Self Assessment Toolki

Elements
Chapter 1: ACCESS, ASSESSMENT AND CONTINUITY OF CARE (AAC)
AAC.1: The organisation defines and displays the services that it can provide.
a The services being provided are clearly defined
b The defined services are prominently displayed.
c The staff is oriented to these services.

AAC.2:
The organisation has a document registration and admission process
T.
a. process addresses registrering and admiting out - patiennts , in-patients and emergency
patients.

b. process addresses mechanism for transfer or referral of patients who do not match the
organizational resources

patients cared for by the organization undergo an established initial

AAC.3
assessment.
a. The organization defiens the content of the assessment for in - patients and emergency
patients.

b. The organization determines who can perform the assessments .

c. The initial assessment for in - patients is documented within 24 hours or earlier.

d Initial Assessment of inpatients includes nursing assessmentwhich is done at the time of

admission and documented
Patients care is continous and all patients cared for by the organization
AAC.4
undergo a regular reassessment .
a. During all phases of care, there is a qualified individual identified as responsible for the
patient’s care who coordinates the care in all the settings within the organization.

b. All patients are reassessed at appropriate intervals.

c. staff involved in direct clinical care document reassessments.

d. patients are reassessed to determine their response to treatment and to plan further
treatment or discharge.

Laboratory services are provided as per the scope of the hospital 's serveces
AAC.5
and Laboratory safety requirments
a. scope of the laboratory services are commensurate to the services provided by the
organisation.

b. procedures guide collection , identification , handdiling , safe transportation , processing and

disposal af specinens.

c. Laboraratory result are available within a defined time feame and critical result are intimated
immediately to the concerened personnel.

d. Adequately qualified and trained personnel perform and/ or supervise the investigations.

e laboraratory persoonel are trained in safe practices and are provided with appropriate safety
equipment / devices.
 f Laboratory Tests not available in the Organization are outsourced

Imaging services are provided as per the scope of the hospital's services and
AAC.6
establisheed rediation saftey programme.
a. Imaging Services Comply with legal n other requirments

b. scope of the laboratory services are commensurate to the services provided by the
organisation.

c imaging results are available within a defined time frame and critical result are intimated
immediately to the concerned
are trained personnel.
d Imaging personnel in safe practices and are provided with appropriate safety
equipment/devices

AAC.7 Organization has a defined dicharge process.

a process addresses dicharge off all patients including medico - legal cases and patients
leaving against medical advice.
b. A discharge summary is given to all the patients leaving the organization (including patients
leaving against medical advice).

c. Dicharge summary contains the reasons for admission, significant findings , investigation
result , diagnosis , procuedure performed [if any], treatment given and the patients condition
at the time of dicharge.
d. Dicharge summary contains follow up advice , medication and other istructions in an unders

e. Dicharge summary incorporates instruction about when and how to obtain urgent care.

f. In case of death the summary of the case also includes the cause of death.

Chapter 2: CARE OF PATIENTS (COP)

COP.1: care of patients is guided by accepted norms and practice.
a The care and treatment orders are signed, named, timed and dated by the concerned doctor.

b clinical practice guidelines are adopted to guide patient care wherever possible.

COP.2: Emergency services including ambulance are guided by documented

procedures and applicable laws and regulations.
a Documented procedures address care of patients arriving in the emergency including
handling og be
medico - legal cases.
b staff should well versed in the care of emergency patients in consonance with the scope
of the servicess of hospital.
c Admission or discharge to home or transfer to another organisation is also documented.

COP.3: Documented procudures define rational use of blood products.

Documented policies and procedures are used to guide the rational use of blood and blood
a products
b Documented procedures govern transfusion of blood and blood products
c The transfusion services are governed by the applicable laws and regulations.
d informed consent is obtained for donation and transfusion of blood and blood products.
e procedure addresses documenting and reporting of transfusion reaction.

COP.4: Document procudures guidethe care of patients as per the scope of services
provided by hospital in intensive care and high dependency units.
a Care of patients is consonance with the documented procedures.
 b Adequate staff and equipment are available.

COP.5: Documented procudures guide the care of obsterical patients as per the scope
of services provided by hospital.
a The organization defines the scope of obsteric services
b obsteric patients care includes regular ante- natal check - ups , maternal nutrition and post
natalorganzation
care.
c The has the facilities to tke care of neonates.

COP.6: Documented procudues guide the care of paediatric patients as per the scope
of services.
a The organzation defines the scope of its paediatric serveces.
b Provisions are made for special care of children by compentent staff.
c Patients assessment includes detailed nutritional growth and immunization assessment.
d Proceudure addresses identification and security measures to prevent
child/neonateabduction and abouse.
e The children’s family members are educated about nutrition, immunization and safe
parenting and this is documented in the medical record.

COP.7: Documented procudures guide the admistraction of anaesthesia

a There is a documented policy and procedure for the administration of anesthesia.
b All patients for anesthesia have a pre-anesthesia assessment by a qualified trained
Anaesthetist
The pre-anesthesia assessment results in formulation of an anesthesia plan which is
c
documented.
d An immediate preoperative re- evaluation is documended
e inform consent for admistriaction of aneasthesia is obatined by the anasethesia.
f Anaesthesia monitoring includes regular and periodic monitoring of heart rate,cardiac
rhythm,respiratory rate,blood pressure,Oxygen saturation,airway,
g Each patient’s post-anesthesia status is monitored and documented.
h Defined criteria are used to transfer the patient from recovery area
i Adverse Anaesthesia events are recorded and monitored

COP.8: Documented procudures guide the care of patients undergoing surgical

procudures.
a surgical patients have preoperative assessment and a provisional diagnosis documented
prior to surgery.
b An informed consent is obtained by a surgeon prior to the procudure.

c Documented procuedures addresses the prevention of adverse events like wrong site, wrong
patients and wrong surgery.
d Qualified personsare permitied to perform the procuedures that they are entitled to perform.

e The operating surgeons documents the operative notes and post operative plan of care

f The operation theatre is adequately equipped and monitored for infection control practices

Chapter 3: MANAGEMENT OF MEDICATION (MOM)

MOM.1: Documented procedures guide the organzation of pharmacy servces and
usage of medication.
a Documented procedure shall incorporate purchase,storage,prescription and dispensation of
medications
These comply with the applicable laws and regulations
b
c Sound Alike and Look alike medicines are stored saperately
d Beyond expiry date medications are not stored/used
e Documented procedures address procurement and storage of implantable prosthesis
MOM.2:Documented Policies and procedures guide the safe Prescription of
medication.
a The organization determines who can write orders
b Orders are written in uniform location in the medical records
c Medication orders are clear,legible,dated and signed
d The organization defines high risk medication and process to prescribe them

MOM.3: There are defined procedures for safe dispensing of medication

a Medication are checked prior to dispensing,including the expiry date to ensure that they are
fit for risk
use medication orders are verified prior to admistraction, medication order including
b High
patients , dosage ,rout and timing are virfied .

MOM.4:There are defined procedures for medication administration.

a Medications are administered by trained Personnel
Prior to administration,medication orders including patient,dosage,route and timing are
b verified
c Prepared medication is labelled prior to preparation of second drug
d Medication administration is documented
e A proper record is kept of the usage,administration and disposal of narcotics and
psychotropic medications

MOM.5: Adverse Drug Events are Monitored.

a Adverse drug events are defined and monitored
b Adverse drug events are documented and reported within specified time frame

Chapter 4: PATIENTS RIGHTS AND EDUCATION (PRE)

PRE.1: Patients rights are documended displayed and support individual beliefs ,
values and involve the patients and family in decision making processes.
a Patients righit include respect for personal dignity and privacy during examination
procedures and tretment.
b Patients rights include protection from physical abouse or neglect.
c Patients rights include treating patient information as confidential.
d Patients rights include obtaining informed consent before carrying out procedures.
e patients rights include information on howto voice a complaint.
f Patients rights includes information on expected cost of Treatment
g Patient has a right to have access to his/her clinical record

Patient and families have a right to information and education about their
PRE.2:
health care needs.
a Patients and their families are educated on plan of care,preventive aspects,possible
complications,medications,the
are taught in language expected
and formatresults andbe
cost as applicable
b Patient that can understand

Chapter 5: HOSPITAL INFECTION CONTROL (HIC)

HIC.1: The hospital has an infection control manual , which is periodically updated
and conducts survreillance activites.
a it focouses on adherence to standard precautionds at all times.
b Cleanliness and genral hygiene of facilities will be maintaineed and monitored.
c Clening and disinfection practices are defined and monitored as approprite .
d Equipment cleaning , disinifection and sterlization practices are included
e Laundry and linen management processes are also included.
HIC.2: The hospital takes action to prevent or reduce the risk of hospital associated
infection [HAI] in patients and employees.
a Hand hygieane facilities in all patients care areas are accessible to health care providers.
b Adequate gloves ,masks, soaps , and disifectants are availble and used cprrectly.
c Approprite pre and post exposure prophylaxis is provided to all concerned staff members.

HIC.3: Bio-medical wasre {BMW} management practices are followed.

a The hospital is authorized by prescrbed authority for the management and handling of bio-
medicalsegregation
waste.
b Proper and collection of Bio-medical Waste from all patient care areas of the
hospital is implemented and monitored.
c Bio -medical waste treatment facility is mananged as per statutory provisions [if in-house] or
out soursed to authorized contractor[s].
d Requisite fees , documents and reports are submitted to competent authorities on stipulated
dates.
e Approprite personal protective measures are used by all categories of staff handling bio-
medical waste.

Chapter 6: CONTINUOUS QUALITY IMPROVEMENT (CQI)

CQI.1: There is a structured quality improvement and continuous monitoring
programme in the organization.
a There is a designated individual for coordinating and implementing the quaility improvement
programme .
b The quality improvement programme is a contineous process and updated at least once in a
year.
c Hospital management makes available adequate resources required for quality improvement
programme.
CQI.2: The organization identifies key indicators to monitor the clinical structures,
processes and outcomes which are used as tools for continual improvement.
a Organzation shall identify theapproprite key performance indicatores in both clinical and
managerial areas.shall be monitored.
b These indicators

Chapter 7: RESPONSIBILITIES OF MANAGEMENT (ROM)

ROM.1: The responsibilities of the management are defined.
a The organization has a documented organogram.
b The organization is registered with appropriate authorities as applicable.
c The organization has a designeded individual [s] to oversee the hospital wide safety
programme.

ROM.2: The organization is managed by the leaders in an ethical manner.

a The management makes public the mission statement of the Organization
b The Management guide the organization to function in an ethical management.
c The organization discloses its ownership.
d The organization's billing process is acurate and ethical

ROM.3: The Organization has setup multi diciplinary committees to oversee specific
areas of quality and patient safety.
a These Committees include quality and safety ,infection control,pharmacy and
Theraputics,Blood Transfusion,and Medical Records.
b The membership,responsibilities,and periodicity of meetings shall be defined

Chapter 8: FACILITY MANAGEMENT AND SAFETY (FMS)

FMS.1: The organization’s environment and facilities operate to ensure safety of
patients, their families, staff and visitors.
a internal and external signages shall be displayed in a language understood by patient,
families and community.
Maintenance staff is contactable round the clock for emergency repairs.
b
c There is the hospital hs a systeem to identify the potential safety and security risks including
hazzardous materials
 d Facility inspection rounds to ensure safety are conducted Periodically
e There is safety education programme for relevant staff

FMS.2: The organization has a program for clinical and support service equipment
management.
a The Organization plans for equipment in accordance with its services

b There is documented operational and Maintenance(Preventive and breakdown) Plan

FMS.3: The organization has provisions for safe water, electricity, medical gases and
vacuum systems.
a Portable water and electricity are available round the clock
b Alternate sources are provided for in case of failure and tested regularly

c There is maintenance plan for medical gases and vaccum systems

FMS.4: The organization has plans for fire and non-fire emergencies within the
facilities.
a The organization has plans and provisions for early detection, containment and abatement of
fire and non-fire emergencies.
b The organization has a documented safe exit plan in case of fire and non-fire emergencies.

c There is maintenance plan for medical gases and vaccum systems

d Mock drills are held at least twice in a year

Chapter 9: HUMAN RESOURCE MANAGEMENT (HRM)

HRM.1: There is an ongoing programme for professional training and development of
the Staff
a All staff is trained on the relebant risks within the hospital environment
b Staff members can demonstrate and take actions on the report,eliminate/minimizerisks
c Training also occurs when job responsibilities change/new equipment is introduced

HRM.2: The organizationhas a well documented diciplinary and grevience handling

procedure
a A documented procedure with regard to this is in place
b The documented procedure is known to all categories of employees in the organization
c Actions are taken to redress the grevience

HRM.3: The organization addresses the health needs of the employes

a Health problems of the employees are taken care of in accordance with the organization’s
policy.
b Occupational health hazards are adequately addressed.

HRM.4: There is a documented health record of each staff member

a personal files are maintained in respect of all employes
b The personnel files contain personal information regarding the employees
qualification,deciplinary actions and health status. The deciplinary procedure is in

Chapter 10: INFORMATION MANAGEMENT SYSTEM (IMS)

IMS.1: The organization has a complete and acurate medical record for every patient
a every medical record has a unique identifier
b organization identifies those authhorized to make entries in medical record
 c Every medical record entry is dated and timed
d The auther of the entry can be identified
e The contents of medical records are identified and documented

IMS.2: The Medical record reflects continuity of care

a The record provides an up-to-date and chronological account of patient care.
b The medical record contains information regarding reasons for admission , diagnosis and
plan of care.
c operative and other procedures performed are incorporated in the medical record.

d The medical record contains a copy of the discharge note duly signed by appropriate and
qualified personnel.

e In case of death , the medical records contain a copy of the death certificate indicating he
cause , date anhas
timeaccess
of death.
f Care providers to the current and past medical record

IMS.3: Documented policies and procudures are in place for maintaning

confidentiality , integrity and security of , data and information.
a Documented procuedures exist for maintanig confeantility , security and integrity of
inforation.
b Privileged health information is used for the purposes identified or as required by law and not
disclosed without the patient’s authorization.
IMS.4: Documented policies and procedures exist for retrntion time of record ,data
and information.
a Documented procedures are in place on retaining the patients clinical records data and
information.
b The retention process provides expected confidentiality and security.
c The destruction of medical records, data and information is in accordance with the laid down
policy.
elf Assessment Toolkit
Remarks
Documentation Implimentation Score RS Remarks
.
0 5 5 10 Services Not Defined clearly.
0 5 5 10 Displayed only in casualty area. Not at enterance
0 5 5 10 Only few ataff is oriented. Needs training
0 15 15 30

0 5 5 10 Registration and admission as in process. Needs

documentation and training
0 5 5 10 Patients are shifted to Sahyadri and other hospital. No MOU
with Organization and ambulance.Defined protocol is not
existing.
0 10 10 20

0 5 5 10 Contents not defined. Forms are available in traditional

mannar
0 5 5 10 Assessments are done by Nursing and RMOs.Needs
documentation and training
0 0 0 10 No uniformality in assessment timing..

0 5 0 10 No uniformality in assessment
0 15 10 40
10
0 5 5 10 Adequate HR not available

0 5 5 10 No uniformality in assessment timing..

0 5 5 10 Needs training and uniformality

0 5 5 10 Needs training and uniformality

0 20 20 50

10 10 10 10 Hematology,Serology,Biochemistry,Clinical, culture and

sensitivity,Endocrinology services available
0 0 0 10 Needs training

0 0 0 10 Time frame and Critical alart results not defined and protocol
is not followed. Need documentation,training, Register
preparation
0 5 5 10 Two MD Pathology consultants and 4 DMLT staff available

0 5 5 10 Needs training
 0 10 5 10 Tests are outsourced but MOU with lab required.

10 30 25 60

10 10 10 10 AERB certificate of X Ray machine, C Arm available

10 10 10 10 X Ray, C Arm machine, Cath Lab available

0 5 5 10 Time frame,Critical results not defined.

0 5 5 10 Training required.TLD bedges not available
20 30 30 40

0 10 5 10 MLC certificate and notification to Police station is followed.

Needs documentation
5 10 5 10 Discharge summery given to all patients. Needs
documentation
5 5 5 10 Contents of discharge summery needs to be reconstructed

5 5 5 10 Contents of discharge summery needs to be reconstructed

0 0 0 10 When and how to obtain urgent care not mentioned in

discharge summery
10 10 10 10
25 40 30 60

0 0 0 10 Consultants signatures are not there on continuation sheets

0 0 0 10 clinical practice guidelines

0 0 0 20

0 5 5 10 No policy or SOP available

0 5 5 10 All staff not oriented. Needs training
0 5 5 10 Needs Documentation

0 15 15 30

0 0 0 10 Needs Documentation
0 5 5 10 Needs to be monotored in prescribed format
10 10 10 10 FDA certificate for blood storage center available
0 0 0 10
0 0 0 10 Needs Documentation
10 15 15 50

0 0 0 10 Needs Documentation
 0 5 5 10 Equipments are available as per scope of services.HR should
be added
0 5 5 20

0 5 5 10 Scope of services not defined

0 5 5 10 No uniformality
0 5 5 10 Only Warmer is available
0 15 15 30

0 5 5 10 Peadiatric services not defined

0 5 5 10 Inadequate staff for special Peadiatric care
10 10 10 10 Maintained
0 0 0 10 No safety majours
0 5 5 10 Educated only orally
10 25 25 50

0 0 0 10 No documented policy
0 0 0 10 No preanaesthesia assessment done
0 0 0 10 No such process conducted
0 0 0 10 No such process conducted
0 0 0 10 No saperate consent for anaesthesia
0 0 0 10 No intraoperative assessment is conducted
0 0 0 10 No such process conducted
0 0 0 10 No such process conducted
0 0 0 10 No such process conducted
0 0 0 90

0 5 5 10 Provisional Diagnosis is there but no preoperative

assessment done
0 5 5 10 No saperate conscent for surgical procedure.Common
conscent is in use
0 0 0 10 No
0 5 5 10 List of approved consultants and their specialty not available

0 0 0 10 Operative notes not available saperately. It is mentioned on

continuation sheet
0 5 5 10 OT is well equipped but OT zoning, CSSD flow,material flow
not maintained.Infection control practiced not maintained

0 20 20 60

0 0 0 10 No documented policy
10 10 10 10 FDA certificate available
0 0 0 10 No
0 0 0 10 No
0 0 0 10 No
10 10 10 50

0 5 5 10 There is no documentation
0 10 10 10 Orders are written on continuation sheet
0 5 5 10 Date and sign of consultant not mentioned
0 0 0 10 No
0 20 20 40

0 5 5 10 Needs Documentation
0 0 0 10 No procedure is followed
0 5 5 20

0 10 10 10 Nursing staff administer the medication

0 10 10 10 Yes

0 0 0 10 Training required.
5 10 10 10 Yes
0 0 0 10 No saperate record foe narcotic medication usage
5 30 30 50

0 0 0 10 No
0 0 0 10 No
0 0 0 20

0 0 0 10 Patients rights are displayed only in billing area.Not bilingual.

0 0 0 10 Not Included
0 0 0 10 Not Included
0 0 0 10 Not Included
0 0 0 10 Not Included
0 0 0 10 Not Included
0 0 0 10 Not Included
0 0 0 70

0 0 0 10 No
0 0 0 10 No
0 0 0 20

0 0 0 10 No
0 0 0 10 No
0 5 5 10 No
0 5 5 10 Partially in practice
0 0 0 10 No
 0 10 10 50

0 0 0 10
0 5 5 10 Partially in practice
0 0 0 10 Not Provided
0 5 5 30

10 10 10 10 Yes. MPCB Certificate available

0 0 0 10 Not followed. Only black bags are in use.Waste is spreaded
at Biomedical storage area at baserment badly.
0 0 0 0 Outsourced. MOU needs to be preapred
10 10 10 10 Yes
0 0 0 10 Improper collection, segrigation,transport and storage of
BMW
20 20 20 40

0 0 0 10 Presently not designated

0 0 0 10
0 5 5 10 Manageement committed to make the sources available
0 5 5 30

0 0 0 10 Indicators not prepared and followed

0 0 0 10 No
0 0 0 20

0 0 0 10 Have to be prepared
10 10 10 10 Registration of hospital is under BNHA for 50 beds
0 0 0 10 Not existing
10 10 10 30

0 0 0 10 Not yet
0 0 0 10 Not yet
0 0 0 10 Not yet
0 5 5 10 Few changes in billing format required
0 5 5 40

0 0 0 10 Not yet
0 0 0 10 Not yet
0 0 0 20

0 5 5 10 Sinages are not bilingual. Inadequate sinages

0 5 5 10 List of maintenance staff to be prepared
0 0 0 10 Not existing
0 0 0 10 Not existing
0 0 0 10 Not existing
0 10 10 50

0 10 10 10 Equipments available. But Detailed listalong with sr

number,AMC CMC status, Caliberation,breakdown register
required
0 0 0 10 Not existing
0 10 10 20

0 10 10 10 RO plant installed
0 5 5 10 Water provision, storage tanks are available. But regular
testing is not conducted
0 0 0 10 Not existing
0 15 15 30

0 0 0 10 Not streamlined.Only three estinguishers are installed in

hospital.MOU with agency needs to prepare
0 5 5 10 Exit sinages and floor evacuation plan are placed but exit
SOPs and training not conducted.
0 0 0 10 No
0 0 0 10 No
0 5 5 40

0 5 5 10
0 0 0 10 Staff not oriented
0 0 0 10 No
0 5 5 30

0 0 0 10 No
0 0 0 10 No
0 0 0 10 No
0 0 0 30

0 0 0 10 No
0 0 0 10 No
0 0 0 20

0 0 0 10 No
0 0 0 10 No
0 0 0 20

0 0 0 10 No
0 5 5 10 Identified but not documented
0 5 5 10 No uniformality in entry, date,time
0 0 0 10 No.Signatures,Name,tome not mentioned
0 0 0 10 No
0 10 10 50

0 0 0 10 Patient file is not uniform and wel documented

0 5 5 10 Needs Training
0 5 5 10 OT notes are written on continuation sheet.No anaesthesia
record, Conscents are improper and inadequate

0 5 5 10 Discharge summery given to all patients. Needs

documentation and contents of discharge summery needs to
be added.
0 10 10 10 Deeath ceertificate is issued
0 10 10 10 MRD unorgenized
0 35 35 60

0 0 0 10 No policy or SOP available

0 5 5 10 Practices followed but no documantation
0 5 5 20

0 0 0 10 No documented policy
0 0 0 10 No documented policy
0 0 0 10 No documented policy
0 0 0 30
169588
54
85
 Care Hospital, Pune
Standard Achieved Score Required Score %
AAC 1 15 30 50 Standards Achievement
AAC 2 10 20 50 Partially Met 54
AAC 3 10 40 25 Not Met 85
AAC 4 20 50 40 Fully Met 18
AAC 5 25 60 42 Total 157
AAC 6 30 40 75
AAC 7 30 60 50
AAC 140 300 47
COP1 0 20 0
COP2 15 30 50
COP3 15 40 38
COP4 5 20 25
COP5 15 30 50
COP6 25 50 50
COP7 0 90 0
COP8 20 60 33
COP 95 340 28
MOM1 10 50 20
MOM2 20 40 50
MOM3 5 20 25
MOM4 30 50 60
MOM5 0 20 0
MOM 65 180 36
PRE1 0 70 0
PRE2 0 20 0
PRE 0 90 0
HIC1 10 50 20
HIC2 5 30 17
HIC3 20 40 50
HIC 35 120 29
CQI1 5 30 17
CQI2 0 20 0
CQI 5 50 10
ROM1 10 30 33
ROM2 5 40 13
ROM3 0 20 0
ROM 15 90 17
FMS1 10 50 20
FMS2 10 20 50
FMS3 15 30 50
FMS4 5 40 13
FMS 40 140 29
HRM1 5 30 17
HRM2 0 30 0
HRM3 0 20 0
HRM4 0 20 0
HRM 5 100 5
IMS1 10 50 20
IMS2 35 60 58
IMS3 5 20 25
IMS4 0 30 0
IMS 50 160 31
 Achieved Required
Standard Score Score Achievement%
AAC 140 300 47
COP 95 340 28 Care Hospital Pune Standard Achievement%
MOM 65 180 36 50 47
PRE 0 90 0 45
HIC 35 120 29 40 36
CQI 5 50 10 35
ROM 15 90 17 28 29 29
30
FMS 40 140 29 25
HRM 5 100 5
20 17
IMS 50 160 31
15
TOTAL 450 1570 29 10
10
5
5
0
AAC 0
COP MOM PRE HIC CQI ROM FMS HRM
ndard Achievement%

31
29 29

17

10
5

CQI ROM FMS HRM IMS TOTAL