3. PLAN stage involves analyzing the current situation, gathering data, and developing ways to make improvements
DO stage involves testing alternatives experimentally in a laboratory establishing a pilot process, or trying it out with
small number of customers.
CHECK stage requires determining whether the trial or process is working as intended, whether any revisions are
needed, or whether is should be scrapped.
ACT stage focuses on implementing the process within the organization or with its customers and suppliers.
Once all this stages are completed to the fullest satisfaction, the improvement is standardized.
With the changing circumstances or new techniques this standardized work, process, product or service is again
subjected to further improvement thus repeating the Deming Cycle again and again.
5. Standards for Quality Management
• Standard G1: Facility has established quality
Assurance Programme as per state/National
guidelines.
• Standard G2 : Facility has established system
for Patients and employees satisfaction.
• Standard G3: Facility has established,
documented &implemented standard
operating procedure system for its all key
processes.
6. QUALITY ASSURANCE PROGRAMME...in Short ,
• Constituting Quality Team in Institutions
• Formation of committee
• Quality Policy and Objectives
• SMART criteria
• Periodical review of Quality objectives.
7. Quality Team
• Benefits;
• Shared Responsibility
• Reduced stress
• Coordination of patient care
process
• Feeling of unity
• Easy implementation of activities
• Increased communication
• Problem solving....etc etc.
8. Quality Team in UPHCs
Be a part of........QA Team.
TEAM MMBERS/COMMITTEE MEMBERS
• Mo i/c
• Staff Nurse
• Lab Technician
• Pharmacist
• JPHN
District level (Special Invitee)
• District Coordinator
• LHV
Frequency of meeting : Once in
Every Month.
9. Team/Commitee Responsibilities
• Defining the road map for Quality assurance for the facility.
• Defining quality policy and objectives and periodic monitoring on them
• Dissemination and orientation for Quality Standards & Standard Operating
Procedures (SOP) among the facility staff.
• Assuring that services being provided to defined quality standards and
clinical protocols.
• Performing baseline as well as subsequent periodic quality assessment
against defined standards with support from district quality assurance
committee.
• Measurement, reporting and review of the key performance indicators
• Providing hands on training and guidance to facility staff for meeting
quality standards
• Facilitating change ideas and focus interventions for Quality Improvement.
10. How to document ???
Name of Meeting with date
Venue & Time (Conference hall @ 12.30pm)
Agenda:
1.Review of action taken report
2. Other agenda
Participants
Name Designation Signature
Dr. ABC MO i/c
Meeting Decisions
Sl.
No
Discussion Action taken Responsible
person
Target date
1.
2.
House keeping monitoring checklist
not available
Decided to implement house
keeping checklist in
wards/OPD/departments..etc
SN
DUHC
20.10.16
Prepared By
Name &Sign
Hospital Seal Approved By
Name & Sign
11. Quality Policy and Objectives
• Quality Policy needs to be framed by the facility in
consultation the staff and other stakeholders.
• Quality policy is a broad statement that describes
what & how the facility intends to improve the
quality of its services. Quality policy should always
acknowledge user satisfaction as key component of
its policy.
• It should be formulated in local language and
displayed at critical places for better understanding.
12. Look some examples;;;;;
• UPHC ……...... aims at providing highest level of Preventive,
Promotive, and Curative Healthcare services to the catchment
community with sustained efforts to ensure that it is
Equitable, Affordable, Accountable and responsive to the
people’s need.
• We are committed to satisfy and delight our clients by
efficient services delivery with an aim of improving areas like
Sanitation and hygiene and safe drinking water, reducing
waiting time, respecting patient’s rights and encouraging
community participation.
• We are committed to delight the end users of our
services by efficient service delivery
13. SMART way to perform....
A Quality Objective is a quality oriented
goal or something you aim to achieve
• S- Specific
• M – Measurable
• A -Attainable
• R- Reviewable
• T – Time bound
14. Answerable ....Is it???
• Is Quality Measurable ?
• How could You measure quality ??
• How would you check your service ???
• How you evaluate your service ????
Let us frame our quality Objectives,,,
15. Quality Objectives ...
Departmen
t Policy Objective Specific Measurable Attainable Reviewable Time bound
OPD
Increase the OP service
from
current 60% to 70% in 3
months Y Y Y Y Y
Laboratory
Reduce the re dos in
laboratory
from current 40% to 30%
two months Y Y Y Y Y
Pharmacy
Reduce the stock out of
drugs
from current 15% to 10% in
3 months Y Y Y Y Y
Dressing room
and
Injection room
Reduce the injection
abscess
reported from current
10%to 7% in one month Y Y Y Y Y
Out reach
session
Increase the house hold visit
of
ANM to 80% from current
70% in one month Y Y Y Y Y
16. SOP/Work Instructions
• A standard operating procedure, or
SOP, is a set of step-by-step
instructions compiled by an
organisation to help workers carry
out routine operations.
• SOPs aim to achieve
efficiency, quality output and
uniformity of performance, reducing
miscommunication and failure to
comply to organizational regulations.
17. Standard G3; Facility has established, documented & implemented
standard operating procedure
system for its all key processes
Contents in an SOP
• SOP Number & SOP Title
• Purpose
• Introduction
• Scope
• Definition
• Process Owner
• Specific Procedures
• References
• Records
18. Formation of an SOP
SOP for SAMPLE DISCARDING IN LABORATORY
SOP Number : UPHC/NT/LAB/SOP- SD/01/A
SOP Title : SOP for Sample Discarding in Laboratory
Purpose:
The SOP is prepared as per the fulfilment of requirement of Compliance to State Guidelines & National
Quality Assurance Standards.
The principal purpose is disposing of samples is to avoid contamination with infectious waste agents known
to be infectious to humans
Introduction
Biomedical laboratories are special and unique work environments that may pose identifiable infectious
disease risks to persons in or near them. Correct discarding of samples is therefore necessary to reduce or
eliminate exposure to laboratory staff, other persons and the outside environment to potentially hazardous
materials: such as blood or other body fluids, which might be contaminated with agents known to be
infectious to humans.
Scope
Laboratory
Definitions
Medical laboratory:
Biological hazards:
Biomedical waste...etc etc
Process Owner
The person responsible for review the process is Laboratory technician
The person responsible to amend the process is Laboratory technician
The person responsible for the approval of the process is Medical Officer
19. SOP- Continuation.............
Specific Procedures- Disposal of Specimens ;
We have a documented procedure for discarding the unused samples. The laboratory assistant in presents of
laboratory technician is responsible for discarding the unused samples as per the rules of biomedical waste
management system.
Procedure
The samples are to be dealt with in the following manner after the test is conducted.
SOP 1.1: Serology:- After the test completed and results gets ready he serum sample is store till ....pm .
SOP 1.1.1: Discard the samples after ...pm the samples as per the bio medical waste management rules.
Sop1.1.2: Treat with bleaching powder/ hypochlorite solution and flushed to drain and the vials are discarded in red
bucket as per biomedical waste management rules.
SOP1.2: All urine samples –Discard on the same day after the results gets ready,
SOP 1.2.1: Treat the samples with bleaching powder/hypochlorite solution and flushed into drain
SOP1.2.2: Put the vials in red colour bucket as per the biomedical waste management procedure.
SOP1.3 : Biochemistry/Hematology samples – Discard everyday at .......pm.
SOP1.3.1: Treat with hypochlorite solution/bleaching powder solution and flushed into drain.
SOP1.3.2: The vials are put in red colour bucket as per the biomedical waste management procedure.
References
(This section is used to list all references, used within the text of the SOP, sufficient for the user to find the source
document(s).
1eg:Handbook of laboratory Methods
Records
1. Sample Discarding Register
20. Patient and Employee satisfaction
• Patient satisfaction surveys are
conducted at periodic intervals (At least
30/month)
• The facility analyse patient feed back and
“root cause analysis “
• The facility prepares the action plans for
the areas, contributing to low
satisfaction of patients
• Employee satisfaction – Yearly once.
23. Internal &External Quality Assurance
programmes
• ME G 3.1
The facility has established internal quality assurance
programme in key departments
• ME G 3.2
The facility has established external assurance
programmes at relevant departments
• ME G 3.3
The facility has established system for use of check lists
in different departments and services
24. Internal Quality Assurance Programmes
• Internal assessment of departments using the
checklist.
Pharmacy:
• Physical verification of Inventory
• Periodic and random sampling of drugs
• Prescription audit
25. Physical Verification
Date Name of
item
Stock as
on date
Physically
checked and
found
correct
Verified
by
Signatur
e
23.09.16 Tab .calpol 550 550 Pharmacist
26. Laboratory- Quality Management
• IQC system
• Control charts- Corrective action taken on the identified outliers
• Cross validation of lab test and corrective action on abnormal
value
• Laboratory assessment using checklist
27. Quality Management- OUT REACH
• ASHA and ANM are represented in Quality Team
• ASHA and ANM are aware of Quality Policy of the UPHC
• Specific Quality Objectives are set for Outreach services
• Quality of outreach services are reviewed during Monthly quality team meeting
• Internal Assessment Conducted for Outreach services
• Feedback is taken during outreach
• Employee Satisfaction survey includes ASHA and ANM serving under UPHC area
28. Further requirements QM
• UPHC performance and Quality indicators are reviewed in meeting
• Quality team review that all the services mentioned in RMNCHA &
National Health Program.
• Quality team report regularly to DQAC about Key Performance Indicators
and Quality Scores
• There is a system of Daily round of MO to all department of UPHC &
Records shall be available.
• SOP shall prepared/ available in all work areas
• All staff should be trained in Work areas
• Work instructions shall be displayed.
30. Why it is important,,??
• Backbone of Hospital Operations
• Usually most neglected area in public
hospitals
• Directly & Indirectly leads to poor quality of
services – Poor Upkeep of facility , long down
time of equipment
• Little efforts in process improvement may give
high & visible results as much more tangible
to Clinical Care
31. Standard D1 The facility has established facility management programme for maintenance
& upkeep of equipment & infrastructure to provide safe & secure environment
to staff & users
Standards
MD1.1 The facility has system for maintenance of critical Equipment
MD1.2 The facility ensures comfortable environment for patients and service
providers
MD1.3 Patient care areas are clean and hygienic
MD1.4 Facility infrastructure is adequately maintained
MD1.5 Facility has policy of removal of condemned junk material
MD1.6 Facility maintains both the internal and open area of the facility.
MD1.7 The facility provides adequate illumination level at patient care areas
MD1.8 The facility provides Clean and adequate linen as per requirement
MD1.9 The facility has adequate arrangement for storage and supply of
potable water in all functional areas
MD1.10 The facility ensures adequate power backup
32. MAINTANANCE OF CRITICAL EQUIPMENT
• Ask staff if all critical equipments are in working condition
• Whether equipment are covered under annual maintenance contract (AMC)
• Does preventive maintenance is done at least one in a year
• What is the system of corrective maintenance if in condition of Equipment breakdown.
How much time it takes
• Is there any practice of daily/routine cleaning, maintenance by the user. Who does it.
Review Maintenance records
• To verify that equipment's are covered in AMC
• Preventive Maintenance is done timely
• How much time it took for repair (log Book)
Observe
• Any equipment is lying idle since long time in need of repair
• In areas like Lab out of order/defective equipment are labelled and kept apart
• Equipments are numbered
33. The facility has established facility management programme for maintenance & upkeep of
equipment & infrastructure to provide safe & secure environment to staff & users
• Floors, walls, roof , sinks patient care and corridors are Clean
• Surface of furniture and fixtures are clean
• Trolley & cupboard etc are painted & in intact condition
• Cold Storage equipments are under AMC and temperature log book
• Temparature control at Pharmacy & medical store
• Drug Storage area and Pharmacy Counter are clean
• No junk, condemned, unused articles in the pharmacy
• Power backup arrangement for cold chain equipments
LABORATORY:
There is system of timely corrective break down maintenance of the equipments
Adequate ventilation in Laboratory
Floors, walls, roof , sinks in patient care area are Clean
Surface of furniture i.e work benches are clean
Fixtures and Furniture are intact and maintained
No condemned/Junk material in the Laboratory
Adequate illumination at work station & Collection area
34. ME D1.5 Facility has policy of removal of condemned junk
material
• Follow state guideline.
• Junk material in patient care areas/ Corridor
• Demarcated space for keeping condemned junk material
35. RecommendedIlluminationlevelinHospital
Area Recommended Min. Illumination
(in LUX)
1. Bathroom 100-150
2. Entrance – hall 200
3 Consultation room 100
4. Corridor , General 300
5. Ward 150-300
6. Diagnostic x ray , Work Place 300
7. Doctors office 300
8. Enquiry Office 500
9. Nursing Station (Day) 300
10. Nursing Station (Night) 30-100
11. Laboratory , Pathology 300-500
12.. Toilets 100-150
13. Store 100
14. Pharmacy 300
36. Standard D2 :Facility has defined procedure for storage, Inventory Management &
dispensing of drugs in Pharmacy ∞
STANDARDS
MD2.1 The facility has established procedures for estimation, indenting and
procurement of drugs and consumables
MD2.2 The facility ensures proper storage of drugs and consumables
MD2.3 The facility ensures management of expiry and near expiry drugs
MD2.4 The facility has established procedure for inventory management
techniques
MD2.5 There is process for storage of vaccines and other drugs, requiring
controlled temperature & storage environment
MD2.6 The facility has established procedure for dispensing of drugs
37. Pharmacy Procedures ..,
• Forecasting and intending of medicines shall be done based on consumption only .
• Consider stock out and wastage drugs
Storage
• Store in alphabetical order, medicines labelled
• LASA Medicines should be listed and store separately (Colour coding system)
• Procedure to identify near expiry drugs and avoid expiry of medicines
• Expiry drugs if any shall be discarded in black bag
• Physical verification of inventory
• BIN CARD SYSTEM (Receipt/issues /balance/audit)/ FIFO/VED
39. Expiry and Near Expiry of drugs
• Check for
Expiry Date of the drug are written on emergency drug tray
There are no expiry drug lying in drug tray or storage
Check for Expiry Drugs
List of expiry dates is of drug available in the department is maintained
Near expiry drugs are marked and list is updated periodically
40. Pharmacy Procedures ..,
DISPENSING
• Store in labelled containers
• Drugs dispensed in envelops (Medicine name/strength/dosage/
route/time of administration)
• LASA should be displayed in dispensing counter
• Drugs are not directly dispensed from drug storage area
• Strip cutting is not done
• Dispensing register is updated in real time
41. Laboratory Procedures
• There is established system of timely indenting of consumables and
reagents
• Reagents are labelled appropriately
• No expired reagent found, Records for expiry and near expiry reagent are
maintained
• Expenditure & stock register of consumables are available at laboratory
• The facility provide monitoring and reporting service for Integrated
Disease Surveillance Programme, as per guidelines
• Reporting format (Form L) are sent to District Surveillance Unit (DSU) as per guidelines)
• Water Quality Checking (Form for Water Quality monitoring
Form W contain information on source of water sample,no. of sample tested from that source and their
results )
42. Standard D3 - The facility has defined & established
procedure for community participation for providing
assured services
43. Compliance to standards..
Formation and functioning of
• MAS( Mahila Arogya Samit)
• Rogy Kalyan Samiti (RKS)
• Community Participation (NGO)
• Ensure participation of non official members in RKS
• Functioning of ASHA- Supporting Mentoring and monitoring
by U- PHC
44. Functions of RKS
• RKS is registered under societies registration act
• RKS meeting are held at prescribed interval Minutes
of meeting are recorded Participation of community
representatives/NGO/Local bodies is ensured
• RKS generates its own resources from
donation/leasing of space
• Community based monitoring/ social audits are done
at periodic intervals
45. Standard D3 Facility has defined & established procedure for
Community Participation for providing assured services
• UPHC monitors the activities assigned to ASHAs
• Incentives and TA/DA to ASHAs are paid on time
• UPHC supports in skill development of ASHAs
• There is system of taking feedback from ASHAs to improve the services
• Mahila Arogya Samiti has been formed in all the slums served by UPHC
• Accounts have been opened for MAS
• MAS meets every month
• Data base regarding functional MAS is available at UPHC
Reporting :
• Reporting on Form S under IDSP
• Reporting under Universal immunization program by ANM
• Reporting for MCTS
• Reporting for HMIS
46. Standard D4 -PHC has defined procedure for Governance & work
management
• The facility ensures the proper utilization of fund provided to it
• There is established system for contract management for out-sourced services
• The facility has established job description(Category wise) as per Govt guidelines
(From Medical Officer to ASHA)
• The facility has a established procedure for duty roster and deputation of staff
(Field visit plan for MO/ANM/LHV- Monitored and reviewed)
• The facility ensures the adherence to dress code as mandated by the department.
(ID Card and Name plate including ASHA)
• The facility has requisite licenses and certificates, as required for operation of a
health facility.
• Availability of authorization for handling Bio Medical waste from pollution control
board
• Availability of NOC for Fire Safety
• Availability of Licensee under Clinical Establishment Act
47. • The facility ensures its processes are in
compliance with statutory and legal requirement
No Smoking sign is displayed at the prominent places in UPHC
• Staff is aware of requirements of medico legal cases
• Any positive report of notifiable disease is intimated to designated authorities
48. Protocol for issue of medical certificates.
Defined formats for issuing Medical Certificate is available
A copy of issued Medical Certificate is kept for records
Register is maintained for keeping details of Medical
Certificate issued
Identification marks and Patients address is mentioned in
medical certificate
Medical Certificate are issued on the day of request
49. Standard D5 Facility has procedure for collecting & Reporting of the
health facility related information
• Facility Reports data for Mother and Child Tracking System as per Guidelines
• Facility reports data regarding Antenatal, Delivery and Postnatal care for availed services
• Facility reports data about child immunization in MCTS
• Facility utilizes MCTS data for action planning
• Facility utilizes MCTS data for tracing of missed out immunization and ANC cases
• HMIS data is reported on monthly basis
• All data elements of HMIS are reported
