AMRI Hospitals

Salt lake

Nursing Review Meeting

Aug 23

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MOM Minutes of the Meeting : Nursing Review Date:13.07.2023

SLNo Points Discussed Owner EDC

Issue of bar codes for sample and manual requisition form filling to be
Dr. Rohit Jaswal
1 discussed by Dr. Rohit Jawasl with the Lab Head and start implementation Dr. Sudipto Roy To be updated
by 20 Jul'23

2 Dr. Rohit Jaswal to discuss with CEO and amend KRA weightage for NS Head Dr. Rohit Jaiswal/Group To be updated
KRA before next NRM HR head
DHK : Nursing educator & Nursing quality personal required for all unit with Dr. Rohit Jaswal/ Mr.
3 defined KRA Reddy On process

All units should do Initial Assesment in the System. Gradually to reach 100%
4 Mr. Sujit/ Dr. Rohit On going
implementation. Mr. Sujit from IT will help on this.

Reporting of technicians to Sr. Technician of respective department under Dr. Rohit Jaswal/ Mr.
5 To be updated
Medical Admin Reddy
6 Nursing staff uniform issue to resolved immediately Unit NS/ Ms. Preeta Done
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Wt for calculation at Achievement

Target
Key Result Area Sl. No Key Performance Indicators Measure
the time of annual appraisal for July 23 Reviewed
Financial
F1 Revenue (as per Budget) for the Unit Rs. Crs 10%
Performance
F2 Cost of consumables to Revenue % 10%
Cost Optimisation
F3 Overtime Payments to Nursing Staff % 5% Zero 0%
C1 Patient Satisfaction Score Score 5% 85% Exce-97%, Good- 2 %, sat-1%
C2 Incidence of Falls Nos. 5% Zero 0.00%
C3 Incidence of HAPU Nos. 5% < 2 pm 0.17%
Patient Safety
C4 No. of medication errors Nos. 5% No of adverse cases 0.00%
Consultants:
C5 Engagement Score Score 5% 6/210
Employees:
Microsoft Excel Within due date
NABH, NABL, Green OT RE - Accreditation by
P1 Timeline &Worksheet
97-2003 NC 10% NC : Zero with timely Nursing Excellence(30th & 1st)
schedule date
closure
P2 % Adherence to BOM % 5% 100% 90%
Timely escalation of breakdown reports of OT
P3 Timeline 5% Immediate escalation 100%
Process Efficiency /CSSD/CathLab or Biomedical equipment’s
Hospital infection control & Biomedical Waste
P4 % 5% 90% adherence 99%
management
Submission of legal formalities such as birth,
death, police cases, infection diseases in
P5 % 5% 90% adherence 100%
appropriate formats to Govt MDR, Ops & Govt
Offices
L1 Nursing Head count management and attrition % 10% <3% attrition pm 1.20%
Capability L2 Adherence to Training calendar % 5% zero deviations 6 class cancelled
Development Number of nurses developed for critical care
L3 Nos. 5% 15 0
deployment
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Nursing Operational KPI
Operational KPIs - Nursing
S .No Operation Bench Marking April-23 May-23 June-23 July -23 Aug-23

351(Including
354(Including
1 Total Number of Nurse Admin + HCA)
363 (Including 373 (Including Admin + HCA)
(80%/100% Occupancy) 365(Including (327+24)
Admin + HCA) Admin + HCA) (330+24)
Admin + HCA) Out source - 20
Out source - 20

2 Qualification Mix BSc N: GNM: ANM 86 : 235: 10

80 : 257: 10 88 : 249: 10 88 : 243: 10 85 : 235: 10

3 Skill Mix L1 : L2 : L3 102:144:117 102:153:117 100:153:112 98 :150:109 98 :151:109

4 Overtime Usage ( hours) 0hrs 0hrs 0hrs 0hrs 110hrs

S. No Patient Service Bench marking

Excellent 86% 90% 93% 96% 97%

1 Overall Satisfaction with Good 11% 9% 7% 4% 2%

Nursing Care
Average 1% 1% 0% 0% 1%
Fair 1% 0% 0% 0% 0%
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Nursing Quality KPI`
Quality KPIs - Nursing
S.No Quality Bench Marking April-23 May -23 June -23 July -23 Aug -23

1 N:P ratio (ICU) Vent 1:1 Vent - 1: 2 Vent - 1: 1 Vent - 1: 1 Vent - 1: 1 Vent - 1: 2
Non Vent 1: 2 Non Vent- 1:4 Non Vent- 1:3 Non Vent- 1:3 Non Vent- 1:3 Non Vent- 1:4

2 N:P ratio (Wards) 01:06 1: 8/9 1: 6 1: 6 1: 6 1: 7

Ward -
Ward - 18 mts Ward - 20 mts Ward - 16.76 mts Ward - 12 mts
Cases where in Nursing Care Plan is Initiation < 30 mins 11.30mts
3 CCU -5.8 mts CCU -5.3 mts CCU - 5.3 mts CCU - 4 mts
documented within 24hrs of admission Complétion <2hrs CCU -5 mts Eme - 4.24 mts Eme - 4.5 mts Eme - 3.78 mts Eme - 3.9 mts
Eme - 3.8 mt

4 Cases wherein Nursing Care Plan is 100% 100% 99.63% 99.60% 98.80% 99.43%
documented within 24hrs of admission

5 Appropriate Handovers during Shift 100% 100% 100% 100% 100% 98.58%
Changes/ Transfers

6 Incidents of Falls 2% 0% 0% 0% 1 (0.20% 0%

7 Incidents of HAPU 2% 0% 0% 0% 0% (1) 0.17%

8 Medication Errors Administration 0.50% 0% 0% 0% 0% 0%

9 Incidents of Delining of Tubes / 2% 0 1(0.035%) 1(0.03%) 2 (0.68%) 0%

Catheters
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What went well

Initiative How You Have Achieved Remarks

 Central & Unit Induction

Nursing Induction

Learning Capsule  Training by Doctors & Out side training

Audit  5s Audit done

NABH  Preparation is Going on

Nursing Excellence  Audit is on 30th & 1ST of October

Celebration  ONAM celebrated

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What did not work well

Initiative Why Lesson

Resignation  27 staff gave resignation ( Govt. Post) & Better oppurtunity

Manpower  Shortage of Manpower

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Process Efficiency

A) % Adherence to NABH regulations/ Nursing Excellence:

 Renewal assessment date is on 30th Sept & 1st of October 23

 Continues Auditing & Data Analysing

 Spot teaching
 CNE
B) Attrition Rate of Nursing Staff :
Nursing Attrition
April 1.9%
May 2.9%
June 2.4%
July 3.28%
Aug 1.12%

C) Overtime

 110hrs
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Discussion with Doctors : Issue Resolution, Closer status & Support required

Salt lake
If any Support
Speciality Doctor Name Issue Description Closer status
Required

Cath lab Dr Arjit Ghosh  Experienced Nursing staff

Man power raised Joined
 Required 2 more staff in cath lab

Cardiac OT Dr Sujoy Chatterjee  Experienced Staff Done Joined

Dr S. Bandhopadhya
Critical Care Experienced Staff On process
Dr R. Roy

Neuro Dr D K Roy Experienced Staff On process

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Capability Development
A) Training Classes, Other program conducted and Employee Engagement Score Aug 2023

Total No. of Training Total No. of Total No of Man

Sl.No Training Program
Program Training Attendees hours

1 Unit Basis Training Programme 633 1032 363.56

2 Leadership Training Programme 12 211 211

3 CNE Training Programme 14 539 539

4 External Training Programme( Faculty) 3 22 27

Total Man Hours 662 1804 1140.56

B) Number of Nurses developed for Critical Care: 0

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Nursing Hostel Visit Report

Hostel Visit on 12 .08. 23

S. No. Department Observation Responsibility EDC Status Remarks

1 Cleaning  Overall cleanliness is good in both the hostels H/K / Warden Done
 Kitchen Painting

NS / Warden / Not so Need 6to look

2 Food Quality  Quality & taste of the food
vendor good for a vendor

NS/ Vendor/
Done
4 Fridge  Required fridge in Old Hostel Maintenance New one given
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Manpower Status – Aug 23

Speciality wise Dhakuria Mukundupur Salt Lake Bhubaneswar
Nurses
Areas No of Beds Nurses deployed No of Beds deployed No of Beds Nurses deployed No of Beds Nurses deployed
ICU Requirement 99 146
Ward Requirement 124 95
OT Requirement 22
Cath lab 6
Emergency 11
NICU 0
MRI/PET CT/ OPD
L.ROOM
Dialysis 13
Gastro 6
Incharges 23
Nurse Educator 1
Quality Nurse 0
ICN 2
Supervisors (M, E & N) 4
Admin 1
Total 223 330
HCAs Count
Deployment
Unit Existing
OPD/Dept IPD Requirement for 80% Occupancy – 380
Dhakuria
Mukundapur Present Nursing Manpower – 351 ( Including Nursing Admin )
Salt Lake 36 27 9
BBSR
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Training
by
Doctor’s
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Training
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Special
Events
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Imagine Innovate Initiate

Thank You

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