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SUSTAINING NABH AND SURVEILLANCE AUDIT

SUSTAINING NABH AND SURVEILLANCE AUDIT. Dr.Aruvi T P NABH Nodal Officer General Hospital Ernakulam. We Achieved NABH Accreditation On 28 th January 2011. India’s First biggest Hospital Kerala’s First Government Hospital to get NABH Accreditation. How we sustain after NABH.

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SUSTAINING NABH AND SURVEILLANCE AUDIT

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  1. SUSTAINING NABH AND SURVEILLANCE AUDIT Dr.Aruvi T P NABH Nodal Officer General Hospital Ernakulam

  2. We Achieved NABH Accreditation On 28th January 2011

  3. India’s First biggest Hospital Kerala’s First Government Hospital to get NABH Accreditation

  4. How we sustain after NABH

  5. How we sustain after NABH • Core Committee and Sub committee meetings • Internal Audit • Medical Audit, Clinical Audit and Death Audit • Periodic Training and updating for Staff • Quarterly Report to QCI • Calibration of Equipments • Patient Feed Back

  6. Core Committee and Sub committee meetings • Core committee constituted by the Conveners of all sub committees –Headed by Hospital Superintendent • Includes Permanent members like DMO , DPM, Deputy Superintendent, RMO,Nursing Superintendent, NABH Nodal Officer and NABH Coordinator, PRO,and Lay Secretary which meets monthly • Analyze and review all NABH Activities • Decision making and implementation by the core committee is quick and easy • Implementation • Institutional level- Superintendent Responsibilty given to team members • District Level-District Collector and District Medical Officer(NRHM fund,MP MLA Fund ,HDC Fund, and Sponsorships) • State Level(Govt.Fund)

  7. Periodic Audits • Internal Audit-Quarterly • Medical Record Audit-Monthly • Death Audit-Monthly • Clinical Audit-Quarterly • Referral Audit-Monthly

  8. Training • Induction training • Periodic CMEs and Skill training • Interpersonal relationship training • Personality Development Training • Pre tests and Post tests • Feed back Analysis • Trainings by NRHM and QCI

  9. Quarterly Report to QCI Quarterly report on the following Ten mandatory indicators submitted to the NABH • Percentage ofmedication errors. • Percentage oftransfusionreactions • SymptomaticUrinary tractinfection rate(SUTI) • Ventilatorassociatedpneumonias • Central /PeripherallineAssociated BloodStream Infection(CLABSI) • Surgical siteinfection rate • Incidence of falls • Incidence of bedsores afteradmission • Bed occupancyRate • Average length of stay • Incidence of needle stick injuries

  10. Calibration of Equipments Timely equipments Calibration • PATIENT FEED BACK

  11. Surveillance Audit • Surveillance Audit conducted on 24th,25th,26th August 2012 by four Assessors from the QCI. • Opening Meeting-”Not a fault finding but just Observations” • Three Days- Three teams • Observations /Suggestions/Guidence • Conclusion Meeting-Appreciate the genuinity and Team Work.

  12. Thank You

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