The table below provides a Department / Service wise effectiveness of ISO certification at the Sadar Hospital, Ara

S. Pre ISO Process Status No Post ISO Process Status Repairing of building, white washing, repairing of roofs, changing of window glasses done.

The physical structure of the building within the premises of the hospital was in poor state. Walls are Cracked and broken with water Seepage begin a common feature. In addition doors and windows were broken.

No Information was displayed regarding the services available, their location maps etc. No signage boards were available inside in the hospital.

Information regarding services available, Doctors Name, Citizen Charter etc installed.

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

3 4

Privacy of female patients was a serious concern as there was no isolation frames present. In absence of any particular dress code, it was difficult to demarcate the patients from others staffs.

Screens are placed in the wards as well as female OPD for the privacy. Dress Code introduced. All the support staffs will be given the uniform. At present only OT staffs are provided with the uniform.

5 6

Only one nursing station was available for Medical as well as surgical ward. There was no Matron or any in-charge for the IPD/Maternity ward. The management is done by the duty nursing staff as per the directions of the Deputy medical superintendent

Separate nursing station has been made for the surgical ward. Although the day to day activities are managed by the duty staff an in charge is appointed for all the wards. Following materials are provided to OT: 1. 2. 3. 4. 5. 6. Electrical autoclaves Fumigation Machine Boyels Apparatus UPS for interrupted power supply. Greaser for hot water Aqua Guard for drinking water.

Operation Theatre was grossly inadequate in terms of equipments and infrastructure. No safety measures taken by personnel while performing procedures. No additional space for preparation and pre operative room, with all the preparation and preoperative procedures was done on the OT table itself.

The condition of the operation theatres is pathetic with immediate action required to improve the services.

Apart from these separate sterilization room, Pre / Post operative room available. OT schedule prepared and all the requisite records are documented like anesthesia record, sterilization record, fumigation

There for scheduling operations is done informally, and nothing is documented. The instruments are autoclaved in the oil fired autoclaves.

record, OT record. Protective gears

Segregation of waste is not done as per BMW Management Rule.

BMW colour coded bins, bags are procured and proper segregation of waste started in the hospital.

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

9 10

There is no standard medical record keeping system in the hospital. Only copies of bed head tickets, discharge summaries are maintained. Syringe and needle are kept open in the hospital. There has been no training for the staff to acquaint them about safe handling of BMW waste and its disposal.

Records are being maintained as per the standard formats manual. Proper treatment of used needles / syringes started. They are deep buried after the use.

11

Basic facilities are not available in the hospital for public conveniences. The following are not available Public telephone Adequate chairs, fans, lights.

Basic facilities are made available like Public telephone booth (outside OPD) Fans, lights are installed for proper illumination and fresh air. Five seater chairs are installed. Sitting arrangement increased to 100.

12

Drinking water facilities No mechanism exists for obtaining patients feedback

on hospital services

Feedback is being taken from OPD & IPD patients. Feedback is being analyzed and proper action is being taken on the weak areas.

13

There is no signage system available in the hospital.

Signage are put in the hospital for different buildings / units / wards / offices etc. Directional signage are installed.

14

15

There is no enquiry counter in the hospital for providing information to the patient for various services. Patient has to stand in the queue and gets the information from the registration counter. Infection control Protocols was not evident. For example; Limited supply of gloves thus hampering the very basic Infection Control measures. Lack of hand washing soaps Infection control techniques such as removal of shoes before entering the OT were not practiced No zoning of OT

Separate May I help You desk is started in OPD where hospital related queries are solved. Adequate number of gloves supplied. The gloves are being used for every procedure and also for patient handling. Adequate supply of soaps for hand washing and strengthening of the practice. Infection control techniques such as removal of shoes before entering the OT have been made mandatory and adhered to strictly. Zoning of OT has been done ANMs have been posted from the PHCs to supplement the nursing staff.

16 17 18 19

The number of nurses was inadequate.

No training plan existed for staffs.

Training schedules prepared and training conducted as per schedule.

License and Registration was not available like AERB, Pollution control etc. There was no Standard Operating Procedure for record maintenance.

Required licenses and registration are available with the hospital. SOP for Record maintenance has been designed and implemented.

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

20 21

There was no Handover Take over system during the change of staff during the change of shift. The BHT and treatment charts, registers were not adequately filled.

Handover Take over registers have been developed and implemented. A system has been developed where by BHT, treatment charts, registers are all completed on time.

22 23 24

There was no existing Quality policy There were no Quality Objectives defined. The BHT and treatment charts, registers were not adequately filled.

A Quality Policy has been defined. The Quality Objectives have been defined. A system has been developed where by BHT, treatment charts, registers are all completed on time.

25 26 27

There was no existing Quality policy There were no Quality Objectives defined.

A Quality Policy has been defined. The Quality Objectives have been defined. A Calibration schedule has been prepared Weighting Machine has been calibrated.

There was no existing system of calibration.

Pressure gauge of an oxygen and an autoclave machine has been calibrated Thermometer and BP instruments calibrated.

28

There were unguarded Multipoint entries to the hospital which were a security concern especially at nights.

Unnecessarily opened gates have been closed. 10 home guards has been deployed to ensure the security of the hospital. A systematic arrangement of store has been done within the limited space available.

29
The store was poorly managed and haphazardly arranged.

The store racks have been numbered Concept of First In First Out (FIFO) has been implemented.

30
There was no fire safety mechanism available

Fire extinguishers have been installed Required signage have been displayed as per the local fire officers plan

31 32

Housekeeping activities were not up to the mark and not monitored. The condemned items were dumped all over the hospital.

Housekeeping has improved significantly under the constant monitoring of the management. All Condemned Items have been removed and auctioned.

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

IMPACT OF QMS
2007-08
Total OPD Total IPD No of patients attended to in emergency No of Deliveries taking place No of C Section performed No of Minor surgery performed No of Major surgery performed

2008 2008-09 150072 16651 38844 10334 8 3636 142

2009-10 201044 19587 32160 11159 83 6237 549

2010-11 121692 12181 24150 7989 91 3140 261

103776 11472 15926 8390 20 3228 230

Year wise Total OPD Attendance

201044 250000 200000 150000 100000 50000 0 150072 103776 121692

2007-08

2008-09

2009-10 Total OPD

2010-11 2010

Year wise Total IPD Attendance

Total IPD
19587 16651 11472 12181

2007-08

2008-09

2009-10

2010-11

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

Year wise Total C Section

No of C Section performed
83 91

20
2007-08

8
2008-09 2009-10 2010-11

Feedback format for CS/MS/DMS/MR /MR

S. No. Attributes
Do Not Agree Neutral

Response
Agree Endorse Remarks

1. 2. 3. 4.

5.

6. 7. 8. 9. 10.

Quality Management System helped you in streamlining the processes of your hospital On-Site Site consultant helped you in routine hospital operations Training provided by TSP helped you in enhancing the skills of your staff QMS helped you in making your documentation and records management more systematic This project incorporated a feel of pride amongst the staff and increases their job satisfaction level. QMS helped you in enhancing the patient satisfaction QMS helped you in enhancing the clinical performance of your hospital This project helped you in improving infrastructure of your facility As-Is Is survey helped you in finding gaps in your infrastructure and processes QMS helped you in measuring and projecting performance of you hospital

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA

11.

12.

13.

14.

15. 16.

17.

18. 19. 20

Project helped you to get more funds and manpower and attention from state health administration Project helped in improving image of your hospital amongst community, media and other stake holders Project helped in increase the utilization of hospitals services like OPD, IPD, Lab, Radiology, Operation theatre, blood bank etc. Supervision, training and technical support provided by NHSRC helped you in implementing this project. QMS helped you managing Rogi Kalyan Samiti efficiently QMS helped you in improving facility management, appearance and signage system QMS helped you in meeting statutory and regulatory requirement including biomedical waste management. QMS helped you in managing outsourced services better Overall quality improvement program is relevant and effective. Program of this kind should be implemented in all public health facilities.

Civil Surgeon Cum Chief Medical Officer Bhojpur, Ara

PROCESS DOCUMENTATION OF ISO CERTIFICATION AND EFFECTIVENESS OF ISO AT SADAR HOSPITAL, ARA