1. CoH 1 1 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Quality Improvement Programme Yearly (2008-13) Progress Report of Quality Improvement Programme Dr ……………………………... Superintendent Medical College Hospital, Government of Gujarat ………………………………………………………………………. Email & Mobile No:………………………………………………… Blood Bank

2. CoH 2 2 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report (Expenditure with Utilization Certificate) Blood Bank

3. CoH 3 3 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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. 12008-09 22009-10 32010-11 42011-12 52012-13 Total Blood Bank

4. CoH 4 4 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Infrastructure Detailed Year 2008-2013 Blood Bank

5. CoH 5 5 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of InfrastructureAmt. Rs. Financial Progress Report Infrastructure Detailed Year 2008 - 09 Blood Bank

6. CoH 6 6 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of InfrastructureAmt. Rs. Financial Progress Report Infrastructure Detailed Year 2009 - 10 Blood Bank

7. CoH 7 7 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of InfrastructureAmt. Rs. Financial Progress Report Infrastructure Detailed Year 2010 - 11 Blood Bank

8. CoH 8 8 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of InfrastructureAmt. Rs. Financial Progress Report Infrastructure Detailed Year 2011 - 12 Blood Bank

9. CoH 9 9 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of InfrastructureAmt. Rs. Financial Progress Report Infrastructure Detailed Year 2012 - 13 Blood Bank

10. CoH 10 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Manpower Detailed Year 2008-2013 Blood Bank

11. CoH 11 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Manpower Detailed Year 2008-09 S. No. Detailed of ManpowerTotal No.Amt. Rs. 1Class – 1 2Class – 2 3Class – 3 4Class – 4 5Service out source (Security or House keeping) 6Total Blood Bank

12. CoH 12 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Manpower Detailed Year 2009-10 S. No. Detailed of ManpowerTotal No.Amt. Rs. 1Class – 1 2Class – 2 3Class – 3 4Class – 4 5Service out source (Security or House keeping) 6Total Blood Bank

13. CoH 13 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Manpower Detailed Year 2010-11 S. No. Detailed of ManpowerTotal No.Amt. Rs. 1Class – 1 2Class – 2 3Class – 3 4Class – 4 5Service out source (Security or House keeping) 6Total Blood Bank

14. CoH 14 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Manpower Detailed Year 2011-12 S. No. Detailed of ManpowerTotal No.Amt. Rs. 1Class – 1 2Class – 2 3Class – 3 4Class – 4 5Service out source (Security or House keeping) 6Total Blood Bank

15. CoH 15 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Manpower Detailed Year 2012-13 S. No. Detailed of ManpowerTotal No.Amt. Rs. 1Class – 1 2Class – 2 3Class – 3 4Class – 4 5Service out source (Security or House keeping) 6Total Blood Bank

16. CoH 16 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Instrument & Equipment Detailed Year 2008-2013 Blood Bank

17. CoH 17 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of Instrument & EquipmentAmt. Rs. Financial Progress Report Instrument & Equipment Detailed Year 2008-09 Blood Bank

18. CoH 18 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of Instrument & EquipmentAmt. Rs. Financial Progress Report Instrument & Equipment Detailed Year 2009-10 Blood Bank

19. CoH 19 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of Instrument & EquipmentAmt. Rs. Financial Progress Report Instrument & Equipment Detailed Year 2010-11 Blood Bank

20. CoH 20 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of Instrument & EquipmentAmt. Rs. Financial Progress Report Instrument & Equipment Detailed Year 2011-12 Blood Bank

21. CoH 21 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of Instrument & EquipmentAmt. Rs. Financial Progress Report Instrument & Equipment Detailed Year 2012-13 Blood Bank

22. CoH 22 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Training Detailed Year 2008-2013 Blood Bank

23. CoH 23 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of TrainingAmt. Rs. Monthly Financial Progress Report Training Detailed year 2008-09 Blood Bank

24. CoH 24 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of TrainingAmt. Rs. Monthly Financial Progress Report Training Detailed year 2009-10 Blood Bank

25. CoH 25 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of TrainingAmt. Rs. Monthly Financial Progress Report Training Detailed year 2010-11 Blood Bank

26. CoH 26 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of TrainingAmt. Rs. Monthly Financial Progress Report Training Detailed year 2011-12 Blood Bank

27. CoH 27 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of TrainingAmt. Rs. Monthly Financial Progress Report Training Detailed year 2012-13 Blood Bank

28. CoH 28 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Financial Progress Report Operational Detailed Year 2008-2013 Blood Bank

29. CoH 29 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of OperationalAmt. Rs. Monthly Financial Progress Report Operational Detailed Year 2008-09 Blood Bank

30. CoH 30 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of OperationalAmt. Rs. Monthly Financial Progress Report Operational Detailed Year 2009-10 Blood Bank

31. CoH 31 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of OperationalAmt. Rs. Monthly Financial Progress Report Operational Detailed Year 2010-11 Blood Bank

32. CoH 32 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of OperationalAmt. Rs. Monthly Financial Progress Report Operational Detailed Year 2011-12 Blood Bank

33. CoH 33 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat S. No.Detailed of OperationalAmt. Rs. Monthly Financial Progress Report Operational Detailed Year 2012-13 Blood Bank

34. CoH 34 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Committee: Quality Improvement Programme Committee Blood Bank

35. CoH 35 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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 1QUALITY IMPROVEMENT COMMITTEEMonthly 2HOSPITAL SAFETY COMMITTEEMonthly 3INFECTION CONTROL COMMITTEEMonthly 4INFECTION CONTROL TEAMEvery 15 days 5MEDICAL AUDIT COMMITTEEQuarterly 6 Clinical risk management & Adverse drug event committee Monthly 7Clinical audit committeeMonthly 8GRIEVANCE REDRESSAL COMMITTEEMonthly 9Sexual harassment committee Monthly & as or when required 10PHARMACOTHERAPEUTIC COMMITTEEMonthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12HOSPITAL ETHICS COMMITTEEMonthly Blood Bank

36. CoH 36 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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 1QUALITY IMPROVEMENT COMMITTEEMonthly 2HOSPITAL SAFETY COMMITTEEMonthly 3INFECTION CONTROL COMMITTEEMonthly 4INFECTION CONTROL TEAMEvery 15 days 5MEDICAL AUDIT COMMITTEEQuarterly 6 Clinical risk management & Adverse drug event committee Monthly 7Clinical audit committeeMonthly 8GRIEVANCE REDRESSAL COMMITTEEMonthly 9Sexual harassment committee Monthly & as or when required 10PHARMACOTHERAPEUTIC COMMITTEEMonthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12HOSPITAL ETHICS COMMITTEEMonthly Blood Bank

37. CoH 37 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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 1QUALITY IMPROVEMENT COMMITTEEMonthly 2HOSPITAL SAFETY COMMITTEEMonthly 3INFECTION CONTROL COMMITTEEMonthly 4INFECTION CONTROL TEAMEvery 15 days 5MEDICAL AUDIT COMMITTEEQuarterly 6 Clinical risk management & Adverse drug event committee Monthly 7Clinical audit committeeMonthly 8GRIEVANCE REDRESSAL COMMITTEEMonthly 9Sexual harassment committee Monthly & as or when required 10PHARMACOTHERAPEUTIC COMMITTEEMonthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12HOSPITAL ETHICS COMMITTEEMonthly Blood Bank

38. CoH 38 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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 1QUALITY IMPROVEMENT COMMITTEEMonthly 2HOSPITAL SAFETY COMMITTEEMonthly 3INFECTION CONTROL COMMITTEEMonthly 4INFECTION CONTROL TEAMEvery 15 days 5MEDICAL AUDIT COMMITTEEQuarterly 6 Clinical risk management & Adverse drug event committee Monthly 7Clinical audit committeeMonthly 8GRIEVANCE REDRESSAL COMMITTEEMonthly 9Sexual harassment committee Monthly & as or when required 10PHARMACOTHERAPEUTIC COMMITTEEMonthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12HOSPITAL ETHICS COMMITTEEMonthly Blood Bank

39. CoH 39 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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 1QUALITY IMPROVEMENT COMMITTEEMonthly 2HOSPITAL SAFETY COMMITTEEMonthly 3INFECTION CONTROL COMMITTEEMonthly 4INFECTION CONTROL TEAMEvery 15 days 5MEDICAL AUDIT COMMITTEEQuarterly 6 Clinical risk management & Adverse drug event committee Monthly 7Clinical audit committeeMonthly 8GRIEVANCE REDRESSAL COMMITTEEMonthly 9Sexual harassment committee Monthly & as or when required 10PHARMACOTHERAPEUTIC COMMITTEEMonthly 11 Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Monthly & as or when required 12HOSPITAL ETHICS COMMITTEEMonthly Blood Bank

40. CoH 40 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of Quality Improvement Committees Blood Bank

41. CoH 41 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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 MeetingMonthly Role & Responsibility of the: Quality Improvement Committee Blood Bank

42. CoH 42 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of HOSPITAL SAFETY COMMITTEE Scope of WorkFunction 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 MeetingMonthly Blood Bank

43. CoH 43 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of INFECTION CONTROL COMMITTEE Scope of WorkFunction 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 updation. Issue antibiotic policyThe 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 MeetingMonthly Blood Bank

44. CoH 44 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of INFECTION CONTROL TEAM Scope of WorkFunction 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 MeetingEvery Fifteen days Blood Bank

45. CoH 45 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of: MEDICAL AUDIT COMMITTEE Scope of WorkFunction 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 InformationThe 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 MeetingQuarterly Blood Bank

46. CoH 46 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of Clinical risk management & Adverse drug event committee Scope of WorkFunction 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 MeetingMonthly Blood Bank

47. CoH 47 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Role & Responsibility of: Clinical audit committee Scope of WorkFunction 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 MeetingMonthly Blood Bank

48. CoH 48 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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. To handle all the employee grievances 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. To issue policy on grievance redressal Frequency of MeetingMonthly Role & Responsibility of: GRIEVANCE REDRESSAL COMMITTEE Blood Bank

49. CoH 49 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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 MeetingMonthly & as or when required Role & Responsibility of: Sexual harassment committee Blood Bank

50. CoH 50 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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 MeetingMonthly Role & Responsibility of: PHARMACOTHERAPEUTIC COMMITTEE Blood Bank

51. CoH 51 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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 MeetingMonthly & as or when required Role & Responsibility of: Disaster management committee & EMERGENCY PREPAREDNESS COMMITTEE (FIRE & NON FIRE) Blood Bank

52. CoH 52 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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 MeetingMonthly Role & Responsibility of: HOSPITAL ETHICS COMMITTEE Blood Bank

53. CoH 53 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Scope of WorkFunction 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 MeetingMonthly Role & Responsibility of: Biomedical Waste & Scrap Disposal Committee Blood Bank

54. CoH 54 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Legal license & Act. Blood Bank

55. CoH 55 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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. Blood Bank

56. CoH 56 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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. Progress of: Legal license & Act. Blood Bank

57. CoH 57 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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. Blood Bank

58. CoH 58 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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. Progress of: Legal license & Act. Blood Bank

59. CoH 59 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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 Progress of: Legal license & Act. Blood Bank

60. CoH 60 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat 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. Progress of: Legal license & Act. Blood Bank

61. CoH 61 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clinical Indicators Year 2008-2013 Blood Bank

62. CoH 62 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 YearTotal Blood Collection Voluntary ( % )No of Blood Donation Camps 2008-09 2009-10 2010-11 2011-12 2012-13 Total Blood Bank

63. CoH 63 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat YearWaiting Period for Donors ( In Minutes ) Adverse Donors Reaction Issue of Components Turn Around Time for issue of blood ( In Minutes ) 2008-09 2009-10 2010-11 2011-12 2012-13 Total Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 Blood Bank

64. CoH 64 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat YearDiscard of Components Feedback of CliniciansBlood Transfusion Reaction Quality Parameters of Components 2008-09 2009-10 2010-11 2011-12 2012-13 Total Yearly Progress of: Graphical representation of Clinical Indicators from April 2008 – Jan 2013 Blood Bank

65. CoH 65 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: NABH Progress of Blood Bank Blood Bank

66. CoH 66 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 1. ORGANISATION AND MANAGEMENT Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 1.1 Legal Identity 1.2 Responsibility 1.3 Ethics in blood bank/ blood centre 1.4 Quality System 1.5 Policies, processes and Procedures Blood Bank

67. CoH 67 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 2. ACCOMMODATION AND ENVIRONMENT Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 2.1 Space Allocation 2.2 Environment Control 2.3 Biological, Chemical and Radiation Safety 2.4 Internal Communication System Blood Bank

68. CoH 68 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 3. Personal Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 3.1 Personnel Requirement 3.2 Qualification 3.3 Job description/ responsibilities 3.4 Responsibilities of Director/ In charge / Medical Officer; Quality Manager &Technical Manager 3.5 Training 3.6 Competence 3.7 Personnel Health 3.8 Personnel Records 3.9 Confidentiality of Information Blood Bank

69. CoH 69 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 4. EQUIPMENT Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 4.1 Equipment requirement 4.2 Selection and validation of Equipment 4.3 Use of equipment 4.4 Equipment detail record, unique Identification 4.5 Programme for calibration and maintenance of equipment 4.6 Equipment for storage of blood and component 4.7 Computer system 4.8 Breakdown of equipment Blood Bank

70. CoH 70 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 5. EXTERNAL SERVICES AND SUPPLIES Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 5.1 Policies and procedures for supplier’s selection 5.2 Inventory control 5.3 Evaluation of suppliers Blood Bank

71. CoH 71 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 6. PROCESS CONTROL Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 6.1 Policies and validation of processes and procedures 6.2 Donor Section 6.3 Component Laboratory 6.4 Quarantine and Storage 6.5 Labeling 6.6 Testing of Donated Blood 6.7 Compatibility Testing 6.8 Transfusion Reaction and Evaluation Blood Bank

72. CoH 72 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 6. PROCESS CONTROL Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 6.9 Documentation in Transfusion Service 6.10 Histocompatibility Testing 6.11 Quality Control 6.12 Proficiency Testing Programme 6.13 Bio-medical waste disposal and laboratory safety in blood bank/ blood centre Blood Bank

73. CoH 73 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 7. IDENTIFICATION OF DEVIATIONS AND ADVERSE EVENTS Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 7.1 Policies and procedures when nonconformity is detected 7.2 Procedure for release of nonconforming blood component 7.3 Preventing recurrence of nonconformity Blood Bank

74. CoH 74 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 8. PERFORMANCE IMPROVEMENT Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 8.1 Addressing Complaints 8.2 Corrective action 8.3 Preventive action Blood Bank

75. CoH 75 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 9. DOCUMENT CONTROL Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 9.1 Procedure for document control and review of documents 9.2 Document required 9.3 Maintenance of documents in computer software Blood Bank

76. CoH 76 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 10. RECORDS Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 The blood bank/ blood centre shall have implemented policy for keeping and retaining of records and may include: 1. record identification: all records relevant to the quality Management system shall be uniquely identified with appropriately labelled. 2. quality and technical records: quality records as well as technical records that may include original observation, calibration record, staff record, Blood Bank

77. CoH 77 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Progress of: Clause 11. INTERNAL AUDIT & MANAGEMENT REVIEW Number of Clause Total No. of Clause Non Compliance (Major) Non Compliance (Minor) Full Compliance 2008-092012-132008-092012-132008-092012-13 Policy for internal audit and management review 11.2 Procedure of internal audit 11.3 Procedure of management review 11.4 Documentation of internal audit and management review Blood Bank

78. CoH 78 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat New initiatives: Blood Bank

79. CoH 79 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat New Initiatives Blood Bank S.No.List of New Initiatives 1 2 3 4 5 6 7 8 9 10 11 12

80. CoH 80 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Any Benefit / Harm to your facility due to Quality Improvement Programme (NABH / NABL):- Blood Bank

81. CoH 81 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Any Benefit to your facility due to Quality Improvement Programme (NABH / NABL) Blood Bank S.No.List of Benefits 1 2 3 4 5 6 7 8 9 10 11 12

82. CoH 82 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Any Harm to your facility due to Quality Improvement Programme (NABH / NABL) Blood Bank S.No.List of Harms 1 2 3 4 5 6 7 8 9 10 11 12

83. CoH 83 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Other issues: Blood Bank

84. CoH 84 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Other issues Blood Bank S.No.List of issues 1 2 3 4 5 6 7 8 9 10 11 12

85. CoH 85 www.gujhealth.gov.inHealth & Family Welfare, Govt of Gujarat Quality Improvement Programme Thanks Quality is a Team work & never achieve by alone Blood Bank