National Guidelines for Improvement of Quality and Safety of ...
National Guidelines for Improvement of Quality and Safety of ...
National Guidelines for Improvement of Quality and Safety of ...
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TABLE OF CONTENTS1. Introduction ……………………………………………………………………………….. 11.1. Target Institutions ……………………………………………………………………… 11.2. The <strong>Guidelines</strong> in the Context <strong>of</strong> <strong>Quality</strong> Assurance Programme ………………... 12. Arrangements <strong>for</strong> <strong>Improvement</strong> <strong>of</strong> <strong>Quality</strong> <strong>and</strong> <strong>Safety</strong> in Hospitals …………….. 32.1. Establishment <strong>of</strong> <strong>Quality</strong> Management Unit (QMU) ……………………………….. 33. Hospital <strong>Quality</strong> <strong>and</strong> <strong>Safety</strong> St<strong>and</strong>ards ……………………………………………….. 4I. Internal <strong>and</strong> External Customer Environment (5S) ………………………………. 61. Seiri (Sorting)2. Seiton (Organisation)3. Seiso (Cleaning with Meaning <strong>and</strong> <strong>for</strong> Beautifying)4. Seiketsu (St<strong>and</strong>ardisation)5. Shitsuke (Training & Self-Discipline)II. Services involving Patient Contacts ……………………………………………….. 166. Reception area7. Immediate service points <strong>and</strong> frontline services8. Responsiveness9. Inpatient care services10. Diagnostic services11. Medical/pharmaceutical supplies <strong>and</strong> equipment management12. Mortuary serviceIII. Overall <strong>Quality</strong> <strong>and</strong> <strong>Safety</strong> <strong>Improvement</strong> ………………………………………….. 3013. Infection control14. Waste management15. Medical record16. Health education activities17. Leadership <strong>and</strong> management18. Productivity <strong>and</strong> quality improvement programmeANNEXES ……………………………………………………………………………………….. 37ANNEX 1: Isles <strong>for</strong> Stationeries ………………………………………………………….. 37ANNEX 2: St<strong>and</strong>ardised Colour Codes ………………………………………………….. 38ANNEX 3: Emergency Tray Checklist (Sample) …….……………………………….…. 39ANNEX 4: Discharge Checklist (Sample) …….………………….……………………... 41ANNEX 5: Cleaning Checklist (Sample) …...……………………………………………. 42ANNEX 6: CSSD Service Flowchart …………………………………………………….. 43ANNEX 7: Visual Control Scheme <strong>for</strong> CSSD …………………………………………… 44ANNEX 8: Protocol <strong>for</strong> Hazardous Waste Management ………………………………. 45ANNEX 9: Patient <strong>and</strong> Employee Satisfaction Survey Forms (Sample) …………….. 47APPENDIX: General Circular on <strong>National</strong> <strong>Quality</strong> Assurance Programme in Health 57
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