Module 1 - IPSG & GLD PDF

CHAPTER-1: International Patient Safety Goals (IPSG) 1. Name the Six International Patient Safety Goals 1. Identify patient correctly 2. Improve effective communication 3. Improve safety of high alert medications 4. Ensure Safe Surgery...

CHAPTER-1: International Patient Safety Goals (IPSG) 1. Name the Six International Patient Safety Goals 1. Identify patient correctly 2. Improve effective communication 3. Improve safety of high alert medications 4. Ensure Safe Surgery 5. Reduce the risk of healthcare associated Infections 6. Reduce the risk of patient harm resulting from falls 2. Which are the two identifiers used for patient identification?  All Health Care givers shall identify patient using at least two (2) identifiers:  Patient’s full name (First name, second name and/or Family name).  Unique Hospital Identification number(UHID).  In case of unconscious unknown Patients:  If no information regarding patient identity is available, a temporary name using letters (UNKNOWN) with the unique hospital identification number will be assigned until identification process is completed (UNKNOWN UUHID).  For the newborn, ID bracelets placed on both ankles with the following information:  Baby of (mother’s name)  Newly generated UHID  In the event of death, the wrist ID band shall remain on the patient’s body.  For verbal communication in areas like outpatient clinics, Physiotherapy and other ambulatory areas, patient birth date will be used with the patient name to identify patients, all other situations the two identifiers must be the patient name and unique hospital identification number. 3. What are the colour codes of wrist ID Band and their indications?  Blue (All Non-Vulnerable),  Orange (All Vulnerable),  Red(Allergies)  Purple (Covid positive patients) 4. What are the Policy for Telephonic Order / verbal orders?  Telephone Order shall: (WRITE DOWN-READ BACK-CONFIRM) Page 4 of 83   Only be given in situation where the doctor is not immediately available e.g. when the patient condition needs an emergency order.  The telephonic must be authenticated by Primary Consultant within 24hours.  Telephonic orders for drugs are taken by DMOs Only.  Non-drug telephonic orders are taken by Nurses.  Verbal order is allowed only in situation when the physician cannot document the order e.g., as in emergency/urgent situation or When the ordering physician is scrubbed for a sterile procedure/surgery etc. Repeat Back-Confirm  The staff shall implement repeat back process.  The receiver repeats it back to the ordering physician.  The ordering physician confirm the order.  The receiver writes down the complete order after carrying out the order.  Verbal order must be authenticated by the ordering physician as soon as emergency is over/ before leaving the area. 5. What do you do if you take a critical result from lab? We get call from lab if any patient has critical results, we follow WRITE DOWN, READ-BACK AND CONFIRM policy while receiving the information and document in "critical results reporting form" and inform DMO and consultant WITHIN 30 MINUTES and initiate the correction as advised. 6. Is it required for doctors to do read back like nurses do? Yes, Doctors have to do read back and document the instructions/orders taken. 7. What do you if you have a “Critical Test Result” in Radiology and how do you handle them? Follow Write down- Read back- Confirm Process. When there is a critical result in the Radiology investigation, the Radiology technician /Radiologist informs the Primary consultant directly within 30 minutes and documents in the Critical Value Register. 8. If you do a glucometer /ABG test at bedside (POCT) and still receive a critical value, what should you do? You need to treat it as any other critical value, inform doctor immediately within 30minutes. The same needs to be documented and initiate treatment. 9. Do we have to document handovers? Yes Page 5 of 83 10. Who has to document handovers? Nurses, DMO’s, Consultants 11. “Patient Handoffs” require what?  Handoff is one important component of effective communication  Provide an opportunity for questions/answers between the giver and receivers  Give up-to-date information with any anticipated changes  Minimize interruptions  Repeat back or read back process  Receiver has opportunity to review the individual’s historical data, neurological status, critical labs, plan of care & any concerns. (SBAR) 12. When “HANDING OFF” Patient information, what format is used while giving or talking a handover by the Nurses?  SBAR- Situation, Background, Assessment, Recommendation  SITUATION- Current situation  BACKGROUND- History, diagnosis, tests, course of care, plan of care)  ASSESSMENT  RECOMMENDATION & Interventions for treatment 13. What happens when a patient is shifted from a ward/ICU to a temporary area in OP? (Radiology/Endoscopy/Bronchoscopy/Dialysis/Chemotherapy/Procedure area) HAND OFF TABLE: Situation Handover documented Handover in documented by Consultant/Primary physician goes on leave Doctors progress notes Consultant End of Shift-Nurses SBAR form Nurses End of Shift-Doctors DMO handover form Floor/In- charge/ICU doctors ER to ICU/Ward ER Admission Record Doctor, Nurse In house transfers, Ward-ward In-house Transfer Form Doctor and nurse of Ward-ICU, ICU-Ward, ICU-ICU sending unit Transfer to diagnostic areas or other treatment Hand off form for Doctor/Nurse from units: diagnostic the unit that sends  Ward to Radiology. procedures/Tests. the patient.  Ward to Dialysis. Page 6 of 83   ER/Ward to Chemotherapy.  Ward to ECG/ ECHO/ TMT/ EEG/ER.  Ward to Endoscopy Bronchoscopy, other procedural arears or physiotherapy.  ER/Ward to Cath lab.  ER/Ward to OT. Transfer from diagnostic areas or other Hand off for diagnostics Nurse/Technician treatment units back to origin: / Tests who receives the  Radiology to ER/Ward patient  Dialysis to ER/Ward.  Chemotherapy to ER/Ward.  ECG/ECHO/TMT to Ward Endoscopy, Bronchoscopy, Other procedural areas, Physiotherapy to ER/ Ward ER/Ward/ICU to operation Theatre Operative record Nurse from the unit that sends the patient ER/Ward/ICU to Cath lab Hand-off form for Nurse from the unit diagnostics that sends the tests/procedure record patient Cath Lab to ward/ICU Hand off form for Nurse & Doctor diagnostic tests/Procedures Operation Theatre to ward/ICU Hand –off form for Nurse & Doctor diagnostics , SBAR & In-house Transfer Form  The handovers may not be compulsorily documented in emergency situations or in situations when a doctor/Nurse or both accompany an unstable patient and is present throughout the investigation process. 14. Define High Alert Medication (HAM)? High Alert medications are the drugs that bear a heightened risk of causing significance patient harm, when they are used inappropriately. 15. What are the categories of High risk medications? Page 7 of 83  I. Concentrated Electrolytes (Blue Colour) 1. Potassium Chloride 15% 2. Potassium Phosphate 3. Magnesium Sulphate 10% 4. Magnesium Sulphate 50% 5. Sodium Chloride 14.61% 6. Sodium Chloride 3% II. Look Alike Sound Alike Drugs Medication identified as look-alike /sound alike will be segregated in the storage areas and labelled with Pink colour for look Alike drug and Green colour for Sound alike. III. High Alert Medications (Orange colour) 1. Adrenergic Agonist 2. Anaesthetic Agents 3. Anti-Thrombotic Agents & Thrombolytic 4. Direct oral anti Coagulants 5. Chemotherapeutic Agents 6. Inotropic medications 7. Insulins (Subcutaneous and IV) 8. Psychotropic drugs 9. Liposomal forms of Drugs 10. Minimal/Moderate Sedation Agents 11. Opioids/Narcotic 12. Neuromuscular Blocking Agents 16. How are the high alert medications identified & Labelled?  High alert medications are identified with CAUTION label from the pharmacy labelled with orange colour sticker.  The list of high alert medications is displayed in nursing stations. 17. How is Site Marking Done?  Site Marking: Surgical site shall be marked for all such surgical cases involving bilateral organs, bilateral limbs and surgeries involving multiple levels such as spine or multiple structure like fingers, toes, or lesions.  The correct sign of marking the site is an ✓ (TICK) pointing towards the incision site. 18. What is Sign-in, Time Out, Sign-Out? Page 8 of 83   Sign-in: Before the patient is induced, the nurse, anaesthetist, technician and member of surgical/procedural team must confirm the patient’s identity, the site & side of surgery/procedure, what procedure is to be carried out and that patient has consented for the procedure, implants availability. Patient is a part of Sign-in process.  Time out procedure: Time out is conducted immediately before starting the invasive procedure or making the incision: Time out is called by the circulating nurse in OT & assisting nurse outside OT.  Time out shall involve all team members of the procedure e.g. anesthesia team, circulating nurse and operating room technicians, surgeon and the assistants, scrub nurse, and others involved in the procedures.  The team members agree to the following:  Correct patient identity using 2 identifiers, patient name and AIG Hospitals UHID number.  Correct surgery / procedure verified with consent.  Correct surgical/invasive procedure site.  Whether appropriate antibiotic prophylaxis has been given.  Essential imaging displayed (if applicable).  Sign-Out:  Before the closure of the operated wound in OT  The instrument, sponge and needle counts are checked, equipment is checked and specimens are checked as appropriately labelled (intra-operative record). The Surgeon, anesthetist and nursing staff then must discuss any key concerns for recovery management of the patient and if necessary a mention of it is made in OT notes. 19. Tell me Where, When and how will you follow IPSG 4?  Marking Surgical Site  Location: At bedside / pre-op area  Done by: Surgeon  Pre-op verification process  PAC: by Anesthetist  Location: at bedside before transfer  Done by: Nurse  Time Out – just before INCISION / start of procedure  Location: OT/Procedural area Page 9 of 83   Done by: Surgical Team  Sign Out – before patient leaves the operating room  OT/procedural area  Done by: Surgical Team  Check: Name of surgical procedure; completion of instrument, sponge, needle count, labelling of specimen; any equipment problems 20. What are the 5 Moments of Hand hygiene as per WHO 2009?  Before touching the patient  Before clean/aseptic procedure  After body fluid exposure risk  After touching a patient  After touching patient surroundings 21. Bundles are set of evidenced based activities when done together are proven to have better patient outcome, than when done individually. We follow the under mentioned 4 bundles.  CLABSI  VAP  CAUTI  SSI 22. What interventions to be done when patient is at risk for fall? Page 10 of 83 23. What happens if there is a patient fall? After a fall, take care of patient - inform Doctor-Assess-Document. Fall risk assessment is conducted again - Raise incident form - RCA to be done. 24. When and how is Fall Risk Assessment done?  IP- All patients (Fall risk assessment by nurses)  OP- All patients (Fall risk screening by nurses) 25. Do we have a "Patient Safety Program" and what is its focus?  Yes, there is a Quality & Patient Safety Program and we have a Hospital Safety and Disaster Management Committee, and also a Patient Safety Officer (Ms Anuradha B.).  Staff are encouraged to report any concerns that might be an actual or a potential safety concern, without having to fear about any retaliatory action against the staff or department. Page 11 of 83 International Patient Safety Goals IPSG 1 1. Patient’s full name (First name, second name and/or Family name). 2. Unique Hospital Identification number(UHID).  POLICY ON – ‘IDENTIFYING PATIENT CORRECTLY’ (IPSG-1) 1. In case of Unconscious/Unknown Patients: If no information regarding patient identity is available, a temporary name using letters (UNKNOWN) with the unique hospital identification number will be assigned until identification process is completed (UNKNOWN UUHID). 2. For the Newborn, ID bracelets placed on both ankles with the following information: 1.Baby of (mother’s name). 2. Newly generated UHID 3. Date of Birth. 4. Gender. 3. In the event of death, the wrist ID band shall remain on the patient’s body. THANK YOU  CHAPTER 10: Governance, Leadership, and Direction (GLD) 1. What is culture of safety?  You Are Empowered- Remember  Safety is valued as a prime priority.  Staff can speak up and raise concerns. There is openness about errors and problems.  Staff is free to report errors, incidents or any other concerns related to safety of patients/employees and any malpractice of care without any fear. We practice - Open door policy without the fear of any punitive action.  ‘Culture of Safety’ survey conducted ONCE A YEAR among the employees to identify areas of safety concerns and opportunities for improvement. o Ex: Hand wash by doctors, Improper consents before shifting the patients to OT, any verbal orders.  Positive areas Identified from the Culture of Safety 2021 results.  Organizational learning -continuous improvement.  Employee engagement & Employee relation.  Areas of Improvement identified from the Culture of Safety 2021 results.  Staffing and Inter Departmental Communication. 2. Name indicators monitored for ensuring compliance to safety culture?  Wrong site wrong patient surgeries, Hand washing compliance / communication errors, sentinel events. 3. Are any research patients admitted in your area today?  No 4. What do you do in case there is conflict in treatment plan?  Discuss with Primary Physician and inform the Clinical Admin if required. 5. How are individual needs identified and care coordinated across care settings?  Information is gathered and assessed on admission and throughout services and reflected in the care plan. 6. What are the issues referred to Ethics and Grievance Redressal committee?  Unethical practice.  Post procedural deaths/ patient complaints against doctor.  Procedure not supported by evidence based medicine.  Procedures being done for which the consultant is not privileged. Page 60 of 83  To review patient records pertaining to selected patients who died in the hospital besides the iatrogenic morbidity by interventions that are referred by the ADMS/ CEO. Page 61 of 83  Employee Code of Conduct 1. Breaches of Code / Monitoring and Compliance The HR Department will monitor those instances of breaches of the General Code of Conduct which have been brought to their attention and if deemed necessary may forward the matter to the Hospital Executive Committee for action. 2. Quality of Service and Care Employees of AIG Hospitals must ensure that the services provided by the Hospital are of the highest quality with compassion and reliable service to the patients.  Employees should honour the dignity and privacy of each of our patients and should treat them at all times with consideration, courtesy and respect.  Employees should provide appropriate and timely care to all patients without regard to race, religion, age, gender, national origin, disability, and political status.  Employees should provide patient care that conforms to acceptable clinical and safety standards.  Employees should maintain complete and thorough records of patient information to fulfil the requirements set forth in the Hospitals policies, insurance requirements, accreditation standards and applicable laws and regulations.  Employees should support and promote a continuous quality and performance improvement program throughout the Hospital  Employees continuously strive toward a culture of patient safety. 3. Confidentiality and Privacy AIG Hospitals is committed to maintaining the confidentiality of patient and employee information in accordance with legal and ethical standards. Breaches of confidentiality will not be tolerated.  Employees must adhere to all established confidentiality and privacy policies, 2  procedures and laws.  Employees must always respect the privacy of the Hospitals patients, bystanders, visitors, fellow employees, and medical staff.  Employees must at all times protect and safeguard patients’ health and personal information and employees’ personal information in all forms, including paper, electronic, verbal, telephonic, or any other form.  Employees should access a patient’s medical data only when involved in that patient’s care, or when access is needed for a legitimate work-related reason such as medical treatment, billing, administrative, teaching or research requirements.  Employees should not discuss patient information in any public area, including elevators, hallways and canteen.  Employees should not discuss patient’s information in front of other patients or with other patients.  Employees should only use patient information for its intended purpose only. 4. Workplace, Environment and Behaviour All Employees of AIG Hospitals should treat all people with respect, dignity and courtesy. AIG Hospitals recognize that its greatest strength lies in the talent of the staff who create the Organization’s success and determine its reputation.  All employees should demonstrate honesty, integrity and fairness in the performance of their duties.  Employees should report time and attendance accurately and work productively while on duty.  Employees must ensure that they adhere to the organization policy.  All employees should encourage teamwork and create structures processes and programs that enable a positive culture to flourish. Disruptive behaviour that intimidates others and affects morale or staff turnover will not be tolerated and will be addressed appropriately.  All employees should refrain from any act of retaliation or reprisal against another employee who in good faith reports a violation of law, regulation, 3  standard, Hospital policy or the Code of Conduct.  All employees should make every effort to prevent and detect, and report any fraudulent, wasteful or abusive activity, which may affect the Hospitals patients and employees or resources.  All employees are prohibited from the use of alcohol, drugs in workplace and should not report to work under the influence of alcohol and/or an addictive drug.  AIG Hospitals expect all employees and to conform to the standards of their professions and exercise appropriate judgment in the performance of their duties.  All prospective employees are required to disclose any documentation that state that they have not been sanctioned by any regulatory agency and are eligible to perform their designated responsibilities.  All Employees should familiarize themselves and comply with the contents of the Hospital’s Employee Handbook and the Code of Conduct as well as with the policies and procedures applicable to the employment and responsibilities at the Hospital.  Employees must report any practice or condition that may violate any law, rule, regulation, safety standard, Hospital policy or the Code of Conduct to Immediate Supervisor, Manager/HOD, HR, Executive Committee through Legal Compliance Officer.  All employees should ensure to procure, maintain, dispense and transport drugs and controlled substances used in the treatment of patients according to applicable laws and regulations.  Any statement to a government body or independent commission by an Employee regarding work related matter should only be made with prior approval from the Management.  Employees must refrain from using social media during working hours, which will hinder the quality of service.  Employees who use social media after office hours should refrain from making statements with regard to the Hospital and its services unless authorized to do so and should not disclose any confidential information of the Hospital, Employees and Patients. 4 5. Conflicts of Interest / Ethical Dilemma All Employees of AIG Hospital should perform their duties on behalf of the Hospital and its patients and should avoid conflicts or the appearance of conflicts between employees’ own interests or an outside interest and the interests of the Hospital.  All employees should devote their full time and ability to the Hospital during working hours.  Employees should not engage in any activity, practice or act that creates an actual or apparent conflict with the interests of the Hospital  Employees should report actual or potential conflicts of interest to the immediate supervisor or manager.  Personal or official fund raising activities should only be conducted with the approval of the Chairman / Managing Director, and unless otherwise are prohibited from being conducted onsite or during work hours. This prohibition includes use of the Hospital facilities and resources.  Employees should act in the best interest of the Hospital, as an agent of the Hospital, and in dealings with suppliers, customers or government and non- government agencies and independent commissions. This obligation includes those acts formalized in written contracts, as well as everyday business relationships with vendors, customers, government officials and government employees.  All Employees are strictly prohibited from giving or receiving payments, kickback or bribe to induce the referral or the purchase of any healthcare service, equipment, medicine and consumables.  No employee shall accept any improper inducements or favours and kickbacks from vendors to influence our patients or others connected with the Hospital to use a particular product or service.  All employees must inform vendors of the Hospitals policies regarding ethical business conduct and compliance with law, as well as our expectation that vendors act in accordance with such law and policies. 5 6. Safeguarding Hospitals Resources and Assets Employees should ensure safeguard the hospitals assets and physical property and ensure the appropriate use of the hospitals resources.  Employees should protect the assets of the Hospital and the assets of others entrusted to the Hospital against loss, theft or misuse. This includes physical and intellectual property.  All employees should maintain internal controls within their areas of responsibility to safeguard the Hospital’s assets and verify the accuracy of financial statements and all other records and reports.  All Employees must use Hospital property appropriately and take measures to prevent any unexpected loss of equipment, supplies, materials or services.  Employees should adhere to established policies and procedures governing record management and comply with the record retention and destruction policies/schedules for their departments. 7. Environment, Health and Safety AIG Hospitals is committed to maintaining a safe and secure environment for the health and safety of its patients, visitors and employees.  Employees must comply with and abide by all applicable environmental, health, and safety laws and regulations established by Management, Government or accrediting organizations.  Employees will take all reasonable precautions such as using safety equipment and gears and follow all rules and regulations to maintain a safe environment for the Hospitals patients, their families, employees, and visitors.  Employees should exercise good judgment with regard to the environmental aspects of the use of Hospital buildings, property, laboratory processes and medical products.  The Hospital is a smoke-free environment and all employees should comply with established policies in this matter.  Employees should immediately advise their supervisor if, as a result of work, 6  they are injured or contract an occupational illness.  Employees should alert the appropriate departments and personnel if unsafe conditions or practices are observed in the work environment.  Employees shall adhere to all regulations and procedures for disposing of medical waste and hazardous material.  Employees should promptly report all spills or accidents involving medical waste or Hazardous materials to a supervisor and take immediate action to help prevent harm and/or further damage.  Employees should safely store, secure, and count all drugs and pharmaceuticals. Missing or diverted drugs will be promptly reported to the appropriate supervisor. 8. Employee Issues and Concerns If there is a question, query or concern about a situation that an employee feels may be illegal or unethical, please seek guidance from the immediate Supervisor. If employees feel uncomfortable addressing the issue with the immediate Supervisor or the Supervisor has failed to address the issue in a timely manner, then please inform Manager/HOD, HR, Executive Committee through Legal Compliance Officer. The Organization is committed in responding to issues or concerns identified by employees. 7  About : AIG Hospitals – where excellence is a way of life. AIG Hospitals is a Multi Superspeciality Hospital. Spread across 14.13 lakh sq.ft, and has about 700 beds. AIG hospitals is led by world renowned Gastroenterologist Dr. D Nageshwar Reddy, as Chairman, and & Dr. G V Rao, Director. AIG Hospitals is designed keeping in mind the comfort of our patients. The serene environment, spacious interiors and advanced facilities create a positive ambience that is conducive to healing. Our Logo : Meaning Our logo is a unique symbol representing AIG’s values, vision and promises. Our logo consists of three elements: A shield, A flag and Three dots. The shield symbol represents protection and knowledge, the flag suggests past achievements and future promises and the three dots stand for Clinical Excellence, Research and training, community service. Color blue in our logo suggests professionalism and adds calmness, while color grey is neutral and emphasizes our approach towards service. In the words of our Chairman… In our constant endeavor to provide the common man with world class healthcare at an affordable cost, we feel extreme pride to see that today Asian Institute of Gastroenterology has become a name that fills the heart with hope and solace. Dr D Nageshwar Reddy Chairman and Managing Director Our Vision EXCELLENCE and INNOVATION to ensure BEST-IN-CLASS HEALTHCARE at AFFORDABLE PRICES Our mission At AIG Hospitals, our mission is to provide world-class healthcare to Indian and International patients whilst ensuring ‘inclusivity for all’ by: Utilizing our resources efficiently and effectively Imparting education to community doctors to ensure early and accurate diagnosis Improving patient awareness about diseases and treatments Deploying latest and relevant technology Investing and participating in Research & Development projects for advancement of healthcare  Our values that … I ntrinsic learner N. S urture elf-driven.P erfection.I ntegrity.R ole Model.E mpathy. Contribute in An intrinsic Strong focus in Communicate Strong orientation Nurture kindness zeal to excel specializing in their actively & Walk the and interest in improving skills & towards our & innovate respective area of accurately while talk; make improving one’s knowledge of patients and work or function upholding things skills continually colleagues at work colleagues; highest happen place; be a team provide support player and work standards of at all times! together to resolve personal and professional and professional patient issues ethics  AIG Organisation Structure AIG operational organizational structure aims to ensure development of functional roles and a strong supervisory mechanism Board Of Directors Hospital Committees Chairman and Managing Director Medical Director Vice President Chief Operating Head Sales & Clinical Department Chief Finance & Supply Chain Officer Marketing Heads Officer LAB Director Clinical Procurement Patient Care International & Accounts GM-HR Operations Services (IP/OP) Domestic BD Quality Tax & Audits Supply Chain Billing Marketing HR Secretarial & Inventory PR & Nursing Security Pay Roll Compliance Communications Strategy / Biomedical Radiology Engineering Planning & MIS Engineering & Laboratory IT Maintenance House Keeping Food & Beverages Medical Director Quality & Patient Safety Structure MEDICAL DIRECTOR / CHIEF OF QUALITY CONTINUOUS QUALITY IMPROVEMENT COMMITTEE ALL COMMITTEES HOSPITAL & LAB NURSING SAFETY CLINICAL INFECTION QUALITY QUALITY OFFICERS ADMINS CONTROL Quality Link Staff Quality Accreditations AIG Meets MAYO AIG Hospitals became the first health care facility in India to become a member of Mayo Clinic Care Network  Facility Overview - Hospital Block and Facility Block Our hospital has two towers: 2nd Floor: Endoscopy rooms, Chemotherapy, Colonoscopy, ERCP, EUS, OPD 1. Main tower comprising of 13 floors (3 Basement+9 floors) and Clusters 2. Facilities towercomprising of 15 floors(3 Basement+11 floors) 3rd Floor: CTVS, OT’s, ICU’s, HDU’s, Isolation rooms 4th Floor: OT’s, ICU’s, HDU’s, Isolation rooms, surgical gastroenterology TOWER - A OT’s, Transplant OT’s, Robotic OT’s Basement 3: MRI, CT scan-1, Nuclear Medicine, Radiation Oncology, 5th Floor: Training rooms, Library, AIG board rooms, doctor’s canteen, IT, Mortuary Cash and Credit Billing. Basement 2: CSSD, Administrative Area, Engineering office, Purchase, 6th Floor: Twin sharing, Dialysis beds Finance department. 7th & 8th Floor: Single beds Basement 1: Entrance & the waiting lounge for Trauma Centre, Stores, 9th Floor: Deluxe, Suite, Presidential suite. Colonoscopy, Preparation lounge, Staff cafeteria, visitor cafeteria, Biomedical Engineering CT Scan-2 TOWER - B Ground Floor: General wards, Emergency wards, Platinum wing entrance, 3rd & 4th Floor: Blood Bank and Labs Auditorium, Screening OPD’s, Pharmacy, Canteen. 5th & 6th Floor: MRD & Basic sciences (Research) 1st Floor: Speciality Clinics cluster wise 7th, 8th & 9th : OPDs and Master Health Check Cluster A - Medical Gastroenterology, Cluster B- Surgical Gastroenterology, 10th & 11th Floors : IP Single Beds Cluster C,D,E-Cardiology, Cluster F-Sample Collection, Cluster G- X Ray, Cluster H- Ultra sound Cluster I- Medical gastroenterology, Cluster J- IP Admissions, Cluster k- Endocrinology, Cluster L- Nephrology, Cluster M- Hepatology, Cluster N- Pulmonology & Internal medicine, Cluster O - Surgical Gastroenterology, Cluster P- urology And Liver transplant, Cluster Q Neurology and Neuro Surgery Focused Clinical Departments / Scope of Services 1. MEDICAL GASTROENTEROLOGY 2. SURGICAL GASTROENTEROLOGY & LIVER TRANSPANT 3. ENDOCRINOLOGY 4. BARIATRIC & METABOLIC SURGERY 5. CARDIOLOGY & ELECTROPHYSIOLOGY 6. CARDIOTHORACIC SURGERY & HEART TRANSPLANT 7. MEDICAL ONCOLOGY 8. SURGICAL ONCOLOGY 9. RADIATION ONCOLOGY 10. HEPATOLOGY 11. ANAESTHESIOLOGY 12. HEART TRANSPLANT 13. EMERGENCY & TRAUMA MEDICINE 14. CRITICAL CARE MEDICINE 15. NEPHROLOGY 16. UROLOGY & RENAL TRANSPLANT 17. ROBOTIC SURGERY Clinical Departments – continued 18. NEUROLOGY 19. NEURO SURGERY 20.INTERNAL MEDICINE 21.RADIOLOGY 22.INTERVENTIONAL RADIOLOGY NON AVAILABLE SERVICES 23.NUCLEAR MEDICINE Obstetrics 24.GENERAL & LAPAROSCOPIC SURGERY Burns 25.ORTHOPAEDICS Psychiatry IP 26. SPECIALITY PAEDIATRICS Neonatology 27. PULMONOLOGY 28. CLINICAL PSYCHOLOGY 29. ENT, CRANIOFACIAL SURGERY 30.TRANSFUSION MEDICINE 31.PLASTIC & COSMETIC SURGERY 32.VASCULAR SURGERY 33. GYNAECOLOGY 34. PAEDIATRICS Allied Clinical Departments – Proposed in AIG Hospitals LABORATORY SERVICES DIETETICS & NUTRITION – MICROBIOLOGY NURSING – BIOCHEMISTRY PHYSIOTHERAPY & REHABILITATION – HISTOPATHOLOGY MEDICAL TRANSCRIPTION & CODING – MOLECULAR BIOLOGY PALLIATIVE CARE – GENETICS AIG HEALTH CHECKUP – HAEMATOLOGY DISASTER MANAGEMENT TRANSFUSION MEDICINE BLOOD BANK DIALYSIS AMBULANCE SERVICE QUALITY & INFECTION CONTROL RESEARCH & ACADEMICS Top five procedures and diagnoses Diagnosis Procedure Gastroenteritis Whipple PD Pancreatitis Lap cholecystectomy Cholelithiasis Endoscopy and ERCP Intestinal obstruction CABG procedures/Cath lab procedures Coronary heart diseases Liver transplant The Quality Committee structure and its relationship with other committees (one or two slides) Sl # Name of the Committee SL# Name of the Committee 1 Quality Improvement Committee 15 Sentinel Events & Incident Reports Review Committee 2 Infection Control Committee 16 Bio Medical Waste Management Committee 3 Mortality and Morbidity Committee 17 Radiation Safety Committee 4 Code Blue Committee 18 Lab Safety Committee 5 Pharmaco - Therapeutic Committee 19 Transplant Committee 6 OT Committee 20 Antibiotic Stewardship committee 7 Hospital Safety & Disaster Management Committee 8 Medical Records & Clinical Audit Committee 9 Grievance Redressal & Ethics Committee 10 Prevention of sexual harassment committee Committee performance and key recommendations are reviewed at board level meetings 11 Blood Transfusion Committee 12 Purchase & Condemnation Committee 13 Credentialing & Privileging Committee 14 Ethics Committee HAZARD IDENTIFICATION & RISK ASSESSMENT (HIRA) / ICRA/PCRA /FMEA Hospital Safety and Disaster Preparedness Committee oversees the HIRA/ICRA/PCRA Program Designation Appointed Person RISK = PROBABILITY x SEVERITY Probability Rating Rare 1 >Month The eight programs are as follows: Infection Control Officer Dr. Pragathi Possible 2 week Likely 3 Day Often 4 48hrs d) Fire safety 1 First Aid No Loss of time e) Medical equipment Radiation Safety Officer Mr. Mallikarjuna f) Utility systems HOSPITAL HAZARD AND RISK QUANTIFICATION MATRIX Issue Revision Date Lab Safety Officer Mr. Narsimha g) Emergency and disaster Probability Pages management Fire Safety Officer Mr. Abdullah S Minor (1) Extreme(4) h) Construction and renovation Rare (1) 1 2 3 4 Medication Safety Officer Dr Santosh Possible(2) 2 4 6 8 Likely (3) 3 6 9 12 Chief Security Officer Mr. Jaipal P Often (4) 4 8 12 16 High High Risk Activity should not proceed in current form Medium Moderate Risk Activity can operate subject to management and/or modification HAZMAT Officer Mr Vikas Low Low Risk No Action required unless escalation of risk is possible THANK YOU