Yearly (2008-13) Progress Report of Quality Improvement Programme Medical College Laboretory Yearly (2008-13) Progress Report of Quality Improvement Programme Dr ……………………………... Dean Medical College Hospital Government of Gujarat ………………………………………………………… Email & Mobile No:…………………………………………………………… Medical College Laboretory

Financial Progress Report (Expenditure with Utilization Certificate) Medical College Laboretory

Financial Progress Report (Yr 2008-12) S. No. Year Total Grant Received (NRHM) Rs. Total Grant Received (State) Rs. Grant Total (NRHM + State) Rs. Total Expenditure Rs. Total Settlement with UC Rs. 1 2008-09 2 2009-10 3 2010-11 4 2011-12 5 2012-13 Total Medical College Laboretory

Financial Progress Report Infrastructure Detailed Year 2008-2013 Medical College Laboretory

Financial Progress Report Infrastructure Detailed Year 2008 - 09 S. No. Detailed of Infrastructure Amt. Rs. Medical College Laboretory

Financial Progress Report Infrastructure Detailed Year 2009 - 10 S. No. Detailed of Infrastructure Amt. Rs. Medical College Laboretory

Financial Progress Report Infrastructure Detailed Year 2010 - 11 S. No. Detailed of Infrastructure Amt. Rs. Medical College Laboretory

Financial Progress Report Infrastructure Detailed Year 2011 - 12 S. No. Detailed of Infrastructure Amt. Rs. Medical College Laboretory

Financial Progress Report Infrastructure Detailed Year 2012 - 13 S. No. Detailed of Infrastructure Amt. Rs. Medical College Laboretory

Financial Progress Report Manpower Detailed Year 2008-2013 Medical College Laboretory

Financial Progress Report Manpower Detailed Year 2008-09 S. No. Detailed of Manpower Total No. Amt. Rs. 1 Class – 1 2 Class – 2 3 Class – 3 4 Class – 4 5 Service out source (Security or House keeping) 6 Total Medical College Laboretory

Financial Progress Report Manpower Detailed Year 2009-10 S. No. Detailed of Manpower Total No. Amt. Rs. 1 Class – 1 2 Class – 2 3 Class – 3 4 Class – 4 5 Service out source (Security or House keeping) 6 Total Medical College Laboretory

Financial Progress Report Manpower Detailed Year 2010-11 S. No. Detailed of Manpower Total No. Amt. Rs. 1 Class – 1 2 Class – 2 3 Class – 3 4 Class – 4 5 Service out source (Security or House keeping) 6 Total Medical College Laboretory

Financial Progress Report Manpower Detailed Year 2011-12 S. No. Detailed of Manpower Total No. Amt. Rs. 1 Class – 1 2 Class – 2 3 Class – 3 4 Class – 4 5 Service out source (Security or House keeping) 6 Total Medical College Laboretory

Financial Progress Report Manpower Detailed Year 2012-13 S. No. Detailed of Manpower Total No. Amt. Rs. 1 Class – 1 2 Class – 2 3 Class – 3 4 Class – 4 5 Service out source (Security or House keeping) 6 Total Medical College Laboretory

Medical College Laboretory Financial Progress Report Instrument & Equipment Detailed Year 2008-2013 Medical College Laboretory

Financial Progress Report Instrument & Equipment Detailed Year 2008-09 S. No. Detailed of Instrument & Equipment Amt. Rs. Medical College Laboretory

Financial Progress Report Instrument & Equipment Detailed Year 2009-10 S. No. Detailed of Instrument & Equipment Amt. Rs. Medical College Laboretory

Financial Progress Report Instrument & Equipment Detailed Year 2010-11 S. No. Detailed of Instrument & Equipment Amt. Rs. Medical College Laboretory

Financial Progress Report Instrument & Equipment Detailed Year 2011-12 S. No. Detailed of Instrument & Equipment Amt. Rs. Medical College Laboretory

Financial Progress Report Instrument & Equipment Detailed Year 2012-13 S. No. Detailed of Instrument & Equipment Amt. Rs. Medical College Laboretory

Financial Progress Report Training Detailed Year 2008-2013 Medical College Laboretory

Monthly Financial Progress Report Training Detailed year 2008-09 S. No. Detailed of Training Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Training Detailed year 2009-10 S. No. Detailed of Training Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Training Detailed year 2010-11 S. No. Detailed of Training Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Training Detailed year 2011-12 S. No. Detailed of Training Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Training Detailed year 2012-13 S. No. Detailed of Training Amt. Rs. Medical College Laboretory

Financial Progress Report Operational Detailed Year 2008-2013 Medical College Laboretory

Monthly Financial Progress Report Operational Detailed Year 2008-09 S. No. Detailed of Operational Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Operational Detailed Year 2009-10 S. No. Detailed of Operational Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Operational Detailed Year 2010-11 S. No. Detailed of Operational Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Operational Detailed Year 2011-12 S. No. Detailed of Operational Amt. Rs. Medical College Laboretory

Monthly Financial Progress Report Operational Detailed Year 2012-13 S. No. Detailed of Operational Amt. Rs. Medical College Laboretory

Committee: Quality Improvement Programme Committee Medical College Laboretory

Functioning of the Committees Year 2008-09 S. No. Name of the Committee Functioning (Yes / No) Fix interval of Meeting No. of Meeting Planned No. of Meeting Conducted 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE 3 INFECTION CONTROL COMMITTEE 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee 7 Clinical audit committee 8 GRIEVANCE REDRESSAL COMMITTEE 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) 12 HOSPITAL ETHICS COMMITTEE Medical College Laboretory

Functioning of the Committees Year 2009-10 S. No. Name of the Committee Functioning (Yes / No) Fix interval of Meeting No. of Meeting Planned No. of Meeting Conducted 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE 3 INFECTION CONTROL COMMITTEE 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee 7 Clinical audit committee 8 GRIEVANCE REDRESSAL COMMITTEE 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) 12 HOSPITAL ETHICS COMMITTEE Medical College Laboretory

Functioning of the Committees Year 2010-11 S. No. Name of the Committee Functioning (Yes / No) Fix interval of Meeting No. of Meeting Planned No. of Meeting Conducted 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE 3 INFECTION CONTROL COMMITTEE 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee 7 Clinical audit committee 8 GRIEVANCE REDRESSAL COMMITTEE 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) 12 HOSPITAL ETHICS COMMITTEE Medical College Laboretory

Functioning of the Committees Year 2011-12 S. No. Name of the Committee Functioning (Yes / No) Fix interval of Meeting No. of Meeting Planned No. of Meeting Conducted 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE 3 INFECTION CONTROL COMMITTEE 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee 7 Clinical audit committee 8 GRIEVANCE REDRESSAL COMMITTEE 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) 12 HOSPITAL ETHICS COMMITTEE Medical College Laboretory

Functioning of the Committees Year 2012-13 S. No. Name of the Committee Functioning (Yes / No) Fix interval of Meeting No. of Meeting Planned No. of Meeting Conducted 1 QUALITY IMPROVEMENT COMMITTEE Monthly 2 HOSPITAL SAFETY COMMITTEE 3 INFECTION CONTROL COMMITTEE 4 INFECTION CONTROL TEAM Every 15 days 5 MEDICAL AUDIT COMMITTEE Quarterly 6 Clinical risk management & Adverse drug event committee 7 Clinical audit committee 8 GRIEVANCE REDRESSAL COMMITTEE 9 Sexual harassment committee Monthly & as or when required 10 PHARMACOTHERAPEUTIC COMMITTEE 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) 12 HOSPITAL ETHICS COMMITTEE Medical College Laboretory

Role & Responsibility of Quality Improvement Committees Medical College Laboretory

Role & Responsibility of the: Quality Improvement Committee Scope of Work Function of the Committee Discuss, decide and Issue hospital Policies related to hospital operations and accreditation. This committee shall have representation from management, various clinical and support departments of the Health Care Organization (HCO). The various quality improvement program shall be developed, implemented and maintained in a structured manner. Documentation and review of policies This committee should have good knowledge of accreditation standards, statutory requirements, hospital quality assurance principles and evaluation methodologies, hospital functioning and operations. Define scope of services This shall incorporate the mission, vision, quality policy, quality objectives, service standards, etc. Define and develop quality parameters for clinical and non-clinical activities Quality assurance manual has to be prepared and updated periodically. Set standards and benchmarks for quality parameters The organization shall ensure that the practices are in consonance with good clinical practices. Function as apex committee for monitoring performance indicators / parameters of QMS and medical statistics As quality improvement is a dynamic process, it needs to be reviewed at regular pre-defined intervals (as defined by the HCO in the quality assurance manual) by the multi-disciplinary committee. The review shall also include analysis of key indicators as defined by the standards. Standardization of professional procedures and equipment Hospital management makes available adequate resources required for quality improvement program. Credentialing and Privileging This shall include the men, material, machine and method. These should be in steady supply so as to ensure that the program function smoothly. Frequency of Meeting Monthly Medical College Laboretory

Role & Responsibility of HOSPITAL SAFETY COMMITTEE Scope of Work Function of the Committee Develop and issue Policy on patient, staff, and visitor safety and security The committee will ensure the total hospital safety & security. The committee will bring to the notice of the administration, any gaps observed for the safety and security of hospital staff & the patients and their attendants. Monitor training and implementation A well documented lab safety manual is available in the lab. This takes care of the safety of the workforce as well as the equipment available in the lab. Documented policies and procedures exist to prevent adverse events like wrong site, wrong patient and wrong surgery. Monitor occupational health and safety Policies and procedures guide the use of medical gases. Sentinel events are intensively analyzed and actions should be taken upon the analysis. The organization has an interdisciplinary group assigned to oversee the hospital wide safety program. Frequency of Meeting Monthly Medical College Laboretory

Role & Responsibility of INFECTION CONTROL COMMITTEE Scope of Work Function of the Committee Document and issue infection control manual including policies The hospital has a multi-disciplinary infection control committee. Training for infection control The organization has a well-designed, comprehensive and coordinated hospital infection control (HIC) programme aimed at reducing/eliminating risks to patients, visitors and providers of care. Surveillance for compliance with policies The hospital has an infection control manual, which is periodically updated. Hospital defines the periodicity of updating. Issue antibiotic policy The hospital infection control programme is documented. Monitor Hospital acquired infection The manual should clearly identify the high risk areas of the hospital e.g. ICU, HDU, OT, post-operative ward, blood bank, CSSD, etc. Outbreak control Proper facilities and adequate resources are provided to support the infection control program. Monitor biomedical waste management practices The hospital is authorized by prescribed authority for the management and handling of bio-medical waste. The organization shall ensure that ensure the sterilization procedure is regularly monitored and in the eventuality of a breakdown it has a procedure for withdrawal of such items. Frequency of Meeting Monthly Medical College Laboretory

Role & Responsibility of INFECTION CONTROL TEAM Scope of Work Function of the Committee Surveillance for infection control The hospital should have an infection control team. Data collection on hospital acquired infections The team is responsible for day-to-day functioning of infection control program. They shall support surveillance process and detect outbreaks. Calculation of HAI rates They shall also participate in infection prevention and control on a day-to-day basis. On job training of healthcare staff on infection control practices The hospital has designated and qualified infection control nurse for this activity. Develop report on HAI trends The Infection control team will work together with infection control committee and bring to their notice if any issues have seen related to infection. Monitor infection control practices Frequency of Meeting Every Fifteen days Medical College Laboretory

Role & Responsibility of: MEDICAL AUDIT COMMITTEE Scope of Work Function of the Committee Review and evaluate patient records for quality, adequacy of patient care, monitor staff for compliance with policies Medical staff participates in this system. Evaluate medical record keeping, quality, content, format, accuracy, pertinence, staff compliance with documentation policies The parameters to be audited are defined by the organization. Review and evaluate fatal cases / deaths in hospital. The medical records are reviewed periodically. Evaluate sentinel events related to patient care The review focuses on the timeliness, legibility and completeness of the medical records. Review, evaluate and monitor adverse drug reaction The review process includes records of both active and discharged patients. Review and evaluate cases needing resuscitation An adequate mix of both active and discharged patients should be used. Implementation of Right to Information The review points out and documents any deficiencies in records. Take decisions regarding improvement in clinical quality For example, missing final diagnosis , absence of OT notes in an operated patient , etc. All audits are documented. The actions taken must be documented and oriented to the hospital staff. Frequency of Meeting Quarterly Medical College Laboretory

Function of the Committee Medical College Laboretory Role & Responsibility of Clinical risk management & Adverse drug event committee Scope of Work Function of the Committee Monitor and analyses sentinel events, accidents, and adverse events. Incident Reporting System. Dealing with external bodies and individuals. Deal with Complaints on Professionals management. Risk management policies to reduce actual potential patient risk. Identify trends amongst incident and initiate action Frequency of Meeting Monthly Medical College Laboretory

Role & Responsibility of: Clinical audit committee Scope of Work Function of the Committee Evaluate medical record keeping, quality, content ,format , accuracy, pertinence ,staff compliance The parameters to be audited are defined by the organization. Proper documentation of policy The medical records are reviewed periodically. Review and evaluate fatal cases /Death in hospital The review focuses on the timeliness, legibility and completeness of the medical records. Frequency of Meeting Monthly Medical College Laboretory

Role & Responsibility of: GRIEVANCE REDRESSAL COMMITTEE Scope of Work Function of the Committee To issue policy on grievance redressal Develop a mechanism of handling employee grievances To handle all the employee grievances The committee has to sort out the problem and find out the solution irrespective of the employee and its position. Preventive measures must be taken by the committee not to repeat the same problem in future. The committee must take a unbiased decision and it has to be respected and accepted by the staff without any issue. Frequency of Meeting Monthly Medical College Laboretory

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 Monthly & as or when required Medical College Laboretory

Role & Responsibility of: PHARMACOTHERAPEUTIC COMMITTEE Scope of Work Function of the Committee Develop and issue Policy on formulary and medication management There is a documented policy and procedure for pharmacy services and medication usage. Supervise purchases and procurement Policies and procedures guide the organization of pharmacy services and usage of medication. The policies and procedures shall address the issues related to procurement, storage, formulary, prescription, dispensing, administration, monitoring and use of medications. Supervise and management of pharmacy A list of medication appropriate for the patient's and the organization's resources is developed. Policies and procedures guide the prescription of medications. Monitor and evaluate adverse drug reactions Policies and procedures guide the safe dispensing of medications. Policies and procedures guide the use of narcotic drugs and psychotropic substances. Manage the control of drugs Policies and procedures govern usage of radioactive or investigational drugs. Policies and procedures guide the usage of chemotherapeutic agents. Supervise drug information service Policies and procedures guide the use of implantable prosthesis. Policies and procedures guide the shortage of medication. Frequency of Meeting Monthly Medical College Laboretory

Scope of Work Function of the Committee Role & Responsibility of: Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Scope of Work Function of the Committee Develop policy on prevention, management, and control of emergency situations within and outside the hospital Patient safety aspects and risk management issues are an integral part of patient care and hospital management. Develop plan for handling fire and non fire emergency situation Staff members, students and volunteers are adequately trained on specific job duties or responsibilities related to safety. Ensure orientation of such plan to all The committee will form the policy and provide guidelines for evaluation control and smooth management in case of events. Supervise training and mock drills This committee will rectify the faults in the system and fill up the gaps. The organization has plans for fire and non-fire emergencies within the facilities. Implementation of policy / plan Management ensures implementation of systems for internal and external reporting of system and process failures. Frequency of Meeting Monthly & as or when required Medical College Laboretory

Role & Responsibility of: HOSPITAL ETHICS COMMITTEE Scope of Work Function of the Committee Issue policy on medical ethics 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 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 Review, evaluate and approve cases for clinical research, organ transplant, experimental therapeutics, ethical dilemmas, terminal care 2. Policy Review and Development The committee will assist the hospital and its professional staff in the development of policies and procedures regarding recurrent ethical issues, questions or problems that arise in the care of patients. In this role the committee may provide analysis of the ethical aspects of existing or proposed policy or assist in the development of new institutional policy in areas of need. Any other potential conflict of ethical issues and medical policy and practice 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; decisions involving disagreement between care providers or between providers and patients/families regarding the ethical aspects of a patient’s care; or 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 Monthly Medical College Laboretory

Role & Responsibility of: Biomedical Waste & Scrap Disposal Committee Scope of Work Function of the Committee No objection certificate under Pollution Control Act. Review for No objection certificate under Pollution Control Act. Air (prevention and control of pollution) Act, 1981. Review Air (prevention and control of pollution) Act, 1981. Biomedical waste management handling rules 1998. Review Biomedical waste management handling rules 1998. Hazardous waste management and handling rules Act Review Hazardous waste management and handling rules Act Water Prevention and control of pollution Act Review Water Prevention and control of pollution Act License under Bio-medical Management and handling Rules, 1998. Review License under Bio-medical Management and handling Rules, 1998. Regular Scrap Disposal from the facility Review Regular Scrap Disposal from the facility Frequency of Meeting Monthly Medical College Laboretory

Progress of: Legal license & Act. Medical College Laboretory

Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 Available (Yes / No) Yr 2012-13 Expiry Date 1 Building Permit (From the Municipality). 2 No objection certificate from the Chief Fire Officer. 3 License under Bio-medical Management and handling Rules, 1998. 4 No objection certificate under Pollution Control Act. 5 Radiation Protection Certificate in respect of X-ray equipments from AERB. 6 Excise permit to store Spirit. 7 Narcotics and Psychotropic substances license and Act. 8 Vehicle registration certificates. 9 Air (prevention and control of pollution) Act, 1981. 10 Atomic energy regulatory body approvals. Medical College Laboretory

Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 Available (Yes / No) Yr 2012-13 Expiry Date 11 Biomedical waste management 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) 19 Indian medical council Act and code of medical ethics, 1956. 20 Indian nursing council Act, 1947. Medical College Laboretory

Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 Available (Yes / No) Yr 2012-13 Expiry Date 21 Nurses and Midwives Act, 1953 22 Indian penal code, 1860. 23 Indian trade unions Act, 1926. 24 Maternity benefit Act, 1961. 25 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. Medical College Laboretory

Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 Available (Yes / No) Yr 2012-13 Expiry Date 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. Medical College Laboretory

Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 Available (Yes / No) Yr 2012-13 Expiry Date 41 Hazardous waste management and handling rules Act 42 Dental Council of India 43 Water Prevention and control of 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 Medical College Laboretory

Progress of: Legal license & Act. S. No. Name of the License / Act. Available (Yes / No) in Yr 2007-08 Available (Yes / No) Yr 2012-13 Expiry Date 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. Medical College Laboretory

Progress of: Clinical Indicators Year 2008-2013 Medical College Laboretory

Yearly Progress of: Pre analytical Variables Physician Test Knowledge Appropriateness of Test Selection Physician Test Ordering Patient Preparation Patient Identification 2008-09 2009-10 2010-11 2011-12 2012-13 Total Medical College Laboretory

Yearly Progress of: Pre analytical Variables Specimen Labelling/ Identification Adequacy of specimen information Specimen Collection/Complication of phlebotomy Sample rejection rate Specimen Delivery Processing and Preparation 2008-09 2009-10 2010-11 2011-12 2012-13 Total Medical College Laboretory

Yearly Progress of: Analytical Variables Specimen Analysis Critical value reporting Housekeeping record ( Incidence of sample spillage) Report Review or Verification 2008-09 2009-10 2010-11 2011-12 2012-13 Total Medical College Laboretory

Yearly Progress of: Analytical Variables Results Review Incidence of needle stick & other injuries Quality control (IQC & EQAS) 2008-09 2009-10 2010-11 2011-12 2012-13 Total Medical College Laboretory

Yearly Progress of: Post analytical Variables Turnaround Time Notification of Critical Values Report Accuracy and Completeness Incidence of Typographical error 2008-09 2009-10 2010-11 2011-12 2012-13 Total Medical College Laboretory

Medical College Laboretory Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 Year Report Delivery Physician Follow-up Interpretive Consultation Customer Satisfaction 2008-09 2009-10 2010-11 2011-12 2012-13 Total Medical College Laboretory

Progress of: Clause (ISO 15189:2007) Medical College Laboretory

Progress of: Clause 4:- Management requirement Number of Clause Total No. of Clause Non Compliance (Major) (Minor) Full Compliance 2008-09 2012-13 4.1 Organization and management 4.2 Quality management system 4.3 Document control 4.4 Review of contracts 4.5 Examination by referral laboratories 4.6 External services and supplies 4.7 Advisory services 4.8 Resolution of complaints Medical College Laboretory

Progress of: Clause 4:- Management requirement Number of Clause Total No. of Clause Non Compliance (Major) (Minor) Full Compliance 2008-09 2012-13 4.9 Identification and control of non-conformities 4.10 Corrective action 4.11 Preventive action 4.12 Continued improvement 4.11 Quality and technical records 4.14 Internal audits 4.15 Management reviews Medical College Laboretory

Progress of: Clause 5:- Technical requirements Number of Clause Total No. of Clause Non Compliance (Major) (Minor) Full Compliance 2008-09 2012-13 5.1 Personnel 5.2 Accommodation and environmental condition 5.3 Laboratory equipment 5.4 Pre-examination procedures 5.5 Examination procedures 5.6 Assuring the quality of examination procedures 5.7 post examination procedures 5.8 Reporting of results Medical College Laboretory

Progress of: Clause:- Management requirement Number of Clause Total No. of Clause Non Compliance (Major) (Minor) Full Compliance 2008-09 2012-13 Medical College Laboretory

Medical College Laboretory New initiatives: Medical College Laboretory

List of New Initiatives Medical College Laboretory S.No. List of New Initiatives 1 2 3 4 5 6 7 8 9 10 11 12 Medical College Laboretory

Medical College Laboretory Any Benefit / Harm to your facility due to Quality Improvement Programme (NABH / NABL):- Medical College Laboretory

Medical College Laboretory Any Benefit to your facility due to Quality Improvement Programme (NABH / NABL) S.No. List of Benefits 1 2 3 4 5 6 7 8 9 10 11 12 Medical College Laboretory

Medical College Laboretory Any Harm to your facility due to Quality Improvement Programme (NABH / NABL) S.No. List of Harms 1 2 3 4 5 6 7 8 9 10 11 12 Medical College Laboretory

Medical College Laboretory Other issues: Medical College Laboretory

Medical College Laboretory Other issues S.No. List of issues 1 2 3 4 5 6 7 8 9 10 11 12 Medical College Laboretory

Thanks Quality is a Team work & never achieve by alone Quality Improvement Programme Quality is a Team work & never achieve by alone Thanks Medical College Laboretory