Patient Safety and Quality Improvement (PSQ) Manual

Document Name
Document Number
Date of Issue
Designation
Prepared By Name
Signature
Designation
Verified By
Name
Signature
Designation
Approved By Name
Signature
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AMENDMENT SHEET

Section no & page Details of the Reasons Signature of the Signature of the
no amendment preparatory approval
authority authority
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CONTENTS

S.No. Topics Page Number

The organisation implements a structured patient–safety programme. 5
The organisation implements a structured quality improvement and 10
continuous monitoring programme.
The organisation identifies key indicators to monitor the structures, 15
processes and outcomes, which are used as tools for continual
improvement.
4 The organisation uses appropriate quality improvement tools for its 21
quality improvement activities.
5 There is an established system for clinical audit. 25
6 The patient safety and quality improvement programme are supported 33
by the management.
7 Incidents are collected and analysed to ensure continual quality 33
improvement
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CONTINIOUS QUALITY IMPROVEMENT (CQI)

CONTROL OF THE MANUAL
The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a
readily identifiable and retrievable.
The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as
and when the amended versions are received.
Accreditation in charge is responsible for issuing the amended copies to the copyholders, the copyholder
should acknowledge the same and he /she should return the obsolete copies to the Accreditation in charge.
The amendment sheet, to be updated (as and when amendments received) and referred for details of
amendments issued.
The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures.
Review and amendment can happen also as corrective actions to the non-conformities raised during the self-
assessment or assessment audits by NABH.

The authority over control of this manual is as follows:

Preparation Verified by Approval

The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’,
and the photocopies of the master copy for the distribution are considered as ‘Control Copy’.

Distribution List of the Manual:

Manual Designation Copy

MC01 Quality Coordinator Master Copy
CC01 Director of nursing Control Copy

PSQ 1- THE ORGANISATION IMPLEMENTS A STRUCTURED PATIENT–SAFETY

PROGRAMME.
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POLICY
a) The patient-safety programme is developed, implemented and maintained by a multidisciplinary
safety committee.
b) The patient-safety programme is comprehensive and covers all the major elements related to patient
safety.
c) The programme covers incidents ranging from “no harm” to “sentinel events”.
d) Designated patient safety officer(s) coordinates implementation of the patient- safety programme.
e) Designated clinical safety officer(s) coordinates implementation of the clinical aspects of the patient-
safety programme.
f) The patient-safety programme identifies opportunities for improvement based on the review at pre-
defined intervals.
g) The organisation performs proactive analysis of patient safety risks and makes improvement
accordingly.
h) The patient-safety programme is reviewed and updated at least once a year.
i) The organisation adapts and implements national/ international patient-safety goals.

PROCEDURE
Quality Management committee- shall be responsible for continuous quality improvement initiatives.
Members
 Hospital Chairman (Chairman)
 Managing Director (Responsible to chair the committee in the absence of hospital chairman)
 Medical Director (Responsible to chair the committee in the absence of Hospital Chairman/Managing
Director)
 Quality Coordinator (Secretary)
 Administrator
 HR Manager
 Director of Nursing
 Infection Control Nurse
 Others as invitees

Structure of Committee and roles

Chairman
The committee shall be headed by Chairman whom shall overlook the functioning of the committee and
system

Secretary
Secretary responsible for coordination of meetings, documentation of minutes and communication of
decisions to respective members. They shall also coordinate with all departments regarding the functioning of
committee

Frequency of meeting
Once in three months and as when required

Responsibilities and functions

 Acts as an apex committee for all others committee.
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 Prepare, review & monitoring related policies and procedures

 Ensure statutory compliances,
 MOU with outsourced agencies etc.
 Establishment, monitoring and review of quality indicators, internal audits, incident reporting
system, committee functioning etc. Analysis of patient satisfaction data and complaints. Ensuring
timely corrective and preventive actions
 Ensuring the availability of resources as required by the quality management system
 Conducting management reviews
 Ensuring continual improvement of the quality management system.
 Reviewing non-conformances related to services
PATIENT SAFETY

All Patient Care Services Staff shall use every reasonable precaution to provide a safe environment to the
patients.

Responsibility: Safety officer, all health care providers and patients.

Process:

The precautions listed herein should not be considered to be all inclusive, as safe practice requires sound
judgment in individual situations and constant awareness of the environment.

1) General Precautions
a) All patients shall be oriented to the clinical area(s). Orientation shall include the following:
i) Room number and unit layout.
ii) Bed operation.
iii) Visiting hours, as applicable.
iv) Non-skid shoes or slippers shall be encouraged.
v) All staff shall wear photo I.D. badges when on duty.
vi) The patient care area and hall shall be clean, well-lighted, and free from clutter.
vii) The floor shall be clean and dry. Appropriate signage is in place when floor is wet.
viii) Patient beds and treatment tables shall be kept at the lowest possible height except when
elevated for delivery of care and when the staff member is continuously at the bedside (e.g.,
intensive care units).
ix) Supplies, machines, and equipment shall be stored in designated areas. Equipment’s not in use
shall be promptly returned.
x) Patient care equipment shall be inspected and labeled by the Biomedical Department prior to
initial use and according to Preventive Maintenance Schedules.

b) Broken or malfunctioning equipment

i) The equipment shall be removed from clinical area
ii) The breakdown shall be reported immediately to the BME Department.
iii) All spills shall be cleaned immediately according to applicable guidelines for the type of spill.
iv) Each staff member shall continuously assess for unsafe conditions and takes appropriate
corrective action.
v) "Near misses", accidents, and occurrences (patients, visitors, and staff) shall be immediately
reported to Quality department in an incident reporting form.
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2) Identification Bands:
a) They shall be used when the patients are admitted in the hospital
b) The identification band shall be placed on the wrist of inpatients.
c) If the patient's medical condition prohibits the application of the identification band to the patient's
wrist or ankle, the identification band shall be attached to a visible part of the patient's body using
tape appropriate to the patient's condition/allergies.
d) If the Identification Band is removed by a staff member, then a new band shall be made,
identification re-confirmed, and the band placed on the patient.
e) Before a patient is transferred, the transferring nurse shall verify the identification band is in place.

3) Side Rails
a) Patients shall be placed in a bed that has functional side rails.
b) The following patients shall have side rails raised when unattended by staff:
i) Vulnerable patients
ii) Those given pre-op or pre-procedural medication.
iii) Patients on stretchers (unless equipped with safety belts)

4) Seizure Precautions:
a) Basic Precautions - In-patients with a history of seizure disorder shall be observed for.
i) Oral airway patency.
ii) Side rails shall be always up and bed shall be in low position.
b) High Risk Precautions - Patients admitted for active seizure disorder or who experience seizures
shall be observed while in hospital/clinic. Suction equipment shall be readily available for all such
patients.

5) Ambulation
a) Staff shall accompany all patients:
i) For initial ambulation after surgery,
ii) After procedures requiring sedation,
iii) After prolonged bed rest, and
iv) In other situations as deemed necessary and as ordered by the physician.

6) Transportation
a) Wheels of stretchers, wheelchairs, and beds shall be locked when a patient is lifted from or assisted
onto them.
b) Side rails shall be raised on stretchers, where no side rails exist, safety belts shall be fastened for
patients in wheel chairs.

7) Patient's Role in Promoting Safe Health Care:

Patients shall be encouraged to become an active, involved, and informed member of their health care team.
Listed below are ways that the patients may be encouraged to promote their own safety.

i) Patients shall be instructed to ask if they have questions about their health or safety.
ii) If the patient is scheduled for a surgery, the patient shall be asked to verify prior to the
procedure, the site/side of the body that will be operated on.
iii) If the patient's identity is not checked before medications are given, blood/blood products are
administered; blood samples are obtained or prior to an invasive procedure, the patient shall be
asked to remind the staff.
iv) Patients shall be instructed to adhere to the hospital’s ‘No Smoking Policy’.
v) Patients shall be instructed to follow the ‘Patients Responsibilities’.
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Hospital National Patient Safety Goals:

The purpose of the National Patient Safety Goals is to improve patient safety. The goals focus on problems in
health care safety and how to solve them.

1. Identify patients correctly:-

Use at least two ways to identify patients. For example, use the patient’s name and date of birth. This is
done to make sure that each patient gets the correct medicine and treatment. Make sure that the correct
patient gets the correct blood when they get a blood transfusion.

2. Improve staff communication:-

Get important test results to the right staff person on time.

3. Use medicines safely:-

Before a procedure, label medicines that are not labelled. For example, medicines in syringes, cups
and basins. Do this in the area where medicines and supplies are set up. Take extra care with patients who
take medicines to thin their blood. Record and pass along correct information about a patient’s medicines.
Find out what medicines the patient is taking. Compare those medicines to new medicines given to the
patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is
important to bring their up-to-date list of medicines every time they visit a doctor.

4. Prevent infection:-
Use the hand cleaning guidelines from the Centers for Disease Control and Prevention or the World
Health Organization. Set goals for improving hand cleaning. Use the goals to improve hand cleaning. Use
proven guidelines to prevent infections that are difficult to treat. Use proven guidelines to prevent infection
of the blood from central lines. Use proven guidelines to prevent infection after surgery. Use proven
guidelines to prevent infections of the urinary tract that are caused by catheters.

5. Identify patient safety risks:-

Find out which patients are most likely to try to commit suicide.

6. Prevent mistakes in surgery:-

Make sure that the correct surgery is done on the correct patient and at the correct place on the patient’s
body. Mark the correct place on the patient’s body where the surgery is to be done. Pause before the surgery
to make sure that a mistake is not being made

NOTE: - For the detailed patient safety issues refer the Patient Safety Programme.

Patient Safety Solution as per WHO:-

They come under the headings of:

1. Look-alike, sound-alike medication names

2. Patient identification
3. Communication during patient hand-overs
4. Performance of correct procedure at correct body site
5. Control of concentrated electrolyte solutions
6. Assuring medication accuracy at transitions in care
7. Avoiding catheter and tubing misconnections
8. Single use of injection devices and
9. Improved hand hygiene to prevent health care-associated infection
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The Patient Safety Solutions, a core programme of the WHO World Alliance for Patient Safety, brings
attention to patient safety and best practices that can reduce risks to patients. It ensures that interventions and
actions that have solved patient safety problems in one part of the world are made widely available in a form
that is accessible and understandable to all.

In the past 12 months, the WHO Collaborating Centre on Patient Safety (Solutions) has brought together
more than 50 recognized leaders and experts in patient safety from around the world to identify and adapt the
nine solutions to different needs. An international field review of the solutions was conducted to gather
feedback from leading patient safety entities, accrediting bodies, ministries of health, international health
professional organizations and other experts.

PSQ 2- THE ORGANISATION IMPLEMENTS A STRUCTURED QUALITY IMPROVEMENT

AND CONTINUOUS MONITORING PROGRAMME.

POLICY

a) Quality Coordinator is responsible for coordinating and implementing the quality improvement
programme.
b) ………………… is responsible to comply statutory requirements as per state and national laws.
c) The quality improvement programme is developed, implemented and maintained by a
multidisciplinary committee.
d) The quality improvement programme is comprehensive and covers all the major elements related to
quality assurance.
e) The quality improvement programme improves process efficiency and effectiveness.
f) The quality improvement programme identifies opportunities for improvement based on the review
at pre-defined intervals.
g) The quality improvement programme is reviewing and updating every year.
h) Audits are conducted at regular intervals as a means a continuous monitoring.
i) Mock drills to be conducted based on schedule and shall submit its result to safety committee as
part of improvement programme.
j) There is an established process in the organisation to monitor and improve the quality of nursing
care.
k) The organisation always tries to create an awareness to reduce energy consumption by displaying
awareness boards like ‘switch off lights and fan as and when required’, tight water taps properly etc.
l) The leaders at all levels in the organisation are aware of the intent of the patient safety and quality
improvement programme and the approach to its implementation.
m) Departmental leaders are involved in patient safety and quality improvement.
n) The management makes available adequate resources required for patient safety and quality
improvement programme.
o) Organisation earmarks adequate funds from its annual budget in this regard.
p) The management identifies organizational performance improvement targets.
q) The management uses the feedback obtained from the workforce to improve patient safety and
quality improvement programme.

PROCEDURE

Mission:
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Vision

Quality Policy:
 We, at Hospital are committed to quality through providing best medical care and services by credentialed
medical and paramedical professionals.
 The implementation of an effective quality system through ethical beliefs and practices, good corporate
governance, innovation, medical excellence and professionalism. The organization maintains the quality
standards committed through its state of the art technologies and facilities. The organization aims at continued
quality improvement through medical education, research, trainings and workshops.

Quality Management Committee: mentioned in 1st policy

PROCEDURE:
Approach to Designing, Measuring, Assessing and Improving Quality
Planning: Planning for the improvement of patient care and health outcomes includes a hospital-wide
approach
Designing: Processes, functions or services are designed effectively based on: Mission and vision of the
Hospital needs and expectations of patients, staff, and others.
Measurement: Data is collected for a comprehensive set of Quality measures. Data is collected as a part of
continuing measurement, in addition to data collected for priority issues. Data collection considers measures
of processes and outcomes. Data collection includes at least the following processes or outcomes:
 Patient assessment
 Diagnostic safety & quality
 Processes related to medication use
 Processes related to anesthesia
 Processes related to medical records content, availability and use
 Risk management activities
Assessment:
 The assessment process involves the relevant departments to draw conclusions about the need for
more intensive measurement.
 A systematic process is used to assess collected data in order to determine whether it is possible to
make improvement of existing processes, actions taken to improve the Quality Improvement
processes, and whether changes in the processes resulted in improvement.
 Collected data is assessed at least annually and findings are documented and are forwarded through
the proper channels.
 When assessment of data indicates, a variation in Quality, more intensive measurement and analysis
will be conducted and in addition, the department/service or team will reassess its Quality
measurement activities and re-prioritize them as deemed necessary.

Internal Communications:
 The management has defined and implemented an effective and efficient process for communicating
the Quality Policy, Objectives, Quality management requirements and accomplishments.
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 This helps the hospital to improve the performance and directly involves its people in the
achievement of the Quality Objectives.
 The Management actively encourages feedback and communication from people in the hospital as a
means of involving them through the following modes: - Monthly Meetings;
Documentation:
Quality Manual
This is an outline of …………..[healthcare facility] policies of …………….together with the Mission,
Vision and Values of …….[Hospital], Quality Policy and Patient Safety priorities. Quality Manual also
contains the structure and functions of the continuous quality improvement programme.
Quality Coordinator at ………..[Hospital] has the overall authority, responsibility and commitment to
communicate, implement, control and supervise the compliance of various departments with the accreditation
standards. The roles and responsibility of the Quality Coordinator include:
 Establishing and maintaining the Quality Improvement and Patient Safety Program.
 Document control.
 Schedule and conduct Internal Audits.
 Schedule and conduct of Management Review meeting.
 Ensuring corrective and preventive action arising from the above
Document Control:
Documents such as regulations, standards, and policies, SOPs, manuals and other normative documents as
well as drawings, software form part of the hospital Quality Management System.
A copy of each of these controlled documents is archived for future reference and the documents is retained
in their respective department. The documents are maintained in paper or electronic media as appropriately
required.
Documents are identified and established as Hospital Policies & Procedures as in Hospital Manual
The Heads of the Departments of the respective departments are review all documents issued to personnel as
a part of management system annually and they are approving it for the use. The Quality Coordinator issues
the finalized document.
The Quality Coordinator ensures that:
 Authorized editions of appropriate documents are available at all locations where operations essential
to the effective functioning of the hospital are performed.
 Documents are periodically reviewed and revised where necessary to ensure suitability and
compliance with applicable requirements.
 Invalid or obsolete documents are promptly removed from all prints of issue or use, or otherwise
assured against unintended use.
 Obsolete documents are retained for either legal and / or knowledge preservation purposes are
suitably marked or destroyed or the record and the record of this maintained in a separate register.
Document Changes:
 Revision of management systems documents is carried out when necessary by the original author and
updated at least once in two years.
 When alternate persons are designated for review, they shall first familiarize themselves with
pertinent background information upon which to base their review and approval.
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 Document control system does not follow for the amendments by hand unless there is an extreme
circumstance.
 These amendments are marked, initialed and dated only by the Head of the Department.
 The amendment are brought to the notice of the NABH coordinator and the same shall be reissued
Various Quality Assurance Programmes.
Data Capturing by the following methods
1. IP Feedback Analysis
2. IP & OP Patient Suggestion and Complaint Analysis
3. Internal Audits- Vertical & Horizontal Audits
4. External Audits
5. Incident Report
6. Quality Indicators
Root Cause Analysis: Deviations are detected by:
 Patient complaints/feedbacks.
 Non-compliance receipt of items/sample.
 Non-compliance at internal/external Quality Audit. Management Reviews.
 The Quality coordinator conducts and coordinates the detailed analysis of the nature and root cause
of non-compliance along with the responsible persons from the respective sections.
Corrective Action:
 The Quality Coordinator takes all necessary corrective action when any deviation is detected in
Quality Management System.
 Selection and Implementation of Corrective Actions: Potential corrective actions are identified
and the one that is most likely to eliminate the problem is chosen for implementation. Corrective
action is taken into consideration the magnitude and degree of impact of the problem. All changes
from corrective action is documented and implemented.
 Monitoring of Corrective Actions: The NABH Coordinator shall monitor the outcome parameters
to ensure that corrective actions taken have been effective in eliminating the problem
Preventive Actions:
 The Quality Coordinator shall be perpetually vigilant and identify potential sources of non-
compliance and areas that need improvement.
 These may include trend analysis of specific markers such as turnaround time, risk analysis, etc.
 Where preventive action is required, a plan is prepared and implemented.
 All preventive actions must have control mechanisms and monitor for efficacy in reducing any
occurrence of non-compliance or producing opportunities for improvement.
IP Patient Feedback Analysis
Collected IP feedback will be analyzed and submitted to Quality department on monthly basis.
IP & OP Patient Suggestion and Complaint Analysis
Complaints and suggestions are received from patients and the received complaints and suggestions are
analyzed by Administrator.
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Internal Audits- Vertical & Horizontal Audits

 Internal audit shall be conducted by the internal audit team members once in six months.
 Internal audit is of two types, vertical and horizontal. Vertical internal audit involves checking all
aspects of a quality system within a particular area, function or department and horizontal audit is the
performance of audit activities, process and evaluation to exactly the same to examine across the
different function or department. The purpose for performing horizontal audit is to examination and
observation whether there is the same standard of control to the different departments. Vertical audit
is done using a scheduled calendar and trained auditors will be assigned to conduct the same. Such
auditors will be privileged by quality committee.
 Internal audit team members shall be trained on NABH standards either internally (a trained person
who in turn trains the other members of the team) or externally (training conducted by Quality
Council of India).
 Audit starts with the opening meeting. All departmental heads shall be informed about the purpose of
audit, audit timings and duration of audit etc.
 All minor correction shall be suggested then and there by the auditor to the departmental staff.
 Audit gets over with the closing meeting, over all observations shall be summarized by the chief
auditor. Audit observations shall be handed over to the chairman of the quality assurance committee
in a standardized format.
 All the audit reports shall be discussed with the core committee members and the observations
noticed will be presented to the Administrator for improvements.
 The Audit reports shall be forwarded to the concerned Departmental Heads. Corrective and
preventive actions will be done by the department staff based on the audit observations. Reports of
the corrective and preventive actions will be submitted to the Quality department by the concerned
Head of the department.
External Audits
External audit is done with the help of any third party upon requirement

Incident Report
Any event Identify & Inform the Quality Root Cause Analysis with suggestions
found to be Categorize Department within 24 hours and recommendation by Quality /ICN.
an incident using incident report format Quality is responsible to prepare
Quality Department is Corrective/ Preventive Action in
responsible for root cause consultation with concerned
Near miss/ analysis within the 24hr Incharge/ Committee.
Incident/ preferably before the shift Administration is responsible for its
Adverse hand over implementation.
Event/
Monitoring of action plan by Quality
Sentinel
Event
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PSQ 3- THE ORGANISATION IDENTIFIES KEY INDICATORS TO MONITOR THE

STRUCTURES, PROCESSES AND OUTCOMES, WHICH ARE USED AS TOOLS FOR
CONTINUAL IMPROVEMENT.

POLICY

a) The organisation identifies and monitors key indicators to oversee the clinical structures, processes
and outcomes.
b) The organisation identifies and monitors key indicators to oversee infection control activities.
c) The organisation identifies and monitors key indicators to oversee the managerial structures,
processes and outcomes.
d) The organisation identifies and monitors key indicators to oversee patient safety activities.
e) The organisation has a mechanism to capture patient reported outcome measures.
f) Verification of data is done regularly by the quality team.
g) There is a mechanism for analysis of data which results in identifying opportunities for
improvement.
h) The improvements are implemented and evaluated
i) Feedback about care and service is communicated to staff.

PROCEDURE
Quality Indicators that are monitored in the Hospital
Procedure for collection of data, interpretation and analysis of Quality Indicators:
 Collection of Data: Reports of all key indicators as decided by the management will be submitted to
the quality coordinator at the end of every month by the Head of each department. All the data will
be collected in the standardized format.
 Analysis of Data: All the data will be assessed in the form of Structure, process and the outcome.
 Structure: Structure includes the facilities provided to the staff. Formula used for calculation.
Training or awareness of the set formulas / quality improvement programme.
 Process: Strict adherence of developed procedures in the daily work routine. In case of deviations
same will be documented in the quality indicator reporting form with proper reasoning.
 Outcome: Based on the reports received trend analysis will be done and the same will be reported to
the Administrator.
Sl. Indicator Formula Depart Sampl Objective Data
No ments e size capturing
method
1. Time for initial Sum of time taken/ Total number of MRD/ 100% Reduce Admission
assessment of patients Casualty initial register
indoor patient assessment
time to less
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than 5
minutes.
2. Number of Number of reporting Laborat 100% Reduce Reporting
reporting errors errors X 1000 ory/Radi error below error
per 1000 ology 3% register
Number of test performed
investigations
3. Percentage of Number of staff adhering Laborat 100% Achieve Safety
adherence to to safety precautions X 100 ory/Radi 100% audit
safety ology
Number of staff audited
precautions by
staff working in
diagnostics
4. Medication Total number of Nursing/ 100% 90% Medication
errors rate medication errors initially error audit
Pharmac
Total number of X 100 ist
opportunities of
medication errors
5. Percentage of Number of Medication Nursing/ 100% 90% Medication
medication chart charts with error prone initially error audit
Pharmac
with error -prone abbreviation(s) X 100 ist
abbreviations
Number of medication
chart reviewed
6. Percentage of in- Number of patients Nursing/ 100% Reduce to Admission
patients with developing adverse drug 5% Register
Pharmac
adverse drug reactions
X 100 ist
reaction (s)
Number of in patients

7. Percentage of Number of unplanned Nursing 100% 0% OT

unplanned return return to OT Register
to OT
Number of patients who
X 100
underwent surgeries in
OT

8. Percentage of Number of surgeries Nursing 100% 100% Surgical

surgeries where where the procedure was safety
the followed checklist
organisation’s X 100 from active
Number of surgeries
procedure to file audit
performed
prevent adverse
events like
wrong site,
wrong patient
and wrongs
surgery have
been adhered to.
9. Percentage of Number of transfusion X 100 Blood 100% less than Transfusio
transfusion 2% n reaction
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reactions reactions bank including form

major and
Number of units
minor
transfued
reactions
due to
improper
care
10. Standardised Actual deaths in ICU ICU 100% Nil Death
Mortality Ratio register
Predicted deaths in ICU X 100
for ICU

11. Return to the Return to the emergency Casualty 100% Nil Initial
emergency department within 72 assessment
department hours with similar form
within 72 hours presenting complaints
with similar X 100
Number of patients who
presenting
have come to the
complaints
emergency.

12. Incidence of Number of patients who Nursing 100% Less than Bundle
hospital develop new/worsening 2% checklist
associated of pressure ulcer
X 1000
pressure ulcers
Total no.of patient days
after
admission( Bed
sore per 1000
patient days)
13. Catheter Number of urinary ICD 100% Less than Bundle
associated catheter associated UTIs 2% checklist
Urinary tract in a month
infection rate
Number of urinary X 1000
catheter days in that
month

14. Ventilator Number of ‘ Ventilator ICD 100% Less than Bundle

associated associated Pneumonia’ in 2% checklist
Pneumonia rate a month
X 1000
Number of ventilator
days in that month

15. Central line- Number of ‘ Central X 1000 ICD 100% Less than Bundle
associated Blood line- associated Blood 2% checklist
stream infection stream infection’ in a
rate month
Number of central line
days in that month
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16. Surgical site Number of surgical site

infection rate infections in a given Reduce SSI
month Bundle
X 100 ICD 100% to below
checklist
Number of surgeries 2%
performed in that month
17. Hand hygiene Total number of Hand ICD 100% 90% Hand
compliance rate hygiene actions compliance hygiene
performed X 100 initially to observation
achieve form
Total number of hand
hygiene opportunities
18. Percentage of Number of patients who did OT 100% 100% OT register
cases who receive appropriate
appropriate prophylactic antibiotic(s)
prophylactic X 100
Number of patients who
antibiotics with
underwent surgeries in the
in the specified
OT
timeframe
19. Percentage of re- Number of cases re- OT 100% 0% OT register
scheduling of scheduled
surgeries X 100
Number of surgeries
performed
20. Turnaround time Sum of time taken Blood 100% Bloodbank
for issue of blood bank register
Total number of blood and
and blood
blood components cross-
components
matched/reserved
21. Nurse –patient Number of nursing staff Nursing 100% 95% of Attendance
ratio for ICUs correlation
Number of occupied beds
and wards
22. Waiting time for Sum total patient-in time for Nursing 100% Maximum Op waiting
out-patient consultation 1 hr time
consultation monitoring
Total number of out-patients
register
23. Waiting time for Sum total of patient reporting Laborat 100% Maximum waiting
diagnostics time ory/Radi 1 hr time
ology monitoring
Number of patients reported
register
in Diagnostics
24. Time taken for Sum of time taken for Nursing 100% Maximum Admission-
discharge discharge 3hr Discharge
register
Number of patients
discharged
25. Percentage of Number of medical records X 100MRD 100% 0% Active file
medical records having incomplete and /or audit
having improper consent
incomplete
Number of discharges and
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and/or improper deaths

consent
26. Stock out Rate Number stock outs of Pharmac 100% Reduce Stock out
of emergency emergency drugs y below 2% register
X 100
medications
Number of drugs listed in
hospital formulary
27. Number of Total number of variations in a mock Quality 100% Variation Mock drill
variations drill should be report
observed in less than
mock drills 5%
28. Patient fall rate Number of falls Nursing 100% Less than Incident
( falls per 1000 2% report
Total number of patient X 1000
patient days)
days
29. Percentage of Number of near misses Quality 100% Report Incident
near misses reported maximum report
X 100
Total number of
incidents reported
30. Incidence of Number of parenteral ICD 100% Reduce Incident
needle stick exposures needle report
X 1000
injuries stick injury
Number of in-patient days
to 2%

31. Appropriate Total number of Nursing/ 100% 100% Active file

handovers during handovers done HR audit
X 100
shift change( To appropriately
be done
Total number of
separately for
handover opportunities
doctors and
nurses)-(per
patient shift)

32. Compliance rate Total number of Pharmac 100% 80% to Prescriptio

to medication prescriptions in capital y achieve n audit
X 100
prescription in letters initially
capitals
Total number of
prescriptions
33. Incidence of (Total number of dispensing error/ Pharmac 50% Reduce to Incidence
dispensing error Number of sample) * 100 y 3% of
Prescriptio
n error

PSQ 4- THE ORGANISATION USES APPROPRIATE QUALITY IMPROVEMENT TOOLS FOR

ITS QUALITY IMPROVEMENT ACTIVITIES.

POLICY
a) The organisation undertakes quality improvement projects.
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b) The organisation uses appropriate analytical tools for its quality improvement activities.
c) The organisation uses appropriate statistical tools for its quality improvement activities.
d) The organisation uses appropriate managerial tools for its quality improvement activities.

PROCEDURE
Quality assurance programme applicable hospital wide

Purpose Methodology Responsibility

Setting goals and objectives Setting of mission, vision, objectives, Quality Committee
quality policy and service standards through
committee discussion and approval of
Medical Director
Infrastructure Identifying infrastructural requirement Hospital Administration and
including State government

 Physical facility
 Manpower
 Equipments

This is determined on the basis of workload

and change in scope of service
Policies, procedures and This documentation is done to develop Various committees, Quality
other documentation systems and processes that are necessary to coordinator and Medical
requirement provide uniform service of desired level of Director
quality and communicate it to relevant
personnel. Refer control of documents
Walk through monitoring Walk through monitoring or physical Medical Director, Quality
monitoring is done by designated member coordinator, Nursing
from various committees and teams. superintendent, ICN,
Following aspects are specially looked for Clinical Pharmacist, Safety
Officer, MRD Inchargeetc
 Infection control
 Hospital safety
 Record maintenance
 Policy compliance

Indicator monitoring A list of indicators has been developed to Quality committee

monitor the key features necessary for
quality assurance. These are developed for
structure, process, clinical and managerial
activities. A monthly report is generated
with all these indicators which is reviewed
for necessary action by Quality committee
Training and orientation Necessary instructions to the staff for HRD
quality assurance are communicated through
their departmental incharges. Quality
Assurance is also included as one of the
training needs, on which training is
organized at regular intervals
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Applicable for infection control

Purpose Methodology Responsibility Remark

Surveillance and Infection control nurse shall do daily Infection This data shall be
collection of data related surveillance of the hospital and record control nurse presented to
to hospital acquired the patients infections in the hospital Hospital
infections infection control
committee for
analysis
Urinary tract infections Urine of all symptomatic catheterized Treating Infection control
patient shall be sent for culture physician nurse and
hospital Infection
control
committee shall
be vigilant about
this.

Respiratory tract All patients on the ventilator having Treating Infection control
infections clinical feature suggestive of infection physician nurse and
shall have their sputum or hospital Infection
ET/tracheostomy secretions (obtained control
using a suction catheter) or committee shall
ET/tracheostomy tip or protected be vigilant about
specimen brusing (PSB) or mini this
bronchoalveolar lavage (BAL) for
culture.

Intra-vascular device For patients with symptoms Treating Infection control

infections suggestive of intra-vascular device physicians nurse and
infection and having central line the hospital Infection
same shall be done by sending the tip control
for culture. For all peripheral lines committee shall
clinical evidence of thrombophlebitis be vigilant about
woul suffice. this
Surgical site infections. Pus / swab of such patients shall be Treating Infection control
sent for culture. physician nurse and
hospital Infection
control
committee shall
be vigilant about
this

ICU

Applicable to Intensive care department

S. Key Characteristics Acceptance Norms / Responsibility And Frequency

No. Criteria Conformance
Verification
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1 Infection control and Swab culture ICU in charge / staff Once in a

sterility of ICU month

2 Monitoring and  Functional status ICU in charge / Monthly/ as and

measurement of life check. Biomedical when required
saving equipment and  Calibration –
other equipments Yearly/as and when
required
 AMC/Preventive
Maintenance – Yearly/as
and when required

OT

Applicable to surgical services department

S. No. Key Acceptance Norms / Criteria Responsibility And Frequency

Characteristics Conformance
Verification
1. Complete pre-  Part preparation O.T. Staff As and when
operative  Nail polish removing. required
preparation before  Removal of all ornaments. Anesthesiologist
patient is shifted to  Consent for procedure
O. T  Change of clothes.

2. Infection Control  Daily carbolization OT incharge/ O.T. Once in a

and sterility of O.  Monthly air culture Staff/ week
T  Monthly swab culture Anaesthesiologist
 Weekly fumigation
 Hypochlorite treatment of
infected linen/ instruments
for 3 – 4 hrs before
autoclaving.

LABORATORY

Applicable to laboratory services

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S. No. Key characteristics Acceptance norms / Responsibility and Frequency

criteria conformance verification.

1. Internal Quality Control Daily surveillance of a Laboratory In-charge / Daily

of tests sample of test results& Technician
Precision
2. Test Calibration 1) As per the Lab In-Charge / Required
manufacturer’s Technician time
instruction.
2) Control out of range

3 Daily Maintenance of Compliance as per Technician Daily

Lab Equipments standards,
&Manufacture’s
manuals
4 Timely intimation of Within ½ hour Technician Daily
critical results
5 External Quality Control Surveillance of a Laboratory In-charge / Monthly
sample of test results& Technician
Accuracy
6 Daily washing of Clean glassware House Keeping Staffs Weekly
equipments with
methanol and distilled
water.
7 Calibration of As per the Biomedical / Engineer Every 6
Equipments manufacturer’s months/
instruction. 1year
8 Tests to be done on Proper covering of Technician Daily
fresh specimens sample with lid
received in containers
with lids.
9 Preparation of media Sterility Technician Weekly
under strict aseptic
precautions
10 Checking of gas cylinder Offensive smell Daily
for any leakage
11 In-house staff training Monthly Lab Staffs Monthly
12 Equipment Training As per the Biomedical / Engineer While the
manufacturer’s time of a new
instruction. technician
joined.

PSQ 5- THERE IS AN ESTABLISHED SYSTEM FOR CLINICAL AUDIT.

POLICY
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a) Clinical audits are performed to improve the quality of patient care.

b) The parameters to be audited are audited are defined by the organisation.
c) Medical and nursing staff participate in clinical audit.
d) Patient and staff anonymity are maintained.
e) Clinical audits are documented.
f) Remedial measures are implemented.

PROCEDURE
Patient care services of the hospital shall be assessing on regular basis by members of Quality Assurance
Committee, which consists of multidisciplinary members of the hospital.

The committee members shall go on round of the hospital both clinical as well as supportive services of the
hospital and find out the things are in proper manner or not. Any issues arises shall be discuss in the
committee’s meeting.

The committee shall meet on monthly basis and discuss the issues related to problem in the patient care
services and make a unanimous decision to solve the problems.

The committee shall also find way to improve the quality of patient care services in the hospital.

The hospital shall hold a patient care review meeting every month to discuss the patient care services carried
out by the hospital. The main objective of this meeting shall be
 To review the overall work carried out in the departments including outpatient department, inpatient
department and also emergency department
 To discuss the institutional death of the previous month
The attendees of this meeting shall be
The meeting shall be presided by the Chief Executive Officer. All audits are documented. All the
important points of discussion shall be taken care of during initiation of any corrective or preventive actions.
In the process of Clinical audit name of the patients and the hospital staff who conducted the clinical audit
not be disclosed in public discussions and conference.
 Medical director (committee chairman)
 DNS (committee convenor)
 Members as follows
o Quality coordinator
o ICN
o Consultants from concerned Dept.
o Nurses from concerned Dept.
o MRD Incharge
o HOD from concerned Dept.
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The hospital shall follow the following parameter for auditing the patient care services:-

Part - I

Identification data for inpatient to whom this case sheet pertains:

1 Registration No
2 Month of admission
3 Ward no
4 Bed No
5 Diagnosis on admission
6 Final diagnosis
7 No of days in hospital
8 "Disposal –
(Discharge/Expired/LAMA/Transferred)"

Part - II

Particulars of Clinician treating the case

1 Specialty
2 Status (Fulltime, part time, honorary)

Part - III

Relating to the records

1 Are the assessments of patients done adequately?

2 Are the records duly named, signed, dated and timed by the concerned
doctors?
3 Are history, physical examination, diagnosis and treatment details available?
4 Are the laboratory and radiographic reports attached and entered in the record at appropriate place?
5 Are the progress notes sufficient and relevant that the clinical course can be followed?
6 Has the discharge summary prepared appropriately?

Relating to Diagnosis

7 Whether a provisional diagnosis was made and endorsed after the admission?

8 Whether the provisional diagnosis tallies with the final diagnosis?

9 Whether laboratory findings support final diagnosis?

10 Whether radiological findings support final diagnosis?
11 Are laboratory investigations sufficient in relation to nature and gradient of illness?

12 Was any laboratory investigation unnecessarily asked for?

13 Was any radiological examination superflous?

14 Was any radiological examination indicated and yet not asked for?
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15 Whether the preoperative diagnosis tallies with the post-operative diagnosis?

16 Was there any avoidable delay in arriving at the diagnosis?

Relating to treatment

17 Are the operation notes adequate?

18 Are the anesthesia notes adequate?
19 If the case required consultation by other specialists, was the same sought for?
20 Was the treatment given generally acceptable or open to question?
21 Whether the overall treatment given to the patient can be judged from the data endorsed in the
medical record?
22 Whether the clinician exceeded the privilege or limits of his or her training and competence?
23 Whether there was adequate indication for surgery?
24 Whether any normal organ or tissue removed?
25 Whether any part of the treatment given was superfluous?
26 Whether the patient refusal to undergo a prescribed treatment was justifiable?

Relating to End result

27 Was the final result in consonance with the nature of the case and expected prognosis?

28 In case of death, whether it was expected, justifiable or not?

29 Were the complications justifiable or not?

Relating to Complications and Cross-infection

30 Whether there was any hospital cross infection which could have been avoided?

31 Whether there was postoperative infection which can be avoided?

32 Whether there was a complication because of faulty surgical operation?

33 Whether there was postoperative complication which could have been avoided?

34 Whether there was any anesthetic complication which could have been avoided?
Relating to Operation cases
35 Was consent for anesthesia and operation obtained?
36 Was there adequate indication for surgery?
37 Was any normal tissue removed and if so was it justified?

38 Was pre anesthetic assessment for anesthesia done and recorded?

Relating to the Length of Stay of Patient

39 Was there any inordinate delay between admission and surgical operation?

40 Whether there was inordinate delay between admission and commencement of Specific/definitive
treatment?
41 Whether there was inordinate delay between admission and ordering of Laboratory or radiological
investigations?
42 Whether there was inordinate delay in arriving at final diagnosis?
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43 Was the length of stay of the patient in hospital longer than was really necessary?

44 Did he or she develop any ailment during stay in hospital necessitating longer stay?

Relating to Post event analysis

45 Whether post event analysis of CPR conducted and recorded?

46 Whether post event analysis of blood transfusion conducted and recorded?

47 Whether post event analysis of adverse drug event conducted and recorded?

NURSING AUDIT:

Introduction

 Nursing audit is a review of the patient record designed to identify, examine, or verify the performance
of certain specified aspects of nursing care by using established criteria.
 Nursing audit is the process of collecting information from nursing reports and other documented
evidence about patient care and assessing the quality of care by the use of quality assurance programmes.
 Nursing audit is a detailed review and evaluation of selected clinical records by qualified professional
personnel for evaluating quality of nursing care.
 A concurrent nursing audit is performed during ongoing nursing care.
 A retrospective nursing audit is performed after discharge from the care facility, using the patient's
record.

Meaning:

1. Quality - a judgement of what constitutes good or bad.

2. Audit - a systematic and critical examination to examine or verify.

3. Nursing audit -

(a) It is the assessment of the quality of nursing care

(b) Uses a record as an aid in evaluating the quality of patient care.

4. Medical audit - the systematic, critical analysis of the quality of medical care, including the procedures for
diagnosis and treatment, the use of resources, and the resulting outcome and quality of life for the patient.

Definition:

I. According to Elison "Nursing audit refers to assessment of the quality of clinical nursing".

II. According to Goster Walfer

 a. Nursing Audit is an exercise to find out whether good nursing practices are followed.
 b. The audit is a means by which nurses they can define standards from their point of view and
describe the actual practice of nursing.

III. Nursing audit is defined as:

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It is a part of the cycle of quality assurance. It incorporates the systematic and critical analysis by nurses,
midwives and health visitors, in conjunction with other staff, of the planning, delivery and evaluation of
nursing and midwifery care, in terms of their use of resources and the outcomes for patients/clients, and
introduces appropriate change in response to that

Purposes of Nursing Audit

1. Evaluating Nursing care given,

2. Achieves deserved and feasible quality of nursing care,

3. Stimulant to better records,

4. Focuses on care provided and not on care provider,

5. Contributes to research.

Methods of Nursing Audit

There are two methods:

a. Retrospective view - this refers to an in-depth assessment of the quality after the patient has been
discharged, have the patients chart to the source of data.

Retrospective audit is a method for evaluating the quality of nursing care by examining the nursing care as it
is reflected in the patient care records for discharged patients. In this type of audit specific behaviours are
described then they are converted into questions and the examiner looks for answers in the record. For
example the examiner looks through the patient's records and asks:

a. Was the problem solving process used in planning nursing care?

b. Whether patient data collected in a systematic manner?

c. Was a description of patient's pre-hospital routines included?

d. Laboratory test results used in planning care?

e. Did the nurse perform physical assessment? How was information used?

f. Were nursing diagnosis stated?

g. Did nurse write nursing orders? And so on.

b. The concurrent review - this refers to the evaluations conducted on behalf of patients who are still
undergoing care. It includes assessing the patient at the bedside in relation to pre-determined criteria;
interviewing the staff responsible for this care and reviewing the patient’s record and care plan.

Method to Develop Criteria:

1. Define patient population.

2. Identify a time framework for measuring outcomes of care,

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3. Identify commonly recurring nursing problems presented by the defined patient population,

4. State patient outcome criteria,

5. State acceptable degree of goal achievement,

6. Specify the source of information.

7. Design and type of tool

Points to be remembered:

a. Quality assurance must be a priority,

b. Those responsible must implement a programme not only a tool,

c. A co-ordinator should develop and evaluate quality assurance activities,

d. Roles and responsibilities must be delivered,

e. Nurses must be informed about the process and the results of the programme,

f. Data must be reliable,

g. Adequate orientation of data collection is essential,

h. Quality data should be annualized and used by nursing personnel at all levels.

Advantages of Nursing Audit:

1. Can be used as a method of measurement in all areas of nursing.

2. Seven functions are easily understood,
3. Scoring system is fairly simple,
4. Results easily understood,
5. Assesses the work of all those involved in recording care,
6. May be a useful tool as part of a quality assurance programme in areas where accurate records of
care are kept.

Disadvantages of the Nursing Audit:

1. Appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing
process has not been implemented,
2. Many of the components overlap making analysis difficult, is time consuming,
3. Requires a team of trained auditors,
4. Deals with a large amount of information,
5. Only evaluates record keeping. It only serves to improve documentation, not nursing care

9.0 REFERENCES: Nil

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10.0 RECORDS AND FORMATS:

Record of Quality Assurance Committee meetings

PSQ 6- THE PATIENT SAFETY AND QUALITY IMPROVEMENT PROGRAMME ARE

SUPPORTED BY THE MANAGEMENT

a) The management creates a culture of safety

b) The leaders at all levels are aware of the intent of the patient safety and quality improvement
programme and the approach of the implementation.
c) Department leaders are involved in patient safety and quality improvement
d) The management makes available adequate resources required for patients safety and quality
improvement programme
e) Organisation earmarks adequate fund from its annual budget in this regard.
f) The management identifies organisational performance improvement targets
g) The management uses the feedback obtained from the workforce to improve patient safety and
quality improvement programme.

PROCEDURE

 As part of developing safety culture at Sunrise hospital, safety officer is responsible to conduct safety
attitude audit at least every 6 months on a random basis and will submit its report to Manager HR to
conduct safety training programmes. Self-reporting of incident will be appreciated
 Safety trainings will be done more frequently and topic will be given to department heads ensure
more involvement.
 Department heads are responsible to report to safety officer if they identified any new/ existing near
miss hazards. Use incident reporting format for the same.
 Management is responsible to maintain annual safety budget and also to provide adequate resources
based on audit reports/ incident reports etc and also the suggestion received from safety committee.
 Safety committee (refer safety manual) to conducted periodically and department targets should be
reviewed on monthly basis.
 Safety officer is responsible to conduct staff survey using a questionnaire to improve safety aspects
at their working area and shall submit its report to committee for corrective and preventive action.

PSQ 7- INCIDENTS ARE COLLECTED AND ANALYSED TO ENSURE CONTINUAL QUALITY

IMPROVEMENT

POLICY
h) The organisation implements an incident management system.
i) The organisation has a mechanism to identify sentinel events.
j) The organisation has established process for analysis of incidents.
k) Corrective and preventive actions are taken based on the findings of such analysis.
l) The organisation incorporates risks identified in the analysis of incidents in to the risk management
system.
m) The organisation shall have a process for informing various stakeholders in case of a near miss/
adverse event/sentinel event.

PROCEDURE
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INCIDENT REPORTING
Types of incidents
 No harm
 Near Miss
 Adverse event
 Sentinel event
Process:
 Encourage self-reporting of any issues. A feedback on the report will be given to the concerned to
promote discussion and follow up within a week.
 Department Heads and In-charges will be responsible to ensure reporting incident.
 Incident form should be made available at all nursing stations and departments
 Incident form to be filled by the person reporting with the following details in short
 What happened
 When happened
 Where it happened
 By whom
 How happened
 Why happened (Route Cause Analysis)
 Corrective action/ immediate action taken from their side.
 If possible, Incharge can suggest/ take preventive action and should document it.
 All completed incident reports should reach the Quality Department within 24 hours of the event.
 Responsibility of Quality team
 Investigate why happened (Route Cause Analysis) is correct as reported.
 Collect explanation from person by whom it happened.
 Adequate corrective & preventive actions taken to eliminate it.
 Administrational issue- If not satisfied with the corrective & preventive actions taken then forward to
Administrator for action/ advice within next 24 hours.
 Medical issue- If not satisfied with the corrective & preventive actions taken then forward to Medical
Director for action/ advice within next 24 hours.
 Forward all training requirement which is suggested in Incident report to HR and copy to Managing
Director. HR is responsible to coordinate the training.
 Forward all incident reports with which no actions taken yet to concerned committee convenor.
Concerned committee convenor is responsible to take it as agenda and to present it in the meeting.
 Committee’s decision not addressed within expected date of completion as mentioned in minutes,
then forward it to Managing Director.