NABH Certification Standards for Emergency Department in Hospitals contains complete set of standards for evaluation of Emergency department

1. Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
NABH CHAPTER- EMERGENCY DEPARTMENT
CHECKLIST & STANDARDS
NABHACCESS ANDASSESSMENTOF EMERGENCY DEPARTMENT
Dr. Ruby Sahney
Deputy Medical Superintendent
Sir Ganga Ram Hospital

2. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
# NABH Chapter Standards
NABH Chapter
for Emergency Department
Standards
1
Access, Assessment
and Continuity of Care
(AAC).
•No Of
Standards : 14
AAC.1.
The organization defines and displaysthe
healthcareservices thatit can provide.
Access, Assessment and
Information (AAI)
•No Of Standards : 11
•No of objective elements:56
NABH CHAPTER 1 AND
CHAPTER 10.(Access,
Assessment and Continuity
of Care (AAC) AND
Information Management
System (IMS)
AAI.1
The organization establishes the emergency
department with an easy access and defines and
displaysthescope of services thatit can provide.AAC.2.
The organization has a well-defined
registration and admission process.
AAI.2
Emergency services areguided by documented
policies,procedures, applicablelawsand
regulations.AAC.3.
There is an appropriatemechanismfor
transfer (in and out) or referral of patients.
AAI.3
The organization has a documented registration,
admission and transfer process.
AAC.4.
Patients cared for by the organization undergo
an established initial assessment.
AAI.4
Documented policies and procedures guide the
availability of Diagnostic Services.
AAI.5
There is an appropriatemechanismfor transfer
(in and out) or referral of patients.
AAC.5.
Patients cared for by the organization
undergo a regular reassessment. AAI.6
Emergency patients cared for by the organization
undergo an established initial assessment.
AAC.6.
Laboratory services areprovided as per the
scope of services of the organization.
AAI.7
Patients cared for by the organization undergo a
regular reassessment.
AAI.8
Patient careis continuous and multidisciplinary
in nature.
AAC.7.
There is an established laboratory quality
assuranceprogram.
AAI.9
The organization has a documented discharge
process.

3. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
AAI.10 The Organization has a complete and
accuratemedical record for every patient ……….
AAC.8.
There is an established laboratory-safety
program.
AAI.11
The medical record reflects continuity of care.
AAC.9.
Imagingservices areprovided as per the
scope of services of the organization.
AAC.10.
There is an established quality assurance
program for imagingservices.
AAC.11.
There is an established
Safety programin Imagingservices.
AAC.12.
Patient careis continuous and
multidisciplinary in nature.
AAC.13.
The organization has a documented discharge
process.
AAC.14.
Organization defines the content of the
dischargesummary.
2 Care of Patients (COP).
•No Of
Standards : 22
COP 1:
Uniform careto patients is provided in all
settings of the organization and is guided by
the applicablelaws,regulationsand guidelines.
Patient Care and Rights
(PCR)
•No Of Standards : 9
•No of objective elements:58
NABH CHAPTER 2 AND 4
Care of Patients (COP) AND
Patient Rights and Education
(PRE).
PCR.1
The ambulanceservices arecommensurate with
the scope of the services provided by the
organization.
PCR.2
The emergency Department plans for handling
community emergencies, epidemics and other
disasters.
COP 2:
Emergency services areguided by documented
policies,procedures applicablelaws and
regulations.

4. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
PCR.3
Documented policies and procedures guidethe
careof patients requiring
Cardio-pulmonary resuscitation.
COP 3:
The ambulanceservices arecommensurate
with the scope of the services provided by the
organization.
PCR.4
Documented policies and procedures guide
nursingcare.
PCR.5
Documented procedures guide the performance
of various procedures.
PCR.6
Documented policies and procedures guide
the careof patients under
Special Conditions such asRestraints (physical
and/or chemical),Pain
Management and End of Life Care.
PCR.7
Patient and family rights supportindividual
beliefs,values and involvethe patient and family
in the decision makingprocesses
PCR.8
A documented procedure for obtainingpatient
and/or family consent exists for informed
decision makingabouttheir care.
COP 4.
The organization plans for handlingcommunity
emergencies, epidemics and other disasters
PCR.9
The emergency Department has a system for
effective communication with patients and/or
families.
COP 5:
Documented policies and procedures guide
the careof patients requiringcardio-
pulmonary resuscitation.
COP 6:
Documented policies and procedures guide
nursingcare.

5. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
COP 7:
Documented procedures guide the
performance of various procedures.
COP 8:
Documented policies and procedures define
rational useof blood and blood components.
COP 9:
Documented policies and procedures guide
the careof patients in the intensivecare and
high dependency units.
COP 10:
Documented policies and
Procedures guide the careof vulnerable
patients.
COP 11:
Documented policies and procedures guide
obstetric care.
COP 12:
Documented policies and procedures guide
pediatric services.
COP 13:
Documented policies and procedures guide
the careof patients undergoing moderate
sedation.
COP 14:
Documented policies and procedures guide
the administration of anesthesia.
COP 15:
Documented policies and procedures guide
the careof patients undergoing surgical
procedures.

6. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
COP.16
Documented policies and procedures guide
organ transplantprogramin the organization.
COP 17:
Documented policies and procedures guide
the careof patients under restraints
(Physical and/or chemical).
COP 18:
Documented policies and procedures guide
appropriatepain management.
COP 19:
Documented policies and procedures guide
appropriaterehabilitativeservices.
COP 20:
Documented policies and procedures guideall
research activities.
COP 21:
Documented policies and procedures guide
nutritional therapy.
COP 22:
Documented policies and procedures guide
the end of lifecare
3 Management of
Medication (MOM)
•No Of
Standards : 13
MOM 1:
Documented policies and procedures guide
the organization of pharmacy services and
usage of medication.
Management of Medication
(MOM)
•No Of Standards : 7
•No of objective elements:48
MOM.1
There is a formulary for the emergency
department depending on its scopeof services.
MOM.2 Documented policies and procedures
guide the storage of medication.
MOM 2:
There is a hospital formulary.
MOM.3
Documented policies and procedures guidethe
safeand rational prescription of medications.

7. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
MOM 3:
Documented policies and procedures guide
the storage of medication.
MOM.4
There are documented policies and procedures
for medication
Administration.
MOM.5
Near misses,medication errors and adverse drug
events are reported and analyzed.
MOM.6
Documented procedures guide the use of
narcotic drugs and psychotropic
Substances.
MOM.7
Documented policies and procedures guidethe
use of medical supplies and consumables.
MOM 4:
Documented policies and procedures guide
the safeand rational prescription of
medications.
MOM 5: Documented policies and procedures
guide the safedispensingof medications.
MOM 6:
There are documented policies and
procedures for medication administration.
MOM 7:
Patients are monitored after medication
administration.
MOM 8:
Near misses,medication errors and adverse
drug events are reported and analyzed.

8. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
MOM 9:
Documented procedures guide the use of
narcotic drugs and psychotropic substances.
MOM 10:
Documented policies and procedures guide
the usage of chemotherapeutic agents.
MOM 11:
Documented policies and procedures govern
usage of radioactivedrugs.
MOM 12:
Documented policies and procedures guide
the use of implantableprosthesisand medical
devices.
MOM 13: Documented policies and
procedures guide the use of medical supplies
and consumables.
4
Patient Rights and
Education (PRE).
•No Of Standards : 8
PRE 1:
The organization protects patient and family
rights and informs them about their
responsibilitiesduringcare.
PRE2:
Patient and family rights supportindividual
beliefs,values and involvethe patient and
family in decision makingprocesses.
PRE3:
The patient and/or family members are
educated to make informed decisions and are
involved in the careplanningand delivery
process.

9. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
PRE4:
A documented procedure for obtainingpatient
and/or family‘s consentexists for informed
decision makingabouttheir care.
PRE5:
Patient and families havea right to
information and education about their
healthcareneeds.
PRE6:
Patients and families havea rightto
information on expected costs.
PRE7:
The organization has a mechanismto capture
patient‘s feedback and redressal of
complaints.
PRE8:
The organization has a systemfor effective
communication with patients and / or families.
5
Hospital Infection
Control (HIC).
•No Of Standards : 9
HIC 1: The organization has a well-designed,
comprehensive and coordinated Hospital
Infection Prevention and Control (HIC)
programme aimed at reducing/eliminating
risks to patients,visitors and providers of care.
Hospital Infection Control
(HIC)
•No Of Standards : 3
•No of objective elements:9
HIC.1
The Emergency Department performs
surveillanceactivitiesto prevent and
Control infections.

10. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
HIC.2
The organization promotes adherence to
standard precautions and provides adequateand
appropriateresources for prevention and control
of HealthcareAssociated Infections (HAI) in
Emergency Department.
HIC 2:
The organization implements the policies and
procedures laid down in the Infection Control
Manual in all areasof the hospital.
HIC.3
Biomedical waste(BMW) is handled in an
appropriateand safemanner.
HIC 3:
The organization performs surveillance
activities to captureand monitor infection
prevention and control data
HIC 4:
The organization takes actions to prevent and
control HealthcareAssociated Infections (HAI)
in patients.
HIC 5:
The organization provides adequateand
appropriateresources for prevention and
control of HealthcareAssociated Infections
(HAI).
HIC 6:
The organization identifies and takes
appropriateaction to control outbreaks of
infections.

11. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
HIC 7:
There are documented policies and
procedures for sterilization activities in the
organization.
HIC 8:
Biomedical waste(BMW) is handled in an
appropriateand safemanner.
HIC 9:
The infection control programme is supported
by the management and includes trainingof
staff.
6
Continuous Quality
Improvement (CQI).
•No Of Standards : 9
CQI 1:
There is a structured quality improvement and
continuous monitoringprogram in the
organization.
Continuous Quality
Improvement (CQI)
•No Of Standards : 4
•No of objective elements:20
CQI 1:
The organization has a well-designed,
comprehensive and multidisciplinary committee
for the Emergency Department which co-
ordinates all activities and
Provides oversight to the functioning of the
Emergency Department.
CQI 2:
There is a structured patient-safety program in
the organization.
CQI.2
There is a structured patient safety program in
the Emergency Department.
CQI.3
The organization identifies key indicatorsto
monitor the clinical structures,
Processes and outcomes which areused as tools
for continual improvement.CQI 3:
The organization identifies key indicatorsto
monitor the clinical structures,processes and
outcomes, which are used as tools for
continual improvement
CQI.4
The organization identifies key indicatorsto
monitor the managerial
structures,processes and outcomes which are
used as tools for continual
Improvement.

12. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
CQI 4:
The organization identifies key indicatorsto
monitor the managerial structures,processes
and outcomes, which areused as tools for
continual improvement.
CQI 5:
There is a mechanismfor validation and
analysisof quality indicatorsto facilitate
quality improvement.
CQI 6:
The quality improvement program is
supported by the management.
CQI 7:
There is an established
System for clinical audit.
CQI 8:
Incidents arecollected and analyzed to ensure
continual quality improvement.
CQI 9:
Sentinel events are intensively analyzed.
7
Responsibility of
Management (ROM)
•No Of Standards : 6
ROM 1:
The responsibilities of thoseresponsiblefor
governance are defined.
Responsibility of
Management (ROM)
•No Of Standards : 3
•No of objective elements:13
ROM 1:
The organization is awareand implements
applicablelegislationsand regulationsrequired
to operate the Emergency
Department in the healthcareorganization
ROM.2
The services provided by Emergency
Department are documented.
ROM.3
Management ensures that patient safety aspects
and risk management issues arean integral part
of patient care and emergency department

13. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
ROM 2:
The organization is responsiblefor and
complies with the laid-down and applicable
legislations,regulations and notifications.
Management ensures that patient safety aspects
and risk management issues arean integral part
of patient care and Emergency Department
management.
ROM 3:
The services provided by each department are
documented
ROM 4:
The organization is managed by the leaders in
an ethical manner.
ROM 5:
The organization displaysprofessionalismin
management of affairs.
ROM 6:
Management ensures that patient-safety
aspects and risk-management issues arean
integral partof patient care and hospital
management.
8
Facility Management
and Safety (FMS).
•No Of Standards : 7
FMS 1:
The organization has a systemin placeto
providea safeand secureenvironment.
Facility Management and
Safety (FMS)
•No Of Standards : 6
•No of objective elements:30
FMS 1:
The emergency's environment and facilities
operate to ensure safety of patients, their
families,staff and visitors.
FMS 2:
The organization’s environment and facilities
operate in a planned manner to ensure safety
of patients, their families,staff and visitorsand
FMS.2
The emergency has a program for bio-medical
equipment management

14. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
promotes environment friendly measures FMS.3
The emergency department has a process for
voice & data management.
FMS 3:
The organization has a programfor
engineering support services and utility
system.
FMS.4
The emergency department has a system for
provision of programfor medical gases,vacuum
& compressed air.
FMS.5
The emergency has plans for fire& non-fire
emergencies.FMS 4:
The organization has a programfor bio-
medical equipment management.
FMS.6
The emergency has a plan for management of
hazardous materials.
FMS 5:
The organization has a programfor medical
gases,vacuum and compressed air.
FMS 6:
The organization has plansfor fireand non-
fireemergencies within the facilities.
FMS 7:
The organization has a plan for management
of hazardous materials.
9 Human Resource
Management (HRM).
•No Of
Standards : 10
HRM 1:
The organization has a documented system of
human resource planning.
Human Resource
Management (HRM)
•No Of Standards : 5
•No of objective elements:21
Hrm.1
Emergency Department has a documented
system of human resource planning.

15. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
HRM.2
There is an ongoing program for trainingand
development of staff in the
Emergency Department.
HRM 2:
The organization has a documented procedure
for recruitingstaff and orientingthem to the
organization’s environment.
HRM.3
An appraisal systemfor evaluatingthe
performance of an employee exists as an integral
part of the human resourcemanagement
process.
HRM 3:
There is an ongoing program for professional
trainingand development of the staff.
HRM.4
The Emergency Department addresses the
health needs of the employees.
HRM.5
There is documented personal information
for each staff member.
HRM 4:
Staffs are adequately trained on various
safety-related aspects.
HRM 5:
An appraisal systemfor evaluatingthe
performance of an employee exists as an
integral partof the human resource
management process.HRM 6: The
organization has documented disciplinary and
grievancehandlingpolicies and procedures.
HRM 7:
The organization addresses thehealth needs
of the employees.
HRM 8:
There is documented personal information for
each staff member.

16. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
HRM 9:
There is a process for credentialingand
privilegingof medical professionals,permitted
to providepatient carewithout supervision.
HRM 10:
There is a process for credentialingand
privilegingof nursingprofessionals,permitted
to providepatient carewithout supervision.
10
Information
Management System
(IMS)
•No Of Standards : 7
IMS 1:
Documented policies and procedures existto
meet the information needs of the care
providers,management of the organization as
well as other agencies that require data and
information from the organization.
IMS 2:
The organization has processes in placefor
effective control and management of data.
IMS 3:
The organization has a complete and accurate
medical record for every patient.
IMS 4:
The medical record reflects continuity of
care...
IMS 5:
Documented policies and procedures arein
placefor maintainingconfidentiality,integrity
and security of records,data and information.
IMS 6:
Documented policies and procedures existfor
retention time of records,data and
information

17. NABH CHAPTER –SGRH EMERGENCY DEPARTMENTS – STANDARDS & CHECKLIST FOR ACCESS, ASSESSMENT & CONTINUITY OF CARE
Sir Ganga Ram Hospital Confidential Sunday, July 16, 2017
IMS 7: The organisation regularly carries out
review of medical records.
Total
 No Of Standards : 105
 No of objective elements: 636
•No Of Standards : 49
•No of objective elements:255