Entry Level AAC1

AAC.1: THE ORGANIZATION DEFINES AND DISPLAY THE SERVICES THAT IT CAN PROVIDE.

A)    THE SERVICES BEING PROVIDED ARE CLEARLY DEFINED.

The services provided are clearly defined by the senior management and also are in consonance with the requirements of the community.

The scope of services for _______________ Hospital.

CLINICAL SERVICES	SUPPORT SERVICES
GENERAL MEDICINE	HUMAN RESOURCES
GENERAL SURGERY	CENTRAL STERILE SUPPLY DEPARTMENT
PEDIATRICS	BIOMEDICAL ENGINEERING SERVICES
GYNECOLOGY & OBSTETRICS	AMBULANCE
OPHTHALMOLOGY	MEDICAL RECORDS DEPT.
ANESTHESIOLOGY	PHARMACY
ENT	HOUSE KEEPING
ORTHOPEDICS	INFORMATION TECHNOLOGY
PSYCHIATRY
RADIOLOGY
DENTAL
EMERGENCY DEPT.
LABORATORY

Task and responsibilities:

NO	TASK	RESPONSIBILITY
1	DEFINE THE GENERAL SCOPE OF SERVICES	HEAD OF _________ HOSPITAL
2	DEFINE THE DEPARTMENTAL SCOPE OF SERVICE	TOP MANAGEMENT IN CONSULTATION WITH THE SPECIFIC DEPARTMENT HEAD
3	DOCUMENT THE ABOVE INTO A POLICY ON ‘SCOPE OF SERVICES’ AND PLACE THE SAME IN AN SOP MANUAL	ASSIGNED STAFF
4	AVAILABILITY OF THE VALID LICENSE RELATED TO THE SPECIFIC DEPARTMENT	ADMINISTRATIVE DEPT.
5	DISPLAY PROMINENTLY THE SCOPE OF SERVICES IN TWO LANGUAGES	ADMINISTRATIVE DEPARTMENT
6	UPDATE THE SCOPE OF SERVICE	TOP MANAGEMENT/HEAD OF CONCERNED DEPT.
7	STAFF ORIENTATION TO THE SCOPE OF SERVICES	QUALITY TEAM/TRAINING CELL

AUDIT CHECKLIST

NO.	CHECKPOINT	YES	NO	REMARKS
1	AVAILABILITY OF SCOPE OF SERVICE POLICY DOCUMENT INCLUDING LICENSE	YES
2	BILINGUAL DISPLAY OF SCOPE OF SERVICE IN A PROMINENT AREA	YES
3	STAFF TRAINING RECORDS	YES

B)     THE DEFINED SERVICES ARE PROMINENTLY DISPLAYED.

·         The services provided by the hospital are displayed prominently in the language of ENGLISH and HINDI.

·         The details of services provided are displayed in an area visible to patients and family members while entering respective facilities/areas.

·         Managing representative is responsible to identify the requirement of signage boards, to provide the same and rectify in case of any damage.

·         Tariff of room and other basic services of hospital are made available at front office.

·         Pamphlets for distribution if needed.

C)    THE RELEVANT STAFF ARE ORIENTED TO THESE SERVICES.

The staff of help desk, admission counter, billing, outpatient dept., diagnostics and causality are to be trained on this policy for the following conditions: joining of new staff, changes/updating of tariff/services/policy.

If identified, any lack of awareness of staff thorough observation/complaints

The relevant staff is oriented on the services provided by the hospital either by in training program or by reading this document, an appropriate, the same to be recorded in training record form.

DAY CARE BED TYPE	NUMBER OF BEDS
EMERGENCY BEDS	3
DAY CARE BEDS	3
RECOVERY ROOM BEDS	3
LABOUR ROOM BEDS	2
DIALYSIS	4
BED TYPE	NUMBER OF BEDS
ICU	11
GENERAL WARD	15
PVT WARD	20
ISOLATION	1
TOTAL	47