WHO ‘Safe Surgery Saves Lives’ Checklist: NABH COP 14

While dealing with care of patients who are undergoing surgical procedures, NABH recommends hospitals to refer to WHO ‘Safe Surgery Saves Lives’ Initiative. In this post, I bring to you a complete detail around the initiative and the checklist. This is also an important example that Dr. Atul Gawande quotes in his book – ‘The Checklist Manifesto: How to get things right’ and is one of my favourite books.

All the references are from the WHO’s website.

You can read an overview of the checklist on this page: http://bit.ly/OgsVIH

You can have a look at this 19 pointer checklist on the 20^th page of the pdf available on this link: http://bit.ly/NStgEM

I am sure you will have a lot of questions on what this checklist is all about and how to use it and is it applicable in your hospital. Don’t worry, WHO provides answers here: http://bit.ly/MtqbcY

And if you want to get a feel of how to do this checklist, watch the video below:

I’ve shown this video to 2 different audiences and both agreed that this checklist is short and crisp and can take care of a lot of elementary goof-ups that happen in their OTs and enhance patient safety. If you noticed, it doesn’t take more than 2 minutes each time you do the checklist. I think that’s time worth spent in protecting our patients.

Update on 30/08/2013
Based on a viewer comment, I felt there have to be other illustrations and videos for Safe Surgery Checklist which helps in better understanding of its implementation.

Below is a video from a hospital in Australia where a patient is undergoing Hip Replacement procedure. This one has the Pre-Incision (Time-Out) and Post-Procedure (Sign-Out) shoot only, but in a better detail.

This is another video from St. John of God Hospital in Australia. This one has two-part, the first one about how to do the Safe Surgery Checklist, and the second one about how not to do the checklist.

NABH COP-5: The new standard on nursing care

NABH 3^rd edition has brought with it a host of new requirements and probably gives a hint on what to expect in the years ahead for quality accreditation and Indian healthcare. There’s this new standard COP-5 on nursing care and I found one objective element, i.e. COP 5G, of particular interest. The statement of the objective elements is “Nurses are empowered to take nursing-related decisions to ensure timely care of patients”. The interpretation says “Self-explanatory”. And I always thought that nurses are required to only follow orders!!

This standard requires nurses to prepare their own ‘Nursing care plan’ for each patient. I wonder whether we have adequate teaching standards in our nursing schools and colleges where they can teach clinical discretion to the new generation of nurses because most nursing superintendents I meet always crib about the quality of new nursing workforce.

I guess this ‘nursing care plan’ requirement will increase the expectations and work load on the already overloaded nurses in our hospitals. And can anyone please explain to me, what is the scope of ‘nursing-related decisions’ in COP 5G, and if these decisions are anyways related to nursing, why do we need to empower them?

My personal knowledge is limited in this aspect of patient care and I have no idea about the nursing protocols. But whatever I have observed, I think nurses are supposed to follow the orders of the doctors as well as manage the care plan for the patient developed by the doctor (in his absence). When we speak of empowering nurses in nursing-related decision making, how can I make sense of it? Knowledgeable people on this topic, please guide me with your comments.

What’s new in NABH 3rd Edition for Hospitals? [Chapter 2: Care of Patients] – Part 2

COP-8 in the revised edition is the corresponding COP-6 in 2^nd edition. Nothing much changes in this standard, except that a new objective element has been added. COP-8a reads as “Documented policies and procedures are used to guide the care of patients in the intensive care and high dependency units” which basically deals with issues which were left out in the previous edition. The element recommends that the documentation should include information on how care is organized, what is the procedure of monitoring the patients and what would be the nurse-patient ratio.

The standard COP-8 in the 2^nd edition only covered care of high-risk obstetrics patients. The corresponding standard COP-10 in the 3^rd edition expands the scope of this stand by covering obstetric care. The revised standard statement (COP-10) states that “Documented policies and procedures guide obstetric care.” The standard opens with a new objective element COP-10a stating “There is a documented policy and procedure for obstetric services.” The standard also incorporates a new objective element COP-10d which states that “Documented procedures guide provision for ante-natal services.” This is followed up by another new objective element COP-10f which states that “Appropriate pre-natal, peri-natal and post-natal monitoring is performed and documented.” These are welcome changes in this standard as NABH views the obstetric care in totality. From the experience of changes in some standards in AAC, we can expect that future revisions will come out with further guidelines on ante-natal services and pre-natal, peri-natal and post-natal monitoring. Overall, three new objective elements have been added to this revised standard.

In the standard COP-11, which corresponds to COP-9 of 2^nd edition, there are not many changes in the existing objective elements. Only a new objective element has been added COP-11a which states that “There is a documented policy and procedure for paediatric services.”

COP-12 in the 3^rd edition deals with care of patients undergoing moderate sedation, which corresponds to standard COP-10 in 2^nd edition. Two new objective elements have been introduced in this revised standard. COP-12a states that “Documented procedures guide the administration of moderate sedation” and COP-12b states that “Informed consent for administration of moderate sedation is obtained”. These two objective elements fill the gap that existed between the standard’s definition and the objective elements elaborating the standard itself.

COP-13 (in 3^rd edition) has tried to removed confusion arising out of various interpretations of the terms ‘anesthetist’ and ‘qualified individual’ used in the earlier standard COP-11 in 2^nd edition. COP-13 replaces each of these terms with an ‘anesthesiologist’ thereby clarifying that the physician qualified for this job has to do it. COP-13 deals with the administration of anesthesia. There are two new objective elements added to this standard – COP-13i and COP-13j. COP-13i states that “The type of anaesthesia and anaesthetic medications used is documented in the patient record” while COP-13j reads as “Procedures shall comply with infection control guidelines to prevent cross-infection between patients.”

Two new objective elements have been added to COP-14 (COP-12 in 2^nd edition) covering surgical procedures. “Patient, personnel and material flow conforms to infection control practices” and “Appropriate facilities and equipment/appliances/instrumentation are available in the operating theatre” have been added as COP-14h and COP-14i respectively. But the objective element on monitoring of surgical site infection rate (COP-12j in 2^nd edition) has been removed from this standard and will be addressed in HIC-4.

In the 2^nd edition, COP-14 addressed pain management issues and COP-16 is the standard that deals with the topic in 3^rd edition. So while the earlier standard required the hospital to support assessment and management of pain for all patients, the new definition makes it mandatory for all patients to undergo screening for pain. The revised standard provides provision for the same through two new objective elements. COP-16b requires that “All patients are screened for pain” and COP-16c recommends that “Patients with pain undergo detailed assessment and periodic re-assessment”.

Standard COP-17 in 3^rd edition (corresponding to COP-15 in 2^nd edition) provides additional requirements on rehabilitative services through three new objective elements in addition to the existing requirements. COP-17c states that “Care is guided by functional assessment and periodic re-assessment which is done and documented by qualified individual(s)”, COP-17d requires “Care is provided adhering to infection control and safe practices” and COP-17f mandates that “There is adequate space and equipment to perform these activities.”

The last standard in the chapter, COP-20, deals with end of life care (corresponding to COP-18 in 2^nd edition). The revised standard has done away with the objective element on autopsy and organ donation (COP-18d of 2^nd edition) and has introduced a new objective element, COP-20d which requires that “Symptomatic treatment is provided and where appropriate measures are taken for alleviation of pain”.

In conclusion, in the chapter COP in the revised edition of NABH (3^rd edition), there was an addition of 37 new objective elements and 2 new standards (which contributed 14 of the 37 new objective elements). 4 objective elements of COP in 2^nd edition were also removed. Therefore, chapter COP in 3^rd edition has 20 standards and 136 objective elements.

What’s new in NABH 3rd Edition for Hospitals? [Chapter 2: Care of Patients] – Part 1

Continuing with our discussion on what’s new in NABH third edition compared to the previous edition, in this post we cover the chapter on Care of Patients (COP).

Like mentioned in the changes in chapter AAC, objective elements in COP also have become more specific. COP-1a begins with uniformity in care delivery in different settings in the hospital. In 3^rd edition, COP-1a also requires care to be uniform for a given health problem. COP-1c and COP-1d in the 2^nd edition required the primary consultant of the patient to sign and provide his name on the treatment orders along with date and time and the care plan be counter-signed by clinician in-charge of the patient. These 2 requirements have been removed from this standard COP-1. These conditions are now addressed in AAC-4 in the revised standards (check here).

In COP-2 in 3^rd edition, a few changes have been made to sentences in the objective elements to bring in specificity. A new objective element COP-2g has also been added – “In case of discharge to home or transfer to another organization a discharge note shall be given to patient”. However, I feel this aspect was adequately addressed in AAC-13d (“A discharge summary is given to all the patients leaving the organization” in revised edition) because this objective element covers all and every kind of discharges happening from the hospital and the remarks in the new objective element also advise the readers to refer to AAC 13 and 14. If being specific was the objective, this could have been dealt with by providing some more explanation in AAC 13 and 14 itself for the emergency patients like they have done for LAMA patients.

COP-3 in 2^nd edition required equipment and emergency medications to be checked on a daily basis (COP-3e and COP-3f) and COP-3d required a checklist of both of these to be maintained. In the 3^rd edition, the checklist part has been added to the existing objective elements of COP-3e and COP-3f and so the particular element COP-3d became redundant. These requirements are now covered under COP-3f and COP-3g as “Equipment are checked on a daily basis using a checklist” and “Emergency medications are checked daily and prior to dispatch using a checklist” respectively. There are also 2 new objective elements introduced in this standard. COP-3b states that “The ambulance adheres to statutory requirements” and COP-3e states that “Ambulance(s) is checked on a daily basis.” Therefore there is a new addition of one objective element in this standard.

In COP-4, the only visible change is in COP-4d. While this element under 2^nd edition required that all cardiac arrests be analyzed, in the 3^rd edition this requirement has been modified and the revised objective element requires all cardio-pulmonary resuscitations to be analyzed.

There are two new standards introduced in COP as “Documented policies and procedures guide nursing care” and “Documented procedures guide the performance of various procedures” finds their place as COP-5 and COP-6 respectively.

The new COP-5 has seven objective elements. These are:

1. “There are documented policies and procedures for all activities of the nursing services.” (COP-5a)
2. “These reflect current standards of nursing services and practice, relevant regulations and purposes of the services.” (COP-5b)
3. “Assignment of patient care is done as per current good practice guidelines.” (COP-5c)
4. “Nursing care is aligned and integrated with overall patient care.” (COP-5d)
5. “Care provided by nurses is documented in the patient record.” (COP-5e)
6. “Nurses are provided with adequate equipment for providing safe and efficient nursing services.” (COP-5f)
7. “Nurses are empowered to take nursing-related decisions to ensure timely care of patients.” (COP-5g)

The new COP-6 also has seven objective elements, as given below:

1. “Documented procedures are used to guide the performance of various clinical procedures.” (COP-6a)
2. “Only qualified personnel order, plan, perform and assist in performing procedures.” (COP-6b)
3. “Documented procedures exist to prevent adverse events like wrong site, wrong patient and wrong procedure.” (COP-6c)
4. “Informed consent is taken by the personnel performing the procedure, where applicable.” (COP-6d)
5. “Adherence to standard precautions and asepsis is adhered to during the conduct of the procedure.” (COP-6e)
6. “Patients are appropriately monitored during and after the procedure.” (COP-6f)
7. “Procedures are documented accurately in the patient record.” (COP-6g)

Because of these two additions in the list, the standard COP-5 in 2^nd edition has now been shifted 2 steps lower in the list and now becomes COP-7 in the revised edition.

COP-7 in the revised edition deals with the standard on rational use of blood and blood products. Compared to the corresponding standard COP-5 in the previous edition, 2 new objective elements have been introduced in this standard. COP-7b states that “Documented procedures guide transfusion of blood and blood products”, so there is specific focus on the activity of transfusion and NABH recommends that its reference guide on ‘NABH standards for blood banks’ be used for preparing the procedures.

The new element COP-7f states that “The organization defines the process for availability and transfusion of blood/blood components for use in emergency”. Hospitals should see this element in context of COP-2 which deals with emergency services.

What's new in NABH Third Edition: Chapter 2 - Care of Patients (Part 2)