A chapter-wise self-assessment for hospital quality teams. Work through it quarterly, not just before the assessor visits.
Patient-centred standards
AAC — Registration, assessment and continuity-of-care processes documented and followed
COP — Care protocols, emergency/ambulance, and high-risk care policies current
MOM — Medication storage, look-alike/sound-alike controls, and high-alert drug policy in place
PRE — Patient rights, informed consent and education records complete
HIC — Infection-control manual, surveillance data and hand-hygiene audits up to date
PSQ — Quality indicators tracked monthly with thresholds; sentinel-event policy defined
Organisation-centred standards
ROM — Organisation chart, statutory licences and committee terms of reference current
FMS — Fire NOC valid, fire drills logged, facility rounds and BMW handling compliant
HRM — Credentialing, mandatory training and competency records current for every staff member
IMS — Medical-records completeness, retention policy and data-privacy controls in place
Evidence & governance
All committee minutes signed and timestamped at the meeting (not reconstructed later)
Every corrective action (CAPA) tracked to verified closure with evidence
Licence/NOC/AMC expiry dates tracked with advance reminders
Evidence organised by chapter and retrievable within minutes
A current 0–100 readiness view available to leadership at any time
Tired of rebuilding this every cycle? Acredify keeps every item above continuously ready — live in 3 days, free 90-day pilot.
→ Start a free pilot at acredify.in/pilot