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)

World Wide Web is the next place for hospitals to compete with each other

Most hospitals are poor marketers and that is very much evident in the conspicuous absence of creativity in their marketing campaigns, indoor patient experience and online presence. While management would spend crores of rupees in building their hospitals and buying the medical gadgets (read equipments) they would not spare even a thought to the marketing of these facilities.

One would have noticed that patients are now becoming smarter and social media has really given wings to the imagination to the customer in us. The patients like to surf more information about the hospitals online, seek advice from their friends and relatives about which one to choose and freely share their experiences about the hospital services on social media platforms. In such a marketplace, can the healthcare providers survive if they do not learn more about the mediums of reaching out to their target customers, i.e. patients and their relatives/friends?

Websites are the virtual existence of a business. For a hospital, it is an extremely cost-effective way to build a sound patient perspective about their services, competencies and outreach programmes. It is a one-time effort to communicate consistently to all your clients in a comprehensive manner.

Search engine optimization (SEO) is another area where one needs to focus. In our own observation, we found that some very good hospitals and with decent (if not great) websites were not appearing in the first 10 pages of Google search results! What can explain this situation? Definitely, the choice of vendor was a big reason because of which hospitals could not leverage their web presence.

Building a new hospital? First refer to NABH standards..

NABH accreditation has become a buzz word in the social circles of hospital administrators and quality professionals but hardly anyone pays attention to the actual NABH standards. Having visited some hospitals, old and new, which are planning for the accreditation, one of the clearly observable deficiencies I came across was the infrastructure. Old hospitals were built in the times when building laws were not as stringent as they are now. One can empathize with their administrators when they say that their hospitals can’t stand NABH’s scrutiny. But what I am shocked at is the lack of attention even new hospitals have paid to the building guidelines.

There is a larger consensus that slowly, but steadily, all healthcare facilities in our country will have to comply with some or the other quality accreditation systems, be it NABH or anything else. Today NABH is voluntary in nature. But who knows, tomorrow government might require certain category of hospitals to mandatorily go for accreditation. While old hospitals may be able to give some reasonable excuses, new hospitals will have no excuse to give. And imagine if medical insurance companies start demanding that all empanelled hospitals should have NABH accreditation. Can the new hospitals and those to come in future miss this opportunity? I am sure revenue and profitability are on top of their minds and they can’t miss the cashless pie of the business.

Therefore, my humble request to such hospitals would be that when they conceptualize their hospitals and sit with their architects and engineers, they should first of all put the basic NABH-related structural compliances in place. The fancy-stuff can wait. Yes, it has its business benefits, but it can’t match the benefits that the accreditation can bring.

Go through the latest standards (whichever are applicable to your facility) of NABH and decide for yourself how you are going to design your hospital around these requirements. I am sure there are sufficient intelligent engineering and architectural consulting firms who can help you meet both quality and aesthetic requirements in the same structure. Make NABH standards as the foundation of your building design.

For the hospitals which were built recently or even as long as 5-10 years back should consider giving NABH standards a try. If you find your hospital is non-compliant to some of the requirements of NABH, it’s still a very cost-effective proposition to make suitable changes (if possible) in your buildings. It is any day easy to change processes and manpower behaviour to suit the accreditation requirements, but building of an operational hospital is one thing which cannot be modified easily.

Interactive workshops on Sterilization and Surgical Safety by NABH

NABH is organizing a one-day workshop on the topic 'Sterilization and Surgical Safety' in Chennai on June 23rd. As per NABH website, the workshop has following objectives:

1. To educate healthcare personnel on the basics aspects on steam & ETO sterilization, sterilization monitoring, CSSD design, work flow and newer technologies.
2. A special emphasis on latest NABH standards that need to be maintained in the Sterilization department.
3. To provide the latest international sterilization guidelines and practices standards.
4. A panel of experts will help design a set of policies and procedures to help you to operate your CSSD in a better way.

You can find more details on this link:
http://nabh.co/main/events/Sterilization_and_Surgical_Safety.asp

Documentation basics for NABH implementation

One thing that keeps hospitals and NABH consultants on their toes is the documentation of policies, processes and SOPs (standard operating procedures). Many times hospitals would engage consultants only to get the documentation work done. Funny, isn’t it?

Do not worry because in this post, we are going to cover some basic aspects of documentation around NABH. To do that, firstly we need to understand what purpose is being served by documentation?

A documented policy, process and procedure becomes a single source of truth in an organizational set-up. The management, the other managers and head-of-departments and senior and junior employees have their own perspectives on how the care has to be delivered. These perspectives may not be in consonance with each other. The single source of truth, or the documentation, serves as a point of reference for everyone in the organization. While their personal perspectives may be respected, the documented system and processes have to be complied with consistently in the organization by everyone.

Coming on to the documentation basics, first you need to identify all standards/objective elements which require mandatory documentation. The NABH book of second edition had a list of documentation required under previous edition. Unfortunately the new one doesn’t have it, but you can still surf through the standards and you will get an idea. In the next step, you should prepare a list of processes and policies you need to document as part of mandatory requirement. You would realize you already have some existing documentation, and you may only need to tweak it a little bit.

When you create a document, ensure that:

• You give a document-code to each document. The code can have a nomenclature which may indicate the department for which the document is applicable, the standard that this documented process is addressing and a few other details.
• The issuing date of the document. A recent date would indicate that either the process is new or some changes were made in it recently.
• Have an objective for each policy/process/procedure.
• If you are documenting a process, define their start and end-points to avoid overlap.
• If you are documenting a policy, define the scope of the policy.
• Do cross-referencing of documentation wherever required for brevity.
• After defining the document scope, also list down the responsible position. For example, a document regarding security of the facility will have security officer or in-charge as the responsible person. Avoid putting any names in this field because responsibility has to be mapped to a designation or position and not to an individual. Individuals may change over time.
• Provide in detail the processes and policies. You can also use flow-charts and responsibility matrix to provide an overall view of the process.
• Try to cover all aspects of the policy/process as defined in the scope of the document.
• At the end, provide the names of the individuals who prepared, reviewed and approved the document. If required, you may skip the reviewer name.

The points above describe the basic steps that need to be followed to prepare your documentation. But ensure that you have taken inputs from other experts and colleagues on the content of each document.

For the cosmetic part of the documents, like where to place different information inside the document, colour schemes, branding etc. you can pick a format from an already accreditated hospital. 

The challenges in training the staff for NABH compliances and some solutions

If there is one area that can make or break your plans of NABH accreditation, process compliance and re-accreditation at later stages, it is the training of staff on NABH compliant processes. Not just that, NABH demands that the employees be re-trained at regular intervals to ensure they are updated on the processes and SOPs (standard operations procedures).

From my personal experience in managing hospital teams and from the experience of my friends in healthcare operations and administration, I’ve learnt that achieving full training of all our employees is easier said than done. Add to this the problem of attrition. You would have spent time and money in training your staff and by the time you are updating your excel sheet with the names of those who received training, 10% of them would have resigned. In many training sessions, trainers observe that the faces keep changing in the series of sessions on particular training topics and it’s hard for them to ensure everyone would have undergone training on all aspects. Then you would ask why NABH is so particular about this aspect of accreditation when it is practically not possible to achieve this requirement given the nature of our industry?

The answer lies in the fact that there is no point in having wonderfully framed SOPs and policies if these are not implemented by your ground force. A lot is at stake, given that one cannot allow the faith in accreditation standards to be questioned. The case in point here is the fire incidence at AMRI (Advanced Medical Research Institute) Kolkata which caught fire in December 2011. In November (a month before the tragedy)NABH inspection had held its accreditation status in abeyance. The standards cannot be compromised, whatever may be the effort and cost required.

Yet, there is a silver lining on the horizon. Technology has made it possible for us to manage complex problems. E-learning is one domain which can significantly bring down the cost of training manpower on standardized learning content. Through our own experience, we have seen the power of e-learning in creating a scalable learning environment which can be customized to the needs of the learners.

Another fantastic tracking mechanism is Checklist. You can create role-specific checklists, say for nursing, laboratory, clinical team etc., which will guide the administrators in achieving training on all aspects for each of their employees. The checklists can be made separately for new joinees and for existing employees.

You can also go for Train-the-Trainer (T3) programs which will be supplementary to the checklists. You can create a pool of trainers from amongst your existing team members and these identified trainers will take the new joinees through an orientation on your organization’s policies as well as NABH-related SOPs. This will also be a good opportunity for career advancement for your senior staff members.

Human Resource Information System (HRIS) is another technology tool which enables management to have a bird’s eye view of the training completion level of their workforce. The training status of all the employees can be updated in the HRIS as and when the training happens. So those employees who haven’t been through some or all of the trainings can be traced through the HRIS’ reporting system.

Clinical and Managerial Quality Indicators become sharper in NABH Third Edition

NABH deserves our appreciation for proving a lot more clear guidelines and better framed objective elements to remove discretion on the part of different HCOs as part of the released third edition. The standards that benefitted most seem to be (purely on quantifiable terms) those of clinical and managerial quality indicators.

The new edition takes all pains to explain in detail each of the mandatory indicators mentioned in CQI chapter. At the back of the new book, you can find several pages (37 to be precise) detailing each of the quality indicators (QI) mentioned in CQI-3 and CQI-4. The section defines the QI, provides the formula to calculate the QI, also suggests a sample size for proper measurement and gives remarks wherever necessary. In case anyone missed this, NABH also demands each indicator to be captured on a monthly basis and that month’s data only to be referred to for calculating the QI using the newly-provided formulae.

Sometime back I heard from an NABH Principal Assessor that NABH is planning to have a system across its accreditated hospitals using which one could compare these hospitals. Such a comparative system would enable ranking of the accreditated hospitals based on their performance on these measurable QIs. Is the third edition first step in that direction?

The impetus on statutory compliances in NABH accreditation

NABH standard ROM-1 (Responsibilities of Management) in the 2^nd edition touched on the requirement for compliances to applicable laws and regulations as part of the objective element ROM-1h. The latest edition of NABH has gone one step ahead, with the formulation of a completely separate standard on this requirement. So now ROM-2 reads as “The organization complies with the laid-down and applicable legislations and regulations”. Indeed this is a welcome step as it leaves little scope for hospitals to non-comply as the new standard deals with management’s knowledge about the laws and regulations, implementation of the same with a proper mechanism to update the licenses, registrations and certifications from time to time.

For organizations planning to put the house in order and start the journey towards NABH accreditation, you can systematically check your compliance to this new standard. From our research, we have observed that most of the statutory and regulatory requirements can be categorized into following categories:

• Air & Water
• Bio-medical waste
• Blood Bank
• Electrical
• Fire safety related
• HR-related
• Pharmacy
• PNDT & MTP
• Radiology equipment
• Software licenses
• Various State and Central Govt. Taxes

Depending on the size of your organization and the scope of your services, each of these categories may have various requirements under them. For example, if you have X-Ray and CT in your hospital, AERB approvals for your equipment and layout become a mandatory requirement. You also should be keeping a track of safety and maintenance related activities for these radiology equipments.

Ideas for improving patient services in hospitals - 3

Healthcare is a part of service industry and shoulders an important social objective, i.e. keeping the citizens of the nation healthy and productive. Service industry is characterized by an intensive use of human beings are part of value creation and in the healthcare environment, doctors, nurses, technicians, pharmacists etc. work together as a team to deliver the experience of care to the patients. That is why hospitals are seen doing a great service to the community.

In the journey of quality improvement, it is always essential to keep learning and making slow yet steady progress on making our services client-centered. This has far more significance in healthcare than probably in another industry because of the very nature of the goal that the industry serves. It is in this context that the idea in this post finds relevance.

Community-Hospital interactions can be a place for a hospital’s patients to interact with the management in a constructive dialogue to improve the services of the hospital as well as provide creative ideas for fixing some of the regular problems facing the hospital and its patients. Unlike other businesses, patients feel a sense of connection to their physicians and the hospitals which they visit. Healthcare facilities are part of the lives of the community-members around it. How many times you would have come across mothers saying both their children were born in your hospital, or patients saying that they had surgery in your hospital last year, or visitors saying they prefer consulting with one of your doctors over other doctors in the city? There are many such instances where you will find patients expressing sense of ownership to the hospital.

A community-hospital, organized once a quarter, is an ideal platform for the management to listen to the needs of the community and also seek feedback from the patients about the plans of the hospital. A gap of 3 months will give management enough time to fix some of the issues raised by the patients in the last interaction and they can respond to them with the status of progress in the next interaction.

It’s interesting to note that when we become a public-listed company, because of regulations we conduct the AGMs and shareholder meets. But as part of a community of ‘stakeholders’, shouldn’t hospitals feel the same need to have a dialogue with its stakeholders, i.e. patients?