Title: - Manual of Quality Assurance Department

Memon Medical Institute Hospital
(Hospital Project of Memon Health and Education Foundation)
Department: Administration Section: Quality Assurance Doc# MMIH-QA
Title- Manual of Quality Assurance Department

Issue date: March, 2012 Rev Date: November,2019 Total pages: 65
Next Rev Date: Nov,2021
Prepared by:
Designation: Q.A Officer
Signature: __________________
Reviewed by:
Designation: GM, Quality Assurance
Signature: __________________
Approved by:
Designation: Chief Executive Officer
Signature: __________________

Table of Contents
Introduction to quality assurance:....................................................................................................4
Mission of quality assurance department:.......................................................................................4
Vision of quality assurance department...........................................................................................4
Values:.............................................................................................................................................5
Goals:...............................................................................................................................................5
Responsibilities:...............................................................................................................................5
Departmental Organogram:.............................................................................................................7
Introduction of Quality Management:.............................................................................................7
Quality Management Process:.........................................................................................................8
CONFLICT OF INTEREST:.........................................................................................................16
CONFIDENTIALITY POLICY:...................................................................................................16
LIST OF DEPARTMENTAL POLICIES:....................................................................................17
1.1. Verbal Complaints:......................................................................................................21
1.2. Written Complaints:....................................................................................................22
1.3. Suggestion...................................................................................................................23
Complaint/suggestion process flow Chart.............................................................................25
Incident Report Flow chart:...................................................................................................30
Sentinel Events......................................................................................................................32
Medical Error.........................................................................................................................38
Medication Error....................................................................................................................41

Key Performance Indicators Policy...........................................................................................47

How to handle difficult situation...............................................................................................49
Employee Job Description.............................................................................................................54
Quality Department Monitoring:...................................................................................................61
Department: Administration Section: Quality Assurance Doc# MMIH-QA 01
Title- Introduction to Quality Assurance

Issue date: January, 2012 Rev Date: November,2017 Total pages: 65
INTRODUCTION TO QUALITY ASSURANCE:
The Quality Assurance department at the Memon Medical Institute Hospital supports the
core objectives/mission of the MMIH by providing:
1. Monitoring and evaluation of services

2. Continuous quality improvement projects
3. Patient satisfaction survey
4. Setting benchmarks
5. Policy and procedure development/compliance
6. Respond to internal and external complaint
MISSION OF QUALITY ASSURANCE DEPARTMENT:
Quality Assurance MMIH, is devoted to ensure the credible quality of services to both
inward and outer clients within the framework of the hospital mission. Our Quality Management
program is intended to materialize this mission to provide a documented system for seeking
opportunity on continuous basis to improve the effectiveness and efficiency of the quality
management framework in the organization.
VISION OF QUALITY ASSURANCE DEPARTMENT
The Vision of Quality Assurance, MMIH, is to promote and up-keep the morale of the
care providing staff through creating an ideal working environment and empowering them.

VALUES:
Quality Assurance, MMIH, shall pursue the following values in order to accomplish our
Mission and Vision and to enlighten our path to create a system of Total Quality Management
through patient safety practices/tools.
 To pursue the approved principles of Quality Management as set by JCI Standards.

 To commit to the Continuous Improvement of health care processes and systems via
monitoring and evaluations.
 To strive to reduce and eliminate errors in the delivery of health care.
 To understand, meet and exceed our customers’ needs and expectations.
 To provide an environment that respects others.
GOALS:
 To facilitate interdisciplinary communications and co-operations.

 To promote accountability amongst individual health care providers by their direct
involvement in the process.
 To ensure that all services and departments monitored are focused on key processes
impacting patient outcomes.

PROPOSED DEPARTMENTAL ORGANOGRAM:
GM-Q.A &
Infection
Control
Manager Manager Manager

Infection Q.A/Clinical Educational
Control affairs Affairs
Assist.
Infection Assist.Manager
Manager
control officer Clinical Affairs
Education
Performance
Infection
Q.A Officer Improvement CME Officer Instructor
Control Nurse
Officer
INTRODUCTION OF QUALITY MANAGEMENT:
The Quality Management Systems provide a planned systematic approach for an

organization in order to monitor and assess a hospital’s performance. Its primary focus is to
provide continuous improvement of key processes impacting the care provided in a hospital.

QUALITY MANAGEMENT PROCESS:
Overview:
To ensure and sustain a planned, systematic and continuous process of monitoring and
evaluation, the following steps summarize the key points of the Quality Management System.
Quality management components:
The Quality Management System will comprise the following:

 Generic Screening and Incident Reporting
 Surveys, questionnaires, interviews and direct observations
 Indicator Monitoring for clinical and non-clinical activities. Organization Wide Indicators
(for volume and quality)
 Departmental /Service Quality
Suggested steps for assessment and improvement activities
Step 1 – To Assign Responsibilities:
Each Department/Service will identify and assign an individual as the Quality Management
liaison to perform or co-ordinate these activities between the Department and the QA
Department.

Monitoring activities can be conducted through department and/or committee structures. Where
applicable, these activities will be multi-disciplinary and cross functional and include all patient
care classifications following the nine dimensions of performance. These are:
1. Efficacy
2. Appropriateness
3. Availability
4. Effectiveness
5. Timeliness
6. Safety
7. Efficiency
8. Continuity
9. Respect and Sharing
Each Department / Service will be responsible for participating in the development of

departmental QM Plans. Clinical Monitoring includes the following patient care services:
MEDICAL STAFF NURSING SERVICES ANCILLARY/

PARAMEDICAL
SERVICES
Department of Medicine and Inpatient Nursing Units Pharmacy
Allied
Department of Surgery and Outpatient Clinics Medical Records
Allied
Department of Obstetrics and Hemodialysis IT Department

Gynecology
Department of Pediatrics Operating Room
Department of Anesthesia Emergency Room
Special Care Services: ICU, Nursing Administration and
SCU, NICU Education
ER services
OPD
Radiology
Pathology
CLINICAL COMMITTEE ADMINISTRATION SUPPORT SERVICES

STRUCTURE
Blood Usage Personnel Maintenance
Surgical and other Invasive Finance Housekeeping
Procedures
Medical Records Review Statistics(Information Safety and Security
Management)
Pharmacy and Therapeutics Computers Communications
Infection Control Biomedical Engineering
Mortality Review Dietary
Step 2 – Delineate Scope of Care / Service
Each Department / Service will be responsible for identifying its scope of care /
service as part of its Departmental Quality Plan.

Step 3 – Important Aspects of Care / Service:
Each Department / Service is responsible for identifying its important aspects of

care / service. Important aspects are those key processes that impact the care
given to patients, based upon the following criteria:
A. High Volume – the process occurs frequently or affects large numbers of

patients
B. High Risk –patients at risk for serious consequences if the process is not
provided correctly in a timely manner, or based upon proper indications.
Step 4 – Identify Indicators:
An indicator is a well-defined objective, measurable, variable and is used to

monitor the quality of important aspects of patient care. The criteria are
sometimes referred to as clinical standards, practice guidelines or parameters and
are developed approved where appropriate.
Indicators may be structure, process or outcome in nature.
A. Structure Indicators relates to the integrity of the facility, the condition of the
equipment, and the quality of the supplies e.g. preventative maintenance checks
shall be completed on all of the hospital equipment at 6 monthly intervals.

B. Process Indicator relates to how care is delivered and includes such variables
as staffing, patterns, implantation of policies and procedures, and medical
techniques.
E.g.: there should be no patient complaints concerning any patient waiting in

excess of 1 hour in any outpatient clinic.
C. Outcome Indicator relates to the condition of the patient following some type
of hospital intervention E.g.: there shall be no unscheduled re-admission to the
hospital within 30 days of discharge.
Step 5 –Establish thresholds for evaluation related to the indicators:
A threshold is a pre-established level or point in the cumulative data that will

trigger further evaluation. Thresholds are determined by the hospital’s history.
NOTE: A threshold is not a standard. A standard of practice specifies an accepted

optimum approach to diagnosis and treatment. A threshold may be at 100%, 95%,
10% etc. Thresholds shall not be changed unless they are found to be unrealistic.
Step 6 – Collect and Organize Data:
Date shall be collected, organized and analyzed for each indicator. The following
shall be established for each indicator, the data source, data collection methods,
frequency of data collection, frequency of data comparison and appropriateness of
sampling.

A. Data Source: May include medical records, incident reports, departmental logs,
patient / family questionnaires, departmental requests, computer reports,
medication reports, committee minutes and infection control reports.
B. Data Collection: It is related to the frequency of the event or activity being

monitored. Data collection may take place daily, weekly, monthly, quarterly,
annually or upon each occurrence. Data shall be collected on the designated
collection forms.
C. Data Comparison: The threshold shall take place at least quarterly
D. Data Sampling: It should not be fewer than 30 cases or less than 6% of the
expected population, whichever is greater. General guide for sampling is based on
a four week period.
Step 7 – Evaluate Care / Service
Designated QA Committees, Interdepartmental and /or Intradepartmental Teams

should meet monthly, or as indicated on the QM Calendars, to assess data specific
indicators being monitored.
The assessment compared the level of compliance to the thresholds when

thresholds are set. Data is evaluated for patterns / trends where applicable.
Peer Review is conducted as an integral part of the medical staff participation. In

cases where medical records are used to evaluate care the designated form(s) shall

be completed. The minutes of these groups will document all evaluated findings,
conclusions, recommendations, action and follow up as per the format.
Step 8 – Take Action:
Actions are taken to improve processes and identified problems. Any actions by
the department/team, committee minutes, recommended actions, etc are
forwarded to the person who has the authority to act, E.g.: Medical Director,
Nursing Director, Head of Department etc.
An action plan must be designated to:
A: Identify who or what is expected to change

B: Test the proposed change on a trial basis, and if necessary, to study the effects.
C. Identify who is responsible for implementing the improvement
D. Estimate of when the change is expected to occur
Step 9 – Assess Effectiveness:
All actions recommended and implemented shall be assessed for their

effectiveness.
Reassessment of activities shall be adequate for determining that improvement

has occurred and has been sustained over time. The results of assessment and
effectiveness of evaluation must be adequately documented to provide a reference

of actions taken. Re-evaluation of actions taken may be necessary if improvement

cannot be demonstrated or shown.
Step 10 – Communicate Relevant Information:
Communication of required information shall be reported by the delegated

individual(s) to the QA Department, for submission to the CQIC. The CQIC will
submit a summary report to the CEO and EC.
CONFLICT OF INTEREST:
No clinician or other health care provider at MMIH shall review services for which they
are, or have been directly responsible for providing.
CONFIDENTIALITY POLICY:
All documents, minutes, reports, memos, letters, findings, conclusions, actions,

recommendations etc. involving MMIH and its patients, families and staff, which are used in the
course of Quality Assurance activities shall be strictly confidential and shall be used only for the
assessment and improvement of patient care.
Providers of care / service, in all reports, will not be identified by name. Individual
identification will only be made available when it has been shown that a person has a
performance problem. Only the person responsible for taking action will be given the name of

the person. Any information released must be requested in writing and be approved by the
Quality Assurance Manager or CEO.
Title- Quality Assurance Framework/Policies

LIST OF DEPARTMENTAL POLICIES:
The following are the policies of the QA department.
1. Customer feedback handling

i. Verbal complaints
ii. Written complaints
iii. Suggestion
2. Incident Report Policy
i. Sub-Policy: Sentinel Event Policy
ii. Sub-Policy: Medical Error
iii. Sub-Policy: Medication Error
3. Key Performance Indicators Policy
4. Handling difficult situation
5. Patient Satisfaction Survey
Title- Quality Assurance Framework/Policies

Policy statement:
To provide the value addition to the healthcare system through continuous monitoring of the
organization processes.
Responsibility
 To monitor quality activities for compliances to predefined standards, policies and

guidelines.
 To conduct quality audits in order to observe routine activities including Proper
documentation and record keeping.
 To assist in development of quality indicators, criteria and policies and procedures for all
departments of hospital.
 To continue with Continuous Quality Improvement on subjects such as:
1. Incident Reporting
2. Patient Complaint
3. Patient Satisfaction Surveys
 Assist the Medical Division in ongoing CME (Continuous Medical Education) Sessions
and developmental activities.
 To review newly created forms and documents by departmental quality circles for
approval.
Title- Customer Feedback/Complaint Handling

Policy Statement:
To ensure the proper handling and reporting of customer feedback.
Purpose:
 The purpose of this system is to provide a transparent opportunity to any individual to

communicate their concerns for formal investigation and to rectify complaints.
 To consider applicable suggestions on continuous basis.
 This documented system also encourages and enables to assess the continual
improvement measures and satisfaction level of patients, internal or external customers
and employees.
 To reassure the patients, customers and staff members towards quality measures and
importance of their voice.
Customer feedback can be raised from;
1. In-patient Department
2. Out-patient Department
3. Emergency Department
4. Walk in Customers
Sources to capture the customer feedback are;
A. Duty administrator round

B. Patient Complaint/Suggestion form

C. SMS
D. E-mail
Categories of Customer Feedback:

Customer feedback will be categorized into three main categories
 Complaint
 Appreciation
 Suggestion
 Perception
There are further two categories in complaints.
1. Resolved: complaints about services that were being done by staff although with delay will be
marked as resolved or complaints that are resolved through intervention of duty administrator
will be marked as resolved.
2. Unresolved: complaints that cannot be resolved such as complaints of bad attitude or slow
response will be marked as unresolved.
Scope:
All patients/attendants who are either availing services of the hospital or visiting the
hospital have a right to give their feedback about the services of the hospital.
Responsibility:
It is the responsibility of front desk staff, marketing department and duty administrator to
timely inform the feedback in quality department.

 Duty administrator officer will daily visit the patients in wards to ask the patients if any
service of the patient is pending.
 Duty administrator will intervene to resolve patients’ complaints and document all the
complaints captured during round.
 Patients’ complaints resolved through intervention of duty administrator will be marked
as resolved.
 Duty administrator will report the patients’ complaints on daily basis to the concerned
departmental head/manager/supervisor.
 Complaint will be reported through e-mail and that e-mail will be cc to quality assurance
department for follow-up and trending of the complaints.
 Proper template will be used for reporting of patients’ complaints.
 Duty administrator will also maintain the monthly log and will send the log to quality
assurance department for preparation of report.
 If the complaint is not marked as resolved by duty administrator, then concerned
department will reply back to quality assurance department to give the follow up of the
complaint and final status of the complaint will be updated in the monthly log.
 Unresolved complaints that are not answered by the concerned departments will remain
be counted as unresolved.
Note: Same complaint that will be received through all sources will be reported to concerned
department once.
Procedure for handling of complaints received through SMS/e-mail
There are two sources for SMS receiving;

1. Marketing
2. Duty Administrator Officer
Case 1: SMS received in Marketing Department

SMS received in marketing department will be reported to concerned departments
through quality assurance
Case 2: SMS received to Duty Administrator
SMS received to duty administrator will be directly reported to the concerned
departmental head/manager and Cc that e-mail to QA department.
Concerned departmental head will reply back to QA to update the status of SMS.
1.1. Verbal Complaints:
I. All the verbal complaints must be recorded by all the departments and directed to QA
department, preferably on the same day or within 48 hours.
II. QA will investigate the verbal complaints and evaluates if it needs a corrective action
III. QA will address the complaint by responding the complainant about the measures
taken and to ensure that the complaint was taken into consideration, if required.
IV. QA will thank and motivate the complainant to encourage for highlighting any issue
for their corrective measures in future.

1.2. Written Complaints:
I. All the written complaints from patients, attendants, visitors and customers are
handled through complaint form which is available in both Urdu and English
version with complaint/suggestion drop-in boxes placed at Front desk.
II. Patients, attendants, visitors, customers and employees can fill
complaint/suggestion form and drop it into the complaint box.
III. QA representative will be responsible to open the complaint box regularly (daily
on working days) and forward it to Consultant CA/QA or designated QA
representative.
IV. After reviewing, QA team will log the complaint in log sheet and forward it to
concerned departmental head for feedback.
V. After taking necessary actions, QA team responds the patient regarding action
taken and maintains the record of response/s of complainant.
VI. If the response makes the complainant satisfy then the complaint will be closed
and recorded in the Complaint/ Suggestion log sheet.
VII. If the response or the corrective action does not satisfy the complainant, then QA
representative will ask for 5 days more to get back to complainant.
VIII. The unresolved complaint with all the backup work will be forwarded to CEO for
further action.
IX. Process of complaint handling can be understood from the “Complaint/
Suggestion process flow Chart”.

1.3. Suggestion
a) Verbal Suggestions
I. All the verbal suggestions must be recorded by all the departments and directed to QA
department, preferably on the same day or within 48 hours.
II. QA will evaluate the verbal suggestion with the help of concerned departments. If
necessary with CEO to decide if the suggestion should be, a) implemented b) partially
implemented c) is already in the system or d) rejected.
III. If the suggestion is already in the system or rejected, the QA team will respond to the
person suggested, on phone, by email or through letter and record the data on the
suggestion log sheet.
IV. If the suggestion is planned to be implemented or partially implemented, then a timeline
must be developed for its implementation.
V. The suggestor will be informed about the timeline and will be thanked formally via
thanks letter duly signed by QA representative or email if the email address is
provided on the form.
b) Written Suggestions:
I. Suggestions are received from the patients, visitors, customers and employees of MMIH.
II. Suggestion Box opened daily on working days by a representative QA team, MMIH. The
data is then logged and analyzed.
III. During analysis the suggestor can be contacted for further details when necessary.
IV. After analysis, suggestor will be informed of the outcome/s (if any) via phone or letter.

V. QA will evaluate the written suggestion with the help of concerned departments. If
necessary with CEO to decide if the suggestion should be a) implanted, b) partially
implemented, c) is already in the system or d) rejected.
VI. If the suggestion is already in the system or rejected, the QA team will respond the
suggestor over the phone, by email or through letter and record the data on the
suggestion log sheet.
VII. If the suggestion is planned to be implemented or partially implemented then a
timeline must be developed for its implementation.
The suggestor will be informed about the timeline and will be thanked formally via
thanks letter duly signed by QA representative or email if the residential address or email
address is not provided on the form.

Complaint/ Suggestion Process flow Chart
Written Complaint/suggestion raised by affected person
QA representative obtains the complaint/suggestion form
QA Department logs the form and evaluates the nature of

complain/suggestion
Immediate action Non-Immediate

required action required
Complaints are handled in priority basis in Non immediate action required

which the CA/QA team goes to the relevant complains/suggestions are referred to the relevant
dept, questions the concerned personnel and department heads and are given five 5 working
Response to complaint/suggestion
satisfies the QA department
Yes No
Case closed, record will Further action as specified in the

be kept for file policy. If not covered then refer to
Report to CEO to report to HMB

Title- Incident Report Policy

Issue date: January, 2012 Rev Date: November,2017 Total pages:65
Definition:
Incident:
An incident is defined as a situation, an event or an act which may result into any unavoidable
consequences. It may involve customers, visitors and staff members of Memon Medical Institute
Hospital (MMIH).
Policy Statement:
This Policy is developed by Memon Medical Institute Hospital to control, minimize,

rectify or reduce the events that directly or indirectly lead to compromise quality care and safety
of all the staff members, patients, customers and visitors during all times within the hospital
premises.
Instructions:
 All the departments should diligently identify and report any untoward incident occurred
at any area within the hospital premises. Also outside the hospital when a patient is
referred under the care of MMIH.
 All the incidents must be reported within 48 hours from the time of occurrence.
 An electronic process of incident reporting must be accessible to all staff members.
 The Incident Report (IR) is the most sensitive document therefore confidentiality must be
maintained at all levels and circumstances. All the staff and QA team will keep all the IR
record in a secure place and must be vigilant about confidentiality during its
transportation and correspondence (if manual)

 All the departments must develop IR Report and must be shared with CEO.
 The response time is up to 5 working days from the concerned department/s on electronic
data base.
 Department of QA should complete its findings and documentation within 5 working
days from the date the IR response is received.
 All the original IRs will be under the custody of QA department. Any staff member/s will
be allowed to view the reports (if required) only in the QA department with prior
authorization.
Following events are covered under this policy and must be reported according to IR Policy.
a. Medical Errors
b. Medication Errors
c. Surgical Errors
d. Diagnostic Errors
e. Sentinel (death) Events
f. Suicide/Homicide
g. Patient Fall
h. Physical or Verbal Assault/Violence/Harassment
i. Theft
j. Delays (Medication, Supplies, Support Services)
k. Communication Errors with patient and staff.
l. Damage and broken equipment.

Purpose:
The purpose of Incident Reporting is to develop safer work practices for patients, staff
members, visitors and customers of Memon Medical Institute Hospital (MMIH). Safer
environment leads to improve patient care. As a matter of fact, a considerable number of
incidents can be prevented through corrective/preventive actions to avoid any big untoward
incident or recurrence of any dealt incident.
Scope:
IR Policy covers all the staff members, trainees, patients, customers and visitors for
prompt corrective preventive measures. The scope also includes all the equipment, assets,
facilities and building acquired by MMIH.
Procedure:
Any staff member/s encounters or witnesses any incident should take an immediate
action to stabilize the situation appropriately (where possible).
 Every department will raise incident in IN-HOUSE and make sure the accessibility to the
staff members of the department.
 There are two types:
 Clinical
 Administrative
 Originator can raise the incident through signing in the electronic incident report system.

 The IR form will be forwarded directly to QA department.

 Any Delays in submitting the IR from the reporting date shall be viewed as an incident in
itself. Such delays will be construed as deliberately trying to hide the incident and will be
considered liable for punitive action.
 QA will evaluate the IR content for action.
 Complains will be forwarded to the relevant department heads and will be given 5
working days for a written response.
 Complains that require a root-cause analysis, such as a sentinel event, will be referred to
a task force for action. Corrective Actions will be made and referred to the concerned
department(s).
 The recipient will only fill the section D, E and F in a legible on the IR form.
 If the response to the incident satisfies the QA department (the process involves evidence
based thorough analysis of the case), the case will be recorded on the IR Log and saved
in the system. The IR response can be seen by respective department via report option in
system.
 If the response is not satisfactory then the IR will be on pending for further action as
specified in the policy and sub policies for the nature of incident.

Incident Report Flow chart:-
Employee login to system electronically If No

Status marked closed if accepted
Select clinical or administrative and write detail.
All employees can see response and closing remarks on system
A officer forward it to concerned department with timeline from system
GR
GR QA officer then follow up on system and close remarks if accepted
ceives mail for incident and responds without any other line of communication
Close the incident
Save incident response

GR Meeting face to face with personnel
Investigate further
GR: gap removed

Related Records:
1. Electronic Incident Reporting system

a) Clinical
b) Administrative
2. Incident Report Log Sheet
3. Attendance Sheet/Evidence of staff training or awareness session/s for the IR Policy.

IR Sub-Policy
Sentinel Events
Definition:
A sentinel event is an unexpected occurrence involving death or serious physical or

psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or
function. The phrase “or the risk thereof” includes any process variation for which a recurrence
would carry a significant chance of a serious adverse outcome. Such events are called “sentinel”
because they signal the need for immediate investigation and response.
The terms “sentinel event” and “medical error” are not synonymous; not all sentinel events
occur because of an error and not all errors result in sentinel events.
Policy Statement:
All the sentinel events must be reported Quality Assurance Department and
studied for CQI.
Purpose:
 The purpose of the Sentinel Event Policy is to define the process for Identification,
reporting, investigation and management of sentinel events that occur at MMIH.

 To have a positive impact in improving patient care, treatment, services and preventing
sentinel’s events.
 To better understand the causes, underlie such events happened in the past at MMIH.
 To increase the general knowledge about sentinel events, their causes, and strategies for
prevention
 To maintain the confidence of the public and accrediting organizations in the
accreditation process.
Scope:
This sub policy applied to all the patient care departments and sections of MMIH.
Reportable sentinel events:
Sentinel events are rare events that lead to catastrophic patient outcomes. It is mandatory
to report sentinel events. This includes both full time and visiting medical practitioners as
Quality requirements set out in the terms and conditions in contracting arrangements.
List of reportable sentinel events includes:
 Procedures involving the wrong patient or body part.

 Suicide of a patient in the hospital.
 Retained instruments or other material after surgery requiring re-operation
or further surgical procedure.
 Intravascular gas embolism resulting in death or neurological damage.

 Hemolytic blood transfusion reaction resulting from ABO incompatibility.

 Medication error resulting in major permanent loss of function or death of a
patient reasonably believed to be due to incorrect administration of drugs.
 Maternal death or serious morbidity associated with labour or delivery.
 Infant discharged to wrong family or infant abduction.
 Other adverse event resulting in serious patient harm or death.
Procedures:
Reporting requirements:
All departments at MMIH including OPD, IPD and also referred cases to any
outside facilities are required to report sentinel events to the Quality Assurance
Team at MMIH within 24 hours of the event occurred.
The QA will determine if the incident meets the definition and criteria to be
considered a Sentinel Event
Sentinel events must be reported on Incident Report (IR) Form and include the
date on which the event, occurred, a brief description of the sentinel event and
whether the investigation will be conducted. The name of a contact person must be
included.
One sentinel event can give rise to several reporting requirements during the
review process.

Incident Analysis Process
Root Cause Analysis:
Root Cause analysis is a process for identifying the basic or causal factors that
underlies variation in performance, including the occurrence or possible occurrence of
a sentinel event.
A root cause analysis focuses primarily on systems and processes. It progresses from
special causes in clinical processes to common causes in organizational processes and
systems.
The process identifies potential improvements in the system that would tend to
decrease the recurrence of such events in the future.
Review of Root Cause Analysis and Action Plans
The main features of the review are as followed:
A root cause analysis will be considered acceptable if it has the following characteristics:
 The analysis focuses primarily on systems and processes, not on individual

performance.
 The analysis progresses from special causes in clinical processes to common
causes in organizational processes.

 The analysis repeatedly digs deeper by asking “Why?”; then, when answered,
“Why?” again, and so on
 The analysis identifies changes that could be made in systems and processes (either
through redesign or development of new systems or processes) which would
reduce the risk of such events in the future
 The analysis is thorough and credible to be thorough.
The root cause analysis must include the following:
 A determination of the human and other factors most directly associated with the sentinel
event and the process(es) and systems related to its occurrence.
 An analysis of the underlying systems and processes through a series of “Why?”
questions to determine where redesign might reduce risk.
 An inquiry into all areas appropriate to the specific type of event.
 An identification of risk points and their potential contributions to this type of event.
 A determination of potential improvement in processes or systems that would tend to
decrease the likelihood of such events in the future, or a determination, after
analysis, that no such improvement opportunities exist. To be credible, the root
cause analysis must do the following:
a) Include participation by the leadership of the organization and by individuals most
closely involved in the processes and systems under review.
b) Be internally consistent (that is, not contradict itself or leave obvious questions
unanswered).

c) Provide an explanation for all findings of “not applicable” or “no problem”. Include
consideration of any relevant literature.
An action plan will be considered acceptable if it does the following:
 Identifies changes that can be implemented to reduce risk or formulates a rationale for
not undertaking such changes.
 Identifies, in situations where improvement actions are planned, who is responsible for
implementation, when the action will be implemented (including any pilot testing),
and how the effectiveness of the actions will be evaluated All root cause analyses and
action plans will be considered and treated as confidential by MMIH.
 A detailed listing of the minimum scope of root cause analysis for specific types of
sentinel events must be recorded (on IR form).
Sub-Policy IR
Medical Error:
Definitions
A Medical error is defined as when a health-care provider chose an inappropriate method

of care or the health provider chose the right solution of care but executed it incorrectly. Medical
errors are often described as human errors in healthcare.

Purpose
The purpose of this policy is to minimize the medical errors in MMIH to have safer
environment for patients, doctors and other staff members of MMIH.
Scope:
This Sub-policy covers patients and staff members who are directly involved in health
care at MMIH.
Policy Statement:
To ensure that medical errors are kept to a minimum.
Procedures:
Immediate Actions:
 Assess the patient’s condition and take necessary actions to maintain patient
stability.
 The error must be reported immediately to the person in charge of care for the
patient.
 Complete Incident Report Form as per the procedure defined in the IR Policy of
MMIH.

Informing the Patient:
MMIH acknowledges that when things go wrong, open and honest communication with the
patient and / or relatives is fundamental to the ongoing partnership between providing their care
and Management for Patient and Staff Safety.
Common Root Causes of Medical Errors
 Medical errors do not occur because of bad people in health care; it is that good people
are working in bad systems that need to be made safer.
 Poor communication
 Unclear lines of authority of physicians, nurses, and other care providers.
 Disconnected reporting systems within a hospital.
 Fragmented systems in which numerous hands-off of patients results in lack of
coordination.
 The impression that action is being taken by other groups within the institution.
 Reliance on automated systems.
 Inadequate systems to share information about errors.
 Cost-cutting measures by hospitals in response to reimbursement cutbacks.
 Environment and design factors.
Competency, Education, and Training
 Variations in healthcare provider training & experience.

 Failure to acknowledge the prevalence and seriousness of medical errors.

Human Factors
 Fatigue or Sleep deprivation.

 Depression and burnout.
 Diverse patients,
 Unfamiliar settings,
 Time pressures.
 Complications increase as patient to nurse staffing ratio increases.
 Drug names that look alike or sound alike.

IR Sub-Policy
Medication Error:
Definition:
A medication error is any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the healthcare
professional, patient, or consumer at MMIH.
Such events may be related to:
 professional practice
 healthcare products
 procedures and
 systems
Medication Error includes
i. Prescribing errors
ii. Dispensing errors
iii. Distribution errors
iv. Preparation and Administration errors
v. Monitoring errors
vi. Communication Errors

Contributing factors are:
a. Order communications
b. Product labeling
c. Education
d. Use of medicine
List of Medication Errors:
The following list gives examples of scenarios where medication errors can occur. Near misses
in any of the sections below should also be considered.
This is not an ultimate list and care providers and management must exercise their
professional judgment prior to the progressing the issue.
o Prescribing Errors:
 Patient prescribed the wrong medication / dose / route / rate
 Medication prescribed to the wrong patient
 Transcription errors
 Prescribing without taking into account the patients clinical condition
 Prescribing without taking into account patients clinical parameters e.g. weight
 Prescription not signed.
o Dispensing Errors:
 Patient dispensed the wrong medication / dose / route

 Medication dispensed to the wrong patient

 Patient dispensed an out of date medicine
 Medication is labeled incorrectly
o Distribution Errors:
 Inappropriate medication selected
 Verbal order misunderstood
 Alert information bypassed or use of nonstandard nomenclature.
 Delay in delivery
 Unorganized schedule
o Preparation and Administration Errors:

 Patient administered the wrong medication / dose / route
 Patient administered an out of date medicine
 Medication administered to the wrong patient
 Medication omitted without a clinical rationale
 Medication incorrectly prepared
 Incorrect infusion rate
 Medication administered late / early MMIH recognizes this is a complex issue and the
full context of late/early administration should be taken into account, however where
it would have a significantly detrimental effect on patient care, this would constitute
an error

o Monitoring Errors:
 Patient allergic to medication but the medication was prescribed and/or dispensed
and/or administered.
 Failure to provide the patient with correct information regarding their medication
e.g. when to take, what it is for, side effects
 Failure to monitor therapeutic levels
 Failure to monitor patient / career who is undertaking self-medication.
o Order Communication Error
 Inappropriate medication selected
 Inappropriate dose, illegible order, duplicate order, order not dated/timed, wrong
patient/chart selected
 Contraindications
 Verbal order misunderstood
 Verbal order not written in the chart
 Wrong frequency
 Route of administration
 Therapy duration
 Alert information bypassed or use of nonstandard nomenclature.
Contributing Factors
Types of contributing factors include:
 Fatigue
 Calculation error

 Knowledge deficit
 Performance deficit
 Workload,
 Computer software issue
 Computer downtime
 Hybrid system (manual/computer processes),
 Lack of communication between practitioners
 Missing critical info
 Alert bypassed
 Order entry into pharmacy system
 Charting related error
Any system breakdown that is not captured with one of the above predefined breakdown point
should be classified as “other” and described.
Policy
To ensure that medical errors are kept to a minimum and that the staff is aware of the list of
medication errors.
Procedures
Immediate Actions:

 Assess the patient’s condition and take necessary actions to maintain patient stability.
 The error must be reported immediately to the person in charge of care for the patient
 Seek advice from Pharmacy regarding the possible outcomes of medication error.
 In the instance of a dispensing error, inform the local pharmacy department manager and
return the incorrect medication to pharmacy for re-dispensing.
 Complete Incident Report Form as per the procedure defined in IR Policy of MMIH
Medication Error Exception:
Omission Error
 The failure to administer an ordered dose to a patient before the next scheduled dose,
if any.
 Exclusions would be
a) Patient’s refusal to take the medication or
b) Decision not to administer the dose because of recognized
contraindications. If an explanation for the omission is apparent
(e.g. patient was away from nursing unit for tests or medication
was not available), that reason should be documented in the
medical record file.
 Informing the Patient:
The trust acknowledges that when things go wrong, open and honest communication with
the patient and / or relatives is fundamental to the ongoing partnership between providing their
care and Management for Patient and Staff Safety.
Title- Key Performance Indicators Policy

Key Performance Indicators Policy
Policy statement
To review monthly Key Performance Indicators of all departments to monitor the progress.
Introduction
A Key Performance Indicator (KPI) is a measurable indicator that demonstrates how well a
company is attaining key business objectives. Organizations use KPIs to assess their
achievement at reaching targets. Selecting the right KPIs will depend on an organization.
Departments use relevant KPIs to measure success based on specific business goals and targets.
The goals of Key Performance Indicators compliance are to evaluate whether business projects
and policies are achieving their stated objectives, ascertain areas in need of improvement and
provide ways to control and monitor employee performance.
Procedure
 All departments shall develop their monthly Key Performance Indicators.

 All departments shall maintain their monthly Key Performance Indicators.
 Monthly Key Performance Indicators shall be approved by Quality Assurance
department.
 Departments shall submit their Key Performance Indicators to Quality Assurance
department by the 5th of every month and add to the sharing folder.
Title- Key Performance Indicators Policy

 Quality Assurance department shall review and send back the remarks by the 10 th of
every month to the respective departments.
 Quality Assurance department shall forward the KPI report to the CEO.
 Only approved Key Performance Indicators shall be presented in the morning meeting.
 If any department wants to add new indicator it has to be reviewed first by Quality
Assurance department.
Title- How to handle difficult situation

How to handle difficult situation
Policy
All employees are responsible for handling/initiating to handle difficult situation.
Sub policy: 1) In-charges/ manager level should be involved immediately to lead
2) Decision for involving /calling law and enforcement agencies shall be taken by
General Manager’s level person.
Responsibility: All employees.
Guidelines:
Occasionally managers and staff will need to address abusive behavior, threats and even physical
attacks by individuals. Most of us encounter unreasonable people and/or get “trapped” with a
difficult individual at work. It’s easy to let a challenging person affect us and ruin our day. In
each instance, safety must be balanced with serving customers and patients. Team approaches
work best in this situation. Try and handle difficult situations before they occur. Staff should
know what protocols/policy exist and why they exist; their role in enforcing policy, as well as the
role of others (board members, police, etc.); and the number of choices/decisions they have in
managing the situation.
The most important ways one can prepare for dealing with difficult individuals and encounters
are:

 Develop communications skills to handle a variety of situations.

 Train all staff in dealing with difficult customers.
 Observe verbal and non-verbal messages, and respond accordingly.
 Paraphrase to ensure that you understand the problem, and ask the customer to validate
your understanding of their problem or concern.
 When necessary, ask questions to learn more.
 Keep the conversation focused on the topic at hand.
 Use silence well. Five or six seconds of your silence will encourage the customer to
elaborate.
 Keep your comments factual. Do not take the customer’s comments personally.
 Say “I’m sorry” and acknowledge the customer’s feelings if necessary.
 Refer to a supervisor, manager or director when necessary, i.e. involve other seniors and
responsible members of the team.
 Know when to involve police.
 If a certain problem occurs regularly, post notices as appropriate.
 Address ongoing issues to Chief Operation Officer and Chief Executive Officer. Explain
the rationale behind the situation/decision/request.
 Be direct, yet remain polite and professional at all times.
 Use positive language (ex: for your safety, we respect all opinions, etc.).
 Refer to policies that relate to the situation. Share them with the customer to help them
understand your position.
 Agree on a resolution and proceed with it immediately.

 Let the customer know what follow-up action (if any) will take place.
 If the situation requires follow-up, do so on a timely basis.
 Be silent if you do not know what to say.
 Do not react in any way to abuse, verbal provocation or physical threat.
 Do not leave a colleague alone if witnessing an awkward situation evolving – if you have
to leave do so briefly to call for help and return to be with your colleague.
 Always talk to your colleague, counseling them continuously to maintain a calm
demeanor.
 Speak slowly, calmly and without any gesticulations (sit on your hands).
Procedure:
i. Call for help i.e. inform the senior/in-charge of his/her department.

ii. Assess the seriousness of situation.
iii. Take measures to control and follow up.
iv. Document the incident.
v. QA department should be informed within 24 hours.
Title- Patient Satisfaction Survey

Policy statement:
The aim is to measure the satisfaction of patients of Memon medical institute hospital
Introduction:
Patient satisfaction is an important indicator for measuring the quality of healthcare provided to
patients it has an impact on efficient and patient satisfaction delivery of quality care. By
identifying the level of patient satisfaction and factors associated with patient dissatisfaction.
Sources of assessing patient satisfaction include
1. Admission procedure
2. Discharge procedure
3. Nursing care
4. Consultant
5. Duty doctors
6. Food service
7. Cleanliness
8. Security
9. Overall services
Definition:
Satisfaction: is a degree to which the patient’s expectation, goal and preferences are met by the
health services
Procedure:
The tool is to measure overall satisfaction in Memon medical institute hospital.
Method 1.
Title- Patient Satisfaction Survey

i. Quality assurance team member visit inpatient wards (GYNAE, GW, PGW, PEADS)
and conduct verbal one to one patient satisfaction survey.
ii. Patient Data maintained on excel sheet
iii. Interpret data and calculate percentage for hospital statistics report.
iv. Prepare PowerPoint presentation
Method 2.
i. Satisfaction survey form shall be given to every patient at the time of discharge which
will be available in billing area
ii. Filled survey form collected through survey box placed on billing counter.
iii. Patient Data maintained on excel sheet
iv. Interpret data and calculate percentage for hospital statistics report.
v. Prepare PowerPoint presentation
Title- Employee Job Descriptions

1. Position title: GM, Quality 2. Reporting Authority: CEO

Assurance
3. Department: Quality 4. Section:

Assurance

5. Job Status: a) Permanent b) Probationary b) Part time
c) Daily wedges e) Contract f) Any other (Please specify) ___________.
6. a) Duty Scheduale: a)Timming : from 9:00am to 5:30pm b) No.of Duty Hours/day ______ hrs
7. c) Fixed d) Rotation
8. Qualification requirments: 9. Minimum Experience:

Bachelors / Maters or above  10 years of experience in hospital quality
assurance program.
 Person with medical background will be
prefered.
EMPLOYEE JOB DESCRIPTION
Job Duties & Responsibilities:
1. To provide/ suggest infrastructure of Quality Assurance Program.

2. To establish the monitoring mechanism.
3. To streamline all healthcare processes.

4. To evaluate the performance of different sections of the hospital.

5. To review the statistics of hospital performance.
6. To provide consultation in developing key performance indicators of different sections.
7. To provide consultation in designing departmental quality assurance program.
8. To guide and mentor the infection control activities.
9. To guide and mentor the risk management activities.
10. To guide and mentor the utilization management activities.
11. To guide and mentor the performance improvement activities.
12. To act as a consultant in clinical affairs management.
13. To participate in all management committees.
14. To represent hospital where needed.

1. Position Title: Statistician, Quality Assurance 2. Report to: GM, Quality Assurance
3. Department: Quality Assurance 4. Section: -------
 
5. Job Status: a) Permanent b) Probationary c) Part time
d) Contract e) Any other (Please specify) ___________.

6. a) Duty Hours/day: 8 hrs. b) Fixed c) Rotation
8.Experience requirements:
7. Qualification requirments:
 Minimum Experience: 2-3 years in Quality
 Minimum Qualification: BSc Statistics Management/ Statistical Analysis of Research
Projects.
 Preferred Qualification: MSc. Statistics
Job Description
Routine Job Responsibilities:
1. Coordinate all routine QA activities.

2. Helps in drafting Hospital Policies
3. Design audit tools.
4. Prepare report of departmental projects
5. Compile statistical reports.

6. Prepare reports and presentation of performance improvement projects.

7. Designs survey questionnaires and data collection instruments for the collection of
data.
8. Applies statistical techniques and methods in the processing and analysis of data.
9. Plan data collection methods for specific projects, and determine the types and sizes
of sample groups to be used.
10. Report results of statistical analyses, including information in the form of graphs,
charts, and tables.
11. Identify relationships and trends in data, as well as any factors that could affect the
results of research.
12. Coordination of CQI sessions.
13. Guiding the clinicians/ department heads for analyzing the data.
14. Any special task assigned (Gap Analysis, any work related with tabulation of data).

1. Position title: Infection Control Officer Grade: Male
2. Reporting 3. Department: Quality 4. Section:

Authority: GM, QA Assurance
 
5. Job Status: a) Permanent b) Probationary b) Part time c) daily wedges
e) Contract f) Any other (Please specify) ___________.
6. a) Duty Scheduale: a)Timming : from 9:00am to 5:30pm b) No.of Duty Hours/day 8.5 hrs
7. c) Fixed d) Rotation
8. Qualification requirments: 9. Experience requirements:
 Minimum Requirement: Registered Nurse/  Minimum 2-3 years

BSc Nursing
 Preffered Requirement: Certified professional
in Infection Control
Job Description
Routine Job Responsibilities:


1. Conduct regular rounds in all hospital departments to discuss, monitor and follow the
infection control practices with staff personnel.
2. Collects data on Nosocomial infections from all hospital departments in records.
3. Conducts continuous surveillance to detect the source of the infection for prevention
purpose.
4. Takes culture swabs as per need from high risk areas to hospital laboratory, obtains the
microbiology culture results from the hospital laboratory and reports positive findings to
responsible persons.
5. Follow and investigates the incidences of Nosocomial hospital infections, generates
report.
6. Ensure the availability of place and supplies required for isolation.
7. Implements educational programs to provide staff with knowledge and skills regarding
infection control practices and preventive measures to provide a safe environment for
clients and employees.
8. Monitors the implementation of preventive measures, provides guidance to staff and
counsels them as per the need.
9. Participates and assists in the organization of regularly scheduled hospital infection
control committee meetings.
10. Prepares monthly statistical data for presentation in the hospital infection control
meetings.
11. Performs other job related duties assigned. Participate in continuous quality improvement
initiatives unit meetings as assigned.
12. Advises and consult with nurses and hospital personnel concerning precautions to be
taken to protect patient, staff and other persons from possible contamination or infection.

13. Order and/or obtain specimen from wounds for culture and sensitivity.
14. Observe and follow isolated patient in the department.
15. Report diagnosed or suspected communicable diseases to hospital treating physician.
Special Tasks:
1. Incident reporting & follow up.

2. Bed sore data collection.
3. Data collection of QA projects.
Title- QUALITY GOALS STEPS

QUALITY DEPARTMENT MONITORING PERIOD
FREQUENC
ACCEPTABLE MONITO REPORTE Y OF COMMENT
QUALITY
MONITOR STANDARD RED BY D TO REPORTIN S
G
EXECUTIV MONTHLY
E
COMMITT
EE
100% DEPART
INCIDENT
REVIEW OF MENT
REPORTS
REPORTS HEAD
TIMELY NO LATER DEPARTM EXECUTIVE 3 MONTH
ISSUANCE THAN 10TH OF ENTAL COMMITTE
EVERY MONTH MEETING E
OF
REPORTS
(MONTHLY
STATISTICS
)
TIMELY 100% DEPARTM CEO 6 MONTH
ORGANIZAT COMPLIANCE ENTAL
ION OF CQI WITH THE MEETING
SESSIONS SCHEDULED
PROGRAM
QA 50% OF THE DEPARTM CEO 6 MONTH
PROJECT STARTED ENTAL

COMPLETIO PROJECTS MEETING

N
EXPANSION 10% INCREASE DEPARTM CEO 6 MONTH
OF THE IN ENTAL
DEPARTME COMPLETION MEETING
NT
DEVELOPM 10% DEPART EXECUTIV 6 MONTH
ENT OF INCREASE IN MENTAL E
POLICY & COMPLETION MEETIN COMMITT
PROCEDUR G EE
ES OF ALL
DEPARTME
NTS
DEVELOPM AT LEAST ONE DEPARTM EXECUTIV 3 MONTH
ENT OF KEY DEPARTMENT ENTAL E
PERFORMA EVERY MONTH MEETING COMMITT
NCE EE
INDICATOR
S

Implementation of QM
Step 1
 Hospital Policy and Procedures shall be introduced and shall be in implementation phase.
 Hospital Clinical and non-Clinical Indicator introduced.
 Concurrent Monitoring for Patient Satisfaction.
 Introducing QM Educational Sessions.
 Quality Culture Development.
 Infection Control
Step 2
 Introduction of departmental Key Performance Indicators.

 Occurrence Screening
 Departmental Quality Reports.
 Start of Inter Department Meetings
 Continuous Quality Improvement Sessions and Continuous Medical Education Sessions.
 Improvement Projects in Clinical Affairs as per JCIA Standards (Library of Congress)
 Departmental Policies and Procedures in implementation phase.
 Utilization Management Program
Step 3
 Initiation of Accreditation/Certification.

 Training for all hospital staff for Accreditation process.

 Risk Management.
 Research Projects.
Title- QUALITY POLICY

QUALITY POLICY
Memon Medical Institute hospital provides health care for all patients, according to the

highest levels of skill and professionalism, ethical practice, which leads to effective treatment,
care and affordable cost.
 Consistent compliance with all imposed requirements.

 Our focus on Patient Safety and Satisfaction.
 Continual improvement of our services and processes.
At MMIH our vision is to create a culture of operational excellence in a workplace free of

accidents, free of environmental emissions, free of health related incidents, free of losses to
processes, free of security incidents.

Title: - Manual of Quality Assurance Department

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Title: - Manual of Quality Assurance Department

Uploaded by

Copyright:

Available Formats

Memon Medical Institute Hospital

(Hospital Project of Memon Health and Education Foundation)

Department: Administration Section: Quality Assurance Doc# MMIH-QA

Title- Manual of Quality Assurance Department

Next Rev Date: Nov,2021

Designation: Q.A Officer

Designation: GM, Quality Assurance

Department: Administration Section: Quality Assurance Doc# MMIH-QA

Title- Manual of Quality Assurance Department

Next Rev Date: Nov,2021

Department: Administration Section: Quality Assurance Doc# MMIH-QA

Title- Manual of Quality Assurance Department

Next Rev Date: Nov,2021

Key Performance Indicators Policy...........................................................................................47

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

INTRODUCTION TO QUALITY ASSURANCE:

1. Monitoring and evaluation of services

MISSION OF QUALITY ASSURANCE DEPARTMENT:

VISION OF QUALITY ASSURANCE DEPARTMENT

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

 To pursue the approved principles of Quality Management as set by JCI Standards.

 To facilitate interdisciplinary communications and co-operations.

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

PROPOSED DEPARTMENTAL ORGANOGRAM:

Manager Manager Manager

INTRODUCTION OF QUALITY MANAGEMENT:

The Quality Management Systems provide a planned systematic approach for an

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

QUALITY MANAGEMENT PROCESS:

Quality management components:

The Quality Management System will comprise the following:

Suggested steps for assessment and improvement activities

Step 1 – To Assign Responsibilities:

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

Each Department / Service will be responsible for participating in the development of

MEDICAL STAFF NURSING SERVICES ANCILLARY/

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

CLINICAL COMMITTEE ADMINISTRATION SUPPORT SERVICES

Step 2 – Delineate Scope of Care / Service

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

Step 3 – Important Aspects of Care / Service:

Each Department / Service is responsible for identifying its important aspects of

A. High Volume – the process occurs frequently or affects large numbers of

Step 4 – Identify Indicators:

An indicator is a well-defined objective, measurable, variable and is used to

Indicators may be structure, process or outcome in nature.

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

E.g.: there should be no patient complaints concerning any patient waiting in

Step 5 –Establish thresholds for evaluation related to the indicators:

A threshold is a pre-established level or point in the cumulative data that will

NOTE: A threshold is not a standard. A standard of practice specifies an accepted

Step 6 – Collect and Organize Data:

Title- Introduction to Quality Assurance

Next Rev Date: Nov,2019

B. Data Collection: It is related to the frequency of the event or activity being