This document provides a procedure documentation list for quality improvement in healthcare facilities. It contains 10 chapters that cover topics such as access assessment and continuity of care, patient care, medication management, patient rights and education, infection control, continuous quality improvement, facility management and safety, human resource management, and information management systems. The list includes over 150 topics that healthcare facilities should document procedures for to improve quality. It is intended to help facilities standardize processes and ensure compliance with quality standards.

1. Sr.No. TOPICS
Available
(Yes / No)
Implementation
(Yes / No)
1 Scope of service
2 Registration
3 Admission
4 Managing patient during non availability of beds
5 Transfer of unstable patients
6 Transfer of stable patients
7 Patient education on treatment
8 Patient education on expected cost
9 Clinical assessments
10 Reassessment
11 Scope of laboratory services
12 Laboratory personnel qualification
13
Collection, identification, handling, safe
transportation, processing and safe disposal of
specimens
14 Turnaround time for laboratory tests
15 Intimation of critical test results
16 Outsourcing of lab tests
17 Lab quality improvement programme
18 Laboratory safety programme
19
Handling and disposal of infectious and
hazardous materials
20 Laboratory safe practices
21 Scope of Imaging services
22 Imaging personnel qualification
23 Identification and safe transportation of patients
24 Turnaround time for imaging tests
25 Intimation of critical imaging test results
26 Outsourcing of imaging test
27 Imaging quality assurance programme
28 Radiation safety programme
29 Handling and disposal of radioactive wastes
1 Uniform care
PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN
HEALTHCARE FACILITIES.
CHAPTER -1: Access assessment and continuity of care
CHAPTER - 2: Care of Patients

2. Sr.No. TOPICS
Available
(Yes / No)
Implementation
(Yes / No)
PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN
HEALTHCARE FACILITIES.
2 Evidence based medicine
3 Emergency care
4 Handling of medico-legal cases
5 Triage
6 Ambulance services
7
Checklist of equipment and emergency
medications
8 Uniform use of resuscitation
9 Rational use of blood and blood products
10 Blood transfusion
11 Admission and discharge criteria
12 Management of bed shortage in ICU
13 Infection control practices in ICU
14 End of life care
15 Quality Improvement programme in ICU
16 Care of vulnerable patients
17 High risk obstetric care
18 Scope of paediatric services
19 Care of neonatal patients
20 Assessment of paediatric patients
21
Prevention of child / neonate abduction and
abuse
22 Care of patient undergoing moderate sedation
23 Criteria for discharge from recovery area
24 Administration of anaesthesia
25 Care of patient undergoing surgical procedure
26 Prevention of adverse events in surgical patients
27
Quality improvement programme in surgical
services
28 Restraint of patients
29 Management of pain
30 Rehabilitative services
31 Clinical research
32 Nutritional assessment and reassessment
1 Pharmacy services
CHAPTER - 3: Management of Medication

3. Sr.No. TOPICS
Available
(Yes / No)
Implementation
(Yes / No)
PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN
HEALTHCARE FACILITIES.
2 Hospital formulary
3 Acquisition of medicines
4 Storage of medication
5 Obtaining medicine when pharmacy is closed
6 Replenishment of emergency medicines
7 Prescription of medication
8 Verbal orders for medication
9 List of high risk medication
10 Dispensing of medication
11 Medication recall
12 Medication administration
13 Management of adverse drug event
14 Use of narcotic and psychotropic substances
15 Usage of chemotherapeutic agents
16 Disposal of chemotherapeutic drugs
17 Use of radioactive drugs
18 Use of implantable prosthesis
19 Use of medical gases
1 Patient rights
2 Protection of patient's rights
3 Patients grievance redressal mechanism
4 General consent
5 Informed consent
6
List of situation where informed consent is
required
7 Patient education
8 Billing policy
1 Infection control programme
2 Infection control manual
3 List of high risk areas for infection control
4 Surveillance for infection control
5 Standard precautions
6 Equipment cleaning and sterilization practices
7 Antibiotic policy / guideline
CHAPTER - 4:Patient rights and education
CHAPTER - 5: Hospital Infection Control

4. Sr.No. TOPICS
Available
(Yes / No)
Implementation
(Yes / No)
PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN
HEALTHCARE FACILITIES.
8 Laundry and linen management
9 Kitchen sanitation and food handling
10 Engineering controls
11 Mortuary practices
12 Monitoring of infections
13 Handling of outbreak of infection
14 Sterilization activities
15 Recall of items in case of sterilization breakdown
16 Management and handling of biomedical waste
1 Quality improvement programme
2 Indicator monitoring system
3 Assessment of patient care services
4
Parameters for assessment of patient care
services
5 Event reporting
6 Analysis of sentinel events
1 Organogram
2 List of applicable legislations and regulations
3 Organization's social responsibility
4 Scope of services each speciality
5 Administrative policies
6 Departmental objectives / key indicators
7 Vision and Mission of the hospital
8 Code of medical ethics - 2002
9 Disclosure of ownership
10 Services not provided by the hospital
11 Billing tariff / schedule of charges
12 Hospital safety programme
13 Reporting of adverse events
1 List of laws applicable to the hospital
2
Mechanism to update
licenses/registrations/certifications
CHAPTER - 6: Continuous Quality Improvement
CHAPTER - 7: Responsibility of Management
CHAPTER - 8: Facility Management and safety

5. Sr.No. TOPICS
Available
(Yes / No)
Implementation
(Yes / No)
PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN
HEALTHCARE FACILITIES.
3 Preventive and breakdown maintenance plan
4 Drawings of the hospital
5 List of major equipment
6 Handling of fire and non-fire emergencies
7 Exit plan in emergency situations
1 Training and development of staff
2 Training programme
3 Performance appraisal
4 Disciplinary rules
5 Grievance handling of staff
6 Personnel file management
7 Credentialing and privileging of consultants
8
Collection, verification and evaluation of
credentials of nursing personnels
9 Job responsibility
1 Information management
2 Management of data
3 Storage and retrieval of data
4 Needle Stick Injury
5 Hand Washing
6 Reporting of Notifiable Diseases
7 Medical records
8
Confidentiality, integrity and security of
information
9 Safeguarding of data / record from loss
10
Response to request for access to information in
the medical record
11 Retention of clinical records
12 Medical audit
151
Member of NABH Accreditation Committee, QCI
Member of Quality Expert Group, Govt of India.
Email:- drjlmeena@gmail.com
CHAPTER - 9: Human resource management
CHAPTER - 10: Information management system
Dr J L Meena
State Quality Assurance Medical Officer
Department of Health & Family Welfare
Government of Gujarat