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Quality Improvement Programme CoH Blood Bank Yearly (2008-13) Progress Report of Quality Improvement Programme Dr ……………………………... Superintendent Medical College Hospital, Government of Gujarat ………………………………………………………………………. Email & Mobile No:………………………………………………… www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 1 CoH Financial Progress Report (Expenditure with Utilization Certificate) www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 2 Financial Progress Report (Yr 2008-12) S. No. Year 1 2008-09 2 2009-10 3 2010-11 4 2011-12 5 2012-13 Total Grant Received (NRHM) Rs. Total Grant Received (State) Rs. Grant Total (NRHM + State) Rs. CoH Total Total Expenditure Settlement Rs. with UC Rs. Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 3 CoH Financial Progress Report Infrastructure Detailed Year 2008-2013 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 4 Financial Progress Report Infrastructure Detailed Year 2008 - 09 S. No. www.gujhealth.gov.in Detailed of Infrastructure Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 5 Financial Progress Report Infrastructure Detailed Year 2009 - 10 S. No. www.gujhealth.gov.in Detailed of Infrastructure Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 6 Financial Progress Report Infrastructure Detailed Year 2010 - 11 S. No. www.gujhealth.gov.in Detailed of Infrastructure Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 7 Financial Progress Report Infrastructure Detailed Year 2011 - 12 S. No. www.gujhealth.gov.in Detailed of Infrastructure Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 8 Financial Progress Report Infrastructure Detailed Year 2012 - 13 S. No. www.gujhealth.gov.in Detailed of Infrastructure Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 9 CoH Financial Progress Report Manpower Detailed Year 2008-2013 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 10 Financial Progress Report Manpower Detailed Year 2008-09 S. No. 1 2 3 4 5 6 Detailed of Manpower Total No. CoH Amt. Rs. Class – 1 Class – 2 Class – 3 Class – 4 Service out source (Security or House keeping) Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 11 Financial Progress Report Manpower Detailed Year 2009-10 S. No. 1 2 3 4 5 6 Detailed of Manpower Total No. CoH Amt. Rs. Class – 1 Class – 2 Class – 3 Class – 4 Service out source (Security or House keeping) Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 12 Financial Progress Report Manpower Detailed Year 2010-11 S. No. 1 2 3 4 5 6 Detailed of Manpower Total No. CoH Amt. Rs. Class – 1 Class – 2 Class – 3 Class – 4 Service out source (Security or House keeping) Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 13 Financial Progress Report Manpower Detailed Year 2011-12 S. No. 1 2 3 4 5 6 Detailed of Manpower Total No. CoH Amt. Rs. Class – 1 Class – 2 Class – 3 Class – 4 Service out source (Security or House keeping) Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 14 Financial Progress Report Manpower Detailed Year 2012-13 S. No. 1 2 3 4 5 6 Detailed of Manpower Total No. CoH Amt. Rs. Class – 1 Class – 2 Class – 3 Class – 4 Service out source (Security or House keeping) Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 15 CoH Financial Progress Report Instrument & Equipment Detailed Year 2008-2013 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 16 Financial Progress Report Instrument & Equipment Detailed Year 2008-09 S. No. www.gujhealth.gov.in Detailed of Instrument & Equipment Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 17 Financial Progress Report Instrument & Equipment Detailed Year 2009-10 S. No. www.gujhealth.gov.in Detailed of Instrument & Equipment Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 18 Financial Progress Report Instrument & Equipment Detailed Year 2010-11 S. No. www.gujhealth.gov.in Detailed of Instrument & Equipment Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 19 Financial Progress Report Instrument & Equipment Detailed Year 2011-12 S. No. www.gujhealth.gov.in Detailed of Instrument & Equipment Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 20 Financial Progress Report Instrument & Equipment Detailed Year 2012-13 S. No. www.gujhealth.gov.in Detailed of Instrument & Equipment Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 21 CoH Financial Progress Report Training Detailed Year 2008-2013 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 22 Monthly Financial Progress Report Training Detailed year 2008-09 S. No. www.gujhealth.gov.in Detailed of Training Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 23 Monthly Financial Progress Report Training Detailed year 2009-10 S. No. www.gujhealth.gov.in Detailed of Training Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 24 Monthly Financial Progress Report Training Detailed year 2010-11 S. No. www.gujhealth.gov.in Detailed of Training Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 25 Monthly Financial Progress Report Training Detailed year 2011-12 S. No. www.gujhealth.gov.in Detailed of Training Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 26 Monthly Financial Progress Report Training Detailed year 2012-13 S. No. www.gujhealth.gov.in Detailed of Training Blood Bank CoH Amt. Rs. Health & Family Welfare, Govt of Gujarat 27 CoH Financial Progress Report Operational Detailed Year 2008-2013 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 28 Monthly Financial Progress Report CoH Operational Detailed Year 2008-09 S. No. www.gujhealth.gov.in Detailed of Operational Blood Bank Amt. Rs. Health & Family Welfare, Govt of Gujarat 29 Monthly Financial Progress Report CoH Operational Detailed Year 2009-10 S. No. www.gujhealth.gov.in Detailed of Operational Blood Bank Amt. Rs. Health & Family Welfare, Govt of Gujarat 30 Monthly Financial Progress Report CoH Operational Detailed Year 2010-11 S. No. www.gujhealth.gov.in Detailed of Operational Blood Bank Amt. Rs. Health & Family Welfare, Govt of Gujarat 31 Monthly Financial Progress Report CoH Operational Detailed Year 2011-12 S. No. www.gujhealth.gov.in Detailed of Operational Blood Bank Amt. Rs. Health & Family Welfare, Govt of Gujarat 32 Monthly Financial Progress Report CoH Operational Detailed Year 2012-13 S. No. www.gujhealth.gov.in Detailed of Operational Blood Bank Amt. Rs. Health & Family Welfare, Govt of Gujarat 33 CoH Committee: Quality Improvement Programme Committee www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 34 Functioning of the Committees Year 2008-09 S. No. Name of the Committee 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE Monthly 3 INFECTION CONTROL COMMITTEE Monthly 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee Monthly 7 Clinical audit committee Monthly 8 GRIEVANCE REDRESSAL COMMITTEE Monthly 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE Monthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12 HOSPITAL ETHICS COMMITTEE Monthly www.gujhealth.gov.in Functioning (Yes / No) Fix interval of Meeting Blood Bank No. of Meeting Planned CoH No. of Meeting Conducted Health & Family Welfare, Govt of Gujarat 35 Functioning of the Committees Year 2009-10 S. No. Name of the Committee 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE Monthly 3 INFECTION CONTROL COMMITTEE Monthly 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee Monthly 7 Clinical audit committee Monthly 8 GRIEVANCE REDRESSAL COMMITTEE Monthly 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE Monthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12 HOSPITAL ETHICS COMMITTEE Monthly www.gujhealth.gov.in Functioning (Yes / No) Fix interval of Meeting Blood Bank No. of Meeting Planned CoH No. of Meeting Conducted Health & Family Welfare, Govt of Gujarat 36 Functioning of the Committees Year 2010-11 S. No. Name of the Committee 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE Monthly 3 INFECTION CONTROL COMMITTEE Monthly 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee Monthly 7 Clinical audit committee Monthly 8 GRIEVANCE REDRESSAL COMMITTEE Monthly 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE Monthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12 HOSPITAL ETHICS COMMITTEE Monthly www.gujhealth.gov.in Functioning (Yes / No) Fix interval of Meeting Blood Bank No. of Meeting Planned CoH No. of Meeting Conducted Health & Family Welfare, Govt of Gujarat 37 Functioning of the Committees Year 2011-12 S. No. Name of the Committee 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE Monthly 3 INFECTION CONTROL COMMITTEE Monthly 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee Monthly 7 Clinical audit committee Monthly 8 GRIEVANCE REDRESSAL COMMITTEE Monthly 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE Monthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12 HOSPITAL ETHICS COMMITTEE Monthly www.gujhealth.gov.in Functioning (Yes / No) Fix interval of Meeting Blood Bank No. of Meeting Planned CoH No. of Meeting Conducted Health & Family Welfare, Govt of Gujarat 38 Functioning of the Committees Year 2012-13 S. No. Name of the Committee 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE Monthly 3 INFECTION CONTROL COMMITTEE Monthly 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee Monthly 7 Clinical audit committee Monthly 8 GRIEVANCE REDRESSAL COMMITTEE Monthly 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE Monthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12 HOSPITAL ETHICS COMMITTEE Monthly www.gujhealth.gov.in Functioning (Yes / No) Fix interval of Meeting Blood Bank No. of Meeting Planned CoH No. of Meeting Conducted Health & Family Welfare, Govt of Gujarat 39 CoH Role & Responsibility of Quality Improvement Committees www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 40 Role & Responsibility of the: Quality Improvement Committee CoH Scope of Work Function of the Committee This committee shall have representation from management, various Discuss, decide and Issue hospital clinical and support departments of the Health Care Organization (HCO). Policies related to hospital operations The various quality improvement program shall be developed, and accreditation. implemented and maintained in a structured manner. This committee should have good knowledge of accreditation standards, Documentation and review of policies statutory requirements, hospital quality assurance principles and evaluation methodologies, hospital functioning and operations. This shall incorporate the mission, vision, quality policy, quality Define scope of services objectives, service standards, etc. Define and develop quality parameters Quality assurance manual has to be prepared and updated periodically. for clinical and non-clinical activities Set standards and benchmarks for The organization shall ensure that the practices are in consonance with quality parameters good clinical practices. Function as apex committee for As quality improvement is a dynamic process, it needs to be reviewed at monitoring performance indicators / regular pre-defined intervals (as defined by the HCO in the quality parameters of QMS and medical assurance manual) by the multi-disciplinary committee. The review shall statistics also include analysis of key indicators as defined by the standards. Standardization of professional Hospital management makes available adequate resources required for procedures and equipment quality improvement program. This shall include the men, material, machine and method. These should Credentialing and Privileging be in steady supply so as to ensure that the program function smoothly. Frequency of Meeting Monthly www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 41 Role & Responsibility of HOSPITAL SAFETY COMMITTEE Scope of Work CoH Function of the Committee The committee will ensure the total hospital safety & Develop and issue security. Policy on patient, staff, The committee will bring to the notice of the administration, and visitor safety and any gaps observed for the safety and security of hospital staff security & the patients and their attendants. A well documented lab safety manual is available in the lab. This takes care of the safety of the workforce as well as the Monitor training and equipment available in the lab. implementation Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery. Policies and procedures guide the use of medical gases. Sentinel events are intensively analyzed and actions should Monitor occupational be taken upon the analysis. health and safety The organization has an interdisciplinary group assigned to oversee the hospital wide safety program. Frequency of Meeting www.gujhealth.gov.in Blood Bank Monthly Health & Family Welfare, Govt of Gujarat 42 Role & Responsibility of INFECTION CONTROL COMMITTEE Scope of Work CoH Function of the Committee Document and issue infection control manual including The hospital has a multi-disciplinary infection control committee. policies The organization has a well-designed, comprehensive and coordinated Training for infection control hospital infection control (HIC) programme aimed at reducing/eliminating risks to patients, visitors and providers of care. Surveillance for compliance The hospital has an infection control manual, which is periodically updated. with policies Hospital defines the periodicity of updation. Issue antibiotic policy The hospital infection control programme is documented. Monitor Hospital acquired The manual should clearly identify the high risk areas of the hospital e.g. infection ICU, HDU, OT, post-operative ward, blood bank, CSSD, etc. Proper facilities and adequate resources are provided to support the Outbreak control infection control program. The hospital is authorized by prescribed authority for the management and handling of bio-medical waste. Monitor biomedical waste The organization shall ensure that ensure the sterilization procedure is management practices regularly monitored and in the eventuality of a breakdown it has a procedure for withdrawal of such items. Frequency of Meeting www.gujhealth.gov.in Monthly Blood Bank Health & Family Welfare, Govt of Gujarat 43 Role & Responsibility of INFECTION CONTROL TEAM Scope of Work Surveillance for infection control Data collection on hospital acquired infections CoH Function of the Committee The hospital should have an infection control team. The team is responsible for day-to-day functioning of infection control program. They shall support surveillance process and detect outbreaks. They shall also participate in infection prevention and control Calculation of HAI rates on a day-to-day basis. On job training of healthcare staff on The hospital has designated and qualified infection control infection control nurse for this activity. practices Develop report on HAI The Infection control team will work together with infection trends control committee and bring to their notice if any issues have Monitor infection seen related to infection. control practices Frequency of Meeting www.gujhealth.gov.in Every Fifteen days Blood Bank Health & Family Welfare, Govt of Gujarat 44 Role & Responsibility of: MEDICAL AUDIT COMMITTEE Scope of Work CoH Function of the Committee Review and evaluate patient records for quality, adequacy of patient care, Medical staff participates in this system. monitor staff for compliance with policies Evaluate medical record keeping, quality, content, format, accuracy, pertinence, The parameters to be audited are defined by the organization. staff compliance with documentation policies Review and evaluate fatal cases / deaths The medical records are reviewed periodically. in hospital. Evaluate sentinel events related to The review focuses on the timeliness, legibility and completeness of the medical patient care records. Review, evaluate and monitor adverse The review process includes records of both active and discharged patients. drug reaction Review and evaluate cases needing An adequate mix of both active and discharged patients should be used. resuscitation Implementation of Right to Information The review points out and documents any deficiencies in records. For example, missing final diagnosis , absence of OT notes in an operated patient Take decisions regarding improvement in , etc. clinical quality All audits are documented. The actions taken must be documented and oriented to the hospital staff. Frequency of Meeting www.gujhealth.gov.in Quarterly Blood Bank Health & Family Welfare, Govt of Gujarat 45 Role & Responsibility of Clinical risk management & Adverse drug event committee Scope of Work CoH Function of the Committee Monitor and analyses Monitor and analyses sentinel events, accidents, and sentinel events, accidents, adverse events. and adverse events. Incident Reporting System. Incident Reporting System. Dealing with external bodies Dealing with external bodies and individuals. and individuals. Deal with Complaints on Deal with Complaints on Professionals management. Professionals management. Risk management policies to Risk management policies to reduce actual potential reduce actual potential patient risk. patient risk. Identify trends amongst Identify trends amongst incident and initiate action incident and initiate action Frequency of Meeting www.gujhealth.gov.in Monthly Blood Bank Health & Family Welfare, Govt of Gujarat 46 Role & Responsibility of: Clinical audit committee Scope of Work Evaluate medical record keeping, quality, content ,format , accuracy, pertinence ,staff compliance CoH Function of the Committee The parameters to be audited are defined by the organization. Proper documentation of The medical records are reviewed policy periodically. The review focuses on the timeliness, Review and evaluate fatal legibility and completeness of the medical cases /Death in hospital records. Frequency of Meeting www.gujhealth.gov.in Monthly Blood Bank Health & Family Welfare, Govt of Gujarat 47 Role & Responsibility of: GRIEVANCE REDRESSAL COMMITTEE CoH Scope of Work Function of the Committee To issue policy on grievance To issue policy on grievance redressal redressal Develop a mechanism of handling employee grievances To handle all the employee grievances Develop a mechanism of The committee has to sort out the problem and find out handling employee the solution irrespective of the employee and its grievances position. Preventive measures must be taken by the committee not to repeat the same problem in future. To handle all the employee The committee must take a unbiased decision and it has grievances to be respected and accepted by the staff without any issue. To issue policy on grievance To issue policy on grievance redressal redressal Frequency of Meeting www.gujhealth.gov.in Monthly Blood Bank Health & Family Welfare, Govt of Gujarat 48 Role & Responsibility of: Sexual harassment committee Scope of Work Function of the Committee Committee is formed to issue policies for complaint system and recommended producers, investigation, and disciplinary action. The employee harassing another employee can be an individual of the same sex. The harasser can be the employee’s supervisor, manager, customer, coworker, supplier, peer, or vendor .any individual who is connected to the employee’s work environment ,other employee’s who observe or learn about the sexual harassment can potentially complain of sexual harassment. In the organization’s harassment policy, advise the potential victims that, if they experience harassment, they should tell the perpetrator to stop, that the advances or other behaviors are unwelcome. Frequency of Meeting www.gujhealth.gov.in CoH Committee is formed to issue policies for complaint system and recommended producers, investigation, and disciplinary action. The employee harassing another employee can be an individual of the same sex. The harasser can be the employee’s supervisor, manager, customer, coworker, supplier, peer, or vendor .any individual who is connected to the employee’s work environment ,other employee’s who observe or learn about the sexual harassment can potentially complain of sexual harassment. In the organization’s harassment policy, advise the potential victims that, if they experience harassment, they should tell the perpetrator to stop, that the advances or other behaviors are unwelcome. Monthly & as or when required Blood Bank Health & Family Welfare, Govt of Gujarat 49 Role & Responsibility of: PHARMACOTHERAPEUTIC COMMITTEE Scope of Work Develop and issue Policy on formulary and medication management CoH Function of the Committee There is a documented policy and procedure for pharmacy services and medication usage. Policies and procedures guide the organization of pharmacy services and usage of medication. Supervise purchases and The policies and procedures shall address the issues related to procurement procurement, storage, formulary, prescription, dispensing, administration, monitoring and use of medications. A list of medication appropriate for the patient's and the organization's Supervise and management of resources is developed. pharmacy Policies and procedures guide the prescription of medications. Policies and procedures guide the safe dispensing of medications. Monitor and evaluate adverse Policies and procedures guide the use of narcotic drugs and psychotropic drug reactions substances. Policies and procedures govern usage of radioactive or investigational Manage the control of drugs drugs. Policies and procedures guide the usage of chemotherapeutic agents. Policies and procedures guide the use of implantable prosthesis. Supervise drug information service Policies and procedures guide the shortage of medication. Frequency of Meeting www.gujhealth.gov.in Blood Bank Monthly Health & Family Welfare, Govt of Gujarat 50 Role & Responsibility of: Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Scope of Work Develop policy on prevention, management, and control of emergency situations within and outside the hospital Develop plan for handling fire and non fire emergency situation Ensure orientation of such plan to all CoH Function of the Committee Patient safety aspects and risk management issues are an integral part of patient care and hospital management. Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety. The committee will form the policy and provide guidelines for evaluation control and smooth management in case of events. This committee will rectify the faults in the system and fill up the gaps. Supervise training and mock drills The organization has plans for fire and non-fire emergencies within the facilities. Management ensures implementation of systems for internal Implementation of policy / plan and external reporting of system and process failures. Frequency of Meeting Monthly & as or when required www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 51 Role & Responsibility of: HOSPITAL ETHICS COMMITTEE CoH Scope of Work Function of the Committee 1. Education In cooperation with the hospital administration, its various departments and divisions, and its medical/nursing and allied health professional staff, the committee will undertake educational efforts in clinical ethics. Depending on the availability of resources, the committee will develop or assist others in the Issue policy on medical ethics development of lectures, seminars, workshops, courses, rounds, in-service programs and the like in clinical ethics. The aims of these educational efforts will be to provide participants with access to the language, concepts, principles and body of knowledge about ethics that they need in order to address the complex ethical dimensions of contemporary hospital practice 2. Policy Review and Development Review, evaluate and approve cases for clinical research, organ The committee will assist the hospital and its professional staff in the development of policies and transplant, experimental procedures regarding recurrent ethical issues, questions or problems that arise in the care of patients. In therapeutics, ethical dilemmas, this role the committee may provide analysis of the ethical aspects of existing or proposed policy or assist in terminal care the development of new institutional policy in areas of need. 3. Case Review Case review is particularly recommended in three specific categories of decision making: decisions involving significant ethical ambiguity and perplexity in which case review may provide insight into complex ethical issues; Any other potential conflict of decisions involving disagreement between care providers or between providers and patients/families ethical issues and medical policy regarding the ethical aspects of a patient’s care; or and practice decisions that involve withholding or withdrawal of life-sustaining treatment which are not adequately addressed in hospital ethical policies In this role the committee will not act as a decision-making body, but will attempt to assist and to provide support to those who do have this responsibility. Its role in all such cases shall be advisory. Frequency of Meeting www.gujhealth.gov.in Monthly Blood Bank Health & Family Welfare, Govt of Gujarat 52 Role & Responsibility of: Biomedical Waste & Scrap Disposal Committee CoH Scope of Work Function of the Committee No objection certificate under Pollution Control Act. Air (prevention and control of pollution) Act, 1981. Biomedical waste management handling rules 1998. Hazardous waste management and handling rules Act Water Prevention and control of pollution Act License under Bio-medical Management and handling Rules, 1998. Regular Scrap Disposal from the facility Review for No objection certificate under Pollution Control Act. Review Air (prevention and control of pollution) Act, 1981. Review Biomedical waste management handling rules 1998. Review Hazardous waste management and handling rules Act Review Water Prevention and control of pollution Act Frequency of Meeting Monthly www.gujhealth.gov.in Review License under Bio-medical Management and handling Rules, 1998. Review Regular Scrap Disposal from the facility Blood Bank Health & Family Welfare, Govt of Gujarat 53 CoH Progress of: Legal license & Act. www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 54 Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) Available (Yes / in Yr 2007-08 No) Yr 2012-13 1 Building Permit (From the Municipality). 2 No objection certificate from the Chief Fire Officer. License under Bio-medical Management and handling Rules, 1998. No objection certificate under Pollution Control Act. 3 4 5 Radiation Protection Certificate in respect of X-ray equipments from AERB. 6 Excise permit to store Spirit. 7 Narcotics and license and Act. 8 Vehicle registration certificates. 9 Air (prevention and control of pollution) Act, 1981. 10 Atomic energy regulatory body approvals. www.gujhealth.gov.in Psychotropic CoH Expiry Date substances Blood Bank Health & Family Welfare, Govt of Gujarat 55 Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 11 Biomedical waste handling rules 1998. 12 Consumer protection Act, 1986. 13 Dentist regulations, 1976. 14 Drugs and cosmetics Act, 1940. 15 Employees provident fund Act, 1952. 16 Equal remuneration Act, 1976. 17 Fatal accidents Act, 1955. 18 Indian lunacy Act, 1912 (MENTAL HEALTH ACT 1987) Indian medical council Act and code of medical ethics, 1956. 19 20 Available (Yes / No) Yr 2012-13 CoH Expiry Date management Indian nursing council Act, 1947. www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 56 Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 21 Nurses and Midwives Act, 1953 22 Indian penal code, 1860. 23 Indian trade unions Act, 1926. 24 Maternity benefit Act, 1961. 25 Available (Yes / No) Yr 2012-13 CoH Expiry Date MTP Act, 1971. 26 Minimum wages Act, 1948. 27 National building code. 28 Negotiable instruments Act, 1881. 29 Payment of wages Act, 1936. 30 Persons with disability Act, 1995. www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 57 Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 31 Pharmacy Act, 1948. 32 PNDT Act, 1996. 33 Licenses under PNDT Act 1996 34 Protection of human rights Act, 1993. 35 BARC, Act. 36 Registration of births and deaths Act, 1969. 37 Tax deducted at source Act. 38 License for the blood bank. 39 Constitution of India. 40 Transplantation of human organs Act, 1994. www.gujhealth.gov.in Blood Bank Available (Yes / No) Yr 2012-13 CoH Expiry Date Health & Family Welfare, Govt of Gujarat 58 Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 41 Hazardous waste handling rules Act 42 Dental Council of India 43 Water Prevention pollution Act 44 Lift license 45 HT connection license 46 125 KV diesel generator license 47 GCSR pension rule 48 GCSR additional pay rule act 49 GCSR joining, foreign service, deputation out of India act 50 Payment during suspension and removal www.gujhealth.gov.in management and Available (Yes / No) Yr 2012-13 CoH Expiry Date and control of Blood Bank Health & Family Welfare, Govt of Gujarat 59 Progress of: Legal license & Act. S. No. Name of the License / Act. 51 GCSR leave rule act 52 GCSR occupation of Govt residence accommodation act 53 GCSR general condition of service act 54 GCSR pay rule act 55 GCSR traveling allowance rule act. www.gujhealth.gov.in Available (Yes / No) in Yr 2007-08 Blood Bank Available (Yes / No) Yr 2012-13 CoH Expiry Date Health & Family Welfare, Govt of Gujarat 60 CoH Progress of: Clinical Indicators Year 2008-2013 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 61 Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 Year Total Blood Collection Voluntary ( % ) No of Blood Donation Camps CoH No of Blood Donation Camps 2008-09 2009-10 2010-11 2011-12 2012-13 Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 62 Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 Year Waiting Period for Adverse Donors Donors ( In Minutes ) Reaction Issue of Components CoH Turn Around Time for issue of blood ( In Minutes ) 2008-09 2009-10 2010-11 2011-12 2012-13 Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 63 Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 Year Discard of Components Feedback of Clinicians Blood Transfusion Reaction CoH Quality Parameters of Components 2008-09 2009-10 2010-11 2011-12 2012-13 Total www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 64 CoH Progress of: NABH Progress of Blood Bank www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 65 Progress of: Clause 1. ORGANISATION AND MANAGEMENT CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 2012-13 Non Compliance (Minor) 2008-09 2012-13 Full Compliance 2008-09 2012-13 1.1 Legal Identity 1.2 Responsibility 1.3 Ethics in blood bank/ blood centre 1.4 Quality System 1.5 Policies, processes and Procedures www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 66 Progress of: Clause 2. ACCOMMODATION AND ENVIRONMENT CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 2.1 Space Allocation 2.2 Environment Control 2.3 Biological, Chemical and Radiation Safety 2.4 Internal Communication System www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 67 Progress of: Clause 3. Personal CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 3.1 Personnel Requirement 3.2 Qualification 3.3 Job description/ responsibilities 3.4 Responsibilities of Director/ In charge / Medical Officer; Quality Manager &Technical Manager 3.5 Training 3.6 Competence 3.7 Personnel Health 3.8 Personnel Records 3.9 Confidentiality of Information www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 68 Progress of: Clause 4. EQUIPMENT CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 4.1 Equipment requirement 4.2 Selection and validation of Equipment 4.3 Use of equipment 4.4 Equipment detail record, unique Identification 4.5 Programme for calibration and maintenance of equipment 4.6 Equipment for storage of blood and component 4.7 Computer system 4.8 Breakdown of equipment www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 69 Progress of: Clause 5. EXTERNAL SERVICES AND SUPPLIES CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 5.1 Policies and procedures for supplier’s selection 5.2 Inventory control 5.3 Evaluation of suppliers www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 70 Progress of: Clause 6. PROCESS CONTROL CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 6.1 Policies and validation of processes and procedures 6.2 Donor Section 6.3 Component Laboratory 6.4 Quarantine and Storage 6.5 Labeling 6.6 Testing of Donated Blood 6.7 Compatibility Testing 6.8 Transfusion Reaction and Evaluation www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 71 Progress of: Clause 6. PROCESS CONTROL CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 6.9 Documentation in Transfusion Service 6.10 Histocompatibility Testing 6.11 Quality Control 6.12 Proficiency Testing Programme 6.13 Bio-medical waste disposal and laboratory safety in blood bank/ blood centre www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 72 Progress of: Clause 7. IDENTIFICATION OF DEVIATIONS AND ADVERSE EVENTS CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 2012-13 Non Compliance (Minor) 2008-09 2012-13 Full Compliance 2008-09 2012-13 7.1 Policies and procedures when nonconformity is detected 7.2 Procedure for release of nonconforming blood component 7.3 Preventing recurrence of nonconformity www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 73 Progress of: Clause 8. PERFORMANCE IMPROVEMENT CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 8.1 Addressing Complaints 8.2 Corrective action 8.3 Preventive action www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 74 Progress of: Clause 9. DOCUMENT CONTROL CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 9.1 Procedure for document control and review of documents 9.2 Document required 9.3 Maintenance of documents in computer software www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 75 Progress of: Clause 10. RECORDS CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 2012-13 Non Compliance (Minor) 2008-09 2012-13 Full Compliance 2008-09 2012-13 The blood bank/ blood centre shall have implemented policy for keeping and retaining of records and may include: 1. record identification: all records relevant to the quality Management system shall be uniquely identified with appropriately labelled. 2. quality and technical records: quality records as well as technical records that may include original observation, calibration record, staff record, www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 76 Progress of: Clause 11. INTERNAL AUDIT & MANAGEMENT REVIEW CoH Total No. of Clause Number of Clause Non Compliance (Major) 2008-09 Non Compliance (Minor) 2012-13 2008-09 2012-13 Full Compliance 2008-09 2012-13 Policy for internal audit and management review 11.2 Procedure of internal audit 11.3 Procedure of management review 11.4 Documentation of internal audit and management review www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 77 CoH New initiatives: www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 78 New Initiatives S.No. CoH List of New Initiatives 1 2 3 4 5 6 7 8 9 10 11 12 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 79 CoH Any Benefit / Harm to your facility due to Quality Improvement Programme (NABH / NABL):- www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 80 Any Benefit to your facility due to Quality Improvement Programme (NABH / NABL) S.No. CoH List of Benefits 1 2 3 4 5 6 7 8 9 10 11 12 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 81 Any Harm to your facility due to Quality Improvement Programme (NABH / NABL) S.No. CoH List of Harms 1 2 3 4 5 6 7 8 9 10 11 12 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 82 CoH Other issues: www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 83 Other issues S.No. CoH List of issues 1 2 3 4 5 6 7 8 9 10 11 12 www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 84 Quality Improvement Programme CoH Quality is a Team work & never achieve by alone Thanks www.gujhealth.gov.in Blood Bank Health & Family Welfare, Govt of Gujarat 85