NABH 6th Edition ROM Chapter: Responsibility of Management Explained

What the ROM chapter is about

NABH's intent for ROM is professional and ethical governance. The people responsible for governance are identified and their roles defined, a clinical governance framework covers clinical audits, clinical pathways, education and research, the responsibilities of leaders at every level are defined, the hospital complies with every applicable regulation, and it addresses its social responsibility. Leaders make patient safety and risk management part of patient care and hospital management, and the hospital has written guidance for change management and a service continuity plan.

Two definitions in the chapter matter:

• Those responsible for governance means the governing entity: the owner or owners, partners, trustees, a board of directors or, for a public hospital, the ministry concerned.
• Leadership means appointed leaders such as the CEO, COO, managing director, dean or director, and medical director or medical superintendent.

For a single-owner or partnership hospital, NABH states that all ROM standards and elements still apply.

Every Core element must score at least 4 out of 5 at every assessment. Our 6th Edition overview explains the scoring. NABH marks 12 ROM elements with an asterisk, meaning they must be documented: ROM.1.a, 1.b, 1.c, 1.f, 2.a, 2.b, 3.b, 5.b, 5.e, 5.f, 6.a and 6.d.

The 6 standards at a glance

Governance (ROM.1)

The Core element is that those responsible for governance are identified and their roles and responsibilities defined and documented (ROM.1.a); the interpretation now stresses documenting the structure of the governing body. Governance lays down the vision, mission and values, approves the strategic and operational plans and the annual budget, measures performance against the mission (moved up from Achievement to Commitment), appoints senior leaders, supports safety, clinical governance and quality plans, and informs the public about the quality and performance of its services.

New in this edition, governance must develop a clinical governance framework (ROM.1.g). Supporting the ethical management framework is an Achievement element.

Evidence that works: a governance document naming the owners, partners, trustees or board and their roles; displayed vision, mission and values; an approved strategic plan and annual budget; governing body minutes reviewing performance and quality; a clinical governance framework document.

Ethics (ROM.2)

The leaders establish an ethical management framework (ROM.2.a, Core) with processes for ethical issues, dilemmas and concerns. The hospital discloses its ownership and honestly portrays its affiliations and accreditations.

Evidence that works: an ethics policy and ethics committee (or a defined route for ethical dilemmas) with minutes; an ownership disclosure; accreditation claims on signage, letterheads and the website that match current certificates.

Sustainability (ROM.3, new)

ROM.3 is the 6th Edition's biggest addition to this chapter. Governance addresses a sustainability programme in terms of environmental, social and governance (ESG) responsibility and the hospital's social responsibility. The hospital takes initiatives towards being energy-efficient and environment-friendly (moved here from FMS; the interpretation stresses saving electricity and water) and promotes staff well-being (moved here from HRM and raised from Achievement to Commitment). Encouraging staff to use common or public transport and ensuring the hospital's financial sustainability are Achievement elements, and sustainable procurement is Excellence.

Evidence that works: a sustainability or ESG policy with targets; electricity and water consumption tracked monthly; LED lighting, solar or rainwater harvesting where feasible; community health camps or other social responsibility records; a staff well-being programme.

The hospital head (ROM.4)

The person heading the hospital has suitable administrative qualifications and experience, and is responsible for complying with all applicable laws, regulations and notifications (ROM.4.b, Core). The leader appoints or helps recruit department leaders. Effective leadership in every department and a review of the leader's own performance are Achievement elements.

Evidence that works: the head's appointment letter and qualifications; a statutory compliance register listing every licence with its renewal date; department heads appointed in writing.

Plans, committees and service standards (ROM.5)

The hospital has strategic and operational plans with long and short-term goals made in consultation with stakeholders, coordinates with departments and external agencies to monitor progress (moved up from Achievement to Commitment), and plans and budgets annually. It documents measurable service standards and monitors them. Reviewing how well committees work is an Achievement element, and systems for change management are Excellence.

Evidence that works: an annual operating plan and budget; service standards such as OPD waiting time or report turnaround times, with monthly monitoring; a committee effectiveness review; a change management procedure.

Risk management and outsourcing (ROM.6)

Leadership ensures proactive risk management across the hospital (ROM.6.a, Core; the interpretation now stresses clinical risk assessment), resources risk assessment and reduction, and integrates quality improvement, risk management and strategic planning. Every outsourced service has a documented agreement that includes service parameters. Systems for internal and external reporting of system and process failures (whose interpretation now includes a service continuity plan for fire and non-fire emergencies) and monitoring the quality of outsourced services are Achievement elements.

Evidence that works: a hospital-wide risk register with owners and review dates; risk assessments for clinical areas; contracts for housekeeping, security, laundry, diet, laboratory and other outsourced services with measurable service levels; a service continuity plan.

What changed from the 5th Edition

• New standard ROM.3 on sustainability, with new elements on ESG, social responsibility, sustainable procurement, public transport and financial sustainability, plus energy (from FMS) and staff well-being (from HRM).
• New: a clinical governance framework (ROM.1.g).
• Level changes: measuring performance against the mission (ROM.1.d) and monitoring progress on goals (ROM.5.b) moved from Achievement to Commitment.
• The intent now covers clinical governance, a service continuity plan and the levels of leadership, and ROM.2 now places ethics with governance rather than only with leaders.

How assessors test ROM

ROM is assessed mostly through interviews with the owner or board, the hospital head and department heads. Assessors ask who governs the hospital and how decisions are recorded, how the budget is approved, how the hospital knows it complies with every law, what the top five risks are and what is being done about them, and how outsourced services are monitored. They also compare what the hospital claims publicly with its real certificates.

Getting ROM ready

1. Document the governance structure, vision, mission and values, and the hospital head's role.
2. Build a statutory compliance register and keep every licence current.
3. Write the ethical management framework and the clinical governance framework.
4. Set up a risk register and review it in management meetings.
5. Put written agreements with service levels in place for every outsourced service, and start a simple sustainability programme.

Our NABH documents checklist lists the ROM documents, our licences service keeps statutory approvals current, and we run 6th Edition gap analyses scored the way assessors score.

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