L1-09 HCAH Governance and Cultural Framework V2.1

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HEALTH CARE AT HOME INDIA PVT. LTD.

L1-09 HCAH GOVERNANCE AND CULTURAL FRAMEWORK V2.1
References
L3-03 SOP for Human Resource Operations
L3-06 SOP for Vendor Management
L4-09 Guidelines for Training Activities for Acute Care Unit
Employee feedback
Document Applicability - Internal to HCAH
Creation, Review and Approval Information

Review and Approval Table for L1-09 HCAH Governance and Cultural Framework V2.1
Created By: Neeti Nayak Created on Date: 10/05/2021
Name Signature Date
Clinical Excellence Clinical Excellence 12/05/2021
Reviewed by Head Head
(Dr.Sidharth Bawa) (Dr.Sidharth Bawa)
COO COO 12/05/2021
Approved by
(Dr. Gaurav Thukral) (Dr. Gaurav Thukral)
Version 2.1
Effective Date 14/05/2021
L1-09 HCAH Governance and Cultural Framework V2.1

Toll Free: 1800-102-4224 | E mail: wecare@hcah.in | Website: www.hcah.in
©Healthcare at Home-Restricted Circulation
Effective From: 14/05/2021
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Version Control
Change
Version Date Created by Reviewed by Approved by
Description
Quality Head COO (Dr Gaurav CEO (Vivek
1 07/08/2017 Initial Version
(Virag Shukla) Thukral) Srivastava)
COO (Dr Gaurav
Operating
Thukral)
Quality Head CEO (Vivek Procedure
2 04/06/2018 Finance
(Virag Shukla) Srivastava) reframed and
Controller
revised
(Alka Saxena)
Clinical COO
2.1 10/05/2021 AM-Quality & Excellence Head (Dr Gaurav Reviewed.
Audit (Dr.Sidharth Thukral) No changes made
(Neeti Nayak) Bawa)
Abbreviations List
Abbreviation Meaning
CAPA Corrective & Preventive Action Plan
COO Chief Operating Officer
CEO Chief Executive Officer
CET Clinical Evaluation Team
HCAH Healthcare at Home
HIC Hygiene and Infection Control
IA Internal Audit
KPI Key Performance Indicators
MRM Management Review Meeting
MSD Management System Document
NA Not Applicable
NOK Next of Kin
QMS Quality Management System
RACI Responsible, Accountable, Consulted, Informed
SOP Standard Operating Procedure

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Table of Contents
References............................................................................................................................................ 1
Document Applicability - Internal to HCAH ......................................................................................... 1
Creation, Review and Approval Information ....................................................................................... 1
Version Control .................................................................................................................................... 2
Abbreviations List ................................................................................................................................. 2
Objective .............................................................................................................................................. 4
Scope .................................................................................................................................................... 4
Measurement of Quality Indicators ................................................................................................... 10
HCAH Clinical Indicators ..................................................................................................................... 11
HCAH Managerial Indicators .............................................................................................................. 12
Other HCAH Indicators ....................................................................................................................... 13
Quality Improvement Program .......................................................................................................... 15
HCAH Cultural Framework ................................................................................................................. 18
Distribution List .................................................................................................................................. 20
All Business Function/Support function Heads .................................................................................. 20
Annexure ............................................................................................................................................ 20
L1-05-RF02 HIC Committee ................................................................................................................ 20
L0-03-RF02 HCAH Quality Committee ............................................................................................... 21
L1-11-RF01 HCAH Safety Committee ................................................................................................. 21
L2-23 Sexual Harassment Committee ................................................................................................ 22
HCAH Whistle Blower Committee...................................................................................................... 23
HCAH Disciplinary Committee............................................................................................................ 23
Policy on Ethical Management........................................................................................................... 23

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Objective
The purpose of this procedure is to define the overall governance model for HCAH functions. Also to
define the methods used to review the Quality System, that is in operation along with continual
suitability, adequately and effectively. The review shall include decisions related to continual
improvement opportunities and changes.
Scope
This procedure applies to all departments of the organization, Management Review Meetings and
associated documentation.
RACI
Responsible Business Function/Support function Heads
Accountable CEO, COO
Consulted Board of Directors, Partners, Market subject matter expert, Strategy and Legal
advisors
Informed All HCAH stakeholders

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HCAH Governance Framework
HCAH Organogram
The organization has a well-defined structure which clearly define the hierarchy, line of control, along
with the functions at various levels. The HCAH organogram is transparent and is disseminated to all the
stakeholders.
HCAH – Leadership Team Structure
Vivek Srivastava
CEO & CO-
Founder
Ankit Goel
Rolli Saxena Alka Saxena
Strategy & M&A
GM HR CFO
Head
ORGANIZATION CHART – CLINICAL SERVICES
CEO
Chief
Operating
Officer
(COO)
Manager - Head- Resourcing Team

Regional Director -
Business Central Mktg Leade-
Head Nursing
Initiatives Operations Manager Telesales r
Service Lab Customer

MIS Team CET -
Delivery Operations PPHC Team Service Unit Head Agents
Executive Leader Nursing
Team Team Manager
Customer Business Unit

Physio Physio Nursing
Service Agents Developme Operations HRBP
Trainer Manager Head
Agents nt Manager Manager
Homecare
Rehabilitati
Key Account Nursing Nursing
on
Manager Superviosr Trainers
Physiothera
pist
Patient Care Nursing

Nurses
Executive Assistant

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HCAH has a clear strategy and direction, which has been defined and derived, in accordance with the
market strategy by the board of HCAH. It helps in making quick and efficient decisions to adopt work
practices and allocating its resources (capital and people). HCAH has a defined mechanism to achieve
mission and vision by pursuing this strategy.
The organization has an effective governance framework in place to support the delivery of strategies/
plans to ensure the highest degree of service/ patient care. All the employees undergo mandatory
trainings required to perform the job in the most effective and efficient manner.
The organization has led down its vision, mission and values defined by the Head of the organization
and Senior Management.
The HCAH governing authority and the senior management approves the strategic and operational
plans and organization’s annual budget strategically allocating budget to each department and other
initiatives like Hand Hygiene, Infection Control, Waste Management and not limited to ensure patient
and staff safety. This budget prepared is reviewed annually to access the effectiveness of resource
allocation and to manage resource optimization.
HCAH defines its culture where in the vision and values are explained to all employees, encourage
openness, transparency and promote good quality care laying emphasis on the needs and experience
of people who use services.
HCAH quality management training ensures only to deploy staff who have the required skills,
knowledge, experience and insight of HCAH values to perform their jobs, these trainings are happening
both when they are appointed and on an ongoing basis. All staff appointed is made clear about their
roles and understand what they are accountable for through discussions and agreement of job
description.
HCAH Management understands the challenges and appreciate delivery of good quality care and
support relationships among staff. There exists a strong emphasis on promoting the safety and
wellbeing of staff, including those who work remotely or on their own.
Vision
HCAH will strive to be the most people- centric, credible and comprehensive home healthcare
solution provider in India.
Where in People Centricity means focus on needs, wants, beliefs and safety of customers and
employees.
Credibility means persuading both customer and employee that something good will happen.
And comprehensive means dealing with nearly all healthcare services and providing solution to all
healthcare needs.
Mission
• Creating service delivery model with ‘people-centricity’ at the core of it
• Delivering credible Clinical Outcomes, for every patient, every time
• Evolving an affordable, scalable, self-sustaining business model

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The governance framework of Health care at home, is based on the four values of quality and patient
safety for home health care to deliver good quality care: Trust, Empathy, Excellence & Care.
1.Trust
We operate with integrity, transparency, and accountability in all our business relationships.
2.Empathy
We believe in forming genuine bonds for an enriching, fulfilling experience for all.
3.Excellence
Achieving excellence is central to our ability for delivering superior results.
4.Care
We operate with integrity, transparency, and accountability in all our business relationships.
While creating the strategy, views of people, employee safety, patient safety, quality outcome, market
trend, financial information and legal aspects but not limited to of the business are taken into the
consideration to develop a fair and ethical framework for patient care. Views of HCAH resources are
also being gathered through various HCAH internal platforms like Jann Manch, Khul ke Bol, Mann ki
Bat, Employee Feedback.
By framing vision, mission and values, HCAH management provides a framework that ensures that
patient care is provided within business, financial, ethical, legal and cultural norms and that protects
patients and their rights.
For further elaboration refer to L2-25 Policy on Ethical Management.
Individual Behaviour and performance that is inconsistent with the vision, values and defined KPIs is
being analysed, appropriate mutually agreed time frame is being provided to improve the performance
and interpersonal skills. In case of no further improvement within/ after agreed time frame appropriate
actions are taken regardless of tenure, seniority or other discriminative factors. Refer L4-01 Guidelines
for Disciplinary Actions.
Responsibility and Accountability of HCAH employees

During the initial days of joining, all the employees mandatorily undergo organizational and
departmental induction with rigorous focus on HCAH Quality Management System (procedure, policy,
guidelines and framework). Induction training at HCAH includes organizational explanation and
understanding of vision, mission and values.
All employees, on the date of joining, are thoroughly explained about the job they will be performing.
Each role has a defined job description and they are made to understand and acknowledged the job
description on the very first day of joining.
Refer L3-03 SOP for HR Operations.

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All The impact of services on quality and sustainability should be considered when considering
developments of services
All HCAH Staff is clearly focused on continuous improvement of the quality of care. HCAH recognizes
and rewards improvements in delivery of quality care and innovation. All information is proactively
used to improve care and set examples for other staff. For elaborated description on Rewards and
Recognition refer to L2-22 Reward and Recognition.
Along with promoting vision and values HCAH also understand the value of both patient and staff
raising concerns and when concerns are raised, the same are being acknowledge within a defined time
frame and appropriate resolutions are also provide in timely manner. Refer to L3-26 SOP for Managing
Complaints V2 and L3-45 SOP for Grievance Redressal respectively.
Vendor Management
HCAH has written agreements in place with all its vendors and third-party provider with all their
detailed working arrangements.
Information Security Policy for supplier relationships
HCAH shall ensure service delivery rendered by service providers conforms to agreed specifications and
expected service levels.
There shall be two 2 categories of service providers:

• Category 1: Service Providers providing services from outside HCAH premises to facilitate
smooth operations of HCAH business.
• Category 2: Service Providers providing services by deputing their staff inside HCAH
premises to facilitate smooth operations of HCAH business.
For elaborated description on Vendor Management please refer to L3-06 SOP for Vendor
Management.
Management Review
Monthly management review happens in the first week of every month and all the senior leadership
team and department heads participate in the same. Challenges for quality care and best practices are
being identified and discussed during MRM. Appropriate actions are identified to fulfil the gaps.
Each Departmental Head has to prepare a Presentation on the status of the functioning of their
department. The Presentation will include: -
1. Status on the pointers of previous MRM

The Department Heads will represent the status of the pointers discussed in the previous MRM to the
Management quoting the outcomes.
2. Tasks and Activities performed during the month

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The MRM includes the representation of tasks and activities performed during the month. These tasks
and activities can be the outcome of the following: -
1. Internal Audit
2. External Audit & Certifications
3. Customer Feedback & Complaints
4. Change in System
5. Vendor/Supplier Assessment
6. Incident Reporting
This will also include the findings, CAPA, Action items, Evidences, Reports, Closures, Impact Analysis
and Benefits to the Organization.
3. Output of the MRM

Based on the presentation delivered by Departmental Heads, the Management undergoes discussion
and reviews all the inputs presented during MRM to strategies and ensure optimum delivery of good
quality care.
Typical outputs might include:

➢ Process improvement actions
➢ QMS improvement actions
➢ Service improvement actions
➢ Resource provision actions
➢ Revised business plans and budgets
➢ Changes to quality objectives and policies
➢ Management meeting minutes
Frequency of MRM
The Management will hold regular review meetings at appropriate intervals (monthly) to review and
improve the processes, inform staff of the effectiveness of the Quality System, review customer
feedback, carry out preventive action (risk analysis) communicate the organizations commitment to
meeting customers’ needs and ensure staff are familiar with the Department's Legal and Regulatory
obligations.
HCAH further have certain committees with defined objectives to review and evaluate organizational
policies and procedures which happen in a defined frequency with a pre-defined agenda focusing on
business, employee and patient needs.
A mail is floated by the convener regarding the meeting Minutes of the meeting to all the committee
members.
S. No Committee Name Committee Frequency

1 L1-05-RF02 HIC Committee Once in a quarter or as and when required

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2 L0-03-RF02 HCAH Quality Committee Once in a quarter or as and when required

3 L1-11-RF01 HCAH Safety Committee Once in a quarter or as and when required
4 L2-23 Sexual Harassment Committee As and when required
5 L2-24 Policy on Whistle Blower As and when required
6 L4-01 Disciplinary Committee As and when required
Committee members for all the committees is enclosed as annexure
Measurement of Quality Indicators

• Data is collected for a comprehensive set of Quality measures
a. To analyse and review the current performance
b. To Establish a baseline for a certain period which will be reference for future
comprehended.
c. To Identify areas for improvement
d. To Describe Process Quality stability
e. To Describe the dimensions of Quality relevant to functions, processes, and outcomes
f. To Determine whether changes in a process have met the agreed objectives
• Data is collected as a part of continual measurement, in addition to data collected for priority issues.
• Data collection considers measures of processes and outcomes.
• Data collection includes at least the following processes or outcomes:
a. Patient assessment
b. Processes related to Home care
c. Surveillance of Home acquired infection
d. Processes related to medical records content and availability
e. Processes related to timely delivery/availability of supplies/equipment
f. Reporting Incident
g. Satisfaction of patients and patient complaints
h. Employee satisfaction
i. Processes related to patient and staff safety
j. Training and training feedbacks
k. Call centre
1. Collected data is analysed at least monthly (or as and when required) and findings are
documented, and appropriate actions are being taken.
2. A pre-determined level of Quality, or threshold, which would trigger a more in-depth review,
is established for each Quality measure to assist in the assessment of the data collected. The
reference used may include the following:
a. Internal comparisons of the process and outcomes with defined intervals (week over
week, month over month, quarter over quarter).
b. Comparison of data with industry benchmark (if required).

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3. The assessment process may include basic data analysis principles or use of statistical process
control techniques/tools as appropriate. Training for use of basic data analysis principles/
statistical process control is provided to the concerned staff where needed; team
members/staff are educated regarding basic data analysis principles/statistical process control
techniques on an ‘as needed’ basis.
4. When assessment of data indicates significant variation, root cause analysis is being conducted
for the variation and appropriate actions are being taken.
5. There is an established Clinical Evaluation Team for audit of patient care services. Team
evaluates/Audits patients all medical/clinical records, with respect to HCAH policies,
procedures, formats of HCAH.
6. All audits are documented & required actions to be taken are documented, implemented and
measured in the next audit cycle.
7. The Quality Improvement Program is reviewed & opportunities for improvements are
identified and updated.
HCAH Clinical Indicators
S.No Indicator Operational Definition Unit of Measure
1 Medication Errors
Total number of errors/ the sum of
Medication Administration
1.1 number of doses + number of Percentage
error
omission x 100
Total number of Transcription
Medication Transcription
1.2 errors/ Total number of Percentage
error
transcriptionx100
Healthcare associated
2
infection
Incident of Central line

Total number of CLABSI / Total
2.1 related blood stream Rate
number of central line days x1000
infection
Catheter related UTI urinary

tract infections (+ ve culture
Total number of CAUTI / Total
2.2 report/ Symptoms Rate
number of Catheter days x 1000
developed during our
service)

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Incident of Ventilator
Total number of VAP / Total
2.3 associated pneumonia Rate
number of ventilator days x1000
(VAP)
Total number of fall/Total number

3 Incidence of Patient fall Rate
of patient days x1000
4 Needle stick injury to staff Total number of NSI Number
5 Pressure Ulcers
Total number of new bedsore

Incident of New bedsore
5.1 /Total number of patient days in Rate
developed
one month x1000
Total number of worsened cases/

Incident of Worsening of
5.2 Total number of bedsore patient Rate
bedsore
days x1000
Number of Patient
6 Unplanned Readmission Readmitted/Total number of Percentage
Admissions during the monthx100
Incidents of burns during No. of incidents of Burns/ total No

7 Percentage
physio Services of Visitsx100
8 Adverse events Number
9 Sentinel events Number
Number of deaths/ total number of

10 Mortality rate Percentage
patients x100
HCAH Managerial Indicators:

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S.No. Indicator / Metric Indicator Type Operational Definition Unit of Measure
1 HR
No. of employee left in a
Managerial month/ Average of Opening &
1.1 Attrition Rate Percentage
Indicator Closing Headcount of a
month*100
Training Managerial No of Trainings completed/No
1.2 Percentage
Compliance Indicator of Trainings Planned
Number of failed BGV/ Total
Managerial
1.3 BGV number of employees in the Percentage
Indicator
month x100
Number of employees did not
Managerial attend BLS x total number of
1.4 BLS compliance Percentage
Indicator employees joined in the
monthx100
Average Customer
Managerial Average of Talktime+Wrap up
2 Handling Time Time
Indicator time
(ACHT)
Incidence of
Managerial Number of incidence/ total
2.1 compromise on Percentage
Indicator number of visits x100
staff safety
Total number of missing

Managerial
2.2 Missing documents documents/ Total number of Percentage
Indicator
documents x100
For elaborated description on Clinical and Managerial Indicators please refer to L0-03-RF01 HCAH
Quality Indicators.
Other HCAH Indicators

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Analysis
Indicator Type Owner Reviewer Frequency Timelines
Responsibility
Physiotherapy Last Quality Team
Clinical: CET
Head working by 3rd working
Indicators Physiotherapy Monthly
Nursing day of the day
Outcomes CET Nursing
Director month Management
Last to Review the
Service same
Central Ops – working
Operational Delivery Monthly
MIS Executive day of the
Manager
month
Last
Customer Quality working
Quality Head Monthly
Satisfaction Manager day of the
month
Last
Employee working
HR Manager HR Head Monthly
Feedback day of the
month
Last
working
Attrition HR Manager HR Head Monthly
day of the
month
Physiotherapy Last
CET
Head working
Faulty Equipment’s Physiotherapy Monthly
Nursing day of the
CET Nursing
Director month
Physiotherapy Last
CET
Employee Head working
Physiotherapy Monthly
Accidents Nursing day of the
CET Nursing
Director month
Last
Training working
Training HR Head Monthly
Manager day of the
month
Last
Quality working
Call Centre Quality Head Monthly
Manager day of the
month

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Quality:
Last
Committee
Quality working
Meetings, Quality Head Monthly
Manager day of the
Drill,
month
Internal Audits
Quality Improvement Program Applicable HCAH Wide

Key Characteristics Particulars Methodology
Setting Goal and Objective Setting Mission, Vision, HCAH has define organization
Quality Policy and Quality objective which they have to review
Objective by Quality annually to achieve state Mission
Assurance Committee
• HCAH Objective
There is organization manpower
Manpower planning done by HR department
When there is requirement of any

equipment and updating of equipment
will be done by the concerned
Equipment
Unit(Operations). All the units also
ensure regular checking of equipment.
Infrastructure
Physical facilities of the patient home

will be assessed at the time of initial
assessment and maintenance of the
Physical Facility same will be ensured by the patient
side as per the need of patient and staff
safety practices.
Policy, Standard Operating For improvement and All the Policy, Standard Operating
Procedures, Frameworks, Templates, maintenance of the system, Process, Manual, forms, Registers,
Guidelines, Manual, forms, Registers, different level documents Files, Checklists and Protocols are as
Files, Checklists and Protocols have been prepared per SOP ON MSD.
• Organization level
• Department / BU
level
Compliance is monitored, and non-
Clinical audits conformity is tracked once a month
Compliance Monitoring Unit audits (through various Audits), and
Call quality Audit appropriate corrective and preventive
actions are being taken.

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Clinical Quality measures are reviewed

Department wise Quality
by CET and nonclinical by the
Quality Indicators Indicators were identified to
concerned department
improve the system
Different types of training to training is organized at regular

be conducted to update the intervals which include training need
Training and Development knowledge outcome of staff assessment and assessment of Trainer
• Organization level as well employees
• Individual level
Feedbacks during the HCAH Feedbacks are being gathered during
Services the HCAH Services and at the end of
Feedback at the end of HCAH HCAH Services and basis that
Services appropriate actions are being taken.
Customer Feedback and Complaints Customer Also, there is a provision for all the
Grievance/Concerns patients to raise their concerns 24*7,
the same are being resolved by
relevant team and communicated back
to the patients
For elaborated description on HCAH Quality Improvement programme please refer to L0-03 Continual
Quality Improvement Program
Quality & Safety Budget Forecast for 2018-19

Annual Individual
Sl. No. Cost Head Applicability Count Frequency
Cost Cost
Employees Immunization Cost - All clinical Staff-
1 25000 100 250 1
pre-prophylaxis (Hepatitis B) Delhi Unit
Employees Immunization Cost -
All clinical Staff -
post exposure prophylaxis
Delhi Unit-
2 (Medical Expense – Lab Test, 15000 3000 5 1
Forecast for 2%
Medicine, Hospital visit, Doctor
of clinical Staff
Consultation)
Training and Awareness on HIC
All clinical Staff-
3 Safe Injection practices & 125000 500 250 1
Delhi Unit
Infection Control Training
Cost of Consumables (Used for
HIC) Delhi Unit -
4 600000 50000 1 12
covering all
Disposable catheters,

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Bed Pans, PPEs, Acute Care

hand wash liquids and hand Patients
rubs
Chemicals for equipment
decontamination
Cost for Color coding plastic
bags and bags to carry bio
medical waste
Resource Cost - Infection
5 Delhi Unit 420000 35,000 1 12
Control Nurse
Delhi Unit -
Resource Cost for Collecting covering all
6 360000 20,000 1.5 12
Waste from Patient Homes Acute Care
Patients
BMW Management Vendor
7 Delhi Unit 336000 28000 1 12
Cost
8 BMW License Cost Delhi Unit 30000 30000 1 1
Cost of Treatment for minor
accidents "First Aid" (not
All HCAH Field
covered through
Staff-Delhi Unit -
9 Mediclaim/ESIC) - other than 10000 2000 5 1
Forecast for 2%
post exposure prophylaxis
of clinical Staff
(During service hours or while
commuting to work place)
Quality & Audit
10 Quality Team Cost 6500000
Staff
Delhi Unit and
11 Accreditation Cost 500000
BSC Noida
Delhi Unit and
12 24 Response App Cost 144000 30 400 12
BSC Noida
Delhi Unit and
13 E-Mitra Cost 432000 90 400 12
BSC Noida
Safety Training Cost-Fire & Self Delhi Unit and
14 100000
Defence BSC Noida
Delhi Unit and
15 Employee Safety-Pepper Spray 48000 200 200 1.2
BSC Noida
Forecasted Quality & Safety
Budget Forecast for 2018-19- 9645000
HCAH

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HCAH Cultural Framework
Providing patient-centered care is the priority for HCAH. The culture of HCAH is centered on the needs
and experience of people who use HCAH services. There are several mechanisms to understand and
gather the experience of HCAH Customers like courtesy call, Post Package Feedback Call and Audit
Visits. One of the objectives of HCAH Business Strategy is to emphasis on patient as well as employee
safety. Culture of HCAH promotes the safety and wellbeing of staff and patient. The same message is
being trickle down from the top management and board to all who are directly or indirectly involved in
patient care. The single objective of HCAH resources is to deliver good quality care. To deliver good
quality care, all HCAH resources work together and proactively discuss & collaborate these discussions
to resolve conflict and provide uniform way of patient care.
Under the strategic plan, the province will strive to deliver health care as a service built around the
individual, not the provider and administrator. This is not an overnight change, but a promise of a
sustained focus that will drive policy, service design, training, service delivery, and service
accountability systems.
This framework for patient-centered care is intended to build on existing efforts and accelerate the
adoption of patient-centered care practices in HCAH by creating a common understanding of what
patient-centered care is and a shared vision for adopting patient-centered care.
Patient-centered care puts patients at the forefront of their health and care, ensures they retain control
over their own choices, helps them make informed decisions and supports a partnership between
individuals, families, and health care service providers. Teams should work collaboratively, resolve
conflict quickly and constructively and share responsibility to deliver good quality care.
Patients, families and caregivers are partners in health care, supported and encouraged to participate
in:
• their own care;
• decision-making about that care;
• choosing their level of participation in decision-making;
• quality improvement; and,
• health care redesign.
HCAH will pursue patient-centered care with a vision for achieving a health care system in which:
• The patient`s voice is anchored in all behaviors and drives all activities of the health system.
• A culture of patient-centeredness is self-evident across the health system and is integrated into
existing health care programs.
• Health care programming is built upon the patient-centered care principles throughout
planning, implementation, and evaluation.

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Four core principles for patient-centered care will provide a foundation for the pursuit of patient-
centered care:
1. Dignity and Respect: This principle speaks to the need for active listening to patients and families
and to honoring their choices and decisions. This is done through incorporating the patients and
family’s values, beliefs and cultural norms into care plans and care delivery.
2. Information Sharing: Participative communication of accurate, valid, reliable, timely and relevant
data with patient and families on what decisions are to be made and validating with the patients and
families what they have heard and understood, is the basis of this principle. This leads to supporting an
informed decision by the patients and families.
3. Participation: Patients and families are encouraged and supported in participating in care and
informed decision making at the level at which they feel comfortable and of their own choice. The
spectrum of engagement range is informed, consult, involve, collaborate and empower.
4. Collaboration: Patients and families are provided meaningful opportunities to engage with care
providers and leaders in the continuum of quality improvement, policy and program development,
implementation and evaluation. This includes the potential for patient/family engagement in health
care facility design, health care system redesign, professional education and the delivery of care.
PATIENT-CENTERED CARE PRACTICES
Four patient-centered care practices are presented in this framework to help guide health care
organizations in the pursuit of patient-centered care.
1. Organization Wide Engagement Support for patient-centered care principles should be

demonstrated by an organization’s leadership through both words and actions. At the same time,
health care providers should demonstrate support for patient-centered care principles at the patient
care level, pushing up in a true partnership with leadership.
2. Workplace Culture Renewal Health care providers and staff have a very important role in developing
a culture of patient centered care. A culture of patient-centered care requires a shift in thinking from
a ‘medical model’ of care (providing information, guidance and expert decision making) to a model of
care where the patient is a partner in making care decisions. HCAH has built a culture where in health
care provider feels that they have the support of the organization to engage in patient-centered care
activities. Health care providers need to have education and clinical opportunities for patient-centered
care principles to become part of their day to day work.
3. Balanced Patient-Provider Relationships In the patient-provider relationship, patients are in the

position of needing help and providers have the knowledge and experience needed by their patients.
This creates a natural power imbalance between patients and providers that requires conscious effort

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to overcome. Providers should be supported to shift their values, attitudes and behaviors to make
patients true partners in the process of making care decisions.
4. Tool Development The pursuit of patient-centered care will be supported by the development of
tools to assist the organization in putting the needs of patients and families at the center of care. This
includes planning, delivering and evaluating programs and services with the voice of the patient at the
center.
This framework provides a consistent definition and approach for patient-centered care and employees
to be used in Healthcare at Home. It is the responsibility of all partners in the health care system to
embrace the patient-centered care approach and act to achieve the vision. Culture shifts take time,
and often change is gradual. By embracing this framework, HCAH will take a significant step forward in
achieving a culture change that will benefit patients/NOK and Employees.
Distribution List
All Business Function/Support function Heads
Annexure
• L0-03-RF01 HCAH Quality Indicators.

• L1-05-RF02 HIC Committee
• L0-03-RF02 HCAH Quality Committee
• L1-11-RF01 HCAH Safety Committee
• L2-23 Sexual Harassment Committee
• L2-24 Policy on Whistle Blower
• L4-01 Guidelines for Disciplinary Action
• L2-25 Policy on Ethical Management
• L3-03-RF17 Engagement Initiative and Process Flow
• L1-09-RF01 HCAH Annual Operating Plan V1
L1-05-RF02 HIC Committee
Members Role
Director Nursing Chairperson
Infection Control Officer Convener
Infection Control Nurse Member
Head of Physiotherapy Member
Head of Quality Department Member
CET representative (Nursing & Physiotherapy) Member

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Critinext coordinator Member

Physiotherapy Training Manager Member
Nursing Training Manager Member
Members of clinical Quality Member
Nursing Head Member
Nursing Supervisor Member
Nursing Trainer Member
Physio: Regional Physio Manager Member
Physio Trainer Member
Unit Operations Member
L0-03-RF02 HCAH Quality Committee
Members Role
COO Chairperson
Head of Quality Convener
Director Nursing Member
Finance Controller Member
Critinext coordinator Member
Regional Physiotherapy Manager Member
Members of Quality & Audit Team Member
Unit Head Member
Nursing Head Member
Unit Operations Representative Member
Human Resource Business Partner(Unit) Member
L1-11-RF01 HCAH Safety Committee
Members Role
COO Chairperson

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Head of the Human Resource Department Convener

Director Nursing Member
Head of Quality Department Member
Members of Central Training Team & Central HR Member
Operations
Unit Operations Representative Member
Unit Head Member
Nursing Head & Regional Physio Manager Member
Human Resource Business Partner(Unit) Member
Escalation level Authority
L2- Immediate Manager/ HR 23
1st Level
Skip Level Manager/ Functional Head
2nd Level
Complaints Committee
Chairperson: - Ms.Alka Saxena
Members: -
• Dr. Gaurav Thukral
• Ms. Rolli Saxena Awasthi
3rd Level
• Ms. Punitha Singh
• Ashish Kumar
Third Party/ NGO Member:
• Mr. Nikhil Gupta
4th Level CEO

Sexual Harassment Committee

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HCAH Whistle Blower Committee
Members Role
COO Member
Physiotherapy Head Member
Human Resource Head Member
HCAH Disciplinary Committee
Members Role
COO Member
Physiotherapy Head Member
Human Resource Head Member
Quality Head Member
Policy on Ethical Management

What Are Ethics?

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Ethics are statements of what is right or wrong…or what ought to be. They are derived from values and
beliefs of society and help to govern behavior, and thus protect human rights. Ethics and the law are
sometimes closely aligned.
What is an Ethical Dilemma?

An ethical dilemma is a situation that requires an individual to make a choice between two equally
unfavorable choices. You might say that in an ethical dilemma, there is no right answer.
How HCAH Care Provide Deals during situations of Ethical Dilemma?

The following are some key concepts to keep in mind when dealing with ethical dilemmas. These
concepts can help when looking at a difficult situation from different perspectives and help the home
health care worker make an ethically sound decision. Keep in mind that at times, conflicts will be
unavoidable.
1. Autonomy…The basis for this statement is that a patient has the right to make his/her own decisions
about health care choices. If a patient is not able to make decisions and he/she has designated another
person to make decisions for him/her, that person can make health care decisions for him/her.
2. Justice…We are required to be fair to all people. All patients have the right to be treated fairly.
3. Doing good (also called Beneficence) …This means we do what is “good” for that patient/family.
Sometimes it is easy to know what “good” is and sometimes it is not.
4. Do no harm (also called Nonmaleficence) …This means that the health care worker must always be
careful and know what is needed for that person. Good hand washing and prevention of infection fall
into the category of doing no harm. Safety and preventing falls means doing no harm. Knowing and
following the patient’s plan of care will also prevent doing harm. Also, listening to the patient and
family’s concerns are essential
5. Be truthful…This means always being honest. The health care worker is required to be truthful with
the family and the supervisor. This doesn’t mean telling everything you know; it means telling the truth.
6. Respect…This means the health care worker is always required to show respect for the patient, the
family, the environment, for their co-workers, their supervisors, and all others as well.
Typical Ethical Dilemmas in Homecare:

• Conflicts between physicians' orders, and patients' family/NOK choices/preferences
• Conflicts between Care Plan activities and Patients/ NOK’s directives
• Patient’s denial to accept or follow care provider’s instructions
Homecare professional providing self-management support are at risk of facing mostly three types of
ethical dilemmas:
1. Respecting patient autonomy versus reaching optimal health outcomes

2. Respecting patient autonomy versus stimulating patient involvement
3. A holistic approach to self-management support versus safeguarding professional boundaries.

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Any service not landing in the scope of HCAH, HCAH denies taking up the services and informs the
customer regarding the same immediately.
The patient has the right to refuse treatment exceptions to this are made in case of minors or those
cases where the patient is incapable of exercising judgment and appreciation of the consequences of
their actions. Other exceptions are in cases where the law restricts this right. The patient and / or NOK
needs to accept the consequences for his/her actions and the outcomes of those actions if he/she
refuses treatment or does not follow the agreed care plan, HCAH will never force the patient to take
the services if the patient/ NOK denies to it and services will be discontinued.
HCAH is also sensitized towards patient opinion and works accordingly and provides patient’s the right
to terminate the service upon dissatisfaction with prior notice. If the patient wants to discontinue with
HCAH services and takes a transfer to another healthcare facility, HCAH will support the patient
decision and will help in smooth patient transfer and shall provide a complete patient discharge
summary to ensure there is a continuity to the patient care without any hinderance.
Refer L2-14 Policy on Patient rights and responsibilities (see the annexure).
HCAH has a platform wherein the patient has the right to file a complaint regarding services, this
platform is introduced to the patient on welcome call and is entitled to information regarding the
HCAH’s mechanism for the initiation, review and resolution of such complaints within a defined
timeframe.
The HCAH professionals deliver services within an ethical framework to protect patients’ rights and
their professional relationships with patients to deliver the highest degree of care. The organization
operates within the following outlines of ethical framework:
• The organization discloses its ownership – Healthcare at Home India Pvt. Ltd.
• The organization honestly portrays its scope of services.
• The documented HCAH policy on Patient rights and responsibilities states that the
confidentiality of patient information is protected.
• There is a non-discriminative access of all patients to avail HCAH services irrespective of any
cultural, religious, caste and socioeconomic status.
• HCAH has documented clear policies on patient’s onboarding, discharge and transfer of
patients & Care Plans are created, basis patient’s conditions and proactively discussed with
patient / NOK.
• Frequency based courtesy calls are made to patient / NOK to get an update on care / listen the
voice of customer proactively. Overall services feedback is also gathered, analyzed and action
taken through post package feedback calls.
• Audits are conducted at patient home, any gaps witnessed are addressed.
• The HCAH appropriately supports the environment that allows free discussion of ethical
concerns. The HCAH ensures nondiscrimination in employment practices and provision of
patient care in context to cultural practices.

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• Patients are informed of their rights and responsibilities during the care process by means of
necessary brochures.
• Patients are informed at all stages of care about personnel responsible, treatment plans,
activities, facilities and services available and responsibilities of the patient and family.
• Patient complaints and grievances are handled with compassion. The same are analyzed and
corrective and preventive actions are taken.


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