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• IMCH, known as Imbichibava Memorial Co-operative Hospital and Research Centre Society Ltd No M841, is named after Shri: E. K Imbichibava.
• IMCH operates with the philosophy that modern medicine should aid anyone seeking medical attention.
• IMCH is a registered 100-bed hospital with a 13-member board of directors providing guidance.
• The board of directors is the top authority in IMCH.

Board of Directors

• Mr. Sivadasan - Chairman
• Mr. V. Abdu Rahiman MLA - Vice Chairman
• Mr. A. P. Sudevan - Executive Director
• Dr. Santhosh kumari - Medical director
• Mr. P.T. Narayanan - Finance Director
• Dr. K. T. Jaleel MLA
• Dr. S. D. Vanaja
• Mr. P. Mohamed Ali
• Mr. P.V Azeez Abdulh Ayyub
• Adv. K. M. Moosa Kutty
• Mr. C. P. Bavakutty
• Ms. P. Indira
• Dr. V. P. Sasidharan

Administration

• Mr. Shuaib Ali. K- Managing Director
• Mr. Renju Alappatt- Deputy General Manager

IMCH Vision

• Provide an unparalleled experience as the most trusted partner for healthcare.
• Excellence in public healthcare, medical research and academics with public support.
• Provide high-quality healthcare at an affordable cost with compassion, grace, and love.
• Focus on quality patient care for patient safety.
• Effective use of resources for patient recovery
• Foster employee efficiency and performance
• Initiate cost-effective patient care strategies

Quality Objectives

• Focus on quality patient care
• Improve performances of all professionals
• Monitor, measure, assess, and improve performance to enhance patient satisfaction
• Guard, measure, and improve patient safety
• Inculcate hygienic treatment process
• Involve all departments in improving quality
• Search for patterns of non-compliance

Departments

Non-Medical:

• Administration
• Human Resource (HR)
• Finance/Accounts
• Front Office/OPD
• PRD (Public Relation)
• Information Technology
• Medical Record (MRD) & Hospital Information System (HIS)
• Purchase
• Facilities (Security, Transportation, Attenders)
• Engineering
• Quality
• Marketing
• In patient Department (IPD)
• Laundry (OS)
• Maintenance (OS)
• Housekeeping (OS)
• Insurance

Medical

• Nursing
• Pharmacy
• Laboratory/Hematology/Microbiology
• Diagnostic Imaging
• Central Sterilization Supply Department (CSSD)
• Biomedical Engineering
• Hospital Infection Control
• Clinical Nutrition & Dietetics
• Physiotherapy
• Dialysis

Clinical Services:

• General Medicine
• General Surgery
• Orthopedics
• Pediatrics
• Cardiology
• ENT
• Anesthesiology
• Pulmonology
• Obstetrics and Gynecology
• Dermatology
• Psychology
• Casualty/ ED
• Dental
• Pain and Regenerative care
• Oncology
• Diabetology
• Family Medicine
• Dietetics
• Physiotherapy
• Dialysis

Diagnostic Services

• Laboratory
• Radiology
• CT scan
• X-ray
• Ultra Sound Scan

Intensive Care Unite

• MICU- Medical Intensive Care Unit
• SICU- Surgical Intensive Care Unit
• CCU- Cardiac/Coronary Care Unit
• NICU- Neonatal Intensive Care Unit
• Operation Theaters - 4

Employee Rights:

• Awareness of hospital policies.
• Safe and healthful workplace.
• Equal opportunities in employment and promotion.
• Awareness of employment terms and conditions.
• Training and orientation per job specification.
• Treatment with respect and dignity.
• Right to leave as per policy.
• Grievance redressal.
• Open communication.
• Performance appraisal details.
• Growth and development based merits.
• Information on key performance indicators.

Employee Responsibilities:

• Report duty on time.
• Support 24/7 hospital operations.
• Devote time to assigned work.
• Obtains leave sanction from HOD.
• Follow the dress code policy.
• Professional ethics.
• Maintain equipment.
• Adhere to professional practices, hospital rules, regulations and practices.
• Adhere to Patients’ rights and responsibilities
• Treat clients, co-workers, and patients with respect and dignity

Expectations

• Not interfere with resources of material provided
• Report any untoward incident, dangerous unsafe practice, or any type of harassment immediately.
• Provide complete and accurate information.

Anti-Sexual Harassment Committee (CASH)

Purpose:

• Addresses complaints of sexual harassment in compliance with Prevention of Sexual Harassment law.

Roles & Responsibilities:

• Receive sexual harassment complaints.
• Investigate complaints following principles of natural justice.
• Decide appropriate actions in accordance with legal guidelines.
• Ensure the rights of the complainant are protected.
• Issue prevention guidelines.
• Prevent discrimination and harassment.
• Deal with cases in a time-bound manner.
• Recommend punitive action against the guilty party.

Grievance Redressal Committee

Purpose:

• Handle grievances of hospital staff based on principles of natural justice and law.

Activities:

• Inform employees of the committee, contact persons, and process of filing a complaint during induction.
• Meets on a half-yearly basis.
• Address grievances that can be personal or service-related through written requests/complaints.
• Employees must adhere to statutory laws, service rules, and code of conduct and report violations.
• The committee will investigate the incident and submit a report with recommendations.
• An enquiry commission can be appointed to investigate the incident and collect more details.
• Distribute minutes of the commission to members within five days.
• No grievance reports will be ignored and appropriate action will be taken.
• The enquiry should follow the principles of natural justice by ensuring there is an even amount of evidence and speaking time is given.
• If the grievance is interdepartmental, resolve it with the consent and presence of management
• Enquiries should be completed in within two weeks of meetings and inform parties in progress.
• Actions such as fines, warnings, cutting of increment, demotion, transfer (to another unit/section), or suspension/dismissal may result.
• Get final decision be implemented by the Secretary through the HR Manager
• The convict can appeal within three days of receiving the final decision
• Send approved meeting minutes to a certified quality coordinator

Patient rights

• Right to respect for personal data.
• Confidentiality
• Knowledge about their personal disease
• Details of the Consultant’s treatment.
• Cost and expected duration of stay/treatment,
• Right to consent to treatment and blood transfusions etc
• Complaint redressal mechanism available.
• Alternative treatment method is available

Patient’s Responsibilities

• Follow hospital rules
• Maintain peace
• Provide accurate information about healthcare
• Pay the bill
• Not to smoke

National Accreditation Board for Hospitals and Healthcare Providers (NABH)

• NABH is a constituent board of the Quality Council of India (QCI).
• NABH is set up to establish and operate an accreditation program for healthcare organizations.
• Accreditation is a process of external review.
• There must be benchmark with assurance for patients.

NABH 5th Edition Compositions:

• 10 Chapters
• 100 Standards
• 651 Objective Elements
• 32 Quality Indicators

NABH Chapters:

• Access, Assess, and Community of Care (AAC)
• Care of Patients (COP)
• Management of Medication (MOM)
• Patient Rights and Education (PRE)
• Hospital Infection Control (HIC)
• Patient Safety & Quality Improvement (PSQ)/Continuos Quality Improvement (CQI)
• Responsibility of Management (ROM)
• Facility Management and Safety (FMS)
• Human Resource Management (HRM)
• Information Management System (IMS)

Committees

• Total 18 committees:
• Infection Control Committee
• Quality Assurance Committee
• Management Review Committee (CORECOMMITTEE)
• Anti Biotic Committee
• Clinical Audit Committee
• Medical Audit Committee
• Condemnation committee
• Blood Transfusion Committee
• Ethics Committee
• CPR & Code Blue Committee
• Pharmacy and Therapeutics Committee
• Safety Committee
• Mortality Review Committee
• Purchase Committee
• HR Committee
• Credentialing & Privilaging Committee
• Anti – Sexual Harrassement Committee
• Staff Greivance Reddressal Committee
• Monthly Committees: Quality Assurance, Management Review (CORECOMMITTEE)
• Bi-Annually committees: Medical Audit Condemnation
• Quarterly committees: Mortality Review, Purchase, HR Committee
• On need basis committees: – Sexual Harassment committee, Staff Grievance Redressal Committee

Hospital Acquired/Nosocomial Infection (HAI)

• Result from treatment in a hospital or healthcare unit.
• Appears 48 hours after hospital admission or 3 days after discharge.
• Examples of HAI:
• UTI (Urinary Tract Infection)
• VAP (Ventilator Associated Pneumonia)
• SSI (Surgical Site Infection)
• BSI (Blood Stream Infection)

Standard Precautions

• Infection prevention practices used in patient care that protect healthcare workers.
• Includes hand hygiene, PPE, safe injection/infusion practices, handling contaminated equipment, and respiratory hygiene.

Hand Hygiene Technique

• Rub palms together.
• Rub palms with interlaced fingers.
• Rub right palm over left dorsum with interlaced fingers and vice versa.
• Interlock fingers and rub the back of fingers.
• Rotational rubbing of right thumb clasped in left palm and vice versa.
• Rotational rubbing backwards and forwards of fingertips and thumb in left palm and vice versa.

Key Moments:

• 1 - Before touching a patient
• 2 - Before a procedure
• 3 - After a procedure or body fluid exposure risk
• 4 - After touching a patient
• 5 - After touching a patient's surroundings

Personal Protective Equipment (PPE)

• Cap
• Mask
• Goggles
• Gloves
• Apron
• Gum boots (shoe cover)

International Patient Safety Goals

Goal - 1: Identify patients correctly:

• Use full name, UHD No, and age.
• Check for id band and do not use room number/location.

Goal - 2: Effective Communication:

• Write down, readback and confirm verbal orders
• Ensure proper handover among all care givers
• Use ISBAR Tool for every patient
• Communicate critical concerns within 10 minutes

Goal - 3: high alert medication

• Separate storage & re-check drug name
• Strict control & check for dilution with concentrated electrolytes.

Goal - 4:

• Ensure correct site/procedure.
• Include patients at time of procedures

Goal - 5:

• Prevent HAI with hand hygiene, Appropriate PPE, or Care bundles

Goal - 6:

• Reduce falls by doing daily assessments and increasing safety measures Barrier Nursing
• Aims to protect medical staff
• Reverse Nursing protects vulnerable patients.

Terminal Disinfection of Isolation Rooms

• Wash all surfaces with warm water, detergent, and disinfectant.
• Mark bed linen and curtains as "infected."
• Wipe mattress and pillow with warm water and detergent or disinfect.
• Send Items that can be autoclaved to clinical waste after being set aside and aired properly

Airborne Infection & Isolation

• Infections spread through droplet nuclei.
• Requires patient placement in a negative pressure room exhausting high up and the constant use of a mask

Notifiable Diseases

• Diseases needing stern steps to prevent epidemics, such as Cholera, Dengue, or Plague

Code Blue and CPR protocol

• Signal the code and start chest compressions and CPR to maintain blood and body flow

End of Life Care Policy

• Guidelines when doctors and patient representatives decide to withhold measures of care for the families.

Near Miss in Medicine

• An unplanned event that did not result in injury, illness, or damage but had the potential.

Sentinel Event

• Signals need for investigation and core committee will address it without delay
• Here is a list of potential events regarding the clarity
• Wrong Surgery on wrong Part
• Unintended Retention of a Foreign Body in the Patient's Body.
• Wrong Patient, Wrong Site, Wrong Procedure.
• Mismatched Blood Transfusion.
• Fall from Bed.
• Patient Suicide.
• Displacement of Joint Due to Mal positioning by the Staff.
• Delay in Treatment which resulted harm to the patient -Any Preventable event that may cause or lead to inappropriate medication use or patient harm, while the medication is in the control of the healthcare staff.
• Prescribing Errors (Not legible, Dose/Route/Concentration etc. mentioned, others)
• Dispensing Errors (Wrong patient, Similar Medicines)
• Administering errors

How to prevent medication errors:

Follow the 6 “R” (Right) every time

• Right Drug
• Right Dose
• Right Patient
• Right Route
• Right Time
• Right Documentation

Adverse Drug Reaction

• A noxious, unintended response to a drug at normal doses, such as rashes.
• High alert if this reaction occurs

Adverse Drug Event (ADE)

• A negative occurrence resulting while using drugs

Protocols for when they Occur

• Stop administering the medicine and immediately notify the treating doctor.
• Give Prophylaxis medicine instructions
• File the adverse reaction so the facility will be better prepared for emergencies

Narcotic Drugs

• Psychoactive compounds with sleep-inducing and euphoric properties like Fentanyl, Morphine, or Pethidine.
• Must be locked at all times

High-Risk Medicines:

• Causing significant patient harm or death when misused, such as Adrenaline or Insulin
• Should be placed into separated shelves with red containers

Look-Alike & Sound-Alike Medications

Guidelines

• Store those names of things in different locations
• Employ checks when dispensing
• Use very little verbal communication or phone orders so that it is not misunderstood
• Mark a distinct “alert” sticker on the area
• Write both the brand and generic brand to keep the doctor’s and patient’s memories fresh and in mind

Rejecting samples

• Should the form request, label, names, numbers, and equipment be incorrect
• Should the patient have some history of clotting

Radiation Safety Devices:

• TLD badges (Thermo Luminescent Dosimeter)
• Lead Aprons.
• Should be tested to show damages in leakage

Medical Records Retention Policy:

• Department must keep it for at least five years under safe custody and ready to be handed
• three year max for out patients
• Lifetime guarantee for medical emergencies or death.
• Policies of restraint

How to help the patient:

• The restrain may be physical or chemical
• When the patient's condition or behavior indicates an immediate & ongoing high risk of self-harm (either deliberate or unintentional), medical staff must pose an ongoing risk themselves or others if property is damaged
• When there is legal support to carry out the prescribed treatment against the person's will
• Uses restrain physicals to limit movement

Medical Safety

Medical gasses used:

• Nitrous Oxide (N20)- Blue lines to operate
• Oxygen- White lines to help airways
• Vacuums- Yellow lines to remove
• Air in pressure with both black and white to run simulators CO2- Grey for surgery air in pressure with both black and white

Emergency Colors to operate:

• CODE RED when fire is detected

• CODE BLUE when person looses breath

• CODE ORANGE if liquid or spillage

• CODE PURPLE if violence

Medical Black

• The facility enters an alert to bomb threat or violent engagement

Medical Yellow

• alert the emergency that the hospital must check to patients with the mental state of a patient missing

Medical Brown:

• Announced to inform the most injured of casualties in cases of earthquakes, floods, and landslides.

Medical Pink

• If kids and infants have been abducted

Biomedical Waste Management

• Follow cleaning protocols that deal with the spread of infection and clean waste

White:

• Needles, syringes with fixed needles, scalpels, blades and razors, contaminated metallic objects, lancets, and nails
• All uninfected waste has either food or paper

Yellow

• All infections that are non-plastic like cotton and fluids in bandages or bedding with parts of blood and the body

Black:

• All plastic

Segregation charts:

• Post operatic parts or placentas with medication

Always PASS medical safety

• P-Pill the pin
• A- Aim at the base of the fire
• S- Squeeze
• S- Sweep

RACE safety is in place

• Save people first

• Activate pull station and alarms right away

• In the event that staff needs more emergency codes it needs to dial facility code 8030

Influencing fire measures

• Implementing measures that ensure there is no reason to have smocking on spot
• Check to see if smoke and extinguishers are ready to operate
• Have very little items that build the fire up
• No sparks
• all things are in working order when used

Evacuation plans

Category 4 is often moved with 3,2 and 1.

• 1 has many babies 2 uses wheelchairs
• patients with help
• all by themselves

Dangers and what they mean

• Mass transit or being in a facility with little to no people and having major fire

Important staff at all times

• Medical superintendents in all areas
• Triage for all events with clear codes and understanding with each action

Triage

The process of properly identifying patients and providing care

• Codes

  1 is red to let those that need to live 2 is yellow to let those watch and come soon 3 is green for the walking wounded 4 is black, for the dead

Hazards to health

• Exposure to hazards of ones’s job whether their biological or mechanical

Needle safety protocol

• Do not suck their wound
• Wash the location for 20-30 seconds with soap and water
• Report to nurses or staff to help administer the medication

Disposing of tools and waste

• Use containers labeled in all sharps and needles and do not recap
• all waste must be separated

Tools for spillage for those to manage it

• PPE, (Gloves, mask, goggles)
• 500 ml container contains 1% sodium hypochlorite
• Small containers
• Biomedical waste cover Zip lock cover
• Syringe, cardboards
• Forceps, Paper towel, torch light

Important guidelines for body management:

• Always clean what is on the surface and have the right gear for the job

Two Spill protocol types

• Major spill: (It is any fluids or blood more than 30ml)-Spill Kit

• Minor spill: (It is any fluids or blood less than 30ml) Hazmat Kit

• Note: spills are managed with 1% hypochlorite solution for 30 mins

• Always discard equal amounts of solution and water

• Follow by wiping all alcohol and surfaces by doing the following:

• Digital Thermometer- Clean with Alcohol swab; Bulbs must be in close contact

• BP cuff - Wash with Detergent _ Stethoscope- Wipe the diaphragm and ear piece with alcohol swab.

• Suction jar- clean immersible 1% sodium hypochlorite for 20 minute

• Humidifiers-Warm water and detergent

• Biomedical Equipments- Aerosept solution