Quality Improvement Programme
CoH
Progress Report of PHC Salun, Dist Kheda
Dr J L Meena
State Quality Assurance Officer
Commissionerate of Health, Gandhinagar
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
1
Progress Report of PHC Salun, Dist Kheda
www.gujhealth.gov.in
CoH
Health & Family Welfare, Govt of Gujarat
2
Quality Improvement Programme
CoH
Financial Progress Report
(Expenditure with Utilization
Certificate)
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
3
Financial Progress Report (Yr 2008-12)
CoH
Year
Total Grant
Received
(NRHM) Rs.
Total Grant
Received
(State) Rs.
Grant Total
(NRHM +
State) Rs.
1
2008-09
0
0
0
0
0
2
2009-10
100000
0
100000
100000
0
3
2010-11
1020000
250000
1270000
1270000
0
4
2011-12
430000
0
430000
295375
134628
1550000
250000
1800000
1665372
134628
S.
No.
Total
www.gujhealth.gov.in
Total
Total
Expenditure Settlement
Rs.
with UC Rs.
Health & Family Welfare, Govt of Gujarat
4
Financial Progress Report (Yr 2008-12)
S.
No.
1
a
b
c
d
2
a
b
c
d
3
a
b
4
5
Detailed
Information
2009-10
Expenditure
Grant
Receive
Infrastructure
New construction
2010-11
Expenditure
Grant
Receive
CoH
2011-12
2012-13
Grant Expenditure Grant Expenditure
Receive
Receive
9500
500000
-
110000
-
237201
-
80000
8074
68124
-
20000
400
68448
-
15000
Man power
-
-
-
-
Class 1
-
-
-
-
Renovation
Maintenance
Display board / Signage
Class 2
100000
Class 3
Class 4
-
1270000
10200
Instrument &
Equipment
New purchased
Maintenance /
Calibration
Training
Operational fund
Total
www.gujhealth.gov.in
-
100000
12500
430000
30000
-
0
30000
41881
86286
113000
-
-
-
40411
105900
24041
20000
-
37079
24730
25000
18134
86719
4887
750743
1821876
1430
128885
293942
15000
110000
538000
1270000
430000
0
Health & Family Welfare, Govt of Gujarat
5
Quality Improvement Programme
CoH
Financial Progress Report
Infrastructure Detailed Year 2008-2012
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
6
Financial Progress Report
Infrastructure Detailed Year 2008 - 09
CoH
S.
No.
Detailed of
Infrastructure
Amt. Rs.
1
NIL
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
7
Financial Progress Report
Infrastructure Detailed Year 2009 - 10
S. No.
Detailed of Infrastructure
Amt. Rs.
1
New Construction, (Ramp, BMW Pit)
2
Renovation( Rain basera, Partition in labour
room , ramp, garden – landscaping )
3
Maintenance( BMW cover, generator
fitting)
Display Board/Signage( Display board,
Fire safety)
4
www.gujhealth.gov.in
CoH
17974
Health & Family Welfare, Govt of Gujarat
8
Financial Progress Report
Infrastructure Detailed Year 2010 - 11
S. No.
Detailed of Infrastructure
1
New Construction (Aluminum Section,
Emergency Room, Injection Room, CSSD,
Many Fold Room, Aluminum Corner)
2
Renovation( PHC & Compound wall Color)
3
Maintenance( Electric Work, Land Filling)
4
Display Board/Signage( Display board of
services, Wall painting of NHP )
www.gujhealth.gov.in
CoH
Amt. Rs.
873773
Health & Family Welfare, Govt of Gujarat
9
Financial Progress Report
Infrastructure Detailed Year 2011 - 12
CoH
S.
No.
Detailed of
Infrastructure
Amt. Rs.
1
NIL
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
10
Quality Improvement Programme
CoH
Financial Progress Report
Manpower Detailed Year 2008-2012
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
11
Financial Progress Report
Manpower Detailed Year 2008-09
S.
No.
1
www.gujhealth.gov.in
CoH
Detailed of
Manpower
Amt. Rs.
NIL
-
Health & Family Welfare, Govt of Gujarat
12
Financial Progress Report
Manpower Detailed Year 2009-10
CoH
S.
No.
Detailed of Manpower
Amt. Rs.
1
2
3
CLASS-1
CLASS-2
CLASS-3
0
0
0
4
CLASS-4 (BIO MEDICAL WASTER
HANDLER SECURITY DAY OR
NIGHT )
10200
TOTAL
10200
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
13
Financial Progress Report
Manpower Detailed Year 2010-11
CoH
S.
No.
Detailed of Manpower
Amt. Rs.
1
CLASS-1
0
2
CLASS-2
0
12500
3
CLASS-3 (DATA OPERATOR)
4
CLASS-4 (DAY & NIGH SECURITY,
GARDENER, BIOMEDICAL WASTE
HANDLER, )
41881
5
Total
54381
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
14
Financial Progress Report
Manpower Detailed Year 2011-12
CoH
S.
No.
Detailed of Manpower
Amt. Rs.
1
CLASS-1
0
2
CLASS-2
0
3
CLASS-3 (COMPUTER OPERATOR)
30000
4
CLASS-4 (DAY & NIGH SECURITY,
GARDENER, BIOMEDICAL WASTE
HANDLER, )
86286
5
Total
116286
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
15
Quality Improvement Programme
CoH
Financial Progress Report
Instrument & Equipment Detailed Year 2008-2012
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
16
Financial Progress Report
Instrument & Equipment Detailed Year 2008-09
S.
No.
1
www.gujhealth.gov.in
CoH
Detailed of
Instrument &
Equipment
Amt. Rs.
NIL
-
Health & Family Welfare, Govt of Gujarat
17
Financial Progress Report
Instrument & Equipment Detailed Year 2009-10
S. Detailed of Instrument &
No.
Equipment
1
New Purchase ( Centrifuge,
LT Kit for basic lab tests)
2
Maintenance & Calibration
3
TOTAL
www.gujhealth.gov.in
CoH
Amt. Rs.
40411
0
40411
Health & Family Welfare, Govt of Gujarat
18
Financial Progress Report
Instrument & Equipment Detailed Year 2010-11
S. Detailed of Instrument &
No.
Equipment
CoH
Amt. Rs.
1
New Purchase ( Centrifuge,
LT Kit for basic lab tests)
105900
2
Maintenance & Calibration
37079
3
TOTAL
142979
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
19
Financial Progress Report
Instrument & Equipment Detailed Year 2011-12
S. Detailed of Instrument &
No.
Equipment
CoH
Amt. Rs.
1
New Purchase ( Centrifuge,
LT Kit for basic lab tests)
24041
2
Maintenance & Calibration
24730
3
TOTAL
48771
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
20
Quality Improvement Programme
CoH
Financial Progress Report
Training Detailed Year 2008-2012
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
21
Monthly Financial Progress Report
Training Detailed year 2008-09
CoH
S.
No.
Detailed of Training
Amt. Rs.
1
Training of all National
Programme to staffs.
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
22
Monthly Financial Progress Report
Training Detailed year 2009-10
CoH
S.
No.
Detailed of Training
Amt. Rs.
1
Training Expense ( Infection
control , Disaster, fire safety,
CPR training and all National
Programme to staffs)
NIL
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
23
Monthly Financial Progress Report
Training Detailed year 2010-11
CoH
S.
No.
Detailed of Training
Amt. Rs.
1
Training Expense ( Infection
control , Disaster, fire safety, CPR
training, FP, LEPROSY and all
National Programme to staffs
etc)
4887
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
24
Monthly Financial Progress Report
Training Detailed year 2011-12
CoH
S.
No.
Detailed of Training
Amt. Rs.
1
Training Expense ( Infection
control , Disaster, fire safety, CPR
training and all National
Programme to staffs)
1430
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
25
Quality Improvement Programme
CoH
Financial Progress Report
Operational Detailed Year 2008-2012
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
26
Monthly Financial Progress Report
Operational Detailed Year 2008-09
CoH
S.
No.
Detailed of Operational
Amt. Rs.
1
Operational Expense( Stationary,
colour Xerox, I- Card, cleaning of
Linen , IEC board, Computer
Expense, Inverter, BMW
equipment, Apron)
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
27
Monthly Financial Progress Report
Operational Detailed Year 2009-10
CoH
S.
No.
Detailed of Operational
Amt. Rs.
1
Operational Expense( Stationary,
colour Xerox, I- Card, cleaning of
Linen , IEC board, Computer
Expense, Inverter, BMW
equipment, Apron)
18134
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
28
Monthly Financial Progress Report
Operational Detailed Year 2010-11
CoH
S.
No.
Detailed of Operational
Amt. Rs.
1
Operational Expense( Stationary,
colour Xerox, I- Card, cleaning of
Linen , IEC board, Computer
Expense, Inverter, BMW
equipment, Apron)
750743
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
29
Monthly Financial Progress Report
Operational Detailed Year 2011-12
CoH
S.
No.
Detailed of Operational
Amt. Rs.
1
Operational Expense( Stationary,
colour Xerox, I- Card, cleaning of
Linen , IEC board, Computer
Expense, Inverter, BMW
equipment, Apron)
128885
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
30
Quality Improvement Programme
CoH
Committee:
Quality Improvement
Programme Committee
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Health & Family Welfare, Govt of Gujarat
31
Overall Functioning of All Committees CoH
Committees shall meet regularly and shall determine the next date of meeting at
every meeting
Agenda of the meeting (as per their scope) shall be determined beforehand and
shall be communicated to all members of the committee
Committees shall discuss, analyze, take a unanimous decision and communicate
the decision for implementation to appropriate department / personnel
Chairman and convener of the committee shall bear the responsibility of
committee functioning
Each committee shall determine the protocols of committee functioning and all
committee members shall abide by it. A copy of committee protocols shall be kept in
committee file
Each committee shall maintain records of proceedings in committee meet in the
form of minutes of the meeting (MoM). The records shall be maintained in
chronological order in committee file.
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
32
Overall Functioning of All Committees CoH
If a detailed analysis of specific agenda under consideration is carried
out a record of same shall be maintained separately and filed in
committee file.
It is advisable that a specific member of the committee shall be given
the responsibility of maintaining all the records of committee
functioning and communicate it to concerned personnel in the
organization.
Committees shall monitor the implementation of decision taken
through physical monitoring / assessments / review etc.
Hospital and staff are obliged to follow the instructions.
Committee shall review their functioning at appropriate intervals, as
decided by chairman of the committee, to assess their functioning
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Health & Family Welfare, Govt of Gujarat
33
Functioning of Committees
S.
No.
Name of the Committee
Functioning
(Yes / No)
Fix interval
of Meeting
1
DRUG / FORMULARY COMMITTEE
YES
3 MNTH
2
HOSPITAL SAFETY COMMITTEE
YES
MONTHLY
3
HOSPITAL ETHICS COMMITTEE
YES
YEARLY
4
DIET COMMITTEE
YES
5
GRIEVANCE HANDLING COMMITTEE
CODE BLUE TEAM/ RESUSCITATION
TEAM
INFECTION CONTROL COMMITTEE
HOSPITAL MAINTENANCE
COMMITTEE
CLINICAL RISK MANAGEMENT
COMMITTEE
EMERGENCY PREPAREDNESS
COMMTTEE
11
No. of Meeting
Planned
CoH
No. of Meeting
Conducted
1st SATURDAY OF
1st SATURDAY OF
JANAUARY, APRIL, JUL & JANAUARY, APRIL, JUL &
OCTOBER
OCTOBER
1st SATURDAY
1st SATURDAY
MONTHLY
2nd SATURDAY
2nd SATURDAY
YES
MONTHLY
2nd SATURDAY
2nd SATURDAY
YES
3 MNTH
1st SATURDAY OF FEB,
MAY, AUG & NOV
1st SATURDAY OF FEB,
MAY, AUG & NOV
YES
MONTHLY
3rd SATURDAY
3rd SATURDAY
YES
MONTHLY
4th SATURDAY
4th SATURDAY
YES
6 MNTH
2nd SATURDAY OF JAN & 2nd SATURDAY OF JAN &
JUL
JUL
YES
6 MNTH
2nd SATURDAY OF FEB &
AUG
CONDEMNATION COMMTTEE
YES
6 MNTH
2nd SATURDAY OF MAR & 2nd SATURDAY OF MAR &
SEP
SEP
12
QUALITY IMPROVEMENT COMMITTEE
YES
MONTHLY
13
SEXUAL HARRESSMENT COMMITTEE
YES
6 MONTH
6
7
8
9
10
www.gujhealth.gov.in
1st SATURDAY
2nd SATURDAY OF FEB &
AUG
1st SATURDAY
2nd SATURDAY OF JAN & 2nd SATURDAY OF JAN &
JUL
JUL
Health & Family Welfare, Govt of Gujarat
34
Quality Improvement Programme
CoH
Yearly Progress of:
Drug Formulary Committee
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Health & Family Welfare, Govt of Gujarat
35
Yearly Progress of:
Drug Formulary Committee
Scope of Work
Develop and issue Policy on
formulary and medication
management
Supervise purchases and
procurement
Supervise and management of
pharmacy
Monitor and evaluate adverse drug
reactions
Manage the control of drugs
Supervise drug information service
Frequency of Meeting
www.gujhealth.gov.in
CoH
Function of the Committee
There is a documented policy and procedure for pharmacy services and medication
usage.
Policies and procedures guide the organization of pharmacy services and usage of
medication.
The policies and procedures shall address the issues related to procurement,
storage, formulary, prescription, dispensing, administration, monitoring and use of
medications.
A list of medication appropriate for the patient's and the organization's resources is
developed.
Policies and procedures guide the prescription of medications.
Policies and procedures guide the safe dispensing of medications.
Policies and procedures guide the use of narcotic drugs and psychotropic
substances.
Policies and procedures govern usage of radioactive or investigational drugs.
Policies and procedures guide the usage of chemotherapeutic agents.
Policies and procedures guide the use of implantable prosthesis.
Policies and procedures guide the shortage of medication.
Monthly
Health & Family Welfare, Govt of Gujarat
36
Yearly Progress of:
Drug Formulary Committee
Name of Committee
Frequency of meeting
Number of members
CoH
Name of the member
Dr. Anjana S. Soni
DRUG / FORMULARY
COMMITTEE
H.G. Shah, Pharmasist
7
7
R.M. Shah MPHS
D.P. Mistri P.R.O.
Helen D. Parmar S.Nurse
Agenda of Meeting
Date of Meeting
Action taken on the decision made
Need of QAC, Function of QAC, Constitution of QAC, Make policy
for Quality Improvement,
Review of standard s/ indicators, Preparation of Quality Manual,
Safety aspect of patients, relatives & staff, training of staff, review
of records/ documents /reports, clinical audits, medical audits,
review of ethical points of staff , co ordination with other
committees, To read and sanction last meeting minute notes; To
review performance indicators of different departments, To discuss
the
reports of all other committees and Suggestions from other stack
holder for continuous quality improvement. Review of infection
control , house keeping & probable disaster.
09/10/10, 04/12/10,
12/02/11, 12/03/11,
05/11/11, 07/04/12,
02/06/12
After reviewing the performance indicators of all
departments, taken proper action to increase the
performance wherever it require.
Also taken action to take daily review concern to
pre-assessment team visit.
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
37
Quality Improvement Programme
CoH
Yearly Progress of:
HOSPITAL SAFETY COMMITTEE
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
38
Yearly Progress of:
HOSPITAL SAFETY COMMITTEE
Scope of Work
CoH
Function of the Committee
The committee will ensure the total hospital safety & security.
Develop and issue Policy
The committee will bring to the notice of the administration, any
on patient, staff, and
visitor safety and security gaps observed for the safety and security of hospital staff & the
patients and their attendants.
A well documented lab safety manual is available in the lab. This
takes care of the safety of the workforce as well as the equipment
Monitor training and
available in the lab.
implementation
Documented policies and procedures exist to prevent adverse
events like wrong site, wrong patient and wrong surgery.
Policies and procedures guide the use of medical gases.
Sentinel events are intensively analyzed and actions should be
Monitor occupational
taken upon the analysis.
health and safety
The organization has an interdisciplinary group assigned to oversee
the hospital wide safety program.
Frequency of Meeting
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Monthly
Health & Family Welfare, Govt of Gujarat
39
Yearly Progress of:
HOSPITAL SAFETY COMMITTEE
Name of Committee
Frequency of meeting
HOSPITAL SAFETY
COMMITTEE
12
Name of committee
HOSPITAL SAFETY COMMITTEE
www.gujhealth.gov.in
Date of Meeting
CoH
Number of members Name of the member
Dr. Anjana S. Soni
Dr. P.R. Trivedi
Mr. Dhanesh P. Mistri
Mr. Mitesh Mistri
8
Mr. Dilipbhai Patel
Smt. F.H. Shah
Smt. Nilam J. Parmar
Mr. Rakesh M. Shah
Agenda of Meeting
30/10/10, 14/03/11, Requirement of day
07/04/12, 04/05/12 or night security,
Decision
Made
Action taken on the
decision made
They
should
recruit
under
NABH
RECURIETED
Health & Family Welfare, Govt of Gujarat
40
Quality Improvement Programme
CoH
Yearly Progress of:
HOSPITAL ETHICS COMMITTEE
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Health & Family Welfare, Govt of Gujarat
41
Yearly Progress of:
HOSPITAL ETHICS COMMITTEE
Scope of Work
CoH
Function of the Committee
1. Education
In cooperation with the hospital administration, its various departments and divisions, and its medical/nursing and
allied health professional staff, the committee will undertake educational efforts in clinical ethics. Depending on the
availability of resources, the committee will develop or assist others in the development of lectures, seminars,
Issue policy on medical ethics
workshops, courses, rounds, in-service programs and the like in clinical ethics. The aims of these educational efforts
will be to provide participants with access to the language, concepts, principles and body of knowledge about ethics
that they need in order to address the complex ethical dimensions of contemporary hospital practice
Review, evaluate and approve cases 2. Policy Review and Development
for clinical research, organ
The committee will assist the hospital and its professional staff in the development of policies and procedures
transplant, experimental
regarding recurrent ethical issues, questions or problems that arise in the care of patients. In this role the committee
therapeutics, ethical dilemmas,
may provide analysis of the ethical aspects of existing or proposed policy or assist in the development of new
terminal care
institutional policy in areas of need.
3. Case Review
Case review is particularly recommended in three specific categories of
decision making:
decisions involving significant ethical ambiguity and perplexity in which case review may provide insight into complex
ethical issues;
Any other potential conflict of ethical
decisions involving disagreement between care providers or between providers and patients/families regarding the
issues and medical policy and
ethical aspects of a patient’s care; or
practice
decisions that involve withholding or withdrawal of life-sustaining treatment which are not adequately addressed in
hospital ethical policies
In this role the committee will not act as a decision-making body, but
will attempt to assist and to provide support to those who do have this
responsibility. Its role in all such cases shall be advisory.
Frequency of Meeting
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Monthly
Health & Family Welfare, Govt of Gujarat
42
Yearly Progress of:
HOSPITAL ETHICS COMMITTEE
Day
Time
Venue
MO
Members
Every 6 month or when required
12:00 to 1:00
MO Chamber
Chairman
Dr. Anjana Soni
Matron
Public Prosecutor (Invitee Member)
SCOPE OF
WORK
www.gujhealth.gov.in
CoH
Dr. Anjana S. Soni
Co Chairman cum
Converier
Smt. H.G. Shah
Member
Smt. Helen D. Parmar
Member
Advocate Son of Ramesh Patel
Issue policy on medical ethics Review, DATE OF MEETING
evaluate and approve cases for clinical 07/04/12, 02/06/12
research,
organ
transplant,
experimental therapeutics, ethical
dilemmas, terminal care
Any potential conflict of ethical issues
and medical policy and practice
Health & Family Welfare, Govt of Gujarat
43
Quality Improvement Programme
CoH
Yearly Progress of:
INFECTION CONTROL COMMITTEE
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Health & Family Welfare, Govt of Gujarat
44
Yearly Progress of:
INFECTION CONTROL COMMITTEE
Scope of Work
Surveillance for infection
control
Data collection on
hospital acquired
infections
Calculation of HAI rates
On job training of
healthcare staff on
infection control practices
Develop report on HAI
trends
Monitor infection control
practices
Frequency of Meeting
www.gujhealth.gov.in
CoH
Function of the Committee
The hospital should have an infection control team.
The team is responsible for day-to-day functioning of infection
control program. They shall support surveillance process and detect
outbreaks.
They shall also participate in infection prevention and control on a
day-to-day basis.
The hospital has designated and qualified infection control nurse for
this activity.
The Infection control team will work together with infection control
committee and bring to their notice if any issues have seen related
to infection.
Every Fifteen days
Health & Family Welfare, Govt of Gujarat
45
Yearly Progress of:
INFECTION CONTROL COMMITTEE
Name of Committee
Frequency of meeting
Number of members
CoH
Name of the member
Dr. Anjana S. Soni
Dr. P.R. Trivedi
Smt. Falguniben H. Shah
Miss Kapila Parmar
INFECTION CONTROL
COMMITTEE
12
8
Smt. Helen D. Parmar
Smt. Meenaben R. Macwan (FHW)
Mr. Rakesh M. SHah
Dr. Manhar Nayak, Nidhi Hospital,
Nadiad.
Date of
Agenda of Meeting
meeting held
Responsibility of infection control committee & team, identification of high
risk area, Discussion about need of BMW equipments, essential records & 23/10/10,
register, surveillance of infection , HAI, Staff safety including immunization & 18/12/10,
periodic medical check up, PEP & PPE , role of house keeping, BMW 29/01/11,
Authorization, BMW disposal & transport services , Reporting of needle stick 05/02/11,
injury & HAI - Action taken, Need of composed pit, training for infection 12/03/11,
control, Review of practical for use of training, BMW annual report , 21/04/12,
Suggestion from stack holder for infection
19/05/12
Control committee.
www.gujhealth.gov.in
Action taken on the decision made
Make sure & supervise every class-4 wear
PPE for BMW handling & also monitor
record of BMW & infection control,
supervise for surveillance & follow of
BMW guideline, supervision for blood
spill & mercury spill management.
Health & Family Welfare, Govt of Gujarat
46
Quality Improvement Programme
CoH
Yearly Progress of:
DIET COMMITTEE
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Health & Family Welfare, Govt of Gujarat
47
Yearly Progress of:
DIET COMMITTEE
Day
Time
Venue
Every 3 month or when required
MO Chamber
RMO
Chairman
Members
Name of committee
DIET COMMITTEE
www.gujhealth.gov.in
DENTIST
DIETICIAN
AHA
Matron
Head Cook
Co Chairman
Converier
Member
Member
Member
CoH
Dr. Anjana S. Soni
Dr. Shital M. Patel[Ayush]
Dietirian
Nilam J. Parmar
J.P. Patel
Hemaben G. Panchal
Number of
Decision Action taken on the
meeting held Agenda of Meeting
Made
decision made
16/10/10,
provide nutritional it should be
02/04/11,
diet to deliverd
supervisied
work started
16/04/1212/05/1
mother
by rch staff
2, 23/06/12
Health & Family Welfare, Govt of Gujarat
48
Quality Improvement Programme
CoH
Yearly Progress of:
GRIEVENCE HANDLING
COMMITTEE
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Health & Family Welfare, Govt of Gujarat
49
Yearly Progress of:
GRIEVENCE HANDLING COMMITTEE
Scope of Work
CoH
Function of the Committee
To issue policy on grievance To issue policy on grievance redressal
redressal
Develop a mechanism of handling employee grievances
To handle all the employee grievances
Develop a mechanism of
The committee has to sort out the problem and find out
handling employee
the solution irrespective of the employee and its
grievances
position.
Preventive measures must be taken by the committee
not to repeat the same problem in future.
To handle all the employee
The committee must take a unbiased decision and it has
grievances
to be respected and accepted by the staff without any
issue.
To issue policy on grievance
To issue policy on grievance redressal
redressal
Frequency of Meeting
www.gujhealth.gov.in
Monthly
Health & Family Welfare, Govt of Gujarat
50
Yearly Progress of:
GRIEVENCE HANDLING COMMITTEE
Day
Time
Venue
Members
Number of meeting held
13/10/10, 08/01/11,
15/03/11, 06/08/11,
21/03/12
www.gujhealth.gov.in
Every month or when RKS Meeting required
12:00 to 1:00 p.m.
MO Chamber
MO
Chairman
RKS Presidence
Co Chairman
QAMO
Member
H.R. Manager
Converier
Member
Junior Pharmasist
Member
X-Ray Assistant
PRO
Member
Matron
Member
Vishakha Sister
Member
Member
Bio-Medical Engineer
Agenda of Meeting
CoH
Dr. Anjana S. Soni
Smt. Renukaben R. Patel
Dr. P. R. Trivedi
Dr. Shital M. Patel[Ayush]
Smt. Hinaben G. Shah
Smt. Falguniben H. Shah
Mr. Dhanesh P. Mistri
Smt. Helen D. Parmar
Smt. Nilam J. Parmar
Smt. Kapilaben Parmar
Decision Made
solution of any grievence reported no grievance
at phc
report reported
Action taken on the decision made
nil
Health & Family Welfare, Govt of Gujarat
51
Quality Improvement Programme
CoH
Yearly Progress of:
Clinical risk management &
Adverse drug event committee
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
52
Yearly Progress of:
Clinical risk management & Adverse drug event committee
Scope of Work
CoH
Function of the Committee
Monitor and analyses
Monitor and analyses sentinel events, accidents, and
sentinel events, accidents,
adverse events.
and adverse events.
Incident Reporting System. Incident Reporting System.
Dealing with external bodies
Dealing with external bodies and individuals.
and individuals.
Deal with Complaints on
Deal with Complaints on Professionals management.
Professionals management.
Risk management policies to
Risk management policies to reduce actual potential
reduce actual potential
patient risk.
patient risk.
Identify trends amongst
Identify trends amongst incident and initiate action
incident and initiate action
Frequency of Meeting
www.gujhealth.gov.in
Monthly
Health & Family Welfare, Govt of Gujarat
53
Yearly Progress of:
Clinical risk management & Adverse drug event committee
Day
Time
Venue
Members
Every Monthor when required
12:00 to 1:00 p.m.
MO Chamber
Medical Officer
Gynecologist
Physician
Matron
Dr. Anjana S. Soni [M.O.]
Dr. Manhar Nayak [Lapro Surgen]
Dr. Harshad Nayak [BHO]
Smt. Helen D. Parmar [RCH S.Nurs]
EMO
Dr. Ajit Thakar
Name of committee
Number of
meeting held
CLINICAL RISK MANAGEMENT
COMMITTEE
16/04/2012,
19/06/12
www.gujhealth.gov.in
Agenda of
Meeting
Decision Made
sensitization of training for the all
staff for class 4
staff
CoH
Action taken on the
decision made
training conducted
Health & Family Welfare, Govt of Gujarat
54
Quality Improvement Programme
CoH
Yearly Progress of:
CODE BLUE TEAM/ RESUSCITATION
TEAM
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
55
Yearly Progress of:
CODE BLUE TEAM/ RESUSCITATION TEAM
Day
Time
Venue
Members
On the site as and when required
12:00 to 1:00 p.m.
MO Chamber
Anesthetist
On Duty
Medical Officers
On Duty
Dr. Anjana S. Soni
Nureses
On Duty
Smt. Nilam. J. Parmar
Smt. Helen D. Parmar/ Miss Kapila
Extra nurse from Emergency
Parmar
Security Guard
On Duty
Dineshbhai Parsottam
Ward Servant
On Duty
Bhanubhai R. Chunara
Name of committee
Number of meeting
held
CODE BLUE TEAM/ RESUSCITATION
TEAM
06/11/10, 02/07/11,
05/05/12
www.gujhealth.gov.in
CoH
Agenda of Meeting
Decision
Made
training for disaster
training taken
management & code blue
Action taken on the decision
made
training taken
Health & Family Welfare, Govt of Gujarat
56
Quality Improvement Programme
CoH
Yearly Progress of:
HOSPITAL MAINTENANCE
COMMITTEE
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
57
Yearly Progress of:
HOSPITAL MAINTENANCE COMMITTEE CoH
Scope of Work
Function of the Committee
The committee will ensure the total hospital safety & security.
Develop and issue Policy
The committee will bring to the notice of the administration, any
on patient, staff, and
visitor safety and security gaps observed for the safety and security of hospital staff & the
patients and their attendants.
Monitor training and
implementation
Monitor occupational
health and safety
Frequency of Meeting
www.gujhealth.gov.in
A well documented lab safety manual is available in the lab. This
takes care of the safety of the workforce as well as the equipment
available in the lab.
Documented policies and procedures exist to prevent adverse
events like wrong site, wrong patient and wrong surgery.
Policies and procedures guide the use of medical gases.
Sentinel events are intensively analyzed and actions should be
taken upon the analysis.
The organization has an interdisciplinary group assigned to oversee
the hospital wide safety program.
Monthly
Health & Family Welfare, Govt of Gujarat
58
Yearly Progress of:
HOSPITAL MAINTENANCE COMMITTEE CoH
HOSPITAL MAINTENANCE COMMITTEE
Every Monthor when required
12:00 to 1:00 p.m.
MO Chamber
Medical Officer
Dr. Anjana S. Soni
AHA
Dr. Shital M. Patel[Ayush]
Day
Time
Venue
Members
Name of committee
Bio Medical Engineer
Hardware Engineer
S.I.
Electrician
Plumber
Gardners
Carpenter
Drivers
Number of meeting
held
20/11/10, 15/01/11,
HOSPITAL MAINTENANCE COMMITTEE 12/03/11, 28/04/12,
19/05/12, 15/06/12,
www.gujhealth.gov.in
Smt. Falguniben H. Shah
Rakesh M. Shah [MPHS]
Rakesh M. Shah [MPHS]
Mr. Gopalbhai
Agenda of Meeting
for providing lighting in
garden of phc
Decision
Made
Action taken on the decision
made
should be
done under
NABH
required electric work done..
Health & Family Welfare, Govt of Gujarat
59
Quality Improvement Programme
CoH
Yearly Progress of:
Sexual harassment committee
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
60
Yearly Progress of:
Sexual harassment committee
Scope of Work
CoH
Function of the Committee
Committee is formed to issue policies for
Committee is formed to issue policies for complaint system and
complaint system and recommended producers,
recommended producers, investigation, and disciplinary action.
investigation, and disciplinary action.
The employee harassing another employee can The employee harassing another employee can be an individual of the
be an individual of the same sex.
same sex.
The harasser can be the employee’s supervisor,
manager, customer, coworker, supplier, peer, or
vendor .any individual who is connected to the
employee’s work environment ,other
employee’s who observe or learn about the
sexual harassment can potentially complain of
sexual harassment.
In the organization’s harassment policy, advise
the potential victims that, if they experience
harassment, they should tell the perpetrator to
stop, that the advances or other behaviors are
unwelcome.
Frequency of Meeting
www.gujhealth.gov.in
The harasser can be the employee’s supervisor, manager, customer,
coworker, supplier, peer, or vendor .any individual who is connected to
the employee’s work environment ,other employee’s who observe or
learn about the sexual harassment can potentially complain of sexual
harassment.
In the organization’s harassment policy, advise the potential victims that,
if they experience harassment, they should tell the perpetrator to stop,
that the advances or other behaviors are unwelcome.
Monthly & as or when required
Health & Family Welfare, Govt of Gujarat
61
Yearly Progress of:
Sexual harassment committee
Name of
Committee
Frequency of meeting
Number of
members
CoH
Name of the member
Dr. Anjana S. Soni
Dr. Shital M. Desai
SEXUAL
HERRESSMENT
COMMITTEE
2
6
Smt. Falguniben H.
Shah
Rakesh M. Shah [MPHS]
Mr. Gopalbhai
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
62
Quality Improvement Programme
CoH
Yearly Progress of:
CONDEMNATION COMMITTEE
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
63
Yearly Progress of:
CONDEMNATION COMMITTEE
CoH
Scope of Work
Function of the Committee
No objection certificate under Pollution
Control Act.
Air (prevention and control of
pollution) Act, 1981.
Biomedical waste management
handling rules 1998.
Hazardous waste management and
handling rules Act
Water Prevention and control of
pollution Act
Review for No objection certificate under Pollution
Control Act.
Review Air (prevention and control of pollution) Act,
1981.
Review Biomedical waste management handling rules
1998.
Review Hazardous waste management and handling
rules Act
Review Water Prevention and control of pollution Act
License under Bio-medical
Review License under Bio-medical Management and
Management and handling Rules, 1998. handling Rules, 1998.
Regular Scrap Disposal from the facility Review Regular Scrap Disposal from the facility
Frequency of Meeting
www.gujhealth.gov.in
Monthly
Health & Family Welfare, Govt of Gujarat
64
Yearly Progress of:
CONDEMNATION COMMITTEE
Day
Time
Venue
Members
Name of committee
CONDEMNATION COMMTTEE
www.gujhealth.gov.in
CoH
Every Monthor and as when required
12:00 to 1:00 p.m.
MO Chamber
Chairman
Dr. Anjana S. Soni [M.O.]
Co Chairman
Dr. H.N. Nayak [BHO]
Convener
Dr. Paresh Trivedi [QAMO]
Memebrs
Mr. R.M. Shah [MPHS]
Memebrs
Mrs. Renukaben Patel {RKS President}
Memebrs
Smt. Hinaben G. Shah [Pharmasist]
Memebrs
Smt. F.H. Shah [Lab. Tech.]
Number of meeting
held
15/03/11,
07/05/11,
19/06/12,
Agenda of Meeting
Decision Action taken on the decision
Made
made
to condomn the not
work done
functional items of phc
under mstc
salun
required procedure
completed
Health & Family Welfare, Govt of Gujarat
65
Quality Improvement Programme
CoH
Yearly Progress of:
Disaster management committee & EMERGENCY
PREPAREDNESS COMMITTEE (FIRE & NON FIRE)
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
66
Yearly Progress of:
Disaster management committee & EMERGENCY
PREPAREDNESS COMMITTEE (FIRE & NON FIRE)
Scope of Work
Develop policy on prevention,
management, and control of
emergency situations within
and outside the hospital
Develop plan for handling fire
and non fire emergency
situation
Ensure orientation of such plan
to all
CoH
Function of the Committee
Patient safety aspects and risk management issues are an
integral part of patient care and hospital management.
Staff members, students and volunteers are adequately
trained on specific job duties or responsibilities related to
safety.
The committee will form the policy and provide guidelines for
evaluation control and smooth management in case of events.
This committee will rectify the faults in the system and fill up
the gaps.
Supervise training and mock
drills
The organization has plans for fire and non-fire emergencies
within the facilities.
Management ensures implementation of systems for internal
Implementation of policy / plan
and external reporting of system and process failures.
Frequency of Meeting
Monthly & as or when required
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
67
Yearly Progress of:
CoH
Disaster management committee & EMERGENCY
PREPAREDNESS COMMITTEE (FIRE & NON FIRE)
Day
Time
Venue
Members
Name of committee
EMERGENCY PREPAREDNESS
COMMTTEE
www.gujhealth.gov.in
Every Monthor and as when required
12:00 to 1:00 p.m.
MO Chamber
Chairman
Dr. Anjana S. Soni [M.O.]
Co Chairman
Dr. Shital M. Patel[Ayush]
Convener
Dr. Paresh Trivedi [QAMO]
Memebrs
Mr. D.P. Mistri [PRO]
Memebrs
Smt. Helen D. Parmar [RCH S.Nurse]
Memebrs
Smt. Hinaben G. Shah [Pharmasist]
Memebrs
Mr. R.M. Shah [MPHS]
Number of meeting
held
1
Agenda of Meeting
Decision
Made
Action taken on the decision
made
sensititation of staff for
disaster management
training for
the all staff
training conducted
Health & Family Welfare, Govt of Gujarat
68
Quality Improvement Programme
CoH
Yearly Progress of:
QUALITY IMPROVEMENT COMMITTEE
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
69
Yearly Progress of:
QUALITY IMPROVEMENT COMMITTEE
Scope of Work
CoH
Function of the Committee
This committee shall have representation from management, various clinical and
Discuss, decide and Issue hospital
support departments of the Health Care Organization (HCO). The various quality
Policies related to hospital operations
improvement program shall be developed, implemented and maintained in a
and accreditation.
structured manner.
This committee should have good knowledge of accreditation standards, statutory
Documentation and review of policies requirements, hospital quality assurance principles and evaluation methodologies,
hospital functioning and operations.
This shall incorporate the mission, vision, quality policy, quality objectives, service
Define scope of services
standards, etc.
Define and develop quality parameters
Quality assurance manual has to be prepared and updated periodically.
for clinical and non-clinical activities
Set standards and benchmarks for The organization shall ensure that the practices are in consonance with good
quality parameters
clinical practices.
Function as apex committee for As quality improvement is a dynamic process, it needs to be reviewed at regular
monitoring performance indicators / pre-defined intervals (as defined by the HCO in the quality assurance manual) by
parameters of QMS and medical the multi-disciplinary committee. The review shall also include analysis of key
statistics
indicators as defined by the standards.
Standardization
of
professional Hospital management makes available adequate resources required for quality
procedures and equipment
improvement program.
This shall include the men, material, machine and method. These should be in
Credentialing and Privileging
steady supply so as to ensure that the program function smoothly.
Frequency of Meeting
Monthly
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
70
Yearly Progress of:
CoH
QUALITY IMPROVEMENT COMMITTEE
Name of Committee
Frequency of meeting
Number of members Name of the member
Dr. Anjana S. Soni
QUALITY
IMPROVEMENT
COMMITTEE
H.G. Shah, Pharmasist
12
5
R.M. Shah MPHS
D.P. Mistri P.R.O.
Helen D. Parmar S.Nurse
Name of committee
QUALITY IMPROVEMENT
COMMITTEE
www.gujhealth.gov.in
Number of
meeting held
11/12/10,
18/12/10,
05/11/11,
07/04/12,
04/05/12
Agenda of Meeting
for providing lighting
in garden of PHC,
Cleaning
Decision Action taken on the
Made
decision made
should be
done
required electric work
under
done..
NABH
Health & Family Welfare, Govt of Gujarat
71
Quality Improvement Programme
CoH
Yearly Progress of:
Legal license & Act.
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
72
Yearly Progress of:
CoH
Legal license & Act.
S.
No.
Name of the License / Act.
Available
(Yes / No)
Date of
Validity
Expiry Date
1
Building Permit (From the Municipality).
Yes
Life Time
-
2
No objection certificate from the Chief Fire Officer.
Yes
Life Time
-
3
License under Bio-medical
handling Rules, 1998.
Yes
9/1/2011
-
Management
and
4
No objection certificate under Pollution Control Act.
Yes
9/1/2011
-
5
Radiation Protection Certificate in respect of X-ray
equipments from AERB.
N.A.
-
-
6
Excise permit to store Spirit.
Yes
3/31/2014
-
7
Narcotics and Psychotropic substances license and
Act.
-
-
-
Yes
7/13/2012
-
8
Vehicle registration certificates.
9
Air (prevention and control of pollution) Act, 1981.
-
-
-
10
Atomic energy regulatory body approvals.
-
-
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
73
Yearly Progress of:
CoH
Legal license & Act.
S.
No.
Name of the License / Act.
11
Biomedical
waste
handling rules 1998.
12
management
Available (Yes /
No)
Date of
Validity
Expiry Date
-
-
-
Consumer protection Act, 1986.
-
-
-
13
Dentist regulations, 1976.
-
-
-
14
Drugs and cosmetics Act, 1940.
YES
02/08/2016
-
15
Employees provident fund Act, 1952.
-
-
-
16
Equal remuneration Act, 1976.
-
-
-
17
Fatal accidents Act, 1955.
-
-
-
18
Indian lunacy Act, 1912
(MENTAL HEALTH ACT 1987)
Indian medical council Act and code of
medical ethics, 1956.
-
-
-
-
-
-
Indian nursing council Act, 1947.
-
-
-
19
20
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
74
Yearly Progress of:
CoH
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes /
No)
Date of
Validity
Expiry Date
21
Nurses and Midwives Act, 1953
-
-
-
22
Indian penal code, 1860.
-
-
-
23
Indian trade unions Act, 1926.
-
-
-
24
Maternity benefit Act, 1961.
-
-
-
25
MTP Act, 1971.
-
-
-
26
Minimum wages Act, 1948.
-
-
-
27
National building code.
-
-
-
28
Negotiable instruments Act, 1881.
-
-
-
29
Payment of wages Act, 1936.
-
-
-
30
Persons with disability Act, 1995.
-
-
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
75
Yearly Progress of:
CoH
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes /
No)
Date of
Validity
Expiry Date
31
Pharmacy Act, 1948.
-
-
-
32
PNDT Act, 1996.
-
-
-
33
Licenses under PNDT Act 1996
-
-
-
34
Protection of human rights Act, 1993.
-
-
-
35
BARC, Act.
-
-
-
36
Registration of births and deaths Act,
1969.
-
-
-
37
Tax deducted at source Act.
-
-
-
38
License for the blood bank.
-
-
-
39
Constitution of India.
-
-
-
40
Transplantation of human organs Act,
1994.
-
-
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
76
Current status of DRS in the country
CoH
Progress of:
Clinical Indicators Year 2008-2012
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
77
Progress of:
CoH
Clinical Indicators Year 2008-2012
S.No.
Indicators
2008-09
2009-10
2010-11
2011-12
1
No. of OPD per month (Average)
865
1076
1086
1210
2
IPD Number per month (Average)
25
58
76
113
3
No. of Major / Minor Operation (Average)
2
37
106
248
4
No. of deliveries per month (Average)
24
43
53
48
5
Patient comments indicators
-
75%
85%
87%
6
Employee Satisfaction Indicators
-
100%
100%
100%
7
Bed Occupancy rate
-
63%
71.17%
81.44%
8
ICU occupancy rate
-
-
-
-
9
% utilization of OT
-
14.25
17.54
20.75
10
% of biomedical equipments under repair condition
-
-
-
-
11
% of Biomedical equipments calibrated
100%
100%
100%
12
Number of Patient falls per 1000 patient days
-
-
-
www.gujhealth.gov.in
-
Health & Family Welfare, Govt of Gujarat
78
Progress of:
CoH
Clinical Indicators Year 2008-2012
S.No.
Indicators
2008-09
2009-10
2010-11
2011-12
13
Number of Medication errors per 1000 patient days
-
2%
1%
0.50%
14
Major / Minor adverse drug reaction rate (per 1000 patient days)
-
0
0
0
15
Blood transfusion reaction rate (per 100 BT)
NA
NA
NA
NA
16
Incidence of wrong surgeries (wrong patient, wrong site, wrong
surgery etc.)
-
-
-
-
17
Sentinel events, needle stick injury
-
-
-
-
18
All Hospital Acquired Infection (HAI) rate
-
-
0.2
0.1
19
Urinary Tract Infection (UTI) rate
-
-
-
-
20
Average length of stay
-
1.58
2.21
1.56
21
Total no of infant death & Total No. of Admission.
-
-
-
-
22
Total no of Maternal death & Total No. of Delivery.
-
-
-
-
23
Total no of death(including all) Net Mortality Rate
-
-
-
-
24
% of film wasted in radiology department
-
-
-
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
79
Progress of:
Clinical Indicators Year 2008-2012
Year
2008-09
2009-10
2010-11
2011-12
Total
www.gujhealth.gov.in
CoH
No. of OPD per
month
IPD Number per
month
No. of Major
/ Minor
Operation
No. of deliveries
per month
10377
305
2
283
12910
691
37
510
13036
909
106
634
14520
1350
248
579
50843
3255
393
2006
Health & Family Welfare, Govt of Gujarat
80
Progress of:
CoH
Clinical Indicators Year 2008-2012
Year
2008-09
2009-10
2010-11
2011-12
www.gujhealth.gov.in
Patient comments
indicators
Employee
Satisfaction
Indicators
Bed Occupancy
rate
ICU
occupancy
rate
-
-
-
-
75
100
63.00
-
85
100
71.16
-
87
100
81.44
-
Health & Family Welfare, Govt of Gujarat
81
Progress of:
Clinical Indicators Year 2008-2012
Year
% utilization
of OT
% of biomedical
equipments under
repair condition
% of Biomedical
equipments
calibrated
Number of Patient falls
per 1000 patient days
-
-
-
14.25
-
-
-
17.54
-
100%
-
20.75
-
100%
-
2008-09
2009-10
2010-11
2011-12
CoH
Total
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
82
Progress of:
Clinical Indicators Year 2008-2012
Year
2008-09
2009-10
2010-11
2011-12
CoH
Major / Minor adverse
Number of
Medication drug reaction rate (per
1000 patient days)
errors per
1000 patient
days
Blood transfusion
reaction rate (per
100 BT)
Incidence of wrong
surgeries (wrong patient,
wrong site, wrong
surgery etc.)
-
0
0
0
2
0
0
0
1
0
0
0
0.50
0
0
0
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
83
Progress of:
Clinical Indicators Year 2008-2012
Year
2008-09
2009-10
2010-11
2011-12
CoH
Sentinel
All HAI rate
events, needle
stick injury
UTI rate
Average length of stay
-
-
-
-
-
-
-
1.58
-
0.2
-
2.21
-
0.1
-
1.56
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
84
Progress of:
Clinical Indicators Year 2008-2012
Year
2008-09
2009-10
2010-11
2011-12
CoH
Total no of infant
death & Total No.
of Admission.
Total no of Maternal
death & Total No. of
Delivery.
Total no of
death(including all)
Net Mortality Rate
% of film wasted in
radiology department
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
85
Progress of:
Clinical Indicators Year 2008-2012
CoH
Year
Total Number of Admission
Number of Death
% of Death
2008-09
305
0
0
2009-10
691
0
0
2010-11
909
0
0
2011-12
1350
0
0
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
86
Progress of:
Clinical Indicators Year 2008-2012
CoH
Year
Total Number of Admission +
Delivery
Number of Death
% of Death
2008-09
305
0
0
2009-10
691
0
0
2010-11
909
0
0
2011-12
1350
0
0
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
87
Current status of DRS in the country
CoH
Progress of:
NABH Standards
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
88
JOURNEY TOWARDS NABH
S. NO.
DETAIL
DATE
1
SELF ASSESSMENT
07-10-2009
2
INTERNAL ASSESSMENT
7-09-2010
3
APPLICATION FOR PREASSESSMENT
22-10-2010
4
PREASSESSMENT
30-11-2010
5
APPLICATION FOR FINAL ASSESSMENT
19-01-2011
6
FINAL ASSESSMENT
12-03-2011
7
AWARD CEREMONY FOR N A B H
AWARD
29-04-2011
www.gujhealth.gov.in
CoH
Health & Family Welfare, Govt of Gujarat
89
Progress of:
NABH Standards
www.gujhealth.gov.in
CoH
Health & Family Welfare, Govt of Gujarat
90
Current status of DRS in the country
CoH
Progress of:
Documentation / Infrastructure / Instrument /
Equipment / Manpower / Training etc.
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
91
Following Gaps are fulfilled
CoH
SECTION A INFRASTRUCTURE
•
•
•
•
•
•
•
•
•
•
•
MOU FOR LAUNDRY,HOUSE KEEPING,DIETARY SERVICES.
SAFTEY ARRANGEMENT
RAMP
ACCOMODATION FOR STAFF
TRAINING TO STAFF
DRUG FORMULARY
PROPER PRESCRIPTION IN CASE PAPER
LEAD TIME
PUBLIC ADDRESS SYSTEM
ATTACHED TOILET IN LABOUR ROOM
ATTENDENCE LOUNGE FOR VISITOR
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
92
Following Gaps are fulfilled
CoH
SECTION A INFRASTRUCTURE
•
•
•
•
•
•
•
•
•
•
•
ATTACH TOILET IN LABOUR ROOM
SEPARATE BIOMEDICAL WASTE STORAGE ROOM
ANIMAL GUARD
PARKING FOR STAFF AND EMPLOYEE
SEPARATE ADMINISRATIVE ZONE
NURSHING STATION
EMERGENCY ROOM
MANIFOLD ROOM
COVERED WASHING AREA
COMPOST PIT
SEPARATE AYUSH ROOM
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
93
Following Gaps are fulfilled
CoH
SECTION B PROCESS
• ADEQUATE SIGNAGE
• SECURITY GUARD FOR 24*7
• STAFF VACCINATED
• DOCUMENTATION IS LEGIBLE,TIMED,DATED,NAMED
• LIST FOR INFORMED CONSENT
• HOSPITAL CLEANLINESS AS PER RULE
• ACCIDENTAL SPILLAGE OF WASTE PROPER
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
94
Following Gaps are fulfilled
CoH
SECTION B PROCESS
• DISASTER ACTION PLAN PROPER
• THREE COLOUR REFER CARD AVAILABLE
• AVAILABILITY OF SPECIFIC OPD,IPD ,DISCHARGE
CARD,PARTOGRAPH,TRI COLOUR REFER CARD
• PROPER PRESCREPTION IN CASE PAPER
• PROPER DISPENSING OF MEDICINE
• PROPER STORAGE,MAINTAINANCE OF MEDICINE
• PROPER RECORD KEEPING
• TRAINING OF STAFF
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
95
Following Gaps are fulfilled
CoH
SECTION C GOVERNANCE
• QUALITY MANUAL
• SOP
• EVALUATION OF ALL TRAINING & DOCUMENTED
• STATUTORY REQUIREMENT & FULFILLED
• QUALITY MANUAL IS READY
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
96
Following Gaps are fulfilled
CoH
SECTION C GOVERNANCE
• SOP FOR SUBCENTER,ANTIBIOTIC POLICY,AVAILABLE
• EMPLOYEE ARE VACCINATED AGAINST HEPATITIS B
,TETANUS
• PATIENT RIGHT AND RESPONSIBILITY DISPLAYED IN LOCAL
VERNACULAR LANGUAGE
• EMPLOYEE RIGHT AND RESPONSIBILITY DISPLAYED
• PATIENT ,EMPLOYEE SATISFACTION SURVEY DONE
• APPRAISAL FOR EMPLOYEE AVAILABLE
• ALL STATURARY REQUIRMENT FULLFILLED
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
97
Following Gaps are fulfilled
CoH
SECTION D OUTCOME
•CONTENT OF THE MEDICAL RECORDARE PRE DEFINED
•AUDIT OF MEDICAL RECORD
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
98
HEALTH GOAL AT NATIONAL LEVEL
SR.
NO.
Indicator
1
2
3
4
IMR
MMR
TFR
Malaria Mortality
5
Dengue Mortality
6
Leprosy Prevelence
rate
Tuberculosis DOTS
Service
Engaging Asha
Worker
7
8
www.gujhealth.gov.in
Goal at National Level
30/1000 Live Birth
100/100000 Pregnancy
2.1
Reduction Rate 50% upto 2010
and additional 10% by 2012
Reduction Rate 50% upto 2010
and Sustaining at the level until
2012
1/10,000 population
Maintain 85% Cure Rate
1/1000 Population
CoH
Achieve at PHC
Level
23.1
0
2.3
0
0
1.6
Maintain 85%
Cure Rate
1/1000
Population
Health & Family Welfare, Govt of Gujarat
99
HEALTH GOAL AT COMMUNITY LEVEL CoH
SR
Goal at Community Level
1
Availability of trained community level
worker with drug kit
Health Day at Anganwadi on fix day per
month
Availability of drug at Sub-center
Quality services at PHC level
Improved immunization services by auto
disposable syringe and improve
mobilization
Improve facility for delivery and JSY for
BPL
Improve outreach service
2
3
4
5
6
7
www.gujhealth.gov.in
Achieve at PHC
Level
Available
Maintain
Available
on NABH Pathway
Available
Available
100% coverage in JSY
Maintained
Health & Family Welfare, Govt of Gujarat
100
NABH AWARD FUNCTION CEREMONY NATIONAL
AWARD FOR NABH PHC : SALUN
www.gujhealth.gov.in
CoH
Health & Family Welfare, Govt of Gujarat
101
CoH
Thanks
www.gujhealth.gov.in
Health & Family Welfare, Govt of Gujarat
102
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