General instructions

Points to be kept in mind while preparing documents for HOPE uploading

Question No.1: What precautions we should take while sending you the documents.

1.        SNDT (Signed Named, Dated and timed) to be followed in all documents.

2.        All columns should be filled. If there is a blank space where you do not need to enter any data, please put a dash or cancel the section.

3.        Whenever there are medicines involved, please write the same in CAPITAL or separated alphabets.

4.        Non-MBBS doctors should not sign the treatment sheet.

5.        Make sure that all consent forms should be signed by respective doctors. At least one consent (out of 5) should be in Marathi.

6.        Scanning of all paper should be done through a computer scanner and not through the phone. All four corners should be captured while scanning the documents.

7.        UHID no. & patient name to be written on each sheet.

8.        At least for submission, please use our formats so that it becomes easier to clear documentation audits.

9.        Ensure that a copy of the discharge summary given to the patient is retained in the hospital.

10.     Try & collect one photo id from patients.

11.     Doctors should take interest in the implementation

Question No.2: Which are the minimum formats required for submission?

Documents required for Medical IPD papers:

1.        Admission Form with Admission Consent

2.        Initial Medical Assessment

3.        Treatment sheet

4.        TPR Chart

5.        Nursing over / Nursing Notes

6.        Feedback Form

7.        Discharge Summary

8.        Consent for Surgical procedure

9.        MRD checklist

Documents required for Surgical IPD papers:

1.        Admission Form with Admission Consent

2.        Initial Medical Assessment

3.        Treatment sheet

4.        TPR Chart

5.        Nursing over / Nursing Notes

6.        Feedback Form

7.        Discharge Summary

8.        Consent for Anaesthesia

9.        Consent for Surgery

10.     Pre-Op checklist

11.     WHO Surgical checklist

12.     Pre-Anaesthesia evaluation

13.     Anaesthesia monitoring record

14.     Operation record

15.     Consent for Blood Transfusion (if applicable)

16.     Blood monitoring chart (if applicable)

17.     MRD checklist

Documents required for Ophthalmic IPD papers:

1.  Admission Form with Admission Consent

2.  Initial Medical Assessment

3.  Selection of IOL

4.  Feedback Form

5.  Discharge Summary

6.  Consent for Anaesthesia

7.  Consent for Surgery

8.   Pre-Op checklist

9.   WHO Surgical checklist

10.  Pre-Anaesthesia evaluation

11.  Anaesthesia monitoring record

12.  Operation record

13.  MRD checklist

Following registers need be maintained by Nursing Homes.

1.             OPD

2.             IPD

3.             OT

4.             Fumigation

5.             Autoclave

6.             Laboratory

7.             Imaging

8.             MLC

9.             Repair

10.           Incidence Complaint

11.           Implant

12. BMW

Documents to be kept ready and complete before the Audit

1.   Registers - IPD, OPD (if any), OT, Fumigation, Autoclave, Lab, Imaging, Incidence Book, Repair Book (if any for equipment maintenance), Refrigerator Temperature.

2.   Pharmacy (if any) – Form20, Form 21, Narcotics (if registered), Emergency Drug List to be Displayed, LASA Drugs, Refrigerator Temperature.

3.   5 Surgical & 5 Medical papers to be completed in all aspects

4.   AMC, CMC or On call basis contract, Service reports, Calibration Report.

5.   OT Swab reports, ICU Swab Reports

6.   All Mandatory Permissions

Virtual Audit Tour

1.   Go out of the hospital premises.

2.   Enter the hospital as the patient enters and show the hospital name displayed outside. Show the ramp for the wheelchair & trolley.

3.   Show displays in two languages the Scope of services, Patients’ Rights & responsibilities, Mission, Vision, OPD Rates & Emergency Numbers.

4.   Now Receptionist has to answer OPD & IPD registration process, what is the process for Emergency & MLC patients? Also, what is his/her role when the Code is activated?

5.   OPD Room – Curtains should be available for examination of patients for privacy.

6.   Emergency Room (If any) – Emergency register, RMO & Nurse on duty, Transfer register, MLC Register.

7.   Wards – Curtains between cots, Medicine label

8.   Patient Interview – are you made aware of your rights and responsibility, treatment cost being discussed, staff response to your needs, Treatment being discussed with patient/ relatives

9.   ICU – Duty roaster of RMO & Nurse to be displayed as per the beds, Code Blue or Code Red can be activated, Medicine station should have a list of Emergency medicine, LASA medicine, Auditor might check the expiry of any medicine from the station, Equipment maintenance procedure of equipment in the ICU, BMW storage area & poster of Segregation. If any patient is available and stable then the auditor might interview.

     10.   OT – OT Nurse required to answer all questions, Emergency Trolley with emergency medicine, Medicine expiry of any vile can be checked, O2, Nitrogen Cylinder, LASA Medicine, OT Register, Autoclave Register, Fumigation register, Equipment Maintenance, Autoclaved Drum with labelling, OT lights working or not, How OT cleaning is done? How is fumigation done? OT handwash area (No touch system), Code Blue or Code Red can be activated, OT instrument cleaning area, Autoclave Area and procedure of Autoclave, If you have different Implant register then that is required or else OT register for Ophthal.

     11. Housekeeping Staff – How many times Hospital is cleaned?, cleaning procedure, Spill Management (Demonstrate if he/she is not able to explain proper steps), How to clean the Infected and Non Infected patient room and the Needle Prick Injury process.

      12. Nursing Staff – Needle Prick Injury process, Spill Management & All Codes.

     13. MRD – How files are arranged? What is the destruction policy? Is, Fire Extinguisher available in MRD or nearby area, IPD papers, Death & MLC records

    14. Admin/ HR – Files of Doctors & Nursing Staff to be completed with the certificate, Immunisation status & Medical Records. Equipment maintenance records, Mandatory permissions, Swab reports and any other relevant files.

     15. All staff should know how to handle fire extinguishers.

     16. All Medical & Housekeeping staff should know BMW segregation.

1.        Procedure(s) guide collection, identification, handling, safe transportation, processing and disposal of specimens.

2.        Process addresses discharge of all patients including Medico-legal cases and patients leaving against medical advice.  

3.        Documented procedure (s) address care of patients arriving in the emergency including handling of medico-legal cases.  

4.        Documented policies and procedures are used to guide the rational use of blood and blood products. 

5.        Documented procedure for the administration of anaesthesia.   

6.        Documented procedure addresses the prevention of adverse events like wrong site, wrong patient and wrong surgery.  

7.        Documented procedure incorporating purchase, storage, prescription and dispensation of medications.

8.        Documented procedures address procurement and usage of implantable prostheses.    

9.        Infection control manual, which is periodically updated and conducts surveillance activities. 

10.     Documented operational and maintenance (preventive and breakdown) plan for clinical and support service equipment.

11.     The organization has a documented safe exit plan in case of fire and non-fire emergencies.  

12.     Documented disciplinary and grievance handling procedure.     

13.     Documented policies and procedures for maintaining confidentiality, integrity and security of records, data and information.    

14.     Documented procedures exist for a  retention time of medical records, data and information.

15.     Define a process to whom the patient record can be released

16.     Procedure on the destruction of medical records

List of Training under HOPE

1.   Training on scope of services

2.   Training on Safe practices in Laboratory 

3.   Training on Safe practices in Imaging

4.   Training on Child Abduction Prevention

5.   Training on Infection Control Practices 

6.   Fire mock drills

7.   Training on Spill Management 

8.   Training on Safety Education programme 

9.   Training on Needle Stick Injury 

10. Training on Medication Error

11. Training on Disciplinary procedures

12. Training on Grievance Handling procedures 

Mock-Audit Points:  Entry Level

Show you following registers:

·   IPD

·   OPD

·   OT

·   Autoclave

·   Fumigation

·   MLC

·   Alert value Laboratory

·   Alert value Imaging

·    

·    

Show following displays:

·   Mission statement

·   Patients’ Rights & Responsibilities

·   Tariff card

·   Services offered

·   Code explanation

·   HAZMAT

·   LASA

·   Escape route

·   Emergency exit door

·   Cylinder storing

·   Fire alarm

·   Smoke detector

·   TAT

·    

Demonstrate:

·             Activation of codes

·             Patients’ rights & Responsibilities

·             Tariff card

·             Services offered

·             Body fluid spill management

·             Code explanation

·             HAZMAT

·             LASA

·             Buddy system

·             Post needle stick injury

·             Dealing with MLC

·             Night Shift emergency

1.   What is the flow of events?

a.   Register with ISAR by paying the relevant fee.

b.   You will receive standards, Annexures and formats along with PPT

c.   You can contact the helpline to get assistance for implementation

d.   Fill in the Annexures and formats and email them to FEQH

e.   Indicate the month during which you want the audit

f.    FEQH will inform you name and contact details of the auditor along with audit fee intimation

g.   Pay the audit fee and contact the auditor for a suitable date and time of audit

h.   After the audit auditor will send you audit report along with deficiencies, if any.

i.    Close the deficiencies and send the closure report to FEQH.

j.    If the Auditor accepts deficiencies, you will be awarded the certificate and the logo will be sent which can be used till the validity of the certificate.

2.   How do we register/ How do we start?

You can call the ISAR office and request them to send you the Accreditation registration form alternatively you can send Whatsapp message to 98200 56944 whereby you will get the form immediately.

3.   What are the various steps?

Once you fill in the form and register, you will get accreditation standard, Forms and formats, a video to assist in filling the forms and formats and a PPT for implementing the Standard in IVF Clinic.

4.   Who will guide for implementation?

Helpline numbers are provided to whom you can contact and can arrange a telephonic talk or a video meeting. This can continue till you are completely satisfied.

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