DILCHORA HOSPITAL CLUSTER EHAQ 4TH CYCLE PROTOCOL

REQUIRED WHICH MUST BE PREPARE & PRESENT AT ALL RESPECTIVE

SERVICE AREA & FOCUS AREA (NICU, NON COMMUNICABLE
DISEASE OPD, EOPD & OR)

1. Interdepartmental Consultation Protocol & form

2. Scope of practice protocol (Scope based practice protocol)
3. Evidence based Clinical Practice Protocols are prepared for at least
surgical Services, OPD Clinics, Emergency Services, and Neonatal
ICU.
4. Protocol for Rounds, Selected nursing procedures, Patient
transportation, Bad news breaking, Surgical scheduling, Standard
treatment guideline & PREPARE TRAINING ON THE LISTED
PROTOCOL FOR STAFFS
5. Surgical services protocol (IN THE PROTOCOL ADD ALL
ELECTIVE SURGERIES SHOULD BE DONE IN THE PRESENCE OF THE
SENIOR PHYSICIAN).
6. Print STG and given in booklet form to clinical staff.
7. Prepare capacity building Plan for staffs working in medical record
unit.
8. Standardized manual for training of medical record unit staff
9. Protocol for patient channeling to the cough clinic
10. Pre-triage screening protocol.
11. OPD Services Protocol.
12. Pediatrics Protocol for rounds and clinical care.
13. Pediatrics vital signs protocol.
14. Rehabilitative and palliative care protocol
15. Preventive maintenance protocol
16. MEM(medical equipment maintainance) notification protocol
17. Human resource development plan.
18. Protocol for Prioritized medical equipment list with an
inspection and preventive maintenance plan.
19. Management guidelines with a focus on the selected
prioritized health conditions and prioritized drug lists.
20. Prepare Prioritized drug list.
21. Protocol to prescribe, dispense and monitor appropriate and
rational use of the selected and prioritized drugs.
22. TOR of the clinical Audit team.
23. Multi-disciplinary round (Grand round) protocol
24. Shift handover protocol
25. Chart round checklist.
26. Staff incentive and recognition procedure/guide
27. Nursing care protocol
28. Protocol for Key Nursing Procedures (IV line securing, NG-
Tube insertion, Catheterization, etc.) and do bi-annual KAP
assessment.
29. Nursing audit team TOR.
30. Nursing code of conduct.
31. ICU nursing care package/protocol
32. Schedule for the utilization of the skill lab.
33. Nurse skill gap assessment.
34. Nursing Capacity building protocol/ guide
35. At least one desktop must available at nursing station with
important information on patient admission and status in each
wards.
36. Elective surgery Protocol
37. pre-operative work-up protocol
38. Pre-operative and post-operative hospital stay protocol
39. OR daily briefing and debriefing protocol
40. Daycare surgery protocol
41. SSC Audit protocol
42. SSI Protocol & include Mechanism for SSI tracking after
discharge.
43. Neonatal care guidelines, protocols
44. DO clinical audits on NICU services
45. ICU admission, treatment, and discharge protocols
46. Protocols and guidelines for referral, triage, burn, poisoning,
trauma ED ICU services
47. Revised ICU, Emergency, Liaison referral, and ambulance
service registers.
48. protocol for discharge planning
49. Create and standardize discharge plan format for selected
diseases based on hospital morbidity and mortality
50. Pain management protocol
51. Chronic pain and Palliative care clinic guidelines/protocol
52. Social service protocol,

PREPARE & DOCUMENT THE FOLLOWING SCHEDULE

1. Schedule of referral Clinic
2. Write letter of assignment for the GP who assigned at Triage
3. Write letter of assignment for the focal person who assigned at
pain clinic.
4. Appointment schedule
5. Preventative maintenance schedule
6. OR shift Schedule