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Policy on Quality Improvement

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AUTHORIZED SIGNATORY

1. Approved By Medical Director

2. Issued By Quality Manager

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AMENDMENT SHEET

Sl. Page No. Clause No. Date of Amendment Made Reasons Signature of Quality
No. Amendment Manager

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INDEX

Sl. No. Policy & Procedure Page No.

1 Policy on Quality Improvement 5-25

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1.0 INTRODUCTION:

The purpose of the hospital is:-

 To provide quality health care which recognizes the intrinsic human merit and dignity of all
persons, and
 To make the programs and services available to all without
restriction;
 To create a healing environment where physicians, allied health professionals and staff work
together to provide personalize care;
 To be a leader in advocating high quality health care programmes and developing resources to
satisfy the primary health care needs of the citizens of our service areas; and
 To operate in an ethically and fiscally responsible manner without compromising the patient care
needs.
 To achieve this, all employees of the hospital will participate in ongoing and systemic quality
improvement efforts will focus on direct patient care delivery process and support processes that
promote optimal patient outcomes and effective business practices. This is accomplished through
peer review, clinical outcomes review, performance appraisals, and other appropriate quality
improvement techniques.

 The Quality Improvement plan demonstrates our commitment to improve the quality of care.
The QI Plan outlines the goals and strategies for ensuring patient safety, delivering optimal care,
and achieving high patient satisfaction.

 The Quality Improvement Plan established here is utilized by all services and departments
throughout the facility.

2.0 POLICY:
To provide a framework for quality assurance and quality improvement, while focusing on patient safety
and quality of care. These include a strong culture of safety that has been inculcated, a decrease in the
incidence of adverse events, and constant monitoring of quality within the system.

3.0 PURPOSE:
The purpose of the quality improvement efforts is to ensure delivery of the best possible care to the
patients. It is the goal of this plan to provide a mechanism and process to identify opportunities to
improve care and services by measuring, assessing, and improving care in a systemic and ongoing

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manner.

4.0 OBJECTIVES:
 Utilize a hospital - wide approach to improve important functions carried out by this organization,
using team efforts whenever possible
 Increase the probability of desired patient outcomes, including patient and physician satisfaction, by
assessing and improving the governance, managerial, clinical and support processes that affect those
outcomes.
 Identify opportunities to improve patient care and services provided.
 Establish priorities for improving care outcomes and patient satisfaction.
 Provide guidance and knowledge to individuals and groups of individuals for improving
processes in which they are involved.
 Coordinate quality improvement activities and integrate the efforts of all disciplines throughout the
organization whenever appropriate.

5.0 GOALS
 To utilize an interdisciplinary hospital–wide approach to Quality Improvements activities.
 To maintain a Quality Improvement team to be responsible for each key function; evaluate
the needs for Quality Improvement activities for the function on an ongoing basis; to review
policies and procedures relating to each function and make necessary revisions; to establish
priorities for measuring Quality; to initiate Quality Improvement measurements in priority areas.
 To develop a patient care pathways relating to operative and other procedures, in a
collaborative Quality improvement team effort.
 To utilize a standard format for documenting and reporting all quality measures hospital
wide.
 To collect data on staff views regarding Quality improvements activities.
 To establish priorities for quality improvement activities.
 To develop a formal tool for prioritizing Quality improvement activities.

6.0 DEFINITION/ ABBREVIATIONS (IF ANY):

NABH: National accreditation board of hospitals and healthcare providers
QCI: Quality Council of India
QI: Quality Improvement

7.0 SCOPE:
To achieve the goal of delivering high quality care. All the employees are given in the responsibility and

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authority to participate in the Quality Improvement program.

8.0 RESPONSIBILITY:
Authority and Accountability

A. Board of Directors

 The Board of Directors shall have overall supervision and control of the Quality Improvement
through the Medical Superintendent.
 The Board of Director shall review periodic reports of findings, actions and results from
Quality Improvements activities in order to assess the program’s efficiency and effectiveness
 The Board of Directors delegates and directs the hospital administration and the medical staff to.

I. Recommend a strategic direction.

II. Implement the Quality Improvement efforts.
III. Assess and prioritize the Quality Improvement activities
IV. Provide resources and support systems for Quality Improvement function
related to patient care services and safety.
V. Require mechanisms to assure that all patients with the same health
problems are receiving a comparable level of care.
VI. Review information needed to educate the members of the board of
directors to their responsibility for the quality of patient care
VII. Evaluate the quality improvement plan annually and improve the
mechanisms as needed.

B. Medical Director/Medical Superintendent

 The Medical Director/Medical Superintendent will be responsible for providing support for the
proper functioning of hospital wide quality improvement activities.

 The Medical Director/Medical Superintendent provides the Board of Directors with pertinent
information regarding Quality Improvement activities.

 The Medical Director/Medical Superintendent provides support, direction, and/ or assists with the
resolution of problems or opportunities to improve care or services needed.

C. Organization Leaders

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The organization’s leaders are responsible for the following:

 Developing and implementing mechanisms designed to ensure the uniform quality of patient
care processes throughout the organization.
 Developing and implementing an effective and continuous program to measure, assess, and
improve quality.
 Continuously assessing and improving the quality of care and services provided.
 Adopting an approach to quality improvement that includes planning the process for
improvement, setting priorities for improvement, assessing quality systematically, implementing
improvement activities based on assessment, and maintaining achieved improvements.
 Participating i n c r o s s - o r g a n i z a t i o n a l a c t i v i t i e s t o i m p r o v e o r g a n i z a t i o n a l quality
as appropriate.
 Communicating information relevant to cross-organizational quality improvement activities to
appropriate individuals.
 Allocating adequate resources for assessing and improving the organization’s governance,
managerial, clinical and support processes, by assigning personnel, as needed, to
participate in quality activities, providing adequate time for personnel to participate in quality
improvement activities, creating and maintaining information systems and appropriate data
management processes to support collecting, managing, and analyzing data need to
facilitate ongoing improvement in quality, and providing for staff training in quality
improvement methods.
 Analyze and assess the effectiveness of their contributions to improving quality.

D. Quality Assurance Committee –

QUALITY CORE COMMITTEE

MEMBERS

Frequency: Every quarterly and as and when required

Functions:

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1. Review the quality of care provided to patients on the various clinical services through the monitoring of
clinical indicators, sentinel events and performance of processes/systems that are intradepartmental as
well as trans departmental.
2. Review of at least a sample of surgical and other invasive procedures that includes selecting appropriate
procedures, preparing the patient for the procedure, performing the procedure and monitoring the patient
and providing post-procedure care.
3. Identifies and evaluates general areas of potential risk in the clinical aspects of patient care and safety
that have been identified following specific case reviews.
4. Institutes action plans to correct or reduce risk in the clinical aspects of patient care and safety.
5. Recommend appropriate actions for improvement in patient care and improvement in processes/systems
of delivering patient care.
6. To prepare for NABH accreditation.
7. It involves taking care of new processes and changes in the system required for the NABH accreditation.
8. It also includes training and educating the staff about NABH and the transformation associated with it.

E. Quality Systems (Quality Assurance Department) – (Functions and Composition)

 Fostering a culture that promotes a commitment to continually improving the quality of patient
care and services.
 Providing education to key personnel, as needed, on the approaches and methods of quality
improvement teams and activities.
 Assessing and prioritizing process improvement projects.
 Monitoring and evaluating the process of Hospital Committees.
 Managing the flow of information to ensure follow- up.
 Reporting quality improvement activities to the Quality Assurance Committee.
 Assigning process improvements activities to the appropriate cross functional team.
 Assisting and providing guidance to teams as needed.
 Assisting and coordinating departments and teams in the transaction to hospital wide- team efforts
in quality improvement activities.
.
F. Quality Improvement Activities

Quality improvement activities shall include, but not be limited to the following.

9.0 DISTRIBUTION:

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Quality Head, HOD’s of respective departments, Medical directors, top management.

10.1 Scope
To achieve the goal of delivering high quality care, all employees are given in the
responsibility and authority to participate in the Quality Improvement program.

10.2 Department / Services

The following departments / services are included in the quality improvement activities:

10.3 Approach to design, measuring, Assessing & improving quality

A. Plan

Planning for the improvement of care and health outcomes includes a hospital wide approach.
1. The organization maintains a plan that describes the organization approach, p r o c e s s , a n d
m e c h a n i s m s t h a t c o m p r i s e t h e o r g a n i z a t i o n ’ s Quality Improvement activities.
2. The team approach serves as a means of collaboration between departments and
disciplines in planning and providing systemic organization – wide improvements.
3. The organization utilizes the Plan – Do-Check –Act Quality Improvement Model as the framework
for improving quality.

B. Design

In order to design effective processes, functions or services, the following key elements are considered
when relevant and available

1. The process design is based on the organization’s mission, vision and strategic plan.
2. Consideration is given to the needs and expectations of patient, staff, and others.
3. Research into current literature and practices guidelines.
4. Design is consistent with sound business practices
5. Baseline quality expectations are utilized to guide measurement and assessment
activities.

C. Measure

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Data collection as the basis of all Quality Improvement activities provides a means of
measuring quality through which informed decision can be made.

1. Data is collected for a comprehensive set quality measures based on the priorities established
for the organization in order to.
a. Establish a baseline when a process is implemented or redesigned
b. Describe process quality or stability.
c. Describe the dimensions of quality or stability.
d. Describe the dimensions of quality relevant to functions, processes, and outcomes.
e. Identify areas for improvement.
f. Determine whether changes in a process have met objectives
2. Data is collected as a part of continuing as a part measurement, in addition to data collected
for priority issues.
3. Data collection considers measures of process and outcomes.
4. Data collection includes at least the following process or outcomes:

D. Assess
The assessment process involves the necessary disciplines or department to draw conclusions
about the need for more intensive measurement. A systemic process is sued to assess collected data in
order to determine whether specification for newly designed processes were met, ;the level quality
and stability for important existing process, priorities for possible improvement processes and
whether changes in the processes resulted in improvement.

a. C o l l e c t e d data is assessed at least monthly and findings are documented and are forwarded through
the proper channels as outlined in this plan
b. A pre- determined level of quality, or threshold (upper and lower control limits), which would
trigger a more in depth review, is established for each quality measure to assist in the assessment of the
data collected. The reference used shall include the following
c. Internal comparisons in Quality of processes and outcomes are made over time.
d. Quality comparisons of data are made about processes with up-to date information.
e. Q u a l i t y comparisons of data is made about processes and outcomes with other hospitals utilizing
reference databases when possible
f. The assessment process includes the use of statistical process control techniques/ tools as
appropriate. Training for use of statistical process control is provided to the hospital leaders; team
members / staff are educated regarding statistical process control techniques on an ‘as needed’ basis.
g. When assessment of data indicates, a variation in quality, more intensive measurement and
analysis will be conducted and in addition, the department/ service or team will reassess its quality

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measurement activities and re- prioritize them as deemed necessary.

h. I n t e n s i v e assessment is initiated when statistical analysis shows the following:
 Important single events, levels of quality, and patterns or trends that vary significantly and
undesirably from those expected.
 Quality that varies significantly from other organizations.
 Quality that varies significantly and undesirably from recognized standards.
 Intense assessment is performed on the following.
 Major discrepancies between preoperative and postoperative diagnosis
 Confirmed major blood transfusion.
 Significant adverse drug reactions
 Adverse events or patterns events during anesthesia use.
 Unexpected patient death.
 Wrong site/side/ patient surgery
 When findings of the assessment process are relevant to an individual’s quality, the pertinent
information will be provided to the Medical Superintendent for determining their use in
peer review and /or periodic evaluations of a licensed independent practitioner’s
competence at reappointment.
 When a Quality measurement does not reach the predetermined acceptable level of quality, of if
it is reached, but evaluation indicates the quality is not acceptable, the quality improvement
process should continue. If the level of quality shows no improvement for the time frame
established by the established departments/ service or team plan, an intensive evaluation should
be conducted with input from the quality Steering Committee regarding the need for
continued measurement.
 When no opportunities to improve are found after two quarters of data collection, the quality
measure should be re-evaluated to determine the need to continue measurement, and
re- prioritization of quality measurements should occur.

E. Improve

When opportunities for improving quality are identified, a systemic approach is used to redesign the
involved process, or to design a new process. The leadership, through the quality Steering committee
will establish hospital – wide priorities.

1 .When an opportunity for improvement is identified by a department or services the department /

service will determine if other disciplines or departments that have an impact on the process in the
design / redesign of the process. If other disciplines or departments are involved, the opportunity for
improvement will be referred to the appropriate established department.

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2. The appropriate department shall establish priorities for improvement based on the guidelines
established in this plan, when necessary the Medical Superintendent will assist the department / service in
establishing priorities.

3. The appropriate department shall use the Plan-Do-Check Act approach to

a) Established an action plan.
b) Identify quality expectations
c) Establish quality measures
d) Implement actions on a trial basis when possible
e) Compare the results of the action taken to the quality expectations
f) Develop a new action plan when the desired result is not achieved.
g) Incorporate effective actions into the hospital’s standard operating
procedures.
h) Verify that improvements are maintained through Quality measurements and
assessment activities

4.When opportunities are identified through quality improvement findings, educational needs
are determined and efforts taken to provide the necessary education.

F. Guidelines for prioritizing Opportunities for improvement

1. Priorities are established based on the element of risk to patients, the number of patients involved,
problem prone areas, newness of the service or process involved, patient satisfaction, and the
organization’s mission vision and strategic plan, patient outcome. Cost to implement, regulatory
compliance, impact on efficiency.

2. Considering these elements, the team members, having knowledge and expertise in the given area, will
evaluate the priorities for the department.

3. When necessary, the Medical Superintendent will assist in prioritizing quality measurement efforts for
the department, or will make recommendations regarding prioritizing.

4. The quality Assurance committee shall establish priorities for quality improvement efforts
for the organization as a whole, based on the above guidelines.

G. Quality Improvement Activities

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Quality improvement activities shall include, but not be limited to the following:

1. Departments / Service
Quality Improvement activities are carried out and are documented by each departments /
service.

2. Medical Superintendent
a. It will be the responsibility of the Medical superintendent to oversee mechanisms used to conduct
Quality Improvements activities and to make recommendations to the Board of Directors regarding the
organization of the quality improvement activities, and the results of efforts to improve care.
b. The Medical superintendent will support and provide participation on interdisciplinary teams as needed,
based on the activities of the team.
c. Relevant findings, conclusions, recommendations and action taken to improve care, shall be
communicated to the appropriate consults.
d. Cases with medical care concerns will undergo medical audit. The cases shall be forwarded to the
Clinical Audit and Death review committee for review and any further actions will be taken based upon
recommendations of the committee.

3. Screening Measures.

a. Quality measures shall be used hospital-wide to screen for adverse or unusual occurrence or
potential problem areas, and as a means of identifying opportunities to improve care or
services as deemed necessary by the Medical Superintendent .
b. When standard of care concerns are raised, Clinical Audit and death review of the individual case
shall be obtained by forwarding the case to the Medical Superintendent
c. Results of screening shall be aggregated monthly for trending purposes, and will be forwarded to
the appropriate departments / services for review (monthly values given to all concerned
departments).

4. Patients feedback
a. Patient feedbacks are utilized to evaluate the needs and expectations of patients.
b. The Quality Assurance Committee reviews a summary of the findings periodically.
c. When opportunities for improvement are noted, pertinent information is forwarded to the
appropriate department or individual for review and evaluation and action as necessary.

5. Operative and other procedures.

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a. Review of operative and other procedures is performed by Quality Assurance committee at least
quarterly
b. Necessary recommendations are forwarded to the Medical Superintendent
c. Pertinent information regarding findings is communicated to the Medical Superintendent
d. Operative and other procedures continuing measurement will include review of the following
1) Surgical Site infection rates.
2) OT surveillance data
3) Incidence of wrong site/ side during patient surgery.
4) OT Utilization
5) Significant discrepancy in pre & post operative diagnosis.
6) Adverse anesthesia events
e. The OT committee will determine priority areas to be included in the review of operative and other
Procedures review.
f. The OT committee will initiate a team effort for data collection, aggregation, and analysis of the selected
Quality measures.
g. The OT committee will forward a summary of their findings to the Director, Medical Services, along
with any actions taken to improve care.
h. The Director, Medical Services will review the findings and make any further recommendations to the
OT Committee, or take any additional actions/ necessary to improve care.

7. Medication Usage
a. The Drugs and Therapeutic Committee, coordinated by the Department of Clinical
Pharmacology & Pharmacy, carries out the Medication Usage functions bimonthly.
b. The Drugs and Therapeutic Committee takes necessary actions or recommendations are forwarded
to the appropriate department, Director, Medical Services or responsible individuals.

c. Pertinent information regarding findings is communicated to the Medical Superintendent and

appropriate individuals.

d. Medication Usage processes include measurement of at least the following:

i) Medication errors.
ii) Antibiotic usage

e. The drugs and therapeutic Committee is also responsible for the development and maintenance of
the drugs formulary as well as approval of policies and procedures relating to the selection,
distribution, & handling, use and administration of drugs.

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f. The committee reviews all significant untoward drug reactions.

8. Blood Usage

a. The Blood Usage Review functions are carried out by the QA department and submitted to
concerned authority for action.
b. The Concerned Authority takes necessary actions or recommendations for action are forwarded to
the Medical Superintendent and the Director, Medical Services

9. Management of information function.

a) The medical records carries out the Medical record review functions at least monthly. The medical
record review functions includes the review of clinical pertinence and timeliness
b) The Medical Record department review and takes necessary actions or recommendations are
forwarded to the appropriate department, Medical Superintendent and the Director, Medical Services.

10. Infection control

a. The infection Control committee meets once a month and the infection Control team
functions on a daily basis monitoring and collecting appropriate data.
b. The committee Review includes approval of policies and procedures relating to infection
Control, review and evaluations of infection statistics, focused review on infection concerns and/or
issues as appropriate, review and input into the hospital’s employee health program.
c. The Infection Control Committee takes necessary actions or recommendations for action are
forwarded to the Medical Superintendent and the medical superintendent.

11. Patient and Employee Safety Functions

a. The safety committee carries out the patient and employee safety function at least quarterly. The safety
review function includes the following.

i) Safety Management: A safety management program is designed to provide a physical environment

free of hazardous and to manage staff activities to reduce the risk of human injury.

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ii) Hazardous Materials Management: A hazardous materials and waste program provides a safe
process for selecting handling, storing, using and disposing of hazardous materials from receipt
through use and hazardous wastes from generation to final disposal.

iii) Emergency Preparedness: An emergency preparedness program provides a process for implementing
specific procedures in response to a variety of disasters (natural or manmade events which cause
major disruption in the environment of care).

iv) Equipment Management: An equipment management program controls the clinical and physical
r i s k o f e q u i p m e n t u s e d for d i a g n o s i s , t r e a t m e n t , monitoring and care of patients.

v) Utilities Management: A utilities management program is designed to ensure reliability,

minimize risks, and reduce failures of utility systems.

b) The Safety Committee takes necessary actions, or forwards

recommendations for action to the appropriate department, or responsible individual/s.

c) Pertinent information regarding findings is communicated to the appropriate department and

individuals and to the Medical Superintendent

12. Risk Management

a. Sentinel events are defined an unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof to a patient, visitors or an employee. Serious injury
specifically includes loss of limb or function.
b. The organization has a sentinel events policy and any event shall result in a Root Cause Analysis.
c. The number of sentinel events shall be monitored on a monthly basis and reported to the Quality
Steering Committee.

X. Communication Plan.
The method of communication of the Quality Improvement efforts is as follows:

A. Chief Administrator

1. The Medical Superintendent shall coordinate quality Improvement effort.

2. The Medical Superintendent w i l l forward problem areas, or areas of concern to the appropriate
team for consideration via the Quality Systems.

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B. Departments

1. Department Managers shall provide the Quality indicators data to the Quality Systems.
2 .Quality Systems shall present a report to the Quality Assurance Committee periodically, as outlined by
the reporting scheduled approved by the committee.
3. Written report is provided to the Medical Superintendent
4. Written summary shall be provided to the Board of Director.

C. Education.

1. Education of Quality Improvement efforts and methodologies will be provided to the Staff on
orientation, and will include information regarding data collection, aggregation, and statistical
process control as the need arises with participation in the process.
2. Education regarding quality Improvement methods and activities will be provided to the
organizational leaders on an ongoing basis.

XI Annual Appraisal
A. Departments / Services and Committees.

Each department or services and active interdisciplinary committees will evaluate Quality Improvement
efforts annually. The annual evaluation will be forwarded to the Medical Superintendent and Director,
Medical Services.

B. Quality Improvement plan

The Quality Improvement plan will be reviewed and evaluated annually by the Quality Steering
Committee. The annual appraisal will consider the achievement of the goals and objectives of the
plan, the efficiency of the plan, and the effectiveness of the plan. Quality systems can make
recommendations to the quality steering Committee for revisions and improvements in the quality
Improvement efforts.

XII Signatories

The quality Improvement plan will be signed by C E O .

11.0 PROCESS DETAILS:

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11.1 DESCRIPTION OF THE PROCESS

1. 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
2. Quality Assurance Committee – Refer the document ‘Hospital Committees’
3. In line with our goal of providing quality services in our hospital, we had developed and set our
mission, vision, quality policy, and service standards.

4. Service standards:
This hospital has
 Specialist

 Doctors

 Nurses

 Beds

 ICU beds

7.1 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.

7.2 To provide access to hospital and professional medical care to all patients who visit the hospital.

7.3 To prescribe a workable maximum waiting time for outpatients, before they are attended to by a
qualified doctor and / or specialists and continuously strive to improve upon it.

7.4 To ensure that all equipment in the hospital are maintained efficiently in proper working order.

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7.5 To ensure availability of beds and operation theatres facilities as freely as possible.

7.6 To ensure treatment of emergency cases with utmost promptitude and attention.

7.7 The patients’ and families’ rights are in consonance to accreditation standards.

7.8 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.

7.9 Reliability and promptness of diagnostic investigation results is ensured and whenever possible
such reports will be made available.

7.10 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.

7.11 A regular system of obtaining feedback from the users is in place through exit interviews and
periodic surveys. The inputs from these are continuously used for improving the service
standards.

7.12 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.

7.13 If any equipment is out of order, information regarding the same shall be displayed suitable
indicating the alternate arrangements, if any, as also the likely date of re-commissioning the
equipment after repairs and replacement.

7.14 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.

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7.15 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.
7.16 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.

7.17 Hospital encourages the patients and the public to inform the authorities when things go
wrong. Suggestion / complaint boxes and registers are provided at the reception, RMO office,
Matron Office, sanitary inspector and administrator.

7.18 Hospital follows all policies, processes, programmes, committee meetings; regulatory
guidelines, which have been prepared to meet the standards of accreditation as, set by
NABH.

5. Structure for Quality Assurance:

Hospital has developed a structure for carrying out processes related to Quality Assurance in the
hospital. This is as follows:
8.1 Documentation system: Hospital has developed its documentation on policies, procedures,
programmes, guidelines etc. These have been developed by committee personnel and staff of
the hospital, reviewed by heads of the departments and have been approved by Medical
superintendent.
8.2 Quality Steering Committee/Department: Quality assurance related activities is planned,
undertaken, and controlled by Quality Assurance Committee/department which is a
multidisciplinary committee having representation from various clinical, non-clinical, and
administrative departments. Details of committee, its scope of work, frequency of meeting
and mode of operations are detailed Quality Assurance Committee’s file.
8.3 Accreditation Coordinator: The hospital has designated an Accreditation coordinator, who has
overall responsibility of coordinating the work of NABH accreditation. His / her
responsibility will include:

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a) To issue various documents to departments from time to time

b) To keep a record of all the documentation of the hospital, in relation to
accreditation
c) To delegate the activities in departments and ensure its timely completion
d) To regularly receive feedbacks from departments regarding status of their
work related to accreditation preparation
e) To plan and execute regular assessment of the hospital in accordance with
accreditation standards
f) To coordinate all such activities required for quality assurance and continuous
monitoring of the hospital

8.4 Departmental coordination: Each department of the hospital has been appointed with one in
charge / coordinator. The responsibility of these coordinators will be

1. To receive and retain all the documents and official correspondence related to
accreditation from time to time

2. To inform and orient the staff of their department on policies and procedures developed
for their department

3. To ensure the completion of all the work assigned to their department for NABH
accreditation preparation

4. To organize regular training programmes for staff of their department

8.5 Departmental pioneers: Each department has identified a pioneer for developing and improving
the quality of service provided by the department. These pioneers continuously strive for
improving the quality standards of the department and train the staff on best practices.

9 The programme:

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a. The programme 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. Applicable for infection control (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 indicators given in S. No. 11 are incorporated in the reports. This report gives the
figures for all indicators, which is reviewed and subsequent actions is taken based on
adherence to standard value, by Hospital administration and QAC.
iii. The programme 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 with the key
characteristics of their department laid. Compliance to the key characteristics shall be
identified from acceptance norms / criteria. The record shall be endorsed in the register as

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C / PC / NC’ (C for Compliance, PC for partial compliance and NC for non-compliance).

The record shall be entered at frequency defined in the table.

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