Dr. Haneesh1

GENERAL HOSPITAL

ERNAKULAM

THE FIRST HOSPITAL IN

GOVT.SECTOR IN THE

STATE AND FOURTH

IN THE COUNTRY TO

RECEIVE NABH

ACCREDITATION

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Hospital Profile..

Multispecialty Hospital started 170 years back.

Bed strength is 783, is the highest among the hospitals under Kerala Health Services.

Apart from Ernakulum District the hospital caters to neighbouring districts like Trichur, Kottayam, Alleppey and Idukki.

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IN THE BEGINNING….

THE BEGINNING 2008

GOVERNMENT DECISION FOR NABH ACCREDITATION

Selection of Hospitals

Administrative Support

HR issues

Gap analysis

Infrastructural Design

Financial constraints

Statutory mandates

Documentation

CHALLENGES FACED

Administration

District medical office/District Administration

Institution

State

Directorate of Health services/NRHM

Policy Decisions

Government

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HR issues

MotivationWork load

incentives

Committment Rights Duties

Awareness Training Owning

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HR issues

ShortageHR

policyStaff

pattern

Transfer

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Gap Analysis

Only Gaps

Demotivation

Herculean task

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Financial

• BudgetShortage of

Funds

• Not in TimeAvailability

• Government norms

• AuditsFlexibility

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statutory

Building

Fire

Pollution control board

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Documentation• consultancy

Manuals

• Patient loadCase sheets

• Fear of reportingEvents reports

Data capturing

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Documentation

•Computer savyComputerization

Audits

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TRANSFORMATION OF QUALITY CARE…

Formation of Hospital committees1. Core committee/ Quality Assurance Committee2. House Keeping Committee3. Infection Control Committee4. Internal Audit Committee5. Medical record audit committee6. Biomedical Equipment Management 7. Safety Committee8. Blood bank committee9. Clinical risk management 10. Condemnation Committee.11. Diet Committee12. Disaster Management/ Emergency preparedness

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13.Drugs formulary committee

14.Ethics Committee

15. Office Management Committee

16.Purchase Committee

17. Safety Committee

18.Staff welfare Committee

Hospital committees

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Absence of written policies and procedures for health care delivery

Quality manual , policies and procedures for all procedures

Transformation of Quality care…

Staff shortage in various categories

Poor sanitation and cleanliness in the hospital

Recruitment of additional staff by NRHM and

HDC

Sanitation made effective and

checklist for all cleaning

procedures

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Absence of audit on -medical records, clinical

practices, infection control practices

,absence of survey on patient and employ

satisfaction .

Lack of awareness about patients rights and

responsibility

Corrective and preventive actions

taken based on audit and survey

Signage on patient’s rights and

responsibilities, citizen charter

updated

Transformation of Quality care …..

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Inadequate calibration for the equipments

Inadequate monitoring and reporting of adverse events, needle

stick injury, sentinel events etc.

Calibration of all equipments done

Audit and root cause analysis

Transformation of Quality care …..

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Poor signage system- developed layout and signages

Slackened Security systems

Security system strengthened

Transformation of Quality care …..

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Awareness and Training

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Trainings and mock drill

CPR training

Fire training

Ventillator training

NABH training

Disaster

Ventilator Training

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FIRE SAFETY TRAINING

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CPR TRAINING

Mock Drills conducted

Code Blue

Code Pink

Code Orange

Code Red

Code Black

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Mock Drills conducted

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CARE FOR EMPLOYEES..

Employees are given health check up on yearly basis, Vaccinations and personal file maintained for all staffs

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HOSPITAL DAYORUMA

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CHANGE OVER…

CHANGE OVER

HOSPITAL ENTRANCE

DIETARY DEPARTMENT

WARDS

Administrative Office

Oncology Ward

Physical Medicine

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PARKING AREA

Admission/RSBY Counter

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First government hospital to computerize registration and admission procedure

SNCU

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SICU

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ICCU

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OPERATION THEATRE

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Operation theatre

Main Theatre Complex

Five OT

suites

Family Planning theatre

Ophthalmology theatre

Minor OT

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LABORATORY

RDC and clinical lab.HistopathologyMicrobiology Biochemistry HaematologyComputerised and automated

CSSD-High Vacuum High pressure Sterilizer

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First government hospital to have CSSD

First time in Government Sector in the state - Digital X-ray

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CT Scan

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OPG Machine for Dental Dept

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Brachy Therapy

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Tele Cobalt Therapy

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TELEMEDICINE

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Mortuary – Cold Room

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Cold room –Capacity 20

ALS – Ambulance – 108 3 BLS Ambulance

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Palliative Care

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Home care Training Centre

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Power Laundry

BLOOD BANK-24 HOURS

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Medical Record

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LANDSCAPING

LANDSCAPING

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Gender Based Violence Management Centre

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The Proud Moment

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The Proud Moment

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Certificate of compliance for QCI-Essential Standard Program for Medical laboratories

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Baby Friendly Hospital Initiative Certificate

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Pollution Control Board Award

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FICCI Award-2012

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Awards Received

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Projects completed after Accreditation NEW OP BLOCK

MRI

CHEMOTHERAPY WARD

DIETARY DEPARTMENT

HAEMODIALYSIS

MODEL INJECTION ROOM

SEWAGE TREATMENT PLANT

PUBLIC CANTEEN

COMFORT STATION

INTERLOCKING TILING OF ENTIRE HOSPITAL PREMISES

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NEW OP

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•Modification and expansion of OP block

• Air-conditioned and spacious OP chambers

• Large waiting area

Dietary Services

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Therapeutic diet provided to all inpatients free of cost-First of its kind in KERALA probably in the country

CHEMOTHERAPY WARD

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•20 bedded •First hospital in government sector with chemo ward•patient privacy ensured through partition.•Fully Air-conditioned•PPP

PUBLIC CANTEEN

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Modified and hygienic new canteen

COMFORT STATION

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SAFE I MODEL INJECTION ROOM

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MRISubsidized rate to patients 24 hours

HAEMODIALYSIS

Free dialysis for patients

SEWAGE TREATMENT PLANT

INTERLOCKING TILING OF ENTIRE HOSPITAL PREMISES

ARTS AND MEDICINE

ARTS AND MEDICINE

Reaccreditation Assessment January 2014

THE QUALITY TEAM OF GH EKM

Hospital Statistics

2008 2013

Average OP Per day 1000-1500 2000 - 2500

Average Admission Per day

40-50 80 - 100

TIMELINE

Pre-assessment - February 2010

Final Assessment-July 2010

Verification Audit- December 2010

NABH Accredited –January 28,2011

Surveillance Audit–August 2012

NABH Reaccreditation Assessment-January 2014

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