NABH Accreditation

 

NABH ACCREDITATION

 

 

 

SVIMS JOURNEY TO NABH

NABH (National Accreditation Board for Hospitals and Healthcare Providers) is a part of Quality Council of India and an institutional member of International Society for Quality in Healthcare (ISQua) which provides accreditation to hospitals which adhere to quality standards.

SVIMS has been providing quality services on par with National and International standards since its inception. With the increasing demand for accreditation and with a motive to further improve the services provided by the institute, SVIMS started its formal quality journey towards accreditation in March 2015. The requirements for accreditation are broadly divided into the managerial and clinical components. Managerial components looks into infrastructure in terms of the buildings, manpower, equipment, budget etc for patient safety while the clinical components include measures in place to ensure quality in patient care and ensuring patient safety.

NABH accreditation can be taken up in two phases i.e. entry level and the full accreditation. Both these have requirements divided under 10 Chapters. The entry level has 45 standards and 167 objective elements while the full accreditation has 100 standards and 651 objective elements. Aiming at full accreditation ground work was initiated for the full accreditation with teams identified to work for preparation of manuals, policies, procedures in line with the 100 standards spread across 10 chapters. Leaders and team members are identified for the 10 chapters. A thorough gap analysis was done to identify what is available and what needs to be done in all the areas under each chapter wise. Monthly goals were identified to close the gaps step by step. Audits were conducted in each area to identify the areas which needed improvement. Staff had to be trained and motivated to take up this extra load of maintaining documentation in spite of their already existing patient and other academic workload. Regular trainings and motivation helped in maintaining their zeal. Another important components are the mandatory regulatory licenses.

Once we reached 75-80% of the requirements, we applied in 2016 for the entry level certification to assess our preparedness for full accreditation. After inspection, we received the entry level certification in Dec 2018. With the confidence gained, we next applied for the full accreditation in March 2019. Full accreditation takes place in two phases: pre-assessment and final assessment. The pre-assessment was successfully completed in Oct 2020. However, due to the COVID pandemic the final assessment was delayed and was conducted in March 2021. The major noncompliance was with regard to the fire NOC.

After submission of fire NOC, SVIMS got full accreditation in January, 2022 for a period 3 years i.e. upto January, 2025.

Now we are under Surveillance of NABH status which is expecting in August, 2023.

 

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Staging of NABH

 

·         Initiation of NABH Entry level accreditation          -  2015-2016

·         Entry Level Accreditation certification                    -  Jan 13, 2019 to Jan 12, 2021

·         Initiation of NABH Full Accreditation                    -  2019

·         Accreditation Granted Date                                    -  Jan 06, 2022 to Jan 05, 2025

 

  

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Organogram of SVIMS - CG & AC (NABH)

 

 

 

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Ø  Standards of NABH

 

NABH Consists:         -        10 Chapters

-          100 Policies

-             8 Manuals

-          45 SOPs

•      Standards are divided into 10 chapters, first five chapters are `patient-centric’ and last five chapters are considered to be `organization-centric’. The standards are statements that defines the structures and processes that must be substantially in place in an organization to enhance the quality of care.

Patient-centric chapters:

•      Access, Assessment and Continuity of Care (AAC)

•      Care of Patients (COP)

•      Management of Medication (MOM)

•      Patient Rights and Education (PRE)

•      Hospital Infection Control (HIC)

 

Organization-centric chapters:

•      Patient Safety and Quality Improvement (PSQ)

•      Responsibilities of Management (ROM)

•      Facility Management and Safety (FMS)

•      Human Resource Management (HRM)

•      Information Management System (IMS)

 

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Ø  Chapter cum Group Leaders

Chapter: 1 - Access, Assessment and Continuity of Care (AAC)

Group Leader: Dr. Y. Mutheeswaraiah, Professor & Head, Department of General Surgery

Co –Ordinator: Mrs.G. Siresha, Medical Records Officer

Task code

(Standard)

Summary of Standards

Group Members

AAC 1

The organization defines and displays the healthcare services that it provides

1.      Mr. V. Rajasekhar, PRO (Lead Member)

2.      Mr. N.V.S. Prasad, MSW

3.      Mr. R. Nagaraja,Sr.Photo Artist

AAC 2

The organization has a well-defined registration and admission process

1.      Smt.G.Sireesha, MRO (Lead Member)

2.      Sri.K.GiriBabu, AMRO

3.      Smt.N. Hemalatha,  H/N, OPD

AAC 3

There is an appropriate mechanism for transfer (in and out) or referral of

patients

1.      Dr. K. RohithGupta, Asst. Prof., Dept. of EMD (Lead Member)

2.      Dr. P.Subramamyam, Asst. Prof., Dept. of EMD

3.      Mrs. C. Sunitha,  NS Gr-I

4.      Smt.C.DhanaRekha, H/N,EMD,

AAC 4

Patients cared for by the organization

undergo an established initial assessment

1.      Dr.A.Sandeep Kumar Reddy, Asst. Prof., Dept. of Medicine(Lead Member)

2.      Dr.P.Suresh Babu, Deptof General Surgery

3.      Mrs. I. Kanthamma, NS Gr-II

AAC 5

Patients cared for by the organization undergo a regular reassessment

1.      Dr.A.Sandeep Kumar Reddy, Asst. Prof.,  Dept. of Medicine (Lead Member)

2.      Dr.P.SureshBabu, Asst. Prof., Dept. of General Surgery

3.      Mrs.E. Bhuvaneswari NS Gr-II

4.      Smt.N. Hemalatha,  H/N, OPD

AAC 6

Laboratory services are provided as per the scope of services of the organization

1.      Dr. M. M.Suchitra, Professor, Dept. of Biochemistry (Lead Member)

2.      Dr. V. Siva Kumar, Asst. Prof., Dept. of Pathology

3.      Dr.N. Ramakrishna, Asst. Prof., Dept of Microbiology

AAC 7

There is an established laboratory quality assurance programme

1.      Dr. M. M. Suchitra, Professor, Dept. of Biochemistry(Lead Member)

2.      Dr. V. Siva Kumar, Asst. Prof., Dept. of Pathology

3.      Dr. N. Ramakrishna, Asst. Prof., Dept. of Microbiology

AAC 8

There is an established laboratory safety programme

1.      Dr. M. M. Suchitra, Professor, Dept. of Biochemistry  (Lead Member)

2.      Dr. V. Siva Kumar, Asst. Prof., Dept. of Pathology

3.      Dr. N. Ramakrishna, Asst. Prof., Dept. of Microbiology

 

AAC 9

Imaging services are provided as per the scope of services of the organization

1.      Dr. S. Sarala, Professor, Dept. of Radiology

(Lead Member)

2.      Mr.S. Balaraju, RSO, Radiotherapy

3.      Dr. R. RamyaPraya, Asst. Prof., Dept. of Nuclear Medicine

4.      Dr.VC. Venkatesh, Lecture, Dept. of Radiology

AAC 10

There is an established quality assurance programme for imaging services

1.      Dr. S. Sarala, Professor, Dept. of Radiology

(Lead Member)

2.      Dr. R. RamyaPraya, Asst. Prof., Dept. of

Nuclear Medicine

3.      Dr.Harshith Sony, Lecture, Dept. of Radiology

AAC 11

There is an established safety programme in the imaging services

1.      Dr. S. Sarala, Professor, Dept. of Radiology

(Lead Member)

2.      Mr.S. Balaraju, RSO, Radiotherapy

3.      Mr.M.V. Rangarao,Technician Gr.I.

4.      Mr.D. Chandra Sekhar, Tech. Nuclear Medicine

AAC 12

Patient care is continuous and multidisciplinary.

1.      Dr. A. Sandeep Kumar Reddy, Asst. Prof., Dept. of Medicine(Lead Member)

2.      Mrs. K. Madhavi, Professor & Principal i/c, College of Physiotherapy

3.      Mrs.E. Bhuvaneswari NS Gr.II

4.      Mrs.J. Sarada Devi, NS Gr.II

5.      Mrs. G. Indiramma, NS. Gr.II

AAC 13

The organization has an established discharge process.

1.      Dr. A. LokeswarReddy,Chief MEDCO

(Lead Member)

2.      Dr. K. Vivekanand, CMRO ( Billing)

3.      Mrs. C. Sunitha,  NS Gr.I

4.      Mrs.G. Indiramma, NS. Gr.II

5.      Mr. B. Prakash, Security Officer

AAC 14

Organization defines the content of the discharge summary.

1.      Dr. A. Lokeswar Reddy,Chief MEDCO ,

(Lead Member)

2.      Dr. K. Vivekanand, CMRO ( Billing)

3.      Mrs. C. Sunitha,  NS Gr.I

4.      Mrs. G.Indiramma, NS. Gr.II

 

 Chapter: 2 - Care of Patients (COP)

Group Leader: Dr. Aloka Samantaray, Professor &  Head, Dept. of  Anesthesiology

Co –Ordinator: Dr.Rohit Gupta, Asst. Professor Department of EMD

Task code

(Standard)

Summary of Standards

Group Members

COP 1

Uniform care to patients is provided in all settings of the organization and is guided by written guidance, and the applicable laws and  regulations

1.      Dr.V. Chandrasekhar, Asst. Prof.,

Dept. of  Community Medicine, (Lead Member)

2.      Dr.A. Lokeswar Reddy, Chief MEDCO

COP 2

Emergency services are provided in accordance with  written guidance, applicable laws and regulations.

Dr. A. Krishna Simha Reddy

Professor, Dept. of  Emergency Medicine,

COP 3

Ambulance services ensure safe patient transportation with appropriate care.

1.      Dr.P. Subramanyam, Asst. Professor

Dept.of EMD, (Lead Member)

2.      Mr. B. Prakash, Security Officer

3.      Mr.Elango Reddy, Fire Safety Officer

COP 4

The organization plans and implements mechanisms for the care of patients during community emergencies, epidemics and other disasters.

1.      Dr.P. Subramanyam, Asst.Professor,

Dept.of EMD.

 

2.      Dr. D.S. Sujith Kumar, Assoc. Professor, Dept. of Community Medicine.

COP 5

Cardio-pulmonary resuscitation services are provided uniformly across the organization.

Dr.N.Hemanth, Professor, Dept.of  Anaesthesiology

COP 6

Nursing care is provided to patients in the organization in consonance with clinical protocols.

Dr. M.Nagarathna,Assoc. Professor,  College of Nursing,

COP 7

Clinical procedures are performed safely

Dr.P.Hemalatha, Asso. Professor

Dept.of Anaesthesiology

COP 8

Transfusion services are provided as per the scope services of the organization, safely.

Dr. B.Suresh Babu,Asst. Professor,

Dept.of Transfusion Medicine

COP 9

The organization provides care in intensive care and high dependency units in a systematic manner.

Dr. V. Sameeraja, Asst.Professor,

Dept.of Medicine,

COP 10

Organization provides safe obstetric care.

Dr.B. Akila, Asst.Professor, Dept.of OBG

COP 11

Organization provides safe Pediatric services.

Dr. P. Puneeth, Assoc. Professor&HoD i/c,Dept.of  Paediatrics

COP 12

Procedural sedation is provides consistently and safely

Dr.A.Krishna SimhaReddy,Professor, Dept. of Emergency Medicine

COP 13

Anesthesia services are provided in a consistent and safe manner

Dr. R. Sri Devi, Asst.Professor, Dept.of Anaesthesiology

COP 14

Surgical services are provided in a carried out safely.

1.      Dr. S. B. Amarnath, Assoc. Professor, Dept. of ENT (Lead Member)

2.      Dr. S. Shameem, Asst.Professor,

Dept.of Anaesthesiology

COP 15

The organ transplant programme is carried out safely.

1.      Dr.Ram, Prof & Head,Dept.of Nephrology,

2.      Dr.Ch.Konda Reddy,Dept.of Urology

COP 16

The organization identifies and manages patients who are at higher risk of morbidity/mortality.

  1. Dr.P.JanakiSubhadra, Professor,

  2. Dept. of Anaesthesiology

COP 17

Pain management for patients is done in a consistent manner.

Dr. M. Madhusudan,Assoc. Prof.,Dept. of  Anaesthesiology

COP 18

Rehabilitation services are provided to the patients in a safe, collaborative and consistent manner.

Mr. K. Senthil Kumar, Asst.Professor, College of Physiotherapy.

COP 19

Nutritional therapy is provided to patients consistently and collaboratively.

Mrs. K. Geetha,Asst. Dietician

 

COP 20

End of life care is provided in a compassionate and considerate manner.

1. Dr.B.V Subramanian, Professor & Head, Dept.of R.T.

2. Dr.D.V.S.Kiran, Asst.Professor, Dept.of Medical Oncology

 

Chapter: 3 Management of Medication (MOM)

 

Group Leader   : Dr. A. UmamaheswarRao, Prof.  &HoD, Pharmacology

Co-ordinator: Dr. K. R. Subash, Professor, Pharmacology & Mr.L.Satheesh, AD Stores

Task code

(Standard)

Summary of Standards

Group Members

MOM 1

Pharmacy services and usage of medication is done safely.

Dr.K.Vijaya Chandra Reddy, Assoc. Prof, Pharmacololgy

MOM 2

The organization develops, updates and implements a hospital formulary.

Dr.M.Sravan, Clinical Pharmacist

MOM 3

Medications are stored appropriately and are available where required.

1.      Mr.L.Satheesh, A.D (Stores)

2.      Dr.Peta.Subramanyam,Sr.Pharmacist

MOM 4

Medication are prescribed safely and rationally

Dr.M.Babu,Asst. Prof, Dept. of Medicine

MOM 5

Medication orders are written in a uniform manner.

Dr.P.Anuhya, Clinical Pharmacist

MOM 6

Medication are dispensed in a safe manner.

1.      Mr.L.Satheesh A.D (Stores)

2.      Dr.Peta.Subramanyam, Sr.Pharmacist

3.      Mrs.T.Prabhavathi, A.D (Nursing)

MOM 7

Medication are administered safely.

1.      Mrs. T. Prabhavathi, A.D (Nursing)

2.      Mrs C. Suneetha, Nursing Suptd., Grade-I

3.      Mrs. E. Bhuvaneswari NS Gr.II

4.      Mrs. J. Sarada Devi, NS Gr.II

5.      Mrs. G. Indiramma, NS. Gr.II

6.      Mrs. I. Kanthamma, NS Gr.II

MOM 8

Patients are monitored after medication administration.

1.      Mrs. T. Prabhavathi, A.D (Nursing)

2.      Mrs C. Suneetha, Nursing Suptd., Grade-I

3.      Mrs. E. Bhuvaneswari NS Gr.II

4.      Mrs. J. Sarada Devi, NS Gr.II

5.      Mrs. G. Indiramma, NS. Gr.II

6.      Mrs. I. Kanthamma, NS Gr-II

MOM 9

Narcotic drugs and psychotropic substances, chemotherapeutic agents and radioactive agents are used safely.

1.      Dr.T.C.Kalawat, Prof &HoD, Dept. Nuclear Medicine.

2.      Dr.T.Bhargavi, Assoc. Prof, Medical Oncology

MOM 10

Implantable prosthesis and medical devices are used in accordance with laid down criteria.

Dr. K. Venkat, Assoc. Prof, Dept. of  Neurosurgery

MOM 11

Medical supplies and consumables are stored appropriately and are available where required.

1.      Mr.L.Satheesh, A.D (Stores) &

2.      Dr.Peta.Subramanyam, Sr.Pharmacist

 

 

 Chapter: 4 - Patients Rights and Education (PRE)

Group Leaders : Dr. Rukmangadha, Professor, of Pathology

Co-ordinator    : Mr. NVS. Prasad, MSW

Task code

(Standard)

Summary of Standards

Group Members

PRE 1

The organization protects and promotes patient and family rights and informs them about their responsibilities during care.

1.      Dr.Anju Ade, Professor, Dept.  Community  Medicine,

2.      Mr. K. Giribabu, AMRO

3.      Smt. N. Hemalatha,  H/N, OPD

PRE 2

Patient and family rights support individual beliefs, values and involve the

patient and family in decision making processes.

1.      Dr. N.Sharvani, Asso. Professor, Dept. of Physiology (Lead Member)

2.      Mr. V. Rajasekhar, PRO

3.      Smt. N. Hemalatha,  H/N, OPD

PRE 3

The patient and/or family members are educated to make informed

decisions and are involved in the care planning and delivery process.

1.      Dr. N..Sharvani, Asso. Professor, Dept. of Physiology (Lead Member)

2.      Mrs. P. Sunitha, Head Nurse

3.      Mrs.D. Sailaja, Head Nurse

4.      Mrs. D. Kalavathi, Head Nurse

5.      Mrs. V. Annie Besant, Head Nurse

6.      Mrs. Y. Nirmala, Head Nurse

PRE 4

Informed consent is obtained from the patient or family about their care.

1.      Dr. K. Venkat, Assoc. Prof, Dept. of  Neurosurgery

2.      Mrs.S. Shakira, OT Head Nurse

3.      Mrs. V. Radha Rani, OT Head Nurse

4.      Mr. B. Prasad, Computer Assistant

PRE 5

Patient and families have a right to information and education about their

healthcare needs.

1.      Dr. K. Prathiba, Assoc. Prof. of  Anatomy

2.      Mrs. S. Vahede, Head Nurse,

3.      Mrs. T. Suseela, Head Nurse,

4.      Mrs. T.L. Varalakshmi, Head Nurse,

5.      Mrs. A. Dhanabhagyam, Head Nurse,

6.      Mrs. K. Saraswathi, Head Nurse,

7.      Mrs. A. Premakumari, Head Nurse,

PRE 6

Patients and families have a right to information on expected costs.

1.      Dr. K. Vivekanand, CMRO

2.      Mrs. S. Santhana Lakshmi, Suptd., Credit Cell

3.      Mr. M.L. Govindarajulu, Suptd., Billing Section

4.      Mr. M. Hari, Sr. Asst., Credit Cell

PRE 7

The organization has a mechanism to capture patient‘s feedback and redress of complaints.

  1. Dr. N. Rukmangadha, Professor &HoD of Pathology,

  2. Mr.V. PranayaTeja, Network Engineer,

  3. Mr. S. Niranjan, Computer Asst.

  4. Mr.N. Dilip, Computer Asst.

PRE 8

The organization has a system for effective communication with patients and / or families.

1.      Dr. C.V. Praveen Kumar Reddy, Professor, Dept. of Plastic Surgery,

2.      Mrs. E. Bhuvaneswari NS Gr.II

3.      Mrs. J. Sarada Devi, NS Gr.II

4.      Mrs. G. Indiramma, NS. Gr.II

5.      Mrs. I. Kanthamma, NS Gr.II

 

 

Chapter: 5 Hospital Infection Control (HIC)

 

Group Leader :Dr. R. Jayaprada, Assoc. Prof. of Microbiology

Co-Ordinator  :Dr. N. Ramkrishna, Asst. Prof. of Microbiology

Task code

(Standard)

Summary of Standards

Group Members

HIC 1

The organization has comprehensive and coordinated Hospital Infection Prevention and Control (HIC) programme aimed at reducing/eliminating risks to patients, visitors and providers of care and community.

1.      Dr. R. Jayaprada, Associate Professor, Dept. of Microbiology

2.      Dr. V. Chandra Sekhar, Asst. Professor, Dept. of Community Medicine

3.      Mrs. M. Lakshmidevi, HICN

4.      Mrs. A. Shoba Rani, HICN

5.      Mrs.K. Karpugam, HICN

6.      Mrs. A. Reddamma, HICN

HIC 2

The organization provides adequate and appropriate resources for infection prevention and control

1.      Dr. K.V. KotiReddy, RMO

2.      Dr. G. SwethaRao, Asst. Professor, Dept. of Psychiatry

3.      Mrs.E. Bhuvaneswari, NS Gr-II

4.      Mrs.S. Shakira, Head Nurse

HIC 3

The organisation implements the infection prevent in and control programme in clinical areas.

1.      Dr. K. M. Bhargav, Asst. Professor, Dept. of Medicine

2.      Dr.M. Bhagya Lakshmi, Asst. Professor, College of Nursing

3.      Mrs.G. Indiramma, NS Gr-II

4.      Mrs. J. Saradadevi, NS Gr-II

5.      Mrs. I. Kanthamma, NS Gr-II

HIC 4

The organisation implements the infection prevention and control programme in support services.

1.      Dr. S. Yamini, Asst. Professor, Dept. of Microbiology

2.      Mr. TVP. Kumar, AE (Tech.)

3.      Mrs. T. Prabhavathi, AD Nursing

4.      Mrs. M. Sunitha Devi, Chief Dietician

5.      Mrs. A. Umamaheswari, Sanitary Dept.

6.      Mr. M. KanthaRao, Sanitary Supervisor

HIC 5

The organisation takes actions to prevent healthcare associated infection (HAI) in patients.

1.      Dr. A.V. ChaitanyaBhanu, Jr.Resident, Dept. of Dentistry.

2.      Dr. S. Noble Ujeesh, Sr. Resident, Dept. of Microbiology

3.      Mrs.Y. Nirmala, Head nurse (RICU)

4.      Mrs.T. Suseela, Head Nurse ( MICU)

5.      Mrs.K. Rajitha, Staff Nurse, (NABH cell)

 

HIC 6

The organisation performs surveillance to capture and monitor infection prevention and control data.

1.    Dr. N. Ramakrsihna, Asst. Professor, Dept. of Microbiology

2.      Mrs.V. Radha Rani, Head Nurse

3.      Mrs. D. Mary Susella , Head Nurse

4.      Mrs. A. Shoba Rani, Head Nurse

HIC 7

Infection prevention measures include sterilization and /or disinfection of instruments, equipment and devices.

1. Dr. R. Jayaprada, Associate Professor, Dept. of Microbiology

2.      Mrs. T. Prabhavathi, AD Nursing

3.      Mrs.B. Prameela, Staff Nurse, (CSSD)

4.      Mr.T.Gangadhara, Sr. Autoclave Tech.

HIC 8

The organisation takes action to prevent or reduce healthcare associated infection in its staff.

1.      Dr. V. Sameeraja, Asst. Professor, Dept. of Medicine

2.  Dr. G. VisweswaraRao,Asst. Professor, Dept. of  Community Medicine

3.      Mrs.J.M. Malathi, Head Nurse

4.      Mrs. C. Reddy Vasantha, Head Nurse

 

Chapter 6 : Patient Safety and Quality Improvement

Group Leader : Dr V S Kiranmayi, Dept. of Biochemistry

Co-ordinator   : Dr R. Arun, Dept. of Transfusion Medicine

Task code

(Standard)

Summary of Standards

Group Members

PSQ 1

The organization implements a structured patient-safety programme.

1.      Dr.Pallavi Chalivendra, Asst. Prof., Dept. of Pharmacology.

 

2.      Mr P.P. Reddy, Driver, PRO office

 

PSQ 2

The organization implements a structured quality improvement and continuous monitoring programme.

1.      Dr B. Deepthi, Asst. Prof., Dept. of Pathology.

 

2.      Mrs.V. Radha Rani, Head Nurse

 

PSQ 3

The organization identifies key indicators to monitor the structures process and outcomes, which are used as tools for continual improvement activities.

1.      Dr B. Hari Prasad, Assoc. Prof., Dept. of General Surgery

2.      Dr N. Lakshmanna, Asst. Prof., Dept. of Biochemistry

3.      Mrs. B. Kokilamma, Asst. Prof., CON

PSQ 4

The organization uses appropriate quality improvement tools for its quality improvement activities.

1.      Dr D. Ravisankar, Assoc. Prof., Dept. of Community Medicine

2.      Mr P. Ravi, Lab Technician, Dept. of Endocrinology

PSQ 5

There is an established system for clinical audit.

Dr R. Arun, Assoc. Prof., Dept. of Transfusion Medicine

PSQ 6

The patient safety and quality improvement programme are supported by the management.

1.      Dr A. Surekha, Assoc. Prof., Dept. of Dermatology.

2.      Mr G. Srinivas, Sr. Assist., Accounts Dept.

PSQ 7

Incidents are collected and analyzed to ensure continual quality improvement.

1.      Dr.Pranabandu Das, Assoc. Professor, Dept. of Radiation Oncology.

2.      Mrs C. Suneetha, Nursing Suptd., Grade-I

 

 Chapter : 7 - Responsibilities of Management (ROM)

Group Leader :Dr.K.V.Sreedhar Babu, Professor & Head of Transfusion Medicine

Co-ordinator   : Dr. M. Yerramma Reddy, Dy. Registrar

Task code

(Standard)

Summary of Standards

Group Members

ROM 1

The organization identifies those responsible for governance and their roles are defined.

1.      Dr.K.V.SreedharBabu, Professor &

Head of Transfusion Medicine,

2.      Dr. M. Yerramma Reddy, Dy.

Registrar, Purchase

ROM 2

The organization is ethically managed by the leaders.

1.      Dr.D.S. MadhuBabu, Professor

Head, Dept.  of Dentistry

2.      Mrs. C. Ushakiran, Assistant

Professor, College of Nursing

ROM 3

The organization is headed by a leader who shall be responsible for operating the organization on a day-to-day basis.

1.      Dr. V. Chandra Sekhar, Assistant

Professor, Department of Community Medicine

2.      Mr. D. Anandbabu, AD, O/o The Director cum VC

3.      Mrs. P. Nagaprasuna, Superintendent, Establishment Section

ROM 4

The organization displays professionalism in its functioning

1.      Dr. D. Srivani,Assistant Professor, Department of Anatomy

2.      Mrs. G.P. Majula, AD, Establishment Section

ROM 5

Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management.

1.      Dr.VinodBhan, Professor, Department of CT Surgery

2.      Mr. A. NagendraBabu, Supdt.,GM Office

3.      Mr. Mohan, PA, GM Office

4.      Mr.K. Narasimha Reddy, AE (Electrical)

 

 Chapter : 8 - Facilities Management and Safety (FMS)

Group Leader : Dr. R. Ram, Medical Superintendent

 Co-ordinator :  Mrs. M. Prasana Lakshmi, Dy. Director (GM)

           Mr. E. Doraiswamy, Sr. BME

Task code

(Standard)

Summary of Standards

Group Members

FMS 1

The organization has a system in place to provide a safe and secure.

1.      Dr. K. Madhavi, Professor, college of Physiotherapy,

2.      Mr.ElangoDamodaran,Fire Safety Officer,

3.      Mr.P.S. PrakashBabu,AE Civil SVIMS

4.      Mr. K. Bannerjee, Sr. Fitter

FMS 2

The organization’s environment and facilities operate in a planned manner and promotes environment friendly measures.

1.      Mrs. M. Prasana Lakshmi, Dy. Director (GM),

2.      P.S. PrakashBabu,AE Civil SVIMS

3.      Mr. K. Narasimha Reddy, AE (Electrical)

FMS 3

The organization environment and facilities operate to ensure the safety of patients, their families, staff and visitors.

1.      P.S. PrakashBabu,AE Civil SVIMS

2.      Mr. B. Prakash, Security Officer

3.      Mr. K. Narasimha Reddy, AE Electrical

4.      Mrs. C. Sunitha,  Nursing Supt. Gr-I ,

5.      4.Dr. EGTV Kumar, Sr. Tech.

FMS 4

The organization has a programme for the facility, engineering support services and utility system.

1.      Mrs. M. Prasana Lakshmi, Dy. Director (GM),

2.      Mrs. T. Prabhavathi, AD Nursing,

3.      Mr. S. Maheshwarnath, AC Plant Tech.

4.      Mr. K. Narasimha Reddy, AE Electrical

5.      Mrs. C. Sunitha,  Nursing Supt. Gr-I, .

6.      Mr. K. Bannerjee,Sr. Fitter,

7.      Mrs. B. Prameela, Staff Nurse, CSSD,

FMS 5

The organization has a programme for medical equipment management.

Mr. E. Doraiswamy, Sr. BME

FMS 6

The organization programme for medical gases, vacuum and compressed air.

Mrs. M. Prasana Lakshmi, Dy. Director (GM) and Gas Room Operating Staff Members

FMS 7

The organization has a plan for fire and non-fire emergencies within the facilities.

1.      Mr.Elango Damodaran, Fire Safety Officer & Fire Safety Team,

2.      Mr. K. Narasimha Reddy, AE Electrical

3.      Mr. B. Prakash,Security Officer

4.      Mr. K. KanthaRao, Sanitary Supervisor

5.      Mr. NVS. Prasad,MSW

6.      Mrs. M. Prasana Lakshmi, Dy. Director

7.      (GM) and Staff Members

8.      Mr. TVP. Kumar, AE Water Workers

9.      Mrs. T. Prabhavathi, AD Nursing

 

Chapter: 9 Human Resource Management (HRM)

Group Leader: Mr. G. Suresh Kumar, A.D-I (Estt. Sec.)

Co-ordinator: Smt. G. P. Manjula, A.D -II (Estt.Sec.)

Task code

(Standard)

Summary of Standards

Group Members

HRM 1

The organization has a documented system of human resource planning.

1. Dr. K. V. SreedharBabu, Registrar
2. Mr.G. Suresh Kumar, A.D-I (Estt. Sec.)
3. Mrs.G.P. Manjula, A.D-II (Estt. Sec.)
4. Mrs.P. Naga Prasuna, Supdt.,
5. Mrs.V. Aruna, Supdt.,
6. Mr.M. VenkataRamana Reddy, Supdt.,

HRM 2

The organization implements a defined process for staff recruitment.

1. Mrs.P. Naga Prasuna, Supdt.,
2. Mrs.V. Aruna,Supdt.,
3. Mr.M. VenkataRamana Reddy, Supdt.,

HRM 3

Staff are provided induction training at the time of joining the organization.

1. Mrs.P. Naga Prasuna, Supdt.,
2. Mrs.V. Aruna, Supdt.,

HRM 4

There is on-going programme for professional training and development of the staff.

1. Mrs.P. Naga Prasuna, Supdt.,
2. Mrs.V. Aruna, Supdt.,
3. Mr.G. Babu, A.D.

HRM 5

Staff are appropriately trained based on their specific job description

1. Mrs. P. Nagaprasuna, Superintendent, Establishment Section

2. Mrs C. Suneetha, Nursing Suptd., Grade-I

HRM 6

Staff are trained in safety and quality-related aspects.

1. Dr. R. Jayaprada, Assoc.Professor, Dept. of Mircrobiology

2. Dr. V S Kirnamayi, Assoc. Professor, Dept. of Biochemistry
3. Mr.ElangoDamodaran Reddy Fire Safety Officer
4. Mr. B. Prakash,Security Officer

HRM 7

An appraisal system for evaluating the performance of staff exits as an integral part of the human resource management process.

1. Mr. G. Suresh Kumar, A.D-I (Estt. Sec.)

2. Mrs. G. P. Manjula , A.D -II (Estt.Sec.)

3. Mrs. M. Prasana Lakshmi, DD (GM)

4. Mrs. T. Prabhavathi, AD Nursing

HRM 8

Process for disciplinary and grievance handling is defined and implemented in the organization.

1. G. Suresh Kumar,A.D-I (Estt. Sec.)
2. G. P. Manjula, A.D-II (Estt. Sec.)

HRM 9

The organization promotes staff well-being addresses their health and safety needs.

1. Dr. V. Vanajakshamma, Professor, Cardiology & Team
2. Mr. M. VenkataRamana Reddy, Supdt.,
3. Mr. A. Rama SubbaRamudu, Supdt.,

4. Mr.K.Giri Babu, AMRO

HRM 10

There is a documented personal information for each staff member.

1.  P. Naga Prasuna, Supdt.,(Estt. Sec.)
2.  A. Rama SubbaRamudu, Supdt., (Estt. Sec.)

HRM 11

There is a process for credentialing and privileging of medical professionals, permitted to provide patient care without supervision.

1. Dr.AlokSachan, Prof & HOD, Dept. of Endocrinology
2. Dr. B. Manilal, Assoc. Prof, Surgical Oncology
3. Dr. K. Venkat, Assoc. Prof, Neuro Surgery
4. Mr. G. Suresh Kumar,A.D -I (Estt. Sec.)
5.Mrs. P. Naga Prasuna, Supdt.,

HRM 12

There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision.

1. Dr. BCM. Prasad, Professor, Dept. of Neurosurgery

2. Ms. T. Prabhavathi, A.D (Nursing)
3. Dr. P. Sudharani, Professor, College of Nursing
4. Mrs.G.P. Manjula,A.D -II(Estt. Sec.)
5. Mrs.V. Aruna, Supdt., (Estt. Sec.)

HRM 13

There is a process for credentialing and privileging of para-clincial professionals, permitted to provide patient care without supervision.

1. Dr. B. VenkataRamana,Assoc.Prof, Microbiology
2. G. Suresh Kumar,A.D-I (Estt. Sec.)
3. M. VenkataRamana Reddy, Supdt.,

 

Chapter: 10 Information Management System (IMS)

Group Leader : Mrs. K. Bhavana, IT Manager

Co-ordinator : Mr. R. Sandeep Kumar, AMRO

Task code

(Standard)

Summary of Standards

Group Members

IMS 1

Information needs of the patients, visitors, staff, management and external agencies are met.

1. Mrs.K.Bhavana, IT Manager

2. Mrs.I.Kanthamma, Nursing Supdt., Grade-II

3. Mr.B.Prasad (Computer Assistant)

IMS 2

The organisation has process in place or management and control of data and information

1. Mr.Pranayatheja (Network Admintrator)

2. Mr. A.Savithri H/N, urology

IMS 3

The patients cared for by the organization have a complete and accurate medical record.

1. Mr.K.GiriBabu, AMRO and

2. Mr. B.Prasad, Computer Assistant.

IMS 4

The medical records reflects the continuity of care.

1. Mr.K.GiriBabu, AMRO

2. Mr.R. Sandeep Kumar, AMRO

IMS 5

The organization maintains confidentiality, integrity and security, data and information.

1. Dr.K.V. Koti Reddy, RMO,

2. Dr.P. PrabhanjanKumar , Asst. Prof. Dept. of Ophthalmology

3. Mr. R. Sandeep Kumar, AMRO

IMS 6

The organization ensures availability of current and relevant documents, records, data and information and provides for retention of the same.

1. Mr. K.S. Mohan Srinivas, Royal, Supdt., MRD

2. Mr.R. Sandeep Kumar, AMRO

IMS 7

The organization carries out a review of medical records.

1. Dr. D.T. Katyarmal, Professor, Dept. of Medicine

2. Mr.N.S.R.Muralikrishna, MRO, Dr. YSR Arogyasri Dept.

3. Mr. K.S. Mohan Srinivas, Royal, Supdt., MRD

4. Mrs.C. .Sunitha, Nursing Supdt., Grade-I

 

 

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Hospital Committees

 

SVIMS Hospital is committed to promote patient centeredness and ensure patient safety through continuous quality improvement. The hospital committees are multi-plural and are formed with care to include the many facets that are needed for an integrative service approach. The safety of the patient and the health care workers is the primary objective of the hospital committees.

 

 Constituted Committees:

Sl. No.

Chapter

Name of

01.

COP

CPR Analysis Committee (CPRA).

02.

COP

Blood Bank Committee

03.

MOM

Pharmaco Therapeutics Committee (PTC)

04.

HIC

Infection Control Committee

05.

HIC

AMS Committee

06.

PSQ

Patient Safety Committee

07.

PSQ

Quality Improvement Committee

08.

PSQ

Sentinel Events Analysis Committee

09.

HRM

Internal Complaints Committee

10.

HRM

Disciplinary  & Grievance Committee

11

IMS

Medical Records Review Committee

 

1.      CPR ANALYSIS COMMITTEE:

S. No.

Name

Role

Responsibility
  1.  

Medical Superintendent

Chairperson

Head & approving authority for Code Blue committee related matters. Supervise the committee functioning. Reconstitute the committee whenever required. Take actions for resolution of issues/problems identified by other committee members. Continuous monitoring of the quality of the committee functions.
  1.  

RMO

Member

Head & approving authority for Code Blue committee related matters. Supervise the committee functioning. Reconstitute the committee whenever required. Take actions for resolution of issues/problems identified by other committee members. Continuous monitoring of the quality of the committee functions.
  1.  

Dr. A.N. Sowmya (EMD Physician)

Member

·         Convene the meeting s with prior approval from Chairperson

·         Conduct Mock drills, audits & debriefing sessions.

·         Attend CPRA monthly BLS & ACLS training programmes. Follow the instructions given and/or responsibilities assigned by the Chairperson.

·         Identify the deficiencies and problems to be rectified to improve the quality of the work.

 

 
  1.  

Dr. Sameraja       (General Physician)

Member
  1.  

Dr. Rama (General Physician)

 
  1.  

Dr. Vinay (Anaesthesiology)

Member
  1.  

Dr. Rajamani  (General Physician)

 
  1.  

Dr. Akila  (Obstretics)

 
  1.  

Dr. Krian  (Cardiology)

 
  1.  

Dr. Sreedevi  (Anaesthesiology)

 
  1.  

Smt. S. Sunitha (NS-I)

Smt. J. Sarada Devi (NS-II)

Smt. G. Indiramma (NS-II)

Smt. I. Kanthamma (NS-II)

Smt. E. Bhuvaneswari (NS-II)

Member

Attend CPRA monthly meetings. Arrangements for training programs. Resource arrangements for Code Blue activities. CAPA analysis and implementation.

 
  1.  

Smt. Y. Nirmala (Head Nurse)

Member

Attend CPRA monthly meetings. Arrangements for training programs. Resource arrangements for Code Blue activities. CAPA analysis and implementation. Follow the instructions given and/or responsibilities assigned by the Chairperson. Identify the deficiencies and problems to be rectified to improve the quality of the work.

  1.  

Smt. T. Suseela  (Head Nurse)

Member
  1.  

Smt. L. Haritha (Head Nurse)

Member
  1.  

Smt. N. Ravanamma (Head Nurse)

Member
  1.  

B. Divyavani (Code Blue Nurse)

Member Secretary

·         Attending the Code Blue calls.

·     Maintaining the Code Blue data base. Collection and documentation of Code Blue census.

·         Follow-up of the Code Blue survivors.

·         Attend CPRA review meetings.

·       Identifying the shortfalls in resources and address them to the Nursing Superintendent / CPRA committee.

·         Participate in Mock drills and audits.
  1.  

P. Geetha (Code Blue Nurse)

Member
  1.  

G.Ramasri  (Code Blue Nurse)

Member
  1.  

P. Chandana  (Code Blue Nurse)

Member
  1.  

P. Haritha (Code Blue Nurse)

Member
  1.  

G. Sunil

Member

 
  1.  

D. Manjusha

 

 
  1.  

G. Praveen Kumar

 

 
  1.  

Mr. B. Prasad            (IT Department)

Member

Coordinate the members of the committee. Making arrangement for the meetings. Documentation minutes of the meetings. Records maintenance. Follow the instructions given and /or responsibilities assigned by the Chairperson.

  1.  

Mr. N.VS. Prasad

MSW

Counselling the patient attendants during Code Blue. Follow the instructions given and/or responsibilities assigned by the Chairperson.
  1.  

Mr. Prakash

Security

Attend all Code Blue calls & provide support for the Code Blue Team. Assist with way finding for staff, and other patients/visitors. Cordon off the area to ensure the Code Blue Team is unimpeded. Controlling the attendants during Code Blue. Follow the instructions given and/or responsibilities assigned by the Chairperson.

 Meeting schedule and quorum of the meeting

·         CPRA committee review meetings are being conducted once in a month preferable on second Monday of every month.

·         Quorum: requires at least 50% of the total committee members i.e., minimum of 10 members.

·         Presence of Cardiologist/General Physician, Anaesthesiologist, Nursing Superintendent, Head Nurse, Nurse from Code Blue team, MSW, Security officer during the review meetings is mandatory to fulfil the quorum.

 

 

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2.      INFECTION CONTROL COMMITTEE:

 

HOSPITAL INFECTION CONTROL COMMITTEE MEMBERS

S. No

Name

Role

Responsibility

1

Director cum Vice-Chancellor

Chairman

Head & approving authority for committee related matters. Supervise the committee functioning.

2

Dr Ram

Co-chairman

Reconstitute the committee whenever required. Take actions for resolution of issues/problems identified by other committee members. Continuous monitoring of the quality of the committee functions.

3

Dr B. Venkata Ramana

Member secretary

Senior Microbiologist. Monitors the activities of Infection control team.

4

Dr A. Mohan

Member

Take actions for resolution of issues/problems identified by other committee members. Continuous monitoring of the quality of the committee functions.

5

Dr Pranabandhu Das

Member

Take actions for resolution of issues/problems identified by other committee members.

Attend monthly review meetings. Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson

6

Dr G. Swetha Rao

Member

Take actions for resolution of issues/problems identified by other committee members.

Attend monthly review meetings. Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson

7

Dr  Chaitanya

Member

Take actions for resolution of issues/problems identified by other committee members.

Attend monthly review meetings. Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson

8

Dr C. Konda Reddy

Member

Take actions for resolution of issues/problems identified by other committee members.

Attend monthly review meetings. Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson

9

Dr D. Satyavathi

Member

Take actions for resolution of issues/problems identified by other committee members.

Attend monthly review meetings. Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson

 

10

Dr Prajakta

Member

Take actions for resolution of issues/problems identified by other committee members.

Attend monthly review meetings. Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson

11

Dr R. Jayaprada

HICO

Coordinate with the Medical Superintendent (Co-Chairman) in planning infection control program and measures.

ICO is responsible for surveillance and supervision of hospital acquired infection as well as preventive and corrective programmes in the hospital.

12

Dr N. Ramakrishna

HICO

13

Dr S. Yamini

HICO

14

Dr V. Harika

HICO

15

Mrs. T. Prabhavathi

Member

Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson / Co-chairperson

16

Mrs. M. Lakshmidevi

Member

Environmental surveillance.

Surveillance of air in OT’s/ICUs.

To check for sterilization & dis-infection practices.

In-use test of disinfectants.

Autoclave checks.

Water testing.

Continuous surveillance of HAI infections.

Educating of HCWs.

17

Mrs. V. Karpugam

Member

18

Mrs. D. Redemma

Member

19

Mrs. A. Shobharani

Member

20

Mrs. Shakira

Member

Monitor OT related IPC practices, Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson / Co-chairperson.

21

Mrs. C. Sunitha

Member

Monitor CSSD related IPC practices, Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson.

22

Mrs. A. Umamaheswari

Member

Monitor sanitation & disinfection activities in all areas, Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson.

23

Dr P. Subramanyam

Member

Monitor Antimicrobial prescriptions for high end antibiotics and antimicrobial prescription audit.

 Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson.

24

Mrs.C. Sunitha

Member

Monitor Laundry & linen related IPC practices, Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson.

25

Mrs. D. Indiramma

Member

26

Mrs.M. Sunitha

Member

Monitor Kitchen sanitation & vaccination of food handlers. Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson.

27

Dr V. Chandrasekar

Member

Monitor any outbreaks if infections & MDR bugs.

Attend monthly review meetings.

Follow the instructions given and/or responsibilities assigned by the Chairperson/Co-chairperson.

28

Mr. T.V.P.Kumar

Member

Monitor water tanks disinfection including RO plants.

Attend monthly review meetings.

Follow the instructions given and/or 28responsibilities assigned by the Chairperson/Co-chairperson.

29

Mr. P. Yashodhar

Member

Air and surface surveillance culture for OT, ICU’s and other high risk areas

Performing water surveillance to test the quality for drinking water

Performing disinfectant testing of a range disinfectant

Sterility checking of blood and blood product

30

Mr. V. Venkatesh

Member

31

Mr. Sai Jagadeesh

Secretarial Assistant

Documentation of minutes of the meetings.

 

Meeting schedule and quorum of the meeting

·         HICC committee review meetings are being conducted once in a month preferably on FIRST TUESDAY of every month.

·         Quorum: Requires at least 50% of the total committee members i.e., minimum of 15 members.

·         Presence of Chairperson/Co-chairperson, member secretary, Physicians, surgeons, HICOs, ICNs, Nursing superintendent, health inspector, CSSD, engineering dept., OT and ICUs in charges during the review meetings is mandatory to fulfil the quorum.

 

3.      PHARMACO THERAPEUTICS COMMITTEE:

S.No

Name

Role

Responsibility

1

Dr.Ram

(Medical Superintendent)

Chairman

Advising medical, administrative and pharmacy departments on pharmaceutical related issues.

Monitor and Supervise the committee functioning. Reconstitute the committee whenever required.

2

Dr.K.Uma Maheswara Rao

(Prof & HOD, Pharmacology)

Executive Secretary

Developing drug policies and procedures.

Evaluating and selecting medicines for the formulary and providing for its periodic revision. Promoting & conducting effective interventions to improve medication use. Monitoring ADRs & Medication errors. Conducting audits and training programmes for improving medication safety.

3

Dr.P.Subramanyam

(Sr.Pharmacist)

Member

Attend PTC monthly meetings. Following the instructions assigned by the chair person and executive secretary. Checking whether medications are stored appropriately and are available when required. Checking whether medications are dispensed in safe manner. Checking whether medical supplies and consumables are stored appropriately and are available when required. Identifying deficiencies to improve the quality of medication safety.

4

Dr. Aloka Samantaray

(Prof & HOD, Anaesthesiology)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking for the proper maintenance of crash cart.

5

Dr.Vinod Bhan

(Prof., CT Surgery)

 

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking whether implantable prosthesis and medical devices are used in accordance with laid down criteria.

6

Dr.Chandramalitheswaran

(Assoc. Prof, Surgical GE)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Advising for surgical items and their storage.

7

Dr.Malathi

(Assoc.Prof, OBG)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings.

8

Dr.Venkata Naveen Prasad

(Assoc Prof, Neurology)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings.

9

Dr.Bhargavi

(Assoc Prof., Medical Oncology)

Member

 

 

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking whether narcotic drugs and psychotropic substances, chemotherapeutic agents are used safely.

10

Dr.M.C.R.Rama

(Asst.Prof.,of Medicine)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings.

11

Dr.Harini Devi

(Assoc.Prof.,Biochemistry)

 

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Advising regarding lab chemicals, reagents and their storage

12

Dr.Sujith Kumar

(Assoc. Prof, Community Medicine)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings.

13

Dr.Akhila

(Asst.Prof.,OBG)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings.

14

Dr.C.Pallavi

(Asst.Prof., Pharmacology)

Member

Attend PTC monthly meetings. Attending clinical audits and training programmes related to medication safety. Monitoring medication errors and CAPA. Reviewing the minutes of meetings. 

15

Dr.G.Ravindra Kumar

(Asst.Prof., Pharmacology)

Member

Attend PTC monthly meetings. Attending clinical audits and training programmes related to medication safety. Monitoring medication errors and CAPA. Reviewing the minutes of meetings.

16

Dr.Ramya Priya

(Asst.Prof., Nuclear Medicine)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings.

17

Dr.Jayaprda

(Assoc.Prof. Microbiology)

 

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Monitoring Antibiotic audit Committee and developing policies concerning usage of antibiotics.

18

Dr.M.Yerram Reddy

(A.D Purchase)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Monitoring for improved medicine procurement and inventory management.

19

Mr.L.Sateesh

(A.D Stores)

Member

Attend PTC monthly meetings. Following the instructions assigned by the chair person and executive secretary. Checking whether medications are stored appropriately and are available when required. Checking whether medications are dispensed in safe manner. Checking whether medical supplies and consumables are stored appropriately and are available when required. Identifying deficiencies to improve the quality of medication safety.

20

Mrs.Prabhavathi

(A.D. Nursing)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking for the safe dispensing and administration of medications. Monitoring the patients after administration. Advising medication administration staff to minimise medication errors and take necessary CAPA for enhancing patient safety.

21

Mrs.C.Sunitha

(Nursing Superintendent Gr-I)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking for the safe dispensing and administration of medications.  Advising medication administration staff to minimise medication errors and take necessary CAPA for enhancing patient safety.

22

Mr.Subramanyam Raju

(Pharmacist Gr-I)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking for the safe dispensing of medicines.

23

Mr.Babu Suresh

(Pharmacist Gr-I)

 

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking for the safe dispensing of medicines.

24

Dr.A.Sai Kiran

(Clinical Pharmacist)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Attending clinical rounds and monitoring medication use. Identifying and reporting ADRs medication errors along with CAPA.

25

Dr.P.Anuhya

(Clinical Pharmacist)

Member

Attend PTC monthly meetings. Reviewing the minutes of meetings. Checking whether medication orders are written in uniform manner or not. Attending clinical rounds and monitoring medication use. Identifying and reporting ADRs medication errors along with CAPA.

Meeting schedule and quorum of the meeting

·         PTC meeting is scheduled once in a month i.e. every 1st Friday of month

·         Quorum: Requires at least 50% of the total committee members

 

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 4.      QUALITY IMPROVEMENT COMMITTEE:

 

Sl. No.

Name  & Designation of the Member

Position in the committee

Roles and Responsibilities of the member

01

Director cum Vice-Chancellor

Chairman

 

02

Dr. Y. Mutheeswaraiah,

Professor & Head, Dept. of Surgery

Member

Implementation of AAC standards through out the hospital.

03

Dr. K. UmamaheswarRao,

Professor & Head, Dept. of Pharmacology

Member

Implementation of MOM chapter through out the hospital and PSQ3 standard.

04

Mrs. K. Bhavana

IT Manager

Member

Implementation of IMS chapter through out the hospital

05

Mrs. GP. Manjula

AD Establishment Section II

Member

Implementation of HRM chapter

06

Dr. VinodBhan

Professor, Dept. of C.T. Surgery

Member – Patient Safety

Implementation of  Patient safety programmes through out the hospital and PSQ 1, & FMS 3 (e)  ( f)

07

1.      Dr. A. Surekha, Assoc. Prof., Dept. of DVL – I/c for Medical Departments

2.      Dr. B. Manilal, Assoc. Prof., Dept. of SO – I/c for Surgical Departments

3.      Dr. V. Sivakumar, Asst. Prof, Dept. of Pathology – I/c for Lab Departments

Member – Clinical safety

Implementation Clinical Safety measures through out the hospital &  PSQ 4 standard.

08

Dr. Pranabandu Das, Assoc. Professor, Dept. of Radiotherapy

Member

In charge for Sentinel events Analysis & Implementation of PSQ 7 standard

09

Dr.H.Narendra Prof. & Head, Dept. of SO 

Member

In charge for clinical audits and Implementation of PSQ 5 standard

10

Dr. R. Jayaprada, Assoc. Professor, Dept. of Microbiology

Member from HIC

Implementation of HIC programme through out the hospital and Implementation of PSQ3,   FMS 1 (e), FMS 7 (c),  standard elements.

11

Mr. Elango Reddy, Fire Safety Officer

Member from support services

Implementation of FIRE SAFETY, Mock drills for CODE RED & FMS 4 (e) & FMS 7 standard elements.

12

Mr. B. Prakesh, Security Officer

Member from Support services

FMS 3 (b)

 

13

Dr V.S.Kiranmayi, Assoc. Professor, Dept. of Biochemistry

Member from Lab services

Implementation of PSQ, chapter through out the hospital and PSQ 3 standard in detail.

14

Dr. V. Vanajakshama, Professor, Dept. of Cardiology

Member from  CPR committee

Implementation of mock drills for code blue FMS 7 (c)

15

Dr. J. Malathi, Assoc. Professor, Dept. of OBG

Member from  OBG services

Implementation of mock drills for CODE PINK , FMS 7 (c) & COP 10 standard elements.

16

Dr. Punith Patak, Assoc. Professor & Ho Di/c, Dept. of Paediatrics

Member from Paediatric services

Implementation of mock drills for CODE PINK, FMS 7 (c) & COP 11 Standard elements.

17

Dr. P. JanakiSubhadhra, Professor, Dept. of Anaesthesiology

Member from ICU services

Implementation of PSQ3 standard through out the hospital.

18

Dr. S. Sarala, Professor, Dept. of Radiology

Member from Imaging Services

Implementation of RADIATION SAFETY PRACTICES ACROSS IMAGING SERVICES - AAC 9, AAC10, & AAC 11 standards.

19

HoD EMD Services

Member from Emergency Services

Implementation of PSQ3,   COP 2, COP3,  COP 4 & FMS 7 (c) standards and elements

20

Mr. K. Kantha Rao, Sanitary Supervisor

Member – Support Services

Implementation of HIC 4(c) through out the hospital.

21

Mrs. M. Prasanna Lakshmi, Deputy Director (GM)

Member – Facility Management

Implementation of FMS 2 (g), FMS 3 (e), FMS 6 standards and elements through out the hospital.

22

Asst. Engneer, Civil, TTD SVIMS

 

Member – Facility Management

Implementation of FMS 1 (a, b, e)  FMS 2 (b, g) FMS 3 (a) FMS 4 (f) standards and elements through out the hospital.

23

Mr. K. Narasimha Reddy, Asst. Engineer (Electrical)

Member – Facility Management

Implementation of FMS 2 (b) (d), (e), ( g) FMS 3 (c), FMS 4 (a,), (b), (c), (d), (e), (f), (g), (h) standards and elements through out the hospital.

24

Mr. T.V.P. Kumar, Asst. Engineer, Technical

Member – Facility Management

Implementation of FMS 1 b, FMS 2(d, e, f, g)& FMS 4 (c, f, g, h)

25

Mr. Dorai Swamy, Sr. Biomedical Engineer

Member from Facility Management

Implementation of FMS 5

26

Account Officer

Member  from Finance/Accounts

PSQ6(e) & ROM 4 (c)

27

Mr NVS. Prasad

Medico social Worker

Member from Patient Reported Outcome Measures (PROM)

PSQ 3 (e) & FMS 7 (c)

28

Patient Safety Committee

Leader

 

Implementation of PSQ1 (a,b,c,d,e,f,g,g,i) FMS 1 (b, d)

29

Mr. R. Nagaraja, Sr. Artist

Member

Implementation of FMS 2 (c)

30

Mrs. T. Prabhavathi

Asst. Director (Nursing)

Member from Nursing Services

Implementation of FMS 3 (e), FMS 4 (d)

  Meeting schedule and quorum of the meeting

·         The quality improvement meeting is scheduled twice in a month i.e. on 2nd  & 4th Tuesday of every month.

·         The meetings are held by involving limited departments to discuss and review the quality improvement activities in patients oriented areas and in the organization oriented standards.

 

5.      PATIENT SAFETY COMMITTEE:

S. No

Name

Role

Responsibility

1

Facility Management Team

1.1  Principal, College of Physiotherapy

Provision of Grab Bars, Special Toilets for differently able persons, wheel chairs, External and Internal signage’s and bed rails.

 

 

1.2  Deputy Executive Engineer, Civil

Before commencement of expansion or maintenance of any work, risk assessment shall be done with the help of HIC coordinator and this shall be covered noise, vibration and infection control.  Built and updated drawings are to be maintained as per statutory requirements, Check the swing doors unsafe for people passing through it. Leakages/seepages in the area rendering it prone to infection.  Height of the ceiling can cause injury to head to people with long height.  Unwanted or unnoticed holes, breaks in the floor/ground that can be hazardous while walking.  Terrace/higher floors lack of grills at the border making it unsafe.

 

 

1.3  Radiation Safety Officer

To follow AERB guidelines.

 

 

 

1.4  AE, SVIMS

Potable water testing, overhead storage cause accidents, Is placement of furniture can cause any fall.

 

 

1.5  Assistant Engineer, Electrical, TTD

    Electricity Back up, Elevators movements to avoid sudden stoppage and jerks, unprotected electrical wirings, lack of adequate lighting can cause which can be reason for accidents or errors. 

 

 

1.6  Security Officer

     Restricted entry into OTs, ICUs and CC TV coverage of the entire hospital and monitoring.

 

 

1.7  Deputy Director (GM)

As per FMS 7 standard

 

 

1.8  Deputy Director (GM)

 As per FMS 6 standard

 

2. Dr. Vinod Bhan, Professor,  Department of  CT Surgery

 

Patient Safety Officer

1.      Environmental Safety

2.      Lab Safety

3.      Equipment risk Eg. Fire/Injury risk from use of LASER

4.      Risk resulting from long term conditions

5.      Internal and External reporting system on process failure

6.      Fire accidents

7.      Leakage of radiation source

8.      Incidents covering from “no harm” to “sentinel events”

9.      Pro-active risk analysis of patient safety risks shall be done through HIRA and FMEA.

10.  At minimum one patient safety related risk shall undergo proactive risk analysis every year.

11.  Avoid Lack of continuity of manpower during surgery due to shift duties

12.  Avoid Patient Fall  from trolley to bed and bed to Trolley

13.  Avoid Cautery burns

14.  Avoid Delay in availability of surgical material in middle of surgery

15.  Connecting all critical equipments to UPS

16.  Continuous medical gas supply

17.  Patient safety officer shall report directly to the top management

 

 

 

Clinical Safety Officer

1.      Radiation Safety – ALARA (As low as reasonably achievable) Eg. X-ray for all ICU, Pediatric or neonatal,  patients.   CT Scan protocols to be modified to use the lowest exposure.  Parameters to maintain the image quality appropriate for clinical indication.  Eg. CT for ur eteric calculi can be done with low dose where as renal tumor will require high dose.

2.      Appropriate screening of the patients before imaging.

3.      Patients in the child bearing age group who need to be exposed to radiation should be scanned for pregnancy.  MRI patients screened for Magnetic substance.  Screening also shall be applicable to the accompanying patient/child into the imaging area.

4.      Shielding of body parts of the patients, attendants shall be adhered to using appropriately.

5.      To identify various risk, record for action taken for risk alleviation of each of these risk and the mechanism for informing the staff regarding the same.

6.      Medication Management covering the issues of Patient/Service user, allergies and antibiotic resistance.

7.      Implementation of current national patient safety/International patient safety goals.

8.      SBAR communication for patients handover

9.      Two identifiers for patients identification

10.  Implement evidence based medicine/ clinical practice guidelines (STGs) Standard Treatment Guidelines bought by GoI.

11.  To define list of high risk medication, Look alike sound alike, different concentrations of the same drug to be stored far away, High risk medications are to be verified before dispensing, Inadvertent administration of drug through wrong route shall be avoided.

12.  Medication orders shall be checked at transition points of the patients.

13.  Hand Hygiene guidelines at all locations of hand washing areas.

14.  One Needle, one syringe and only one time policy. To implement CDC recommendations.

15.  Retained missing instruments and gauze

 

 

Paramedical staff

1.      Follow HIC practices while attending patients.

2.      Avoid to storing of listed hazardous material in unsafe condition

3.      Maintain MSDS sheets

 

 

Clinicians

 

1.      Implementation National/International patient Safety Goals

2.      Implement the Clinical Safety Officer guidelines pertaining to the respective Clinical and Diagnostic departments as suggested by the Clinical Safety Officer.

3.      Implement evidence based medicine/ clinical practice guidelines (STGs) Standard Treatment Guidelines bought by GoI.

 

 

Nurses

1.      Implement the guidelines pertaining to the respective clinical departments as suggested by the Clinical Safety Officer.

2.      Follow HIC practices while attending patients.

3.      Fall risk assessment of the patients and to take pro-active risk management.

 

 

Support Services

1.      Slippery floor and probable to cause slip falls.

2.      Rodents and pests in the area which can cause harm to patients, staff and equipments.

Meeting schedule and quorum of the meeting

·         The Patient safety committee meeting is scheduled once in a month i.e. on 4th Saturday of every month.

·         Quorum: Requires at least 50% of the total committee members

·         Patient safety aspects like development, implementation and monitoring of the safety plans and policies to provide as safe and secure facility and environment. Proactive risk assessment, FEMA, HIRA, facility inspection rounds, patient safety incident, risk management and analysis of key-safety indicators and sentinel events.

6.      INTERNAL COMPLAINTS COMMITTEE:

 

S. No.

Name of the Member

Designation &  Department

Status in Internal Complaints Committee

01

Dr Aparna R Bitla

Professor, Department of Biochemistry

Presiding Officer

02

Dr.V.Venkatarami Reddy

Professor & HOD, Department of Surgical G.E.

Member

03

Dr.K.Prathiba

Associate Professor, Department of Anatomy

Member

04

Sri. Ashok Kumar

Advocate & Standing Counsel, SVIMS

Member-External (legal)

 The respective HoD’s /College Principals/Administrative HoD’s shall be co-opted on case to case basis depending upon the need.

 Roles & Responsibilities

 The Internal Committee, SVIMS plays an important role in the functioning of the provisions of the Act and to ensure the fulfillment of its objectives of the Internal Committee Policy thus the main function of the Internal Committee is:

 

·         Implementation of the Internal Committee Policy relating to the prevention of sexual harassment.

·         Resolving complaints by the aggrieved based on the guidelines of the Internal Committee Policy.

·         Recommending actions to be taken by the Employer.

As per Section 11(3) the internal Committee enjoys the powers same as that of a civil court and therefore:

·         It is empowered to initiate an inquiry into a complaint of sexual harassment at the workplace according to the Internal Committee Policy.

·         IC has the power to summon witnesses and parties to state the committee.

·         It enjoys the discretion of summoning evidence to be examined if it may be deemed necessary to do so by the members of the committee.

·         All the members thus have an active role in each of the above. The external legal advisor shall give opinion related to the legal issues pertaining to the case. Inclusion of the external member ensures transparency and authenticity to the entire process and gives an outside perspective. 

 

Responsibilities of Internal Complaints Committee:

 SVIMS is bound by Prevention of Sexual Harassment Act and displays the names and details of the current IC members on the premises at prominent places as well as in the official website.

 

·         Receive complaints of sexual harassment at the workplace

·         Initiate and conduct an inquiry as per the policy

·         Submit findings and recommendations of all such inquiries

·         Maintain strict confidentiality throughout the process as per established guidelines of the Internal Committee Policy

·         Submit annual report in the prescribed format as prescribed.

 

Meeting schedule and quorum of the meeting

·         Once in a month and as and when a case is registered, the committee shall meet immediately.

·         Quorum: Requires 100% of the total committee members.

 

 

7.      DISCIPLINARY & GRIEVANCE COMMITTEE:

S. No.

Name of the Member

Status in Disciplinary & Grievance Committee

Roles & Responsibility

01

Dr. D. Rajasekhar

Chairperson

The Grievance Committee shall be responsible to ensure that grievances are dealt with effectively in accordance with the Grievance Procedures set out for the implementation of this Policy.

In doing so, the Committee shall adhere to the following principle

 ·         Take grievances seriously taking on board why the employee feels aggrieved, unhappy or dissatisfied

·         Investigate the facts and surrounding circumstances, and showing the employees that this been done thoroughly and sensitively.

·         Actively look for a solution that will satisfy the employee, where practical without causing disproportionate difficulty for the organization or the Employee’s colleagues.

·         Provide feedback to the employee about what can, and cannot be done to resolve the grievance

·         Take necessary follow-up action

·         All the members thus have an active role in each of the above.

02

Dr. A. Mohan

Member – Ex-Officio – Dean

 

03

Dr. K.V. Sreedhara Babu

Member – Ex-Officio – Registrar

04

Dr. K. Nagaraj

Member – Secretary

05

Dr. Dr. Chandramal Theswaran

Member

06

Dr. K. Prathiba

Member

07

Dr. A. Surekha

Member

08

Dr. M. Ganesh Kumar

Member

09

Dr. V. Srikumari

Member

10

Mrs. G.P. Manjula

Convener & Coordinator

 

Meeting schedule and quorum of the meeting

·         The disciplinary & Grievance Committee meeting shall be held on 1st Saturday of every month between 3 and 4 pm in the committee hall.

·         Quorum requires at least 50% of the total committee members.

 

8.      MEDICAL RECORDS REVIEW COMMITTEE:

 S. No.

Name of the Member

Status in Disciplinary &

Grievance Committee

Roles & Responsibility

01

Medical Superintendent

Chairperson

·   Responsible or overall supervision of the Committee activities.

·   Responsible for sending lacunas for CAPA to the concerned HoD’s.

02

Medical Record Officer

Coordinator

·   Co-ordinate the Medical Record Review Committee Meeting.

·   Prepares the minutes of the meeting.

·   Dispatches the minutes to the concerned and inform the deficits to the concerned.

·   Responsible for sample bases review

03

Resident Medical Officer

Member

·   Address the members in the meeting, discuss with the concerned members to complete the lacunas at the earliest.

04

HoD, Dept. of Anaesthesiology

Member

·   Responsible to conduct audit for complete consent form, anaesthesia record & operation record.

05

HoD, Dept. of Pharmacology

Member

·   Responsible to conduct audit for medication chart, regarding administered drug properly, legibility of author name, signature time and to write in capitals, using no short forms, dosage.

06

Prof. Dept. of Medicine

Member

·   To audit the medical cases.

07

Assoc. Prof Dept. of General Surgery

Member

·   To audit the surgical cases.

08

AD Nursing & Nursing Group

Member

·   To audit the nursing assessment / Nurses notes and various consent forms used at the time of admission.

 Meeting schedule of the Medical Record Review Committee meeting

The Medical Record Review committee shall meet once in a month i.e. on 3rd Thursday at 10:30 am in the committee hall to review the medical records of current patients. 

9. AMS COMMITTEE

Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.

THE FOLLOWING ARE THE MEMBERS OF ANTIMICROBIAL STEWARDSHIP COMMITTEE:

 

1.      Dr R. Ram (Medical superintendent)                                                 -    Chairman

2.      Dr R. Jayaprada (Microbiology)                                                          -   Member

3.      Dr N. Ramakrishna (Microbiology)                                                    -    Member

4.      Dr C. Sunil Kumar  (GM)                                                                    -   Member

5.      Dr M.C.R. Rama   (GM)                                                                      -   Member

6.      Dr C.V.S.Manasa (GM)                                                                       -   Member

7.      Dr V. Manolasya, (GM)                                                                       -   Member

8.      Dr Surekha.A   (Dermatology)                                                            -   Member

9.      Dr B.Hari Prasad (GS)                                                                         -   Member

10.   Dr V. Nagateja (Plastic surgery)                                                        -    Member

11.   Dr K. Venkat   (Neurosurgery)                                                          -    Member

12.   Dr B. Manilal   (SO)                                                                          -    Member

13.   Dr J. Malathi     (OBG)                                                                      -    Member

14.   Dr D. Bhargavi  (MO)                                                                       -    Member

15.   Dr A. Naga Sowmya  (EMD)                                                            -    Member

16.   Dr Jonnakuti Rani        (EMD)                                                          -    Member

17.   Dr P. Hemalatha    (Anaesthesiology)                                               -    Member

18.   Dr C. Sumadhu     (Anaesthesiology)                                                -    Member

19.   Dr V. Chandra sekhar (PSM)                                                            -    Member

20.   Dr K. Vijaya Chandra Reddy (Pharmacology)                                 -    Member

21.   Dr J.P. Joshi Sowmya (Pharm D)                                                      -    Member              

22.   Dr C. Pallavi    (Pharmacology)                                                         -    Member

23.   Dr Peta subramanyam (Pharmacist)                                                   -    Member

24.   Mr V. Babu suresh (Pharmacist)                                                        -    Member

25.  K.V. Kishore Tangella                                                                        -    Member

26.   AMS & HIC Link nurses (All ICU and RR)                                    -    Member

27.   Nursing Superintendents  (Mrs Indiramma & Mrs Sharada devi)     -    Member

 

Meeting schedule of the Medical Record Review Committee meeting

 

Ø  The committee shall meet once in a month as per Medical Superintendent orders.

·         Quorum requires at least 50% of the total committee members.

 

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