ara before after iso

7/28/2019 Ara Before After ISO

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PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

3 Privacy of female patients was a serious concern asthere was no isolation frames present.

Screens are placed in the wards as well as female

OPD for the privacy.

4 In absence of any particular dress code, it was difficultto demarcate the patients from others staffs.

Dress Code introduced. All the support staffs will

be given the uniform. At present only OT staffs

are provided with the uniform.

5 Only one nursing station was available for Medical aswell as surgical ward.

Separate nursing station has been made for the

surgical ward.

6 There was no Matron or any in-charge for theIPD/Maternity ward. The management is done by the

duty nursing staff as per the directions of the Deputy

medical superintendent

Although the day to day activities are managed

by the duty staff an in charge is appointed for all

the wards.

7 Operation Theatre was grossly inadequate interms of equipments and infrastructure.

No safety measures taken by personnel whileperforming procedures.

No additional space for preparation and preoperative room, with all the preparation and

preoperative procedures was done on the OT

table itself.

The condition of the operation theatres ispathetic with immediate action required to

improve the services.

There for scheduling operations is doneinformally, and nothing is documented.

The instruments are autoclaved in the oilfired autoclaves.

Following materials are provided to OT: -1. Electrical autoclaves2. Fumigation Machine3. Boyels Apparatus4. UPS for interrupted power supply.5. Greaser for hot water6. Aqua Guard for drinking water.

Apart from these separate sterilizationroom, Pre / Post operative room available.

OT schedule prepared and all the requisiterecords are documented like anesthesia

record, sterilization record, fumigation

record, OT record.

Protective gears

8 Segregation of waste is not done as per BMWManagement Rule.

BMW colour coded bins, bags are procured and

proper segregation of waste started in the

hospital.


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9 There is no standard medical record keeping systemin the hospital. Only copies of bed head tickets,

discharge summaries are maintained.

Records are being maintained as per the

standard formats manual.

10 Syringe and needle are kept open in the hospital.There has been no training for the staff to acquaint

them about safe handling of BMW waste and its

disposal.

Proper treatment of used needles / syringes

started. They are deep buried after the use.

11 Basic facilities are not available in the hospital forpublic conveniences.

The following are not available

Public telephone Adequate chairs, fans, lights. Drinking water facilities

Basic facilities are made available like

Public telephone booth (outside OPD) Fans, lights are installed for proper

illumination and fresh air.

Five seater chairs are installed. Sittingarrangement increased to 100.

12 No mechanism exists for obtaining patients feedbackon hospital services

Feedback is being taken from OPD & IPD

patients. Feedback is being analyzed and proper

action is being taken on the weak areas.

13 There is no signage system available in the hospital. Signage are put in the hospital for different

buildings / units / wards / offices etc. Directional

signage are installed.

14 There is no enquiry counter in the hospital forproviding information to the patient for various

services. Patient has to stand in the queue and gets

the information from the registration counter.

Separate May I help You desk is started in OPD

where hospital related queries are solved.

15 Infection control Protocols was not evident. For

example;

Limited supply of gloves thus hampering thevery basic Infection Control measures.

Lack of hand washing soaps Infection control techniques such as removal

of shoes before entering the OT were not

practiced

No zoning of OT

Adequate number of gloves supplied.The gloves are being used for every

procedure and also for patient handling.

Adequate supply of soaps for handwashing and strengthening of the

practice.

Infection control techniques such asremoval of shoes before entering the OT

have been made mandatory and

adhered to strictly.

Zoning of OT has been done16 The number of nurses was inadequate.

ANMs have been posted from the PHCs tosupplement the nursing staff.

17 No training plan existed for staffs. Training schedules prepared and training

conducted as per schedule.

18 License and Registration was not available like AERB,Pollution control etc.

Required licenses and registration are available

with the hospital.

19 There was no Standard Operating Procedure for

record maintenance.

SOP for Record maintenance has been designed

and implemented.


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20 There was no Handover Take over system during the

change of staff during the change of shift.

Handover Take over registers have been

developed and implemented.

21 The BHT and treatment charts, registers were notadequately filled.

A system has been developed where by BHT,

treatment charts, registers are all completed on

time.

22 There was no existing Quality policy A Quality Policy has been defined.

23 There were no Quality Objectives defined. The Quality Objectives have been defined.

24 The BHT and treatment charts, registers were not

adequately filled.

A system has been developed where by BHT,

treatment charts, registers are all completed on

time.

25 There was no existing Quality policy A Quality Policy has been defined.

26 There were no Quality Objectives defined. The Quality Objectives have been defined.

27

There was no existing system of calibration.

A Calibration schedule has been prepared

Weighting Machine has been calibrated.

Pressure gauge of an oxygen and an autoclave

machine has been calibrated

Thermometer and BP instruments calibrated.

28 There were unguarded Multipoint entries to the

hospital which were a security concern especially at

nights.

Unnecessarily opened gates have been closed.

10 home guards has been deployed to ensure

the security of the hospital.

29

The store was poorly managed and haphazardly

arranged.

A systematic arrangement of store has been

done within the limited space available.

The store racks have been numbered

Concept of First In First Out (FIFO) has been

implemented.

30There was no fire safety mechanism available

Fire extinguishers have been installed

Required signage have been displayed as per the

local fire officers plan

31 Housekeeping activities were not up to the mark and

not monitored.

Housekeeping has improved significantly under

the constant monitoring of the management.

32 The condemned items were dumped all over the

hospital.

All Condemned Items have been removed and

auctioned.


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PROCESS DOCUMENTATION OF IS

Total OPD

Total IPD

No of patients attended to in emerge

No of Deliveries taking place

No of C Section performed

No of Minor surgery performed

No of Major surgery performed

Year wise Total OPD Att

Year wise Total IPD Atte

0

50000

100000

150000

200000

250000

2007

11472

2007-08

CERTIFICATION AND EFFECTIVENESS OF ISO AT SA

IMPACT OF QMS

2007-08 2

103776 1

11472

ncy 15926

8390

20

3228

230

ndance

dance

08 2008-09 2009-10 2

103776

150072

201044

Total OPD

16651

19587

2008-09 2009-10

Total IPD

AR HOSPITAL, ARA

08-09 2009-10 2010-11

50072 201044 121692

6651 19587 12181

8844 32160 24150

0334 11159 7989

8 83 91

3636 6237 3140

142 549 261

10-11

121692

12181

2010-11


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PROCESS DOCUMENTATION OF IS

Year wise Total C Sectio

Feed

S.

No.

Attribut

1. Quality Management Sys

streamlining the process

2. On-Site consultant helpe

hospital operations

3. Training provided by TSP

enhancing the skills of yo

4. QMS helped you in maki

documentation and recor

more systematic

5. This project incorporated

amongst the staff and inc

satisfaction level.6. QMS helped you in enha

satisfaction

7. QMS helped you in enha

performance of your hos

8. This project helped you i

infrastructure of your fac

9. As-Is survey helped you i

your infrastructure and p

10. QMS helped you in meas

projecting performance

20

2007-08

CERTIFICATION AND EFFECTIVENESS OF ISO AT SA

back format for CS/MS/DMS/M

es Resp

Do Not

Agree

Neutral Agree

em helped you in

s of your hospital

you in routine

helped you in

ur staff

g your

ds management

a feel of pride

reases their job

cing the patient

cing the clinical

ital

improving

ility

finding gaps in

rocesses

ring and

f you hospital

8

83

2008-09 2009-10

No of C Section performed

AR HOSPITAL, ARA

onse

Endorse Remarks

91

2010-11


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11. Project helped you to get more funds and

manpower and attention from state health

administration

12. Project helped in improving image of your

hospital amongst community, media and

other stake holders

13. Project helped in increase the utilization of

hospitals services like OPD, IPD, Lab,

Radiology, Operation theatre, blood bank

etc.

14. Supervision, training and technical support

provided by NHSRC helped you in

implementing this project.

15. QMS helped you managing Rogi Kalyan

Samiti efficiently

16. QMS helped you in improving facility

management, appearance and signage

system

17. QMS helped you in meeting statutory and

regulatory requirement including

biomedical waste management.

18. QMS helped you in managing outsourced

services better

19. Overall quality improvement program is

relevant and effective.

20 Program of this kind should beimplemented in all public health facilities.

Civil Surgeon

Cum

Chief Medical OfficerBhojpur, Ara

ara before after iso

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