Quality Assurance Manual GMERSGHH/CQI/A Quality Manual G.M.E.R.S General Hospital, Himmatanagar, Gujarat

INDEX

S. No. Pages

1. Responsibility for Implementation 4-4

2. Amendment sheets 5-6

3. Services available at GMERSGHH 7-8

4. Quality Management System

Quality Assurance Committee

Our Vision

Our Mission

Quality Policy Statement

Objectives

Service Standards

8-14

5. Structure for Quality Assurance

Documentation System

Quality Assurance Committee

Accreditation Coordinator

Departmental Coordination

14-17

6. Quality Assurance Programme 17-36

RESPONSIBILITY FOR IMPLEMENTATION:

The overall responsibility for formulating, revising, implementing,

provisioning of education material to patients/ workers, training of trainers/

supervisors/ concerned hospital personnel and monitoring for this manual

is the responsibility of the Co-Chairperson Quality Assurance Committee

and its committee members.

Also the top management is responsible for implementation of this

manual.

All individual Incharges of the related units are directly responsible for the

implementation / training of supervisors / concerned hospital personnel

and monitoring / reporting for this policy in their respective areas of work.

For this they shall take guidance from and coordinate with the Co-

Chairperson Quality Assurance Committee.

ABBREVIATIONS USED:

CRBSI – CR Blood Stream Infection

SSI – Surgical Site Infection

VAP – Ventilator Associated Pneumonia

SERVICES AVAILABLE AT GMERSGHH:

MG General Hospital is a 180 bedded district hospital which serves as a referral center for 10 CHCs, 36 PHCs and 281 subcentres of Navsari. The Secondary level health care services provided by hospital include OPD, Indoor and Emergency services. The list of services provided at MG General Hospital is as follows: I) Clinical Services:

a) General Surgery b) General Medicine c) Obstetric & Gynecology d) Pediatrics e) Emergency services ( Accident & other emergency) f) Critical Care (ICU & ICCU) g) Anesthesia h) Ophthalmology i) ENT (Only OPD services) j) Dermatology & Venerology including STI / RTI k) Orthopedics l) Psychiatry m) Dental Care n) PP Unit

II) Paraclinical Services:

a) Laboratory Services - Clinical Biochemistry

- Clinical Pathology

- Hematology

- Histopathology

- Cytopathology

- Serology

- Therapeutic Drug Monitoring

b) X- ray c) Sonography (Ultrasound) d) ECG e) VCTC Counseling Services f) Blood Transfusion g) Physiotherapy h) Medical Stores & Dispensary

III) Support Services: a) Medico legal / postmortem b) Ambulance services c) Dietary Services (only for patients)

d) Laundry Services (Outsourced) e) Security Services f) Waste management services g) CSSD (Central Sterile & Supply Department) h) Medical Records Department i) Mortuary Facility. j) Medical gases ( cylinders & piped medical gases) k) General Stores

IV) Administrative Services:

a) Accounts Section b) Establishment Section c) Housekeeping Services d) HMIS (Hospital Management Information System).

QUALITY MANAGEMENT SYSTEM The hospital follows a structured quality assurance and continuous monitoring

programme, developed by Quality Assurance Committee of the hospital, on the

basis of NABH standards

1. Quality Assurance Committee

MGG Hospital has formed a Quality Assurance Committee with following

membership and scope of work:

Name of Committee Members Designation / Department

Dr. J.M Uperia – Chairperson Medical Superintendent

Dr. R.D Parikh - Co-Chairperson RMO

Ms. Priyanka Patel AHA

Members:

Dr. Hina Shah Anesthetist

Dr. Akhilesh Pandey DQAO

Dr. Mittal Gandhi Dentist

Mrs Manda Solanki OT Incharge

Mrs Heeraben Patel Staff Nurse

Scope of Work:

Issue Quality Policy

Documentation of policy

Deal with all matters concerning quality management system, quality

improvement, accreditation of the health care service.

To provide support and guidance to other committees and department in

developing indicators.

Function as apex committee for monitoring performance indicators /

parameters of QMS and medical statistics

Standardization of procedures and systems

Credentialing and Privileging of medical and nursing staff.

Provision of resources for successful implementation of quality program at

MGG hospital.

Evaluate sentinel events related to patient care.

Conducting regular meetings of all respective committee chairpersons to

keep a track of the activities carried out by them and trouble shooting if

any in implementation in their respective areas.

Plan and act for Continuous Quality improvement of hospital

NABH Chapter Ref: CQI, HRM -10, 12

In line with our goal of providing quality services in our hospital, we have

developed and set our vision, mission, quality policy, and service standards.

2. OUR VISION:

"To be the part of network of finest public health care institutions in the State of

Gujarat, providing quality medical care services with the state of art technology

with easy accessibility, affordability and equity to the people of Gujarat and

beyond."

3. OUR MISSION:

The GMERS General Hospital is dedicated to carry forward the dream of

government of Gujarat to provide quality care of national standards to all in a

caring & compassionate environment.

4. QUALITY POLICY STATEMENT:

GMERSGHH is committed to provide Health Care par excellence at reasonable

cost. This would be achieved through:

a. Complying with National and International Quality standards

b. To provide services within the framework of Regulatory requirements

c. Up gradation of Technology and Facilities on regular basis

d. Training the manpower in the relevant discipline

e. Continuous Quality improvement in the processes

f. Striving to increase external and internal customer satisfaction level.

5. OBJECTIVES:

To provide high quality care according to the health needs of the

catchment population

To facilitate patient satisfaction by service and ensuring the dignity and

rights of patients and other stakeholders.

To provide a safe and conducive work environment for staff.

To ensure accountable, consultative and transparent management

process.

To provide basic and continuing education for staff.

To integrate with district and state health system, by providing referral

systems, technical, and logistic support to primary and community health

care.

6. SERVICE STANDARDS:

GMERS General Hospital has:

11 Specialists

5 Medical Officers and 37 Nurses

Standards of service and adequate degree of patient care can be provided

to the extent proper and workable ratio between doctor to patient, nurse to

patient and beds to patients are maintained, as also the extent of

availability of resources and facilities. Consistent with this every possible

effort will be made by this hospital to provide standard services.

To provide access to hospital and professional medical care to all patients

who visit the hospital.

To prescribe a workable maximum waiting time for outpatients, before

they are attended to by a qualified doctor and I or specialists and

continuously strive to improve upon it.

To ensure that all equipment in the hospital are maintained efficiently in

proper working order.

To ensure availability of beds and operation theatres facilities as freely as

possible.

To ensure treatment of emergency cases with utmost promptitude and

attention.

Every outpatient seeking treatment at the hospital will be registered and

issued a case for recording various details of the symptoms, diagnosis

and treatment being provided. Efforts will be made to computerize the

record system in the hospital, to provide better service to the patients.

The patients' and families' rights are in consonance to accreditation

standards and are documented separately in this charter.

All patients and visitors to the hospital will receive courteous and prompt

attention from the staff and officials of the hospital in the use of its various

services.

Reliability and promptness of diagnostic investigation results is ensured

and whenever possible such reports will be made available.

Operation theatre is maintained on a regular basis to ensure that they are

serviceable all the time and every effort will be made to keep the hospital

and its surroundings, clean, infection-free and hygienic.

A regular system of obtaining feedback from the users is in place through

periodic surveys. The inputs from these are continuously used for

improving the service standards.

The hospital has necessary equipments required for provision of service

mentioned in 'scope of services and system to ensure proper maintenance

and working of various equipments.

When things go wrong or fail, appropriate action is taken on those

responsible for such failures and action taken to rectify the deficiencies.

Complainants will also be informed of the action taken, if requested.

In case of likely persistence of the deficiency, the reasons for the delay in

rectifying the deficiency and the time taken for rectifying the same will be

displayed prominently for the information of the public.

Special directions are given to the non-medical staff to deal with the

patients and public courteously. Any breach in this regard when brought to

the notice of the hospital authorities shall be dealt with appropriately.

Hospital encourages the patients and the public to inform the authorities

when things go wrong. Suggestion I complaint boxes alongwith complaint

tracking forms and registers are provided at the reception, at each ward

level, RMO office, Matron Office, sanitary inspector and administrator.

To resolve patient complaints the hospital has formed a Patient Complaint

Cell.

Hospital follows all policies, processes, programmes, committee meetings;

regulatory guidelines, which have been prepared to meet the standards of

accreditation as, set by NABH.

7. STRUCTURE FOR QUALITY ASSURANCE:

Hospital has developed a structure for carrying out processes related to Quality

Assurance in the hospital. This is as follows:

Documentation system: Ten chapter wise committees were formed for the

purpose of documentation at MGG Hospital which had representation from

various clinical and non clinical and administrative departments. These

committees have developed their documentation on policies, procedures,

programmes, guidelines etc. These documents have been reviewed by

Management Representative, respective committee chairpersons and have been

approved by MEDICAL SUPRINTENDENT The ten chapter wise committees

were:

1) AAC Committee

2) COP Committee

3) MOM Committee

4) PRE Committee

5) HIC Committee

6) CQI Committee

7) ROM Committee

8) FMS Committee

9) HRM Committee

10) IMS Committee

Details of the membership of these committees have been mentioned in the

Apex Quality Manual. These committees have been resolved into following

committees details of which are mentioned in the Apex Quality Manual.

1) Quality Assurance Committee

2) Hospital Infection control Committee

3) Hospital Ethics Committee

4) Drugs & Therapeutic Committee

5) Hospital Safety Committee

6) Grievance Redressal Committee

7) Biomedical Waste Management Committee

8) Medical Audit Committee

9) Disaster Management Committee

10) Biomedical equipment management & medical gases management

committee.

11) Blood Transfusion Reaction monitoring Committee.

Quality Assurance Committee: Quality assurance related activities is planned,

undertaken, and controlled by Quality Assurance Committee which is a

multidisciplinary committee having representation from various clinical, non-

clinical and administrative departments.

Accreditation Coordinator: The hospital designated Accreditation, Co-

ordinator, will have overall responsibility of coordinating the work of NABH

accreditation. His I her responsibility will include:

To issue various documents to departments from time to time.

To keep a record of all the documentation of the hospital, in relation to

accreditation.

To delegate the activities in departments and ensure its timely

completion.

To regularly receive feedbacks from departments regarding status of their

work related to accreditation preparation.

To coordinate all such activities required for quality assurance and

continuous monitoring of the hospital.

Departmental Coordination:

Each department of the hospital has been appointed with one NABH coordinator.

The responsibility of these coordinators will be:

a) To receive and retain all the documents and official correspondence

related to NABH accreditation from time to time

b) To inform and orient the staff of their department on policies and

procedures developed for their department

c) To ensure the completion of all the work assigned to their department

for NABH accreditation preparation.

d) To coordinate with NABH assessors for their departmental assessment.

QUALITY ASSURANCE PROGRAM

a) The program is comprehensive and covers quality assurance of input,

process and outcome. This has been developed by quality assurance

committee and implemented by various committees, accreditation

coordinator and other personnel.

b) Quality assurance and continuous monitoring programme is developed for

following areas

i. Applicable hospital wide (Table 1)

ii. Applicable for laboratory (Table 2)

iii. Applicable for radiology (Table 3)

iv. Applicable for intensive care areas (Table 4)

v. Applicable for surgical services (Table 5)

Vi.Other Clinical & Managerial Indicators used for quality assurance and

continuous monitoring. (Table 6)

c) Procedure for implementing the programme is as follows:

i. The programme which is applicable hospital wide and which is

applicable for infection control is explicitly tabulated. Quality

Assurance committee and Hospital Infection committee shall

implement, monitor and improve the programme.

ii. The hospital has developed medical indicators which are monitored on

monthly basis and recorded in HMIS. Report on these indicators is

generated for hospital through HMIS. This report gives the figures for

all indicators, which is reviewed and subsequent actions shall be

taken based on adherence to standard value, by Hospital

administration and QAC.

iii. The program applicable for laboratory, radiology, intensive care area

and surgical services shall be implemented through departmental in

charge under the vigilance of QAC. Each of these departments shall

maintain a quality assurance register. The record shall be endorsed in

the register as 'C I PC I NC' (C for Compliance, PC for partial

compliance and NC for non-compliance). The record shall be entered

at frequency defined in the table.

i. Quality assurance programme applicable hospital wide (Table 1)

Purpose Methodology Responsibility Remark

Setting goals

and objectives

Setting of mission,

vision, objectives,

quality policy and

service standards

through committee

discussion and

approval of MEDICAL

SUPRINTENDENT

QAC Refer S. No 1 to 7 of

this document

Infrastructure Identifying

infrastructural

requirement including

Physical facility

Manpower

Equipments

This is determined on

the basis of workload

and change in scope

of service

Hospital

Administration and

State government

Reference is taken

from Bureau of Indian

Standards and IPH

standards.

Policies

procedures

and other

This documentation is

done to develop

systems and

Various

committees,

accreditation

documentation

requirement

processes that are

necessary to provide

uniform service of

desired level of quality

and communicate it to

relevant personnel.

coordinator and

MEDICAL

SUPRINTENDENT

Compliance

monitoring

Compliance is

monitored and non-

conformity is tracked

for taking corrective

and preventive actions.

This is done through

compliance monitoring

registers kept in

various departments

All the staff of the

hospital and

Quality Assurance

Committee

Walk through

monitoring

Walk through

monitoring or physical

monitoring is done by

designated member of

QAC, Hospital

infection control

committee, hospital

safety committee

Accreditation co-

ordinator, RMO, AO

and MEDICAL

SUPRINTENDENT.

QAC, Hospital

infection control

committee,

hospital safety

committee,

Accreditation

coordinator, RMO

Matron, Sanitary

inspector and

MEDICAL

SUPRINTENDENT

Following aspects are

specially looked for

Infection

control

Hospital safety

Record

maintenance

Policy

compliance

Indicator

monitoring

A list of indicators has

been developed to

monitor the key

features necessary for

QAC Refer Tables 2, 3, 4 5

& 6.

quality assurance.

These are developed

for structure process,

clinical and managerial

activities. A monthly

report is generated

with all these

indicators which is

reviewed for necessary

action by Quality

Assurance committee.

Training and

orientation

Necessary instructions

to the staff for quality

assurance are

communicated through

their departmental in

charges. Quality

Assurance is also

included as one of the

training needs, on

which training is

organized at regular

intervals.

QAC and hospital

administration

Continuous

process

The contents of this

programme are

reviewed every year by

Quality Assurance

Committee for

adequacy.

QAC Following aspects is

reviewed every year.

Objective and

service standards

Adequacy of

documentation

Monitoring

systems

Various indicators

and their

standards

Structure for

implementation of

quality assurance

programme

Any other system

required for

quality

improvement

ii. Applicable to Laboratory (Table 2)

Sr.

No. Key characteristics

Acceptance norms

I criteria

Responsibility

and

conformance

Verification.

Frequency

1. Surveillance of test

results

Weekly surveillance

of a sample of test

results

HOD I

Laboratory In

charge

Weekly

2. Check of calibration

and maintenance of

equipments according

to standard.

As per the manufacturer's

instruction. (at every

reconstitution)

Technician Weekly

3 Compliance

monitoring

Compliance as per

standards, SOP and

policies

Laboratory staff Continuous

4 Timely intimation of

critical results

Within ½ hour Technician Daily

Biochemistry

1. Calibration through

control ( Biochemistry

Kit)

As per the manufacturer's

instruction.

Technician Quarterly

Haematology

1. Maintenance of

equipment

As per the instruction in

operation manual.

Technician Daily

2. Calibration through

Control.

(Heamatology kit)

As per the

manufacturer's

instruction.

Service

Engineer

of the company.

Once in

three

months

Pathology

1. Tests to be done on

fresh specimens

received in

containers with lids.

Proper covering of

sample with lid

Technician Daily

iii. Applicable for Radiology (Table - 3)

sr.

No.

Key Characteristics Acceptance

Norms I

Criteria

Responsibility

And

Conformance

Verification

Frequency

1. Compliance monitoring Compliance as per

standards, SOP and

policies

Imaging Staff Continuous

2. Waiting time for

investigation.

X ray: 30 mins or

less (90% cases)

Ultrasound: 40 min

after preparation

(90% cases)

Technician

I

Radiologist

Weekly

3. Report delivery time 90% x-ray and

ultrasound

reports delivery on

time as per policy

Technician

I

radiologist

Weekly

4. Wastage of film because

of repeat process

Less than 7% Technician /

Radiologist

Monthly

5. Uptime of equipment 95 % - 98 % Supervisor

Technician

I

Radiologist

Monthly

iv. Applicable to Intensive care department (Table 4)

S.

No.

Key

Characteristics

Acceptance

Norms

/

Criteria

Responsibility

And

Conformance

Verification

Frequency

1 Infection control and

sterility

Weekly swab

culture

In charge / staff Once in a

week

2 Monitoring and

measurement of life

saving equipment and

other equipments

Functional status

check.

Calibration -

Yearly/as and

when required

AMC/Preventive

Maintenance -

Yearly/as and

when required

In charge I staff Monthly

v. Applicable to surgical services department (Table 5)

S.

No.

Key

Characteristics

Acceptance Norms I

Criteria

Responsibility

And

Conformance

Verification

Frequency

1. Punctuality of O. T staff Start functioning at

time

OT in charge Once in a week

2. Complete pre operative

preparation before patient

is shifted to O.T

Part preparation

Removal of all

ornaments.

Consent for

procedure

Change of

clothes.

Ward staff &

O.T. Staff

Daily

3. Anesthesia induced after

17.00 hrs.

Acceptable only during

emergency

Anesthetist Once in a week

4. Cases continuing beyond

19.00 hrs.

Acceptable only when

necessary

Anesthetist Once in a week

5. Infection Control and

sterility of O. T

Weekly air culture

Weekly fumigation

Hypochlorite

treatment of

infected linen /

instruments for 3 –

4 hrs before

autoclaving.

Restricted entry of

visitors into O.T.

complex

OT incharge /

OT

Staff

Once in a

week.

vi. Other Clinical & Managerial Indicators used for quality assurance and

continuous monitoring: (Table 6)

Following indicators are measured and monitored by quality assurance

committee as a part of quality assurance and continuous monitoring programme

Indicators for clinical & managerial structure, process and outcome.

S No.

Indicator NABH Std.

Definition Numerator Denominat

or

Source of Data /

Responsibility

Patient Assessment

1 Allergy Documentation

IMS.7 (CQI -

2.a)

Appropriate documentation of all the drugs and other agents to which a patient is allergic is called allergy documentation

No. of cases where allergy was recorded in History & Physical Examination Sheet

No. of discharged files checked

MRD

2

Completion of History & Physical Examination (Initial Assessment Form)

AAC.5

Completion of History & Physical Examination Sheet implies that on admission, the doctor has done the initial assessment of the patient and filled up all fields of H & P Sheet

No. of complete H & P sheets

No. of discharged files.

MRD

S No.

Indicator NABH Std.

Definition Numerator Denominat

or

Source of Data /

Responsibility

3

Completion of Nursing Admission Assessment

AAC.2

Completion of Admission Assessment form by filling up all fields

No. of cases where assessment were completed

No. of discharges

MRD

4 Nutritional Assessment AAC.5

Assessment of patient’s nutritional status at the time of admission of the patient is called nutritional assessment

No. of cases where assessment was completed

No. of discharges

MRD

5 Pre Anesthesia Check up

(CQI - 2.e)

Pre Anesthetic Assessment completed for patients undergoing any kind of anesthesia

No. of cases where assessment was completed

No. of surgeries

MRD

Anesthesia Use

6 Adverse Anesthesia Events

COP.11 (CQI - 2-e)

Adverse Anesthesia Events are the incidents which occur directly or indirectly due to administration of Anesthesia in the form of Drug, Procedure, Invasive monitoring or position of the patient, which has resulted in unpleasant outcome.

No. of adverse anesthesia events

Total no. of surgeries done

Medical Record of

patient

S No.

Indicator NABH Std.

Definition Numerator Denominat

or

Source of Data /

Responsibility

Blood and Blood Products

8. Hemolytic Reactions

Any Serious adverse reactions arising after blood & blood products transfusion

Total Number of Such Reactions

Total Number of units transfused

BTR Committee

Legal Issues

9. Notifiable Disease Reporting

HIC.3 (CQI - 3.b)

All notifiable diseases are to be notified to the office of DGHS within 24-48 hrs of confirmation of the disease by lab services

Number of incidences when notifiable disease was not reported within time frames

Total incidences of notifiable diseases

MRD

Average Length of Stay (ALOS)

S No.

Indicator NABH Std. Definition Numerator Denominat

or

Source of Data /

Responsibility

10. ALOS

Average length of stay (ALOS) - Average stay counted by days of all or a class of inpatients discharged over a given period, calculated by dividing the number of inpatient days by the number of discharges.

Number of inpatient days

Number of discharges

Nursing

Waiting time in OPD

11

Waiting time in OPD ( After the completion of the registration Process)

CQI - 3.h

Average time required by the patients for Consultation by Physician after registration

Total waiting time in an OPD for all the patients in a given period of time

Total number of patients

OPD

Discharge Time

S No.

Indicator NABH Std.

Definition Numerator Denominat

or

Source of Data /

Responsibility

12 Discharge

Time

Average time required by the organization to discharge the patient after the decision to discharge has been conveyed to the patient & documented

Total time taken for discharge process of all the patients in a day

Total number of patients discharged in that day

Discharge Register

Infection Control

13 UTI HIC.4 (CQI - 2.h)

Urinary tract infection includes symptomatic UTI asymptomatic bacteriuria & other infections of urinary tract.

No. of Catheterized patients developing UTI in the hospital

Total no of urinary catheter days

Infection Control Team

14 CRBSI HIC.4

CR Blood Stream infection includes positive cultures from patients with central lines(after 48 hrs of infection)

No. of patients with central lines developing BSI in the hospital

Total central line days

Infection Control Team

S No.

Indicator NABH Std.

Definition Numerator Denominat

or

Source of Data /

Responsibility

15 SSI HIC.4

Involves patients developing SSI within 30 days of surgery

No. of patients developing SSI after surgery

No. of patients undergoing same surgeries

Infection Control Team

16 VAP HIC.4

Pneumonia involves a combination of clinical, radiological & lab evidence of infection. Any new progressive lesion that develops after 48 hrs of hospital admission or subsequent to ventilator use is labeled as VAP

Patient with 3 out of 4 criteria for hospital onset pneumonia

Total ventilator days

Infection Control Team

17 Hand Hygiene HIC.5

Hand Hygiene is defined as either using soap and water to wash hands or use of Hand rubs before and after opportunities as indicated in Infection Control Manual

Total number of times hands have been washed for the activities defined

Total number of hand hygiene episodes defined for the activities included

Infection Control Team

S No.

Indicator NABH Std.

Definition Numerator Denominat

or

Source of Data /

Responsibility

Utilization Management

18 OT utilization FMS.3 (CQI - 3.d)

It is the no. of hours per day for which the OT is utilized for Operative purposes.

No. of hrs OT is utilized

Operational hrs of OT

OT registers, OT Staff

Patient Satisfaction

20 Patient satisfaction

Number of patients satisfied with the organization's services and

No. of patients who gave very satisfied score in Patient

Total no. of discharge feedbacks collected

Data assistants, Patient Satisfaction Survey

award a grading of very satisfied in the patient satisfaction survey

satisfaction survey

Staff Satisfaction

21 Nursing staff satisfaction

HRM (CQI - 3.f)

Being the largest group in hospital, this group's satisfaction measurement will give a representation of staff satisfaction

No. of staff scored above average

Total no. of feedbacks

HR Manager

22 Other Staff Satisfaction

Do

The satisfaction index of the other employees is also required to foresee the organizational climate

No. of staff scored above average

Total no. of feedbacks

HR Manager

Safety Issues

23 Needle Stick Injury Reporting

HIC.5

Sustenance of injury due to accidental needle stick by any health care worker at the workplace resulting in inoculation of infectious material.

No. of incidents Occurred & Reported

Nursing