NABH MASTER CLASS

ON
UPGRADATION & MIGRATION TO
NABH 6TH EDITION

CHAPTER-4: PRE

ACME CONSULTING
 Training Sessions for NABH 6th Edition

NABH STANDARDS – DISTRIBUTION OF “OEs”

Chapters STDs. OBJECTIVE ELEMENTS (OEs)
Core Commitment Achieve- Excellence Total OE
ment
AAC 13 6 68 9 4 87
COP 20 13 107 12 4 136
MOM 11 13 48 6 1 68
PRE 8 13 32 6 1 52
IPC 8 13 34 2 0 49
PSQ 7 8 27 7 4 46
ROM 5 4 21 9 3 37
FMS 7 11 29 2 1 43
HRM 13 16 55 5 0 76
IMS 7 9 33 2 1 45
TOTAL 100 105 457 60 17 639
Core & Commitment OEs are mandatory min. requirements For Surveillance For Re-Accreditation
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 2
 Training Sessions for NABH 6th Edition

CHAPTER-4: PATIENT RIGHTS & EDUCATION (PRE)….

STANDARD OBJECTIVE ELEMENT (OE)

PRE.1. The organisation protects and promotes patient and family
rights and informs them about their responsibilities during
care.

PRE.2. Patient and family rights support individual beliefs, values

and involve the patient and family in decision-making
processes.

PRE.3. The patient and/or family members are educated to make

informed decisions and are involved in the care planning
and delivery process.

PRE.4. Informed consent is obtained from the patient or family

about their care.

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 3
 Training Sessions for NABH 6th Edition

CHAPTER-4: PATIENT RIGHTS & EDUCATION (PRE)….

STANDARD OBJECTIVE ELEMENT (OE)

PRE. 5. Patient and families have a right to information and
education about their healthcare needs.

PRE.6. Patients and families have a right to information on

expected costs.

PRE.7. The organisation has a mechanism to capture patient's

feedback, experience and to redress complaints.

PRE.8. The organisation has a system for effective communication

with patients and/or families.

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 4
 Training Sessions for NABH 6th Edition

PRE.1. The organisation protects and promotes patient

and family rights and informs them about their
responsibilities during care.

C a Patient and family rights and responsibilities are

documented, displayed and they are made aware of
the same. * (Slides: 6 To 13)

A b Patient and family rights and responsibilities are

actively promoted. * (Slide: 14)

Core c The organisation protects patient and family rights.

Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 5
 Training Sessions for NABH 6th Edition

PRE.1.a. Patient and family rights and responsibilities

are documented, displayed and they are made aware
of the same. .
The Rights of Patients are as follows….:

5. Your Rights include treating patient information as confidential

6. You have every right for refusal of treatment.

7. Decision making: You have the right to know the details of your
condition, diagnosis, various treatment options, prognosis, and cost.

Continued……
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 6
 Training Sessions for NABH 6th Edition

PRE.1.a. Patient and family rights and responsibilities

are documented, displayed and they are made aware
of the same. .
The Responsibilities of Patients are as follows….:
Every Patient Shall:
 Respect the rights and treat all healthcare workers and other
patients and visitors with dignity.

 Comply by medications and other matters relating to your health.

 Comply with all hospital policies and guidelines as informed or

displayed.

 Be available for any appointments made or notify the hospital as early

as possible if you are unable to do so
Continued……
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 7
 Training Sessions for NABH 6th Edition

PRE.1.a. Patient and family rights and responsibilities

are documented, displayed and they are made aware
of the same. .
The Responsibilities of Patients are as follows….:

 Acknowledge that some other patients’ medical condition may be more

urgent than yours and accept that your doctor may need to attend
them first. Kindly cooperate in such situations.

 Provide the Hospital with comprehensive and accurate details about

your past medical records and be compliant as regard to taking
medication or following any other prescribed treatment.

 Follow the prescribed and agreed treatment plan and carefully comply
with the instructions given

 Do not take medication independent of medical advice.

 Do not ask the hospital to provide incorrect information, receipts or

certificates. Continued……
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 8
 Training Sessions for NABH 6th Edition

PRE.1.a. Patient and family rights and responsibilities

are documented, displayed and they are made aware
of the same. .
The Responsibilities of Patients are as follows….:

 Do not waste medical resources and time unnecessarily

 Strictly observe the Hospitals Visitors Policy as displayed.

 Protect the environment.

 To utilize the health care system appropriately and do not abuse it.

 To maintain cleanliness & hygiene in the Hospital.

 To follow hospital safety rules.

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 9
 Training Sessions for NABH 6th Edition

PRE.1. The organisation protects and promotes patient

and family rights and informs them about their
responsibilities during care.

Core d The organisation has a mechanism to report a violation

of patient and family rights.

Core e Violation of patient and family rights are monitored,

analysed and corrective / preventive action taken by
the top leadership of organisation. (Slide: 16)

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 10
 Training Sessions for NABH 6th Edition

PRE.2: Patient and family rights support individual

beliefs, values and involve the patient and family in
decision making processes.

C a Patients and family rights include respecting values

and beliefs, any special preferences, cultural needs
and responding to requests for spiritual needs.

C b Patient and family rights include respect for

personal dignity and privacy during examination,
procedures and treatment.

C c Patient and family rights include protection from

neglect or abuse.
Core d Patient and family rights include treating patient
information as confidential.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 11
 Training Sessions for NABH 6th Edition

PRE.2: Patient and family rights support individual

beliefs, values and involve the patient and family in
decision making processes.

C e Patient and family rights include refusal of treatment.

C f Patient and family have a right to seek an additional

opinion regarding clinical care.

Core g Patient and family rights include informed consent

before the transfusion of blood and blood components,
anaesthesia, surgery, initiation of any research
protocol and any other invasive / high risk procedures
/ treatment.

C h Patient and family rights include a right to complain

and information on how to voice a complaint. Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 12
 Training Sessions for NABH 6th Edition

PRE.2: Patient and family rights support individual

beliefs, values and involve the patient and family in
decision making processes.

C i Patient and family rights include information on the

expected cost of the treatment.

C j Patient and family rights include access to their

clinical records.

C k Patient and family rights include information on the

name of the treating doctor, care plan, progress and
information on their health care needs.

A l Patient and family rights include determining what

information regarding their care would be provided to
self and to family.

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 13
 Training Sessions for NABH 6th Edition

PRE.3: The patient and/ or family members are educated

to make informed decisions and are involved in the care
planning and delivery process.

Core a The Patient and/or family members are explained

about the proposed care, (including the risks,
benefits and alternatives), expected results and
possible complications.
A b The care plan is prepared and modified in
consultation with patient and/or family members.
(Slide: 21)
C c The patient and/or family members are informed
about the results of diagnostic tests and the
diagnosis.
C d The patient and/or family members are explained
about any change in the patient's condition in a timely
manner.
Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 14
 Training Sessions for NABH 6th Edition

PRE.4: Informed consent is obtained from patient or

family about their care.

Core a The organisation obtains informed consent from

patient or family for situations where informed
consent is required. (Slide:25, 26)

C b Informed consent process adheres to statutory

norms. (Slide: 27)

Core c Informed consent includes information regarding

the procedure, it's risks, benefits, alternatives
and as to who will perform the procedure in a
language that they can understand.

Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 15
 Training Sessions for NABH 6th Edition

PRE.4: Informed consent is obtained from patient or

family about their care.

C d The organisation describes who can give consent when a

patient is incapable of independent decision making and
implements the same. *

 Next of kin (OR) Legal

guardian……Spouse/Son/daughter/parents/brother/sist
er.. In that order

 In case of life-threatening situation, then the treating

doctor and another clinician can together decide the
course of action (when next of kin is Not available)

Core e Informed consent is taken by the person performing the

procedure.

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 16
 Training Sessions for NABH 6th Edition

PRE.5: Patient and families have a right to information

and education about their healthcare needs.

Core a Patient and/or family are educated in a language and

format that they can understand.

C b Patient and/or family are educated about the safe

and effective use of medication and the potential
side effects of the medication, when appropriate.
(Slide:30)

C c Patient and/or family are educated about food-drug

interaction. (Slide:31)

Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 17
 Training Sessions for NABH 6th Edition

PRE.5: Patient and families have a right to information

and education about their healthcare needs.

C d Patient and/or family are educated about diet and

nutrition. (Slide:33)

C e Patient and/or family are educated about

immunizations. (Slide:34)

C f Patient and/or family are educated on various pain

management techniques, when appropriate.
(Slide:35)

Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 18
 Training Sessions for NABH 6th Edition

PRE.5: Patient and families have a right to information

and education about their healthcare needs.

C g Patient and/or family are educated about their

specific disease process, complications and
prevention strategies.

C h Patient and/or family are educated about preventing

healthcare associated infections.

A i The patients and / or family members' special

educational needs are identified and addressed.
(Slide: 37)
E h The organisation has a mechanism to promote
patient engagement to enhance clinical outcomes,
safety and quality. (Slide: 38)
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 19
 Training Sessions for NABH 6th Edition

PRE.6: Patient and families have a right to information

on expected costs.

Core a The patient and/or family members are made

aware of the pricing policy in different settings
(out-patient, emergency, ICU and inpatient).
(Slide:40).
C b The relevant tariff list is available to patients.

C c The patient and/or family members are explained

about the expected costs.

C d Patient and/or family are informed about the

financial implications when there is a change in the
care plan. (Slide:41)

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 20
 Training Sessions for NABH 6th Edition

PRE.7: The Organisation has a mechanism to capture

patient's feedback, experience and to redress
complaints.

C a The organisation has a mechanism to capture

feedback from patients which includes patient
satisfaction. (Slide: 43)

A b The organisation has a mechanism to capture patient

experience. (Slide: 43)

Core c The organisation redress patient complaints as per

the defined mechanism. *

Continued…
CORE Commitment Achievement Excellence
©ACME CONSULTING Chapter-4: Patient Rights And Education 21
 Training Sessions for NABH 6th Edition

PRE.7: The Organisation has a mechanism to capture

patient's feedback and to redress complaints.

C d Patient and/or family members are made aware of

the procedure for giving feedback and / or lodging
complaints.

C e Feedback and complaints are reviewed and / or

analysed, within a defined time frame. (Slide: 45,
46)
C f Corrective and/or preventive action (s) are taken
based on the analysis where appropriate.

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 22
 Training Sessions for NABH 6th Edition

PRE.8: The organisation has a system for effective

communication with patients and / or families.

C d The organisation ensures that there is no

unacceptable communication. (Slide: 54)

A e The organisation has a system to monitor and

review the implementation of effective
communication. (Slide: 55, 56)

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 23
 Training Sessions for NABH 6th Edition

PRE.8.e. The organisation has a system to monitor and

review the implementation of effective communication……

 Feedbacks are taken from patients and other stake holders on

periodical basis (monthly) and these are reviewed for
effectiveness of communication;

 The fallout from such reviews are put to action immediately for
ensuring more effective communication / improvements.

Continued….

CORE Commitment Achievement Excellence

©ACME CONSULTING Chapter-4: Patient Rights And Education 24
THANK YOU