Quality Improvement

Home Quality Improvement

Quality may be defined as consistent delivery of a product or service according to expected standards. Quality of health care, according to WHO is the “level of attainment of health systems’ intrinsic goals for health improvement and responsiveness to legitimate expectations of the population” .

In the case of a hospital quality improvement, this translates into doing right things to the right people at the right time and doing things right, first time. This also brings in different levels of experience and satisfaction to patients, visitors and our staff members.

We firmly believe that quality is not an accident and as an NABH accredited hospital, we are committed to achieve international standards of healthcare through a Continuous Quality Improvement (CQI) program in our structure, process and outcomes. Through this program, we strive to deliver the most advanced medical knowledge and practices to our patients, while treating them with empathy, respect and concern.

Our quality culture and methodology

Our hospital has a total quality culture summed up as “Changing hearts, Minds and Attitudes”. We emphasize on continual improvement in all our processes that involve patient care. The importance of hospital quality improvement is well understood and supported by our top management and the entire organization is part of the quality improvement journey.

We ensure employee participation through quality circles. It implies the development of skills, capabilities, confidence and creativity of the people through cumulative process of education, training, work experience and participation. A process centric approach is used for quality assurance and “measure first” is our policy.

How we strive to achieve Continuous Hospital Quality Improvement?

Infection Control
One of our key clinical priorities is to protect our patients, visitors and staff from the risk of healthcare-associated infections caused by bacteria (germs). We actively tackle healthcare-associated infections, which are infections acquired in hospital or as a result of treatment.
Our Infection Control Team works closely with the board of directors, managers and healthcare workers to minimise the infection risk to patients and other persons who visit our facilities.
All hospital staff undergo regular training on infection prevention and control. We carry out weekly audits to check compliance with our strict hand hygiene policies and ensure that all our employees are vaccinated for Hepatitis B.
We regularly collate information on rates of antibiotic-resistant infections in each ward and department, and we use this data to modify our procedures to improve the ratings.

Hand Hygiene
• The best way to prevent infection from spreading is good hand hygiene practice.
• Awareness campaigns are planned with posters and signs displayed in the premises to urge patients and visitors to follow the best practices.
• Staff members have to clean their hands with liquid soap and water or alcohol hand rub as per the WHO guidelines before and after they come into contact with patients and their environment, regardless of whether or not the patients have infections.
• There are alcohol dispensers at the foot of all beds, in addition to the entrance to every bay and ward.
• Training sessions for all staff and scheduled audits are regularly performed to monitor the implementation of our hand hygiene policy.
• We have 87% compliance to our accepted hand hygiene practice.

Environment Cleaning
EMC ensures a clean and safe environment for patients, their families, visitors and staff in the hospital. The Housekeeping department is fully equipped to implement the policies set by the management related to the cleanliness of the patient visiting areas and the hospital premises.
Intravenous Line care
We follow the WHO guidelines for intravenous line care for our patients and the set parameters are strictly followed by the concerned hospital staff and documented.

Use of Clinical Practices, Guidelines and protocols
Guidelines as per NABH protocols are followed for usage and care of intravascular devices, catheters and in the usage of other such invasive devices. Care of equipment, linen disinfection, air conditioning for operating rooms and CCUs as well as management of blood spills and needle stick injuries is done according to International protocols. We also have an established waste management policy and lab safety program.

Patient Safety
Our patient safety policies are formulated to protect the health and well being during your stay in the hospital. We also ensure to safeguard other possible risks such as medication errors, falls, pressure ulcers and needle stick injuries during the course of your treatment.

Education & Training
All new staff members joining the hospital are taken through a well-structured hospital hospital quality improvement induction program before they join active duty. Spread over three days, the program includes classroom training and audio-visual presentations by key persons from the management and operational streams. Apart from their respective professional skills, the areas covered during the induction program include practical application of soft skills such as personality development, communication skills and interaction with the patients and their family as per the hospital policies. Through these sessions we ensure to inculcate the mission, vision and the values of the hospital to the new joiners to enable them provide quality service to our patients.

Staff education and training activities in EMC is an on-going process where refresher training programs are conducted for all staff on a routine basis, as necessary.

Audits & Review
We believe that anything that is not measured cannot be improved.
We constantly measure the hospital quality improvement Indicator parameters set for all the operating units on a daily, weekly or monthly basis through a process of scheduled audits. Some of the major audits conducted include Internal audit, Clinical audit, Patient Safety audit, Nursing audit and Facility audit. The analysis of the audit results help us to review our existing processes and/or implement any course correction measures, if required.