NABH Documentation Kit for Eye Care Organisation Accreditation

Eye Care Organization is an integral part of the health care system. The National Accreditation Board for Hospitals and Healthcare (NABH) has released standard for NABH Accreditation of Eye Care Organization. This standard is meant for ECO who want to get started on the quality certification journey. Accreditation is an incentive to improve the capacity of national ECO to provide quality of care.

B. Documentation:-

Our document kit is having sample documents required for implementation of NABH hospital accreditation as per latest National accreditation board of hospitals. The documents are prepared by the highly experienced team of people with rich experience of hospitals system establishment and process improvement and many hospitals are appraised successfully. You need to study it do necessary changes as per your company need and within 4 days your entire editable documents with all necessary details are ready as well as your team will got many ideas for system establishment to reduce the cost and effort with all necessary controls and your total documents are ready. We had given all type of templates and organization use it as per their need and many organization are certified globally in 1st trial with the help of our documents from any kind of stringent lead appraisal audit.
Under this directory further files are made in word document as per the details listed below. All the documents are related to NABH accreditation standards for eye care organisation for and user can edit it in line with their own processes.

1. Hospital Manual:

It covers sample copy of hospital manual details for NABH accreditation standards for eye care organisation is implemented. It covers Introduction, scope of service, hospital policy, vision and
mission, applicable laws and regulations, Quality policy and organization structure and covers 1st tier of NABH documents

Details of hospital manual

1. Cover page
2. Introduction
3. Scope of services
4. Hospital policies (Applicability of NABH Standards)
5. Vision and Mission
6. Applicable laws and regulation
7. Quality Policy
8. Organization structure

2. Department Manual:

It covers sample copy of department manual for NABH is implemented. It covers 5 department manual of NABH documents details given below Details of department manual

1. Central sterility supply department (CSSD) manual
2. Emergency Preparedness Manual
3. Infection control manual
4. Medical Record manual
5. Human Resource management (HR Manual )
6. Bio Medical Manual

3. System Procedures (08 Procedures):

It covers sample copy of system procedures covering all the specific practice areas of 08 processes. Our procedures help the organization to make the best system and quick process
improvements. All procedures are divided in 08 system procedures as listed below.

List of system procedure

1. Procedure for control of non–conforming services
2. Procedure for management review
3. Procedure for document and data control
4. Procedure for corrective and preventive action
5. Procedure for control of quality records
6. Procedure for internal audit
7. Procedure for control of monitoring and measuring equipments
8. Procedure for Training

4. Blank Formats (72 Formats):

It covers sample copy of forms required to maintain records in the hospital as well as establish control and make system in the organization. The samples given are as a guide and not
compulsory to follow and hospitals are free to change the same to suit own requirements. The formats list given below;

List of Formats

1. Sanitation audit report
2. Fumigation report
3. Toilet Cleaning record
4. Suggestion Card
5. Near Miss Report
6. Evaluation Of OHS Hazards and Risks
7. OHSMP Progress Monitoring Report
8. Investigation Report
9. Work Permit Report
10. Fire fighting checklist
11. Location List of fire extinguisher
12. Ambulance review checklist
13. Disposal of non confirming work
14. DG Set monitoring report
15. Daily Equipment Cleaning record
16. Operation theatre readiness form
17. Patient Complaint Report
18. List of chain pulley blocks, lifts ,pressure vessels etc
19. OHS Review Of Prioritization Of Significant OHS Hazards Its Risks Feasibility Analysis
20. Safety Inspection Check List
21. First aid box check list
22. Earthing pit test report
23. Fire hydrant checklist
24. PPE Preventive Maintenance check points
25. Steam Boiler Monitoring report
26. Sterilization report
27. Incineration plant report
28. Breakdown History card
29. Room Check list
30. Rodent Treatment
31. Purchase Order
32. Supplier Registration form
33. Daily stock statement
34. Preservation assessment Report
35. Change Note
36. Master list of records
37. Audit schedule/plan
38. Indoor file papers arrangement
39. Corrective Action report
40. Training calendar
41. Induction training report
42. Discharge Check list
43. Credentialing and privileging for Nursing professionals/Allied healthcare professionals
44. Blood Transfusion _Patient Information and Consent
45. Emergency Medicine Crash cart
46. Nurse Medicine Administration Report
47. Surgical safety Check List
48. Vital Signs and Intake Output Chart
49. Blood Transfusion and Adverse Effects Form
50. Preventive maintenance schedule
51. Request for microbiological testing
52. Gate pass
53. Pest control report
54. Indent cum incoming inspection report
55. Approved Vendor list
56. Cockroach Treatment
57. Anti termite treatment
58. Master list cum distribution list of documents
59. Calibration status of instruments
60. Internal audit non conformity report
61. Preventive Action report
62. Training need cum record sheet
63. Job description and specification
64. Admission Check list
65. Credentialing and privileging for Medical professionals
66. Checklist for personal file
67. Transfer Check list
68. Pre Operative Check list
69. Multi skill Index
70. Discharge Against Medical Advice
71. Discharge Summary
72. Estimate Form

5. Standard operating procedures (40 SOPs):

It covers sample copy of SOPs covering Access, assessment and continuity care (AAC), Care of patient (COP), continuous quality improvement (CQI), Management of Medicine (MOM) and
patient rights and education (PRE) departments. It covers all SOPs details list given below;

List of SOPs

Access, assessment and continuity care (AAC)
1. SOP for Scope of services
2. SOP for Registration
3. SOP for Policy for Admission
4. SOP for Filling the admission form
5. SOP for Procedure during non availability of beds
6. SOP for Laboratory safe practices
7. SOP for Assessment Policy
8. SOP for Discharge Procedure
9. SOP for Patient Education on expected cost
Care of patient (COP)
10. SOP for Uniform care of patient
11. SOP for Administration of Anesthesia
12. SOP for Ambulance services
13. SOP for Care of patient under Surgical Procedure
14. SOP for Care of Vulnerable Patient
15. SOP for Cardiac Pulmonary Resuscitation
16. SOP for Criteria for Discharge of Patient
17. SOP for Emergency care
18. SOP for Handling of Medical Legal Cases
19. SOP for Pediatric patient
20. SOP for Prevention on Adverse Event in Surgical Patient
21. SOP for Quality Assurance Programme- Surgical Services
22. SOP for Rationale use of Blood & Blood Products
23. SOP for Sedation
Continuous quality improvement (CQI)
24. SOP for Indicator Monitoring System
25. SOP for Sentinel Events

Management of Medicine (MOM)
26. SOP for Pharmacy Services
27. SOP for Hospital Formulary
28. SOP for Acquisition of medicines
29. SOP for Storage of medication
30. SOP for Use of medical gases
31. SOP for Medication administration
32. SOP for Prescription of medicines
33. SOP for Verbal order of medication
34. SOP for List of high risk medication
35. SOP for Dispensing of medication
36. SOP for Use of Implantable Prosthesis
Patient rights and education (PRE)
37. SOP for patient rights
38. SOP for informed consent
39. SOP for protection of patient rights
40. SOP for communication

6. Hospital committee:

This gives the list of all 8 committees and formation of committee and functions and guidelines for the committee.

List of committees

1. Quality Improvement Committee
2. Infection Control Committee
3. Pharmaco- Therapeutic Committee
4. Medical Audit Committee
5. Safety Committee
6. Grievance Re-dressal Committee
7. Disaster Preparedness Committee
8. Ethics Committee

7. Audit checklist (more than 300 questions)

There covers audit questions to be used for eye care organization system auditing for objectively evaluate the adherence of system by functional heads to establish processes. It also includes
audit questions as a quick reference for all related work areas of the hospital. Total more than 300 audit questions gives better understanding to the process owners as well as to the auditors to
establish good system and process discipline in hospital as well as for each department. It will be very good tool for the auditors to make audit Questionnaire while auditing and make effectiveness in auditing in the hospital.