INDEX

S. No. CONTENTS Page No.

1. Organization Overview 2
2. Scope of Services 3
3. General Instructions 6
4. Professional Etiquettes 7
5. Rights and Responsibilities - Patient & Employee 7
6. Hospital Wide Policies 11
7. BLS/ACLS/PALS/NALS 15
8. Fire Safety Management 16
9. IPSG goals 17
10. Infection Control Practices 17
11. Overview of NABH 23
12. Emergency Codes 30
13. Biomedical Waste Management 31
14. Committees Roles and Responsibilities 32
15. Ethics Committee (Research / Trial) 38
16. Quality Indicators 39
17. Education and Performance Appraisal 42
18. Grievance Handling Procedures 42
19. Service Standards 44
20. Code of Conduct Policy 44
21. Eco-Friendly Measures 47
22. Save Electricty 48
23. Save Water 49
24. Good Samaritans 50
25. New Quality Initiatives, CSR Activities, Awards
and Recognition 51
26. Patient Safety Programme 53
27. BLS Algorithm (AHA 2020 Guidelines) 57
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1. ORGANIZATION OVERVIEW
GENESIS
Sri Ramakrishna Hospital, Coimbatore has been started in
the year 1975 by SNR Sons Charitable Trust, as a non-profitable
institution with the vision to provide quality health care at affordable
cost to the lower and middle income people around this region. Sri
Ramakrishna Hospital is a 950 bedded multi specialty hospital
having state-of-the-art diagnostic and therapeutic equipments with
well qualified and experienced Doctors, and dedicated nurses. The
Hospital have all specialized Intensive Care Units, Modern
Operating Rooms. Sri Ramakrishna Hospital has been accreditated
by Quality Control of India for adhering NABH standards on April
11th 2017. The Laboratory sevices has been Accredited for NABL
in the year 2020 (Molecular biology) and 2021 (Biochemistry).
The Ethics Committee and Nursing services have been accreditated
for NABH in 2019 and 2021. Sri Ramakrishna Hospital being FIRST
HOSPITAL in Coimbatore to get Accreditated for NABH NURSING
EXCELLENCE. Sri Ramakrishna Hospital Advanced Stroke Centre
has been accreditated by QAI (Quality and Accreditation Institute
in August 2024.
Our Management is committed to Corporate Social
Responsibility by associating with Tamilnadu Chief Minister’s
Comprehensive Health Insurance Scheme serving to highest number
of people among the private hospitals in the Tamilnadu.
VISION STATEMENT : To be globally respected destination
for excellence in patient care and most trusted Centre for
personalized health Care.
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úNûYdLôL EXLjRWmªdL ×L-PUôL §LrYÕ.
MISSION STATEMENT : To provide exceptional, compassionate
care, using cutting - edge technology and latest advances in medicine
and medical expertise in a cost effective way.
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Ïû\kR ùNX®p UÚjÕY YpÛ]oL[ôp úNûY A°jRp.
2
QUALITY POLICY
c Provide holistic, timely patient care
c Inspire hope and nurture the wellbeing of the patient by
respecting physical, emotional and spiritual needs.
c Ensure compassion in patient relationship management.
c Treat patients and their families with empathy and sensitivity.
c Continually upgrade the knowledge and techniques in patient care.
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c úSôVô°L°u EQoÜ NôokR úNûY.
c úSôVô°LÞPu SpÛ\Ü.
c úSôVô°Lû[Ùm, AYoLs ÏÓmTjRôûWÙm T¬ÜPu AÔÏRp.
c NÁTj§V UÚjÕYm NôokR ùRô¯pÖhTeLû[Ùm ARu
£\lTmNeLû[Ùm ùRôPof£VôL LtL F¯VoLû[ úUmTÓjÕRp.

2. SCOPE OF SERVICES
CLINICAL SERVICES
Ø Anaesthesiology
Ø Burns less than 30%
Ø Cardiothoracic surgery
Ø Cardiothoracic Surgery
Ø Cardiology (Interventional & Non Interventional)
Ø Cardiac Anaesthesia
Ø Critical and Intensive Care
Ø Dentistry
Ø Dermatology and Venereology
Ø Emergency Medicine
Ø Endocrinology
Ø Gastroenterology (Medical, Surgical)
Ø General Medicine
Ø General Surgery including Laparascopic Surgery
Ø Nephrology including Dialysis
Ø Neurosurgery
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Ø Neurology
Ø Nuclear Medicine
Ø Obstetrics and Gynaecology
Ø Oncology (Medical, Surgical, Radiation)
Ø Ophthalmology (OPD Only)
Ø Orthopaedics Surgery including Joint Replacement Surgery
Ø Otorhinolaryngology
Ø Reproductive Medicine including IVF
Ø Paediatric Cardiothoracic Surgery
Ø Paediatric Cardiology
Ø Paediatrics
Ø Plastic and Reconstructive Surgery
Ø Psychiatry (OPD Only)
Ø Respiratory Medicine
Ø Rheumatology
Ø Transplant Services (Renal)
Ø Urology
Ø Vascular Surgery
Ø Transplant Services (Liver)
Ø Pain Management & Interventional Pain
LABORATORY SERVICES
Ø Clinical Bio-Chemistry
Ø Clinical Microbiology, Serology
Ø Clinical Pathology
Ø Cytopathology
Ø Haematology
Ø Histopathology
DIAGNOSTIC SERVICES
Ø 2D ECHO
Ø Audiometry
Ø Bone Densitometry
Ø CT Scan
Ø DSA / Cath Lab

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 Ø ECG
Ø EEG
Ø EMG / EP
Ø Gamma Camera
Ø Holter Monitoring
Ø Linear Accelerator
Ø Mammography
Ø MRI Scan
Ø PET Scan
Ø Spirometry
Ø Tread Mill Testing
Ø Ultrasound
Ø X - Ray
TRANSFUSION SERVICES
Ø Blood Transfusion Services
Ø Blood Bank
` PHARMACY
Ø Dispensary
PROFESSIONS ALLIED TO MEDICINE
Ø Dietetics
Ø Physiotherapy
Ø Occupational Therapy
Ø Speech and Language Therapy
Ø Psychology
SUPPORT SERVICES
Ø Ambulance
DURING NON AVAILABILITY OF SERVICES, PATIENTS
ARE REFERRED TO:
Ø Ophthalmology- IP admissions : M/s. ARAVIND EYE HOSPITAL
Ø PET CT (during breakdown) : M/s. ROYAL CARE HOSPITAL
Ø Burns (Above 30% admissions) : M/s. GANGA HOSPITAL
Ø Psychiatric Patient Admission : M/s. PSG HOSPITALS
5
3. GENERAL INSTRUCTIONS :
v PUNCTUALITY
Ø Maintain punctuality at all times
Ø Late punching and Mispunching shall be avoided
v DISCIPLINE
Ø Strict discipline must be maintained.
Ø Mobile phones are not allowed during the working hours.
v PHONE MANNERS
Ø Always greet the person as soon as you pick up the receiver –
“Good Morning”, “Good Afternoon”, “Good Evening”.
Ø Introduce yourself by your Name, Designation and Department
Ø Attend the phone calls as early as possible; preferably within 3 rings.
v GROOMING
Ø Present yourself with well groomed appearance
Ø Keep up your uniforms perfect with spick & span
Ø Always wear ID card when you are in duty
Ø Follow your uniform policy with your respective department
v HR DEPT POLICIES
Ø Follow employment rules and regulations as per HR guidelines
Ø Pre employment Health checkup and annual health checkups to
be completed as per HR instructions
v LEAVE RULES:
Ø Casual Leave (CL) 12 days per calendar year.
Ø Public Holidays (PH), as per hospital rules.
Ø Day off once in a week.
Ø Earn Leave (EL): 12 days per year after one year
Ø Sick Leave (SL): 12 days from the date of joining
Ø Maternity Leave: This shall be sanctioned as per candidate
eligibility.
v RESIGNATION :
Ø In case of resignation, prior notification is necessary – Generally
one month notice is accepted.
Ø For immediate relievers such as 24 Hrs resignations, need to
pay one month salary before leaving the organization.
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v TEAM WORK
Ø It is a collaborative effort of a group to achieve a common goal.
Ø In health care, the goal is to improve the quality of life and
outcomes for the patient.
Ø This is achieved as all the team members involved in the
patient’s care work together to provide the highest possible
quality of care.
4. PROFESSIONAL ETIQUETTE
Ø Use appropriate introductions – introduce someone by their title
and last name (Ms., Mrs., Mr., Dr.), unless otherwise specified
Ø Show common respect and consideration for others
Ø Avoid arguments if the conflict arises
Ø Maintain good eye contact
Ø Avoid emotional outbursts
Ø Maintain confidentiality
Ø Do not use office supplies for personal use
Ø Be punctual and Maintain time management effectively
Ø Say “Thank you” when someone is doing a favour for you.
Ø Maintain eye contact and sit face to face when listening to someone.
Ø Never let others secret go out of you. Maintain Confidentiality
of informations.
Ø Excuse yourself before you interfere with others engaged in a
talking or doing some work.
5. RIGHTS & RESPONSIBILITIES
A) PATIENT RIGHTS
I. RESPECT FOR PRIVACY
a. To have dietary preferences as per the ailment likes and dislikes.
b. To ask any worship requirements, or any specific requirements
after death. Rights to specify and fulfill their wishes.
c. Patient’s cultural, psychosocial, spiritual and personal values,
beliefs and special preferences, privacy during examination /
procedure / treatment are respected and are considered during
the process of care delivery.
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II. PROTECTION FROM ABUSE
a. To have special precautions especially with respect to
vulnerable patients. E.g. Elderly, neonates, physical and
mentally challenged, comatose, anaesthetized patients.
b. To get protected from neglect or any kind of abuse, unwanted
examination and to maintain personal privacy and dignity.
III. CONFIDENTIALITY OF PATIENT INFORMATION
ARE MAINTAINED .HIV/MTP INFORMATION WILL
NOT BE REVEALED AT PUBLIC PLACES.
IV. PLAN OF CARE
a. Aware of plan of treatment including diagnosis, progress,
risks, alternatives and benefits expected results provided by
the consultant.
b. To get sufficient health education and special health
educational & health care needs
c. To get educated on pain management techniques, specific
disease process, complication, prevention strategies and how
to prevent healthcare associated infections and person who
perform the procedure in understandable language and
awareness on handwash techniques, visitors policy and
reduce overcrowding.
d. To get explanation about the proposed care including risk,
alternatives and benefits, referral to internal or external Doctor
in an understandable language.
V. REFUSAL TO TREATMENT AND SEEK SECOND
OPINION REGARDING TREATMENT
VI. INFORMED CONSENT
a. To get General consent form during admission
b. To get informed consent for procedure / surgery, for
transfusion of blood & blood components, for restraining
patient, for initiation of any research protocol, to provide
prior informed consent before making of recordings, films or
other images that may be used externally, for anaesthesia &
other invasive / high risk procedures / treatment.
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 e. Aware that one witness will be available during informed
consenting process.
d. Aware that the risk, benefits and alternatives is communicated
effectively by the doctor before consenting.
[Link] A COMPLAINT
a. Through the suggestion box provided at various areas of
hospital. Also, Complaints are addressed through patient
feedback form to capture patient satisfaction level.
b. Aware that patient experience is also monitored by the
Hospital with regard to Hospital environment (cleanliness,
quietness), responsiveness of hospital staff, communication with
Doctors and nurses, Pain Management, Discharge information.
c. To contact Grievance Handling Committee member for
addressing their grievances. For member details, contact
enquiry / reception staff.
d. Aware that the feedback & complaints are reviewed &
analysed by hospital heads and the corrective action is updated
to the patient/ attender.
VIII. ESTIMATED COST OF TREATMENT
a. To get awareness on pricing policy (Consultation charges,
bed charges, nursing charges) in different settings like OP,
IP, Emergency, ICU.
b. To know about financial implications whenever there is
change in the care plan and to get explained on expected cost
of treatment and care.
IX. ACCESS TO THE MEDICAL RECORDS BY GETTING
AUTHORIZED SIGNATURE FROM MEDICAL
DIRECTOR WITH RELEVANT PROOF.
X. PATIENT & FAMILY MEMBER RIGHTS
a. To get explained on the results of all diagnostic tests in broad
terms and their implication on progress and treatment and to
get information of diagnostic test results.
b. Awareness on any change in patient condition in a timely
manner, on possible complications, name of treating doctor,
care plan, patient progress and healthcare needs.
c. Avail multidisciplinary counseling especially for critically
ill patients, potential organ donors and family, long stay
patients, whenever needed.
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 d. To request for additional information on a particular Physician
in terms of Qualification and Experience and to get relevant
information on clinical evaluation.
e. Aware that withholding of resuscitation request shall be
discussed in consideration with ethical and legal parameters
and violations of patient rights are monitored.
f. In case of life threatening situations, if the patient is incapable
and next of kin is not available, then the treating doctor and
another clinician can decide to safeguard patient’s life.
g. To receive clear and understandable information about their
health condition, the treatments available to them, the benefits
and risks of each treatment, and the expected outcomes.
h. To participate in decisions about their care, including the
right to give or withhold informed consent for medical
treatments, procedures, or tests.
i. To make an informed decision about their treatment, understand
the information and make a decision based on it.
j. Aware that consent is taken based on competent and age factor
of the patient. In case of incapable independent decision
making, next of kin/ legal guardian will be spouse/son /
daughter/parents/brothers/sisters
B. PATIENT RESPONSIBILITIES
a. Abide by the hospital rules & regulations. Follow “NO
SMOKING” policy within premises.
b. Expected to provide complete, accurate personal detail,
medical and surgical history.
c. To get Information regarding health & disease and to follow
the treatment plan specified by the physician during admission
and after discharge.
d. Respect the rights of other patients, doctors, nurses and other
staff of the hospital.
e. Do not keep any valuables in your possession and to safeguard
the hospital property.
f. Settle bills on time. Follow the treatment plan specified by
the Physician during admission and after discharge.
g. Incase, the above rights are violated, you can report
immediately to patient welfare team. Action will be taken
within 24 hrs of reporting.
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C. EMPLOYEE RIGHTS
a. Right to have workplace free of harassment.
b. Right to know about hospital policy.
c. Right to get fair pay.
d. Right to know about terms and conditions of employment.
e. Right to get information.
f. Right to report grievances.
D. EMPLOYEE RESPONSIBILITIES
a. Report to work on time
b. Provide committed patient care
c. Notify Seniors / HOD prior to absence
d. Maintain confidentiality regarding patient and hospital
Information
e. Provide friendly and courteous services to the patients, general
public as well as to colleague at all times
f. Work to the best of their ability throughout the day.
6. HOSPITAL WIDE POLICIES
i) ADMISSION POLICY
a. Patients will be admitted in the hospital if their treatment
falls within the Scope of services.
b. 24/7 service
c. Consent forms are received during stay of the patient.
d. General Consent is obtained in the Admission counter.
ii) DISCHARGE POLICY
a. Discharge Summary is provided at the time of discharge.
Discharge is planned 24 hours in advance.
b. Discharge process is discussed with patient and family and
planned accordingly.
c. Discharge is made by an authorized consultant with written
discharge order. Patient may also discharge himself / herself
against medical advice (LAMA), after explaining the risk.
d. In case of MLC, Plan for discharge shall be informed to the
MS /ARMO, who inturn shall intimate to the police in case
of discharge against medical advice or death of MLC patient.
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iii) Biomedical Waste Management Policy (Refer Page No : 28)
iv)COLOUR CODES (Refer Page No : 27)
v) CONSENT POLICY :
Consent forms shall be signed by Doctor / Patient and patient
attender before any procedure / surgery. General consent form
is received at time of admission. Other consent forms are
received by Doctors before surgery / procedure.
vi)DISASTER MANAGEMENT POLICY
a. Weapons of mass destruction
b. Types of disaster (Fire, Earthquake, Natural and manmade
disasters)
c. Code Yellow Team :
a) Site Recovery Team
b) Internal Triage Team
c) Cordon Team
d) Salvage Team
e) Media Management and Patient information team
d. Code Red Team / Code Black Team :
a) Fire Fighting Team
b) Rescue Team
c) Medical Team
d) Shifting and Transportation Team
e) Media Management Team
vii) EMPLOYEE RIGHTS & RESPONSIBILITIES
(REFER PAGE NO : 11)
viii) END OF LIFE CARE POLICY
a. Respecting patient's values, religion, cultural and philosophy.
b. Responding to the psychological, social, emotional, spiritual and
cultural concerns of the patient and family & counsel them.
ix)GRIEVANCE HANDLING PROCEDURE
(REFER PAGE NO : 39)
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x) INFANT, CHILD ABDUCTION, PREVENTION AND
ABUSE POLICY
a. Dial 2666 & inform operator to announce Code Pink
b. Search entire ward / department
c. Close all the entrance as soon as possible. The team shall
search every person exit, even search in baskets / bags.
d. Ensure that there is an adequate security/surveillance to
prevent such happenings.
e. Staff shall ensure that child abuse is not allowed in the
Hospital premises.
xi) INITIAL ASSESSMENT OF PATIENT POLICY (REFER
PAGE NO : 23)
xii) MANAGEMENT OF NON-AVAILABILITY OF BED
POLICY :
a. In case of non availability of bed, the hospital shall offer
available beds (special / new / deluxe).
b. The billing tariff is made transparent to the patient / relative.
Patient is admitted to the available bed and later she / he
shall be shifted to the bed of choice. Charges shall be as per
the bed of choice only.
c. Non - Availability of Emergency bed - Patient shall be
transferred to the nearby hospital after stabilizing the patient.
xiii) OCCUPATIONAL HEALTH HAZARDS
a. Biological hazard
b. Chemical hazard
c. Psychological hazard
d. Physical hazard
xiv) PATIENT RIGHTS & RESPONSIBILITIES
(REFER PAGE NO : 7)
xv) POLICY ON ORGAN TRANSPLANTATION
Two Situations Under Which Organ Donation Occurs Are:
a. Live Donations- When the person making the donation is alive
b. Cadaver/Deceased Donations. - After the donor dies
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 ORGAN WITHIN HOW MANY HOURS
ORGAN CAN BE DONATED
Heart 6 Hours
Liver 6 Hours
Lungs 12 Hours
Pancreas 12 Hours
Kidneys 48 Hours
xvi) SENTINEL EVENT MANAGEMENT POLICY
There are 4 types of events - Near Miss, No harm Adverse event,
Sentinel event.
a. An injury resulting from a medical intervention related to a
medication, including harm from an adverse drug reaction or a
medication error.
b. A near miss is an unplanned event that did not result in injury,
illness, or damage-but had the potential to do so. Errors that did
not result in patient harm, but could have, can be categorised as
near-misses.
c. In no harm scenario, the error is not recognised, and the deed is
done, but fortunately for the healthcare professional, the expected
adverse event does not occur.
Incident Report shall be handover to quality control department
within 24 hours of incident. If adverse event prolonged for 2
weeks, then it is considered as Sentinel event.
xvii) INTERNAL COMPLAINT COMMITTEE (ICC)
POLICY (REFER PAGE NO: 34)
xviii) SMOKING & NON - SMOKING POLICY
a. Staff are not allowed to smoke and chew tobacco while on
duty, in patient areas or anywhere inside hospital in uniform
where they may be identified by the public.
b. The hospital is marked as "NON SMOKING AREA"
xix) UNIFORM CARE POLICY
The hospital shall ensure that patients with the same health
problems and care needs receive the same quality of healthcare
throughout the organization irrespective of category of ward and
also in emergency, providing first aid treatment, handling MLC
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 patient and ambulance services, Cardio Pulmonary Resuscitation,
use of blood and blood products, care of patients in the ICUs, and
other high dependency areas, Post-surgical recovery rooms etc.
xx) VISION, MISSION, QUALITY POLICY (REFER PAGE NO : 2)
xxi) VISITORS HOURS POLICY:
Visitors time is implemented in the hospital for reducing the risk
of infection. Visitors pass is issued for every patient. The visiting
time is 11am – 1 pm & 4pm – 7 pm.(Wards)
xxii) VULNERABLE PATIENT CARE POLICY:
Vulnerable patients are those who cannot do their own work.
The facilities given for the vulnerable patients are:
a. Identify the patient with RED ID BAND
b. Provide side railing cot
c. FRAT Assessment
d. Call bell system
e. Documentation
f. Vulnerable sticker is affixed
g. Toilets for disabled patients.
h. “V” Sticker is pasted on OP Patient dress for identification
and prioritization.
7. BLS/ACLS/PALS/NALS
All employees of the hospital has to undergo Basic Life Support
program Critical care nurses and technicians shall undergo
training on their respective discipline, Critical Care Departments,
Cathlab, CVICU and OT staff should undergo ACLS, Neonatology
nurses should complete NALS / NRP and pediatric nurses should
complete their PALS courses as well. All these programs are
based on American Heart Association’s updated guidelines.
8. FIRE AND SAFETY MANAGEMENT
What to do in case of FIRE?
R: Rescue P : Pull the safety pin
A: Activate the Alarm A : Aim the hose base of the Fire
C: Confine the fire S : Squeeze the Handle
E: Extinguish / Evacuate S : Swipe side to side
Code Red : (Internal Disaster) includes Fire, Terrorist
Attack, Building Collapse, Earthquake, Bomb Blast etc.
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 Do’s Dont’s
Dial 2666 and inform operator to activate Do not panic
code Red
Press MCP button Do not use lift
Use nearest fire extinguisher Do not pour water on
electrical fire
Follow nearest escape route Do not run
Follow the instructions of Fire Safety
Officer
9. INTERNATIONAL PATIENT SAFETY GOALS

91 WHO PATIENT SAFETY SOLUTIONS

Look-Alike Sound - Alike Medication
Names
2 Patient Identification
3 Communication During Patient Handover
4 Performance of Correct Procedure at Correct Body Site
5 Control of Concentrated Electrolyte Solutions
6 Medication Reconciliation
7 Avoid Catheter and Tubing Misconnections
8 Single Use of Injection Devices
Improved Hand Hygiene to Prevent Healthcare Associated
9 infections

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10. INFECTION CONTROL PRACTICES
Introduction
v Nosocomial infection or healthcare associated infections are
infections acquired by the person in the hospital.
v HAND WASHING:
Hand washing is the corner stone of infection control.
Ideal time for Hand Washing and Hand rub
• Medical/Aseptic Hand washing: 40-60 seconds
• Hand rub: 20-30 seconds (Wait until Dry)

FIVE MOMENTS OF HAND HYGIENE

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SPILLAGE MANAGEMENT
Types of Spillage
Biological Spill Chemical spill
• Blood • Drugs
• Body Fluids • Cytotoxic Drugs
• Chemicals
BIOLOGICAL SPILL :
The spillage should be cleaned properly by using spillage kit.
The content of Spillage kit are:
• Caution Board
• Personal Protective Equipments (Gloves, Mask, Apron, Leggins)
• Tissue Paper
• 1% Sodium hypochlorite solution
• Artery forceps
• Cardboard
• Biomedical waste cover (Yellow colour cover)
Classification of Spillage
1. Large Spillage
2. Small Spillage
The spillage less than 30 ml are considered as Small spill & the
spillage more than 30 ml are considered as large spill.
In case of large spill, staff should inform operator to announce
Code Orange by dialing 2666 & the HAZMAT team will arrive to
the spot and cleaning procedure is done according to the protocol.
Housekeeping staff has been trained in the cleaning procedure.
The small spillage should be cleaned by using spillage kit by
following spill cleaning procedure. The spillage cleaning procedure
as follows :
• Restrict the spillage area with caution board.
• Inform co-employees.
• Bring the spill kit.
• Wear Personal protective equipments.

18
• Place the tissue paper over the spill.
• Pour equal amount of 1% Sodium hypochlorite solution above
the spilled area.
• Wait for 20 to 30 minutes to get disinfected (Contact period).
• Scoop the tissue paper with cardboard and discard into the
yellow colour cover.
• Pour soap solution, place tissue paper and clean the spilled
area in “8” shaped manner and discard in yellow colour cover.
• Wash the hands properly.
• Replace items in the spillage kit.
• Report to Infection control team (ICO, ICN).
• Write Incident report form within 24 hours and submit to Quality
Control Department.
(Note: In case of spillage with broken glass bottles, pick up the
glass bottles with an artery forceps before placing tissue paper
over that).
LARGE CHEMICAL SPILLAGE PROCEDURE :
(House keeping staff need to perform procedure)
Code Orange shall be announced as soon as chemical spills.
Procedure to do :
1. Do not panic
2. Wear Personal Protective Equipments such as gloves, mask, Apron etc.
3. Check the spill Content
4. Cordon the area
5. Ensure no one enters the spilled area
6. Check MSDS (Material Safety Data Sheet) chart.
7. Do the procedure according to MSDS
8. If the spilled solution is not known, clean the chemical spill
using sand bags by outer to inner method.
9. Clean the area.
[Link] it in yellow colour bag.
[Link] the details in Incident report form.

19
[Link]. CHEMICAL CLEANING STEPS

1. SULPHURIC ACID Put Sand, follow Cleaning Procedure

2. ACETONE Pour Copius Volumes of Water follow
Cleaning Procedure
3. ETHYL ALCOHOL Put Sand, follow Cleaning Procedure
4. AERODESIN Put Sand, follow Cleaning Procedure
5. BACILLOL / BACILLOCID Put Sand, follow Cleaning Procedure
SPECIAL
6. STERILLIUM Keep away from heat, put Sand, follow
Cleaning procedure
7. CRYSTAL VIOLET Sweep up, Place in a Bag and hold for
Waste disposal. Avoid raising dust.
8. GRAMS IODINE Put Sand, follow Cleaning Procedure
9. SAFRANIN CARBOL Sweep up, select a suitable container
FUCHSIN for disposal. Remove all sources of
Ignition. Put Sand, follow Cleaning
Procedure
10. METHYLENE BLUE Sweep up, keep in suitable, closed
containers for disposal.
11. SODIUM HYPOCHLORITE Equalise with water follow cleaning
procedure.
Cleaning a chemotherapeutic Medicine spill
Cleaning a chemotherapeutic medicine spill in a hospital
requires careful attention to minimize exposure to healthcare
workers and the general public. The cleaning procedure for
chemotherapeutic medicines/drugs in a hospital typically involves
a combination of several steps to ensure that any residual drug or
contamination is effectively removed.
1. Evacuate the area: If possible, remove patients and personnel
from the immediate area to prevent unnecessary exposure to the
spilled material. The work area should be isolated and clearly
marked as a chemotherapy drug handling area.

20
2. Wear appropriate personal protective equipment (PPE):
Before beginning the cleanup process, put on gloves, a gown,
eye protection, and a respirator mask (if required) to prevent
skin, eye, and respiratory exposure to the spilled material.
Personal Protective Equipment (PPE) should be worn to prevent
contact with the drugs or their residues.
3. Contain the spill: Use absorbent materials (such as spill pillows
or absorbent pads) to contain and absorb the spilled material.
Place the contaminated materials in leak-proof bags or
containers, and label them as hazardous waste. Any equipment
or surfaces that come into contact with the drugs should be
thoroughly cleaned and decontaminated using specialized cleaning
agents specifically designed for use with chemotherapy drugs.
4. Decontaminate the area: Wipe down surfaces with a clean,
damp cloth soaked in a detergent solution to remove any residual
contamination. Dispose of contaminated cloths in a hazardous
waste container.
5. Disinfect the area: Once the area has been cleaned and
decontaminated, apply a disinfectant solution to ensure that all
remaining traces of contamination are eliminated. Leave the
solution on the surfaces for the recommended contact time
before wiping away excess solution with a clean, damp cloth.
6. Dispose of PPE and contaminated materials: Place all PPE
and contaminated materials in a hazardous waste container,
and dispose of them according to local regulations. All waste
generated during the cleaning process should be disposed of in
accordance with hospital policies and applicable regulations.
Once cleaning is complete, the area should be thoroughly
inspected to ensure that all traces of drug residues have been
removed. After completion of the cleaning procedure, proper
ventilation and air exchange should be carried out to eliminate
any remaining fumes or odors. It’s worth noting that specific
procedures may vary depending on the type of chemotherapy
drug being handled, the hospital’s policies, and the local
regulations.
21
 Therefore, it is essential to follow the guidelines and
recommendations provided by the hospital and regulatory
bodies to ensure safety and effective cleaning.
7. Document the spill: Record the location, time, and volume of
the spill, as well as the cleanup measures taken. It’s important
to note that cleaning up chemotherapeutic medicine spills
requires specialized training and experience. If you are not
trained in this process, it is best to contact a qualified hazardous
waste cleanup company to handle the spill.
NEEDLE STICK INJURY :
WHAT TO DO IF YOU GET STUCK?
ü Immediately wash exposure site with running water
ü Do not squeeze or rub the injury site
ü Immediately report to the Team Leader & ICN
11. OVERVIEW OF NABH
NABH stands for “National Accreditation Board for Hospitals
and Healthcare providers”
v Set benchmarks for progress of Hospital.
v Center for patient safety
v Structured to cater much desired needs of the Patients.
NABH (6th Edition) consists of
10 Chapters
100 Standards
639 Elements
v PATIENT CENTERED CHAPTERS
1. Access, Assessment and Continuity of Care (AAC)
2. Care of Patients (COP)
3. Management of Medication (MOM)
4. Patient Rights and Education (PRE)
5. Infection Prevention and Control (IPC)

22
v ORGANIZATION CENTERED CHAPTERS
6. Patient Safety and Quality Improvement (PSQ)
7. Responsibilities of Management (ROM)
8. Facility Management & Safety (FMS)
9. Human Resource Management (HRM)
[Link] Management System (IMS)
1. ACCESS,ASSESSMENT & CONTINUITY OF CARE (AAC)
ü Orientation to Hospital Scope of Services
ü WaitingTime and Turnaround Time
ü Registration and Admission Policy
ü Initial Assessment -
OP -Doctor’s - 1 Hour
OP -Staff Nurse - 30 Minutes
IP -Doctor’s - 45 Minutes
IP -Staff Nurse - 30 Minutes
Critical Care Areas (Doctors) - 10 Minutes
Critical Care Areas (Nurses) - 3 Minutes
Nutritional Assessment - 24 hours
ü Reassessment by primary Consultant - 24 hours
ü Quality Assurance for Lab and Imaging Services
ü Discharge process
2. CARE OF PATIENTS (COP)
ü Uniform Care to all patients
ü Emergency and Ambulance services - Crash Cart Medications,
BLS and ACLS trained personnel, Triage, transfer of patient
policy.
ü Cardio Pulmonary Resuscitation
ü Nursing Care Services
ü Rational use of Blood and Blood products
ü Rehabilitative Services
ü Nutritional Therapy
ü Care of patients with Anaesthesia and Sedation
ü Handling community, emergencies, epidemics and other
disasters.
ü Organ transplant programme
23
VALIDATION TOOL USED:
1. MUST (Malnutrition Universal Screening Tool) is used for IP
Adult for identification of early malnutrition patient.
MUAC (Mid Upper Arm Circumference) is used for bedridden
patient/ unable to walk.
2. Fall assessment scale:
MORSE – Adult
Humpty Dumpty – Paediatric
3. Pressure Ulcer:
Braden Scale – Adult
Braden Q – Paediatric
4. DVT (Deep Vein Thrombolysis):
Well’s Scale (All age group)
5. PAIN
Adult: 1. Numerical Pain Rating Scale (NPRS).
2. Wong Baker Scale
Ventilator patient: Behavioral Pain Scale.
Paediatric: FLACC (Face, Leg, Activity, Cry, Consolability)
Neonates: NPASS (Neonatal Pain, Agitation and Sedation
Scale)
6. SPIKES (For breaking bad news)
[Situation, Perception, Invitation, Knowledge, Emotion,
Strategy and Summary]
7. MNA tool (Mini Nutritional Assessment) for Nutritional
Assessment.
8. PNST tool (Paediatric Nutritional Screening check list Tool)
for Paediatric Nutritional Assessment.
9. PHQ -9 (Mental Screening Checklist for depression
patients).
10. Distress thermometer tool (Mental screening Checklist for
oncology patients).
11. SWOT analysis (for strategic and operational plan)
[Strength, Weakness, Opportunity, Threats]
24
3. MANAGEMENT OF MEDICATION (MOM)
ü Antimicrobial Stewardship Programme
ü Storage, usage and safe dispensing of Medication
ü Prescription of medication
ü Hospital formulary
ü 14 Rights of medication Administration
ü Analyzing of Adverse drug event
ü Handling of narcotic drug and psychotropic substances
ü Usage of chemotherapeutic and radioactive drugs
ü Implantable prosthesis and medical devices.
4. PATIENT RIGHTS AND EDUCATION (PRE)
ü Patients Education on their Rights and Responsibilities
ü Informed Consent
ü Complaint Redressal procedure
ü Effective communication with patient and families.
ü Breaking bad news using SPIKES.
5. INFECTION PREVENTION AND CONTROL (IPC)
ü Infection Control Team, HIC Committee
ü Hospital Acquired Infection
ü Outbreaks of Infection
ü Sterilization and disinfection of Equipments
ü Employee training and Vaccination
ü Isolation of Patient
ü Infection Control Practices
ü Personal Protective Equipments
ü Biomedical Waste Management
ü Hand Washing
ü Needle Stick Injury
ü Spillage Management
6. PATIENT SAFETY AND QUALITY IMPROVEMENT
(PSQ)
ü Patient Safety Programme
ü Risk Assessment, Management and Mitigation Techniques
ü Quality Indicators
ü Analysis of Sentinel Events
ü Continuous Quality Improvement
25
 ü Analysis of Sentinel Events
ü Continuous Quality Improvement
ü Clinical Audit
ü Validation and analysis of quality indicators to facilitate
quality improvement.
ü Committees and CAPA
7. RESPONSIBILITIES OF MANAGEMENT (ROM)
ü Risk management
ü Display of Hospital Vision, Mission, Quality policy
ü Departmental scope of services
ü Statutory requirements
ü Strategic and Operational Plan (“SWOT” TOOL)
8. FACILITY MANAGEMENT AND SAFETY (FMS)
ü Patient and employee safety
ü Management of Hazardous Material
ü Fire and non Fire Emergencies
ü Occupational Health Hazards
ü Management of Bio-Medical equipment, Medical gases,
vaccum, compressed air
9. HUMAN RESOURCE MANAGEMENT (HRM)
ü Man power planning
ü Recruitment and selection
ü Training and Development
ü Performance appraisal
ü Disciplinary action
ü Grievance Handling procedure
ü Employee Rights and responsibilities
ü Personal record for each employee
ü Staff wellbeing
ü Health Checkups and Code of Conduct
ü Employee Satisfaction
ü Credential and Privilege for Doctors, Nurses and Paraclinical
Staff
ü Exit Interview
10. INFORMATION MANAGEMENT SYSTEM (IMS)
ü Medical records documentation
ü Retention time for all the records, data’s
ü Confidentiality and security of records
ü Effective management of data’s through IT
26
12. EMERGENCY CODES

27
 13.

28
14. ROLES AND RESPONSIBILITIES OF COMMITTEES
(1) ANTIMICROBIAL STEWARDSHIP PROGRAMME
v To Improve awareness and understanding of AMR
(Antimicrobial resistence) through effective communication,
education and training.
v To strengthen the knowledge and evidenced base through
surveillance and research.
(2) BLOOD TRANSFUSION COMMITTEE
v To review the appropriateness of ordering policies of blood
and blood components.
v To review handling and administration of blood and its
components.
(3) CLINICAL AUDIT COMMITTEE
v To conduct Clinical audits based on the clinical scenario
v To take decision on re-audit based on the clinical audit
presentation.
(4) CLINICO PATHOLOGICAL MEETING
v Review of histopathological reports with Clinicians as an
aspect of quality control for diagnostic pathology.
v To assess the effects of clinic-pathological review by formal
analysis with Doctors intervention.
(5) CLINICO - RADIOLOGICAL MEETING
v The committee correlates the imaging results of CT/ MRI
with the referring clinicians.
v Ensuring that the discussion and recommendations suggested are
used as tool for improving the quality of the imaging results.
v Discussing on the validation of imaging results by Clinicians
and Radiologist.
(6) CORE COMMITTEE
v To ensure compliance to the institution's Mission, Vision and
Values & to ensure necessary resources availability to
implement and monitor NABH standards
v To establish policies and procedures related to Clinical and
Non Clinical activities and implement the same.
29
(7) CPR COMMITTEE
v Recording and reporting critical incidents related to
resuscitation
v To plan for continuous quality improvement in relation to CPR events.
(8) EMERGENCY AND CRITICAL CARE COMMITTEE
v Reviewing and evaluating the medical record for quality,
content, format, pertinence, accuracy, and accessibility.
v Provides recommendations for improvement of current ICU
& ER ambience and monitors staff compliance with
documentation policies.
(9) CREDENTIAL AND PRIVILEGE COMMITTEE
v To evaluate credential of Doctors, nurses, paraclinical staff
prior to selection.
v To provide privilege and check the competency of Doctors,
nurses, paraclinical staff.
(10) DISCREPANCY MEETING
v To review the imaging results of CT and MRI through Peer
Review (External/ Internal)
v To analyse using RADPEER score which is used to prevent
errors in future, and for continuous quality improvement rather
that computation or error rates of the individuals.
(11) DISASTER MANAGEMENT COMMITTEE
v To test the documented disaster Management plan (Mock-
drills)/ table top exercise and take appropriate corrective
and preventive action.
(12) DRUG SUB COMMITTEE
v Reviewing the addition and deletion of drugs forms with the
existing brands.
v Approving the drugs based on movement of drugs, Doctor's
input on procurement, quality of product, burden on the
pharmacy inventory, price, frequency of medication.
(13) DRUG LITERATURE REVIEW MEETING
v Anticipate and evaluate the Drug Information needs based on
the literature review.
v Providing Drug information to Committee members,
Consultants, Doctors, patients, caregivers, and health care
professionals.
30
(14) EMPLOYEE GRIEVANCE HANDLING COMMITTEE
v To deal with any type of Grievances of the employees.
v Ensure that all the employees adhere to the organisation policy
and procedures.
(15) ETHICS COMMITTEE
v To review the protocol submitted for DNB thesis, Clinical
research and clinical trials (Phase 3, Phase 4) by reviewing
the informed consent.
v To look into the research protocol / proposal and state whether
or not it is ethically acceptable.
(16) INFECTION PREVENTION & CONTROL COMMITTEE
v To develop and implement the infection control policies and
procedures.
v To ensure the conduct of sterilization and disinfection
practices and to ensure the central sterile supply services,
housekeeping, laundry, engineering maintenance, food
sanitation and waste Management are in conformity with the
Infection Control practices.
v To solve issues pertaining to housekeeping practices & laundry
services in the Hospital.
v To ensure that scrap/ condemned Biomedical/ electrical / e-
waste are disposed properly.
v Ensure that Biomedical wastes are disposed properly in its
bin at wards and final disposal area.
(17) HUMAN MILK BANK COMMITTEE
v To ensure that Donors are safe and identity are not revealed.
v For the betterment of the society and improve the standard of
care.
(18) LINEN CONDEMNATION COMMITTEE
v To scrap damaged linen after the approval of the committee
v Ensure that damaged linens are reused for house
keeping purposes in the HCO.
(19) MATERIAL CONDEMNATION COMMITTEE
v To scrap unused material after the approval of the committee.
v To analyse quantity of condemnation pertaining to Biomedical,
Electrical & IT related Spare parts.
31
(20) MEDICAL RECORDS COMMITTEE
v Review and evaluate patient records for quality, adequacy of
patient care, monitor staff for compliance with policies.
v To conduct medical record audits frequently implement CAPA
and document the same.
(21) MORTALITY COMMITTEE
v To have an interactive and in depth analysis in an open forum
with all the concerned HODs to identify the errors made in
the heath sector.
v To compile the reports made by post death audit (for all cases)
and to analyze it in the mortality committee.
(22) OT COMMITTEE
v To advise on smoothening the functions of OT
v To facilitate, guide and advice for sustaining a regular,
objective, explicit and effective method of quality assurance
through a system based on peer review.
(23) NURSING REVIEW MANAGEMENT COMMITTEE
v Adherence of NABH Nursing Excellence standards.
v Complying with Quality assurance programme of nursing
departments by analysing CAPA for every incidents.
(24) PATIENT GRIEVANCE HANDLING COMMITTEE
v Ensuring that patient grievances specified in the suggestion
box / Patient feedback form / oral communication are
addressed & CAPA taken.
v To implement changes in the structure / process / outcomes
based on the feedback received.
(25) PHARMACY AND THERAPEUTIC COMMITTEE
v To formulate and implement the policies and procedures
relating to Pharmacy services and medication usage.
v To analyze the audits and do the CAPA in specialty wise.
(26) PURCHASE COMMITTEE
v Procurement of all equipments, supplies required by HCO.
v To ensure that the condemnation things after the approval of
the Condemnation Committee are replaced with the existing
or new product.
32
(27) QUALITY IMPROVEMENT COMMITTEE
v To discuss regarding new Quality tools, techniques &
initiatives.
v To highlight performance improvement using targets by
various departments.
v To analysis the indicators when there is hike / lower in the
data being captured & analyse patient feedback.
(28) RADIATION SAFETY COMMITTEE
v To ensure that usage of radioactive material is conducted in
a safe manner and in accordance with AERB guidelines.
v To ensure that all individuals who work with or in the vicinity
of radioactive materials have sufficient training and
experience to perform their duties safely and in accordance
with AERB and established guidelines.
(29) SAFETY COMMITTEE
v To identify the potential safety and security risks to patients,
staff, visitors in all phases of activities by involving PSO.
v To identify root cause, to take appropriate corrective /
preventive actions for the gaps identified through Facility
inspection rounds.
v Safety Rounds is conducted monthly once CAPA of safety
rounds is discussed in Safety Committee.
(30) SCIENTIFIC COMMITTEE
v To promote high quality collaborative research (Study thesis)
v To establish, and continuously develop, the study needed in
order to facilitate research activities.
(31) SENTINEL EVENT MANAGEMENT COMMITTEE
v To have a positive impact in improving patient care, treatment,
and services and preventing sentinel events.
v To analyze the near miss, adverse events based on the Incident
report forms and do CAPA using RCA
33
(32) INTERNAL COMPLAINT COMMITTEE (Sexual
Harassment Management)
v Sexual harassment will not be tolerated at Sri Ramakrishna
Hospital. Individuals who engage in such behaviour will be
subject to disciplinary action, including termination. The
Vishaka Committee / Internal Complaint Commitee is held
confidential and actions are taken accordingly. Sexual
harassment includes the following :
v Objectionable, coercive or vulgar comment of a sexual nature
to a person or persons.
v Actions or communications with a sexual connotation that
create an intimidating, demeaning, or offensive work
environment.
v Unwanted sexual request or advance, inappropriate touching,
or sexual assault.
v An implied or expressed reprisal or threat of reprisal, or denial
of opportunity for refusing to comply with a sexual request.
v Any implied or expressed reward for complying with a
sexually oriented advance or request.
v Displaying pornographic, offensive or derogatory pictures or text.
THE COMMITTEE MEMBERS ARE
1. Mr. C.V. Ramkumar - Chief Executive Officer
2. Mr. Mahesh Kumar - Chief Administrative Officer
3. Dr. Rajagopal - Medical Director
4. Dr. Alagappan - Medical Superintendent
5. Dr. Banumathy. M - Consultant Gynaecologist
6. Dr. Bhargavi - Consultant Oncologist
7. Dr. Geethanjali - Consultant - Radiology / Chairperson
8. Dr. [Link] - Consultant - General Surgeon
(On Call based on issue)
9. Dr. Karthikesh. K - Consultant Oncologist
(On Call based on issue)
10. Mrs. Girija - Chief Nursing Officer
11. Mr. Vijay Kumar - Head - HR
12. Mrs. Remya.S - Manager - Quality Control & Training
13. Mrs. Mathivathana - HR Officer
14. Mrs. Latha Sundaram - NGO (External)
34
(33) CLINICAL GOVERNANCE COMMITTEE:
1. Ensuring high standards of patient care, Safety and
Continuous improvement in clinical practices
2. Identify and mitigate clinical risk that could affect Patient
outcome.
3. Compliance with hospital policies, regulations and
accreditation requirement.
4. To define strategic and operational plan.
5. Quarterly review of performance improvement of various
departments and ensures implementation.
6. The head of governing body and members responsible for
ethical management framework.
15. ETHICS COMMITTEE (RESEARCH / TRIAL)
Sri Ramakrishna Hospital Ethics Committee is Accredited
by DCGI, NABH and DHR. Phase 3, Phase 4 Clinical trials are
conducted in the Hospital. Any research / Clinical trial shall be
carried out after approval of Ethics Committee. The EC Committee
Membership consist of Chairman, Scientific Member, Member
Secretary, Clinical Scientist, Basic Scientist, Social Scientist, Legal
Expert, Layperson. Many Research Activities are conducted at Sri
Ramakrishna Hospital. A minimum of 50% of EC members are
Non-Affiliated to Sri Ramakrishna Hospital. For further details,
Contact Quality Control Department.
16. QUALITY INDICATORS
1. CLINICAL INDICATORS
1. Time taken for IP, ER & OP initial assessment within time
frame - Nurses & Doctors
2. Percentage of cases(in-patients) where care plan with desired
outcome documented, counter signed by Clinician
3. Percentage of cases(in-patients) wherein screening for
nutritional needs has been done within 24 hours
4. Percentage of cases(in-patients) wherein the nursing care plan
is documented.
5. Number of reporting errors / 1000 investigations : Diagnostics
and laboratory.
35
6. Rate of Re-do's - Diagnostics and laboratory
7. Percentage of reports co-relating with clinical diagnosis -
Diagnostics and laboratory
8. Percentage of adherence to safety precautions by employees
working in diagnostics
9. Incidence of medication errors (including administration
errors, prescription errors, dispensing errors etc)
10. Percentage of admission with adverse drug reaction(s)
11. Percentage of medication charts with error prone abbreviations
12. Percentage of patients receiving high risk medications
developing adverse drug event
13. Percentage of modification of anaesthesia plan
14. Percentage of unplanned ventilation following anaesthesia.
15. Percentage of adverse anaesthesia events
16. Anaesthesia related mortality rate
17. Percentage of unplanned return to OT within 48 hours
18. Percentage of re-scheduling of surgeries
19. Percentage of cases where the organisation procedure to
prevent adverse events like wrong site, wrong patient and
wrong surgery have been adhered to.
20. Percentage of cases who received appropriate prophylactic
antibiotics within the specified time frame (60 minutes)
21. Percentage of cases in which the planned surgery is changed
intraoperatively.
22. Reexploration rate
23. Percentage of transfusion reactions recipient
24. Percentage of wastage of blood components
[Link] of usage of blood components
26. Turn around time for issue of blood components
27. Catheter Associated Urinary Tract Infection (Per 1000 cases)
28. Ventilator Associated Pneumonia (PVAP/ VAC/ IVAC) (Per
1000 cases)
29. Central line Associated Blood Stream Infection (Per 1000 cases)
30. Surgical Site Infection (Per 100 cases), SSI in clean surgeries
31. Mortality Rate
32. Patients Returning to ICU within 48 hours
36
33. Patients Returning to Emergency within 72 hours
34. Re - Intubation Rate
35. Percentage of research activities approved by Ethics Committee
36. Percentage of patients withdrawing from the study
37. Percentage of protocol violations / deviations reported
38. Percentage of serious adverse events reported to the Ethics
committee within the defined time frame.
39. Percentage of Beta Blocker prescription with a diagnosis of
CHF with reduced EF
40. Percentage of patients with myocardial infarction for whom
Door to balloon time of 90 minutes is achieved
41. Percentage of Hospitalized patients with hypoglycemia who
achieved targeted blood glucose level
42. Spontaneous Perineal Tear Rate
43. Percentage of patients undergoing Colonoscopy who are
sedated
44. Bile Duct injury rate requiring operative intervention during
Laparoscopic Cholecystectomy
45. Percentage of POCT results which led to a clinical
intervention.
46. Functional gain following rehabilitation
47. Percentage of sepsis patients who receive care as per the
Hour-1 sepsis bundle.
[Link] of COPD patients receiving COPD Action plan
at the time of discharge
[Link] of stroke patients in whom the Door-to Needle
Time (DTN) of 60 minutes is achieved.
[Link] of bronchiolitis patients treated inappropriately
[Link] of oncology patients who had treatment initiated
following Multidisciplinary meeting (Tumour board)
52. Percentage of adverse reaction to radiopharmaceutical.
53. Percentage of Intravenous Contrast Media Extravasation
[Link] taken for triage
55. Percentage of patients undergoing dialysis who are able to
achieve target haemoglobin levels.
37
2. MANAGERIAL INDICATORS
1. Percentage of drugs & Consumables procured by local purchase
2. Percentage of stock outs including emergency drugs
3. Percentage of drugs and consumables rejected before
preparation of Good receipt note
4. Percentage of variations from Procurement Process
5. Mockdrill Variations
6. Incidence of falls
7. Incidence of hospital associated pressure ulcers after admission
8. Percentage of employees provided pre-exposure prophylaxis.
9. Bed occupancy rate & Average length of stay.
10. OT & ICU utilisation rate
11. Critical equipment down time (in hours)
12. Nurse-patient ratio for ICUs and Wards
13. Outpatient satisfaction index
14. In patient satisfaction index
15. Waiting time for services for out-patient consultation and
diagnostics
16. Time taken for discharge
17. Employee satisfaction index
18. Employee attrition rate
19. Employee absenteeism rate
20. Percentage of employees aware on rights and responsibilities
and welfare schemes
21. Number of Sentinel events reported, collected and analysed
within the defined time frame (24 hours)
22. Percentage of near misses
23. Incidence of blood and body fluid exposures
24. Incidence of Needle Stick Injuries (IPD & OPD)
25. Percentage of medical records not having discharge summary
26. Percentage of medical records not having codification as per ICD
27. Percentage of medical records having incomplete and/or
improper consent
28. Percentage of missing records
29. Appropriate handovers during shift change for nurses /
Doctors per patient per shift
38
 30. Incidence of patient identification errors
[Link] to handhygiene practices
[Link] rate to Medication prescription (OP) in Capitals
[Link] & PERFORMANCE APPRAISAL
Education programme consists of two aspects
1. Orientation
2. Continuing educational programme.
v ORIENTATION PROGRAMME:
Orientation is the first step in personnel development. There are 3
areas to which a new staff needs to be oriented
1. The Hospital
2. The Department
3. Patient care.
Induction training program will be conducted for newly joined
employees once in 15 days (Hospital Policy). Orientation on
Department Policies and Procedures will be given by Department
Heads for all newly joined employees.
PERFORMANCE APPRAISAL
Performance appraisal will be done by the department heads and
approved by Medical Superintendent / Medical Director / CEO
once in a year.
18. GRIEVANCE HANDLING PROCEDURE:
The Grievances Policy of SRH defines the manner in which
employees can resolve grievances and facilitate a fair and timely
settlement of a dispute. It aims to create a positive and constructive
work environment.
The grievance may be in regard to :
v Duties
v Relationship with co-workers
v Working conditions
v Mal - Administration
v Disciplinary Matters
39
v When an Employee has a grievance which has not been
resolved with an informal discussion with his immediate
Supervisor, even after 24 hours of the time period,then staff
should submit grievance in writing to the HR Department
through the HOD or can drop the complaints in any of the
‘Suggestion / Grievance Box’ placed inside the hospital
premises.
v There may be circumstances where an Employee may believe
inappropriate to lodge a grievance with the HOD. In these
circumstances based on the discretion of the HR department,
the written grievance is to be directly lodged with the
committee dealing with the same.
v The HR department mediates a meeting between the
aggrieved Employee and the Department HOD. The grievance
shall resolved within a time limit of 7 working days.
v If the issue still remains unsolved within a time limit of 7 working
days, it is the responsibility of the HR Department to submit the
written grievance report to Medical Director / CEO. The
grievance is to be resolved within a time of 14 working days.
v At every stage the employee is allowed to explain complaint
and even suggest how he thinks it may be resolved. If further
advice or investigation is required before a response, the
meeting can be adjourned to undertake this process.
v The time limit given at each stage is considered as the
maximum time limit. However the time limit may be extended
by mutual agreement.
v No employee is permitted to refer any grievances to any
outside authority for redressal of any grievance under any
circumstances except provided under the existing law on the
subject.
v Unwanted disturbance by an employee affecting the peaceful
functioning of the routine activities of the Hospital,
Management have every right to terminate such employees
service without any notice.

40
v While addressing the grievances, both parties are given equal
rights to address their individual purview towards grievance
in the grievance handling committee, and the individual
representations will be taken into consideration by the
Grievance Handling Committee members before taking the
final judgement.
v If any of the aggrieved employees is unhappy with the committee
judgement, he can appeal the decision to the Hospital Appellate
Authority (CEO) to reconsider the decision.
19. SERVICE STANDARDS:
Sri Ramakrishna Hospital is committed to provide the best possible
outcomes and experiences for patients, their families and employees.
The Five service excellence standards that are consistent with
our Mission to provide patient-centered care are as follows. All
employees of the hospital, including consultants, Nurses,
Technicians and Administrative Staff are expected to practice the
service excellence standards that are expected from them.
1. Compassionate Care
2. Response Time
3. Loyalty of Staff
4. Expertise
5. Accountability
MONITORING OF SERVICE STANDARDS
A. PATIENT CARE STANDARDS
1. Patient Safety & Infection Control
v Standard: Maintain a zero-tolerance approach to
hospital-acquired infections (HAIs) and medication errors.
v Measurement:
v Infection rate tracking (e.g., surgical site infections,
ventilator-associated pneumonia).
v Hand hygiene compliance audits (e.g., WHO’s 5
Moments for Hand Hygiene).
v Medication error reports and adverse event tracking.
2. Waiting Time for Services
v Standard: Patients should receive outpatient consultation
within 30 minutes and emergency care within 5 minutes
41
v Measurement:
v Time logs at patient registration, consultation,
diagnostics, and pharmacy.
v Patient feedback surveys on wait times.
3. Emergency Response Time
v Standard: Critical emergency cases should be attended
to within 5 minutes of arrival.
v Measurement:
v Time-stamped incident reports from ER and trauma teams.
v Ambulance response time tracking.
B. CLINICAL EXCELLENCE STANDARDS
Treatment Outcomes & Mortality Rates
v Standard: Maintain a high survival rate for critical
illnesses and post-surgical recovery.
v Measurement:
v Mortality rates per department and condition.
v Hospital readmission rates within 30 days of discharge.
v Length of hospital stay for specific procedures.
Compliance with Clinical Protocols
v Standard: 100% adherence to national and international
clinical guidelines (e.g., WHO, NABH, JCI).
v Measurement:
v Medical audits and peer reviews.
v Case reviews for protocol deviations.
v Checklists and compliance monitoring tools.
C. PATIENT SATISFACTION & EXPERIENCE STANDARDS
Communication & Informed Consent
v Standard: Patients should receive clear communication
regarding diagnosis, treatment, and follow-up care.
v Measurement:
v Patient surveys on doctor-nurse communication.
v Audit of informed consent documentation.
Cleanliness & Hygiene
v Standard: Maintain a 99% cleanliness compliance rate in
wards, OPD, ICU, and surgical rooms.
42
v Measurement:
v Regular environmental audits.
v Patient and visitor feedback on hospital hygiene.
v Housekeeping performance tracking.
Patient Grievance Redressal
v Standard: Resolve 80% of complaints within 48 hours.
v Measurement:
v Number of complaints received vs. resolved.
v Tracking resolution time per case.
v Patient satisfaction scores post-resolution
D. Operational Efficiency Standards
Bed Occupancy & Turnaround Time
v Standard: Optimize bed occupancy to 85%-90%, ensuring
efficient turnover.
v Measurement:
v Daily census reports.
v Bed turnover rate calculations.
Pharmacy & Medication Availability
v Standard:Ensure 95% drug availability at all times.
v Measurement:
C Inventory tracking and stock audits.
C Medication dispensing time monitoring
20. CODE OF CONDUCT POLICY
Sri Ramakrishna Hospital follows a strict code of conduct when
it comes to handling issues of patient privacy and other related
aspects. The code of conduct lays down the various aspects of
our performance and attitude towards the patients.
v To practice the highest ethical and moral and professional
standards which are required for providing patient care.
v To adhere to all rules and regulations which are laid down by
the governing bodies, which includes the Medical & Nursing
Councils and other governing medical bodies.
v To practice the highest professional standards in all aspects of our
treatment and deliver the best patient experience possible.
43
v To emphasize and promote medical awareness in all aspects of
operations and provide the best patient education and
communication at all times.
v To act in an ethical and responsible manner for providing quality
services for other supportive departments.
v To ensure that every treatment aspect is carefully monitored and
documented for the patient.
v Do not mislead others.
v Do not cheat, steal, plagiarize, or otherwise act dishonestly.
v When using information that is not your own in verbal or written
communication or in medical records, give proper attribution,
including the sources and date.
v Do not abuse privileges.
v Be truthful in negotiations and business transactions.
Assume Responsibility for Patient Care
v Do not engage in unsupervised involvement in areas or
situations where you are not adequately trained unless in an
urgent or emergency situation.
v Obtain the patient's informed consent for diagnostic tests or therapies.
v Maintain your objectivity in all decision making and avoid
creating any perceptions of impaired objectivity.
v Take responsibility for the patients under your care; when off
duty, or on vacation, assure that your patients are adequately
cared for by another practitioner.
v Follow up on ordered laboratory tests and complete patient
record documentation conscientiously.
v Do not abuse alcohol or drugs that could diminish the quality
of patient care.
Avoid Conflict of Interest
v Follow institutional policies regarding disclosure of real or
perceived conflicts of interest in a timely manner.
v Avoid conflicts of interest, but when conflicts of interest exist,
always resolve all of them in favor of the patient.
Promote Personal and Environmental Health and Safety
v Adhere to institutional regulations and accepted practices
governing the safe use of chemicals, drugs, equipment, and
products in the workplace.
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 v Take precautions to safely perform our duties and protect our
coworkers.
v Assure that your physical and mental health render you fit to
work.
v Promote a healthy work environment for us and our patients.
v Maintain a standard treatment code for all patients
v To ensure the set quality standards of each department is
followed and documented properly.
OBLIGATIONS
1. Practice Respect for Persons
v Treat those whom you serve, with whom you work, and the
public with the same degree of respect you would wish them
to show you.
v Treat patients and colleagues with kindness, gentleness, and dignity.
v Include patient preferences for treatment in the plan of care
to the fullest extent possible.
v Respect the privacy and modesty of patients.
v Do not use discriminatory, harassing, hostile or profane
language, verbally or in writing.
v Do not discriminate on the basis of gender, religion, race,
disability, age, sexual orientation, national origin, or marital
status.
2. Maintain Patient Confidentiality
v Do not share the medical or personal details of a patient with
anyone except those health care professionals integral to the
well-being of the patient or within the context of an
educational endeavor.
v Do not seek data on patients unless you have a professional
"need to know."
v Do not discuss patients or their illnesses in public places
where the conversation may be overheard.
v Do not publicly identify patients, verbally or in writing,
without documented permission or adequate justification.
v Do not invite or permit unauthorized persons into patient care areas.
v Do not share your confidential computer system passwords
with unauthorized persons.
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3. Maintain Personal Honesty, Communication and Integrity
v Be truthful in negotiations and business transactions.
v Acknowledge your errors of omission (if any) to colleagues.
4. Promote Diversity, Equal Opportunity, and Respect in the
Work place
v Practice the principles of equal opportunity and non-
discrimination.
v Promote an atmosphere in which we can discuss concerns
about diversity and equal opportunity without fear of
retaliation or retribution.
v Maintain dignity and respect for all persons.
v Discuss and resolve disagreement in the workplace in a
professional manner.
IDEALS
1. Virtues
v Strive to cultivate and practice virtues, such as caring,
empathy, and compassion.
2. Conscientiousness
v Fulfill your professional and work-related responsibilities
conscientiously.
v Notify the responsible supervisor if something interferes with
your ability to perform clinical or support tasks effectively.
v Learn from experience and knowledge gained from errors in
order to avoid repeating them.
v Dedicate yourself to lifelong learning and self-improvement
by implementing a personal program of continuing education
and continuous quality improvement.
3. Personal Health
v Develop a personal life style of dietary habits, recreation, disease
prevention, exercise, and outside interests to optimize physical
and emotional health and enhance professional performance.
4. Responsibility to Society
v Avoid unnecessary patient or societal health care monetary
expenditures.
5. Advancement of Professionalism
v Strive to further professionalism.
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22. ECO FRIENDLY MEASURES

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SAVE ELECTRICTY

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SAVE WATER

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22. GOOD SAMARITANS :
Good Samaritans or people who help road accident victims by
taking them to the hospital had everything going against them
from legal wrangles to harassment.
1. A bystander or Good Samaritan including an eyewitness of a
road accident can take an injured person to Sri Ramakrishna
Hospital, and the bystander or good Samaritan will be allowed
to leave immediately except after furnishing address by the
eyewitness only and no question shall be asked to such bystander
or good Samaritan by our Hospital.
2. The bystander or good Samaritan shall be suitably rewarded or
compensated as decided by the State Governments to encourage
other citizens to come forward to help the road accident victims.
3. The bystander or good Samaritan shall not be liable for any
civil and criminal liability.
4. A bystander or good Samaritan, who makes a phone call to
inform the police or emergency services for the person lying
injured on the road, will not be compelled to reveal his/ her
name and personal details on the phone or in person.
5. The disclosure of personal information, such as name and contact details
of the good Samaritan shall be made voluntary and optional including
in the Medico Legal Case (MLC) Form provided by our Hospital.
6. The disciplinary or departmental action shall be initiated by
the Government concerned against public officials who coerce
or intimidate a bystander or good Samaritan for revealing his
name or personal details.
7. In case a bystander or good Samaritan, who has voluntarily
stated that he is also an eye-witness to the accident and is
required to be examined for the purposes of investigation by
the police or during the trial, such bystander or good Samaritan
shall be examined on a single occasion.
8. Video conferencing will be used extensively during examination
of bystander or good Samaritan who is an eye witness in order
to prevent harassment and inconvenience to good Samaritans.
9. Hospital will not detain bystander or good Samaritan or demand
payment for registration and admission costs, unless the good
Samaritan is a family member or relative of the injured and the
injured is to be treated immediately.
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 10. In case a bystander or good Samaritan so desires, Sri
Ramakrishna hospital shall provide an acknowledgement to
such good Samaritan, confirming that an injured person was
brought to the hospital and the time and place of such occurrence.
Source: The Gazette of India No. 25035/101/2014-RS

23. NEW QUALITY INITIATIVES, CSR ACTIVITIES,

AWARDS & RECOGNITION
Ø Sri Ramakrishna Hospital has created a new “Guinness World
Record” for ‘Most people to sign up as organ donors in 8
hours’ signed by 13,206 donors to create awareness among
society on the importance of organ donation in India.
Ø The Hospital has been recognized as “REGIONAL BLOOD
BANK CENTRE”
Ø 3R – Reduce, Reuse, Recycle & eco-friendly papers has been
implemented to conserve natural resources.
Ø Management has taken the required initiatives for implementing
“Guidelines for the protection of Good Samaritans” as directed
by MOHFW.
Ø SRI RAMAKRISHNA INSTITUTE OF ONCOLOGY AND
RESEARCH has been recognized as a member of the
“National Cancer Grid”.
Ø Antimicrobial Stewardship Programme has been initiated in
the Hospital.
Ø New block has been designed, built, operated and certified
through LEED (Leadership in Energy and Environmental
Design) concept, enabling an environmental and social
wellbeing with improved quality of life.
Ø The Hospital has been certified for E-waste recycling for
disposing in a scientific and environmental friendly manner.
Ø Sri Ramakrishna Hospital being a part of SNR Sons charitable
trust gives Free Treatment every year.
Ø Hospital has been certified by ITC Limited (Paper Board &
speciality Papers division) for partnering WOW- Wellbeing
Out of Waste, a National Recycling Initiative by contributing
of waste papers and saving trees.
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Ø Established Free Cancer Ward for Children offering them free Beds,
Medicine, Diet & offering food to attenders also for the past few years.
Ø Laboratory Services has been Accreditated by NABL for
Molecular Biology and Biochemistry.
Ø Received an Award and a Gold Medal from Government of
Tamil Nadu in November 2022 for treating highest number of
patients under Chief Minister Comprehensive Health Insurance
Scheme among Private Hospitals.
Ø Lakhs of women were screened for Breast Cancer and cervical cancer
at free of cost under DEEPAM Project by the Oncology department.
Ø The Hospital has been recognised for Best Multispecialty
Hospital in the field of “Swacchh Bharat”.
Ø Sri Ramakrishna Hospital has been ranked First among the Top
Multi Speciality Hospitals in Coimbatore by THE TIMES
OF INDIA – 2020.
Ø Pharmacy has been awarded for “Best Citation Pharmacy” for
its efficient services.
Ø Hospital has been accreditated by Quality Council of India for
Ethics Committee dealing with the clinical trials and ethical
challenges.
Ø Hospital Ethics Committee has been collaborated with DHR
(Department of Health and Research)
Ø Sri Ramakrishna Hospital has been recognized as a centre for
ADR monitoring and Materiovigilance centre by Indian
Pharmacopoeia Commission, Ghaziabad.
Ø The Hospital has been certified by MTQuA (Medical Travel
Quality Alliance).
Ø The Hospital is recognized by the Tamil Nadu Dr. MGR
Medical University for conducting Allied Health Science
Courses, DNB programme in four specialities by National
Board of Examinations, Compulsory residential Rotatory
Internship programme by Medical Council of India.
Ø Hospital Nursing Services has been Accreditated by Quality
Council of India (NABH) in 2021.
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Ø Sri Ramakrishna Hospital Advanced Stroke Centre has been
certified for “Best Clinical Excellence in Acute Stroke
Care” in 2024.
Ø Sri Ramakrishna Hospital has been collaborated with CAHO
as lifetime Member (for trainings/ Conferences).
21. PATIENT SAFETY PROGRAMME
Every department head shall nominate patient safety / quality
champions who will coordinate with patient safety officer .
Proactive risk analysis is identified based on the probability
of getting risk. Various tools are used to identify these risk
such as FMEA (Failure mode and effect analysis), HIRA
(Hazard identification and risk analysis), PREMs (Patient
reported experience measure), PROMs (Patient reported
outcome measure), etc.
Ø Patient Safety Programme highlights on "ZERO HARM" to
improve patient safety satisfaction and experience through
concentrating safety aspects for a patient from admission till
discharge. Effective patient safety aims at reducing the medical
negligence by decreasing the mortality rate.
PATIENT SAFETY
PATIENT SAFETY OFFICER – Mr. N. DEEPAK
In Sri Ramakrishna Hospital, the improvements made in terms
of patient safety are:
Engineering works (Grab bars, hand rails, vulnerable toilets) –
Grab bars, Hand rails are installed in the hospital for patient safety
including vulnerable patients.
IPSG goals – The Hospital follows 6 IPSG Goals for ensuring
patient safety & to provide safe environment to the patients.
PREMS – PREMs using “CARE MEASURE TOOL” is a
validation tool used to collect patients’ views on how healthcare
services are delivered, including communication with nurses and
Physicians, staff responsiveness, the coordination of care and of
hospital discharge and their experiences while receiving the care.
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Risk assessment before doing any construction - The risk
assessment calculates the risk score by identifying the probability
(likelihood) and consequences (severity) of hazard/ risk. Once the
probability and consequences for each hazard is estimated, mitigation
techniques are identified and rectified based on high risk.
Safety committee - Safety committee bears the responsibility of
ensuring safety of patients and employees across the organization.
Safety committee is held once in a month. Safety rounds with its
budget are also discussed in the safety committee.
Safety rounds are also conducted by the hospital management
monthly once to check the adherence of safety for patients and
CAPA taken accordingly in the Safety committee meetings.
Safe dispensing of medications - Good dispensing practices ensures
to deliver correct medicine to the right patient, in the correct dosage
and quantity, with clear instructions, and in a package that maintains
the potency of the medicine. FIFO method is followed at Sri
Ramakrishna Hospital.
Biomedical waste - Segregation refers to the separation of different
categories of waste generated at source and thereby reducing the risks as
well as cost of handling and disposal. Segregation is the most crucial step
in bio-medical waste management. Effective segregation alone can
ensure effective biomedical waste management. Sri Ramakrishna
Hospital follows 2018 guidelines.
Implant procurement – Implants are procured after the approval from
the Drug (sub) committee by confirming the quality of implant & the
manufacturer with good reports on R&D (Research and Development).
LASA drugs –LASA drugs are arranged according to NABH 6th edition.
Drug allergy intimation - Vague, incomplete, or inaccurate drug-allergy
histories can be detrimental to patient safety and affect patient care.
There is an increased chance of medication errors if details of a drug
allergy are not documented. Drug allergies are identified, documented
and intimated to the patients by the Clinical Pharmacist using Allergy card.
Drug counseling given by Clinical Pharmacist – Patients are
counseled for drug – drug interactions, intake of medications etc by
the clinical pharmacist/ nurses during their discharge.
Surgical safety - It is a final check prior to surgery used to make
sure everyone knows the important medical information they need
to know about the patient, all equipment is available and in working
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order, and everyone is ready to proceed. WHO Surgical safety
checklist is used by the concerned stakeholders.
Injection safety (single use device) - Promoting the single use of
injection devices as a safety priority that requires leadership and
the active engagement of all frontline health-care workers. Single
use device of injections are followed at Sri Ramakrishna Hospital.
Reduction of HOSPITAL ASSOCIATED INFECTION (HAI) -
Healthcare-associated infections (HAI) are a threat to patient safety. HAI
data are monitored by the Infection control team and CAPAdone effectively.
Hazard Identification And Risk Analysis - Hazard identification is
part of the process used to evaluate the risk at various levels. A risk
assessment is the process of identifying what hazards currently exist
or may appear in the hospital. A risk assessment defines which
workplace hazards are likely to cause harm to patients, employees and
visitors. Tools used are : HIRA, MAPSaf, AHRQ etc.
AHRQ (Agency for healthcare research & Quality) Surveys on
Patient Safety Culture - The AHRQ Evidence Model is used for
delivering external support to primary care practices to improve
healthcare quality and implement new evidence into care delivery.
MaPSaf (Manchester Patient Safety Framework) - The Manchester
Patient Safety Framework (MaPSaF) is a tool to help healthcare teams
and organizations assess their progress in developing a safety culture.
It has been adapted for different healthcare teams.
Validated tools are used in the hospital for pediatrics and adult falls,
Consent form for vulnerable patient, WEll’S Tool for DVT,
Nutritional assessment tool, BRADEN scale for pressure ulcer etc.
Radiation safety & Electrical safety - Radiation safety is safe
practices and precautionary measures put in place to promote safety
when working with or near radiation and electricity according to AERB
guidelines. Staff are also trained in Electrical safety by the Engineers.
Capturing patient safety indicators (such as medication errors,
patient fall, dispensing error etc) – If occurrence happens, intimation
and documentation procedures are followed as per NABH 6th edition.
The team is working towards achieving ZERO Defects.
FMEA (Failure Mode and Effect Analysis) - Failure Modes and
Effects Analysis (FMEA) is a systematic, proactive method for
evaluating a process to identify where and how it might fail and to
assess the relative impact of different failures, in order to identify the
parts of the process that are most in need of change.
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Analyzing the sentinel events – A sentinel event as an unexpected
occurrence involving death, serious physical or psychological injury.
In case of sentinel event, the incident has to be reported to QC
department and analysed within 2 hours of occurrence. Adverse event
beyond 2 weeks are also considered as SENTINEL EVENT. A
comprehensive systematic analysis is defined simply as a process for
identifying basic or causal factors underlying variation in performance,
including the occurrence or possible occurrence of a sentinel event.
OT according to NABH – NABH Guidelines for OT are followed
at Sri Ramakrishna Hospital.
Reuse policy in certain areas – According to the manufacturer
recommendation and hospital policy, reuse policy is followed.
Patient alarm (Call bell) – Patient call bell system is installed in each
patient room for easy accessibility during any kind of emergencies.
Equipment calibration: All equipments are calibrated based on
the schedule for accuracy in results. Documents are maintained by
the biomedical engineering department.
Employee survey: On yearly basis, employee survey is taken based on the
awareness level of patient safety and quality and the same is analysed.
Patient feedback: Patient feedbacks are received for both OP
patients and IP patients using modern technology. To ensure GREEN
HOSPITAL, papers are reduced in usage. Using TAB, patient
feedbacks are collected by the patient welfare team, analysed on
weekly basis and CAPA taken accordingly. Patients are intimated
about the corrective action taken by the Hospital for improving
patient experience and patient satisfaction. Even QR code scanner
is available for OP patients to give their feedbacks. The concerned
stakeholders are also intimated about the patient constructive
feedback on monthly basses to do the corrective action. Patient
feedbacks are also surveyed by external person on yearly basis.
Green Hospital Concept: Sri Ramakrishna Hospital undertakes
Green Hospital concept. Hospital has installed solar energy, RO
plant, STP plant, gardening and plantations etc. Hospital has also
been certified for the LEED certification for using eco-friendly
materials across the Hospital (Green Hospital)
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25. BLS ALGORITHM - (AHA 2020 GUIDELINES)

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