About

By rapid advance in health care sector, the government plan to improve all government hospitals to upgrade state of good quality wellness centers by achieving different accreditation standards thereby improving the quality care to patients and develop a high skilled group of health care professionals. In vision of this objective, the government medical college hospital, Kottayam started a new team named Quality Improvement Cell (QUIC) from 01.01.2020 onwards staffing a doctor, a head nurse and a staff nurse. The team started their preliminary assessment of the hospital by performing gap analysis of various clinical, supportive and academic areas comparing with the national standards.

          By coordinating different departments, the quality improvement cell initiated to form different committee and subcommittee in the hospital (Fire &safety, quality control, laboratory, drug and therapeutic, condemnation committee etc). Team started training health care professionals regarding accreditation programmes (LAQSHYA, MBFHI, NABH, KAYAKALP), hand hygiene, BLS, triaging.

The team introduces the topic KAYAKALP, NABH activities and its standards to the hospital head nurse and link nurses meeting on 23/01/2020.

The team visited General Hospital Ernakulum on 29/01/2020 in order to identify the infection control practices, to obtain ideas about SOPs, MOPs, compare the practices in their area to achieve standardization.

Along with CNE, HICC the quality improvement cell started to educate the health care workers about the basic topics- hand washing, triaging, BLS, cleaning practices and methods. Regarding this, the team coordinates a teachers group including senior residents, post graduates, CNE members, staff nurses, infection control nurses, and staff nurses and housekeeping personnel. The education session started on 19/02/2020 with Kudumbasree cleaning workers.

The gap analysis in the laundry and CSSD done and report submitted to authority. The gap analysis of different ICUs, wards, operation theatre complex and other supporting service areas conducted and report submitted to the authority regularly. Theteam initiated to check the water quality in different water sources in the hospital.

The team also participated in “HARITHA KERALAM” inspection, MCF activities, patient satisfaction surveys etc.

The current practices of cleaning in the hospital were assessed and categorized the areas. The team conducted head nurses meeting for the same to discuss the checklists and distributed to them. The requirements for cleaning articles from all areas were calculated and request submitted. The team prepared the list of items for distribution in various areas, items for repair and submitted to authorities.

COVID CARE WORKS

• In the month of March onwards the team designated for fighting Covid 19 in our hospital in accordance with Covid Control Cell.
• The team coordinates and cooperates with HICC, CNE, housekeeping and MCF in setting up of different wards, ICUs, emergency covid areas, critical care units.
• Conduct regular inspection different areas in the hospital regarding safety practices, infection control measures and conduct education to the staff and public to fight against COVID 19 and documented auditing report to the authorities.
• The team regularly monitor the in and out movement of patient transport, admission, managed care, purchasing different items for covid care areas, participating different zoom sessions , academic meetings, education and psychological support to all health care staff along with covid control team.
• The team arranged and supervised the Covid vaccination of the hospital employees.

LAQSHYA WORKS

Along with the Covid related works the QUIC restarted the accreditation works with LAQSHYA from the month of August 2021 in Obstetrics and Gynecology block with the gap analysis based on the standards. We achieved LaQshya accreditation with a score of 87%, one among the first government medical college hospital in Kerala.

• Monthly quality circle meeting conducted and discussed the gaps and solutions.
• Risk assessment and internal assessment were conducted as per the requirements and discussed.
• KPI calculations done based on standard.

DISTRICT ASSESSMENT ON 21-10-2021

STATE LEVEL ASSESSMENT ON 13-01-2022

FIRE & SAFETY TRAINING

HOSPITAL INFECTION PREVENTION AND CONTROL TRAINING

MBFHI

• With 97.26%, Government medical college achieved MBFHI accreditation in the month on 17/10/2022.
• KPI calculations done.
  • 
• MBFHI SCORE CARD
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ACCREDITATION WORKS

• Selected areas and orientation classes are started in coordination with CNEU.
• In the month of October 2022, we started the work for achieving NABH.
• Gap study started in the entire hospital from November.
• Kick of meeting with all HOD conducted on January.
• Collected gap study report of emergency department and we were working on it currently.
• Preparing SOPs for emergency department.
• Arranging emergency department based on NABH 5th standard.

GENERAL CARE AREAS

Other than LAQSHYA, MBFHI Covid care area regular visits and need assessment is conducting in the general area.

• Registers numbering and uniformity in maintaining registers started,
• Crash cart check list made and distributed
• Mission, vision, Quality policy, values are prepared bilingually for the hospital.
• Burns care unit with ICU and ward arranged as per standards and opened on 06/01/2022.

MEETINGS

Conducting or be a part in regular meetings in relation with smooth and efficient functioning of the hospital like OMU, Quality Circle, Supervisory meetings, Head nurses meeting, Link Nurses meeting etc.

Members of QUIC

1. Dr.Murali T V, Nodal officer, Quality Improvement Cell
2. Ms.Nicemol George, Staff Coordinator
3. Ms. Chaithra.R, Assistant Staff Coordinator
4. Ms.Rajalekshmi S, Assistant Staff Coordinator.