The two most important aspects of any good and successful work are discipline and process mapping - these enable us to avoid confusion
This video highlights the importance of discipline in work and the simplest and most effective way of preparing a process flow chart / work flow chart (process mapping)
This video gives a guideline on how to do the process mapping, without following the standard corporate rules or process mapping format
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ISO has released the 1st edition of Healthcare Organization Management (HOM), requirements for management systems for quality in healthcare organisations
It is based on Annex SL structure of 10 Clauses, where auditable Clauses are from 4 to 10
Here I have given a brief overview of these auditable Clauses and those requirements which I feel are important. Later on in my other videos, I shall give a detailed analysis of the auditable clauses
On going through the Clauses, it is obvious that many aspects have been taken from NABH, to align with its requirements
Clause 4 - Context of the Organization
What is important?
Here your hospital is required to determine whether climate change is a relevant issue or not, and whether your stakeholders have any requirements related to climate change
Under clause 4, one more important requirement is your scope should include both clinical and non-clinical activities, and you are also required to consider those clinics, sites or outreach centres where services are being provided by you
Clause 5 - Leadership
What is important?
Out of many I have identified the following as the important ones:-
Defining a code of conduct
Creating a culture of quality by implementing, empowering and rewarding quality monitoring across the organisation
Promoting safety for service users
Promoting safety and wellbeing of the workforce
Ensuring transparency of communication and knowledge management
Ensuring impartiality, confidentiality and privacy are maintained and monitored
A very important requirement is that the healthcare Quality Policy should also be communicated, understood, and applied to services that are provided at a distance, like mobile and satellite clinics, health outposts, outreach centres, and professionals providing telehealth
Under Clause 5, the top management is required to demonstrate leadership and commitment towards service user focus (that means towards the patients)
This means:-
Meeting the requirements of the patients and ensuring that the patients are clearly aware of their rights
There is an established method for patient feedback and grievances, and resolving their issues effectively
Making changes to the hospital’s processes based on lessons learned from patients’ experiences
The top management is also required to create an environment of co-production to encourage the patients to participate in their own care
One more important requirement here is that healthcare services should be made available and affordable to the economically challenged, underprivileged and vulnerable sections of the society
Clause 6 - Planning
What is important?
Here risk identification, and risk management plan have been addressed in details, more in line with the requirements of NABH, including near misses, adverse events, and sentinel events
Your healthcare quality objectives should include assessment of patients’ experiences. You are also required to consider the socio-economic status, culture, and diversity of the patients
As per Clause 6, your hospital is required to consider the United Nations Sustainable Development Goals (SDGs) to establish the healthcare quality objectives
Clause 7 - Support
What is important?
Here “competence” has been given a lot of importance.
Your hospital is required to:-
Maintain a documented procedure for recruitment defining the requirements for competence, education, qualification, training, technical knowledge, skills, and experience
Maintain a documented procedure for credentialing and privileging of healthcare professionals and support workforce, as appropriate (support workforce here would indicate Nurses and Paramedics, and maybe also Dieticians)
In Clause 7, service user communication, clinical communication, and external communication have been added
Under service user communication, the hospital is required to:-
Provide information on services, rights and responsibilities
Handle enquiries, agreements or requests, and actions taken, if any
Obtain patients’ feedback regarding services, and also their complaints
Ensure that the feedback mechanisms are accessible, understandable, and are appropriate to the patient’s education level and access to resources
Under clinical communication, the hospital is required to:-
Safeguard the security and privacy of patients’ personal information
Ensure that verbal orders and communication of clinical results are controlled and verified for accuracy
There should be a proper system of maintaining the clinical records to demonstrate proper tracking of communication between different professionals and service sites
Communication containing personal health information should follow proper national or international standards of privacy
Maintain documented information about clinical communication training of employees
Under external communications, the hospital is required to define the communication channels with external parties
An important requirement of maintaining and retaining documented information is management and control of:-
The hospital’s Information Management System (IMS)
Electronic information
Audit of records
Your hospital’s IMS should be validated for its proper functionality. Whenever changes are made to the IMS, those should be tested and validated before implementation
IMS should be protected from unauthorised access, tampering and loss, there should be provisions for backup, and there should be contingency plans to prevent service disruption
If your hospital has outsourced IMS services to an external service provider, then you should ensure that the provider conforms to the requirements of this ISO Standard
Your hospital should have a process to decide how and when you will share data required by external databases and for reporting purpose
Clause 7 has further stated that there should be an established process for using and safeguarding electronic health information, maintaining proper backups of the digital files
Your hospital is required to maintain complete clinical records of every patient, and you should ensure that both the healthcare providers and patients have access to the clinical records in a timely manner
Your hospital is required to define and identify both what is considered as clinical records and non-clinical records, and you are required to conduct audits of both clinical and non-clinical records periodically
Clause 8 - Operation
What is important?
Clause 8 is too long containing 12 sub-clauses, and each clause has various sub-points. Here I have given a brief about the important requirements
Clause 8 is basically about:-
Controlling externally provided processes, products, and services, including services provided by governmental agencies
Hospital infrastructure and building maintenance
Monitoring the turnaround time for breakdowns and repairs of equipment
Safety and facility inspections
Having a maintenance plan of the entire hospital premises
Having adequate backups of water, electricity, and medical gases
Preventing water contamination
Conducting preventive maintenance of buildings, firefighting systems, air-conditioning systems, electrical systems, water supply systems and medical gas systems at predefined intervals
Conducting mock drills of emergency plans
Having properly displayed exit plans and assembly areas, and proper emergency evacuation plans
Proper maintenance of the air conditioning system, as per defined requirements, with provision for positive pressure and negative pressure rooms with proper air exchange facilities
Making provisions for unforeseen natural and manmade calamities
Having adequate fire detection, abatement and containment plan
Making provisions for personal protective gear to the workers who handle equipment and devices
Having adequate infection control implementations
Having emergency response plans for both man-made and natural calamities
Inspection and calibration of measuring equipment, with traceability certificates
Equipment and devices used for service deliveries should be identified and controlled (you can assign specific identification numbers to the equipment and devices)
Clause 9 - Performance evaluation
What is important?
To evaluate the performance of your hospital, you are required to establish a healthcare quality monitoring system in accordance with your hospital’s healthcare quality policy and quality requirements
The top management has to ensure that the quality monitoring system is effective and efficient, and produces time-sensitive and usable results
The organisation has to define which clinical and non-clinical indicators will be used to measure the effectiveness of its operations
The defined indicators should be in alignment with recognized national and international health indicators
Healthcare quality indicators should be identified on the basis of:-
Outcomes from clinical and non-clinical services
Patient safety issues
Adverse events
Clinical and non-clinical risk identification, minimisation and mitigation strategies and results
Delivering appropriate and continued care to patients, including during transfer to other healthcare facilities
Waiting time
Experiences of patients
Waste reduction efforts
Morbidity, mortality and quality of life and wellbeing
Your hospital is required to define the methods to be used by the quality monitoring system, which should mandatorily include:
Internal and external audits
Use of clinical and non-clinical indicators
Use of data from internal Health Information Systems (HIS)
Benchmarking
Your hospital is required to conduct internal audits at planned intervals
To ensure that the quality management requirements of your hospital:-
Conform to your own requirements and to the requirements of this ISO Standards
Is effectively implemented and maintained
This ISO Standard has specified that audit should be conducted at least once every 12 months. It is also ISO requirement that the audits should be conducted by trained and qualified individuals
The top management is required to conduct review of the hospital’s quality management system at planned intervals. It is preferable if you condut this review after conclusion of the internal audit
Clause 10 - Improvement
What is important?
Improvement activities should involve identification, management and reporting of non-conformities arising out of:-
Process deviations
Effectiveness of planning
Patient / family member feedbacks
Workforce performance
Workforce complaints and grievances
Undesired clinical outcomes
Risk management
Patient safety incidents and near misses
Internal audits
The organisation should empower all the relevant persons, including patients, their relatives and other visitors, to report real and potential non-conformities
I have covered the important aspects of all the auditable clauses to the best of my abilities. In my later blogs I will try to give detailed explanations of each Clause separately
The NABH 6th edition draft has been released in January 2024. Here I have given a brief summary of the important changes that can be expected when the final version is released for implementation
I have identified 37 possible significant changes in the 6th Edition
What I have given here is only an assumption based on the draft. The final version may be different from the draft
You can expect the 6th edition to have lesser numbers of Objective Elements, as seen in this comparative chart. Numbers of Chapters and Standards remain unchanged
CHAPTER 1 - Access Assessment and Continuity of Care
Important changes expected
Change No.1
AAC.7 and AAC.8 of 5th edition have been combined in AAC.7 of 6th edition
5th edition AAC.7 - There is an established laboratory quality assurance programme.
5th edition AAC.8 - There is an established laboratory safety programme.
6th edition AAC.7 - There is an established laboratory quality assurance and safety programme.
Change No.2
A new Objective Element has been incorporated in AAC.7, 6th edition
This new Objective Element may actually be AAC.7-b of 5th edition - The programme addresses verification and/or validation of test methods.
We will know it only after the final version is released, because the draft does not contain the Interpretations of the Objective Elements
Change No.3
AAC.10 and AAC.11 of 5th edition have been combined in AAC.9 of 6th edition
5th edition AAC.10 - There is an established quality assurance programme for imaging services.
5th edition AAC.11 - There is an established safety programme in imaging services.
6th edition AAC.9 - There is an established quality assurance and safety programme for imaging services.
Change No.4
In Chapter 1 of 6th edition, a new Standard AAC.11 has been introduced
This new Standard is
The preventive and promotive health services are provided in a safe, collaborative and consistent manner.
The new Standard AAC.11 has 5 Objective Elements
The salient points covered in this new Standard are:
Implementation of preventive and promotive health care as per the scope of services
Promotive and preventive evidence based and contextual age-appropriate screening for non-communicable diseases
Mental health screening and appropriate intervention, wherever needed
Evidence based and contextual paediatric and adult immunization
A multi-disciplinary approach in imparting health education on life-style modifications
Change No.5
6th edition AAC.12 - The organisation has an established discharge process
(in the 5th edition this Standard is AAC.13)
A new Objective Element has been introduced in AAC.12, 6th edition:
AAC.12-f - The care shall be provided by expanding access to health practices through domiciliary visits, wherever applicable.
Change No.6
AAC.12-g of 6th edition states that - The organisation monitors the discharge time, sets appropriate benchmarks and makes continual improvement.
AAC.13-f of 5th edition states that - The organisation conforms to the defined timeframe for discharge and makes continual improvement.
This, according to me, is an improvement upon AAC.13-f of 5th edition
CHAPTER 2 - Care of Patients
Important changes expected
Change No.7
COP.1 of both the editions - Uniform care to patients is provided in all settings of the organisation and is guided by written guidance, and the applicable laws and regulations.
“applicable laws and regulations” have been removed from the 6th edition
Change No.8
5th edition COP.1-c - Care shall be provided in consonance with applicable laws and regulations.
This Objective Element is not there in COP.1 of 6th edition
The details of this should be available only after release of the final version of the 6th edition
Change No.9
COP.10 of both the editions - Organisation provides safe obstetric care.
The 6th edition has introduced 4 new Objective Elements, these are:
COP.10-e - Organisation encourages and welcomes the presence of a birth companion during labour.
COP.10-f - Organisation treats pregnant woman and her companion cordially and respectfully, ensures privacy and confidentiality for pregnant woman during her stay.
COP.10-g - The treating doctor explains danger signs and important care activities to pregnant woman and her companion.
COP.10-k - Organization shall adhere to legal and defined Assisted Reproductive Technology (ART) practices.
Change No.10
COP.11 of both the editions - Organisation provides safe paediatric services.
The 6th edition has introduced one new Objective Element:
COP.11-h - The organisation provides for adolescent friendly health care services.
The Interpretation will be available only after the final version of the 6th edition is released
CHAPTER 3 - Management of Medication
Important changes expected
Change No.11
MOM.1
5th edition MOM.1 - Pharmacy services and usage of medication is done safely.
6th edition MOM.1 - Pharmacy services and medication management is done safely.
The word management has been incorporated in the new edition. And this change has been reflected also in the Objective Elements, wherever applicable
Change No.12
MOM.9
5th edition MOM.9 - Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents are used in a safe manner.
6th edition MOM.9 - Narcotic drugs and psychotropic substances, chemotherapeutic agents and radio-pharmaceuticals are used in a safe manner.
“Radioactive agents” has been replaced with “radio-pharmaceuticals”. And this change has been reflected also in the Objective Elements, wherever applicable
CHAPTER 4 - Patient Rights and Education
Important changes expected
Change No.13
PRE.3 of both the editions - The patient and/or family members are educated to make informed decisions and are involved in the care planning and delivery process.
5th edition PRE.3-a - The Patient and/or family members are explained about the proposed care, including the risks, alternatives and benefits.
6th edition PRE.3-a - The patient and / or family members are explained about the proposed care (including the risks, benefits, alternatives), expected results and possible complications.
In PRE.3-a of 6th edition the requirements of 5th edition PRE.3-b and PRE.3-c have been included. That is why, these two Objective Elements have been removed from the 6th edition
Change No.14
PRE.5 of both the editions - Patient and families have a right to information and education about their healthcare needs.
The 6th edition has introduced a new Objective Element
PRE.5-j - The organisation has a mechanism to promote patient engagement to enhance clinical outcomes, safety and quality.
CHAPTER 5
Important changes expected
Change No.15
In the 5th edition the heading is – Hospital Infection Control (HIC)
In the 6th edition, this has been changed to - Infection Prevention and Control (IPC)
Change No.16
IPC.2 - The organisation provides adequate and appropriate resources for infection prevention and control.
(HIC.2 of 5th edition)
5th edition HIC.2-a - The management makes available resources required for the infection control programme.
6th edition IPC.2-a - The management makes available resources required for the infection control programme including allocation of adequate funds from its annual budget.
In the 6th edition, the requirement of 5th edition HIC.2-b has also been incorporated. That is why in the 6th edition this Objective Element has been removed
Change No.17
HIC.3 of 5th edition - The organisation implements the infection prevention and control programme in clinical areas.
In the 6th edition IPC.3, “control programme” has been changed to “control processes”
Change No.18
5th edition HIC.3-f - The organisation implements the antimicrobial usage policy and monitors the rational use of antimicrobial agents.
This is not there in the 6th edition. This requirement may have been incorporated into some other Objective Element. We will come to know of it only after the final version is released
Change No.19
IPC.5 - The organisation takes actions to prevent healthcare associated infections (HAI) in patients.
(HIC.5 of 5th edition)
5th edition HIC.5-b - The organisation takes action to prevent infection-related ventilator associated complication / ventilator-associated pneumonia.
6th edition IPC.5-b has been changed to - The organisation takes action to prevent ventilator-associated pneumonia.
Change No.20
5th edition HIC.5-c - The organisation takes action to prevent catheter linked blood stream infections.
6th edition IPC.5-c has been changed to - The organisation takes action to prevent central line associated blood stream infections.
CHAPTER 6 - Patient Safety and Quality Improvement
Important changes expected
Change No.21
PSQ.1 of both the editions - The organisation implements a structured patient-safety programme.
5th edition PSQ.1-e - Designated clinical safety officer(s) coordinates implementation of the clinical aspects of the patient-safety programme.
This Objective Element has been removed from the 6th edition, maybe because Objective Element PSQ.1-d is almost similar to this (PSQ.1-d - Designated patient safety officer(s) coordinates implementation of the patient safety programme.)
Change No.22
PSQ.2 of both the editions - The organisation implements a structured quality improvement and continuous monitoring programme.
In the 6th edition, a new Objective Element has been added
PSQ.2-d - The quality improvement programme focuses on appropriateness of clinical care.
Change No.23
PSQ.3 of both the editions - The organisation identifies key indicators to monitor the structures, processes and outcomes, which are used as tools for continual improvement.
5th edition PSQ.3-e - The organisation has a mechanism to capture patient reported outcome measures.
This Objective Element has been added to PSQ.4-d of 6th edition
Change No.24
PSQ.4 of both the editions - The organisation uses appropriate quality improvement tools for its quality improvement activities.
6th edition PSQ.4-b - The Quality improvement projects shall include improvements in patient care delivery and hospital operations which will have an impact on cost and efficiency.
I am presuming the PSQ.4-c and PSQ.4-d of 5th edition have been indicated here, because these two Objective Elements of the 5th edition are not there in PSQ.4 of the 6th edition.
The details can be known only after the final version is released
5th edition PSQ.4-c is - The organisation uses appropriate statistical tools for its quality improvement activities.
5th edition PSQ.4-d is - The organisation uses appropriate managerial tools for its quality improvement activities.
CHAPTER : 7 - Responsibilities of Management
Important changes expected
Change No.25
ROM.1 of both the editions - The organisation identifies those responsible for governance and their roles are defined.
6th edition has included one new Objective Element
ROM.1-g - Those responsible for governance shall develop clinical governance framework.
Change No.26
ROM.2
5th edition ROM.2 - The leaders manage the organisation in an ethical manner.
6th edition ROM.2 - Those responsible for governance manage the organisation in an ethical manner.
in the 6th edition, “The leaders” has been replaced with “Those responsible for governance”
Change No.27
5th edition ROM.2-a - The leaders make public the vision, mission and values of the organisation.
This Objective Element is not evidenced in the 6th edition
Change No.28
6th edition has incorporated a new Standard as ROM.3
6th edition ROM.3 - Management ensures sustainability in hospitals by addressing environmental, social and economic factors from long term well-being of healthcare system and community.
This new Standard ROM.3 has 7 Objective Elements
The salient points covered in this new Standard are
Those responsible for governance have to:
Address the organisation’s sustainability programme in terms of Environment Social and Governance (ESG) responsibility
Take initiatives towards an energy-efficient and environmentally friendly hospital.
Address the organisation’s social responsibility.
Promote staff well-being
Take responsibility for sustainable procurement practices
Ensures financial sustainability of the hospital’s healthcare services
Encourage employees to use common / public transportation to reduce the environmental impact of commuting and carbon footprint. – I personally would not like to have this as a part of NABH accreditation programme
Change No.29
ROM.4 (5th edition) and ROM.5 (6th edition)
5th edition ROM.4 - The organisation displays professionalism in its functioning.
6th edition ROM.5 - The top leadership of the organisation displays professionalism in its functioning.
“The organization” has been replaced with “The top leadership of the organization”
NOTE:
In the 6th edition it is ROM.5 because a new Standard (ROM.3) has been introduced
Change No.30
ROM.5 (5th edition) and ROM.6 (6th edition)
5th edition ROM.5 - Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management.
6th edition ROM.6 - Top leadership ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management.
in the 6th Edition, “Management” has been replaced with “Top leadership”
This change has also been reflected in all the Objective Elements of ROM.6
CHAPTER : 8 - Facility Management and Safety
Important changes expected
Change No.31
5th edition FMS.2-g - The organisation takes initiatives towards an energy-efficient and environmentally friendly hospital.
This Objective Element has been removed from 6th edition FMS.2, because it has been made a part of the new Standard ROM.3 of 6th edition
Change No.32
5th edition FMS.6-c - The procedures for medical gases address the safety issues at all levels.
This has been removed from 6th edition, may be because this has already been addressed in FMS.6-b - Medical gases are handled, stored, distributed and used in a safe manner.
Change No,33
5th edition FMS.7-a - The organisation has plans and provisions for early detection, abatement and containment of the fire, and non-fire emergencies. *
In the 6th edition, this Objective Element has been broken up into two separate parts for fire and non-fire emergencies
6th edition FMS.7-a - The organisation has plans and provisions for early detection, abatement, containment of fire and evacuation in the event of fire emergencies.
6th edition FMS.7-b - The organisation has plans and provisions for identification, and management of non-fire emergencies.
Change No.34
5th edition FMS.7-e - The organisation has a service continuity plan in case of fire and non-fire emergencies
This is not there in 6th edition. This could have been incorporated in some other Objective Element.
We will be able to know it only after the Interpretations are made available in the final version of 6th edition
CHAPTER : 9 - Human Resource Management
Important changes expected
Change No.35
HRM.3 of both the editions - Staff are provided induction training at the time of joining the organisation.
In the 6th edition, a new Objective Element has been introduced
HRM.3-j - Staff is trained on information systems, information security, information use and management.
Change No.36
5th edition HRM.9-a - Staff well-being is promoted.
This is not there in the 6th edition, because it has been made a part of the new Standard ROM.3
CHAPTER : 10 - Information Management System
Important changes expected
Change No.37
IMS.1 of both the editions - Information needs of the patients, visitors, staff, management and external agencies are met.
In the 6th edition, a new Objective Element has been introduced
IMS.1-h - The organisation shall make efforts to use digital health technology to improve operational efficiency, patient safety and patient experience.
These are the important changes expected in the 6th Edition of NABH
Objective Element COP.2-i of NABH 5th Edition - states that the organization should implement a quality assurance programme, but actually the initiative for this should come from the Emergency department
Given here are the salient NABH requirements that you should consider while planning the Quality Assurance programme of the Emergency department
These are only guidelines, you may or may not agree with me. But this video will help you to prepare your own QA programme
You should consider at least the following for preparing the QA programme
Requirements of the Key Performance Indicators (KPI)
Requirements of COP.2
Requirements of COP.3
By including these in your QA programme, you will be able to maintain the quality requirements of NABH
I have identified 9 key factors that should be included in your department’s QA programme. Apart from these, you can also include other parameters which you feel are very important
Key Factor 1
This is a Key Performance Indicator (KPI) - PSQ.3-a
Return to the emergency department within 72 hours with similar presenting complaints
There may be quite a few reasons for this. May be the treatment during the first visit was not appropriate, or may be the patient has developed some other complications after going back home
Such return visits should be investigated to find out the root cause and, wherever applicable, suitable actions should be taken. The findings of the root cause should be documented properly
Key Factor 2
This is a Key Performance Indicator (KPI) - PSQ.3-b
Hand hygiene compliance rate
Since hands are the main source of infection, so it is important to monitor this. It is usually the responsibility of the Infection Control department to ensure that hand hygiene protocol is adhered to
Key Factor 3
This is a Key Performance Indicator (KPI) - PSQ.4-d
Percentage of near misses
It is important to monitor near miss incidents because a near miss is a good indication. It means that your quality checks and balances are strong, that is why the error was detected before it actually took place
Such near miss incidents should be investigated, to ensure that they are not repeated. If required, you may have to make changes to your existing processes to strengthen them further
Key Factor 4
This is a Key Performance Indicator (KPI) - PSQ.3-d
Compliance rate to medication prescription in capitals
NABH demands that the Doctors should write all prescriptions in capital letters, to prevent misinterpretation by the person reading the prescription
It is mandatory to monitor this requirement, otherwise it may lead to medication administration error by the Nurse, or dispensing error by the Pharmacist
I have given these 3 Key Performance Indicators, because if you will include these in your QA programme, you will be able to ensure that the mandatory KPIs requirements are complied with. Rest of the key factors given here are from the Objective Elements COP.2 and COP.3
Key Factor 5
This is an Objective Element - COP.2-e
Initiation of appropriate care is guided by a system of triage
This is a mandatory requirement, whereby you should have a well-planned protocol for attending to patients as per their severity of medical conditions
You should have a written guideline on which medical conditions demand immediate attention, what types of medical conditions should be attended to within 5 minutes, what types of medical conditions can be kept waiting for 10 minutes, and so on
Key Factor 6
This is an Objective Element - COP.3-c
The ambulance(s) is fit for purpose and is appropriately equipped
This is self-explanatory. The ambulances should not only be appropriately and adequately equipped; but should also be kept in proper running condition all the time
The legal documents of the ambulances should always be kept updated
Key Factor 7
This is an Objective Element - COP.3-d
The ambulance(s) is operated by trained personnel
The ambulance driver and other ambulance attendants should be well trained in Basic Life Support (BLS)
Key Factor 8
This is an Objective Element - COP.3-e
The ambulance(s) is checked daily
Read this with reference to COP.3-c, whereby the ambulance is required to be appropriately equipped
Your department should have a Daily Check List of all the ambulance equipment and other medical devices
It is the responsibility of the Nurse to tally the contents of the ambulance with the contents of the Daily Check List, and ensure that the ambulance is kept fully stocked always
Key Factor 9
This is an Objective Element - COP.3-g
A mechanism is in place to ensure that emergency medications are available in the ambulance
Your department should have a Daily Check List of ambulance emergency medications
It is the responsibility of the Nurse to tally the contents of the ambulance with the contents of the Daily Check List, and ensure that all the required emergency medications are always available in the ambulance
Along with these 9 key factors, I have given two more additional factors of your department:
The Emergency Crash Cart, the Medicine Crash Cart, and the Dressing Trolley are always fully stocked
The emergency staff are well trained in discharge of their duties
Your department should have separate Daily Check Lists for Emergency Crash Cart, Medicine Crash Cart, and Dressing Trolley
The Nurse should tally the contents of the Crash Carts and the Trolley with the contents of the Check Lists on a daily basis, and ensure that they are well stocked all the time
All the emergency department staff should be well trained in discharge of their duties
The Doctors attending to emergency patients and the Senior Nurses should be fully aware of ACLS and CPR
All the other emergency staff, ambulance drivers and ambulance attendants should be trained in BLS
If you so desire, you can also watch the video given right at the beginning of this blog article
This is an awareness article. Here I have given information about the Hospital Administration Department and its functions
Hospital Administration Department is the central point of hospital operations and management, and plays a vital role in ensuring the smooth and efficient operation of a hospital
The administrative functions are distributed among various departments for better management
The heads of these departments are required to report to the hospital management team on a daily basis, and keep them updated on the work status
Here I have given only a breakdown of the key functions of each administrative department, without going into the details of the functions, because each hospital has its own method of executing their responsibilities
The key administrative departments are:
Finance Management
Human Resource Management
Patient Management (non-medical category)
Medical Records Management
Facility Management
Materials Management
Pharmacy Management
Information Technology Management
Quality and Risk Management
Infection Control
Strategic Planning and Development
Marketing and Public Relations
Legal and Regulatory Affairs
These departments are the backbone of the organization, working behind the scenes to handle a wide range of tasks that keep the hospital running and providing quality care to patients
Finance Management
The key functions of the department consist of at least the following:
Overseeing the hospital's budget and ensuring financial stability
Cash management
Preparing financial reports and conducting audits
Hospital’s payroll
Doctors’ payments
Payments to part time and contract workers
Payments to suppliers, contractors, and other interested parties
Inventory management for capital purchases and building maintenance
Negotiating contracts with insurance companies and other healthcare providers (in some hospitals this is done by the HR department and the hospital management team)
Human Resource Management
The key functions of the department consist of at least the following:
Developing and implementing employee policies and procedures
Maintaining personal files and health data of employees
Employee management
Managing employment contracts of Doctors and Surgeons
Recruitment, probation, confirmation and termination of services
Training and development of full time and part time workers
Orientation and induction of new employees
Employee resignation management
Salary and incentives management
Disciplinary rules and grievance handling
Attendance and leave rules
Performance appraisals (this is also done by the respective department heads)
Promotions and transfers
Defining competency Matrix
Defining job responsibilities and authorities for all the employees
Patient Management (non-medical category)
The key administrative functions of the department consist of at least the following:
Overseeing the registrations, admissions, discharges, and transfers of patients
Bed allocations of patients
Managing billing and insurance claims of patients
OPD appointment schedules of patients
Handling report despatch of patients
Medical Records Management
The key functions of the department consist of at least the following:
Managing patient records and medical information
Ensuring security and confidentiality of medical records
Proper storage of medical records
Maintaining births, still births, and deaths records
Maintaining infectious diseases records, also known as notifiable diseases
Maintaining medical termination of pregnancy records
Maintaining Vaccination records
Maintaining records of DAMA and LAMA patients
Maintaining MLC records
Maintaining records of TPA patients
Proper disposal of medical records
Compliance with Statutory and Regulatory requirements
Facility Management
The key functions of the department consist of at least the following:
Maintaining the hospital buildings and grounds
Maintaining the fire-fighting system
Maintaining the security and CCTV systems
Maintaining the lift operating systems
Maintaining the power supply and water supply systems
Maintaining the medical gas supply systems
Ensuring the safety and security of the hospital infrastructure
Planning and managing construction projects and renovations
Managing compliance with pollution control board requirements
Materials management
The key functions of the department consist of at least the following:
Inventory management
Raising indents, receiving quotations and placing purchase orders
Procurement of medical and clinical items
Procurement of consumables required for patient care
Procurement of non-medical daily use office items
Procurement of medical and non-medical equipment
Supplying items to different departments
Scraping and condemnation of items
Vendor selection and evaluation
Pharmacy Management (if your hospital has its own Pharmacy)
The key functions of the department consist of at least the following:
Creating and maintaining the Hospital Drug Formulary
Inventory management
Proper management of Pharmacy Stores and Retail Pharmacies
Ensuring that the Pharmacy Stores never runs out of medications
Procurement of medications and other items categorized under FDA
Supplying medications and other items to different departments
Ensuring proper storage and security of medications
Vendor selection and evaluation
Management of medication recall in case of ADR
Maintain ADR records
Pharmacovigilance
Information Technology Management
The key functions of the department consist of at least the following:
Implementing and maintaining hospital information systems
Ensuring the security and privacy of patient data
Providing technical support to hospital staff
Maintaining the Servers to prevent breakdown and data loss
Software and hardware maintenance and repairing
Data backup and data security
Planning and procuring software and hardware
Scraping and condemnation of hardware
End-user training and education
Quality and Risk Management
The key functions of the department consist of at least the following:
Developing and implementing quality improvement programs
Identifying and mitigating risks to patient safety
Monitoring and reporting on quality measures
Ensuring patient safety and quality of care
Ensuring good quality of services through audits of patient care and non-patient care processes
Infection Control
The key functions of the department consist of at least the following:
Formulating and maintaining the antibiotic policy
Antimicrobial management programme
Infection control of patient care services
Infection control of hospital premises
Maintaining asepsis in patient care
Biomedical waste management
Vaccination program for hospital staff
Strategic Planning and Development
The key functions of the department consist of at least the following:
Setting the long-term goals and objectives for the hospital
Reviewing the current goals and objectives of the hospital
Developing and implementing strategic plans
Ensuring sustainability of hospital’s services
Identifying and evaluating new opportunities for growth
Marketing and Public Relations
The key functions of the department consist of at least the following:
Handling patient grievances
Ensuring wellbeing of the Doctors and maintaining good relations with them
Promoting the hospital's services to the community
Managing the hospital's brand and reputation
Conducting community outreach programs
Conducting health education programs for the general public
Building relationships with the media and other stakeholders
Legal and Regulatory Affairs
The key functions of the department consist of at least the following:
Ensuring compliance with all applicable laws and regulations
Managing legal risks and liabilities
Handling medico-legal cases
Providing legal advice to hospital staff
These are the core departments and core functions. I have given these details to the best of my abilities
In addition to these, a hospital may have other administration departments and more responsibilities to perform, depending on the size and type of the hospital
