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“QUALITY IS NOT AN ACT, IT IS A HABIT.”
Aristotle
Quality council of India (QCI) is an
autonomous body set up by Government of
India to establish and operate the National
Accreditation Structure in the country.
National Accreditation Board for Hospitals
& Healthcare Providers (NABH) is a
constituent board of Quality Council of
India, set up to establish and operate
accreditation programme for healthcare
organizations.
NABH programme is being implemented in
Kerala in selected hospitals. Four
Government Hospitals and one blood bank
are accredited by NABH.
General Hospital, Ernakulam is one of the
largest district level hospitals in Kerala, with
NABH NATIONAL ACCREDITATION
BOARD FOR HOSPITALS AND HEALTH
CARE PROVIDERS
LOOKING BACK 2013-14
National Health Mission Kerala
Quality Kerala
QUALITY ASSURANCE PROGRAMME IN HEALTH CARE
No 2. May 2014
Page 2 of 60
highest bed strength, has got National
Accreditation Board for Hospital & Health
Care Providers (NABH) accreditation.
General Hospital Ernakulam is the 4th
Government hospital in India and first
Government hospital in Kerala, which got
NABH accreditation.
THQH Cherthala has been awarded
certificate of NABH accreditation. This is the
first taluk level hospital in India achieved
such a certificate from QCI.
Women and Children Hospital, Thycaud.
This is the first W&C hospital in India
achieved such a certificate from QCI. Blood
Bank Aluva is the first NABH accredited
institution in Kerala.
Women and Children Hospital Kozhikode is
accredited by NABH in this year. Final
assessment was conducted in ICCONS
Shoranur by Quality Council of India and will
be accredited soon.
It is a remarkable achievement as there are
only 18 NABH accredited health care
institutions in Kerala of which 5 are from
Government sector. Accreditation is an
incentive to improve capacity of Heath Care
Organisations to provide quality of care.
Dr K Sandeep
Government of Kerala has introduced an
Accreditation Program for Health care
institutions in the state covering all the
Government owned health care
institutions. The aim of the State Level
Accreditation Programme is to provide the
better patient care, health care quality
improvement, patient safety, infection
control, medication safety, facility safety
and equity in health care.
KASH KERALA ACCREDITATION
STANDADRS FOR HOSPITALS
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The Kerala Accreditation Standards for
Hospitals (KASH) are prepared for 4
different levels of hospital, which are
Primary Health Centre (PHC), Community
Health Centre (CHC), Taluk level Hospitals
(THQH) and District level Hospitals including
specialty and General Hospitals.
The standards were developed in such a
way that the implementing the programme
is possible with moderate investment in
most of the health care institutions. After
the achievement of Kerala Accreditation
Standards for Hospitals, the individual
hospitals may opt for higher standards viz
NABH, which require more investment and
effort.
The major emphasis of Quality Assurance
Programme is on sensitization of health
care organization towards importance of
quality healthcare services, involvement of
staffs for improving the quality of patient
service, development, review and
implementation of policies and procedures
for implementation of Quality Management
System.
So far 14 Government Health Care
Institutions were accredited under this
programme.
Dr K Sandeep
Many health indices of Kerala are
comparable to that of the developed
nations. Maternal Mortality Ratio in Kerala
is lowest in India, however it is many times
higher than that of the developed nations.
This need to be brought down to a vary low
level.
The confidential auditing of all maternal
death in Kerala is in place and cause of
MEASURES TO REDUCE MATERNAL
MORTALITY RATE IN KERALA
Page 4 of 60
Maternal mortality has been studied in
detail. The confidential audit of Maternal Death
has been in started in Kerala in 1990s and
Kerala is the first state to implement
confidential audit of Maternal Death.
Department of Health, Government of
Kerala recently took steps to reduce
Maternal mortality in Kerala. A programme
has been started by NRHM, Health Services
Department, Medical Education
Department with the technical support
from NICE international United Kingdom
and Kerala Federation of Obstetrics and
Gynecology.
A quality standard document has been
prepared for reducing the maternal death
during the delivery services. Quality
standards that are derived from evidence-
based clinical guidelines and that are
agreed by relevant stakeholders provide
powerful levers to drive and measure
quality improvement in health care
institutions. It focuses on improving the
care mothers in hospitals, public and
private, and to help reduce maternal
mortality.
In the pilot phase, Quality Standards
developed is being implemented in selected
hospitals.
State Mission Director, NRHM team and
KFOG members visited all the selected
health institutions.
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The disposable delivery kits are introduced
in the hospitals, to improve the quality of
care, reduce hospital infections and also to
measure the blood lose during the delivery.
Kerala Medical Services Corporation has
supplied disposable delivery kits to all
delivery centers in the Government sector.
A training has been conducted by Kerala
Federation of Obstetrics and Gynecologists
at Trivandrum, Ernakulam and Shoranur. All
the Gynecologists and other staff from
selected hospitals participated in the
training.
Flow charts were developed by the KFOG
was printed and supplied to all selected
hospitals.
As a measure to reduce blood lose during
the emergency situations, Non Pneumatic
Anti shock Garments were supplied to all
selected hospitals.
The programme will be upscaled to more
health care institutions in this year.
Dr K Sandeep
NABH ACCREDITATION GOVERNMENT
HOSPITALS
W and C Hospital Kozhikode is the second
Women and Children Hospital in India to
NABH ACCREDITATION OF W AND C
HOSPITAL KOZHIKODE
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receive the NABH accreditation. It is the 4th
Hospital in Kerala has got the NABH status.
NABH Accreditation Certificate had been
handed over to Government Women &
Children Hospital, Kozhikode on 27th Feb
2014 by Honb’le Health Minister Mr.
Sivakumar. Honb’le minister Dr. Muneer,
MP Mr. M.K. Raghavan & MLA Mr. Pradeep
Kumar were presented on the function.
Medical Superintended, Senior Doctors,
DPM, DMO, Sr. Consultant Monitoring and
Evaluation, Lay Secretary, Nursing Supt,
NABH Coordinator & Consultant Quality
Assurance were present in the function.
New Renovated SNCU also inaugurated on
the same day by Hon’ble minister.
A team TH Perambra has visited W & C
Hospital on 18th Feb 2014 as it is NABH
accredited hospital in the district.
Swathy Laxmi . A. P
ICCONS SHORANUR – FINAL
ASSESSMENT BY QUALITY COUNCIL OF
INDIA
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Quality Council of India had conducted Final
assessment at Institute of Communicative
and Cognitive neurosciences (ICCONS),
Shoranur on 29th and 30th March 2013.The
hospital has taken great efforts in the
Quality improvement activity as per NABH
Standards.
Institute for Communicative and Cognitive
Neuro Sciences [ICCONS] is the first
institute of its kind in the Asian countries
for comprehensive multidisciplinary
management, research and rehabilitation of
cognitive and communicative disorders
affecting all age groups. The Institute has
established its activities in the field of
Autism, Learning Disability, Developmental
Language Disorders, Mental Retardation,
Cerebral Palsy, Hearing Impairment, Adult
Stroke and related problems, Parkinson’s
Disease, Dementia, Aphasia and other
Genetic and Metabolic Disorders affecting
Speech, Language and Cognitive functions
in children and adults.
The major activities involves sensitization of
health care organization towards
importance of quality healthcare services;
involvement of staffs for improving the
quality of patient service; development,
review and implementation of policies and
procedures for implementation of Quality
Management System.
The hospital has also constituted
committees, defined the oriented role and
responsibility of all committee at the facility
level with scope of work as per requirement
like quality Assurance committee hospital
infection control committee drugs &
therapeutic committee, grievance redressal
committee, disaster management
committee, hospital ethics committee.
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Training and mock drills were conducted as
per the requirement of NABH standards.
Patient and employee satisfaction survey
has been conducted. The institution is
regularly monitoring the quality indicators.
The hospital also developed good infection
control practices. Mock drill on cardiac
Pulmonary resuscitation, child abduction,
medicine recall procedure, Fire, disaster
management where conducted.
During the preparation for NABH
accreditation process, Senior Consultant M
and E, Senior Consultant Quality Assurance
and Assistant Quality Assurance Officer
were visited the institutions many times
and reported that all the standards with the
reference to NABH 3rd edition was
implemented in the institution.
The detailed assessment conducted in the
institution by Assessors from Quality
Council of India. This is second level of
assessment conducted by the Quality
Council of India. All the non conformities to
the institutions reported during the
previous assessment were corrected.
The Assessors has listed out 56 minor non
compliances which the NABH standards.
The hospital will take Corrective and
preventive actions for non compliances
observed by the assessors within two
months.
The quality improvement in the ICCONS was
due to the joint effort by the staff of
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institution under the leadership of the
hospital. National Health Mission has
supported the NABH accreditation process
from the beginning. District Programme
Manager, Quality Assurance Officer,
Biomedical Engineer and other staff of the
district NRHM has helped in the
development and improvement of the
quality of services offered by the institution.
Sindhu .V
In General Hospital Ernakulam, after the
three year completion of NABH, Quality
council of India conducted renewal
assessment on 23, 24 and 25 January 2014.
A team of five assessors from QCI visited
the hospital for renewal assessment. A
detailed assessment was carried out and
they gave a final report with fifty seven non
compliances.
All the hospital staffs are actively
participated in the renewal assessment.
Many changes are made in the hospital
apart from the standards. All the
amendments made in the manuals
according to the third edition.
All committee meeting are conducted at
regular intervals. Continual training in
different topics given to all doctors, nursing
and paramedical staff , housekeeping staff
and other category staffs. Internal audits
are conducted and find out the
noncompliance and rectified before
assessment. Minor modifications are made.
Quality indicators are collected and verified
by the quality team to know the quality
progress monthly. New MRI was installed in
the Hospital.
NABH ACCREDITATION.- RENEWAL
ASSESSMENT GENERAL HOSPITAL
ERNAKULAM
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Nigini Paulose
Government Women and Children’s
Hospital Thycaud Thiruvavnanthapuram is
the India’s first Women and Children’s
Hospital to get NABH Accreditation. The
Government Women and Children’s
Hospital Thycaud is one of the largest
specialty hospital in Kerala for Obstetrics &
Gynecology. Many people, not only from the
district, but also from some others districts
of Kerala and Tamilnadu are coming in this
hospital for treatment.
This hospital has been accredited by NABH
on 14th April 2012 and thus becomes the
second Government Hospital in the state
getting accreditation.
W&C Hospital was established on 1814 by
Her Highness Sethu Parvathy Bai from the
Royal Travancore family. It started its
beginning as a dispensary but later it was
changed in to health centre on 1839. A new
building was inaugurated on 1916. Training
for caring newborn babies and taking
deliveries & Nursing training started here.
After the Independence there was a
tremendous change in the growth of this
institution. The hospital was upgraded on
1996 as the 'First Referral Unit' and later as
District Hospital.
She became the Medical Superintendent of
the Hospital on 1916 and continued in this
post for 22 years, which may be a record in
Medical Professional to hold the post.
GOVERNMENT WOMEN & CHILDREN’S
HOSPITAL, THYCAUD,
THIRUVANANTHAPURAM
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Another important characteristic feature of
the hospital is that this is first hospital in
Kerala conducted the cesarean surgery.
The first Gynecologist of Kerala, Dr. M
Ponnen Lukose was appointed in this
hospital in 1916.
She became the Medical Superintendent of
the Hospital on 1916 and continued in this
post for 22 years, which may be a record in
Medical Professional to hold the post.
Identifying, complying with and monitoring
the effective implementation of meeting
legal, statutory and regulatory
requirements is the first important outcome
parameter identified on the basis of the
implementation of NABH accreditation
programme in the Government Women and
Children’s Hospital Thycaud. Prior to the
accreditation process, the hospital
authorities aware less concerned about the
legal requirement such as permits, NOC,
license etc. Now the hospital has got all
legal requirement such building permit,
NOC from Pollution Control Broad, AERB
approval and Blood Bank License.
The hospital is now able to implement a
well documented policies and procedures
of various serviced delivered. The well
documented and updated quality manual
maul is the apex among these document.
Besides these, hospital safety manuals,
quality assurance manuals manual for
standards operating procedures are other
documented maintained by the hospital.
Better quality care are being provided in the
hospital as a consequence of NABH
accreditation. Emergency patient are given
life saving treatment and then admitted to
the wards. Applicable laws and regulations,
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policies and procedures guide the patients
care. High risk pregnancies are clearly
defined and immediate attention is being
given.
The hospital has a policy that patients sixth
same health problems and care needs
receive same quality of health care
irrespective of creed, caste, category of
ward, income status. General and informed
consent are being taken in relevant cases.
All the staff are trained in many activities
such s emergency services CPR, Fire safety,
Disaster management etc.
The hospital maintains a good and hygienic
environment by providing good
housekeeping practices. Cleaning machines
are being used in the cleaning areas and
cleaning is being done three times a day.
Basic cleaning operations are being done
and training to cleaning staff are
periodically done.
Continuous training is another parameter in
connection with NABH accreditation
process in Government Women & children’s
Hospital. The hospital is maintaining a
training calendar indicating the details of
training , participants, trainers for various
training needs such as services available,
OPD Services, Infection Control Activities,
CPR, Fire Safety Devices, Disaster
Management, Employees safety devices
such as Personal Protective Equipments etc.
periodical training is also being given to the
staff relating to care of patients, handling of
new equipments, methods devices etc.
In order to ensure the good housekeeping
practices a check list is being maintained in
all wards and patient caring areas. The
sister in charge of the hospital after
satisfying the cleaning operations, fills the
check. Besides a surveillance is being done
by the HIC sister for ensuring the
housekeeping practices.
Mock drills relating code alerts is also
conducted in the hospital regarding child
abduction, Cardio Pulmonary Resuscitation,
fire safety etc.
Proper disposal of biomedical waste is
another important outcome parameter as a
result of the NABH accreditation program in
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the Hospital. The final disposal of the
biomedical waste is being done by IMAGE
by making an MOU with them. Color coded
bins are being for the segregation of the
biomedical waste and personal protective
devices are being used by the staff who deal
in biomedical waste.
The hospital is preparing for surveillance
from the NABH. As a part of it an internal
audit has been conducted in the hospital
by the internal audit team. Further various
levels of training is going on . some of the
training conducted are NABH awareness,
Code alert, data collection and analysis of
indicators, fire and safety, code blue etc.
The hospital quality team are in the
preparation of manual revision, prescription
audit. Etc.
Ajithkumar.S
NABH - ACCREDITATION OF BLOOD BANK
Regional blood transfusion Centre (RBTC),
District Hospital Aluva is the first
government blood bank to get NABH
accreditation in the State. Regional blood
transfusion Centre, Aluva figures out to be
49 in the country and second in the Kerala
to get accredited.
Regional blood transfusion centre, Aluva is
the first regional blood transfusion centre in
the state in 2002.
First blood bank in the State in Health
services to get license for BLOOD
COMPONENTS
Regional blood transfusion centre ,Aluva is
the first in the State to be recognized as
training center for blood bank medical
officers and technicians
The Major Objectives of the RBTC is to
ensure safety of blood that of the donor to
REGIONAL BLOOD TRANSFUSION
CENTRE (RBTC)
Page 14 of 60
the recipient The blood bank promotes
voluntary blood donation by holding
awareness classes, for Red Ribbon Clubs,
Libraries, Arts & Sports Clubs, Youth &
Labour wings of political parties. This
includes audio visual aids, poster sessions
and film shows for the voluntary blood
donation.
The blood bank has created passion
especially among the youth for voluntary
blood donation. They hold outdoor blood
grouping cum donation camps and maintain
a well indexed donor directory for
emergency needs.
The blood bank conducts training programs
for blood bank medical officers and
technicians to hold academic sessions for
clinicians on rational use of blood.
The RBTC issues safe blood at the rates
specified by the Government to the needy
private hospital patients also. The major
concern is for the poorest section of the
community by providing the subsidized
rate.
This was the first blood bank in India to
enunciate and display a Quality Policy on
Nov 1st2001.
All the processes undertaken in connection
with the manufacture of blood and blood
products conform to well-defined standard
operating procedures is ensured. The
procedures are clearly defined, periodically
reviewed and critical steps and changes
validated.
The most remarkable that the staff is free
to own up mistakes without fear of
retribution and corrective measures taken
to avoid similar mistakes in future. Regular
monitoring and evaluation with stress on
error management is also in place.
Quality manual, standard operating
procedures (SOP) were prepared by the
blood bank.
The Calibration, preventive maintenance
plan and calibration plan are done for all
equipment’s. The Fire safety measures were
undertaken and training given to staffs.
The NABH implementation started on
2011.National Rural health Mission had
given financial support and shored up the
whole process of Accreditation by
providing funds for structural modification,
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conducting trainings , calibration of the
equipment’s ,support in documentation
process, maintenance of equipment etc.
Signage placed and Structural modification
was undertaken in the blood bank.
The trainings were given to internal audit
team to conduct internal audit of the
implementation of the standards.
The Regional Blood Transfusion Centre has
won accolades from all quarters both
Governmental and Non-Governmental
agencies.
The Government has recognized this as the
best one in the Government sector and also
the most outstanding institution in the
efforts for HIV/AIDS prevention on many
occasions.
Pre assessment was conducted by Quality
Council of India on 23/07/2012. The Final
Assessment was conducted on 09 and 12
August 2012 by Quality Council of India.
Accreditation Board of QCI announced
NABH Accreditation on 29.12.2012 by the
Quality Council of India to the hospital.
Sindhu V
MEASURES TO REDUCE MMR IN
KERALA
The project Measures to reduce MMR in
Kerala is in the process of up scaling to
more health care institutions in the State.
A training programme regarding the same
was conducted for the Gynecologists at
Shoranur on 14-02-2014. Gynecologists
from the Woman and child hospital
MEASURES TO REDUCE MMR IN
KERALA MEETING AT SHORANUR
Page 16 of 60
Kozhikode, DH Manjeri, DH Manathawady,
Woman and child Hospital Palakkad and
Tribal Specialty hospital Kottathara has
participated in the training.
Dr Beena M State Mission Director NRHM
has provided a brief introduction on the
MMR project is being implemented in the
state.
Dr K Sandeep Senior Consultant M and E, Dr
Sree Hari District Programme Manager
Palakkad and Salini Raj Consultant QA also
have participated in the training.
Dr V P Paily, Kerala Federation of Obstetrics
and Gynecology have provided a detailed
presentation on the activities done to
reduce MMR in Kerala.
New Labor room register was provided to
all selected hospitals.
Dr. K .Sandeep
Department of Health, Government of
Kerala recently took steps to reduce
maternal mortality in Kerala. A programme
has been started by NRHM and Health
Services Department with the technical
support from NICE international United
Kingdom and Kerala Federation of
Obstetrics and Gynecology.
A quality standard document has been
prepared for reducing the maternal death
during the delivery services.
Meeting on development of Score card held
on 13 March 2013 at NRHM SPMSU. Score
cards were developed for the antenatal
mothers. The patients are given scores by
the doctors based on the risks that may
likely develop during the antenatal period.
The patients are treated or referred as per
the scores in their cards. The patients are
categorized as per risk and treated
appropriate centers from early pregnancy
itself.
MEASURES TO REDUCE MMR IN
KERALA - DEVELOPMENT OF SCORE
CARD
Page 17 of 60
The hospitals are also classified as per the
facilities for treating the antenatal cases.
The high risk antenatal cases will be
referred to the appropriate institutions
based on the score in the score card. The
important parameters to assess the score
are age, BMI, proximity to maternity centre,
AN factors, BOH, gravida, medical
complications, Obstetric complications,
previous caesarean etc.
Dr. K .Sandeep
The Review meeting of the Maternal
mortality in Kerala has been held on 22
March 2013 at NRHM SPMSU .
The selected hospitals for the
implementation of the standards in the First
phase are Woman and Child hospital
Trivandrum, SAT Hospital, District Model
Hospital Peroorkada, THQH Chirayinkeezh,
General hospital Ernakulam, CHC
Kanyakulangara, SUT hospital and Mother
hospital .
The programme is in the process of up
scaling to more institutions in the State. The
other hospitals selected in the Second
phase include Woman and child hospital
Kozhikode, Victoria hospital Kollam, DH
Manjeri, DH Manathawady, Woman and
child hospital Palakkad and Tribal Specialty
hospital Kottathara.
In the meeting it was pointed out that there
is a reduction in primary CS rates from
28.75 to 20.75 when the figures for 2012
and 2013 April-Dec periods were compared.
This trend was reflected in other
parameters like referrals, blood
transfusions etc.
Quality Standards on Sepsis and Amniotic
Fluid Embolism will be shortly developed
for piloting.
Dr .K. Sandeep
Training on implementation of Quality
Standards was conducted at General
Hospital Manjeri on 04-04-2014. Dr V P
Paily from Kerala Federation of Obstetrics
and Gynecology have visited General
Hospital Manjeri to appraise the
obstetricians and labor room staff regarding
the data collection for the project. The
Measures to reduce MMR in Kerala is
jointly run by the Kerala Health Services
Department, National Health Mission,
MEASURES TO REDUCE MATERNAL
MORTALITY IN KERALA -TRAINING AT
GENERAL HOSPITAL, MANJERI
MMR REVIEW MEETING OF SELECTED
HOSPITALS
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Kerala Federation of Obstetrics and
Gynecology and technical support from
NICE International.
He has visited the Labor room and
Operation Theatre along with the
Gynecologist. The objective of the training
is to improve the quality of care provided to
the patient.
Bhadra .C. P
In Palakkad District, as part of the
“Measures to reduce Maternal Mortality
Rate in Kerala” program two hospitals viz.
Women and Children Hospital Palakkad and
Government Tribal Specialty Hospital
Kottathara were selected. The
Superintendent and Sr. Gynecologists in
both of the institutions attended the
training sessions conducted by National
Health Mission on 14.02.2014 at Shoranur.
The Women and Children Hospital Palakkad
is a 100 bedded hospital and is bifurcated
from the District Hospital Palakkad since
2012 onwards. The hospital has an average
delivery of 550 including caesarian sections
per month. Dr. Paily visited the hospital on
03.04.2014 and conducted a practical
training session for all Gynecologists and
observed the practices in labor room. He
also conveyed suggestions for the same.
On the next day Dr. Paily visited GTSH
Kottathara. The Government Tribal
Specialty Hospital Kottathara is a 54 bedded
institution situated in the most difficult hilly
rural area of Palakkad District and majority
of the patients are poor tribes and have to
go more than 80km from here to next
higher center. Dr. Paily conducted a
practical training session for all
Gynecologists and observed the daily
practices in labor room. Dr. Paily had given
suggestions to improve Quality Patient Care
and Maternal mortality rate in the
Attappady area.
Salini Raj
MEASURES TO REDUCE MATERNAL
MORTALITY RATE IN KERALA –
PALAKKAD DISTRICT
Page 19 of 60
A training on implementation of Quality
standards was conducted at District
Hospital Mananthavady on 05-04-2014. Dr.
V.P Paily from Kerala Federation of
Obstetrics and Gynecology have visited
District Hospital Mananthavady to appraise
the obstetricians and labour room staff
regarding the data collection for the
project. District Medial Officer (DMO),
District Programme Manager (DPM), RCH
Officer and Superintendent from District
Hospital Mananthavady are also
participated in the training. The objective of
the training is to improve the quality of care
provided to the patient.
Dr Paily has visited the Labour room and
Operation Theatre along with the
Gynecologist.
Jojin George
As part of the programme Measures to
Reduce MMR in Kerala, the following
hospitals were selected from Trivandrum
District; they are Women and Children
Hospital Thycaudu, SAT Hospital, District
Model Hospital Perrrorkada, THQH
Chirayankeezhu and CHC Kanyakulangara.
The strategies implemented so far are
posted JPHNs to all selected institutions
specifically for MMR reduction; Supplied
disposable delivery kits to all institution;
Started data collection from the prescribed
format; Introduced delivery register to all
selected hospitals; Conducting periodical
visit to all pilot hospitals and verified
documents; Formulated Quality standards
as centralized and distributed to all the
selected Hospitals; Displayed Quality
Standards Flow Charts to labour rooms as
well as gynecology wards.
IMPROVING MATERNITY CARE IN
TRIVANDRUM DISTRICT
MEASURES TO REDUCE MATERNAL
MORTALITY IN KERALA TRAINING AT
DISTRICT HOSPITAL, MANANTHAVADY
Page 20 of 60
Dr. Pailly from KFOG has conducted
orientation training on quality standards at
institutional level.
The District Programme Manager visits
periodically to all pilot hospitals and
verifying documents and other
requirements. The Quality Assurance team
also assists him and preparing report for
further developments.
Thushara Bhaskar
As a part of the implementation of
Measures to Reduce MMR project in Kerala,
a new data format was circulated to all
selected hospitals.
The format intended to collect the details of
maternal health care in the selected
hospitals. The pilot hospitals were sent
MMR data in every month to the state
office. The data set of individual hospitals
includes the consolidated details of the
labor room register.
The quality assurance team of SPMSU
consolidated the data before 15th of every
month in excel format. The detailed analysis
of the collected data was done in every
month and presented before the members
of the working group and gynecologists of
the selected hospitals in review meeting.
Ashitha G R
MMR DATA ANALYSIS
Page 21 of 60
KERALA ACCREDITATION STANDARDS
FOR HOSPITALS (KASH)
In Trivandrum District so far 8 hospitals
were KASH accredited. Taluk Hospital
Parassala is the last KASH accredited
hospital in the district and this is the first
accredited Taluk Hospital in the state. This
Hospital covers an average OP of 1500 per
day. The Hospital has separate OP rooms
with waiting chairs, token system, and
information counters, drinking water and
IEC facilities.
All wards have well equipped nursing
stations with rest rooms. Hospital has a well
scheduled cleaning policy and effective
supervision which promotes cleanliness in
the hospital. The hospital has a well
equipped laboratory which is working for 24
hours. All the lab tests, normal values,
turnaround time, sample acceptance and
rejection criteria, complaint readdressal etc
are displayed outside the laboratory.
Internal and external quality control is
doing for the lab tests. Separate dining
areas for patients in each wards and
availability of hot water for bath are
provided for patients. Separate area is ear
marked for the disposal of general waste
and biomedical waste storage.
As part of reducing infection control in the
hospital an infection control nurse is
designated to oversee all the infection
control activities. Separate registers are
kept for monitoring the Hospital acquired
infections in the departments and trainings
are given to all staffs to capture the same.
Geriatric friendly toilets for patients, zoning
of the operation theatre, Operation theatre
infection control practices, Quality
assurance for the X-ray services, Calibration
of the equipments, training to all staffs ,
health checkups for staffs ,formulation of
committees, documentation of all the
procedures ,formulation code blue team,
code red team , etc are done as part of
KASH accreditation program . All the rooms,
beds and furniture’s are numbered,
KASH - THQH PARASSALA
Page 22 of 60
displayed citizen charter, patient rights and
responsibilities, displayed layout of the
hospital ,placed fire extinguishers with fire
exit route plan etc.
As part of KASH accreditation more than 20
trainings conducted in the hospital. The
training comprises the KASH general
awareness, infection control practices, CPR,
Spill management, code blue, code red,
housekeeping, fire safety etc. The hospital is
maintained healthy liaison work with local
authorities especially the Block president
and the MLA. The superintendent and other
supporting staff is more interested tin
implementing KASH standards.
Reshmi.G
The KASH Certificate Handing over function
had been conducted at PHC Thiruvambady
on 28th Feb 2014. Hon’ble MP Mr.
Shanavas handed over the certificate to
Medical Officer Mrs Radhika. DPM, Sr.
Consultant Monitoring and Evaluation,
Panchayat President and other important
officials at Thiruvambady Panchayath &
Consultant Quality Assurance were
presented on the function.
Swathy Laxmi .A.P
KASH ACCREDITATION OF PHC
THIRUVAMBADY KOZHIKODE
Page 23 of 60
THQH Punalur was accredited with Kerala
Accreditation Standards for Hospitals on
December 2013. The hospital is maintained
healthy liaison work with local authorities
and other public as well as private
organizations. The superintendent and
other supporting staff is more interested to
implementing KASH standards.
Physical achievements includes Bilingual
signage’s in all areas, Citizen Charter in
Display & Booklet, Institutional level
trainings for all hospital staff, Formulated
committees, Conducted Internal audits,
Implemented new case record file, Started
hospital infection control activities &
infection control training for all staff,
Monitoring of Indicator for data collection,
Placed fire extinguishers at identified areas,
Internal and external quality check in
laboratory & radiology, Swab Culture from
different areas & also from drinking water
and Employees personnel file.
Different Trainings conducted includes
KASH orientation training, infection control
training, BLS training, housekeeping,
laboratory quality improvement training,
CPR, Safe Injection & Infusion Practices and
Fire Safety. Infrastructure changes includes
pharmacy block, toilet for physically
handicapped, operation theatre rearranged,
labor Room and NBSU.
Devi. G
KASH ASSESSMENT AT PHC VALAKOM ,
ERNAKULAM
KASH - THQH PUNALUR- KOLLAM
Page 24 of 60
Kerala Accreditation Standards for Hospitals
Assessment was conducted in Primary
Health Centre, Valakom on 25 March 2014
by the NABH Assessors.
Implementation of KASH Programme
started in PHC Valakom on February 2012.
PHC Valakom has implemented KASH
standards during the last two years.
Signage are placed in all areas.
During these period New OP registration
area constructed, breast feeding area.
Garden and Beautification work done. All ,
rooms and beds numbered.
Proper Biomedical Waste disposal is in
place and agreement with IMAGE for
biomedical waste management. Fire
extinguishers are placed in appropriate
places.
Personnel record file for all staff introduced.
Committees formed for the implementation
of standards.
Page 25 of 60
The committees formed in the hospital are
Core committee, Quality Assurance
Committee, Biomedical Equipment
Management Committee, Code blue
/resuscitation Committee, Condemnation
Committee, Drugs formulary committee.
House Keeping & Infection Control
Committee, Office Management
Committee, Purchase Committee, Safety
committee and Staff welfare Committee.
Hnad wash policy was introduced.
The trainings conducted in the hospital are
KASH awareness, fire and safety, patient
care, infection control, Management of
blood spill, Infection Control, Bio Medical
wastage management and BLS.
Nigini Paulose
Page 26 of 60
Only two MHC were selected from the state
for KASH accreditation and one of them was
MHC Thrissur. Quality assurance
programme is being implemented in the
hospital. Hospital has tied-up with IMAGE
for the proper biomedical waste
management. Equipments in the institution
were calibrated. Side rails were fixed in cots
of all wards. Old case sheet modified as per
the quality standard. Patient information
boards were fixed in appropriate locations.
Buildings were divided and named as per
the quality standard. Fire safety equipments
were implemented. Training programmes
were conducted to improve the proficiency
of staff.
Muthulakshmy .K.S
For KASH accreditation assessors had
conducted final assessment at Community
Health Centre, Kanjeetukara on 5th January
2014. The hospital has taken great efforts in
the Quality improvement activity as per
KASH Standards.
Community Health Centre Kanjeettukara is
at Ayroor panchayath and under the
Koipuram block panchayath which is
situated about 7 km from Kozhencherry.
The CHC was established since 1952. It is a
30 bedded hospital and providing the OPD
services, in patient services, laboratory
services, Pharmacy, vision testing, referral
services, maternal and child healthcare
including family planning. District hospital
Kozhencherry and General hospital
Pathanamthitta are the referrals centers for
this hospital.
The KASH programme started in
Community Health Centre, Kanjeettukara in
2012. The programme faced difficulties in
initial phase of implementation; however
the staffs of the institution have provided
full support for the implementation of the
programme.
KASH - COMMUNITY HEALTH CENTRE,
KANJEETUKARA PATHANAMTHITTA
KASH - MENTAL HEALTH CENTRE,
THRISSUR
Page 27 of 60
The major activities involves sensitization of
health care organization towards
importance of the quality healthcare
services; involvement of staffs for
improving the quality of patient service;
development, review and implementation
of policies and procedures etc.
The hospital has also constituted
committees, defined the role and
responsibility of all committee at the facility
level, and with the scope of work as per
requirement. The committees formed are
quality Assurance committee hospital
infection control committee drugs &
therapeutic committee, grievance redressal
committee, disaster management
committee and hospital ethics committee.
Training and mock drills were conducted as
per the requirement of KASH standards.
Patient and employee satisfaction survey
has been conducted. The institution is
regularly monitoring the quality indicators.
The hospital also developed good infection
control practices. Mock drill on cardiac
Pulmonary resuscitation, child abduction,
medicine recall procedure, Fire, disaster
management where conducted.
The detailed assessment conducted in the
institution by KASH Assessors from State
accreditation board on 5th January 2014 and
the Assessors has listed 27 non
Compliances. All the non conformities to
the institutions reported during the
assessment were corrected in two weeks.
Page 28 of 60
The quality improvement in the Community
Health Centre Kanjeetukara was due to the
joint effort by the staff of institution under
the leadership of the hospital. National
Health Mission has supported the Quality
assurance programme. District Programme
Manager, Quality Assurance Officer,
Biomedical Engineer and other staff of the
district NRHM has helped in the
development and improvement of the
quality of services offered by the institution.
Shylesh Chandran
PHC Kollayil is situated at kollayil
panchayath under perumkadavila CHC. This
hospital is having 160 OP per day. The
Hospital voluntary applied for KASH
accreditation program and the
implementation process has started on
September 2013. KASH assessment has
been conducted on March 21st 2014. All
the staffs and local governments are very
much interested in implementing the
program.
As part of KASH accreditation program
placed signage board on the adjoining areas
of the main road, displayed the services
available and the citizen charter, placed
drinking water and IEC materiel’s for
patients, displayed patient rights and
responsibilities.
All the ordinary taps were replaced with
elbow tapes, tissue paper and soap
solution. Maintained privacy for patients in
the observation and OP room. Placed fire
extinguisher and displayed fire exit route
plan and floor plan. Displayed layout of the
hospital.
Sound-alike look alike medicines are
arranged separately in pharmacy. All the
medicines are kept in neat and well lit
environment with proper labeling. List of
available medicines are displayed outside
the laboratory. Emergency checklist are
kept for medicines. Registers are placed for
monitoring HAI. Trainings are given to all
staffs on CPR, Infection control, house
keeping, KASH.
Reshmi.G
KASH - PHC KOLLAYIL, TRIVANDRUM
Page 29 of 60
PHC Karavalur was accredited with Kerala
Accreditation Standards for Hospitals on
December 2013. Physical achievement
includes bilingual signage in all areas,
formulated various committees, Purchased
waiting chairs, wheel chairs & trolleys, New
OP counter, renovated waiting area, new
physically handicapped toilet and pharmacy
renovation.
Other achievements includes Citizen
Charter, Institutional level trainings for all
hospital staff, Conducted Internal audits,
and Placed fire extinguishers, and
Employees personnel file.
Devi .G
Women and Children hospital was
established in 1942 as “Sachivothama Sir C
P Ramaswami Aiyar Shashtyabda Poorthi
Memorial Hospital”. It is situated nearly to
Alappuzha Beach, Near Railway Station and
old Port. It is the major maternity hospital
in government sector in Alappuzha district.
The institution is 308 bedded and spreads in
9 acres of land.
Patient safety and risk assessment is the
process of minimizing risk to an
organization by developing systems to
identify and analyze potential hazards to
prevent accidents, injuries, and other
adverse occurrences, and by attempting to
handle events and incidents which do occur
in such a manner that their effect and cost
WOMEN AND CHILDREN HOSPITAL,
ALAPPUZHA
PHC- KARAVALUR- KOLLAM
Page 30 of 60
are minimized and development of systems
to prevent accidents, injuries, and other
adverse occurrences in an institutional
setting. The concept includes prevention or
reduction in adverse events or incidents
involving employees, patients, or facilities.
In WCH Provision for toilets for physically
challenged patients made available. Fire
extinguishers are provided in all hospitals
periodically checked and maintained ,
provision for safe drinking water made
available, identification tag for mother and
child implemented, floor mats / anti skid
tiles provided in slippery areas….etc. Before
the introduction of the program the
institution conducts only sanitary rounds,
focusing only on cleanliness of ward, but
the hospitals are started to do safety
rounds quarterly. Safety rounds focuses on
electrical safety, plumbing inspection for
leakage and block, fire safety, risk
associated with day to day functioning,
facilities for patient, patient and staff safety
etc. The quarterly safety rounds are
conducting by a team comprising of
Superintendent, RMO, Nursing
superintendent, HIC Nurse, JC(QA) NHM,
PRO and electrician cum plumber and
records are maintained.
Infection control activities and proper
housekeeping are one of the most
important aspects of the program, A good
housekeeping service is an asset which no
hospital can afford to neglect. It is an
important variable in ensuring quality
assurance of hospitals. Dr. Sathyan
Infection control officer and Mrs. Leela
Infection control nurse are holding the
steering of IC activities in hospital. Registers
to track the hospital acquired infections and
needle stick injuries are implemented and
staff trained on it. Facilities for proper hand
washing are made available. System for
identifying, reporting, investigating and
controlling infections are in place. Hospital
have developed an antibiotic policy. The
institution ensures periodic training of staff.
Spill management kit made available in all
patient care areas. HIC team ensures
periodic training of staff in infection control
related activities. The hospital has received
award from pollution control board in past
consecutive years.
Page 31 of 60
Information displays are one of the
important criteria to achieve the
accreditation. The hospital displayed scope
of services, hospital lay out, mission and
vision, applicable user charge and tariff list,
no bribing policy, no smoking policy, patient
rights and responsibility, signage boards,
displayed medicine list and instruction in
pharmacy etc.
The institution has developed 32 quality
indicators as part of KASH programme.
Periodical collection and analysis of data is
helping the institution to measure the
improvements and to take Corrective
actions based on it.
In WCH there is an evidenced remarkable
change in health care quality. The support
of Superintendent, Consultants, medical
officers, nursing, administrative and
supportive staff for the implementation of
KASH programme helped the institution to
made a dynamic change in implementation
of quality standards. The hospital applied
for KASH assessment in 2nd week of April.
Margaret Lincy
PKKSM Taluk Hospital, Kayamkulam is a 125
Bedded Govt Hospital upgraded to the
level of ‘Taluk Hospital’ Kayamkulam on
6th November 2009 GO(MS No. 568/2008
Health & Family Welfare Dept. TVM Dtd.
6/11/2008) which is functioning in 2.7 acres
of land, the Hospital is functioning in 10
Blocks with 17 various departments /units.
The institutions have an OP of 30000 and IP
of 780 per month.
The QA activities done in the hospitals are
hospital Apex manuals and policy
procedures drafted, registers implemented
to track and analyze hospital quality
indicators. Proper hand washing facility
implemented. Racks and containers are
purchased for the storage of medicines in
ward and Pharmacy and for the storage of
medical records. Hospital Lay out prepared
and exhibited. House keeping checklist
THQH KAYAMKULAM
Page 32 of 60
implemented in all areas. Contact number
of ambulance drivers with tariff rate
exhibited near casualty. Curtain separation
provided in casualty, labour room for
ensuring patient privacy.
Margaret Lincy
THQH Chavakkad is the only hospital
selected for NABH accreditation
programme from Thrissur. Pre assessment
of the NABH was done on 9th & 10th of
June 2012 by the QCI assessors. Now
hospital closed 60% of NCs regarding the
pre-assessment. We hope the hospital will
get the accreditation in this year itself.
For the State level accreditation programme
we have selected, in the preliminary phase,
Thqh Kodungallur, Chc Puthenchira, Chc
Erumapetty, Phc Manalur and Phc Puthur.
THQH Kodungallur:- This hospital’s bed
strength is 176. More than 1000 out-
patients were visiting the hospital per day
and around 182 patients were treated as in-
patient per day. Before the quality
accreditation programme, it was a very
tedious job to control the huge number of
patients with the limited facilities in the
OPD, so additional staff were engaged for
the smooth running of the OPD. But
through the quality accreditation
programme, the hospital implemented
token system which controlled the rush in
the OPD without any manpower. The
computerized OPD will be a reality in the
near future. The work is in the final stage.
New case-sheet was implemented in the
hospital as per the quality standards instead
of old paper pieces. Hospital has got AERB
license for the x-ray unit. Fire safety
equipments were installed for the hospital
safety purpose. Hospital renovation work
has been going on.
CHC Puthenchira and CHC Erumapetty:-
CHC Puthenchira had undergone KASH
assessment on 2nd September 2013 and
submitted the NC closing report to
QUALITY ASSURANCE PROGRAMME IN
THRISSUR DISTRICT
Page 33 of 60
accreditation board. The low IP occupancy
rate which is the only reason in delay of
accreditation. As per the KASH standard Chc
Puthenchira had achieved 75 %. These
CHC’s got a new phase through the state
level accreditation programme. Before the
starting of state level accreditation, they
have no hospital signage boards and
informatory displays, no water purifier for
patient’s drinking purpose . But after the
implementation of the state level
accreditation programme, the hospital
obtained display boards of hospital
facilities, patient rights & responsibilities,
Doctor’s name, notice boards, hospital
layout &floor plan. New OP and enquiry
counter, breast feeding corner, separate
toilet for physically handicapped patient,
new case sheet were also implemented as
per the quality standard.
Token system has been implemented in
these CHC’s. Equipment’s calibration has
completed. Curtains fixed in all patient care
areas for the privacy of patients. Infection
control monitoring system, Patient
feedback & complaint redressal system
have also been started as part of total
quality management and we are regularly
conducting the continuous trainings in
different subjects for improving the skills of
all category of staff. In CHC Erumapetty
the construction work of new building is in
the full swing.
PHC Manalur & PHC Puthur:- Tremendous
changes have been happened after
implementing the KASH. They all got up
from the ventilator and they can easily
breath now. Before the implementation
these hospitals were in a very pathetic
condition in all means. Through the quality
standard implementation programme the
standard of the hospitals have been grown
up step by step and it is going to be a high-
tech PHC’s in near future. It has undergone
structural modification, conducted training
programmes for improving skills of staffs
and also conducting patient awareness
classes. Breast feeding corner, IUD corner,
OP Counter, Consultation rooms, Separate
toilet for handicapped patients, patient
waiting areas were constructed and new
token system was also implemented. Phc
Manalur tied-up with IMAGE for the proper
bio-medical waste disposal. Equipments
were calibrated. PHC Manalur had
undergone KASH assessment on 16th
November 2013. NC closing activities are
going on in full swing.
DH Thrissur, THQH Wadakkanchery, THQH
Chalakkudy, THQH Kunnamkulam, THQH
Irinjalakkuda, TH Chelakkara; These
hospitals are in a preliminary stage of
implementation process of quality
standard. The above hospitals were trying
their level best to take part this tedious
Page 34 of 60
process within their limitation. New case
sheet implemented, fixed various patient
informatory boards, new baby feeding
room installed, provided continuous
training for staffs, curtains fixed in all
patient care areas, equipments calibrated,
periodical monitoring of infection control
practices were some of the modifications
done through the implementation of quality
up gradation programme.
Muthuleshmy K S
Kerala government has introduced a new
Accreditation program (KASH) for uplifting
the quality standards and services given by
the Government hospitals in all care
settings. KASH seems to have drawn
inspiration from the new environment in
the government hospitals that have gone
through or are going through the National
Accreditation Board for Hospital and
Healthcare Providers (NABH) accreditation
process. This program focuses on the total
quality development of the Hospitals and
the practices of the healthcare Institutions.
Under KASH, government hospitals will
receive accreditation from the State if these
fulfill certain criteria. KASH standards have
been evolved out of the Indian Public
Health Standards and the NABH guidelines
so that each level of health care institution
maintains an essential standards charter
within its scope and limitations. KASH
Program started in the year 2010- 2011 and
the first phase includes 2 PHC’s, 2 CHc’s and
one District Hospital. The second phase
started in the year 2012 and it includes all
the secondary and tertiary care Hospitals.
KASH program in Trivandrum district
started in the year 2012. District Program
Manager Dr. B. Unnikrishnan has taken
strong initiative in implementing this
program in the district.
KASH IMPLIMENTATION TRIVANDRUM
DISTRICT
Page 35 of 60
In Trivandrum District other than the
selected hospitals for KASH implementation
many hospitals voluntarily come forward
for the implementation of this program. Till
date 14 hospitals in the state got KASH
accreditation out of this 8 is from
Trivandrum District and three hospitals are
in the phase of KASH assessment.
The District which has made a pioneer
achievement in KASH Accreditation process
is Trivandrum, which have the first KASH
accredited Community Health Centre (CHC
Manamboor) first KASH Accredited Primary
Health Centre (PHC Chemmaruthy) and first
KASH Accredited Taluk Hospital (TH
Parassala). CHC Vellarada, PHC
Mangalapuram, PHC Vattiyoorkavu, PHC
Chenkal and PHC Keezhattingal are the
other 5 Institutions which have got KASH
Accreditation. Staffs of NHM Triavandrum,
LSG’s and the Hospital staffs had taken a
great effort in pull off this recognition to
the district.
The folk wisdom is “roots have to go deep
for the tree to stand erect” and similarly, in
public health system, the roots are PHC and
CHC and unless these are qualitatively deep
to play its role, the rest of the system would
fail. Taking this into mind DPM together
with quality team, LSG’s and the medical
officers of the concerned PHC’s and CHC’s
work hard towards achieving the quality
parameters point out in the KASH
standards.
Like thousands of PHC’s and CHC’s in our
country, the CHC’s and PHC’s in Trivandrum
are not different. Health programmes in the
past have been beset with problems such as
limited capacity, lack of programme
standards and guidelines, and an obsession
with quantified targets rather than client
satisfaction.
Page 36 of 60
The new quality parameters introduced by
the state Government seek to address
problems of poor sanitation and cleanliness
in hospitals, staff shortage in every
category, damaged and pathetic condition
of the building and campus, poor signage
system in hospitals, absence of patient
satisfaction monitoring system, lack of a
measurable parameter for patient safety
and absence of legal compliances etc
Hence, KASH Accreditation program was
introduced to tackle all these problems, as
also the issues of lack of accountability and
planning in delivery of care to patients, lack
of blood bank/ storage facility in some
hospitals, and the absence of quality
standards such as medical audit,
management of medication, patient care,
facility management and safety,
information management system,
Biomedical waste management and
infection control.
Before implementing KASH program the
condition of the institutions was very poor.
The hospital doesn’t have a proper signage
system, layouts, display boards, basic
amenities like drinking water, waiting areas
in the OP, Pharmacy, IEC materials
,Geriatric friendly toilets, safety belts for
wheel chairs and trolleys, Emergency
medicine checklists with equipments and
medicines, display of available medicines in
pharmacy ,privacy for patients during
examination, lack of awareness among
staffs about the quality parameters to be
followed ,unhygienic sterilization practices,
spill management techniques, handling of
BMW wastes and its treatment, lack of
awareness about the code alerts, infection
control practices, unhygienic environments,
damaged and pathetic condition of the
buildings etc.
Page 37 of 60
NHM followed a three phase strategy for
implementing the KASH program in our
District. First Phase include the gap analysis
of the concerned institution, the quality
team visited each hospital and prepared a
gap analysis report. Based on the gap
analysis report the hospital took corrective
action. The second Phase include the
development of Quality Manuals, Training
Programs, Onsite assistance in
implementing the standards in every
departments, renovations, maintenance
,Core committee and subcommittee
formation, team building ,visits and
meetings by DPM , LSG Members for
assistance, and proper guidance . The third
phase includes the self-assessment by the
hospital and application sent for final
assessment.
Some of the practices implemented are
patient satisfaction survey, employee
satisfaction survey, quality indicators, code
blue alert (red for fire, orange for mass
casualties, blue for cardiac arrest, pink for
child abduction), disaster preparedness
plan, basic infection control practices,
fulfillment of patient rights, medication
safety practices, facility management
practices, incidence reporting system,
safety inspection system, patient
information, inventory management,
quality control in diagnostics.
The hospital introduced token system, safe
drinking water facility, seating facility, IEC
materials ,Signage boards at main roads –
bilingual, Separate notice board for
displaying IEC material,
complaint/suggestion box – OP, IP, Lab,
Separate cabin with doctors name,
department name, Open drains closed,
Hanging loose wires tightened, closed open
circuit panels, periodic cleaning of water
tank & chlorination with documentation,
periodic Water sample checking – Biological
and Chemical with documentation, periodic
cleaning of water source , placed fire
extinguishers with checklist, fire exit
signage (white letters in green background)
with exit plan, Unique id number for all
equipments and furniture, Equipment
checklist for all equipments, Housekeeping
checklist board, Breast feeding area, Safety
belt for wheel chairs and trolleys, Handrails
for ramps and bathrooms (for vulnerable
patients) ,Railing of cots for pediatric and
Page 38 of 60
vulnerable group, Equipment calibration,
removal of old posters and unwanted items,
Infrastructure renovation, Landscaping and
beautification etc has been implemented in
the hospitals.
Besides this, training on biomedical waste
management, Needle prick injuries, CPR,
fire safety, housekeeping, incident
reporting, KASH awareness, Infection
control etc were given. About 53 trainings
conducted in the district as part of KASH
program. Registers for calculating Blood
stream infection rate, UTI rate, Adverse
drug reaction register, Sentinel/Near miss
Event register, Needle prick injury register,
Housekeeping register, Equipment
sterilization register ,CV register, IQC/EQC
register, Sample discard register, Complaint
register ,Reagents with expiry date, Stock
register, Equipment register, Redo register
etc put in place.
In a short period of its implementation
since 2012, the QM system has led to major
positives and overhauls the District’s
healthcare system. Patients have benefited
immensely in terms of the quality of care,
access to privileged medical staff, better
safety conditions, safer transport and
continuity of care.
The benefits of QM have not, however,
been limited to patients. The hospital staff
has also gained in terms of their
professional development, increased
professional satisfaction, leadership and
ownership, and a good working
environment. For the community, this has
translated into a quality revolution, marked
by access to comparative database and
disaster preparedness.
Page 39 of 60
The Quality management system execution
in Trivandrum District is a collaborative
process under the leadership of District
Program Manager Dr. B. Unnikrishnan. The
initiative and support from the top level
management is very renowned in carrying
out the process. DPM together with quality
team visited all the hospitals which are
ready for KASH accreditation, carry out
meetings with LSG’s and staffs of the
hospital. All this would not have been
achieved had we not maintained this
continuous quest towards Quality
improvement.
Quality is an ongoing conquest and we
should not be judging it on our own. It
should be judged by our patients and every
other stakeholder involved in the
healthcare process. It is, after all, not our
belief but the society’s in our Quality that
will make all the difference.
Reshmi G
NABH Programme is being carried out in
District Hospital, Kannur. Pre Assessment
had been conducted on 24th & 25th May
2013. About 101 non – conformities and
observations has been noted. The major
non-conformities assessors pointed out
were non availability of bilingual signage,
documentation, no breast feeding area,
inadequate training of staff, structural
modification for operation theatres and x
ray department etc. The amount allotted is
fully utilized. Sign boards with bilingual
signages has been fixed, play area & breast
feeding areas were established, training is
provided for staff, documentation is now
properly maintained. We had corrected
almost all non - conformities and submitted
the correction report on 19/01/2014.
KASH is being implimented in Taluk Hospital
Payyannur, Taluk Hospital Taliparambu,
Taluk Hospital Koothuparambu, General
Hospital Thalaserry, Taluk Hospital
Peravoor, PHC Edakkad. Bilingual signage
boards has been fixed, proper waste
disposal mechanism has been established,
OPs has been made wheel chair friendly,
hand washing facilities with elbow tap has
been provided and many more. The fund
allotted to all of these institutions are fully
utilized for improving the quality of
services.
Regional Level Training on IMEP was
conducted on 03/01/2014 & 04/01/2014.
QUALITY ASSURANCE PROGRAMME IN
KANNUR DISTRICT
Page 40 of 60
The participants were from Kannur &
Kasargode. District Level Fire and Safety
Training was conducted on 04/11/2013.
Revathi
Essential standards for laboratory
certification programme.
The standards created by QCI using a multi
stake holder approach, balance the needs
of urban and rural settings and apply to all
medical testing laboratories. The Essential
standards contains 9 clauses (ISO 15189) ie,
organization and management, Personnel,
Laboratory equipments, procurement and
external supplies, Process control,
document control, Internal audit, Control of
non conformities and continual quality
improvement. Compliance with above 9
clauses related standards will be measured
during the assessment by the QCI
empanelled assessors and laboratory gets
laboratory certification .
The following activities are implemented in
laboratories as part of the programme. All
laboratory manuals are amended (Quality
manual, Sample collection manual, Safety
manual, standard operating procedures and
Quality system procedures). Scope of
services with turnaround time and tariff
rate are exhibited in front of labs. Signage
boards placed. Proper waste segregation.
Documentation of environmental
conditions (Temperature charts are
maintained for water bath, fridge and
room.). IQC- Internal quality control by
replicate test method are introduced, and
started to maintain register, Test controls
are used in haematology analyzer and
Biochemistry analyzer, started plotting LJ
charts. Test calibration using commercial
controls are started to do and records are
maintained. Adopted universal precautions
in labs. Proper record keeping. Equipment
labeling done. Sample collection
area separated from the work area using
curtain / screen and Work area specified.
Organogram displayed. Policy and
Objectives are displayed in bilingual
language. Patient grievance redressel
system introduced. Periodic Internal audit
ESSENTIAL STANDARDS FOR
LABORATORY PROGRAMME.
ALAPPUZHA
Page 41 of 60
completed. Equipment calibration
completed. Periodic staff training in waste
management, blood spillage, mercury
spillage, management of needle prick and
acid spillage and in standard operating
procedures of laboratory. In THQH
Kayamkulam, Laboratory shifted to new
building, Constructed work bench with
granite slabs , electrical works completed.
Margaret Lincy
Quality Council of India is conducting a
laboratory accreditation programme based
on Essential Standards for Medical Testing
Laboratories in India. Kerala is the first and
only state to involve in the Programme
certification process for government
medical laboratories. In the first year so far
194 Government Medical Laboratories were
certified by Quality Council of India. In the
second year programme only 22 labs were
selected. In Trivandrum district two labs are
selected for the second year program. W&C
Thycaud and Public Heath lab Triavndrum.
Out of this W&C lab is certified by QCI for
the second year. PH lab is on the way for
assessment.
During the implementation of programme
induction training has been provided to all
staff working in the laboratory followed by
training on preparation of documents for
the laboratory.
All these laboratories are providing high
quality laboratory services to the patients.
Reliability of the laboratory tests are
assured, which helps the treating doctor to
provide effective treatment and follow up
of the patients. Safe working environment
is provided to all laboratory staff.
All the laboratories have quality manual,
standard operating procedures (SOPs),
sample collection manual and laboratory
safety manual. Internal audit in the form of
self-assessment has been done in all
laboratories prior to final assessment. All
process in the laboratories starting from
reception and specimen collection,
registration of samples, authentic
numbering and storage of samples,
rejection of improperly collected
specimens, checking of labeling of
containers and conditions of specimen,
codification of the samples, testing of the
samples and reporting were standardized.
The internal quality controls were done in
all labs to verify the reliability of the
laboratory test. The patient’s suggestion
ESSENTIAL STANDARDS FOR
LABORATORY PROGRAMME IN
TRIVANDRUM DISTRICT
Page 42 of 60
and complaints were reviewed for
improving the patient’s satisfaction .The
Biological wastes from all the laboratories
in the district are handled as per biomedical
waste management rules.
Reshmi G
Laboratory of Taluk Head quarters hospital
is the first laboratory in Kerala which got
the QCI certification in IInd year lab
programme. Laboratory achieved this
certification on the basis of implementation
of quality standard in medical testing and
other related quality parameters. After the
accreditation, the number of samples have
been increased tremendously when we
consider the pre-accredited period. This
points out the acceptance of this laboratory
in the public. Other hospitals including
private hospitals are suggesting this hospital
laboratory for medical testing. Medical
Superintendent and Lab technicians are the
key people behind this success. Their
enthusiasm to the accreditation process will
be very much appreciated. Now this lab
generate computerized results.
District level and institutional level
sensitization programmes conducted
regularly for up gradation of quality
standards and also conducted IMEP
trainings, exposure visit to any accredited
hospitals. Review meetings (NABH & KASH
selected hospitals only) has been
conducting on a regular basis to evaluate
the progress of accreditation status as well
as the expenditure of fund in the hospitals
under the quality assurance.
Muthulakshmy K S
TRAINING - QUALITY ASSURANCE .
The Ministry of Health & Family Welfare
commissioned the development of a
National Policy document to address the
issues relating to infection control and
waste management and defined a
TRAINING ON TRAINERS IN INFECTION
MANAGEMENT & ENVIRONMENT
PLAN
ESSENTIAL STANDARD FOR MEDICAL
LABORATORY PROGRAMME IN THQH
CHAVAKKAD
Page 43 of 60
framework for implementation of an
Infection Management and Environment
Plan (IMEP) in healthcare facilities.
This policy document was commissioned
under the Reproductive and Child Health
Programme Phase - II, with technical and
financial support from DFID and the World
Bank. The Infection Management and
Environment Plan (IMEP) is an approach or
framework for managing – avoiding,
reducing and controlling – health and
environmental risks arising from healthcare
facilities.
Many government hospitals in Kerala are
not managing the infectious waste as per
the biomedical Waste management rules,
disposal of sharps, use of auto disables
syringes, potable water facilities,
sanitations, skills attitude and behavior of
the staff etc were other issues related with
the infection control program.
The aim of the training is to setting up of
well designed, comprehensive and
coordinated infection control programme
aimed at reducing/ eliminating risks to
patients, visitors and providers of care in
government health care institution in
Kerala.
The major objectives of the training are to
assess the awareness of Infection control
activities among the health care providers
in the government health care institutions;
to identify deficiencies of awareness of
Infection control activities among the
health care providers in the government
health care institutions; to impart the state
of the art training on the awareness of
Infection control activities among the
health care providers in the government
health care institutions; to analyze the
effectiveness of Infection control activities
among the health care providers in the
government health care institutions; and to
set up Infection Control Programme in the
government health care institution in
Kerala.
Page 44 of 60
Methodology of the training was such that
two days Regional level TOT on Infection
Management and Environment Plan was
conducted by National Rural Health Mission
held at five regions; Ernakulam covered
three districts - Ernakulam, Thrissur and
Palakakdu; Thiruvananthapuram covered
Thriuvannathapuram, Kollam,
Pathanamthitta; Kozhikkode covered
Kozhikkode, Wayandu, Malappuram;
Kannur covered Kasargode and Kannur and;
Kottayam covered Alappuzha, Kottayam
and Idukki.
Initially a pre test was conducted to assess
the awareness of the programme. Various
sessions related with Infection control
Activities were conducted by Subject
Experts. Exposure Visit NABH Accredited
Hospitals, Group Discussions, experience
sharing etc were used.
Training materials such as IMEP policy
frame work, Operational Guidelines, soft
copies of power point presentation, Format
for Evaluation of IMEP training, brochures
related with Biomedical Waste
Management, Infection control practices,
Specimen Infection control manual etc were
supplied.
After the training post test was conducted
and certificate for participation were also
issued to the participants.
The topic were covered in the training are
Introduction & Concept - Hospital Infection
Control, IMEP Guidelines & Policies Action
Plan- Policy Frame work 2007, Infection
Control Programme with special emphasis
to Quality Aspects, Standard precautions,
Sterilisation and Disinfection, Isolation
Practices, Occupational Hazards, Hand
Hygiene Practices, Housekeeping in
Hospital. Safe Injection practices, Anti
microbial Resistance, Antibiotic Policy,
Rational Prescription, Biomedical Waste
Management and Sewage Treatment.
Five regional levele training were conducted
at Ernakulam, Trivandrum, Kozhikkode,
Kannur and Kottayam. 197 participants
were attended, which include DyDMOs,
RCH Officers, Junior Administrative Medical
Officers, District Nursing Officers, Medical
Superintendents, Medical Officers and
Senior level Nurses from hospitals were
attended the training.
One of the parameter for assessing the
impact of the IMEP TOT is to setup the
Infection Control Committee in those
Page 45 of 60
hospital that were attended the TOT. The
participants from the hospitals were asked
to furnish the details of Hic constituted in
their hospital in prescribed format. The
details are shown in the following table.
Sl No
District No Of Hospital
s attended
TOT
Hospitals
constituted HIC
%
1 Trivandrum 6 4 67
2 Pathanamthitta
6 4 67
3 Kollam 6 4 67
4 Malappuram
9 4 44
5 Kozhikode 7 3 43
6 Wayanad 4 2 50
7 Ernakulam 4 4 100
8 Thrissur 5 1 20
9 Palakkad 4 3 75
10 Kasargode 8 2 25
11 Kannur 12 6 50
12 Kottayam 4 1 25
13 Alappuzha 7 4 57
14 Idukki 5 3 60
Total 87 45 52
Ajithkumar. S
A two days workshop on hospital safety was
conducted at THQH Cherthala as part of
National safety day on 4th and 5th at
Conference hall. Target participants are
core members from Major institutions
including Medical superintendents. Total 58
staff Participated in the programme. Five to
Six members from each institutions
participated in the programme. This
workshop mainly concentrated on various
safety aspects related to staff and patients
in the hospital. The programme was
inaugurated by Dr. Subaida,
Superintendent, THQH Cherthala. Mr. Davis
Director of Radiation Safety was a special
invitee for the workshop.
This workshop start with an introductory
section on hospital safety by Dr. Venugoal
(THQH Cherthala) and he emphasized the
importance of ensuring safety in hospitals.
Mr. Davis, Director of Radiation Safety
delivered a talk on “Radiation safety
measures in hospital”. It was an eye
opening section for all participants. Mr.
Davis explained the importance of ensuring
radiation safety in radiology department
and the procedures for getting radiation
safety approval.
TWO DAYS WORKSHOP ON PATIENT
SAFETY – ALAPUZHA DISTRICT
Page 46 of 60
Mr. Sreekumar, Asst. Drugs Controller
Trivandrum was delivered a detailed
presentation on medication safety. Topic
mainly concentrated on storage, handling
,dispensing and administration of drugs.
Last session on the 1st day was focused on
infrastructure and electrical safety.
Implementation of fire fighting systems and
its usage is explained in detail by Mr.
Pushparaj, project engineer CAPE. Different
ways to ensure electrical safety is also
explained in detail.
In second day of the workshop, the first
session started with “Communication safety
in hospital”. Ensuring proper
communication and maintaining a good
relationship between employees is most
important in a complex organization like
hospital. So the importance of proper
communications explained in detail by Mr.
Philip , an HR Trainer.
Another important session in the 2nd day
was handled by Er. Mythili, Chief
environmental engineer, RPCB Ernakulam.
She explained in detail “The Biomedical
waste management rules 1998 and
amendments”.
Last session dealt with “Patient Safety in OT
and wards” by Ms. Lessamma (NABH
Assessor) .All safety aspects related to
NABH, KASH and infection control practices
were included in the presentation.
The workshop wind up with a conclusion
section and certificate distribution by Dr.
Manoj, District Programme Manger NHM,
Alappuzha.
Margaret Lincy
Two days hands on training on BLS (Basic
response provider course) conducted for all
staff in THQH Cherthala except doctors on
14th and 15th March 2014. Total 201 number
of staff trained in BLS in 4 sessions.
Training conducted by MIMS School of
resuscitation, training academy of American
Heart Association. All staff provided with
first response provider course certificates.
TWO DAYS HANDS ON TRAINING IN
BASIC LIFE SUPPORT (FIRST RESPONSE
PROVIDER COURSE
Page 47 of 60
All staff individually demonstrated Adult
CPR, Infant CPR and Choking management.
This programme was organized by DPMSU ,
Alappuzha.
Margarat Lincy
One day training was conducted at General
Hosptila payyannur in connection the
preparation of the hospital for Kerala
Accreditation standards for Hospitals
(KASH). The training was conducted on
04/04/2014 at the conference hall of the
hospital.
The Superintendent and about 45 staff in
the hospital attended the training. The
District Quality Assurance Officer and the
Bio medical engineer of Kannur District
coordinated the meeting.
The training was conducted mainly to
sensitize the staff of the hospital for
preparing for the KASH accreditation.
A motivational session has been conducted
initially to sensitse and motive the staff for
the preparation. The staff were made aware
about the importance of the quality
improvement programme and role fo the
staff to improve the quality of the health
care services.
All the chapters in the KASH accreditation
standards were covered in brief to get a
overview of the KASH standards. The feed
back from the staff were also collected in
the session.
The superintendent and staff of the hospital
has informed that they will start the
preparation of the hospital for KASH
standards and application shall be sent with
in three months.
Ajithkumar.S
District level training on IMEP & KASH
standards was conducted on 23rd Jan 2014
at KGMOA Hall, Kotooli, Kozhikode. Dr.
Anitha, Prof: Microbiology, Calicut Medical
college, Mr. Gee, Engineer, Pollution
DISTRICT LEVEL TRAINING ON IMEP &
KASH STANDARDS
KASH AWARENESS TRAINING AT GH
PAYYANNUR
Page 48 of 60
Control Board, Mrs. Vincy Varghese BD safe
injection practices, DPM Kozhokode,
Consultant Quality Assurance and Regional
Quality Assurance Officer were taken
classes for the participants.
Sixty participants from health care
institutions under health services
department participated in the training.
Swathy Laxmi AP
Infection Management and Environment
Plan trainings were conducted on 3rd and 4th
March 2014 in Thrissur District for Staff
nurses and Lab technicians. The aim of the
training was to create awareness on
hospital infection control and biomedical
waste management. Total 51 staff
participated in the training. Mrs. Sumithra
Assistant Executive Engineer Pollution
Control Board Thrissur, Dr. Chithra Valsan
Associate Professor Microbiology Jubilee
Mission Medical College Hospital Thrissur,
Smt. Marikkutty Rtd. Nursing
Superintendent, General Hospital,
Ernakulam and Mr. Praveen Kumar
Coordinator, IMAGE presented various
topics for the training.
Infection Control, Biomedical Waste
Management, Safe Injection Practice,
Standard Precautions, Hand washing and
Housekeeping are the topics included in the
training. The training was very helpful to all
health staff to improve their skills and
implementation of infection control
practices in the hospital. As per the feed
back received from the participants, the
training was very informative and inspiring
and they got the opportunity to attend a
district level training conducted on the
subject. Pre and Post test were conducted
in the training and prizes were distributed
to the winners by Dr. V.V.Veenus, DMO (H),
Thrissur.
Muthulakshmy .K.S
INFECTION MANAGEMENT AND
ENVIRONMENT PLAN TRAININGS AT
THRISSUR
Page 49 of 60
Hospital infection control committee
introduced in the District Hospital Tirur as a
part on Quality Assurance Programme. A
staff training has been conducted on 02-03-
2014. The mandatory standards of Hospital
infection control programme have been
already implemented by the Hospital
Infection Control Committee.
District Programme Manager,
Superintendent, HICC convener, Jr.
Consultant (QA) addressed the trainees.
District programme Manager inspected all
areas in the hospital.
PPEs
Food waste central collection
News paper report by Malayala Manorama
on 03-04-2014
HOSPITAL INFECTION CONTROL COMMITTEE LAUNCHING &
STAFF TRAINING IN DISTRICT HOSPITAL, TIRUR
Page 50 of 60
Bhadra .C. P
A KASH awareness training was conducted
in THQH Chengannur on 15-03-2014.
Dr.Joseph Joseph delivered a detailed talk
on KASH standards with emphasis on
Infection control activities. Total 30 staff
participated in the programme.
A training to all staff in THQH Chengannur
conducted on 26.03.14 from 11.00am to
2.30 to all categories of staff .All staff
including doctors participated in the
programme. The training starts with a brief
outline of KASH programme and covers all
chapters in KASH guidelines. Total 30 staff
participated in the programme. Ms
Margaret Lincy JC ( QA) NHM , Alpy was the
trainer.
Margaret Lincy
District level infection control training
conducted at District Training Centre Kollam
on 14th February 2014. Nursing
Superintendent, Infection Control Nurses &
PRO’s from District Hospital, Victoria
Hospital, Taluk Hospitals and CHC’s
participated in the training programme.
Devi .G
DISTRICT LEVEL INFECTION CONTROL
TRAINING - KOLLAM
KASH AWARENESS TRAINING IN THQH
CHENGANNUR
Page 51 of 60
Zonal wise IMEP training conducted in
Pathanamthitta for Nursing Assistants and
Hospital Attenders at District hospital
Kozhencherry and Thaluk hospital Thiruvalla
as part of district quality assurance
programme. The training was 6 days in
THQH Thiruvalla with 70 participants and 8
days in DH Kozhencherry with 95
participants, there were two sessions per
day.
The topics were on Introduction & concept
of Hospital infection control, Biomedical
waste management; Sterilization,
Disinfection, Isolation practices &
Occupational Hazards; Communication
Skills, NABH & KASH, IMEP Guidelines and
policies action plan, Hand Hygiene practices
& Housekeeping in Hospital, Infection
control programme with special emphasis
on quality aspects.
The aim of the training was to create
awareness on hospital infection control,
Biomedical waste management, Hand
Hygiene and to understand the importance
of Communication skills in the hospitals. Dr.
Thomas Alphonse (Suptd. Tvla), Miss
Thressiamma (Head nurse, TVLA), Mr
Ajaykumar (LS,Tvla), Mr Sebastian, Dr
Anitha Kumari (Dy.DMA), Dr Ganga
(Const.Tvla), Dr Sunil Mathew (Const.Tvla),
Dr Sandhya (Suptd.DH), Mr Shylesh
Chandran(QAO.Pta) presented various
topics for the training.
Shylesh Chandran
Training on cardiac pulmonary resuscitation
conducted in CHC Muhamma on 09/10/13
as part of KASH programme. Dr. Deeptilal
had given a well explained lecture on CPR. It
was a hands on training and all staff in CHC
Muhamma demonstrated the CPR steps to
CPR TRAINING AND HOSPITAL
INFECTION CONTROL TRAINING - CHC
MUHAMMA ALAPPUZHA
IMEP TRAINING (ZONAL WISE) IN
PATHANAMTHITTA
Page 52 of 60
be followed in case of cardiac emergencies.
Total 35 staff participated.
Training on 7 steps of Hand washing
conducted in CHC Muhamma as part of
KASH programme on 15.10.13. Proper hand
washing is an effective way to control
hospital acquired infections. Mrs. Deepti ,
Staff Nurse CHC muhamma had given a
well structured presentation on the need
of proper hand washing and demonstrated
the 7 steps of hand washing. All staff from
bottom to top level, individually
demonstrated the hand washing steps in
the supervision of Medical Officer Dr. Don
Bosco and verified using a checklist. Total
35 staff participated.
Training on “Biomedical waste
management” conducted at CHC
Muhamma on 23/12/14 as part of
implementation of IMAGE waste
management system introduced as part of
KASH programme in hospital. Training given
by IMAGE district co-ordinator. Topics
covered includes types of hospital waste,
segregation, transportation and storage.
Total 34 staff participated in the
programme.
Margaret Lincy
Training on neonatal resuscitation
conducted in W & C Hospital, Alappuzha
on 12/11/13 as part of KASH programme.
Dr.Satyan, Paediatrician delivered an
informative presentation on the topic.
Targeted participants are doctors and
nurses working in W&C. Total 24 staff
participated in the programme.
A training on Infection control and house
keeping practices has conducted in W& C
on 2/12/13 Mrs. Leesamma delivered a
wonderful very informative presentation on
Infection control and house keeping
practices. Targeted participants are nurses
and grade II staff. Total 35 staff
participated. Topics include formation of
infection control committee, surveillance
activities, Care of systems and indwelling
devices, disinfection, waste management,
good house keeping practices etc.
TRAINING ON NEONATAL
RESUSCITATION AND OTHER TRINING
AT W AND C HOSPITAL ALAPPUZHA
Page 53 of 60
A training on “Biomedical waste
management and Spillage management “
has conducted in W & C Hospital,
Alappuzha on 22/10/13 as part of KASH
programme. Ms. Margaret Lincy JC( QA)
NHM, ALPY conducted the training.
Targeted participants are Nursing
assistants, grade I and Grade II staff. Total
30 staff participated in the programme.
Topics include Biomedical waste
classification, segregation and
transportation, Management of blood spill,
mercury spill and chemical spill.
A training on “POST PARTUM
HAEMORRHAGE – Care of high risk
obstetrics patients “ has conducted in W &
C Hospital, Alappuzha on 22/10/13 as part
of KASH programme. Dr. Geetha Cherian ,
Senior consultant W & C hospital delivered
an excellent talk on recognizing, diagnosing
and initializing appropriate measures to
manage PPH. Total 30 nurses participated in
the programme.
A Training on Blood Transfusion services
conducted in W & C Hospital, Alappuzha
on 12/11/13 as part of KASH programme.
Dr.Meena Beegum , Blood bank medical
officer delivered an informative
presentation on the topic. Targeted
participants are doctors and nurses working
in W&C Hospital. Total 21 staff participated
in the programme.
Margaret Lincy
A training on “hospital infection control
and house keeping practises“ has
conducted in THQH Hospital, Kayamkulam
on 24/10/13 as an initial step of
Implementation of infection control
measures in hospital as part of KASH
programme. Mrs. Leesamma Head Nurse,
THQH Cherthala (NABH & Safe I assessor)
had given an awareness on KASH
standards, Chapter 6 - Infection control and
followed by detailed explanation on
infection control and house keeping
practises in hospitals. Total 30 staff
participated.
Margaret Lincy
TRAINING ON HOSPITAL INFECTION
CONTROL AND HOUSE KEEPING
PRACTISES – THQH KAYAMKULAM
Page 54 of 60
A workshop on NABH 3rd Edition standards
conducted in THQH Cherthala on
17/10/2013 as part of its ongoing quality
improvement programmes. The programme
started at 8.45 am with a meeting chaired
by Hospital superintendent Dr. Subaida. Dr.
Junaid Rehman Ex.DMO, Ernakulam district
was a special invitee in the programme. He
delivered an excellent talk on “quality
movement of Kerala” and he emphasised
that Kerala health care institutions has
achieved a remarkable position in the
country through its twinkling achievements
in quality services and he congratulated the
effort of staff in THQH Cherthala, that leads
the institution to the achievement“ Ist
accredited Taluk Head Quarters Hospital In
India”. He also explained the strategies
adopted by GH Ernakulam, for the effective
management of hospital.
After the inaugural meeting Dr G.
Venugopal, Orthopedician, THQH Cherthala
has given an overall introduction about the
NABH 3 rd edition, the revised standards
and objective elements. He explained each
standards of NABH in a simple and easily
digestible way. The programme conducted
in two sessions. Total 151 staff participated
in the programme.
Margaret Lincy
NRHM kasaragod conducted an institutional
wise inspection and KASH awareness
programme at TH Trikaripur on12/5/2014.
Inspection has conducted by Regional
Quality Assurance Officer Mr. Ajith Kumar S.
He assessed how much they could attain
the quality accreditation standards. After
this overall assessment, area wise
assessment was done. OP, laboratory,
pharmacy, medical record room, every
wards, etc are included in different areas.
After assessment a training on KASH
standards conducted by Mr Ajith Kumar S,
Regional Quality Assurance officer. The
superintendent of Taluk Hospital,
Thrikaripur has welcomed the deligates and
quality assurance officer has delivered vote
of thanks.
Libiya M Cyriac
NRHM kasaragod conducted an institutional
wise inspection and KASH awareness
programme at CHC Badiaduka on
14/5/2014. Inspection has conducted by
Regional Quality Assurance Officer Mr. Ajith
Kumar S. After assessment institution had
conducted training for the staff on KASH
implimentation by Mr. Ajith Kumar S,
TRAINING AT CHC BADIADUKA
INSTITUTIONAL TRAINING
AT TH TRIKARIPUR
NABH WORKSHOP AT THQH
CHERTHALA
Page 55 of 60
regional quality assurance officer, it was an
inspiring experience for all of them.
Libiya M Cyriac
NRHM Kasaragod has conducted a District
Level Training On KASH Awareness at DMO
(H) conference hall, Kanhangad, on 13-5-
2014. The programme started at 10 a m,
and inauguration done by DMO(H) Dr. P
Gopinathan in the presence of Dr.
Dineshan, superintendent of TH Nileswhar,
Dr. V. Sureshan, MO of CHC Panathady, Dr.
Mohammed P, MO of PHC Uduma, Dr.
Suresh MO of PHC Vellarikkundu, and Dr.
Sathya Sankara Bhat MO of CHC Badiaduka.
Ajith Kumar S, state quality assurance
officer was the trainer. There were three
sessions for the training which covered all
the topics of KASH, enough time has been
given for discussions, feedback, and to
make action plans.
There were 49 participants for the training
from 7 KASH institution. They were GH
Kasaragod, TH Trikaripur, TH Nileswar, CHC
Panathady, CHC Badiaduka, PHC Uduma,
PHC Vellarikkundu. Superintendents,
medical officers, nursing superintendents,
head nurse, staff nurses, doctors from each
departments, clerks, coordinators,
pharmacists, lab in charges, housekeeping
staffs, health inspectors and head of each
departments were participated in the
training programme.
Libiya M Cyriac
DISTRICT LEVEL TRAINING ON KASH
Page 56 of 60
QUALITY ASSURANCE - REVIEW MEETINGS
A review meeting of Quality Assurance
Programme was conducted on 24th March
2014 at State Institute of Health and Family
Welfare, Trivandrum. Quality Assurance
Officers from all districts were participated
in the meeting along with officials from
SPMSU. Quality Assurance Programmes,
NABH, KASH, NABL, MMR has been
reviewed in detail.
Quality Assurance Officers from district
presented the details of programme
implemented with a power point
presentation. During the review meeting it
was decided that all Quality Assurance
Officers shall submit monthly report before
10th of every month. All Quality Assurance
Officers shall also submit a report of Quality
Assurance Programme implemented in the
district.
Ashitha .G. R
QA - BIOMEDICAL ENGINEERING
Efficiency of any health care institution
depends to a large extent on the availability
and judicious usage of the Bio-Medical
equipments. Biomedical Enginees were
conducted Equipment Audit in districts. The
Equipment audit includes gap analysis at
delivery points based on the availability of
existing equipments, infrastructure, IP and
OP per day, Delivery rate per month etc.
Aswathy . L
GOVERNMENT / DHS ORDERS.
The Director of Health Services has issed a
circular dated 24-02-2014 on introduction
on code blue in all health care organization
under Health Services Department.
All health care institution recognized the
importance of managing the emergency
situation in the hospital settings. "Code
Blue" is generally used to indicate a patient
requiring resuscitation or otherwise in need
of immediate medical attention, most often
as the result of a respiratory arrest or cardiac
arrest. Code Blue is an event of utmost
emergency, a mode of alerting all medical,
nursing, paramedical and allied health care
services and other personnel.
CIRCULAR ON CODE BLUE BY DIRECTOR
OF HEALTH SERVICES
BIOMEDICAL ENGINEERING-
EQUIPMENT AUDIT
REVIEW MEETING OF QUALITY
ASSURANCE PROGRAMME
Page 57 of 60
The copy of the circular has been posted in
the website of NRHM.
Dr .K. Sandeep
As per the Government Order No (MS) No
06/2014/H&FWD dated 03-01-2014, Health
and Family Welfare Department
Government of Kerala has revised the
preservation and disposal of case records
and registers in Government Hospitals
under Health Services Department. The GO
is available in the website of NHM in the
Quality Assurance page.
Dr. K. Sandeep
NEW PROGRAMMES - QA
Kerala Accreditation Standards for Vaccine
Stores has been developed by the drafting
committee. The Committee members
include Additional DHS FW, State Cold
Chain Officer, Deputy Chief Engineer, Senior
Consultant M and E, Senior Consultant QA,
Regional Quality Assurance Officer, Junior
Consultant QA, Bio Medical Engineer etc.
The draft standards were finalized at the
meeting held on 9 March 2013 and 17
March 2013 at NRHM SPMSU.
KERALA STANDARDS FOR VACCINE
STORAGE CENTRES – DRAFTING THE
STANDARDS
GO - PRESERVATION OF MEDICAL
RECORDS AND REGISTERS REVISED
Page 58 of 60
The Standards were developed for the
Regional vaccine storage centre, State
vaccine Storage centre and District Vaccine
Storage Centers
Sindhu. V
NHM has taken a new initiative for
developing the Quality Standards for
Ayurveda and Homoeopathy hospitals and
dispensaries in Kerala Government sector
under Kerala Accreditation Standards for
Health care (KASH) programme. This will
helps to improve the quality of service so as
to provide better health care delivery
system to the people. A quality standards
are being developed for the different
categories of institutions in Ayurveda and
Homeopathy.
Dr G S Balachandran Nair
The Quality Assurance team of Trivandrum
district as per the direction of DPM, NHM
conducted a detailed study on the present
conditions of the Operation theatres and
labor rooms in the hospital. The team
submitted the report to DPM as well as the
superintendents of the hospitals together
with suggestions and recommendations.
Instruction given to take monthly swab
culture reports, cleaning of the AC ducts,
filters, maintain registers to document the
cleaning of the OT etc. Based on the report
the superintendents taken a very good
initiative in maintaining the infection
control practices and this lead to a drastic
change in the present set up.
Reshmi G
Largest number of trainings conducted in
the Health services department is for
improving the Quality of Health Care in
health care institutions. During the last year
431 trainings were conducted with the
technical support from Quality Assurance
wing of NRHM and 12327 staff were
trained.
The important challenges the health
services are now facing is to keep pace with
TRANSFORMATION OF QUALITY CARE
THROUGH TRAINING
OPERATION THEATRE INFECTION
CONTROL STUDY
AYUSH KERALA ACCREDITATION
STANDARDS FOR HEALTH CARE (KASH)
Page 59 of 60
advances of constant medical and
technological advancement, growing legal
implications, monitoring of the quality
improvement methods. Most of the
professionals in government hospitals have
not received training on quality and safety
as a part of their formal education.
The training in Quality Assurance is the
highest number of training in Kerala health
services department. The training
conducted in Quality Assurance is more
specific which increases the skill, knowledge
and attitude of the staffs.
Training is an important component in the
implementation of quality assurance
programme. The trainings are provided at
State level, district level and institution
level.
One of the major topics, where hospitals
level training provided is infection control.
As part of Implementation of QA standards,
the hospital has conducted training on
Hospital acquired Infection and Control
methods, various trainings like Bio Medical
Waste Management, infection Control
Practices, Bio Medical Waste Segregation,
Safe injection practice, hand washing
techniques, antibiotic policy, hospital
cleaning and Aseptic Precautions.
Training on Advanced Life Support (ALS)
and Basic life support (BLS) were provided
to different hospital staff. Basic life support
(BLS) is the level of medical care which is
used for patients with life-threatening
illnesses or injuries until the patient can be
given full medical care at a hospital. It can
0 50 100 150 200
HIC related topics
ALS/ BLS / …
Fire safety
NABH Awareness
KASH Awareness
MMR
care of patients
others
Topics of training
Sl.
No
Quality Assurance
training
programme-State ,
district and
institutional level
programme
Numb
er of
trainin
gs held
Numb
er of
Partici
apnts
attend
ed
1 2013-14 431 12327
2 2012-13 353 14654
3 2011-12 208 8072
Page 60 of 60
be provided by trained medical personnel,
including emergency medical technicians
and paramedics who have received BLS
training. All other technical, management,
fire safety and administrative topics were
covered during the training.
The hospital provides training for the code
alerts, how to counter act during disasters
and outbreaks, role and responsibility of the
staffs. Trainings were conducted to improve
the quality of care of patients which
includes uniform care to the patients, ICU
patients, vulnerable patients, obstetric
patients , paediatric patients etc.
The concept of Quality in Government
hospitals has been transformed through
training programmes. Quality relies on 80%
Policy and Procedures, patient safety,
employee safety, better patient care etc, 10
% in infrastructure and 10% in Human
resources. The training in quality Assurance
is an ongoing process and this would help in
improving the skill, attitude and
performance for better patient care.
Sindhu. V
Whatever moving should be trained,
Whatever not moving should be calibrated,
Whatever happens should be documented,
Whatever not happened, not document.
QMS PHILOSOPHY