1. NCs Unplugged Dr. Anand R Professor of Pulmonary Medicine
Kasturba Medical College HOSPITAL, MangalURU
Karnataka, India

2. NC-1
No evidence to suggest that the initial assessment of out-patients includes screening for nutritional needs. – AAC 4f
CAHOCON-2016

3. Closure Nutritional screening is now being done for all patients.
Staff have been sensitized and now this is being done for all patients. Please find attached 5 samples.
Staff have ben sensitized and now this is being done for all patients. Please find attached 2 samples from 5 different areas.
CAHOCON-2016

4. NC-2
Evidence to suggest that events during a cardio- pulmonary resuscitation are recorded is found deficient as it is noted that in more than 90% of cases the form is incomplete. – COP 4c
CAHOCON-2016

5. Closure
Re-training has been conducted for all staff and this is now being filled. Relevant samples are attached.
The importance of capturing this has ben explained to all concerned, especially members of the CPR team. 5 filled samples are attached.
The importance of capturing this has ben explained to all concerned, especially members of the CPR team. 5 filled samples are attached. A video is also attached & this shows correlation between what is filled and what has happened.
CAHOCON-2016

6. NC-3
Evidence to suggest that medication orders are dated, timed, named and signed is found lacking. For example, there is no name or time mentioned in the orders of , – MOM 4g
CAHOCON-2016

7. Closure This is now being done for all patients.
All doctors including visiting consultants have been sensitized and now this is being done for all patients. Please find attached 5 samples.
All doctors including visiting consultants sensitized and now this is being done for all patients. Please find attached 2 samples from 5 different areas. Further, please find attached the results of the audit done by the quality team.
CAHOCON-2016

8. NC-4
On review of the organization’s informed consent process it is noted that no side is mentioned in the consent form for pigtail insertion to the chest of dated 18/03/ This is in contradiction to what the organization’s documentation for informed consent states wherein it has ben stated that the side (where applicable) has to be stated. – PRE 4d
CAHOCON-2016

9. Closure It was an oversight and the same has been corrected.
The concerned consultant has been counselled and in the documentation, stating the side has been made optional. Refer to the attached sample.
The organization has conducted a training programme for all its consultants and duty doctors. The issues with respect to consent were discussed and it was agreed that no change in documentation is required. Quality department now conducts audits once in every 15 days and please find attached the results of the last audit.
CAHOCON-2016

10. NC-5
Evidence to suggest that the antibiotic policy is adhered to is found lacking. For example, based on interview of the infection control officer (and also based on the data presented as a part of indicators) it is noted that the best compliance has been only 20%. Further, it is noted that there is no antibiotic policy for any urological surgery. - HIC 2g
CAHOCON-2016

11. Closure
Urology has been included in documentation. The policy is now being adhered to 100%. Representative samples (5) are attached.
The documentation has been revised extensively after review of literature & urology has been included. The quality department is monitoring adherence to this. OE of document change and samples from 5 case sheets are attached.
CAHOCON-2016

12. Closure
The documentation has been revised extensively after review of literature & consultation with doctors and infection control experts. Departments which were excluded including urology have been included. Organization has decided to identify a consultant/department as “champion” on a monthly basis. The quality department has been monitoring adherence to this on a weekly basis for the past 1 month and this has shown an improvement to 70%. The endeavor will be continued and henceforth the quality department will be monitoring this on a monthly basis.
CAHOCON-2016

13. NC-6
Although “audit” of patient care services is being done it is noted that the parameters to be audited are not defined by the organisation keeping in mind all the requirements of this standard. The present “audit parameters” appear to be more like “research questions”. – CQI 6b
CAHOCON-2016

14. Closure The audit has been done as per the guidance provided by NABH.
The quality team has taken a re-look at all the clinical audit topics and has modified the same as per the guidance provided by NABH. Refer to attached the clinical audit sample.
CAHOCON-2016

15. Closure
The organization has formed a clinical audit team with representation from clinical side, nursing side, administrators and quality. The team will be coordinating with clinicians and nurses to ensure that the audit is done as per the guidance laid down. 3 of the staff have completed training in clinical audit and over the next 6 months another 7 will complete the training. Please find attached a clinical audit protocol sample. Data is being collected as per the protocol. Aim has been defined with the objectives laid down. Standards have been clearly defined stating the criteria and target.
CAHOCON-2016

16. NC-7
On review of the organization’s compliance with the laid down and applicable legislations and regulations it is noted that the organization is yet to get its renewed authorisation for MTP. The previous one expired on 31st December. The letter has been sent only on 16th March – ROM 2a
CAHOCON-2016

17. Closure
The renewal has been obtained and the same is submitted for reference.
The renewal has been obtained and a mechanism has been put in place to ensure that this does not recur.
The organization has prepared a matrix listing the various statutory requirements, the date on which it was obtained, the date on which it is due for renewal and where applicable the date by which the application for renewal has been sent. The renewed MTP authorization and the “statutory matrix” are attached for reference.
CAHOCON-2016

18. NC-8
Evidence to suggest that the organization has a documented safe exit plan in case of fire and non- fire emergencies for all areas is found lacking For example, upper basement area. – FMS 6b
CAHOCON-2016

19. Closure Safe exit plan was present. The same has been attached.
The organization has a safe exit plan for all areas of the hospital. During the assessment, since it was being modified it was removed from the area and it has now been replaced. OE is attached.
CAHOCON-2016

20. Closure
The organization has a safe exit plan for all areas of the hospital which is now displayed in every area. After the assessment, the organization has got an external audit done wherein aspects of signage, availability of functional fire- fighting material and mock drills have been checked. OE of the display of upper basement area and results of the external audit are attached.
CAHOCON-2016

21. NC-9 The organisation is not providing induction training. – HRM 2c
CAHOCON-2016

22. NC-9
Although induction training is provided by the organization, evidence to suggest that all eligible staff are trained is found lacking. For example, as against 23 staff who had to be provided induction training by March 15th (based on the hospital’s policy of providing induction training to all staff who have joined in the previous 2 weeks) only 6 have been provided training. – HRM 2c
CAHOCON-2016

23. Closure All staff have been trained. OE is attached
All staff have been trained. After reviewing the documentation it was decided that henceforth it will be done within one month of joining. OE is attached
All staff have been trained. After reviewing the documentation it was decided that henceforth it will be done within one month of joining. The HR department has included adherence to the induction training schedule as one of its objective and this data will be discussed with the management every 6 months.
CAHOCON-2016

24. NC-10
After the medical record audit, evidence to suggest that appropriate corrective and preventive measures are undertaken within a defined period of time and are documented is found deficient. – IMS 7g
CAHOCON-2016

25. Closure
All deficiencies pointed out in the previous audit have been closed.
All deficiencies pointed out in the previous audit have been closed. Henceforth a copy of the closure report will be sent to quality.
CAHOCON-2016

26. Closure
All deficiencies pointed out in the previous audit have been closed. Since an analysis revealed that the reason for this was lack of what the audit team was supposed to do, they have now specifically been provided training on the same. OEs in the form of closure report of previous audit findings, training record and training effectiveness are submitted.
CAHOCON-2016

27. CAHOCON-2016