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PATEL HOSPITAL PRIVATE LTD.

QUALITY MANUAL

Issue No. 1 Issue Date Revision No. 00 Revision Date

Prepared By : Dr. Harpreet Kaur Approved By: Dr. Swapan Sood 1 of 47

PH/INT/QC/MAN/QC/6251/14-15/REV-00

HOSPITAL QUALITYMANUAL

PATEL HOSPITAL PRIVATE LTD.CANCER & SUPERSPECIALITY HOSPITAL

CIVIL LINES, JALANDHAR - 144001


QUALITY MANUAL



PREFACE

This document has been prepared to define and communicate the Patel Hospitals’s Quality

Policy for the purpose of effective implementation of Quality Management system designed to

assist in the achievement of total customer satisfaction. The quality Management system has been

based on the requirement of NABH 3rd Edition. The Quality Manual is the property Patel Hospital

Pvt. Jalandhar, Punjab so its circulation is limited to those mentioned in the distribution list, unless

otherwise specified, no part of this manual may be reproduce or utilized in any form or by means,

electronic or mechanical including photocopying & microfilm without permission in writing

without authorized permission. Preparation of additional copies is not permitted without authorized

approval.

APPROVED BY:

SIGN:_________________________________ DATE:_______________

DR. SWAPAN SOOD

MEDICAL SUPERINTENDENT

AUTHORIZED BY:

SIGN:_________________________________ DATE:_______________

DR. S.K SHARMA

MANAGING DIRECTOR


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AMENDMENT SHEET

DISTRIBUTION LIST:

S.NO DESIGNATION FORMAT SIGN

1 Managing Director Controlled Hard Copy 1

2 Medical Superintendent Controlled Hard Copy 2

3 Hospital Administrator Controlled Copy 3 (Hard & SoftCopy )

4 Accreditation Coordinator Master ( Hard & Soft Copy )

5 Quality Department Controlled Copy 4 (Hard Copy)

Page No: ReasonsSr. No:

Section/ Clause

Date of Amendment

Amendment made by

Signature of Hospital Administrator


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S. No PARTICULARS Page no.1 INTRODUCTION 5

2 SCOPE 5

3 OBJECTIVES 5

4 ORGANIZATION CHART 65 RESPONSIBILITY & STAFFING & JOB PROFILE 7

6 QUALITY POLCY 87 ORGANIZATION MISSION 98 ORGANIZATION VISION 99 QUALITY OBJECTIVES 1010 SERVICE STANDARDS 1011 QUALITY MANAGEMENT SYSTEM 13

11.1 QUALITY DOCUMENT CONTROL 1511.2 DOCUMENT CHANGES 1511.3 DOCUMENT REVIEW 1612 QUALITY IMPROVEMENT PROGRAMME 17

12.1 AUDIT AS A TOOL FOR QUALITY CONTROL 1912.2 PERFORMANCE INDICATORS 21 – 2812.3 COMMITTEE MEETINGS 2913 QUALITY IMPROVEMENT METHODLOGY 29

13.1 PLANNING 2913.2 MEASUREMENT 3013.3 PREVENTIVE ACTIONS 3213.4 CORRECTIVE ACTION 3213.5 SERVICE DELIVERY 3414 RESPONSIBILITY OF MANAGEMENT AT PATEL HOSPITAL3615 QUALITY COMMITTEES 37 – 4216 RECORDS AND FORMATS 4317 NABH POLICIES APPLICABLE 43 – 4718 ORGANOGRAM 47


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1. INTRODUCTION :

This Quality Manual is prepared according to the guidelines of NABH 3RD EDITION for assuringquality and competence of Patel Hospital.

This Quality Manual covers the Organization, Quality management System, Quality Assuranceactivities and processes initiated for continuous improvement.

The manual is intended for use throughout the PATEL HOSPITAL.

To ensure that the hospital follows all the standards and guidelines in accordance to NABH anautonomous body set by the QCI.

2. SCOPE OF QUALITY MANUAL:

Hospital Wide - All Hospital employees and patients coming to the hospital.

3. OBJECTIVE OF QUALITY MANUAL:

To ensure that the hospital follows all the standards and guidelines in accordance to NABH anautonomous body set by the QCI.


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4. ORGANOGRAM

MANAGEMENT ORGANOGRAM ATTACHED ON PAGE 45.

QUALITY DEPARTMENT ORGANOGRAM:

MANAGING DIRECTORDr. S.K Sharma

MEDICAL SUPERINTENDETDr. Swapan Sood

ASST. HOSPITAL ADMINISTRATORDr. Harpreet Kaur

HOSPITAL ADMINISTRATORMr. Suman Roy

ASST. QUALITY MANAGERDr. Aman Dhillon


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5. RESPONSIBILITY:

MEDICAL SUPERINTENDENT - The MS is responsible for providing support for the proper functioning of hospital-wide Quality

improvement activities. The MS provides support, direction, and/or assists with the resolution of problems or

opportunities to improve care or services as needed. The MS provides the administration office with pertinent information regarding Quality

improvement activities.

HOSPITAL ADMINISTRATOR:

● The Administrator is responsible for providing support for the proper functioning of hospital-wideQuality improvement activities.

● The Administrator provides support, direction, and/or assists with the resolution of problems oropportunities to improve care or services as needed.

ACCREDITATION COORDINATOR:

The hospital has designated an Accreditation coordinator, who has overall responsibility ofcoordinating the work of NABH accreditation. His / her responsibility will include:

1) To issue various documents to departments from time to time2) To keep a record of all the documentation of the hospital, in relation to accreditation3) To delegate the activities in departments and ensure its timely completion

QUALITY DEPARTMENT: is responsible and authorized to:

a. Carry out the inspection of all activities of the hospital.

b. Maintain the records of inspection.

c. Keep the record of non-conforming service.

d. Prepare Quality Plans.

e. Analyze complaints & take corrective & preventive actions.


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HEAD OF DEPARTMENTS:

The HOD’s are responsible for the following:

• Developing and implementing mechanisms designed to ensure the uniform quality of patientcare processes within their department.

• Developing and implementing an effective and continuous program to measure, assess, andimprove Quality.

• Continuously assessing and improving the Quality of care and services provided.• Adopting an approach to Quality improvement that includes planning the process for

improvement, setting priorities for improvement, assessing Quality systematically,implementing improvement activities based on assessment, and maintaining achievedimprovements.

• Participating intra and interdepartmental activities to improve organizational Quality asappropriate.

• Communicating information relevant to cross-organizational Quality improvement activities toappropriate individuals.

• Allocating adequate resources for assessing and improving the organization’s governance,managerial, clinical, and support processes, by assigning personnel, as needed, to participate inQuality activities; providing adequate time for personnel to participate in Quality improvementactivities, creating and maintaining information systems and appropriate data managementprocesses to support collecting, managing, and analyzing data to facilitate ongoingimprovement in Quality, and providing for training of staff in Quality improvement methods.

6. QUALITY POLICY:

QUALITY POLICY STATEMENT:We, at Patel Hospital strive to achieve the Quality Objective of Jo Ave So Raazi Jave,

(Patient Satisfaction) by

"Comprehensive, Compassionate, Dedicated and Efficient

Patient care with latest Healthcare Techniques."

• Providing comprehensive range of services which meet all the legal requirements and

health care standards at affordable prices


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• Continuous training of the staff on all facets of quality systems and safety policy of the

hospital and continually monitoring the effectiveness of the training program

• Continually monitoring and auditing all the quality systems through the committees which

follow the plan, do, check, act cycle.

• Collecting patient feedback, analysing them and undertaking corrective actions, thereby

using patient satisfaction as the key determinant of the quality of care being provided.

7. HOSPITAL MISSION:

MISSION

To provide efficent and quality patient care through a dedicated and compassionate team, acomprehensive range of services and latest health care techniques. (Jo Ave So Raazi Jave)

8. VISION:

To transform the healthcare experience through building a culture of care and quality,

VALUES

We are committed to excellence with integrity through innovation and teamwork

To transform the healthcare experience through building a culture of care and quality.


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9. QUALITY OBJECTIVES:

1. To focus on Quality of patient care.2. To improve the performance of all professionals & protect patients3. To monitor, measure, assess and improve performance and to enhance patient satisfaction.4. To guard, measure and improve patient safety.5. To inculcate an excellent hygienic treatment process. 6. To involve all employees to participate in improving Quality. 7. To search for pattern of non-compliance with goals, objectives & standards through. 8. Problem identification.9. Problem assessment. 10. Finding the root cause. 11. Solution Generation.12. Plan for the solution implementation.13. Implementation of corrective action.14. Monitoring

10. SERVICE STANDARDS:SERVICES AVAILABLE AT PATEL HOSPITAL


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The services provided at Patel Hospital are displayed and the staff are trained and oriented to this

LEVEL AREA / ACTIVITY

BLOCK AGround floor

Blood Bank, Dialysis Unit, General Ward, Semi Icu

Laboratory complexBLOCK B

Radiotherapy Department

Ground floor

Pre Operative Area, ICU Complex

OT Complex, Recovery, Cardiac Cath Lab

Electric Panel, Chiller Plant

OUTER AREAGround floor Laundry

Parking Food Pantry

Ground floor Maintenance DepartmentAdministration DepartmentMarketing & Conferance Hall

BUILDING / BLOCK

OPD complex – Dematology, Medicine, Emergency, Sample collection area

1st Floor Urology Department, Mother And Child Care Department, NICU, Gynecology Ward, Kidney Ward

2nd Floor

3rd Floor Chemotherapy Ward, OT & Recovery For Gastro Cases And Minor Cases

4th Floor

Basement ( Lower )

Basement ( Upper )

Radiology Department ( MRI, CT Scan, Digital X- Ray, Ultrasonography, Mamography) , Department of Nuclear Medicine, PET- CT, Gamma Camera

OPD Complex- General and Laproscopic Surgery , Head and Neck Department Cardiology, Orthopedic, Sports Medicine, Psycology Department.Administration office, Quality control and HR.Admission Discharge OfficeOPD Pharmacy,Dietetics,Cafeteria,Dressing Room,Registration/ Billing/ Reception.

1st floor Private Rooms, Semi Private Rooms, General ward, Consultant's Lounge

2nd floor Private Rooms, Semi Private Rooms, General ward, IPD Drug Store, Nursing Superintendent

3rd floor

4th floor

5th floor

ANCILLARY BLOCK

1st Floor2nd Floor


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information.

1. Standards of service and adequate degree of patient care can be provided to the extent properand workable ratio between doctor to patient, nurse to patient and beds to patients aremaintained, as also the extent of availability of resources and facilities. Consistent with thisevery possible effort will be made by this hospital to provide standard services. ( ClinicalServices Manual )2.To provide access to hospital and professional medical care to all patients who visit thehospital. ( Clinical Services Manual )3. To prescribe a workable maximum waiting time for outpatients, before they are attended toby a qualified doctor and / or specialists and continuously strive to improve upon it. ( OPD –IPD Manual )4. To ensure that all equipment in the hospital are maintained efficiently in proper workingorder. ( Maintenance Manual )5. To ensure availability of beds and operation theatres facilities as freely as possible. ( OPD –IPD Manual )6. To ensure treatment of emergency cases with utmost promptitude and attention. ( EmergencyManual )7. The patients’ and families’ rights are in consonance to accreditation standards. ( OPD – IPDManual )All patients and visitors to the hospital will receive courteous and prompt attention from thestaff and officials of the hospital in the use of its various services.8. Reliability and promptness of diagnostic investigation results is ensured and wheneverpossible such reports will be made available.9. Operation theatre is maintained on a regular basis to ensure that they are serviceable all thetime and every effort will be made to keep the hospital and its surroundings, clean, infection-free and hygienic.10. A regular system of obtaining feedback from the users is in place through exit interviewsand periodic surveys. The inputs from these are continuously used for improving the servicestandards.

The hospital has necessary equipments required for provision of service mentioned in ‘scope ofservices' and system to ensure proper maintenance and working of various equipments.If any equipment is out of order, information regarding the same shall be displayed suitableindicating the alternate arrangements, if any, as also the likely date of re-commissioning theequipment after repairs and replacement.When things go wrong or fail, appropriate action is taken on those responsible for such failures andaction taken to rectify the deficiencies. Complainants will also be informed of the action taken, ifrequested.In case of likely persistence of the deficiency, the reasons for the delay in rectifying the deficiencyand the time taken for rectifying the same will be displayed prominently for the information of thepublic.


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Special directions are given to the non-medical staff to deal with the patients and publiccourteously. Any breach in this regard when brought to the notice of the hospital authorities shallbe dealt with appropriately.Hospital encourages the patients and the public to inform the authorities when things go wrong.Suggestion / complaint boxes and registers are provided at the reception, RMO office, MatronOffice, sanitary inspector and administrator.

11. QUALITY MANAGEMENT SYSTEM

Quality Management System of hospital is established, documented, implemented andmaintained for continual improvement in accordance with requirements of QualityObjectives.The hospital has established, implemented and maintains a Quality Management Systemappropriate to the scope mentioned earlier. Hospital has documented its policies, process,program, procedure, and instructions and has communicated this to all relevant personneland has ensured that these documents are understood and implemented.The respective Department Head/ In Charge ensure that all the personnel working in theHospital have understood the Quality Policy, Quality Assurance system and the objectivefor adopting the Quality Assurance System.Hospital outlines its Quality Assurance System through three-tier documentation structureas below.

• Quality Manual- An outline of Hospital and functioning of its management system.• Quality System Procedures- The system’s functioning is detailed in separate documents

that are maintained by the quality assurance officer as controlled documents. The qualitymanual makes continuous references to system procedures in the relevant sections.

• Work instructions/Standard-operating procedure: A higher degree with regard toactivities and standards maintained are also maintained with the quality assurance officer ascontrolled documents.

11.1 QUALITY DOCUMENT CONTROL

1. Documents such as regulations, standards, and other normative documents a well asdrawings, software, and specifications, instructions and manuals form part of the HospitalManagement System. A copy of each of these controlled documents shall be archived forfuture reference and the documents shall be retained in their respective department .Theprocedures and equipment details are retained in respective as long as he machine is beingor until condemned .The documents are maintained in paper or electronic media asappropriately required.Documents are identified and established as three levels namely:


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Quality manuals Records Forms & Formats used

Title and naming of documents as outlined in SOP.The HODs of the respective departments shall review all documents issued to personnel inthe departments as a part of management system annually and shall approve it for the use.The Medical Superintendent issues the finalized document.

Management system documents are uniquely identified & have unique document heads:• Patel Hospital documentation• Internal Documentation /Accounts & EDP / Human Resource / Marketing / Operations

/Quality Control documentation• Manual / Committee / Minutes• Specific name• System generated Document Number• Year for which valid/Revision Number• eg. Quality Manual Unique Number is : PH/INT/QC/MAN/QC/6251/14-15/REV-00

LIST OF PATEL HOSPITAL MANUALS:S.NO NAME S.NO NAME

1 Hospital Quality Manual 15 Security Services Manual

2 Hospital Infection Control Manual 16 Maintenance Services Manual

3 Hospital Safety Manual 17 Laboratory Services Manual

4 Nursing Manual 18 Laboratory Safety Manual

5 Purchase & Stores Manual 19 Laboratory Quality Manual

6 Operation Theater Manual 20 Blood Bank Manual

7 Radio-Diagnosis Manual 21 Human Resource Manual

8 Radiotherapy Manual 22 Laundry Services Manual

9 Anesthesia & Sedation Manual 23 Housekeeping Manual

10 Icu Manual 24 Medical Records Manual

11 Emergency Department Manual 25 Hospital Information System Manual

12 Dietitics Manual 26 Central Sterile Supply DepartmentManual

13 Physiotherapy Manual 27 Obstetrics & Gynecology Manual

14 Dialysis Department Manual 28 Clinical Services Manual


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11.2 DOCUMENT CHANGES

Revision of management systems documents is carried out when necessary by the originalauthor. When alternate persons are designated for review, they shall first familiarizethemselves with pertinent background information upon which to base their review andapproval.Any alteration in the text is documented on the document or by way of maintenance ofobsolete documents issued prior to review.Document control system does not follow for the amendments by hand unless there isextenuating circumstances. These amendments shall be marked, initialed and dated only bythe HOD.The amendment shall be brought to three notices of the Medical Superintendentand Quality Assurance Officer and the same shall be reissued in 7 working days of thechange being in effect.Hospital maintains documentation status currently in hard and soft versions. Hospitaldescribing the changes in documents, its maintenance and its control in the computerizedsystem establishes adequate procedures.

Amendments sheet format

Amendment Sheet Format:


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11.3 DOCUMENT REVIEW

Specific time intervals to be set by Quality comiitee to document reveiw. In case of any statutory /Regulatory requirement document reveiw could be done before specified time period.

Quality Manuals – Once every YearForms & Formats – Once every YearOrAs & When Required.

Page No: ReasonsSr. No:

Section/ Clause

Date of Amendment

Amendment made by

Signature of Hospital Administrator


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12.QUALITY IMPROVEMENT PROGRAMME

Quality improvement is about ensuring that our focus is on improving, not just maintaining ourservices at Hospital. Quality improvement involves a focus on the safety, effectiveness, efficiency,acceptability, accessibility and appropriateness of services for consumers (who might be patients,relatives/parents, or the hospital and other health care professionals).

1. Purpose of quality improvement programme is to- • Monitor patient and staff satisfaction• Monitor of quality indicators• Monitor of Adverse Drug reactions and medication errors • Monitor patient safety indicators• Monitor of medical audit results• Monitor Utilization of Facilities• Monitor Patient Satisfaction Rate• Monitor Employee Satisfaction Rate• Ensuring fire safety mock drill twice in a year.• Ensuring facility safety round twice a year in patient care areas and once a year in non- patient care

areas.

2. Goals of Continuous quality Improvement:

• To utilize an interdisciplinary hospital-wide team approach to Quality improvement activities. • To maintain a Quality improvement team to be responsible for each key function and will evaluate

the need for Quality improvement activities for the function on an ongoing basis by reviewingpolicies and procedures relating to that function and make necessary revisions as well as to establishpriorities for measuring

• Quality to initiate Quality improvement measures in a prioritized manner.• To improve patient care guidelines relating to operative and other procedures, in a collaborative

effort.• To utilize a standard format for documenting and reporting all Quality measures hospital-wide. • To collect data on staff views regarding Quality improvement activities. • To establish priorities for Quality improvement activities.

To develop a formal tool for prioritizing Quality improvement activities. To strive to raise the benchmark in all aspect of service delivery and meet the quality standardexpected for thesame.

• To ensure optimum utilization of resources in terms of human resource, infrastructural resource andfinancial resource.

• The programme is comprehensive and covers quality assurance of input, process and outcome. Thishas been developed by quality assurance committee and implemented by various committees,accreditation coordinator and other personnel.


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Quality assurance and continuous monitoring programme is developed for followingareas:

LABORATORY QUALITY PROGRAMME – REFERANCE LAB QA MANUAL

RADIOLOGY QUALITY PROGRAMME – REFERANCE RADIO QA MANUAL

ICU QUALITY PROGRAMME – REFERANCE ICU QA MANUAL

OPERATION THEATRE QUALITY PROGRAMME – REFERANCE OT QA MANUAL

HIC QUALITY PROGRAMME – REFERANCE HIC MANUAL


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12. 1 Audit as a Tool for Quality Control

An audit is a systematic and official examination of a record, process or account to evaluate performance.Auditing in health care organization provide managers with a means of applying control process todetermine the quality of service rendered. Nursing audit is the process of analyzing data about the nursingprocess of patient outcomes to evaluate the effectiveness of nursing interventions. The audits mostfrequently used in quality control include outcome, process and structure audits.

1. Outcome audit

Outcomes are the end results of care; the changes in the patients’ health status and can be attributed todelivery of health care services. Outcome audits determine what results if any occurred as result of specificnursing intervention for clients. These audits assume the outcome accurately and demonstrate the quality ofcare that was provided. Example of outcomes traditionally used to measure quality of hospital care includemortality, its morbidity, and length of hospital stay.

2. Process audit

Process audits are used to measure the process of care or how the care was carried out. Process audit is taskoriented and focus on whether or not practice standards are being fulfilled. These audits assumed that arelationship exists between the quality of the nurse and quality of care provided.

3. Structure audit

Structure audit monitors the structure or setting in which patient care occurs, such as the finances, nursingservice, medical records and environment. This audit assumes that a relationship exists between quality careand appropriate structure. These above audits can occur retrospectively, concurrently and prospectively.


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Audits Done are:

AUDITS

HR AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYMRD AUDIT TWICE A MONTHNURSING AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYHIC AUDIT TWICE A MONTHTRAININGS AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYHOSPITAL GENERAL SAFETY AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLY

Fire EquipmentMaintenance

Oxygen ManifoldEMERGENCY DEPARTMENT AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYCSSD AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYHOUSEKEEPING AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYLAB safety audit ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYRADIATIOLOGY SAFETY AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYPATIENT SAFETY AUDIT ONCE A MONTH FOR NEXT THREE MONTHS THEN QUATERLYPURCHASE & STORES DAILY


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12.2 PERFORMANCE INDICATORS:

Performance indicators are defined as statistics or other units of information that, directly orindirectly, reflect either the extent to which an anticipated outcome is achieved or the quality of theprocesses leading to that outcome .

HOSPITAL GENERAL INDICATORS:

INDICATOR RESPONSIBILITY TOOL FREEQUENCYBed occupancy Rate (BOR) Quality Department SYSTEM MONTHLY

Average Length of Stay (ALOS) Quality Department SYSTEM MONTHLY

No. of Complaints/Suggestions Received Quality Department MONTHLY

Quality Department AUDIT MONTHLY

OP & IP Satisfaction Index Quality Department FEEDBACK FORM MONTHLY

Quality Department

Waiting time for services including diagnostics Quality Department TIME MOTION STUDY MONTHLY

% Utilization of ICU beds Quality Department SYSTEM MONTHLY

COMPLAINT / SUGGESTION FORM

% of Adherence to Safety precautions by Emlpoyees working in Diagnostics

% age of Employees aware of their Rights & Responsibilities & Welfare schemes

EMPLOYEE INTERVIEWS & EMPLOYEE ASSESSMENT

STARTING MONTHLY THEN ONCE IN TWO MONTHS


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LABORATORY INDICATORS:

RADIOLOGY INDICATORS:

INDICATOR RESPONSIBILITY TOOL

LAB INCHARGE DAILY RECORD MONTHLY

PERCENTAGE OF REDOS LAB INCHARGE DAILY RECORD MONTHLY

CRITICAL RESULTS INFORMED LAB INCHARGE DAILY RECORD MONTHLY

FREEQUENCY

NUMBER OF REPORTING ERRORS PER THOUSAND INVESTIGATIONS

INDICATOR RESPONSIBILITY TOOL FREEQUENCY

MONTHLY

MONTHLY

CRITICAL RESULTS INFORMED MONTHLY

MONTHLY

NUMBER OF REPORTING ERRORS PER THOUSAND INVESTIGATIONS

RADIOLOGY INCHARGE

Indicator format

PERCENTAGE OF REDOS ( Separaete PET – CT, CT, MRI, USG, Mammography, Xray )

RADIOLOGY INCHARGE

Indicator format

RADIOLOGY INCHARGE

Indicator format

PERCENTAGE OF CONTRAST RELATED REACTIONS

RADIOLOGY INCHARGE

Indicator format


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PURCHASE & STORES DEPARTMENT INDICATORS:


PURCHASE WEEKLY

% of stock outs including emergency drugs PURCHASE WEEKLY

PURCHASE WEEKLY

PURCHASE WEEKLY

% of Drugs procured by local purchase per 1000 indents

INDICATOR REGISTER

INDICATOR REGISTER

% of consumables rejected before preparation of GRN

INDICATOR REGISTER

Incidence of variation from the procurement process

INDICATOR REGISTER


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NURSING INDICATORS

INDICATOR TOOL FREEQUENCY

Floor Incharge Indicators Online Monthly


INCIDENCE OF MEDICATION ERRORS Floor Incharge Indicators Online Monthly


INCIDENCE OF FALL Floor Incharge Indicators Online Monthly



Wrong therapeutic diet prescribed Floor Incharge Indicators Online Monthly

RETURN TO ICU within 48 hrs. Indicators Online Monthly

Emergency Record Monthly

REINTUBATION RATE Indicators Online Monthly

Indicators Online Monthly

RESPONSIBILITY

PERCENTAGE OF ACCIDENTAL REMOVAL OF TUBES AND CATHETTERS

INCIDENCE OF HEMATOMA AT PUNCTURE SITE

INCIDENCE OF ADVERSE DRUG REACTIONS

INCIDENCE OF BED SORES AFTER ADMISSION

Discrepancies between diet recommended & diet given

ICU Floor Incharge

RETURN TO EMERGENCY DEPARTMENT WITHIN 72 HRS WITH SIMILAR PRESENTING COMPLAINTS

EMERGENCY FLOOR INCHARGEICU Floor Incharge

Post operative hemorrhage / hematoma ICU Floor Incharge


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ANESTHESIA INDICATORS:

SURGERY INDICATORS:

INDICATOR RESPONSIBILITY TOOL

ANESTHESIA INDICATORS% of modification of Anesthesia plan OT SUPERVISOR Anesthesia Sheet MONTHLY% of unplanned ventilation following anesthesia OT SUPERVISOR Anesthesia Sheet MONTHLY% of Adverse Anesthesia events OT SUPERVISOR OT INDICATOR MONTHLYAnesthesia related mortality rate OT SUPERVISOR OT INDICATOR MONTHLY

FREEQUENCY

MONTHLY

PERCENTAGE OF UNPLANNED RETURN TO OT OT SUPERVISOR OT INDICATOR MONTHLY

Wrong Site/ Wrong Surgery / Wrong Patient Incidents OT SUPERVISOR OT INDICATOR MONTHLY

Delayed surgeries ( beyond 2 hours ) OT SUPERVISOR OT INDICATOR MONTHLY

Cancellation of operation OT SUPERVISOR OT INDICATOR MONTHLY

% age of Re-scheduling of Procedures OT SUPERVISOR OT INDICATOR MONTHLY

Post operative hemorrhage / hematoma RECOVERY NURSE / FLOOR INCHARGE


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MAINTENANCE INDICATORS:

BLOOD BANK INDICATORS:

INDICATOR RESPONSIBILITY TOOL FREEQUENCYEquipment Downtime

General Equipment Maintenance Head Monthly

Biomed equipment BME Monthly

Equipment Log Book

Equipment Log Book


% of transfusion reactions MONTHLY

% of wastage of blood and blood products BLOOD BANK RECORD MONTHLY

% of blood component usages BLOOD BANK RECORD MONTHLY

MONTHLY

BLOOD BANK INCHARGE

BLOOD TRANSFUSION FORM

BLOOD BANK INCHARGEBLOOD BANK INCHARGE

Turnaround time for issue of blood and blood component

BLOOD BANK INCHARGE


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HOSPITAL INFECTION INDICATORS:


HIC INCHARGE MONTHLY


Ventilator associated Pneumonia HIC INCHARGE MONTHLY

Surgical Site infection rate HIC INCHARGE MONTHLY

Needle Stick Injury HIC INCHARGE MONTHLY



BMW management Discrepancies HIC INCHARGE MONTHLY

No. of Notifiable disease HIC INCHARGE MONTHLY

Catheter Associated Urinary tract infection rate

DAILY RECORDS OF HIC

Catheter Related Blood Stream Infection Rate

DAILY RECORDS OF HICDAILY RECORDS OF HICDAILY RECORDS OF HICDAILY RECORDS OF HIC

Percentage of Nurses following Handwash

DAILY RECORDS OF HIC

Percentage of Nurses following Handwash

DAILY RECORDS OF HICDAILY RECORDS OF HICDAILY RECORDS OF HIC


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HUMAN RESOURCE INDICATORS:


Employee Attrition rate HR MANAGER HR RECORD MONTHLY

Employee Absenteeism Rate HR MANAGER HR RECORD MONTHLY

Employee Satisfaction Index HR MANAGER MONTHLY

TOTAL MEMOS ISSUED HR MANAGER HR RECORD MONTHLY

VACANT POST HR MANAGER HR RECORD MONTHLY

NEW RECRUITMENTS HR MANAGER HR RECORD MONTHLY

TOTAL EARLY ARRIVAL HR MANAGER HR RECORD MONTHLY

TOTAL LATE DEPARTURES HR MANAGER HR RECORD MONTHLY

HR MANAGER HR RECORD MONTHLY

EMPLOYEE FEEDBACK FORM

TOTAL DUTY RESCHEDULING DONE


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12.3 COMMITTEE MEETINGS

Details in Committee documents & in section 15 of Quality Manual.

13. QUALITY IMPROVEMENT METHODOLOGY

-APPROACH TO DESIGNING, MEASURING, ASSESSING AND IMPROVING QUALITYAT PATEL HOSPITAL

The Hospital has:

• Identified the processes needed for the QMS and their application throughout the hospital.

• Determine the sequence and interaction of these processes.

• Determine criteria and methods needed to ensure that both the operation and control of theseprocesses are effective.

• Ensure the availability of resources and information necessary to support the operation andmonitoring of these processes.

• Monitor, measures and analyses these processes.

• Implement the actions necessary to achieve planned results and continual improvement of theseprocesses.

13.1 PLANNING:

Planning for the improvement of patient care and health outcomes includes a hospital-wideapproach.

The hospital maintains a plan that describes the hospital’s approach, processes, and mechanisms thatcomprise the hospital’s Quality improvement activities.

The Team approach serves as a means of collaboration between departments and disciplines inplanning and providing systematic organisation-wide improvements.


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Processes, functions or services are designed effectively based on:

Mission and vision of Patel Hospital, needs and expectations of patients, staff, and others.

Baseline Quality expectations are utilised to guide measurement and assessment activities

13.2 MEASUREMENT:• Data is collected for a comprehensive set of Quality measures • To Establish a baseline when a process is implemented or redesigned• To Describe process Quality or stability• To Describe the dimensions of Quality relevant to functions, processes, and outcomes• To Identify areas for improvement• To Determine whether changes in a process have met objectives

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

• Operative and other invasive and non-invasive procedures that place patients at risk

• Laboratory safety & quality

• Diagnostic Radiology safety & quality

• Processes related to medication use

• Processes related to anaesthesia

• Processes related to the use of blood and blood components

• Processes related to medical records content, availability and use

• Processes related to timely procurement of supplies

• Reporting as required by law

• Risk management activities

• Needs, expectations, and satisfaction of patients

• Staff expectations and satisfaction

• Processes related to patient and staff safety

• Surveillance of hospital acquired infection

• Utilisation of facility.

The assessment process involves the necessary departments to draw conclusions about the need for moreintensive measurement. A systematic process is used to assess collected data in order to determine whether


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specifications for newly designed processes were met & the level of Quality and stability of importantexisting processes, priorities for possible improvement of existing processes, actions taken to improve theQuality Improvement processes, and whether changes in the processes resulted in improvement.

Collected data is assessed at least quarterly and findings are documented and are forwarded through theproper channels.

A pre-determined level of Quality, or threshold, which would trigger a more in-depth review, isestablished for each Quality measure to assist in the assessment of the data collected. The referenceused may include the following:

Internal comparisons in Quality of processes and outcomes are made over time1. Quality comparison of data is made about processes with up-to- date information2. Quality comparison of data is made about processes and outcomes with other hospitals utilizing

reference databases when possible3. The assessment process includes the use of statistical process control techniques/tools as

appropriate. Training for use of statistical process control is provided to the hospital leaderswhere needed; team members/staff are educated regarding statistical process control techniqueson an ‘as needed’ basis.

4. When assessment of data indicates, a variation in Quality, more intensive measurement andanalysis will be conducted and in addition, the department/service or team will reassess itsQuality measurement activities and re-prioritize them as deemed necessary. Intensiveassessment is initiated when statistical analysis shows the following:

5. Important single events, levels of Quality, and patterns or trends that vary significantly andundesirably from those expected

6. Quality that varies significantly from other organisations7. Quality that varies significantly and undesirably from recognised standards8. Intense assessment is performed on the following.9. Major discrepancies between preoperative and postoperative diagnoses in pathology reports.10. Confirmed major transfusion reactions.11. Significant adverse drug reactions.12. Adverse events or patterns of adverse events during anaesthesia use.13. Unexpected patient death.14. Wrong site/side/patient surgery.

When findings of the assessment process are relevant to an individual’s Quality, the pertinentinformation will be provided to the Hospital Administrator for determining their use in peer reviewand/or periodic evaluations of a licensed independent practitioner’s competence at reappointment

When a Quality measurement does not reach the predetermined acceptable level of Quality, or if it isreached, but evaluation indicates the Quality is not acceptable, the Quality improvement processshould continue. If the level of Quality shows no improvement for the time frame established by the


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department/service team plan, an intensive evaluation is conducted with input from the QualitySteering Committee regarding the need for continued measurement or reprioritization.

The quality assurance programme is reviewed & opportunities for improvements are identified and updated.There is an established medical Audit Committee for audit of patient care services. Committee evaluatesmedical record keeping, quality, content, formats, accuracy, pertinence, staff compliance withdocumentation, policies, review, and evaluate fatal cases/ death in hospital.All audits are documented & required actions to be taken are documented & implemented.

13.3 PREVENTIVE ACTIONS

The Administrator is perpetually vigilant and identifies potential sources of non-compliance and areas thatneed improvement. These may include trend analysis of specific markers such as turnaround time, riskanalysis and introducing proficiency testing for self-assessment.Where preventive action is required, a plan is prepared and implemented. All preventive actions must havecontrol mechanisms and monitor for efficacy in reducing any occurrence of non-compliance or producingopportunities for improvement.

13. 4 CORRECTIVE ACTIONThe Hospital Administrator, takes all necessary corrective action when any deviation is detected in QualityManagement System.

Cause Analysis:

Deviations are detected by:1. Patient complains/feedbacks2. Non-compliance receipt of items/sample3. Non-compliance at Internal/external Quality Audit4. Management Reviews

The Hospital Administrator conducts and coordinates the detailed analysis of the nature and root cause ofnon-compliance along with the responsible persons from the respective sections.

Selection and Implementation of Corrective Actions

Potential corrective actions are identified and the one that is most likely to eliminate the problem is chosenfor implementation. Corrective action is taken into consideration the magnitude and degree of impact of theproblem. All changes from corrective action is documented and implemented.


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Monitoring Of Corrective Actions:

The Administrator shall monitor the outcome parameters to ensure that corrective actions taken have beeneffective in eliminating the problem.

Additional Audits:

When the magnitude of non-compliance cases doubts on the departments’ overall compliance withdocumented procedure, additional audits are conducted.

Internal communications:

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

Weekly, fortnightly & monthly meets:

Management Review Meetings. Team briefings and other meetings.Notice Board, Email, Intramail


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13.5 SERVICE DELIVERY:

Planning and development of processes required for the service delivery has been developed anddocumented in process map in accordance with the other requirements of QMS. While planning for anynew service, hospital shall determine the following.

Quality Objectives and requirements for the services

The need to establish processes, documents and provide resources specific to the service. Requiredverification, validation, monitoring, inspection and test activities, specific to the service and the criteria forservice acceptance. Record needed to provide evidence that the service delivery process meet therequirement.

Patient/s – Related Process

Determination of requirements related to the Services

Patients/their relatives’ stated and implied requirements (including if any additional requirementsdetermined by the hospital, legal & regulatory requirements) are identified before delivery of the service,initiating action to provide necessary treatment to the patient which are as per the documented procedure

Review of requirements related to the service

The type of treatment (OPD or indoor) is reviewed for its adequacy based on the information available forthe concerned patient or accompanying relative along with the records of vital parameters and investigationresults. Any changes required subsequently, its communication to the concerned patient/ relative and to therelevant department is done as per the documented procedures.

Records of type of treatment identified/ provided are maintained as per the documented procedures.

Where the patient is unable to provide enough details the statement of requirements as capture by theconcerned doctors are taken as base for providing necessary service and same is conveyed to the patient and/or the relatives before providing the treatment for acceptance.During the course of the treatment or at the end of one set of treatment the consent of the patient/relative istaken for subsequent treatment, subject to the willingness of the patient and in case of their unwillingnessthey may be discharged or referred to other hospital as the case may be.

Patient Communication


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The arrangements for communication on enquiries and service related information, approximate charges arecarried out at the time of registration or at the time of admission of treatment by the concerned authorities.

Patient feedbacks including complaints are handled as per the various service procedures for the differenttype of treatments.

Competence, Awareness and Training

Competence of the personnel is assessed on the basis of the education, experience, skill and training beforethey are assigned the responsibilities in the QMS.

Training needs of all the personnel are identified, established and reviewed to ensure competence for theresponsibility to be assigned. The responsibility for these lies with the department heads while theAdministrative Officer does the overall coordination.Training needs of the new recruits and personnel transferred to new assignments are identified andestablished as per the requirements. The responsibility of general training program is with theAdministrative department, while specific job related training is the responsibility of the department head.

Department In-charge along with the Administrative Officer is responsible for ensuring the training onidentified needs is provided to the employees. In-charge- Administrative Department evaluates theeffectiveness of training conducted .A consolidated database of training records of all the employees ismaintained.

Records of personnel qualified for performing specific assigned tasks and activities also maintained by theAdministrative Officer & the individual department In-charge.InfrastructureInfrastructure required by all personnel to achieve the conformity of the service requirements are identifiedand provided before the commencement of the work/ activity and are maintained and improved regularly asper the documented procedure.

Work Environment

Work environment needed by all personnel to achieve the conformity of the service requirements areidentified and provided before the commencement of the work/activity and are maintained and improvedregularly.


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14. RESPONSIBILITY OF MANAGEMENT AT PATEL HOSPITAL:

Top Management of the hospital is totally committed to development and implementation of an effectiveand efficient QMS for continual improvement

Top management has established vision, mission, policy and strategic objectives consistent with the purposeof the hospital, which leads to the achievement of patient satisfaction.Top Management provides its full support by participating in improvement projects, searching for newmethods & Solution. Top management also ensures the availability of the resources that are necessary tosupport the Hospital’s strategic plan.

Patient needs and expectations are determined and converted into requirements and fulfilled as documentedin process map & procedure for service delivery process and Management Responsibility.

Obligations related to the statutory and regulatory requirements are taken care as appropriate.

Top management takes initiatives in communicating the Hospital’s values, vision, mission, policies andobjectives and targets. Some examples are as follows:

The Medical Superintendent has released the vision, values and policies to all the employees.

The Accreditation coordinator communicates the Quality Policy and Objectives of the hospital to all theemployees.

Medical Superintendent presides over the management review meeting as per the agenda and reviews theprogress of the implementation of the quality system periodically.

Medical Superintendent addresses all the employees through inter officer Memo whenevernew initiatives are taken towards improvement.

The top management of the hospital is highly committed towards process - oriented approach. Accordinglyall the processes are documented and implemented. Internal audits and management review meetings areused as effective tools to ensure the implementation of the laid down processes and also verifying theircontinuing suitability, effectiveness and adequacy of the system.Various committees have been incorporated into the managements system of the hospital for effectiveimplementation of the QMS.


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15. QUALITY COMMITTES

1. Code Blue committee2. Quality Committee3. Hospital Infection Control committee4. Operation Theatre committee5. Purchase & Condemnation6. Hospital safety committee7. Blood Transfusion Committee8. Medical Records committee9. Sexual Harassment Committee10. Drugs & Therapeutic Committee

Detailed description of committees is given in committee manual.

Sr.no. NAME

1 Dr. Shammit Chopra Chairperson2 Consultant Anaesthesiology Dr. Abhishek Gupta Nodal Officer3 Medical Superintendent Dr. Swapan Sood Member4 Hospital Administrator Mr. Soman Roy Member5 Consultant Intensivist Dr. Amit Madan Member6 Consultant Medicine Dr. Daljit Chauhan Member7 Asst. Administrator Dr. Harpreet Kaur Member8 Nursing Superintendent Sis. Shammi Member9 Security Supervisor Mr. Ratan Singh Member

FREQUENCY OF MEETING - MONTHLY / as & when required

CODE BLUE COMMITTEE

DESIGNATION IN ORGANIZATION

DESIGNATION IN COMMITTEE

Consultant Head and neck surgery oncologist


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Sr.no. NAME1 Director Dr. B.S. Chopra Chairperson2 Consultant Chemotherapy Dr. Anubha Bhartuar Nodal Officer3 Medical Superintendent Dr. Swapan Sood Member

4 Dr. Shammit Chopra Member5 Consultant Radiation oncology Dr. Harpreet Singh Member6 Consultant Medicine Dr. Ravi Kumar Member7 Department of Administration Mr. Suman Roy Member8 Dr. Harpreet Kaur Member9 Department of Quality Dr. Aman Dhillon Member10 Pharmacist Member

FREQUENCY OF MEETING - Biannualy / as & when required

DRUG AND THERAPEUTIC COMMITTEE




MEDICAL RECORD COMMITTEE

Sr.no. NAME1 Consultant Medical Oncologist Dr. Anubha Bhartuar Chairperson2 Asst. Administrator Dr. Harpreet Kaur Nodal Officer

3 Medical Superintendent Dr. Swapan Sood Member4 Department Of Medicine Member5 Department of Surgery Dr. Shamit Chopra Member6 Hospital Administrator Mr. Suman Roy Member7 Asst. Quality Manager Dr. Aman Dhillon Member





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HOSPITAL SAFETY COMMITTE

Sr.no. NAME1 Managing Director Dr. S.K. Sharma Chairperson2 Administrator Mr. Suman Roy Nodal Officer3 Medical Superintendent Dr. Swapan Sood Member4 Department of Laboratory Dr. Sanjay Wadhwa Member5 Department of Radiology Mr. Rojas Jose Member6 Department of Critical care Dr. Amit Madan Member7 Department of Surgery Dr. Shammit Chopra Member8 Asst. Administrator Dr. Harpreet Kaur Member9 Asst. Quality Manager Dr. Aman Dhillon Member10 Nursing Supritendent Sis. Shammi Member11 Maintenance Head Mr. Ratan Lal Member12 Security Supervisor Mr. Ratan Singh Member

HOSPITAL FIRE SAFETY COMMITTE

Hospital Administrator Mr. Soman Roy ChairpersonSecurity Supervisor Mr. Ratan Singh Nodal OfficerAsst. Administrator Dr. Harpreet Kaur MemberDepartment of Quality Dr. Aman Dhillon MemberMaintenance Head Mr. Ratan Lal MemberSecurity Supervisor Mr. Ratan Singh MemberBiomedical Engineer Mr. Akshay Member

FREQUENCY OF MEETING - Initially once a month / as & when required




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OPERATION THEATRE COMMITTEE

Sr.no. NAME1 Managing Director Dr. S.K Sharma Chairperson

2 Dr. Shammit Chopra Nodal Officer

3 Consultant Orthopaedic Surgery Dr. R.R.Saggar Member

4 Consultant Surgery Dr. Deepak Chawla Member

5 Consultant Anaesthesiology Dr. Abhishek Gupta Member

6 Medical Superintendent Dr. Swapan Sood Member7 Hospital Administrator Mr. Suman Roy Member8 Asst. Administrator Dr. Harpreet Kaur Member9 OT In charge Mr. Tejinderpal Singh Member





Sr.no. NAME1 Director Dr. B.S. Chopra Chairperson2 Asst. Purchase & Stores Manager Mr. Rakesh Khosla Nodal Officer3 Medical Superintendent Dr. Swapan Sood Member

4 DR. Shammit Chopra Member5 Consultant Radiation oncology Dr. Shikha Chawla Member6 Asst. Quality Manager Dr. Aman Dhillon Member

FREQUENCY OF MEETING - BIANNUALY / as & when required

PURCHASE & CONDEMNATION COMMITTEE





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Sr.no. NAME1 Medical Superintendent Dr. Swapan Sood Chairperson2 Consultant Microbiologist Dr. Lovely Razdan Nodal Officer3 Hospital Administrator Mr. Suman Roy Member4 Asst. Manager Quality Control Dr. Aman Dhillon Member5 Infection control Coordinator Mr. Vakil Singh Member6 Infection Control Nurse Ms. Rekha, Member7 Nursing Superintendent Sis. Shammi Member8 CSSD Incharge Ms. Rajdeep Member9 OT Supervisor Mr. Tejinderpal Singh Member

FREQUENCY OF MEETING - MONTHLY

HOSPITAL INFECTION CONTROL COMMITTEE



Sr.no. NAME1 Medical Superintendent Dr. Swapan Sood Chairperson2 Blood bank Incharge Dr. Manjeet Kaur Nodal Officer3 Department of Anesthesia Dr. Abhishek Member4 Department of Surgery Dr. Deepak Chawla Member5 Department Of Medicine Member6 Department of Orthopeadics Dr. R.R.Saggar Member7 Department of Administration Mr. Suman Roy Member

Dr. Harpreet Kaur MemberFREQUENCY OF MEETING - MONTHLY / as & when required

BLOOD TRANSFUSION COMMITTEE




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Sr.no. NAME1 Medical Superintendent Dr. Swapan Sood Chairperson2 Hospital Administrator Mr. Soman Roy Nodal Officer3 Asst. Administrator Dr. Harpreet Kaur Member4 Asst. Manager Quality Dr. Aman Dhillon Member5 Quality Cordinator Ms. Aarti Member6 Asst. Manager HR Mr. Rohit Chopra Member

7 Security Supervisor Mr. Ratan Singh Member8 Maintenance Head Mr. Ratan Lal Member

QUALITY ASSURANCE EXTENDED COMMITTE

1 Medical Superintendent2 Hospital Administrator3 Asst. Administrator4 Asst. Manager Quality5 Quality Cordinator6 Asst. Manager HR7 Asst. Manager Finance8 Asst. Manager Purschase & Stores9 Asst. Manager IT10 Laboratory Head11 Radiology Head12 Radiation Safety Officer13 Hospital Infection Control Head14 OT Supervisor15 CSSD Supervisor16 Nursing Superintendent17 Dietitian18 Clinical Care Head19 Security Supervisor20 Maintenance Head


QUALITY ASSURANCE CORE COMMITTEE




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16. RECORDS AND FORMATS:

• Minutes of meetings

• Record of Quality Indicator with their Analysis,

• Internal audit reports.

17.NABH POLICIES APPLICABLE:


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a

b

c

d

e

f

g

h Audits are conducted at regular intervals as a means of continuous monitoring.

i

CQI.1: There is a structured quality improvement and continuous monitoring programme in the organization.

The quality improvement programme is developed, implemented and maintained by a multi-disciplinary committee.

The quality improvement programme is documented.

There is a designated individual for coordinating and implementing the quality improvement programme.

The quality improvement programme is comprehensive and covers all the major elements related to quality assurance and supports innovation.

The designated programme is communicated and coordinated amongst all the staff of the organization through appropriate training mechanism.

The quality improvement programme identifies opportunities for improvement based on review at pre-defined intervals.

The quality improvement programme is a continuous process and updated at least once in a year.

There is an established process in the organization to monitor and improve quality of nursing and complete patient care.


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a Monitoring includes appropriate patient assessment.

b

c Monitoring includes medication management.

d

e Monitoring includes surgical services.

f Monitoring includes use of blood and blood products.

g Monitoring includes infection control activities.

h Monitoring includes review of mortality and morbidity indicators.

i Monitoring includes clinical research.

j Monitoring includes data collection to support further improvements.

CQI.3: The organization identifies key indicators to monitor the clinical structures, processes and outcomes which are used as tools for continual improvement.

Monitoring includes safety and quality control programmes of all the diagnostic services.

Monitoring includes use of anaesthesia.


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MANAGEMENT ORGANOGRAM

a Monitoring includes procurement of medication essential to meet patient needs.

b Monitoring includes risk management.

c Monitoring includes utilisation of space, manpower and equipment.

d Monitoring includes patient satisfaction which also incorporates waiting time for services.

e Monitoring includes employee satisfaction.

f Monitoring includes adverse events and near misses.

g Monitoring includes availability and content of medical records.

h Monitoring includes data collection to support further improvements.

i Monitoring includes data collection to support evaluation of these improvements.

CQI.4: The organization identifies key indicators to monitor the managerial structures, processes and outcomes which are used as tools for continual improvement.


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Board of Directors

Managing Director

Medical Superintendent

Hospital Administrator

Accounts (Ref.Chart No.3.1.1)

IT(Ref.Chart No.3.1.2)

Marketing(Ref. Chart No.3.1.3)

Purchase & Stores(Ref.Chart No.3.2.1)

Administration & Operations

Maintenance (Ref to Chart no 3.2.5)

Human Resource (Ref.Chart No.3.3.1)

Quality Assurance(Ref. Chart No.3.3.6)

Education(Ref. Chart No3.3.8.)