A step towards NABH accreditation
National Institute of Siddha is marching towards the land mark of obtaining NABH Accreditation for the Ayothidoss Pandithar Hospital (APH) attached with this Institute.
As a part of complying NABH norms, APH-NIS is undertaking the following activities.
* Apex manual
* Safety manual
* Quality manual
* HIC manual
* Essential Documents
* Training schedule, Certificates and Register
* Employees medical record catalogue
Forms & Reports
* Medical audit forms & reports
* Patient satisfaction index forms & reports
* Hospital forms
ACRs for Regular & Contract employees
Floor plan with fire safety exit indication
Continuous quality improvement program shall be implemented by all committees and staff associated with each activity. Core Committee (CC) of NABH process will deliberate all policy related issues submitted by various committees and finalise the action plan for implementation. The remaining issues which necessitates the attention of Hospital Superintendent/Quality Manager shall be brought to their notice by different committees constituted for NABH process and put into implementation, otherwise the committee can put into practice. APH of NIS is committed to provide Quality Services to the public across the Country and Globe. Continuous quality improvement programmes are monitored by Quality Assurance Committee (QAC) through regular internal quality audits, physical checks, data analysis, random sample checks etc.
The quality improvement programme is reviewed once in every three months and opportunities for improvement are identified by CC. APH of NIS has identified key performance indicators to monitor the clinical structures, administrative structures, process and outcomes. All the key indicators shall be reported every month to the Administration and on later stage amendments shall be placed before the CC for necessary actions. Proper awareness to all employees is provided through proper training programmes. Hospital conducts QAC meeting every three months to ensure that all employees are strictly adhering to policies, procedures and work instructions/SOPs related to them.
Quality indicators across the hospital are collected and the same are evaluated and action is taken to improve the same.
APH of NIS has set up various committees, which meets in a defined interval for ensuring the Continual Quality care and improvement of the Hospital.
Committees of APH-NIS:
2.Quality Assurance Committee
3.Medical Record Audit committee
4.Mortality and Morbidity Committee
5.Hospital Infection Control Committee
6.Biomedical Waste Management Committee
7.Drug and Pharmaco-Therapeutic Committee
8.Local Purchase Committee
10.Hospital Safety and Disaster management Committee
11.Institutional Ethical committee
12.CPR Analysis committee
13.Patient Grievance Redressal Committee
14.Internal Compliance Committee Sexual Harassment of women in Hospital.
Goals of the Committees :
a.To ensure proper health care service to the mankind.
b.To protect the rights of patients
c.To provide safe environment to the patients, public and employees.
d.To promote shared decision making between patients and clinicians
e.To promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes.
Responsibility of Committees:
• Every committee shall meet periodically to discuss and take necessary steps to implement and monitor the scope of activities identified for the respective committee.
• Chairman of the Committee shall bear the responsibility of smooth functioning of the committee.
• Distribution of work amongst the committee members by the Chairman
• Committee shall review their functioning at appropriate intervals as decided by the Chairman to assess the functioning
• Monitoring the implementation of Decision taken.
In this above subject, various committees are constituted for undertaking specified tasks in compliance with NABH Accreditation process.