Quality Kerala - Arogyakeralam Kerala May 2014.pdf · only 18 NABH accredited health care...

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“QUALITY IS NOT AN ACT, IT IS A HABIT.”

Aristotle

Quality council of India (QCI) is an

autonomous body set up by Government of

India to establish and operate the National

Accreditation Structure in the country.

National Accreditation Board for Hospitals

& Healthcare Providers (NABH) is a

constituent board of Quality Council of

India, set up to establish and operate

accreditation programme for healthcare

organizations.

NABH programme is being implemented in

Kerala in selected hospitals. Four

Government Hospitals and one blood bank

are accredited by NABH.

General Hospital, Ernakulam is one of the

largest district level hospitals in Kerala, with

NABH NATIONAL ACCREDITATION

BOARD FOR HOSPITALS AND HEALTH

CARE PROVIDERS

LOOKING BACK 2013-14

National Health Mission Kerala

Quality Kerala

QUALITY ASSURANCE PROGRAMME IN HEALTH CARE

No 2. May 2014

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highest bed strength, has got National

Accreditation Board for Hospital & Health

Care Providers (NABH) accreditation.

General Hospital Ernakulam is the 4th

Government hospital in India and first

Government hospital in Kerala, which got

NABH accreditation.

THQH Cherthala has been awarded

certificate of NABH accreditation. This is the

first taluk level hospital in India achieved

such a certificate from QCI.

Women and Children Hospital, Thycaud.

This is the first W&C hospital in India

achieved such a certificate from QCI. Blood

Bank Aluva is the first NABH accredited

institution in Kerala.

Women and Children Hospital Kozhikode is

accredited by NABH in this year. Final

assessment was conducted in ICCONS

Shoranur by Quality Council of India and will

be accredited soon.

It is a remarkable achievement as there are

only 18 NABH accredited health care

institutions in Kerala of which 5 are from

Government sector. Accreditation is an

incentive to improve capacity of Heath Care

Organisations to provide quality of care.

Dr K Sandeep

Government of Kerala has introduced an

Accreditation Program for Health care

institutions in the state covering all the

Government owned health care

institutions. The aim of the State Level

Accreditation Programme is to provide the

better patient care, health care quality

improvement, patient safety, infection

control, medication safety, facility safety

and equity in health care.

KASH KERALA ACCREDITATION

STANDADRS FOR HOSPITALS

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The Kerala Accreditation Standards for

Hospitals (KASH) are prepared for 4

different levels of hospital, which are

Primary Health Centre (PHC), Community

Health Centre (CHC), Taluk level Hospitals

(THQH) and District level Hospitals including

specialty and General Hospitals.

The standards were developed in such a

way that the implementing the programme

is possible with moderate investment in

most of the health care institutions. After

the achievement of Kerala Accreditation

Standards for Hospitals, the individual

hospitals may opt for higher standards viz

NABH, which require more investment and

effort.

The major emphasis of Quality Assurance

Programme is on 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.

So far 14 Government Health Care

Institutions were accredited under this

programme.

Dr K Sandeep

Many health indices of Kerala are

comparable to that of the developed

nations. Maternal Mortality Ratio in Kerala

is lowest in India, however it is many times

higher than that of the developed nations.

This need to be brought down to a vary low

level.

The confidential auditing of all maternal

death in Kerala is in place and cause of

MEASURES TO REDUCE MATERNAL

MORTALITY RATE IN KERALA

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Maternal mortality has been studied in

detail. The confidential audit of Maternal Death

has been in started in Kerala in 1990s and

Kerala is the first state to implement

confidential audit of Maternal Death.

Department of Health, Government of

Kerala recently took steps to reduce

Maternal mortality in Kerala. A programme

has been started by NRHM, Health Services

Department, Medical Education

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. Quality

standards that are derived from evidence-

based clinical guidelines and that are

agreed by relevant stakeholders provide

powerful levers to drive and measure

quality improvement in health care

institutions. It focuses on improving the

care mothers in hospitals, public and

private, and to help reduce maternal

mortality.

In the pilot phase, Quality Standards

developed is being implemented in selected

hospitals.

State Mission Director, NRHM team and

KFOG members visited all the selected

health institutions.

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The disposable delivery kits are introduced

in the hospitals, to improve the quality of

care, reduce hospital infections and also to

measure the blood lose during the delivery.

Kerala Medical Services Corporation has

supplied disposable delivery kits to all

delivery centers in the Government sector.

A training has been conducted by Kerala

Federation of Obstetrics and Gynecologists

at Trivandrum, Ernakulam and Shoranur. All

the Gynecologists and other staff from

selected hospitals participated in the

training.

Flow charts were developed by the KFOG

was printed and supplied to all selected

hospitals.

As a measure to reduce blood lose during

the emergency situations, Non Pneumatic

Anti shock Garments were supplied to all

selected hospitals.

The programme will be upscaled to more

health care institutions in this year.

Dr K Sandeep

NABH ACCREDITATION GOVERNMENT

HOSPITALS

W and C Hospital Kozhikode is the second

Women and Children Hospital in India to

NABH ACCREDITATION OF W AND C

HOSPITAL KOZHIKODE

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receive the NABH accreditation. It is the 4th

Hospital in Kerala has got the NABH status.

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.

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

ICCONS SHORANUR – FINAL

ASSESSMENT BY QUALITY COUNCIL OF

INDIA

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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.

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.

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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

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

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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

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

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Nigini Paulose

Government Women and Children’s

Hospital Thycaud Thiruvavnanthapuram is

the India’s first Women and Children’s

Hospital to get NABH Accreditation. The

Government Women and Children’s

Hospital Thycaud is one of the largest

specialty hospital in Kerala for Obstetrics &

Gynecology. Many people, not only from the

district, but also from some others districts

of Kerala and Tamilnadu are coming in this

hospital for treatment.

This hospital has been accredited by NABH

on 14th April 2012 and thus becomes the

second Government Hospital in the state

getting accreditation.

W&C Hospital was established on 1814 by

Her Highness Sethu Parvathy Bai from the

Royal Travancore family. It started its

beginning as a dispensary but later it was

changed in to health centre on 1839. A new

building was inaugurated on 1916. Training

for caring newborn babies and taking

deliveries & Nursing training started here.

After the Independence there was a

tremendous change in the growth of this

institution. The hospital was upgraded on

1996 as the 'First Referral Unit' and later as

District Hospital.

She became the Medical Superintendent of

the Hospital on 1916 and continued in this

post for 22 years, which may be a record in

Medical Professional to hold the post.

GOVERNMENT WOMEN & CHILDREN’S

HOSPITAL, THYCAUD,

THIRUVANANTHAPURAM

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Another important characteristic feature of

the hospital is that this is first hospital in

Kerala conducted the cesarean surgery.

The first Gynecologist of Kerala, Dr. M

Ponnen Lukose was appointed in this

hospital in 1916.

She became the Medical Superintendent of

the Hospital on 1916 and continued in this

post for 22 years, which may be a record in

Medical Professional to hold the post.

Identifying, complying with and monitoring

the effective implementation of meeting

legal, statutory and regulatory

requirements is the first important outcome

parameter identified on the basis of the

implementation of NABH accreditation

programme in the Government Women and

Children’s Hospital Thycaud. Prior to the

accreditation process, the hospital

authorities aware less concerned about the

legal requirement such as permits, NOC,

license etc. Now the hospital has got all

legal requirement such building permit,

NOC from Pollution Control Broad, AERB

approval and Blood Bank License.

The hospital is now able to implement a

well documented policies and procedures

of various serviced delivered. The well

documented and updated quality manual

maul is the apex among these document.

Besides these, hospital safety manuals,

quality assurance manuals manual for

standards operating procedures are other

documented maintained by the hospital.

Better quality care are being provided in the

hospital as a consequence of NABH

accreditation. Emergency patient are given

life saving treatment and then admitted to

the wards. Applicable laws and regulations,

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policies and procedures guide the patients

care. High risk pregnancies are clearly

defined and immediate attention is being

given.

The hospital has a policy that patients sixth

same health problems and care needs

receive same quality of health care

irrespective of creed, caste, category of

ward, income status. General and informed

consent are being taken in relevant cases.

All the staff are trained in many activities

such s emergency services CPR, Fire safety,

Disaster management etc.

The hospital maintains a good and hygienic

environment by providing good

housekeeping practices. Cleaning machines

are being used in the cleaning areas and

cleaning is being done three times a day.

Basic cleaning operations are being done

and training to cleaning staff are

periodically done.

Continuous training is another parameter in

connection with NABH accreditation

process in Government Women & children’s

Hospital. The hospital is maintaining a

training calendar indicating the details of

training , participants, trainers for various

training needs such as services available,

OPD Services, Infection Control Activities,

CPR, Fire Safety Devices, Disaster

Management, Employees safety devices

such as Personal Protective Equipments etc.

periodical training is also being given to the

staff relating to care of patients, handling of

new equipments, methods devices etc.

In order to ensure the good housekeeping

practices a check list is being maintained in

all wards and patient caring areas. The

sister in charge of the hospital after

satisfying the cleaning operations, fills the

check. Besides a surveillance is being done

by the HIC sister for ensuring the

housekeeping practices.

Mock drills relating code alerts is also

conducted in the hospital regarding child

abduction, Cardio Pulmonary Resuscitation,

fire safety etc.

Proper disposal of biomedical waste is

another important outcome parameter as a

result of the NABH accreditation program in

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the Hospital. The final disposal of the

biomedical waste is being done by IMAGE

by making an MOU with them. Color coded

bins are being for the segregation of the

biomedical waste and personal protective

devices are being used by the staff who deal

in biomedical waste.

The hospital is preparing for surveillance

from the NABH. As a part of it an internal

audit has been conducted in the hospital

by the internal audit team. Further various

levels of training is going on . some of the

training conducted are NABH awareness,

Code alert, data collection and analysis of

indicators, fire and safety, code blue etc.

The hospital quality team are in the

preparation of manual revision, prescription

audit. Etc.

Ajithkumar.S

NABH - ACCREDITATION OF BLOOD BANK

Regional blood transfusion Centre (RBTC),

District Hospital Aluva is the first

government blood bank to get NABH

accreditation in the State. Regional blood

transfusion Centre, Aluva figures out to be

49 in the country and second in the Kerala

to get accredited.

Regional blood transfusion centre, Aluva is

the first regional blood transfusion centre in

the state in 2002.

First blood bank in the State in Health

services to get license for BLOOD

COMPONENTS

Regional blood transfusion centre ,Aluva is

the first in the State to be recognized as

training center for blood bank medical

officers and technicians

The Major Objectives of the RBTC is to

ensure safety of blood that of the donor to

REGIONAL BLOOD TRANSFUSION

CENTRE (RBTC)

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the recipient The blood bank promotes

voluntary blood donation by holding

awareness classes, for Red Ribbon Clubs,

Libraries, Arts & Sports Clubs, Youth &

Labour wings of political parties. This

includes audio visual aids, poster sessions

and film shows for the voluntary blood

donation.

The blood bank has created passion

especially among the youth for voluntary

blood donation. They hold outdoor blood

grouping cum donation camps and maintain

a well indexed donor directory for

emergency needs.

The blood bank conducts training programs

for blood bank medical officers and

technicians to hold academic sessions for

clinicians on rational use of blood.

The RBTC issues safe blood at the rates

specified by the Government to the needy

private hospital patients also. The major

concern is for the poorest section of the

community by providing the subsidized

rate.

This was the first blood bank in India to

enunciate and display a Quality Policy on

Nov 1st2001.

All the processes undertaken in connection

with the manufacture of blood and blood

products conform to well-defined standard

operating procedures is ensured. The

procedures are clearly defined, periodically

reviewed and critical steps and changes

validated.

The most remarkable that the staff is free

to own up mistakes without fear of

retribution and corrective measures taken

to avoid similar mistakes in future. Regular

monitoring and evaluation with stress on

error management is also in place.

Quality manual, standard operating

procedures (SOP) were prepared by the

blood bank.

The Calibration, preventive maintenance

plan and calibration plan are done for all

equipment’s. The Fire safety measures were

undertaken and training given to staffs.

The NABH implementation started on

2011.National Rural health Mission had

given financial support and shored up the

whole process of Accreditation by

providing funds for structural modification,

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conducting trainings , calibration of the

equipment’s ,support in documentation

process, maintenance of equipment etc.

Signage placed and Structural modification

was undertaken in the blood bank.

The trainings were given to internal audit

team to conduct internal audit of the

implementation of the standards.

The Regional Blood Transfusion Centre has

won accolades from all quarters both

Governmental and Non-Governmental

agencies.

The Government has recognized this as the

best one in the Government sector and also

the most outstanding institution in the

efforts for HIV/AIDS prevention on many

occasions.

Pre assessment was conducted by Quality

Council of India on 23/07/2012. The Final

Assessment was conducted on 09 and 12

August 2012 by Quality Council of India.

Accreditation Board of QCI announced

NABH Accreditation on 29.12.2012 by the

Quality Council of India to the hospital.

Sindhu V

MEASURES TO REDUCE MMR IN

KERALA

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


KERALA MEETING AT SHORANUR

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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

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.


KERALA - DEVELOPMENT OF SCORE

CARD

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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 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 it was pointed out that there

is a reduction in primary CS rates from

28.75 to 20.75 when the figures for 2012

and 2013 April-Dec periods were compared.

This trend was reflected in other

parameters like referrals, blood

transfusions etc.

Quality Standards on Sepsis and Amniotic

Fluid Embolism will be shortly developed

for piloting.

Dr .K. Sandeep

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

Department, National Health Mission,


MORTALITY IN KERALA -TRAINING AT

GENERAL HOSPITAL, MANJERI

MMR REVIEW MEETING OF SELECTED

HOSPITALS

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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

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


MORTALITY RATE IN KERALA –

PALAKKAD DISTRICT

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A training on implementation of Quality

standards was conducted at District

Hospital Mananthavady on 05-04-2014. Dr.

V.P Paily from Kerala Federation of

Obstetrics and Gynecology have visited

District Hospital Mananthavady to appraise

the obstetricians and labour room staff

regarding the data collection for the

project. District Medial Officer (DMO),

District Programme Manager (DPM), RCH

Officer and Superintendent from District

Hospital Mananthavady are also

participated in the training. The objective of

the training is to improve the quality of care

provided to the patient.

Dr Paily has visited the Labour room and

Operation Theatre along with the

Gynecologist.

Jojin George

As part of the programme Measures to

Reduce MMR in Kerala, the following

hospitals were selected from Trivandrum

District; they are Women and Children

Hospital Thycaudu, SAT Hospital, District

Model Hospital Perrrorkada, THQH

Chirayankeezhu and CHC Kanyakulangara.

The strategies implemented so far are

posted JPHNs to all selected institutions

specifically for MMR reduction; Supplied

disposable delivery kits to all institution;

Started data collection from the prescribed

format; Introduced delivery register to all

selected hospitals; Conducting periodical

visit to all pilot hospitals and verified

documents; Formulated Quality standards

as centralized and distributed to all the

selected Hospitals; Displayed Quality

Standards Flow Charts to labour rooms as

well as gynecology wards.

IMPROVING MATERNITY CARE IN

TRIVANDRUM DISTRICT


MORTALITY IN KERALA TRAINING AT

DISTRICT HOSPITAL, MANANTHAVADY

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Dr. Pailly from KFOG has conducted

orientation training on quality standards at

institutional level.

The District Programme Manager visits

periodically to all pilot hospitals and

verifying documents and other

requirements. The Quality Assurance team

also assists him and preparing report for

further developments.

Thushara Bhaskar

As a part of the implementation of

Measures to Reduce MMR project in Kerala,

a new data format was circulated to all

selected hospitals.

The format intended to collect the details of

maternal health care in the selected

hospitals. The pilot hospitals were sent

MMR data in every month to the state

office. The data set of individual hospitals

includes the consolidated details of the

labor room register.

The quality assurance team of SPMSU

consolidated the data before 15th of every

month in excel format. The detailed analysis

of the collected data was done in every

month and presented before the members

of the working group and gynecologists of

the selected hospitals in review meeting.

Ashitha G R

MMR DATA ANALYSIS

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KERALA ACCREDITATION STANDARDS

FOR HOSPITALS (KASH)

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,

KASH - THQH PARASSALA

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displayed citizen charter, patient rights and

responsibilities, displayed layout of the

hospital ,placed fire extinguishers with fire

exit route plan etc.

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

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

KASH ACCREDITATION OF PHC

THIRUVAMBADY KOZHIKODE

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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 ASSESSMENT AT PHC VALAKOM ,

ERNAKULAM

KASH - THQH PUNALUR- KOLLAM

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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.

Personnel record file for all staff introduced.

Committees formed for the implementation

of standards.

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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

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Only 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

hospital. Hospital has tied-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

the quality standard. Fire safety equipments

were implemented. Training programmes

were conducted to improve the proficiency

of staff.

Muthulakshmy .K.S

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

KASH Standards.

Community Health Centre Kanjeettukara is

at Ayroor panchayath and under the

Koipuram block panchayath which is

situated about 7 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

this hospital.

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.

KASH - COMMUNITY HEALTH CENTRE,

KANJEETUKARA PATHANAMTHITTA

KASH - MENTAL HEALTH CENTRE,

THRISSUR

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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.

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.

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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

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

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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,

and Placed fire extinguishers, and

Employees personnel file.

Devi .G

Women and Children hospital was

established in 1942 as “Sachivothama Sir C

P Ramaswami Aiyar Shashtyabda Poorthi

Memorial Hospital”. It is situated nearly to

Alappuzha Beach, Near Railway Station and

old Port. It is the major maternity hospital

in government sector in Alappuzha district.

The institution is 308 bedded and spreads in

9 acres of land.

Patient safety and risk assessment is the

process of minimizing risk to an

organization by developing systems to

identify and analyze potential hazards to

prevent accidents, injuries, and other

adverse occurrences, and by attempting to

handle events and incidents which do occur

in such a manner that their effect and cost

WOMEN AND CHILDREN HOSPITAL,

ALAPPUZHA

PHC- KARAVALUR- KOLLAM

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are minimized and development of systems

to prevent accidents, injuries, and other

adverse occurrences in an institutional

setting. The concept includes prevention or

reduction in adverse events or incidents

involving employees, patients, or facilities.

In WCH Provision for toilets for physically

challenged patients made available. Fire

extinguishers are provided in all hospitals

periodically checked and maintained ,

provision for safe drinking water made

available, identification tag for mother and

child implemented, floor mats / anti skid

tiles provided in slippery areas….etc. Before

the introduction of the program the

institution conducts only sanitary rounds,

focusing only on cleanliness of ward, but

the hospitals are started to do safety

rounds quarterly. Safety rounds focuses on

electrical safety, plumbing inspection for

leakage and block, fire safety, risk

associated with day to day functioning,

facilities for patient, patient and staff safety

etc. The quarterly safety rounds are

conducting by a team comprising of

Superintendent, RMO, Nursing

superintendent, HIC Nurse, JC(QA) NHM,

PRO and electrician cum plumber and

records are maintained.

Infection control activities and proper

housekeeping are one of the most

important aspects of the program, A good

housekeeping service is an asset which no

hospital can afford to neglect. It is an

important variable in ensuring quality

assurance of hospitals. Dr. Sathyan

Infection control officer and Mrs. Leela

Infection control nurse are holding the

steering of IC activities in hospital. Registers

to track the hospital acquired infections and

needle stick injuries are implemented and

staff trained on it. Facilities for proper hand

washing are made available. System for

identifying, reporting, investigating and

controlling infections are in place. Hospital

have developed an antibiotic policy. The

institution ensures periodic training of staff.

Spill management kit made available in all

patient care areas. HIC team ensures

periodic training of staff in infection control

related activities. The hospital has received

award from pollution control board in past

consecutive years.

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Information displays are one of the

important criteria to achieve the

accreditation. The hospital displayed scope

of services, hospital lay out, mission and

vision, applicable user charge and tariff list,

no bribing policy, no smoking policy, patient

rights and responsibility, signage boards,

displayed medicine list and instruction in

pharmacy etc.

The institution has developed 32 quality

indicators as part of KASH programme.

Periodical collection and analysis of data is

helping the institution to measure the

improvements and to take Corrective

actions based on it.

In WCH there is an evidenced remarkable

change in health care quality. The support

of Superintendent, Consultants, medical

officers, nursing, administrative and

supportive staff for the implementation of

KASH programme helped the institution to

made a dynamic change in implementation

of quality standards. The hospital applied

for KASH assessment in 2nd week of April.

Margaret Lincy

PKKSM Taluk Hospital, Kayamkulam is a 125

Bedded Govt Hospital upgraded to the

level of ‘Taluk Hospital’ Kayamkulam on

6th November 2009 GO(MS No. 568/2008

Health & Family Welfare Dept. TVM Dtd.

6/11/2008) which is functioning in 2.7 acres

of land, the Hospital is functioning in 10

Blocks with 17 various departments /units.

The institutions have an OP of 30000 and IP

of 780 per month.

The QA activities done in the hospitals are

hospital Apex manuals and policy

procedures drafted, registers implemented

to track and analyze hospital quality

indicators. Proper hand washing facility

implemented. Racks and containers are

purchased for the storage of medicines in

ward and Pharmacy and for the storage of

medical records. Hospital Lay out prepared

and exhibited. House keeping checklist

THQH KAYAMKULAM

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implemented in all areas. Contact number

of ambulance drivers with tariff rate

exhibited near casualty. Curtain separation

provided in casualty, labour room for

ensuring patient privacy.

Margaret Lincy

THQH Chavakkad is the only hospital

selected for NABH accreditation

programme from Thrissur. Pre assessment

of the NABH was done on 9th & 10th of

June 2012 by the QCI assessors. Now

hospital closed 60% of NCs regarding the

pre-assessment. We hope the hospital will

get the accreditation in this year itself.

For the State level accreditation programme

we have selected, in the preliminary phase,

Thqh Kodungallur, Chc Puthenchira, Chc

Erumapetty, Phc Manalur and Phc Puthur.

THQH Kodungallur:- This hospital’s bed

strength is 176. More than 1000 out-

patients were visiting the hospital per day

and around 182 patients were treated as in-

patient per day. Before the quality

accreditation programme, it was a very

tedious job to control the huge number of

patients with the limited facilities in the

OPD, so additional staff were engaged for

the smooth running of the OPD. But

through the quality accreditation

programme, the hospital implemented

token system which controlled the rush in

the OPD without any manpower. The

computerized OPD will be a reality in the

near future. The work is in the final stage.

New case-sheet was implemented in the

hospital as per the quality standards instead

of old paper pieces. Hospital has got AERB

license for the x-ray unit. Fire safety

equipments were installed for the hospital

safety purpose. Hospital renovation work

has been going on.

CHC Puthenchira and CHC Erumapetty:-

CHC Puthenchira had undergone KASH

assessment on 2nd September 2013 and

submitted the NC closing report to

QUALITY ASSURANCE PROGRAMME IN

THRISSUR DISTRICT

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accreditation board. The low IP occupancy

rate which is the only reason in delay of

accreditation. As per the KASH standard Chc

Puthenchira had achieved 75 %. These

CHC’s got a new phase through the state

level accreditation programme. Before the

starting of state level accreditation, they

have no hospital signage boards and

informatory displays, no water purifier for

patient’s drinking purpose . But after the

implementation of the state level

accreditation programme, the hospital

obtained display boards of hospital

facilities, patient rights & responsibilities,

Doctor’s name, notice boards, hospital

layout &floor plan. New OP and enquiry

counter, breast feeding corner, separate

toilet for physically handicapped patient,

new case sheet were also implemented as

per the quality standard.

Token system has been implemented in

these CHC’s. Equipment’s calibration has

completed. Curtains fixed in all patient care

areas for the privacy of patients. Infection

control monitoring system, Patient

feedback & complaint redressal system

have also been started as part of total

quality management and we are regularly

conducting the continuous trainings in

different subjects for improving the skills of

all category of staff. In CHC Erumapetty

the construction work of new building is in

the full swing.

PHC Manalur & PHC Puthur:- Tremendous

changes have been happened after

implementing the KASH. They all got up

from the ventilator and they can easily

breath now. Before the implementation

these hospitals were in a very pathetic

condition in all means. Through the quality

standard implementation programme the

standard of the hospitals have been grown

up step by step and it is going to be a high-

tech PHC’s in near future. It has undergone

structural modification, conducted training

programmes for improving skills of staffs

and also conducting patient awareness

classes. Breast feeding corner, IUD corner,

OP Counter, Consultation rooms, Separate

toilet for handicapped patients, patient

waiting areas were constructed and new

token system was also implemented. Phc

Manalur tied-up with IMAGE for the proper

bio-medical waste disposal. Equipments

were calibrated. PHC Manalur had

undergone KASH assessment on 16th

November 2013. NC closing activities are

going on in full swing.

DH Thrissur, THQH Wadakkanchery, THQH

Chalakkudy, THQH Kunnamkulam, THQH

Irinjalakkuda, TH Chelakkara; These

hospitals are in a preliminary stage of

implementation process of quality

standard. The above hospitals were trying

their level best to take part this tedious

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process within their limitation. New case

sheet implemented, fixed various patient

informatory boards, new baby feeding

room installed, provided continuous

training for staffs, curtains fixed in all

patient care areas, equipments calibrated,

periodical monitoring of infection control

practices were some of the modifications

done through the implementation of quality

up gradation programme.

Muthuleshmy K S

Kerala government has introduced a new

Accreditation program (KASH) for uplifting

the quality standards and services given by

the Government hospitals in all care

settings. KASH seems to have drawn

inspiration from the new environment in

the government hospitals that have gone

through or are going through the National

Accreditation Board for Hospital and

Healthcare Providers (NABH) accreditation

process. This program focuses on the total

quality development of the Hospitals and

the practices of the healthcare Institutions.

Under KASH, government hospitals will

receive accreditation from the State if these

fulfill certain criteria. KASH standards have

been evolved out of the Indian Public

Health Standards and the NABH guidelines

so that each level of health care institution

maintains an essential standards charter

within its scope and limitations. KASH

Program started in the year 2010- 2011 and

the first phase includes 2 PHC’s, 2 CHc’s and

one District Hospital. The second phase

started in the year 2012 and it includes all

the secondary and tertiary care Hospitals.

KASH program in Trivandrum district

started in the year 2012. District Program

Manager Dr. B. Unnikrishnan has taken

strong initiative in implementing this

program in the district.

KASH IMPLIMENTATION TRIVANDRUM

DISTRICT

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In Trivandrum District other than the

selected hospitals for KASH implementation

many hospitals voluntarily come forward

for the implementation of this program. Till

date 14 hospitals in the state got KASH

accreditation out of this 8 is from

Trivandrum District and three hospitals are

in the phase of KASH assessment.

The District which has made a pioneer

achievement in KASH Accreditation process

is Trivandrum, which have the first KASH

accredited Community Health Centre (CHC

Manamboor) first KASH Accredited Primary

Health Centre (PHC Chemmaruthy) and first

KASH Accredited Taluk Hospital (TH

Parassala). CHC Vellarada, PHC

Mangalapuram, PHC Vattiyoorkavu, PHC

Chenkal and PHC Keezhattingal are the

other 5 Institutions which have got KASH

Accreditation. Staffs of NHM Triavandrum,

LSG’s and the Hospital staffs had taken a

great effort in pull off this recognition to

the district.

The folk wisdom is “roots have to go deep

for the tree to stand erect” and similarly, in

public health system, the roots are PHC and

CHC and unless these are qualitatively deep

to play its role, the rest of the system would

fail. Taking this into mind DPM together

with quality team, LSG’s and the medical

officers of the concerned PHC’s and CHC’s

work hard towards achieving the quality

parameters point out in the KASH

standards.

Like thousands of PHC’s and CHC’s in our

country, the CHC’s and PHC’s in Trivandrum

are not different. Health programmes in the

past have been beset with problems such as

limited capacity, lack of programme

standards and guidelines, and an obsession

with quantified targets rather than client

satisfaction.

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The new quality parameters introduced by

the state Government seek to address

problems of poor sanitation and cleanliness

in hospitals, staff shortage in every

category, damaged and pathetic condition

of the building and campus, poor signage

system in hospitals, absence of patient

satisfaction monitoring system, lack of a

measurable parameter for patient safety

and absence of legal compliances etc

Hence, KASH Accreditation program was

introduced to tackle all these problems, as

also the issues of lack of accountability and

planning in delivery of care to patients, lack

of blood bank/ storage facility in some

hospitals, and the absence of quality

standards such as medical audit,

management of medication, patient care,

facility management and safety,

information management system,

Biomedical waste management and

infection control.

Before implementing KASH program the

condition of the institutions was very poor.

The hospital doesn’t have a proper signage

system, layouts, display boards, basic

amenities like drinking water, waiting areas

in the OP, Pharmacy, IEC materials

,Geriatric friendly toilets, safety belts for

wheel chairs and trolleys, Emergency

medicine checklists with equipments and

medicines, display of available medicines in

pharmacy ,privacy for patients during

examination, lack of awareness among

staffs about the quality parameters to be

followed ,unhygienic sterilization practices,

spill management techniques, handling of

BMW wastes and its treatment, lack of

awareness about the code alerts, infection

control practices, unhygienic environments,

damaged and pathetic condition of the

buildings etc.

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NHM followed a three phase strategy for

implementing the KASH program in our

District. First Phase include the gap analysis

of the concerned institution, the quality

team visited each hospital and prepared a

gap analysis report. Based on the gap

analysis report the hospital took corrective

action. The second Phase include the

development of Quality Manuals, Training

Programs, Onsite assistance in

implementing the standards in every

departments, renovations, maintenance

,Core committee and subcommittee

formation, team building ,visits and

meetings by DPM , LSG Members for

assistance, and proper guidance . The third

phase includes the self-assessment by the

hospital and application sent for final

assessment.

Some of the practices implemented are

patient satisfaction survey, employee

satisfaction survey, quality indicators, code

blue alert (red for fire, orange for mass

casualties, blue for cardiac arrest, pink for

child abduction), disaster preparedness

plan, basic infection control practices,

fulfillment of patient rights, medication

safety practices, facility management

practices, incidence reporting system,

safety inspection system, patient

information, inventory management,

quality control in diagnostics.

The hospital introduced token system, safe

drinking water facility, seating facility, IEC

materials ,Signage boards at main roads –

bilingual, Separate notice board for

displaying IEC material,

complaint/suggestion box – OP, IP, Lab,

Separate cabin with doctors name,

department name, Open drains closed,

Hanging loose wires tightened, closed open

circuit panels, periodic cleaning of water

tank & chlorination with documentation,

periodic Water sample checking – Biological

and Chemical with documentation, periodic

cleaning of water source , placed fire

extinguishers with checklist, fire exit

signage (white letters in green background)

with exit plan, Unique id number for all

equipments and furniture, Equipment

checklist for all equipments, Housekeeping

checklist board, Breast feeding area, Safety

belt for wheel chairs and trolleys, Handrails

for ramps and bathrooms (for vulnerable

patients) ,Railing of cots for pediatric and

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vulnerable group, Equipment calibration,

removal of old posters and unwanted items,

Infrastructure renovation, Landscaping and

beautification etc has been implemented in

the hospitals.

Besides this, training on biomedical waste

management, Needle prick injuries, CPR,

fire safety, housekeeping, incident

reporting, KASH awareness, Infection

control etc were given. About 53 trainings

conducted in the district as part of KASH

program. Registers for calculating Blood

stream infection rate, UTI rate, Adverse

drug reaction register, Sentinel/Near miss

Event register, Needle prick injury register,

Housekeeping register, Equipment

sterilization register ,CV register, IQC/EQC

register, Sample discard register, Complaint

register ,Reagents with expiry date, Stock

register, Equipment register, Redo register

etc put in place.

In a short period of its implementation

since 2012, the QM system has led to major

positives and overhauls the District’s

healthcare system. Patients have benefited

immensely in terms of the quality of care,

access to privileged medical staff, better

safety conditions, safer transport and

continuity of care.

The benefits of QM have not, however,

been limited to patients. The hospital staff

has also gained in terms of their

professional development, increased

professional satisfaction, leadership and

ownership, and a good working

environment. For the community, this has

translated into a quality revolution, marked

by access to comparative database and

disaster preparedness.

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The Quality management system execution

in Trivandrum District is a collaborative

process under the leadership of District

Program Manager Dr. B. Unnikrishnan. The

initiative and support from the top level

management is very renowned in carrying

out the process. DPM together with quality

team visited all the hospitals which are

ready for KASH accreditation, carry out

meetings with LSG’s and staffs of the

hospital. All this would not have been

achieved had we not maintained this

continuous quest towards Quality

improvement.

Quality is an ongoing conquest and we

should not be judging it on our own. It

should be judged by our patients and every

other stakeholder involved in the

healthcare process. It is, after all, not our

belief but the society’s in our Quality that

will make all the difference.

Reshmi G

NABH Programme is being carried out in

District Hospital, Kannur. Pre Assessment

had been conducted on 24th & 25th May

2013. About 101 non – conformities and

observations has been noted. The major

non-conformities assessors pointed out

were non availability of bilingual signage,

documentation, no breast feeding area,

inadequate training of staff, structural

modification for operation theatres and x

ray department etc. The amount allotted is

fully utilized. Sign boards with bilingual

signages has been fixed, play area & breast

feeding areas were established, training is

provided for staff, documentation is now

properly maintained. We had corrected

almost all non - conformities and submitted

the correction report on 19/01/2014.

KASH is being implimented in Taluk Hospital

Payyannur, Taluk Hospital Taliparambu,

Taluk Hospital Koothuparambu, General

Hospital Thalaserry, Taluk Hospital

Peravoor, PHC Edakkad. Bilingual signage

boards has been fixed, proper waste

disposal mechanism has been established,

OPs has been made wheel chair friendly,

hand washing facilities with elbow tap has

been provided and many more. The fund

allotted to all of these institutions are fully

utilized for improving the quality of

services.

Regional Level Training on IMEP was

conducted on 03/01/2014 & 04/01/2014.

QUALITY ASSURANCE PROGRAMME IN

KANNUR DISTRICT

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The participants were from Kannur &

Kasargode. District Level Fire and Safety

Training was conducted on 04/11/2013.

Revathi

Essential standards for laboratory

certification programme.

The standards created by QCI using a multi

stake holder approach, balance the needs

of urban and rural settings and apply to all

medical testing laboratories. The Essential

standards contains 9 clauses (ISO 15189) ie,

organization and management, Personnel,

Laboratory equipments, procurement and

external supplies, Process control,

document control, Internal audit, Control of

non conformities and continual quality

improvement. Compliance with above 9

clauses related standards will be measured

during the assessment by the QCI

empanelled assessors and laboratory gets

laboratory certification .

The following activities are implemented in

laboratories as part of the programme. All

laboratory manuals are amended (Quality

manual, Sample collection manual, Safety

manual, standard operating procedures and

Quality system procedures). Scope of

services with turnaround time and tariff

rate are exhibited in front of labs. Signage

boards placed. Proper waste segregation.

Documentation of environmental

conditions (Temperature charts are

maintained for water bath, fridge and

room.). IQC- Internal quality control by

replicate test method are introduced, and

started to maintain register, Test controls

are used in haematology analyzer and

Biochemistry analyzer, started plotting LJ

charts. Test calibration using commercial

controls are started to do and records are

maintained. Adopted universal precautions

in labs. Proper record keeping. Equipment

labeling done. Sample collection

area separated from the work area using

curtain / screen and Work area specified.

Organogram displayed. Policy and

Objectives are displayed in bilingual

language. Patient grievance redressel

system introduced. Periodic Internal audit

ESSENTIAL STANDARDS FOR

LABORATORY PROGRAMME.

ALAPPUZHA

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completed. Equipment calibration

completed. Periodic staff training in waste

management, blood spillage, mercury

spillage, management of needle prick and

acid spillage and in standard operating

procedures of laboratory. In THQH

Kayamkulam, Laboratory shifted to new

building, Constructed work bench with

granite slabs , electrical works completed.

Margaret Lincy

Quality Council of India is conducting a

laboratory accreditation programme based

on Essential Standards for Medical Testing

Laboratories in India. Kerala is the first and

only state to involve in the Programme

certification process for government

medical laboratories. In the first year so far

194 Government Medical Laboratories were

certified by Quality Council of India. In the

second year programme only 22 labs were

selected. In Trivandrum district two labs are

selected for the second year program. W&C

Thycaud and Public Heath lab Triavndrum.

Out of this W&C lab is certified by QCI for

the second year. PH lab is on the way for

assessment.

During the implementation of programme

induction training has been provided to all

staff working in the laboratory followed by

training on preparation of documents for

the laboratory.

All these laboratories are providing high

quality laboratory services to the patients.

Reliability of the laboratory tests are

assured, which helps the treating doctor to

provide effective treatment and follow up

of the patients. Safe working environment

is provided to all laboratory staff.

All the laboratories have quality manual,

standard operating procedures (SOPs),

sample collection manual and laboratory

safety manual. Internal audit in the form of

self-assessment has been done in all

laboratories prior to final assessment. All

process in the laboratories starting from

reception and specimen collection,

registration of samples, authentic

numbering and storage of samples,

rejection of improperly collected

specimens, checking of labeling of

containers and conditions of specimen,

codification of the samples, testing of the

samples and reporting were standardized.

The internal quality controls were done in

all labs to verify the reliability of the

laboratory test. The patient’s suggestion

ESSENTIAL STANDARDS FOR

LABORATORY PROGRAMME IN

TRIVANDRUM DISTRICT

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and complaints were reviewed for

improving the patient’s satisfaction .The

Biological wastes from all the laboratories

in the district are handled as per biomedical

waste management rules.

Reshmi G

Laboratory of Taluk Head quarters hospital

is the first laboratory in Kerala which got

the QCI certification in IInd year lab

programme. Laboratory achieved this

certification on the basis of implementation

of quality standard in medical testing and

other related quality parameters. After the

accreditation, the number of samples have

been increased tremendously when we

consider the pre-accredited period. This

points out the acceptance of this laboratory

in the public. Other hospitals including

private hospitals are suggesting this hospital

laboratory for medical testing. Medical

Superintendent and Lab technicians are the

key people behind this success. Their

enthusiasm to the accreditation process will

be very much appreciated. Now this lab

generate computerized results.

District level and institutional level

sensitization programmes conducted

regularly for up gradation of quality

standards and also conducted IMEP

trainings, exposure visit to any accredited

hospitals. Review meetings (NABH & KASH

selected hospitals only) has been

conducting on a regular basis to evaluate

the progress of accreditation status as well

as the expenditure of fund in the hospitals

under the quality assurance.

Muthulakshmy K S

TRAINING - QUALITY ASSURANCE .

The Ministry of Health & Family Welfare

commissioned the development of a

National Policy document to address the

issues relating to infection control and

waste management and defined a

TRAINING ON TRAINERS IN INFECTION

MANAGEMENT & ENVIRONMENT

PLAN

ESSENTIAL STANDARD FOR MEDICAL

LABORATORY PROGRAMME IN THQH

CHAVAKKAD

of 60

framework for implementation of an

Infection Management and Environment

Plan (IMEP) in healthcare facilities.

This policy document was commissioned

under the Reproductive and Child Health

Programme Phase - II, with technical and

financial support from DFID and the World

Bank. The Infection Management and

Environment Plan (IMEP) is an approach or

framework for managing – avoiding,

reducing and controlling – health and

environmental risks arising from healthcare

facilities.

Many government hospitals in Kerala are

not managing the infectious waste as per

the biomedical Waste management rules,

disposal of sharps, use of auto disables

syringes, potable water facilities,

sanitations, skills attitude and behavior of

the staff etc were other issues related with

the infection control program.

The aim of the training is to setting up of

well designed, comprehensive and

coordinated infection control programme

aimed at reducing/ eliminating risks to

patients, visitors and providers of care in

government health care institution in

Kerala.

The major objectives of the training are to

assess the awareness of Infection control

activities among the health care providers

in the government health care institutions;

to identify deficiencies of awareness of

Infection control activities among the

health care providers in the government

health care institutions; to impart the state

of the art training on the awareness of

Infection control activities among the

health care providers in the government

health care institutions; to analyze the

effectiveness of Infection control activities

among the health care providers in the

government health care institutions; and to

set up Infection Control Programme in the

government health care institution in

Kerala.

of 60

Methodology of the training was such that

two days Regional level TOT on Infection

Management and Environment Plan was

conducted by National Rural Health Mission

held at five regions; Ernakulam covered

three districts - Ernakulam, Thrissur and

Palakakdu; Thiruvananthapuram covered

Thriuvannathapuram, Kollam,

Pathanamthitta; Kozhikkode covered

Kozhikkode, Wayandu, Malappuram;

Kannur covered Kasargode and Kannur and;

Kottayam covered Alappuzha, Kottayam

and Idukki.

Initially a pre test was conducted to assess

the awareness of the programme. Various

sessions related with Infection control

Activities were conducted by Subject

Experts. Exposure Visit NABH Accredited

Hospitals, Group Discussions, experience

sharing etc were used.

Training materials such as IMEP policy

frame work, Operational Guidelines, soft

copies of power point presentation, Format

for Evaluation of IMEP training, brochures

related with Biomedical Waste

Management, Infection control practices,

Specimen Infection control manual etc were

supplied.

After the training post test was conducted

and certificate for participation were also

issued to the participants.

The topic were covered in the training are

Introduction & Concept - Hospital Infection

Control, IMEP Guidelines & Policies Action

Plan- Policy Frame work 2007, Infection

Control Programme with special emphasis

to Quality Aspects, Standard precautions,

Sterilisation and Disinfection, Isolation

Practices, Occupational Hazards, Hand

Hygiene Practices, Housekeeping in

Hospital. Safe Injection practices, Anti

microbial Resistance, Antibiotic Policy,

Rational Prescription, Biomedical Waste

Management and Sewage Treatment.

Five regional levele training were conducted

at Ernakulam, Trivandrum, Kozhikkode,

Kannur and Kottayam. 197 participants

were attended, which include DyDMOs,

RCH Officers, Junior Administrative Medical

Officers, District Nursing Officers, Medical

Superintendents, Medical Officers and

Senior level Nurses from hospitals were

attended the training.

One of the parameter for assessing the

impact of the IMEP TOT is to setup the

Infection Control Committee in those

of 60

hospital that were attended the TOT. The

participants from the hospitals were asked

to furnish the details of Hic constituted in

their hospital in prescribed format. The

details are shown in the following table.

Sl No

District No Of Hospital

s attended

TOT

Hospitals

constituted HIC

%

1 Trivandrum 6 4 67

2 Pathanamthitta

6 4 67

3 Kollam 6 4 67

4 Malappuram

9 4 44

5 Kozhikode 7 3 43

6 Wayanad 4 2 50

7 Ernakulam 4 4 100

8 Thrissur 5 1 20

9 Palakkad 4 3 75

10 Kasargode 8 2 25

11 Kannur 12 6 50

12 Kottayam 4 1 25

13 Alappuzha 7 4 57

14 Idukki 5 3 60

Total 87 45 52

Ajithkumar. S

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

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.

TWO DAYS WORKSHOP ON PATIENT

SAFETY – ALAPUZHA DISTRICT

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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

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

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All staff individually demonstrated Adult

CPR, Infant CPR and Choking management.

This programme was organized by DPMSU ,

Alappuzha.

Margarat Lincy

One day training was conducted at General

Hosptila payyannur in connection the

preparation of the hospital for Kerala

Accreditation standards for Hospitals

(KASH). The training was conducted on

04/04/2014 at the conference hall of the

hospital.

The Superintendent and about 45 staff in

the hospital attended the training. The

District Quality Assurance Officer and the

Bio medical engineer of Kannur District

coordinated the meeting.

The training was conducted mainly to

sensitize the staff of the hospital for

preparing for the KASH accreditation.

A motivational session has been conducted

initially to sensitse and motive the staff for

the preparation. The staff were made aware

about the importance of the quality

improvement programme and role fo the

staff to improve the quality of the health

care services.

All the chapters in the KASH accreditation

standards were covered in brief to get a

overview of the KASH standards. The feed

back from the staff were also collected in

the session.

The superintendent and staff of the hospital

has informed that they will start the

preparation of the hospital for KASH

standards and application shall be sent with

in three months.

Ajithkumar.S

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

DISTRICT LEVEL TRAINING ON IMEP &

KASH STANDARDS

KASH AWARENESS TRAINING AT GH

PAYYANNUR

of 60

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.

Swathy Laxmi AP

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

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 all

health staff to improve their skills and

implementation of infection control

practices in the hospital. As per the feed

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

INFECTION MANAGEMENT AND

ENVIRONMENT PLAN TRAININGS AT

THRISSUR

of 60

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.

District programme Manager inspected all

areas in the hospital.

PPEs

Food waste central collection

News paper report by Malayala Manorama

on 03-04-2014

HOSPITAL INFECTION CONTROL COMMITTEE LAUNCHING &

STAFF TRAINING IN DISTRICT HOSPITAL, TIRUR

of 60

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

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

trainer.

Margaret Lincy

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

KASH AWARENESS TRAINING IN THQH

CHENGANNUR

of 60

Zonal wise IMEP training conducted in

Pathanamthitta for Nursing Assistants and

Hospital Attenders at District hospital

Kozhencherry and Thaluk hospital Thiruvalla

as part of district quality assurance

programme. The training was 6 days in

THQH Thiruvalla with 70 participants and 8

days in DH Kozhencherry with 95

participants, there were two sessions per

day.

The topics were on Introduction & concept

of Hospital infection control, Biomedical

waste management; Sterilization,

Disinfection, Isolation practices &

Occupational Hazards; Communication

Skills, NABH & KASH, IMEP Guidelines and

policies action plan, Hand Hygiene practices

& Housekeeping in Hospital, Infection

control programme with special emphasis

on quality aspects.

The aim of the training was to create

awareness on hospital infection control,

Biomedical waste management, Hand

Hygiene and to understand the importance

of Communication skills in the hospitals. Dr.

Thomas Alphonse (Suptd. Tvla), Miss

Thressiamma (Head nurse, TVLA), Mr

Ajaykumar (LS,Tvla), Mr Sebastian, Dr

Anitha Kumari (Dy.DMA), Dr Ganga

(Const.Tvla), Dr Sunil Mathew (Const.Tvla),

Dr Sandhya (Suptd.DH), Mr Shylesh

Chandran(QAO.Pta) presented various

topics for the training.

Shylesh Chandran

Training on cardiac pulmonary resuscitation

conducted in CHC Muhamma on 09/10/13

as part of KASH programme. Dr. Deeptilal

had given a well explained lecture on CPR. It

was a hands on training and all staff in CHC

Muhamma demonstrated the CPR steps to

CPR TRAINING AND HOSPITAL

INFECTION CONTROL TRAINING - CHC

MUHAMMA ALAPPUZHA

IMEP TRAINING (ZONAL WISE) IN

PATHANAMTHITTA

of 60

be followed in case of cardiac emergencies.

Total 35 staff participated.

Training on 7 steps of Hand washing

conducted in CHC Muhamma as part of

KASH programme on 15.10.13. Proper hand

washing is an effective way to control

hospital acquired infections. Mrs. Deepti ,

Staff Nurse CHC muhamma had given a

well structured presentation on the need

of proper hand washing and demonstrated

the 7 steps of hand washing. All staff from

bottom to top level, individually

demonstrated the hand washing steps in

the supervision of Medical Officer Dr. Don

Bosco and verified using a checklist. Total

35 staff participated.

Training on “Biomedical waste

management” conducted at CHC

Muhamma on 23/12/14 as part of

implementation of IMAGE waste

management system introduced as part of

KASH programme in hospital. Training given

by IMAGE district co-ordinator. Topics

covered includes types of hospital waste,

segregation, transportation and storage.

Total 34 staff participated in the

programme.

Margaret Lincy

Training on neonatal resuscitation

conducted in W & C Hospital, Alappuzha

on 12/11/13 as part of KASH programme.

Dr.Satyan, Paediatrician delivered an

informative presentation on the topic.

Targeted participants are doctors and

nurses working in W&C. Total 24 staff

participated in the programme.

A training on Infection control and house

keeping practices has conducted in W& C

on 2/12/13 Mrs. Leesamma delivered a

wonderful very informative presentation on

Infection control and house keeping

practices. Targeted participants are nurses

and grade II staff. Total 35 staff

participated. Topics include formation of

infection control committee, surveillance

activities, Care of systems and indwelling

devices, disinfection, waste management,

good house keeping practices etc.

TRAINING ON NEONATAL

RESUSCITATION AND OTHER TRINING

AT W AND C HOSPITAL ALAPPUZHA

of 60

A training on “Biomedical waste

management and Spillage management “

has conducted in W & C Hospital,

Alappuzha on 22/10/13 as part of KASH

programme. Ms. Margaret Lincy JC( QA)

NHM, ALPY conducted the training.

Targeted participants are Nursing

assistants, grade I and Grade II staff. Total

30 staff participated in the programme.

Topics include Biomedical waste

classification, segregation and

transportation, Management of blood spill,

mercury spill and chemical spill.

A training on “POST PARTUM

HAEMORRHAGE – Care of high risk

obstetrics patients “ has conducted in W &

C Hospital, Alappuzha on 22/10/13 as part

of KASH programme. Dr. Geetha Cherian ,

Senior consultant W & C hospital delivered

an excellent talk on recognizing, diagnosing

and initializing appropriate measures to

manage PPH. Total 30 nurses participated in

the programme.

A Training on Blood Transfusion services

conducted in W & C Hospital, Alappuzha

on 12/11/13 as part of KASH programme.

Dr.Meena Beegum , Blood bank medical

officer delivered an informative

presentation on the topic. Targeted

participants are doctors and nurses working

in W&C Hospital. Total 21 staff participated

in the programme.

Margaret Lincy

A training on “hospital infection control

and house keeping practises“ has

conducted in THQH Hospital, Kayamkulam

on 24/10/13 as an initial step of

Implementation of infection control

measures in hospital as part of KASH

programme. Mrs. Leesamma Head Nurse,

THQH Cherthala (NABH & Safe I assessor)

had given an awareness on KASH

standards, Chapter 6 - Infection control and

followed by detailed explanation on

infection control and house keeping

practises in hospitals. Total 30 staff

participated.

Margaret Lincy

TRAINING ON HOSPITAL INFECTION

CONTROL AND HOUSE KEEPING

PRACTISES – THQH KAYAMKULAM

of 60

A workshop on NABH 3rd Edition standards

conducted in THQH Cherthala on

17/10/2013 as part of its ongoing quality

improvement programmes. The programme

started at 8.45 am with a meeting chaired

by Hospital superintendent Dr. Subaida. Dr.

Junaid Rehman Ex.DMO, Ernakulam district

was a special invitee in the programme. He

delivered an excellent talk on “quality

movement of Kerala” and he emphasised

that Kerala health care institutions has

achieved a remarkable position in the

country through its twinkling achievements

in quality services and he congratulated the

effort of staff in THQH Cherthala, that leads

the institution to the achievement“ Ist

accredited Taluk Head Quarters Hospital In

India”. He also explained the strategies

adopted by GH Ernakulam, for the effective

management of hospital.

After the inaugural meeting Dr G.

Venugopal, Orthopedician, THQH Cherthala

has given an overall introduction about the

NABH 3 rd edition, the revised standards

and objective elements. He explained each

standards of NABH in a simple and easily

digestible way. The programme conducted

in two sessions. Total 151 staff participated

in the programme.

Margaret Lincy

NRHM kasaragod conducted an institutional

wise inspection and KASH awareness

programme at TH Trikaripur on12/5/2014.

Inspection has conducted by Regional

Quality Assurance Officer Mr. Ajith Kumar S.

He assessed how much they could attain

the quality accreditation standards. After

this overall assessment, area wise

assessment was done. OP, laboratory,

pharmacy, medical record room, every

wards, etc are included in different areas.

After assessment a training on KASH

standards conducted by Mr Ajith Kumar S,

Regional Quality Assurance officer. The

superintendent of Taluk Hospital,

Thrikaripur has welcomed the deligates and

quality assurance officer has delivered vote

of thanks.

Libiya M Cyriac

NRHM kasaragod conducted an institutional

wise inspection and KASH awareness

programme at CHC Badiaduka on

14/5/2014. Inspection has conducted by

Regional Quality Assurance Officer Mr. Ajith

Kumar S. After assessment institution had

conducted training for the staff on KASH

implimentation by Mr. Ajith Kumar S,

TRAINING AT CHC BADIADUKA

INSTITUTIONAL TRAINING

AT TH TRIKARIPUR

NABH WORKSHOP AT THQH

CHERTHALA

of 60

regional quality assurance officer, it was an

inspiring experience for all of them.

Libiya M Cyriac

NRHM Kasaragod has conducted a District

Level Training On KASH Awareness at DMO

(H) conference hall, Kanhangad, on 13-5-

2014. The programme started at 10 a m,

and inauguration done by DMO(H) Dr. P

Gopinathan in the presence of Dr.

Dineshan, superintendent of TH Nileswhar,

Dr. V. Sureshan, MO of CHC Panathady, Dr.

Mohammed P, MO of PHC Uduma, Dr.

Suresh MO of PHC Vellarikkundu, and Dr.

Sathya Sankara Bhat MO of CHC Badiaduka.

Ajith Kumar S, state quality assurance

officer was the trainer. There were three

sessions for the training which covered all

the topics of KASH, enough time has been

given for discussions, feedback, and to

make action plans.

There were 49 participants for the training

from 7 KASH institution. They were GH

Kasaragod, TH Trikaripur, TH Nileswar, CHC

Panathady, CHC Badiaduka, PHC Uduma,

PHC Vellarikkundu. Superintendents,

medical officers, nursing superintendents,

head nurse, staff nurses, doctors from each

departments, clerks, coordinators,

pharmacists, lab in charges, housekeeping

staffs, health inspectors and head of each

departments were participated in the

training programme.

Libiya M Cyriac

DISTRICT LEVEL TRAINING ON KASH

of 60

QUALITY ASSURANCE - REVIEW MEETINGS

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

QA - BIOMEDICAL ENGINEERING

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

GOVERNMENT / DHS ORDERS.

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.

CIRCULAR ON CODE BLUE BY DIRECTOR

OF HEALTH SERVICES

BIOMEDICAL ENGINEERING-

EQUIPMENT AUDIT

REVIEW MEETING OF QUALITY

ASSURANCE PROGRAMME

of 60

The copy of the circular has been posted in

the website of NRHM.

Dr .K. Sandeep

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

NEW PROGRAMMES - QA

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.

KERALA STANDARDS FOR VACCINE

STORAGE CENTRES – DRAFTING THE

STANDARDS

GO - PRESERVATION OF MEDICAL

RECORDS AND REGISTERS REVISED

of 60

The Standards were developed for the

Regional vaccine storage centre, State

vaccine Storage centre and District Vaccine

Storage Centers

Sindhu. V

NHM has taken a new initiative for

developing the Quality Standards for

Ayurveda and Homoeopathy hospitals and

dispensaries in Kerala Government sector

under Kerala Accreditation Standards for

Health care (KASH) programme. This will

helps to improve the quality of service so as

to provide better health care delivery

system to the people. A quality standards

are being developed for the different

categories of institutions in Ayurveda and

Homeopathy.

Dr G S Balachandran Nair

The Quality Assurance team of Trivandrum

district as per the direction of DPM, NHM

conducted a detailed study on the present

conditions of the Operation theatres and

labor rooms in the hospital. The team

submitted the report to DPM as well as the

superintendents of the hospitals together

with suggestions and recommendations.

Instruction given to take monthly swab

culture reports, cleaning of the AC ducts,

filters, maintain registers to document the

cleaning of the OT etc. Based on the report

the superintendents taken a very good

initiative in maintaining the infection

control practices and this lead to a drastic

change in the present set up.

Reshmi G

Largest number of trainings conducted in

the Health services department is for

improving the Quality of Health Care in

health care institutions. During the last year

431 trainings were conducted with the

technical support from Quality Assurance

wing of NRHM and 12327 staff were

trained.

The important challenges the health

services are now facing is to keep pace with

TRANSFORMATION OF QUALITY CARE

THROUGH TRAINING

OPERATION THEATRE INFECTION

CONTROL STUDY

AYUSH KERALA ACCREDITATION

STANDARDS FOR HEALTH CARE (KASH)

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advances of constant medical and

technological advancement, growing legal

implications, monitoring of the quality

improvement methods. Most of the

professionals in government hospitals have

not received training on quality and safety

as a part of their formal education.

The training in Quality Assurance is the

highest number of training in Kerala health

services department. The training

conducted in Quality Assurance is more

specific which increases the skill, knowledge

and attitude of the staffs.

Training is an important component in the

implementation of quality assurance

programme. The trainings are provided at

State level, district level and institution

level.

One of the major topics, where hospitals

level training provided is infection control.

As part of Implementation of QA standards,

the hospital has conducted training on

Hospital acquired Infection and Control

methods, various trainings like Bio Medical

Waste Management, infection Control

Practices, Bio Medical Waste Segregation,

Safe injection practice, hand washing

techniques, antibiotic policy, hospital

cleaning and Aseptic Precautions.

Training on Advanced Life Support (ALS)

and Basic life support (BLS) were provided

to different hospital staff. Basic life support

(BLS) is the level of medical care which is

used for patients with life-threatening

illnesses or injuries until the patient can be

given full medical care at a hospital. It can

0 50 100 150 200

HIC related topics

ALS/ BLS / …

Fire safety

NABH Awareness

KASH Awareness

MMR

care of patients

others

Topics of training

Sl.

No

Quality Assurance

training

programme-State ,

district and

institutional level

programme

Numb

er of

trainin

gs held

Numb

er of

Partici

apnts

attend

ed

1 2013-14 431 12327

2 2012-13 353 14654

3 2011-12 208 8072

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be provided by trained medical personnel,

including emergency medical technicians

and paramedics who have received BLS

training. All other technical, management,

fire safety and administrative topics were

covered during the training.

The hospital provides training for the code

alerts, how to counter act during disasters

and outbreaks, role and responsibility of the

staffs. Trainings were conducted to improve

the quality of care of patients which

includes uniform care to the patients, ICU

patients, vulnerable patients, obstetric

patients , paediatric patients etc.

The concept of Quality in Government

hospitals has been transformed through

training programmes. Quality relies on 80%

Policy and Procedures, patient safety,

employee safety, better patient care etc, 10

% in infrastructure and 10% in Human

resources. The training in quality Assurance

is an ongoing process and this would help in

improving the skill, attitude and

performance for better patient care.

Sindhu. V

Whatever moving should be trained,

Whatever not moving should be calibrated,

Whatever happens should be documented,

Whatever not happened, not document.

QMS PHILOSOPHY

Quality Kerala - Arogyakeralam Kerala May 2014.pdf · only 18 NABH accredited health care...

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Transcript of Quality Kerala - Arogyakeralam Kerala May 2014.pdf · only 18 NABH accredited health care...