LIST OF CONTENTS

ABSTRACT
 Introduction Of LCH
 Scope Of Services
a) Services
b) Outsource services
c) Bed distribution
d) Visit timings
 Emergency Department
a) Scope of services
b) Goals
c) Policy
d) Procedure
 Pharmacy
a) Policy
b) Objective
c) Scope
d) Responsibility
e) Forms and formats
f) Efficiency criteria
g) Documentation and reporting
 Front office
a) Purpose
b) Responsibility
c) Procedure
d) Display
e) Admission Policy
f) Efficiency Criteria
g) Discharge Policy
[1]
 IPD
a) Purpose
b) Scope
c) Policy
d) Initial assessment
e) Reassessment
 MRD
a) Purpose
b) Policy
c) Responsibility
d) Procedure
e) Forms and formats
f) Efficiency criteria
g) Medical certification
h) Form no. 4
i) Form no. 2
j) Record retention and destruction
 HRD
a) Purpose
b) Scope
c) Abbreviations
d) Policies
e) Workforce planning
f) Manpower Planning
g) Induction Policy
h) Training policy
i) Attendance and working hours
j) Employee rights and responsibility
k) Procedure
l) Employee personal record
m) Duty hours and shift
n) Promotion
o) Grievance redresses
p) Hospital safety
 CQI
a) Purpose
b) Scope
c) Responsibility
[2]
d) Definition
e) ‘reference
f) Policy
g) Quality policy
h) Procedure
i) Internal communication
j) Documentation
k) Preventive action
l) Corrective action
m) Key indicators

[3]
INTRODUCTION TO LCH

Fig: LIFE CARE HOSPITAL

ABOUT LCH:
Life Care Hospital cares for human lives in every possible way. Located
at Booti More, Ranchi, Jharkhand, it is a multi-specialty, state-of-the-art
hospital offering 24x7x365 world-class Orthopaedics, Plastic Surgery
and Trauma Surgery treatments to patients from Jharkhand, Bihar,
Chhattisgarh and West Bengal. It has created a niche in the field of
complex Trauma and Plastic Surgery. Helmed by young, energetic, and
committed surgeon Dr. Rajnish Kumar, it is dedicated to providing the
best possible care and treatment to patients from the local and rural
areas at the lowest possible cost.

Life Care Hospital Ranchi is also known for its team of Pediatric
Ophthalmologists. The Pediatric Ophthalmology services at Life Care
are equipped to provide the best possible care for children’s eye
problems. The team diagnoses and treats children suffering from simple
eye diseases or complex vision-related problems, and they are well
trained in minimally invasive squint procedures, sutureless squint
correction, and adjustable squint surgeries.

[4]
Scope of Services
Life Care Hospital is a Multi Specialty Hospital. All patients suffering from diseases
and injuries are treated here.
Address and Location:
Near Shivaji Nagar Booty More- 824009

Staff Strength:
143( total)
Services:
1. OPD : Daily from 12:00 PM to 7:00 PM
Prior Appointment is necessary for all patient
(Emergency and Outstation patients are exempted from prior appointment however
exemption is limited and require prior approval of the chief Orthopedic surgeon).
2. IPD: If the patient come with complain that matches our Scope of services can
admitted here. Admission is done after the orders of the treating doctor &
consenting patient.
3. OT Services.
4. Laboratory Services.
5. Physiotherapy & Rehabilitation
6. X-Ray
7. BMD Dexa Scan
8. ICU/HDU/NICU
9. Opthalmology
Support Services (Out Sourced)
1. Security Services
2. Sanitation & House keeping
3. Laundry
4. Kitchen and Canteen
5. Biomedical Waste Management
6. Pest control
7. CT scan and MRI
8. Ambulance

[5]
Bed Distribution

S.N Type of Room No of Number of Beds

Rooms (49)

1 Deluxe Rooms 4 4

2 Super Deluxe 2 2
Rooms
3 Twin sharing 2 4

4 Triple sharing 2 4

5 General Ward 3 17

6 ICU 1 4

7 HDU 1 6

8 NICU 1 3

9 Emergency 1 5

[6]
SERVICE NAME CONSULTANT TIMINGS

ORTHOPEDICS Dr. Rajnish Kumar 10:00 AM TO 5:00

(MBBS, MS) PM

OPHTHALMOLOG Dr. Hemlata Bharti 11:00 AM TO 5:00

Y (MBBS, MS ) PM

GYNECOLOGY Dr. Akhaori Tripti 11:00 AM TO 2:00

Prakash PM
(MBBS, DGO, Obs
and Gynecology)

GENERAL/ Dr. Alok Chandra 10:00 AM TO 12:00

LAPAROSCOPIC Prakash PM
SURGERY (MBBS, MS, General
and Lap)

GENERAL Dr. Kunal Raj 10:00 AM TO 5:00

MEDICINE ( MBBS, MD),Dr. PM
JAI SHANKAR
(MBBS, DIP-CARD)

PAEDIA Dr. Ranjeet Kumar 12:30 PM TO 5:00

(MBBS, MD) PM
PLASTIC Dr. Vivek Goswami 11:00 AM TO 2:00
SURGERY ( MBBS, MS, MCH) PM

[7]
Different Departments of Life Care Hospital and their
work:

ER department
Pharmacy
Front Office
IPD
MRD
HRD
Quality Department

 During my internship in LIFE CARE HOSPITAL I

worked in above mentioned departments.

[8]
STANDARD OPERATING PROCEDURE
(EMERGENCY DEPARTMENT)

TITLE:
Scope of Services at Emergency Department of LCH

a. Emergency Department would provide a comprehensive emergency

service to all patients presenting to the department on 24*7 bases.
b. The department would accept patients of all age groups and they would
receive emergency care and referral as necessary.

GOALS
1) To provide priority care for individuals who require immediate medical
attention as per triage guidelines.
2) To provide rapid resuscitation, stabilization and referral of critically ill
patients.
3) To provide necessary definitive medical care to stabilize an emergency
condition within discretion of the doctor doing screening of patients.
4) To provide continuity in care through mechanisms for admission, treat-
ment, discharge and or referral to another facility.
5) To ensure that all the patients coming to emergency are assessed by
qualified individuals.
6) To provide Pre-hospital care by serving as base station for referral
transport services.

Scope of services in Emergency Dept. Of LCH Hospital

1. Injury
ORTHOPEDICS
2. Road Traffic Accident (RTA)
3. Poly Trauma
4. Fracture
5. MLC CASES

[9]
TITLE:
RECEIVING OF THE PATIENT IN EMERGENCY DEPARTMENT

PURPOSE:
To avoid delay in treatment of critical patients and to facilitate their safe
transfer inside emergency department.

SCOPE:
Clinical Care Areas

RESPONSIBILITY:
On duty staff at entrance of emergency. (Strecher bearers)

PROCEDURE:

 Receiving area at emergency department is ensured of the availability

of wheelchairs and stretchers.
 Whenever a non-ambulatory patient reaches near the emergency door,
on duty staff on the gate shifts the patient on stretcher or wheelchair de-
pending on patient’s condition and shift the patient inside to the consul-
tation area.
 In case of walk-in patients, patients walk in directly to the consultation
area.
 Doctor on duty immediacy attends and examines the patient with nurs-
ing officer.
 After stabilizing the patient (as the case may be) an accident and emer-
gency registration card is made for the patient.

CONCEPT OF GOLDEN HOUR.

GOLDEN HOUR: ‘The first hour after injury largely determines a
critically-injured person’s chances for survival, it is also known as the
Golden Time.

a. It is the time period which can range from a few minutes to a few
hours, i.e. not necessarily one hour, but the amount of time which fol-
[10]
lows a traumatic injury sustained; during which there is highest likeli-
hood that prompt medical treatment will prevent death.
b. During this time period, the possibility of saving one’s life is the high-
est through emergency medical treatment. Special trauma centres and
many other emergency medical services are designed just because of
this reason and to make sure that the injured person is properly treated
in the case.
c. Death following Trauma generally occurs due to a shock. Major causes
include internal bleeding leading to hemorrhage shock. It is crucial to
provide proper and instant medical help to someone in dire need of it. If
the injury can be treated on time, the blood flow controlled and blood
pressure restored in that course of time, a life can be saved.
d. Since the patient is in a state of shock, a well trained medical practi-
tioner can provide the help they need and that can be vital in saving
their life.

2. Registration of the patient in emergency dept.

Registration done in Reception Area

[11]
STANDARD OPERATING PROCEDURE
(PHARMACY)

TITLE:
Overall organization of LCH Pharmacy services

PURPOSE:
To provide guide lines for the organization of pharmacy services for efficient
and safe delivery of healthcare services. LCH pharmacy services, includes
procurement, storage and distribution of drugs

OBJECTIVES:
To make available all the drugs at all times required for patient care through
evidence based scientific management practices.

SCOPE:
All activities and areas in a health facility (Hospital) concerned with
procurement, storage, use and disposal of drugs.

RESPONSIBILITY:
 Head of the Institute
 DTC
 Departmental Heads
 Purchase Officer
 Officer in-charge MAIN DRUG STORE
 Pharmacist in-charge MAIN DRUG STORE
 Officer in-charge OPD Pharmacy
 Pharmacist in-charge OPD Pharmacy
 Nursing Sister in-charges of Department sub-stores.

PROCEDURE:
1. The overall management of pharmacy services in LCH shall be a coor-
dinated activity involving the DTC, Purchase officer, Officer in-charge
Main drug Store, all Heads of departments, Pharmacist in-charge Main
drug Store and Pharmacy, Nursing Sister in-charges of different wards
[12]
and sub stores. They will all work under the guidance of the Head of
the Institute.
2. The Pharmacy shall comply with the following laws and regulations:
Drugs and Cosmetics Act; Narcotics and Psychotropic Substances Act;
Drugs and Magic Remedies Act.
3. The principles enunciated in the Drug Policy of Government of NCT of
Delhi, 1994 (or any revision) shall be followed in the health facility
4. Only drugs as included in the Essential Drugs (medicines) List of Gov-
ernment of NCT of Delhi will be procured and used. In addition the
health facility may specify other drugs which they specifically require
for the patients. This will be decided by the Drug & Therapeutic Com-
mittee (DTC) and justification for the same will have to be given. In-
clusion of drugs must be based on their efficacy, safety, suitability and
cost.
5. LCH's DTC shall annually review the appropriateness of the health fa-
cility drug list to meet the needs of the health facility. The DTC will
form the core group for coordinating all activities related to rational use
of medicines in the health facility.
6. Scientific and rational principles (evidence based criteria and cost ef-
fectiveness) will be followed for selecting the list of essential
medicines for the health facility, estimating quantities of medicines re-
quired, storage, dispensing, prescribing, administering and use of
medicines.
7. Documentation of all aspects related to the drug management cycle
must be in place there and the records must be maintained preferably
electronically. These must be audited regularly by Officers appointed
by the Head of the Institute.
8. The Main Drug store to make a comprehensive annual demand list for
medicines based on previous consumption & the list to be vetted by
DTC, concerned HOD and to be finally approved by the Medical super-
intendent.
9. A system for providing updated information in relation to drugs, to the
doctors, nurses, pharmacists, should be readily available within the

[13]
health facility. Electronically available, peer reviewed sources of drug
information can be used for the same.
10. The policies and processes of the health facility as regards the
drug supply and their use cycle must be informed to all the health care
providers within the health facility
11. A system for continuous monitoring of the drugs supply use cycle
in the health facility must be established. The DTC must coordinate the
monitoring within the LCH. Regular review, with an analysis of the
strengths and weaknesses of the drug supply use cycle in the LCH must
be done and corrective action should be taken for further improvement
from time to time.
12. Standard Operating Procedures as specified for procurement, stor-
age, distribution, and dispensing, prescribing, administering, disposal
of drugs must be strictly followed.
13. All processes must be followed, to ensure that patients receive ap-
propriate drugs for their medical illness and do not suffer any harm.

Forms and Formats:

All records pertaining to activities related to drug supply use cycle as written
in the specific SOP (SOP 54-70) must be maintained.

EFFICIENCY CRITERIA:
There should be no shortages of quality, essential drugs in the health facility
for the patients. These must be stored and rationally used causing no harm to
the patients.
Following outcome indicators to be used for measuring efficiency of
Pharmacy services (monthly)
1. Percentage of drugs available against essential drug list for OPD
2. Preparation of Annual Drug consumption and demand list
3. Number of stock out situations in vital category medicines.
4. Number of adverse drug reaction per thousand patients.
5. Percentage of irrational use of drugs/over prescription
All activities as related to drug supply use cycle as given in the specific SOP
(SOP 54-70)
[14]
Documentation & Reporting:
1. Annual Demand consumption and demand list.
2. Reporting of Stock outs
3. Reporting of Near expiry drugs

STANDARD OPERATING PROCEDURES

(Front Office)

TITLE:
Registration policy and procedure
PURPOSE:
To ensure that all needy patient have access to the available services, in
outpatient
department and accident and emergency department, as per their need and
the
scope of services of LCH
RESPONSIBILITY:
Registration Clerk,
PROCEDURE:
For Pre Booked Patients
a) There is no prerequisite for client registration at LCH Anyone wants to see
a doctor can call on the Following Numbers for an Appointment.
b) There are two categories of Booking Normal appointment and Premium
Bookings (with differential Charges) Charges are displayed at the
registration
counter.
c) Registration is mandatory for all specialty OPD Patients.

[15]
d) Computerized Registration & Billing counters is located near Main
gate
Outside OPD and Accident and emergency department.
e) OPD Appointment Booking is done round the clock, any one who calls for
an appointment he is informed about the available date and time slot for
visit, Patients are also informed about the fee payable at the day of
consultation.
f) Patients or client are also informed about possible variation in timing
during
booking.

g) Patients Visting LCH from far flung areas, or having time constrains due
to transport communication and sick patients are seen immediately /on
priority basis, on request and approval of the consultant without any
differential charges.
h) Patients Report to the reception/ registration counter on the prefixed date
and time slot.
i) Client deposit the applicable fee at the registration counter and he is given
a
token no and registration slip and asked to wait for his turn. Patients are also
informed about the expected timing of consultation.
Premium Patient Consultation:
a) LCH has provisioned slots for premium /VIP patients. The service is
provided on demand.
b) Patient has to pay a differential fee ( charges displayed at reception
Counter
/ OPD waiting Hall for premium consultation.
c) Patient after payment and billing are seen at the next available time slot by
[16]
the available consultant. (This is done wit the prior permission of the
consultant and situation prevailing at that time.)
For Emergency Cases:
a) Patients are directly wheeled in to the Casualty room, by hospital staff and
are immediately attended by nursing/Paramedic on duty, paramedics takes
the vitals of the patient and at the same time RMO or available consultant is
informed.
b) All primary and necessary care is given to the patient. (No charge levied
for
Emergency care)
k) After patient is stabilized the condition and available options are
Communicated to the patient or his attendants. (Which Including : Probable
Charges, Transfer, Discharge and action is taken according to the will and
Wishes of the client or their attendant.

DISPLAY & REPORTING:

1. OPD Tariff Display
2. What to expect during OPD Consultation Display.
3. Education of relative & patient about expected cost.

TITLE:
PURPOSE:
The purpose of the admission policy of LCH is to provide all client a
reasonable unbiased chance for admission (Based on evidence based clinical
criteria), and can access quality care in a cost effective manner.

SCOPE:
Admission / Registration & Billing Clerk
[17]
RESPONSIBILITY:
Consultants/Specialist/CMD LCH

PROCEDURE:
a) All Admission to LCH is done either through OPDs, accident and
emergency department.
b) The decision to admit a patient to hospital is a clinical decision based
on evidence based clinical criteria as well as availability of requisite
services in the hospital.
c) The decision for admitting the patient is taken only by authorized
clinicians LCH.
i. Availability in terms of skills and equipment required to deliver
the services necessary for treating the patient. (Scope of services).
ii. The person’s condition requires clinical management and/or
facilities not available in their usual residential environment;
iii. The person requires continuous observation in order to be
assessed or diagnosed;
iv. The person requires at least daily assessment of their medication
needs;
v. The person requires a procedure(s) that cannot be performed in a
stand-alone facility, such as a doctor’s room, without specialized
support facilities and/or expertise available (for example cardiac
catheterization);
vi. There is a legal requirement for admission
vii. As decided by the treating Specialist for any other reason ( Has to
be recorded in the admission slip)
d) Order for Admission should be clearly written and duly signed and
Dated by the CONSULTANT along with Special instructions if
any.
e) After being prescribed admission client need give the details (Such as
Name/DOB/ Age/Sex/ Fathers Name/ Mothers Name/ Mobile No./ of
the client at the computerized admission counter Filling of Admission
Form.

[18]
f) Admission clerk also takes the signature of the patient or legal guardian
on
i. General Consent (Authorization for treatment)
ii. Certificate of effect that patient is not keeping any
valuables.
g) Depending on the condition of the patient the patient is shifted to the
ward by Nursing Assistants, where he/she has been admitted
h) After Getting the admission done the client gets a admission slip and
visitor card (2 Nos). The client need to report to the concerned ward
and a bed is allotted to the patient; the patient is again assessed
clinically (Nursing assessment) and provided with clean linen and diet.

EFFICIENCY CRITERIA:
A. Time Taken for each admission.
B. Client satisfaction score w.r.t. admission clerk

Documentation & Reporting:

1. Admission Clerk Generates compiled Daily Admission List (of
previous day) and submits a Hard copy and a soft copy of the same to
MRD.
2. Submits Monthly Summary of All admissions.

Forms and Formats:

2. Admission Form
3. Patient File (Content of Blank File)

[19]
TITLE:
Discharge policy

PURPOSE:
To ensure that there are effective processes for the discharge of patients from
LCH which meets the needs of the patient, ensures continuity of care and
facilitates discharge in a timely manner.

Definitions:
Discharge: it is a process that is executed at end of a patient’s current
episode of care at the Hospital.
Discharge Planning: A dynamic process requiring collaboration between
the patients, their family/ and health care team to anticipate and respond to
changes in health care needs beyond hospitalization.
Simple Discharge: Patient is discharged home with family/ support and
requires minimal or no additional health care or personal care services.
Complex Discharge: Patient has increased health and / or social care needs
or requires a temporary or permanent change of residence.
Discharge Summary: A written summary of care provided during the
admission episode, and details of follow-up and or advice post-discharge.
Emergency Discharge: The safe discharge of as many patients as possible
to accommodate a sudden influx of patients as the result of a local or regional
emergency.
Self-Discharge: Patients who wish to discharge themselves from
LCHagainst the advice of clinical staff, or a legal guardian(s) who wishes to
remove a patient from the hospital against the advice of clinical staff.
“At Risk” patients: Patients who are elderly & /or debilitated, alcohol or
drug dependent or those with physical or mental disabilities.

SCOPE:

RESPONSIBILITY:
Concerned clinical care Team
Doctor on Duty
[20]
PROCEDURE:
Discharge of patient from ward:
1. Decision of discharge of patient is taken by the HOD/ consultant or the
team, it must be based on evidence based sound clinical criteria.
2. The reason for discharge and condition of the patient at the time of dis-
charge must be noted on the Discharge summary of the patient.
3. As soon as decision of discharge is taken on account of cure/ or im-
provement or patient willfully wants to get discharged against advise.
4. Before a discharge summary is issued to the patient leaving the ward a
pre discharge counseling is done for every patient to explain the:
a. Current condition and the prognosis. It is to be done by senior
staff nurse or consultants.
b. Instruction and what to do, and where to contact or approach in
case of emergency.
c. Instruction for follow up visits, with days, date/ room number.
d. Medications and precautions if any.
Essential components of discharge summary
1) Referrals after discharge if required (such as for management of other
medical/ surgical disorder).
2) Obtain a patient feedback regarding quality of services.
3) Discharge summary must contain the following:
4) DOA & DOD
5) Personal detail of the patient
6) Diagnosis (with ICD-10 CODE)
7) Investigations with reports /results SUMMARY.
8) Pre-op, Operative note and post-op notes.
9) Treatment/intervention/ medications provided during the stay.
10) Advise on discharge: should also include, Medicines, precautions,
any special instruction
11) Instructions for follow-up visits. With day, date and timing.

[21]
References:
1. DHS Guidelines for transfer of Patients

EFFICIENCY CRITERIA:
1. Discharge rate

Documentation & Reporting:

3. Ward discharge register
4. Daily/ Monthly compilation and analysis of all discharge

Forms and Formats:

1. Discharge summary

[22]
STANDARD OPERATING PROCEDURES
(IPD)

Title
Policy on uniform care of patients

PURPOSE

To delineate policy for the planning and providing of uniform

patient care, for following clinical practice guidelines in line with
the laws and regulations prevailing in India.

SCOPE

To ensure uniform care to all patients using the services of the hospital.
The scope includes policies and procedures for:

 The care of Emergency Patients

 Use of Blood and Blood Products
 Care of ICU & High Dependency Unit patients
 Care of Pediatric Patients
 Care of patients requiring anesthesia
 Care of patients undergoing surgical procedures

POLICY

Uniform Care of Patients

[23]
The planning and provision of care shall be based on individual patient
assessment and shall focus on the patient's response to actual or potential
alterations to health.

o All patients are treated alike irrespective of their religion, cast, social
status, financial ability etc. The safety of all patients seeking health care
at this hospital is the prime responsibility of this hospital. A uniform pa-
tient care system is laid down in all areas so as to provide excellent ser-
vice

o Similar care is given in different settings which are guided by applicable

laws and regulations; care delivery shall be uniform in emergency and
ambulance services, Cardio Pulmonary Resuscitation, while using blood
and blood products, during care of patients in the ICUs, and other high
dependency areas, Post-surgical recovery rooms, etc.

LCH has the policy for delivering uniform care to all patients irrespective
of the care setting right from the admission to discharge for IPD cases.

o Laboratory facilities, OT facility, Diagnostics, Nursing Care are uni-

formly provided to all patients irrespective of category of patients.

o All protocols are uniformly given in the same manner to all patients irre-
spective of the category status.

o Uniform care is guided by all laws &regulations.

o It is further ensured that the care and treatment orders are legibly signed,
named, timed and dated by the concerned doctors and nurses, the main
idea being that the authors of these orders are identifiable by all and the
chronology of care process is maintained.

o Clinical practice guidelines are adopted to guide patient care whenever

[24]
possible.

o Laboratory facilities, OT facility, Diagnostics, Nursing Care are uni-

formly provided to all patients irrespective of category of patients.

o All protocols are uniformly given in the same manner to all patients irre-
spective of the category status.

o Uniform care is guided by all laws &regulations.

o It is further ensured that the care and treatment orders are legibly signed,
named, timed and dated by the concerned doctors and nurses, the main
idea being that the authors of these orders are identifiable by all and the
chronology of care process is maintained.

o Clinical practice guidelines are adopted to guide patient care whenever

possible.

Title
Policy and procedure on patient initial assessment & regular re-
assessment
PURPOSE

To outline a systematic process for gathering pertinent clinical data

about a patient.

[25]
To establish a comprehensive information base for decision
making about patient care.
To provide patient with the right care at the time, it is needed.

SCOPE

This procedure applies to all Patients treated at LCH.

DEFINITION

ASSESSMENT

All activities including history taking, physical examination,

laboratory investigations that contribute towards determining the
prevailing clinical status of the patient.

RESPONSIBILITY

Treating Doctor, Casualty Medical Officer, Duty Medical Officer

and Nurses are responsible to implement this Policy and Proce-
dure.
Patient assessment at LCH. is an ongoing process that begins before
the Patient is admitted and continues throughout treatment.

POLICY

INITIAL ASSESSMENT– Residential Medical Officer/ Treating

Doctor, DMO are responsible to carryout initial assessment
within One hour or Admission and to document the same
within the 24 hours of Admission.
Every Inpatient should be reassessed at least once in a day (Non –
[26]
Critical Care areas) or, as and when necessary.

Critical care patient should be reassessed minimum of every 6 hours

or, as and when necessary (depending on condition of the patient).

PROCEDURES

 INITIAL ASSESSMENT

Initial assessments of Patient at emergency ward are to be

carried out by Nurse, RMO immediately, as soon as
patient arrives at emergency ward.
Assessment of Patient in Outpatient department is done by the Con-
sultant. History and Physical examination of the patient is writ-
ten in the prescription form which is given to patient after scan-
ning at registration desk.
Initial Assessment for In Patient to be carried out by RMO,
Treating Doctor or his / her Team Member (as appro-
priate) within one hour of admission to determine im-
mediate care needs and to decide on plan of care.
Nursing Initial Assessment is done within 30 minutes of pa-
tient admission into the ward.
Treating Doctor should assess nutritional needs of the Patient.
Treating Doctor should document plan of care based on initial assess-
ment.
This plan of care should include preventive aspect of the care, e.g. Diet,
Drugs, etc.
Analysis of information from initial assessment drives the following
Initial treatment and discharge planning.
May trigger additional assessment for nutrition, physiother-
apy, and education.
Other specialized treatment needs.

[27]
 REASSESSMENT

Patient acuity and needs determine the frequency of

reassessment i.e. a patient at high risk to be assessed
continually while a stable patient to be assessed at least
once in a day in non-critical care units & every 2 hours or as
and when necessary in critical care units.
Reassessment is to be performed by medical and nursing
staff. Ancillary Services involved in the patients care also
perform reassessment as required by patient’s needs.
Reassessment is to be performed to identify and determine /
monitor patient’s response to care / treatment.
When a Patient is transferred from one setting to another
setting. Example: ICU to ward.
At the time of discharge.
Based on initial assessment of the Patient and established
plan of care, reassessments are to be performed and to be
documented throughout the care process (Hospitalization).
Multidisciplinary approach to be adopted for performing
patient assessment based on the patient diagnosis, the care
setting, patient desire for care and patient response to any
previous care. This includes involvement of treating Doctor,
RMO, Nurse, Dietician, Physiotherapist etc…
The plan of care to be reviewed regularly by Treating
Doctor or his / her Team Member. This review should
include information from other Doctor, Dietician,
Physiotherapist, Patient and Patient family.
When required the plan of care should be revised as
appropriate to the patient condition and ongoing assessment
process to be carried and this same to be documented.
Discharge planning needs to be included in the initial
assessment and reassessment process throughout the patient
hospitalization.
The patient and Patient family to be involved in discharge
[28]
planning process, as appropriate by Treating Doctor or his /
her Team Member.
The decision of discharge to be taken in consultation with
patient and/or family members. The same to be documented
in IP Record as “FIT FOR DISCHARGE” with signature,
name, date and time by Treating Doctor or his / her team.

STANDARD OPERATING PROCEDURE

(MRD)

TITLE:
Policy and Procedure for Maintenance of Medical records of Patients

PURPOSE:
To provide guidelines to the medical team for making medical records in
such a way that it remain useful for all the stake holders. To make all
medical records Clear, concise, complete, correct and accessible for all
stake holder while maintaining the security and confidentiality of
information to the highest level; to enhance the quality of patient care at
LCH.

POLICY:
A Medical Record shall be maintained for every individual who is evaluated
or treated as an inpatient, (outpatient, or emergency patient) of a LCH
hospital (Currently Records of Outpatient and emergency patient is not
being maintained.) in 1st phase records of emergency patient shall be
maintained and subsequently records of OPD shall also be maintained in
MRD.
All Patient Records are confidential and once received in MRD it is the
responsibility of MRO to maintain it. No records should be shown to any
unauthorized person. Any movement/ Photocopying of record (Within or
[29]
outside the hospital such as court etc.) to be done only on receipt of
formal request, all such request are to be filed.

SCOPE:
Hospital wide

RESPONSIBILITY:
Medical Record Officer

PROCEDURE:
a. Admission record must contain reason for admission of the
patient, admitting diagnosis and plan of care, or it must be
recorded not later than 48 hours after admission.
b. Only authorized members of the medical care team are al-
lowed to make entry in to the patient's medical records.
c. Every page in the medical record should include the patient’s
name, CR number and name of the principal treating doctor
(Or under whom the patient has been admitted).
d. The contents of the records should have a standardized struc-
ture and layout. Where possible medications should be identi-
fied using their generic name.
e. Documentation within the record should reflect the continuum
of patient care and should be viewable in chronological order.
f. Data communicated on, Medical/ surgical procedure, Blood or
blood product transfusion, admission, handover and discharge
should be recorded using a standard Performa (Surgical safety
checklist, transfusion checklist, Admission summary, Discharge
summary, Transfers summary etc.)
g. Every entry must be timed, dated, legible and signed by the
person making the entry. The name and designation of person
making the entry should be legibly written/ stamped against
their signature. Deletion and alterations should be counter-

[30]
signed.
h. Every entry should identify the most senior healthcare profes-
sional present (who is responsible for decision making) at the
time the entry is made, on each occasion the consultant re-
sponsible for the patient’s care

[31]
i. An entry should be made in the medical record whenever the
patient is seen by a doctor or any healthcare professional.
When there is no entry in the hospital record for more than
two days the next entry should explain why.
j. The discharge record/ discharge summary should be com-
menced at the time a patient is admitted to hospital
k. Advance directives,(such as peri-operatve orders, instructions,
medications, precautions, consent and resuscitation status
statements must be clearly recorded in the medical record.
l. Upon discharge/Death/LAMA/DAMA/ Transfer; the original
patient file with all documents and investigation reports ate to
be sent to MRD.
m. It is responsibility of the concerned department to complete
the patients records in every respect, any deficiency observed/
find during check in MRD should be attended promptly by the
concerned doctor. File once moved to MRD should not be re-
called for entry, all entry are to be made in MRD only.
n. Entry of reports, Opinion should preferably be done before
the discharge of patients in all Medico legal cases, however if
it is not possible for any reason concerned doctor should visit
MRD to complete records, no MLC should be recalled from
MRD for any reason.
o. It is Duty of the concerned HOD to complete all Medico legal
records either by directing the concerned Resident doctor/
Specialist, Medical officer if the concerned doctor is not
available for any reason HOD must ensure the completion of
record, or he himself complete the record at the earliest, He
may record the reason for doing so in file.
p. All entries made by RMO must be countersigned by HOD or
Specialist of the department (To be authorized by HOD)
q. Any deficiency pointed out by MRD should be rectified by
any authorized member of the medical care team at the earliest
by visiting the

[32]
MRD. Records once submitted in the MRD cannot be recalled in the department.
However Department can recall patient record in the event of Readmission of the
patient by sending a Formal request on Medical (Record Recall Performa)

FORMS AND FORMATS:

1. MRD check List
2. Clinical Audit Checklist

EFFICIENCY CRITERIA:
1. Percentage of Incomplete medical records received in MRD.
2. Department wise % of Incomplete medical records received

Title

Medical Certification of Cause of Death

(Issue of death certificate)
Purpose:
Registrar General of India is the highest official who compiles the information about
deaths and births received from Registrars & Sub-registrars of Births and Deaths at
district level, Municipal Corporations and Municipalities of towns and Cantonment
Boards of Military Cantonments. Registration of not only the occurrence of death, but
also its cause is equally important. Statistical analysis of causes of death forms
important morbidity & mortality statistics, which is the backbone of National Health
Policy and Planning.
Thus it is a legal and statutory Duty of Hospital to report all deaths according to the
prevailing laws.
Responsibility:
Doctor/ RMO on Duty, Chief Admin , CMD

[33]
Procedure:
Following procedure is applicable for all inpatient deaths.
1. Handling death is a sensitive issue, do not panic if you encounter an eminent
death; call available senior doctor or staff available for your help., see the patient
try to help him, counsel the attendants and relatives.
2. After the Death is pronounced explain every thing to the relatives of the patient.
3. RMO On Duty Fills the form No 4 : Medical Cause of Death
4. Also Fill up the form No. 2 (Death Report to be sent to the registrar of birth and
death along with the form No. 4.
5. Lower part of the Form 4 (Death certificate ) to be issued to the relative of the pa-
tient.
6. A copy of Form 4 and Form 2 should be kept with the patients record.
7. No Death certificate in any form to be issued to patient brought dead to the
Hospital.

[34]
FORM NO. 4
NAME OF DECEASED
Sex Age at Death For use of
If 1 year or If less than 1 If less than If less than one Statistical
more, year, one month, day, age in Office
age in years age in months age in Days Hours
1. Male
2. Female
CAUSE OF DEATH Interval
between on set
& death approx.
I. (a)……………………………………
Immediate cause …………….……………………
State the disease, injury or complication which Due to (or as a consequences of)
caused death, not the mode of dying such as
heart failure, asthenia etc.
Antecedent cause (b)……………………………………
Morbid conditions, if any, giving rise to the …………………..…………………
above Cause, stating underlying condition last Due to (or as a consequences of)
II (c)
Other significant conditions contributing to the ………………………………………
death but not related to the disease or conditions ………………………………………
causing II ………………………………………
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in-patients. Not to be used for still births)
To be sent to Registrar along with Form No. 2 (Death Report)

Name of the Hospital ……………………………................……………..

I hereby certify that the person whose particulars are given below died in the hospital in Ward No.
………. On at.....................................AM/PM.

Manner of Death How did the injury occur?

1. Natural 2. Accident 3. Suicide 4. Homicide
5. Pending Investigation
-------------------------------------------------------------------------------------------------------
If deceased was a female, was pregnancy the death associated with? 1. Yes 2. No If yes, was there a
delivery? 1. Yes 2. No

Name and signature of the Medical Attendant certifying the cause of death Date of
verification ……………………………………………

(To be detached and handed over to the related of the deceased) Certified that
Shri/Smt/Km ……………………S/W/D of Shri. ……………………
R/O ………………………was admitted to this hospital on.....and expired on
……………………………………..

Doctor ………………
[35]
(Medical Supdt.
of Hospital).Name

[36]
FORM No.2

DEATH REPORT (See Rule 5)

Statistical information
This part to be detached and sent for
Legal Information statistical processing
This part to added to the Death Register 9. Town or Village of Residence of the Deceased:
a) Name of the Town/Village
To be filled by the informant b) Is it a town or village (Tick the appropriate
1.Date of Death entry below)
2. Name of the 1) Town 2) Village
Deceased c) Name of District:
3. Permanent d) Name of State:
Address 10. Religion: (Tick the appropriate entry below)
1) Hindu 2) Muslim
3) Christian
4. Name of the 4) Any Other Religion (write name of the
Father/Mother/ religion)
Husband:
To be detached and send for Statistical Processing
5. Sex of the Deceased 11. Occupation of the Deceased:
6. Age of the
Deceased 12. Type of the medical attention received before
7. Place of Death death(Tick the appropriate entry below):
1. Hospital/Institution a. Institutional
Name: b. Medical attention other than
Address: institution
c. No medical attention
2) House: 13. Was the cause of death medically certified
3) Other (Tick the appropriate entry below)
8. Informant’s Name: 1. Yes 2. No
Address: 14. Name of Decease or actual cause of death
15. In case of this is a female death did the death
occur while pregnant, at the time of delivery
or within six weeks after the end of
Date: pregnancy: (Tick the appropriate entry below)
1. Yes 2. No
Signature or left thumb mark of 16. If use to habitually smoke
the informant for how many years?
To be filled by Registrar 17. If used to habitually chew
Registration No: Registration Date: tobacco in any form –
for how many years?
18. . If used to habitually chew
Registration Unit: arecanut in any form (including pan masala)
Town/Village: District: –
Taluk: for how many years?
Remarks: (if any) 19. If used to habitually drink alcohol
for how many years?

Name and signature of the Registrar

[37]
To be filled by Registrar

Name: Code No:

District:

Tahsil: Town/Village:

Registration Unit:

Registration No:

Registration Date:

Date of Death:

Sex: 1) Male 2) Female

Age: Years/months/days/hours

Place of Death: 1) Hospital/Institution

2) House 3) Other place

Name and signature of the Registrar

[38]
[39]
Title

Record retention and destruction schedule in respect of LCH hospital records

Purpose:
To ensure that the Patients Records at LCH Hospital Medical Record Department are
neither destroyed prematurely nor kept for longer than necessary. The Medical Council
of India (MCI) has imposed an obligation on Hospitals as per the regulations notified
on March 11, 2002, amended up to December 2010 to maintain the medical record and
provide patient access to it.
According to them every physician shall maintain the medical records pertaining to
his/her indoor patients for a period of three years from the date of commencement of
the treatment in a standard proforma laid down by the MCI.
Medical records are at times required by The Patient, The Doctor, Hospital
Administrators, Court of Law and other medico legal purposed, further it cannot be
predicted that after which time the record will not be required by the above said
entities.
Keeping in view of the guidelines and experience from our working a Record retention
schedule has been prepared which is as per the law and also gives the hospital ample
flexibility.
LCH Record retention schedule is as under.
RECORD RETENTION AND DESTRUCTION SCHEDULE IN RESPECT OF LCH HOSPITAL
RECORDS
.
S.NO RETENTION
NAME OF RECORD
. PERIOD
1 ELECTRONIC RECORDS 10 Years
2 Records of weeding ( Weeding 10 Years
[5]
S.NO RETENTION
NAME OF RECORD
. PERIOD
record )
3 Casualty Register 5 Years
4 Attendance Registers 2 Years
Patients Medical Records (IPD)
5 5 years
Non MLC
Patients Medical Records (IPD)
6 7 years
Medico Legal Cases
1 All ward registers and Books 3 Years
2 Lab Registers & Reports 3 Years

3 X- Ray register and Reports 3 Years

4 ICU Register and Reports 3 Years

Destruction of records:

After completion of retention period of the documents, following method shall be

adopted for destruction of records.
A list of all records shall be prepared in the following format :
S.No Name of Record Last entry Retention Period
. made on the (AS PER LCH
record (Date) RRS)
1.
2.
3.

[6]
Patient IPD Files shall be destroyed after creating following record. And this Record
shall be Kept in MRD for another 10 years in a folder Named details of destroyed
patient records.
S.No UHID PT. Name Address Discharg Method of
. e Date destruction

After the records are compiled it should be duly checked by a committee specially
created (Weeding committee) to check that the records are being destroyed as per the
retention schedule and a record of same has been properly made.
After approval of the weeding committee all the record shall be destroyed in a
environment friendly manner such as shredding and handing over the shredded record
to paper recycling unit.

[7]
Standard Operating Procedure
(HRM)

Human Resource Management requires good planning of human resources

while at the same time use the human touch, expertise, and commitment
towards ensuring productive use of human capital while at the same time
motivating the employees to make them give their fullest potential towards
patient care activities in the Hospital.

PURPOSE:

 To plan the right mix of manpower for the Hospital in line with the
volume of scope of the services being provided by the hospital.
 To recruit competent people with a positive attitude towards organi-
zation and customers, and have the capability to guide or work in a
group to achieve the goal of the hospital.
 To ensure that employees are selected, trained, promoted and treated
on the basis of their relevant skills, talents and performance without
any discrimination as per the requirement of the organization.
 To provide a clean, safe, healthy, professional and enjoyable working
environment.
 To motivate employees through reward system and build confidence
among staffs.
 To provide training and development for all the employees to enable
them to achieve the highest level of skills possible and provide job
satisfaction to a large extent.

SCOPE OF THE DEPARTMENT:

[8]
This manual covers the following:
 Manpower planning
 Recruitment and selection, and placement
 Joining induction
 Training & Development
 Promotion and incentives
 Employee Health care & Occupational Hazards
 Employee personal file maintenance

ABBREVIATIONS:
NABH: National Accreditation Board For Hospitals And Healthcare Providers
HR : Human Resources
IT: Information Technology

[9]
DEFINITIONS
Human Resources Department: Shall mean the ‘Department having
charge of the HR function of the hospital’.

PLANNING AND POLICIES:

Planning: Manpower Planning is done in the hospital taking in to
account the services scope, the volume of out patients, Emergency
patients and Inpatients, based on the past. This also takes in to account
the periodical staff turnover. The Chairman analysis at the beginning of
every year such manpower requirements of various categories of staff –
Clinicians (full time), Clinicians (On Call), Nursing staff, other
paramedics – technicians for Diagnostic Labs, Medical records
department, Administrative staff, Front office staff, Maintenance staff,
Housekeeping staff (both in-house & contractual), other hospital
workers, etc.

Workforce Planning (Non-Medical):

Responsibility for manpower planning for the hospital rests with HR
department and the management ensures availability of the right mix of
manpower required to provide quality healthcare services taking in to
consideration the patient load, number of beds, number and type of
procedures, type and level of care, specializations, infrastructure etc.
The assessment of manpower requirement in each department/division is
periodically reviewed depending on increase or decrease of workload,
technological changes or any other relevant factor.
In case any new staff is required to affect continuity of care either directly
or indirectly, the same is communicated to the Chairman through Human
Resources Manager, who is responsible for the approval and provision of
[10]
the required manpower.
On approval by the Chairman, these manpower plans will constitute
sanction for creation of posts including posts of trainees and form the
general basis of recruitment according to the need of staff in each
department.

Manpower Planning (Recruitment, Selection & Induction):

While merit would be the main criteria for filling up a vacant position,
seniority and past performance shall be kept in mind.
For filling up position at higher levels, employees of the Hospital shall be
given preference and would be considered before outside sources are
tapped.
The mix of the employees shall be cosmopolitan.
The best available talent would be absorbed without giving any
consideration to region, religion or race.

[11]
All recruitment along with the chairman shall be done through the HR
Department.

Induction Policy:
To ensure that a new employee settles down smoothly into the hospital so
that he/she reaches standard level of performance as soon as possible.
It gives maximum relevant information to the new employees in shortest
time.
It eliminates the feeling of the uneasiness, apprehensions etc. in the new
employee.
It enhances the image of the hospital as people friendly.
It helps reducing the turnover of the employees.

Training Policy:
Training is the process of imparting necessary knowledge, skills and
attitudes to the employees to enrich their existing knowledge, skills and
attitudes, and develop newer ones.
Induction:
This training is provided to all the new recruits at the time of joining. This
training generally introduces the employee to the hospital’s quality
policy, Vision, Mission, hospital policies and procedures, employees Job
Description etc.
On Job Training:
On-job training is imparted by the department leads. The training includes
management of various risks associated with the care environment.
Nursing staff, OT/ICU staff, housekeeping staff, laboratory staff, imaging
dept. staff etc., are trained on infection control practices that include
needle stick injury, hand wash practices, use of appropriate personal
protective equipment’s (PPEs), injection & infusion practices and bio-
[12]
medical waste management practices.
Change of Department/Rotation /Transfer:
Training is imparted to the employee at the time of Change of
Department/Rotation /Transfer to other department in order to make him
familiar of the new department, roles and responsibilities of the employee
and equipment etc.
Advancement/introduction/change in Technology / equipment:
All concerned employee will be provided training to upgrade them to
such situation. In case of installation of new equipment training is also
provided by the Service/installation Engineer to all the concerned staff.
Mock Drills:
Mock drills will be conducted twice in a year for different category of
employee to provide them practical experience of handling critical
situations such as various Emergency Codes like fire, bomb threats, mass
casualties, etc.
Training Methodology:
Training shall be done by issuing manuals to the employees. Basic
training manual is issued to every class of employee.
Sexual Harassment Policy:
The Hospital policy is to totally prohibit any form of sexual harassment in
the way employees behave with each other.
This applies equally to relations between superior and subordinates as
well as between peers.
Any incident of sexual harassment will be viewed extremely serious.
A complaint or report of sexual harassment will be immediately
investigated and appropriate action will be taken against the offending
employee or employees.
Such action will depend on the nature and seriousness of the offense and

[13]
will include strict disciplinary action including termination of service.

Attendance & Working Hours:

Working Hours: Employee in all departments / sections of the Hospital
shall work for 70 hours a week which includes their tea & lunch breaks.
Attendance: All employees working in the wards shall punch their
Attendance to the manager.
Punctuality: All employees are expected to report for work as per the
duty timings allotted. For those who report late for more than 30 minutes
three occasions, every third occasion of late coming will count the loss of
one leave. For those who report late for more than 35 minutes, will be
considered as half a day leave.
Identification: All the employees are required to display the Identity
Cards on their person while on duty.
Absenteeism: Unauthorized absenteeism in the Hospital results in
disruption of the work in the Hospital besides making an employee liable
for disciplinary action. In case of habitual/ unauthorized absenteeism the
management shall take suitable disciplinary action in accordance with the
law.

Employee Personal Record Policy:

An employee’s personal file is maintained by the HR department.
The employee can access to his / her Records by a written Request to the
HR Manager- HRD & Personnel.
Once an employee leaves the organization or on cessation of his/her
employment, the employee’s file will be labeled as Ex-employee file.

[14]
PLANNING AND PROCEDURES:

Workforce Planning
Classification Of Employee
Annual Manpower Planning (Recruitment, Selection & Induction)
Manpower requirements of each department/section of the Hospital shall
be determined and done. The manpower requirements so arrived, after
approval of Chairman/HR Manager-(HRD & Personnel) shall constitute
the approved strength of the department/section and shall form the basis
of manpower planning of the department/section. All recruitment shall be
as per the approved strength of each department/section.
Care must be taken that all recruitment exercise is done at a minimum cost
and time.
Interview Call:
All interview call shall be done through the telecom communication by
HRD Department.
Selection Process:
Shortlisting of all ‘CV’ shall be done by the HR Department with active
involvement of the Departmental Head. While recruiting manual
employees their physical attributes shall be taken into consideration. Only
those candidates, who fulfill the pre-defined minimum physical attributes,
shall be recruited. All arrangements for interviews shall be carried out by
the HR department with involvement of Chairman/HR Manager-(HRD &
Personnel).
Appointment Letter:
The selected candidate will be issued a letter of intent immediately on his
selection. A detailed appointment letter would be issued preferably after
receiving the favorably medical reports. Acceptance of appointment
[15]
would be obtained on the duplicate copy of the appointment letter before
a person joins.
Joining Formalities:
Every employee on joining would be required to fill up the following
forms: Employee Application Form. P.F. Nomination Form. Two
Passport size photograph. Selected candidates should submit complete
CV with proper address. Selected candidate should submit all certificates,
should be verified with all original certificates.
Probation:
All employees would be appointed on probation of Six months. During
this period performance would be reviewed. The performance review
shall be initiated by the General Manager (HRD Department).
Confirmation of the services of employees would be done only after
successful completion of the probation period. In case the employee’s
performance does not meet the desired level, his probation may be
extended for a period of Six Months/Twelve Months.
Reference Checking:
The HRD Department will verify the information submitted by him in the
application, from previous employer of the new employee.

[16]
Employees’ Rights And Responsibilities:
Employee Rights
To be aware of the hospital wide policies.
To be treated considerably and respectfully without any
discrimination.
To be aware of the terms and conditions of his/her employment before
joining the organization.
If any one believes that he/she has been the victim of any kind of
harassment, or knows of another employee who has the right to, report it
immediately to the HR Department.
To seek clarity on the targets to be achieved and the
roles/responsibilities associated with the task to be performed.

Employee Responsibilities
Employees are expected to work on their duty hours to support the
Hospital’s 24*7 operations and are also required to work overtime
when the workload necessitates.
Employees shall be responsible for the equipment allocated to them and
maintain it in accordance with the standard operating procedures.
Employees are expected to maintain proper discipline, professional
ethics.
Employees are expected to plan leave well in advance and if unable to

[10]
report to work on schedule he/she shall intimate to the department head.
Employees are responsible to maintain complete confidentiality

[11]
Duty Hours & Shift Working:
The rules regarding hours of work, shift, weekly holidays and rest
intervals, etc. shall be in accordance with the law applicable to the
establishment and as specified by the Management. The provisions
regarding period of duty and hours of work of each category of
employees and each shift will be fixed by the HRD Dept. and the same
are liable to be altered from time to time either to suit the Administrative
requirements of the Hospital or to ease the pressure of work, as the case
may be. No employee shall change his shift without orders and
permission from the Departmental Head. Such change may be made
either temporarily or permanently.

Attendance:
An employee has to punch his attendance while coming on duty and
while leaving from duty. No employee shall mark attendance for another
employee. After marking the attendance every employee shall present
himself in uniform where provided, and keep himself ready for work in
his/her respective department at the appointed time. An employee who
does not report for duty at the appointed time will be considered as late.
Promotion:
The Management will promote only qualified and eligible employees to
higher positions when vacancies arise in such higher cadre. Promotions
will be effected strictly on the basis of merit, efficiency, and suitability for
Para-medical staff and for other categories wherever applicable on the
basis of past record of service, performance, requisite skills, seniority and
state of health and suitability of the employee. The suitability of an
employee for promotion will be decided solely by the Management. Upon
promotion or regularization, the employee will be granted such benefit
and increase in wages as may be decided by the management. The
management’s decision on promotions shall be final and conclusive.
Redressal of Grievance of Employees Against Unfair Treatment:

All complaints arising out of employment including those relating to

unfair treatment and wrongful application of these service rules shall be
submitted to the Chairman. The employees shall exhaust the above
procedure before resorting to any legal remedy.

Hospital Safety Rules:

The only way to do a job in the Hospital is the safe way. Urgency is not a
justifiable excuse for neglecting safety. Know your job thoroughly, when
in doubt, do not indulge in guesswork, ask your supervisor. Do not handle
or operate machinery, tools and equipment’s without authorization. Be
alert and observe keenly. Report immediately any faulty equipment,
unsafe condition or act, and defective or
 broken equipment. Do not try amateur repair. Stay physically and emotionally
fit for work by maintaining good health and a proper diet. Abstain from
alcoholic drinks. Take sufficient rest and practice cleanliness. Personal hygiene
is important. Wash your hands often in many areas of the Hospital. This is
absolutely necessary. Wear proper uniform or clothing for your job: Neither to
tight nor too loose. Tight clothing does not permit freedom of movement, while
loose one runs the risk of getting entangled. Jewelry and high-heeled footwear
may be hazardous. Prevent the spread of infection and contagious disease.
Cooperate with the Hospital infection control committee by observing
established procedures. When you are ill with an infectious disease, report to
the doctor immediately and stay at home. Walk, not run particularly when you
are carrying delicate, breakable article or instrument. Be extra cautious at the
corridor intersections, in front of swinging doors (especially when they do not
have view panels), as blind corners and in congested areas. If you see some
foreign material, loose wire, oil spill, etc., on the floor that may cause an
accident, make sure it is removed as once. Never indulge in horseplay or
practical jokes involving fire, acid, water, compressed air and other potentially
dangerous things. Pay attention to all warning boards. Their signs caution you
about dangerous and hazards that may cause injury or harm. For example,
smoking in an area where oxygen is being administered or oxygen cylinders are
stored. Be familiar with your work procedure. All departments have within
work procedures that include safety practices at work and handling
equipment’s. Always remember to use handrails on stairways. They are there to
ensure your safety and are meant to be used by all, not just the sick and the old.
When you want to reach overhead objects, always use a good ladder. Do not
climb on chairs or boxes.
Employee Personal Record:

 Employee’s Personal Records contains:

 Employee Detail Form With Photograph
 Appointment Order Photocopy
 Employee Biodata / CV.
 Employee documents supporting his/her Educational Qualification
in the order- Matriculation, Inter, Degree, Post-Graduation,
Professional courses,
 Employee Health Record.
RECORDS:

All the below mentioned records shall be maintained for one year in
the HRD and destruction shall be done by the Medical Record
department after getting approval from the management.

Retenti
S.N Titl Responsibili Cod on
o e ty e Period
1 Attendance register HR Manager LCH/REG/HR/1 6 Months
2 Time attendance register HR Manager LCH/REG/HR/2 6 Months
3 Training register HR Manager LCH/REG/HR/3 6 Months
4 Vaccination Register HR Manager LCH/REG/HR/4 6 Months

Occupational Health Hazard

Vaccination: Our hospital is providing vaccination against vaccine

preventable diseases (HBV) to all employees those who are working in
patient care areas and have direct contact with patients. Eg: Doctors,
Nurses, Laboratory staff, HK staff, Maintenance staff and biomedical
engineers. The register is maintained in the HR department.
Standard Operating Procedure

(Continuous Quality Improvement)

PURPOSE:
To guide and ensure the continuous improvement of quality services provided by RPOC.
To fix key indicators for the processes, to organize measurement process to assess
the performance index on such key indicators.
Scheduling of periodical measurement of performance index of key indicators explained above.
To identify appropriate tools for continual improvement.

SCOPE:
Hospital Wide – All Inpatient care areas
Applicable to all employees of the hospital

RESPONSIBILTY:
Consultants / Doctors
All hospital staff
Core/Quality Assurance Committee

ABBREVIATION:
NABH : National Accreditation Board For Hospitals and Healthcare providers
CQI : Continuous Quality Improvement
DEFINITION:
Quality Indicators: Quality indicators are the means to judge the real performance of
certain clinical as well as managerial parameters selected for monitoring and evaluation.
Sentinel Events: An unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof to a patient, visitor, or an employee.
Quality improvements: It is an ongoing response to quality assessment data
about a service in ways that improve the process by which services are provided to
the patients.

Risk management: Clinical and administrative activities to identify evaluate and

reduce the risk of injury.
REFERENCE:
NABH: Pre Accreditation Entry Level Standards for Hospitals, First Edition, April
2014.

POLICY:
Organization has designated a person as NABH coordinator to meet the quality standards.
Quality improvement and patient safety programme shall be implemented by Quality & Safety
Team.
The Hospital management makes available adequate resources required for quality
improvement and patient safety program.
LCH has identified key performance indicators to monitor the clinical and managerial areas.

Quality Policy:
We hereby assure quality healthcare to patients through reliable healthcare services, available
medicines and maintainable equipments.
We shall ensure efficiency of operations and effectiveness of treatment through our competent
human resources.
We shall review this policy for continuing suitability, adequacy and effectiveness.
We shall achieve this through the quality objectives and targets set for various departments.
PROCEDURE:
Approach To Designing, Measuring, Assessing And Improving Quality:

Planning: Planning for the improvement of patient care and health

outcomes includes a hospital-wide approach.

Designing: Processes, functions or services are designed effectively based

on: Mission and vision of LCH needs and expectations of patients, staff, and
others.
Measurement: Data is collected for a comprehensive set of Quality
measures. Data is collected as a part of continuing measurement, in
addition to data collected for priority issues. Data collection considers
measures of processes and outcomes. Data collection includes at least the
following processes or outcomes:
 Patient assessment
 Laboratory safety & quality
 Diagnostic Radiology safety & quality
 Processes related to medication use
 Processes related to anesthesia
 Processes related to the use of blood and blood components

Internal Communications:
The top management has defined and implemented an effective and efficient
process for communicating the Quality Policy, Objectives, Quality
management requirements and accomplishments.
This helps the hospital to improve the performance and directly involves
its people in the achievement of the Quality Objectives.
The Management actively encourages feedback and communication
from people in the hospital as a means of involving them through the
following modes:

Documentation:
Quality Manual:

This is an outline of hospital policies of

Lch together with the Mission, Vision and Values of LCH Quality Policy
and Patient Safety priorities. Quality Manual also contains the structure and
functions of the continuous quality improvement programme.
Preventive Actions:
The NABH Coordinator shall be perpetually vigilant and identify potential
sources of non-compliance and areas that need improvement.
These may include trend analysis of specific markers such as turnaround
time, risk analysis, etc.
Where preventive action is required, a plan is prepared and implemented.
All preventive actions must have control mechanisms and monitor for
efficacy in reducing any occurrence of non-compliance or producing
opportunities for improvement
Corrective Action:
The NABH Coordinator takes all necessary corrective action when any
deviation is detected in Quality Management System.
Root Cause Analysis:
Deviations are detected by:
Patient complaints/feedbacks.
Non-compliance receipt of items/sample.
Non-compliance at Internal/external Quality Audit.
Management Reviews.
The NABH coordinator conducts and coordinates the
detailed analysis of the nature .

Selection and Implementation of Corrective Actions:

Potential corrective actions are identified and the one that is most likely to
eliminate the problem is chosen for implementation. Corrective action is
taken into consideration the magnitude and degree of impact of the problem.
All changes from corrective action is documented and implemented.
Monitoring Of Corrective Actions:
The NABH Coordinator shall monitor the outcome parameters to
ensure that corrective actions taken have been effective in eliminating
the problem.
Procedures for Internal Quality Audit:
Internal audit shall be conducted by the internal audit team members
once in six months.
Internal audit team members shall be trained on Pre Accreditation Entry
Level NABH standards either internally (a trained person who in turn trains
the other members of the team) or externally (training conducted by Quality
Council of India).
Audit starts with the opening meeting. All departmental heads shall be
informed about the purpose of audit, audit timings and duration of audit
etc.
All minor correction shall be suggested then and there by the auditor
to the departmental staff.
Audit gets over with the closing meeting, over all observations shall be
summarized by the chief auditor. Audit observations shall be handed over to
the chairman of the quality assurance committee in a standardized format.
All the audit reports shall be discussed with the core committee members
and the observations noticed will be presented to the Chairman for
improvements.

The Audit reports shall be forwarded to the concerned Departmental Heads.

Corrective and preventive actions will be done by the department staff based
on the audit observations. Reports of the corrective and preventive actions
will be submitted to the Quality department by the concerned Head of the
Selection and Implementation of Corrective Actions:

Potential corrective actions are identified and the one that is most likely to
eliminate the problem is chosen for implementation. Corrective action is
taken into consideration the magnitude and degree of impact of the problem.
All changes from corrective action is documented and implemented.
Monitoring Of Corrective Actions:
The NABH Coordinator shall monitor the outcome parameters to
ensure that corrective actions taken have been effective in eliminating
the problem.
Procedures for Internal Quality Audit:
Internal audit shall be conducted by the internal audit team members
once in six months.
Internal audit team members shall be trained on Pre Accreditation Entry
Level NABH standards either internally (a trained person who in turn trains
the other members of the team) or externally (training conducted by Quality
Council of India).
Audit starts with the opening meeting. All departmental heads shall be
informed about the purpose of audit, audit timings and duration of audit
etc.
All minor correction shall be suggested then and there by the auditor
to the departmental staff.
Audit gets over with the closing meeting, over all observations shall be
summarized by the chief auditor. Audit observations shall be handed over to
the chairman of the quality assurance committee in a standardized format.
All the audit reports shall be discussed with the core committee members
and the observations noticed will be presented to the Chairman for
improvements.
The Audit reports shall be forwarded to the concerned Departmental Heads.
Corrective and preventive actions will be done by the department staff based
on the audit observations. Reports of the corrective and preventive actions
will be submitted to the Quality department by the concerned Head of the
department.
Procedure for collection of data, interpretation and analysis of Quality
Indicators:

Collection of Data: Reports of all key indicators as decided by the

management will be submitted to the quality coordinator at the end of every
month by the Head of each department. All the data will be collected in the
standardized format.
Analysis of Data:
All the data will be assessed in the form of Structure, process and the
outcome.
Structure:
Structure includes the facilities provided to the staff. Formula used for
calculation. Training or awareness of the set formulas / quality improvement
programme.
Process:
Strict adherence of developed procedures in the daily work routine. In case
of deviations same will be documented in the quality indicator reporting
form with proper reasoning.
Out Come:
Based on the reports received trend analysis will be done and the same will
be reported to the chairman/ Management.
Key Indicators Followed in LCH

STANDAR
SL
N INDICATO NUMERATO DENOMENATO DIZATIO Definition
R R R N
O FACTOR
The time shall begin
Time for Sum of Total number from the time that the
1 Initial time taken of patients 100 patient has arrived at
Assessment the bed of the ward
of Indoor till the time that the
patients initial assessment has
been conducted by a
doctor. In case of
Time for emergency, time
Initial Sum of Total number shall begin from the
2 Assessment time taken of patients 100 time patient has
of come to the door of
Emergency emergency till the
patients time initial
assessment
completed by
the doctor
Percentage of Re-scheduling of
3 re-scheduling Number of Total number of 100 patients includes
of surgery cases re- surgeries cancellation and
scheduled performed postponement (beyond
4
hours) of the surgery.

A medication error is
any preventable event
that may cause or lead
to inappropriate
medication usage or
Percentage of Number of Number of harm to a patient. Eg:
4 medication medication patients under 100 errors in prescribing,
errors errors reported medication transcribing,
dispensing,
administering and
monitoring of
medications; wrong
drug, wrong dose, or
wrong strength errors;
wrong
patient errors
Percentage of Number of Medication chart with
medication medication number of illegible handwriting
5 chart with chart with medication chart 100 and unaccepted error
error prone error prone reviewed prone abbreviations
abbreviations abbreviations

Adverse drug event is

any untoward medical
Percentage of Number of Number of occurance that may
7 Adverse patients who patients who 100 present during
Anesthesia developed underwent treatment with
Events adverse anesthesia anesthetic product but
anesthesia which does not
events necessarily have causal
relationship with this
treatment
a systemic response of
Percentage of Number of the body to the
8 blood and transfusion Number of blood 100 administration of blood
blood reactions and blood in compatible with that
products occurred products of the recipient. The
transfusion transfusions done causes include red cell
reactions
incompatibility.
A medical record is
Percentage of Total number of considered as missing,
9 missing Number of medical records 100 when it could not be
records records generated per found out from the
month MRD after 72nd hour
of record
request
Urinary Number of Number of
10 Tract Urinary patients who were 1000
As per latest CDC
Infection Catheter inserted with
guidelines
Rate due to associated Urinary Catheter
urinary UTIs
catheter

Ventilator Number of
11 associated ventilator Number of 1000
As per latest CDC
pneumonia associated patients on a
guidelines
Rate pneumonias ventilator