Resources

Plain-language reference for quality teams

Written by us as implementation guidance. The official NABH publication remains the authoritative source and every hospital should work from it.

Reference 01

The ten chapters

AAC

Access, Assessment and Continuity of Care

Scope of services, registration and admission, initial and re-assessment, laboratory and imaging services, transfer, referral and discharge.

COP

Care of Patients

Uniform care delivery, emergency and ambulance services, resuscitation, high-risk and vulnerable patients, anaesthesia, surgery, obstetric, paediatric, ICU, end-of-life and pain management.

MOM

Management of Medication

Formulary, procurement, storage, prescription, dispensing, administration, high-alert drugs, narcotics, sample and recall management, adverse drug event monitoring.

PRE

Patient Rights and Education

Rights and responsibilities, informed consent, tariff transparency, protection of vulnerable patients, patient education and grievance redressal.

IPC

Infection Prevention and Control

Infection control programme and committee, hand hygiene, surveillance of healthcare associated infections, isolation, sterilisation, laundry, kitchen and biomedical waste.

PSQ

Patient Safety and Quality Improvement

Structured quality and safety programme, patient safety goals, quality indicators, clinical audit, incident and sentinel event reporting, CAPA and internal audit.

ROM

Responsibilities of Management

Governance, organogram, leadership, statutory and regulatory compliance, ethics, risk management and service continuity.

FMS

Facility Management and Safety

Safe environment, facility inspection rounds, fire and non-fire emergencies, medical gas, utilities, equipment and hazardous material management.

HRM

Human Resource Management

Staffing plan, recruitment, credentialing and privileging, orientation, training, appraisal, health and disciplinary processes.

IMS

Information Management System

Medical record content and retention, confidentiality and integrity, data and information management, digital health adoption and IT security.

Reference 02

Mandatory quality indicators

The indicator set hospitals are expected to collect, file monthly and act on. Most are computable from HIS data.

QI-01 · CLINICAL

Time taken for initial assessment of indoor patients

QI-02 · MANAGERIAL

Percentage of medical records not having discharge summary

QI-03 · PATIENT SAFETY

Percentage of medication errors

QI-04 · CLINICAL

Incidence of catheter associated urinary tract infection

QI-05 · CLINICAL

Incidence of central line associated blood stream infection

QI-06 · CLINICAL

Incidence of ventilator associated pneumonia

QI-07 · CLINICAL

Surgical site infection rate

QI-08 · PATIENT SAFETY

Hand hygiene compliance rate

QI-09 · PATIENT SAFETY

Incidence of patient falls

QI-10 · CLINICAL

Incidence of bed sores after admission

QI-11 · CLINICAL

Percentage of re-exploration

QI-12 · CLINICAL

Percentage of unplanned return to ICU within 48 hours

QI-13 · PATIENT SAFETY

Percentage of transfusion reactions

QI-14 · PATIENT SAFETY

Percentage of adverse drug reactions

QI-15 · PATIENT SAFETY

Percentage of cases where safe surgery checklist completed

QI-16 · MANAGERIAL

Percentage of rescheduling of surgery

QI-17 · MANAGERIAL

Turnaround time for laboratory reports

QI-18 · MANAGERIAL

Percentage of re-dos of investigations

QI-19 · MANAGERIAL

Percentage of LAMA and DAMA

QI-21 · MANAGERIAL

Average length of stay

QI-22 · MANAGERIAL

Discharge turnaround time

QI-23 · CLINICAL

Mortality rate

QI-24 · MANAGERIAL

Percentage of patient and family complaints resolved within defined time

QI-25 · MANAGERIAL

Patient satisfaction index

QI-26 · MANAGERIAL

Employee satisfaction index

QI-27 · MANAGERIAL

Employee attrition rate

QI-28 · MANAGERIAL

Percentage of staff who received training as per plan

QI-29 · PATIENT SAFETY

Incidence of needle stick injuries

QI-30 · MANAGERIAL

Percentage of downtime of critical equipment

Reference 03

Mandatory hospital committees

Quality improvement committee

Owns the quality programme, reviews indicators and internal audit findings.

Infection control committee

Surveillance data, antibiotic policy, outbreak response, hand hygiene compliance.

Safety committee

Facility rounds, incident trends, fire and non-fire emergency preparedness.

Pharmacotherapeutics committee

Formulary revision, high-alert and LASA lists, adverse drug reaction review.

Medical records committee

Record completeness audit, retention policy, confidentiality and release of information.

Transfusion committee

Blood utilisation, transfusion reactions, wastage review.

Ethics committee

Ethical issues in care, research oversight where applicable.

Grievance redressal committee

Patient and staff complaints, closure turnaround, systemic corrections.

Disaster and code teams

Disaster management plan, code blue performance, mock drill evaluation.

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