Quality Assurance Programme for Emergency department - COP.2-i - NABH (Healthcare)

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

1. Requirements of the Key Performance Indicators (KPI)
2. Requirements of COP.2
3. 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:

1. The Emergency Crash Cart, the Medicine Crash Cart, and the Dressing Trolley are always fully stocked
2. 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

Thank you for reading till the end

Hospital Administration Department and its Functions - Healthcare - NABH

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