List of Policies & Procedure for QIP
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This document provides a procedure documentation list for quality improvement in healthcare facilities. It contains 10 chapters that cover topics such as access assessment and continuity of care, patient care, medication management, patient rights and education, infection control, continuous quality improvement, facility management and safety, human resource management, and information management systems. The list includes over 150 topics that healthcare facilities should document procedures for to improve quality. It is intended to help facilities standardize processes and ensure compliance with quality standards.
List of Policies & Procedure for QIP
- 1. Sr.No. TOPICS Available (Yes / No) Implementation (Yes / No) 1 Scope of service 2 Registration 3 Admission 4 Managing patient during non availability of beds 5 Transfer of unstable patients 6 Transfer of stable patients 7 Patient education on treatment 8 Patient education on expected cost 9 Clinical assessments 10 Reassessment 11 Scope of laboratory services 12 Laboratory personnel qualification 13 Collection, identification, handling, safe transportation, processing and safe disposal of specimens 14 Turnaround time for laboratory tests 15 Intimation of critical test results 16 Outsourcing of lab tests 17 Lab quality improvement programme 18 Laboratory safety programme 19 Handling and disposal of infectious and hazardous materials 20 Laboratory safe practices 21 Scope of Imaging services 22 Imaging personnel qualification 23 Identification and safe transportation of patients 24 Turnaround time for imaging tests 25 Intimation of critical imaging test results 26 Outsourcing of imaging test 27 Imaging quality assurance programme 28 Radiation safety programme 29 Handling and disposal of radioactive wastes 1 Uniform care PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN HEALTHCARE FACILITIES. CHAPTER -1: Access assessment and continuity of care CHAPTER - 2: Care of Patients
- 2. Sr.No. TOPICS Available (Yes / No) Implementation (Yes / No) PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN HEALTHCARE FACILITIES. 2 Evidence based medicine 3 Emergency care 4 Handling of medico-legal cases 5 Triage 6 Ambulance services 7 Checklist of equipment and emergency medications 8 Uniform use of resuscitation 9 Rational use of blood and blood products 10 Blood transfusion 11 Admission and discharge criteria 12 Management of bed shortage in ICU 13 Infection control practices in ICU 14 End of life care 15 Quality Improvement programme in ICU 16 Care of vulnerable patients 17 High risk obstetric care 18 Scope of paediatric services 19 Care of neonatal patients 20 Assessment of paediatric patients 21 Prevention of child / neonate abduction and abuse 22 Care of patient undergoing moderate sedation 23 Criteria for discharge from recovery area 24 Administration of anaesthesia 25 Care of patient undergoing surgical procedure 26 Prevention of adverse events in surgical patients 27 Quality improvement programme in surgical services 28 Restraint of patients 29 Management of pain 30 Rehabilitative services 31 Clinical research 32 Nutritional assessment and reassessment 1 Pharmacy services CHAPTER - 3: Management of Medication
- 3. Sr.No. TOPICS Available (Yes / No) Implementation (Yes / No) PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN HEALTHCARE FACILITIES. 2 Hospital formulary 3 Acquisition of medicines 4 Storage of medication 5 Obtaining medicine when pharmacy is closed 6 Replenishment of emergency medicines 7 Prescription of medication 8 Verbal orders for medication 9 List of high risk medication 10 Dispensing of medication 11 Medication recall 12 Medication administration 13 Management of adverse drug event 14 Use of narcotic and psychotropic substances 15 Usage of chemotherapeutic agents 16 Disposal of chemotherapeutic drugs 17 Use of radioactive drugs 18 Use of implantable prosthesis 19 Use of medical gases 1 Patient rights 2 Protection of patient's rights 3 Patients grievance redressal mechanism 4 General consent 5 Informed consent 6 List of situation where informed consent is required 7 Patient education 8 Billing policy 1 Infection control programme 2 Infection control manual 3 List of high risk areas for infection control 4 Surveillance for infection control 5 Standard precautions 6 Equipment cleaning and sterilization practices 7 Antibiotic policy / guideline CHAPTER - 4:Patient rights and education CHAPTER - 5: Hospital Infection Control
- 4. Sr.No. TOPICS Available (Yes / No) Implementation (Yes / No) PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN HEALTHCARE FACILITIES. 8 Laundry and linen management 9 Kitchen sanitation and food handling 10 Engineering controls 11 Mortuary practices 12 Monitoring of infections 13 Handling of outbreak of infection 14 Sterilization activities 15 Recall of items in case of sterilization breakdown 16 Management and handling of biomedical waste 1 Quality improvement programme 2 Indicator monitoring system 3 Assessment of patient care services 4 Parameters for assessment of patient care services 5 Event reporting 6 Analysis of sentinel events 1 Organogram 2 List of applicable legislations and regulations 3 Organization's social responsibility 4 Scope of services each speciality 5 Administrative policies 6 Departmental objectives / key indicators 7 Vision and Mission of the hospital 8 Code of medical ethics - 2002 9 Disclosure of ownership 10 Services not provided by the hospital 11 Billing tariff / schedule of charges 12 Hospital safety programme 13 Reporting of adverse events 1 List of laws applicable to the hospital 2 Mechanism to update licenses/registrations/certifications CHAPTER - 6: Continuous Quality Improvement CHAPTER - 7: Responsibility of Management CHAPTER - 8: Facility Management and safety
- 5. Sr.No. TOPICS Available (Yes / No) Implementation (Yes / No) PROCEDURE DOCUMENTATION LIST FOR QUALITY IMPROVEMENT IN HEALTHCARE FACILITIES. 3 Preventive and breakdown maintenance plan 4 Drawings of the hospital 5 List of major equipment 6 Handling of fire and non-fire emergencies 7 Exit plan in emergency situations 1 Training and development of staff 2 Training programme 3 Performance appraisal 4 Disciplinary rules 5 Grievance handling of staff 6 Personnel file management 7 Credentialing and privileging of consultants 8 Collection, verification and evaluation of credentials of nursing personnels 9 Job responsibility 1 Information management 2 Management of data 3 Storage and retrieval of data 4 Needle Stick Injury 5 Hand Washing 6 Reporting of Notifiable Diseases 7 Medical records 8 Confidentiality, integrity and security of information 9 Safeguarding of data / record from loss 10 Response to request for access to information in the medical record 11 Retention of clinical records 12 Medical audit 151 Member of NABH Accreditation Committee, QCI Member of Quality Expert Group, Govt of India. Email:- drjlmeena@gmail.com CHAPTER - 9: Human resource management CHAPTER - 10: Information management system Dr J L Meena State Quality Assurance Medical Officer Department of Health & Family Welfare Government of Gujarat