Access, Assessment & Continuity Of Care (AAC)

Standard 1 AAC-1: Laboratory Services are provided as per the requirements of patient
Standard 2 AAC-2: Imaging Services are provided as per the requirements of patient
Care of Patients (COP)
Standard 3 COP-1: Emergency services are guided by policies, procedures and applicable laws and regulations
Standard 4 COP-2: Policies and procedures define rational use of blood and blood products
Standard 5 COP-3: Policies and procedures guide the care of high risk obstetrical patients
Standard 6 COP-4: Policies and procedure guide the administration of anesthesia
Standard 7 COP-5: Policies and procedures guide the care of patients undergoing surgical procedures
Management of Medication (MOM)
Standard 9 MOM-2: Policies and procedures guide the safe dispensing of medications
Standard 10 MOM-3: There are defined procedures for medication administration
Ind-62
Medications are administered (dispensed) by those who are permitted by law to do so
Ind-63
Prepared medications are labeled prior to preparation of a second drug
Ind-64
Patient is identified prior to administration
Ind-65
Medication is verified from the order prior to administration
Ind-66
Dosage is verified from the order prior to administration
Ind-67
Route is verified from the order prior to administration
Ind-68
Timing is verified from the order prior to administration
Ind-69
Medication administration is documented
Ind-146 Every medical record entry is dated and timed
Patients Rights and Education (PRE)
Standard 11 PRE-1: A documented process for obtaining patient consent for informed decision making about their care
Standard 12 PRE-2: Patient and families have a right to information on expected costs
Standard 13 PRE-3: Patient Rights for Appeals and Complaints
Hospital Infection Control (HIC)
Standard 14 HIC-1: The organization has a well-designed, comprehensive and coordinated infection control programmed
aimed at reducing/eliminating risks to patients, visitors and providers of care
Standard 15 HIC-2: There are documented procedures for sterilization activities in the organization
Continuous Quality Improvement (CQI)
Standard 16 CQI-1: There is a structured quality improvement and continuous monitoring programme in the organization
Standard 17 CQI-2: The organization identifies key indicators to monitor the clinical structures, processes and outcomes
which are used as tools for continual improvement
Standard 18 CQI-3: Sentinel events are intensively analyzed
Responsibilities of Management (ROM)
Standard 19 ROM 1: The responsibilities of the management are defined
Standard 20 ROM-2: A suitably qualified and experienced individual heads the organization
Facility Management and Safety (FMS)
Standard 21 FMS-1: The organization is aware of and complies with the relevant rules and regulations, laws and bylaws
& facility inspection requirements under relevant building & associated codes applicable to
hospitals
Standard 22 FMS-2: The organization has a program for clinical and support service equipment management
Standard 23 FMS-3: The organization has plans for the fire and non-fire emergencies within the facilities
Human Resource Management (HRM)
Standard 24 HRM-1: The staff members joining the organization are oriented to the hospital environment, the institution,
respective departments and their individual jobs
Standard 25 HRM-2: An appraisal system for evaluating the performance of an employee exists as an integral part of the
human resource management process
Standard 26 HRM-3: There is a documented personnel record for each staff member

Standard 27 HRM-4: There is a process for collecting, verifying & evaluating credentials (education, registration, training
& experience) of medical professionals including physicians, nurses, pharmacists and others
permitted to provide patient care without supervision
Information Management System (IMS)
Standard 28 IMS-1: The organization has a complete and accurate medical record for every patient
Standard 29 IMS-2: The medical record reflects continuity of care
Standard 30 IMS-3: The organization regularly carries out review of medical records