Sample In-Service

Training Module

Quality and Safety Policy

Introduction to ISO 9001-2008

ISO stands for the International Organization for
Standardization. It is an international standard for
Quality Management System (QMS) and is
recognized worldwide.
AKUH has been certified on ISO-based Quality
Management System since 1998. Our current
certification is on ISO 9001:2008 which was
achieved in 2009. Our next recertification is due in
May/June 2012.
Under ISO 9001:2008, following are the main
requirements:
Quality Management System
Management Responsibility
Resource Management

Introduction to JCIA
Joint Commission International Accreditation
Its mission is to improve the quality of health care
in the international community by providing
accreditation services
AKUH got JCI Accreditation in 2006 and was
reaccredited in 2009
Our next reaccreditation survey is due in Aug./Sep.
2012
In 2012, we will be surveyed against the 4th edition
of JCIA Standards for Hospitals.
JCIA Standards are grouped under 14 chapters with
315+ standards and 1020+ measureable elements

Division/Department Process
Approach Model

Environment of Care

Safety
Management

Utilities
Management

Fire Safety
Management
Security
Management

Patient-Care

Medical Equipment
Management

Emergency
Management

Hazardous
Materials & Waste
Management

FIRE SAFETY
MANAGEMENT

Fire Safety and Evacuation

In case of Fire incident, follow R.A.C.E.

Rescue
Alarm
Contain
Extinguish

Patients and others

Pull Fire Alarm and Dial 1600

Close doors and windows

If safe to do so, otherwise

Evacuate

To use a Fire Extinguisher, remember P.A.S.S.

Pull/Push
Pin/Clip
Aim
fire
Squeeze
Sweep

the Safety

the nozzle at the base of

the handle

from side to side

EMERGENCY
MANAGEMENT

Emergency Color Codes

Type Of Emergency
1. Disaster (Patient Influx)
2. Fire
3. Evacuation
4. Bomb Threat/Search

Color Code
Orange
Red
Green
Black

5. Nuclear/Chemical Contamination

Yellow
Blue

6. Cardiac Arrest/Medical Emergency

Pink

7. Infant/Child Abduction

Types of Emergencies
EXTERNAL
EMERGENCIES

INTERNAL
EMERGENCIES

Extremes of
Weather/Natural
Disaster

Fire

Terrorism/Bio-Terrorism
Fire

Loss of Environmental
Support
Loss of Medical Gases

Transport Accidents

Bomb
Threat/Explosion

Civil Disturbance

Acts of Terrorism/BioTerrorism

Hazardous Material
Release
Evacuation of

Natural Disaster
Strikes and Pickets

HAZARDOUS
MATERIALS
& WASTES
MANAGEMENT

Hazardous Materials & Waste

Never work with a chemical without first
understanding its hazards;
Always read chemical label and MSDS for
necessary information and follow safety
measures;
MSDS (Material Safety Data Sheet) provides
detailed chemical information;
Label gives pictorial and written brief
information;

Explosive Flammable

Toxic

Irritant

Corrosiv

Hazardous Materials & Waste

Always label secondary containers with
chemical name and its hazard.
Ensure spill kit are properly located
in the area, fully filled and staff
knows
how and when to use
these kits.
Ensure proper waste segregation at
source normal waste in
green liner and infectious waste in red liner.

Classification of Hospital

Non-medical
waste

(Domestic)

Medical
Waste

(Infectious)

SECURITY
MANAGEMENT

SMOKING IS PROHIBITED AT
AKU

AKU IS A WEAPON FREE

HOSPITAL

AKU HAS A ZERO TOLERANCE

POLICY ON WORKPLACE VIOLENCE

Code 10
(If patient becomes
violent)

Code 10
Alpha
(If visitor becomes violent)

Panic Alarm System

Panic Alarms are installed at around 42

inpatient and Cash Handling areas.
Panic Alarm Response Time is 3 minutes

Emergency Response Team

ERT Responding to Panic Alarm

Emergency Response Time is 3 minutes

How Can We Enhance Our

Security?
We must;
Keep our work areas secure.
Monitor access control in our work areas.
Safeguard our equipment.
Report all security emergencies, incidents,
suspicious activity or persons at EXT 1900
Wear our ID while at work.
Follow traffic and parking regulations.

Some Other Potential Topics

(where applicable)

Required Infection Control practices

Radiation safety
Medication safety and storage
Temperature monitoring of refrigerators
Any special hazards/risks in the area and related
protection.
Utilities and Medical Equipment management.