AAC 10 Standards of Nabh

Proposed Draft Standards of Emergency

Medical Services Certification Program

in Hospital
First Edition - August 2015

NATIONAL ACCREDITATION BOARD FOR

HOSPITALS AND HEALTHCARE PROVIDERS
@ National Accreditation Board for Hospitals and Healthcare Providers 1

© All Rights Reserved
No part of this book may be reproduced or transmitted in any form without permission in
writing from the author.
First Edition August 2015

Table of Contents
Sr. No. Particulars Page No.
Patient Centered Standards
01. Access, Assessment and Information (AAI) 6
02. Patient Care and Rights (PCR) 14
03. Management of Medication (MOM) 20
04. Hospital Infection Control (HIC) 25
Organization Centered Standards
05. Continuous Quality improvement (CQI) 29
06. Responsibilities of Management (ROM) 33
07. Facility Management and Safety (FMS) 37
08. Human Resource Management (HRM) 42

Summary of Chapters, Standards and
Objective Elements
No. of No. of Objective
Chapters
Standards Elements
56
Access, Assessment and Information (AAI) 11
49
Patient Care and Rights (PCR) 7
48
Management of Medication (MOM) 7
9
Hospital Infection Control (HIC) 3
19
Continuous Quality Improvement (CQI) 4
13
Responsibilities of Management (ROM) 3
29
Facility Management and Safety (FMS) 7
21
Human Resource Management (HRM) 5
47 244
Total

Chapter 1
Access, Assessment and Information (AAI)
Intent of the chapter:
The organization defines its scope of service provision and provides information to
patients about the services available. This will facilitate appropriately matching patients
with the resources. Once the patient is in the organization, the patient is
registered and assessed, whether in OPD, IPD or Emergency. The laboratory and
imaging services are provided by competent staff in a safe environment for both
patients and staff.
A standardized approach is used for referring or transferring patients in case the

services they need do not match with the services available at the organization. Further,
the chapter lays down key safety and process elements that the organization should
meet, in the continuum of the patient care within the hospital and till discharge.
The medical record is an essential patient care document which contains all the details
of assessment and care that has been provided in a chronological manner.

Summary of Standards
The organization establishes the emergency department with an easy

AAI.1
access and defines and displays the scope of services that it can provide.
Emergency services are guided by documented policies, procedures,

AAI.2
applicable laws and regulations.
The organization has a documented registration, admission and transfer

AAI.3
process.
Documented policies and procedures guide the availability of Diagnostic

AAI.4
Services.
There is an appropriate mechanism for transfer (in and out) or referral of

AAI.5
patients.
Emergency patients cared for by the organization undergo an established

AAI.6
initial assessment.
AAI.7 Patients cared for by the organization undergo a regular reassessment.
AAI.8 Patient care is continuous and multidisciplinary in nature.
AAI.9 The organization has a documented discharge process.
The organization has a complete and accurate medical record for every
AAI.10
patient
AAI.11 The medical record reflects continuity of care.

Standards and Objective Elements
Standard
AAI.1 The organization establishes the emergency department with an easy

access and defines and displays the scope of services that it can
provide.
Objective Elements
a. The Emergency Department should have an easy and direct access from the
approach road / main gate.
b. An alert mechanism is activated upon arrival of the patient. Staff should be

trained to respond promptly to the alerts.
c. The services which are being provided are clearly defined.

.
d. The defined services are prominently displayed.
e. Staff is oriented to these defined services
Standard
AAI.2 Emergency services are guided by documented policies, procedures,

applicable laws and regulations.
Objective Elements
a. Policies and procedures for emergency care are documented and are in
consonance with statutory requirements.
b. This also addresses handling of medico-legal cases
c. The patients receive care in consonance with the policies.
d.
patients / death in the Emergency Department.
e. Documented policies and procedures guide the triage of patients for initiation of
appropriate care.
f. Staff is familiar with the policies and trained on the procedures for care of
emergency patients.
g. There are documented standard clinical guidelines for common and critical
conditions which are framed using evidence based medicine.

h. Admission or discharge to home or transfer to another organization is documented.
i. In case of discharge to home or transfer to another organization a discharge note
shall be given to the patient.
Standard
The organization has a documented registration, admission and

AAI.3
transfer process.
Objective Elements
a. Documented policies and procedures are used for registering, admitting and billing
patients in the emergency department.
b. A unique patient identification number is generated at the end of registration.
c. After stabilization of the patient, at least two identifiers are used to establish the
identity of patients admitted to Emergency Department.
d. Criteria are applied for prioritization of patient transfer to appropriate department

based on the clinical requirement.
e. Documented process also addresses managing patients during non-availability of

beds.
f. Staff is aware of these processes.
Standard
Documented policies and procedures guide the availability of

AAI.4 diagnostic services.
Objective Elements
a. Documented policies and procedures are in place for ordering and reporting of
laboratory and radiological investigations which have been requisitioned from the
Emergency Department.
b. Documented policies and procedures guide the movement of patients from the
Emergency Department for investigations (within or outside the hospital) in a safe
manner.
c. Staff is aware and trained on these processes.

Standard
There is an appropriate mechanism for transfer (in and out) or referral

AAI.5 of patients.
Objective Elements
a. Documented policies and procedures guide the transfer in of patients into the
organization.
b. Documented policies and procedures guide the transfer-out/referral of stable and

unstable patients to another facility in an appropriate manner.
c. The documented procedures identify staff who are responsible for the patient
during transfer/referral.
d. The organization gives a summ

was given.
Standard
Emergency patients cared for by the organization undergo an

AAI.6 established initial assessment.
Objective Elements
a. The organization defines and documents the content of the initial assessment for
emergency patients.
b. The organization determines who can perform the initial assessment.
c. The organization defines the time frame within which the initial assessment is
completed based on the
d. The initial assessment fo

condition and as defined in the triage policy.
e. Initial assessment also includes nursing assessment which is done at the time of
admission and this is documented.
f. The initial assessment results in a documented care plan which is signed by the
attending doctor.

Standard
Patients cared for by the organization undergo a regular

AAI.7
reassessment.
Objective Elements
a. Patients are reassessed at appropriate intervals.
b. Patients are informed of their next follow-up where appropriate.
c. Staff involved in direct clinical care, documents reassessments.
d. Patients are reassessed to determine their response to treatment and to plan

further treatment or discharge from the Emergency Department.
Standard
AAI. 8 Patient care is continuous and multidisciplinary in nature.
Objective Elements
a. During all phases of care, there is a qualified medical professional responsible for
b. Information is exchanged and documented during each staffing shift, between

shifts and during transfers between units/departments.
c. Transfers between departments/units are done in a safe manner.
d. Documented procedures guide the referral of patients to other departments/

specialties.

Standard
AAI.9 The organization has a documented discharge process.
Objective Elements
a.
b. Documented procedures exist for coordination of various departments and agencies

involved in the discharge process (including medico-legal and absconded cases).
c. Documented policies and procedures are in place for patients leaving against
medical advice and patients being discharged on request.
d. A discharge summary is given to all the patients leaving the hospital from the
Emergency department (including patients leaving against medical advice and on
request).
e. The organization defines the content of the discharge summary.
f. In case of death, the summary of the case also includes the cause of death.
Standard
The organization has a complete and accurate medical record for

AAI.10
every patient.
Objective Elements
a. Every medical record has a unique identifier.
b. Organization policy identifies those authorized to make entries in medical record.
c. Entry in the medical record is named, signed, dated and timed.
d. The author of the entry can be identified.
e. The record provides a complete and chronological account of patient care.

Standard
AAI.11 The medical record reflects continuity of care.
Objective Elements
a. When a patient is transferred to another hospital, the medical record contains the
date of transfer, the reason for the transfer and the name of the receiving hospital
where applicable.
b. The medical record contains a copy of the discharge summary duly signed by
appropriate and qualified personnel.
c. In case of death, the medical record contains a copy of the death certificate.
d. Care providers have access to current and past medical record.

Chapter 2
Patient Care and Rights
Intent of the chapter:
Patients in the Emergency Department are provided urgent care in consonance with
their clinical requirements and in accordance to the statutes of the land. Policies and
procedures guide the activities in the emergency department including the ambulance
services. Standard protocols are uniformly followed for cardio-pulmonary resuscitation
and provision of resources and trained manpower is available for satisfactory
resuscitation efforts.
There are also policies and procedures to guide the nursing practices for the patients in
the emergency departments. Patients may need to undergo surgical or other clinical
procedures in the emergency department and there are safeguards in place to prevent
any adverse events. Situations needing special attention such as sedation, restraints,
end of life care and pain management and recognized and attended to according to laid
down policy and procedure.
The rights and responsibilities of the patient and family are outlined. The staff is aware
of these and is trained to protect patient rights. Patients are informed of their rights and
educated about their responsibilities at the time of admission. The costs are explained
in a clear manner to patient and/or family. A documented process for obtaining patient
and/or families consent exists for informed decision making about their care.
Patient and families have a right to information and education about their healthcare
needs in a language and manner that is understood by them.

PCR.1 The ambulance services are commensurate with the scope of the services
provided by the organization.
PCR.2 Documented policies and procedures guide the care of patients requiring
cardio-pulmonary resuscitation.
PCR.3 Documented policies and procedures guide nursing care.
PCR.4 Documented procedures guide the performance of various procedures.
PCR.5 Documented policies and procedures guide the care of patients under
Special Conditions such as Restraints (physical and/or chemical), Pain
Management and End of Life Care.
PCR.6 Patient rights are documented displayed and support individual beliefs,
values and involve the patient and family in decision making processes.
PCR.7 Patient and families have a right to information and education about their
healthcare needs.

Standard
The ambulance services are commensurate with the scope of the

PCR.1
services provided by the organization.
Objective Elements
a. There is adequate access and space for the ambulance(s).
b. The ambulance(s) adheres to statutory requirements.
c. The Ambulance(s) is appropriately equipped.
d. The Ambulance(s) is manned by trained personnel.
e. The Ambulance(s) is checked on a daily basis.
f. Equipment is checked on a daily basis using a checklist.
g. Emergency medications are checked daily and prior to dispatch using a checklist.
h. The ambulance(s) has a proper communication system.
Standard
Documented policies and procedures guide the care of patients

PCR.2
requiring cardio-pulmonary resuscitation.
Objective Elements
a. Documented policies and procedures guide the uniform use of resuscitation in

b. Staff providing direct patient care is trained and periodically updated in

cardiopulmonary resuscitation
c. The events during a cardio-pulmonary resuscitation are recorded.
d. A post-event analysis of all cardio-pulmonary resuscitations is done through a

multidisciplinary approach.
e. Corrective and preventive measures are taken based on the post-event analysis.

Standard
PCR.3 Documented policies and procedures guide nursing care.
Objective Elements
a. There are documented policies and procedures for all activities of the nursing
services.
b. These reflect current standards of nursing services and practice, relevant regulations
and purposes of the services.
c. Assignment of patient care is done as per current good practice guidelines.
d. The nursing care is aligned and integrated with overall patient care.
e. The care provided by nurses is documented in the patient record.
f. Nurses are provided with adequate equipment for providing safe and efficient
nursing services.
g. Nurses are empowered to take nursing-related decisions to ensure timely care of

patients
Standard
Documented procedures guide the performance of various

PCR.4
procedures.
Objective Elements
a. Documented procedures are used to guide the performance of various clinical

procedures.
b. Only qualified personnel order, plan, perform and assist in performing procedures.
c. Documented procedures exist to prevent adverse events like wrong site, wrong
patient and wrong procedure.
d. Informed consent is taken by the personnel performing the procedure, where

applicable.
e. Standard precautions and asepsis are adhered to during the conduct of procedures.

f. Patients are appropriately monitored during and after the procedure.
g. Proce
h. The organization defines the process, time frame for availability and rationality in
usage of blood and blood products in Emergency Department. It also addresses all
statutory requirements.
Standard
Documented policies and procedures guide the care of patients under

PCR.5 Special Conditions such as Restraints (physical and/or chemical),
Pain Management and End of Life Care.
Objective Elements
a. Documented policies and procedures guide the care of patients with special
requirements.
b. These policies and procedures are in consonance with the legal requirements.
c.
d. Patients on restraints are monitored appropriately.
e. Patients receiving sedation are monitored appropriately.
f. The organization respects and supports management of pain and patient and family
are educated about the same.
Standard
Patient and family rights support individual beliefs, values and

PCR.6
involve the patient and family in the decision making processes.
Objective Elements
a. Patient and family rights include respect for personal dignity, privacy and
confidentiality during examination, procedures and treatment.
b. Patient and family rights include protection from physical abuse or neglect.

c. Patient and family rights include refusal of treatment.
d. Patient and family rights include access to his / her clinical records.
e. Patient and family rights include right to be informed about triage.
f. Patient and family rights include right to be informed about the findings of the initial
assessment.
g. Patient and family rights include right to be informed about the care plan and
treatment.
h. Patient and family rights include right to know the attending doctor and nurse by
name.
i. Patient and family rights include right to know the drug and route of administration.
j. Patient and family rights include right to give feedback and get complaint redressal
k. Patient and family rights include right to be informed about the expected cost of
treatment.
Standard
PCR.7 consent exists for informed decision making about their care.
Objective Elements
a. Informed consent includes information regarding the procedure, risks, benefits,

alternatives and as to who will perform the requisite procedure and this is
explained to the patient/family in a language that they can understand.
b. The procedure describes who can give consent when patient is incapable of
independent decision making.
c. Informed consent is taken by the person performing the procedure.
d. Staff are aware of the informed consent procedure.

Chapter 3
Management of Medication (MOM)
Intent of the standards
The Emergency Department has a safe and organized medication process. The
process includes policies and procedures that guide the availability, safe storage,
prescription, dispensing and administration of medications.
The availability of emergency medication is stressed upon. The organization should

have a mechanism to ensure that the emergency medications are standardized, readily
available and replenished in a timely manner. There should be a monitoring mechanism
to ensure that the required medications are always stocked and well within expiry dates.
The process also includes monitoring of patients after administration and procedures for
reporting and analyzing adverse drug events, which include errors and events.

There is a formulary for the emergency department depending on its scope

MOM.1
of services.
MOM.2 Documented policies and procedures guide the storage of medication.
Documented policies and procedures guide the safe and rational

MOM.3
prescription of medications.
There are documented policies and procedures for medication

MOM.4
administration.
Near misses, medication errors and adverse drug events are reported and
MOM.5
analyzed.
Documented procedures guide the use of narcotic drugs and psychotropic

MOM.6
substances.
Documented policies and procedures guide the use of medical supplies

MOM.7
and consumables.

Standard
There is a formulary for the emergency department depending on its

MOM. 1 scope of services.
Objective Elements
a. A list of medication appropriate for the patients and Emergency

resources is developed.
b. The formulary is available for clinicians to refer and adhere to.
c. There is a defined process for acquisition of these medications.
d. There is a process to obtain medications not listed in the formulary.
e. There is a procedure to obtain medication when the pharmacy is closed.
Standard
Documented policies and procedures guide the storage of

MOM. 2 medication.
Objective Elements
a. Documented policies and procedures exist for storage of medication.
b. Medications are stored in a clean, safe and secure environment, and incorporate
.
c. Sound inventory control practices guide storage of the medications.
d. Look alike and sound alike medications are stored separately.
e. The list of emergency medications is defined and is stored in a uniform manner

across all the crash trolleys in the Emergency Room.
f. Emergency medications are available all the time.
g. Emergency medications are replenished in a timely manner when used.

Standard
MOM. 3 Documented policies and procedures guide the safe and rational
prescription of medications.
Objective Elements
a. Documented policies and procedures exist for prescription of medications.
b. Known drug allergies are ascertained before prescribing.
c. The organization determines who can write orders.
d. Orders are written in a uniform location in the medical records.
e. Medication orders are clear, legible, dated, timed, named and signed.
f. Medication orders contain the name of the medicine, route of administration, dose
to be administered and frequency/time of administration.
g. Documented policy and procedure on verbal orders is implemented and monitored.
h. The organization defines a list of high risk medication.
i. Audit of medication orders/prescription is carried out to check for safe and rational
prescription of medications and corrective and/or preventive action (s) is taken
based on the analysis where appropriate.
Standard
MOM. 4 There are documented policies and procedures for medication

administration.
Objective Elements
a. Medications are administered by those who are permitted by law to do so.
b. Prepared medication is labeled prior to preparation of a second drug.
c. Patient is identified prior to administration.
d. Medication name is verified from the order prior to administration.

e. Dosage is verified from the order prior to administration.
f. Route is verified from the order prior to administration.
g. Timing is verified from the order prior to administration.
h. Medication administration is documented.
i. self-administration of
medications.
j.
outside the organization.
k. Expiry dates are checked prior to dispensing.
l. There is a procedure for near expiry medications.
m. High risk medication orders are verified prior to administering.
n. Documented policies and procedures guide the monitoring of patients after

medication administration.
Standard
MOM. 5 Near misses, medication errors and adverse drug events are reported
and analyzed.
Objective Elements
a. Documented procedure exists to capture near miss, medication error and adverse
drug reaction.
b. Near miss, medication error and adverse drug event are defined.
c. These are reported within a specified time frame. These are collected and
analyzed.
d. Corrective and/or preventive action(s) is taken based on the analysis where

appropriate.

Standard
MOM. 6 Documented procedures guide the use of narcotic drugs and

psychotropic substances.
Objective Elements
a. Documented policies and procedures guide the use of narcotic drugs and
psychotropic substances.
b. These drugs are stored in a secure manner.
c. These policies are in consonance with local and national regulations.
d. A proper record is kept of the usage, administration and disposal of these drugs.
e. These drugs are handled by appropriate personnel in accordance with policies.
Standard
Documented policies and procedures guide the use of medical

MOM. 7 supplies and consumables.
Objective Elements
a. There is a defined process for acquisition of medical supplies and consumables.
b. Medical supplies and consumables are used in a safe manner where appropriate.
c. Medical supplies and consumables are stored in a clean, safe and secure
environment, and incorporatin (s).
d. Sound inventory control practices guide storage of medical supplies and

consumables.

Chapter 4
Hospital Infection Control (HIC)
The standards guide the provision of an effective infection control program in the
Emergency department. The program is documented and aims at reducing/eliminating
infection risks to patients, visitors and providers of care.
The organization proactively monitors adherence to infection control practices such as

standard precautions, cleaning disinfection and sterilization. Adequate facilities for the
protection of staff are available. Bio Medical Waste is managed as per policies and
procedures and in accordance to legal requirements.

The Emergency Department performs surveillance activities to prevent and

HIC.1
control infections.
The organization provides adequate and appropriate resources for

HIC.2 prevention and control of Healthcare Associated Infections (HAI) in
Emergency Department .
HIC.3 Biomedical waste (BMW) is handled in an appropriate and safe manner.

Standard
HIC.1 The Emergency Department performs surveillance activities to

prevent and control infections.
Objective Elements
a. Surveillance activities are appropriately directed towards the activities in the

emergency department.
b. Surveillance activities also include monitoring the compliance with hand hygiene
guidelines.
c. Surveillance activities include monitoring the effectiveness of housekeeping

services.
Standard
HIC.2 The organization provides adequate and appropriate resources for

prevention and control of Healthcare Associated Infections (HAI) in
Objective Elements
a. Adequate and appropriate personal protective equipment, soaps, and

disinfectants are available and used correctly.
b. Adequate and appropriate facilities for hand hygiene in all patient care areas are
accessible to health care providers.
c. Barrier nursing facilities are available and implemented.
d. Appropriate pre and post exposure prophylaxis is provided to all concerned staff
members.

Standard
HIC.3 Biomedical waste (BMW) is handled in an appropriate and safe

manner.
Objective Elements
a. Proper segregation and collection of Biomedical waste is implemented and

monitored.
b. Appropriate personal protective measures are used by all categories of staff

handling Bio-medical waste.

Chapter 5
Continuous Quality Improvement (CQI)
The standards encourage an environment of continual quality improvement. The quality

and safety program should be documented and involve all aspects of the functioning in
the Emergency department. Processes should be in place to ensure the patient safety.
The Emergency department should collect data on key performance indicators as part
of its quality improvement program. The collected data should be collated, analysed and
used for further improvements. The improvements should be sustained.
The organization should define its sentinel events and intensively investigate when such
events occur.
The quality program should be supported by the management.

The organization has a well-designed, comprehensive and coordinated

CQI.1 committee for the Emergency Department which co-ordinates all activities
and provides oversight to the functioning of the Emergency Department.
There is a structured patient safety program in the Emergency

CQI.2
Department.
The organization identifies key indicators to monitor the clinical structures,

CQI.3 processes and outcomes which are used as tools for continual
improvement.
The organization identifies key indicators to monitor the managerial

CQI.4 structures, processes and outcomes which are used as tools for continual
improvement.

Standard
The organization has a well-designed, comprehensive and

CQI.1 coordinated committee for Emergency Department which co-
ordinates all activities and provides oversight to the functioning of
the Emergency Department.
Objective Elements
a. The committee is multidisciplinary and meets at regular intervals.
b. Scope of activities also includes oversight of emergency services and data review.
c. The quality improvement program is reviewed at predefined intervals and

opportunities for improvement are identified.
d. Audits are conducted at regular intervals as a means of continuous monitoring.
e. There is an established process in the organization to monitor and improve quality

of patient care.
Standard
There is a structured patient safety program in the Emergency

CQI.2 Department.
Objective Elements
a. The patient safety program is comprehensive and covers all the major elements
related to patient safety and risk management.
b. The scope of the program is defined to include adver
c. The patient safety program identifies opportunities for improvement based on

review at pre-defined intervals.
d. The Emergency Department adapts and implements national/international patient

safety goals/solutions.

Standard
The organization identifies key indicators to monitor the clinical

CQI.3 structures, processes and outcomes which are used as tools for
continual improvement.
Objective Elements
a. Monitoring includes appropriate patient assessment.
b. Monitoring includes medication management.
c. Monitoring includes use of sedation.
d. Monitoring includes use of blood and blood products.
e. Monitoring includes infection control activities.
f. Monitoring includes review of mortality.
g. Monitoring also includes unplanned return to Emergency Department within 72

hours with the similar complaints.
Standard
The organization identifies key indicators to monitor the managerial

CQI.4 structures, processes and outcomes which are used as tools for
continual improvement.
Objective Elements
a. Monitoring includes risk management.
b. Monitoring includes utilisation of space, manpower and equipment.
c. Monitoring includes availability and content of medical records.
d. Monitoring includes data collection to support further study for improvements.

Chapter 6
Responsibilities of Management (ROM)
The standards encourage the governance of the organization in a professional and

ethical manner. The responsibilities of the management are defined. The services
provided by each department are documented.
Leaders ensure that patient-safety and risk-management issues are an integral part of
patient care and hospital management.

The organization is aware and implements applicable legislations and

ROM.1 regulations required to operate the Emergency Department in the health
care organization.
ROM.2 The services provided by Emergency Department are documented.
Management ensures that patient safety aspects and risk management

ROM.3 issues are an integral part of patient care and Emergency Department
management.

Standard
ROM.1 The organization is aware and implements applicable legislations and

regulations required to operate the Emergency Department in the
health care organization.
Objective Elements
a. The management is conversant with the laws and regulations and knows their
applicability to the organization.
b. The management ensures implementation of these requirements, and gives an

undertaking accordingly.
Standard
ROM.2 The services provided by Emergency Department are documented.
Objective Elements
a. The scope of services of the Emergency Department is defined.
b. Administrative policies and procedures for the Emergency Department are

maintained.
c. The organization is managed by the leaders in an ethical manner.
d. The organization accurately bills for its services based upon a standard billing
tariff.
e. The person heading the Emergency Department has requisite and appropriate
qualification or experience.
f. The organization allocates adequate resources for effective functioning of the

g. The organization documents employee rights and responsibilities.
h. The organization has a formal documented agreement for all outsourced services
applicable to Emergency Department and has a mechanism to monitor the same.

Standard
Management ensures that patient safety aspects and risk

ROM.3 management issues are an integral part of patient care and
Emergency Department management.
Objective Elements
a. The management ensures proactive risk management across the Emergency

Department.
b. The management ensures implementation of systems for internal and external

reporting of system and process failures.
c. The management ensures that appropriate corrective and preventive action is

taken to address safety related incidents.

Chapter 7
Facility Management and Safety (FMS)
The standards guide the provision of a safe and secure environment for patients, their
families, staff and visitors. To ensure this, the organization conducts regular facility
inspection rounds and takes the appropriate action to ensure safety.
The organization provides for equipment management, safe water, electricity, medical
gases and vacuum systems.
The organization plans for emergencies within the facilities and the community.

The emergency's environment and facilities operate to ensure safety of

FMS.1
patients, their families, staff and visitors.
FMS.2 The emergency has a program for bio-medical equipment management.
FMS.3 The emergency department has a process for voice & data management.
The emergency department has a system for provision of program for

FMS.4
medical gases, vacuum & compressed air.
FMS.5 The emergency has plans for fire & non-fire emergencies.
The emergency department plans for handling community emergencies,

FMS.6
epidemics and other disasters.
FMS.7 The emergency has a plan for management of hazardous materials.

Standard
The Emergency's environment and facilities operate to ensure safety

FMS.1 of patients, their families, staff and visitors.
Objective Elements
a. Patient-safety devices are installed across the emergency department and

inspected periodically.
b. There is internal and external sign postings in the emergency in a language

understood by the patient, families and community.
c. The provision of space shall be in accordance with the available literature on good
practices (Indian or international standards) and directives from government
agencies.
d. Potable water and electricity are available round the clock and maintained and
evaluated appropriately.
e. Alternate sources for electricity and water are provided as backup in case of any
failure/shortage.
f. Maintenance staff is contactable round the clock for emergency repairs.
Standard
The emergency has a program for bio-medical equipment

FMS.2
management.
Objective Elements
a. The emergency department plans for equipment in accordance with its services.
b. Equipments in the emergency department are selected, rented, updated or

upgraded by a collaborative process.
c. Medical equipment in the emergency department is inventoried and proper logs

are maintained as required.
d. Qualified and trained personnel operate and maintain the medical equipment.
e. Medical Equipments are periodically inspected and calibrated for their proper
functioning.

f. There is a documented operational and maintenance (preventive and breakdown)
plan.
g. There is a documented procedure for equipment replacement and disposal.
Standard
The emergency department has a process for voice & data

FMS.3
management.
Objective Elements
a. Adequate number of data points are provided.
b. Adequate number of computers and printers are provided.
Standard
The emergency department has a system for provision of program

FMS.4 for medical gases, vacuum & compressed air.
Objective Elements
a. Adequate oxygen, air & vacuum medical gas terminal are provided on each
emergency bed.
b. Alternate sources for medical gases, vacuum and compressed air are provided for
in case of failure.
c. There is an operational and maintenance (preventive and breakdown) plan for

piped medical gas, compressed air and vacuum installation.
Standard
FMS.5 The emergency has plans for fire & non-fire emergencies.
Objective Elements
a. The emergency department has plans and provisions for early detection,
abatement and containment of fire and non-fire emergencies.
b. The emergency has a documented safe-exit plan in case of fire and non-fire
emergencies.

Standard
The emergency department plans for handling community

FMS.6 emergencies, epidemics and other disasters.
Objective Elements
a. The emergency identifies potential community emergencies.
b. The Emergency department has a disaster management plan.
c. Provision is made for availability of medical supplies, equipment and materials

during such emergencies.
d. Emergency staff is trained in the hospital's disaster management plan.
e. The disaster management plan in the Emergency Department is tested at least

twice a year
Standard
FMS.7 The emergency has a plan for management of hazardous materials
Objective Elements
a. Hazardous materials are identified within the emergency.
b. The emergency department implements processes for sorting, labeling, handling,

storage, transporting and disposal of hazardous material.
c. There is a plan for managing spills of hazardous materials.
d. Emergency staff is educated and trained for handling such materials.

Chapter 8
Human Resource Management (HRM)
The most important resource of an Emergency department is the human resource.

Human resources are an asset for effective and efficient functioning of an emergency
department. Without an equally effective human resource management system, all
other inputs like technology, infrastructure and finances come to naught. Human
The goal of human resource management is to acquire, provide, retain and maintain
competent people in right numbers to meet the needs of the patients and community
served by the organization. This is based on the mission, objectives,
goals and scope of services. Effective human resource management involves the
following processes and activities:-
(a) Acquisition of Human Resources which involves human resource planning,

recruiting and socialization of the new employees.
(b) Training and development relates to the performance in the present and future
anticipated jobs. The employees are provided with opportunities to advance
personally as well as professionally.
(c) Motivation relates to job design, performance appraisal and discipline.
(d) Maintenance relates to safety and health of the employees.

Emergency Department has a documented system of human resource

HRM.1
planning.
There is an ongoing program for training and development of staff in the

HRM.2
An appraisal system for evaluating the performance of an employee exists

HRM.3
as an integral part of the human resource management process.
The Emergency Department addresses the health needs of the

HRM.4
employees.
HRM.5 There is documented personal information for each staff member.

Standard
Emergency Department has a documented system of human

HRM.1
resource planning
Objective Elements
a. Human resource planning supports the Emergency Departments current and future
requirements to meet the care, treatment and service needs of the patient.
b. The job specification and job description are well defined for each category of staff
in Emergency Department.
Standard
There is an ongoing program for training and development of staff in

HRM.2 the Emergency Department.
Objective Elements
a. All staff joining the Emergency Department undergo a job-specific training.
b. Training also occurs when job responsibilities change/new equipment is

introduced.
c. All staff is trained on the risks within the hospital environment.
d. Staff members can demonstrate and take actions to report, eliminate / minimize
risks.
e. Staff members are made aware of procedures to follow in the event of an incident.
f. Staff are trained on occupational safety aspects.
g. The doctors and Nurses working in the Emergency Department are trained in
triaging.

Standard
An appraisal system for evaluating the performance of an employee

HRM.3 exists as an integral part of the human resource management
process.
Objective Elements
a. The employees are made aware of the system of appraisal at the time of induction.
b. Performance is evaluated based on the performance expectations described in the

job description.
c. The policies and procedures regarding disciplinary and grievance handling are
known to all categories of staff of the Emergency Department.
Standard
The Emergency Department addresses the health needs of the

HRM.4
employees.
Objective Elements
a. A pre-employment medical examination is conducted on all the employees.
b. Health problems of the employees are taken care of in accordance with the
c. Regular physical and medical checks are done for the staff at-least once a year
and the findings/ results are documented.
d. Occupational health hazards are adequately addressed.
Standard
HRM.5 There is documented personal information for each staff member.
Objective Elements
a. Personal files are maintained in respect of all employees.
b.
qualification, disciplinary background and health status.

c. All records of in-service training and education are contained in the personal files
for all staff.
d. There is a process for credentialing and privileging of medical professionals.
e. There is a process for credentialing and privileging of nursing professionals.

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Proposed Draft Standards of Emergency

Medical Services Certification Program

First Edition - August 2015

NATIONAL ACCREDITATION BOARD FOR

@ National Accreditation Board for Hospitals and Healthcare Providers 1

First Edition August 2015

@ National Accreditation Board for Hospitals and Healthcare Providers 2

Sr. No. Particulars Page No.

Patient Centered Standards

01. Access, Assessment and Information (AAI) 6

02. Patient Care and Rights (PCR) 14

03. Management of Medication (MOM) 20

04. Hospital Infection Control (HIC) 25

Organization Centered Standards

05. Continuous Quality improvement (CQI) 29

06. Responsibilities of Management (ROM) 33

07. Facility Management and Safety (FMS) 37

08. Human Resource Management (HRM) 42

@ National Accreditation Board for Hospitals and Healthcare Providers 3

@ National Accreditation Board for Hospitals and Healthcare Providers 4

Intent of the chapter:

A standardized approach is used for referring or transferring patients in case the

@ National Accreditation Board for Hospitals and Healthcare Providers 5

The organization establishes the emergency department with an easy

Emergency services are guided by documented policies, procedures,

The organization has a documented registration, admission and transfer

Documented policies and procedures guide the availability of Diagnostic

There is an appropriate mechanism for transfer (in and out) or referral of

Emergency patients cared for by the organization undergo an established

AAI.7 Patients cared for by the organization undergo a regular reassessment.

AAI.8 Patient care is continuous and multidisciplinary in nature.

AAI.9 The organization has a documented discharge process.

AAI.11 The medical record reflects continuity of care.

@ National Accreditation Board for Hospitals and Healthcare Providers 6

AAI.1 The organization establishes the emergency department with an easy

b. An alert mechanism is activated upon arrival of the patient. Staff should be

c. The services which are being provided are clearly defined.

e. Staff is oriented to these defined services

AAI.2 Emergency services are guided by documented policies, procedures,

@ National Accreditation Board for Hospitals and Healthcare Providers 7

The organization has a documented registration, admission and

b. A unique patient identification number is generated at the end of registration.

d. Criteria are applied for prioritization of patient transfer to appropriate department

e. Documented process also addresses managing patients during non-availability of

f. Staff is aware of these processes.

Documented policies and procedures guide the availability of

c. Staff is aware and trained on these processes.

@ National Accreditation Board for Hospitals and Healthcare Providers 8

There is an appropriate mechanism for transfer (in and out) or referral

b. Documented policies and procedures guide the transfer-out/referral of stable and

d. The organization gives a summ

Emergency patients cared for by the organization undergo an

b. The organization determines who can perform the initial assessment.

d. The initial assessment fo

@ National Accreditation Board for Hospitals and Healthcare Providers 9

Patients cared for by the organization undergo a regular

a. Patients are reassessed at appropriate intervals.

b. Patients are informed of their next follow-up where appropriate.

c. Staff involved in direct clinical care, documents reassessments.