1.0 OBJECTIVE: The organization has a system in place to provide a safe and secure environment.
2.0 DEFINITION: The organization has a system in place to provide a safe and secure environment.
3.0 SCOPE: Hospital wide
4.0 RESPONSIBILITY: Managed by Safety Committee.
5.0 PROCEDURE:
5.1 The Sanjeevan Hospital have several committees which functions on a ruglar basis to coordinate development, implementation and monitoring of the plans and the policies. All the plans are fully implemented and also there is a process for periodic review of plans. Our safety committee include the representatives from facility management, clinicans, administrator, nursing and paramedical staff. {Ref to Safety Manual}
5.2 Patient safety is the prime consern of Sanjeevan Hospital. We have well defined Safety and security protocol and installed all the patient safety devices and inspected periodically time to time. The hospital has monthly/ annual schedules of inspection and calibration / Validation of equipment which involve measurement, in an appropriate manner. The hospital either calibrates the equipment in-house or out sources; maintaining traceability.
5.3 Safety devices like Grab bar, bed rails, sign posting, safety belts on stretchers and wheel chairs, warning signs like radiation or biohazard, call bells, fire safety devices etc. {Ref to Safety Manual}. In order to reduce and if possible eliminate smoking and tobacco use, in the hospital the campus and premises of the hospital have been made a **no smoking, no tobacco zone**. Indulging in any of this is strictly forbidden. The staff is encouraged to set a good example by not smoking and not using tobacco in any form. Damaging effects of smoking/use of tobacco products on the health are emphasized regularly during public lectures and other awareness campaigns. All meetings, courses and conferences organized under the auspices of the hospital are no smoking, no tobacco meetings. All parties and/or functions held on the campus are organized in a no smoking, no tobacco environment. Appropriate signage for this is displayed all over the hospital. All staff members are made responsible for implementing this policy and they are especially asked to try and promote awareness of these policies among patients and visitors to the hospital. (Ref to display of No Smoking}
5.4 The hospital plans and budgets for upgrading or replacing key systems, buildings or components based on the facility inspection, in keeping with laws and regulations. During these rounds potential safety risks are identified through a checklist. The facility inspection rounds are conducted at least **twice in a year in patient care areas** and at least **once in a year in non-patient care areas**. Ref to Safety Checklist}
5.5 All the inspection reports are documented and corrective and preventive measures are undertaken. Preventive maintenance activities are carried out as per plans and records of breakdowns are maintained. Ref to Preventive and Maintenance Plan and Record Checklist}
5.6 The Sanjeevan Hospital has provided an **employee handbook** to all the staff to educate them about safety programme. Safety training is also organized for the staff. (Ref to Employee Handbook}
6 REFERENCE DOCUMENTS
- Safety Manual
- NABH-SHCO Chapter 8
- Safety Committee Checklist / Register
- Facility Inspection Round
- Fire Exit Signage
- No Smoking Poster
- No Smoking Policy
- Bio-Hazard Poster
- Hospital Budget Plan
- Training Calender
- Training Record Sheet
- Safety Codes
1.0 OBJECTIVE: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
2.0 DEFINITION: The organization’s environment and facilities operate to ensure safety of patients, their families, staff and visitors.
3.0 SCOPE: Hospital wide
4.0 RESPONSIBILITY: Managed by Safety Committee
5.0 PROCEDURE:
5.1. The Sanjeevan Hospital has well defined scope of services and deliver appropriate facilities for the patient and their family according to national. {Ref to Display of Scope of Services)
5.2. Designated personnel maintain the up-to-date drawings which detail the site layout, floor plans and fire escape routes. Ref to Fire escape layout, Site layout, Floor Plans Layouts and drawings of each floor}
5.3. The hospital has made available **signage’s** in internal and external parts of the hospital which are symbolic and are in **local languages** which are understood by patient, families and community. {Ref to Display of Signages}
5.4. Provision of space is in accordance to the nursing home registration act and other directives from government agencies and hospital’s own experiences. Indian standards.
5.5. The hospital has **24×7 availability of electricity and water supply** by the MCD.
5.6. In case of any failure/shortage, we have an **alternate supply** of electricity and water. We have **generator** as a backup of electricity and **water tank** for water. {Ref to checklist for alternate supply of electricity and water}
5.7. The hospital has a checklist of regularly test for quality of water. (Ref to checklist for test of water}
5.8. Trained person in the hospital management is designated to be in-charge of maintenance of facilities. The hospital has the required number of supervision and tradesmen to manage the facilities. Ref to JD/organogram}
5.9. Maintenance activities are carried out as per the **preventive maintenance plan**. Break down maintenance activities are also carried out as per established procedures. {Ref to Preventive maintenance schedule, Breakdown plan and notes List of contact nos.}
5.10. Maintenance staff is **contactable round the clock** for emergency repairs. {Ref to Daily Duty Chart & List of contact nos.}
5.11. A **complaint attendance register** is maintained to indicate the date and time of receipt of complaint, allotment of job and completion of job. {Ref to Corrective Action Taken reports}
6 REFERENCE DOCUMENTS
- NABH-SHCO Chapter 8
- Scope of Services
- Signage of Departments
- Floor Plans Layouts Drawings of each floor
- Site layout
- Job Distribution
- Fire Exit Sign
- No Smoking Poster, Do not enter Poster, No Parking poster
- Water Checklist, RO, Water tank cleaning detail
- Electricity Checklist
- Breakdown Register, Breakdown Memo
- Maintenance sheet
- List of maintenance staff
1.0 OBJECTIVE: The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies.
2.0 DEFINITION: The organization has plans and provisions for early detection, abatement and containment of fire and non-fire emergencies.
3.0 SCOPE: Hospital wide
4.0 RESPONSIBILITY: Managed by maintenance officer
5.0 PROCEDURE:
5.1 The Sanjeevan Hospital has a dedicated **emergency illumination system** which comes into effect in case of a fire. The hospital takes care of non-fire emergency situations by identifying them and by deciding appropriate course of action. The hospital has a safety committee to review the hospital preparedness which reviews the fire plan covering fire arising out of burning of inflammable items, explosion, electric short circuiting or act of negligence or due to incompetence of the staff on duty, deployed adequate and qualified personnel for this, acquired adequate fire fighting equipment for this which records are kept up-to-date, adequate training plans, scheduled for conduct of mock fire drills, mock drill records, exit plans well displayed. The hospital safety committee takes care of **non-fire emergency situations** by identifying them and by deciding appropriate course of action like **invasion of stray animals** (stopped with guards), **hysteric fits of patients and/or relatives** (managed by staff and PR), **civil disorders** (handled by security), **anti-social behaviour** (handled by security), **spillage of hazardous/infected materials/medical wastes** (managed by safety committee), **building or structural collapse, fall or slips, fall of patient from bed, bursting of pipe lines, sudden flooding of areas** like basements due to clogging in pipe lines, **Sudden failure of supply of electricity, gas, vacuum, etc** (managed by safety committee).
5.2 **Fire exit plan is displayed on each floor** particularly close to the lifts. Exit doors remain open on the time. (Ref to display of Fire escape layout, signages
5.3 Sanjeevan Hospital has well trained person for an emergency. In case of fire designated person are assigned particular work. {Ref to Training register, Mock drill records }
5.4 Sanjeevan Hospital is maintaining **mock drills register**, which are held at defined intervals each year. {Ref to Training register, Mock drill records}
5.5 Sanjeevan Hospital has maintenance of **fire related equipments**, which are monitored periodically like fire extinguisher.
6 REFERENCE DOCUMENTS
- NABH-SHCO Chapter 8
- Safety Manual
- Safety codes
- Fire Race & Pass Display
- Fire Exit Signages
- Fire escape layout
- Mock Dril observation sheet
- Training calendar
- Location of fire fighting equipments
- Safety Committee
1.0 OBJECTIVE/DEFINITION: **Quality improvement** is about ensuring the hospital continuously improves its services. It involves putting efforts towards ensuring the **safety, effectiveness, efficiency, acceptability, accessibility and appropriateness of services** for our customers, both internal and external.
3.0 PURPOSE: To ensure the following:
- 2.1. Monitoring patient and staff satisfaction
- 2.2. Monitoring of hospital quality indicators
- 2.3. Monitoring of Sentinel events.
- 2.4. Monitoring of Adverse Drug reactions and medication errors
- 2.5. Monitoring patient safety indicators
- 2.6. Ensuring fire safety mock drill **twice in a year**.
- 2.7. Monitoring of medical assessment results
- 2.8. Ensuring facility safety round **twice a year in patient care areas** and **once a year in non-patient care areas**
4.0 SCOPE: Hospital wide
5.0 RESPONSIBILITY: Managed by Quality Department
6.0 PROCEDURE:
6.1. There is a committee for quality improves which shall have a representation from management clinical departments and support departments. [PSQ-1a] {Ref to Safety Committee}
6.2. There is a quality improvement program has been formed in the form of **manual** by the quality improvement committee. The manual includes the: a) Mission statement, b) Vision statement, c) Quality policy, d) Service Standards, e) Other important indicators. [PSQ-1b] {Ref to Quality Manual}
6.3. There is a designated **quality department** who is supervising the quality programme of the Sanjeevan Hospital. [PSQ-1c] {Ref to Quality Manager, Safety Committee}
6.4 The programme is guided by **key indicators** by data collection, review of policy and policy actions.
6.5 The regular quality training programme is executed by a regular training.
6.6 As per the policy the quality programme is reviewed **every four months**. It will have an audit and performance indicators and the register shall be maintained for the review meetings.
6.7 Programme shall be **updated at least every year**.
6.8 Audit shall be done the entire programme including all applicable standards and objectives.
6.9 The audit report shall be monitored to improve the quality of nursing and complete patient care.
7 REFERENCE DOCUMENTS
- NABH-SHCO Chapter 6
- Safety Committee
- Quality Manual
- Quality assurance Committee
- Quality Policy
- Core Committee
- Vision, Mission
- ICU QAP
- OT QAP
- Imaging QAP
- Lab QAP
- Accreditation Co-Ordinator
- PSQ-1,2,3,4
- Training Calender
- Internal Audit Sheet
- Clinical Audit Committee
1.0 OBJECTIVE: This policy is dedicated to the patient safety and is known as **patient safety programme**.
2.0 DEFINITION: The programme related to patient safety.
3.0 PURPOSE: To maintain a seamless facility for patient care services in the hospital by listing down various parameters on which patient care services and safety would be assessed within the resources provided by the management.
4.0 SCOPE: Hospital Wide
5.0 RESPONSIBILITY: Quality control Officer shall ensure that the patient care safety is conducted at specific intervals and frequency and covers the entire scope of services. **MS** is responsible for clarifying the deficiency observed with the department staff concerned, do the root cause analysis and ensures that corrective actions are adequately taken within the agreed time limit.
6.0 PROCESS / PROCEDURE:
6.1 There is a patient safety programme which is developed and maintained by a **safety committee**.
6.2 The safety programme is documented in the form of **safety manual**.
6.3 The safety manual shall be comprehensive and shall include **risk management**.
6.4 No harm and **sentinel events** are also defined in safety manual.
6.5 One person in the hospital shall be nominated as **Safety officer**.
6.6 The regular training shall be done to all the concerned staff regarding the safety manual.
6.7 The safety programme shall be reviewed at least **four months interval** and also will be analysis of safety indicators. The minutes shall be reviewed and recorded.
6.8 The safety manual shall be reviewed and **updated at least once in a year**.
6.9 The safety manual shall adhere to safety goal nationally and internationally.
7.0 REFERENCES:
- NABH – SHCO Chapter 6
- Progress Notes
- Hospital Safety Manual
- Safety Committee
- Sentinel Event Form
- Incident Reporting Form
- Patient Safety Officer
- Water Checklist
- Surgical Safety Checklist
- Electricity Checklist
- RO Checklist
- International patient safety goal
1. OBJECTIVE/DEFINITION: The organization shall have identified **key indicators** to monitors the managerial structures, processes and outcomes which are used as tools for continual improvement.
3. RESPONSIBILIY: Managed by Quality Department
4. SCOPE: Hospital wide
5. PROCESS:
5.1 Monitoring shall include procurement of medication essential to meet patient needs. 4 key indicators are developed for this purpose:
- a) Percentage of drugs and consumables procured by local purchase,
- b) Percentage of stock outs including emergency drugs,
- c) Percentage of drugs and consumables rejected before preparation of goods receipt note,
- d) Percentage of variations from the procurement process.
5.2 Monitoring shall include **risk management**. 4 key indicators are developed for this purpose:
- a) Number of variations observed in mock drills,
- b) Incidence of falls,
- c) Incidence of bed sores after admission,
- d) Percentage of employees provided pre-exposure prophylaxis.
5.3 Monitoring shall includes **utilization of space, manpower and equipment**. 4 key indicators are developed for this purpose:
- a) Bed occupancy rate and average length of stay.
- b) OT and ICU utilization rate,
- c) Critical equipment down time,
- d) Nurse patient ratio for ICUs and wards.
5.4 Monitoring shall includes **patient satisfaction** which incorporates waiting time for services. 4 key indicators are developed for this purpose:
- a) Out-patient satisfaction index,
- b) In-patient satisfaction index,
- c) Waiting time for services including diagnostics and out-patient consultation,
- d) Time taken for discharge.
5.5 Monitoring shall includes **employee satisfaction**. 4 key indicators are developed for this purpose:
- a) Employee satisfaction index,
- b) Employee attrition rate,
- c) Employee absenteeism rate,
- d) Percentage of employees who are aware of employee rights, responsibilities and welfare schemes.
5.6 Monitoring shall includes **adverse events and near misses**. 4 key indicators are developed for this purpose:
- a) Percentage of sentinel events reported, collected and analysed within the defined time frame,
- b) Percentage of near misses,
- c) Incidence of blood body fluid exposures,
- d) Incidence of needle stick injuries.
5.7 Monitoring shall includes **availability and content of medical records**. 4 key indicators are developed for this purpose:
- a) Percentage of medical records not having discharge summary,
- b) Percentage of medical records not having codification as per international classification of disease (ICD),
- c) Percentage of medical records having incomplete and/or improper consent,
- d) Percentage of missing records.
5.8 Monitored data are collected to support further improvements.
5.9 Monitoring includes data collection to support evaluation of these improvements.
6.0 REFERENCES:
- NABH – SHCO Chapter 6 Quality Indicators
1.0 OBJECTIVE/DEFINITION: The policy must be supported by the management.
3.0 SCOPE: Hospital wise
4.0 RESPONSIBILIY: Managed by MS/MD.
5.0 PROCEDURE/ PROCESS:
5.1 The management of Sanjeevan Hospital shall make available **adequate resources** required for quality improvement programme[cite: 539].
5.2 Sanjeevan Hospital shall yearmark **adequate funds from its annual budget** for smooth functioning of the programme[cite: 540].
5.3 The management of the Sanjeevan Hospital shall identify **quality indicators** and set target and monitor them[cite: 541].
5.4 The management shall support the quality reports with statistical methods and management tools to achieve expected results[cite: 542].
6.0 REFERENCES:
- NABH – SHCO Chapter 6 Budget Plan [cite: 543]
1. OBJECTIVE/DEFINITION: Incident, complaints and feedback are collected and analyzed to ensure **continual quality improvement**[cite: 544].
3. RESPONSIBILIY: Managed by MD& MS[cite: 545].
4. SCOPE: Hospital wide [cite: 545]
5. PROCEDURE/ PROCESS:
5.1 Sanjeevan Hospital has an **incident reporting system** which includes identification, reporting, review & action on incidents[cite: 546].
5.2 Sanjeevan Hospital has a process to collect **feedback and receive complaints**[cite: 547].
5.3 The quality committee of Sanjeevan Hospital has established processes for analysis of incidents, feedback and complaints[cite: 548].
5.4 The **corrective and preventive actions** are taken after analysis of data[cite: 549].
5.5 Every feedback about care and services are communicated with the staff on the **monthly basis**[cite: 550].
6.0 REFERENCES:
- NABH – SHCO Chapter 6 Feedback Form (OPD) [cite: 550]
- Incident Reporting Form [cite: 550]
1. OBJECTIVE/POLICY: Patient information is **confidential** and protected from access, use, or disclosure except to **authorized individuals** requiring access to such information[cite: 551, 557]. Unauthorized or improper attempts to obtain or use information will result in performance counseling or disciplinary action up to and including **termination**[cite: 552, 558]. All hospital staff members must access and use protected patient information on a **”need to know” basis** as defined by their job role[cite: 553, 559].
2. DEFINITION: To define protected patient information, which includes verbal, written and electronic information and to provide guidelines for preserving confidentiality[cite: 554].
3. SCOPE: Hospital wide [cite: 555]
4. RESPONSIBILITY: Managed by **MRD Officer** [cite: 555]
5. PURPOSE: The medical records are strictly confidential and may be released only by **consent of the patient or by an authorization letter duly signed by the patient**[cite: 556]. This written consent is necessary before any information is shared with any organization, prospective employer, insurance company or other individual(s)[cite: 556]. Only authorized staff members and care providers have access to patient’s medical record[cite: 556].
7.0 PROCEDURE:
7.1 **MRD** (Medical Records Department) has control accessibility of Hospital Information System (HIS) to maintain the confidentiality, integrity and security of the records[cite: 560]. Only the relevant care providers have access to the patient’s record; it ensures that records and data are not taken out from the areas where they are stored[cite: 560]. In case of electronic systems it shall ensure that these cannot be copied at all locations[cite: 561]. The procedure shall also address how entries in the patient record are corrected or overwritten[cite: 562]. {Ref. to Poster of Restrict entry in MRD} [cite: 563]
7.2 The documented policies and procedures are in consonance with the **Indian Evidence Act, Indian Penal Code and Code of Medical Ethics law**[cite: 563]. {Reg. to Indian Evidence Act, Indian Penal Code and Code of Medical Ethics law} [cite: 564]
7.3 The hospital has adequate **pest and rodent control measure** for physical records[cite: 565]. For electronic data, the hospital has protection against **virus/Trojans** and also a proper **backup procedure**[cite: 565]. To prevent tampering of physical records access are limited only to the healthcare provider concerned[cite: 566]. In electronic format, it is done by adequate **passwords**[cite: 567]. In electronic systems, the access is different for different types of personnel and specific for that user[cite: 567]. Hospital has a system to keep a track of changes made in the medical record or data[cite: 568]. All the physical records and data are stored in **fire safe cabinets with fire-fighting equipment**[cite: 569]. {Ref. to FMS checklist for paste controlling, fire safety & Computer authorized Id, Password} [cite: 570]
7.4 Hospital carries out **regular audits/rounds** to check compliance of the medical records[cite: 571]. {Ref to MRD Audit checklist} [cite: 571]
7.5 The Hospital has HIS system, which review and updates its technological features to improve confidentiality, integrity and security of information[cite: 572]. {Ref to Software & Hardware updation Register} [cite: 572]
7.6 **Privileged communication** is available for patient if any patient wants their health information record then keeps a copy of Xerox with written authorization letter and do not disclosed without patient permission[cite: 573]. {Ref to Authorized letter written by patient attendant} [cite: 573]
7.7 Proper **authorization letter** is allowed for access the information which is sending to other public agencies and accordance to all the rules and regulations[cite: 574]. Information given to outside agencies will be first approved by **Medical Director**[cite: 574]. Patient information given to external agencies will be as per the protocols in MRD and ER manual[cite: 575]. {Ref. to Notifiable Disease reporting, Birth and Death Reporting}
8. REFERENCE DOCUMENTS
- NABH – SHCO Chapter 10
- Tracer Card
- Pesticide Regiaster – MRD
- Medical Ethics in MRD
- MRD Audit Checklist