The document outlines the induction program for a private hospital, detailing its mission to provide high-quality, cost-effective healthcare while supporting patients and families. It also covers the scope of services offered, employee rights and responsibilities, infection control measures, safety protocols, and quality accreditation standards to ensure optimal care and patient safety. Furthermore, it emphasizes the importance of quality indicators and monitoring for continuous improvement within the organization.

1. Welcome to Private Hospital Induction Program

2. Mission & Vision
Mission:-
 To deliver high quality, cost effective and personalized health care services
 To support individual and families at the most sensitive and critical moments of their lives by
maximizing the power of our health care expertise
 To deliver trusted and innovative services to our patients to positively influence their total
health and well being.
VISION:
 To be the healthcare provider of choice for patients as well professionals
 To perform at a superior level maintaining sound ethical, moral and regulatory standards

3. Scope of Service
Clinical Service
 Emergency Department
 Anesthesiology
 Cardiology and Cardiothoracic Surgery
 Laboratory services (Clinical Pathology,
Microbiology, Biochemistry, Immunology,
Serology, Hematology & Histopathology)
 Intensive coronary care unit
 Cardiac coronary unit
 Physiotherapy & Rehabilitation
 Cardiac Rehabilitation
 Radiology
 Nuclear medicine
Supportive Service
 Administrative Office
 Accounts & billings,
 Marketing,
 Quality Assurance ,Infection control ,
Customer care ,
 Information technology (IT Dept.)
 Central sterile supply dept. (CSSD),
 General store , Pharmacy
 Medical gas services
 Blood Bank,
 Linen & Laundry, House keeping,Dietary and
Kitchen services,
 Security, Transport services & Ambulance,
Biomedical engineering , Engineering &
Maintenance, Medical record, Mortuary
services
24 X 7 services
o
 Emergency
 Ambulance
 Pharmacy
 Blood Bank
 Laboratory
 Imaging

5. Employee Rights
Employees have got the following rights:
 Right to know the policies related to their job and employment.
 Right to enjoy leaves facilities as per Policy of the Group.
 Right to know and have their entitlements of their positions as per Group policy
 Right for professional developments.
 Right to submit their grievances to HR Department.
 Right to get any information regarding any change which may affect them?
 Right to leave the job by giving necessary notification as per contract.
 Right to apply for higher positions against any openings.
 Right to give opinion for the improvement of the services.
 Accessibility to the highest authority of the Group through proper channel.
 Right to get treatment as per hospital medical care policy.
 Right to receive remuneration as per the service contract.

6. Employee Responsibility
 To submit documents at the time of joining
 To performed Job Responsibility rigorously.
 To follow hospital service standard, rules & regulation.
 To know organization Mission, Vision & Quality policy.
 To protect organization property, dignity, value & culture.

7. HR Policy
 Recruitment & Selection Policy
 Induction Policy
 Employee Code of Conduct
 Training and Development Policy
 Leave Policy
 Performance Appraisal Policy
 Disciplinary Policy
 Grievance Handling Policy

8. Hospital Infection Control
1. Hand Hygiene
2. Personal hygiene, work attire
3. Environmental cleaning
4. Personal Protective Equipment:
Standard, transmission &
airborne precaution
5. Spill Management:
6. Biomedical Waste Management:
7. Patient care: morning care, back
care, perineal care, tube care
8. Management of medication
9. Linen Management
10. Importance of documentation
11. Patient transportation:
12. Sample collection procedure-
blood, urine, respiratory
13. Needle stick injury:
14. Awareness of hospital codes

9. Hospital Safety Program
 Code Blue
 Code Orange
 Code Red
 Code Yellow
 Code Violate

10. Quality
NABH
 National Accreditation Board for Hospitals & healthcare providers (NABH)
 Accreditation:-
a. Process of external review of the quality of the health care being provided
b. Represents the outcome of the review and the decision that an eligible organization meets an
applicable set of standards .

11. International accreditations
 Joint commission international
 NABH
 JCAHO USA.
 The Canadian Council on Health Service Accreditation (CCHSA),
 The Australian Council on Healthcare Standards (ACHS),
 Health Quality Services (HQS). England.
 Council on Health Services Accreditation for South Africa (COHSASA).
 The Malcolm Baldrige National Quality Award, USA.

12. Advantages of accreditation
 Results in high quality of care and patient safety.
 Credentialing of medical staff.
 Rights of patients are respected and protected.
 Patient satisfaction is regularly evaluated.
 Stimulates continuous improvement.
 Raises community confidence in the hospital.
 Benchmark with the best.
 Continuous learning, good working environment, leadership and ownership of
clinical processes for the staff
 Improves overall professional development of Clinicians and Paramedical staff
 An objective system of empanelment

13. NABH Chapters
1. Access, Assessment and Continuity of Care (AAC)
2. Care of Patients (COP)
3. Management of Medications (MOM)
4. Patients Rights and Education (PRE)
5. Hospital Infection Control (HIC)
6. Continuous Quality Improvement (CQI)
7. Responsibilities of Management (ROM)
8. Facility Management & Safety (FMS)
9. Human Resource Management (HRM)
10. Information Management Systems (IMS)

14. Definition of Quality
Degree to which a set of inherent
characteristics fulfill requirements
Degree of adherence to
pre established criteria or standard

15. QUALITY INDICATORS
 Clinical indicators
 Managerial indicators

16. CLINICAL INDICATORS
 Patient assessment
 Time for initial assessment of indoor & emergency patients
 Percentage of cases where care plan is documented & counter
signed by the clinician
 Percentage of cases where screening for nutritional needs has
been done
 Percentage of cases where pre defined nutritional assessment
is completed within 30 min

17. CLINICAL INDICATORS
 Safety & quality control programmed of diagnostics
– Number of reporting errors/1000 investigations
– Percentage of Re-do's
– Percentage of reports co-relating with clinical diagnosis
– Percentage of adherence to safety precautions by employee working in diagnostics

18. CLINICAL INDICATORS
 Invasive procedures monitoring
 Re-exploration rate
 Percentage of accidental removal of tubes and catheters
 Incidence of hematoma at puncture site
 Percentage of Re-scheduling of procedures

19. CLINICAL INDICATORS
 Adverse drug events
 Percentage of medication errors
 Incidence of adverse drug reaction
 Percentage of medication charts with illegible writing over a
given period
 Percentage of contrast related reactions

20. CLINICAL INDICATORS
 Use of anesthesia
 Percentage of modification of anesthesia plan
 Percentage of unplanned ventilation following anesthesia
 Percentage of adverse anesthesia events
 Anesthesia related mortality rate

21. CLINICAL INDICATORS
 Use of blood & blood products
 Percentage of transfusion reactions
 Percentage of wastage of blood and blood products
 Percentage of blood component usage
 Turnaround time for issue of blood and blood components

22. CLINICAL INDICATORS
 Medical Records
 Percentage of medical records not having discharge summary
 Percentage of medical records not having initial assessment and the
plan of care
 Percentage of medical records having incomplete and/or improper
consent
 Percentage of missing records

23. CLINICAL INDICATORS
 Infection control activities
 Urinary tract infection rate
 Respiratory infection rate
 Intra-vascular device infection rate
 Surgical site infection rate

24. CLINICAL INDICATORS
 Clinical Research
 Number of research activities being carried out
 Percentage of patients withdrawing from the study
 Percentage of protocol violations /deviations reported
 Percentage of serious adverse events reported to the ethics
committee within the defined time frame

25. MANAGERIAL INDICATORS
 Procurement of medication essential to meet patient needs
 Percentage of drugs procured by local purchase
 Percentage of stock outs including emergency drugs
 Percentage of consumables rejected before preparation of goods
receipt Note
 Incidence of variations from the procurement process

26. MANAGERIAL INDICATORS
 Reporting of activities as required by laws and regulations
 Number of births & deaths
 Number of notifiable diseases
 Submission of report/ data/ form pertaining to bio-medical waste,
PNDT act and radiation safety within the defined timeframe.
 Submission of tax returns and deduction of taxes at the specified
time frame

27. MANAGERIAL INDICATORS
 Risk management
 Number of variations observed in mock drills
 Incidence of falls
 Incidence of bed sores after admission
 Percentage of employees provided pre-exposure prophylaxis

28. MANAGERIAL INDICATORS
 Utilization (space, manpower and equipment)
 Bed occupancy rate
 Average length of stay
 OT utilization
 ICU utilization
 Equipment down time
 Nurse-patient ratio

29. MANAGERIAL INDICATORS
 Employee Satisfaction
 Employee Satisfaction index
 Employee attrition rate
 Employee absenteeism rate
 Percentage of employee who are aware of employee
rights ,responsibility & welfare schemes

30. MANAGERIAL INDICATORS
 Adverse events and near misses
 Number of sentinel events
 Percentage of near misses analyzed
 Number of security related incidents including thefts
 Incidence of needle stick injuries

31. MONITORING OF INDICATORS
 Benchmark every indicator
 Apply statistical and managerial tools whenever required
 RCA
 FMEA
 PERT
 CPM
 Take Appropriate action

32. ROOT CAUSE ANALYSIS
 problem solving methods aimed at identifying the root causes of problems or events
 problems are best solved by attempting to correct or eliminate root causes
 Ishikawa diagram
 Pareto analysis