Dental Accreditation Standards

Accreditation Standards for Dental

Institutions/ Hospitals/ Centres

NATIONAL ACCREDITATION BOARD FOR

HOSPITALS AND HEALTHCARE PROVIDERS
Table of Contents
Sr. No. Particulars Page No.
Introduction 01
Patient Centered Standards
01. Access, Assessment and Continuity of Care (AAC) 03
02. Care of Patients (COP) 11
03. Management of Medication (MOM) 18
04. Patient Rights and Education (PRE) 22
05. Hospital Infection Control (HIC) 25
Organization Centered Standards
06. Continuous Quality Improvement (CQI) 30
07. Responsibilities of Management (ROM) 34
08. Facility Management and Safety (FMS) 37
09. Human Resource Management (HRM) 42
10. Information Management System (IMS) 47
Glossary 51
Reference Guide on Sentinel Events 63

NEED OF THE STANDARDS
Quality is the need of the present time with development of technology and availability of new
equipment, Dentistry is becoming more and more effective but along with that unsafe. If as
professionals we stick to basic standards we can have safe practices and deliver high quality
treatment. Introducing quality management systems are very important and the standards help
us to achieve it.
INTRODUCTION OF NABH
The NABH standards have been laid down keeping the Indian ethos and working environment
in mind. The main focus of the standards is on patient, employee, visitor and environment
safety. These standards are applicable to multidisciplinary Dental hospitals and single specialty
hospitals providing secondary, tertiary and quaternary levels of dental care. All the standards
are core standards and no optional standards have been laid down. . The compliance with
these standards will indicate that the hospital is patient, staff and environment friendly.
The standards are deceptively simple. On going through the details during the phase of
implementation of the standards one would realize that extra efforts and resources are indeed
required for ensuring compliance with the standards. It may also be observed, at the time of
implementation, that there may be some duplication at a few places. Duplication is a necessity
since it will ensure compliance with the said standards and also emphasize the importance of
the standards and the objective elements.
We are aware that apart from extra resources needed for implementation, a few guidelines are
equally necessary for easy comprehension and correct implementation. The ensuing guidelines,
chapter-wise in tabulated form, have been laid down for easy comprehension, better
understanding of the standards and the objective elements, removing and clarifying ambiguities
uniform application of standards across the organization, and smoother and more efficient
implementation. The best way to implement the standards is to have an in-house quality
committee/team that will be responsible for making the quality manual based on the NABH
standards, the initial implementation of the standards and the subsequent monitoring of the
same. While there might be initial expenses for ensuring implementation and monitoring of the
standards, in the long term these costs will be recovered by the organization owing to the better
and more efficient and effective quality of patient care. Finally it must also be understood that
accreditation is an ongoing process. Each time one has to raise the bar and hence the
National Accreditation Board for Hospitals and Healthcare Providers 1

importance of continual quality improvement. Accreditation is thus a journey and not a
destination.
Dental institution/ hospital/ centre is referred as Dental Facility in this standard.

CHAPTER-1 Access, Assessment and Continuity of Care (AAC)
AAC.1. The organization defines and displays the services that it can provide.
Objective Element Guidance

1.1 The services being provided A policy to be framed clearly stating the services the
are clearly defined and are dental facility can provide.
inconsonance with the needs of
the community.
1.2 The defined services are The services so defined should be displayed
prominently displayed. prominently in an area visible to all patients entering
the organization. The display could be in the form of
boards, citizens charter, scrolling messages, etc.
Care should be taken to ensure that these are
displayed in the language (s) the patient
understands.
1.3 The staff is oriented to these All the staff in the dental facility mainly in the
services reception/registration, OPD, IPD is oriented to these
facts through training program regularly or through
manuals.
AAC.2.The organization has a well documented registration, admission and transfer or

referral process.

2.1 Processes addresses Dental facility has prepared document (s) detailing
registering and admitting out the policies and procedures for registration,
patients, inpatients and admission of patient
emergency patients
2.2 Patients are accepted only if The staff handling admission and registration needs
the organization can provide to be aware of the services that the organization can
the required service provide. It is also advisable to have a system wherein
the staff is aware as to whom to contact if they need
any clarification on the services provided.
2.3 The policies and procedures The dental facility is aware of the availability of
also address managing alternate facilities where the patients may be directed
patients during non-availability in case of non-availability of beds.
of beds
2.4 The staff is aware of these All the staff handling these activities should be
processes oriented to these policies and procedures.
Orientation can be provided by documentation/
training.

2.5 Processes addresses The documented policy and procedure should
mechanism for transfer or address the methodology of safe transfer of the
referral of patient who do not patient in a life threatening situation to another dental
match the organizational facility. Availability of an appropriate ambulance fitted
resources with life support facilities and accompanied by trained
personnel
The dental facility gives a case summary mentioning
the significant findings and treatment given in case of
patients who are being transferred from emergency.
For admitted patients a discharge summary has to be
given (refer AAC9).The same shall also be given to
patients going against medical advice.
AAC.3. Patients cared for by the organization undergo an established initial assessment

3.1 The organization defines the The hospital shall have a protocol/policy by which a
content of the assessments for standardized initial assessment of patients is done in
the out-patients, in-patients and the OPD, emergency and IPD. The initial assessment
emergency patients. could be standardized across the hospital or it could
be modified depending on the need of the
department. However, it shall be the same in that
particular area. The organization can have different
assessment criteria for the first visit and for
subsequent visits. In emergency department this
shall include recording the vital parameters.
3.2 The organization determines The assessment can be done by the treating doctor
who can perform the or junior doctor under supervision of treating doctor
assessments. or a dental hygienist under supervision of treating
doctor. The organization shall determine who can do
what assessment and it should be the same across
the hospital.
3.3 The organization defines the The dental facility has defined and documented the
time frame within which the time frame within which the initial assessment is to
initial assessment is completed. be completed with respect to emergency/indoor
patients.
3.4 Initial assessment for OPD and If required treatment is done in the same OPD visit.
Emergency cases is done and Waiting time is monitored to make it minimum
documented within a
reasonable timeframe
3.5 The initial assessment for in- The facilitys documented protocol mentions that the
patients is documented within initial assessment is to be completed within 24 hours
24 hours or earlier as per the or earlier depending upon the patients condition.
patients condition or hospital This should also cover history, progress notes,
policy. investigation ordered and treatment ordered and all
these are to be authenticated by treating doctor.

3.6 The initial assessment results This shall be documented by the treating
in a documented plan of care doctor/dental surgeon or by a member of his team in
and includes preventive aspect the case sheet.
of the care.
The documented plan of care should cover
preventive actions as necessary in the case and
should include diet, drugs, etc.
AAC.4. patients care is a continuous process and all patient care for by the organization
undergo a regular reassessment

4.1 During all phases of care, there The facility to ensure that the care of patients is
is a qualified individual always given by appropriately qualified dental
responsible for the patient care personnel (resident doctor, surgeon, consultant
who co-ordinates the care in all and/or nurse).
the setting with-in the
organization
Care of patients is coordinated among various care
providers in a given setting viz OPD, emergency, IP
etc. The organization shall ensure that there is
effective communication of patient requirements
amongst the care providers in all settings.
4.2 All patients are reassessed at After the initial assessment, the patient is reassessed
appropriate intervals. periodically and this is documented in the case sheet.
The frequency may be different for different areas
based on the setting and the patient's condition.
4.3 Staff involved in direct clinical Actions taken under reassessment are documented.
care documents The staff could be the treating doctor or any member
reassessments of the team. The nursing staff and trained dental
hygienist where available can document patients
vitals.
4.4 Patients are reassessed to Self explanatory
determine their response to
treatment and to plan further
treatment or discharge.

AAC.5. Clinical Laboratory services are provided as per the requirements of the patients

5.1 Scope of the laboratory The facility should ensure availability of laboratory
services are commensurate to services commensurate with the health care services
the services provided by the offered by it. See also (5.5) below for outsourced lab
organization. facilities.
5.2 Adequately qualified and The staff employed in the lab should be suitably
trained personnel perform qualified (appropriate degree) and trained to carry out
and/or supervise the the tests under supervision of specialist.
investigations.
5.3 Policies and procedures guide The facility has documented procedures for
collection, identification, collection, identification, handling, safe
handling, safe transportation transportation, processing and disposal of
and disposal of specimens. specimens, to ensure safety of the specimen till the
tests and retests (if required) are completed.
5.4 Laboratory results are available The facility shall define the turnaround time for all
within a defined time frame. tests. The facility should ensure availability of
Critical results are intimated adequate staff, materials and equipment to make the
immediately to the concerned laboratory results available within the defined time
personnel frame.
5.5 Laboratory tests not available The facility has documented procedure for
in the organization are outsourcing tests for which it has no facilities. This
outsourced to organization(s) should include: a) list of tests for outsourcing b)
based on their quality identity of personnel in the outsourced facilities to
assurance system. ensure safe transportation of specimens and
completing of tests as per requirements of the patient
concerned and receipt of results at facility c) manner
of packaging of the specimens and their labeling for
identification and this package should contain the test
requisition with all details as required for testing. A
methodology to check the performance of service
rendered by the outsourced laboratory as per the
requirements of the facility.
5.6 Quality assurance for The facility has a documented quality assurance
laboratory should be as per program. The laboratory in-charge shall periodically
accepted practices and also survey tests results. The program includes the
include periodic calibration and documentation of corrected and preventive action.
maintenance of all the
equipments.

AAC.6. There is an established laboratory safety program.

6.1 The laboratory safety program A well documented lab safety manual is available in
is documented. the lab. This takes care of the safety of the workforce
as well as the equipment available in the lab.
6.2 This program is integrated with Lab safety program is incorporated in the safety
the organizations safety program of the hospital.
program
6.3 Written policies and procedures The lab staff should follow standard precautions .The
guide the handling and disposal disposal of waste is according to biomedical handling
of infectious and hazardous and management rules, 1998.
materials.
6.4 Laboratory personnel are All the lab staff undergoes training regarding safe
appropriately trained in safe practices in the lab. Adequate safety devices are
practice are provided with available in the lab e.g. fire extinguishers, dressing
appropriate safety materials, standard precautions, disinfectants, etc
equipment/devices
AAC.7. Imaging services are provided as per the requirements of the patients

7.1 Imaging services comply with legal The facility is aware of the legal and other
and other requirements requirements of imaging services and the same
are documented for information and compliance
by all concerned in the facility. The facility
maintains and updates its compliance status of
legal and other requirements in a regular manner.
7.2 Scope of the imaging services are Self explanatory
commensurate to the services
provided by the organization.
7.3 Adequately qualified and trained As per AERB guidelines
personnel perform and/or
supervise the investigations.
7.4 Policies and procedures guide The facility has documented policies and
identification and safe procedures for informing the patients about the
transportation of patients to imaging activities, their identification and safe
imaging services. transportation to the imaging services. This should
also address transfer of unstable patients to
imaging services.

7.5 Imaging results are available The organization shall document turnaround time
within a defined time frame. of imaging results.
Critical results are intimated
immediately to the concerned
Critical results are intimated immediately to the
personnel
concerned personnel
7.6 Imaging tests not available in the The facility has documented procedure for
organization are outsourced to outsourcing tests for which it has no facilities. This
organization(s) based on their should include: a) list of tests for outsourcing b)
quality assurance system. identity of personnel in the outsourced facilities to
ensure safe transportation of specimens and
completing of imaging tests, c) the manner of
identification of patients and the test requisition
with all details as required for testing and d) a
methodology to check the selection and
performance of service rendered by the
outsourced imaging facility as per the
requirements of the facility.
7.7 Quality assurance for radiology Refer to AERB guidelines.
services should be as per
accepted practices and also
Documents for verification and validation of
include periodic calibration and
imaging methods shall be available.
maintenance of all equipments
HOD shall periodically survey the imaging results.

Calibration and maintenance of all equipment
shall be carried out by competent persons.
7.8 Imaging personnel are trained in Refer to AERB guidelines
radiation safety and are provided The safety program of the imaging department
with appropriate safety equipment has reference in the hospital safety manual.
devices
Protective devices e.g. lead aprons should be
exposed to X-ray for verification of cracks and
damages.
7.9 Imaging signage are prominently Self explanatory
displayed in all appropriate
locations

AAC.8. The organization has a documented process for generating and maintains OPD
records of patient care

8.1 Policy and procedures are in Facility devise OPD dental records which has
place to maintain OPD records patient card and institutional OPD folder. Patient
of patient care card contains OPD registration number, diagnosis,
procedure done, treatment prescribed, advice given
and appointment. Institutional OPD folder contains
history, examination, diagnosis investigations,
procedures done, treatment prescribed and
appointment.
8.2 The record contains the
diagnosis and plan of treatment
8.3 The record contains
investigations ordered and the
results thereof.
8.4 The record contains the
treatment received and
procedures conducted on the
patient
8.5 Patients take home OPD The organization decides the contents of the
Card/slip contains procedural Procedural Summary
summary, medications,
instruction and follow up
appointment.
Organization defines the time
frame for which these records
are retained
AAC.9. The organization has a documented discharge process and contents of discharge
summary

9.1 Process addresses discharge Self explanatory
of all patients including medico-
legal patients leaving against
medical advice
9.2 A discharge summary is given The facility hands over the discharge papers to the
to all the patients leaving the patient/attendant in all cases and copy retained. In
organization (including patients LAMA cases, the declaration of the patient/attendant
leaving against medical advice) is to be recorded on proper format

9.3 Discharge summary contains Self explanatory
the reasons for admission,
significant findings and
diagnosis, investigation results,
procedure performed treatment
given and the patients
condition at the time of
discharge.
9.4 Discharge summary contains Self explanatory
follow-up advice medications
follow up instructions in an
understandable manner
9.5 Discharge summary Self explanatory
incorporates instructions about
when and how to obtain urgent
care
9.6 In case of death the summary
of the case also includes the
cause of death

Chapter 2. Care of Patients
COP.1. Uniform care of patients is provided in all settings of the organization and is
guided by the applicable laws, regulations and guidelines.

1.1 Care delivery is uniform when The organization shall ensure that patients with the
similar care is provided in more same health problems and care needs receive the
than one setting same quality of healthcare throughout the
organization irrespective of the category of ward.
1.2 Uniform care is guided by Self explanatory
policies and procedures which
reflect applicable laws and
regulations
1.3 The care and treatment orders The treatment of patient could be initiated by a junior
are signed, named, timed and dental surgeon or student trainee but same should be
dated by the concerned doctor countersigned and authorized by the treating
and countersigned by consultant of the case within 24 hours.
consultant I/C of case
1.4 Evidence based dentistry and The organization could develop clinical protocols
acceptable clinical practice based on these and the same could be followed in
guidelines are adopted to guide management of patients.
patient care whenever possible
COP.2. Emergency services are guided by policies, procedures, applicable laws and
regulations

2.1 Documented procedure These could include SOPs/protocols to provide either
addresses care of patient general emergency care or management of specific
arriving in emergency including conditions The policy shall be in line with statutory
the medico-legal cases requirements
2.2 Policies and procedures guide
the triage of patients for
initiation of appropriate care
2.3 Staff is familiar with the policies All the staff working in the dental casualty where
and trained on the procedures functioning should be oriented to the policies and
for care of emergency patients practices through training/documents. Staff should
preferably be trained/well versed in ACLS and BCLS
2.4 Admission or discharge to home All the staff working in the dental casualty where
or transfer to another functioning should be oriented to the policies and
organization is also practices through training/documents. Staff should
documented preferably be trained/well versed in ACLS and BCLS.

2.5 The ambulance is appropriately Ambulance should have at least equipment for basic
equipped and manned by life support and manned by a trained driver.
trained personnel
2.6 In the ambulance, there is a
check-list of all equipments and
emergency medications on
regular basis
COP.3. Policies and procedures guide the care of patients requiring cardio-pulmonary
resuscitation

3.1 Documented procedures guide The organization shall document the procedure for the
the uniform use of resuscitation same. This shall be in consonance with accepted
throughout the organization practices.
3.2 Staff providing direct patient These aspects shall be covered by hands-on training.
care is trained and periodically If the organization has a CPR team (e.g. code blue
updated in cardio-pulmonary team) it shall ensure that they are all trained in ALS
resuscitation and are present in all shifts.
3.3 The events during a cardio- In the actual event of a CPR or a mock drill of the
pulmonary resuscitation are same, all the activities along with the personnel
recorded attended should be recorded.
COP.4 Policies and procedures define rational use of blood and blood products

4.1 Documented policies and This shall address the conditions where blood and
procedures are used to guide blood products can be used.
rational use of blood and blood
products
4.2 Informed consent is obtained for Self explanatory. Also refer to PRE3.4 and 3.5.
transfusion of blood and blood
products
4.3 Procedure addresses The organization shall ensure that any transfusion
documenting and reporting of reaction is reported. These are then analyzed (by
Transfusion reaction. individual/committee as decided by the organization)
and appropriate corrective/preventive action is taken.
The organization shall maintain a record of
transfusion reactions.

COP.5. Policies and procedures guide the dental laboratory services

5.1 The scope of the dental Dental facility should ensure availability dental lab
laboratory services are facilities commensurate with the services offered by it.
commensurate to the services See (5.7) also for the outsourced Lab facilities.
provided by the hospital
5.2 Adequately qualified and trained
personnel perform and
supervise the work
5.3 Policies and Procedures guide The impressions and models need to be disinfected
the identification, disinfection properly
handling, processing, safe The model should be accompanied by a properly
transportation of the models completed authorization form duly signed by treating
and prosthesis as well as safe dental surgeon/ dental specialist.
disposal of the waste
5.4 All models and prosthesis are
available within a defined time
frame.
5.5 Quality assurance for dental lab
should be as per accepted
practices and also includes
periodic calibration and
maintenance of all equipments
5.6 Corrections and alterations are
attended to through a structured
and time based programme.
5.7 Lab jobs not available in the
organisation are out sourced to
organisations based on their
quality assurance programme
5.8 Lab has a documented safety A well documented dental Lab safety manual is
programme which is integrated available which take care of all staff as well all
with the organisations safety equipment available in the Lab. This could be as per
program. All personnel are Occupational health & Safety Management System-
trained in lab safety and are OSHAS 1800.
provided safety equipment and
devices

COP.6. Policies and procedures guide the care of vulnerable patients (elderly, children,
physically and/or mentally challenged)

6.1 Policies and procedures are Self explanatory.
documented and are in
accordance with the prevailing
laws and the national and
international guidelines
6.2 Care is organized and delivered Facility develops SOP's for delivery of care.
in accordance with the policies
and procedures
6.3 The organization provides for a The organization shall provide proper environment
safe and secure environment taking into account the requirement of the vulnerable
for this vulnerable group group
COP.7. Policies and procedures guide the care of pediatric dental patients

7.1 The organization defines and
displays the scope of its
pediatric dental services
7.2 Those who care for children These shall not just be for doctors but shall include
have age-specific competency hygienist and nursing staff also. The competency shall
be based on qualification, experience and training.
7.3 Provisions are made for special Adequate amenities for the care of children to be
care of children available in the hospital.
7.4 The childrens family members Self explanatory
are educated about oral
hygiene and safe parenting and
this is documented in the
medical record
COP.8. Policies and procedures guide the administration of anesthesia

9.1 There is a documented policy Facility shall document on the indications, the type of
and procedure for the anesthesia and procedure for the same. Authorization
administration of local and for administration of local & regional anesthesia in
regional anesthesia. dental clinics is defined

9.2 An immediate preoperative This shall be done by an anesthesiologist just before
reevaluation is documented. the patient is wheeled in to the respective OT.
9.3 Informed consent for Self explanatory.
administration of anesthesia is
obtained by the anesthetist
9.4 During anesthesia monitoring Self explanatory
includes regular and periodic
recording of heart rate, cardiac
rhythm, respiratory rate, blood
pressure, oxygen saturation,
airway security and potency and
level of anesthesia
9.5 Each patients post-anesthesia This shall be done in the recovery area/OT and at
status is monitored and least include monitoring of vitals till the patient
documented recovers completely from anesthesia and shall be
done by an anesthesiologist. If the patients condition
is unstable and he/she requires ICU care the same
shall be monitored there.
9.6 A qualified individual applies This shall be done by a designated individual as
defined criteria to transfer the decided by the facility and shall be in consonance with
patient from the recovery area best clinical practices.
9.7 All adverse anesthesia events Self explanatory
are recorded and monitored
COP.10. Policies and procedures guide the care of patients undergoing surgical
procedures

10.1 The policies and procedures are This shall include the list of surgical procedures as
documented well as competency level for performing these
procedures.
10.2 Surgical patients have a All patients undergoing surgery are assessed
preoperative assessment and a preoperatively and a provisional diagnosis is made
provisional diagnosis which is documented. This shall be applicable for both
documented prior to surgery routine and emergency cases
10.3 An informed consent is obtained Self explanatory
by a surgeon prior to the
procedure

10.4 Documented policies and Policies should be available for preventing adverse
procedures exist to prevent events like wrong patients, wrong site, and wrong
adverse events like wrong site, teeth by a suitable mechanism.
wrong patient and wrong
surgery
10.5 Persons qualified by law are The facility identifies the individuals who have the
permitted to perform the required qualification (s), training and experience to
procedures that they are perform procedures in consonance with the law.
entitled to perform
10.6 A brief operative note and This note provides information about the procedure
postoperative plan of care is performed, post operative diagnosis and the status of
documented prior to transfer out the patient before shifting and shall be documented by
of patient from recovery area/ the surgeon/member of the surgical team.
detention area
10.7 The operating surgeon Self explanatory
documents the post-operative
plan of care
10.8 A quality assurance program is This shall be an integral part of the facility's overall
followed for the surgical quality assurance program. It shall focus on post
services and all procedures on operative complications e.g. bleeding, rational use of
the dental chair antibiotics, etc.
10.9 The quality assurance program Surveillance activities include monitoring the quality of
includes surveillance of the air provided, rate of air exchange , cleaning and
operation theatre environment disinfection processes, etc.
and dental clinic
10.1 The plan also includes Self explanatory
monitoring of surgical site
infection rates
COP.11 Policies and procedures guide appropriate pain management

11.1 Documented policies and The facility shall define the group of patients for whom
procedures guide the this is applicable. A good reference point for defining
management of pain these patients could be those having pain as the
predominant debilitating symptom.
11.2 The organization respects and Self explanatory
supports the appropriate
assessment and management
of pain for all patients

COP.12. Policies and procedures guide all research activities

12.1 Documented policies and Self explanatory
procedures guide all research
activities in compliance with
national and international
guidelines
12.2 The organization has an ethics An ethics committee should be framed in the hospital
committee to oversee all to monitor activities undertaken by various providers.
research activities Any research undertaken in the hospital falls under its
ambit.
12.3 The committee has the powers Self explanatory
to discontinue a research trial
when risks outweigh the
potential benefits
12.4 Patients informed consent is Self explanatory
obtained before entering them
in research protocols
12.5 Patients are informed of their Self explanatory
right to withdraw from the
research at any stage and also
of the consequences (if any) of
such withdrawal
12.6 Patients are assured that their Self explanatory
refusal to participate or
withdrawal from participation
will not compromise their
access to the organizations
services

Chapter 3. Management of Medication (MOM)
MOM.1. Policies and procedures guide the organization of pharmacy services, usage of
medication and usage of dental materials

1.1 There is a documented policy The policies and procedures shall address the issues
and procedure for pharmacy related to procurement, storage, formulary,
services, medication and dental prescription, dispensing, administration, monitoring
materials usage and use of medications and dental materials.
1.2 These comply with the Self explanatory.
applicable laws and regulations
1.3 1.3 a multi disciplinary There shall be representative of major clinical
committee guides the departments, administration and shall include a
formulation and implementation pharmacist
of these policies and procedure
1.4 A list of medication and dental The hospital formulary shall be prepared and be
materials appropriate for the preferably updated at regular intervals.
patients and organizations
resources is developed
1.5 There is a defined process for The process should preferably address the issues of
acquisition of these medications vendor selection, vendor evaluation, and generation
and dental materials of purchase order and receipt of goods as per rules.
1.6 Documented policies and These should address issues pertaining to
procedures exist for storage of temperature (refrigeration), light, ventilation,
medication and dental materials preventing entry of pests/rodents and worms.
The organization shall also ensure that the storage

requirements of the drug and dental materials as
specified by the manufacturer are adhered to. If the
recommendations are conflicting in nature, the
organization shall follow the manufacturers
recommendation. This shall be applicable to all areas
where medications are stored including dental clinics,
OT and wards.
1.7 Beyond expiry date medications Self explanatory.
and dental materials are not
stored/ used
1.8 Sound-alike and look-alike Many drugs in ampoules, vials or tablets may look-
medication/ dental materials are alike or sound-alike. They should be segregated and
stored separately stored separately.
1.9 Emergency medications are Adequate amount of emergency medicines should be
available all the time and stocked at all times. Re-order level at definite quantity
replenished in a timely manner should be done.
when used

MOM.2 Policies and procedures guide the prescription of medications

2.1 The organization determines This shall be done by the treating dental
who can write orders surgeon/specialist.
2.2 Orders are written in a uniform All the orders for medicines are recorded on a uniform
location in the medical records location of the case sheet. Electronic orders when
typed shall again follow the same principles.
2.3 Medication orders are clear, Self explanatory.
legible, dated, named and
signed
2.4 The organization defines a list The organization shall develop the list taking into
of high risk medication consideration statutory requirements e.g. NDPS Act
2.5 Use of consumable dental

materials are recorded along
with justification of use
MOM.3 Policies and procedures guide the safe dispensing of medications

3.1 Documented policies and Clear policies to be laid down for dispensing of
procedures guide the safe medication e.g. route of administration, dosage, rate
dispensing of medications and of administration, expiry date, etc.
dental materials
3.2 Expiry dates are checked prior Self explanatory
to dispensing
3.3 Labeling requirements are At a minimum, labels must include the drug name,
documented and implemented strength and frequency of administration.
by the organization
MOM.4. There are defined procedures for medication administration and for
monitoring adverse drug event

4.1 Medications are administered Self explanatory
by those who are permitted by
law to do so
4.2 Patient is identified prior to Self explanatory
administration

4.3 Medication dosage, route and Staff administering medications should go through the
timings are verified from the treatment orders before administration of the
order prior to administration medication and then only administer them. It is
preferable that they also check the general
appearance of the medication (e.g melting, clumping,
etc.) before dispensing.
4.4 Medication administration is The organization shall ensure that this is done in a
documented uniform location and it shall include the name of the
medication, dosage, route of administration, timing
and the name and signature of the person who has
administered the medication
4.5 A proper record is kept of usage This is in context of narcotic drugs and psychotropic
administration safe storage and substance act These shall be kept in accordance with
disposal of narcotics and the statutory requirements.
psychotropic medication
4.6 Adverse drug events are The organization shall define as to what constitutes
defined, documented and an adverse drug event. This shall be in consonance
reported within specific time with best practices.
4.7 Adverse drug events are All the adverse drug reactions are analyzed regularly
collected and analyzed, if by the multi-disciplinary committee (Refer to MOM
necessary modify practices to 1.3).
reduce the same
MOM.5. Policies and procedures guide the use of implantable prosthesis

procedures govern procurement
and usage of implantable
prosthesis
5.2 Selection of implantable The organization shall ensure that relevant and
prosthesis is based on scientific sufficient scientific data are available before selection.
criteria and internationally It shall also look for international (e.g.US-FDA) or
recognized standards national notification (Drugs and Cosmetics Act
notification October 2005) for approval of the
particular product
5.3 The batch and serial number of Self explanatory
the implantable prosthesis are
recorded in the patients
medical record and the master
logbook

MOM.6. Policies and procedures guide the use of medical gases

6.1 Documented policies and This shall be applicable to all gases used in the
procedures govern organization. It shall also address the issue of
procurement, handling, storage, statutory requirements and approvals wherever
distribution, usage and applicable. It shall follow the international color coding
replenishment of medical system.
gases.
6.2 Procedures address the safety This shall include from the point of storage/source
issues at all levels area, gas supply lines and the end user area.
Appropriate safety measures shall be developed and
implemented for all levels.
6.3 Appropriate records are This is the context of the Indian explosives act of
maintained in accordance with 1884, Gas cylinder rules 1981 and Static and mobile
procedures and legal pressure vessels (unfired) 1981
requirements.

Chapter 4. Patient Rights and Education (PRE)
PRE.1. The organization protects patient and family rights and informs them about their
responsibilities during care

1.1 Patient and family rights and Hospital should respect patients rights. All the rights
responsibilities are documented of the patients should be displayed in the form of a
citizens charter which should also give information of
the charges and grievance redressal mechanism.
1.2 Patients and families are Self explanatory
informed of their rights in a
format and language that they
can understand
1.3 Staff is aware of their Training and sensitization programs shall be
responsibility in protecting conducted to create awareness among the staff.
patients rights
1.4 Violation of patient rights is Where patients' rights have been infringed upon,
recorded , reviewed and management must keep records of such violations, as
corrective/preventive measures also a record of the consequences, e.g. corrective
taken by the organizations actions to prevent recurrences.
leader
PRE.2. Patient rights support individual beliefs values and involve the patient and family
in decision making processes

2.1 Patient and family rights Self explanatory
address any special
preferences, spiritual and
cultural needs
2.2 Patient rights include respect forDuring all stages of patient care, be it in examination
personal dignity and privacy or carrying out a procedure, hospital staff shall ensure
during examination, procedures that patients privacy and dignity is maintained. The
and treatment organization shall develop the necessary guidelines
for the same. During procedures the organization
shall ensure that the patient is explained just before
the actual procedure is undertaken. With regards to
photographs/recording procedures; the organization
shall ensure that consent is taken and that the
patients identity is not revealed.
2.3 Patient rights include protection Self explanatory. Special precautions shall be taken
from physical abuse or neglect especially w.r.t vulnerable patients e.g. elderly..
2.4 Patient rights include treating Self explanatory. Statutory requirements w.r.t.
patient information as privileged communication shall be followed at all
confidential times.

2.5 Patient rights include refusal of During management, the patients should be given the
treatment choice of treatment. The treating doctor shall discuss
all the available options and allow the patient to make
an informed choice including the option of refusal.
2.6 Patient rights include informed Self explanatory
consent before anesthesia,
blood and blood product
transfusions and any
invasive/high risk
procedures/treatment
2.7 Patient rights include The organization shall ensure that International
information and consent before conference on harmonization (ICH) of good clinical
any research protocol is practice (GCP) and declaration of Helsinki Somerset
initiated (1996) and ICMR requirements are followed.
2.8 Patient rights include Grievance redressal mechanism must be accessible
information on how to voice a and transparent. Displayed information must be
complaint clearly available on how to voice a complaint.
2.9 Patient rights include Refer AAC4d
information on the expected
cost of the treatment or user
charges
2.10 Patient has a right to have an The organization shall ensure that every patient has
access to his/her clinical access to his/her record. This shall be in consonance
records with The code of medical ethics and statutory
requirements.
PRE.3. A documented process for obtaining patient and/or families consent exists for
informed decision making about their care

3.1 General consent for treatment is Self explanatory
obtained when the patient
enters the organization
3.2 Patient and/or his family The organization shall define as to what is the scope
members are informed of the of this consent and the same shall be communicated
scope of such general consent to the patient and/or his family members.
3.3 The organization has listed A list of procedures should be made for which
those procedures and treatment informed consent should be taken.
where informed consent is
required
3.4 Informed consent includes Self explanatory. The consent shall have the name of
information on risks , benefits, the doctor performing the procedure. If it is a doctor
alternatives and as to who will under training the same shall be specified, however
perform the requisite procedure the name of the qualified doctor supervising the
in a language that they can procedure shall also be mentioned. Consent form
understand shall be in the language that the patient understands.

3.5 The policy describes who can Self explanatory. The organization shall take into
give consent when patient is consideration the statutory norms.
incapable of independent
decision making.
PRE.4 Patient and families have a right to information on expected costs

4.1 There is uniform pricing policy There should be a billing policy which defines the user
in a given setting (out-patient charges to be levied for various activities
and ward category)
4.2 The user charges list is made The organization shall ensure that there is an updated
known to patients user charges list and that this information is available
to patients when required. The organization shall
charge as per the list. Any additional charge should
also be enumerated in the tariff and the same
communicated to the patients. The user charges
should be uniform and transparent
4.3 Patients are educated about the
estimated costs of treatment

Chapter 5. Hospital Infection Control (HIC)
HIC 1 The organization has a well-designed, comprehensive and coordinated Hospital
Infection Control (HIC) programme aimed at reducing/ eliminating risks to patients,
visitors and providers of care.

1.1 The hospital infection control Self explanatory
programme is documented
which aims at preventing and
reducing risk of nosocomial
infections.
1.2 The hospital has a multi- Self explanatory. This shall preferably have
disciplinary infection control administrator, microbiologist, physician, surgeon and
committee. the hospital infection control nurse.
1.3 The hospital has an infection The team is responsible for day-to-day functioning of
control team. infection control program. They shall support
surveillance process and detect outbreaks. They shall
also participate in audit activity and in infection
prevention and control on a day-to-day basis.
1.4 The hospital has designated The qualification shall be either a graduate nurse or
and qualified infection control qualified nurse with competence gained by
nurse(s)/assistant for this experience
activity
HIC 2 The hospital has an infection control manual, which is periodically updated.
(and conducts surveillance activities

2.1 The manual identifies the The manual should clearly identify the high risk areas
various high-risk areas and of the hospital e.g. OT, specialized dental clinics,
procedures radiology department and dental labs.
2.2 It outlines methods of It shall define the frequency and mode of surveillance.
surveillance in the identified
high-risk areas.
2.3 It focuses on adherence to Self explanatory
standard precautions at all
times.
2.4 Equipment cleaning and It shall address this at all levels e.g. ward, OT and
sterilization practices are CSSD. It is preferable that the organization follow a
included. uniform policy across different departments within the
organization.

2.5 An appropriate antibiotic policy The facility shall develop a system of monitoring drug
is established and implemented. susceptibility (based on culture sensitivity) and
accordingly develop its antibiotic policy. which shall be
reviewed at periodic intervals (may be once in 3
months) for its continuing applicability.
2.6 Laundry and linen management Self explanatory. If outsourced the organization shall
processes are also included. ensure that it establishes adequate controls to ensure
infection control.
2.7 Engineering controls to prevent Engineering controls shall address air changes, air
infections are included conditioning, replacement of filters, seepage leading
to fungal colonization, etc.
2.8 The organization defines the Self Explanatory
periodicity of updating the
infection control manual.
2.9 Surveillance activities are The organization shall ensure that it has a process in
appropriately directed towards place to collect surveillance data and also to ensure
the identified high risk areas that it is able to capture all such data which is verified
and surveillance data is ,analysed and take suitable steps to control infection
collected, verified,analysed
HIC 3 The hospital takes actions to prevent or reduce the risks of Hospital Associated
Infections (HAI) in patients and employees.

3.1 The organization monitors This shall be done by sending pus/swab for culture.
surgical site infections.
3.2 Appropriate feedback regarding The feedback shall include the rates, trends and
HAI rates are provided on a opportunities for improvement. It could also provide
regular basis to dental and specific inputs to reduce the HAI rate.
nursing staff.
HIC 4 Proper facilities and adequate resources are provided to support the infection
control program

4.1 Hand washing facilities in all The organization shall ensure that it provides
patient care areas are necessary infrastructure to carry out the same.
accessible to health care
providers.
4.2 Compliance with proper hand The organization shall preferably display the
washing is monitored regularly. necessary instructions near every hand washing area.
Compliance could be verified by random checking,
observation, etc.

4.3 Adequate gloves, masks, Self explanatory. They should be available at the point
soaps, and disinfectants are of use and the organization shall ensure that it
available and used correctly. maintains an adequate inventory.
HIC 5 There are documented procedures for sterilization activities in the hospital.

5.1 There is adequate space Self explanatory
available for sterilization
activities
5.2 Regular validation tests for This shall be done by accepted methods e.g.
sterilization are carried out and bacteriologic, strips, etc.
documented.
5.3 There is an established recall The organization shall ensure that the sterilization
procedure when breakdown in procedure is regularly monitored and in the
the sterilization system is eventuality of a breakdown it has a procedure for
identified. withdrawal of such items.
HIC 6 Statutory provisions with regard to bio-medical waste (BMW) management and
handling, 1998 are complied with.

6.1 The hospital is authorized by The occupier shall apply in the prescribed form and
prescribed authority for the get approval from the prescribed authority e.g.
management and handling of pollution control board/committee
bio-medical waste.
6.2 Proper segregation and Wastes to be segregated and collected in different
collection of bio-medical waste color coded bags and containers as per statutory
from all patient care areas of provisions. Monitoring shall be done by members of
the hospital is implemented and the committee
monitored.
6.3 The organization ensures that The waste is transported to the pre-defined site at
bio-medical waste is stored and definite time intervals (maximum within 48 hours)
transported to the site of through proper transport vehicles in a safe manner. If
treatment and disposal in this activity is outsourced the organization shall
proper covered vehicles within ensure that it is done to an authorized contractor.
stipulated time limits in a secure
manner.
6.4 Bio-medical waste treatment If the hospital has waste treatment facility within its
facility is managed as per premises then they have to be in accordance with
statutory provisions (if in-house) statutory provisions or they can outsource it to a
or outsourced to authorized central facility.
contractor(s).

6.5 Requisite fees, documents and The facility facility ensure that the fees are deposited
reports are submitted to in a timely manner. In addition, the annual reports
competent authorities on have to be submitted by the 31st of January of every
stipulated dates. year and accident reporting has to be carried out in
the prescribed form.
6.6 Appropriate personal protective Self explanatory
measures are used by all
categories of staff handling bio-
medical waste.
6.7 Policy and procedure for proper There needs to be provision of Mercury spill kit and a
storage, handling and disposal SOP for mercury spills
of mercury and mercury
waste/amalgam
HIC 7 The infection control program is supported by hospital management and includes
training of staff and employee health.

7.1 Hospital management makes The facility shall ensure that the resources required by
available resources required for the personnel should be available in a sustained
the infection control program manner. This includes both men and materials.
7.2 The hospital regularly earmarks There shall be a separate budget demarcated for HIC
adequate funds from its annual activity. This shall be prepared taking into
budget in this regard. consideration the scope of the activity and previous
years experience.
7.3 It conducts regular pre-induction Self explanatory
training for appropriate
categories of staff before joining
concerned department(s).
7.4 It also conducts regular in- Self explanatory
service training sessions for all
concerned categories of staff at
least once in a year.
7.5 Appropriate pre and post Self explanatory
exposure prophylaxis is
provided to all concerned staff
members.
7.6 There needs to be The Dental Aerosol/Dust Splash guard for
Implementation of Engineering chairs must Evacuation lathe and table
systems to reduce dust, have an in built Hood in Dental top rotary
aerosol/splash contamination hi-vacuum Laboratory devices
suction system
to prevent
aerosol
contamination

7.7 These Engineering controls Maintenance records
should be examined and tested
periodically and the same
should be documented
7.8 All personnel handling patients Self explanatory
are provided with specific
personal protective equipment
and eye shield, mask, apron,
gloves and shoe cover, etc.

Chapter 6. Continuous Quality Improvement (CQI)
CQI 1. There is a structured quality improvement and continuous monitoring program in
the organization.

1.1 The quality improvement This committee shall have representation from
program is developed, management, various clinical and support
implemented and maintained by departments of the facility. This program shall be
a multi-disciplinary committee. developed, implemented and maintained in a
structured manner.
1.2 The quality improvement This could be documented as a manual. This shall
programme is documented. incorporate the mission, vision, quality policy, quality
objectives, service standards, etc. The manual could
be stand alone or it could have cross linkages with
other manuals.
1.3 There is a designated individual This should preferably be a person having a good
for coordinating and knowledge of accreditation standards, statutory
implementing the quality requirements, hospital quality assurance principles
assurance program and evaluation methodologies, hospital functioning
and operations.
1.4 The quality improvement This shall preferably cover all aspects including
program is comprehensive and documentation of the program, monitoring it, data
covers all the major elements collection, review of policy and corrective action. Also
related to quality assurance and refer to CQI 1b
risk management.
1.5 The designated program is Self explanatory
communicated and coordinated
amongst all the employees of
the organization through proper
training mechanism.
1.6 The quality improve mental As quality improvement is a dynamic process, it
program is reviewed at needs to be reviewed at regular pre-defined intervals
predefined intervals and (as defined by the facility in the quality assurance
opportunities for improvement manual) by the multi-disciplinary committee. The
are identified. review shall also include analysis of key indicators as
defined by the standards. Refer to CQI 2 and CQI 3.
1.7 The quality improvement Self explanatory. The inputs for updating could be
program is a continuous based on the review carried out by the quality
process and updated at least assurance committee.
once in a year.

CQI 2. The organization identifies key indicators to monitor the clinical structures,
processes and outcomes which are used as tools for continual improvement.

2.1 Monitoring includes appropriate Self explanatory. The facility shall develop appropriate
patient assessment. key performance indicators suitable to it. The data
pertaining to the identified indicators shall be captured
from all patients; however, monitoring could be done
using suitable samples. Certain illustrative examples
are given in the remarks column.
2.2 Monitoring includes diagnostic As stated in the remarks column
services safety and quality
control programs.
2.3 Monitoring includes all invasive As stated in the remarks column
procedures.
2.4 Monitoring includes adverse As stated in the remarks column
drug events.
2.5 Monitoring includes use of As stated in the remarks column
anesthesia.
2.6 Monitoring includes use of As stated in the remarks column
blood and blood products.
2.7 Monitoring includes availability As stated in the remarks column
and content of medical records.
2.8 Monitoring includes infection As stated in the remarks column
control activities.
2.9 Monitoring includes clinical As stated in the remarks column
research.
2.10 Monitoring includes data
collection to support further
improvements
2.11 Monitoring includes data
collection to support evaluation
of these improvements.
CQI 3. The organization identifies key indicators to monitor the managerial structures,
processes and outcomes which are used as tools for continual improvement.

3.1 Monitoring includes Self explanatory.
procurement of medication and
dental materials essential to
meet patient needs.

3.2 Monitoring includes reporting of The facility shall identify all these requirements and
activities as required by laws accordingly report them as laid down by the
and regulations. law/regulation
3.3 Monitoring includes risk Refer to glossary for definition of "risk management"
management.
3.4 Monitoring includes utilization of Self explanatory.
space, manpower and
equipment.
3.5 Monitoring includes patient Self explanatory.
satisfaction which also
incorporates waiting time for
services.
3.6 Monitoring includes employee Self explanatory.
satisfaction.
3.7 Monitoring includes adverse Self explanatory. The organization shall define
events and near misses. "adverse events" and capture the same.
3.8 Monitoring includes data This shall include any data as deemed fit by the
collection to support further facility and should enable it to improve its services.
study for improvements.
3.9 Monitoring includes data All improvement activities carried out by the facility
collection to support evaluation shall have an evaluable outcome. The same shall be
of the improvements. captured and analyzed.
CQI 4. The quality improvement program is supported by the management.

4.1 Hospital management makes This shall include the men, material, machine and
available adequate resources method. These should be in steady supply so as to
required for quality ensure that the program functions smoothly
improvement program.
4.2 Hospital earmarks adequate Appropriate fund allocation is done by the
funds from its annual budget in organization for the smooth functioning of the
this regard. program.
4.3 Appropriate statistical and Self explanatory
management tools are applied
whenever required.

CQI 5. There is an established system for audit of patient care services.

5.1 Dental staff participates in this The facility shall identify such personnel. It could be a
system. mix of clinicians, administrators and nurses.
5.2 The parameters to be audited As medical audits are retrospective/concurrent in
are defined by the organization. nature, it is imperative that this be done using
predefined parameters so that there is no bias.
5.3 Patient and clinician anonymity Self explanatory.
is maintained.
5.4 All audits are documented. Self explanatory.
5.5 Remedial measures are Self explanatory.
implemented
CQI 6. Sentinel events are intensively analyzed.

6.1 The organization has defined Self explanatory
sentinel events.
6.2 The organization has Self explanatory
established processes for
intense analysis of such events
when occurs
6.3 Corrective and preventive This should be done based on root cause analysis so
actions are taken upon findings as to prevent recurrences.
of such analysis.

Chapter 7. Responsibility of Management (ROM)
ROM 1 The responsibilities of the management are defined

1.1 The organization has a The shall have an organization structure/chart and
documented organogram this shall clearly document the hierarchy line of control
and function
1.2 Those responsible for Self explanatory
governance appoint the senior
leaders in the organization
1.3 Those responsible for Self explanatory
governance support research
activities and quality
improvement plans.
1.4 The organization complies with Self explanatory
the laid down and applicable
legislations and regulations
1.5 Those responsible for The facility shall develop social responsibility policy
governance address the and accordingly address it.
organizations social
responsibility
1.6 The management defines the
rights and responsibilities of
employees
ROM 2 The services provided by each department are documented

2.1 Each organizational program, The organization of hospital is usually a matrix one.
service, site or department has There needs to be an effective leadership style by
effective leadership which it is governed.
2.2 Scope of services of each Each department's activity is to be predefined. This
department is defined could be documented either at individual department
level or the facility could have a brochure detailing the
scope of each department.
2.3 Administrative policies and This shall include administrative procedures like
procedures for each department attendance, leave, conduct, etc.
is maintained
2.4 Departmental leaders are Self explanatory
involved in quality improvement

ROM 3 The organization is managed by the leaders in an ethical manner.

3.1 The leaders make public the The facility shall have a mission statement and the
mission statement of the same shall be displayed prominently.
organization
3.2 The leaders establish the The facility shall function in an ethical manner.
organizations ethical
management
3.3 The organization discloses its The ownership of the hospital e.g. trust, private, public
ownership has to be disclosed
3.4 The organization honestly Self explanatory

portrays the services which it
can and cannot provide
3.5 The organization honestly
portrays its affiliations and
accreditations.
3.6 The organization accurately bills Self explanatory
for its services based upon a
standard billing tariff/ user
charges.
ROM 4 A suitably qualified and experienced individual heads the organization

4.1 The designated individual has Self explanatory.
requisite and appropriate
administrative qualifications
4.2 The designated individual has Self explanatory.
requisite and appropriate
administrative experience
ROM 5 Leaders ensure that patient safety aspects and risk management issues are an
integral part of patient care and hospital management

5.1 The organization has an Self explanatory
interdisciplinary group assigned
to oversee the hospital wide
safety program.

5.2 The scope of the program is Self explanatory
defined to include adverse
events ranging from no harm
to sentinel events.
5.3 Management ensures The facility has a system in place for internal and
implementation of systems for external reporting of system and process failures in
internal and external reporting the context of adverse events as defined above.
of system and process failures.

Chapter 8. Facility of Management and Safety (FMS)
FMS.1. The organization is aware of and complies with the relevant rules and regulations,
laws and byelaws and requisite facility inspection requirements.

1.1 The management is conversant A designated management functionary has been
with the laws and regulations given the responsibility to enlist the laws and
and knows their applicability to regulation as applicable to the. This functionary has
the organization and regularly identified the appropriate personnel in the facility who
updates are supposed to implement the respective laws and
regulations.
1.2 The management ensures Self explanatory
implementation of these
requirements.
1.3 There is a mechanism to Self explanatory
regularly update licenses/
registrations/certifications.
FMS.2. The organizations environment and facilities operate to ensure safety of patients,
their families, staff and visitors.

2.1 There is a documented Self explanatory
operational and maintenance
(preventive and breakdown)
plan.
2.2 Up-to-date drawings are Designated personnel maintain the drawings.
maintained which detail the
site layout, floor plans and fire
escape routes.
2.3 There is internal and external
sign posting in the organization
in language understood by
patient, families and community
2.4 The provision of space shall be Self explanatory
in accordance with the
available literature on good
practices (Indian or International
standards) and directives from
government agencies

2.5 There are designated A person in the facility management is designated to
individuals responsible for the be in-charge of maintenance of facilities. The facility
maintenance of all the facilities. has the required number of supervision and
tradesmen to manage the facilities.
2.6 Maintenance staff is contactable A complaint attendance register is to be maintained to
round the clock for emergency indicate the date and time of receipt of complaint,
repairs. allotment of job and completion of job
2.7 The organization has a system
to identify the potential safety
and security risks includes the
hazardous material
FMS.3 The organization has a program for clinical and support service equipment
management.

3.1 The organization plans for Self explanatory. This shall also take into
equipment in accordance with consideration future requirementsans has a
its services and strategic plan collaborated process where equipment selection is
done end user and by management..
3.2 All equipment is inventoried and Self explanatory.
proper logs are maintained
as required.
3.3 Qualified and trained personnel Self explanatory.
operate and maintain the
equipment
3.4 Equipment is periodically The facility has weekly/monthly/ annual schedules of
inspected and calibrated for inspection and calibration of equipment which involve
their proper functioning. measurement, in an appropriate manner. The facility
either calibrates the equipment in-house or out
sources; maintaining traceability.
3.5 There is a documented Self explanatory.
operational and maintenance
(preventive and breakdown)
plan

FMS.4 The organization has provisions for safe water, electricity, medical gases and
vacuum system.

4.1 Potable water and electricity are The facility shall make arrangements for supply of
available round the clock adequate potable water and electricity.
4.2 Alternate sources are provided Alternate electric supply could be from DG sets, solar
for in case of failure. energy, UPS and any other suitable source.
4.3 The organization regularly tests Self explanatory
the alternate sources.
4.4 There is a maintenance plan for Self explanatory
piped medical gas and vacuum
installation
FMS.5 The organization has plans for fire and non-fire emergencies within the facilities.

5.1 The organization has plans and The facility has a fire and non-fire emergency
provisions for early detection, committee (FNEC) to review the facilitys
abatement and containment of preparedness. The facility has conducted an exercise
fire and non-fire emergences of hazard identification and risk analysis (HIRA) and
including community accordingly taken all necessary steps to eliminate or
emergencies reduce such hazards and associated risks. The facility
has:
a) fire plan covering fire arising out of burning of
inflammable items, explosion, electric short
circuiting or act of negligence or due to
incompetence of the staff on duty.
b) deployed adequate and qualified personnel for this
c) acquired adequate fire-fighting equipment for this
which records are kept up-to-date.
d) adequate training plans
e) scheduled for conduct of mock fire drills
f) mock drill records
g) exit plans well displayed
The facility has a dedicated emergency illumination

system which comes into effect in case of a fire. The
facility takes care of non-fire emergency situations by
identifying them and by deciding appropriate course of
action. These may include:
a) terrorist attack
b) invasion of swarms of insects and pests
c) earthquake

d)
invasion of stray animals
e)
hysteric fits of patients and/or relatives
f)
civil disorders effecting the facility
g)
anti-social behavior by patients/ relatives
h)
temperamental disorders of staff causing
deterioration in patient care
i) spillage of hazardous (acids, mercury, etc,
infected materials (used gloves, syringes, tubing,
sharps, etc) medical wastes (blood, pus, amniotic
fluid, vomits, etc)
j) building or structural collapse
k) fall or slips (from height or on floor) or collision of
personnel in passageway
l) fall of patient from bed
m) bursting of pipe lines
n) sudden flooding of areas like basements due to
clogging in pipe lines
o) Sudden failure of supply of electricity, gas,
vacuum, etc.
p) Bursting of boilers and/or autoclavesThe facility
has established liaison with civil and police
authorities and fire brigade as required by law for
enlisting their help and support in case of an
emergency.
5.2 The organization has a Fire exit plan shall be displayed on each floor
documented safe exit plan in particularly close to the lifts. Exist doors should
case of fire and non-fire remain open on the time.
emergencies.
5.3 Staff is trained for their role in In case of fire designated person are assigned
case of such emergencies particular work.
5.4 Mock drills are held at least Self explanatory
twice in a year
FMS 6 The organization has a plan for management of hazardous materials

6.1 Hazardous materials are Special attention to be given for management of
identified within the organization Mercury spill and amalgam.
6.2 The hospital implements
processes for sorting, handling,
storage, transporting and
disposal of hazardous material.

6.3 There is a plan for managing
spills of hazardous materials
6.4 Staff is educated and trained for
handling such materials.
FMS 7. The organization has system in place to provide a safe and secure
environment

7.1 The hospital has a safety Facility should have a RO system to supply safe water
committee to identify the for dental chairs to prevent infection
potential safety and security
risks.
7.2 This committee coordinates
development, implementation,
and monitoring of the safety
plan and policies.
7.3 Patient Safety devices are
installed across the organization
and inspected periodically
7.4 Facility inspection rounds to
ensure safety are conducted at
least twice in a year in patient
are areas and at least once in a
year in non-patient care areas.
7.5 Inspection reports are
documented and corrective and
preventive measures are
undertaken.
7.6 There is a safety education
programme for all staff

Chapter 9: Human Resource Management
HRM.1 The Organization has a documented system of human resource planning.

1.1 The organization maintains an Self explanatory
adequate number and mix of
staff to meet the care, treatment
and service needs of the
patient.
1.2 The required job specifications Self explanatory
and job description are well
defined for each category of
staff
1.3 The organization verifies the Self explanatory
antecedents of the potential
employee with regards to
criminal/negligence
background.
HRM.2 The staff joining the organization is socialized and oriented to the hospital
environment.

2.1 Each staff member, employee Self explanatory
student and voluntary worker is
appropriately oriented to the
organizations mission and
policies and procedure
2.2 Each staff member is made The facility shall define the same in consonance with
aware of his/her rights and statutory requirements and the same shall be
responsibilities communicated to the employees.
2.3 All employees are educated For patient rights refer to PRE 2.
with regard to patients rights
and responsibilities.
HRM.3 There is an ongoing program for professional training and development of the
staff.

3.1 A documented training and Self explanatory
development policy exists for
the staff.

3.2 Training also occurs when job Self explanatory
responsibilities change/new
equipment is introduced.
3.3 Feedback mechanisms for Self explanatory
assessment of training and
development program exist
3.4 All staff is trained on the risks The facility shall define such risks which shall include
within the hospital both patient and employee related.
environment.
3.5 Staff members can demonstrate Self explanatory
and take actions to report,
eliminate/ minimize risks.
3.6 Reporting processes for The facility has a defined procedure for reporting of
common problems, failures and these events.
user errors exist
HRM.4 An appraisal system for evaluating the performance of an employee exists as an

integral part of the human resource management process.

4.1 A well-documented Self explanatory
performance appraisal system
exists in the organization.
4.2 The employees are made Self explanatory
aware of the system of
appraisal at the time of
induction
4.3 Performance is evaluated Self explanatory
based on the performance
expectations described in job
description.
4.4 Performance appraisal is Self explanatory
carried out at pre defined
intervals and is documented.
HRM.5 The organization has a well-documented disciplinary and grievance handling

mechanism procedure.

5.1 Documented procedures with Self explanatory
regards to disciplinary action
and grievances handling exist in

the organization
5.2 The policy and procedure is This implies that both parties (employee and
known to all categories of employer) are given an opportunity to present their
employees of the organization. case and decision is taken accordingly
5.3 The disciplinary procedure is in Self explanatory
consonance with the prevailing
laws.
5.4 There is a provision for appeals The facilityc designate an appellate authority to
in all disciplinary cases. consider appeals in disciplinary cases.
5.5 Actions are taken to redress the Self explantory
grievance
HRM.6 The organization addresses the health needs of the employees.

6.1 A pre-employment medical Self explanatory. This shall however be in
examination is conducted on all consonance with the law of the land
the employees
6.2 Health problems of the Self explanatory. This shall be in consonance with
employees are taken care of in the law of the land and good clinical practices.
accordance with the
organizations policy.
6.3 Regular health checks of staff Self explanatory. The results should be documented
dealing with direct patient care in the personal file.
are done at-least once a year
and the findings/ results are
documented.
6.4 Occupational health hazards Self explanatory
are adequately addressed.
HRM.7 There is a documented personal record for each staff member.

7.1 Personal files are maintained in Self explanatory
respect of all employees.
7.2 The personal files contain Self explanatory
personal information regarding
the employees qualification,
disciplinary background and
health status.

7.3 All records of in-service training Self explanatory
and education are contained in
the personal files.
7.4 Personal files contain results of Evaluations would include performance appraisals,
all evaluations. training assessment and outcome of health checks.
HRM.8 There is a process for collecting, verifying and evaluating the credentials
(education, registration, training and experience) of medical and Dental professionals
permitted to provide patient care without supervision.

8.1 Medical/ Dental professionals The facility identifies the individuals who have the
permitted by law, regulation and required qualification (s), training and experience to
the hospital to provide patient provide patient care in consonance with the law.
care without supervision is
identified.
8.2 The education, registration, Self explanatory. Updating is done after acquisition of
training and experience of the new skills and/or qualification
identified medical professionals
is documented and updated
periodically.
8.3 All such information pertaining The facility shall do the same by verifying the
to the medical/ Dental credentials from the organization which has awarded
professionals is appropriately the qualification/ training
verified when possible.
HRM.9 There is a process for authorizing all medical and Dental professionals to admit
and treat patients and provide other clinical services commensurate with their
qualifications.

9.1 Dental professionals admit and The facility shall identify as to what each medical
care for patients as per the laid professional is authorized to do.
down policies and authorization
procedures of the organization.
9.2 The services provided by the Self explanatory
Dental professionals are in
consonance with their
qualification, training and
registration.

9.3 The requisite services to be Self explanatory
provided by the Dental
professionals are known to
them as well as the various
departments/units of the
hospital.
HRM.10 There is a process for collecting, verifying and evaluating the credentials
(education, registration, training and experience) of nursing staff/Dental Hygienist, Dental
Technician and Dental Assistant

10.1 The education, registration, The facility identifies the individuals who have the
training and experience of required qualification (s), training and experience to
nursing staff/ dental Hygienist, provide nursing care to patients in consonance with
dental, technician and dental the law. Updating is done after acquisition of new
Assistant is documented and skills and/or qualification
updated periodically.
10.2 All such information pertaining The facility shall do the same by verifying the
to the nursing/ Dental Hygienist, credentials from the organization which has awarded
dental technician and Dental the qualification/training
Assistant staff is appropriately
verified when possible.
HRM.11 There is a process to identify job responsibilities and make clinical work
assignments to all nursing staff Dental Hygienist, Dental Technician/ Dental Mechanic
and Dental Assistant commensurate with their qualifications and any other regulatory
requirements.

11.1 The clinical work assigned to The facility shall identify as to what each nurse is
nursing staff, dental hygienist, authorized to do.
dental mechanics and assistant
is in consonance with their
qualification, training and
registration.
11.2 The services provided by Self explanatory
nursing staff, dental hygienist,
dental mechanics and
assistants are in accordance
with the prevailing laws and
regulations.

Chapter 10. Information Management System (IMS)
IMS.1.Documented Policies and procedures exist to meet the information needs of the
care providers, management of the organization as well as other agencies that require
date and information from the organization.

1.1 The information needs of the The facility has manual and/or electronic Hospital
organization are identified and Information System and/or Management Information
are appropriate to the scope of System which provides relevant information to all
the services being provided by concerned stakeholders.
the organization and the
complexity of the organization.
1.2 Policies and procedures to meet A policy document is available where the HIS/MIS is
the information needs are described
documented.
1.3 These policies and procedures Self explanatory
are in compliance with the
prevailing laws and regulations.
1.4 The organization contributes to Self explanatory
external databases in
accordance with the law and
regulations.
IMS.2. The organization has processes in place for effective management of data.

2.1 Formats for data collection are MIS/HIS data is collected in standardized format from
standardized. all areas/services in the facility.
2.2 Necessary resources are This could be men, material, space and budget.
available for analyzing data.
2.3 Documented procedures are Self explanatory
laid down for timely and
accurate dissemination of data.
2.4 Documented procedures exist Self explanatory
for storing and retrieving data.

IMS.3. The organization has a complete and accurate medical record for every in patient.

3.1 Every medical record has a This shall also apply to records on digital media
unique identifier.
3.2 Organization policy identifies Facility has a written policy stating who all can make
those authorized to make entries.
entries in medical record.
3.3 Every medical record entry is Self explanatory
dated and timed.
3.4 The author of the entry can be This could be by writing the full name or by
identified. mentioning the employee code number, with the help
of stamp, etc. In case of electronic based records,
authorized e-signature provision as per statutory
requirements must be kept.
3.5 The contents of medical record The facility identifies which documents form part of
are identified and documented. the medical records, documents and implements the
same
3.6 The record provides an up-to- The facility decides the format (POMR/SOMR/IMR)
date and chronological account for maintaining medical records.
of patient care.
IMS.4. The medical record reflects continuity of care.

4.1 The medical record contains Self explanatory
information regarding reasons
for admission, diagnosis and
plan of care.
4.2 Operative and other procedures Self explanatory
performed are incorporated in
the medical record.
4.3 When patient is transferred to Self explanatory. It is mandatory to mention the
another hospital, the medical clinical condition of the patient before transfer is
record contains the date of effected
transfer, the reason for the
transfer and the name of the
receiving hospital.
4.4 The medical record contains a Self explanatory. Discharge note is the same as
copy of the discharge note duly discharge summary
signed by appropriate and
qualified personnel.

4.5 In case of death, the medical Self explanatory. The facility provides the death
record contains a copy of the certificate as per the International Certification of
death certificate indicating the cause of death
cause, date and time of death.
4.6 Care providers have access to The facility provides access to medical records to
current and past medical designated health care providers (those who are
record. involved in the care of that patient).
IMS.5. Policies and procedures are in place for maintaining confidentiality, integrity and
security of information.

5.1 Documented policies and Self explanatory. This is applicable for both manual
procedures exist for maintaining and electronic
confidentiality, security and
integrity of information
5.2 Policies and procedures are in This is in the context of Indian Evidence Act, Indian
consonance with the applicable Penal Code of medical Ethics and code of dental
laws. ethics
5.3 The policies and procedures For physical records the facility shall ensure that there
incorporate safeguarding of is adequate pest and rodent control measures. For
data/record against loss, electronic data there should be protection against
destruction and tampering. virus/Trojans and also a proper backup procedure. To
prevent tampering, for physical records access shall
be limited only to the concerned health care provider.
In electronic format this could be done by adequate
passwords.
5.4 Privileged health information is Self explanatory
used for the purposes identified
or as required by law and not
disclosed without the patients
authorization.
5.5 A documented procedure exists Self explanatory. In this context the release of
on how to respond to information in accordance with the Code of Medical
patients/physicians and other Ethics 2002 and Code of Dental Ethics should be kept
public agencies requests for in mind.
access to information in the
medical record in accordance
with the local and national law.

IMS.6. Policies and procedures exist for retention time of records, data and information.

procedures are in place on
retaining the patients clinical
records, data and information.
6.2 The policies and procedures are Some of the related laws in this context are Code of
in consonance with the local Medical Ethics 2002, Code of Dental Ethics,
and national laws and Consumer protection act 1987 and relevant state
regulations. legislation, if any.
6.3 The destruction of medical Destruction can be done after the retention period is
records, data and information is over and after taking approval of the competent
in accordance with the laid authority.
down policy.
IMS.7. The organization regularly carries out review of medical records and Dental
records

7.1 The medical records are Self explanatory
reviewed periodically.
7.2 The review uses a Self explanatory. The review could be based on
representative sample based on conditions of clinical and/or community importance
statistical principles.
7.3 The review is conducted by Self explanatory
identified care providers.
7.4 The review focuses on the Self explanatory
timeliness, legibility and
completeness of the medical
records.
7.5 The review process includes Self explanatory
records of both active and
discharged patients.
7.6 The review points out and Self explanatory
documents any deficiencies in
records.
7.7 Appropriate corrective and Self explanatory
preventive measures
undertaken are documented.

GLOSSARY
The commonly used terminologies in the NABH standards are briefly described and explained
herein to remove any ambiguity regarding their comprehension. The definitions narrated have
been taken from various authentic sources as stated where ever possible. Notwithstanding the
accuracy of the explanations given, in the event of any discrepancy with a legal requirement
enshrined in the law of the land, the provisions of the latter shall apply.
Accreditation 1. A process of external review of the quality of the health care being
provided by a health care organization. This is generally carried out by
a non-governmental organization
2. It also represents the outcome of the review and the decision that an
eligible organization meets an applicable set of standards.
Accreditation The evaluation process for assessing the compliance of an organization

survey with the applicable standards for determining its accreditation status.
NABH survey includes the following:

a) Documentation review.
b) Facility tour
c) Interview of staff, patients and visitors
d) On-site observations by surveyors
e) Education about standards compliance
Advance life Emergency medical care for sustaining life, including defibrillation, airway
support management, and drugs and medications.
The main algorithm of ALS, which is invoked when actual cardiac arrest has
been established, relies on the monitoring of the electrical activity of the
heart on a cardiac monitor. Depending on the type of cardiac arrhythmia,
defibrillation is applied, and medication is administered. Oxygen is
administered and endotracheal intubation may be attempted to secure the
airway. At regular intervals, the effect of the treatment on the heart rhythm,
as well as the presence of cardiac output, is assessed.
Medication that may be administered may include adrenaline (epinephrine),

amiodarone, atropine, bicarbonate, calcium, potassium and magnesium.
Saline or colloids may be administered to increase the circulating volume.

While CPR is given (either manually, or through automated equipment such
as AutoPulse), members of the team consider eight forms of potentially
reversible causes for cardiac arrest, commonly abbreviated as "4H4T":
Hypoxia (low oxygen levels in the blood)
Hypovolemia (low amount of circulating blood, either absolutely due to
blood loss or relatively due to vasodilatation)
Hyperkalemia or hypokalemia (disturbances in the level of potassium in
the blood) and related disturbances of calcium or magnesium levels
and hypoglycaemia (low glucose levels).
Hypothermia (under-cooling)
Tension pneumo-thorax (tear in the lung leading to collapsed lung and
twisting of the large blood vessels)
Tamponade (fluid or blood in the pericardium, compressing the heart)
Toxic and/or therapeutic (chemicals, whether medication or poisoning)
Thrombo-embolism and related mechanical obstruction (blockage of
the blood vessels to the lungs or the heart by a blood clot or other
material)
Amalgam This is a mixture of silver alloy and mercury to prepare a restorative

material used in the cavities of teeth. The union of mercury with an alloy of
other metals is accomplished by the process of amalgamation. Silver alloy
is a mixture of silver And tin with small amounts of copper and zinc.
(CLINICAL PEDODONTICS FINN)
Ambulance A patient carrying vehicle having facilities to provide unless otherwise

indicated at least basic life support during the process of transportation of
patient. There are various types of ambulances that provide special
services viz. coronary care ambulance, trauma ambulance, air ambulance,
etc.
Anaesthesia It consists of general anaesthesia and spinal or major regional anaesthesia

and does not include local anaesthesia. General anaesthesia is a drug-
induced loss of consciousness during which patient cannot be aroused
even by painful stimulation. The ability to independently maintain ventilatory
function is often impaired.
Assessment All activities including history taking, physical examination, laboratory

investigations that contribute towards determining the prevailing clinical
status of the patient.
Autopsy 1 An examination of a cadaver in order to determine the cause of death or
to study pathologic changes.
2. A surgical procedure performed after death to examine body tissues and
determine the cause of death

Barrier nursing Type of nursing for Immuno-compromised patients with a view to prevent
any secondary infections e.g. use of gloves, masks and relatively
disinfected environment.
Basic life support Emergency procedures performed to sustain life that include
cardiopulmonary resuscitation, control of bleeding, treatment of shock,
stabilization of injuries and wounds and first, aid.Basic life support consists
of a number of life-saving techniques which are focused on the "ABC"s of
pre-hospital emergency care:
Airway: the protection and maintenance of patient airway including the
use of airway adjuncts such as an oral or nasal airway
Breathing: the actual flow of air through respiration, natural or artificial
respiration, often assisted by emergency oxygen
Circulation: the movement of blood through the beating of the heart or
the emergency measure of CPR
BLS may also include considerations of patient transport such as the

protection of the cervical spine and avoiding additional injuries through
splinting and immobilization.
Bylaws A rule governing the internal management of an organization. It can

supplement or complement the government law but cannot countermand it.
e.g. municipal bylaws for construction of hospitals/nursing homes, for
disposal of hazardous and/or infectious waste
Cast In Dentistry should always imply that it is an accurate reproduction of the
tissues being studied or on which restoration may be fabricated.
(McCrackens removable partial Prosthodontics)
Clincal audit Analysis of clinical aspects of patient care for improving the quality of health
care services e.g. tissue audit, X-Ray audit, lab investigation audit, etc.
Clinical practice Guidelines that assist practitioners to provide appropriate clinical care for
guidelines specific clinical conditions, for example recommendation on management of
cerebral malaria. The guidelines include relevant history taking, physical
signs to look for, lab investigations to be carried out and treatment to be
prescribed.
Competence Demonstrated ability to apply knowledge and skills.

Knowledge is the understanding of facts and procedures. Skill is the ability
to perform specific action. For example, a competent gynaecologist knows
about the patho-physiology of the female genitalia and can conduct both
normal as well as abnormal deliveries.
Confidentiality Restricted access to information to individuals who have a need, a reason

and permission for such access. It also includes an individuals right to
personal privacy as well as privacy of information related to his/her health
care records.

Consent 1. Willingness of a party to undergo examination/procedure/ treatment by
a health care provider. It may be implied (e.g. patient registering in
OPD), expressed which may be written or verbal. Informed consent is
a type of consent in which the health care provider has a duty to inform
his/her patient about the procedure, its potential risk and benefits,
alternative procedure with their risk and benefits so as to enable the
patient to take an informed decision of his/her health care.
2. In law, it means active acquiescence or silent compliance by a person
legally capable of consenting. In India legal age of consent is 18 years.
It may be evidenced by words or acts or by silence when silence
implies concurrence. Actual or implied consent is necessarily an
element in every contract and every agreement.
Credentialing The process of obtaining, verifying and assessing the qualification of a

health care provider.
Data Raw facts, clinical observations, or measurements collected during an

assessment activity.
Dental Laboratory: The written instructions sent to commercial laboratories. It serves two
Laboratory primary functions (1) it identifies the laboratory procedures delegated to the
Procedure technician, the materials to be used and any special instructions requested
Authorizations by the dentist that differ from customary laboratory procedures and, (2) it is
a legal document that may be used in arbitration between the dentist &
laboratory technician or in cases of alleged illegal practice of dentistry.
The laboratory procedure authorization should contain the following

information:
1) name& address of the dental laboratory to which the work is sent
2) name& address of the dentist delegating the laboratory work
3) the date of the work authorization
4) identification of the patient
5) specific instructions for the work to be performed by the laboratory
technicians
6) desired date the work is to be completed
7) signature of the dentist; and
8) the registered licence number of the dentist
Laboratory Procedure Authorizations are prepared in duplicate .The original

copy is sent to the laboratory. The copy is retained in the dentists file. It
should be retained by the dentist & laboratory for atleast two years. (John
E.Ward, Essentials of complete denture prosthodontics Sheldon Winkler
Pg 292-293)
Discharge A part of a patient record that summarizes the reasons for admission,
summary significant clinical findings, procedures performed, treatment rendered,
patients condition on discharge and any specific instructions given to the
patient or family (for example follow-up medications).

Disciplinary Sequence of activities to be carried out when staff does not conform to the
proceedings laid down norms, rules and regulations of the health care organization.
Employees All members of the health care organization who are employed full time and
are paid suitable remuneration for their services as per the laid down policy.
End of life Period of time marked by disability or disease that is progressively worse
until death.
Ethics Medical ethics is the discipline of evaluating the merits, risks, and social
concerns of activities in the field of medicine.(en.wikipedia.org/wiki/Medical
ethics)
Evidence 1.It is the conscientious, explicit and judicious use of current best evidence
based medicine in making decisions about the care of individual patient
2. It also implies making medical decisions and applying the same to
patients based on the best external evidence combined with the physicians
clinical expertise and the patients desires.
Family The person(s) with a significant role in the patients life. It mainly includes
spouse, children, and parents. It may also include a person(s) not legally
related to the patient but can make health care decisions for a patient if the
patient loses decision making ability.
Formulary An approved list of prescription drugs that a health care facility may provide
to their clientele. Some plans restrict prescriptions to those contained on the
formulary and others also provide non-formulary prescriptions. Drugs
contained on the formulary are generally those that are determined to be
cost effective and medically effective.
The list is compiled by professionals and physicians in the field and is
updated preferably each year Changes may be made depending on
availability or market.
Grievance Sequence of activities carried out to address the grievances of patients,

handling visitors, relatives and staff.
procedures
Hazardous Substances dangerous to human and other living organisms. They include
materials radioactive or chemical materials.
Hazardous waste Waste materials dangerous to living organisms. Such materials require
special precautions for disposal .They include biologic waste that can
transmit disease (for example, blood, tissues) radioactive materials, and
toxic chemicals. Other examples are infectious waste such as used
needles, used bandages and fluid soaked items.
Health care Generic term is used to describe the various types of organization that
organization provide health care services. This includes ambulatory care centres,
hospitals, laboratories, etc.

High dependency A high dependency unit (HDU) is an area for patients who require more
unit intensive observation, treatment and nursing care than are usually provided
for in a general ward. It is a standard of care between the general ward and
full intensive care.
Impression Defined as an imprint or negative likeness of the teeth, of the edentulous

areas where the teeth have been removed, or of both, made in a plastic
material that becomes relatively hard or set while in contact with these
tissues. (George E. Smutko Essentials of complete denture prosthodontics
Sheldon Winkler Pg 88).
In service Organized education/ training usually provided in the workplace for

education/ training enhancing the skills of staff members or for teaching them new skills
relevant to their jobs/ tasks.
Indicator A statistical measure of the performance of functions, systems or processes

overtime. For example, hospital acquired infection rate, mortality rate,
caesarean section rate, absence rate, etc.
Information Processed data which lends meaning to the raw data.
Intent A brief explanation of the rational, meaning and significance of the

standards laid down in a particular chapter.
Inventory control The method of supervising the intake, use and disposal of various goods in
hands. It relates to supervision of the supply, storage and accessibility of
items in order to ensure adequate supply without stock outs/excessive
storage. It is also the process of balancing ordering costs against carrying
costs of the inventory so as to minimise total costs.
Isolation Separation of an ill person who has a communicable disease (e.g.,

Measles, chicken pox, mumps, SARS) from those who are healthy.
Isolation prevents transmission of infection to others and also allows the
focused delivery of specialized health care to ill patients. The period of
isolation varies from disease to disease. Isolation facilities can also be
extended to patients for fulfilling their individual, unique needs.
Job description 1. It entails an explanation pertaining to duties, responsibilities and

conditions required to perform a job.
2. A summary of the most important features of a job, including the
general nature of the work performed (duties and responsibilities) and
level (i.e., skill, effort, responsibility and working conditions) of the work
performed. It typically includes job specifications that include employee
characteristics required for competent performance of the job. A job
description should describe and focus on the job itself and not on any
specific individual who might fill the job.

Job specification 1. The qualifications/physical requirements, experience and skills
required to perform a particular job/task.
2. A statement of the minimum acceptable qualifications that an

incumbent must possess to perform a given job successfully.
Laws Legal document setting forth the rules of governing a particular kind of
activity e.g. organ transplantation act which governs the rules for
undertaking organ transplantation.
Medical audit A peer review carried out by analysis of medical records with a view to
improve the quality of the patient care
Medical equipment Any fixed or portable non drug item or apparatus used for diagnosis,
treatment, monitoring and direct care of patient.
Mission A written expression that sets forth the purpose of the organization. It
usually precedes the formation of goals and objectives.
Model Term used to only designate a reproduction for display or demonstration

purpose. A model of a dental arch or any portion thereof may be made of
durable and attractive material. it need not be an accurate reproduction but
should be a reasonable facsimile of the original.(McCrackens removable
partial prosthodontics)
Monitoring The performance and analysis of routine measurements aimed at

identifying and detecting changes in the health status or the environment,
e.g. monitoring of growth and nutritional status, air quality in operation
theatre. It requires careful planning and use of standardised procedures
and methods of data collection.
Multi-disciplinary A generic term which includes representatives from various disciplines,

professions or service areas.
Nosocomial/ An infection occurring in a patient in a hospital or other healthcare facility in

hospital acquired/ whom it was not present or incubating at the time of admission; or the
hospital associated residual of an infection acquired during a previous admission. Includes
infection (s) infections acquired in the hospital but appearing after discharge, and also
such infections among the staff of the facility (Synonym: hospital-acquired-
infection).(www.hardydiagnostics.com/ Glossary N.html)

Notifiable disease Certain specified diseases which are required by law to be notified to the
public health authorities. Under the international health regulation the
following diseases are notifiable to WHO:-
(a) Cholera
(b) Plague
(c) Yellow fever
In India the following diseases are also notifiable and may vary from state to
state:
(a) Polio
(b) Influenza
(c) Malaria
(d) Rabies
(e) HIV/AIDS
(f) Louse-borne typhus
(g) Tuberculosis
(h) Leprosy
(i) Leptospirosis
(j) Viral hepatitis
(k) Dengue fever
The various diseases notifiable under the factories act are lead poisoning,
bysinnosis, anthrax, asbestosis and silicosis.
Objective element It is that component of standard which can be measured objectively on a

rating scale. The acceptable compliance with the measureable elements
will determine the overall compliance with the standard.
Occlusion It refers to the contact relationship of the teeth resulting from neuro-
muscular control of the masticatory system (musculature,
temporomandibular joints, mandible and the periodontium). Clinical
Periodontology Carranza Newman.
Occupational The hazards to which an individual is exposed during the course of

health hazard performance of his job. These include physical, chemical, biological,
mechanical and psychosocial hazards.
Organogram A graphic representation of reporting relationship in an organization.
Outsourcing Hiring of services and facilities from other organization based upon ones
own requirement in areas where such facilities are either not available or
else are not cost-effective. e.g. outsourcing of house keeping, security,
laboratory/certain special diagnostic facilities with other institutions after
drawing a memorandum of understanding that clearly lays down the
obligations of both the organizations, the one which is outsourcing and the
one which is providing the outsourced facility. It also addresses the quality
related aspects.

Patient care setting The location where a patient is provided health care as per his needs e.g.
ICU, speciality ward, private ward and general ward.
Patient record/ A document which contains the chronological sequence of events that a
medical patient undergoes during his stay in the health care organization. It
record/clinical includes demographic data of the patient, assessment findings, diagnosis,
record consultations, procedures undergone, progress notes and discharge
summary. (Death certificate where required).
Performance It is the process of evaluating the performance of employees during a

appraisal defined period of time with the aim of ascertaining their suitability for the
job, potential for growth as well as determining training needs.
Plan of care A plan that identifies patient care needs, lists the strategy to meet those
needs, documents treatment goals and objectives, outlines the criteria for
ending interventions, and documents the individuals progress in meeting
specified goals and objectives. The format of the plan may be guided by
specific policies and procedures, protocols, practice guidelines or a
combination of these. It includes preventive, promotive, curative and
rehabilitative aspects of care.
Policies They are the guidelines for decision making, e.g. admission, discharge
policies, antibiotic policy, etc.
Privileging It is the process for authorising all medical professionals to admit and treat
patients and provide other clinical services commensurate with their
qualifications and skills.
Procedure 1. A specified way to carry out an activity or a process.

2. A series of activities for carrying out work which when observed by all
help to ensure the maximum use of resources and efforts to achieve the
desired output.
Process A set of interrelated or interacting activities which transforms inputs into

outputs
Program A sequence of activities designed to implement policies and accomplish

objectives
Protocol A plan or a set of steps to be followed in a study, an investigation or an

intervention.
Quality 1. Degree to which a set of inherent characteristics fulfil requirements;

Characteristics imply a distinguishing feature; Requirements are a
need or expectation that is stated, generally implied or obligatory.
2. Degree of adherence to pre-established criteria or standards.
Quality assurance Part of quality management focussed on providing confidence that quality
requirements will be fulfilled.

Re-assessment It implies continuous and on-going assessment of the patient which are
recorded in the medical records as progress notes.
Resources It Implies all inputs in terms of men, material, money, machines, minutes
(time), methods, meters (space), skills, knowledge and information that are
needed for efficient and effective functioning of an organization.
Restraints Devices used to ensure safety by restricting and controlling a persons

movement. Many facilities are restraint free or use alternative methods to
help modify behaviour.
Risk management Clinical and administrative activities to identify, evaluate and reduce the risk
of injury.
Safe transfer In these standards refers to Transfer of the patients who are in In-patient
department and those who have any kind of complications on the Dental
chair.
Safety The degree to which the risk of an intervention/ procedure, in the care
environment are reduced for a patient, visitors and health care providers.
Scope of services Range of clinical and supportive activities that are provided by a health care
organization.
Security Protection from loss, destruction, tampering, and unauthorized access or

use.
Sedation The administration to an individual, in any setting for any purpose, by any
route, moderate or deep sedation. There are three levels of sedation:
Minimal sedation (anxiolysis) A drug induced state during which patients

respond normally to verbal commands. Although cognitive function and
coordination may be impaired, vertilatory and cardiovascular functions are
not affected.
Moderate sedation / analgesia (Conscious sedation) A drug induced

depression of consciousness during which patients respond purposefully to
verbal commands either alone or accompanied by light tactile stimulation.
No interventions are needed to maintain a patent airway.
Deep sedation/Analgesia A drug induced depression of consciousness

during which patients cannot be easily aroused but respond purposefully
after repeated or painful stimulation. Patients may need help in maintaining
a patent airway.

Sentinel events A relatively infrequent, unexpected incident, related to system or process
deficiencies, which leads to death or major and enduring loss of
function* for a recipient of health care services
* Major and enduring loss of function refers to sensory, motor,

physiological, or psychological impairment not present at the time services
were sought or begun. The impairment lasts for a minimum period of two
weeks and is not related to an underlying condition
Social A balanced approach for organization to address economic, social and

rresponsibility environmental issues in a way that aims to benefit people, communities and
society, e.g. adoption of villages for providing health care, holding of
medical camps and proper disposal of hospital wastes.
Staff All personnel working in the organization either as full paid employees or as
consultants on honorarium basis.
Standard 1. A method of infection control in which all human blood and other bodily
precautions fluids are considered infectious for HIV, HBV and other blood-borne
pathogens, regardless of patient history. It encompasses a variety of
practices to prevent occupational exposure, such as the use of
personal protective equipment (PPE), disposal of sharps and safe
housekeeping
2. A set of guidelines protecting first aiders or healthcare professionals
from pathogens. The main message is "Don't touch or use anything
that has the victim's body fluid on it without a barrier." It also assumes
that all body fluid of a patient is infectious, and must be treated
accordingly
Standard Precautions apply to Blood, all body fluids, secretions, and

excretions (except sweat) regardless of whether or not they contain visible
blood, non-intact skin and mucous membranes.
Standards A statement of expectation that defines the structures and process that
must be substantially in place in an organization to enhance the qualify of
care.
Sterilization It is the process of killing or removing microorganisms including their spores

by thermal, chemical or irradiation means.
Surveillance The continuous scrutiny of factors that determines the occurrence and
distribution of diseases and other conditions of ill health. It implies watching
over with great attention, authority and often with suspicion. It requires
professional analysis and sophisticated interpretation of data leading to
recommendations for control activities.
Unstable patient A patient whose vital parameters need external assistance for their
maintenance.

Validation 1. Confirmation through the provision of objective evidence that the
requirements for a specific intended use or application have been
fulfilled
Objective Evidence Data supporting the existence or variety of
something
2. The checking of data for correction or for compliance with applicable

standards, rules or conventions. These are the tests to determine
whether an implemented system fulfils its requirements. It also refers to
what extent does a test accurately measures what it purports to
measure.
Vulnerable patient Those patients who are prone to injury and disease by virtue of their age,
sex, physical, mental and immunological status, e.g. infants, elderly,
physically and mentally challenged those on immunosuppressive and/or
chemotherapeutic agents.

REFERENCE GUIDE ON SENTINEL EVENTS
Definition:
An unexpected incident, related to system or process deficiencies, which leads to death or

major and enduring loss of function* for a recipient of health care services.
Major and enduring loss of function refers to sensory, motor, physiological, or psychological
impairment not present at the time services were sought or begun. The impairment lasts for a
minimum period of two weeks and is not related to an underlying condition.
Event type description
1. Surgical events
o Surgery performed on the wrong body part
o Surgery performed on the wrong patient
o Wrong surgical procedure performed on the wrong patient
o Retained instruments in patient discovered after surgery/procedure
o Patient death during or immediately post surgical procedure
o Anesthesia related event
2. Device or product events Patient death or serious disability associated with:

o the use of contaminated drugs, devices, products supplied by the organization
o the use or function of a device in a manner other than the devices intended use
o the failure or breakdown of a device or medical equipment
o intravascular air embolism
3. Patient protection events
o Discharge of an infant to the wrong person

o Patient death or serious disability associated with elopement from the health care facility
o Patient suicide, attempted suicide, or deliberate self-harm resulting in serious disability
o Intentional injury to a patient by a staff member, another patient, visitor, or other
o Any incident in which a line designated for oxygen or other came to be delivered to a
patient and contains the wrong gas or is contaminated by toxic substances
o Nosocomial infection or disease causing patient death or serious disability
4. Environmental events
Patient death or serious disability while being cared for in a health care facility
associated with:
o a burn incurred from any source
o a slip, trip, or fall
o an electric shock
o the use of restraints or bedrails

5. Care management events
o Patient death or serious disability associated with a hemolytic reaction due to the
administration of ABO-incompatible blood or blood products
o Maternal death or serious disability associated with labor or delivery in a low-risk
pregnancy
o Medication error leading to the death or serious disability of patient due to incorrect
administration of drugs, for example:
o omission error
o dosage error
o dose preparation error
o wrong time error
o wrong rate of administration error
o wrong administrative technique error
o wrong patient error
Patient death or serious disability associated with an avoidable delay in treatment or
response to abnormal test results
6. Criminal events
o Any instance of care ordered by or provided by an individual impersonating a clinical

member of staff
o Abduction of a patient
o Sexual assault on a patient within or on the grounds of the health care facility
o Death or significant injury of a patient or staff member resulting from a physical assault
or other crime that occurs within or on the grounds of the health care facility.

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Accreditation Standards for Dental

Institutions/ Hospitals/ Centres

NATIONAL ACCREDITATION BOARD FOR

Sr. No. Particulars Page No.

Patient Centered Standards

01. Access, Assessment and Continuity of Care (AAC) 03

02. Care of Patients (COP) 11

03. Management of Medication (MOM) 18

04. Patient Rights and Education (PRE) 22

05. Hospital Infection Control (HIC) 25

Organization Centered Standards

06. Continuous Quality Improvement (CQI) 30

07. Responsibilities of Management (ROM) 34

08. Facility Management and Safety (FMS) 37

09. Human Resource Management (HRM) 42

10. Information Management System (IMS) 47

Reference Guide on Sentinel Events 63

National Accreditation Board for Hospitals and Healthcare Providers 1

Dental institution/ hospital/ centre is referred as Dental Facility in this standard.

National Accreditation Board for Hospitals and Healthcare Providers 2

Objective Element Guidance

AAC.2.The organization has a well documented registration, admission and transfer or

Objective Element Guidance

National Accreditation Board for Hospitals and Healthcare Providers 3

Objective Element Guidance

National Accreditation Board for Hospitals and Healthcare Providers 4

Objective Element Guidance

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Objective Element Guidance

National Accreditation Board for Hospitals and Healthcare Providers 6

Objective Element Guidance

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HOD shall periodically survey the imaging results.

National Accreditation Board for Hospitals and Healthcare Providers 8

Objective Element Guidance

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Objective Element Guidance

Objective Element Guidance

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Objective Element Guidance

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Objective Element Guidance

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Objective Element Guidance

Objective Element Guidance

COP.8. Policies and procedures guide the administration of anesthesia

Objective Element Guidance

National Accreditation Board for Hospitals and Healthcare Providers 14

Objective Element Guidance

National Accreditation Board for Hospitals and Healthcare Providers 15

COP.11 Policies and procedures guide appropriate pain management

Objective Element Guidance

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Objective Element Guidance

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Objective Element Guidance