Module 1: Foundations of Quality & Our Commitment to Excellence

(Slide 1: Title Slide - INDUCTION - QUALITY)

• I. Welcome & Setting the Stage

  • A. Trainer's Introduction & Purpose of the Session:

    • "Good morning/afternoon, everyone. My name is [Trainer's Name], and I'm part of the Quality Team here at Believers Church Medical College Hospital. It's my pleasure to welcome you to this essential Quality Induction program."

    • "Our primary goal today isn't just to present information, but to engage in a dialogue about what quality healthcare truly means in our daily practice and how each one of us, especially you as clinicians, plays an indispensable role in upholding and advancing it."

    • "This induction is designed to provide you with a foundational understanding of our hospital's commitment to quality, the standards that guide us (specifically NABH 5th Edition, JCI 5th Edition, KUHS QUAS, and NAAC requirements as outlined on your first slide), and the systems we have in place to support you in delivering the highest standard of care."

    • "We aim for this to be an interactive session. Please feel free to ask questions, share your insights, and challenge us. Your perspective is invaluable."

  • B. Icebreaker: Personalizing Quality

    • "To start, I'd like to invite a few of you to share briefly: When you hear the term 'quality healthcare,' what's one key word or phrase that immediately comes to mind based on your clinical experience?"

    • (Trainer facilitates a brief, non-judgmental sharing, acknowledging responses like "patient safety," "good outcomes," "effective communication," "compassion," "efficiency," etc. This helps to ground the concept in their reality from the outset.)

(Slide 4: QUALITY - Definition, Attained through, OVRs, KPIs, Risk Analysis)

• II. Defining and Understanding Quality in the Clinical Context

  • A. Deconstructing the Definition of Quality:

    • "Slide 4 provides a formal definition: 'The totality of features and characteristics of a product or service that bear on its ability to satisfy stated or implied needs.' Let's unpack this in our healthcare setting."

    • "Totality of features and characteristics":

      • "In healthcare, this isn't just about a single successful surgery or a correct diagnosis. It encompasses everything from the accuracy of that diagnosis, the skill of the intervention, the clarity of communication with the patient and family, the cleanliness of the environment, the efficiency of our processes, the empathy shown, right down to the accuracy of the bill."

      • "Think of it as the entire patient journey and all the touchpoints where we can influence their experience and outcome."

    • "Product or service":

      • "Our 'service' is the comprehensive care we provide. Elements of 'product' could be the medications administered, the medical devices used, or even the informational materials given to patients."

    • "Ability to satisfy stated or implied needs": This is the crux.

      • "Stated Needs": These are what the patient or family explicitly tells us. For example:

        • "I have chest pain; please make it stop."

        • "My child has a fever; please find out why."

        • "We need to understand the next steps in treatment."

        • Clinically, this also includes achieving desired therapeutic outcomes, such as infection resolution or functional recovery.

      • "Implied Needs": These are often unspoken but are fundamental expectations. Patients inherently expect:

        • Safety: "I will not be harmed by the care I receive." (This is paramount).

        • Respect and Dignity: "I will be treated as an individual with courtesy and consideration."

        • Effective Communication: "I will understand what is happening to me and be listened to."

        • Timeliness: "I will receive care without undue delays."

        • Competence: "The people caring for me are knowledgeable and skilled."

        • Confidentiality: "My personal health information will be protected."

• • B. How Quality is Attained: The Role of Systems and Processes:

    • "As the slide indicates, quality is 'Attained through (Policies/Procedures)' which translates to a 'Systematic Process defined by policy and procedures.'"

    • "Why is this critical? Because systematic processes reduce variability. Variability is often the enemy of quality and safety. If every clinician approaches the same problem in a vastly different way, without an evidence-based framework, the chances of error or suboptimal outcomes increase."

    • "Our policies and procedures are not meant to be restrictive for the sake of restriction. They are developed based on:

      • Evidence-based medicine and best practices.

      • Regulatory and accreditation standards.

      • Learnings from past incidents (internal and external).

      • Risk assessments."

    • "Your role as clinicians is to understand, adhere to, and where appropriate, contribute to refining these policies and procedures. They are living documents designed to support you in delivering consistent, high-quality care."

• • C. Key Components of Our Quality Management System (Introduction):

    • "Slide 4 also introduces some vital components of how we manage and monitor quality, which we'll delve into more deeply later:"

    • "OVRs (Occurrence Variance Reports): Reports the variations from the defined processes."

      • "Think of OVRs as our early warning system and learning tool. Whenever something doesn't go as planned, or a deviation from a standard procedure occurs, an OVR is raised. This isn't about blame; it's about understanding why it happened and how to prevent it from happening again."

    • "KPIs (Key Performance Indicators): Check point/Key process performance monitoring."

      • "KPIs are how we measure our performance in critical areas. Examples could include rates of hospital-acquired infections, medication error rates, patient satisfaction scores, or waiting times. They tell us where we are doing well and where we need to focus our improvement efforts."

      • "Many of these KPIs are directly influenced by clinical practice, and your understanding and contribution to achieving these targets are vital."

    • "Risk Analysis: Proactive reduction or elimination of harm/adverse events."

      • "This is about looking ahead. Instead of just reacting to problems, risk analysis involves identifying potential hazards or weaknesses in our systems before they cause harm to patients. We then implement strategies to mitigate these risks."

  • D. The Undeniable Imperative of Quality in Healthcare:

    • "Why do we invest so much time, effort, and resources into quality? Because in healthcare, the stakes are incredibly high."

    • Impact on Patient Outcomes: "High-quality care directly translates to better clinical outcomes – reduced morbidity, lower mortality rates, fewer complications, and faster recovery."

    • Enhanced Patient Safety: "This is our 'First, do no harm' principle in action. Robust quality systems are designed to prevent errors and minimize risks to our patients."

    • Improved Patient Experience: "Quality care isn't just about clinical success; it's also about how patients feel treated – with compassion, respect, and clear communication. This directly impacts their satisfaction and trust in us."

    • Increased Efficiency & Resource Optimization: "Well-defined, quality processes often lead to more efficient use of resources, reducing waste (e.g., unnecessary tests, prolonged stays due to complications) and streamlining workflows."

    • Professional Satisfaction: "Working within a system that prioritizes and supports quality can be more professionally rewarding for clinicians. It reduces frustration from system failures and allows you to focus on what you do best – caring for patients."

    • Hospital Reputation and Trust: "Our commitment to quality is fundamental to maintaining the trust of our community and upholding the reputation of Believers Church Medical College Hospital."

  • E. The Clinician's Pivotal Role as a Quality Champion:

    • "While the Quality Team helps facilitate and guide these efforts, quality is ultimately achieved at the point of care. As clinicians, you are at the forefront."

    • Direct Care Providers: "You make critical decisions every minute that impact patient care."

    • Implementers of Standards: "You are the ones translating policies and best practices into action."

    • Eyes and Ears: "You are best positioned to identify potential risks or areas where our systems can be improved."

    • Team Leaders & Collaborators: "You influence the culture of quality within your teams and departments."

    • Advocates: "You advocate for your patients and for the resources needed to provide quality care."

    • "We don't see quality as something 'done to you' by another department. We see it as something 'done by you, with you, and for your patients.'"

(Slide 1: Title Slide - Accreditation Bodies; Slide 7: TIMELINE; Slides 8 & 9: NABH STANDARDS OVER THE YEARS)

• III. Navigating the Accreditation Landscape: Our Guiding Standards

  • A. Introduction to Key Accreditation and Quality Bodies (Slide 1):

    • "Our commitment to quality is benchmarked against recognized national and international standards. The primary bodies mentioned on Slide 1 that guide our hospital and academic practices are:"

    • NABH (National Accreditation Board for Hospitals & Healthcare Providers) Standards 5e:

      • "NABH is India's premier body for hospital accreditation. The '5e' or 5th Edition standards are what we currently operate under. These standards provide a comprehensive framework for quality assurance and quality improvement, covering patient-centered care, organizational management, and facility safety."

      • "NABH accreditation signifies that our hospital meets established national benchmarks for quality of care and patient safety.

    • JCI (Joint Commission International) Standards 5e:

      • "JCI is the international arm of The Joint Commission (USA) and is recognized globally as a leader in healthcare accreditation. Adherence to JCI standards demonstrates our commitment to achieving and maintaining international best practices in patient care and organizational management."

      • "The '5e' here also refers to the 5th Edition of their hospital standards, which are rigorous and patient-focused."

    • KUHS QUAS (Kerala University of Health Sciences Quality Assurance System):

      • "As a medical college hospital affiliated with KUHS, we also adhere to their Quality Assurance System. This framework specifically addresses the quality of medical education, training, and research, ensuring that our academic programs meet high standards."

      • "This is particularly relevant for our faculty and residents involved in teaching and academic activities."

    • NAAC (National Assessment and Accreditation Council):

      • "NAAC is an autonomous body that assesses and accredits higher education institutions in India, including medical colleges. NAAC accreditation focuses on the overall quality of the institution, including its teaching-learning processes, research, infrastructure, governance, and student support."

      • "This reinforces the quality of the academic environment within which our clinical care is delivered and future healthcare professionals are trained."

• • B. Our Hospital's Quality Journey: A Story of Continuous Improvement (Slide 7 - TIMELINE):

    • "Slide 7 visually represents our ongoing quality journey. Accreditation isn't a one-time achievement; it's a continuous cycle of assessment, improvement, and re-assessment."

    • "FINAL ASSESSMENT - 23 NCs":

      • "This likely refers to an initial comprehensive accreditation assessment. 'NCs' stand for Non-Compliances – areas where we were found to have gaps against the standards. Identifying 23 NCs means there were specific areas needing focused improvement, which the hospital would have worked diligently to address."

    • "SURVEILLANCE - 91 NCs, 4 RETURNED":

      • "Surveillance audits are periodic checks conducted between full re-accreditation cycles to ensure standards are being maintained and improvements are sustained. It's not uncommon to identify new NCs or areas for further refinement during surveillance. The '91 NCs' indicates a thorough review, and '4 RETURNED' could imply that upon re-evaluation, 4 previously identified NCs were found to be satisfactorily closed or significantly improved."

      • "This demonstrates the dynamic nature of quality – we are always looking for ways to get better."

    • "RENEWAL - 3 ASSESSORS, 3*5":

      • "Renewal signifies a full re-accreditation cycle, a comprehensive re-evaluation of all standards. '3 Assessors' indicates the team size from the accrediting body, reflecting the thoroughness of the audit. '3*5' might denote the duration or intensity of the assessment (e.g., 3 core assessors over 5 days, or a similar metric)."

      • "Successfully navigating these stages, as depicted on the map of Kerala leading to these milestones, showcases the institution's sustained commitment and significant effort across all departments."

• • C. The Evolution of Standards: NABH Standards Over The Years (Slides 8 & 9):

    • "Slides 8 and 9 illustrate how accreditation standards themselves evolve. Let's look at NABH as an example:"

    • "Timeline of Editions (Top part of slides 8 & 9):"

      • Shows progression from 1st edition (10 chapters, 100 standards, 505 Objective Elements) through 2nd, 3rd, 4th, to the current 5th edition (10 chapters, 100 standards, 651 Objective Elements).

      • "You can see that while the number of chapters and core standards has remained consistent at 10 and 100 respectively, the number of Objective Elements (OEs) – the specific, measurable components of each standard – has increased. This reflects a growing depth and specificity in quality expectations."

    • "Anticipating NABH 6th Edition (Slide 8 - Bottom Table 'Accreditation Standards for Hospitals'):"

      • "We are also preparing for the upcoming NABH 6th Edition, expected in Jan 2025. This table gives a preview, again showing 10 Chapters, 100 Standards, but with 639 Objective Elements. It also breaks down OEs into Core, Commitment, Achievement, and Excellence categories."

      • "This breakdown into categories like 'Achievement' and 'Excellence' suggests a tiered approach, encouraging hospitals not just to meet basic requirements but to strive for higher levels of performance."

    • "NABH 5th Edition Breakdown (Slide 9 - Bottom Table 'NABH 5th Edn'):"

      • "This table provides a detailed count of Objective Elements for the current 5th Edition across different chapters (AAC, COP, MOM, PRE, HIC/IPC, PSQ, ROM, FMS, HRM, IMS), totaling 60 Achievement, 459 Commitment, 102 Core, and 30 Excellence OEs, summing to 651 Grand Total OEs."

      • "Why this evolution? Standards are refined based on:

        • New medical knowledge and technological advancements.

        • Emerging patient safety risks and research.

        • Learning from incidents and best practices globally.

        • Changing healthcare needs and patient expectations."

      • "For us as clinicians, this means that our learning and adaptation must also be continuous. We need to stay informed about these evolving standards as they directly impact how we practice."

(Slide 2: Dr. Riju Mathew; Slide 3: QR Code - read only slides; Slide 55: QR Code - detailed notes & test)

• IV. Meet Our Quality Leadership & Accessing Your Resources

  • A. Our Dedicated Quality Leadership (Slide 2 - Dr. Riju Mathew):

    • "Behind our quality initiatives is a dedicated and highly qualified team. Slide 2 introduces Dr. Riju Mathew, our Assistant Director for Laboratory, Quality & Risk, and Associate Professor, among many other roles."

    • "Dr. Mathew's extensive credentials (MSc, Ph.D., FAGAR, PGDEUC, LHA, POI, CPQIL), including being a NABH Assessor, Certified ICD-11 Coder, and holding certifications like Lean Six Sigma White Belt, highlight the level of expertise guiding our quality journey."

    • "His experience as a former representative for Clinical Biochemistry Section in the governing board of CAHO, and involvement in NABH Full Accreditation implementation, among many other achievements listed, demonstrates deep engagement with national quality frameworks."

    • "The accreditations and certifications shown at the bottom of Slide 2 (Full NABH HCO H-2017-0459 valid 2017-2027, NABH Emergency E-2024-0060 valid 2024-2026, NABL ISO 15189:2022 MC-3293 valid 2019-2026, Medical College QAS A+ valid 2024-2027) are tangible evidence of the hospital's commitment across various domains."

    • "Having such leadership reinforces that quality is a strategic priority for Believers Church Medical College Hospital."

  • B. Your Toolkit for Continuous Learning: Accessing Support Materials:

    • (Slide 3) QR Code for Presentation Slides:

      • "We understand a lot of information is shared today. To help you review this at your own pace, the QR code on Slide 3 provides access to the read-only version of these presentation slides. Please feel free to scan it now or later for your reference."

    • 
      

    • (Slide 55 - Thank You Slide) QR Code for Detailed Notes & Skill Certificate:

      • "At the end of our session, on the 'Thank You' slide (Slide 55), you'll find another QR code. This one links to more detailed notes complementing this induction and also provides an opportunity to take a test. Successfully completing this test can earn you a Skill Certificate, recognizing your understanding of these crucial quality principles."

      • "We encourage you to utilize these resources. They are designed to support your ongoing learning and your active participation in our quality culture."

• Transition to Module 2:

  • "Now that we've established a common understanding of what quality means, why it's vital, and the standards that guide us, let's move into Module 2, where we'll explore some of the core clinical standards and patient safety goals that are directly applicable to your daily practice."

This detailed expansion aims to transform the initial slides of Module 1 into a rich, engaging, and informative start to the quality induction program, setting a strong foundation for the modules to follow.

Module 2: Mastering Core Clinical Standards & Championing Patient Safety

(Slide 10: International Patient Safety Goals)

• I. The Six Pillars: International Patient Safety Goals (IPSG) in Action – A Clinician's Mandate

  • "We now turn our attention to a cornerstone of global healthcare quality – the International Patient Safety Goals, or IPSGs, as shown on Slide 10. These goals, often promoted by organizations like the WHO and JCI, address high-risk areas in patient care and provide evidence-based solutions to prevent harm. For us as clinicians, these are not just guidelines; they are fundamental to our practice."

  • A. Goal 1: Identify Patients Correctly

    • The "What": "This goal mandates the use of at least two unique patient identifiers before initiating any diagnostic or therapeutic intervention. Common identifiers include the patient's full name and their Unique Hospital Identification Number (UHID) or Medical Record Number (MRN)."

    • The Critical "Why": "Misidentification can lead to catastrophic errors: wrong medication, wrong procedure, wrong blood transfusion, wrong diagnostic test performed on the wrong patient. These are 'never events' we must strive to eliminate."

    • The Clinician's "How":

      1. Always Use Two Identifiers: Before administering medications, drawing blood or other samples, providing any treatment or procedure, or transferring a patient.

      2. Active Confirmation:

         • If the patient is conscious and oriented, ask them to state their full name and UHID/MRN.

         • Compare this verbal confirmation with the information on their ID band, the medication chart, requisition forms, or consent forms.

      3. ID Band Check: Always verify the patient's ID band. If it's missing or illegible, ensure it's replaced before proceeding with any intervention.

      4. Avoid Unreliable Identifiers: Never use the patient's room number or bed number as an identifier, as patients can be moved.

      5. Specific Scenarios:

         • Unconscious/Confused Patients: Rely on the ID band and cross-reference with medical records and, if possible, with a family member who can confirm identity.

         • Neonates: Follow specific hospital protocols for identifying newborns, which may include mother's details and unique neonatal identifiers.

         • Similar Names: Exercise extreme caution if two patients have similar names on the same ward. Double and triple-check!

    • Interactive Question: "Can anyone share a quick example from their experience where using two identifiers was crucial or where a potential misidentification was caught?"

• • B. Goal 2: Improve Effective Communication

    • The "What": "This goal focuses on ensuring that information exchanged among caregivers is timely, accurate, complete, unambiguous, and understood by the recipient."

    • The Critical "Why": "Communication breakdowns are consistently cited as one of the leading root causes of adverse events and medical errors. Assumptions, incomplete information, and misinterpretations can have severe consequences."

    • The Clinician's "How":

      1. Standardized Handovers (e.g., SBAR):

         • SBAR (Situation, Background, Assessment, Recommendation): Use this structured format for shift handovers, patient transfers, and consultations.

           1. Situation: "Dr. X, I'm calling about Mr. Y in Room 201, who is experiencing sudden shortness of breath."

           2. Background: "He is a 65-year-old male, admitted yesterday with community-acquired pneumonia, on IV antibiotics."

           3. Assessment: "His O2 saturation has dropped to 88% on room air, respiratory rate is 30, and he appears anxious."

           4. Recommendation: "I think he needs urgent assessment and possibly O2 therapy. Could you please come and see him?"

      2. Read-Back and Verify (RBV):

         • For all verbal orders (in emergencies only, per policy) and telephone orders.

         • For critical test results reported verbally or over the phone.

         • The person receiving the information writes it down, reads it back to the sender, and the sender confirms its accuracy. Document "RBV" or "Read Back & Verified."

      3. Managing Critical Values:

         • Understand the hospital's list of critical laboratory values and imaging findings.

         • Ensure prompt communication of critical values to the responsible clinician.

         • Document the communication (who was called, when, what was said, and the action taken – link to Slide 34, point 14).

      4. Avoid Dangerous Abbreviations: Use only hospital-approved abbreviations. Refer to the "Do Not Use" list. Ambiguous abbreviations can lead to serious medication errors.

      5. Clear and Legible Documentation: Ensure all entries in the medical record are legible, dated, timed, and signed (link to Slide 34, point 1).

      6. Clarify Doubts: If an order or piece of information is unclear, always seek clarification before acting on it. Never assume.

    • Scenario Discussion: "A nurse calls you about a patient's blood sugar of 350 mg/dL. What steps would you take to ensure effective communication regarding the action plan?"

• • C. Goal 3: Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery (and other invasive procedures)

    • The "What": "This goal is about implementing robust processes to prevent wrong-site, wrong-procedure, and wrong-patient errors for all surgical and other invasive procedures."

    • The Critical "Why": "These are devastating, 'never events' that are entirely preventable with systematic checks and teamwork."

    • The Clinician's "How" - The Universal Protocol:

      1. Pre-Procedure Verification Process:

         • Confirm the patient's identity (two identifiers).

         • Verify the correct procedure and site against consent forms, medical records, imaging studies, and patient understanding.

         • Ensure all relevant documents (H&P, consent, labs, imaging) are available and reviewed.

         • Verify availability of necessary implants, special equipment.

      2. Surgical Site Marking:

         • The site must be marked by the clinician who will perform the procedure.

         • Marking should be unambiguous (e.g., initials, "YES"), visible after prepping and draping, and made with a permanent marker resistant to skin prep solutions.

         • Involve the patient (if conscious and able) in confirming the site marking.

         • Exceptions (e.g., mucosal surfaces, teeth, bilateral organs where laterality isn't the issue) should follow specific hospital policy.

      3. "Time-Out" (Surgical Pause):

         • Conducted immediately before the incision or start of the invasive procedure.

         • Involves the entire surgical/procedural team (surgeon, anaesthesiologist, nurses).

         • Actively confirm: Correct patient, correct site, correct procedure.

         • Verify availability of implants, special equipment, relevant imaging.

         • Address any concerns or discrepancies before starting.

         • Document the completion of the Time-Out. (Link to Slide 34, point 11 - Surgical Safety Checklist).

• • • Trainer Note: "Our hospital has a specific Surgical Safety Checklist (link to Slide 6, OPERATIVE CHECKLIST - OT/SURGICAL SAFETY(MED-085) and Slide 34, point 11). Familiarize yourselves with all its components: Sign In, Time Out, Sign Out."

• • D. Goal 4: Improve the Safety of High-Alert Medications (HAM)

    • The "What": "This goal focuses on implementing safeguards for medications that, if used in error, carry a heightened risk of causing significant patient harm."

    • The Critical "Why": "While any medication error is serious, errors involving HAMs (e.g., insulin, anticoagulants, narcotics, concentrated electrolytes like potassium chloride, chemotherapeutic agents) can have particularly severe or fatal consequences."

    • The Clinician's "How":

      1. Know Your HAMs: Be familiar with the hospital's approved list of High-Alert Medications. This list should be readily accessible.

      2. Standardized Processes:

         • Ordering: Clear, complete, unambiguous orders. Avoid trailing zeros (e.g., write 5 mg, not 5.0 mg) and use leading zeros for doses less than 1 (e.g., write 0.5 mg, not .5 mg).

         • Storage: Store HAMs securely. Separate Look-Alike, Sound-Alike (LASA) medications. Concentrated electrolytes should NOT be stored in patient care areas unless specific protocols are in place (e.g., ICU, CCU with safeguards).

         • Preparation: Standardized concentrations and labeling.

         • Administration: Adhere strictly to the "5 Rights" (Right Patient, Right Drug, Right Dose, Right Route, Right Time) plus Right Documentation, Right Reason, Right Response.

      3. Independent Double-Checks:

         • For high-risk steps like dose calculations, pump settings, and administration of certain HAMs (as per hospital policy).

         • Two qualified individuals independently check the process. This is not one person watching another; it's two separate checks.

      4. Patient Education: Educate patients and families about their HAMs (e.g., insulin, warfarin) including potential side effects and precautions.

      5. Monitoring: Closely monitor patients receiving HAMs for therapeutic effects and adverse reactions.

    • Discussion: "What are some common HAMs used in your specialty, and what specific precautions do you take?"

• • E. Goal 5: Reduce the Risk of Healthcare-Associated Infections (HAI)

    • The "What": "This goal emphasizes the implementation of evidence-based practices to prevent infections that patients acquire while receiving treatment for other conditions."

    • The Critical "Why": "HAIs are a major cause of morbidity, mortality, prolonged hospital stays, and increased healthcare costs. Many are preventable."

    • The Clinician's "How":

      1. Hand Hygiene:

         • The SINGLE MOST IMPORTANT measure. Adhere to the WHO "5 Moments for Hand Hygiene":

           1. Before touching a patient.

           2. Before a clean/aseptic procedure.

           3. After body fluid exposure risk.

           4. After touching a patient.

           5. After touching patient surroundings.

         • Use alcohol-based hand rub (ABHR) or soap and water. Know the correct technique and duration.

      2. Standard Precautions: Apply to ALL patients, regardless of their diagnosis. Assume everyone is potentially infectious. This includes hand hygiene, use of Personal Protective Equipment (PPE – gloves, gowns, masks, eye protection) based on anticipated exposure, safe injection practices, respiratory hygiene/cough etiquette, and proper handling of contaminated equipment and linen.

      3. Transmission-Based Precautions: For patients known or suspected to be infected with specific pathogens (Contact, Droplet, Airborne Precautions). Know when and how to apply these.

      4. Care Bundles: Implement evidence-based bundles to prevent specific HAIs (e.g., Catheter-Associated Urinary Tract Infections - CAUTI, Central Line-Associated Bloodstream Infections - CLABSI, Ventilator-Associated Pneumonia - VAP, Surgical Site Infections - SSI).

      5. Aseptic Techniques: For all invasive procedures, medication preparation, and wound care.

      6. Biomedical Waste (BMW) Management: Proper segregation and disposal of BMW (link to Module 5, Slide 51).

      7. Environmental Cleaning & Disinfection: Ensure patient care areas and equipment are appropriately cleaned and disinfected.

    • Quick Demo/Reminder: "Let's quickly review the correct steps for hand rubbing with ABHR."

  • F. Goal 6: Reduce the Risk of Patient Harm Resulting from Falls

    • The "What": "This goal focuses on assessing patients for their risk of falling and implementing interventions to reduce that risk and prevent fall-related injuries."

    • The Critical "Why": "Falls are among the most common adverse events in hospitals, particularly affecting elderly or debilitated patients. They can lead to fractures, head injuries, increased length of stay, and fear of falling."

    • The Clinician's "How":

      1. Initial and Ongoing Fall Risk Assessment:

         • Use a standardized fall risk assessment tool for all patients upon admission and regularly thereafter (e.g., daily, or with any change in condition or medication that might increase fall risk).

         • Consider factors like age, history of falls, mobility issues, medications (polypharmacy, sedatives, diuretics), cognitive impairment, and environmental hazards.

      2. 
         

      3. Implement Individualized Fall Prevention Strategies: Based on the assessed risk level:

         • Universal Precautions: Keep bed in low position, brakes locked, call bell within reach, adequate lighting, clear pathways.

         • Moderate/High-Risk Interventions: Bed alarms, chair alarms, non-slip footwear, scheduled toileting, assistance with ambulation, physical therapy consultation, medication review to minimize psychoactive drugs.

      4. 
         

      5. Patient and Family Education: Educate patients and their families about fall risks and the prevention strategies being used. Encourage them to call for assistance.

      6. Environmental Safety: Regularly check for and address environmental hazards (e.g., spills, clutter, poor lighting).

      7. Post-Fall Management: If a fall occurs, assess the patient for injury, provide appropriate medical care, notify the physician, document the event (including an OVR), analyze the circumstances of the fall, and revise the care plan to prevent recurrence.

    • Interactive Poll: "What are the top 3 risk factors for falls you see in your patient population?"

(Slide 11 [5th Edn], Slide 12 [6th Edn] - Access, Assessment, and Continuity of Care - AAC)
(Slide 13 [6th Edn], Slide 14 [5th Edn], Slide 15 [5th Edn], Slide 16 [6th Edn] - Care of Patients - COP)
(Slide 17 [5th Edn], Slide 18 [6th Edn] - Management of Medication - MOM)
(Slide 19 [5th Edn], Slide 20 [6th Edn] - Patient Rights and Education - PRE)
(Slide 21 [HIC], Slide 22 [IPC] - Hospital/Infection Prevention & Control)

• II. NABH Patient-Centric Standards: A Clinician's Deep Dive into Excellence

  • "Beyond the universal IPSGs, our national accreditation body, NABH, provides a comprehensive set of standards. We will now explore key patient-centric chapters from both the 5th and 6th Editions, focusing on your direct role as clinicians. The highlighted text on some slides refers to the 5th Edition, while plain text often indicates the 6th Edition focus."

  • A. Access, Assessment, and Continuity of Care (AAC) (Slides 11 & 12)

    • Core Principle: "Ensuring patients receive the right care, at the right time, based on a thorough understanding of their needs, and that this care is seamless across different settings and providers."

    • Key Clinician Responsibilities & Actions (Referencing standards AAC.1 to AAC.14 [5th Edn] / AAC.1 to AAC.13 [6th Edn]):

      1. AAC.1 (Defines and displays healthcare services): Be aware of the scope of services your department and the hospital provides. Communicate this clearly to patients.

      2. AAC.2 (Well-defined registration and admission process): Ensure you follow the established protocols for admitting patients, verifying information, and initiating the care record.

      3. AAC.3 (Appropriate mechanism for transfer (in and out) or referral):

         • When transferring a patient internally or externally, or referring for consultation, ensure a complete and accurate handover of clinical information (SBAR is key here).

         • Document the reason for transfer/referral clearly (link to Slide 34, point 15 - intra-hospital referral categorization).

      4. AAC.4 (Patients undergo an established initial assessment):

         • This is CRITICAL. Perform a comprehensive initial assessment as per hospital policy upon admission (link to Slide 34, point 2 – History, Physical Exam, Nutrition Screening, Comorbidities, Medication Reconciliation, Provisional Diagnosis, Risk Analysis).

         • Ensure this is documented thoroughly and serves as the baseline for the care plan.

         • For junior residents, ensure consultant countersignature with SNDT (Slide 34, point 3).

      5. AAC.5 (Patients undergo a regular reassessment):

         • Continuously monitor patient progress and re-evaluate their condition as per policy (e.g., daily for stable patients, more frequently for unstable/ICU patients – link to Slide 34, point 5).

         • Document these reassessments, including changes in condition, response to treatment, and modifications to the care plan.

      6. AAC.6 (Laboratory/AAC.9 Imaging services are provided as per scope):

         • Understand the scope of lab and imaging services available. Order tests appropriately and ensure relevant clinical information is provided with requests (Slide 34, point 4).

         • Be aware of quality assurance and safety programs in these departments (AAC.7, AAC.8, AAC.10 [5th Edn]).

      7. AAC.12 [5th Edn] / AAC.10 [6th Edn] (Patient care is continuous and multidisciplinary):

         • Collaborate effectively with other members of the healthcare team (nurses, therapists, pharmacists, other specialists) to ensure coordinated and holistic care.

         • Participate in multidisciplinary team meetings where applicable.

      8. AAC.13 [5th Edn] / AAC.12 [6th Edn] (Established discharge process) & AAC.14 [5th Edn] / AAC.13 [6th Edn] (Defines content of the discharge summary):

         • Plan for discharge from the time of admission.

         • Provide clear discharge instructions to the patient and family in an understandable manner.

         • Prepare a comprehensive, accurate, and timely discharge summary containing all essential elements (link to Slide 34, point 8 – final diagnosis, reason for admission, significant findings, treatment given, follow-up, etc.). This is vital for continuity of care with outpatient providers.

         • (6th Edn - AAC.11: Preventive and promotive health services provided in a safe, collaborative, and consistent manner).

    • Clinical Reflection: "Think about a recent complex patient discharge. How did these AAC principles ensure a smooth transition of care?"

• • B. Care of Patients (COP) (Slides 13, 14, 15, 16)

    • Core Principle: "Providing safe, effective, and evidence-based clinical care tailored to the individual needs of each patient, across all settings within the organization."

    • Key Clinician Responsibilities & Actions (Referencing standards COP.1 to COP.9 [6th Edn, Slide 13] / COP.1 to COP.8 [5th Edn, Slide 14] AND COP.9 to COP.20 [5th Edn, Slide 15] / COP.10 to COP.20 [6th Edn, Slide 16]):

      1. COP.1 (Uniform care guided by written guidance): Adhere to established clinical protocols, guidelines, and pathways. Strive for consistency in care delivery based on best practices.

      2. COP.2 (Emergency services in accordance with written guidance, laws, regulations): Be proficient in managing emergencies within your scope. Understand activation of Code Blue, RRT, etc.

      3. COP.3 (Ambulance services ensure safe patient transportation): If involved in patient transport, ensure appropriate care and monitoring.

      4. COP.4 (Mechanisms for care during community emergencies, epidemics, disasters): Understand your role in the hospital's disaster preparedness and response plan.

      5. COP.5 (Cardio-pulmonary resuscitation (CPR) services provided uniformly): Maintain current CPR certification (BLS/ACLS as appropriate). Respond promptly and effectively to cardiac arrests.

      6. COP.6 (Nursing care in consonance with clinical protocols): Collaborate closely with nursing staff, ensuring care aligns with established protocols.

      7. COP.7 (Clinical procedures are performed safely):

         • Obtain informed consent.

         • Perform pre-procedure verification (Universal Protocol).

         • Use aseptic techniques.

         • Monitor the patient during and after the procedure.

         • Document accurately. (Link to Surgical Safety Checklist, Slide 34, point 11).

      8. COP.8 (Transfusion services provided safely): Ensure correct patient identification, blood product verification, and monitoring for transfusion reactions.

      9. COP.9 (Care in intensive care and high dependency units in a systematic manner): Adhere to specialized protocols for critical care, including APACHE scoring (Slide 34, point 19).

      10. COP.10 (Safe obstetric care) & COP.11 (Safe paediatric services): Follow specific guidelines and safety protocols for these vulnerable populations. This includes nutritional assessment of obstetric patients (NC COP10.e, Slide 36) and paediatric growth/development/immunization assessment (NC COP 11.e, Slide 36).

      11. COP.12 (Procedural sedation provided consistently and safely): Assess patients for sedation, use appropriate agents and monitoring (e.g., Ramsay Sedation Score, Slide 34, point 16). Ensure consent for procedural sedation includes specific risks (NC COP 12.b, Slide 36). Ensure person monitoring sedation is appropriate (NC COP 12.d, Slide 36).

      12. COP.13 (Anaesthesia services provided consistently and safe manner): Collaborate with anaesthesia team for safe administration and monitoring. Ensure monitoring of adverse anaesthesia events (NC COP 13.j, Slide 36).

      13. COP.14 (Surgical services provided in a consistent and safe manner): Adhere to surgical safety protocols, including complete and accurate operative notes (Slide 34, point 12). Ensure operation notes are consistently present (NC COP 14.e, Slide 36). Ensure material flow in OT confirms to IPP (NC COP 14.g, Slide 36). Monitor intra-operative mishaps (NC COP 14.i, Slide 36).

      14. COP.15 (Organ transplant programme carried out safely): Follow stringent protocols if involved in transplant services.

      15. COP.16 (Identifies and manages patients at higher risk of morbidity/mortality): Proactively identify and implement strategies for high-risk patients. This includes identification of vulnerable patients (NC COP 16.a, Slide 36).

      16. COP.17 (Pain management done in a consistent manner): Assess pain regularly using a standardized scale, provide appropriate pain relief, and reassess effectiveness. Ensure periodic pain reassessment (NC COP 17.c, Slide 36) and titration after assessment/reassessment (NC COP 17.d, Slide 36).

      17. COP.18 (Rehabilitation services provided safely, collaboratively, consistently): Collaborate with rehabilitation team for optimal patient recovery. Ensure care pathways are developed, implemented, and reviewed for rehabilitative services (NC COP 18.g, Slide 36).

      18. COP.19 (Nutritional therapy provided consistently and collaboratively): Assess nutritional status and collaborate for appropriate nutritional support.

      19. COP.20 (End-of-life care provided in a compassionate and considerate manner): Focus on comfort, dignity, and support for patients and families.

    • Clinical Application: "Describe how you would apply 3-4 COP standards when managing a patient undergoing a common surgical procedure in your specialty."

• • C. Management of Medication (MOM) (Slides 17 & 18)

    • Core Principle: "Ensuring that medications are prescribed, dispensed, administered, and monitored safely and effectively throughout the patient's stay."

    • Key Clinician Responsibilities & Actions (Referencing standards MOM.1 to MOM.11):

      1. MOM.1 (Pharmacy services and usage of medication done safely): Understand and utilize pharmacy services appropriately.

      2. MOM.2 (Organisation develops, updates, implements a hospital formulary): Prescribe medications according to the hospital formulary whenever possible. Understand the process for non-formulary requests.

      3. MOM.3 (Medications stored appropriately and available where required): Ensure medications in clinical areas under your purview are stored correctly (temperature, light protection, security for narcotics).

      4. MOM.4 (Medications prescribed safely and rationally):

         • Crucial for Prescribers! Base prescriptions on accurate diagnosis and evidence-based guidelines.

         • Ascertain drug allergies and previous adverse drug reactions BEFORE prescribing (NC MOM 4.c, Slide 37). Document this clearly (Slide 34, point 6).

         • Consider drug interactions, food-drug interactions, therapeutic duplication, and need for dose adjustments (NC MOM 4.d, Slide 37).

         • Ensure audit of medication orders/prescriptions checks for safe and rational prescribing including all parameters like drug interactions (NC MOM 4.f, Slide 37).

      5. MOM.5 (Medication orders written in a uniform manner):

         • Write legibly, in BLOCK LETTERS, using GENERIC names (Slide 34, point 9).

         • Include patient identifiers, drug name, dose, route, frequency, duration.

         • All sampled medication orders must be legible and SIGNED (NC MOM 5.c, Slide 37).

         • Avoid dangerous abbreviations.

      6. MOM.6 (Medications dispensed in a safe manner): While primarily pharmacy's role, understand the dispensing process to ensure clarity of your orders.

      7. MOM.7 (Medications administered safely): While often nursing's role, be aware of safe administration practices. Implement measures to prevent disconnection of catheter and tubing for medicine administration (NC MOM 7.h, Slide 37).

      8. MOM.8 (Patients monitored after medication administration): Monitor for therapeutic effects, side effects, and adverse reactions. Document findings.

      9. MOM.9 (Narcotic drugs, psychotropic substances, chemotherapeutic agents, radioactive agents used safely): Follow strict protocols for prescribing, storing, documenting, and administering these high-risk medications. Ensure use of Form 3E for narcotics (NC MOM 9.a, Slide 37) and proper maintenance of narcotic drug prescriptions (NC MOM 9.b, Slide 37).

      10. MOM.10 (Implantable prosthesis and medical devices used in accordance with laid down criteria): Ensure appropriate selection and use based on established criteria.

      11. MOM.11 (Medical supplies and consumables stored appropriately and available): Ensure necessary supplies are available and properly stored in your clinical areas.

    • Medication Safety Moment: "What is the most common type of medication error you are concerned about in your practice, and what one system change could help prevent it?"

• • D. Patient Rights and Education (PRE) (Slides 19 & 20)

    • Core Principle: "Respecting and promoting the rights of patients and their families, and empowering them with the information and education needed to participate actively in their care."

    • Key Clinician Responsibilities & Actions (Referencing standards PRE.1 to PRE.8):

      1. PRE.1 (Organisation protects and promotes patient and family rights and informs them about their responsibilities): Be an advocate for patient rights. Ensure corrective/preventive action by top leadership for violation of patient/family rights (NC PRE 1.e, Slide 37).

      2. PRE.2 (Patient and family rights support individual beliefs, values and involve the patient and family in decision-making): Respect cultural, religious, and personal preferences. Actively involve patients and families in care decisions to the extent they desire.

      3. PRE.3 (Patient and/or family members are educated to make informed decisions and are involved in the care planning and delivery process): Provide clear, understandable explanations about their condition, treatment options, risks, benefits, and alternatives.

      4. PRE.4 (Informed consent is obtained from the patient or family about their care):

         • This is a cornerstone of ethical practice. Ensure informed consent is obtained before any non-emergency invasive procedure or significant treatment (Slide 34, point 10).

         • Informed consent must be taken uniformly for all patients (NC PRE 2.g, Slide 37 - examples TMT, Derma Skin biopsy, Ophthalmology for Laser).

         • The consent form must adequately explain the procedure (NC PRE 4.c, Slide 37 - examples Labour room, gynec surgeries, Dermatology, dental).

         • Elements of valid informed consent include: diagnosis, nature and purpose of proposed treatment/procedure, risks and benefits, alternatives (including no treatment), likelihood of success, who will perform it, right to refuse.

         • Ensure the patient has the capacity to consent and that it's voluntary. Document the consent process thoroughly.

      5. PRE.5 (Patient and families have a right to information and education about their healthcare needs): Proactively provide information and answer questions.

      6. PRE.6 (Patients and families have a right to information on expected costs): Be transparent about potential costs where appropriate and direct them to relevant departments for detailed information.

      7. PRE.7 (Organisation has a mechanism to capture patient's feedback and to redress complaints): Encourage patients to provide feedback. Be aware of the complaint redressal mechanism and support its fair use. Ensure patient experience is captured (NC PRE 7.b, Slide 37). Ensure redressal of patient complaints is evidenced for all complaints (NC PRE 7.c, Slide 37). Ensure patient/family are uniformly aware of procedure for giving feedback/lodging complaints (NC PRE 7.d, Slide 37, noting QR code for private rooms only initiated 1 month before). Ensure corrective/preventive actions are evident for complaints captured by QR code (NC PRE 7.f, Slide 38).

      8. PRE.8 (Organisation has a system for effective communication with patients and/or families): Use clear language, avoid jargon, ensure understanding (teach-back method), and be empathetic. Ensure no unacceptable communication (NC PRE 8.d, Slide 38) and that system to monitor/review effective communication is evidenced (NC PRE 8.e, Slide 38).

    • Ethical Dilemma Discussion: "A patient refuses a life-saving treatment due to religious beliefs. How do you navigate this situation respecting PRE standards?"

• • E. Hospital Infection Control (HIC) / Infection Prevention & Control (IPC) (Slides 21 & 22)

    • Core Principle: "Protecting patients, staff, and visitors from acquiring infections during their time in the hospital through a comprehensive and coordinated program." (Note: HIC is often older terminology, IPC is current).

    • Key Clinician Responsibilities & Actions (Referencing standards HIC.1 to HIC.8 / IPC.1 to IPC.8):

      1. HIC.1/IPC.1 (Comprehensive and coordinated HIC/IPC programme): Understand and actively participate in the hospital's IPC program.

      2. HIC.2/IPC.2 (Adequate and appropriate resources for infection prevention and control): Utilize IPC resources correctly (e.g., PPE, hand hygiene products).

      3. HIC.3/IPC.3 (Implements the infection prevention and control programme/processes in clinical areas):

         • Crucial! This is where clinicians make the biggest impact.

         • Adhere to hand hygiene (Goal 5 IPSG).

         • Use Standard and Transmission-Based Precautions.

         • Employ aseptic techniques for all procedures.

         • Ensure proper disinfection/sterilization of any equipment you use (HIC.7/IPC.7).

      4. HIC.4/IPC.4 (Implements the infection prevention and control programme/processes in support services): Be aware that support services also follow IPC protocols that impact your work environment.

      5. HIC.5/IPC.5 (Takes actions to prevent healthcare-associated Infections (HAI) in patients): Actively implement care bundles (CAUTI, CLABSI, VAP, SSI) and other preventive measures.

      6. HIC.6/IPC.6 (Performs surveillance to capture and monitor infection prevention and control data): Cooperate with surveillance activities, report suspected HAIs to the IPC team.

      7. HIC.7/IPC.7 (Infection prevention measures include sterilization and/or disinfection of instruments, equipment and devices): Ensure all reusable devices are properly processed before use. Ensure all devices being reused are included in reuse list and uniformly monitored for re-use (NC HIC 7.c, Slide 38).

      8. HIC.8/IPC.8 (Takes action to prevent or reduce healthcare-associated infections in its staff): Follow protocols for staff safety (e.g., needle-stick injury prevention, post-exposure prophylaxis). Ensure implementation of restriction for healthcare staff with airborne infections is evidenced (NC HIC 8.c, Slide 38).

    • IPC Challenge: "What is the biggest barrier to consistent hand hygiene practice on your unit, and how could it be overcome?"

• III. Interactive Learning: Clinical Conundrums – Bringing Standards to Life

  • "Let's now work through 2-3 detailed clinical scenarios. For each, I want us to identify:

    • The potential quality and patient safety issues.

    • Which IPSGs are relevant?

    • Which NABH standards (AAC, COP, MOM, PRE, IPC) are applicable?

    • What are the best actions the clinical team should take according to these standards?"

  • 
    

  • (Trainer presents pre-prepared scenarios, e.g.:

    • Scenario 1: A patient admitted for chest pain develops a fever and new cough post-cardiac catheterization; communication about a critical lab value was delayed.

    • Scenario 2: A surgeon plans an operation on the left knee, but the consent form vaguely says "knee surgery," and the pre-op nurse notices the patient seems confused about which knee.

    • Scenario 3: An elderly patient on multiple medications, including a sedative, is found on the floor next to their bed.

  • 
    

  • (Facilitate group discussion, guiding participants to link the scenario elements to specific IPSGs and NABH standards, reinforcing the learning from this module.)

• Transition to Next Module:

  • "Excellent discussion. You can see how these core standards and safety goals are interwoven into every aspect of clinical care. In our next module, we will focus specifically on the critical area of clinical documentation, further explore your responsibilities, and learn from real-world assessment findings."

This extensive expansion of Module 2 aims to provide clinicians with a deep, practical understanding of the core standards and patient safety goals, using interactive elements and direct links to the provided slide content, including the Non-Compliance examples.

Module 3: The Art & Science of Clinical Documentation, Responsibilities, & Learning from Real-World Experiences

• I. Medical Record Management: The Foundation of Quality Care & Legal Integrity

  • "Welcome back. In this module, we delve into one of the most critical aspects of our professional practice – medical record management. Accurate, complete, and timely documentation is not just a regulatory requirement; it's fundamental to providing safe, continuous, and high-quality patient care. It's also our primary legal record of the care provided."

  • A. Understanding the Journey: Flow of Medical Records (Slide 5)

    • "Slide 5 provides a visual overview of the typical 'FLOW OF MEDICAL RECORDS' within our hospital. Let's trace this journey to understand the interconnectedness of each step:"

      • Registration Counter: "The record often begins here, where patient demographics and initial visit information are captured."

      • Consultants (IP/OP): "Clinicians like yourselves then begin documenting clinical assessments, diagnoses, treatment plans, and orders. This happens in both In-Patient (IP) and Out-Patient (OP) settings."

      • Wards (for IP): "For admitted patients, ongoing care, progress notes, nursing notes, medication administration records, and other vital information are added by the multidisciplinary team on the wards."

      • Medical Records Department (Post-Discharge/Visit): "Once the patient encounter is complete (e.g., discharge for IP, visit completion for OP), the physical and/or electronic record transitions to the Medical Records Department (MRD)."

      • Assembling: "The various forms and notes are collated in a standardized order."

      • Deficiency Check and Coding: "MRD staff review the record for completeness (e.g., missing signatures, reports) and assign appropriate diagnostic and procedural codes (e.g., ICD-10, CPT) for billing, statistical analysis, and research."

      • Indexing: "The record is indexed for easy retrieval."

      • Computer Entry / Scanning: "Key information may be entered into the Hospital Information System (HIS), and/or the physical record is scanned to create a digital copy."

      • Permanent Filing: "The record (physical or digital) is stored securely and archived according to hospital policy and legal requirements for retention."

    • Significance for Clinicians: "Understanding this flow helps you appreciate why your timely and complete documentation at the point of care is so vital. Delays or deficiencies upstream can create significant problems downstream for coding, billing, quality reviews, and future patient care if the record is needed again."

• • B. Structuring the Narrative: In-patient Records Assembling Format (Slide 6)

    • "For our admitted patients, there's a specific 'Assembling format' for medical records, as detailed on Slide 6. This standardized order ensures consistency and makes it easier for all healthcare providers to find information quickly. Let's review some key components you are directly responsible for or interact with:"

      • FINAL SUMMARY SHEET (BCMCH/MRD/MED-065): Often a key administrative and clinical overview.

      • DISCHARGE SUMMARY / LAMA / TRANSFER DEATH (MED-018): CRITICAL document you prepare, summarizing the entire hospital stay (we'll revisit this).

      • ADMISSION REQUEST SLIP (MED-001): Initial documentation for admission.

      • ADMISSION CONSENT (MED 046) & OTHER CONSENTS AS APPLICABLE: Vital legal documents.

      • HISTORY & PHYSICAL EXAMINATION (MED-003): Your comprehensive initial assessment.

      • OPERATIVE CHECKLIST; PRE (NUR-014), OT/SURGICAL SAFETY (MED-085), POST/RECOVERY ROOM RECORD (NUR-044): Essential for any surgical patient.

      • PAIN ASSESSMENT (MED-063): Consistent documentation of pain.

      • NUTRITIONAL ASSESSMENT (DIET-009): Important for holistic care.

      • DOCTORS PROGRESS NOTES (MED-017): Your daily (or more frequent) narrative of the patient's progress and your clinical reasoning.

      • CROSS CONSULTATION (MED-071): Records of consultations sought and provided.

      • INVESTIGATION FLOW CHART (NUR-007), VITAL SIGNS (NUR-005) / TPR CHARTS (NUR-006), INTAKE OUTPUT (NUR-001) /GRBS (MED-072), MEDICATION/DRUG CHARTS (NUR-022): While often maintained by nursing, clinicians rely heavily on these for decision-making and must ensure orders are clear.

      • NURSES INITIAL ASSESSMENT (NUR-045) / NURSING CARE NOTE (NUR-023): Provides a comprehensive nursing perspective.

      • MULTIDISCIPLINARY SHEET (MED-076): For collaborative care planning.

      • ICU FLOW SHEET (NUR-080) & OTHER FORMS (): Specialized documentation for critical care.

    • Why the Order Matters: "A standardized order ensures that anyone reviewing the chart can efficiently locate specific information, which is crucial for ongoing care, handovers, medico-legal reviews, and audits."

  • C. The Pillars of Good Record Keeping: Information Management System (IMS) (Slide 30 [5th Edn], Slide 31 [6th Edn Summary])

    • "The NABH standards for Information Management System (IMS) provide the framework for why and how we manage medical records. Let's look at the core principles from a clinician's viewpoint, as highlighted on Slides 30 and 31."

    • IMS.1 (Information needs of patients, visitors, staff, management, and external agencies are met):

      • "Your documentation contributes to meeting these diverse information needs. For patients, it’s the basis of understanding their care. For staff, it’s for continuity. For management, it’s for quality monitoring and resource allocation."

    • IMS.2 (Organisation has processes in place for management and control of data and information):

      • "This refers to the systems (like HIS, MRD processes) that support record keeping. Your adherence to these processes (e.g., timely entry, using designated forms) is key."

    • IMS.3 (The patients cared for by the organisation have a complete and accurate medical record):

      • This is YOUR direct responsibility. Every patient encounter, decision, intervention, and observation must be documented.

      • Accuracy: Ensure what you write is factually correct. Avoid speculation presented as fact.

      • Completeness: Don't leave out pertinent positive or negative findings, changes in condition, or rationale for decisions.

      • (NC IMS 3.e, Slide 38 highlights a critical gap: "All entries in medical record were not named, signed and timed." We will emphasize this repeatedly.)

      • (NC IMS 3.f, Slide 38 notes: "All entries in case records were not signed, hence author of each entry could not Br uniformly identified." This underscores the importance of clear attribution.)

    • IMS.4 (The medical record reflects the continuity of care):

      • "A well-documented record should tell a clear, chronological story of the patient's journey, allowing another clinician to pick up the chart and understand what has happened, what was planned, and what the current status is."

    • IMS.5 (The organisation maintains confidentiality, integrity, and security of records, data, and information):

      • Confidentiality: Protect patient privacy. Do not discuss patient information inappropriately or leave records accessible to unauthorized individuals. Adhere to data privacy laws.

      • Integrity: Ensure the record is not tampered with or altered inappropriately. Corrections should be made per policy (e.g., single line through error, date, time, initial – no white-out).

      • Security: Follow protocols for accessing electronic records (e.g., strong passwords, not sharing login credentials) and handling physical records.

    • IMS.6 (The organisation ensures availability of current and relevant documents, records data and information and provides for retention of the same):

      • "Your timely completion of records ensures they are available when needed for ongoing care or other legitimate purposes. The hospital has policies for how long records are retained."

    • IMS.7 (The organisation carries out a review of medical records):

      • "Records are periodically reviewed for quality, completeness, and compliance with standards. These audits help identify areas for improvement in documentation practices." (NC IMS 7.d, Slide 38: "The review of medical records is not based on all the parameters." This indicates a need for more comprehensive record audits, which will, in turn, drive better documentation.)

    • Slide 31 Note: "This implies that the objective element requires documentation." – "This is a crucial reminder from NABH 6th Edition. If a standard requires something to be done, there must be documented evidence that it was done."

• II. The Clinician's "Golden Rules": Non-Negotiable Documentation & Practice Standards (Slide 34)

  • "Slide 34 is perhaps one of the most important slides for your daily clinical practice. It outlines 'Must Do's for Clinicians' – these are non-negotiable standards that directly impact patient safety, quality of care, and medico-legal integrity. Let's go through each one in detail, discussing the 'why' behind it."

  • (Trainer will meticulously go through each of the 22 points from Slide 34, as detailed extensively in the previous AI response for Module 3, Section II. For each point, the trainer should:

    • Read the point aloud.

    • Explain the rationale and importance.

    • Provide practical examples or common pitfalls.

    • Link it to potential adverse events if not followed.

    • Reference any specific policies mentioned (e.g., "Refer Policy on Initial assessment & Reassessment").

    • Emphasize points that were highlighted as Non-Compliances in Slides 35-38 if directly related, e.g.:

      • Point 1 (UHID, Name, Signature, SNDT): Directly links to NC IMS 3.e.

      • Point 2 (Initial Assessment): Links to NC AAC 4.a.

      • Point 8 (Discharge Summary): Comprehensive content is vital.

      • Point 9 (Prescriptions): Legibility, block letters, generic names links to NC MOM 5.c.

      • Point 10 (Consent): Links to NC PRE 2.g and PRE 4.c.

      • Point 11 (Surgical Safety Checklist): Links to NC COP 7.d.

      • Point 12 (Operative Note): Links to NC COP 14.e.

  • Key Themes to Emphasize from Slide 34:

    • The "SNDT" Principle: Signature, Name, Date, Time on ALL entries.

    • Legibility: If it can't be read, it wasn't written (or is unsafe).

    • Timeliness: Document as close to the time of event/care as possible.

    • Completeness & Accuracy: The record must be a true and full account.

    • Communication: The record is a primary communication tool.

    • Accountability: Your signature signifies responsibility.

    • Patient Safety: Poor documentation leads to errors.

• III. Learning from Our Collective Experiences: Analyzing Recent Non-Compliances (NCs) (Slides 35-38)

  • "We've talked about the standards and best practices. Now, let's look at real-world examples from our recent NABH Re-assessment in May 2023. Slides 35 through 38 list Non-Compliances (NCs) identified in the Medical/MS areas. This is not about pointing fingers, but about collective learning and identifying system vulnerabilities so we can strengthen them."

  • Framework for Discussing NCs:

    • "For each NC we discuss, I want us to consider:"

      • What does this NC mean in practical terms for patient care or safety?

      • What are the potential underlying reasons or root causes for this NC? (e.g., lack of awareness, system issues, workload, communication gaps, training needs).

      • What specific actions can we as clinicians take to prevent this NC from recurring?

      • How does this NC relate to the 'Must Do's' on Slide 34 or the IMS standards we just discussed?

• • Detailed Discussion of Selected Clinically-Relevant NCs from Slides 35-38:

    • (Trainer selects 5-7 high-impact NCs for detailed discussion. Below are examples, referencing the previous AI response's list and incorporating the NCs highlighted on the slides which are particularly pertinent to documentation and clinician responsibility.)

    • Example 1: AAC 4.a (Slide 35) "Initial assessment of OPD and daycare patients was not uniformly done using the defined structured format."

      • Impact: Incomplete baseline data, potential missed diagnoses or risk factors, inconsistent care planning.

      • Root Causes (Possible): Lack of clarity on the structured format, time pressures in OPD, insufficient training on the form.

      • Clinician Action: Familiarize with and consistently use the defined structured format for ALL initial assessments. Advocate for system supports if time is a genuine barrier. Link to Slide 34, point 2.

    • Example 2: COP 14.e (Slide 36) "'All sampled post operative active case files did not uniformly have the operation notes.'" (Highlighted in green on slide).

      • Impact: Critical information gap for post-op care, potential medico-legal issues, difficulty in audits or research.

      • Root Causes (Possible): Delays in dictation/writing, oversight, system for tracking missing notes.

      • Clinician Action: Ensure timely and complete dictation/writing of operative notes for EVERY surgical case. Link to Slide 34, point 12.

    • Example 3: MOM 5.c (Slide 37) "All sampled medication orders were not legible, signed." (Highlighted in red on slide).

      • Impact: High risk of medication errors (wrong drug, wrong dose), delays in administration, potential patient harm.

      • Root Causes (Possible): Rushing, poor handwriting habits, lack of awareness of impact.

      • Clinician Action: Prioritize legibility in ALL handwritten orders. ALWAYS sign medication orders. Advocate for CPOE (Computerized Physician Order Entry) if not fully implemented. Link to Slide 34, points 1 & 9.

    • Example 4: PRE 2.g (Slide 37) "Informed consent is not being taken uniformly for all patients as seen in TMT department, Derma Skin biopsy, Ophthalmology departments for Laser."

      • Impact: Violation of patient rights, potential for legal repercussions, lack of shared decision-making.

      • Root Causes (Possible): Misunderstanding of when formal consent is needed, perception of "minor" procedures, inconsistent processes across departments.

      • Clinician Action: Ensure a robust informed consent process is followed for ALL procedures requiring it, regardless of perceived complexity. Link to Slide 34, point 10.

    • Example 5: IMS 3.e (Slide 38) "All entries in medical record were not named, signed and timed." (Highlighted in yellow on slide).

      • Impact: Lack of accountability, difficulty in reconstructing events, compromised legal validity of the record, potential safety risks if authorship or timing of an order/note is unclear.

      • Root Causes (Possible): Oversight, habit, rushing, misunderstanding of importance.

      • Clinician Action: Make it an unbreakable habit: Every single entry, no matter how small, must have your name (or clear identifier/seal), signature, date, and time (SNDT). This is non-negotiable. Link to Slide 34, point 1.

    • Example 6: PSQ 5.a (Slide 38) "HCO has not conducted one clinical audit per department per year." (Highlighted in yellow on slide).

      • Impact: Missed opportunities for quality improvement, lack of systematic review of clinical practices against standards.

      • Root Causes (Possible): Lack of dedicated time, insufficient training in audit methodology, unclear responsibility.

      • Clinician Action: Actively participate in departmental clinical audits. Suggest audit topics. Volunteer to be part of audit teams. (This links forward to Module 4, Slide 44).

    • Example 7: HRM 3.a (Slide 38) "Induction training of all consultants was not uniformly evidenced." (Highlighted in green on slide).

      • Impact: Potential for new consultants to be unaware of hospital-specific policies, procedures, and quality expectations, leading to inconsistencies in care.

      • Root Causes (Possible): Gaps in HR onboarding process, scheduling conflicts.

      • Clinician Action (for existing consultants/HODs): Ensure all new team members (including consultants) complete the required induction. For new consultants: prioritize and complete this training.

  • Concluding the NC Discussion:

    • "These examples, drawn directly from our hospital's experience, underscore why adherence to documentation standards and established processes is so critical. Each NC represents an opportunity for us to learn, adapt, and strengthen our systems to ensure the highest quality and safety for our patients."

• Transition to Module 4:

  • "Having explored the vital role of documentation and learned from real-world assessment findings, we are now better equipped to understand how we can proactively manage incidents and drive quality improvement. In Module 4, we will look at our incident reporting system, root cause analysis, and other tools for enhancing patient safety."

This detailed expansion of Module 3 emphasizes the practical application of documentation principles, directly connects them to the "Must Do's" slide, and uses the provided Non-Compliance examples as powerful, context-specific learning tools for clinicians.

Module 4: Driving Improvement: Incident Management, Analysis & Proactive Quality

• I. Our Blueprint for Safer Care: The Patient Safety and Quality Improvement (PSQ) Framework (Slides 23 [5th Edn], 24 [6th Edn])

  • "Welcome to Module 4. Having established the importance of standards and documentation, we now focus on how we actively learn from events, manage risks, and continuously improve the quality and safety of care we provide. This is guided by our hospital's Patient Safety and Quality Improvement (PSQ) Program, outlined on Slides 23 and 24."

  • A. Core Components of the PSQ Program:

    • PSQ.1 (Organisation implements a structured patient-safety programme):

      • "This isn't just a vague idea; it's a deliberate, organized approach. It involves having clear policies, procedures, and defined responsibilities aimed at preventing patient harm. Your adherence to the IPSGs and NABH standards we've discussed is a key part of this."

      • "It means fostering a culture where safety is prioritized, and staff feel empowered to speak up about concerns."

    • PSQ.2 (Organisation implements a structured quality improvement and continuous monitoring programme):

      • "Quality improvement (QI) is an ongoing cycle, not a one-off project. We use data to monitor our performance, identify areas for improvement, implement changes, and then measure the impact of those changes (PDSA cycle - Plan, Do, Study, Act)."

      • "Clinicians are vital to this: by participating in QI projects, providing data, suggesting improvements, and adopting evidence-based changes in practice."

    • PSQ.3 (Organisation identifies key indicators to monitor the structures, processes and outcomes, which are used as tools for continual improvement):

      • "We track specific Key Performance Indicators (KPIs) – measurable values that reflect the performance of critical processes and outcomes. Examples include:

        1. Clinical Outcomes: Infection rates (CLABSI, CAUTI, SSI), medication error rates, adverse drug event rates, re-admission rates, mortality rates.

        2. Process Measures: Hand hygiene compliance, adherence to surgical safety checklist, timeliness of critical value reporting.

        3. Patient Experience: Patient satisfaction scores (link to PREMs, Slide 45).

        4. Patient Reported Outcomes: PROMs (Slide 45).

      • "These indicators help us see trends, benchmark ourselves, and identify areas where targeted QI efforts are needed. The recent NC PSQ 3.e (Slide 38: 'HCO has not initiated capture of patient reported outcome measures') highlights an area for development – incorporating the patient's voice more directly into our outcome measures."

    • PSQ.4 (Organisation uses appropriate quality improvement tools for its quality improvement activities):

      • "We don't just guess what to do. We use established QI tools and methodologies to analyze problems and develop solutions. We'll touch upon some of these tools (like RCA tools on Slide 43) later in this module."

    • PSQ.5 (There is an established system for clinical audit):

      • "Clinical audits are a systematic way to review our clinical practices against explicit criteria (standards or best practices) and then implement changes to improve care."

      • "As we discussed (Slide 44), each clinical department is expected to conduct at least one clinical audit per year. The NC PSQ 5.a (Slide 38: 'HCO has not conducted one clinical audit per department per year') indicates a gap we need to collectively address. Clinicians are key to identifying audit topics, collecting data, and implementing changes."

      • "Furthermore, NC PSQ 5.f (Slide 38: 'Remedial measures were not uniformly implemented after clinical audit') emphasizes that audits are only effective if the findings lead to action and improvement."

    • PSQ.6 (The patient safety and quality improvement programme are supported by the management):

      • "Our hospital leadership is committed to providing the resources, training, and environment necessary for a successful PSQ program. This top-level support is crucial for driving a culture of safety and quality."

    • PSQ.7 (Incidents are collected and analysed to ensure continual quality improvement):

      • "This is the cornerstone of learning from experience. Every incident, near miss, or adverse event reported provides valuable data. Analyzing these incidents helps us understand system vulnerabilities and implement changes to prevent recurrence. This leads us directly to our OVR system."

• II. Your Voice in Safety: The OVR (Occurrence Variance Reporting) System (Slides 39 & 40)

  • "A critical component of our PSQ program is our Occurrence Variance Reporting, or OVR system. This is our primary mechanism for reporting and learning from incidents, near misses, and any deviations from expected standards of care or operational processes. Your active participation in OVR reporting is essential for patient safety."

  • A. The OVR Process – A Step-by-Step Guide (Slide 39):

    • RECORD ALL INCIDENTS IN OVR FORM:

      • "This is the first and most crucial step. Any event that is not consistent with routine patient care or hospital operations, or that could potentially (or actually did) cause harm, should be reported."

      • Who reports? ANY staff member can and should create an OVR. This includes doctors, nurses, technicians, support staff – everyone.

      • What to report? Patient-related incidents (medication errors, falls, procedural complications), staff safety incidents, facility issues, security breaches, near misses. When in doubt, report.

      • Key personnel involved (as per OVR process flow): Incident reporter, Witness(es), Supervisor, Manager, Domain Leader.

    • ROOT CAUSE ANALYSIS (RCA):

      • "Once an OVR is submitted, particularly for more significant events, a Root Cause Analysis is conducted."

      • "Defined, Systematic, Using Tools": RCA is not a cursory review; it's a structured investigation to dig deep and identify the underlying system failures or latent conditions that contributed to the incident, rather than just focusing on individual errors (blame-free approach). We'll look at RCA tools shortly (Slide 43).

    • RISK ANALYSIS:

      • "The incident is often assessed for its risk level using a matrix: Probability of Occurrence (1-5) x Severity (1-5) (as shown on Slide 42)."

      • "This helps prioritize incidents for investigation and determines the intensity of the response."

    • CORRECTIVE ACTION (REACTIVE) - Action on identified Risk:

      • "Based on the RCA findings, actions are taken to address the identified root causes."

      • "CORRECTION: Immediate Correction (IN OVR FORM)": This is the immediate action taken to manage the situation or mitigate harm at the time of the incident (e.g., providing immediate medical care to a patient who fell, securing a hazardous area). This should be documented directly in the OVR when it's submitted.

      • "CORRECTIVE ACTION (IN CAPA FORM)": These are longer-term, systemic changes designed to prevent the incident from happening again (e.g., revising a policy, providing additional training, changing a process, implementing new equipment safeguards). This is often documented in a Corrective And Preventive Action (CAPA) form.

      • "Evidence of correction to be attached": It's crucial to document that the corrective actions have actually been implemented.

    • PREVENTIVE ACTION (PROACTIVE) - Acting on Potential Risk/Opportunities:

      • "Sometimes, the RCA or other analyses might identify potential risks that haven't yet caused an incident. Preventive actions are then taken to address these proactively."

    • VERIFICATION OF EFFECTIVENESS OF CA/PA:

      • "It's not enough to just implement actions; we need to check if they worked. This involves monitoring to see if the corrective/preventive actions have actually reduced the risk or prevented recurrence of the incident."

    • OVR System Logistics:

      • "Any staff can create an OVR." (Re-emphasize empowerment).

      • "Assigned to Respective department(s) by Quality" for investigation and action.

      • "RCA, CA & PA done as required."

      • "Verified for adequacy by Quality Department."

      • "Closed by the MS/QM/QAO" (Medical Superintendent/Quality Manager/Quality Assurance Officer) once actions are completed and verified.

      • Accessing OVR Help: "The slide mentions 'CLICK HERE TO VIEW THE OVR HELP FILE.' [Trainer should point out where this resource is located on the intranet or quality portal if known, or state that the Quality Department can provide this]."

• • B. How to Submit an OVR – Practical Steps using ovr.bcmch.org (Slide 40):

    • "Slide 40 gives us a detailed look at our online OVR submission portal. Let's walk through the key steps and fields:"

    • Accessing the System:

      • "You can type ovr.bcmch.org directly into your Chrome browser (as noted on the screenshot showing 'CAN ALSO TYPE OVR.BCMCH.ORG DIRECTLY IN CHROME BROWSER')."

      • "Alternatively, there's a direct link: https://ovr.bcmch.org/ (large text at the bottom of Slide 40)."

    • Logging In:

      • "As shown on the screenshots (Slide 39 'BCMCH WEB Services' login & Slide 40 'TYPE IN YOUR SAP USER NAME AND PASSWORD'), you will use your SAP User Name and Password to log in."

      • "Click the 'CLICK SIGN IN' button."

    • Navigating the OVR Dashboard:

      • "Once logged in, you'll likely see a dashboard (top right of Slide 40 shows 'Awaiting your Action,' 'My OVRs,' 'New OVR Request,' 'View All OVRs'). To report a new incident, you'd click on 'New OVR Request.'"

    • Filling the OVR Form - Key Fields (referencing the numbered list and form screenshot on Slide 40):

      • User Details: "This will likely auto-populate with your login information."

      • Current Date and Time: "This usually defaults to the time of submission."

      • Very short title of OVR: "Provide a brief, concise title that summarizes the event (e.g., 'Patient Fall in Ward A,' 'Medication Near Miss - LASA drugs,' 'Equipment Malfunction OT2')."

      • Where did OVR Occur (Specific Location Of Event): "Use the dropdown or search function to select the precise location (e.g., Ward, Room, OT, Lab)."

      • Date and Time of Incident (Incident Date, Incident Time): "Accurately record when the incident happened, not necessarily when you are reporting it."

      • OVR Category (Select Category): "Choose the most appropriate category from the dropdown list (e.g., Patient Safety Event, Staff Safety, Medication Event, Equipment Related)."

      • OVR Subcategory (for RCA) (Sub Category): "Select a more specific subcategory. This helps in trending and analysis for RCA."

      • Incident Type by users (Type): "Further classify the type of incident from the user's perspective."

      • Patient Details (Patient UHID, Name, Mobile): "If the incident involves a patient, enter their details accurately. This is crucial for linking the OVR to the patient's record and for any necessary follow-up."

      • Confidential (Checkbox): "Check this box if the incident involves sensitive information that requires a higher level of confidentiality in its handling, as per hospital policy."

      • Factual description of the incident (Description Of The Event):

        1. "This is the most important part. Describe clearly and objectively what happened. Stick to the facts."

        2. "Include: Who was involved? What occurred? When did it happen? Where did it happen? What was the immediate outcome or impact?"

        3. "Avoid opinions, blame, or speculation. For example, instead of 'Nurse X was careless,' write 'Medication Y was administered at 10:00 instead of the prescribed 14:00.'"

      • Immediate Correction Done: "Describe any actions taken immediately at the time of the incident to mitigate harm or correct the situation (e.g., 'Patient assessed by RMO, vitals stable,' 'Spill cleaned up as per protocol,' 'Incorrect medication retrieved before administration')."

      • Witness (more than one possible) (Search Employee): "If there were witnesses to the event, add their names here. This can be important for investigation."

      • Attachments (More than one possible) (Attach Evidence link): "You can attach relevant documents or photos (e.g., a photo of a mislabeled drug, a copy of an incorrect order – ensuring patient confidentiality is maintained if sharing images)."

      • Submit (Button): "Once all information is accurately entered, click 'Submit.'"

      • Clear (Button): "If you need to start over, use the 'Clear' button."

    • Importance of Timely & Factual Reporting: "Report incidents as soon as possible after they occur, while details are fresh. Accurate and factual reporting is key for effective analysis and learning."

    • Blame-Free Culture Reminder: "Our OVR system is designed for learning and system improvement, not for blaming individuals. We need open and honest reporting to make our hospital safer."

    • Interactive Activity (if feasible): "Let's quickly walk through a hypothetical OVR submission on a test environment, or I can demonstrate using screenshots for a common scenario."

• III. Classifying and Understanding Healthcare Events for Prioritization (Slide 41 - was Slide 40 in previous outline)

  • "Once an OVR is reported, understanding the type and severity of the event helps us prioritize the response. Slide 41 outlines different 'Types of Events' based on increasing severity:"

  • A. Sentinel Event:

    • Definition: "An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. The phrase 'Major and enduring loss of function' is key."

    • Examples: Wrong-site surgery resulting in loss of limb/organ, patient suicide in the hospital, infant abduction, hemolytic transfusion reaction due to blood group incompatibility, severe medication error causing permanent disability or death.

    • Reporting Mandate: "Report within 4 hours" (This usually means immediate notification to hospital leadership and the Quality Department, followed by a formal OVR).

    • Response: Requires immediate investigation, intensive RCA, and significant corrective actions.

  • B. Adverse Event:

    • Definition: "An injury related to medical management, rather than the underlying condition of the patient." Harm has occurred.

    • Examples: Post-operative infection requiring additional treatment, fall resulting in a fracture, adverse drug reaction requiring intervention, pressure ulcer development.

    • Reporting Mandate: "Report within 24 hours."

    • Response: Requires investigation, RCA (may be less intensive than for sentinel events depending on severity), and corrective actions.

  • C. No Harm Event:

    • Definition: "An incident reached the patient but did not cause discernible harm. 'The expected adverse event does not occur.'"

    • Examples: A patient received a medication intended for another patient but experienced no ill effects (due to similar medication class or low dose), a patient slipped but did not fall or sustain injury.

    • Why Report? These events highlight system vulnerabilities that could have led to harm. They are valuable learning opportunities.

  • D. Near Miss (Close Call):

    • Definition: "An error that could have harmed the patient but did not reach the patient due to chance or timely intervention. 'An error caught before reaching the patient.'"

    • Examples: A pharmacist catches a prescribing error before the drug is dispensed, a nurse notices an incorrect drug drawn up before administering it, a piece of equipment malfunctions but is identified and replaced before it can be used on a patient.

    • Why Report? Extremely valuable! Near misses provide rich insights into system weaknesses without patient harm. Analyzing them can lead to powerful preventive actions.

  • E. Unknown:

    • "If the nature of the event or its potential impact isn't immediately clear, it can be reported as 'Unknown' initially, and then reclassified as more information becomes available."

  • Clinician Role: "Your accurate initial classification (if you have a clear idea) when reporting an OVR helps the Quality team triage and prioritize responses effectively."

• IV. Assessing and Mitigating Risks Proactively and Reactively (Slide 42 - was Slide 41)

  • "Risk management is a core part of our quality program, involving both reacting to incidents and proactively identifying potential hazards."

  • A. Risk Matrix (Impact/Consequences vs. Probability/Likelihood):

    • "As mentioned earlier, and shown on Slide 42, we use a risk matrix to score and prioritize risks. The axes are:"

      • Probability/Likelihood: From Improbable (1) to Frequent (5).

      • Impact/Consequences: From Negligible (1) to Catastrophic (5).

    • "The product of these scores gives a risk rating: Low Risk (1-5), Medium Risk (6-10), High Risk (11-25)."

    • "The scoring guidance at the bottom of Slide 42 provides more context for assigning these scores:"

      • Probability: Event happening daily (score 5), Weekly (4), Monthly (3), 6-monthly (2), Yearly (1).

      • Impact (Severity of Event): Note: There seems to be a potential confusion in the "Event that is Near miss is score 5" under impact. Typically, a "Near Miss" means no harm occurred, so its impact score would be low. "Catastrophic" or "Sentinel-like" events would have high impact scores. Clarify this point internally based on hospital definitions. Assuming standard severity scaling: No impact (1), Minor/Near Miss potential (2), Moderate/No Harm (3), Major/Adverse (4), Catastrophic/Sentinel (5).

    • "This matrix is used both reactively (after an incident) and proactively (during FMEA, for example)."

  • B. Four Types of Risk Mitigation:

    • "Once a risk is identified and assessed, we decide how to manage it. The four common strategies are:"

      • Accept: "For very low risks where the cost or effort of mitigation outweighs the potential benefit. The risk is acknowledged but no specific action is taken."

      • Avoid: "Eliminate the activity, process, or substance that causes the risk (e.g., discontinuing use of a particularly hazardous chemical if a safer alternative exists)."

      • Transfer: "Shift the financial or operational impact of the risk to a third party (e.g., purchasing insurance, outsourcing a high-risk service to a specialized provider)."

      • Reduce (Mitigate): "This is the most common strategy in healthcare. Implement controls, safeguards, or changes to decrease either the likelihood of the risk occurring or the severity of its impact if it does occur (e.g., implementing double-checks for HAMs, improving hand hygiene compliance, using safety-engineered devices)."

    • "Clinicians often play a key role in implementing risk reduction strategies in their daily work."

• V. Tools for Digging Deeper: Introduction to Root Cause Analysis (RCA) Techniques (Slide 43 - was Slide 42)

  • "When a significant incident occurs, a simple review isn't enough. We need to perform a Root Cause Analysis (RCA) to understand the deep, underlying system issues. Slide 43 introduces some common RCA tools:"

  • A. Pareto Chart (80/20 Rule):

    • "A bar graph that ranks causes from most significant to least significant. It helps identify the 'vital few' causes (e.g., 20% of causes) that are responsible for the majority (e.g., 80%) of the problems. This helps focus improvement efforts where they will have the greatest impact."

    • Example: An analysis of medication errors might show that 80% of errors are due to 2-3 specific causes (e.g., LASA drugs, transcription errors).

  • B. 5 Whys:

    • "A simple but powerful interrogative technique. By repeatedly asking 'Why?' (typically five times), you can drill down past the superficial symptoms of a problem to uncover its underlying root cause(s)."

    • Example:

      • Problem: Patient received wrong dose of medication.

        1. Why? Nurse administered wrong dose.

        2. Why? Order was misread.

        3. Why? Handwriting was illegible.

        4. Why? Prescriber was rushed and didn't verify.

        5. Why? System allows for handwritten orders without mandatory legibility checks or CPOE backup. (Root cause points to system issues).

• • C. Fishbone Diagram (Ishikawa / Cause-and-Effect Diagram):

    • "A visual tool that helps brainstorm and categorize the potential causes of a specific problem (the 'effect'). Causes are typically grouped into major categories (the 'bones' of the fish), such as:"

      • People: Staffing issues, training, competency, communication.

      • Process (or Method): Policies, procedures, workflow, guidelines.

      • Equipment (or Machine): Malfunctions, availability, maintenance.

      • Materials: Supplies, drugs, quality of materials.

      • Environment: Physical space, lighting, noise, workload.

      • Measurement: Data collection, accuracy of measures.

    • "This helps ensure a comprehensive exploration of all potential contributing factors."

  • D. Failure Mode and Effects Analysis (FMEA):

    • "Unlike the other tools which are often reactive (used after an incident), FMEA is a proactive risk assessment tool."

    • "It involves systematically examining a process (e.g., medication administration, patient handover) to identify potential 'failure modes' (what could go wrong), the potential 'effects' (consequences) of those failures, and the existing controls. Then, it scores each failure mode for severity, occurrence, and detectability to calculate a Risk Priority Number (RPN). This helps prioritize areas for proactive improvement before failures occur."

    • "The example on the slide shows FMEA for 'Left Front Seat Belt Install,' with failure modes like 'Select Wrong Color Seat Belt,' 'Seat Belt Bolt Not Fully Tightened,' and calculation of RPN."

  • Clinician Involvement: "Clinicians are often key participants in RCA teams, bringing their firsthand knowledge of processes and potential failure points."

• VI. Systematic Review and Learning: Audits, PROMs/PREMs, & Pathways (Slides 44, 45, 46 - were 43, 44, 45)

  • A. Clinical Audits (Slide 44):

    • "We've touched on clinical audits, but let's reiterate their importance as a QI tool (diagram shows the audit cycle: Identify question -> Search for evidence -> Audit practice -> Modify practice -> Apply to practice -> (Re-audit))."

    • "Remember: AT LEAST ONE FOR EACH CLINICAL DEPARTMENT EVERY YEAR. And crucial: REMEDIAL MEASURES FOR CLINICAL AUDIT FINDINGS must be implemented and documented."

    • "The QR code on this slide likely links to further resources or examples of clinical audits."

  • B. Patient-Reported Outcome Measures (PROMs) & Patient-Reported Experience Measures (PREMs) (Slide 45):

    • "These tools help us understand care from the patient's perspective:"

      • PROMs (Focus: Health Status): Gather information on symptoms, functioning due to condition/treatment (e.g., Arthritis questionnaire - pain, mobility). Overall Purpose: Assess health outcomes and treatment effectiveness.

      • PREMs (Focus: Patient Experience): Gather information on communication, timeliness, respect, satisfaction with process (e.g., Hospital survey - doctor explanation, listened to, informed). Overall Purpose: Evaluate quality of care and patient experience.

    • "As noted in NC PSQ 3.e, incorporating these more formally is an area of focus for us."

  • C. Clinical Care Pathways (Slide 46):

    • "Clinical Care Pathways are essentially blueprints or roadmaps for providing standardized, evidence-based care to patients with a specific condition (e.g., community-acquired pneumonia, total hip replacement) or undergoing a particular procedure."

    • "They outline the recommended course of treatment, from admission to discharge, including key interventions, timelines, and expected outcomes."

    • Benefits: Improved consistency of care, adherence to best practices, better multidisciplinary coordination, potentially reduced length of stay and complications, enhanced patient education.

    • "Our hospital's pathways can be accessed at: http://quality.bcmch.org/care-pathways/. We encourage you to familiarize yourselves with pathways relevant to your specialty." (NC COP 1.e, Slide 35: "HCO has not developed clinical care pathways" – this suggests that while the link exists, the actual development and implementation of pathways may be an ongoing or targeted effort. This NC should be acknowledged if discussing pathways as an ideal vs. current widespread reality).

• Transition to Module 5:

  • "This comprehensive look at incident management, risk analysis, and quality improvement tools demonstrates our commitment to creating a learning healthcare system. In Module 5, we will shift our focus to some essential hospital-wide protocols and resources that every clinician needs to be proficient in."

This detailed expansion of Module 4 fully integrates the updated OVR process information from Slides 39 and 40, connects it with the broader PSQ framework, and discusses the various tools and mechanisms for driving continuous quality improvement.

Module 5: Navigating Essential Hospital Protocols & Key Resources

• "Welcome to Module 5. Having explored how we manage incidents and drive quality improvement, this module focuses on essential hospital-wide systems, protocols, and resources that are critical for safe and effective daily operations. Your understanding and adherence to these are paramount."

• I. Understanding Governance & Ensuring a Safe Environment: ROM & FMS (Slides 25 [5th Edn], 26 [6th Edn ROM], 27 [6th Edn FMS])

  • "Our hospital operates within a framework of defined responsibilities and a commitment to a safe physical environment. This is guided by the NABH standards for Responsibility of the Management (ROM) and Facility Management System (FMS)."

  • A. Responsibility of the Management (ROM) – The Leadership's Commitment to Quality & Safety:

    • "While you are at the frontline of care, strong leadership and governance are essential to support a culture of quality. Slides 25 and 26 outline these responsibilities."

    • ROM.1 (Organisation identifies those responsible for governance and their roles are defined):

      • "There's a clear structure of accountability, from the governing board down through senior management, for overseeing the quality and safety of care provided."

    • ROM.2 (Those responsible for governance manage the organisation in an ethical manner):

      • "Ethical conduct in all aspects of operations – financial, clinical, and interpersonal – is a foundational principle."

    • ROM.3 (Organisation is headed by a leader who shall be responsible for operating the organisation on a day-to-day basis [5th Edn] / Those responsible for governance ensure sustainability in hospital by addressing environmental, social and economic factors from long term well-being of healthcare system and community [6th Edn]):

      • "There's clear leadership for daily operations, and (in 6th Edn) a broader focus on long-term sustainability and community well-being, which includes responsible environmental practices."

    • ROM.4 (Organisation displays professionalism in its functioning [5th Edn] / The organisation is headed by a leader who shall be responsible for operating the organisation on a day-to-day basis [6th Edn]):

      • "Professionalism is expected at all levels. The day-to-day operational leader ensures that the hospital functions effectively and efficiently."

    • ROM.5 (Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management [5th Edn] / The organisation displays professionalism in its functioning [6th Edn]):

      • Crucial Link: "This directly connects to everything we've discussed in Module 4. Management actively embeds patient safety and risk management into all hospital processes. Professional conduct supports this."

    • ROM.6 (Management ensures that patient-safety aspects and risk-management issues are an integral part of patient care and hospital management [6th Edn]):

      • "The 6th Edn reiterates this critical point, emphasizing that safety and risk management are not add-ons but core components of how we deliver care and manage the hospital."

    • Clinician Relevance: "While these are management responsibilities, they create the environment in which you practice. Management support for safety initiatives, resources for quality programs, and a culture that promotes ethical and professional behavior directly impacts your ability to provide good care. Be aware of who your leaders are and the channels for escalating concerns if system issues impede safe care."

    • (NC ROM 5.e, Slide 38: "MOU with outsourced hospital for irradiation of cellular product and total body irradiation for BMTU was not evidenced." NC ROM 5.f, Slide 38: "Monitoring of Services of all outsourced agencies including Teleradiology was not evidenced." – These NCs, while under ROM, highlight the importance of management oversight of outsourced services to ensure they meet quality and safety standards, which can indirectly impact clinical care.)

• • B. Facility Management System (FMS) – Ensuring a Safe & Functional Physical Environment:

    • "The physical environment plays a huge role in patient and staff safety. Slides 25 and 27 outline our FMS standards."

    • FMS.1 (The organisation has a system in place to provide a safe and secure environment):

      • "This covers everything from building safety, security measures to prevent unauthorized access or abduction (links to Code Pink/Purple), and ensuring the general safety of the premises."

    • FMS.2 (The organisation's environment and facilities operate in a planned manner and promotes environment-friendly measures):

      • "This includes planned maintenance, efficient use of utilities, and initiatives to minimize our environmental footprint (e.g., waste management, energy conservation)."

    • FMS.3 (The organisation's environment and facilities operate to ensure the safety of patients, their families, staff and visitors):

      • "A broad standard covering aspects like slip/trip/fall prevention in common areas, adequate lighting, clear signage, and managing risks associated with the physical plant."

    • FMS.4 (The organisation has a programme for the facility, engineering support services and utility system):

      • "This means we have planned preventive maintenance and response systems for essential utilities like electricity (backup generators), water, HVAC (Heating, Ventilation, Air Conditioning – critical for infection control in OTs/ICUs), and other engineering systems."

    • FMS.5 (The organisation has a programme for medical equipment management):

      • Critical for Clinicians: "This involves ensuring all medical equipment is:

        • Properly inspected and calibrated.

        • Regularly maintained.

        • Safe to use.

        • Staff are trained on its correct operation.

        • There's a system for reporting and repairing malfunctioning equipment."

      • "If you encounter faulty equipment, report it immediately through the designated channels. Do not use equipment you suspect is unsafe."

    • FMS.6 (The organisation has a programme for medical gases, vacuum and compressed air):

      • "Ensuring the safe and reliable supply of medical gases (oxygen, nitrous oxide, etc.), as well as functional vacuum and compressed air systems, is vital, especially in critical care areas and OTs."

    • FMS.7 (The organisation has plans for fire and non-fire emergencies within the facilities):

      • "This directly links to our Emergency Codes (Module 5, Section III). We have plans, equipment (fire extinguishers, alarms), and conduct drills for various emergencies."

    • Clinician's Role in FMS:

      • "Be vigilant: Report any environmental hazards, facility issues, or equipment malfunctions you observe."

      • "Follow safety protocols: Use equipment correctly, participate in emergency drills, know evacuation routes."

      • "Conserve resources: Be mindful of energy and water use."

• II. Our Most Valuable Asset: Human Resource Management (HRM) – Clinician Aspects (Slides 28 [5th Edn], 29 [6th Edn])

  • "Quality healthcare is delivered by competent, well-trained, and supported staff. The HRM standards, shown on Slides 28 and 29, outline how we manage our human resources to ensure this."

  • Key HRM Standards Relevant to Clinicians:

    • HRM.1 (Organisation has a documented system of human resource planning): "Ensuring we have the right number and mix of staff to meet patient needs."

    • HRM.2 (Organisation implements a defined process for staff recruitment): "Hiring qualified individuals."

    • HRM.3 (Staff are provided induction training at the time of joining the organisation):

      • "This very session is part of that! All new staff, including clinicians, must undergo induction to understand hospital policies, safety protocols, and quality expectations."

      • (NC HRM 3.a, Slide 38: "Induction training of all consultants was not uniformly evidenced." This highlights a critical gap. It's essential for ALL clinicians, including senior ones, to receive this foundational training.)

    • HRM.4 (There is an on-going programme for professional training and development of the staff):

      • "Learning doesn't stop after induction. The hospital supports CMEs, workshops, and other training opportunities to keep your skills and knowledge current."

    • HRM.5 (Staff are appropriately trained based on their specific job description):

      • "You receive training relevant to your specific roles and responsibilities."

      • (NC HRM 5.e, Slide 38: "Staff (doctors) involved in direct patient care were not uniformly provided training on cardiopulmonary resuscitation periodically." This is a critical safety training that needs consistent, periodic refreshers like BLS/ACLS.)

      • (NC HRM 5.f, Slide 38: "'All staff (doctors) were not uniformly provided training on infection prevention and control at least once a year.'" This is another essential annual training for all clinical staff.)

    • HRM.6 (Staff are trained in safety and quality-related aspects):

      • "This reinforces the importance of training in areas like patient safety, infection control, emergency preparedness, and quality improvement methodologies."

    • HRM.7 (An appraisal system for evaluating the performance of staff exists as an integral part of the human resource management process):

      • "Regular performance appraisals help identify strengths, areas for development, and ensure ongoing competency."

    • HRM.8 (Process for disciplinary and grievance handling is defined and implemented in the organisation):

      • "There are fair and transparent processes for addressing performance issues or employee grievances."

    • HRM.9 (The organisation addresses their health and safety needs of the staff):

      • "This includes measures to protect staff from occupational hazards (e.g., needle-stick injuries, exposure to infections, ergonomics) and promote well-being."

    • HRM.10 (There is documented personal information for each staff member): "Maintaining accurate employee records."

    • HRM.11 (There is a process for credentialing and privileging of medical professionals, permitted to provide patient care without supervision):

    • HRM.12 (There is a process for credentialing and privileging of nursing professionals, permitted to provide patient care without supervision):

    • HRM.13 (There is a process for credentialing and privileging of para-clinical professionals, permitted to provide patient care without supervision):

      • Credentialing: "The process of verifying a clinician's qualifications (education, training, licensure, certifications)."

      • Privileging: "The process of granting a clinician permission to perform specific procedures or provide specific types of care within the hospital, based on their demonstrated competence."

      • "This is crucial for ensuring that only qualified and competent individuals are providing patient care. Your scope of practice within the hospital is defined by your approved privileges. (Links to Slide 34, point 22: HODs to ensure Credentials and Privileges are documented and noted in HR)."

  • Clinician's Role in HRM:

    • "Actively participate in required training (induction, refreshers for BLS/ACLS, IPC)."

    • "Maintain your own professional development and competencies."

    • "Understand your approved clinical privileges and practice within that scope."

    • "Adhere to hospital policies and codes of conduct."

• III. Environmental Responsibility & Infection Control: Biomedical Waste (BMW) Management (Slide 51 - was Slide 50)

  • "Proper management of biomedical waste is critical for infection prevention, environmental protection, and regulatory compliance. Slide 51 provides a clear guide to our 'Colour Coding instructions for segregation at the point of generation.'"

  • The Golden Rule: Segregation at the Point of Generation!

    • "This means the person who generates the waste is responsible for disposing of it in the correct color-coded bin/container immediately and at the location where it was generated (e.g., patient bedside, procedure room, lab)."

  • Detailed Review of Colour Coding (as per BELIEVERS CHURCHMEDICAL COLLEGE HOSPITAL chart on Slide 51):

    • GREEN BAG (Plastic bags/Containers):

      • Contents: "Green Coloured non-chlorinated plastic bags / Containers - Food Waste."

    • YELLOW BAG (non-chlorinated plastic bags):

      • Contents:

        • Human Anatomical Waste: Tissues, organs, body parts, foetus.

        • Soiled Waste: Items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs, and bags containing residual or discarded blood and blood components.

        • Microbiology and Biotechnology and other clinical laboratory waste: Wastes from laboratory cultures, stocks or specimens of micro-organisms, live or attenuated vaccines, human and animal cell culture used in research, and other clinical laboratory waste. Discarded linen, mattresses, beddings contaminated with blood or body fluid, Masks, Gowns. (Biohazard Symbol required).

        • (Also, Yellow Bag with CYTOTOXIC Symbol [C]): Expired or Discarded Medicines, Pharmaceutical waste like antibiotics, cytotoxic drugs.

    • RED BAG (non-chlorinated plastic bags or containers): (Biohazard Symbol required)

      • Contents: Contaminated Waste (Recyclable) - Tubing, Bottles, intravenous tubes and sets, Catheters, Urine bags, Syringes (without needles), Gloves.

    • BLACK BAG (plastic bags / Containers):

      • Contents: General Waste - Papers, Wrappers, Paper cups.

    • WHITE CONTAINER (PPC - Puncture Proof Container, Translucent):

      • Contents: Waste sharps including Metals - Needles, syringes with fixed needles, needles from needle tip cutter or burner, scalpels, blades. (Must be puncture-proof, leak-proof, tamper-proof).

    • BLUE CONTAINER (PPC - Puncture Proof Container):

      • Contents: Glassware - Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes. (Puncture-proof, Leak proof).

  • Why Proper Segregation Matters:

    • Infection Control: Prevents spread of infection to healthcare workers, patients, visitors, and the community.

    • Staff Safety: Protects those who handle the waste (e.g., from sharps injuries).

    • Environmental Protection: Ensures hazardous waste is treated appropriately before disposal, preventing pollution.

    • Regulatory Compliance: Adherence to national and local BMW management rules is mandatory.

  • Interactive Activity: "Let's go through some common clinical scenarios. You generate the waste item – tell me which color bin/container it goes into." (e.g., used IV tubing, a bloody gauze, a broken glass vial of saline, a scalpel blade, leftover food from a patient tray, an expired antibiotic vial).

• IV. Responding Effectively When Seconds Count: Hospital Emergency Codes (Slide 52 - was Slide 51)

  • "Rapid and coordinated response during emergencies is critical for patient and staff safety. Slide 52 details our 'BCMCH Emergency Codes.' You MUST be familiar with these codes and how to activate them."

  • Activation Protocol (As per Ver 1.2, Dt:22.04.2025, BCMCHQLTY/PFLOW-027):

    • Dial: 7070 (on any Landphone in the hospital).

    • Announce Clearly & Repeatedly (3 Times): Code <codename>, <Floor #>, <Ward/Area>, <Bed #>

      • Example: "Code Blue, Fourth Floor, Medical ICU, Bed 5! Code Blue, Fourth Floor, Medical ICU, Bed 5! Code Blue, Fourth Floor, Medical ICU, Bed 5!"

      • Do not say "hello" or engage in conversation; state the code and location clearly.

• • Detailed Review of Key Emergency Codes & Clinician Roles (from the chart on Slide 52):

    • (Trainer should go through each code symbol, name, description, Primary Responding Team, and relevant hospital policy number, emphasizing clinician's expected immediate actions and role as part of the response team where applicable.)

    • CODE RED (Fire):

      • Symbol: Flame in triangle.

      • Description: Fire. RACE (Rescue, Alarm, Confine, Extinguish/Evacuate); PASS (Pull, Aim, Squeeze, Sweep).

      • Clinician Action: Ensure immediate safety of patients and self, activate alarm, attempt to confine/extinguish if small and safe, otherwise evacuate. Follow directions of fire team.

    • CODE RRT (Rapid Response Team - Patient Condition Deteriorating):

      • Symbol: Stethoscope with heart.

      • Description: Patient deteriorating. Criteria given (EWS >/=5, Temp <35.0 or >39.0 C, HR <40 or >130, SBP <90 or >220, RR <8 or >30, change in LOC, significant fall, new/worsening chest pain).

      • Clinician Action: Recognize deteriorating patient, activate RRT, initiate immediate supportive measures while awaiting team.

    • CODE BLUE (Cardiac Arrest):

      • Symbol: Blue heart.

      • Description: Cardiac Arrest.

      • Clinician Action: Assess responsiveness/breathing/pulse. Start CPR immediately. Call Code Blue. Use crash cart. Lead or participate in resuscitation as per ACLS/BLS.

    • CODE STROKE (Stroke Emergency):

      • Symbol: Brain with lightning.

      • Description: Stroke Emergency. BEFAST (Balance, Eyes, Face, Arm, Speech, Time).

      • Clinician Action: Recognize stroke symptoms, activate Code Stroke, ensure rapid assessment and transfer for imaging/thrombolysis if indicated.

    • CODE WHITE (Physical Assault):

      • Symbol: Raised fist.

      • Description: Physical Assault on staff/patient/visitor.

      • Clinician Action: Ensure personal safety first, de-escalate if possible, call Code White for security/management assistance

    • CODE GREY (Psychiatric Patient Agitation):

      • Symbol: Two heads facing.

      • Description: Agitated psychiatric patient.

      • Clinician Action: Similar to Code White, but with involvement of psychiatric team. Focus on safety and de-escalation.

    • CODE YELLOW (Mass Casualty Incident - MCI):

      • Symbol: Multiple figures with exclamation.

      • Description: Hospital emergency protocol activated in response to large-scale incident.

      • Clinician Action: Report to your designated area/role as per the hospital's MCI plan. Be prepared for surge capacity.

    • CODE PINK (Infant or Child Missing / Abduction):

      • Symbol: Pink baby carriage.

      • Description: Child or infant missing (no suspicion of abduction) or suspected abduction.

      • Clinician Action: Secure area, search immediate vicinity, notify security, provide description, monitor exits.

    • CODE BROWN (Blood/Body fluids/Chemical spillage):

      • Symbol: Brown drop.

      • Description: Spillage of blood/body fluids (>10 cm diameter) or chemicals.

      • Clinician Action: Contain spill, alert housekeeping/appropriate team, follow spill management protocol.

    • CODE INDIGO (Failure of sterilisation process / Recall of failed CSSD items):

      • Symbol: Purple biohazard-like symbol.

      • Description: Failure of sterilization or contaminated items from CSSD.

      • Clinician Action: Identify and quarantine affected items, notify CSSD/IPC.

    • CODE PURPLE (Adult Patient Missing / Elopement):

      • Symbol: Purple figure running.

      • Description: Adult patient missing/eloped.

      • Clinician Action: Similar to Code Pink, search area, notify security, provide description.

    • CODE GREEN (Recall of Medications / Pharmacy Related Emergency):

      • Symbol: Green Rx symbol.

      • Description: Recall of medication due to safety issues, defects, or regulatory violations.

      • Clinician Action: Identify and remove recalled medication from patient use and stock, follow pharmacy instructions.

  • Code Clear Announcement:

    • "For most codes, once the situation is resolved, a 'Code {code Name} clear' announcement will be made 3 times by the authorized person (e.g., 'Code Red Clear, Code Red Clear, Code Red Clear')."

    • "Note that some codes like Code RRT, Code Blue, Code Stroke do not have a general 'Code Clear' announcement over the PA system, as the team manages the situation directly.

  • Importance of Drills: "Participate actively in emergency code drills. They are essential for practicing your response and ensuring team coordination."

  • Scenario Drill: "You are in the OPD and hear 'Code Red, Second Floor, Pharmacy!' What are your immediate actions based on your location?"

• V. Navigating Your Knowledge Hub: Accessing Policies, Manuals & Training Resources (Slides 47, 48, 49, 50 - were Slides 46, 47, 48, 49)

  • "To effectively adhere to all these standards and protocols, you need to know where to find the relevant documents and information."

  • A. Key Hospital Documents for Clinicians:

    • (Slide 47) Manual for Clinical Documentation (BCMCH/MAN/0082 - CLINICAL GUIDELINES MANUAL):

      • "This is your primary reference for all aspects of clinical documentation. The large '82' on the slide emphasizes its importance. The URL http://quality.bcmch.org/nabh-manuals/bcmch-man-0082-bcmch-clinical-guidelines-manual/ will take you there."

    • 
      

    • (Slide 48) Policy on Institutional/Administration (BCMCHPOL1013.31 - BCMCH Institutional/Administration Policy):

      • "This policy, numbered 1013.31, likely covers broader institutional and administrative guidelines. Note that the URL provided currently points to the same clinical guidelines manual as above. [Trainer: Clarify if there's a separate location for this specific policy or if it's a section within the main manual]."

  • B. Centralized Location for Policies and Manuals (Slide 49):

    • "All quality-related documents, including NABH manuals and policies, can generally be found by navigating our hospital intranet or quality portal:"

      • Start at: HOME.BCMCH.ORG

      • Navigate to: ⇒ QUALITY

      • Then to: ⇒ HOSPITAL QUALITY

      • Finally to: ⇒ NABH HOME

    • "We strongly encourage you to explore this portal and familiarize yourself with the documents relevant to your practice area."

  • C. Ongoing Training & Documentation Support (Slide 50):

    • "Your learning journey in quality and safety is continuous. The hospital provides ongoing support through:"

      • Key Training Programs:

        • Induction (like this session).

        • BLS & ACLS (Basic and Advanced Cardiac Life Support – periodic refreshers are crucial, linking to NC HRM 5.e).

        • Training on NABH Standards.

        • CMEs (Continuing Medical Education).

      • Training Support Systems:

        • Training Calendar: To know upcoming training sessions.

        • Communication: How training opportunities are announced.

        • Pre-test & Post Test: To assess learning and effectiveness of training.

        • Each Training session should have a Summary Sheet: For your reference.

      • Online Resource: Further information on training and documentation can be found at: http://quality.bcmch.org/training-documentation/

  • Clinician Responsibility: "It's your professional responsibility to stay updated with hospital policies, attend required training, and know where to access these crucial resources."

• Transition to Module 6:

  • "We've covered a lot of ground on essential hospital protocols and resources. In our final module, we'll look at how our performance against these standards is scored, briefly touch upon the broader quality landscape for academic institutions, and then conclude with a recap and Q&A."

This detailed expansion of Module 5 aims to provide clinicians with a thorough understanding of key operational systems, safety protocols like BMW and Emergency Codes, and how to access vital hospital resources, all directly linked to the provided slide content.

Module 6: Gauging Our Performance, Broader Quality Landscape & Concluding Thoughts

• "Welcome to our final module, Module 6. In this session, we'll explore how our adherence to the standards we've discussed is assessed, take a brief look at the quality frameworks relevant to our academic mission, and then bring our Quality Induction program to a close with a recap and an opportunity for your questions."

• I. Understanding How We Are Assessed: The NABH Scoring System (Slides 32 [5th Edn visual], 33 [6th Edn table])

  • "Accreditation bodies like NABH don't just provide standards; they also have a systematic way of assessing an organization's compliance. Understanding this scoring system helps us appreciate the importance of consistent adherence to every objective element."

  • A. The Rationale Behind Scoring:

    • "Scoring provides an objective measure of our performance against established benchmarks."

    • "It helps identify areas of strength and, more importantly, areas needing improvement."

    • "It allows for comparison over time (e.g., between surveillance audits and re-accreditation) to track progress."

    • "The overall score contributes to the final accreditation decision (accredited, provisionally accredited, not accredited)."

  • B. NABH Scoring Levels (as per Slide 33 - 6th Edn Rationale, and visually represented on Slide 32 - 5th Edn):

    • "NABH uses a 5-point scoring system for assessing compliance with each Objective Element (OE) of a standard."

    • Score 1: No compliance

      • Rationale: "No systems in place and there is no evidence of working towards implementation."

      • Sample Performance: "None or little (≤ 20%) of the samples meet the requirement(s) of the objective element."

      • Outcome: "Non-conformity exists."

      • Visual on Slide 32: "NO COMPLIANCE," "SYSTEM FAILURE," representing 0-20%.

      • Implication: A critical failure to meet the standard.

    • Score 2: Poor compliance

      • Rationale: "Elementary (limited) systems in place and there is some evidence of working towards implementation."

      • Sample Performance: "Minimal (between 21-40%) of the samples meet requirement(s) of the objective element."

      • Outcome: "Non-conformity exists."

      • Visual on Slide 32: "POOR COMPLIANCE," "LIMITED SYSTEM," representing 21-40%.

      • Implication: Some effort visible, but systems are weak and inconsistent.

    • 
      

    • Score 3: Partial compliance

      • Rationale: "Systems are partially in place, and there is evidence of working towards implementation."

      • Sample Performance: "Some (between 41-60%) of the samples meet the requirement(s) of the objective element."

      • Outcome: "Non-conformity exists."

      • Visual on Slide 32: "PARTIAL COMPLIANCE," "PARTIAL SYSTEM," representing 41-60%.

      • Implication: Progress made, but full implementation and consistency are lacking.

    • Score 4: Good compliance

      • Rationale: "Systems are in place, and there is evidence of working towards implementation."

      • Sample Performance: "The majority (between 61-80%) of the samples meet the requirement(s) of the objective element."

      • Outcome: "Non-conformity could exist." (Meaning minor deviations might still be found).

      • Visual on Slide 32: "GOOD COMPLIANCE," "SYSTEM" (partially formed), representing 61-80%.

      • Implication: Systems are largely effective, but there's still room for refinement to achieve full consistency.

    • Score 5: Full compliance

      • Rationale: "Systems are in place, and there is evidence of implementation across the organisation."

      • Sample Performance: "Almost all (between 81-100%) of the samples meet the requirement(s) of the objective element."

      • Outcome: "No Non-conformity."

      • Visual on Slide 32: "FULL COMPLIANCE," "SYSTEM" (fully formed), representing 81-100%.

      • Implication: The ideal state – systems are robust, consistently implemented, and meet all requirements.

• • C. How Scoring Impacts Clinicians:

    • "During an accreditation survey, assessors will review medical records, observe practices, interview staff (including clinicians), and examine documentation."

    • "Your adherence to policies (e.g., correct documentation on Slide 34, following IPSGs on Slide 10, proper BMW segregation on Slide 51) directly contributes to the scores achieved for relevant objective elements."

    • "For instance, if assessors review 10 patient charts and find that only 3 have a fully compliant initial assessment (as per Slide 34, point 2), that OE might score a '2' (Poor compliance). Multiple such scores can impact the overall accreditation status."

    • "Our goal is to consistently achieve 'Full Compliance' (Score 5) across all applicable standards. This requires a collective effort from everyone."

• II. A Glimpse into the Academic Quality Landscape (For Clinicians in Teaching Roles) (Slides 53 & 54 - were 52 & 53)

  • "As Believers Church Medical College Hospital, we have a dual role: providing patient care and educating future healthcare professionals. Therefore, in addition to hospital accreditation standards like NABH and JCI, we are also guided by academic quality frameworks like NAAC and KUHS QAS. This section is particularly relevant for our faculty members and residents involved in teaching and academic activities."

  • A. NAAC BINARY (National Assessment and Accreditation Council) (Slide 53)

    • Purpose: "NAAC assesses and accredits higher education institutions in India, focusing on the overall quality and performance of the institution."

    • Framework: "As shown on Slide 53, NAAC uses a 'Binary' framework, meaning criteria are either met or not met, often with associated weightages. The assessment is typically across 10 Domains (as listed, though the slide shows 1 General Domain with 10 sub-criteria, plus Discipline Specific)."

    • Key Domains/Criteria (Total - 1000 points):

      • General:

        • 1.1. Curriculum (50)

        • 1.2. Faculty Resources (100)

        • 1.3. Infrastructure (75)

        • 1.4. Financial Resources & Management (50)

        • 1.5. Learning and Teaching (150)

        • 1.6. Extended Curricular Engagements (125)

        • 1.7. Governance and Administration (125)

        • 1.8. Student Outcome (100)

        • 1.9. Research and Innovation (50)

        • 1.10. Sustainability Outcomes and Green Initiatives (75)

      • Discipline Specific (100)

    • Clinician Relevance (for Faculty/Teaching Staff):

      • "Your contributions to curriculum development, teaching methodologies, student mentorship, research activities, and even sustainable practices within your departments all contribute to the NAAC assessment."

      • "Quality patient care environments also serve as excellent learning environments for students."

    • Resource: "For more details, you can visit https://sites.google.com/view/bcmcka (as noted on the slide)."

  • B. KUHS QAS (Kerala University of Health Sciences Quality Assurance System) (Slide 54)

    • Purpose: "As an affiliated medical college, KUHS QAS provides specific quality benchmarks for our medical education programs, ensuring they meet the standards set by the university."

    • Framework: "Slide 54 outlines the 10 Domains of the KUHS QAS, with associated weightages:"

      • I. INFRASTRUCTURE FACILITIES - 200

      • II. TEACHER PROFILE AND TEACHING LEARNING - 200

      • III. CURRICULUM IMPLEMENTATION MONITORING - 100

      • IV. QUALITY ASSURANCE SYSTEM - 100

      • V. RESEARCH ENABLING ENVIRONMENT - 100

      • VI. OUTREACH PROGRAMMES - 100

      • VII. STUDENT SUPPORT AND GUIDANCE PROGRAMME - 50

      • VIII. INSTITUTIONAL GOVERNANCE - 50

      • IX. INNOVATION AND BEST PRACTICES - 50

      • X. FEEDBACK IMPLEMENTATION PROCESS - 50

    • Clinician Relevance (for Faculty/Teaching Staff):

      • "Similar to NAAC, your involvement in teaching, curriculum implementation, research, student support, and institutional governance directly impacts our performance under KUHS QAS."

      • "The 'Quality Assurance System' domain itself links back to many of the hospital quality principles we've discussed today, emphasizing the synergy between clinical and academic quality."

    • Resource: "The same link https://sites.google.com/view/bcmcka is provided for further information."

  • Interconnection: "It's important to see that quality in patient care (NABH/JCI) and quality in medical education (NAAC/KUHS) are interconnected. A strong clinical quality system supports a strong academic program, and vice-versa."

• III. Synthesis, Open Forum & Your Continuing Role in Quality

  • A. Recap of Key Takeaways for Clinicians:

    • "Over these modules, we've covered a significant amount of ground. Let's quickly summarize the most critical 'take-home messages' for you as clinicians:"

      • Quality is Intrinsic: Quality and patient safety are not optional add-ons; they are integral to every aspect of your clinical practice.

      • Standards are Your Guide: NABH, JCI, and other standards provide the framework for excellence. Familiarize yourselves with those relevant to your work.

      • Patient Safety First: The International Patient Safety Goals (IPSGs) are non-negotiable.

      • Documentation is Paramount: Your medical record entries (accurate, complete, timely, legible, signed with SNDT – Slide 34!) are critical for patient care, communication, and legal protection.

      • Report & Learn: Actively use the OVR system (Slide 39 & 40) to report all incidents and near misses. This is vital for learning and system improvement.

      • Protocols & Policies Matter: Adhere to established hospital protocols, including Emergency Codes (Slide 52) and BMW Management (Slide 51).

      • Know Your Resources: Understand where to find policies, manuals, and training information (Slides 47-50).

      • You are a Quality Champion: Every clinician has a responsibility to contribute to a culture of safety and continuous quality improvement.

  • B. Open Forum – Your Questions, Concerns, and Insights:

    • "We now open the floor for your questions. This is your opportunity to seek clarification on anything we've discussed, raise any concerns you might have, or share any insights based on your experience."

    • (Trainer facilitates an open Q&A session, addressing questions thoughtfully and transparently. If a question cannot be answered immediately, commit to finding the answer and getting back to the individual or group.)

    • "Are there any aspects of our quality systems that you feel could be improved or made more clinician-friendly? Your feedback is valuable."

  • 
    

  • C. Call to Action – Embracing Your Role in Our Quality Journey:

    • "This Quality Induction is just the beginning. Upholding and enhancing the quality and safety of care at Believers Church Medical College Hospital is an ongoing, collective journey."

    • "We urge you to:"

      • Be Vigilant: Always keep patient safety at the forefront of your mind.

      • Be Proactive: Don't wait for an incident to happen; if you see a potential risk, speak up or report it.

      • Be Accountable: Take ownership of your role in adhering to standards and protocols.

      • Be a Team Player: Quality and safety are team sports. Communicate effectively, support your colleagues, and foster a culture of mutual respect and open dialogue.

      • Be a Lifelong Learner: Stay updated on best practices, new guidelines, and learnings from our quality initiatives. Participate in ongoing training.

    • "Your commitment, expertise, and daily actions are what truly define the quality of care our patients receive. Thank you for your dedication."

• IV. Knowledge Check & Program Evaluation (Slide 55 - was Slide 54)

  • A. Post-Test Administration:

    • "To help reinforce the key concepts from this induction and assess understanding, we will now administer a short post-test. Please take your time and answer to the best of your ability."

    • (Distribute and allow time for completion of the post-test mentioned on Slide 50.)

  • B. Training Feedback Collection:

    • "Your feedback on this induction program is extremely important to us. It helps us refine and improve future sessions. Please take a few minutes to complete the feedback form."

    • (Distribute and collect feedback forms.)

  • C. Accessing Further Resources & Skill Certification (Slide 55):

    • "As a final reminder, the QR code on this 'Thank You' slide (Slide 55) provides access to more detailed notes related to this induction program."

    • "Additionally, this QR code will link you to an opportunity to take a test. Successfully completing this test can earn you a Skill Certificate, further recognizing your understanding and commitment to our quality standards."

    • "We encourage you to take advantage of these resources."

  • D. Closing Remarks:

    • "On behalf of the Quality Team and the entire Believers Church Medical College Hospital, thank you once again for your active participation in this Quality Induction program. We look forward to working together to continuously enhance the quality and safety of care for all our patients."

    • "If you have any further questions after this session, please don't hesitate to reach out to the Quality Department or your respective HODs."

This detailed expansion of Module 6 aims to effectively summarize the program, reinforce key learnings, provide context on performance assessment and academic quality, and conclude the induction with a strong call to action and clear guidance on next steps for the clinicians.