Transcript e-Governance initiatives in Gujarat

Quality Improvement Programme
CoH
Blood Bank
Yearly (2008-13) Progress Report of
Quality Improvement Programme
Dr ……………………………...
Superintendent
Medical College Hospital, Government of Gujarat
……………………………………………………………………….
Email & Mobile No:…………………………………………………
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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CoH
Financial Progress Report
(Expenditure with Utilization
Certificate)
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
(Yr 2008-12)
S.
No.
Year
1
2008-09
2
2009-10
3
2010-11
4
2011-12
5
2012-13
Total Grant
Received
(NRHM) Rs.
Total Grant
Received
(State) Rs.
Grant Total
(NRHM +
State) Rs.
CoH
Total
Total
Expenditure Settlement
Rs.
with UC Rs.
Total
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Blood Bank
Health & Family Welfare, Govt of Gujarat
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CoH
Financial Progress Report
Infrastructure Detailed Year 2008-2013
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Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
Infrastructure Detailed Year 2008 - 09
S. No.
www.gujhealth.gov.in
Detailed of Infrastructure
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
5
Financial Progress Report
Infrastructure Detailed Year 2009 - 10
S. No.
www.gujhealth.gov.in
Detailed of Infrastructure
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
6
Financial Progress Report
Infrastructure Detailed Year 2010 - 11
S. No.
www.gujhealth.gov.in
Detailed of Infrastructure
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
7
Financial Progress Report
Infrastructure Detailed Year 2011 - 12
S. No.
www.gujhealth.gov.in
Detailed of Infrastructure
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
8
Financial Progress Report
Infrastructure Detailed Year 2012 - 13
S. No.
www.gujhealth.gov.in
Detailed of Infrastructure
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
9
CoH
Financial Progress Report
Manpower Detailed Year 2008-2013
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
Manpower Detailed Year 2008-09
S.
No.
1
2
3
4
5
6
Detailed of Manpower
Total No.
CoH
Amt. Rs.
Class – 1
Class – 2
Class – 3
Class – 4
Service out source
(Security or House
keeping)
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
Manpower Detailed Year 2009-10
S.
No.
1
2
3
4
5
6
Detailed of Manpower
Total No.
CoH
Amt. Rs.
Class – 1
Class – 2
Class – 3
Class – 4
Service out source
(Security or House
keeping)
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
Manpower Detailed Year 2010-11
S.
No.
1
2
3
4
5
6
Detailed of Manpower
Total No.
CoH
Amt. Rs.
Class – 1
Class – 2
Class – 3
Class – 4
Service out source
(Security or House
keeping)
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
Manpower Detailed Year 2011-12
S.
No.
1
2
3
4
5
6
Detailed of Manpower
Total No.
CoH
Amt. Rs.
Class – 1
Class – 2
Class – 3
Class – 4
Service out source
(Security or House
keeping)
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Financial Progress Report
Manpower Detailed Year 2012-13
S.
No.
1
2
3
4
5
6
Detailed of Manpower
Total No.
CoH
Amt. Rs.
Class – 1
Class – 2
Class – 3
Class – 4
Service out source
(Security or House
keeping)
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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CoH
Financial Progress Report
Instrument & Equipment Detailed Year 2008-2013
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
16
Financial Progress Report
Instrument & Equipment Detailed Year 2008-09
S. No.
www.gujhealth.gov.in
Detailed of Instrument & Equipment
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
17
Financial Progress Report
Instrument & Equipment Detailed Year 2009-10
S. No.
www.gujhealth.gov.in
Detailed of Instrument & Equipment
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
18
Financial Progress Report
Instrument & Equipment Detailed Year 2010-11
S. No.
www.gujhealth.gov.in
Detailed of Instrument & Equipment
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
19
Financial Progress Report
Instrument & Equipment Detailed Year 2011-12
S. No.
www.gujhealth.gov.in
Detailed of Instrument & Equipment
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
20
Financial Progress Report
Instrument & Equipment Detailed Year 2012-13
S. No.
www.gujhealth.gov.in
Detailed of Instrument & Equipment
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
21
CoH
Financial Progress Report
Training Detailed Year 2008-2013
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Blood Bank
Health & Family Welfare, Govt of Gujarat
22
Monthly Financial Progress Report
Training Detailed year 2008-09
S. No.
www.gujhealth.gov.in
Detailed of Training
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
23
Monthly Financial Progress Report
Training Detailed year 2009-10
S. No.
www.gujhealth.gov.in
Detailed of Training
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
24
Monthly Financial Progress Report
Training Detailed year 2010-11
S. No.
www.gujhealth.gov.in
Detailed of Training
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
25
Monthly Financial Progress Report
Training Detailed year 2011-12
S. No.
www.gujhealth.gov.in
Detailed of Training
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
26
Monthly Financial Progress Report
Training Detailed year 2012-13
S. No.
www.gujhealth.gov.in
Detailed of Training
Blood Bank
CoH
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
27
CoH
Financial Progress Report
Operational Detailed Year 2008-2013
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Blood Bank
Health & Family Welfare, Govt of Gujarat
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Monthly Financial Progress Report
CoH
Operational Detailed Year 2008-09
S. No.
www.gujhealth.gov.in
Detailed of Operational
Blood Bank
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
29
Monthly Financial Progress Report
CoH
Operational Detailed Year 2009-10
S. No.
www.gujhealth.gov.in
Detailed of Operational
Blood Bank
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
30
Monthly Financial Progress Report
CoH
Operational Detailed Year 2010-11
S. No.
www.gujhealth.gov.in
Detailed of Operational
Blood Bank
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
31
Monthly Financial Progress Report
CoH
Operational Detailed Year 2011-12
S. No.
www.gujhealth.gov.in
Detailed of Operational
Blood Bank
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
32
Monthly Financial Progress Report
CoH
Operational Detailed Year 2012-13
S. No.
www.gujhealth.gov.in
Detailed of Operational
Blood Bank
Amt. Rs.
Health & Family Welfare, Govt of Gujarat
33
CoH
Committee:
Quality Improvement
Programme Committee
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
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Functioning of the
Committees Year 2008-09
S.
No.
Name of the Committee
1
QUALITY IMPROVEMENT COMMITTEE
Monthly
2
HOSPITAL SAFETY COMMITTEE
Monthly
3
INFECTION CONTROL COMMITTEE
Monthly
4
INFECTION CONTROL TEAM
Every 15 days
5
MEDICAL AUDIT COMMITTEE
Quarterly
6
Clinical risk management & Adverse
drug event committee
Monthly
7
Clinical audit committee
Monthly
8
GRIEVANCE REDRESSAL COMMITTEE
Monthly
9
Sexual harassment committee
Monthly & as or
when required
10
PHARMACOTHERAPEUTIC COMMITTEE
Monthly
11
Disaster management committee &
EMERGENCY PREPAREDNESS
COMMITTEE (FIRE & NON FIRE)
Monthly & as
or when
required
12
HOSPITAL ETHICS COMMITTEE
Monthly
www.gujhealth.gov.in
Functioning
(Yes / No)
Fix interval of
Meeting
Blood Bank
No. of Meeting
Planned
CoH
No. of Meeting
Conducted
Health & Family Welfare, Govt of Gujarat
35
Functioning of the
Committees Year 2009-10
S.
No.
Name of the Committee
1
QUALITY IMPROVEMENT COMMITTEE
Monthly
2
HOSPITAL SAFETY COMMITTEE
Monthly
3
INFECTION CONTROL COMMITTEE
Monthly
4
INFECTION CONTROL TEAM
Every 15 days
5
MEDICAL AUDIT COMMITTEE
Quarterly
6
Clinical risk management & Adverse
drug event committee
Monthly
7
Clinical audit committee
Monthly
8
GRIEVANCE REDRESSAL COMMITTEE
Monthly
9
Sexual harassment committee
Monthly & as or
when required
10
PHARMACOTHERAPEUTIC COMMITTEE
Monthly
11
Disaster management committee &
EMERGENCY PREPAREDNESS
COMMITTEE (FIRE & NON FIRE)
Monthly & as
or when
required
12
HOSPITAL ETHICS COMMITTEE
Monthly
www.gujhealth.gov.in
Functioning
(Yes / No)
Fix interval of
Meeting
Blood Bank
No. of Meeting
Planned
CoH
No. of Meeting
Conducted
Health & Family Welfare, Govt of Gujarat
36
Functioning of the
Committees Year 2010-11
S.
No.
Name of the Committee
1
QUALITY IMPROVEMENT COMMITTEE
Monthly
2
HOSPITAL SAFETY COMMITTEE
Monthly
3
INFECTION CONTROL COMMITTEE
Monthly
4
INFECTION CONTROL TEAM
Every 15 days
5
MEDICAL AUDIT COMMITTEE
Quarterly
6
Clinical risk management & Adverse
drug event committee
Monthly
7
Clinical audit committee
Monthly
8
GRIEVANCE REDRESSAL COMMITTEE
Monthly
9
Sexual harassment committee
Monthly & as or
when required
10
PHARMACOTHERAPEUTIC COMMITTEE
Monthly
11
Disaster management committee &
EMERGENCY PREPAREDNESS
COMMITTEE (FIRE & NON FIRE)
Monthly & as
or when
required
12
HOSPITAL ETHICS COMMITTEE
Monthly
www.gujhealth.gov.in
Functioning
(Yes / No)
Fix interval of
Meeting
Blood Bank
No. of Meeting
Planned
CoH
No. of Meeting
Conducted
Health & Family Welfare, Govt of Gujarat
37
Functioning of the
Committees Year 2011-12
S.
No.
Name of the Committee
1
QUALITY IMPROVEMENT COMMITTEE
Monthly
2
HOSPITAL SAFETY COMMITTEE
Monthly
3
INFECTION CONTROL COMMITTEE
Monthly
4
INFECTION CONTROL TEAM
Every 15 days
5
MEDICAL AUDIT COMMITTEE
Quarterly
6
Clinical risk management & Adverse
drug event committee
Monthly
7
Clinical audit committee
Monthly
8
GRIEVANCE REDRESSAL COMMITTEE
Monthly
9
Sexual harassment committee
Monthly & as or
when required
10
PHARMACOTHERAPEUTIC COMMITTEE
Monthly
11
Disaster management committee &
EMERGENCY PREPAREDNESS
COMMITTEE (FIRE & NON FIRE)
Monthly & as
or when
required
12
HOSPITAL ETHICS COMMITTEE
Monthly
www.gujhealth.gov.in
Functioning
(Yes / No)
Fix interval of
Meeting
Blood Bank
No. of Meeting
Planned
CoH
No. of Meeting
Conducted
Health & Family Welfare, Govt of Gujarat
38
Functioning of the
Committees Year 2012-13
S.
No.
Name of the Committee
1
QUALITY IMPROVEMENT COMMITTEE
Monthly
2
HOSPITAL SAFETY COMMITTEE
Monthly
3
INFECTION CONTROL COMMITTEE
Monthly
4
INFECTION CONTROL TEAM
Every 15 days
5
MEDICAL AUDIT COMMITTEE
Quarterly
6
Clinical risk management & Adverse
drug event committee
Monthly
7
Clinical audit committee
Monthly
8
GRIEVANCE REDRESSAL COMMITTEE
Monthly
9
Sexual harassment committee
Monthly & as or
when required
10
PHARMACOTHERAPEUTIC COMMITTEE
Monthly
11
Disaster management committee &
EMERGENCY PREPAREDNESS
COMMITTEE (FIRE & NON FIRE)
Monthly & as
or when
required
12
HOSPITAL ETHICS COMMITTEE
Monthly
www.gujhealth.gov.in
Functioning
(Yes / No)
Fix interval of
Meeting
Blood Bank
No. of Meeting
Planned
CoH
No. of Meeting
Conducted
Health & Family Welfare, Govt of Gujarat
39
CoH
Role & Responsibility of
Quality Improvement
Committees
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
40
Role & Responsibility of the:
Quality Improvement Committee
CoH
Scope of Work
Function of the Committee
This committee shall have representation from management, various
Discuss, decide and Issue hospital
clinical and support departments of the Health Care Organization (HCO).
Policies related to hospital operations
The various quality improvement program shall be developed,
and accreditation.
implemented and maintained in a structured manner.
This committee should have good knowledge of accreditation standards,
Documentation and review of policies statutory requirements, hospital quality assurance principles and
evaluation methodologies, hospital functioning and operations.
This shall incorporate the mission, vision, quality policy, quality
Define scope of services
objectives, service 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
quality parameters
good clinical practices.
Function as apex committee for As quality improvement is a dynamic process, it needs to be reviewed at
monitoring performance indicators / regular pre-defined intervals (as defined by the HCO in the quality
parameters of QMS and medical assurance manual) by the multi-disciplinary committee. The review shall
statistics
also include analysis of key indicators as defined by the standards.
Standardization
of
professional Hospital management makes available adequate resources required for
procedures and equipment
quality improvement program.
This shall include the men, material, machine and method. These should
Credentialing and Privileging
be in steady supply so as to ensure that the program function smoothly.
Frequency of Meeting
Monthly
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
41
Role & Responsibility of
HOSPITAL SAFETY COMMITTEE
Scope of Work
CoH
Function of the Committee
The committee will ensure the total hospital safety &
Develop and issue
security.
Policy on patient, staff,
The committee will bring to the notice of the administration,
and visitor safety and
any gaps observed for the safety and security of hospital staff
security
& 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
Monitor training and equipment 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
Monitor occupational
be taken upon the analysis.
health and safety
The organization has an interdisciplinary group assigned to
oversee the hospital wide safety program.
Frequency of Meeting
www.gujhealth.gov.in
Blood Bank
Monthly
Health & Family Welfare, Govt of Gujarat
42
Role & Responsibility of
INFECTION CONTROL COMMITTEE
Scope of Work
CoH
Function of the Committee
Document and issue infection
control manual including
The hospital has a multi-disciplinary infection control committee.
policies
The organization has a well-designed, comprehensive and coordinated
Training for infection control hospital infection control (HIC) programme aimed at reducing/eliminating
risks to patients, visitors and providers of care.
Surveillance for compliance The hospital has an infection control manual, which is periodically updated.
with policies
Hospital defines the periodicity of updation.
Issue antibiotic policy
The hospital infection control programme is documented.
Monitor Hospital acquired
The manual should clearly identify the high risk areas of the hospital e.g.
infection
ICU, HDU, OT, post-operative ward, blood bank, CSSD, etc.
Proper facilities and adequate resources are provided to support the
Outbreak control
infection control program.
The hospital is authorized by prescribed authority for the management and
handling of bio-medical waste.
Monitor biomedical waste
The organization shall ensure that ensure the sterilization procedure is
management practices
regularly monitored and in the eventuality of a breakdown it has a
procedure for withdrawal of such items.
Frequency of Meeting
www.gujhealth.gov.in
Monthly
Blood Bank
Health & Family Welfare, Govt of Gujarat
43
Role & Responsibility of
INFECTION CONTROL TEAM
Scope of Work
Surveillance for
infection control
Data collection on
hospital acquired
infections
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
Calculation of HAI rates
on a day-to-day basis.
On job training of
healthcare staff on
The hospital has designated and qualified infection control
infection control
nurse for this activity.
practices
Develop report on HAI
The Infection control team will work together with infection
trends
control committee and bring to their notice if any issues have
Monitor infection
seen related to infection.
control practices
Frequency of Meeting
www.gujhealth.gov.in
Every Fifteen days
Blood Bank
Health & Family Welfare, Govt of Gujarat
44
Role & Responsibility of:
MEDICAL AUDIT COMMITTEE
Scope of Work
CoH
Function of the Committee
Review and evaluate patient records for
quality, adequacy of patient care,
Medical staff participates in this system.
monitor staff for compliance with
policies
Evaluate medical record keeping, quality,
content, format, accuracy, pertinence,
The parameters to be audited are defined by the organization.
staff compliance with documentation
policies
Review and evaluate fatal cases / deaths
The medical records are reviewed periodically.
in hospital.
Evaluate sentinel events related to
The review focuses on the timeliness, legibility and completeness of the medical
patient care
records.
Review, evaluate and monitor adverse
The review process includes records of both active and discharged patients.
drug reaction
Review and evaluate cases needing
An adequate mix of both active and discharged patients should be used.
resuscitation
Implementation of Right to Information The review points out and documents any deficiencies in records.
For example, missing final diagnosis , absence of OT notes in an operated patient
Take decisions regarding improvement in , etc.
clinical quality
All audits are documented.
The actions taken must be documented and oriented to the hospital staff.
Frequency of Meeting
www.gujhealth.gov.in
Quarterly
Blood Bank
Health & Family Welfare, Govt of Gujarat
45
Role & Responsibility 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
Blood Bank
Health & Family Welfare, Govt of Gujarat
46
Role & Responsibility of:
Clinical audit committee
Scope of Work
Evaluate medical record
keeping, quality, content
,format , accuracy,
pertinence ,staff
compliance
CoH
Function of the Committee
The parameters to be audited are defined
by the organization.
Proper documentation of The medical records are reviewed
policy
periodically.
The review focuses on the timeliness,
Review and evaluate fatal
legibility and completeness of the medical
cases /Death in hospital
records.
Frequency of Meeting
www.gujhealth.gov.in
Monthly
Blood Bank
Health & Family Welfare, Govt of Gujarat
47
Role & Responsibility of:
GRIEVANCE REDRESSAL COMMITTEE CoH
Scope of Work
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
Blood Bank
Health & Family Welfare, Govt of Gujarat
48
Role & Responsibility of:
Sexual harassment committee
Scope of Work
Function of the Committee
Committee is formed to issue policies for
complaint system and recommended
producers, investigation, and disciplinary
action.
The employee harassing another employee
can be an individual of the 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
CoH
Committee is formed to issue policies for complaint system
and recommended producers, investigation, and disciplinary
action.
The employee harassing another employee can be an
individual of the 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.
Monthly & as or when required
Blood Bank
Health & Family Welfare, Govt of Gujarat
49
Role & Responsibility of:
PHARMACOTHERAPEUTIC COMMITTEE
Scope of Work
Develop and issue Policy on
formulary and medication
management
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.
Supervise purchases and
The policies and procedures shall address the issues related to
procurement
procurement, storage, formulary, prescription, dispensing, administration,
monitoring and use of medications.
A list of medication appropriate for the patient's and the organization's
Supervise and management of
resources is developed.
pharmacy
Policies and procedures guide the prescription of medications.
Policies and procedures guide the safe dispensing of medications.
Monitor and evaluate adverse
Policies and procedures guide the use of narcotic drugs and psychotropic
drug reactions
substances.
Policies and procedures govern usage of radioactive or investigational
Manage the control of drugs drugs.
Policies and procedures guide the usage of chemotherapeutic agents.
Policies and procedures guide the use of implantable prosthesis.
Supervise drug information
service
Policies and procedures guide the shortage of medication.
Frequency of Meeting
www.gujhealth.gov.in
Blood Bank
Monthly
Health & Family Welfare, Govt of Gujarat
50
Role & Responsibility 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
Blood Bank
Health & Family Welfare, Govt of Gujarat
51
Role & Responsibility of:
HOSPITAL ETHICS COMMITTEE CoH
Scope of Work
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
Issue policy on medical ethics
development of lectures, seminars, 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
2. Policy Review and Development
Review, evaluate and approve
cases for clinical research, organ
The committee will assist the hospital and its professional staff in the development of policies and
transplant, experimental
procedures regarding recurrent ethical issues, questions or problems that arise in the care of patients. In
therapeutics, ethical dilemmas, this role the committee may provide analysis of the ethical aspects of existing or proposed policy or assist in
terminal care
the development of new 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
decisions involving disagreement between care providers or between providers and patients/families
ethical issues and medical policy
regarding the ethical aspects of a patient’s care; or
and 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
www.gujhealth.gov.in
Monthly
Blood Bank
Health & Family Welfare, Govt of Gujarat
52
Role & Responsibility of:
Biomedical Waste & Scrap Disposal 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
License under Bio-medical
Management and handling Rules,
1998.
Regular Scrap Disposal from the
facility
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
Frequency of Meeting
Monthly
www.gujhealth.gov.in
Review License under Bio-medical Management
and handling Rules, 1998.
Review Regular Scrap Disposal from the facility
Blood Bank
Health & Family Welfare, Govt of Gujarat
53
CoH
Progress of:
Legal license & Act.
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
54
Progress of:
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes / No) Available (Yes /
in Yr 2007-08
No) Yr 2012-13
1
Building Permit (From the Municipality).
2
No objection certificate from the Chief Fire
Officer.
License under Bio-medical Management and
handling Rules, 1998.
No objection certificate under Pollution
Control Act.
3
4
5
Radiation Protection Certificate in respect of
X-ray equipments from AERB.
6
Excise permit to store Spirit.
7
Narcotics and
license and Act.
8
Vehicle registration certificates.
9
Air (prevention and control of pollution) Act,
1981.
10
Atomic energy regulatory body approvals.
www.gujhealth.gov.in
Psychotropic
CoH
Expiry
Date
substances
Blood Bank
Health & Family Welfare, Govt of Gujarat
55
Progress of:
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes /
No) in Yr 2007-08
11
Biomedical
waste
handling rules 1998.
12
Consumer protection Act, 1986.
13
Dentist regulations, 1976.
14
Drugs and cosmetics Act, 1940.
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.
19
20
Available (Yes /
No) Yr 2012-13
CoH
Expiry Date
management
Indian nursing council Act, 1947.
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
56
Progress of:
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes /
No) in Yr 2007-08
21
Nurses and Midwives Act, 1953
22
Indian penal code, 1860.
23
Indian trade unions Act, 1926.
24
Maternity benefit Act, 1961.
25
Available (Yes /
No) Yr 2012-13
CoH
Expiry Date
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
Blood Bank
Health & Family Welfare, Govt of Gujarat
57
Progress of:
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes /
No) in Yr 2007-08
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
Blood Bank
Available (Yes /
No) Yr 2012-13
CoH
Expiry Date
Health & Family Welfare, Govt of Gujarat
58
Progress of:
Legal license & Act.
S.
No.
Name of the License / Act.
Available (Yes /
No) in Yr 2007-08
41
Hazardous waste
handling rules Act
42
Dental Council of India
43
Water Prevention
pollution Act
44
Lift license
45
HT connection license
46
125 KV diesel generator license
47
GCSR pension rule
48
GCSR additional pay rule act
49
GCSR joining, foreign service, deputation
out of India act
50
Payment during suspension and removal
www.gujhealth.gov.in
management
and
Available (Yes /
No) Yr 2012-13
CoH
Expiry Date
and
control
of
Blood Bank
Health & Family Welfare, Govt of Gujarat
59
Progress of:
Legal license & Act.
S.
No.
Name of the License / Act.
51
GCSR leave rule act
52
GCSR occupation of Govt residence
accommodation act
53
GCSR general condition of service
act
54
GCSR pay rule act
55
GCSR traveling allowance rule act.
www.gujhealth.gov.in
Available (Yes /
No) in Yr 2007-08
Blood Bank
Available (Yes /
No) Yr 2012-13
CoH
Expiry Date
Health & Family Welfare, Govt of Gujarat
60
CoH
Progress of:
Clinical Indicators Year 2008-2013
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
61
Yearly Progress of:
Graphical representation of Clinical Indicators
from April 2008 – Jan 2013
Year
Total Blood
Collection
Voluntary ( % )
No of Blood
Donation
Camps
CoH
No of Blood
Donation Camps
2008-09
2009-10
2010-11
2011-12
2012-13
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
62
Yearly Progress of:
Graphical representation of Clinical Indicators
from April 2008 – Jan 2013
Year
Waiting Period for
Adverse Donors
Donors ( In Minutes ) Reaction
Issue of
Components
CoH
Turn Around
Time for issue
of blood
( In Minutes )
2008-09
2009-10
2010-11
2011-12
2012-13
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
63
Yearly Progress of:
Graphical representation of Clinical Indicators
from April 2008 – Jan 2013
Year
Discard of
Components
Feedback of Clinicians
Blood Transfusion
Reaction
CoH
Quality Parameters of
Components
2008-09
2009-10
2010-11
2011-12
2012-13
Total
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
64
CoH
Progress of:
NABH Progress of Blood Bank
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
65
Progress of:
Clause 1. ORGANISATION AND MANAGEMENT
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
2012-13
Non Compliance
(Minor)
2008-09
2012-13
Full Compliance
2008-09
2012-13
1.1 Legal Identity
1.2 Responsibility
1.3 Ethics in blood bank/ blood
centre
1.4 Quality System
1.5 Policies, processes and
Procedures
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
66
Progress of:
Clause 2. ACCOMMODATION AND ENVIRONMENT
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
2.1 Space Allocation
2.2 Environment Control
2.3 Biological, Chemical and
Radiation Safety
2.4 Internal Communication
System
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
67
Progress of:
Clause 3. Personal
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
3.1 Personnel Requirement
3.2 Qualification
3.3 Job description/
responsibilities
3.4 Responsibilities of Director/ In
charge / Medical Officer; Quality
Manager &Technical Manager
3.5 Training
3.6 Competence
3.7 Personnel Health
3.8 Personnel Records
3.9 Confidentiality of Information
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
68
Progress of:
Clause 4. EQUIPMENT
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
4.1 Equipment requirement
4.2 Selection and validation of
Equipment
4.3 Use of equipment
4.4 Equipment detail record,
unique Identification
4.5 Programme for calibration and
maintenance of equipment
4.6 Equipment for storage of
blood and component
4.7 Computer system
4.8 Breakdown of equipment
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
69
Progress of:
Clause 5. EXTERNAL SERVICES AND SUPPLIES
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
5.1 Policies and procedures for
supplier’s selection
5.2 Inventory control
5.3 Evaluation of suppliers
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
70
Progress of:
Clause 6. PROCESS CONTROL
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
6.1 Policies and validation of
processes and procedures
6.2 Donor Section
6.3 Component Laboratory
6.4 Quarantine and Storage
6.5 Labeling
6.6 Testing of Donated Blood
6.7 Compatibility Testing
6.8 Transfusion Reaction and
Evaluation
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
71
Progress of:
Clause 6. PROCESS CONTROL
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
6.9 Documentation in Transfusion
Service
6.10 Histocompatibility Testing
6.11 Quality Control
6.12 Proficiency Testing
Programme
6.13 Bio-medical waste disposal
and laboratory safety in blood
bank/ blood centre
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
72
Progress of:
Clause 7. IDENTIFICATION OF DEVIATIONS AND ADVERSE
EVENTS
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
2012-13
Non Compliance
(Minor)
2008-09
2012-13
Full Compliance
2008-09
2012-13
7.1 Policies and procedures
when nonconformity is
detected
7.2 Procedure for release of
nonconforming blood
component
7.3 Preventing recurrence of
nonconformity
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
73
Progress of:
Clause 8. PERFORMANCE IMPROVEMENT
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
8.1 Addressing Complaints
8.2 Corrective action
8.3 Preventive action
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
74
Progress of:
Clause 9. DOCUMENT CONTROL
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
9.1 Procedure for document
control and review of documents
9.2 Document required
9.3 Maintenance of documents in
computer software
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
75
Progress of:
Clause 10. RECORDS
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
2012-13
Non Compliance
(Minor)
2008-09
2012-13
Full Compliance
2008-09
2012-13
The blood bank/ blood centre shall
have implemented policy for
keeping and retaining of
records and may include:
1. record identification: all records
relevant
to
the
quality
Management system shall be
uniquely
identified
with
appropriately labelled.
2. quality and technical records:
quality records as well as technical
records that may include original
observation, calibration record,
staff record,
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
76
Progress of:
Clause 11. INTERNAL AUDIT & MANAGEMENT REVIEW
CoH
Total No. of Clause
Number of Clause
Non Compliance
(Major)
2008-09
Non Compliance
(Minor)
2012-13 2008-09
2012-13
Full Compliance
2008-09
2012-13
Policy for internal audit and
management review
11.2 Procedure of internal audit
11.3 Procedure of management
review
11.4 Documentation of internal
audit and management review
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
77
CoH
New initiatives:
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
78
New Initiatives
S.No.
CoH
List of New Initiatives
1
2
3
4
5
6
7
8
9
10
11
12
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
79
CoH
Any Benefit / Harm to your facility
due to Quality Improvement
Programme (NABH / NABL):-
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
80
Any Benefit to your facility due to Quality
Improvement Programme (NABH / NABL)
S.No.
CoH
List of Benefits
1
2
3
4
5
6
7
8
9
10
11
12
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
81
Any Harm to your facility due to Quality
Improvement Programme (NABH / NABL)
S.No.
CoH
List of Harms
1
2
3
4
5
6
7
8
9
10
11
12
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
82
CoH
Other issues:
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
83
Other issues
S.No.
CoH
List of issues
1
2
3
4
5
6
7
8
9
10
11
12
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
84
Quality Improvement Programme
CoH
Quality is a Team work &
never achieve by alone
Thanks
www.gujhealth.gov.in
Blood Bank
Health & Family Welfare, Govt of Gujarat
85