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Quality Manual

Standards of HCOs

01 PCS AAC: Access, Assessment

and Continuity of Care

02 PCS COP: Care Of Patients

03 PCS MOM: Management Of

Medication

04 PCS PRE: Patient Rights and

Education

05 PCS HIC: Hospital Infection Control

06 OCS CQI: Continuous Quality

Improvement

07 OCS ROM: Responsibilities Of

Management

08 OCS FMS: Facility Management

and Safety

09 OCS HRM: Human Resource

Management

10 OCS IMS: Information Management

System

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Quality Manual for ISO 9001:2008

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STANDARD MANUAL FOR

HOPE

FOR A COMPLETE SET CLICKHERE

2116

Quality Manual for ISO 9001:2008

HOPEQUALITY

MANUAL

Document No. HOPE/QM

Issue No. 1

Revision No. 0

Effective From: 01.08.2007

QUALITYMANUAL

ISO 9001:2000

HOPE MULTISPECIALITY HOSPITAL &RESEARCH CENTER

3RD FL., GIRISH HEIGHTS, BESIDESBHARAT TALKIES, KAMPTEE ROAD,

SADAR, NAGPUR.Ph. 0712-2556866

CONTENT SHEET

SECTION QUALITY MANUAL PAGE NO.REV.

NO.

0.1 Cover Sheet 1 0

0.2 Content Sheet 2-4 0

0.3 Issue History 5 0

0.4 Revision History of Issue 6 0

1.0 Introduction, Scope, Exclusion, Approval andDistribution

7-9 0

2.0 Hospital Profile 10 0

3.0 Quality Policy & Objectives 11 0

4.0 Quality Management System 12 0

4.1 General Requirements 12-13 0

4.2 Documentation Requirements 13 0

4.2.1 General 13 0

4.2.2 Quality Manual 13-14 0

4.2.3 Control of documents 14 0

4.2.4 Control of Records 14 0

5.0 Management Responsibility 15 0

ty Manual for ISO 9001:2008 - Quality Manual http://qc.hopehospitals.in/nabh-stan

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days sinceProject Due Date

Try these samples

Sample case summary

Sample patient file

Sample bill

5.1 Management Commitment 15 0

5.2 Customer Focus 15 0

5.3 Quality Policy 15-16 0

5.4 Planning 16 0

5.4.1 Quality Objectives 16 0

5.4.2 Quality Management System Planning 17 0

5.5 Responsibility, Authority & Communication 17 0

5.5.1 Responsibility and Authority 17 0

5.5.2 Management Representative 17 0

5.5.3 Internal Communication 18 0

SECTION QUALITY MANUAL PageNo.

Rev.No.

5.6 Management Review 18 0

5.6.1 General 18 0

5.6.2 Review Input 19 0

5.6.3 Review Output 19 0

6 Resource Management 20 0

6.1 Provision of Resources 20 06.2 Human Resources 20 0

6.2.1 General 20 0

6.2.2 Competence Awareness & Training 20-21 0

6.3 Infrastructure 21 0

6.4 Work Environment 21 0

7 Service Realization 22 0

7.1 Planning of Service Realization 22-23 0

7.2 Customer related processes 23 0

7.2.1 Determination of requirements related to service 23 0

7.2.2 Review of Requirements related to the Service 23-24 0

7.2.3 Customer Communication 24 0

7.3 Design & Development 24 0

7.4 Purchasing 25 0

7.4.1 Purchasing Process 25

7.4.2 Purchasing Information 25

7.4.3 Verification of Purchased Product/Service 26

7.5 Production and Service provision 26 0

7.5.1 Control of Production and Service provision 26 0

7.5.2 Validation of Process for Production and ServiceProvision

26 0

7.5.3 Identification and Tractability 26-27 0

7.5.4 Customer Property 27 0

7.5.5 Preservation of Service 27 0

7.6 Control of Monitoring and Measuring Device 28 0

SECTION QUALITY MANUAL Page No. Rev. No.

8. Measurement, Analysis and Improvement 29 0

8.1 General 29 0

8.2 Monitoring and Measurement 29 0

8.2.1 Customer Satisfaction 29 0

8.2.2 Internal Audit 29-30 0

8.2.3 Monitoring and Measurement of Processes 30-31 0

8.2.4 Monitoring and Measurement of Service 31 0

8.3 Control of Non-Conforming Service 31 0

8.4 Analysis of Data 31-32 0

8.5 Improvement 32 0

8.5.1 Continual Improvement 32 0


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requirements of the services provided, adopted as a strategic decision, implemented and

practiced by HOPE MULTISPECIALITY HOSPITAL & RESEARCH CENTER.

SCOPE

The Quality Management System covers all aspects and facets of: “providing

multispeciality medical care under one roof especially expertise in managing criticalmedical emergencies and specialized surgeries”.

QUALITY MANAGEMENT SYSTEM

The Quality Management System flows out of the Quality Policy and objectives stated inthis manual, and is customer- focused & aimed at enhancing customer satisfaction and

winning his loyalty. It also meets the regulatory and legal requirements of the service. Ituses the process approach, systematic identification and management of activities /

processes that are employed through, a sequential process of Plan -Do -Check -Act(PDCA) Cycle.

Plan: It is to establish the objectives & processes necessary to deliverresults.

Do: Implement the processes identif ied.Check: Monitor & measure processes and service against plan & report results.

Act: Take actions to continually improve process performance.

EXCLUSIONS:

ISO 9001:2000 Requirements EXCLUSION TABLE

Exclusion Justification

Design and Development(Clause 7.3)

Hospital does not perform design and developmentactivities. It provides the Services, surgery andtreatments, which are accepted worldwide in

medical circles. Hence the applicability of clause7.3 is excluded

Validation of Processes forService Provision (Clause

7.5.2)

Hospital’s Service does not require any process tobe carried out on experimental basis. Hence the

applicability of clause 7.5.2 is excluded.

APPROVAL

The Management approves this Quality Manual and is committed,

· To diligently practice the QMS and thus to serve customers with great &prompt responsiveness.

· To enhance customer satisfaction by meeting their requirements &

expectations besides complying with relevant statutory and legal obligations.

· To establish, implement and review the quality policy and its objectives,with a view to ensuring their continuous suitability through improvements asnecessary.

· To make available all necessary resources including providing an

infrastructure of facilities for achieving this purpose.

DISTRIBUTION

This Manual, its copies or extract from it, must not be passed on to any person withoutthe written permission of the Proprietor of the Hospital. Unnumbered / Uncontrolled

copies may be given to customer / outside agencies purely for information purpose.UNCONTROLLED copies are not covered under “change control” but are current at the

time of issue.

Management Representative (MR), appointed by the Proprietor, is responsible forestablishing and maintaining the processes of the Quality Management System, for


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periodically reporting to the management on the performance of the system and forpromoting awareness of customer requirements through out the Hospital.

The CONTROLLED copies are covered by “Change Control” and are stamped in red on all

pages. It is the responsibility of CONTROLLED copyholder of this manual to maintainand incorporate all revision on receipt and keep it up to date.

The controlled copy is given to the following:

Master Copy (with the Proprietor)Copy no. 1 (with Chief Executive)

Copy no. 2 (with Chief Manager)All the staff members of the Hospital are allowed to have access to controlled copy lyingwith the Chief Manager.

HOSPITAL PROFILE

HOPE MULTISPECIALITY HOSPITAL & RESEARCH CENTER is a MULTISPECIALITYHOSPITAL established in the year 2005 to render various medical services.

The overall management of the Hospital is looked after under the supervision of Dr. B. K.

Murli, PROPRIETOR. Further the Hospital also employs qualified and highly experiencedpeople to run its operations. The Hospital has the required infrastructure to render theservices.

The Hospital has been following quality management systems stringently, which is clear

from the fact that it has been meeting the tough quality standards prescribed by itscustomers. However now with a view to demonstrate it publicly, it has decided to get it

certified as per ISO 9001:2000 standards so that its working team is motivated tomaintain quality standards regularly thus resulting in better quality services.

1. This Quality Manual is the apex document that describes the Quality

Management System established and implemented by HOPE

MULTISPECIALITY HOSPITAL & RESEARCH CENTER to meet the requirementsof International Standard ISO 9001: 2000 and to consistently provide services thatmeet customer and, where applicable, regulatory requirements. Quality

Management System, which is customer focused, aims to enhance customersatisfaction through the effective application of the system and the processes for its

continual improvement and the assurance of conformity to customer and applicableregulatory requirements.

2. This Manual applies to all activities, which contribute to the quality of

services provided by the Hospital.

OUR QUALITY POLICY

We ensure for our patients:

· The highest standards of clinical care.

· Safe environment.

· Medication safety.

· Respect for right and privacy.

· International injection control standards.

· Access to a dedicated well-trained staff.

OUR QUALITY OBJECTIVES


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The important quality objectives of the Hospital are:

· To regularly upgrade the quality of services provided by the Hospital.

· To provide satisfactory customer service through continuous

improvements of service Quality.

· Achieve, sustain and improve its reputation for excellence in medical

treatment by using modern and effective methods.

· Continuously explore the developments in surgery, medicine and

diagnosis and adopt the latest methods and medicines accordingly.

· Ensure the availability of adequate resources to sustain and maintain

the quality assurance programme of the Hospital and continually

improve its effectiveness.

4. QUALITY MANAGEMENT SYSTEM

4.1 General Requirements

The Hospital has developed and implemented a documented Quality Management

System to meet the requirements of ISO 9001:2000 standards. The Quality Management System is implemented by:

a) Identifying the processes throughout the Hospital including those formanagement activities, provision of resources, service realization andmeasurement needed for the QMS.

b) Determining the sequence and interaction of these processes.

c) Determining the criteria and methods required to ensure the effective

operation and control of these processes.

d) Ensuring the availability of resources and information necessary tosupport the operation and monitoring of these processes.

e) Measuring, monitoring and analyzing these processes.

f) Implementing actions necessary to achieve planned results and

continual improvement of these processes.

The Hospital plans & manages these processes in accordance with QMS. Thesystem also has a framework for controlling processes, which are outsourced.

Main Service Processes:

· Consultation & Diagnostic Process (ODP & IPD)

· Operation Process

· ICU (Intensive Care Unit), Recovery Room, Special ward, General ward,Neonatology Process

· Pharmacy procurement of medicine and sale process

· Pathology Process

· Physiotherapy Process

· Radiology Process

Support Service Processes:

· Registration process· Insurance cover Patients

· Stores Process

Outsourced Processes:

· Meal process

· House-keeping process

Reference for Service Processes:

Annexure - C

4.2 Documentation Requirements


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4.2.1 General

a. The organization chart and job specifications of the key personnel defineand document the level and responsibilities.

b. The statement of the organization’s Quality Policy & Quality Objectivesprovides the basis for QMS.

c. The Quality Manual, which is established and maintained, details the

scope of the QMS and exclusions with justifications.

d. The Quality Management System enjoins documented procedures as

required by ISO 9001:2000.

e. Documented operating process wherever required by the Hospital, suchas Process flow chart and Quality Plans etc.

f. Quality records as required by standard ISO 9001:2000 (4.2.4) for

effective operation and control of activities/processes.

The procedures describing the logical sequence of activities withnecessary control and responsibility are established, documented,

implemented and maintained.

NOTE: The documentation including procedures is based on the sizeand type of our Hospital, complexity and inter-relation of activities and

competence/skill level of personnel. It can be in any form or type of

medium e.g. hard copy/electronic media.

4.2.2 Quality Manual

This Quality Manual, which is established and maintained, details the scope of theQMS, exclusions with justifications & documented procedures or reference to them.

It also describes the interaction between the processes of QMS.

4.2.3 Control of Documents

All Documents of the Quality Management System are controlled. A documentedprocedure (QP 4.1) is established to cover the following:

a. To approve documents for adequacy prior to issue.

b. To review, update and re-approve documents.c. To identify the current revision status of documents.

d. To ensure that relevant version of documents are available at thepoints of use.

e. To ensure legibility, identifiably & irretrievability of the documents.

f. To identify the documents of external origin & control their

distribution.

g. To prevent unintended use of obsolete documents and suitably identify them, if they are retained for any purpose.

Reference:

CONTROL OF DOCUMENTS QP 4.1

4.2.4 Control of Records

A documented procedure, QP 4.2 is established, for the identification, storage,retrieval, protection, retention-period and disposition of all quality records. Quality records are legible, readily identifiable and retrievable.

Records required, as evidence of conformance to requirements and for effectiveoperation, of Quality Management System are controlled.

Reference:

CONTROL OF RECORDS QP 4.2


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5. MANAGEMENT RESPONSIBILITY

5.1 Management Commitment

Management is committed for the development, implementation and improvementof the Quality Management System through:

a) Its Communication to all concerned in the Hospital (through internalmeetings, display on the notice board, internal circulars, internal audit etc.),

the importance of meeting customer as well as regulatory and legal

requirements of the service provided.b) Establishing of the Quality Policy.

c) Establishing of the Quality Objectives.

d) Conducting management review meetings (at least once in ninemonth).

e) Ensuring the availability of necessary resources, physical and human,

for all activities.

5.2 Customer Focus

The Management ensures that customer requirements are determined and arefulfilled with the aim of enhancing customer satisfaction. The top management of

the company believes that “Organizations depend on their customers and thereforeshould understand current and future customer needs, should meet customer

requirements and strive to exceed customer expectations.” Customer requirementsare generated through internal meetings, management review meeting, customerSuggestion / Complaint Form etc.

Reference:

CUSTOMER SUGGESTION / COMPLAINT FORM HOPE /F/5/01

5.3 Quality Policy

The Quality Policy Statement defines the Hospital’s quality policy. Employees arefully briefed about this policy on joining the Hospital and during planned training.

All employees are responsible to implement the Quality Policy of the Hospital. TheQuality Policy is displayed at prominent places within the Hospital and is controlled.

Management, while defining Quality Policy, considers the following;

a. I t is appropriate to the purpose of the services provided by the

Hospital.

b. It reflects commitment to meet the requirements, and continually improve the effectiveness of Quality Management System.

c. It has a framework for defining and reviewing of Quality Objectives.

d. It is communicated and understood by all concerned in the Hospital.

e. I t is regularly reviewed (at least once in a year) for continuingsuitability.

5.4 Planning

5.4.1 Quality Objectives

Management has established the Quality Objectives at relevant functional levelswithin the Hospital.

These objectives are measurable and consistent with the quality policy, commitmentto continual improvement and also provide for meeting the requirements of the

service.

These objectives are reviewed at least once in a year.

5.4.2 Quality Management System Planning

The Quality Management System is planned to meet the requirement of ISO


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9001:2000 and also the Quality Objectives defined by the Hospital. Thedocumented Quality Management System is the result of planning and is in line

with the Quality Objectives that the Management sets. The requirement, which thesystem is meant to meet, are:

1. Determination of the processes needed for the system and application

thereof throughout the Hospital.

2. Determination of the sequence and interaction of these processes.

3. Determination of the criteria and method to ensure the effectiveness

of the operation and control of the processes.

4. Making available the requisite resources, human as well as physical,to support the operation & maintenance of the processes.

5. Monitoring, measuring and analyzing the processes.

6. Initiating actions to achieve planned results and also for continual

improvement of the processes.

The management further ensures that the integrity of the QMS is maintainedwherever and whenever any changes to the system are planned & made.

5.5 Responsibility Authority & Communication

5.5.1 Responsibility And Authority

Responsibility and authority are defined and communicated, to all concerned foreffective quality management. The responsibility and authority of key persons and

organization chart are given in Annexure A & Annexure B respectively.

5.5.2 Management Representative:

Management appoints Chief Executive of the Hospital as a ManagementRepresentative, who, irrespective of other responsibilities, is responsible and

authorized for following:

a. To establish, implement and maintain the processes of Quality Management System.

b. To report to Management on the performance of the Quality Management System and also on any need for improvement.

c. To promote awareness of customer requirements, throughout theHospital.

d. To liaise with external agencies on matters relating to Quality

Management System as deemed necessary.

e. Maintaining the master list of documents and records of all the formsand formats.

f. Control and disposal of obsolete documents in the Hospital

5.5.3 Internal Communication:

Appropriate communication processes regarding Quality Management System & its

effectiveness are established within the Hospital. Management verifies theeffectiveness of such communication(s) and ensures that the same leads andcontributes to effective Quality Management System.

Internal communication is through display of quality policy at appropriate places,briefing the requirements of QMS during internal meetings, internal memo’s, face

to face verbal communication, or communication through telephone etc. Proprietoraddresses the staff to build quality culture in the Hospital at regular interval. Use of

these tools will depend on the type of activity.

5.6 Management Review


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5.6.1 General:

Management reviews the implementation of Quality Management System, at

planned intervals (once in nine months) to ensure its continuing suitability,adequacy and effectiveness.

The review covers:

1. Assessing opportunity for improvement.

2. Evaluation of the need for changes to the QMS.

3. Hospital’s Quality Policy.

4. Hospital’s Quality Objectives.

5. Customer requirements and expectation.

6. Resource requirement.

7. Any other point, which come to the notice of the management.

For this purpose a Management Committee consisting of Proprietor, Chief

Executive and Chief-Manager is appointed. Records of management review aremaintained.

5.6.2 Review Inputs:

The inputs for the management review include the current performance and

opportunities for improvements on the following:

· Follow up action from previous reviews.

· Result of audit reports.

· Customer feedback.

· Customer Suggestion / complaint.

· Process performance and service conformity.

· Resources needed.

· Status of Preventive and Corrective Actions.

· Planned changes that could affect Quality Management System suchas issues related to Quality Policy and Objectives, Technological up-gradation,

Training needs, Resource profiles etc.

· Continued suitability and effectiveness of Quality System.· Recommendation for improvement.

· Any other issue.

5.6.3 Review outputs:

The outputs from the management review meeting, include actions relating to:

a. Improvement of the effectiveness of the Quality Management Systemand its processes.

b. Improvement of service related to the customer requirements.

c. Resources requirements/needs.

The proceedings of the Management Review Meetings are recorded in the form of minutes and extracts circulated to concerned functionaries for action.

Reference:

MANAGEMENT REVIEW MEETING RECORDS HOPE/F/5/02

6. RESOURCE MANAGEMENT

6.1 Provision Of Resources

The Management determines and provide in a timely manner the resources needed:

a. To implement, maintain and improve the Quality Management

System and continually improve its effectiveness; and

b. To enhance customer satisfaction by meeting the customer


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requirements.

Resources include doctors, infrastructure, medicines, equipment, consumables,

equipments, trained personnel, and process control equipments.

Review of resource requirements is carried out formally during internal meetings,

management reviews meetings, resource requirement form and also when any change in courses is required. The requirements for resources are informally

monitored continuously to ensure compliance with statutory regulations, needs andexpectations of patients and Industry.

Reference:RESOURCE REQUIREMENT FORM HOPE/F/6/01

6.2 Human Resources

6.2.1 General

The management ensures that personnel who are assigned responsibilities underthe Quality Management System are competent and are suitably qualified on thebasis of education, training, skill and/or experience. Competency requirements for

various employees have been spelt out by the Hospital.Reference:

QUALITY PLAN FOR COMPETENCE CRITERIA FOR EMPLOYEES QPL 6.2

6.2.2 Competence, Awareness and Training:

The Management takes action to:

a. Lay down competence requisites for personnel performing activitiesaffecting service quality.

b. Provide suitable training to satisfy these needs.

c. Evaluate the effectiveness of the training provided.

d. Ensure that its employees are aware of the relevance and importanceof their activities and their contribution to achieve quality objectives.

e. Maintain appropriate personnel records of education,

skills/experience & training.

Reference:

EMPLOYEE COMPETENCE, EXPERIENCE, COMPETENCE

AND TRAINING RECORD HOPE/F/6/02

EMPLOYEE TRAINING ATTENDENCE RECORD HOPE/F/6/03

6.3 Infrastructure

The Hospital determines, provides and maintains the requisite infrastructure and

facilities (in internal meetings, management review meetings and through resourcerequirement form) for achieving conformity of service including:

a. Buildings, Workspace and associated Utilities.

b. Process equipments, hardware and software.

c. Supporting services, if any.

Reference:

RESOURCE REQUIREMENT FORM HOPE/F/6/01

HOUSE KEEPING CHECK LIST HOPE/F/6/04

6.4 Work Environment

The Hospital further identifies and manages the human and physical factors of thework environment necessary to achieve conformity to service requirements.

7. SERVICE REALIZATION


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7.1 Planning Of Service Realization

Service realization is the sequence of processes and sub-processes required forachieving the service conformity and requirements. Management prepares Process

flow chart, Quality Plans and other associated documents that describe how theprocesses of quality management system are applied.

In planning the processes for realization of service, the Hospital determines the

following, as appropriate:

a) Quality Objectives and requirements related to the characteristics of the service.

b) The need to establish processes and documentation and to provide

resources specific to the service.

c) Verification, validation, monitoring and inspection, specific to theservice and the criteria for its acceptance.

d) The records evidencing the realization process and that the samemeets and fulfills the requirements of the processes and conformance of theresulting service.

The Hospital determines service realization processes & acceptance criteria,through Process flow chart, Quality Plans and other documents for specific service.

To meet the requirements of service planning, following steps are followed:

a) Adhere to diagnostic/ treatment plan as prepared by the consulting doctor.

b) Provide skilled doctors and competent para-medical staff. Provide equipment andmaintain in fit and reliable condition equipment required for - diagnosis, treatment,operation and support services.

c) Establish procedures and stick to these procedures required for rendering quality services- from appointment to discharge of patient.

d) Create and maintain medical records, review records, progress records, diagnosisrecords and surgery records.

e) Identification and verification of patient's progress at appropriate stages duringthe course of treatment.

f) Prepare and maintain quality records.

7.2 Customer Related Processes

7.2.1 Determination of requirement related to the service:

The Hospital determines the customer requirements, which includes the following:

a. Service requirements including availability and support before,during and post treatment as specified by the customer.

b. Requirements necessary for service, if not specified by the customer.

c. Statutory and Regulatory requirements applicable to the service.

d. Additional requirements as decided by the management/ specialist /

consultants, related to the service.

The Hospital has determined and implemented effective arrangements for communicating

with customers in relation to:

a) Information pertaining to range of treatment, the facilities, fee structure andother pertinent details that the patient/ customer may seek.

b) Enquiries and corporate contracts.c) Patient / customer feedback including suggestions & complaints from patients/

customers.

The Hospital has ensured that all patient contracts are subject to contract review. This


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includes release of health record information for, patient/ client payment agreements andthird party administrator arrangements.

7.2.2 Review of Requirements related to service:

The Hospital reviews the customer requirements related to service, together withadditional requirements as determined.

This review is conducted prior to the commitment to supply the service to the

customer to ensure:

a. Service requirements are defined.

b. Contract requirements differing from those previously expressed are

resolved, if any.

c. The Hospital has the ability to meet the defined service requirements.

The results of the review and subsequent follow-up actions are recorded in thecustomer file.

Where the customer does not provide any documented statement of requirements,

the customer requirements are consociated before acceptance, wherever required.

It is ensured that, wherever service requirements are changed, the relevant

documents are amended and the concerned persons are made aware of thechanged requirements.

Note: Such awareness is relevant in the case of service informationcatalogues, brochures, advertisements etc.

7.2.3 Customer Communication

The Hospital identifies and implements effective arrangements for communicatingwith the customer relating to following:

a. Service information. (Through information catalogues, brochures,advertisements etc.)

b. Enquiries, contracts including amendments.

c. Customer feedback including Customer complaints.

7.3 Design & Development

Hospital does not perform design and development activities. It provides the

Services, surgery and treatments, which are accepted worldwide in medical circles.Hence the applicability of clause 7.3 is excluded.

7.4 Purchasing

7.4.1 Purchasing Process

The Hospital controls its purchasing processes to ensure that purchased

Product/Services conform to specified purchase requirements. The type and extentof control applied to the suppliers and purchased Product/Service depends upon

the effect on subsequent Product/Service realization processes or the final resultsof the Service.

The Hospital evaluates and selects suppliers/consultant Doctors/service providersbased on their ability to supply Product/Service in accordance with Hospital’s

requirement. Criteria for selection, evaluation and periodical re-evaluation of suppliers are established. The results of evaluations and necessary follow up

actions are recorded and maintained.

Reference:

QUALITY PLAN FOR EVALUATION AND RE-EVALUATION OF

SUPPLIER / SERVICE PROVIDER/CONSULTANTS QPL/7.4.1QUALITY PLAN FOR PURCHASE QPL/7.4


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7.4.2 Purchasing Information

Purchasing documents contains information describing the Product/Service to bepurchased including, where appropriate, the following:

a. Requirement for approval of Product/Service, procedures, processes and

equipment.b. Requirement for qualification of Product/Service.

c. Quality management system requirements.

The Hospital ensures the adequacy of specified purchase requirements contained in

the purchasing documents, prior to their communication to the supplier. Thepurchasing order can be verbally, telephonic or through purchase order.

Reference:

QUALITY PLAN FOR PURCHASE QPL/7.5

7.4.3 Verification of Purchased Product/Service

The Hospital establishes and implements, inspection and other activities necessary for verification of the purchased Product/Service vis a vis the specified purchase

requirements. Where it is proposed either by the Hospital or its customer, toperform verification activities at the suppliers premises, the intended verification

arrangements and method of Product/Service release, are clearly specified in thepurchasing information.

7.5 Service Provision

7.5.1 Control of Service Provision

The Hospital plans and controls all operations/ service provision under controlled

conditions including as applicable:

a. Making available, information that describes the characteristics of theservice.

b. Availability of work instructions, as necessary.

c. Using and maintaining suitable support services.d. Availability and use of the monitoring and measuring devices, where

applicable.

e. Implementing o f monitoring and measurement activities, whereapplicable.

f. The implementation of release and post-service activities.

7.5.2 Validation of Processes for Service Provision

Hospital’s Service does not require any process to be carried out on experimentalbasis. Hence the applicability of clause 7.5.2 is excluded.

7.5.3 Identification and Traceability

The Hospital identifies, the service provided by suitable means throughout theprocess of service realization.

The Hospital does identify the status of the service with respect to monitoring andmeasurement requirements.

The Hospital does control and record the unique identification of the all the patientsto whom the service has been provided.

7.5.4 Customer Property

The Hospital takes care of the customer property like medical documents etc. while


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it is under its control or is being used by the people working in the Hospital. TheHospital identifies, verifies, protects and safeguards the property of customer. These

medical documents are kept with the incharge/head of the related department. TheHospital duly informs the customer if any of the customer property is lost damaged

or is otherwise found to be unsuitable for use.

7.5.5 Preservation of Product / Service

The Hospital does preserve the conformity of the service / product, includingconstituent parts, with the customer requirements during internal processing and

till release of patient / delivery. This covers identification, handling, storage andprotection.

The Hospital ensures that medicines, equipment, documents, patient items used inthe Hospital are maintained and delivered in a manner that prevents damage,deterioration and loss. Instructions have been given to staff for handling, storage,preservation and timely delivery of services to patients so as to achieve the highest

level of customer satisfaction.

Adequate care is taken during treatment of patients, staff takes appropriate care atapplicable stages of treatment / diagnosis.

The diagnostic records etc. are preserved against damage and deterioration.

The Hospital ensures that the services provided match the treatment plan evolved

during the initial visit of the patient and in the time frame as decided during theinitial consultation. On completion of the treatment, the patient is given detailrecord.

7.6 Control Of Monitoring And Measuring Devices

Hospital has determined the Monitoring and Measurement to be undertaken andMonitoring & Measuring devices to provide evidence of conformity of service

provided.

To ensure valid results, measuring equipment’s are: -

(a) Periodically calibrated or verified against measurement

standards traceable to National or International Standards and CalibrationRecords are reviewed/maintained.

(b) Adjusted or Re-adjusted as necessary.(c) Identified for the Calibration Status.

(d) Safeguarded from Adjustments.(e) Protected from Damage and Deterioration during Handling,

Maintenance and Storage.

When the results of calibration are found to be unsatisfactory or the instrumentgoes out of order, the equipment is immediately discontinued from use and theservice agency is informed. The equipment is put back in use only after the defect issatisfactorily rectified.

In addition the Hospital assess and record the validity of the previous measuringresults when the equipment is found not to conform to requirements.

When used in the monitoring and measurement of specified requirements, the

ability of computer software to satisfy the intended application is confirmed. This isundertaken prior to initial use and reconfirmed as necessary.

Reference:EQUIPMENT CALIBERATION CUM MAINTENANCE

REGISTER HOPE/F/7/11CALIBERATION REPORT HOPE/F/7/12

RECORD OF VALIDITY OF THE PREVIOUSMEASURING RESULT HOPE/F/7/13

8. MEASUREMENT, ANALYSIS & IMPROVEMENT


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8.1 General

The Hospital does define, plan and implement the monitoring, measurement,

analysis and improvement processes needed:

1. To demonstrate conformity of the service.

2. To ensure conformity of Quality Management System.

3. To continually improve the effectiveness.

8.2 Monitoring And Measurement

8.2.1 Customer Satisfaction:

The Hospital does monitor information relating to customer satisfaction as one of the measurements of performance of the quality management system. The Hospitalalso monitors information relating to customer perception for fulfillment of customer requirement. The methodologies for obtaining and using this informationare determined.

Reference:

CUSTOMER FEED BACK FORM HOPE/F/8/01

8.2.2 Internal Audit:

The Hospital conducts periodic planned internal audits (at least once in nine month)

to determine whether the quality management system:

a. Conforms to planned arrangement of the requirements of the

International Standard and to the Quality Management System established by the Hospital.

b. That the internal audit system is effective ly implemented and

maintained.

The Hospital plans the audit program taking into consideration, the status andimportance of the processes and areas to be audited, as well as the results of theprevious audits. The audit criteria, scope, frequency and methods are defined.Selection of auditors is done in a manner, which brings about objectivity and

impartiality of the audit process. In case the audit is conducted departmentally then it is ensured that no person conducts audit in respect of his own area of activity.

A documented procedure (QP 8.2.2) specifying the responsibilities and

requirements for planning and conducting audits and for reporting results andmaintaining records are defined in documented procedures.

Management takes timely corrective actions on deficiencies found and eliminates

non-conformities and the causes detected during the audit without undue delay.Follow up activities includes the verification of the implementation of corrective

actions, and reporting of verification results.

Reference:

QUALITY PLAN FOR INTERNAL AUDIT QP 8.2.2

8.2.3 Monitoring and Measurement of Processes

The Hospital applies suitable methods for monitoring & where applicablemeasurement of QMS processes. These methods do demonstrate their ability to

achieve planned results. When planned results are not achieved, appropriatepreventive & corrective action is taken to ensure conformity of the service.

· QMS process will be monitored and measured by No. of N.C. from

Internal Audit.

· Resource requirement process will be monitored by no. of resourcerequirement raised and there compliance status.

· Purchase Process will be monitored and measured by supplier / serviceprovider performance rating and consultant performance rating.

· HRD process will be monitored and measured by No. of Training


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Programs arranged and effectiveness of training.

· Service Process will be monitored by the progress of service and result of

the service.

· Quality Control process will by monitored and measured by no. of

complaints on Quality.

· Monitoring of quality objectives also is one of the ways to monitor processperformance and its effectiveness and other way is to have a formal review of

the process during management review and index the effectiveness based ona questionnaire (Monitoring and Measurement of QMS Processes).

Reference:

MONITORING AND MEASUREMENT OF QMS PROCESSES HOPE/F/8/08

8.2.4 Monitoring and Measurement of Service

The Hospital monitors and measures the characteristic of the service, to verify thatrequirements for the service are fulfilled. This is carried out at appropriate stage of

the service realization process according to planned arrangement.

Evidence of conformity with the acceptance criteria is documented in the patientfile. Records do indicate the person authorizing for release of service.

Discharge of patient does not proceed until all the planned arrangements havebeen satisfactorily completed, unless otherwise approved by the relevant authority and where applicable by the customer.

8.3 Control Of Non Conforming Service

The Hospital ensures that the service, which does not confirm to the requirements,is identified and controlled to prevent unintended use, delivery and treatment. Thecontrol and related responsibilities and authorities for dealing with

non-conformance service are defined in a documented procedure (QP 8.3).

Reference:

CONTROL OF NON-CONFORMING SERVICES QP 8.3

8.4 Analysis of Data

The Hospital collects and analyzes appropriate data to determine the suitability andeffectiveness of the Quality Management System and to evaluate where continual

improvements of the Quality Management System can be made. This includes datagenerated as a result of monitoring & measurement and from other relevantsources. The Hospital analyses this data, to provide information on:

a. Customer satisfaction.

b. Conformance to service requirements.

c. Characteristics and trends of processes and service including opportunities

for preventive action.

d. Suppliers / Consultants contribution.

8.5 Improvements

8.5.1 Continual Improvement

The Hospital plans and manages the processes necessary for the continual

improvement of the ef fectiveness of Quality Management System and facilitates thecontinual improvement of Quality Management System through the use of Quality Policy, Quality Objectives, Audit results, Analysis of data, Corrective and Preventive

actions and Management Review.

8.5.2 Corrective Action

The Hospital takes actions to eliminate the cause of non-conformity in order toprevent recurrence. Corrective actions are appropriate to the effect of

non-conformities encountered.


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The documented procedure (QP 8.5.2) for corrective action defines requirementsfor:

a. Reviewing Non-conformities (including customer complaints).

b. Determining the causes of non-conformities.

c. Evaluating the need for actions to ensure that non-conformities do notrecur.

d. Determining and implementing the action needed.

e. Recording results of action taken.f. Reviewing of corrective action taken.

Reference:

CORRECTIVE / PREVENTIVE ACTIONS QP 8.5

8.5.3 Preventive Action

The Hospital determines action to eliminate the causes of potential non-conformitiesin order to prevent their occurrence. Preventive action(s) taken are appropriate to

the effect of the potential problems.

The documented procedure (QP 8.5.3) for preventive action defines requirementsfor:

a. Determining potential non-conformities and their causes.

b. Evaluating the need for action, to prevent occurrence of non-conformities.

c. Determining and implementing preventive action needed.

d. Recording results of action taken.

e. Reviewing of preventive action taken.

Reference:

CORRECTIVE / PREVENTIVE ACTIONS QP 8.5ANNEXURE-A

RESPONSIBILITY AND AUTHORITY

PROPRIETOR - All statutory and regulatory requirements related to service

- Service planning and Service control

- Effective utilization of resources

- Over all responsibility for service quality

- Evaluation, Selection and Re-evaluation of Consultants

- To mobilize and monitor finances

- Analysis of QMS data

- Overall incharge for continual improvement of QMS

- Controlling Non confirmity Services

- Taking action for customer Suggestion and complaints

CHIEF EXECUTIVE - Overall responsibility to see whether all the documents are controlledand records are maintained

- To communicate properly the decision of the Management to the allemployees

- Planning and Conducting management review meetings

- Planning and conducting internal audits

- Corporate Empanelment

- Overall Pharmacy & store control and authorizing purchase

- Pathology & Physiotherapy


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- Business Development

- Patient Outstanding

- Evaluation, Selection and Re-evaluation of Suppliers

- Mobilize and monitor human-resource requirement

- To create and provide environment and facility for development of

human resources

- Ensure availability of all type of resources and infrastructure

- Total responsibility for recruitment and training

- Taking corrective & preventive action

CHIEF MANAGER - Developing market and establishing Brand

- Customer Communication, Customer Complaints and Customer

Support & Customer Relation

- Overall control on outsourced process

- To maintain the equipments in working condition

- Taking care of calibration process

- Ensure timely correction of breakdowns

- Ensure effective planning & implementation of preventive maintenance

- Maintain safety of employees

- Preparing all QMS related data

CMO - Billing of Patients

- Consultant Co-Ordination

RMO

- Total responsibility to plan and control the Service

- Discharge Summary

- Appointments

- Consultant Co-Ordination

- Leave approval

- Marinating consultants log sheet

ACCOUNT OFFICER

- Hospital & Pharmacy overall Accounting, Auditing and related legalcompliance

- Prepare and distribute Salary

- Manage Bank operations

- Maintain Management information system (MIS)

FRONT OFFICE EXECUTIVE - Complaints

- Telephone Handing

- STD/Coin Box

- Asst. Patient Relation

- Repair & Maintenance

NURSE IN-CHARGE - Sister In charge

- Medical Equipment Maintenance


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WARD ASSISTANT- Assistant House Keeping

- Maintaining Of H/R Stock

- Repairs & Maintenance Report Sister In charge

PHARMACY ASSISTANT- Party Purchase

- Pharmacy Purchase

- Maintain minimum stocks, where applicable

- Maintain stock record in computer and Maintain physical and ledgerbalance

25

SOP FOR DOCTORS

1. INTRODUCTION:

This department assists all the patients for treatment.

2. SCOPE OF THE DEPARTMENT:


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Counseling of the relatives while admission(by CMO

Billing)

20 min

Meeting the patient after admission / transfer(RMO) 15 min

Information to the consultant(RMO) 10 min

Doctor’s referral(RMO) 30 min

Reporting of the investigation (to consultant)(RMO) Acc to lab TAT

Complaint or query of patient (RMO) 30 min

Filling pre Auth Form(RMO) 1 hour

Filling Discharge card after intimation(RMO) 30 min

2.1 GoalTo give the patients immediate and right treatment

2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the ServicesProvided

2.3 Type of customers and age groups of patients served

· All types of patients (Pvt,TPA,Corporate)

· All types of patients (Below Poverty Line to Higher class)· All age groups (infants to adults)

2.4 Timeliness of services provided

2.5 Extent to whichlevel of care / servicemeets patient needs.Administering the

deliverance of inpatient

care on time with

accuracy and zero error.

3. STRUCTURE:

3.1 Organization chart

4.2 Job descriptionMedical Suprintendent

1. He shall be the head of the medical department, responsible for supervision of the doctors and

making policies for them. He shall hold meetings with the RMO incharge weekly.

2. He sees the establishment and administers the proper treatment and medicines to the patient byRMO.

3. He shall be answerable for all the medico legal cases.4. He shall be the head medical records and responsible for making policies for medical records.5. He is the authority to the release any information from the medical records (patient’s file).6. Address the medical issues / complaints of the patients and take action.7. Communicating with the consultant in case if there is any problem.8. He shall examine every patient on admission and make proper entries thereof and take care that

such medicines as he may think proper for their certain and speedy cure be duly administered.

9. 6. He shall see every patient once a day and oftener, if requested. He shall order and be

responsible for the drugs, surgical instruments and books belonging to the asylum and he shall report

the case of every patient fit for discharge to one or more of the Committee of Visitors.

10. At each monthly meeting he shall state the number of patients received and discharged, thenumber of deaths, the manner of employment, the weekly cost of maintenance with such matters as

may appear as desirable.11. He shall be responsible for the management and condition of the establishment of the medical,surgical and moral treatment of the patients and of all general arrangements within the institute, and in

case of emergency shall have the power of calling on the assistance of any physician or surgeon. He

shall also in all cases of fatal or dangerous accident or other emergency immediately communicate to

the Director.

12. He shall regulate the duties of the Doctors and and prepare from time to time a manual there of for

their guidance.

13. He shall review all the discharge summaries before giving it to the patients.

5.1 Qualification:


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MS, MD or diploma in any specialized field after

Experience5 years experience in hospital.

5.2 Key skills-Managerial skills, Leadership.

Knowledge of medico legal systems.

5.3 Staffing model

1 FTE

5.4 Infrastructure

Working area Medical superintendent office.

1 PC, Printer,Telephone line-1

RMO Incharge-1. He shall be the incharge of all RMOs and responsible for supervision of the RMOs.2. He will make sure that all the medical policies are adhered by the RMOs.3. Helping Director or Medical superintendent in drafting policies and implementing them.4. Address RMO inter-personal issues.

5. He shall lead the team of RMOs and motivate the time to time.6. He shall hold meetings with the RMOs weekly Address the medical issues / complaints of the

patients and take action.

7. He sees the establishment and administers the proper treatment and medicines to the patient by

RMO.

8. He shall handle all the medico legal issues.9. He shall check the entire patient’s files everyday.10. Helping RMOs in Providing answer to queries / justification to the TPA regards to any patient.11. Communicating with the consultant in case if there is any problem.12. He should take round everyday ,speak to the patient relative and ask for feedback.13. He shall see every patient once a day and oftener, if requested.14. At each monthly meeting he shall state the number of patients received and discharged the number of deaths, DAMA, any mismanagement at our end.

15. He shall be responsible for the management and condition of the establishment of the medical,surgical treatment of the patients and of all general arrangements within the institute, and in case of

emergency shall have the protocol of calling on the assistance of any physician or surgeon. He shall

also in all cases of fatal or dangerous accident or other emergency immediately communicate to the

medical superintendent.

16. He shall regulate the duties of the Doctors and and prepare from time to time a manual there of for their guidance.

A. Resident Medical Officer (R.M.O.)(1) RESIDENT MEDICAL OFFICER is the most responsible member of the staff of the Hospital and is

present all times of the day and night on his shift duty. As such no moment the Hospital can be leftuncovered by R.M.O. Even at the end of his shift, he will not leave the post till the other RMO takes

over.(2) He should also be responsible for the conduct of other junior staff posted in his department.

(3) Though they are administratively responsible to hospital managers but for their work they are

directly responsible to consultants.

(4) He is responsible for all the patients admitted in his department (Pvt./Semi- Pvt./ICU/ICCU orEconomy wards) towards proper medical care. Though a patient as always admitted being on thespot under a consultant, but he on the spot, will be responsible for either first-aid if consultant has

not seen the case or for carrying out the orders of that consultant.

(5) He will also he responsible for nursing care being provided by the nursing staff. He will ensurethat all advised tests and procedures are carried out without any delay.

(6) On admission or in emergency he will always carry out necessary examination and historytaking so that case sheet of the patient is completed in all respect. He will ensure that the patient’s

documents are complete more so in cases of medico legal. He should also make sure that

uncommon abbreviations are not used in the case sheet. He will sign the case sheet with hiscomments during all his rounds.

(7) He will also be providing medical aid to admitted cases under a consultant, in time of emergency, but latter informing the consultant about the action taken. He will also consult the


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Meeting the patient after admission / transfer(Checking vitals)

10 min

Doctor’s referral 30 minInvestigation appointment 30 min

Reporting of the investigation Acc to lab TAT

Complaint or query o f patient 30 min

Forms to get filled (insurance) 1 hour

Discharge process 2 hour

Returns of medicine 15 min

Discharge card (doctor to be called) 30 min

· Feedback verbal and written

· Patients/ relatives / RMO/consultant



· All types of patients (Below Poverty Line to Higher class)

· All age groups (infants to adults)

2.4 Timeliness of services provided

2.5 Extent to whichlevel of care / servicemeets patient needs.Administering thedeliverance of inpatient care on timewith accuracy and zeroerror.

3. STRUCTURE: 3.1 Organization chart


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4.2 Job describtion

1. Nursing Superintendent / Matron The Matron will be responsible to the MS for the administrative and technological aspects of nursing in the hospital. Her charter of duties will include the following:

1) Administration of nurses, their accommodation and messing, viz. equitable distribution andeconomic utilization of nursing staff, maintenance of duty roster, turnout and discipline,supervision over living conditions, amenities and messing facilities in the Nurse mess and hostel;leave, temporary duty, training etc.; reports and returns; service record of nurses.2) Nursing care of patient in the hospital:

(a) Supervision of nursing by Sister/Nurses to ensure that the highStandard is maintained all the time.

(b) Welfare of patients including recreational facilities.(c) Cleanliness of Wards/Departments.(d) Accompany the MS on his round.

3) Such other duties, as may be delegated to her by MS.

2. Nursing Supervisor Duties of Nursing/Superintendent/Matron/Nursing Supervisor can be clubbed or divided as peravailable manpower.A. General Management:To ensure

1. Adequate nursing staff.

2. Duty roster well planned.3. Punctuality of staff working under her.4. Nurses in proper uniform.5. Visit to all the patients.6. Availability of material consumable and non-consumable items.7. Availability of life-saving drugs.

8. Availability and functioning of the saving equipment.9. To check and ensure the judicious use of telephone.10. Eatables are not allowed/used at OT or ICU Nursing Stations.

B. Patient Welfare and Safety:Call be well within easy reach.1.Patient clean and presentable.2.Patient appears comfortable, free from pain and tension.3.Bed neatly made.4.

Patient position is correct.5.Used bed pans and urinals removed promptly.6.After meals, the food trays removed promptly.7.

E. Ward General Appearance:Ward/room cleaned and ventilation satisfactory.1.Patients bathroom are clean and in order.2.All wash basins clean.3.All the beds in line.4.All bed pans, kidney trays and dustbins clean and dry.5.All drugs to be checked for expiry date.6.Injection, medicines trolleys fully equipped, clean and tidy.7.Nursing station clean and organized.8.Notice board tidy and outdated notice removed.9.Medicine containers labeled, legible and clean, cupboard tidy and locked.10.Oxygen cylinders and suction apparatus are adequate and in working order.11.Adequate supply of linen, thermometer, syringes, dressing sets and other materials are kept out for

use in the ward in her absence.12.

3. Ward In-Charge/Sister She will be responsible to the Matron/Nursing Superintendent for the efficiency of the Nursingservices in her ward/department.

Her duties wil l be administrative and professional.

A. Administrative duties of her will include the following: Public relations.1.General sanitation in the Ward/department.2.


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Attention to prevention of hospital cross-infection.3.Nursing documentation and reports are required.4.Allotment of duties to subordinates their disciplines, welfare and supervision.5.Attention to economy in manpower and materials.6.Maintenance of stock register/inventories and periodicals checks.7.Check of custody, expenditure and accounting of dangerous and controlled stores.8.

B. Professional duties of her will be as follows:Supervision of Patient care as laid-down under duties of staff nurses and other ward staff.1.Attention to details of arrangements for medical and surgical procedures carries out in

ward/department such as sterilization and observation of asepsis, administration of oxygen,

medicines etc.

2.

Supervisions over demands for and utilization of diets.3.Training of nurses and paramedical personnel.4.Actual nursing care of patients, if required.5.Participation in training programs.6.

4. Staff Nurse General: A nurse by the very nature of her duties is in closer touch with the patients and therefore isin a better position to win his confidence. It is the duty of every nurse to uphold the noble traditions of her profession and dedicate herself to the care of patient in her charge. She should pay particularattention to her turnout and conduct. While maintaining the dignity and decorum of her profession, shemust at all times be cheerful, kind and courteous and sympathetic towards her patients and their anxiousrelatives. These qualities along with professional skill will win her respect and cooperation of herpatients. She must remember as good nursing is as important part of efficient patient care as gooddoctoring.

Specific :All staff nurses should be –wearing white aprons as well overall supplied from the hospital.1.All nurses should enter the hospital from the back gate as specified for staff entry.2.Staff nurses posted in any department (ward, ICU, ICCU, OT etc.) are responsible to the Sisterin-charge of that department for all administrative and clinical work. As far as clinical work isconcerned, they are also responsible to the Resident Doctors on duty and to specialists.

3.

The nurses are assisted by the other staff of the ward such as ward boy, ward girl, Housekeepingstaff.

4.

She has to perform some administrative duties as well along with her professional duties.5.Any other duty, administrative or clinical, assigned by her seniors related to nursing.6.The administrative duties are concerned with efficient and economical ward management and

include activities, which are subsidiary to but cannot be divorced from patient care.7.

These duties are as follows:i) Handing over and taking over charges on change of duty staff.

ii) Cleanliness of ward, annexes, furniture, linen, equipment and stores.iii) Preparation of demands for diet.iv) Preparation of dressings, bandages and splints and items required for dealing withemergencies.v) Keeping an inventory of all items under their charge.vi) Ensuring the serviceability of all equipment and store on charge and accounting forthem.vii) Safe custody and accounting of dangerous and controlled drugs.viii) Replacement of expandable stores and obtaining replacement of unserviceablenon-expandable items, in accordance with standing orders.ix) Exchange of clean linen and patient’s clothing for solid ones.x) Disinfecting the ward, when required.xi) Safe custody and maintenance of medical records of patients.xii) Control of visitors and public relation.

Her Professional Duties are:1.

i) General Nursing Care.ii) Technical Nursing Care.iii) Training Responsibilities.

General nursing care consist of the care of attention to the patient in the interest of his/her comforts andgeneral well being of his/her physical health. The activities grouped under this functional heading aregenerally speaking common to all patients irrespective of the nature of his/her illness. These duties willbe as follows:

i) Admission and Discharge of patients.ii) Assistance and instruction to the patient and their relatives.iii) Personal hygiene of the patient, viz. sponging, care of mouth, eyes, hair and nails.iv) 4-hourly or more frequent attention to pressure points, as ordered, in the case of bed ridden patients.v) Serving and removing hot water bottles, bedpans and urinals.vi) Bed-making.


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vii) Feeding of patient incapable of feeding themselves, distribution of diet andpreparation of special items of food.viii) Ward rounds with Sister/Doctor.ix) Supervision of work of staff placed under her.

Technical nursing care comprises those tasks and activities concerned with the treatment andmanagement of the particular illness of which the patient is suffering. These duties will be as follows:

i) Administration medicines and/or injections as ordered and recording the same.ii) Assisting or actually caring out technical procedures sterilization preparation of injections, preparing and serving of enemas, catheterization, fomentation, irrigation,dressing, oxygen therapy etc. and cleaning up thereafter.iii) Preparation for and assistance in carrying out clinical tests, investigations,including collecting, labeling and dispatching specimens.iv) Taking and recording Pulse, Temperature and Respiration.v) Rounds with doctors.vi) Pre and Pos-operative care.vii) Escorting patients to and from departments.viii) Technical reports.

Training Responsibilitiescover not only the training of those placed under her control but also attention toself-improvement. These will be as follows:

i) Demonstration and guidance to student nurses and domestic staff.ii) Assistance in orientation of new staff .iii) Participation in training program and other professional activities for theadvancement of knowledge and skill.iv) Any other duties related to nursing services.

Main points in nursing duties and responsibilities (Clinical) :1. Admission and Discharge of patients.2. Preparation of patient’s file.3. Sending the patient’s file at the reception at the time of discharge.4. Getting discharge summery prepared by RMO.5. Informing the reception about the room no. of the new admission.6. Informing all transfers to the reception.7. Assistance and instructions to the patients and their relatives.8. Personal hygiene of the patient, viz. sponging, care of mouth, back etc.9. Serving and removing hot water bottles, bedpans and urinals.10. Feeding of patients who can not eat themselves.11. Ward rounds with Nursing Superintendent, M.S. and Consultant if required.12. Administration of medicines and /or injections as ordered and recording the same incase sheet.13. Assisting doctors in carrying out certain procedures whenever required.

14. Assisting or actually carrying out technical procedures, sterilization preparationof injections, indenting of medicines, giving enemas, oxygen therapy etc.15. Collecting samples for investigation whenever required. Getting all tests done,which the treating doctor ordered.16. Taking and recording of vital signs like Pulse, Temperature and Respiration.17. Pre and Pos-operative care.18. Escorting patients to and from departments. OT, either herself or with the help of ward boy.19. Supervision and housekeeping staff getting patient’s room cleaned thrice a day.20. At each change of over, the outgoing nurse will go with the incoming to each patientfrom bed to bed, room to room and thus hand over to the patient.21. Any worsening of the condition of the patient must be reported to theRMO/Consultant in-Charge.22. Imparting health education to the patients and relatives.23. Staff nurse on duty should be changing of IV fluid bottles and in no circumstances

attendant help should be sought for the same.24. While putting cannula to the patient, there should be deep plastic sheet under thesite of arm so as not to strain the bed sheet. This should be strictly followed part should beproperly fixed after confirming its patency.25. In obstetric cases special attention should be given in care of breasts and perineumcare, catheterization of female patient, baby care, assisting in breastfeeding.26. Please ensure that no torn up linen, i.e bed sheets, pillow covers, draw sheets,blankets etc. are given to the patient at any cost.27. Extra caution to be taken for deluxe/VIP suit room patients.

· Tissue Box.

· Small Soap.

28. A fresh towel should be given to the patient at the time of admission.29. In case of surgical patient to prepare patient for operation, i.e. shaving, cleaning and


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dressing etc.30. To confirm that pre-op papers are complete and fully documented (consent,investigation etc.). Proper consent must be taken signature of patient (if major and mentallysound) and nearest relative must in presence of proper witness.31. To confirm that advance for surgery has been paid, before sending the patient forsurgery.

ICU Patients32. Taking care of bedsore and bedridden patients (after physician’s permission).33. Any terminal ill patient should not be left alone.34. Strict vitals charting of ICU patients.35. Assisting in physiotherapy.36. Take care while administering NTG drip, Dopamine drip etc. and should start inpresence of doctor on duty.37. ICU should not be misused for sitting purposes by any other staff while on duty.38. Assistance in orientation of new nurses.39. Any other duty related to nursing services.40. Last but not least, to see chargeable procedures and consumable are written in thepatient’s file in charge sheet.

Some of the chargeable items are:(a) Blood transfusion. (b) Enema.(c) Bowl wash. (d) Gastric lavage.(e) All lab tests. (f) All imaging tests.(g) Oxygen inhalation (h) Cut down.(i) Aspiration (j) Dressing.(k) Baby care for new born. (l) All consultants’ visits.

(m) Medicines are from ward (n) ECG, Echo, U.S., TMT, Endoscopy. but not replaced.

Main Points in Nursing Duties and Responsibilities (Administrative)1. Night nurses, if found sleeping either with patient or attendant or security staff willbe terminated immediately.2. No junior nurse will give an I.V. injection either in vein or in drip set, special drugslike Insulin, Potassium chloride and Lariago.3. Do not appear for duty without your nametag/Identity Card.4. Telephone should not be used for personal chat and staff nurse on duty must checkits misuses, by all means.5. Eatable should not be allowed or used at Nursing Stations of ICU/OT complex.

5. Additional responsibilitiesAttend the phone calls and enquiries about the ward

Make entries in admissions and discharge bookCoordinate with various departments (Admission counter, Casualty, Wards, OT, Medical Records,Diagnostics, Linen, Security, Food & Beverages etc.) for facilitating services.

Providing reference information to consultantsOrdering stationary twice a month and weekly orders of materials.

Co oordinating discharge summary to the patients.Completing the documents in the file before dispatching.

Ensure accurate documentation of treatment related documentsScheduling tests and invasive procedures/ investigations

Liaison with other support services (Housekeeping, F&B, Maintenance, Waste Management andothers) to ensure delivery of careRequisition for medicines and other medical supplies

Ensure accurate billing entries and facilitate discharge planningTo meet the patients daily and assist them in their queries.

Check the insurance status of the patients.To coordinate with different departments and to see the best comfort of the patients during their

stay.Escalate the feedback to the GRO for proper action to be taken.

Complaints received by the nurses to be recorded, follow up is taken if not resolved, and areescalated to guest relations executives.

Updating the documents in the file in the proper sequence.

5.1 Qualification:


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GNM. Multi-lingual preferred.

5.2 Key skills-Good communication skills, mannerism, telephone etiquettes, helping attitude.

Multi-task and to enjoy costumers interactionKnowledge of customer management techniques to deliver higher satisfaction.

5.3 Staffing model

Total staff- 37

Ward M E NSpecial ward-1 3 2 2Special ward-2 3 2 2Special ward-3 3 2 2ICU 3 2 2OT ( including nurses 3 2 2and tech)

5.4 Infrastructure

Working area is at the nursing station of the respective ward.1 PC, Telephone line-1

Documents to be maintainedPatient file-charting1.Nurse record written (TPP – I/O).2.All medications are charted correctly.3.All other treatments charted correctly4.Stock Register5.Investigation reports file6.IP register- entry of the details to be made in the register on admission, discharge, transfer in ortransfer outg

7.

Medication register8.Intubation register9.Linen Register- Daily stock taking of linen is to be maintained.10.Maintenance Log book- the maintenance complaint/issues.11.Inventory register12.

CT MRI register13.Blood issue register14.Communication book15.Duty book16.Stationary order book17.

6. PROCESS FLOW

NO


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Flowchart: Decision:

Blood

test

YES

NO


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YES

7. INTERDEPARTMENTAL LINKS

Text Box: H.R.D


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8. OUTCOMES

8.1 Quality objectivesHigher patient satisfaction through efficient nursing and accurate documentation.

Develop an empathetic approach towards patient care.Positively impact discharge-planning process by reducing the time taken for discharge

8.2 Quality MonitorsComplaint resolution rate of 95%( at ward level)

Turnaround time (getting the room ready after discharge)Average time taken for discharge per patients

8.3 Performance Metrics

No. of Feedback forms collected from the patients

No. of pending discharge cardsNo. of Medication errorNo. of bedsore

No of patient fall

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SOP FOR FRONT OFFICE

TABLE OF CONTENTS

Guest Relations Department Page No

· Introduction 2· Scope of the Department 2

· Structure 3

· Job Descriptions 4

· General Instructions 8

· Stationary / records to be maintained 9

· Process Maps10

· Interdepartmental Links 13

· Infrastructure 14

· Quality Outcomes 15

1. INTRODUCTION: The Front office department assists for the all OPD processes and avoiding errors.


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2. SCOPE OF THE DEPARTMENT:

2.1 GoalTo give the patients best service with no grievance. Being the first contact point of patients with the

hospital, the experience should be delightful.

2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the ServicesProvided

· Feedback verbal and written

· Patients/ relatives / consultant



· All types of patients (Below Poverty Line to Higher class)

· All age groups (infants to adults)

2.4 Timeliness of services provided· Enquiry 3-5 minutes

· Registration 5-7 minutes

· Admission 5-10minutes(depending upon bed availability)

· OPD billing 5-10 minutes

· Doctor’s appointment 5 minutes

Retrieving file 10 –15 minutes (subject to godown files)

2.5 Extent to which level of care / service meets patient needs.Administering the deliverance of inpatient care on time with accuracy and zero error.

3. STRUCTURE: 3.1 Organization chart


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3.2 Day- to -day activities

· Enquiry

· Registration

· Admission

· OPD billing· Doctor’s appointment

2.1 Job Descriptions

2.3.1. ENQUIRY

· This is generally the first interface of customer interaction, when a prospective customer, patient,

relative, or visitor comes to the hospital for any reason.

· This desk may be required to furnish information on –

· Availability of consultants in various specialties.

· Timings of consultants.(Lists are made available at terminal for information for staff.)

· Various diagnostic services available in the hospital and their location.

· Information on admitted patients and their ward and bed numbers, etc. – Refer

computer system provided for the same.

· Information on various programmes, seminars, workshops being conducted inthe hospital. F.O. Executive/ assistants will communicate these through IOCs and

circulars.

· Information on procedures involved in admission, O.P.D. consultation, taking

appointments for diagnostic services, etc.

· Company tie-ups – Marketing department will inform from time to time aboutcredit facilities offered to various companies.

Duties of front office assistant -

a) A pleasant countenance and eagerness to serve the customers are basic requirements

for this counter.

b) Patience and careful understanding of the customer’s / visitor’s requirements.

c) Clear and comprehensive guidance, in reply to different enquiries.

2.3.2 REGISTRATION

This terminal deals with the registration of the patient. In this process a Registration No. is given to thepatient. The file is created for the patient and it is continued for any a OPD process consultation / procedure .The registration no. is mandatory for any treatment or investigation in the hospital.

Procedure For Registration –

This involves filling up the patient’s details by the patient / relative. Registration is mandatory for allpatients

· Patient’s particulars like name, age, address, phone no, family physician and consultingdoctors name.

· The above data is fed in the system and permanent registration no. is generated. The file ismade and given to the patient.

· For company patients the a note is written in file for differentiation.

· For Company patients credit facility is provided on presenting company referral letter and


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the same information is fed in the system.

Other duties-

1. Ensure registration numbers and other details are accurately written on registrationdocuments (registration file, registration card etc..).2. Help the patient’s relative in filling up the details of the patient if the relative is illiterate.3. Handle registration related queries.

4.

2.3.3 ADMISSION

This terminal deals with the formalities related to admission. Any patient who comes for admissionshould be registered with the hospital. If the patient comes back for admission in few days then hisdischarge summary is retrieved from the system, (and file if needed)

Procedure For Admissio n –

This involves the admission of the patient by the admission staff based on the information given bypatient/ relative.

· The different categories of bed and the tariffs are explained to the relative.

· With the help of occupancy chart, if The room of choice/ward is available ,is allotted to thepatient.

· Facilit ies are explained to the patient/relative.

· IPD registration is done

· A print out of the registration form is taken and signature of the relative is taken.

· A consent for treatment is taken,form is filled up by the relatives, in that at least 2 relativesmobile no. is taken. The declaration is to be signed by the patient or his relative / next of kin with thefull name written clearly on the consent.

· Once the Performa is completed, it should be filed in the patient’s record. The person on dutyat admission counter must sign on the admission form for identification of originator, if therequirement arises.

· The patient’s relative is then sent to the I.P billing department, with details of admission andthe bed/ room allotted, for payment of deposit.

· A call is made to the ward regarding the new admission.

Other Duties-

· Patients are often admitted in emergency situation. Ensure that the admission procedures arequickly completed and the patient’s record is delivered to theemergency department as speedily as possible.

· Contact various wards from time to time, (2 hourly, from 8 a.m. to 2 p.m.)And keep yourself updated with the bed situation and expected discharges.

· The occupancy chart has to be updated and kept handy.

· Responding to enquiries regarding admission is duty of front office staff at this counter.Correct information expeditiously given, is of paramount importance.

· In case of out station enquiries for admission, it is advisable to counter check with wards beforeconfirming bed availability. This is even more significant when a patient is being transferred underemergency circumstances.


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2.3.4 OPD BILLING

This counter handles

1. Centralized collection of cash (consultation, follow-up, investigation, pharmacy diagnostics and

various procedures i.e. dressing, minor O.T and major O.T.)

2. Collecting payments by Credit card and Debit card.

3. Refund if any.

Duties Of Staff

· A pleasant countenance and eagerness to serve the customers are basic requirements for thiscounter.

· Patience and careful understanding of the customer’s / visitor’s requirements.

· Clear and comprehensive guidance, in reply to different enquiries.

General Instructions -

1. In case of any difficulty, inform the administrator.

2. Every patient should get the receipt against the payment.

3. On change of shift the information should be meticulously handed over with all-important

messages recorded in writing in log book.

4. Person handing over charge will be held responsible if any lapse occurs on that account.

2.3.5 DOCTOR’S APPOINTMENT

This counter handles

1. The doctors appointment

2. Calling consultant

3. Making file

4. Retrieving files from medical record

5. Sending file to Doctor’s chamber

6. Attending patients and consultants queries

7. Attending phone calls

8. Keeping record of the files.

9. Keeping track of doctors availability.

Duties Of Staff

· A pleasant countenance and eagerness to serve the customers are basic requirements for this

counter.

· Patience and careful understanding of the customer’s / visitor’s requirements.

· Clear and comprehensive guidance, in reply to different enquiries.

3.General Instructions for all the