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

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

3. 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 2 3 4 5
Total
Medical College Laboretory

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

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

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

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

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

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

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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Medical College Laboretory
Financial Progress Report Instrument & Equipment Detailed Year
Medical College Laboretory

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

34. Committee: Quality Improvement Programme Committee
Medical College Laboretory

35. 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

36. 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

37. 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

38. 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

39. 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

40. Role & Responsibility of Quality Improvement Committees
Medical College Laboretory

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. 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

54. Progress of: Legal license & Act.
Medical College Laboretory

55. Progress of: Legal license & Act.
S. No.
Name of the License / Act.
Available (Yes / No) in Yr
Available (Yes / No) Yr
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

56. Progress of: Legal license & Act.
S. No.
Name of the License / Act.
Available (Yes / No) in Yr
Available (Yes / No) Yr
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

57. Progress of: Legal license & Act.
S. No.
Name of the License / Act.
Available (Yes / No) in Yr
Available (Yes / No) Yr
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

58. Progress of: Legal license & Act.
S. No.
Name of the License / Act.
Available (Yes / No) in Yr
Available (Yes / No) Yr
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

59. Progress of: Legal license & Act.
S. No.
Name of the License / Act.
Available (Yes / No) in Yr
Available (Yes / No) Yr
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

60. Progress of: Legal license & Act.
S. No.
Name of the License / Act.
Available (Yes / No) in Yr
Available (Yes / No) Yr
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

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

62. Yearly Progress of: Pre analytical Variables
Physician Test
Knowledge
Appropriateness
of Test Selection
Physician
Test
Ordering
Patient
Preparation
Patient Identification
Total
Medical College Laboretory

63. 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
Total
Medical College Laboretory

64. Yearly Progress of: Analytical Variables
Specimen Analysis
Critical value reporting
Housekeeping record
( Incidence of sample spillage)
Report Review or Verification
Total
Medical College Laboretory

65. Yearly Progress of: Analytical Variables
Results Review
Incidence of needle stick & other injuries
Quality control (IQC & EQAS)
Total
Medical College Laboretory

66. Yearly Progress of: Post analytical Variables
Turnaround Time
Notification of Critical Values
Report Accuracy and Completeness
Incidence of Typographical error
Total
Medical College Laboretory

67. 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
Total
Medical College Laboretory

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

69. Progress of: Clause 4:- Management requirement
Number of Clause
Total No. of Clause
Non Compliance
(Major)
(Minor)
Full Compliance
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

70. Progress of: Clause 4:- Management requirement
Number of Clause
Total No. of Clause
Non Compliance
(Major)
(Minor)
Full Compliance
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

71. Progress of: Clause 5:- Technical requirements
Number of Clause
Total No. of Clause
Non Compliance
(Major)
(Minor)
Full Compliance
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

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

73. Medical College Laboretory
New initiatives:
Medical College Laboretory

74. 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

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

76. 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

77. 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

78. Medical College Laboretory
Other issues:
Medical College Laboretory

79. 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

80. 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