Initiatives for infection control prevention in public facilities gujarat

1Health & Family Welfare Dept, Govt of Gujaratwww.gujhealth.gov.in
Initiatives for Infection Control
Prevention In Public Facilities - Gujarat
3rd National Conference on Safety and Risk
Management for Healthcare Professionals
Dr J L Meena
State Quality Assurance Medical Officer
Department of Health & Family Welfare
Government of Gujarat
Member of NABH Accreditation Committee, QCI
Member of Quality Expert Group, Govt of India.
Email:- drjlmeena@gmail.com

Why is it an important area?
Over 1.4 million people worldwide are reported
to be suffering from hospital acquired infections.
Figures coming from India are alarming with
hospital infections rate at over 25 per cent.
One-third of all such episodes are potentially
preventable.

Causes of Neonatal deaths
(SNCU data, India 2015)
Causes of Maternal Deaths
(MDR 2013-14 , Dept H&FW, GOG)
Causes of Neonatal and Maternal Deaths

•IN OUR PROFESSION THERE IS NO SCOPE FOR ERROR.
FOR ANY ERROR COMMITTED IS ALL THE DIFFERENCE
BETWEEN LIFE AND DEATH, BETWEEN RELIEF AND
DISABILITY
•THERE IS NO SECOND CHANCE
Then ....

Quality Never without Truth

• High risk certificate given by PWD on
31st March 2004 for condemnation but
still It’s functioning up to three years
(on the risk of Pt. and employee
safety. )
• No safe drinking water facilities.
• Very Poor condition of dressing table.
• Non sterile suction tube & oxygen
mask?
• Labour room’s instrument with rust &
Lack of Cleanliness

• Patients & employee safety ?
• Open transformer with Parking facilities. Invite for
disaster ?
• Very poor Biomedical waste & infection control
practice.
• Poor sanitation and cleanliness.
• Poor housekeeping service.
• Very poor Drainage facility.
• No cattle guard.
• No responsible person for proper monitoring.

Bio Medical Waste Management Issue &
Challenge

A report on the current status of BMW authorization had been
submitted by Rajkot AG (ACCOUNTANT GENERAL) with the
following finding:-

National Human Right Commission (NHRC )
Report – Year 1999
Mental Asylum was constructed in 1863 and
had retained prison like structure and
ambience; building maintenance was
extremely unsatisfactory – Leaking roof,
eroded floors, over flowing toilets, broken
doors, poor lighting and no ventilation sign
of gloom or morbidity.
No emergency facility and staff burn out due
to unsecured environment and monotonous
work.
D - Grade

Many patients had skin and dental
problems due to poor hygienic
condition.
Problems in electricity and water
supply, overcrowding of patients,
many patients slept on floor (Sentinel
events). Patient had to urinate and
defecate in cell it self.
D - Grade

Request to all,
Kindly Handle with Care & Care with Quality
“ Kyoki hum bhi Kabhi Insan The”

Why should we care?
Is improvement possible?
What seems to make a difference?
Why aren’t we doing a better job?
Whose responsibility it is?
 What is my role in this process
??????

Quality Improvement Programme
Gujarat is the first state in India which initiated for actively
pursuing quality improvements in the public healthcare facilities
through the network of Primary Health Centers (PHCs),
Community Health Centers (CHCs), District Hospitals, Blood
Banks, Medical College Laboratories, Food & Drug Laboratories,
Dental Colleges, Mental Colleges, Paraplegia Hospital & Medical
Colleges. In order to institutionalize Quality Assurance, Gujarat is
the only state which has set up the District Quality Assurance cell
& State Quality Assurance cell for implementation of Quality
Management System and Accreditation.

 Swachhata Mission (Cleanliness) Audit (Every Month) in all healthcare facilities.
 Kayakalp Award (after Internal, Peer and External Assessment) to Best Performing
Healthcare Facilities. – 79 Award given in 2015-16 and 148 Award in 2016-17
 NABH / NABL / NAQS Accreditation of Government Healthcare facilities – 158
Healthcare facilities are NQAS Accreditation at State level & 37 NABH / NABL
Accredited Healthcare facilities
 Implementation of Kaizen & 5 S in all healthcare facilities - Under scrap disposal Total
@ Rs. 7,71,85,873 was generated after elimination of waste.
 Biomedical Waste Management - 1902 Healthcare facilities.
 WASH Project - 172 Functional Delivery Points is undergoing in the WASH
assessments.
 Capacity Building - 13336 participants were trained in Quality Improvement
Programme.
Initiatives for Infection Control
Prevention In Public Facilities – Gujarat

“Swachh Bharat Abhiyan”
SwachhBharat
Abhiyan
NABH/NABL
/NQAS
Swachhta
Guidelines
‘KAYAKALP’
Clean
Facility
Regular Swachhata Mission Audit by Padadhikari or
Adhikari to Create Quality Culture. “Clean Facilities”
Appreciation of Best Performing Facilities for
Motivation “Kayakalp”.
Implementation of Area Specific Swachhata Mission
Guideline for Prevent Healthcare Acquired Infection
(HIC) “Swachhta Mission Guideline”.
Implementation of Minimum Quality Standards (NABH
/ NABL / NAQS) to Provide Quality Healthcare Service
“NABH / NABL / NQAS”.
Patient and Employee Satisfaction
Survey “Swachh Bharat Abhiyan”.

Gujarat is the 1st State in India for
Regular Swachhata Mission Audit

Implementation
Launch of state wide campaign of swachata
mission by Chief Minister of Gujarat on 6th
December, 2014 at Civil Hospital - Ahmedabad
Various office orders
issued by
Commissionerate of
Health for activities to
implement action plan of
swachata mission
State Specific
Guidelines of Swachata
Mission in Public
Health Facilities and
area wise monitoring
checklist

Social Audit & Free Online Reporting
System

Use of Social Media

Grading As per %:- A= Score >90 %, B= Score >75-90 %, C= Score >50-75 % & D= Score 0-50%
Audit Report of Health Facilities
(6th Dec 2014 & 6th Dec 2016)

Question wise Swachhata Mission Visit Report
Dt:-6th January 2017
Question
Very
Satisfied
(%)
Satisfied
(%)
Neither Satisfied
nor
Dissatisfied (%)
Dissatisfied
(%)
Very
Dissatisfied
(%)
Not
applicable
(%)
Condition of the Approach
road to facility
24.8 54.2 9.4 2.2 0.7 8.6
Colour and appearance of
Compound wall
20.3 44.7 9.9 2.2 1.4 21.5
Colour and appearance
outside of the building
23.2 52.6 11.8 2.8 1.1 8.5
Inside the building, Colour
& Appearance
27.2 52.6 8.5 2.4 0.9 8.5
Repairing and Painting of
Stools, Beds and Closets
etc.
24.1 57.5 7.6 1.4 0.4 9.1

Question
Very
Satisfied
(%)
Satisfied
(%)
Neither Satisfied
nor
Dissatisfied (%)
Dissatisfied
(%)
Very
Dissatisfied
(%)
Not
applicable
(%)
Repairing of Broken
Window, Doors And Glass
21.0 54.9 10.3 2.3 1.2 10.3
Cleanliness of Compound
wall / outside of Fencing
17.2 51.6 11.1 2.3 1.2 16.5
Cleanliness of Health
facility’s ground (e.g.
Unnecessary stockpiling
water, weeds, trash & Kudo
etc)
20.6 57.5 8.3 1.7 0.9 10.9
Cleaning of Building
terraced porticos, porch and
terrace.
18.0 57.8 9.3 1.9 1.1 11.9
Cleaning of Corridor,
staircase and lifts
11.3 28.8 4.4 0.7 0.6 54.2

Question
Very
Satisfied
(%)
Satisfied
(%)
Neither Satisfied
nor
Dissatisfied (%)
Dissatisfied
(%)
Very
Dissatisfied
(%)
Not
applicable
(%)
Cleaning of Patient care
area e.g. OPD, Ward,
Labour Room, Laboratory
etc.
27.1 53.6 3.6 0.8 0.7 14.3
Cleanliness of Post-mortem
Room.
4.1 8.4 2.3 0.6 0.5 84.1
Cleanliness of Toilets &
Bathroom.
27.9 54.4 5.6 1.2 0.8 10.0
Cleanliness of Washbasin
etc.
28.8 53.5 4.4 1.0 0.5 11.9
Cleaning of Mattresses,
Pillow, covers, Beds sheets
and curtain.
26.9 57.7 4.8 0.8 0.4 9.3

Question
Very
Satisfied
(%)
Satisfied
(%)
Neither Satisfied
nor
Dissatisfied (%)
Dissatisfied
(%)
Very
Dissatisfied
(%)
Not
applicable
(%)
Cleaning and functional of
Bulbs, such as electrical
appliances, fans, switches and
fever.
26.9 56.5 6.4 1.1 0.9 8.3
Cleaning of Canteen / Kitchen
of Health organisation.
3.1 4.7 0.6 0.0 0.1 91.3
Cleaning of commercial and
non-profit organizations,
Shops etc with in the health
organization's premises.
1.9 3.8 0.6 0.0 0.2 93.5
Health organizations comply
with the law for a ban on
tobacco and related products
29.3 54.6 5.9 0.9 0.6 8.7
Suitable dustbins for dumping
waste with in Campus.
31.4 55.5 3.9 1.0 0.8 7.5

Question
Very
Satisfied
(%)
Satisfied
(%)
Neither Satisfied
nor
Dissatisfied (%)
Dissatisfied
(%)
Very
Dissatisfied
(%)
Not
applicable
(%)
Wash compliance by staff 41.4 49.8 2.2 0.4 0.5 5.6
Use of uniforms, hand gloves,
masks and aprons by Staffs
37.1 52.5 3.5 0.5 0.7 5.7
Adequate and clean water
availability
29.5 52.2 6.4 2.2 1.1 8.6
Cleaning of the water tank
and lid
23.9 54.2 6.4 1.4 0.9 13.3
Cleaning & Functionality of
Water Cooler and RO.
10.2 12.2 1.5 0.3 0.4 75.5

Proper Directional

Gujarat is the 1st State in India for Highest
Kayakalp Award in India

એવોર્ડ માટેના માપદંર્ો
 આરોગ્ય સંસ્થા / સુવવધાનો વનભાવ (Hospital/Facility Upkeep )
 સ્વચ્છતા અને વ્યક્તતગત સફાઇ (Sanitation and hygiene)
 કચરાનું વ્યવસ્થાપન (waste Management)
 ચેપ વનયંત્રણ (Infection control)
 સહાયક સેવાઓ (Support Services)
 વ્યક્તતગત સફાઇને ઉત્તેજન (Hygiene Promotion)

Assessment Method
OBSERVATION (OB) STAFF INTERVIEW (SI)
RECORD REVIEW (RR) PATIENT INTERVIEW (PI)

Compliance & Scoring Rules
Full
Compliance
Partial
Compliance
Non
Compliance
2
1
0
 All Requirements in Checkpoint are Meeting
 All Tracers given in Means of verification are available
 Intent of check point is meeting
 Some of the requirements in checkpoints are meeting
 All Least 50% of tracers in Means of verification are
available
 Intent of check point is partially meeting
 Most of the requirements are not meeting
 Less than 50% of tracers in Means of verification are
available
 Intent of Check point is not meeting

Criteria for
Assessment
Hospital upkeep Sanitation & Hygiene
Support Services.
Waste Management
Infection Control Hygiene promotions
100
100 100
100 50 50
500
PHC – 60
UPHC-40
PHC – 60
UPHC-40
PHC – 60
UPHC-40
PHC – 30
UPHC-20
PHC – 30
UPHC-20
PHC – 60
UPHC-40
PHC 300
UPHC 200

Pest & Animal
Control
Landscaping & Gardening
Maintenance of open area
Hospital Appearance
Illumination
Removal of Junk
Material
Water
Conservation
Maintenance of
Furniture & Fixtures
Work Place
Management
Hospital Upkeep
Theme
A
Infrastructure
Maintenance

Clean Circulation area
Clean Wards
Clean procedure area
Clean Ambulatory area
Clean Toilets
Standard methods for
cleaning
Monitoring of
cleanliness
activities
Drainage and sewage
management
Sanitation &
Hygiene
Theme
B
Clean Auxiliary areas
Standard material and
equipment for
cleaning

Segregation
Collection & transportation
Sharp Management
Storage of BMW
Management of
hazardous waste
Liquid waste
management
Equipment &
supplies of BMW
Solid general waste
management
Statuary Compliances
Waste
Management
Theme
C
Disposal of BMW

Theme D: Infection Control
D1 Hand
Hygiene
D2:
Personal
Protective
Equipment
D3: Personal
Protective
Practices
D4:
Decontamina
tion &
cleaning of
instruments
D5:
disinfection
and
sterilization
of
instruments

Theme-E, Support Services
Laundry Water and Sanitation Kitchen and food Security outsource

Highest Kayakalp Award given in
India by Govt of Gujarat
Sr.
No.
Awarded facilities Year 2015 - 2016 Year 2016 - 2017
1 Primary Health Center 33 99
2 Community Health Center 34 33
3 Urban Health Center 1 3
4 Sub-District Hospital 3 3
5 Super Speciality Hospitals 1 1
6 District Hospital 3 3
7 Medical College Hospital 1 1
8 Dental College 1 2
9 Mental College 1 2
10 Medical College(GMERS) 1 1
Total 79 148
Note:- 3 Kayakalp Awards at National level (DH- Nadiyad, Vyara & PKG Rajkot) in Year 2015-16

Kayakalp Award & >70% scored facility
Year 2016-2017
Kayakalp Progress - Gujarat 2016-2017
S.No.
Name of
Facilities
Total No. of
Healthcare Facilities
Total No Facilities
completed External
Assessment
No of Facilities received
Kayakalp Award
Total No Facilities received
>70% marks in External
Assessment
1 MCH (Govt) 6 5 1 5
2 MCH (GMERS) 7 6 1 6
3 Mental 4 2 2 2
4 Dental 2 2 3 2
5 Super 3 1 1 1
6 DH 22 19 3 16
7 SDH 33 8 3 15
8 CHC 351 231 33 124
9 PHC 1393 518 99 370
10 UPHC 81 12 3 13
Total 1902 804 146 554

Gujarat is the 1st State in India for Highest NABH / NABL /
NQAS Accreditation of Healthcare facilities (Total 37 NABH &
NABL and 158 NQAS State level Accreditation Certificate.

NABH Standards
Section I:
Patient-Centered Standards
Std. OE
Access, Assessment and Continuity
of Care (AAC)
14 96
Care of Patients (COP) 22 151
Management of Medications
(MOM)
13 76
Patients Rights and Education (PRE) 8 54
Hospital Infection Control (HIC) 9 54
Section II:
Management Centered Standards
Std. OE
Continuous Quality Improvement
(CQI)
9 59
Responsibilities of Management
(ROM)
6 39
Facility Management & Safety
(FMS)
7 56
Human Resource Management
(HRM)
10 53
Information Management Systems
(IMS)
7 45
Total 105 683

1. India’s 1st PHC NABH Accredited, Primary Health Center Gadboriayad, Dist.:- Vadodara,
Gujarat.
2. India’s 1st UHC NABH Accredited, Urban Health Center Nana mauva, Dist.:- Rajkot, Gujarat.
3. India’s 1st CHC NABH Accredited, Community Health Center Bardoli, Dist.- Surat, Gujarat.
4. India’s 1st District hospital NABH Accredited, District Hospital, Gandhinagar – Gujarat
5. India’s 1st Govt Blood Bank NABH Accredited, B J Medical College Blood Bank, Ahmedabad–
Gujarat
6. India’s 1st Govt Super specialist NABH Accredited, Govt Spine Institute Ahmedabad – Gujarat
7. India’s 1st Govt Mental Hospital NABH Accredited, Mental Hospital, Vadodara - Gujarat.
8. India’s 1st Govt Medical College Laboratory NABL Accredited, Govt Sir T Medical College
Laboratory, Bhavnagar– Gujarat
9. India’s 1st Govt Food and Drug Laboratory NABL Accredited, Govt Food and Drug Laboratory,
Vadodara– Gujarat
Quality Improvement Programme –
Gujarat

46
High Quality of Care cont…

National Quality Assurance Standards
(Areas of Concern)
Service
Provision
Inputs Support
Services
Clinical
Care
Infection
Control
Quality
Management
Outcome
Patient Rights

NQAS (Internal, Peer & Final External) Assessment of MCHs,
Dental, Mental, DHs, SDHs, CHCs & PHCs for
“State level NQAS Accreditation Certificate”
S.N. Name of District
Total
Healthcare
Facilities
Internal
Assessment
Peer
Assessment
Final External
Assessment
1 Ahmedabad - Region 229 125 91 43
2 Bhavnagar – Region 223 122 50 25
3 Gandhinagar – Region 388 113 63 35
4 Rajkot – Region 226 123 48 25
5 Surat – Region 240 49 21 12
6 Vadodra – Region 390 106 38 15
State Total 1696 638 311 155

I Happy to share that Dist. Hospital Vyara is the 1st
Hospital in The country that has met all the criteria for
NQAS Certification.

Biomedical Waste Management as per Rule 2016

Biomedical Waste Management
100 % GPCB Authorization of Public Healthcare facilities.
Biomedical Waste management by Common Biomedical Waste Treatment facilities-
CBWTF) in all Healthcare facilities.
Use Biomedical Waste Management Check list for regular Monitoring .
Use Biomedical Waste Management Film for IEC & Skill Development.
Proper implementation of 5 S and Regular Swachhata Mission Audit.
Focused on injection safety:- Not used of multiple dose vials & education to prevent
needle stick injury.
Regular Meeting of Biomedical Waste Management Task Force, Infection Control
Committee etc.
The CBWTF has the function of collection, transportation & disposal of waste
following proper standard protocols and CBWTF also visited by our District Quality
Assurance Committee (DQAC).

Available staff should be immunized
and insured for health / hospitalization.

PERSONAL PROTECTION EQUIPMENT
FOR LABORATORIES

S.No. Detailed PHC CHC SDH DH MCH State Total
1 Total available Instrument 281845 120273 17572 30296 57551 507537
2 Functional 262876 102206 15844 28762 54564 464252
3 Non functional 18969 18067 1248 1504 2987 42775
Reasons for not functioning
a Equipment/Instrument is not required 2550 1616 36 10 14 4226
b Equipment/Instrument is not installed 153 182 176 6 3 520
c Need repairing 2087 1376 206 401 971 5041
d Can't be repaired 10656 12090 613 830 1907 26096
e Necessary space is not available 112 462 7 4 2 587
f Necessary electrical arrangement is not available 31 15 14 8 0 68
g Trained manpower is not available 235 1168 68 11 3 1485
h Extra qty. 2778 751 96 31 23 3679
i Others 367 407 32 203 64 1073
Total Non functional 18969 18067 1248 1504 2987 42775
Instrument and equipment’s Audit

Capacity Building

Capacity Building for Healthcare Staffs for Quality
Improvement in Health Care Organization
• One day orientation training for Programme orientation (e.g.
Swachhata Mission, Kayakalp, NABH, NQAS, NABL, Biomedical
Waste, WASH, Radiation Safety and Medical Audit to all staff.
• Two days & three days Training for Internal & Peer Assessor for
continues Improvement (e.g. Kayakalp, NABH, NQAS and NABL etc.)
to Min 5 years experience staffs.
• Four days to Seven days training for External Assessor and Principal
Assessor for Kayakalp, NABH, NQAS and NABL etc.) to Min 5 years
experience staffs (Administrator, Clinician and Staff Nurse only).

Capacity Building for QIP
Sr. No. Name of the Traininig
No. of Participants
Trained
1 NABH Assessor Course for District Hospitals, Medical Colleges, CHCs & PHCs. 327
2 NABL-“LABORATORY MANAGEMENT & INTERNAL AUDIT” as per ISO 15189:2007. 305
3 Post Graduation Certification in Quality Management & Accreditation of Health care Organization. 679
4 "QIP for (NABH, BMW, Kaizen, HOPE, Fire & Non Fire Emergency, Radiation Safety, Cleanliness) Training". 111
5 National Quality Assurance Standards (NQAS) orientation workshop by NHSRC 29
6 “Quality Improvement initiative Training of Trainers on CQI in healthcare services & housekeeping services through 5S & kaizen”. 3540
7
“Quality Improvement initiative Training of Trainers on CQI in healthcare services & housekeeping services through 5S & kaizen” 5 S Training
Special Batches For Commissioner of Health.
112
8 Infection Control Training (IMEP). 742
9 4 days Extended Internal Counsellor Training Program, Ahemdabad of NABH Hospital Standards. 21
10 Training on Management of Bio-Medical Waste in the State of Gujarat. 1269
11 Internal Assessors Training. 2065
12 National Quality Assurance Standards (NQAS) External Assessors Training. 110
13 QIP Orientation One day Workshop. 155
14 Swachhata Mission & Kayakalp Workshop. 3616
15 National Conference on Bio Medical Waste Management. 126
16 ATP International Workshop (DQAMO, Infection Control Nurse & Physiotherapist). 20
17 NABH Pre Accreditation Entry Level Standards Course. 212
18 NABH Standard for Nursing Excellence Course. 140
19 POI for Medical Imaging Services (MIS) Stantdard Implementation for Radiologist. 27
20 Post Graduation in Health and Law 30
21 Internal Audit and QMS Training. 30
Total no. of Participants :- 13666

Change the scenario after
Quality Management System

Change Scenario after
Quality Management System................
Past Present
Lack of standards
NABH Standards for Hospitals, Blood bank, Imaging service, Nursing
Excellence & CHC / PHC), National Quality Standards for (Dist. Hospital,
Community Heath Centre, Primary Health Centre & Urban Health
Centre etc), ISO 15189:2007 for lab in place
No Gap analysis report in standard format. Gaps identified and addressed as per standards
Lack of Statutory requirements (e.g.
Licenses, Acts, Rules & Certificates).
Statutory requirements fulfilled
Absence of written policies, procedures,
forms & formats.
Written policies, Standard Operation Procedures (SOPs), forms &
formats. available.
Poor sanitation and cleanliness. Hygienic Hospital environment
Staff shortage. Recruitment of staff as per workload through RKS.
Lack of trained health care staffs Staff trained and its on ongoing

Past Present
No concept of internal audit
Staff trained as internal auditors, audits conducted to find out non
conformances, corrective & preventive measures taken to rectify it
No Management meeting9 & Meeting with
clinicians conducted
Regular Management meeting & clinical meetings conducted which
facilitates the important decisions affecting the quality of care, hence
achieving the total quality management.
Inadequate infrastructure for handling
biomedical waste and infection control
safety practices
All required practices in place
Damaged and poor condition of building Repairing & renovation done
No Calibration system of Instruments for
Quality check & Regular AMC
Calibration system of Instruments for Quality check are available.

Past Present
Shortage of equipments, no proper utilisation and
no proper ambulances (Transport vehicle) .
Sufficient equipments, properly utilized and proper ambulances
services.
Lack of accountability & planning. Policy and processes for care of the patients in place
Absence of quality standards.
Quality standards e.g. medical audit, management of
medication, care of patients etc practiced
No participation in EQAS/ inter laboratory
comparisons
Participation in EQAS / inter laboratory comparison and
achieving good scores in it.
No feedbacks from patients & clinicians
Feedback of patients & clinician is used to monitor the continual
improvement
Poor signage system. Well developed signage and displays for patient information

Past Present
Only some Major Equipments covered under AMC.
No monitoring of downtime of equipment.
AMC for all sophisticated equipments is done with their
respective companies& others are maintained by biomedical
workshop CHA. Downtime of equipment monitoring regularly.
Absence of Patient & Employees’ satisfaction. Established
No measurable parameter for patient safety. Measurable parameters for patient safety are available.
No realization of problems and weaknesses
A clear understanding of what is lacking and what needs to be
done
No monitoring or reporting of adverse events,
needle stick injury, Sentinel events etc.
These are being reported and are monitored.

Past Present
Sub optimal team efforts , performance was
individual based rather then team base .
illdefined roles and responsibility of staffs.
Team work is available, role and responsibility of all staff is clearly mentioned
and made known to all.
No Evaluation and monitoring system by PRI
members (3rd party evaluation).
3rd Party evaluation & monitoring system by PRI members available.
inadequate publicity of available services in the
villages and in the community. Poor social
marketing
All the service which are provided by the healthcare centre are displayed in
the community and emergency contact number also displayed.
No monitoring of Up time & down time of the
instruments and equipments.
Proper monitoring of Up time, down time & utilization of the instrument &
equipment.
Progress of referred patients were not
followed up the Hospital.
Progress of the referred patient also monitored by the health centre on regular
basis.( Bi directional referral service).
No display of the Rights and responsibly of the
patients and employees in the facilities.
Proper display of Right and responsibly of the patients and employees in the
facilities.

Past Present
Practically non-existent
security arrangement
Availability of well trained security guards
Non Implementation of
Different Codes in the
facilities.
RED for FIRE,
YELLOW for EXTERNAL CALAMITIES,
BLUE for CARDIAC ARREST,
BLACK for BOMB THREAT,
PINK for CHILD ABDUCTION

Change the Scenario….
Infrastructure ……………..
Changing

Safety of patients & employees…
Before After

Before After
Crush Card trolley contained:-
Comb, Toothpaste, Oil, Glass
etc for save the pt. ?
Crush Card trolley
contained:- all life saving
drugs for save the pt.

Change the Scenario of OT….
Before After

Change the Scenario of employee Safety
working environment……
Before After

Before After
Change the Scenario……
Unused to proper used……

Management of Medicine
(stored in well lit and well ventilated rooms. )…

A unified formulary based on workload, essential drug list as specified by
State Government to be maintained and display with expiry date.

Provide guidance or basic information to the patients and their families.

Citizen charter and rights of the patients
displayed

Centre should have in use feedback mechanism like use of
suggestion / complaint boxes , Visit book , PRI Monitoring &
evaluation

Recreational & skill development in Mental Hospital

Occupational Therapy Unit in Mental Hospital

All the Services provided by Healthcare facility are
displayed in all the villages & roadside

Well Maintain PM
Room
Change the Scenario of PM Room
End of life care………………..

Remarks of representative of National Human Right
Commission (NHRC) now…
Community services programme run on an
appreciable scale and with exemplary
efficiency is another significant feature of
institute .
HMH Ahmedabad presents an excellent
example of effective functioning of Boards of
visitors and active involvement of NGO sector
in patients Care ,Capacity building &
rehabilitation , and has the potential to
become a good center of education and
research in Mental Health Field .
A - Grade

Awards received by Government of
Gujarat for QIP
•Appreciation awarded by QCI to Ministry of Health and Family Welfare Government of Gujarat for establishing Quality
Assurance framework in providing quality healthcare to the people of Gujarat in 5th National Quality Conclave, New Delhi.
•Appreciation awarded to Department of Health and Family Welfare Government of Gujarat for their pioneering effort to
spearhead the Quality and Accreditation Programme in health care organization. In 3rd International Health Care Quality
Conclave on “Role of Quality in Globalization of Indian Healthcare”. Place: - Gurgaon, Haryana Date: 30th August 2010.
•FICCI Health care Excellence Award to Dist Hospital Gandhinagar & PHC Gadboriad, Govt of Gujarat in FICCI Heal 2010, New
Delhi Date: 6th Sept 2010
•FICCI Health care Excellence Award to Dist Hospital Gandhinagar, Govt of Gujarat in FICCI Heal 2011, New Delhi Date: 8th Sept
2011
•FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal 2013, New Delhi Date:
2nd Sept 2013
•Operational excellence award in IndiZen 2014 to Govt. of Gujarat-department of health and family welfare was achieved.
•FICCI Health care Excellence Award to Community Health Centre Bardoli, Govt of Gujarat in FICCI Heal 2014, New Delhi
Date: 1st Sept 2014
•FICCI Health care Excellence Award to Paraplegia Hospital- Ahmedabad, Govt of Gujarat in FICCI Heal 2014 New Delhi
Date: 1st Sept 2014
•FICCI Healthcare Excellence Award to Laboratory Information System, B J Medical College – Ahmedabad, Govt of
Gujarat in FICCI Heal 2016 New Delhi Date: 31st August 2016.

•Certificate of Appreciation awarded to Ministry of Health
and Family Welfare Government of Gujarat for
establishing Quality Assurance framework in providing
quality healthcare to the people of Gujarat in 5th National
Quality Conclave, New Delhi
•Appreciation awarded to Department of Health and
Family Welfare Government of Gujarat for their
pioneering effort to spearhead the Quality and
Accreditation Programme in health care organization.
In 3rd International Health Care Quality Conclave.
•FICCI Health care Excellence Award to
Dist Hospital Gandhinagar & PHC
Gadboriad, Govt of Gujarat
Award Ceremony

Thanks
Web:-
1. www.gujhealth.gov.in/quality-assurance-program.htm
2. http://www.facebook.com/drjitulal?ref=tn_tnmn
3. https://www.youtube.com/user/drjlmeena
Email:-
drjlmeena@gmail.com, sqipgujarat@gmail.com
Mobile No:- 09099075162

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