NABH 6th Edition PSQ Chapter: Patient Safety and Quality Improvement Explained

What the PSQ chapter is about

NABH's intent for PSQ is a documented patient safety and quality programme that reaches every department and every staff member. Management builds a culture of safety and designates patient safety officers. The hospital follows national or international patient safety goals, collects data on structures, processes and outcomes (above all in high-risk areas), uses specialty-specific indicators to bring clinical departments into quality work, runs clinical audits, captures patient reported outcomes and investigates every incident.

Every Core element must score at least 4 out of 5 at every assessment, and Achievement and Excellence elements start counting at surveillance and re-accreditation. Our 6th Edition overview explains the scoring. NABH also marks nine PSQ elements with an asterisk, meaning they must be documented: PSQ.1.a, 2.a, 2.b, 2.e, 2.f, 2.h, 2.i, 7.a and 7.b.

The 7 standards at a glance

The patient safety programme (PSQ.1)

Two of the chapter's eight Core elements sit here. The programme is developed, implemented and maintained by a multidisciplinary safety committee (PSQ.1.a), and the hospital adapts and implements national or international patient safety goals, solutions or a framework (PSQ.1.g). NABH's change notes say the interpretation of this element now explicitly includes international patient safety goals, so expect assessors to ask how you handle patient identification, communication, high-alert medicines, surgical safety, infection risk and falls.

The other elements: the programme covers all the major safety areas, covers incidents from "no harm" to "sentinel events", is coordinated by designated patient safety officer(s), includes proactive analysis of safety risks (a failure mode and effects analysis is a common way to show this) and is reviewed and updated at least once a year.

Evidence that works: a patient safety programme document; committee terms of reference and minutes; the patient safety officer's appointment letter; a proactive risk analysis with the changes it led to; the annual review.

The quality improvement programme (PSQ.2)

The quality programme is run by a multidisciplinary committee (PSQ.2.a, Core) and there is an established process to monitor and improve the quality of nursing care (PSQ.2.i, Core). NABH's change notes say nursing quality must now be integrated into the hospital's main quality programme rather than run separately.

The programme must be comprehensive, coordinated by a designated individual, reviewed at predefined intervals to find improvement opportunities, reviewed and updated at least once a year, and supported by audits at regular intervals. Two of the chapter's three Excellence elements are here: the programme improves process efficiency and effectiveness (PSQ.2.c), and it focuses on the appropriateness of clinical care (PSQ.2.d), an element new to the 6th Edition.

Evidence that works: the quality manual or programme; the quality coordinator's appointment and training records; nursing quality indicators reported to the quality committee; audit schedules and reports; minutes showing improvement opportunities chosen and followed up.

Indicators and data (PSQ.3)

The hospital monitors key indicators for clinical, managerial, infection and safety areas. The two Core elements are infection prevention and control indicators (PSQ.3.b) and patient safety indicators (PSQ.3.d). The quality team verifies the data regularly (PSQ.3.e, which NABH's change notes say now carries extra emphasis), analyses it to find opportunities for improvement, and implements and evaluates the improvements. Feeding results back to staff is an Achievement element.

The 6th Edition's KPI annexure defines 32 hospital-wide and 18 department-specific indicators, each with a formula, unit and sampling rule. See the full NABH quality indicators list.

Evidence that works: an indicator list with definitions and data owners; monthly indicator reports with trends; a data verification log; committee minutes that act on the numbers.

Improvement projects, tools and PROMs (PSQ.4)

Quality improvement projects are Core (PSQ.4.a). The hospital uses suitable analytical, managerial and statistical tools for them, such as PDCA cycles, root cause analysis, fishbone diagrams, Pareto charts and run or control charts. Projects that improve patient care delivery and hospital operations with an impact on cost and efficiency (PSQ.4.b, new in the 6th Edition) and a mechanism to capture patient reported outcome measures (PSQ.4.d) are Achievement elements. PROMs moved here from the indicators standard as a tool for improvement.

Evidence that works: project files with a problem statement, baseline data, analysis, actions and results; PROM questionnaires with collected responses.

Clinical audit (PSQ.5)

The hospital runs clinical audits on parameters it defines, keeps patient and staff identities anonymous, documents each audit and implements remedial measures. Participation by medical and nursing staff is an Achievement element. NABH's change notes say the interpretation of PSQ.5.a changed the expected audit frequency, so check the current interpretation guide when you plan your audit calendar.

Evidence that works: an audit calendar; audit tools with explicit criteria; anonymised audit reports; re-audits showing the change worked.

Management support (PSQ.6)

Leaders at every level know the programme's intent, departmental leaders take part in it, and the hospital earmarks adequate funds from its annual budget for it (PSQ.6.d). Creating a culture of safety and setting organisational performance improvement targets are Achievement elements, and using feedback from the workforce to improve the programme is Excellence.

Evidence that works: a budget line for quality and patient safety; departmental heads presenting their indicators; performance targets approved by management; a staff safety culture survey.

Incidents and sentinel events (PSQ.7)

An incident management system is Core (PSQ.7.a). The hospital also needs a way to identify sentinel events, a process to analyse incidents, corrective and preventive actions, and a process for telling the relevant stakeholders about a near miss, adverse event or sentinel event. Carrying the risks found in incidents into the risk management system is an Achievement element.

NABH's glossary describes a sentinel event as an unexpected event involving death or serious physical or psychological injury caused by the care, equipment or supplies rather than the patient's illness. Hospitals usually investigate sentinel events with a root cause analysis, which the glossary describes as a system-based review of critical incidents.

Evidence that works: an incident reporting form available in every department; an incident register with near misses; root cause analyses for sentinel events; CAPA records with closure dates; a risk register that changes after incidents.

What changed from the 5th Edition

• The intent now stresses a culture of safety, involving clinical departments and capturing patient reported outcomes.
• New: PSQ.2.d (appropriateness of clinical care, Excellence) and PSQ.4.b (improvement projects with an impact on cost and efficiency, Achievement).
• Patient reported outcome measures moved from the indicators standard to PSQ.4.d.
• Several 5th Edition elements were merged, including two management elements in PSQ.6 and three quality-tool elements in PSQ.4.
• Interpretations now emphasise international patient safety goals, training for the quality coordinator, integrated nursing quality, clinical quality indicators and data verification.

How assessors test PSQ

Assessors ask for the patient safety and quality programmes, the committee minutes and the last annual review. They pick an indicator and trace it from raw data to the decision it led to, ask the quality team how they verify data, and open a quality improvement project file. In the wards they ask nurses how to report an incident and what happened to the last one they reported. A hospital that reports almost no incidents usually has a reporting culture problem, not a perfect safety record.

Getting PSQ ready

1. Constitute or revive the quality and patient safety committees and appoint the patient safety officer and quality coordinator.
2. Write the two programmes, adopt patient safety goals and set the annual review date.
3. Choose your indicators from the KPI annexure, assign data owners and start monthly reporting with data verification.
4. Run at least one improvement project and one clinical audit cycle end to end.
5. Launch non-punitive incident reporting, including near misses, and review incidents every month.

Our NABH documents checklist lists the PSQ policies, and we run 6th Edition gap analyses scored the way assessors score. Hospitals up to 50 beds follow the equivalent chapter in the SHCO standards.

All ten NABH 6th Edition chapter guides: AAC · COP · MOM · PRE · IPC · PSQ · ROM · FMS · HRM · IMS