Page 1 of 24

NABH Accreditation Certificate had been

handed over to Government Women &

Children Hospital, Kozhikode on 27th Feb

2014 by Honb’le Health Minister Mr.

Sivakumar. Honb’le minister Dr. Muneer,

MP Mr. M.K. Raghavan & MLA Mr. Pradeep

Kumar were presented on the function.

Medical Superintended, Senior Doctors,

DPM, DMO, Sr. Consultant Monitoring and

Evaluation, Lay Secretary, Nursing Supt,

NABH Coordinator & Consultant Quality

Assurance were present in the function.

New Renovated SNCU also inaugurated on

the same day by Hon’ble minister.

NABH ACCREDITATION OF W AND C

HOSPITAL KOZHIKODE

A LOOK BACK - JANUARY, FEBRUARY AND MARCH

National Health Mission Kerala

Quality Kerala

QUALITY ASSURANCE PROGRAMME IN HEALTH CARE

No 1. April 2014

Page 2 of 24

A team TH Perambra has visited W & C

Hospital on 18th Feb 2014 as it is NABH

accredited hospital in the district.

Swathy Laxmi . A. P

Quality Council of India had conducted Final

assessment at Institute of Communicative

and Cognitive neurosciences (ICCONS),

Shoranur on 29th

and 30th

March 2013.The

hospital has taken great efforts in the

Quality improvement activity as per NABH

Standards.

Institute for Communicative and Cognitive

Neuro Sciences [ICCONS] is the first

institute of its kind in the Asian countries

for comprehensive multidisciplinary

management, research and rehabilitation of

cognitive and communicative disorders

affecting all age groups. The Institute has

established its activities in the field of

Autism, Learning Disability, Developmental

Language Disorders, Mental Retardation,

Cerebral Palsy, Hearing Impairment, Adult

Stroke and related problems, Parkinson’s

Disease, Dementia, Aphasia and other

Genetic and Metabolic Disorders affecting

Speech, Language and Cognitive functions

in children and adults.

ICCONS SHORANUR – FINAL

ASSESSMENT BY QUALITY COUNCIL OF

INDIA

Page 3 of 24

The major activities involves sensitization of

health care organization towards

importance of quality healthcare services;

involvement of staffs for improving the

quality of patient service; development,

review and implementation of policies and

procedures for implementation of Quality

Management System.

The hospital has also constituted

committees, defined the oriented role and

responsibility of all committee at the facility

level with scope of work as per requirement

like quality Assurance committee hospital

infection control committee drugs &

therapeutic committee, grievance redressal

committee, disaster management

committee, hospital ethics committee.

Training and mock drills were conducted as

per the requirement of NABH standards.

Patient and employee satisfaction survey

has been conducted. The institution is

regularly monitoring the quality indicators.

The hospital also developed good infection

control practices. Mock drill on cardiac

Pulmonary resuscitation, child abduction,

medicine recall procedure, Fire, disaster

management where conducted.

During the preparation for NABH

accreditation process, Senior Consultant M

and E, Senior Consultant Quality Assurance

and Assistant Quality Assurance Officer

were visited the institutions many times

and reported that all the standards with the

reference to NABH 3rd edition was

implemented in the institution.

The detailed assessment conducted in the

institution by Assessors from Quality

Council of India. This is second level of

Page 4 of 24

assessment conducted by the Quality

Council of India. All the non conformities to

the institutions reported during the

previous assessment were corrected.

The Assessors has listed out 56 minor non

compliances which the NABH standards.

The hospital will take Corrective and

preventive actions for non compliances

observed by the assessors within two

months.

The quality improvement in the ICCONS was

due to the joint effort by the staff of

institution under the leadership of the

hospital. National Health Mission has

supported the NABH accreditation process

from the beginning. District Programme

Manager, Quality Assurance Officer,

Biomedical Engineer and other staff of the

district NRHM has helped in the

development and improvement of the

quality of services offered by the institution.

Sindhu .V

Department of Health, Government of

Kerala recently took steps to reduce

maternal mortality in Kerala. A programme

has been started by NRHM and Health

Services Department with the technical

support from NICE international United

Kingdom and Kerala Federation of

Obstetrics and Gynecology.

A quality standard document has been

prepared for reducing the maternal death

during the delivery services.

Meeting on development of Score card held

on 13 March 2013 at NRHM SPMSU. Score

cards were developed for the antenatal

mothers. The patients are given scores by

the doctors based on the risks that may

likely develop during the antenatal period.

The patients are treated or referred as per

the scores in their cards. The patients are

categorized as per risk and treated

appropriate centers from early pregnancy

itself.

MEASURES TO REDUCE MMR IN

KERALA - DEVELOPMENT OF SCORE

CARD

Page 5 of 24

The hospitals are also classified as per the

facilities for treating the antenatal cases.

The high risk antenatal cases will be

referred to the appropriate institutions

based on the score in the score card. The

important parameters to assess the score

are age, BMI, proximity to maternity centre,

AN factors, BOH, gravida, medical

complications, Obstetric complications,

previous caesarean etc.

Dr. K .Sandeep

The project Measures to reduce MMR in

Kerala is in the process of up scaling to

more health care institutions in the State.

A training programme regarding the same

was conducted for the Gynecologists at

Shoranur on 14-02-2014. Gynecologists

from the Woman and child hospital

Kozhikode, DH Manjeri, DH Manathawady,

Woman and child Hospital Palakkad and

Tribal Specialty hospital Kottathara has

participated in the training.

Dr Beena M State Mission Director NRHM

has provided a brief introduction on the

MMR project is being implemented in the

state.

Dr K Sandeep Senior Consultant M and E, Dr

Sree Hari District Programme Manager

Palakkad and Salini Raj Consultant QA also

have participated in the training.

Dr V P Paily, Kerala Federation of Obstetrics

and Gynecology have provided a detailed

presentation on the activities done to

reduce MMR in Kerala.

New Labor room register was provided to

all selected hospitals.

Dr. K .Sandeep

MEASURES TO REDUCE MMR IN

KERALA MEETING AT SHORANUR

Page 6 of 24

In Trivandrum District so far 8 hospitals

were KASH accredited. Taluk Hospital

Parassala is the last KASH accredited

hospital in the district and this is the first

accredited Taluk Hospital in the state. This

Hospital covers an average OP of 1500 per

day. The Hospital has separate OP rooms

with waiting chairs, token system, and

information counters, drinking water and

IEC facilities.

All wards have well equipped nursing

stations with rest rooms. Hospital has a well

scheduled cleaning policy and effective

supervision which promotes cleanliness in

the hospital. The hospital has a well

equipped laboratory which is working for 24

hours. All the lab tests, normal values,

turnaround time, sample acceptance and

rejection criteria, complaint readdressal etc

are displayed outside the laboratory.

Internal and external quality control is

doing for the lab tests. Separate dining

areas for patients in each wards and

availability of hot water for bath are

provided for patients. Separate area is ear

marked for the disposal of general waste

and biomedical waste storage.

As part of reducing infection control in the

hospital an infection control nurse is

designated to oversee all the infection

control activities. Separate registers are

kept for monitoring the Hospital acquired

infections in the departments and trainings

are given to all staffs to capture the same.

Geriatric friendly toilets for patients, zoning

of the operation theatre, Operation theatre

infection control practices, Quality

assurance for the X-ray services, Calibration

of the equipments, training to all staffs ,

health checkups for staffs ,formulation of

committees, documentation of all the

procedures ,formulation code blue team,

code red team , etc are done as part of

KASH accreditation program . All the rooms,

beds and furniture’s are numbered,

displayed citizen charter, patient rights and

responsibilities, displayed layout of the

hospital ,placed fire extinguishers with fire

exit route plan etc.

KASH - THQH PARASSALA

Page 7 of 24

As part of KASH accreditation more than 20

trainings conducted in the hospital. The

training comprises the KASH general

awareness, infection control practices, CPR,

Spill management, code blue, code red,

housekeeping, fire safety etc. The hospital is

maintained healthy liaison work with local

authorities especially the Block president

and the MLA. The superintendent and other

supporting staff is more interested tin

implementing KASH standards.

Reshmi.G

Kerala Accreditation Standards for Vaccine

Stores has been developed by the drafting

committee. The Committee members

include Additional DHS FW, State Cold

Chain Officer, Deputy Chief Engineer, Senior

Consultant M and E, Senior Consultant QA,

Regional Quality Assurance Officer, Junior

Consultant QA, Bio Medical Engineer etc.

The draft standards were finalized at the

meeting held on 9 March 2013 and 17

March 2013 at NRHM SPMSU.

The Standards were developed for the

Regional vaccine storage centre , State

vaccine Storage centre and District Vaccine

Storage Centers

Sindhu. V

A two days workshop on hospital safety was

conducted at THQH Cherthala as part of

National safety day on 4th

and 5th

at

Conference hall. Target participants are

core members from Major institutions

including Medical superintendents. Total 58

staff Participated in the programme. Five to

Six members from each institutions

participated in the programme. This

workshop mainly concentrated on various

safety aspects related to staff and patients

in the hospital. The programme was

inaugurated by Dr. Subaida,

Superintendent, THQH Cherthala. Mr. Davis

TWO DAYS WORKSHOP ON PATIENT

SAFETY – ALAPUZHA DISTRICT

KERALA STANDARDS FOR VACCINE

STORAGE CENTRES – DRAFTING THE

STANDARDS

Page 8 of 24

Director of Radiation Safety was a special

invitee for the workshop.

This workshop start with an introductory

section on hospital safety by Dr. Venugoal

(THQH Cherthala) and he emphasized the

importance of ensuring safety in hospitals.

Mr. Davis, Director of Radiation Safety

delivered a talk on “ Radiation safety

measures in hospital”. It was an eye

opening section for all participants. Mr.

Davis explained the importance of ensuring

radiation safety in radiology department

and the procedures for getting radiation

safety approval.

Mr. Sreekumar, Asst. Drugs Controller

Trivandrum was delivered a detailed

presentation on medication safety. Topic

mainly concentrated on storage, handling

,dispensing and administration of drugs.

Last session on the 1st

day was focused on

infrastructure and electrical safety.

Implementation of fire fighting systems and

its usage is explained in detail by Mr.

Pushparaj, project engineer CAPE. Different

ways to ensure electrical safety is also

explained in detail.

In second day of the workshop, the first

session started with “Communication safety

in hospital”. Ensuring proper

communication and maintaining a good

relationship between employees is most

important in a complex organization like

hospital. So the importance of proper

communications explained in detail by Mr.

Philip , an HR Trainer.

Another important session in the 2nd

day

was handled by Er. Mythili, Chief

environmental engineer, RPCB Ernakulam.

She explained in detail “The Biomedical

waste management rules 1998 and

amendments”.

Last session dealt with “Patient Safety in OT

and wards” by Ms. Lessamma (NABH

Assessor) .All safety aspects related to

NABH, KASH and infection control practices

were included in the presentation.

The workshop wind up with a conclusion

section and certificate distribution by Dr.

Manoj, District Programme Manger NHM,

Alappuzha.

Margaret Lincy

Page 9 of 24

Kerala Accreditation Standards for Hospitals

Assessment was conducted in Primary

Health Centre, Valakom on 25 March 2014

by the NABH Assessors.

Implementation of KASH Programme

started in PHC Valakom on February 2012.

PHC Valakom has implemented KASH

standards during the last two years.

Signage are placed in all areas.

During these period New OP registration

area constructed, breast feeding area.

Garden and Beautification work done. All ,

rooms and beds numbered.

Proper Biomedical Waste disposal is in

place and agreement with IMAGE for

biomedical waste management. Fire

extinguishers are placed in appropriate

places.

KASH ASSESSMENT AT PHC VALAKOM ,

ERNAKULAM

Page 10 of 24

Personnel record file for all staff introduced.

Committees formed for the implementation

of standards.

The committees formed in the hospital are

Core committee, Quality Assurance

Committee, Biomedical Equipment

Management Committee, Code blue

/resuscitation Committee, Condemnation

Committee, Drugs formulary committee.

House Keeping & Infection Control

Committee, Office Management

Committee, Purchase Committee, Safety

committee and Staff welfare Committee.

Hnad wash policy was introduced.

The trainings conducted in the hospital are

KASH awareness, fire and safety, patient

care, infection control, Management of

blood spill, Infection Control, Bio Medical

wastage management and BLS.

Nigini Paulose

Page 11 of 24

The Review meeting of the Maternal

mortality in Kerala has been held on 22

March 2013 at NRHM SPMSU .

The selected hospitals for the

implementation of the standards in the First

phase are Woman and Child hospital

Trivandrum, SAT Hospital, District Model

Hospital Peroorkada, THQH Chirayinkeezh,

General hospital Ernakulam, CHC

Kanyakulangara, SUT hospital and Mother

hospital .

The programme is in the process of up

scaling to more institutions in the State. The

other hospitals selected in the Second

phase include Woman and child hospital

Kozhikode, Victoria hospital Kollam, DH

Manjeri, DH Manathawady, Woman and

child hospital Palakkad and Tribal Specialty

hospital Kottathara.

In the meeting Dr.Renuka Leslie pointed out

that there is a reduction in primary CS rates

from 28.75 to 20.75 when the figures for

20112 and 2013 April-Dec periods were

compared. This trend was reflected in other

parameters like referrals, blood

transfusions etc.

Dr. Nirmala presented the comparative

statistics for the same period., but such

reduction was not obvious in the statistics

from SAT hospital. Her explanation is that

there is better capture of data so that the

trend is not obvious.

Dr.Sandeep pointed out that for 14-15

budget, there is provision for blood sugar

estimation strips. So also laundry in two

hospitals per district.

Dr.Paily highlighted that QS on Sepsis and

Amniotic Fluid Embolism will be shortly

developed for piloting.

Dr .K. Sandeep

Two days hands on training on BLS (Basic

response provider course) conducted for all

staff in THQH Cherthala except doctors on

14th

and 15th

March 2014. Total 201 number

of staff trained in BLS in 4 sessions.

Training conducted by MIMS School of

resuscitation, training academy of American

Heart Association. All staff provided with

first response provider course certificates.

TWO DAYS HANDS ON TRAINING IN

BASIC LIFE SUPPORT (FIRST RESPONSE

PROVIDER COURSE

MMR REVIEW MEETING OF SELECTED

HOSPITALS

Page 12 of 24

All staff individually demonstrated Adult

CPR, Infant CPR and Choking management.

This programme was organized by DPMSU ,

Alappuzha.

Margarat Lincy

The Director of Health Services has issed a

circular dated 24-02-2014 on introduction

on code blue in all health care organization

under Health Services Department.

All health care institution recognized the

importance of managing the emergency

situation in the hospital settings. "Code

Blue" is generally used to indicate a patient

requiring resuscitation or otherwise in need

of immediate medical attention, most often

as the result of a respiratory arrest or cardiac

arrest. Code Blue is an event of utmost

emergency, a mode of alerting all medical,

nursing, paramedical and allied health care

services and other personnel.

The copy of the circular has been posted in

the website of NRHM.

Dr .K. Sandeep

District level training on IMEP & KASH

standards was conducted on 23rd Jan 2014

at KGMOA Hall, Kotooli, Kozhikode. Dr.

Anitha, Prof: Microbiology, Calicut Medical

college, Mr. Gee, Engineer, Pollution

Control Board, Mrs. Vincy Varghese BD safe

injection practices, DPM Kozhokode,

Consultant Quality Assurance and Regional

Quality Assurance Officer were taken

classes for the participants.

Sixty participants from health care

institutions under health services

department participated in the training.

DISTRICT LEVEL TRAINING ON IMEP &

KASH STANDARDS

CIRCULAR ON CODE BLUE BY DIRECTOR

OF HEALTH SERVICES

Page 13 of 24

Swathy Laxmi AP

In General Hospital Ernakulam, after the

three year completion of NABH, Quality

council of India conducted renewal

assessment on 23, 24 and 25 January 2014.

A team of five assessors from QCI visited

the hospital for renewal assessment. A

detailed assessment was carried out and

they gave a final report with fifty seven non

compliances.

All the hospital staffs are actively

participated in the renewal assessment.

Many changes are made in the hospital

apart from the standards. All the

amendments made in the manuals

according to the third edition. All

committee meeting are conducted at

regular intervals. Continual training in

different topics given to all doctors, nursing

and paramedical staff , housekeeping staff

and other category staffs .Internal audits

are conducted and find out the

noncompliance and rectified before

assessment. Minor modifications are made.

Quality indicators are collected and verified

by the quality team to know the quality

progress monthly. New MRI was installed in

the Hospital.

NABH ACCREDITATION.- RENEWAL

ASSESSMENT GENERAL HOSPITAL

ERNAKULAM

Nigini Paulose

Infection Management and Environment

Plan trainings were conducted on 3

March 2014 in Thrissur District for Staff

nurses and Lab technicians. The aim of the

training was to create awareness on

hospital infection control and biomedical

waste management. Total 51 staff

participated in the training. Mrs. Sumithra

Assistant Executive Engineer Pollution

Control Board Thrissur, Dr. Chithra Valsan

Associate Professor Microbiology Jubilee

Mission Medical College Hospital Thrissur,

Smt. Marikkutty Rtd. Nursing

Superintendent, General Hospital,

Ernakulam and Mr. Praveen Kumar

Coordinator, IMAGE presented various

topics for the training.

Infection Control, Biomedical Waste

Management, Safe Injection Practice,

Standard Precautions, Hand washing and

Housekeeping are the topics included in the

training. The training was very helpful to a

health staff to improve their skills and

implementation of infection control

practices in the hospital. As per the feed

INFECTION MANAGEMENT AND

ENVIRONMENT PLAN TRAININGS AT

THRISSUR

Page 14 of 24

Infection Management and Environment

Plan trainings were conducted on 3rd

and 4th

March 2014 in Thrissur District for Staff

nurses and Lab technicians. The aim of the

training was to create awareness on

hospital infection control and biomedical

waste management. Total 51 staff

participated in the training. Mrs. Sumithra

utive Engineer Pollution

Control Board Thrissur, Dr. Chithra Valsan

Associate Professor Microbiology Jubilee

Mission Medical College Hospital Thrissur,

Smt. Marikkutty Rtd. Nursing

Superintendent, General Hospital,

Ernakulam and Mr. Praveen Kumar

or, IMAGE presented various

topics for the training.

Infection Control, Biomedical Waste

Management, Safe Injection Practice,

Standard Precautions, Hand washing and

Housekeeping are the topics included in the

training. The training was very helpful to all

health staff to improve their skills and

implementation of infection control

practices in the hospital. As per the feed

INFECTION MANAGEMENT AND

ENVIRONMENT PLAN TRAININGS AT

Page 15 of 24

back received from the participants, the

training was very informative and inspiring

and they got the opportunity to attend a

district level training conducted on the

subject. Pre and Post test were conducted

in the training and prizes were distributed

to the winners by Dr. V.V.Veenus, DMO (H),

Thrissur.

Muthulakshmy .K.S

The KASH Certificate Handing over function

had been conducted at PHC Thiruvambady

on 28th Feb 2014. Hon’ble MP Mr.

Shanavas handed over the certificate to

Medical Officer Mrs Radhika. DPM, Sr.

Consultant Monitoring and Evaluation,

Panchayat President and other important

officials at Thiruvambady Panchayath &

Consultant Quality Assurance were

presented on the function.

Swathy Laxmi .A.P

A training on implementation of Quality

Standards was conducted at General

Hospital Manjeri on 04-04-2014. Dr V P

Paily from Kerala Federation of Obstetrics

and Gynecology have visited General

Hospital Manjeri to appraise the

obstetricians and labor room staff regarding

the data collection for the project. The

Measures to reduce MMR in Kerala is

jointly run by the Kerala Health Services

MEASURES TO REDUCE MATERNAL

MORTALITY IN KERALA -TRAINING AT

GENERAL HOSPITAL, MANJERI

KASH ACCREDITATION OF PHC

THIRUVAMBADY KOZHIKODE

Page 16 of 24

Department, National Health Mission,

Kerala Federation of Obstetrics and

Gynecology and technical support from

NICE International.

He has visited the Labor room and

Operation Theatre along with the

Gynecologist. The objective of the training

is to improve the quality of care provided to

the patient

Bhadra .C. P

Hospital infection control committee

introduced in the District Hospital Tirur as a

part on Quality Assurance Programme. A

staff training has been conducted on 02-03-

2014. The mandatory standards of Hospital

infection control programme have been

already implemented by the Hospital

Infection Control Committee.

District Programme Manager,

Superintendent, HICC convener, Jr.

Consultant (QA) addressed the trainees.

HOSPITAL INFECTION CONTROL

COMMITTEE LAUNCHING &

STAFF TRAINING IN DISTRICT

HOSPITAL, TIRUR

Page 17 of 24

District programme Manager inspected all

areas in the hospital.

PPEs

Food waste central collection

News paper report by Malayala Manorama

on 03-04-2014

Bhadra .C. P

A KASH awareness training was conducted

in THQH Chengannur on 15-03-2014.

Dr.Joseph Joseph delivered a detailed talk

on KASH standards with emphasis on

Infection control activities. Total 30 staff

participated in the programme.

A training to all staff in THQH Chengannur

conducted on 26.03.14 from 11.00am to

2.30 to all categories of staff .All staff

including doctors participated in the

KASH AWARENESS TRAINING IN THQH

CHENGANNUR

programme. The training starts with a brief

outline of KASH programme and covers

chapters in KASH guidelines. Total 30 staff

participated in the programme. Ms

Margaret Lincy JC ( QA) NHM , Alpy was the

trainer.

Margaret Lincy

Only two MHC were selected from the state

for KASH accreditation and one of them was

MHC Thrissur. Quality

programme is being implemented in the

hospital. Hospital has tied-up with IMAGE

for the proper biomedical waste

management. Equipments in the

were calibrated. Side rails were fixed in cots

of all wards. Old case sheet modified as per

the quality standard. Patient information

boards were fixed in appropriate locations.

Buildings were divided and named as per

the quality standard. Fire safety equipments

were implemented. Training programmes

were conducted to improve the proficiency

of staff.

Muthulakshmy .K.S

KASH - MENTAL HEALTH CENTRE,

THRISSUR

programme. The training starts with a brief

outline of KASH programme and covers all

chapters in KASH guidelines. Total 30 staff

participated in the programme. Ms

Margaret Lincy JC ( QA) NHM , Alpy was the

ly two MHC were selected from the state

for KASH accreditation and one of them was

MHC Thrissur. Quality assurance

programme is being implemented in the

up with IMAGE

for the proper biomedical waste

management. Equipments in the institution

were calibrated. Side rails were fixed in cots

of all wards. Old case sheet modified as per

the quality standard. Patient information

boards were fixed in appropriate locations.

Buildings were divided and named as per

e safety equipments

were implemented. Training programmes

were conducted to improve the proficiency

For KASH accreditation assessors had

conducted final assessment at

Health Centre, Kanjeetukara

2014. The hospital has taken great efforts in

the Quality improvement activity as per

KASH Standards.

Community Health Centre Kanjeettukara is

at Ayroor panchayath and under the

Koipuram block panchayath which is

situated about 7 km

The CHC was established since 1952. It is a

30 bedded hospital and providing the OPD

services, in patient services, laboratory

services, Pharmacy, vision testing, referral

services, maternal and child healthcare

including family planning. Distr

Kozhencherry and General hospital

Pathanamthitta are the referrals centers for

this hospital.

KASH - COMMUNITY

KANJEETUKARA PATHANAMTHITTA

MENTAL HEALTH CENTRE,

Page 18 of 24

For KASH accreditation assessors had

conducted final assessment at Community

Health Centre, Kanjeetukara on 5th

January

2014. The hospital has taken great efforts in

the Quality improvement activity as per

Community Health Centre Kanjeettukara is

at Ayroor panchayath and under the

Koipuram block panchayath which is

km from Kozhencherry.

The CHC was established since 1952. It is a

30 bedded hospital and providing the OPD

services, in patient services, laboratory

services, Pharmacy, vision testing, referral

services, maternal and child healthcare

including family planning. District hospital

Kozhencherry and General hospital

Pathanamthitta are the referrals centers for

COMMUNITY HEALTH CENTRE,

PATHANAMTHITTA

Page 19 of 24

The KASH programme started in

Community Health Centre, Kanjeettukara in

2012. The programme faced difficulties in

initial phase of implementation; however

the staffs of the institution have provided

full support for the implementation of the

programme.

The major activities involves sensitization of

health care organization towards

importance of the quality healthcare

services; involvement of staffs for

improving the quality of patient service;

development, review and implementation

of policies and procedures etc.

The hospital has also constituted

committees, defined the role and

responsibility of all committee at the facility

level, and with the scope of work as per

requirement. The committees formed are

quality Assurance committee hospital

infection control committee drugs &

therapeutic committee, grievance redressal

committee, disaster management

committee and hospital ethics committee.

Training and mock drills were conducted as

per the requirement of KASH standards.

Patient and employee satisfaction survey

has been conducted. The institution is

regularly monitoring the quality indicators.

Page 20 of 24

The hospital also developed good infection

control practices. Mock drill on cardiac

Pulmonary resuscitation, child abduction,

medicine recall procedure, Fire, disaster

management where conducted.

The detailed assessment conducted in the

institution by KASH Assessors from State

accreditation board on 5th

January 2014 and

the Assessors has listed 27 non

Compliances. All the non conformities to

the institutions reported during the

assessment were corrected in two weeks.

The quality improvement in the Community

Health Centre Kanjeetukara was due to the

joint effort by the staff of institution under

the leadership of the hospital. National

Health Mission has supported the Quality

assurance programme. District Programme

Manager, Quality Assurance Officer,

Biomedical Engineer and other staff of the

district NRHM has helped in the

development and improvement of the

quality of services offered by the institution.

Shylesh Chandran

District level infection control training

conducted at District Training Centre Kollam

on 14th

February 2014. Nursing

Superintendent, Infection Control Nurses &

PRO’s from District Hospital, Victoria

Hospital, Taluk Hospitals and CHC’s

participated in the training programme.

Devi .G

DISTRICT LEVEL INFECTION CONTROL

TRAINING - KOLLAM

Page 21 of 24

As per the Government Order No (MS) No

06/2014/H&FWD dated 03-01-2014, Health

and Family Welfare Department

Government of Kerala has revised the

preservation and disposal of case records

and registers in Government Hospitals

under Health Services Department. The GO

is available in the website of NHM in the

Quality Assurance page.

Dr. K. Sandeep

PHC Karavalur was accredited with Kerala

Accreditation Standards for Hospitals on

December 2013. Physical achievement

includes bilingual signage in all areas,

formulated various committees, Purchased

waiting chairs, wheel chairs & trolleys, New

OP counter, renovated waiting area, new

physically handicapped toilet and pharmacy

renovation.

Other achievements includes Citizen

Charter, Institutional level trainings for all

hospital staff, Conducted Internal audits,

PHC- KARAVALUR- KOLLAM GO - PRESERVATION OF MEDICAL

RECORDS AND REGISTERS REVISED

Page 22 of 24

and Placed fire extinguishers, and

Employees personnel file.

Devi .G

In Palakkad District, as part of the

“Measures to reduce Maternal Mortality

Rate in Kerala” program two hospitals viz.

Women and Children Hospital Palakkad and

Government Tribal Specialty Hospital

Kottathara were selected. The

Superintendent and Sr. Gynecologists in

both of the institutions attended the

training sessions conducted by National

Health Mission on 14.02.2014 at Shoranur.

The Women and Children Hospital Palakkad

is a 100 bedded hospital and is bifurcated

from the District Hospital Palakkad since

2012 onwards. The hospital has an average

delivery of 550 including caesarian sections

per month. Dr. Paily visited the hospital on

03.04.2014 and conducted a practical

training session for all Gynecologists and

observed the practices in labor room. He

also conveyed suggestions for the same.

On the next day Dr. Paily visited GTSH

Kottathara. The Government Tribal

Specialty Hospital Kottathara is a 54 bedded

institution situated in the most difficult hilly

rural area of Palakkad District and majority

of the patients are poor tribes and have to

go more than 80km from here to next

higher center. Dr. Paily conducted a

practical training session for all

Gynecologists and observed the daily

practices in labor room. Dr. Paily had given

suggestions to improve Quality Patient Care

and Maternal mortality rate in the

Attappady area.

Salini Raj

A review meeting of Quality Assurance

Programme was conducted on 24th

March

2014 at State Institute of Health and Family

Welfare, Trivandrum. Quality Assurance

Officers from all districts were participated

in the meeting along with officials from

SPMSU. Quality Assurance Programmes,

NABH, KASH, NABL, MMR has been

reviewed in detail.

Quality Assurance Officers from district

presented the details of programme

implemented with a power point

presentation. During the review meeting it

was decided that all Quality Assurance

Officers shall submit monthly report before

10th

of every month. All Quality Assurance

Officers shall also submit a report of Quality

Assurance Programme implemented in the

district.

Ashitha .G. R

REVIEW MEETING OF QUALITY

ASSURANCE PROGRAMME

MEASURES TO REDUCE MATERNAL

MORTALITY RATE IN KERALA –

PALAKKAD DISTRICT

Page 23 of 24

THQH Punalur was accredited with Kerala

Accreditation Standards for Hospitals on

December 2013. The hospital is maintained

healthy liaison work with local authorities

and other public as well as private

organizations. The superintendent and

other supporting staff is more interested to

implementing KASH standards.

Physical achievements includes Bilingual

signage’s in all areas, Citizen Charter in

Display & Booklet, Institutional level

trainings for all hospital staff, Formulated

committees, Conducted Internal audits,

Implemented new case record file, Started

hospital infection control activities &

infection control training for all staff,

Monitoring of Indicator for data collection,

Placed fire extinguishers at identified areas,

Internal and external quality check in

laboratory & radiology, Swab Culture from

different areas & also from drinking water

and Employees personnel file.

Different Trainings conducted includes

KASH orientation training, infection control

training, BLS training, housekeeping,

laboratory quality improvement training,

CPR, Safe Injection & Infusion Practices and

Fire Safety. Infrastructure changes includes

pharmacy block, toilet for physically

handicapped, operation theatre rearranged,

labor Room and NBSU.

Devi. G

KASH - THQH PUNALUR- KOLLAM

Page 24 of 24

Efficiency of any health care institution

depends to a large extent on the availability

and judicious usage of the Bio-Medical

equipments. Biomedical Enginees were

conducted Equipment Audit in districts. The

Equipment audit includes gap analysis at

delivery points based on the availability of

existing equipments, infrastructure, IP and

OP per day, Delivery rate per month etc.

Aswathy . L

PHC Kollayil is situated at kollayil

panchayath under perumkadavila CHC. This

hospital is having 160 OP per day. The

Hospital voluntary applied for KASH

accreditation program and the

implementation process has started on

September 2013. KASH assessment has

been conducted on March 21st

2014. All

the staffs and local governments are very

much interested in implementing the

program.

As part of KASH accreditation program

placed signage board on the adjoining areas

of the main road, displayed the services

available and the citizen charter, placed

drinking water and IEC materiel’s for

patients, displayed patient rights and

responsibilities.

All the ordinary taps were replaced with

elbow tapes, tissue paper and soap

solution. Maintained privacy for patients in

the observation and OP room. Placed fire

extinguisher and displayed fire exit route

plan and floor plan. Displayed layout of the

hospital.

Sound-alike look alike medicines are

arranged separately in pharmacy. All the

medicines are kept in neat and well lit

environment with proper labeling. List of

available medicines are displayed outside

the laboratory. Emergency checklist are

kept for medicines. Registers are placed for

monitoring HAI. Trainings are given to all

staffs on CPR, Infection control, house

keeping, KASH.

Reshmi.G

KASH - PHC KOLLAYIL, TRIVANDRUM

BIOMEDICAL ENGINEERING-

EQUIPMENT AUDIT