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POLICY
 Continuous quality improvement program shall be implemented by Quality
Improvement Committee Team.
 The quality improvement programme shall be supported by the Hospital management.
 The quality improvement program is documented in the form of quality improvement
manual.
 The program shall be comprehensive & covers all the major elements related to
quality improvement & risk management. (Refer quality improvement manual)
 The NABH co-ordinator & quality team shall be responsible for coordinating &
implementing the quality improvement program
 There shall be a continuous training mechanism to communicate & coordinate the
designated program among the employees.
 Monitoring shall be done by quality control team through physical checks, data
analysis, and random sample checks.
 There shall be an established system for audit of patient care services (Refer
Annexure III: Quality improvement manual).
 Sentinel events shall be clearly defined & intensively analyzed.
 The quality improvement program is reviewed at predefined intervals and
opportunities for improvement are identified. The quality improvement programme is
a continuous process and updated at least once in year.

RESPONSIBILITY
Quality Improvement Committee/ Hospital Safety Committee

PROCEDURE
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Key Performance indicators

 The organization identifies key indicators to monitor the clinical structures,
managerial structures, processes and outcomes which are used as tools for continual
improvement. Clinical indicators and key performance indicators are one way of
evaluating services. Indicators allow a broad overview of performance over time.
 Indicators used for continual improvement in our hospital (Refer Annexure II:
Quality improvement manual )

Continual Improvement
Continual improvement of the hospital services is achieved through
 Conformance to quality objectives.
 Setting up of measurable objectives & indicators at functional level and their periodic
review
 Analysis
 Timely and effective corrective and preventive actions.
 Management Review.
 The quality improvement programme is comprehensive and covers all the major
elements related to the quality improvement and risk management.
 Proper training need to be provided to all employees on quality objectives, indicators
& how to capture the data in divisions & organizational level
 The quality improvement programme is continuous process and updated at least once
in a year.
 The quality improvement programme should be reviewed every three months by the
quality improvement committee team and the scope for further improvement should
be sought.
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 The quality improvement programme is analyzed every year and newer ideas and
strategies are incorporated with the aim of attaining excellence in quality health care.

Corrective and preventive Action

 Various corrective actions taken is reviewed in the Quality Improvement meeting and
recorded.
 Preventive actions are documented and monitored for the effective implementation
and are reviewed in management review meetings.
 A review of the Quality improvement is carried out by core committee, as required
The purpose of the Quality improvement Meeting is to ensure that the documented
Quality System remains effective and is revised where necessary to reflect the changes in the
Organization’s operations, and that the purpose of having a Quality policy and related
objectives is being accomplished. The review committee is empowered to take action, as felt
appropriate. The review is as per a fixed agenda, with flexibility to discuss any other matter
pertaining to the performance of the Quality improvement program.
Review Inputs
 The inputs to the Quality Improvement Meeting are the data required to substantiate
the agenda points, generated from the different operation records
Review Outputs
 The output of the Management Review Meetings are the minutes of the meetings,
which systematically describes the proceedings of the meeting, decisions,
Responsibility assigned to whom, target date and status.
 The responsibility for convening the Review Meeting and compiling the inputs for the
review rests with the Medical Superintendent. The fixed agenda for the review will
cover the following topics. The relevant points pertaining to the proceedings of the
meeting are recorded.
o Review of the minutes of the previous Meeting.
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o Review of the current status of processes vis-à-vis quality objectives.

o Internal Audit/Clinical audit Records
o Training Records
o Review of changes in the Organization which could affect the Quality
improvement and ongoing suitability of policy and objectives
o Feed back
o Recommendations for improvement.
o Any other point brought to the notice of the Committee

The quality improvement programme is supported by the Management.

1. The hospital has got adequate resources in terms of man, machine, money and
material. Each process has got defined procedure and the same has been effectively
implemented.
2. Improvement of quality is an important agenda for the hospital management.
Adequate funds are set aside by the Finance department for this purpose at the time of
annual budgeting. The hospital has earmarked adequate resources for the quality
programme and clearance has been obtained from the Finance department.
3. The requirements of the quality control team for upgrading the various services are
taken into account. The priority areas are identified and fund allotment is done
accordingly.
a. The Management is responsible for the implementation and maintenance of
quality improvement programme
b. The Management is responsible for and has the authority for ensuring the
establishment, implementation and maintenance of quality improvement
programme in addition to his regular / routine responsibilities.
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c. The Representative of the Management shall appraise Management about the

status of quality improvement program in the organization periodically and shall
provide the required information for the Management Review.
d. A structured training program has been implemented by the individual
departments and a system has been adopted to monitor the effectiveness of
training.

Incidents, complaints and feedback are collected and analysed to ensure continual
quality improvement
 The organization has an incident reporting system which includes identification,
reporting, review and action on incidents. The type of incidents is clearly defined and if
any incident happens incident report form (refer form RCC/MRD/37) is filled and should
be submitted to immediate supervisor and forwarded to the medical superintendent before
the staff leaving the duty. This should be analysed in Quality improvement committee
meetings and appropriate preventive and corrective action taken.
 The organization has a process to collect feedback and receive complaints. If the patient
is not satisfied with any aspect of the hospital service:
 They should contact the Medical superintendent or PRO and put in the complaint directly
or demand for the complaints book available at the reception counter and note the
complaints in the book. They could also write down the complaints in the feedback
questionnaire available in the hospital
 Complaints will be immediately looked into and appropriate action will be taken
 The patients have a right to express their satisfaction about the services rendered by the
hospital. Feedbacks from the patients regarding the services provided by this hospital will
in the long term help the management to know about the good aspects and the
deficiencies in the services provided and thereby help to take corrective actions.
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 The Public Relations Officer (PRO) of this hospital can be contacted by the patient to
convey the feed back in person or for help in filling up the provided feedback form
 This should be analysed in Quality improvement committee meetings and appropriate
preventive and corrective action taken.
 Positive as well as negative feedback about care and service is also communicated to the
staff.