipeline coding).

  • 2016-F-22, 22, 2016-F-22, FMS 3g: (Maintenance plan for water management in dialysis).

VIII. Human Resources (HR) Department / Administration

• Staff Records, Training Documentation, Credentialing (HRM):

  • All HRM NCs regarding incomplete personal files, missing training records, lack of documented evaluations, and improper credentialing/privileging fall under HR's responsibility to manage and audit.

  • (Examples: 2019-S, 87; 2023-R, 108; 2020-R, 56; 2020-R, 57; 2023-R, 110).

• Staff Awareness Programs (HRM, PRE):

  • Ensuring staff are aware of employee rights, patient rights, anti-sexual harassment policies.

  • (Examples: 2019-S, 83; 2020-R, 54).

• Occupational Health (HRM):

  • Facilitating health checks, ensuring safety measures for workplace hazards.

  • (Examples: 2019-S, 86; 2023-R, 107).

IX. Quality Department / NABH Coordinators / Management

• Policy & Procedure Development & Implementation:

  • All NCs stating "no policy/procedure/system exists" are ultimately a failure of management and quality systems to identify and address these gaps.

• Quality Assurance Programs & CQI (CQI):

  • All NCs related to undocumented/unimplemented QA programs, lack of monitoring, no data analysis, no CAPA, ineffective clinical audits point to weaknesses in the quality department's functioning and management oversight.

  • (Examples: 2019-S, 11; 2019-S, 19; 2019-S, 68; 2019-S, 69; 2020-R, 46; 2020-R, 47; 2020-R, 48).

• Statutory & Legal Compliance (ROM):

  • Management is responsible for ensuring all licenses are current and legal mandates are met.

  • (All ROM 2b, ROM 3.c NCs).

• Risk Management & Patient Safety Program (ROM, CQI, PSQ):

  • Management's responsibility to ensure these programs are in place and effective.

  • (Examples: 2019-S, 74; 2019-S, 67; 2023-R, 83).

• Committee Functioning & Outsourced Services Monitoring (ROM):

  • (Examples: 2019-S, 72; 2019-S, 73).