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1
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There is a structured quality improvement and
continuous monitoring programme in the organization.
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a)The
quality improvement programme
is developed, implemented
and maintained by a
multi-disciplinary committee.
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Immediate
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Form core committee with representatives from
various departments
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0
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b)The quality
improvement programme is documented
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0
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Remote
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Document the following:
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0
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1.Mission
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2.Vision
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3.Quality Policy
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4.Service Standards
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5.Important Indicators
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6.Mock Drills
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7.Data Collection
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8.Audit Schedule
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9.Review Policy
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c)There is
a designated individual
for coordinating and
implementing the quality improvement programme.
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d)The quality improvement
programme is comprehensive and
covers all the
major elements related to
quality improvement and
risk management
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#########
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Remote
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Mentioned in cqi 1(b)
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e)The designated
programme is communicated and
coordinated amongst all
the employees of the organization through
proper training mechanism.
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Remote
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Awareness and staff training with issue of
printed material
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f)The quality
improvement programme is
reviewed at predefined
intervals and
opportunities for improvement are identified.
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#########
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Remote
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a)Department
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wise review
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b)Formulate manual for quality improvement
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c)Meeting with recording of minutes
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g)The quality
improvement programme is a continuous
process and updated
at least once in
a year.
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#########
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Remote
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a)conduct audit
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b) Feedback
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c) Review
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h)Audits are conducted at
regular intervals as a means
of continuous monitoring
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#########
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a)Audit conducted once in 6 months
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b)Train assessors
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Remote
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c)Meeting for corrective and preventive measures
documented
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2
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There is
a structured patient safety programme in the organisation
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The patient-safety programme
is developed, implemented
and maintained by a
multi-disciplinary committee.
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Immediate
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Form
patient safety committee
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The patient-safety programme
is documented.
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#########
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Remote
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Prepare
manual
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The patient-safety programme
is comprehensive and
covers all the
major elements related to patient
safety and risk management
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#########
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Remote
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Documented
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There is
a designated individual
for coordinating and
implementing the patient safety programme.
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#########
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Immediate
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Can be
assigned
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The scope
of the programme
is defined to include
adverse events ranging
from “no harm” to “sentinel events”.
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#########
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Remote
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The designated
programme is communicated and
coordinated amongst all
the staff of the
organization through appropriate
training mechanism.
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#########
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Immediate
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Conduct regular training programmes
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The patient-safety programme
identifies opportunities for
improvement based on review
at pre-defined intervals.
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Remote
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Prepare
manual
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The patient-safety programme
is a continuous
process and updated
at least once in
a year.
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#########
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Remote
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Hold
meetings
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The organization adopts
and implements national/international patient-safety goals/solutions.
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#########
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Remote
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Formulate
database with reference to WHO patient safety standards
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The organization uses
at least two
identifiers to identify
patients across the organization.
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#########
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Immediate
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Central
monitoring system Can be assigned
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3
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The organization identifies
key indicators to
monitor the clinical structures, processes
and outcomes which
are used as
tools for continual improvement.
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Monitoring includes
appropriate patient assessment.
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#########
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Remote
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a)develop care plan ip and emergency patients
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b)formulate screening for nutritional needs
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c)formulate and document nursing care plan
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Monitoring includes
safety and quality control programme of all the diagnostic sevices
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#########
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Remote
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a)Implement KPI for diagnostic services
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b)capture errors in reports before dispatching
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c)Find out percentage of redos
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d)percentage of safety precautions by employees
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Monitoring includes
medication management
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#########
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Immediate
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a)Document incidence of medical error
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b)document ADR
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Monitoring includes
availability and content
of medical records
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#########
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Remote
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Document and update all medical records
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Monitoring includes
infection control activities.
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#########
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Remote
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Prepare KPI
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Monitoring includes
Parasurgical services
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#########
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Immediate
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Prepare
KPI
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Monitoring includes
Panchakarma therapies and
Treatment procedures
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#########
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Immediate
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Prepare
KPI
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Monitoring includes
clinical research.
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#########
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Immediate
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a)Prepare KPI
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b)Document number of patients withdrawing from
study
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c)percentage of protocol violation, adverse
events
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Data collection
to support further improvements.
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#########
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Remote
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Data
collection from other committees and its analysis
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Monitoring includes
data collection to
support evaluation of
these improvements.
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#########
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Remote
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Data
collection from other committees and its analysis
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Monitoring includes
use of anaesthesia
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#########
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NA
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Monitoring includes
surgical services.
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#########
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NA
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Monitoring includes
use of blood
and blood products.
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#########
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NA
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4
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The organization identifies
key indicators to
monitor the managerial structures,
processes and outcomes
which are used as
tools for continual improvement
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Monitoring includes
procurement of medication
essential to meet
patient needs.
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0
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Remote
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a)Prepare KPI
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b)document drugs procured from local purchase,
stock out and rejection
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Monitoring includes
reporting of activities
as required by laws and
regulations.
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0
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Remote
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Refer
the respective guidelines
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Monitoring includes
risk management.
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0
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Remote
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a)Prepare KPI
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b)Mock drills
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c)provide pre exposure prophylaxis
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Monitoring includes
utilization of space,
manpower and equipment.
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0
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Remote
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a)Prepare KPI
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Monitoring includes
patient satisfaction which
also incorporates waiting
time for services.
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0
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immediate
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a) Prepare KPI b)Feedback forms are given and op
ip satisfaction index noted
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Monitoring includes
employee satisfaction.
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0
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immediate
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a)Prepare KPI
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b)employee satisfaction index
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Monitoring includes
adverse events and
near misses.
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0
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Remote
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Prepare
KPI
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Monitoring includes
availability and content
of medical records.
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0
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Remote
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Proper
documentation
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Monitoring includes
data collection to
support further improvements.
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0
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Remote
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Prepare
KPI
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Monitoring includes
data collection to
support evaluation of
these improvements.
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0
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Remote
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Prepare
KPI
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5
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The
quality improvement programme is supported by the
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Hospital
Management makes available adequate resources required for quality
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0
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Remote
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Provide
manpower, infrastructure money and method
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management
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improvement
programme.
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Hospital
earmarks adequate funds from its annual budget in this regard.
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0
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Remote
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Fund
allocation
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The
management identifies organizational performance improvement targets.
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0
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Remote
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Set
obejectives and targets and monitor them
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Appropriate statistical and management tools are
applied whenever required
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0
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Remote
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Prepare KPI
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6
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There is an established system for clinical audit
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Medical and nursing staff participates in this
system.
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0
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Immediate
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Form a commitee
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The parameters to be audited are defined by the
organization
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0
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Remote
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Prepare KPI
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Patient and staff anonymity is maintained
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0
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Remote
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All audits are documented
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0
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Remote
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Remedial measures are implemented.
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0
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Remote
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Document root cause analysis report
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7
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Incidents, cofeedback are collected and analysed
to
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The organization has an incident reporting system
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5
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immediate
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Prepare KPI
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ensure continual quality improvement.
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The organization has a process to collect feedback
and receive complaints
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0
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Remote
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Prepare a format
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The organization has established processes for
analysis of incidents, feedbacks
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0
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Remote
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and complaints
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Corrective and preventive actions are taken based
on the findings of such analysis
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0
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Remote
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Feedback about care and service is communicated
to staff.
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0
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Remote
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8
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Sentinel events are intensively analyzed
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The organisation has defined sentinel events.
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0
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The organization has established processes for
intense analysis of such events
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0
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Sentinel events are intensively analyzed when
they occur
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0
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Corrective and Preventive Actions are taken based
on the findings of such
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0
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analysis.
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Total score
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15
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| Total score is 15 |
| Averageis 1.5% |