Introduction : -
As per the Chapter – 6 continuous quality improvement of NABH standards, the group has analyzed the current/existing situation of the nursing department and following is the analysis.
5 standards with objective : -
CQI.2
The organization identifies key indicators to monitor the clinical structures, processes and outcomes
• Objective elements
a) Monitoring includes appropriate patient assessment.
b) Monitoring includes diagnostics services’ safety and quality control programmes.
c) Monitoring includes all invasive procedures.
d) Monitoring includes adverse drug events.
e) Monitoring includes use of anaesthesia.
f) Monitoring includes use of blood and blood products.
g) Monitoring includes availability and content of medical records.
h) Monitoring includes infection control activities.
i) Monitoring includes clinical research.
CQI.3
The organisation identifies key indicators to monitor the managerial structures, processes and outcomes
Objective elements
• Monitoring includes procurement of medication essential to meet patient needs.
• Monitoring includes reporting of activities as required by laws and regulations.
• Monitoring includes risk management.
• Monitoring includes utilisation of facilities.
• Monitoring includes patient satisfaction.
• Monitoring includes employee satisfaction.
• Monitoring includes adverse events.
• Monitoring includes data collection to support further study for improvements.
• Monitoring includes data collection to support evaluation of the improvements.
CQI.4
The quality improvement programme is supported by the management
• Objective elements
a) Hospital Management makes available adequate resources required for quality improvement programme.
b) Hospital earmarks adequate funds from its annual budget in this regard.
c) Appropriate statistical and management tools are applied whenever required
CQI.5
There is an established system for audit of patient care services
• Objective elements
a) Medical staff participates in this system.
b) The parameters to be audited are defined by the organisation.
c) Patient and clinician anonymity is maintained.
d) All audits are documented.
e) Remedial measures are implemented.
CQI.6
Sentinel events are intensively analysed
• Objective elements
a) The organisation has defined sentinel events.
b) The organisation has established processes for intense analysis of such events.
c) Sentinel events are intensively analysed when they occur.
d) Actions are taken upon findings of such analysis

BAR GRAPH
Quality assurance plan (continuous quality improvement – 2)
The organisation identifies key indicators to monitor the clinical structures, process and outcomes
2 a) Monitoring includes appropriate patient assessment.

Structure-
Organization Structure

Manpower
Equipment’s
Activities  Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

Total strength - In ward (depending on the bed strength: 6 per shift)
 assessment of a patient's physical, spiritual and emotional well- being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses
Existing Quality assurance practices Brief nursing assessment
Standards Nursing assessment to be done on admission time.
GAP Nursing assessment not done within one hr and at each shift.
Monitoring
-What to monitor? Nursing assessment
-Where to monitor? Patient admission form and nursing notes.
Desired changes  Nursing assessment to be done within one hr and during each shift.
 Patient assessment form for the nurses assessment will include:
• Physical assessment
• Psychosocial assessment
• Spiritual assessment
• Emotional assessment.
 The nurse will assess:
• Allergic reactions
• Patient safety
 Skin assessment.
Process of change Meeting, discussion, TRAINING, document customization.
Change Agents people, staff, management.
New Standards  Nursing assessment to be done within one hr and during each shift.
 Patient assessment form for the nurses assessment will include:
• Physical assessment
• Psychosocial assessment
• Spiritual assessment
• Emotional assessment.
 The nurse will assess:
• Allergic reactions
• Patient safety
• Skin assessment.
NEW Mechanism for Evaluation

-What to monitor?

Nursing assessment.
-Where to monitor? Patient admission form and nursing notes.
-How to monitor? Personal observation, Discussion with staff.

Flowchart Audit: Nursing assessment is done within one of the patient admission. A separate column should be allotted for the nurse to sign and compare with the admission time.

CQI 2 (B):
Monitoring includes diagnostics services’ safety and quality control programmes.
Protocols:
All patients for diagnostic procedures will be asked for a brief history (includes allergy, past history) and documentation will be done. Specific diagnostic test like MRI
 Patient will counselled before procedure
 Patient will be advised to remove all ornaments
 Patient with pacemaker and other implants will be advised to stay out of the magnetic area. Pregnant women will be instructed to keep away from the area. Symbolic representation of the contra-indicated patients will be displayed. Patients visiting the hospital for CT scan will be instructed before procedure for IV contrast, 18 gauge or 20 gauge IV cannula inserted and secured. Patients visiting the hospital for X-ray.
 Pregnant women will not be allowed.
 Lead apron will be worn by the staff.
 All ornaments should be removed.
Structure-
Organization Structure

Manpower
Equipment’s
Activities  Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

Total strength - In ward (depending on the bed strength: 6 per shift)
 assessment of a patient's physical, spiritual and emotional well- being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses
Existing Quality assurance practices diagnostic services comply with standards given by BARC and OSHA.

Standards all patients are prepared for diagnostic procedure in compliance to patient safety.

Gap analysis Monitoring of diagnostic services safety not done frequently.

Monitoring:

What to monitor?

 whether all patients are prepared for diagnostic procedures as per the requirement (considering patient safety).
 Whether patient history is taken before the procedure.
 The way diagnostic procedure being carried in the department.
Where to monitor? Diagnostic department, patient floor.
How to monitor? Observation, check documentation.

Desired changes Monitoring of diagnostic services safety is done on a weekly basis.
Process of change Training to the staff.
Change agents Staff and management.
New standards Monitoring of diagnostic services safety is done on a weekly basis.
New mechanism for evaluation:
-What to monitor?

- Where to monitor?

-How to monitor?

 whether all patients are prepared for diagnostic procedures as per the requirement (considering patient safety).
 Whether patient history is taken before the procedure.
 The way diagnostic procedure being carried in the department.

diagnostic department, patient floor.

observation, check documentation.

Flowchart: Audit: Documentation check. Observation of process.

CQI 2 (C) Monitoring includes all invasive procedures
Protocols
All invasive procedures will be carried out under strict aseptic techniques. Hand washing should be done before and after the procedure. Hand washing SHOULD BE Done before and after handling the invasive line. All indwelling catheters must be dated at all times (with date of insertion)
IV cannulation Must be changed after three days of insertion or when blocked, as the case may be.
Central line Must be changed after 14 days of insertion or when infected, as the case may be. If patient develops fever, a swab of the central line insertion site must be sent.
Folley’s catheter Must be changed after 14 days. If the patient develops fever, urine sample is sent for culture and sensitivity.
Silicon catheter Must be changed after 30 days. If the patient develops fever, urine sample is sent for culture and sensitivity.

Structure-
Organization Structure

Manpower
Equipment’s
Activities  Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

Total strength - In ward (depending on the bed strength: 6 per shift)
 assessment of a patient's physical, spiritual and emotional well- being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses
Existing Quality assurance practices invasive procedures are carried with aseptic techniques
Standards All invasive procedures are carried out with aseptic precautions.

GAP Handling of invasive lines done poorly and monitoring of invasive lines for infection control is not done.

Monitoring -What to monitor? Staffs handling invasive line. Patients with invasive line for chances of infection. Insertion site.
-Where to monitor?

-How to monitor? Patient floor

Observation, discussion, documentation.
Desired changes All invasive lines should be handled with aseptic techniques. Monitoring of invasive line should be done daily.
Process of change Training Chlorhexidine at the bed side of patients. Check for documentation.
Change Agents Staff and management
New Standards All invasive lines should be handled with aseptic techniques. Monitoring of invasive line should be done daily.
NEW Mechanism for Evaluation

-What to monitor?

Staffs handling invasive line. Patients with invasive line for chances of infection. Insertion site.
-Where to monitor? Patient floor
-How to monitor? Observation, discussion, documentation.

Flowchart: Audit: Check invasive lines for signs of infection and date. Cross check with patient records to know the date of insertion. Procedure of insertion.
CQI 2 ,,,d,,,e ,,,,??????
CQI-2 (f)
Monitoring includes use of blood and blood products
Protocol
After doctor gives an order for blood transfusion. Patient consent has to be taken for giving blood and blood products. Consent needs to be taken by RMO. Patient blood sample is sent for blood grouping and cross matching to the blood bank, along with the blood requisition slip filled by the RMO. On blood product being ready, it is made available for transfusion to patient. The blood product has to be checked by RMO before transfusion and has to be cross checked by nurse. Blood has to be given slowly initially to observe for reaction. Monitor patient vital during transfusion.
Structure-
Organization Structure

Manpower
Equipment’s
Activities
 Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

 Total strength -

 assessment of a patient's physical, spiritual and emotional well-being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses

Existing Quality assurance practices  Blood product is checked before transfusion.
Standards  All patient is identified before giving blood transfusion
 Blood and blood product are checked by RMO before transfusion.
GAP
 Patient is not taken before transfusion
 No strict monitoring exist for patient condition during transfusion.
Monitoring

- -What to monitor?

-

-Where to monitor?

-How to monitor?
Desired changes

Process of change

Change Agents
New Standards  Patient consent to be taken before transfusion
 Monitoring of patient should be done ½ hourly till transfusion gets over.

NEW Mechanism for Evaluation

- What to monitor?

- Where to monitor?

- How to monitor?

Flow chart

Audit
CQI 2 (g),,,??
CQI 2 (d) (h)
Monitoring includes infection control activities
PROTOCOLS:

Structure-
Organization Structure

Manpower
Equipment’s
Activities  Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

Total strength - In ward (depending on the bed strength: 6 per shift)
 assessment of a patient's physical, spiritual and emotional well- being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses
Existing Quality assurance practices Following all infection control practices.
Standards  Use of blood and blood products under the supervision of the nurse incharge.
 Biomedical waste is segregated under the supervision of the concerned person every day.
 Use of hand washing techniques before and after the patient examination.
 Use of protective gears while handling blood products and other body fluids.
 All the sterilization protocols for the instruments should be followed prior to the use.
 Fumigation should also be done after every 15days.
GAP  ¾ of the waste coming from wards and departments is not properly segregated.
 Needles are destroyed at place however most of the needles(destroyer are not functioning, and the work is done manually.
 Scattering of bio medical waste in hospital premises.
 Protective gears are not used by the staff.
 Staff does not follow the hand washing techniques.
 Fumigation not done on a timey basis.
Monitoring
-What to monitor? - BMW segregation according to colour codes.
- Use of protective gears.
- Sealing of BMW bag and transportation.
- Needles destroyer.
-Where to monitor?

-How to monitor? - BMW department
- All clinical departments
- Operation theatre
- ICU

- Personal observation.
- Discussion with staff.
- Incidence reporting
Desired changes Proper segregation of waste at the site of genesis. - No mixing of biomedical waste with other waste. - Use of the thickened impermeable rubber gloves. - Properly functioning needle destroyer. - Proper sterilization procedures to be followed. - Fumigation should be done after every 15 days.

Process of change -Meeting, discussion. -Hospital waste management training for staff-Medical, paramedical, Technical ,nurses and class IV -Placing of sign boards for colour coding in both the (Local and English) in wards and in department or staff, patients and relatives -repair of old or purchase of new needle destroyer. -mandatory for the staff to follow the standards of hand washing

Change Agents - People and staff. - Protective gears. - Needle destroyers. - Management

New Standards No biomedical waste will be mixed with other wastes. - Biomedical waste will be segregated into containers/bags. - These containers are to be made up different materials and have different color coding signifying the different types of Wastes. -The container must comprise of an inner plastic bag of varied Color depending on type of waste. -Labelling of container with type of waste and site of genesis - Proper sterilization procedures to be followed. - Fumigation should be done after every 15 days.

NEW Mechanism for Evaluation

-What to monitor?

- BMW segregation according to colour codes.
- Use of protective gears.
- Sealing of BMW bag and transportation.
- Needles destroyer.
-Where to monitor? - BMW department
- All clinical departments
- Operation theatre
- ICU
-How to monitor? - Personal observation.
- Discussion with staff.
- Incidence reporting

FLOWCHART

Audit

CQI 3 : - the organisation identifies key indicator to monitor the managerial structure, process and outcomes.
CQI 3 (a) Monitoring includes procurement of medication essential to meet patient needs.
Protocol-
- After the doctor prescribes treatment in the treatment sheet, CPOE system is followed.

Structure-
Organization Structure

Manpower
Equipment’s
Activities
 Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

 Total strength -

 assessment of a patient's physical, spiritual and emotional well-being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses

Existing Quality assurance practices  As soon, any drug is prescribed, the nurse indents the drug through the system.

Standards  Nurse must indent the drug on time ( within 1 hour of prescription )
GAP

 Extra drugs are ordered on patient’s name.
 No policy to ensure that the drug indented cross matches with the treatment sheet.

Improvement standard
• CPOE ( computerised physician order entry )
• The doctor after prescribing the treatment in the treatment sheet, the RMO has to do a CPOE.
Monitoring

• Treatment sheet.
• Patient indent.

• Patient file.
• Hospital information system.
What to monitor?

Where to monitor?
Implementation • Training to doctors.

FLOWCHART-

AUDIT-
• Patient treatment sheet.
• Patient’s indent on Hospital Information System.

CQI-3 (b) Monitoring includes reporting of activities as required by law and regulation
Protocol:
Any incident occurring must be reported to the following manner: The person (staff concern) and HOD of unit must fill the incident reporting form before the end of the shift. Incident reporting form will be submitted to the Patient Safety Committee for review and analysis.

Structure-
Organization Structure

Manpower
Equipment’s
Activities
 Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

 Total strength -

 assessment of a patient's physical, spiritual and emotional well-being
 administration of medications.
 patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses

Existing Quality assurance practices  Any incident which occurs is reported by the unit head, but not done within 24 hours.
Standards  All incident which occur must be reported.
GAP
 Reporting is not done within the end of the shift/ 24 hours.
Monitoring

- Incident reporting form
- Patient file

- Quality department -What to monitor?

-

Where to monitor?

How to monitor?
Desired changes
-
Process of change -Meeting, discussion.
- inter departmental audits.
-Intra departmental audits.
- re audits
- monitoring mechanism for checking whether patient and staff identity is maintained.
- particular standard and protocols to form the audit team.

Change Agents - People and staff. - management - audit committee

New Standards - Reporting should be done within end of the shift and incident reporting form should be filled.

NEW Mechanism for Evaluation

- What to monitor?

Where to monitor?

How to monitor?

Implementation:- Training of the staff
Flow chart

Audit Incident form for date and time. Patient record

CQI 3(c)
Monitoring includes patient satisfaction.
Protocols
• Feedback form at the time of discharge.
• Review the forms for patient complaints and dissatisfactions.
• If major complaint, then analyse it and contact the patient and apologize to patient.
• If number of complaint pertaining in a department is high, then audit the department and do a root cause analysis to arrive at the problem.
Structure-
Organization Structure

Manpower
Equipment’s
Activities
 Nursing Head (superintendent)
 Senior staff nurse
 Junior staff nurse
 Auxiliary nurse midwife
 Nursing attendant.

 Total strength -

 assessment of a patient's physical, spiritual and emotional well-being
 Administration of medications.
 Patient advocacy.
 Listening to what the patient is saying
 A nurse counsels her patients at every meeting
 Spread Awareness
 Managing the activities of hospital
 Giving bed side nursing care.
 Maintains regular records, report concerning the patient’s care.
 Makes duty roaster for 24 hrs coverage
 Maintains inventories, reports, breakages and losses

Existing Quality assurance practices  Patient satisfaction review is taken.

Standards  All patients hospitalised must be provided feedback form.

GAP

 Patient feedback forms to assess patient satisfaction are not reviewed
1. for complaints and
2. To know which department is functioning poor.

Improvement standard
• All feedback forms must be assessed within a week of patient discharge for complaints.
• Audit of the department should be done which is functioning poor, as per the patient’s feedback form.

Monitoring

• Patient feedback form.

• Quality department.

What to monitor?

Where to monitor?

Implementation
• Training to Quality department staff to review the feedback forms faster.

FLOWCHART-

AUDIT-
• Patient feedback forms.

CQI 3 (d)
Monitoring includes employee satisfaction (Kasturi)
CQI (e) monitoring include adverse event ??
CQI (f) monitoring includes data collection to support further study for improvement ??
CQI (g) monitoring includes data collection to support evaluation of the improvements??
CQI.4
The quality improvement programme is supported by the management
• Objective elements
d) Hospital Management makes available adequate resources required for quality improvement programme.
e) Hospital earmarks adequate funds from its annual budget in this regard.
f) Appropriate statistical and management tools are applied whenever required
CQI.5
There is an established system for audit of patient care services
• Objective elements
f) Medical staff participates in this system.
g) The parameters to be audited are defined by the organisation.
h) Patient and clinician anonymity is maintained.
i) All audits are documented.
j) Remedial measures are implemented.
CQI.6
Sentinel events are intensively analysed
• Objective elements
e) The organisation has defined sentinel events.
f) The organisation has established processes for intense analysis of such events.
g) Sentinel events are intensively analysed when they occur.
h) Actions are taken upon findings of such analysis