S.N.

Training topic Coverage Relevant to

A.      Training topics related to Access, Assessment and Continuity of Care

1.         Scope of hospital services Clinical services offered All staff, especially staff
by the hospital of front
office and admission
Services not in scope

2.         Registration and admission of Admission policies Staff of

patient reception, registration and
Managing during non-
admission (including staff
availability of beds
handling emergency
Handling un-identified admissions)
patients

3.         Safe transfer of patient Internal and External
transfers
Transfer of stable
and unstable patients
Nurses and duty doctors
Hospital attendants (for
safety measures to be
taken while transferring)

4.         Standard operating procedures of Lab technicians

various lab tests

5.         Collection of samples Aseptic sample Phlebotomist, Lab

collection, patient safety, technician
labelling or samples, safe
transportation and
storage

6.         Intimation of critical lab results Panic values, Lab technicians

identification,
confirmation and
communication of
critical results

7.         Quality control in laboratory Calibration, verification, Technical supervisors, Lab

validation, surveillance, technicians
Internal quality and pathologists
assurance, external
quality assurance

8.         Laboratory safety Lab waste disposal, All laboratory

infection control, staff (technical and non-
chemical safety, Use of technical)
 PPE

9.         Standard operating procedures of Imaging technicians

various imaging tests

10.     Safety of patient undergoing Safe transportation and All lab technicians and

imaging shifting of patient, supervisors
patient screening, safety
in MRI

11.     Intimation of critical imaging Panic findings, Imaging technicians

findings Identification,
confirmation and
communication of critical
results

12.     Quality control in Imaging Calibration, verification, Technical

validation, surveillance, supervisors, imaging
clinical correlation, technicians
clinician’s feedback and radiologists

13.     Radiation safety AERB regulations, Use All staff in imaging

and upkeep of radiation (technical and non-
safety devices technical)

14.     Safe disposal of radio-active waste Types of radio-active Technical

waste, health and supervisors, imaging
environmental effect, technicians
disposal and radiologists

15.     Discharge process Normal discharge, Nurses, Duty doctors,

Discharge on request, Customer care
DAMA, Death executives, Admission and
discharge staff, staff from
pharmacy, billing and
insurance

16.     Discharge summary Contents to be included Duty doctor, Consultants

in discharge summary to be oriented

B.      Training topics related to Care of Patient

17.     Uniform care to patients Policies of Evidence Consultants, duty doctor

based medicine, clinical and nurses
practice guideline,
provision of emergency
care, applicable laws
such as PCPNDT, MTP,
organ transplant etc.,
 informed consent

18.     Triaging of patients Triage in routine cases Triage nurse

and triaging during mass
casualty situation

19.     Handling of medico-legal cases Doctor in-charge of

emergency, Nurse in-
charge or admin in-charge
of emergency dept.

20.     Maintenance of ambulance Equipment, medicines, Ambulance

maintenance, staff and nurse-in-charge
communication of emergency

21.     Handling of emergency patient on- Road traffic accidents, Ambulance staff and
site trauma, unconscious emergency medical
patients, patient in technicians
cardiac arrest etc.

22.     Handling of disaster situations, Entire plan of managing All staff for their role,
community emergencies and mass epidemic and disaster and specifically to all staff
casualty situations situation. of emergency.

Mock drills must be

conducted for this

23.     Basic Life support CPR, use of crash cart, All nurses and
other life support doctors, other staff
measures involved in healthcare such
as technicians and
therapists

24.     Code blue system Code blue process, CPR All nurses and doctors, All
other staff for
Mock drills must be
understanding of code blue
conducted for this
process

25.     Safe blood transfusion Rational use of blood, Blood bank technicians,
blood storage, duty doctors and
prevention of error while nurses. Consultants to be
transfusion, transfusion oriented on rational use of
monitoring blood

26.     Disposal of blood Blood bank staff

27.     Admission and discharge criteria Orientation to all

consultants

28.     Care of vulnerable patients Vulnerability assessment, All nurses and duty
 identification and care doctors. Other healthcare
staff

29.     Care of paediatric patients Paediatric assessment, Staff in paediatric

safety of children, ward/ICU
dealing with children

30.     Prevention of child abduction and Code pink procedure, Staff in paediatric

abuse safety measures, action ward/ICU, Security
in case of such events staff, All other staff

31.     Surgical safety Pre-surgery, during Operation theatre nurses,

surgery and post-surgery surgery resident doctors,
safety measures. These surgeons
include things like site
and side marking, time
out and sign out process,
infection control etc.
WHO surgical safety
checklist would be a
good reference material.

32.     Care of patients under restraint Physical and chemical Nurses, nursing in-charges,
restraints resident doctors,
consultants

33.     Nutritional screening and Dietician, Nurses

assessment

34.     End of life care Nurses and doctors in ICU

C.      Training topics related to Management of Medication

35.     Procedure to obtain medicine Nurses and duty doctors

when pharmacy is closed

36.     Safe storage of medication Store in-charge, pharmacy

in-charge, nurse in-charge
(for storing in wards)

37.     Safe and rational prescription of Consultants, Duty doctors

medicines

38.     Inventory analysis and control Store and pharmacy in-

charge

39.     Look-alike and sound alike Storage, issue and Store and pharmacy staff,
medication administration of LASA nurses and duty doctors
medicines
40.     High-risk medicine safety Nurses and duty doctors

41.     Verbal orders for medicines Nurses, duty doctors and

consultants

42.     Safe dispensing of medicine Pharmacy staff

43.     Medication recall Store and pharmacy in-

charge and nurse in-
charges

44.     Safe administration of medicines Patient Nurses and duty doctors

identification, checks
during administration,
post administration
monitoring

45.     Reporting of medication errors Nurses and duty doctors

46.     Safe usage of chemotherapeutic Preparation, Staff involved in

medication administration and chemotherapeutic
disposal medicines

47.     Safe usage of radio-active drugs Safe usage and disposal Staff involved in
radioactive drugs usage

D.      Training topics related to Patients’ Rights and Education

48.     Rights of a patient and how to All staff specially front

protect the same office, nurses, duty
doctors, consultants and
managers of patient care
departments

49.     Taking consent from patients General Consultants, duty doctors

consent and informed and nurses
consent

50.     Patient feedback and complaints Feedback mechanism Customer care executives,

and complaint processes nurses, nursing in-charges

E.       Training topics related to Hospital Infection Control

51.     Standard precautions Hand hygiene, use of PPE Nurses and duty doctors

52.     Safe injection and infusion Nurses and duty doctors

practices

53.     Antibiotic policy Consultants and duty

doctors
54.     Laundry and linen management Nurses and laundry staff
process

55.     Safe handling of food Kitchen staff and dietician

56.     Housekeeping procedures Housekeeping staff and

supervisors

57.     Bio-medical waste safety Segregation, storage, Nurses, doctors,

transportation, disposal housekeeping staff. Other
staff such as lab and blood
bank technicians, OT
technicians, therapists etc.

58.     Needlestick injury protocol All patient care staff

59.     Infection control surveillance Infection control team

60.     Prevention of HAI in patients Care bundles for CA-UTI, Nurses, especially ICU
VAP, SSI and CA-BSI nurses

61.     Isolation/barrier nursing Nurses and duty doctors

62.     Infection outbreak handling Identification and action Infection control

team, Nursing in-charges

63.     Sterilization activities Sterilization process and CSSD staff

quality control

F.       Training topics related to Continual Quality Improvement

64.     Quality indicators of each In-charge and staff of each

department department

65.     Patient safety practices All staff involved in patient

care activities

66.     Reporting of patient safety events All staff involved in patient

care activities

67.     Medical audit Consultants and clinical

committee

68.     Sentinel events All staff involved in patient

care activities

G.      Training topics related to Responsibilities of Management

69.     Vision, Mission and Values of the Top management

organization personnel and heads of
departments
70.     Scope of services in each Services in scope and not In-charge and staff of each
department in scope department, especially
of obstetric and paediatric
departments

H.      Training topics related to Facility Management and Safety

71.     Preventive and breakdown Maintenance staff

maintenance of equipment

72.     Calibration of equipment Maintenance staff

73.     Handling of fire emergency Code red alert system All staff specifically security
and maintenance
Mock drills must be
conducted for this

74.     Use of fire extinguisher All staff

I.        Training topics related to Human Resources Management

75.     Induction training Vision, mission, values, All staff upon recruitment
patients’ rights, infection
control, safety, service
standards

76.     Employee rights and All staff

responsibilities

77.     Training and development policy All staff

78.     Performance appraisal system All staff

79.     Disciplinary and grievance All staff

handling process

80.     Prevention of sexual harassment All staff

81.     Credentialing and privileging of Consultants to be

medical professionals oriented. Duty doctors and
nursing in-charges to be
informed

82.     Credentialing and privileging of All nurses and nursing in-

nursing professionals charge to be oriented

J.        Training topics related to Information Management System

83.     Safety and security of patient’s Data in medical records, All nurses, nursing in-
data registers and computers. charges, duty doctors,
Access to medical patient care executives
records and MRD staff

84.     Medical record documentation Contents, legibility, use Consultants, duty doctors,
of abbreviation, nurses, therapists and
endorsements MRD staff

85.     Medical record maintenance Screening, completion, MRD staff

storage, retrieval

86.     Hospital statistics from medical Various stats and reports MRD in-charge
record

87.     Retention time of medical record MRD in-charge and staff

88.     Process of condemnation of MRD in-charge and staff

records