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You are a part of our team... You are a part of an organization that has established a reputation in healthcare services and is a benchmark for Premium Healthcare Premium Hospitality. The credit for this goes to every one in our team.

We want you to feel that your association With Aditya Birla Memorial Hospital will be mutually Beneficial and a pleasant one.

JCI ADVANTAGES International recognition in providing high quality healthcare services. Standardized processes to enhance patient care. Ensuring Patient and Employee safety inside the healthcare facility.

CONTENTS 1. Hospital Introduction 2. Introduction to JCI 3. Tracer Methodology 4. How to work with the Surveyors 5. Hospital Wide Policies 6. International Patient Safety Goals 7. Access to Care and Continuity of Care (ACC) 8. Patient and Family Rights (PFR) 9. Assessment of Patients (AOP) 10. Care of Patients (COP) 11. Anesthesia and Surgical Care (ASC) 12. Medication Management and Use (MMU) 13. Patient and Family Education (PFE) 14. Quality Improvement and Patient Safety (QIPS) - Quality Improvement Methodology (PDCA) - Incident Reporting 15. Prevention and Control of Infection (PCI) - Standard Precautions - Hand Washing Guidelines and Techniques - Activities to Prevent Hospital Acquired Infection - Sharps Bad Practices - Sharps Injury Process - Needle Stick Injury - Waste Segregation Process - Linen Segregation


16. Facility Management and Safety (FMS) - Safety Management - Security Management - Hazardous Materials Management - How to Handle Chemical Spills - How to Handle Mercury Spills - How to Handle Blood Spills - Emergency Management - Emergency Codes - Fire Safety - Medical Equipment Management - Utilities Management - Oxygen Cylinder Safety 17. Staff Qualification and Education 18. Management of Communication and Information

From the desk of Chairman

Aditya Birla Group, amongst other tenets is deeply involved and practices with zeal “QUALITY” across all its enterprises and endeavours. Total “Quality in Health care” and “Care with Compassion” will definitely and should be practiced at Aditya Birla Memorial Hospital. Re-emphasizing this personal commitment, I sincerely request all the members of TEAM ABMH to adopt this mantra for the years ahead at ABMH. I am conscious that proper and strict protocols are a necessity-Practice thereof must be a religion in every aspect of all our medical deliverables. Satisfying every need of our costumer effectively should be our goal. I am sure that everyone at ABMH would sincerely participate in these objectives. 7


Rajashree Birla

From the desk of Trustees

We ensure delivery of quality care with highest level of expertise from medical experts backed by well trained support staff, robust infrastructure and efficient systems & processes.



Aditya Birla Hospital is committed to maintain the highest standard of care & respond to the needs of the community in a compassionate manner. We believe in building and maintaining long-term patient relationships, so as to become an essential resource for their well being.

From the desk of Chief Executive Officer Dr. S.P. Singh

Our endeavor is to achieve utmost satisfaction of our users by delivering compassionate, affordable Quality services on a sustainable basis. Our focus is on continuos improved patient care , aligning ourselves with technological advances in medical field. All efforts are made and will continue to be made to put medical practices in place to comply with national and international standards like ISO, NABH, NABL, JCI to maintain excellence . We are committed to abide by ethical codes of practices and are responsive to the safety, welfare and needs of all our stake holder. 9


We, at Aditya Birla Memorial Hospital , a multi super speciality institute, are committed to serve our users and society at large.

From the desk of Chief Operating Officer Rekha Dubey

We today pledge our commitment to achieve this objective.



The entire team at Aditya Birla Memorial Hospital is seized and aware that the cornerstone of the progress of the institution will be our interest to deliver quality healthcare to our patients and customers. To achieve this, not only proper protocols should be in place on paper but much more in practice

Introduction to HOSPITAL

Aditya Birla Memorial Hospital (ABMH) is a multi-speciality medical centre located at Pimpri-Chinchwad in the west Indian state of Maharashtra. The quaternary healthcare centre provides high quality and cost-effective medical services. A tribute to the visionary founder of the Aditya Birla Group, the hospital fulfils the late Mr. Aditya Vikram Birla’s dream of building a world-class healthcare facility in India. Mrs. Rajashree Birla, chairperson of the Aditya Birla Foundation, which is funding the medical centre, is personally steering this project. The 500-bed hospital functions in a filmless and paperless digital environment, backed by cutting edge medical technology and IT resources. The aim is to create a centre of life where elements of nature augment the healing environment and offer holistic healthcare under one roof. In keeping with the traditions of the Aditya Birla Group, ABMH offers comprehensive healthcare facilities to all strata of society. Special provisions will 11 be made for those unable to afford high medical costs.


Aditya Birla Memorial Hospital

JCIA stands for Joint Commission International Accreditation for Hospitals. JCI’s mission is to improve the quality of healthcare in the international community by providing worldwide accreditation services.


Accreditation is a process in which an entity, separate and distinct from the health care organization, assesses the health care organization. To determine if it meets a set of requirements (standards) designed to improve the safety and quality of patient care. Accreditation provides visible commitment by an organization to improve the safety and quality of patient care, ensure a safe care environment, and continually work to reduce risks to patients and staff.

Purpose of an Accreditation Survey To evaluate the organization’s compliance based on Interviews with staff and patients and other verbal information; On-site observations of patient care processes (also see Glossary) by the surveyors; Policies, procedures, and other documents provided by the organization; and The results of self-assessments when part of the accreditation process.



What is Accreditation?

Primary objectives of tracer activities are: To follow course of care and services provided to the patient. Assess relationships among disciplines and important functions. Evaluate performance of processes relevant to the individual. More specifically the following are tracer selection criteria, i.e., determinants of how surveyors will select processes: Identified clinical / service groups as identified by RAK Hospital. Patients who have received complex services (often those close to discharge). Patient’s who cross different programs, e.g., hospital. Patient’s/resident’s who relate to “system” tracers: a. Infection Control. b. Medication Management.



This survey method traces a number of patients through the organization’s entire health care process. Tracer activity is customized to the individual organization and surveys care across services and programs. This methodology uses multi -level participation, i.e., as cases are examined, the surveyor may identify performance issues in one or more steps of the process – or in the interfaces between processes. The surveyors determine which process to focus on using information from the Priority Focus Areas and clinical / service groups as identified by our Hospital.

Patient’s in complex situations, e.g.,: a. ICU b. Emergency Department. c. Receiving anesthesia services. d. Obs &Gyne e. Observation status.

Tracer visits include: Evaluation of top 4-5 Priority Focus Areas identified by our Hospital. Observation of care areas and environment of care issues. Review of the medical record with staff and with the Nurse being the initial interviewee.



Tracer activity: Comprises 50 – 60% of on-site survey time. Will be approximately 90 minutes per activity but can be up to 3hours. Starts in the setting/unit where the tracer patient is located. May include sequential following of the course of care – but no mandated order for visits to other care areas.

Surveyor activities may include: Review of closed records (if issues are found in initial tracer activities). Areas not included in the tracer, e.g., home care. Building tour (areas not visited during the tracer), if applicable. For example: kitchen, pharmacy, etc.

This methodology focuses on execution i.e., i.e., the actual delivery of care and services!



Tracer visits may include: Observation of direct care. Observation of medication processes. Observation of care planning process. Individual/family/significant other interview. Review of additional medical records, as needed. Staff level interaction: a. Performance measurement (see Quality Improvement section), activity. b. Daily roles and responsibilities. c. Orientation, competency assessment/reassessment (maintenance), and continuing education.


Example of a hospital tracer: Medication management is a Priority Focus Area and surgical care is one of the top clinical / service groups. Surveyor will select a surgical patient who received anesthesia from an active patient list, follow the care provided to that patient, and focus on medication management, e.g.: a. Dispensing, administering, monitoring. b. Training of staff responsible for processes.

Example of a laboratory tracer: Chemistry is one of the top clinical / service groups and analytical procedures is one of the top Priority Focus Areas. Surveyor will select a patient who received chemistry tests and trace the analytical procedures provided to that patient’s testing experience, e.g.: a. Sample collection, transport, receipt and processing. b. Testing process and interpretation of results. c. Reporting of results: Turnaround times. Critical values. Program-specific surveyors evaluate specialty standards requiring evaluation at an individual program level. Sample Collection

Transportation of samples

Receipt of Samples

Processing of samples 16

Interpretation of Results

Reporting of Results

Keep the conversation professional. Ask questions if you do not understand. NEVER argue with the surveyors. Be professional and use appropriate language and behaviors.

Be truthful. If you do not know an answer say so and tell the surveyor where you would go or whom

Remember you may use any resources available to you, e.g., intranet policies, any departmental resources, or ask your manager.

Keep your answers focused and specific to their question. Whenever possible answer in your own words. Remember the surveyors are here to assess our compliance not to be distracted by internal issues or problems.

Support your co-workers. If you are present when someone is being questioned, feel free to add any relevant information. Respond to questions with confidence – you know the answers better than anyone. Speak freely about all of the great things we do – and there are many!



you would ask for the answer.


Fire extinguishers or other fire control mechanisms Evacuation routes Oxygen shut-offs Emergency showers/eyewash stations Personal Protective Equipment (PPE) Spill Kits Alcohol-based dispensers Disaster plan How to access ABMH’s policies (Intranet)



Locations of: Fire pull boxes (Red Boxes)

Other tips on professional interaction with surveyors: Surveyors use a “tracer methodology” to choose a patient and trace their care throughout the organization. This is accomplished by rounding in each department that cared for the patient and

Surveyors may come at night to interview staff, review records, tour the building, etc. Patient safety and performance improvement are always very important things to know about. Relax – surveyors are physicians, nurses, administrators, medical technologists and others who have worked in hospitals. Always be honest. Falsification or misrepresentation is absolutely not tolerated and can cause the organization to lose its accreditation. Just as in sports, success is dependent on teamwork. Excellent patient care is no different. Your communication and interaction with other members of the healthcare team are critical to provide excellent care for the patient!



interviewing staff, reviewing policies, looking at HR competencies.

There are 14 chapters out of which 8 are Patient Centric Standards and the 6 are Health Care Organization Management standards. They are Patient Centric Standards:

International Patient Safety Goals (IPSG) Access to Care and Continuity of Care (ACC) Patient and Family Rights (PFR) Assessment of Patients (AOP) Care of Patients (COP) Anesthesia and Surgical Care (ASC) Medication Management and Use (MMU) Patient and Family Education (PFE)

Organization Management Standards:

9. Quality Improvement and Patient Safety (QIPS) 10. Prevention and Control of Infection (PCI) 11. Governance, Leadership and Direction (GLD) 12. Facility Management and Safety (FMS) 13. Staff Qualification and Education (SQE) 14. Management of Communication and Information (MCI)



1. 2. 3. 4. 5. 6. 7. 8.

Goal 1 : Identify patients correctly

Goal 2: Improve Effective Communication 1. All telephone orders or telephonic reporting of critical test results must be verified. The complete order or test result(s) is written down as received and verbally read-back to the person communicating the information. 2. Telephone and Verbal orders must be limited to situations where immediate written or electronic communication is not possible in the case of urgent /emergency situations. 3. Verbal orders are usually only accepted during an emergency situation where the physician is present in the unit. E.g. During Cardiac Arrest. 4. Telephone and Verbal orders must only be accepted by a Registered Nurse or licensed Doctor. 5. Medication orders are to be written directly onto the Drug Order Sheet. 6. Non –Drug orders are to be written directly onto the patients Non-Drug Order sheet. 21


1. Use 2 patient identifiers – patient’s name and MRN No. in all instances when identifying patients, whenever administering medications or blood/blood products; taking blood samples and other specimens for clinical testing, or providing any other treatments or procedures and services. The patient’s room number is not to be used as an identifier. 2. Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a “time out,” to confirm the correct patient, procedure and site using active communication techniques. 3. The ID band should be removed only at the time of discharge.

Goal 3: Improve the safety of High Alert Medication 1. Concentrated potassium and all other electrolytes are not permitted on patient care units. This includes saline solutions > 0.9%. They must be obtained from the pharmacy. 2. Aditya Birla Memorial Hospital has standardized and limited the number of drug concentrations available. 3. Aditya Birla Memorial Hospital has identified a list of lookalike/ sound- alike drugs used in the organization, and actions for practitioners to take to prevent errors.

Goal 4: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery 1.

Using a checklist, including a "time-out" just before starting a surgical procedure, to ensure the correct site, correct procedure, correct patient, current surgery and body part. 2. Before doing any surgery we mark the precise site where the surgery will be performed by involving the patient in doing this. 3. Prior to induction of anesthesia and immediately before beginning of surgery, the operation theatre team shall conduct a final verification to confirm the correct patient, procedure and surgical site and, as applicable, implants using the “Time Out “check list. 22


7. Telephone and Verbal orders must be clearly communicated and include two correct patient identifiers. 8. Do not use any of the abbreviations that our hospital has identified as “Prohibited.” If a provider uses one of those abbreviations, clarification must be obtained prior to the order being acted upon. 9. All values defined as critical by the laboratory are reported directly to a responsible licensed caregiver within pre-defined time frames established by the laboratory, nursing and medical staff. When the patient’s responsible caregiver is not available within the time frames, then the critical information will be reported to the covering responsible caregiver.

Goal 5: Reduce the risk of Healthcare Associated Infection 1. Aditya Birla Memorial Hospital complies with WHO hand hygiene guidelines Hand washing is the single most important factor for Infection Control. Wash hands before and after patient contact, use of toilets. Follow “Standard precautions� in the hospital.

Definition: - A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. An un-witnessed fall occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there. 23


Goal 6: Reduce the risk of Patient harm resulting from fall

1. 2. 3.

5. 6. 7. 8.




All patients will be assessed for risk of fall on admission and reassessed routinely to determine ongoing need for fall prevention precautions. Patients who have history of frequent falls or have high risk factors for falling will be identified in an effort to prevent falls. Any patient determined to be at risk for fall and identified more than one fall risk on integrated initial assessment upon admission will be placed on Fall Risk Assessment Tool and Fall Prevention Management . Interventions to protect patients at risk for falling and harming self will be initiated using the least restrictive alternative available. Restraints are utilized only after other options are unsuccessful. See Policy on Restraints Bed rails are designed to reduce the risk of patients accidentally slipping, sliding, falling or rolling out of bed. Patients who are independently mobile may be restricted by bedrails. Bedrails may also increase the risk of injury to patients who are confused enough to try and climb over them. Several interventions to prevent falls include, but are not limited to: having the bed in the lowest position with brakes locked, bed and chair alarms, orienting the patient to surroundings & call light nonskid footwear, and providing a safe environment (no clutter on the floor).

Information about the hospital is provided to patients in patient guide book.


CULTURAL BARRIER •Different types of food are available. •Patient`s needs to observe auspicious times for any procedures are honoured.

PHYSICAL BARRIER •Wheelchair / stretchers are readily available at the entrance. •Lifts available for all floors.

RELIGIOUS BARRIER •Prayer Room available. •Spiritual services are provided when asked for.

Continuity of Care


Use at least two patients identifiers (not to be the patients room number) whenever taking blood samples, administering medications, or blood products. They are:

For Inpatients Name, MRN

For Outpatients

For Comatose patient in the emergency

Name, MRN

Unknown 1/2/3, MRN 25


•Interpreters are available to avoid the language barriers. •A list of interpreters is available on all nursing stations.

Discharge, Referral and Follow-up Discharge Planing

Discharge Summary Medication instructions are written in layman`s terms. Doctors write information on when to seek advice. They write information on how to seek advice in case of routine appointments and emergency care. Wound dressing instruction , if any, are also written. Advice on diet and physical activity will be included. Any allergies present or not, need to be mentioned in the discharge summary. Color Coding in Triage



Discharge planing is done at the time of admission so that a patient`s needs even after discharge can be planed well ahead in time. This improves the quality of patient care and decreases readmissions due to lack of availability of vital equipment at home, after discharge.

Care, treatment and services are provided in a way that respects and fosters dignity, autonomy, positive selfregard, civil rights, and involvement of patients. Family to be involved in care, treatment, and service decisions with the patient’s approval.

Patient Rights

Patient Responsibilities Provide accurate and complete information about medical complaints, past illnesses, hospitalizations, medications, pain, and other matters relating to their health. Follow the treatment plan recommended by those responsible for their care. To pay the bills promptly as possible as per the hospital rules and regulations Ask questions if what is said by their care giver is not understood Treat staff with respect 27


Right to medical care Information on identity of the staff taking care of them A second opinion Dignity Confidentiality Privacy Inform consent Access to medical information Right to Pain Management

Patient Possessions: Hospital shall not be responsible for patient valuables/property that is not deposited with the Hospital Security for safekeeping. Does a patient have a right to refuse treatment? Yes, our standards promote the patient and family/significant other’s involvement in all aspects of their care, including refusal of care. 28


To ensure patient’s privacy and confidentiality 1. Cover patients during transport. 2. Knock before entering a room. 3. Keep doors closed during treatments and times of care. 4. Refrain from discussing patient information publicly. 5. Discuss care only in the presence of the patient or in the presence of others with permission from the patient. 6. Patient related information to be disposed posed properly through shredders. 7. Computer passwords should never be shared with anyone. Leaving one’s screens up on the computer and walking away has the same effect as sharing your password. Always remember to lock / log off the computer when you are finish or need to step away from computer. All staff sign confidentiality agreement.

Assessment How are the needs of patient known or identified? Information about the patient’s physical, psychological, social, cultural and spiritual status is obtained during the initial assessment, primarily by the physician and nurse caring for the patient but also by other members of the health care team such as dietitians, pharmacists, and physical therapists. The initial medical and nursing assessments are to be completed within the first 24 hours after the patient’s admission as an inpatient or earlier as indicated by the patient’s condition. Medical assessments are to be documented in the patient’s record within 24 hours of admission. Nursing assessments are to be documented in the patient’s record within 24 hours of admission. Patients are to be screened for nutritional status and functional needs by the nurse and are referred for further assessment and treatment when necessary. All patients are to be screened for pain and assessed when pain is present.



Care, treatment, and services are provided through the successful coordination and completion of a series of processes that include: Appropriate initial assessment of needs Development of a plan for care, treatment, and services The provision of care, treatment, and services Ongoing assessment of whether the care, treatment, and services provided are meeting the patient’s needs Either the successful discharge of the patient or referral or transfer of the patient for continuing care, treatment, and services.

What do you do for patients with functional needs? Nutritional needs? Nurse assesses patients on admission and refers as necessary to appropriate disciplines.

What age groups or population are served in this Hospital? Age ranges stated in the policy and accepted by our medical staff are the following: 1. Older Adult, Geriatric (65 years and beyond). 2. Adult (18 years-65 years). 3. Pediatric (18 years & Below) 4. Neonatal (upto 28 days) 1






What does “age-specific� (populations served) assessment mean and how do you know about these needs? Different age groups have different psychosocial and clinical needs. This must be taken into consideration when assessing and caring for patients. As necessary for your job at Aditya Birla Memorial Hospital, you are educated to address individual patient needs specific to the age and populations served. For example, a 2year old patient requires an appropriate pediatric blood pressure cuff rather than an adult size. Also, when administering an intramuscular medication, an appropriate gauge and length of needle would need to be considered. (A frail elderly person may have decreased muscle mass.)

What is evidence of interdisciplinary and collaborative care planning? After patient’s needs are determined, the health care team develops a care plan. The primary care physician and specialists coordinate the team. Evidence of care planning includes but is not limited to the following: 1. Integrated Progress Notes. 2. Integrated Initial Assessment Record 3. Patient / family / significant other teaching information (Interdisciplinary Health Education Record). 4. Interdisciplinary plan of care. 31


How is a patient’s plan of care determined? The information gathered by the patient’s health care team is assessed and care is delivered according to those needs. Patients are reassessed whenever there is a significant change in the patient’s condition and/or diagnosis and response to treatment. The plan of care is reprioritized according to the changing needs of the patient.

End of Life Care: 1. Assessments and reassessments to be done for dying patients. 2. Dying patient’s pain to be managed effectively. 3. Patient and family’s psychological status and spiritual needs are assessed and reassessed. 4. Dying patients are given comfort and dignity. DNR Never use the word DNR. do not “Resuscitate”(DNR) Order are not legal. For brain dead patient fill the “End of Life Form” Who is a vulnerable patient? A child below 16 years of age An adult above 60 years of age A physically/ mentally challenged person Any patient who can not perform ADL (Activities of Daily Living) Terminally ill and all ICU / MICU/ PICU / NICU patients Women in labor 32


How does interdisciplinary and collaborative patient care planning occur? Communication via documentation in assessments and progress notes, requests for referrals to the appropriate disciplines, shift to shift report, case management discussions, and verbal discussion as needed to provide the mechanism for interdisciplinary care planning. Is there a document that comprehensively addresses the plan of care and how is it prioritized? The nursing plan of care incorporates interdisciplinary care needs of the patient. Nurse reviews and updates the care plan daily or upon a change in patient condition.

For vulnerable patient, prevention of falls is the most important precautions to be taken. The doctor identifies a vulnerable patient through a tick mark against”Safety first” in “Request For admission” Form.

Restraints: Restraints – Is the involuntary use of a physical or mechanical device to limit or prevent movement of the whole or a portion of the patient’s body as a means of controlling his or her physical activities. When do we restrain a patient? When less restrictive alternatives are ineffective in protecting the safety of the patient or others. Restraints should be discontinued at the earliest possible time. Clinical justification and other requirements must be documented. Restraint order form has to be filled which is valid for 12 hours only. Document need for restraint (restraint order) prior to tying down a person. We have to do two hourly restraint monitoring and four hourly documentation. 33


What special care is given to a vulnerable patient? For children, there is a different history and physical examination form. Side rails are always put up on the beds of vulnerable patients . “Safety First “ program is followed. A yellow “safety first” tag is placed at the head end of their bed. ‘Plan of care’ form is added to the medical record . Frequent assessments are done by doctor and nurses. All this is documented in the patients` file. Like all other patients, an incident form is filled in case of something untoward happening with such a patient.

Pain management When are patients assessed/ reassessed for pain? Upon admission, every shift, after pain medication, as needed and prior to discharge. Assessment and reassessment of pain is documented in the initial and follow up notes. Patient and the family are educated on pain VAS Pain rating scale to be used for assessment of pain.



High Risk Patients and Services Extra cautions should be practiced in providing high risk services and for high risk patients, according to laid policies. Emergency patients Resuscitation services Handling, usage, and administration of blood and blood products Comatose patients and patients on life support Patients with communicable diseases and immunosuppressed patients Patients on dialysis Patients in restraints Elderly patients, disable, children and populations at risk of abuse Patients receiving chemotherapy or other high risk of abuse Patients receiving chemotherapy or other high risk medications


Anesthesia and Surgical care


Surgical Care Patients surgical Care is planned and recorded Risks, benefits, potential complications and options discussed with patient and family are documented Surgey done is recorded: Pre-op and Post-op diagnosis and operation notes are written clerly Care after surgey is planned and documented.


Pre anesthetic assessment and documentation mandatory. Care- planned and documented. Risks, Complications, options etc are discussed with patients and family memebers. Separate consent of Anesthesia is obtained. Anesthesia used is documented. Physiological status during anesthesia is monitored and recorded. Post anesthesia status is documented. Discharge or transfer from recovery is done using established criteria.

Time Out Prior to the start of any surgical procedure, conduct a final verification process such as a to conform the correct patient, procedure and site using active communication technique . Time Out MUST verify: 1. Correct patient 2. Correct side and site (Marked) 3. Agreement to the procedure (Consent) 4. Correct patient position for procedure 5. Presence of implants and/or special equipment. Surgical site marking is done using only arrows in all cases where we need to denote laterality, digit or level. 36

1. Right patient 3. Right Dose 5. Right route 7. Right Documentation

2. Right Drug 4. Right Time 6. Right Purpose



We have a medication policy in place to reduce medication errors. 1. Medication orders are to be written clearly in the drug chart. 2. Start and discontinuation order of any drug has to be signed, dated and timed. 3. Any wrong entry has to be crossed out with a single line and signed error. 4. Effect of medication is to be documented in the progress notes. 5. Medications are administrated at standard times other than stat orders. 6. Self medication and medication from outside are not encouraged in the hospital. 7. Never leave medicines unattended in the open. lock them in bedside cabinets. 8. Label all open in use vials and pre-filled syringes. 9. All medication error to be reported. 10. All ADR need to be reported in ADR form for clinical audit. 11. All orders (including diet and nursing stands cancelled when patient under go surgery or is transfered out of ICU`s. All order including dietary order , need to be written a fresh in the situation.

How are patient’s educational needs determined? At the time of admission and throughout the patient’s stay, the healthcare team assesses the patient and family to determine their individual education needs. Education methods include the patient’s and family’s values and preferences and allow sufficient interaction among the patient, family, and staff for learning to occur.



The patient / family /significant other receives education and training specific to their needs and as appropriate to the care, treatment and services provided. As appropriate to the patient’s condition and assessed needs, the patient is educated about the following: 1. The plan for care, treatment and services. 2. Care decisions and care processes 3. Informed Consent 4. Basic health practices and safety. 5. Safe and effective use of medication. 6. Nutrition. 7. Safe and effective use of medical equipment. 8. Pain Management. 9. Food drug interactions 10. Education on falls prevention

Organizational Quality Indicators



• Procurement & Supply • Patient Satisfaction • Reporting as per law and regulation • Biomedical Waste management • Utilization Management • Needle stick Injuries • Staff Satisfaction • Risk management • Patient demographics & Clinical diagnosis • Financial management




• Patient Assessment • Lab safety and Quality control programs • Radiology Quality control programs • Surgical procedures • Use of Anesthesia & Sedation • Use of Blood & Blood products • Availability, use and content of patient records • Use of antibiotic and other medication • Monitoring of medication errors and near misses • Infection control, Surveillance and reporting

Near Miss: - An event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Example: Request for an invasive procedure with a wrong patient identification that could have resulted in a sentinel event but caught at the last minute. Both, sentinel events and near misses, are situations that present a real opportunity for improvement. Root Cause Analysis: It is a systematic process of investigating a critical incident or a sentinel outcome to determine the multiple, underlying contributing factors. The analysis focuses on identifying the latent conditions that underlie variation in performance and if applicable, developing recommendations for improvements to decrease the likelihood of a similar event in the future.



Sentinel Event: - An unanticipated occurrence involving death or major permanent loss of function unrelated to the natural course of the patients’ illness or underlying condition. Sentinel Events include but not limited to: 1. Suicide or attempted suicide in patient care areas. 2. Infant abduction or discharge to the wrong family. 3. Surgery on the wrong patient, wrong procedure or wrong site. 4. Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities 5. Events relating to medication errors 6. Patient Falls 7. Infant abduction or infant who was sent home with the wrong parents Such events are called “sentinel� because they signal a need for immediate investigation and response. A root-cause analysis must be conducted resulting in a clear action plan for improvement.

Quality Improvement methodology The organization utilizes the Plan – Design-- Measure- Validate- Assess- Improve Quality Improvement Model as the framework for improving Quality.


Quality Improvement tools used are - Open File Audit Quality means- Closed Medical Record Review “Doing it right - Facility and Safety Audits - Infection Control and Medication Management audits when no one is - Failure Mode and Effects Analysis (FMEA) looking’ - Root Cause Analysis (RCA) - By Henry Ford - Patient feedback mechanism - Primary Source Verification - Credentialing - “5S” philosophy How are the staff and physicians involved in performance improvement? All staff and physicians are responsible for and involved in performance improvement activities either through ongoing data collection, analysis of results, development of action plans, and/or measurements of success or Quality improvement committee participation. What is your responsibility for improving care and services at A ABMH? It is everyone’s responsibility to look for opportunities to improve care and services. When you see opportunities, discuss them with your department head and participate in making improvements. Also, incorporate performance improvement principles and values into your everyday work processes. 41

Hand Washing Handwashing is the single most important factor for infection control. Wash hand before/ after patient contact and use of toilets. Follow ‘Standard Precaution’ in the hospital.



Infection control is everyone`s responsibility..... Everyone can prevent infection and all of us need to be equally concerned with infection control in the hospital. Wash hands before and after patient contact, before eating, after visiting toilet and even after touching inanimate objects like files, equipments etc. An infection committee has been constituted ,which serves as an advisory body. An infection control manual(Also called as GREEN BOOK ) has been complied and is available with members of the infection control committee & at all nursing stations. The hospital has identified procedures associated with risk of infection and has strategies to reduce infection risk.

Scrub Policy

Handling Soiled Linen Any linens visibly soiled with blood any body fluid of a patient is to be treated as soiled. At the laundry, there is a special procedure for cleaning and disinfecting of soiled & infected linen, before sending it back to the floors.

Handling Contaminated Files If blood &body fluid is spilled onto a file, that file is to be treated as contaminated, and following instructions to be done: Place the file in a plastic impervious black bag. Fill up an incident form. The nurse shall send the file to MRD where it will be photocopied, attested and that copy of the file will be sent back to the floor.



Avoid wearing scrubs outside restricted areas. Wear a long coat over the scrubs if you have to go out of restricted areas.

Biomedical Waste management



Our Vision

Our Mission Compassionate Quality Healthcare




Excellence First And Always

The basic responsibilities of the staff are: 1. Handling hazardous material spills (mercury spills, Formalin and Cidex spill) 2. Fire Safety 3. Smoking control policy



The management and safety of the hospital facilities is an important part of quality improvement and patient safety. A safety committee has been constituted to act as an advisory body. The safety committee conducts extensive safety rounds of the facilities and offers suggestions for improvement. A safety manual(also called the RED BOOK has been complied by the safety committee, which gives information on staff response to hazardous situation. Disaster plans have also been formulated, and gives information on staff response to various “code� situations ,part of which is also included in the safety manual. Mock drills for external &internal disasters are conducted. A policy for hazardous materials has been formulated, and must be strictly followed by all staff members.



Formalin ,Cidex and other Hazardous Material Spill Minor spills: < or = 30cc 1. Place tissue paper over the spills. 2. Wear PPE. 3. Place this tissue paper in the black plastic bag. 4. Place this bag in another black plastic bag, and lable it as â&#x20AC;&#x153;.............â&#x20AC;? spill. 5. Ask housekeeping to mop the area and dispose off the plastic bag. 6. Fill up the incident form. Major Spill: > 30 cc 1. Place tissue paper over the spill. 2. Place inverted trash can over the spill. 3. Inform HAZMAT team to clean up (83) 4. Fill up Incident Form Mercury Spill 1. All Mercury Spills are major spills. 2. They are caused by BP apparatus / thermometer break. 3. Place tissue paper over the spill. 4. Place inverted trash can over the mercury. 5. Inform HAZMAT team to clean up (call 83) 6. Fill an incident form.

nature , safe use and precautions while

Material Safety Data Sheet(MSDS)- List the handling hazardous Materials.

Smoking Policy


Hospital is a “NO SMOKING ZONE”

Fire Safety

Medical Equipment Management Equipment must be tagged. Disinfect and remove equipment from use area and store. File a work order with Biomedical Engineering. If immediate assistance is needed, during the day shift, call Biomedical Engineer Extn . After working hours and holidays contact the “On-Call” Biomedical Engineer. 48

Emergency Codes

Call 81

Call 80

Call 85

Call 83

Call 84



Call 82

Utilities Management Where is the oxygen shut-off valve in your work area? Know the oxygen shut-off valve location in your area. If you do not know, ask your department head / Incharge / Biomedical Engineer.

What do you do if there is a utility system failure, i.e., water, power, gas, etc.? Refer to the Hospital Utility System Management plans, located in the FMS section of the Hospital Wide Policies on our Hospital Intranet. How is our Hospital prepared for a power outage? The facility has emergency generators that provide power during power outages. Essential equipment is always to be plugged into outlets. All non-essential equipment is to be removed from outlets during power outages. Fire safety equipment is powered by emergency generators, such as exit lights, smoke detectors, and emergency lighting, is powered by emergency generators.



When do you turn off the oxygen for your area? In the event of a fire in your immediate area, follow the RACE protocol for a fire, assess your patients, provide alternate life support, i.e., portable oxygen, shut off oxygen and evacuate the area if directed to.

Oxygen Cylinder Safety



When moving oxygen cylinders, even for short distances, use a cart or carrier designed for their transport. If transporting via hospital bed or stretcher, ensure the cylinder is safely secured. Never position an oxygen tank between a mattress and bedrail; Containers should be stored in the vertical position and properly secured by a chair or similar device. Oxygen cylinders should never be left in any area unsecured, even for a short period of time. Close the container valve after each use and when empty, even if still connected to equipment. Open valve slowly to avoid pressure shock. If you have any questions, please feel free to contact Biomedical engineering department



Required skills. Knowledge and education are defined in the job description. There is a documented personal file for every staff member. Every staff member undergoes orientation to the organization and to his / her specific job descriptions. Desired level of training on resuscitation techniques â&#x20AC;&#x201C; BLS / ACLS are given to staff members. Every staff member is given opportunity to participate in internal / external training programmes to update / acquire skills and knowledge. There is a process of gathering, verifying and evaluating credentials for the healthcare professionals. All the staff are included in the organizationâ&#x20AC;&#x2122;s Quality Improvement Programme.


Dont’s 1. Do not disclose information about the patient to anyone except the patient or a person approved by the patient. 2. Do not discuss about patient in the lift if identifiable information is being discussed, it can de a violation of confidentiality 3. Nurses shall not take verbal medication orders from doctors except in an emergency. Doctor to doctor verbal order, however is allowed, with read back policy.

Nurses to be Conversant with Nurses Manual. Senior Medical Staff to be conversant with Medical Staff Bylaws and Code of Ethics. 53


1. Maintained confidentiality of information pertaining to a patient. Confidentiality is a patient`s right. 2. All staff Members are required to sign a “Confidentiality Agreement” Whereby they pledge to abide by the hospital policy on management of information. 3. Doctor to Doctor communication: Read back and verify telephone orders and (limited) verbal orders. 4. Nurses and doctors to read back and verify critical test results. 5. Take Informed consents.

TIMELINE Within 24 hours

Nursing Assessment

Within 24 hours

Restraint From validity

12 Hours

Restraint monitoring Documentation of Restraint Monitoring Validity of Blood/ Dialysis Consent Form IDTR Rounds

Every 2 hours Every 4 hours 30 days

Nutrition assessment

1st round on completion of 48 hours Then every 7 days Within 24 hours of referral

Physiotherapy assessment

Withi24 hours of referral



H&P Sheet







ABMH Quality and Safety Guidebook  

Quality and safety Guide based on JCI Standards

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