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Yearly (2008-12) Progress Report of Quality Improvement Programme

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Title: Yearly (2008-12) Progress Report of Quality Improvement Programme


1
Yearly (2008-12) Progress Report of Quality
Improvement Programme
  • Dr ...
  • Head of the Institute
  • Medical College Hospital / Dental Hospital /
  • Mental Hospital / Paraplegia Hospital / District
    Hospital /
  • Community Health Center / Primary Health Center
  • Government of Gujarat
  • Email-
  • Mobile No

2
Financial Progress Report(Expenditure with
Utilization Certificate)
3
Financial Progress Report (Yr 2008-12)
S. No. Year Total Grant Received (NRHM) Rs. Total Grant Received (State) Rs. Grant Total (NRHM State) Rs. Total Expenditure Rs. Total Settlement with UC Rs.
1 2008-09
2 2009-10
3 2010-11
4 2011-12
Total Total
4
Financial Progress ReportInfrastructure Detailed
Year 2008-2012
5
Financial Progress ReportInfrastructure Detailed
Year 2008 - 09
S. No. Detailed of Infrastructure Amt. Rs.









6
Financial Progress ReportInfrastructure Detailed
Year 2009 - 10
S. No. Detailed of Infrastructure Amt. Rs.









7
Financial Progress ReportInfrastructure Detailed
Year 2010 - 11
S. No. Detailed of Infrastructure Amt. Rs.









8
Financial Progress ReportInfrastructure Detailed
Year 2011 - 12
S. No. Detailed of Infrastructure Amt. Rs.









9
Financial Progress ReportManpower Detailed Year
2008-2012
10
Financial Progress ReportManpower Detailed Year
2008-09
S. No. Detailed of Manpower Amt. Rs.









11
Financial Progress ReportManpower Detailed Year
2009-10
S. No. Detailed of Manpower Amt. Rs.









12
Financial Progress ReportManpower Detailed Year
2010-11
S. No. Detailed of Manpower Amt. Rs.









13
Financial Progress ReportManpower Detailed Year
2011-12
S. No. Detailed of Manpower Amt. Rs.









14
Financial Progress ReportInstrument Equipment
Detailed Year 2008-2012
15
Financial Progress ReportInstrument Equipment
Detailed Year 2008-09
S. No. Detailed of Instrument Equipment Amt. Rs.









16
Financial Progress ReportInstrument Equipment
Detailed Year 2009-10
S. No. Detailed of Instrument Equipment Amt. Rs.









17
Financial Progress ReportInstrument Equipment
Detailed Year 2010-11
S. No. Detailed of Instrument Equipment Amt. Rs.









18
Financial Progress ReportInstrument Equipment
Detailed Year 2011-12
S. No. Detailed of Instrument Equipment Amt. Rs.









19
Financial Progress ReportTraining Detailed Year
2008-2012
20
Monthly Financial Progress ReportTraining
Detailed year 2008-09
S. No. Detailed of Training Amt. Rs.









21
Monthly Financial Progress ReportTraining
Detailed year 2009-10
S. No. Detailed of Training Amt. Rs.









22
Monthly Financial Progress ReportTraining
Detailed year 2010-11
S. No. Detailed of Training Amt. Rs.









23
Monthly Financial Progress ReportTraining
Detailed year 2011-12
S. No. Detailed of Training Amt. Rs.









24
Financial Progress ReportOperational Detailed
Year 2008-2012
25
Monthly Financial Progress Report Operational
Detailed Year 2008-09
S. No. Detailed of Operational Amt. Rs.









26
Monthly Financial Progress Report Operational
Detailed Year 2009-10
S. No. Detailed of Operational Amt. Rs.









27
Monthly Financial Progress Report Operational
Detailed Year 2010-11
S. No. Detailed of Operational Amt. Rs.









28
Monthly Financial Progress Report Operational
Detailed Year 2011-12
S. No. Detailed of Operational Amt. Rs.









29
Committee Quality Improvement Programme
Committee
30
Overall Functioning of All Committees
Committees shall meet regularly and shall determine the next date of meeting at every meeting
Agenda of the meeting (as per their scope) shall be determined beforehand and shall be communicated to all members of the committee
Committees shall discuss, analyze, take a unanimous decision and communicate the decision for implementation to appropriate department / personnel
Chairman and convener of the committee shall bear the responsibility of committee functioning
Each committee shall determine the protocols of committee functioning and all committee members shall abide by it. A copy of committee protocols shall be kept in committee file
Each committee shall maintain records of proceedings in committee meet in the form of minutes of the meeting (MoM). The records shall be maintained in chronological order in committee file.
31
Overall Functioning of All Committees
If a detailed analysis of specific agenda under consideration is carried out a record of same shall be maintained separately and filed in committee file.
It is advisable that a specific member of the committee shall be given the responsibility of maintaining all the records of committee functioning and communicate it to concerned personnel in the organization.
Committees shall monitor the implementation of decision taken through physical monitoring / assessments / review etc.
Hospital and staff are obliged to follow the instructions.
Committee shall review their functioning at appropriate intervals, as decided by chairman of the committee, to assess their functioning
32
Functioning of the Committees
S. No. Name of the Committee Functioning (Yes / No) Fix interval of Meeting No. of Meeting Planned No. of Meeting Conducted
1 QUALITY IMPROVEMENT COMMITTEE
2 HOSPITAL SAFETY COMMITTEE
3 INFECTION CONTROL COMMITTEE
4 INFECTION CONTROL TEAM
5 MEDICAL AUDIT COMMITTEE
6 Clinical risk management Adverse drug event committee
7 Clinical audit committee
8 GRIEVANCE REDRESSAL COMMITTEE
9 Sexual harassment committee
10 PHARMACOTHERAPEUTIC COMMITTEE
11 Disaster management committee EMERGENCY PREPAREDNESS COMMITTEE (FIRE NON FIRE)
12 HOSPITAL ETHICS COMMITTEE
33
Progress of Quality Improvement Committee
34
Progress of Quality Improvement Committee
Scope of Work Function of the Committee
Discuss, decide and Issue hospital Policies related to hospital operations and accreditation. This committee shall have representation from management, various clinical and support departments of the Health Care Organization (HCO). The various quality improvement program shall be developed, implemented and maintained in a structured manner.
Documentation and review of policies This committee should have good knowledge of accreditation standards, statutory requirements, hospital quality assurance principles and evaluation methodologies, hospital functioning and operations.
Define scope of services This shall incorporate the mission, vision, quality policy, quality objectives, service standards, etc.
Define and develop quality parameters for clinical and non-clinical activities Quality assurance manual has to be prepared and updated periodically.
Set standards and benchmarks for quality parameters The organization shall ensure that the practices are in consonance with good clinical practices.
Function as apex committee for monitoring performance indicators / parameters of QMS and medical statistics As quality improvement is a dynamic process, it needs to be reviewed at regular pre-defined intervals (as defined by the HCO in the quality assurance manual) by the multi-disciplinary committee. The review shall also include analysis of key indicators as defined by the standards.
Standardization of professional procedures and equipment Hospital management makes available adequate resources required for quality improvement program.
Credentialing and Privileging This shall include the men, material, machine and method. These should be in steady supply so as to ensure that the program function smoothly.
Frequency of Meeting Monthly
35
Progress of Quality Improvement Committee
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

36
Progress of HOSPITAL SAFETY COMMITTEE
37
Progress of HOSPITAL SAFETY COMMITTEE
Scope of Work Function of the Committee
Develop and issue Policy on patient, staff, and visitor safety and security The committee will ensure the total hospital safety security.
Develop and issue Policy on patient, staff, and visitor safety and security The committee will bring to the notice of the administration, any gaps observed for the safety and security of hospital staff the patients and their attendants.
Monitor training and implementation A well documented lab safety manual is available in the lab. This takes care of the safety of the workforce as well as the equipment available in the lab.
Monitor training and implementation Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery.
Monitor occupational health and safety Policies and procedures guide the use of medical gases.
Monitor occupational health and safety Sentinel events are intensively analyzed and actions should be taken upon the analysis.
Monitor occupational health and safety The organization has an interdisciplinary group assigned to oversee the hospital wide safety program.
Frequency of Meeting Monthly
38
Progress of HOSPITAL SAFETY COMMITTEE
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

39
Progress of INFECTION CONTROL COMMITTEE
40
Progress of INFECTION CONTROL COMMITTEE
Scope of Work Function of the Committee
Document and issue infection control manual including policies The hospital has a multi-disciplinary infection control committee.
Training for infection control The organization has a well-designed, comprehensive and coordinated hospital infection control (HIC) programme aimed at reducing/eliminating risks to patients, visitors and providers of care.
Surveillance for compliance with policies The hospital has an infection control manual, which is periodically updated. Hospital defines the periodicity of updation.
Issue antibiotic policy The hospital infection control programme is documented.
Monitor Hospital acquired infection The manual should clearly identify the high risk areas of the hospital e.g. ICU, HDU, OT, post-operative ward, blood bank, CSSD, etc.
Outbreak control Proper facilities and adequate resources are provided to support the infection control program.
Monitor biomedical waste management practices The hospital is authorized by prescribed authority for the management and handling of bio-medical waste.
Monitor biomedical waste management practices The organization shall ensure that ensure the sterilization procedure is regularly monitored and in the eventuality of a breakdown it has a procedure for withdrawal of such items.
Frequency of Meeting Monthly
41
Progress of INFECTION CONTROL COMMITTEE
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

42
Progress of INFECTION CONTROL TEAM
43
Progress of INFECTION CONTROL TEAM
Scope of Work Function of the Committee
Surveillance for infection control The hospital should have an infection control team.
Data collection on hospital acquired infections The team is responsible for day-to-day functioning of infection control program. They shall support surveillance process and detect outbreaks.
Calculation of HAI rates They shall also participate in infection prevention and control on a day-to-day basis.
On job training of healthcare staff on infection control practices The hospital has designated and qualified infection control nurse for this activity.
Develop report on HAI trends The Infection control team will work together with infection control committee and bring to their notice if any issues have seen related to infection.
Monitor infection control practices The Infection control team will work together with infection control committee and bring to their notice if any issues have seen related to infection.
Frequency of Meeting Every Fifteen days
44
Progress of INFECTION CONTROL TEAM
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

45
Progress of MEDICAL AUDIT COMMITTEE
46
Progress of MEDICAL AUDIT COMMITTEE
Scope of Work Function of the Committee
Review and evaluate patient records for quality, adequacy of patient care, monitor staff for compliance with policies Medical staff participates in this system.
Evaluate medical record keeping, quality, content, format, accuracy, pertinence, staff compliance with documentation policies The parameters to be audited are defined by the organization.
Review and evaluate fatal cases / deaths in hospital. The medical records are reviewed periodically.
Evaluate sentinel events related to patient care The review focuses on the timeliness, legibility and completeness of the medical records.
Review, evaluate and monitor adverse drug reaction The review process includes records of both active and discharged patients.
Review and evaluate cases needing resuscitation An adequate mix of both active and discharged patients should be used.
Implementation of Right to Information The review points out and documents any deficiencies in records.
Take decisions regarding improvement in clinical quality For example, missing final diagnosis , absence of OT notes in an operated patient , etc.
Take decisions regarding improvement in clinical quality All audits are documented.
Take decisions regarding improvement in clinical quality The actions taken must be documented and oriented to the hospital staff.
Frequency of Meeting Quarterly
47
Progress of MEDICAL AUDIT COMMITTEE
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

48
Progress of Clinical risk management Adverse
drug event committee
49
Progress of Clinical risk management Adverse
drug event committee
Scope of Work Function of the Committee
Monitor and analyses sentinel events, accidents, and adverse events. Monitor and analyses sentinel events, accidents, and adverse events.
Incident Reporting System. Incident Reporting System.
Dealing with external bodies and individuals. Dealing with external bodies and individuals.
Deal with Complaints on Professionals management. Deal with Complaints on Professionals management.
Risk management policies to reduce actual potential patient risk. Risk management policies to reduce actual potential patient risk.
Identify trends amongst incident and initiate action Identify trends amongst incident and initiate action
Frequency of Meeting Monthly
50
Progress of Clinical risk management Adverse
drug event committee
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

51
Progress of Clinical audit committee
52
Progress of Clinical audit committee
Scope of Work Function of the Committee
Evaluate medical record keeping, quality, content ,format , accuracy, pertinence ,staff compliance The parameters to be audited are defined by the organization.
Proper documentation of policy The medical records are reviewed periodically.
Review and evaluate fatal cases /Death in hospital The review focuses on the timeliness, legibility and completeness of the medical records.
Frequency of Meeting Monthly
53
Progress of Clinical audit committee
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

54
Progress of GRIEVANCE REDRESSAL COMMITTEE
55
Progress of GRIEVANCE REDRESSAL COMMITTEE
Scope of Work Function of the Committee
To issue policy on grievance redressal To issue policy on grievance redressal
To issue policy on grievance redressal Develop a mechanism of handling employee grievances
Develop a mechanism of handling employee grievances To handle all the employee grievances
Develop a mechanism of handling employee grievances The committee has to sort out the problem and find out the solution irrespective of the employee and its position.
To handle all the employee grievances Preventive measures must be taken by the committee not to repeat the same problem in future.
To handle all the employee grievances The committee must take a unbiased decision and it has to be respected and accepted by the staff without any issue.
To issue policy on grievance redressal To issue policy on grievance redressal
Frequency of Meeting Monthly
56
Progress of GRIEVANCE REDRESSAL COMMITTEE
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

57
Progress of Sexual harassment committee
58
Progress of Sexual harassment committee
Scope of Work Function of the Committee
Committee is formed to issue policies for complaint system and recommended producers, investigation, and disciplinary action. Committee is formed to issue policies for complaint system and recommended producers, investigation, and disciplinary action.
The employee harassing another employee can be an individual of the same sex. The employee harassing another employee can be an individual of the same sex.
The harasser can be the employees supervisor, manager, customer, coworker, supplier, peer, or vendor .any individual who is connected to the employees work environment ,other employees who observe or learn about the sexual harassment can potentially complain of sexual harassment. The harasser can be the employees supervisor, manager, customer, coworker, supplier, peer, or vendor .any individual who is connected to the employees work environment ,other employees who observe or learn about the sexual harassment can potentially complain of sexual harassment.
In the organizations harassment policy, advise the potential victims that, if they experience harassment, they should tell the perpetrator to stop, that the advances or other behaviors are unwelcome. In the organizations harassment policy, advise the potential victims that, if they experience harassment, they should tell the perpetrator to stop, that the advances or other behaviors are unwelcome.
Frequency of Meeting Monthly as or when required
59
Progress of Sexual harassment committee
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

60
Progress of PHARMACOTHERAPEUTIC COMMITTEE
61
Progress of PHARMACOTHERAPEUTIC COMMITTEE
Scope of Work Function of the Committee
Develop and issue Policy on formulary and medication management There is a documented policy and procedure for pharmacy services and medication usage.
Supervise purchases and procurement Policies and procedures guide the organization of pharmacy services and usage of medication.
Supervise purchases and procurement The policies and procedures shall address the issues related to procurement, storage, formulary, prescription, dispensing, administration, monitoring and use of medications.
Supervise and management of pharmacy A list of medication appropriate for the patient's and the organization's resources is developed.
Supervise and management of pharmacy Policies and procedures guide the prescription of medications.
Monitor and evaluate adverse drug reactions Policies and procedures guide the safe dispensing of medications.
Monitor and evaluate adverse drug reactions Policies and procedures guide the use of narcotic drugs and psychotropic substances.
Manage the control of drugs Policies and procedures govern usage of radioactive or investigational drugs.
Manage the control of drugs Policies and procedures guide the usage of chemotherapeutic agents.
Supervise drug information service Policies and procedures guide the use of implantable prosthesis.
Supervise drug information service Policies and procedures guide the shortage of medication.
Frequency of Meeting Monthly
62
Progress of PHARMACOTHERAPEUTIC COMMITTEE
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

63
Progress of Disaster management committee
EMERGENCY PREPAREDNESS COMMITTEE (FIRE NON
FIRE)
64
Progress of Disaster management committee
EMERGENCY PREPAREDNESS COMMITTEE (FIRE NON
FIRE)
Scope of Work Function of the Committee
Develop policy on prevention, management, and control of emergency situations within and outside the hospital Patient safety aspects and risk management issues are an integral part of patient care and hospital management.
Develop plan for handling fire and non fire emergency situation Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety.
Ensure orientation of such plan to all The committee will form the policy and provide guidelines for evaluation control and smooth management in case of events.
Supervise training and mock drills This committee will rectify the faults in the system and fill up the gaps.
Supervise training and mock drills The organization has plans for fire and non-fire emergencies within the facilities.
Implementation of policy / plan Management ensures implementation of systems for internal and external reporting of system and process failures.
Frequency of Meeting Monthly as or when required
65
Progress of Disaster management committee
EMERGENCY PREPAREDNESS COMMITTEE (FIRE NON
FIRE)
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

66
Progress of HOSPITAL ETHICS COMMITTEE
67
Progress of HOSPITAL ETHICS COMMITTEE
Scope of Work Function of the Committee
Issue policy on medical ethics 1. Education
Issue policy on medical ethics In cooperation with the hospital administration, its various departments and divisions, and its medical/nursing and allied health professional staff, the committee will undertake educational efforts in clinical ethics. Depending on the availability of resources, the committee will develop or assist others in the development of lectures, seminars, workshops, courses, rounds, in-service programs and the like in clinical ethics. The aims of these educational efforts will be to provide participants with access to the language, concepts, principles and body of knowledge about ethics that they need in order to address the complex ethical dimensions of contemporary hospital practice
Review, evaluate and approve cases for clinical research, organ transplant, experimental therapeutics, ethical dilemmas, terminal care 2. Policy Review and Development
Review, evaluate and approve cases for clinical research, organ transplant, experimental therapeutics, ethical dilemmas, terminal care The committee will assist the hospital and its professional staff in the development of policies and procedures regarding recurrent ethical issues, questions or problems that arise in the care of patients. In this role the committee may provide analysis of the ethical aspects of existing or proposed policy or assist in the development of new institutional policy in areas of need.
Any other potential conflict of ethical issues and medical policy and practice 3. Case Review
Any other potential conflict of ethical issues and medical policy and practice Case review is particularly recommended in three specific categories of
Any other potential conflict of ethical issues and medical policy and practice decision making
Any other potential conflict of ethical issues and medical policy and practice decisions involving significant ethical ambiguity and perplexity in which case review may provide insight into complex ethical issues
Any other potential conflict of ethical issues and medical policy and practice decisions involving disagreement between care providers or between providers and patients/families regarding the ethical aspects of a patients care or
Any other potential conflict of ethical issues and medical policy and practice decisions that involve withholding or withdrawal of life-sustaining treatment which are not adequately addressed in hospital ethical policies
Any other potential conflict of ethical issues and medical policy and practice In this role the committee will not act as a decision-making body, but
Any other potential conflict of ethical issues and medical policy and practice will attempt to assist and to provide support to those who do have this
Any other potential conflict of ethical issues and medical policy and practice responsibility. Its role in all such cases shall be advisory.
Frequency of Meeting Monthly
68
Progress of HOSPITAL ETHICS COMMITTEE
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

69
Progress of Biomedical Waste Scrap Disposal
Committee
70
Progress of Biomedical Waste Scrap Disposal
Committee
Scope of Work Function of the Committee
No objection certificate under Pollution Control Act. Review for No objection certificate under Pollution Control Act.
Air (prevention and control of pollution) Act, 1981. Review Air (prevention and control of pollution) Act, 1981.
Biomedical waste management handling rules 1998. Review Biomedical waste management handling rules 1998.
Hazardous waste management and handling rules Act Review Hazardous waste management and handling rules Act
Water Prevention and control of pollution Act Review Water Prevention and control of pollution Act
License under Bio-medical Management and handling Rules, 1998. Review License under Bio-medical Management and handling Rules, 1998.
Regular Scrap Disposal from the facility Review Regular Scrap Disposal from the facility
Frequency of Meeting Monthly
71
Progress of Biomedical Waste Scrap Disposal
Committee
Name of Committee Members- Agenda identified
by Committee- Date of Committee Meetings-
Meeting Minutes of the Committee
Meetings- Action Taken Report on the Agenda-

72
Progress of Legal license Act.
73
Progress of Legal license Act.
S. No. Name of the License / Act. Available (Yes / No) Date of Validity Expiry Date
1 Building Permit (From the Municipality).
2 No objection certificate from the Chief Fire Officer.
3 License under Bio-medical Management and handling Rules, 1998.
4 No objection certificate under Pollution Control Act.
5 Radiation Protection Certificate in respect of X-ray equipments from AERB.
6 Excise permit to store Spirit.
7 Narcotics and Psychotropic substances license and Act.
8 Vehicle registration certificates.
9 Air (prevention and control of pollution) Act, 1981.
10 Atomic energy regulatory body approvals.
74
Progress of Legal license Act.
S. No. Name of the License / Act. Available (Yes / No) Date of Validity Expiry Date
11 Biomedical waste management handling rules 1998.
12 Consumer protection Act, 1986.
13 Dentist regulations, 1976.
14 Drugs and cosmetics Act, 1940.
15 Employees provident fund Act, 1952.
16 Equal remuneration Act, 1976.
17 Fatal accidents Act, 1955.
18 Indian lunacy Act, 1912 (MENTAL HEALTH ACT 1987)
19 Indian medical council Act and code of medical ethics, 1956.
20 Indian nursing council Act, 1947.
75
Progress of Legal license Act.
S. No. Name of the License / Act. Available (Yes / No) Date of Validity Expiry Date
21 Nurses and Midwives Act, 1953
22 Indian penal code, 1860.
23 Indian trade unions Act, 1926.
24 Maternity benefit Act, 1961.
25 MTP Act, 1971.
26 Minimum wages Act, 1948.
27 National building code.
28 Negotiable instruments Act, 1881.
29 Payment of wages Act, 1936.
30 Persons with disability Act, 1995.
76
Progress of Legal license Act.
S. No. Name of the License / Act. Available (Yes / No) Date of Validity Expiry Date
31 Pharmacy Act, 1948.
32 PNDT Act, 1996.
33 Licenses under PNDT Act 1996
34 Protection of human rights Act, 1993.
35 BARC, Act.
36 Registration of births and deaths Act, 1969.
37 Tax deducted at source Act.
38 License for the blood bank.
39 Constitution of India.
40 Transplantation of human organs Act, 1994.
77
Progress of Legal license Act.
S. No. Name of the License / Act. Available (Yes / No) Date of Validity Expiry Date
41 Hazardous waste management and handling rules Act
42 Dental Council of India
43 Water Prevention and control of pollution Act
44 Lift license
45 HT connection license
46 125 KV diesel generator license
47 GCSR pension rule
48 GCSR additional pay rule act
49 GCSR joining, foreign service, deputation out of India act
50 Payment during suspension and removal
78
Progress of Legal license Act.
S. No. Name of the License / Act. Available (Yes / No) Date of Validity Expiry Date
51 GCSR leave rule act
52 GCSR occupation of Govt residence accommodation act
53 GCSR general condition of service act
54 GCSR pay rule act
55 GCSR traveling allowance rule act.
79
Progress of Clinical Indicators Year 2008-2012

80
Monthly Progress of Graphical representation of
Clinical Indicators from April 2008 March 12
S.No. Indicators
1 No. of OPD per month
2 IPD Number per month
3 No. of Major / Minor Operation
4 No. of deliveries per month
5 Patient comments indicators
6 Employee Satisfaction Indicators
7 Bed Occupancy rate
8 ICU occupancy rate
9 utilization of OT
10 of biomedical equipments under repair condition
11 of Biomedical equipments calibrated
12 Number of Patient falls per 1000 patient days
13 Number of Medication errors per 1000 patient days
14 Major / Minor adverse drug reaction rate (per 1000 patient days)
15 Blood transfusion reaction rate (per 100 BT)
16 Incidence of wrong surgeries (wrong patient, wrong site, wrong surgery etc.)
17 Sentinel events, needle stick injury
18 All Hospital Acquired Infection (HAI) rate
19 Urinary Tract Infection (UTI) rate
20 Average length of stay
21 Total no of infant death Total No. of Admission.
22 Total no of Maternal death Total No. of Delivery.
23 Total no of death(including all) Net Mortality Rate
24 of film wasted in radiology department
81
Monthly Progress of Graphical representation of
Clinical Indicators from April 2008 March 2012
Year No. of OPD per month IPD Number per month No. of Major / Minor Operation No. of deliveries per month
2008-09
2009-10
2010-11
2011-12
Total
82
Monthly Progress of Graphical representation of
Clinical Indicators from April 2008 March 2012
Year Patient comments indicators Employee Satisfaction Indicators Bed Occupancy rate ICU occupancy rate
2008-09
2009-10
2010-11
2011-12
Total
83
Monthly Progress of Graphical representation of
Clinical Indicators from April 2008 March 2012
Year utilization of OT of biomedical equipments under repair condition of Biomedical equipments calibrated Number of Patient falls per 1000 patient days
2008-09
2009-10
2010-11
2011-12
Total
84
Monthly Progress of Graphical representation of
Clinical Indicatorsfrom April 2008 March 2012
Year Number of Medication errors per 1000 patient days Major / Minor adverse drug reaction rate (per 1000 patient days) Blood transfusion reaction rate (per 100 BT) Incidence of wrong surgeries (wrong patient, wrong site, wrong surgery etc.)
2008-09
2009-10
2010-11
2011-12
Total
85
Monthly Progress of Graphical representation of
Clinical Indicators from April 2008 March 2012
Year Sentinel events, needle stick injury All HAI rate UTI rate Average length of stay
2008-09
2009-10
2010-11
2011-12
Total
86
Monthly Progress of Graphical representation of
Clinical Indicators from April 2008 March 2012
Year Total no of infant death Total No. of Admission. Total no of Maternal death Total No. of Delivery. Total no of death(including all) Net Mortality Rate of film wasted in radiology department
2008-09
2009-10
2010-11
2011-12
Total
87
Total no of infant death
Year Total Number of Admission Number of Death of Death
2008-09
2009-10
2010-11
2011-12
Total
88
Total no of Maternal death
Year Total Number of Admission Delivery Number of Death of Death
2008-09
2009-10
2010-11
2011-12
Total
89
Progress of NABH Standards
90
Progress of Patient-Centered Standards
Name of Chapter Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements
Name of Chapter (Non Compliance) (Non Compliance) (Non Compliance) Partially Compliance Partially Compliance Partially Compliance Full Compliance Full Compliance Full Compliance
Name of Chapter 2009-10 2010-11 2011-12 2009-10 2010-11 2011-12 2009-10 2010-11 2011-12
Access, Assessment and Continuity of Care (AAC)
Care of Patients (COP)
Management of Medications (MOM)
Patients Rights and Education (PRE)
Hospital Infection Control (HIC)
91
Progress of Health Care Organization Management
Standards
Name of Chapter Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements Total No. of Objective Elements
Name of Chapter (Non Compliance) (Non Compliance) (Non Compliance) Partially Compliance Partially Compliance Partially Compliance Full Compliance Full Compliance Full Compliance
Name of Chapter 2009-10 2010-11 2011-12 2009-10 2010-11 2011-12 2009-10 2010-11 2011-12
Continuous Quality Improvement (CQI)
Responsibilities of Management (ROM)
Facility Management Safety (FMS)
Human Resource Management (HRM)
Information Management Systems (IMS)
92
Progress of Documentation / Infrastructure /
Instrument / Equipment / Manpower / Training
etc.
93
New initiatives
94
Other issue
95
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