NABH Questionnaire

Shalby Hospital, Surat

Dec ,2019

1. What is NABH?
✓ National Accreditation Board for Hospitals and Healthcare provider
2. Main focus of NABH
✓ Patient Safety
✓ Employee Safety
✓ Environment Safety
✓ Community Safety
3. Chairman of the Company
✓ Dr. Vikram I. Shah
4. Vision of our Hospital
✓ Exceeding expectations from health
5. Mission of our Hospital
✓ Leveraging Global Leadership In Joint Replacement To Establish Multi-specialty Care
Across Geographies
6. When was our hospital inaugurated?
✓ 2017
7. How many bedded hospital are?
✓ 243 bedded (110 functional)
8. Which services are not in our scope?
✓ Radiotherapy
✓ Nuclear Medicine
✓ Organ Transplant
9. Who is Accreditation Coordinator?
✓ Ms. Neha Chouhan
10. What are the outsourced services we have in hospital?
✓ Blood Bank (Savior Blood Bank, SRK)

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✓ PET CT (Zircon Nuclear Lab)

✓ Mammography (Dr. Dhara Shah)
11. How many chapters, Standards and Objectives are in NABH Pre accreditation Entry level?
✓ Chapters – 10
✓ Standards – 105
✓ Objectives – 683
12. . Name the 10 chapters
✓ Access, Assessment and Continuity of Care (AAC)
✓ Care of Patients (COP)
✓ Management of Medication (MOM)
✓ Patient Rights and Education (PRE)
✓ Hospital Infection Control (HIC)
✓ Continuous Quality Improvement (CQI)
✓ Responsibilities of Management (ROM)
✓ Facility Management and Safety (FMS)
✓ Human Resource Management (HRM)
✓ Information Management System (IMS)
13. What is the hospital policy on smoking?
✓ No Smoking Zone & No tobacco zone
14. Codes
✓ Reach to Nearest Landline phone → Call appropriate number (*888/*999) → Wait for
the receptionist’s response saying “HELLO” → Code <colour> , <Number of floor> ,
<location: area or room number> → wait for the receptionist’s response saying “OK”
✓ Code Red (*888): Fire
✓ (*888): External disaster (road traffic accidents; mass casualty;
earthquakes)

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Shalby Hospital, Surat
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✓ Code Black (*888): Bomb threat

✓ Code Pink (*888): Baby missing
✓ Code Purple (*888): Patient Violence

✓ Code Blue (*999): Person’s Life at risk (Cardiac Arrest)

14. TRIAGE CRITERIA

✓ important in cases of Code Yellow/mass casualties; important role of EW
✓ Role of emergency department –
i. Staff to be on alert to receive the casualties without delay
ii. Ensure sufficient stock of life saving drugs & equipment
iii. Ample amount of stretchers and wheel chairs
iv. Guard to ensure easy flow of patients to the emergency department
v. Easy access of ambulance in the hospital premises
✓ Red color band – Immediate priority 1 – injury with respiratory or circulatory
compromise, facial maxillary injuries involving trachea neck (send to resuscitation area)
✓ Yellow color band – Urgent priority 2 – compound fractures without vascular bleed;
stable abdominal injury; head injuries without signs of cerebral compression (send to
area designated for stable patients)
✓ Green color band – Delayed priority 3 – minor cuts bruises, burns <20% (<10% in
children) send to OPD area to wait
✓ Black color band – Brought dead – cardiac arrest on arrival in hospital, massive injuries
incompatible with life; burns more than 60% (send to morgue area)
15. What is BMW (Bio Medical Waste)?
✓ Any waste generated in hospital during patient’s diagnosis, treatment, immunization,
investigations
16. How is waste segregated?
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✓ Segregation at the point of generation Segregation in color coded bags

17. Segregation of BMW

Disposal
Color Waste types
Method

✓ Human anatomical waste includes body hair, material

containing human faeces
Yellow ✓ Blood filled blood bags Incineration
✓ Infected cotton gauzes, dressings Discarded medicines
✓ Diapers

✓ All plastic waste like catheter tubing, iv sets, & urine

bags, plastic syringes, used gloves masks & head Autoclave shredder
Red
caps. Chemical treatment
✓ All the tubing shall be cut and then kept it in Red bag

✓ All sharp waste

White (Puncture
✓ Needles in puncture proof box Scalpels; blades; Breakage Chemical
proof)
✓ Lab slides

Autoclave shredder
Blue ✓ Ampoules, Glass Vials
Chemical treatment

✓ General kitchen waste

Black ✓ Papers, wrappers, fruit & vegetable peels Sanitizer Land fill
bottles

*NOTE: Any waste generated from HIV/HBsAg or infected patient should be disposed in YELLOW BAG
WITH A LABEL as well as linen of such patients should be carried in yellow bag to the laundry.
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Shalby Hospital, Surat
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18. When should we wash hands?

✓ Before touching a patient
✓ Before clean/aseptic procedure
✓ After body fluid exposure risk
✓ After touching a patient
✓ After touching patient surroundings
✓ Between patients
✓ After every 5 hand rubs wash hands with soap and water
19. How frequent the Blood Transfusion consent required?
✓ For every blood transfusion the consent is required except;
i. The duration between two blood transfusion less than 1 hour
ii. All the blood transfusion given in one sitting
20. How long should we wash hands with soap & water/hand rub/hand scrub?
✓ Soap & water – 2-3 min
✓ Hand rub – 30 sec
✓ Hand scrub (surgical hand wash) – 3-5 min
21. How many steps of hand washing?
✓ 11 steps of hand washing
22. Who is Safety Officer?
✓ Mr. Collince Taylor
23. How to manage HAZMAT SPILLS?
✓ For managing these spills there are HAZMAT KITS available at every nursing station on
each floor
✓ Blood spill – Wear PPE ( Gloves, cap, specs & boots)
i. Mark the area with a chalk
ii. Put 1% Hypo chloride solution over the spill wait for 15 min

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iii. Now put the tissue paper & wipe from outside to inside
iv. Mop with sodium hypo chloride & then phenyl
✓ Mercury spill - Wear PPE ( Gloves, cap, specs & boots)
i. Check with torch where the mercury has spilled and mark with a chalk
ii. Collect with a syringe/card board pieces
iii. Put the mercury in a container half filled with water
iv. Send the container to Biomedical Engineering department with label area date &
time of spill mentioned
v. Now mop with sodium hypo chloride and then phenyl
vi. For managing more than 30ml hazmat spill Please call ICN (Infection Control
Nurse)
24. Who is RSO(Radiation Safety Officer)
✓ Dr. Ajay Desai
25. What are sentinel events?
✓ Any unexpected occurrence involving death or serious physical or psychological injury, or
the risk thereof.
✓ Serious injuries specifically include loss of limb or function(s).
✓ Restraint death
✓ Patient death due to fall
✓ Blood transfusion death
✓ Amputation of wrong limb
✓ Medication error-related death
26. What are Adverse Events?
✓ Any expected incident related to system or process failure which caused damage that
was not serious/lasting:
i. Medication error causing minor allergy

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ii. Plaster falling from ceiling minor injuries

iii. Slip/trip/fall causing minor injuries
iv. Fall from bed causing minor injuries
v. Theft of patient/hospital property
27. What are near miss events?
✓ The events which could have caused damaged but didn’t
✓ Example: medication error causing no harm, patient about to fall but saved
28. What is the time frame for reporting such events?
✓ Sentinel event – immediate within <2hrs
✓ Adverse event – same day within 6-8 hrs
✓ Near miss event – same day /next morning
29. Whom to report such events?
✓ There is an incident report form with the nursing incharge (superintendent) which has to
be filled on reporting.
30. What to do in case of needle stick injury?
✓ Wash the area immediately under running water
✓ Inform the nurse in-charge
✓ Report to emergency department
✓ Fill the incident report form
31. What is ADR (Adverse drug reaction)? How is it identified and reported?
✓ Any unwanted, unintended at therapeutic doses occurs within a specified time of drug
administration, reported on a ADR form send form to Nursing Supervisor
32. What is a medication error? How is it reported?
✓ Any preventable event that may cause or lead to inappropriate medication use or
patient harm, while the medication is in the control of the healthcare professional,
patient, or consumer.

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✓ Reported on Medication Error Reporting form by NS/Clinicians/ QA

33. What is a hospital drug formulary?
✓ Booklet with list of drugs in generic, brand names, strengths and dosage forms available in
hospital stock.
✓ Reviewed in Pharmacotherapeutic Committee meeting for addition of any new drug
34. What is the hospital policy on sample drugs?
✓ Discourages use of sample drugs
35. What is protocol on open vials?
✓ Open Vials have to be labeled for its date of opening and date of discard with initials of the
assigned staff.
36. Are herbal medicines used in our hospital?
✓ No
37. What happens to medicines once they are discontinued?
✓ In case of full strips and unopened bottles they are returned to pharmacy, otherwise
they are handed over to patient or discarded.
38. What should be the temp of refrigerator in which medication is stored?
✓ 2-8’ Celsius
✓ Temperature log should filled in every shift.
39. What is hospital policy on pre filled syringes?
✓ Labeled with name of patient, name of drug, concentration of drug, date of preparation,
disposal, and initials.
40. What is the retention period for a MLC file and normal file?
✓ MLC File - Kept Indefinitely (Life Time)
✓ Death Case - Kept Indefinitely (Life Time)
✓ Normal Files - 8 Years

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Shalby Hospital, Surat
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41. What are the seven R’s of drug administration?

✓ Right patient
✓ Right drug
✓ Right dose
✓ Right time
✓ Right route
✓ Right purpose/Reason
✓ Right documentation
42. Name two valid patient identifiers?
✓ IP No. (76xxxxx) or OP No. (26xxxx)
✓ Name of Patient
43. What are vulnerable patients?
✓ Patients less than 12 years of age
✓ Patients more than 70 years of age
✓ Physically and mentally challenged
✓ Patients who cannot perform ADLs (Activities of Daily Livings)
✓ Chemo therapy patient
✓ Patient under the effect of sedation
✓ Patients with psychiatric illness
44. Who is the COO of the hospital?
✓ Dr. Virendra Chauhan
45. What is PPE (Personal protective equipment)?
✓ Example: cap/mask/specs/gloves/boots or shoe covers & gown/apron
46. Who is Infection Control Nurse (ICN)?
✓ Ms. Suma Besaly

47. State three measures to ensure patients right to confidentiality?

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✓ Covering the patient during transport

✓ Knocking before entering patient room
✓ Refraining from discussing patient related information publically
48. How to store narcotics drug? Name a few?
✓ Stored separately
✓ Under double lock, both keys with 2 different persons
✓ Two copy of prescription required with Name & Sign of either Anesthetist or Intensivist
✓ Examples of Narcotic Drugs available with SHS:
i. morphine (tablets & injections)
ii. fentanyl (injections & patches)

49. How often is a patient on restraint assessed?

✓ Every 2 hours
50. Name 2 hospital wide indicators for patient incidence
✓ Patient falls
✓ Pressure Ulcer (Bed Sore)
51. Illustrate SIX international patient safety goals (IPSG)?
✓ Improve accuracy of patient identification
✓ Improve effectiveness of communication among caregivers
✓ Improve safety of high alert medication
✓ Eliminate wrong site, wrong patient, wrong procedure/surgery
✓ Reduce the risk of health care acquired infection
✓ Reduce risk of harm resulting from patient fall
52. How do we help prevent patient falls?
✓ By accurately assessing the patient for fall risk in Initial Admission assessment sheet
✓ By reassessing the patient at every shift
✓ Adequate education should be imparted for patients regarding prevention of fall
✓ By keeping the side rails up while transporting patient on stretchers
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53. Name two radiation safety devices?

✓ TLD badges ✓ Lead aprons ✓ Lead collar
54. How can we ensure that a patient is operated on/at the right site?
✓ By ensuring that surgical site is correctly marked
✓ By filling Surgical Safety Check list form
55. What are the infection control indicators?
✓ VAP – ventilator associated pneumonia
✓ CAUTI – Catheter Associated urinary tract infections
✓ SSI – Surgical Site Infection
✓ CLABSI – Central Line Associated blood stream infections
56. What are Patient Rights?
✓ Respect for dignity and Privacy
✓ Right for confidentiality
✓ Right for refusal of treatment
✓ Right to voice a complaint
✓ Right to informed consent.
✓ Right to access clinical record
57. What are Patient Responsibility?
✓ Provide correct information to doctor
✓ Follow treatment plan by doctors
✓ Pay bills on time
✓ Maintain hospital cleanliness
✓ Follow hospital rules and regulations
58. What are Employee Rights?
✓ Aware of hospital policies
✓ Right against harassment

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✓ Right to treated with respect and dignity

✓ Right to clear about job roles and responsibilities
✓ Right to know the benefits avail by hospital
59. What are Employee Responsibility?
✓ Serve faithfully
✓ Cooperate with the employer
✓ Maintain confidentiality.
✓ Provide all certificates and degrees to the HR
✓ Perform duties with proper care and diligence.
60. What is procedure for Grievance Redressal ?

✓ HR to meet up with the aggrieved employee on the same day of the complaint.
✓ HR to discuss the issue with reporting senior/ HOD and close it within 24 hours of the grievance
being raised.
✓ It needs to be referred it to the Grievance Redressal Committee in case the grievance is not
resolved or settled amicably.
✓ An employee can directly approach to Grievance Redressal committee through coordinator for
any sought of grievance. The committee should consider and take a decision on the grievances
within 4 working days.
✓ Effective time of closing the issue in writing is 4 working days.
✓ An employee can appeal further to COO if he/she is not satisfied with decision of the committee .

61. How patient can voice a complaint?

✓ In three ways.
i. By writing into Feedback Form
ii. By dropping complaint in a suggestion box.
iii. By writing in a complaint Register
✓ Quality department will analysis the same complaint during their daily rounds.
62. How many ambulance we have?
✓ We have two ambulances.
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i. Small (Patient Transport Vehicle) (Bolero) (with Oxygen only)

ii. ICU on Wheels (with cardiac ambulance with all facilities like ventilator, Oxygen,
Monitoring for BP, Pulse, Defibrillator etc)
63. What are our leave policy for employees?
✓ Sick Leave (SL) : 7
✓ Casual Leave (CL) : 7
✓ Paid Leave (PL) : 21
✓ Public Holiday (PH) :6
64. Name of Hospital committee
i. Internal Complaint Committee
1. Chairperson: Dr. Amisha Gheewala
2. Secretary: Gargi
ii. Grievance Redressal Committee
1. Chairperson: Dr. Virendra Chauhan
2. Secretary: Gargi
iii. Credential & Previleging Committee
1. Chairperson : Dr. Virendra Chauhan
2. Secretary: Dr. Dushyant Patel
iv. Pharmaco Therapeutic Committee
1. Chairperson: Dr. Mehul Desai
2. Secretary: Mayur Bhesaniya
v. Audit Committee
1. Chairperson: Dr. Arool Shukla
2. Secretary: Dr. Dushyant Patel
vi. Infection Prevention & Control Committee
1. Chairperson: Dr. Pankaj Agrawal.
2. Secretary: Ms. Suma

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vii. Quality Improvement Committee

1. Chairperson : Dr. Virendra Chauhan
2. Secretary : Ms. Neha Chouhan
viii. Condemnation Committee
1. Chairperson : Mr. Raghav Bhagrodiya
2. Secretary : Mr. Mayur Bhesania
ix. CPR Analysis Committee
1. Chairperson : Dr. Arool Shukla
2. Secretary : Dr. Dushyant Patel
x. Safety Committee
1. Chairperson : Mr. Shreepalsinh Vaghela
2. Secretary : Mr. Collince Taylor
xi. Disaster Preparedness and Prevention Committee
1. Chairperson: Mr. Shreepal Singh Waghela
2. Secretary: Mr. Collince Taylor

65. Floor wise facilities

✓ Basement

Mortuary Biomedical
IP pharmacy Maintenances
General store MRD
Linen Department Rehabilitation / Physiotherapy
Security Office

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✓ Ground Floor

Main Reception P Billing

Dental OPD Emergency
X-Ray and USG Pharmacy (24 x 7)
Minor OT
✓ First Floor

OPD Echo / ECG / TMT

CT Scan EMG / NCV
MRI Sample Collection & Labour OT
✓ Second Floor
i. Surgical ICU
ii. Cath Lab
iii. Dialysis
iv. OT
✓ Third Floor
i. Economy Ward
ii. Medical ICU
iii. CSSD
✓ Fourth & Fifth Floor
i. Twin Sharing Rooms
✓ Sixth Floor
i. Premier Room
✓ Seventh Floor
i. Premier Room
ii. Suite Room
✓ Eighth Floor
i. Pathology
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ii. Auditorium
iii. Admin department
✓ Ninth Floor
i. Canteen
ii. NICU & PICU
iii. Economy Ward
iv. Onco Ward
v. Clinical Research Department & Library
66. What is Reception Desk Timing?
✓ OPD Reception function from 8 am to 8 pm.
✓ Main Reception function 24 x 7
67. What are Patient Visiting Hours?
✓ Morning : 11 am to 1 pm (Wards) Evening : 5 pm to 7 pm (Wards)
✓ Morning : 12 pm to 1 pm (ICCU) Evening : 6 pm to 7 pm (ICCU)

68. Scope of OPD Services

✓ Consultation
✓ Radiology Investigation
✓ Pathology Investigation
✓ 2D Echo
✓ Audiometery (Outsourced) Soft Tone
✓ TMT (Tread Mill Test)
✓ ECG & Echo Cardiography
✓ Holter Monitoring
✓ Dialysis
✓ Health Check Ups
✓ Physiotherapy and Rehabilitation
✓ Mammography (Outsourced) Dr. Dhara Shah
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✓ EEG
✓ USG (Ultra – Sonography)
✓ EMG-NCV
✓ CT Scan
✓ MRI
✓ PFT (Pulmonary Function Test)
✓ Uroflowmetry
✓ Urodynamic Studies
✓ G I Endoscopy
69. What is SOP?
✓ Standard Operating Procedure
70. Which services are 24x7 in our hospital?
✓ Pharmacy
✓ Radiology
✓ Pathology
✓ Ambulance
✓ Emergency (9512660096)
71. Where to gather in Fire Hazardous Time (Assembly Point)?
✓ Ground Floor Parking Area (Road side)
72. Where is Location of Gas Manifold Area?
✓ Ground Floor Parking Area(Near Emergency Department)
73. Which path is to be used in Fire Situations?

✓ Fire Exit Staircase, Never use the lifts in case of fire.

74. What are the Types of Extinguishers used for different types of Fire?
✓ Dry Chemical Powder – Paper, Wood, Clothes
✓ CO2 – Electrical Hazardous Fire
✓ ABC – Multipurpose Fire
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✓ Mechanical Foam – Liquid form like oil, petrol etc

75. What is a PASS method to use fire extinguisher?
✓ P – Pull,
✓ A – Aim
✓ S – Squeeze
✓ S - Sweep
76. Management of OPD patient AAC-04
✓ All patients visited to OPD have to register first.
✓ Appointment base or first cup first serve
✓ We must informed about non availability of consultant
i. Reception Attendant would provide wheel chair for physically disabled patient
✓ All information related patient query must provide by reception and OPD staff
✓ Patient coming for first time must register with hospital from OPD counter
✓ Registration form filled up by the patient or relatives
✓ Sign of patients or close relatives is must on the form
✓ A unique number is then generated
✓ If patient is illiterate thumb impression is required
✓ If patient want to make changes in registration on follow up, documented proof for
making changes have to be submitted.
77. Patient Consent (SHS/SOP/PRE/4)

✓ The purpose of Patient’s consent is to inform patient about the routine medical and
nursing care provided to the patient on which he takes decision of getting registered
and admitted.
78. Guideline for patient consent:
✓ Consent should be taken before surgery or procedure
✓ Consent should be taken every time (especially before every procedure)
✓ Fresh consent should be taken before in case the procedure has to be change midway

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✓ Adult patient signature or thumb impression should be taken with signature and name of
the witness
i. Below 18 years consent is obtained from the parents
ii. Mentally ill or unconscious patient the left thumb impression in presence of
parents or guardian
79. General Consent :
✓ Every patient entering the inpatient care areas is required to give General Consent for all
types of treatment.
✓ The consent form is available in English and Gujarati
✓ Scope of General Consent informed to patients or relatives in understandable language.
80. Informed Consent :
✓ The designated person obtaining Informed Consent from patients before starting the
procedure, explaining possible risk and complications.
✓ Informed Consent is obtained for procedures in ward/Minor OT/Diagnosis department.
✓ Informed Consent for surgery is obtained by Surgeon after explaining the procedure,
possible complication and duration for recovery.
✓ Informed Consent for anesthesia is obtained by Anesthetists.
81. Consent is to be given by :
✓ The patient, unless he is a minor.
✓ If patient is incapable then consent obtained from wife/ parent / son / daughter / first
blood relation / guardian / neighbor or friend.
✓ For unidentified patient, treating doctor shall take a decision for further procedure for life
saving.
82. Information to patient
✓ Patients / Relatives are informed in detailed.
✓ Information on risks, benefits

83. Informed consent is to be taken in following situations

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✓ Consent for Anesthesia

✓ Consent for Surgery
✓ Blood Transfusion
✓ CT or USG Guided
✓ CT Scan and MRI
✓ Chemotherapy
✓ Surgical procedure
✓ Incisional, Excisional, punch or shave biopsy
✓ Foley’s Catheterization
✓ Nasogastric tube insertion
✓ Intubation
✓ Immunotherapy, intravenous or sub-cutaneous
✓ Abdominal, pleural drainage tube insertion
✓ Central line placement
✓ Patient Transfer Consent
✓ Restraint Consent
✓ HIV Consent Form
✓ Angiography & Angioplasty Consent Form
✓ TKR / THR Consent Form
✓ Dialysis Consent Form
✓ Consent for DAMA / DOR

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