1. AAC.

1: The organisation defines and displays the healthcare services it

provides.
 Requirement: The healthcare services offered by the organisation must be
clearly defined and available to the community. The services should reflect
the needs of the population it serves.
 Fulfillment: The services should be documented and publicly displayed. This
includes outpatient, inpatient, and emergency services. The scope of services
should also be specified for each department, ensuring that staff and patients
are aware of what is available. This is important for transparency and guiding
patient expectations.
 Requirement:
 Define and document all healthcare services.
 Display services prominently for patients and staff.
 SOP Needs:
 Procedure for documenting, reviewing, and updating healthcare services.
 Process for displaying services in public areas (e.g., boards, websites).

 KPI 1: Percentage of healthcare services defined and documented in the service

directory.
 Target: 100% of services should be clearly defined and documented.
 KPI 2: Frequency of review and update of services.
 Target: Annually or as needed based on changes in healthcare offerings or
community needs.
 KPI 3: Percentage of services displayed in public areas (e.g., reception, website,
brochures).
 Target: 100% of services listed on display boards, websites, and brochures.
2. AAC.2: The organisation has a well-defined registration and admission
process.
 Requirement: The registration process for patients must be well-organized
and easy to follow. There must be written procedures for admitting patients,
which include a unique patient ID and clear guidelines for handling situations
like the unavailability of beds.
 Fulfillment: There should be a written protocol for patient registration,
ensuring every patient is assigned a unique identification number. This helps
in maintaining accurate patient records and managing admissions
systematically. Priority for healthcare services should be based on the clinical
needs of the patient. Additionally, if there is a shortage of beds, the
procedure for managing this should be clear, and patients should be
transferred appropriately to other facilities if necessary.
 Requirement:
 Ensure a smooth, well-documented registration and admission system.
 Address situations like unavailability of beds.
 Generate unique identification numbers for patients.
 SOP Needs:
 Registration process, including mandatory data collection and ID generation.
 Admission protocol for planned and emergency admissions.
 Handling bed shortages (e.g., triage or referral procedures).

 KPI 1: Time taken for patient registration from arrival to entry in the system.
 Target: Less than 10 minutes for routine cases, immediate for emergency
cases.
 KPI 2: Percentage of patient admissions with complete documentation.
 Target: 100% of admitted patients should have their admission
documentation complete.
 KPI 3: Percentage of patients transferred to other facilities due to unavailability
of beds.
 Target: No more than 5% of patients should be transferred due to
unavailability of resources.

3. AAC.3: There is an appropriate mechanism for transfer (in and out) or

referral of patients.
 Requirement: Patients should be transferred or referred to other healthcare
providers if needed. The process for transferring patients both to and from
the organisation must be appropriate, ensuring patient safety and continuity
of care.
 Fulfilment: There must be written guidelines for the transfer or referral
process. The staff involved in transferring patients should be appropriately
trained, and the patient’s condition, treatment summary, and transfer details
must be communicated to the receiving institution. This includes ensuring
that the receiving institution has the necessary resources to handle the
patient’s condition.

 Requirement:
o Ensure safe and systematic transfer or referral.
o Communicate patient details and provide transfer summaries.
 SOP Needs:
o Protocols for initiating and managing patient transfers.
o Communication guidelines for sharing patient information.
o Procedure for selecting and preparing escort staff for transfers.

 KPI 1: Time taken for patient transfer from one unit to another within the hospital.
o Target: Within 30 minutes for non-critical cases, immediate for critical cases.
 KPI 2: Percentage of transfers that are documented accurately.
o Target: 100% of transfers should have complete and accurate documentation.
 KPI 3: Percentage of transfer cases where the receiving facility was adequately prepared.
o Target: 100% of transfers should ensure the receiving facility is informed and
prepared.
4. AAC.4: Patients undergo an established initial assessment.
 Requirement: All patients must undergo a thorough initial assessment upon
admission, which includes a detailed evaluation of their medical condition,
special needs, and a care plan.
 Fulfillment: The assessment should be performed by qualified personnel
(doctors, nurses, etc.) and should cover all aspects of the patient’s health.
The assessment should be documented, and a care plan should be developed
and reviewed regularly. Special needs, such as those related to discharge
planning, should also be identified.
 Requirement:
 Conduct and document a thorough initial assessment for all patients.
 Include nursing and medical evaluations.
 SOP Needs:
 Process for conducting initial assessments for outpatients, inpatients, and
emergencies.
 Guidelines on timelines for assessments and documenting care plans.

 KPI 1: Time taken for initial patient assessment after admission.

 Target: Initial assessment completed within 1 hour for emergency cases, 24
hours for routine admissions.
 KPI 2: Percentage of patients with a documented care plan post-initial
assessment.
 Target: 100% of patients should have a documented care plan developed
after the initial assessment.
 KPI 3: Percentage of assessments conducted by qualified personnel.
 Target: 100% of assessments should be performed by qualified medical or
nursing staff.
5. AAC.5: Patients undergo regular reassessments.
 Requirement: Patients should not only have an initial assessment but also
regular reassessments during their stay to monitor their response to
treatment and adjust care plans accordingly.
 Fulfillment: Reassessments should be scheduled at appropriate intervals
depending on the patient’s condition. This process includes reassessing the
care plan and making adjustments as needed. In addition, systems should be
in place to detect early warning signs of patient deterioration, prompting
immediate intervention.
 Requirement:
 Reassess patients periodically to monitor progress.
 Update and modify care plans based on findings.
 SOP Needs:
 Frequency and scope of reassessments for different patient categories.
 Protocols for detecting and addressing early warning signs.
 Documentation of reassessment findings and care plan updates.

 KPI 1: Percentage of patients reassessed within the prescribed intervals.

 Target: 100% of patients should undergo reassessments as per the care plan.
 KPI 2: Time taken to update care plans based on reassessment findings.
 Target: Care plans should be updated within 24 hours after reassessment.
 KPI 3: Percentage of reassessments involving multidisciplinary teams.
 Target: 90% of reassessments should involve a multidisciplinary approach.
6. AAC.6: Laboratory services are provided as per the organisation's scope
of services.
 Requirement: The organisation must offer laboratory services that align
with the scope of its healthcare services. This includes ensuring the
laboratory has the appropriate infrastructure and personnel.
 Fulfillment: Laboratory services should be available for diagnostic purposes,
and they must be provided by qualified personnel. The laboratory should
meet safety standards, and test results must be available in a timely manner.
Laboratory procedures should follow written protocols for specimen handling,
processing, and reporting.
 Requirement:
 Ensure availability of diagnostic laboratory services with qualified personnel.
 Provide timely and accurate results.
 SOP Needs:
 Guidelines for sample collection, handling, and transportation.
 Testing, reporting, and turnaround time management.
 Procedure for outsourcing tests.


 KPI 1: Turnaround time (TAT) for routine and critical laboratory tests.
 Target: Routine tests completed within 24 hours, critical tests communicated
within 2 hours.
 KPI 2: Percentage of laboratory tests conducted according to the hospital's scope
of services.
 Target: 100% of tests outsourced or conducted should align with the defined
scope of services.
 KPI 3: Percentage of tests where sample handling protocols are followed.
 Target: 100% adherence to sample collection, handling, and transportation
protocols.
7. AAC.7: There is an established laboratory quality assurance
programme.
 Requirement: A comprehensive quality assurance (QA) programme for
laboratory services must be in place to ensure accuracy, reliability, and
safety in laboratory testing.
 Fulfillment: The QA programme must cover all aspects of laboratory work,
including calibration of equipment, validation of test methods, and
monitoring the quality of results. Periodic reviews and audits should be
conducted to ensure compliance with QA standards.
 Requirement:
 Maintain a quality assurance (QA) programme to validate test accuracy.
 SOP Needs:
 Regular calibration and validation processes for lab equipment.
 Audit protocols for verifying QA compliance.
 Documentation of corrective and preventive actions.

 KPI 1: Percentage of laboratory tests passed in internal audits.

o Target: 100% of laboratory tests should pass internal quality checks.

 KPI 2: Frequency of calibration of laboratory equipment.

o Target: Equipment should be calibrated at least quarterly or as per
manufacturer guidelines.
 KPI 3: Percentage of corrective actions taken within the prescribed time after
audit findings.
o Target: 100% of corrective actions should be completed within 30 days.
8. AAC.8: There is an established laboratory safety programme.
 Requirement: The laboratory must have a safety programme that ensures
the protection of both patients and staff during laboratory procedures.
 Fulfillment: This includes ensuring safe handling of specimens, safe use of
equipment, and appropriate training for laboratory personnel in safety
protocols. Safety measures should be aligned with national and international
safety guidelines.
 Requirement:
 Protect patients and staff by ensuring safe laboratory practices.
 SOP Needs:
 Safe handling and disposal of biohazard materials.
 Training for staff in safety protocols.
 Incident management for lab-related safety breaches.

 KPI 1: Percentage of laboratory staff trained in safety protocols.

 Target: 100% of laboratory personnel should be trained in safety protocols
annually.
 KPI 2: Number of safety incidents reported in the laboratory.
 Target: Zero safety incidents should be reported annually.
 KPI 3: Percentage of lab safety equipment maintained and tested.
 Target: 100% of laboratory safety equipment should be maintained and
tested as per safety protocols.
9. AAC.9: Imaging services are provided as per the organisation's scope of
services.
 Requirement: Imaging services, such as X-rays, CT scans, and MRIs, should
be available in accordance with the scope of services provided by the
organisation.
 Fulfillment: Imaging services should be appropriately equipped, staffed, and
managed. The infrastructure must support the imaging procedures necessary
for the patient care provided. Imaging tests should be performed safely, and
the results should be promptly reported to the medical team.
 Requirement:
 Provide imaging services aligned with the organisation’s healthcare scope.
 SOP Needs:
 Patient preparation and safety during imaging procedures.
 Safe transport of patients to and from imaging areas.
 Reporting imaging results within a defined timeline.

 KPI 1: Time taken for imaging results to be delivered to the clinical team.
 Target: Imaging results should be available within 1 hour for urgent cases, 24
hours for routine cases.
 KPI 2: Percentage of imaging services performed using up-to-date equipment.
 Target: 100% of imaging services should use calibrated and current
equipment.
 KPI 3: Percentage of patients screened for imaging contraindications.
  Target: 100% of patients should undergo safety screening before imaging
procedures.

10. AAC.10: There is an established quality assurance programme for

imaging services.
 Requirement: Just like laboratory services, imaging services must have a
formal quality assurance programme to ensure the accuracy and reliability of
results.
 Fulfillment: The QA programme should include protocols for calibration and
maintenance of imaging equipment, periodic internal and external reviews of
imaging results, and adherence to radiation safety standards. It should also
include regular training for personnel.
 Requirement:
 Implement a QA programme to ensure imaging accuracy and safety.
 SOP Needs:
 Regular equipment calibration and quality control checks.
 Review protocols for imaging results.
 Training sessions on imaging best practices.

 KPI 1: Frequency of imaging quality reviews and audits.

 Target: At least 2 quality reviews per year for imaging services.
 KPI 2: Percentage of imaging results that meet the defined accuracy standards.
 Target: 100% of imaging results should meet accuracy standards as per
internal reviews.
 KPI 3: Percentage of imaging equipment inspected and calibrated regularly.
  Target: 100% of imaging equipment should be inspected and calibrated as
per schedule.

11. AAC.11: There is an established safety programme in imaging services.

 Requirement: A safety programme must be in place to ensure that imaging
services are carried out in a safe manner, protecting both patients and
healthcare workers.
 Fulfillment: This involves ensuring proper radiation safety measures,
screening patients for risks before imaging, and using appropriate protective
devices for both patients and staff. Personnel should be trained in radiation
safety practices, and imaging facilities should have clear safety signage.
 Requirement:
 Ensure safety in imaging, particularly with radiation.
 SOP Needs:
 Radiation safety protocols, including the use of shielding and monitoring
devices.
 Pre-imaging screening for safety risks.
 Maintenance and testing of radiation equipment.

 KPI 1: Percentage of staff trained in radiation safety.

 Target: 100% of imaging staff should undergo radiation safety training
annually.
 KPI 2: Number of radiation-related incidents reported.
 Target: Zero radiation-related incidents should be reported annually.
 KPI 3: Percentage of imaging facilities adhering to safety protocols.
 Target: 100% of imaging facilities should comply with safety protocols.

12. AAC.12: Patient care is continuous and multidisciplinary.

 Requirement: Care for patients must be continuous and provided by a
multidisciplinary team, ensuring comprehensive treatment throughout the
patient’s stay.
 Fulfillment: A multidisciplinary approach ensures that all aspects of a
patient’s care are considered, including medical, nursing, nutritional, and
psychological needs. Regular communication between the various care
providers is essential to ensure coordinated and effective care delivery.
 Requirement:
 Ensure continuous and collaborative patient care across all disciplines.
 SOP Needs:
 Guidelines for multidisciplinary team meetings and care coordination.
 Handover protocols for staff changes.
 Communication strategies among caregivers.

 KPI 1: Percentage of patient care plans developed by multidisciplinary teams.

 Target: 100% of care plans should be developed in collaboration with
multidisciplinary teams.
 KPI 2: Percentage of patients with documented handovers between shifts.
  Target: 100% of patients should have a documented handover between
shifts.
 KPI 3: Frequency of multidisciplinary team meetings for complex cases.
 Target: Monthly meetings or as required for patient care coordination.

13. AAC.13: The organisation has an established discharge process.

 Requirement: The discharge process must be well-defined, ensuring that
patients leave the hospital with all necessary information, instructions, and
follow-up care details.
 Fulfillment: The discharge process should include patient education, a
discharge summary, and instructions for follow-up care. The process should
be coordinated between different departments (e.g., medical, nursing, and
pharmacy), and the patient should be consulted to ensure they understand
the discharge plan.

 Requirement:
o Facilitate smooth and coordinated patient discharge.
o Provide clear instructions to patients and families.
 SOP Needs:
o Discharge procedures, including patient education.
o Managing cases of discharge against medical advice (LAMA) or absconding.
o Coordination with other departments (e.g., pharmacy, billing).

 KPI 1: Time taken to complete the discharge process after a decision is made.
 Target: Discharge process should be completed within 2 hours after the
discharge decision.
 KPI 2: Percentage of discharged patients with a completed discharge summary.
 Target: 100% of discharged patients should receive a discharge summary.
 KPI 3: Percentage of patients educated on post-discharge care.
 Target: 100% of patients should receive post-discharge care instructions.

14. AAC.14: The organisation defines the content of the discharge

summary.
 Requirement: The discharge summary should contain essential information
to guide the patient’s post-discharge care.
 Fulfillment: The discharge summary should include the reason for
admission, diagnoses, treatment provided, and the patient’s condition at
discharge. It should also include follow-up instructions, medication details,
and information on how to access urgent care if necessary. The discharge
summary must be provided in a clear and understandable manner to the
patient and their caregivers.

 Requirement:
o Ensure discharge summaries include essential details for post-hospital care.
 SOP Needs:
o Standardized discharge summary templates.
o Approval process for finalizing discharge summaries.
o Process for educating patients/families about the summary content.

 KPI 1: Percentage of discharge summaries including all mandatory content (e.g.,

diagnosis, treatment, follow-up care).
o Target: 100% of discharge summaries should contain all required elements.
 KPI 2: Time taken to provide the discharge summary to patients.
 o Target: Discharge summary should be provided to the patient before discharge.
 KPI 3: Patient satisfaction with the discharge summary.
o Target: Achieve a satisfaction rate of 90% or higher from patient surveys.