Dr J L Meena - Health and Family Welfare Department
Dr J L Meena - Health and Family Welfare Department
Dr J L Meena - Health and Family Welfare Department
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<strong>Dr</strong> J L <strong>Meena</strong><br />
State Quality Assurance Officer<br />
<strong>Department</strong> of <strong>Health</strong> & FW<br />
Govt. of Gujarat
AS A PATIENT WHAT QUALITY<br />
LEVELS WOULD YOU ACCEPT<br />
FROM YOUR HEALTH SERVICES?<br />
90%<br />
95%<br />
98%<br />
96%<br />
99%<br />
99.9%
IF 99.9% IS ACCEPTABLE TO YOU, THEN…<br />
•YOUR HEART FAILS<br />
TO BEAT 32,000<br />
TIMES EACH YEAR<br />
* 500 SURGICAL<br />
OPERATIONS ARE<br />
PERFORMED<br />
WRONGLY<br />
EVERY WEEK<br />
* 20,000 WRONG<br />
DRUG<br />
PRESCRIPTIONS<br />
MADE EVERY YEAR<br />
* 19,000 BABIES ARE<br />
DROPPED BY<br />
DOCTORS<br />
AT BIRTH
WELL …..<br />
“ THERE IS ONLY A 1 %<br />
DIFFERENCE IN THE DNA<br />
GENETIC CODE BETWEEN A<br />
CHIMPANZEE AND A<br />
HUMAN BEING”
•IN OUR PROFESSION THERE IS NO SCOPE<br />
FOR ERROR. FOR ANY ERROR COMMITTED<br />
IS ALL THE DIFFERENCE BETWEEN<br />
LIFE AND DEATH, BETWEEN RELIEF AND<br />
DISABILITY<br />
•THERE IS NO SECOND CHANCE<br />
Then …..
HOW TO ACHIEVE<br />
EXCELLENCE IN HEALTH
ALL HOSPITALS ARE<br />
NOT CREATED EQUAL<br />
CUSTOMER WANTS TO KNOW<br />
AM I GOING TO RIGHT HOSPITAL<br />
Only one answer satisfy to your customer is:<br />
ACCREDITATION
Is Quality necessary ?
SAFETY ?<br />
‣67% do NOT have a safety policy<br />
‣92% do NOT have a safety programme<br />
‣71% do NOT have a safety officer<br />
‣88% do NOT have a written waste disposal<br />
procedure<br />
‣83% have fire extinguishers but only 8%<br />
have fire drills (Mock drills)<br />
As per Lab Survey report
Are you thinking Quality costly ?<br />
• Yes Quality is a Costly affair,<br />
but the cost of poor quality &<br />
the loss of life due to poor<br />
quality services are much more<br />
than adopting quality services.<br />
10
Are you Aware ?<br />
15% of patient’s test report in a study<br />
receive either incorrect or delayed<br />
reports or abnormal results.<br />
Boone DJ, IQLM, 2005<br />
IN OUR PROFESSION THERE IS NO SCOPE FOR ERROR.<br />
FOR ANY ERROR COMMITTED IS ALL THE DIFFERENCE<br />
BETWEEN….. LIFE AND DEATH….. BETWEEN RELIEF<br />
AND DISABILITY<br />
THERE IS NO SCOPE OF A SECOND CHANCE…
MISSION STATEMENT<br />
To enhance the quality of healthcare services by<br />
providing specialized treatment <strong>and</strong> preventive<br />
healthcare at free / affordable cost.<br />
To develop a pool of healthcare professionals in<br />
the public health sector trained in the<br />
implementation of health care quality st<strong>and</strong>ards<br />
<strong>and</strong> information technology to bring productivity<br />
<strong>and</strong> effectiveness in health care delivery system.
NABH St<strong>and</strong>ards for Hospitals<br />
10 Chapters<br />
100 St<strong>and</strong>ards<br />
514 Objective Elements<br />
NABH St<strong>and</strong>ards for PHCs/CHCs<br />
4 Sections<br />
38 St<strong>and</strong>ards<br />
238 Objective Elements<br />
(PHCs & CHCs NABH St<strong>and</strong>ards have been made by Govt.of Gujarat with the<br />
support of Quality Council of India)
Implementation of<br />
safety <strong>and</strong> quality<br />
practices<br />
Incorporation of<br />
management tools<br />
PROJECT<br />
OBJECTIVES<br />
Building<br />
sustainability<br />
Continuous Quality<br />
Improvement<br />
Benchmarking the<br />
indicators
PROJECT STRATEGY<br />
Selection of the hospital (NABH / NABL)<br />
MOU (7 th July 2007)<br />
Sensitization programme at all level<br />
Study tour to accredited hospitals<br />
On-site study to identify gaps<br />
(Infrastructure, Equipment, Documentation, Processes <strong>and</strong> Practices),human<br />
resource
PROJECT STRATEGY (Cont….)<br />
Involvement of staff (Skill development & Motivation )<br />
Development, Review <strong>and</strong> Implementation of policies <strong>and</strong><br />
procedures<br />
Development of Quality Management System (e.g. Patient /<br />
Employee Satisfaction, Clinical Record Indicators <strong>and</strong> quality indicators etc )<br />
Intensive & continuous trainings<br />
Process Monitoring<br />
Internal Assessment <strong>and</strong> Gap fulfillment<br />
Pre & Final Assessment (By NABH, New Delhi)
Patient satisfaction<br />
survey<br />
Employee<br />
satisfaction survey<br />
PRACTICES<br />
IMPLEMENTED<br />
Clinical protocols<br />
Code alerts<br />
RED for FIRE,<br />
YELLOW for EXTERNAL CALAMITIES,<br />
BLUE for CARDIAC ARREST,<br />
BLACK for BOMB THREAT,<br />
PINK for CHILD ABDUCTION<br />
Quality Indicators
Disaster<br />
Preparedness Plan<br />
Basic Infection<br />
Control Practices<br />
PRACTICES<br />
IMPLEMENTED<br />
Implementation of<br />
Patient Rights &<br />
Responsibilities<br />
Facility<br />
Management<br />
Practices<br />
Management of<br />
Medication
Incidence Reporting<br />
System<br />
Hospital Safety<br />
Programme<br />
PRACTICES<br />
IMPLEMENTE<br />
D Cont…<br />
Patient Information<br />
Quality Control &<br />
Safety in diagnostics<br />
Inventory<br />
Management
Outcomes…..
Journey of Quality Improvement (Cont)…<br />
3 Years Back Today<br />
Lack of st<strong>and</strong>ards<br />
No Gap analysis report in st<strong>and</strong>ard<br />
format.<br />
Lack of Statutory requirements (e.g.<br />
Licenses, Acts, Rules & Certificates).<br />
Absence of written policies &<br />
procedures.<br />
Poor sanitation <strong>and</strong> cleanliness.<br />
Staff shortage.<br />
Lack of trained health care staff for<br />
emergency (resuscitation) services.<br />
No concept of internal audit<br />
NABH St<strong>and</strong>ards for Hospitals, Blood<br />
bank & CHC / PHC) & ISO 15189:2007 for<br />
lab in place<br />
Gaps identified <strong>and</strong> addressed<br />
Statutory requirements fulfilled<br />
Written policies & procedures available.<br />
Hygienic Hospital environment<br />
Recruitment of staff as per workload<br />
through RKS.<br />
Staff trained in Basic Life Support <strong>and</strong><br />
Advanced Cardiac Life Support<br />
Staff trained as internal auditors, audits<br />
conducted to find out non conformances,<br />
corrective & preventive measures taken to<br />
rectify it
Journey of Quality Improvement (Cont)…<br />
3 Years Back Today<br />
Inadequate infrastructure for h<strong>and</strong>ling<br />
biomedical waste <strong>and</strong> infection control<br />
safety practices<br />
Damaged <strong>and</strong> poor condition of building<br />
No Calibration system of Instruments for<br />
Quality check<br />
All required practices in place<br />
Repairing & renovation done<br />
Calibration system of Instruments for<br />
Quality check are available.<br />
No blood bank / storage facility in some<br />
hospitals.<br />
Shortage of equipments <strong>and</strong> proper<br />
ambulances .<br />
Lack of accountability & planning.<br />
Absence of quality st<strong>and</strong>ards.<br />
No participation in EQAS/ inter laboratory<br />
comparisons<br />
Hospitals have blood bank / storage<br />
facility in as per need<br />
Sufficient equipments <strong>and</strong> ambulances.<br />
Policy <strong>and</strong> processes for care of the<br />
patients in place<br />
Quality st<strong>and</strong>ards e.g. medical audit,<br />
management of medication, care of<br />
patients etc practiced<br />
Participation in EQAS / inter laboratory<br />
comparison <strong>and</strong> achieving good scores in<br />
it.
Journey of Quality Improvement<br />
3 Years Back Today<br />
Poor signage system.<br />
Absence of Patient & Employees’<br />
satisfaction.<br />
No measurable parameter for patient<br />
safety.<br />
No realization of problems <strong>and</strong><br />
weaknesses<br />
No monitoring or reporting of adverse<br />
events, needle stick injury, Sentinel<br />
events etc.<br />
Practically non-existent security<br />
arrangement<br />
Non Implementation of Different Codes<br />
in the facilities.<br />
Well developed signage <strong>and</strong> displays for<br />
patient information<br />
Established<br />
Measurable parameters for patient safety<br />
are available.<br />
A clear underst<strong>and</strong>ing of what is lacking<br />
<strong>and</strong> what needs to be done<br />
These are being reported <strong>and</strong> are<br />
monitored.<br />
Availability of well trained security guards<br />
RED for FIRE,<br />
YELLOW for EXTERNAL CALAMITIES,<br />
BLUE for CARDIAC ARREST,<br />
BLACK for BOMB THREAT,<br />
PINK for CHILD ABDUCTION
“Achievements”<br />
India’s 1 st NABH / NABL Accredited Govt. Facilities:-<br />
•Dist. General Hospital G<strong>and</strong>hinagar<br />
•Primary <strong>Health</strong> Centre Gadboriad, Dist: Vadodara<br />
•Medical College Hospital Labs Bhavanagar<br />
•Blood Bank (BJMC Ahmadabad)<br />
•Food & <strong>Dr</strong>ug laboratory Badodara<br />
India’s 2 nd NABH / NABL Accredited Govt. Facilities:-<br />
•Primary <strong>Health</strong> Centre Mahuwas, Dist: Navsari<br />
•Govt. Medical College lab (BJMC Ahmadabad)<br />
•Civil Hospital Sola, Ahmedabad (Progressive)<br />
•Blood Bank, Medical College Surat.<br />
Other NABH / NABL Accredited Govt. Facilities:-<br />
•Primary <strong>Health</strong> Centre Salun, Dist: Kheda<br />
•Primary <strong>Health</strong> Centre Sokhada, Dist: Badodara<br />
•Primary <strong>Health</strong> Centre Jetalpur, Dist: Ahmedabad<br />
•Blood Bank, Medical College Bhavanagar<br />
•Blood Bank, Medical College Vadodara<br />
•Blood Bank, Medical College Jamnagar<br />
•Primary <strong>Health</strong> Centre Dabhoda, Dist: G<strong>and</strong>hinagar
Quality Improvement Programme (NABH/NABL)<br />
S.<br />
No<br />
Name of the Facility<br />
Total Facility<br />
Under NABH<br />
/NABL<br />
Total<br />
Accredited<br />
facilities<br />
Final<br />
Assessm<br />
ent done<br />
Pre<br />
Assessmen<br />
t done<br />
1 District Hospitals 15 2 3 3 7<br />
2 Medical college, Blood<br />
banks<br />
6 5 0 0 1<br />
Facilities<br />
under<br />
Process for<br />
NABH/<br />
NABL<br />
3 Medical college,<br />
Laboratories.<br />
6 2 0 1 3<br />
4 Mental Hospitals 2 0 2 0 0<br />
5 Dental Hospitals 2 0 0 0 2<br />
6 Paraplegia Hospitals, A’bad 1 0 0 1 0<br />
7 Primary <strong>Health</strong> Centers 29 6 0 4 19<br />
8 Community <strong>Health</strong> Centers 26 0 0 0 26<br />
9 NABL Food & <strong>Dr</strong>ug<br />
Laboratories.<br />
2 1 0 1 0
Patient-Centered St<strong>and</strong>ards<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
57<br />
90<br />
Access, Assessment <strong>and</strong><br />
Continuity of Care (AAC)<br />
44<br />
97<br />
Care of Patients (COP)<br />
50<br />
94<br />
Management of Medications<br />
(MOM)<br />
69<br />
91<br />
Patients Rights <strong>and</strong><br />
Education (PRE)<br />
Before<br />
17<br />
87<br />
Hospital Infection Control<br />
(HIC)<br />
100<br />
90<br />
80<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
<strong>Health</strong> Care Organization<br />
Management St<strong>and</strong>ards<br />
District Hospital G<strong>and</strong>hinagar<br />
0<br />
0<br />
80<br />
Continuous Quality<br />
Improvement (CQI)<br />
50<br />
95<br />
Responsibilities of<br />
Management (ROM)<br />
After<br />
47.6<br />
85<br />
Facility Management &<br />
Safety (FMS)<br />
55.3<br />
91<br />
Human Resource<br />
Management (HRM)<br />
46.3<br />
95<br />
Information Management<br />
Systems (IMS)
PHC GADBORIAD NABH ASSESSMENT SCORE<br />
10.00<br />
10.00<br />
9.30 9.33 9.17<br />
9.45<br />
9.00<br />
8.00<br />
7.00<br />
6.00<br />
5.00<br />
4.00<br />
4.47<br />
4.75 4.72<br />
3.92<br />
4.46<br />
3.00<br />
2.00<br />
1.00<br />
0.00<br />
Before<br />
After
1 st NABL Govt. Medical College &<br />
Hospital Labs in India
India’s 1 st Govt. Blood Bank (BJMC Ahmadabad) NABH Accredited
‣High quality of care<br />
‣Dedicated <strong>and</strong> sincere medical staff<br />
‣Access to a quality focused organization<br />
‣Rights respected <strong>and</strong> protected<br />
‣Patient Satisfaction evaluated<br />
‣Involvement in care process<br />
‣Patient safety<br />
‣Pain management<br />
‣Safe transport<br />
‣Continuity of care
High Quality of Care cont…
High Quality of Care cont…<br />
ABC-VED Classification for<br />
Management of Medicine
Provided baby<br />
kits to new born to<br />
prevent hypothermia
Crush Card trolley<br />
contained:-<br />
Comb, Toothpaste, Oil, Glas<br />
s etc for save the pt. ?<br />
Crush Card trolley<br />
contained:- all life<br />
saving drugs for save<br />
the pt.
Proper Maintenance of<br />
Medical Records<br />
Implementation of Initial<br />
Clinical Assessment
Outdoor patients in PHC (Jan – Dec 09 / 10)<br />
14000<br />
12000<br />
10012<br />
10196<br />
9903<br />
11736<br />
10278<br />
12546<br />
11629<br />
12316<br />
10000<br />
8000<br />
6000<br />
4000<br />
2000<br />
0<br />
PHC Gadboriad PHC Mahuwas PHC Salun PHC Jetalpur<br />
Jan -Dec 2009 Jan- Dec 2010
Outdoor patients in DH & Civil (Jan – Dec 09 / 10)<br />
700000<br />
600000<br />
580533<br />
614443<br />
500000<br />
419216<br />
410961<br />
400000<br />
300000<br />
273172<br />
302190<br />
200000<br />
100000<br />
139439<br />
163595<br />
95052<br />
119425<br />
138700<br />
145454<br />
113802<br />
142223<br />
0<br />
DH<br />
G<strong>and</strong>hinagar<br />
DH Sola DH Amreli DH Navsari DH Nadiyad Civil<br />
Bhavnagar<br />
Civil Surat<br />
Jan -Dec 2009 Jan- Dec 2010
Indoor patients in PHC (Jan – Dec 09 / 10)<br />
1400<br />
1206<br />
1200<br />
1000<br />
800<br />
789<br />
636<br />
628<br />
757<br />
600<br />
454<br />
408<br />
456<br />
400<br />
200<br />
0<br />
PHC Gadboriad PHC Mahuwas PHC Salun PHC Jetalpur<br />
Jan -Dec 2009 Jan- Dec 2010
Indoor patients in DH & Civil (Jan – Dec 09 / 10)<br />
60000<br />
54248<br />
50000<br />
40000<br />
32174<br />
40295<br />
47188<br />
45493<br />
47701<br />
35494<br />
39864<br />
30000<br />
24376<br />
25830<br />
20000<br />
10000<br />
7252<br />
10704<br />
11085<br />
14035<br />
0<br />
DH<br />
G<strong>and</strong>hinagar<br />
DH Sola DH Amreli DH Navsari DH Nadiyad Civil Bhavnagar Civil Surat<br />
Jan -Dec 2009 Jan- Dec 2010
Delivery in PHC (Jan – Dec 09 / 10)<br />
800<br />
749<br />
772<br />
700<br />
600<br />
500<br />
513<br />
585<br />
400<br />
300<br />
200<br />
190<br />
216<br />
100<br />
30<br />
63<br />
0<br />
PHC Gadboriad PHC Mahuwas PHC Salun PHC Jetalpur<br />
Jan -Dec 2009 Jan- Dec 2010
Delivery in DH & Civil (Jan – Dec 09 / 10)<br />
6000<br />
5445<br />
5000<br />
4343<br />
4000<br />
3000<br />
2631<br />
2613<br />
2848<br />
2404<br />
2000<br />
1903<br />
1869<br />
1000<br />
693<br />
991<br />
1028<br />
1161<br />
446<br />
886<br />
0<br />
DH<br />
G<strong>and</strong>hinagar<br />
DH Sola DH Amreli DH Navsari DH Nadiyad Civil Bhavnagar Civil Surat<br />
Jan -Dec 2009 Jan- Dec 2010
PHC Gadboriad, Dist Vadodara (2006-2010)<br />
OPD<br />
12000<br />
10000<br />
10012 10196<br />
8000<br />
7312<br />
8138<br />
6000<br />
4056<br />
4000<br />
2000<br />
0<br />
2006 2007 2008 2009 2010
PHC Gadboriad, Dist Vadodara (Jan – Dec)<br />
Deliveries<br />
800<br />
719<br />
749<br />
772<br />
700<br />
632<br />
600<br />
500<br />
400<br />
300<br />
200<br />
100<br />
78<br />
0<br />
2006 2007 2008 2009 2010
PHC Jetalpur, Dist Ahmadabad (Jan – Dec)<br />
Deliveries<br />
250<br />
216<br />
200<br />
190<br />
150<br />
128<br />
100<br />
78<br />
50<br />
44<br />
0<br />
2006 2007 2008 2009 2010
Sir T Bhavnagar Laboratory (Total test)<br />
500000<br />
455119<br />
450000<br />
400000<br />
350000<br />
300000<br />
250000<br />
200000<br />
203883<br />
278072<br />
177407<br />
209849<br />
257022<br />
341711<br />
150000<br />
108527<br />
100000<br />
50000<br />
2071<br />
9224<br />
23099<br />
29871<br />
0<br />
Biochemistry Microbiology Histopathology<br />
2007 2008 2009 2010
BJMC Ahmadabad Laboratory (Total test)<br />
1800000<br />
1600000<br />
1529858<br />
1703964<br />
1708998<br />
1400000<br />
1200000<br />
985966<br />
1000000<br />
800000<br />
577636<br />
675601<br />
600000<br />
400000<br />
200000<br />
156624<br />
180213<br />
189055<br />
0<br />
Biochemistry Histopathology Microbiology<br />
2008 2009 2010
BJMC Ahmedabad Laboratory (Jan – Dec)<br />
% TAT Outlier<br />
1.40<br />
1.40<br />
1.20<br />
1.20<br />
1.00<br />
1.00<br />
0.95<br />
0.90<br />
0.80<br />
0.80<br />
0.60<br />
0.60<br />
0.50 0.50 0.50<br />
0.40<br />
0.40 0.40<br />
0.20<br />
0.00<br />
Turn around Time
BJMC Ahmedabad Laboratory (Jan – Dec)<br />
% of Rejected Samples<br />
3.5<br />
3.0<br />
3.0<br />
2.9<br />
2.5<br />
2.0<br />
2.2<br />
2.1<br />
1.9<br />
1.5<br />
1.5<br />
1.3 1.3<br />
1.2 1.2<br />
1.1 1.1<br />
1.0<br />
0.5<br />
0.0<br />
Sample Rejection Rate 2010
BJMC Blood Bank Ahmadabad<br />
50000<br />
45100<br />
45000<br />
40000<br />
35000<br />
32154<br />
30000<br />
25000<br />
20572<br />
20832<br />
20000<br />
15000<br />
10000<br />
5000<br />
0<br />
2009 2010<br />
Total Blood Collection<br />
Issue of Components
Adverse Donors Reaction BJMC Blood Bank Ahmadabad<br />
20<br />
19<br />
18<br />
17<br />
17<br />
16<br />
16<br />
16<br />
15<br />
16<br />
14<br />
14<br />
12<br />
12<br />
11<br />
12<br />
10<br />
9<br />
9<br />
9<br />
8<br />
8<br />
7<br />
8<br />
7<br />
7<br />
6<br />
6<br />
5<br />
6<br />
6<br />
4<br />
2<br />
2<br />
0<br />
2009 2010
Blood Transfusion Reaction BJMC Blood Bank Ahmadabad<br />
3<br />
3<br />
2.5<br />
2<br />
2<br />
2<br />
2<br />
1.5<br />
1<br />
1<br />
1 1<br />
1 1 1<br />
1<br />
0.5<br />
0<br />
0<br />
0 0 0 0 0<br />
0 0 0<br />
0<br />
0<br />
0 0<br />
2009 2010
BJMC Blood Bank Ahmedabad (Jan – Dec)<br />
Blood Transfusion Reaction<br />
25<br />
25<br />
20<br />
20<br />
15<br />
12<br />
10<br />
5<br />
4<br />
0<br />
2007 2008 2009 2010
Discard of Components BJMC Blood Bank Ahmadabad<br />
120<br />
118<br />
117<br />
101<br />
100<br />
95<br />
96<br />
94<br />
86<br />
88<br />
86<br />
80<br />
69<br />
81<br />
77<br />
79<br />
65<br />
69<br />
78<br />
79<br />
63<br />
73<br />
60<br />
62<br />
62<br />
60<br />
53<br />
43<br />
40<br />
20<br />
0<br />
2009 2010
Turn Around Time for issue of blood ( In Minutes )<br />
BJMC Blood Bank Ahmadabad<br />
60<br />
60 60 60 60 60 60 60 60 60 60 60 60<br />
50<br />
45 45 45 45 45 45 45 45 45 45 45 45<br />
40<br />
30<br />
20<br />
10<br />
0<br />
2009 2010
BJMC Blood Bank Ahmedabad (Jan – Dec)
BJMC Blood Bank Ahmedabad Quality Indicators<br />
Month Feedback of Clinicians Quality Parameters of Components<br />
Waiting Period for<br />
Donors ( In Minutes )<br />
2009 2010 2009 2010 2009 2010<br />
January Good V.Good Within range Within range 10min 10min<br />
February Good V.Good Within range Within range 20min 12min<br />
March Average V.Good Out of Range Within range 10min 05min<br />
April Good Excellent Out of Range Within range 16min 10min<br />
May Good .Good Out of Range Within range 12min 10min<br />
June Good Good Out of Range Within range 15min 05.min<br />
July Good V.Good Within range Within range 10min 10min<br />
August Good V.Good Within range Within range 16min 08.min<br />
September Average V.Good Within range Within range 10min 05min<br />
October Good V.Good Out of Range Within range 15min 07.min<br />
November V.Good V.Good Within range Within range 12min 05.min<br />
December V.Good Excellent Within range Within range 12min 07min<br />
Total Good V.Good<br />
58 % With in<br />
range<br />
100 % With in<br />
range 14 Min 08 Min
1 st time Joint replacement surgery in Dist. Hospital G<strong>and</strong>hinagar
surgery<br />
Expect. Cost Rs. in<br />
Thous<strong>and</strong><br />
Private<br />
Our hospital<br />
Knee<br />
replacement<br />
165 55<br />
Hip replacement 215 65<br />
arthroscopy 35 5<br />
laparoscopy 45 3<br />
Infertility<br />
surgeries<br />
30 1.5
Benefits to Staff<br />
‣Professional staff development<br />
‣Provides education on laid down<br />
st<strong>and</strong>ards<br />
‣Provides leadership for quality<br />
improvement within medicine <strong>and</strong> nursing<br />
‣Increases satisfaction with continuous<br />
learning, good working<br />
environment, leadership <strong>and</strong> ownership
Continuous Learning
Benefits to Hospital<br />
‣Improves care<br />
‣Brings in Corporate Governance<br />
‣Stimulates continuous improvement<br />
‣Demonstrates commitment to quality care<br />
‣Raises community confidence<br />
‣Opportunity to benchmark with the best
Changing
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After
All the Services provided by PHC Gadboriad are<br />
displayed in all the villages & roadside
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Primary <strong>Health</strong> Center<br />
Sokhda<br />
Maternity<br />
Block
Pharmacy
Documentation & MRD
Sinages
Maternity
Wards
Clinic Room
IEC
Food Trolley
CSSD With Proper<br />
Zoning
End of Life<br />
care ?<br />
Well Maintain<br />
PM Room
NABH ACCREDITATION AWARD FUNCTION BY<br />
GOVT. OF GUJARAT & QCI, NEW DELHI
NABH ACCREDITATION AWARD FUNCTION BY<br />
GOVT. OF GUJARAT & QCI, NEW DELHI
Niziriya Team Visit<br />
Visit by Rajasthan Govt.<br />
MLAs with Speaker<br />
WHO Team Visit
It has been a quality revolution which is a “rewarding experience”.<br />
The National delegates (Teams from<br />
Rajasthan, Bihar, Delhi, Madhya<br />
Pradesh, Kerala, Maharashtra, Chhattishghadh, Andhra Pradesh,<br />
Orissa, Karnataka etc) <strong>and</strong> International delegates<br />
(Nigeria, WHO, Irel<strong>and</strong> etc ) visited the organizations, observed<br />
tremendous changes <strong>and</strong> have commendable remarks “which were<br />
thought to be unattainable in public sector. thus setting up an<br />
example for <strong>Health</strong> Care Organizations to deliver best health care<br />
services to masses”.
Express <strong>Health</strong>care
Benefits to Community<br />
‣Quality revolution<br />
‣Disaster preparedness<br />
- Epidemics<br />
- Physical<br />
‣Access to comparative database
Disaster Preparedness<br />
Fire Safety Training
Benefits to the Government<br />
‣Efficiency of Government hospitals as key<br />
contributors for building trust <strong>and</strong> confidence for the<br />
hospitals in the hearts of the citizens of the State<br />
through actively pursuing quality improvement<br />
programme in various facilities.<br />
‣Given a sense of pride to the government for<br />
ensuring quality services to the poorest of the poor.<br />
Confidence has been restored of the community in<br />
Govt hospitals
NABH ACCREDITATION AWARD FUNCTION BY<br />
GOVT. OF GUJARAT & QCI, NEW DELHI
AWARD FOR<br />
QIP
Awards received by Govt. of Gujarat for NABH/NABL<br />
Certificate of Appreciation awarded to Ministry of <strong>Health</strong> <strong>and</strong><br />
<strong>Family</strong> <strong>Welfare</strong> Government of Gujarat for establishing Quality<br />
Assurance framework in providing quality healthcare to the people<br />
of Gujarat in 5 th National Quality Conclave, New Delhi<br />
•Appreciation awarded to <strong>Department</strong> of <strong>Health</strong> <strong>and</strong> <strong>Family</strong> <strong>Welfare</strong><br />
Government of Gujarat for their pioneering effort to spearhead the Quality<br />
<strong>and</strong> Accreditation Programme in health care organization. In 3 rd<br />
International <strong>Health</strong> Care Quality Conclave.<br />
FICCI <strong>Health</strong> care Excellence Award 2010<br />
Award<br />
DH G<strong>and</strong>hinagar, Govt of Gujarat<br />
PHC Gadboriad, Govt of Gujarat
Strategies Adopted for sustainability:<br />
•Appointment of Quality Assurance officers at State level, District level,<br />
Assistant Hospital Administrator (AHA) at facility level. We are<br />
designated NABH Coordinators & NABL Directors at Facility level.<br />
•NABH lead assessor training (Total trained persons 290 for hospitals &<br />
PHC / CHC) & NABL Internal audit training (Total trained persons121) to<br />
administrators, clinicians, paramedical & staff nurses etc.<br />
•Post Graduation Certificate Course in Quality Management <strong>and</strong><br />
Accreditation of <strong>Health</strong> care Organization (PGQM & AHO) to the<br />
Additional Directors, Superintendents, Chief District Medical Officers,<br />
Clinicians <strong>and</strong> District Quality Assurance Officers (Total trained<br />
persons186) etc.<br />
•New posts of clinicians, paramedical <strong>and</strong> other are sanction by<br />
Government of Gujarat as per requirement.<br />
•Extra budget as per requirement of NABH / NABL are sanction from<br />
13 th finance commission, Government of Gujarat <strong>and</strong> NRHM.<br />
•Formation of the state level review committee under the Chairmanship<br />
of Commissioner of <strong>Health</strong>, Medical Service & Medical Education <strong>and</strong><br />
Member secretary is State Quality Assurance Officer.
Road Ahead<br />
‣To get the Medical Colleges, District<br />
Hospitals, Blood Banks, Laboratories, PHCs<br />
& CHCs across the State accredited by<br />
NABH/ NABL in a phased manner.
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