Transformation of Quality care - CIPS
Transcript of Transformation of Quality care - CIPS
Dr. Haneesh1
GENERAL HOSPITAL
ERNAKULAM
THE FIRST HOSPITAL IN
GOVT.SECTOR IN THE
STATE AND FOURTH
IN THE COUNTRY TO
RECEIVE NABH
ACCREDITATION
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Hospital Profile..
Multispecialty Hospital started 170 years back.
Bed strength is 783, is the highest among the hospitals under Kerala Health Services.
Apart from Ernakulum District the hospital caters to neighbouring districts like Trichur, Kottayam, Alleppey and Idukki.
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IN THE BEGINNING….
THE BEGINNING 2008
GOVERNMENT DECISION FOR NABH ACCREDITATION
Selection of Hospitals
Administrative Support
HR issues
Gap analysis
Infrastructural Design
Financial constraints
Statutory mandates
Documentation
CHALLENGES FACED
Administration
District medical office/District Administration
Institution
State
Directorate of Health services/NRHM
Policy Decisions
Government
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HR issues
MotivationWork load
incentives
Committment Rights Duties
Awareness Training Owning
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HR issues
ShortageHR
policyStaff
pattern
Transfer
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Gap Analysis
Only Gaps
Demotivation
Herculean task
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Financial
• BudgetShortage of
Funds
• Not in TimeAvailability
• Government norms
• AuditsFlexibility
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statutory
Building
Fire
Pollution control board
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Documentation• consultancy
Manuals
• Patient loadCase sheets
• Fear of reportingEvents reports
Data capturing
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Documentation
•Computer savyComputerization
Audits
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TRANSFORMATION OF QUALITY CARE…
Formation of Hospital committees1. Core committee/ Quality Assurance Committee2. House Keeping Committee3. Infection Control Committee4. Internal Audit Committee5. Medical record audit committee6. Biomedical Equipment Management 7. Safety Committee8. Blood bank committee9. Clinical risk management 10. Condemnation Committee.11. Diet Committee12. Disaster Management/ Emergency preparedness
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13.Drugs formulary committee
14.Ethics Committee
15. Office Management Committee
16.Purchase Committee
17. Safety Committee
18.Staff welfare Committee
Hospital committees
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Absence of written policies and procedures for health care delivery
Quality manual , policies and procedures for all procedures
Transformation of Quality care…
Staff shortage in various categories
Poor sanitation and cleanliness in the hospital
Recruitment of additional staff by NRHM and
HDC
Sanitation made effective and
checklist for all cleaning
procedures
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Absence of audit on -medical records, clinical
practices, infection control practices
,absence of survey on patient and employ
satisfaction .
Lack of awareness about patients rights and
responsibility
Corrective and preventive actions
taken based on audit and survey
Signage on patient’s rights and
responsibilities, citizen charter
updated
Transformation of Quality care …..
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Inadequate calibration for the equipments
Inadequate monitoring and reporting of adverse events, needle
stick injury, sentinel events etc.
Calibration of all equipments done
Audit and root cause analysis
Transformation of Quality care …..
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Poor signage system- developed layout and signages
Slackened Security systems
Security system strengthened
Transformation of Quality care …..
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Awareness and Training
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Trainings and mock drill
CPR training
Fire training
Ventillator training
NABH training
Disaster
Ventilator Training
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FIRE SAFETY TRAINING
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CPR TRAINING
Mock Drills conducted
Code Blue
Code Pink
Code Orange
Code Red
Code Black
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Mock Drills conducted
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CARE FOR EMPLOYEES..
Employees are given health check up on yearly basis, Vaccinations and personal file maintained for all staffs
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HOSPITAL DAYORUMA
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CHANGE OVER…
CHANGE OVER
HOSPITAL ENTRANCE
DIETARY DEPARTMENT
WARDS
Administrative Office
Oncology Ward
Physical Medicine
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PARKING AREA
Admission/RSBY Counter
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First government hospital to computerize registration and admission procedure
SNCU
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SICU
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ICCU
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OPERATION THEATRE
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Operation theatre
Main Theatre Complex
Five OT
suites
Family Planning theatre
Ophthalmology theatre
Minor OT
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LABORATORY
RDC and clinical lab.HistopathologyMicrobiology Biochemistry HaematologyComputerised and automated
CSSD-High Vacuum High pressure Sterilizer
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First government hospital to have CSSD
First time in Government Sector in the state - Digital X-ray
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CT Scan
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OPG Machine for Dental Dept
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Brachy Therapy
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Tele Cobalt Therapy
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TELEMEDICINE
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Mortuary – Cold Room
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Cold room –Capacity 20
ALS – Ambulance – 108 3 BLS Ambulance
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Palliative Care
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Home care Training Centre
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Power Laundry
BLOOD BANK-24 HOURS
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Medical Record
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LANDSCAPING
LANDSCAPING
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Gender Based Violence Management Centre
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The Proud Moment
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The Proud Moment
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Certificate of compliance for QCI-Essential Standard Program for Medical laboratories
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Baby Friendly Hospital Initiative Certificate
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Pollution Control Board Award
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FICCI Award-2012
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Awards Received
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Projects completed after Accreditation NEW OP BLOCK
MRI
CHEMOTHERAPY WARD
DIETARY DEPARTMENT
HAEMODIALYSIS
MODEL INJECTION ROOM
SEWAGE TREATMENT PLANT
PUBLIC CANTEEN
COMFORT STATION
INTERLOCKING TILING OF ENTIRE HOSPITAL PREMISES
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NEW OP
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•Modification and expansion of OP block
• Air-conditioned and spacious OP chambers
• Large waiting area
Dietary Services
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Therapeutic diet provided to all inpatients free of cost-First of its kind in KERALA probably in the country
CHEMOTHERAPY WARD
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•20 bedded •First hospital in government sector with chemo ward•patient privacy ensured through partition.•Fully Air-conditioned•PPP
PUBLIC CANTEEN
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Modified and hygienic new canteen
COMFORT STATION
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SAFE I MODEL INJECTION ROOM
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MRISubsidized rate to patients 24 hours
HAEMODIALYSIS
Free dialysis for patients
SEWAGE TREATMENT PLANT
INTERLOCKING TILING OF ENTIRE HOSPITAL PREMISES
ARTS AND MEDICINE
ARTS AND MEDICINE
Reaccreditation Assessment January 2014
THE QUALITY TEAM OF GH EKM
Hospital Statistics
2008 2013
Average OP Per day 1000-1500 2000 - 2500
Average Admission Per day
40-50 80 - 100
TIMELINE
Pre-assessment - February 2010
Final Assessment-July 2010
Verification Audit- December 2010
NABH Accredited –January 28,2011
Surveillance Audit–August 2012
NABH Reaccreditation Assessment-January 2014
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