TEST EVALUATION Neelam Rani LCH- SUSHMA-05 DEEPKALA-06 NIKHIL KUMAR LH-07 LH-08 LH-09 LH-10 LH-11 LH-12

DEEPKALA-06 NIKHIL KUMAR LH-07 LH-08 LH-09 LH-10 LH-11 LH-12 LH-13 LAKHAN LH-14 LH-15 SHARWAN KUMAT LH-16 LH-17 KAVITA LH-18 ANU RANI LH-19 LH-20 ANURADHA LH - 21 KAMALJEET KAUR LH-22 RAVINDER KUMAR LH-23 LH-24 LH-25 LH-26 LH-27 LH-28 LH-29 RENU GARUVA LH-30 LH-31 LH-32 LH-33 BABALJEET SINGH LH-34 MEENA SHARMA LH-35 LH-36 PAWAN KUMAR LH-37 SUMAN LH-38 MAMTA LH-39 LH-40 LH-41 LH-42 LH-43 KULDEEP SINGH GNM BALRAM LH-44 LH-45 LH-46

Sr. No. DATE TOPICS P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome
1 4/1/2023 File and formats Documentation (MRD) A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED P 5 9 IMPROVED A 0 0 - A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
2 4/3/2023 Admission and discharge criteria of Patients in ICU. P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - IMPROVED P 6 8 IMPROVED P 5 7 IMPROVED IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED IMPROVED P 6 8 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
Usages of different types of Personal Protective 0 0 - 0 0 - 8 9 IMPROVED 0 0 - 0 0 - 5 9 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - IMPROVED 0 0 - 0 0 - IMPROVED 8 9 IMPROVED 0 0 - 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED 0 0 - 0 0 - IMPROVED 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
4/4/2023 A A P A A P A A A A A A A A A P A A A A A
3 Equipments
Induction Policy and Employees Rights and 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 8 IMPROVED 0 0 - IMPROVED 0 0 - 0 0 - IMPROVED 0 0 - 6 8 IMPROVED 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED 0 0 - 0 0 - IMPROVED 8 8 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
4/5/2023 A A A A P 6 A A A P 6 A A P 6 A A A A P A A A P
4 Responsibilities.
8 IMPROVED 8 IMPROVED 0 0 - 8 IMPROVED 0 0 - 0 0 - 7 8 IMPROVED 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - IMPROVED 8 IMPROVED 0 0 - IMPROVED 0 0 - 0 0 - 8 8 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED 8 8 IMPROVED 8 8 IMPROVED IMPROVED 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
4/7/2023 Spill Management (Major or Minor) as per HK policy. P 6 P 6 A P 6 A A P A A A P 6 A A P 6 A A A P P P A
5
6 4/10/2023 Patient's Complaints and soft skills P 8 8 IMPROVED A 0 0 - P 7 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - A 0 0 - A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
Nursing care plan and monitoring of patients & Situations 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 6 8 IMPROVED 0 0 - 0 0 - 8 IMPROVED IMPROVED 0 0 - 6 8 IMPROVED IMPROVED 0 0 - 0 0 - 6 8 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED 6 8 IMPROVED 6 8 IMPROVED IMPROVED 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
4/11/2023 A A P A A A A P 7 A P A A P 7 A P A A P P P A
7 of close monitoring
4/12/2023 CPR A 0 0 - P 8 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - IMPROVED P 8 8 IMPROVED A 0 0 - IMPROVED A 0 0 - P 5 7 IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED P 6 7 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
8
9 4/14/2023 Emergency Codes in Hospital A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - P 5 7 IMPROVED A 0 0 - P 6 9 IMPROVED P 8 8 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - P 5 7 IMPROVED P 8 8 IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED P 8 8 IMPROVED P 8 8 IMPROVED IMPROVED P 7 7 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
10 4/17/2023 Effective commnucation of staff P 6 7 IMPROVED P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - IMPROVED P 6 8 IMPROVED P 5 7 IMPROVED IMPROVED P 4 10 IMPROVED A 0 0 - A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
7 7 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - IMPROVED 0 0 - 0 0 - IMPROVED 0 0 - 7 IMPROVED 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED 0 0 - 0 0 - IMPROVED 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
4/18/2023 Linen and Laundary Management & BMW management. P A A A A A P 6 A A A A A A A A A P 5 A A A A
11
Patient's satisfaction and IPD feedback form and their 0 0 - 8 8 IMPROVED 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 0 0 - 5 9 IMPROVED 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 5 9 IMPROVED IMPROVED 8 8 IMPROVED 0 0 - IMPROVED 0 0 - 0 0 - 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED 0 0 - 0 0 - IMPROVED 6 9 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
4/20/2023 A P A P A A A P A A P A P P A A A A A A P
12 importance for quality improvements.
13 4/21/2023 Concent forms A 0 0 - A 0 0 - P 7 8 IMPROVED A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - A 0 0 - P 6 7 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED P 6 7 IMPROVED P 6 7 IMPROVED IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
14 4/25/2023 Risks inside the hospital P 6 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - A 0 0 - A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED P 7 7 IMPROVED P 7 7 IMPROVED IMPROVED P 8 9 IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
15 4/27/2023 ADR and Needle Stick Injury P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 9 9 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - IMPROVED A 0 0 - P 6 8 IMPROVED IMPROVED A 0 0 - A 0 0 - A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
16 4/28/2023 MLC Cases documents A 0 0 - P 6 7 IMPROVED P 6 9 IMPROVED P 6 7 IMPROVED A 0 0 - A 0 0 - A 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 7 IMPROVED A 0 0 - A 0 0 - IMPROVED P 6 7 IMPROVED A 0 0 - IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED A 0 0 - A 0 0 - IMPROVED A 0 0 - IMPROVED IMPROVED IMPROVED IMPROVED IMPROVED
17 5/1/2023 Patient's admission and discharge procedure A 0 0 - P 7 7 IMPROVED A 0 0 - P 7 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 7 7 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 9 IMPROVED P 6 9 IMPROVED A 0 0 -
Hand hygiene and 6 types of hand washing + Surgical 8 IMPROVED 0 0 - 6 8 IMPROVED 0 0 - 0 0 - 0 0 - 5 9 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 6 8 IMPROVED
5/2/2023 P 6 A P A A A P A A A A A A A A A A A A A P
18 hands scrub with signage.
Usages of different types of Personal Protective 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 7 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 7 IMPROVED 0 0 - 7 IMPROVED 0 0 - 8 9 IMPROVED 8 9 IMPROVED 7 7 IMPROVED
5/4/2023 A A A A A P 7 A A A P 5 A A A A P 5 A P 5 A P P P
19 Equipments
20 5/6/2023 Oral Care and Back Care A 0 0 - P 6 9 IMPROVED A 0 0 - P 6 9 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - P 8 9 IMPROVED P 8 8 IMPROVED A 0 0 - P 6 9 IMPROVED P 8 8 IMPROVED P 8 9 IMPROVED P 6 9 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
21 5/9/2023 Soft skills and Patient's counselling. P 8 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 -
0 0 - 6 8 IMPROVED 0 0 - 6 8 IMPROVED 6 8 IMPROVED 6 8 IMPROVED 0 0 - 0 0 - 6 8 IMPROVED 0 0 - 6 8 IMPROVED 6 8 IMPROVED 0 0 - 6 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 6 9 IMPROVED
5/10/2023 Spill Management (Major or Minor) as per HK policy. A P A P P P A A P A P P A P A A A A A A P
22
Scope of service, Outsourced Services of Hospital and list 7 IMPROVED 0 0 - 4 9 IMPROVED 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 6 8 IMPROVED 0 0 - 6 8 IMPROVED 0 0 -
5/12/2023 P 5 A P A A A P 6 A A A A A A A A A A A P A P A
23 of services not provided by Hospital.
24 5/13/2023 Types of Emergency Codes in Hospitals. A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 7 8 IMPROVED P 8 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED P 7 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 5 7 IMPROVED P 5 7 IMPROVED P 7 7 IMPROVED P 6 9 IMPROVED P 7 7 IMPROVED P 6 8 IMPROVED
Induction Policy and Employees Rights and 0 0 - 0 0 - 5 10 IMPROVED 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -
5/16/2023 A A P A A P 6 A A A A A A A A A A A A A A A A
25 Responsibilities.
26 5/17/2023 Discipline in Nursing and Handover of Pt. A 0 0 - A 0 0 - A 0 0 - P 5 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 9 IMPROVED A 0 0 - A 0 0 - P 5 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 -
27 5/19/2023 Ryles tube feeding procedure. A 0 0 - P 6 8 IMPROVED P 5 9 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - P 6 9 IMPROVED A 0 0 -
28 5/22/2023 Surgical Dressing P 5 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED P 5 7 IMPROVED P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 -
29 5/25/2023 Cleaning and disinfection policy A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED
30 5/27/2023 Emergency Procedures A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 -
31 5/29/2023 ICU Equipments usages A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED
32 6/2/2023 Induction Training P 4 10 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 7 9 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - P 4 10 IMPROVED A 0 0 -
33 6/3/2023 Patient's admission and discharge procedure A 0 0 - P 8 8 IMPROVED P 7 7 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
Hospital committees and their function and committee 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 7 IMPROVED 0 0 - 0 0 - 7 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 6 7 IMPROVED 0 0 - 0 0 - 0 0 - 6 7 IMPROVED 0 0 - 0 0 - 6 8 IMPROVED
6/5/2023 A A A A A A P 7 A P 5 A A P 5 A A A A A P A A A P A A P
34 members
Hand hygiene and 6 types of hand washing + Surgical 0 0 - 6 8 IMPROVED 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 9 IMPROVED 8 9 IMPROVED 8 9 IMPROVED 7 7 IMPROVED 6 7 IMPROVED 0 0 - 0 0 -
6/7/2023 A P A A P A A A A A A A A A A A A A P P P P P A A
35 hands scrub with signage.
36 6/10/2023 File and formats Documentation (MRD) P 6 9 IMPROVED A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - P 8 8 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - P 7 8 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - P 5 7 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED P 8 8 IMPROVED P 8 8 IMPROVED A 0 0 - P 7 7 IMPROVED P 6 9 IMPROVED A 0 0 -
Usages of different types of Personal Protective 0 0 - 8 8 IMPROVED 8 IMPROVED 0 0 - 0 0 - 0 0 - 6 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 5 9 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 7 IMPROVED
6/12/2023 A P P 7 A A A P A A A A A A A A A P A A A A A A A P 5
37 Equipments
38 6/14/2023 Admission and discharge criteria of Patients in ICU. A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 -
39 6/16/2023 Oral Care and Back Care A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - P 6 8 IMPROVED
40 6/19/2023 Soft skills and Patient's counselling. A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 7 IMPROVED P 6 7 IMPROVED P 6 7 IMPROVED P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 -
41 6/20/2023 Grievances Redressal Policy A 0 0 - P 6 8 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 IMPROVED P 7 7 IMPROVED A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 -
8 IMPROVED 0 0 - 0 0 - 8 IMPROVED 0 0 - 7 IMPROVED 0 0 - 0 0 - 8 IMPROVED 0 0 - 8 IMPROVED 8 IMPROVED 0 0 - 8 IMPROVED 0 0 - 8 IMPROVED 8 IMPROVED 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 7 IMPROVED
6/23/2023 Spill Management (Major or Minor) as per HK policy. P 6 A A P 7 A P 5 A A P 6 A P 7 P 6 A P 7 A P 7 P 6 P 6 A A A A A P 6 P 5
42
Scope of service, Outsourced Services of Hospital and list 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -
6/24/2023 A A A A A A P A A A A A A A A A A A A A A A A A A A
43 of services not provided by Hospital.
44 6/29/2023 Types of Emergency Codes in Hospitals. P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 7 8 IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - P 7 8 IMPROVED P 8 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 6 9 IMPROVED P 6 9 IMPROVED P 6 9 IMPROVED P 6 9 IMPROVED P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 -
45 7/1/2023 Importance of documents in Hospitals A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 4 10 IMPROVED P 7 8 IMPROVED P 6 8 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 -
46 7/3/2023 Quality indicators A 0 0 - A 0 0 - A 0 0 - P 4 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 4 9 IMPROVED A 0 0 - A 0 0 - P 4 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 -
47 7/5/2023 Needle stick injury, accidental body splash P 6 8 IMPROVED P 8 8 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - P 6 8 IMPROVED P 7 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 7 8 IMPROVED A 0 0 - P 5 7 IMPROVED P 5 7 IMPROVED P 5 9 IMPROVED P 7 7 IMPROVED P 7 7 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED
Drug Formulary, look alike and sound alike drugs, 0 0 - 0 0 - 0 0 - 5 10 IMPROVED 8 8 IMPROVED 0 0 - 0 0 - 6 9 IMPROVED 0 0 - 0 0 - 5 10 IMPROVED 0 0 - 6 9 IMPROVED 5 10 IMPROVED 0 0 - 5 10 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 0 0 - 0 0 0 6 9 IMPROVED 0 0 - 0 0 - 0 0 -
7/7/2023 emergency drugs, high risk drugs and do not crush drug A A A P P A A P A A P A P P A P A A A A A 0 A P A A A
48 list and their usage.
49 7/8/2023 Self assessment of medicine A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 -
50 7/10/2023 Hospital safety policy P 8 8 IMPROVED A 0 0 - A 0 0 - P 5 9 IMPROVED A 0 0 - P 7 9 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 5 9 IMPROVED A 0 0 - P 6 8 IMPROVED P 5 9 IMPROVED A 0 0 - P 5 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 5 9 IMPROVED A 0 0 - P 5 9 IMPROVED P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED P 5 7 IMPROVED
51 7/12/2023 Types of Consent forms and their importance A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 4 10 IMPROVED A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 -
52 7/14/2023 How to prevent infection in Hospital P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 7 IMPROVED A 0 0 - P 7 7 IMPROVED P 6 9 IMPROVED P 5 7 IMPROVED P 5 9 IMPROVED A 0 0 - P 5 7 IMPROVED P 6 9 IMPROVED A 0 0 - P 5 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 -
53 7/17/2023 Hand hygiene and its practices A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 -
54 7/19/2023 Patients rights and responsibilities P 8 8 IMPROVED A 0 0 - P 7 8 IMPROVED A 0 0 - P 6 8 IMPROVED P 4 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 -
55 7/21/2023 Usages of PPE in hospital premises A 0 0 - P 6 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED P 8 8 IMPROVED P 6 9 IMPROVED P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 4 10 IMPROVED A 0 0 - P 6 8 IMPROVED
56 7/25/2023 Discipline in nursing P 6 9 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 -
57 7/27/2023 Patient's nursing assessment A 0 0 - A 0 0 - A 0 0 - P 4 10 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED P 4 10 IMPROVED P 6 8 IMPROVED A 0 0 - P 4 10 IMPROVED P 6 8 IMPROVED P 4 10 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 -
58 7/29/2023 Crash card trolley usage and importance & code blue P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 9 IMPROVED A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 -
0 0 - 0 0 - 9 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 8 IMPROVED 9 IMPROVED 0 0 - 6 8 IMPROVED
8/1/2023 Departwise quality indicators and data collection system A A P 7 A A A A P 6 A A A A P 6 A A A A A A A A A P P 6 A P
59
60 8/3/2023 Grivences readdressal policy A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED P 5 7 IMPROVED P 6 9 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
61 8/5/2023 Medication administration P 8 8 IMPROVED A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 -
62 8/7/2023 Infection control mechanisms P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED P 6 8 IMPROVED P 5 7 IMPROVED A 0 0 - P 6 8 IMPROVED P 8 8 IMPROVED A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED P 6 8 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 -
63 8/8/2023 Scope of the imaging services in hospital P 6 8 IMPROVED P 6 8 IMPROVED P 4 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED P 8 8 IMPROVED P 8 8 IMPROVED A 0 0 - P 7 7 IMPROVED A 0 0 - P 6 7 IMPROVED A 0 0 - P 6 8 IMPROVED P 5 7 IMPROVED
64 8/10/2023 Moderate sedation A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - P 8 8 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 -
65 8/12/2023 Paediatric patients assessment A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 -
66 8/14/2023 Lab Safety Policy P 8 8 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 5 7 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 4 9 IMPROVED P 6 8 IMPROVED P 4 9 IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED P 5 7 IMPROVED
67 8/16/2023 Risk inside the hospital A 0 0 - A 0 0 - P 6 9 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - P 6 8 IMPROVED P 5 7 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED P 8 8 IMPROVED P 5 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 -
68 8/18/2023 Induction training P 5 7 IMPROVED P 6 8 IMPROVED A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED P 5 10 IMPROVED A 0 0 - A 0 0 - P 8 9 IMPROVED P 7 8 IMPROVED P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 5 10 IMPROVED A 0 0 - P 5 10 IMPROVED A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 -
69 8/21/2023 Fumigation and sterlization process A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 -
Usage and maintenance of Multi para monitor, Ventilator 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 8 8 IMPROVED 5 9 IMPROVED 0 0 - 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 -
8/23/2023 A P A A P 6 A A A A P P A A A P A A A A P 5 9 IMPROVED A P 5 9 IMPROVED A P 6 A A
70 and defibrillator
Medical safety data sheet and their usage and importance 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 9 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 8 9 IMPROVED 0 0 - 0 0 - 0 0 - 6 7 IMPROVED 6 7 IMPROVED 10 IMPROVED 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 6 8 IMPROVED
8/26/2023 A A A A A A A P A A A A P A A A P P P 4 A 0 0 - A A 0 0 - P A A P
71 (Chemical safety)
72 8/28/2023 What is the aim of quality indicator A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
NABH Sensitization Training and Knowing NABH 5 9 IMPROVED 0 0 - 8 IMPROVED 4 8 IMPROVED 8 8 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 5 9 IMPROVED 0 0 - 0 0 - 0 0 - 4 8 IMPROVED 5 9 IMPROVED 4 8 IMPROVED 0 0 - 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 8 8 IMPROVED 0 0 - 8 8 IMPROVED 5 9 IMPROVED 0 0 -
9/1/2023 P A P 6 P P A A A A P A A A P P P A A A P A P A P P A
73 Standards
74 9/2/2023 Patient's admission and discharge procedure A 0 0 - P 6 7 IMPROVED P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 5 7 IMPROVED
75 9/4/2023 Nursing care plan and monitoring of patients A 0 0 - P 7 7 IMPROVED A 0 0 - P 7 10 IMPROVED P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 7 10 IMPROVED A 0 0 - A 0 0 - P 6 9 IMPROVED P 6 9 IMPROVED P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 -
76 9/6/2023 Hospital Ambulance and transportation policy. A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED
77 9/7/2023 The radiation safety programme P 4 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED P 5 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 4 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED P 4 10 IMPROVED A 0 0 -
78 9/9/2023 Use of blood and blood products A 0 0 - P 6 9 IMPROVED A 0 0 - P 6 9 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED P 8 8 IMPROVED P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED P 6 8 IMPROVED P 6 9 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
79 9/11/2023 Emergency codes A 0 0 - A 0 0 - P 7 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED P 6 9 IMPROVED A 0 0 - P 5 7 IMPROVED
80 9/13/2023 Hand hygiene A 0 0 - P 6 8 IMPROVED P 7 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 4 9 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
81 9/15/2023 Behavoiural training P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 9 IMPROVED A 0 0 -
82 9/18/2023 MRD records maintenance A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 10 IMPROVED P 5 10 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - P 4 10 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 0 A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
 LH-47 LH-48 LH-49

P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome
IMPROVED IMPROVED IMPROVED IMPROVED
IMPROVED IMPROVED IMPROVED IMPROVED
IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED
IMPROVED IMPROVED IMPROVED IMPROVED
IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED

IMPROVED IMPROVED IMPROVED IMPROVED
IMPROVED IMPROVED IMPROVED IMPROVED
IMPROVED IMPROVED IMPROVED IMPROVED
 TEST EVALUATION VIKASH KUMAR LH - 24 JAPAN LH - 47 POOJA - 11 JITENDER SINGH - 11 MOHIT - 10 RAMANDEEP - 28 SOURABH KUMAR LH - 48 HARMESH SINGH LH - 45 YOGENDER LH - 37

Sr. No. DATE TOPICS P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome
14 5/22/2023 Cleaning and disinfection policy A - - - A - - - A - - - A 0 0 - P 5 7 IMPROVED P 9 10 IMPROVED A - - - P 7 8 IMPROVED A 0 0 -
15 5/29/2023 Linen and Laundary Management & BMW management. P 7 8 IMPROVED P 7 8 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED A 0 0 - A 0 0 -
16 5/30/2023 Near miss and sentinel events A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - P 8 8 IMPROVED A 0 0 -
17 6/3/2023 Importance of documents in Hospitals A - - - A - - - A - - - P 6 8 IMPROVED A 0 0 - A 0 0 - A - - - A 0 0 - P 6 8 IMPROVED
18 6/5/2023 Discharge process and billing A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
19 6/7/2023 Quality indicators A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - P 5 7 IMPROVED A 0 0 -
Adverse Events (No Harm, Near Miss, Sentinel Events & incident - - - - - - - - - 0 0 - 8 IMPROVED 0 0 - - - - 0 0 - 0 0 -
20 A A A A P 7 A A A A
6/11/2023 monitoring System)
21 6/16/2023 Hospital safety policy P 5 8 IMPROVED P 6 7 IMPROVED P 6 7 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - P 5 8 IMPROVED P 8 8 IMPROVED P 6 8 IMPROVED
22 6/17/2023 Performance apprisals system A - - - A - - - A - - - A 0 0 - P 8 8 IMPROVED P 8 8 IMPROVED A - - - A 0 0 - A 0 0 -
23 6/20/2023 How to prevent infection in Hospital A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
24 6/23/2023 Patients rights and responsibilities A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - P 7 8 IMPROVED
25 7/1/2023 Importance of documents in Hospitals A - - - A - - - A - - - P 5 7 IMPROVED P 5 7 IMPROVED A 0 0 - A - - - P 7 8 IMPROVED P 7 8 IMPROVED
26 7/3/2023 Quality indicators A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
27 7/8/2023 Self assessment of medicine A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - P 8 8 IMPROVED A 0 0 -
28 7/10/2023 Hospital safety policy A - - - A - - - A - - - P 5 7 IMPROVED A 0 0 - A 0 0 - A - - - A 0 0 - P 7 9 IMPROVED
29 7/12/2023 Types of Consent forms and their importance A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
30 7/14/2023 How to prevent infection in Hospital P 7 8 IMPROVED P 7 8 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED P 5 9 IMPROVED A 0 0 -
31 7/17/2023 Hand hygiene and its practices A - - - A - - - A - - - A 0 0 - P 7 8 IMPROVED P 8 8 IMPROVED A - - - A 0 0 - A 0 0 -
32 7/19/2023 Patients rights and responsibilities A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
33 7/21/2023 Usages of PPE in hospital premises P 5 7 IMPROVED P 5 7 IMPROVED P 5 7 IMPROVED P 6 8 IMPROVED P 8 8 IMPROVED P 8 9 IMPROVED P 5 7 IMPROVED A 0 0 - P 6 8 IMPROVED
34 7/25/2023 Discipline in nursing A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
35 7/27/2023 Patient's nursing assessment A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - P 6 8 IMPROVED A 0 0 -
36 8/1/2023 Departwise quality indicators and data collection system A - - - A - - - A - - - A 0 0 - P 5 9 IMPROVED A 0 0 - A - - - A 0 0 - A 0 0 -
37 8/3/2023 Grivences readdressal policy A - - - P 8 8 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - P 7 8 IMPROVED
38 8/5/2023 Medication administration A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - P 8 9 IMPROVED A 0 0 -
39 8/7/2023 Infection control mechanisms A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
40 8/8/2023 Scope of the imaging services in hospital A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - P 5 7 IMPROVED A 0 0 -
41 8/18/2023 Induction training P 7 9 IMPROVED P 7 9 IMPROVED P 7 9 IMPROVED P 5 7 IMPROVED P 6 8 IMPROVED P 8 9 IMPROVED P 7 9 IMPROVED A 0 0 - P 5 7 IMPROVED
42 8/21/2023 Fumigation and sterlization process A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A 0 0 - A 0 0 -
Medical safety data sheet and their usage and importance (Chemical - - - - - - - - - 0 0 - 0 0 - 0 0 - - - - 0 0 - 0 0 -
43 8/26/2023 A A A A A A A A A
safety)
44 8/28/2023 What is the aim of quality indicator A - - - A - - - A - - - A 0 0 - P 8 9 IMPROVED A 0 0 - A - - - A 0 0 - A 0 0 -
45 8/31/2023 6 Internaltion patient safety goals (IPSG goals) P 6 7 IMPROVED P 6 7 IMPROVED P 6 7 IMPROVED P 6 7 IMPROVED A 0 0 - A 0 0 - P 6 7 IMPROVED A 0 0 - P 6 8 IMPROVED
46 9/1/2023 NABH Sensitization Training and Knowing NABH Standards A - - - A - - - A - - - A 0 0 - P 5 7 IMPROVED P 8 9 IMPROVED A - - - P 7 8 IMPROVED A 0 0 -
47 9/2/2023 Patient's admission and discharge procedure A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A - - - A 0 0 -
48 9/6/2023 Hospital Ambulance and transportation policy. A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A - - - A 0 0 -
49 9/11/2023 Emergency codes P 6 9 IMPROVED A - - - A - - - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED P 6 9 IMPROVED A 0 0 -
50 9/13/2023 Hand hygiene A - - - P 7 8 IMPROVED P 5 7 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - A - - - A - - - P 5 8 IMPROVED
51 9/15/2023 Behavoiural training A - - - A - - - A - - - A 0 0 - A 0 0 - A 0 0 - A - - - A - - - A 0 0 -
52 9/18/2023 MRD records maintenance A - - - A - - - A - - - A 0 0 - P 7 8 IMPROVED P 8 10 IMPROVED A - - - A - - - A 0 0 -
 TEST EVALUATION DR RAJENDRA SINGH LAMBA DOC-1 DR AKSHAY LAMBA DOC-2 DR SAT BHUSHAN JAIN DOC-03 DR RAHUL DUHAN DOC-6 DR NANCY SAHARAN DOC-7 DR VATANVEER DOC-8 DR POONAM DOC-10

Sr. No. DATE TOPICS P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome P/A Pre-Score Post-Score Outcome
11 4/18/2023 Linen and Laundary Management & BMW management. P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
Patient's satisfaction and IPD feedback form and their importance for 0 0 - 10 IMPROVED 0 0 - 0 0 - 7 10 IMPROVED 0 0 - 0 0 - 0 0 - 5 9 IMPROVED
4/20/2023 A P 9 A A P A A A P
12 quality improvements.
13 4/21/2023 Concent forms A 0 0 - A 0 0 - P 9 10 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 -
14 4/25/2023 Risks inside the hospital P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 -
15 4/27/2023 ADR and Needle Stick Injury P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 9 9 IMPROVED A 0 0 -
16 4/28/2023 MLC Cases documents A 0 0 - P 10 10 IMPROVED A 0 0 - P 6 9 IMPROVED P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
17 5/1/2023 Patient's admission and discharge procedure A 0 0 - A 0 0 - P 10 10 IMPROVED A 0 0 - P 8 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED
Hand hygiene and 6 types of hand washing + Surgical hands scrub with 9 10 IMPROVED 0 0 - 0 0 - 6 8 IMPROVED 0 0 - 0 0 - 0 0 - 8 9 IMPROVED 0 0 -
5/2/2023 P A A P A A A P A
18 signage.
19 5/4/2023 Usages of different types of Personal Protective Equipments A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED A 0 0 - A 0 0 -
20 5/6/2023 Oral Care and Back Care A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - P 9 10 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - P 8 9 IMPROVED
21 5/9/2023 Soft skills and Patient's counselling. A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
22 5/10/2023 Spill Management (Major or Minor) as per HK policy. A 0 0 - P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 -
Scope of service, Outsourced Services of Hospital and list of services 10 IMPROVED 0 0 - 10 IMPROVED 4 9 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -
5/12/2023 P 8 A P 10 P A A A A A
23 not provided by Hospital.
24 5/13/2023 Types of Emergency Codes in Hospitals. A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 7 8 IMPROVED
25 5/16/2023 Induction Policy and Employees Rights and Responsibilities. A 0 0 - A 0 0 - A 0 0 - P 5 10 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 -
26 5/17/2023 Discipline in Nursing and Handover of Pt. A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
27 5/19/2023 Ryles tube feeding procedure. A 0 0 - P 10 10 IMPROVED P 10 10 IMPROVED P 5 9 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 -
28 5/22/2023 Surgical Dressing P 8 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED P 9 10 IMPROVED P 6 9 IMPROVED
29 5/25/2023 Cleaning and disinfection policy A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
30 5/27/2023 Emergency Procedures A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED
31 5/29/2023 ICU Equipments usages A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED
32 6/2/2023 Induction Training A 0 0 - A 0 0 - P 10 10 IMPROVED P 6 8 IMPROVED A 0 0 - P 7 9 IMPROVED P 7 8 IMPROVED A 0 0 - A 0 0 -
33 6/3/2023 Patient's admission and discharge procedure A 0 0 - P 10 10 IMPROVED A 0 0 - P 7 7 IMPROVED A 0 0 - P 8 8 IMPROVED A 0 0 - A 0 0 - P 8 8 IMPROVED
34 6/5/2023 Hospital committees and their function and committee members A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
Hand hygiene and 6 types of hand washing + Surgical hands scrub with 0 0 - 10 IMPROVED 0 0 - 0 0 - 0 0 - 8 8 IMPROVED 0 0 - 0 0 - 0 0 -
6/7/2023 A P 10 A A A P A A A
35 signage.
36 6/10/2023 File and formats Documentation (MRD) P 8 10 IMPROVED A 0 0 - P 10 10 IMPROVED A 0 0 - P 9 10 IMPROVED A 0 0 - P 8 8 IMPROVED P 9 10 IMPROVED A 0 0 -
37 6/12/2023 Usages of different types of Personal Protective Equipments A 0 0 - P 10 10 IMPROVED A 0 0 - P 7 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 10 10 IMPROVED A 0 0 -
38 6/14/2023 Admission and discharge criteria of Patients in ICU. A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
39 6/16/2023 Oral Care and Back Care A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 7 7 IMPROVED
40 6/19/2023 Soft skills and Patient's counselling. P 8 10 IMPROVED A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - P 8 9 IMPROVED
41 6/20/2023 Grievances Redressal Policy A 0 0 - P 9 10 IMPROVED P 10 10 IMPROVED P 8 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
42 6/23/2023 Spill Management (Major or Minor) as per HK policy. A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - P 5 7 IMPROVED A 0 0 - A 0 0 -
Scope of service, Outsourced Services of Hospital and list of services 9 10 IMPROVED 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 -
6/24/2023 P A A A A A A A A
43 not provided by Hospital.
44 6/29/2023 Types of Emergency Codes in Hospitals. A 0 0 - P 10 10 IMPROVED A 0 0 - A 0 0 - P 8 10 IMPROVED A 0 0 - P 6 8 IMPROVED A 0 0 - P 7 8 IMPROVED
45 7/1/2023 Importance of documents in Hospitals A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 4 10 IMPROVED P 7 8 IMPROVED A 0 0 - P 7 7 IMPROVED
46 7/3/2023 Quality indicators A 0 0 - A 0 0 - P 10 10 IMPROVED A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
47 7/5/2023 Needle stick injury, accidental body splash P 8 10 IMPROVED A 0 0 - P 9 10 IMPROVED P 5 7 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
Drug Formulary, look alike and sound alike drugs, emergency drugs, 0 0 - 0 0 - 0 0 - 0 0 - 9 10 IMPROVED 0 0 - 0 0 - 0 0 - 6 9 IMPROVED
7/7/2023 A A A A P A A A P
48 high risk drugs and do not crush drug list and their usage.
49 7/8/2023 Self assessment of medicine A 0 0 - P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
50 7/10/2023 Hospital safety policy A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - P 7 9 IMPROVED A 0 0 - P 6 8 IMPROVED
51 7/12/2023 Types of Consent forms and their importance P 9 10 IMPROVED P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
52 7/14/2023 How to prevent infection in Hospital A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 7 IMPROVED A 0 0 - P 8 9 IMPROVED P 6 9 IMPROVED
53 7/17/2023 Hand hygiene and its practices A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
54 7/19/2023 Patients rights and responsibilities A 0 0 - A 0 0 - A 0 0 - P 7 8 IMPROVED A 0 0 - P 6 8 IMPROVED P 4 10 IMPROVED A 0 0 - A 0 0 -
55 7/21/2023 Usages of PPE in hospital premises A 0 0 - P 9 10 IMPROVED P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
56 7/25/2023 Discipline in nursing A 0 0 - P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
57 7/27/2023 Patient's nursing assessment P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
58 7/29/2023 Crash card trolley usage and importance & code blue A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED P 6 9 IMPROVED A 0 0 - P 7 7 IMPROVED
59 8/1/2023 Departwise quality indicators and data collection system A 0 0 - A 0 0 - A 0 0 - P 7 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED
60 8/3/2023 Grivences readdressal policy A 0 0 - P 9 10 IMPROVED P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
61 8/5/2023 Medication administration P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
62 8/7/2023 Infection control mechanisms A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED
63 8/8/2023 Scope of the imaging services in hospital A 0 0 - A 0 0 - A 0 0 - P 4 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
64 8/10/2023 Moderate sedation A 0 0 - A 0 0 - P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 6 8 IMPROVED
65 8/12/2023 Paediatric patients assessment A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 -
66 8/14/2023 Lab Safety Policy A 0 0 - P 10 10 IMPROVED P 10 10 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - P 9 10 IMPROVED P 8 8 IMPROVED
67 8/16/2023 Risk inside the hospital A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED P 9 10 IMPROVED P 6 8 IMPROVED A 0 0 - A 0 0 - A 0 0 -
68 8/18/2023 Induction training A 0 0 - P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
69 8/21/2023 Fumigation and sterlization process P 8 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 9 9 IMPROVED A 0 0 -
Usage and maintenance of Multi para monitor, Ventilator and 0 0 - 10 IMPROVED 10 0 0 - 0 0 - 8 IMPROVED 0 0 - 0 0 - 0 0 -
8/23/2023 A P 10 P 9 IMPROVED A A P 6 A A A
70 defibrillator
Medical safety data sheet and their usage and importance (Chemical 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 0 0 - 8 9 IMPROVED
8/26/2023 A A A A A A A A P
71 safety)
72 8/28/2023 What is the aim of quality indicator P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 8 IMPROVED A 0 0 - A 0 0 -
73 9/1/2023 NABH Sensitization Training and Knowing NABH Standards A 0 0 - A 0 0 - P 10 10 IMPROVED P 6 8 IMPROVED P 9 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 -
74 9/2/2023 Patient's admission and discharge procedure A 0 0 - P 10 10 IMPROVED A 0 0 - P 8 9 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED
75 9/4/2023 Nursing care plan and monitoring of patients P 8 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 9 10 IMPROVED P 6 8 IMPROVED A 0 0 - P 10 10 IMPROVED A 0 0 -
76 9/6/2023 Hospital Ambulance and transportation policy. A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
77 9/7/2023 The radiation safety programme A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 8 IMPROVED P 5 7 IMPROVED P 8 9 IMPROVED A 0 0 -
78 9/9/2023 Use of blood and blood products A 0 0 - P 10 10 IMPROVED A 0 0 - A 0 0 - P 9 9 IMPROVED P 7 7 IMPROVED A 0 0 - A 0 0 - P 6 8 IMPROVED
79 9/11/2023 Emergency codes A 0 0 - A 0 0 - A 0 0 - P 7 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 -
80 9/13/2023 Hand hygiene P 9 10 IMPROVED P 10 10 IMPROVED P 10 10 IMPROVED P 7 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - P 8 9 IMPROVED A 0 0 -
81 9/15/2023 Behavoiural training A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 6 9 IMPROVED A 0 0 - A 0 0 - A 0 0 -
82 9/18/2023 MRD records maintenance P 10 10 IMPROVED A 0 0 - A 0 0 - A 0 0 - A 0 0 - A 0 0 - P 8 10 IMPROVED A 0 0 - A 0 0 -