Jipmer Quality Council
JQC Monthly meetings will be held every month with Director as chair person to discuss the previous month activities and to decide the activities to be done in coming month. The group leader will not only present their group activities for knowledge of other members but also get critical appraisal and feedback from them.
The implementation steps will be: engagement of stake holders, creating multidisciplinary structure (e.g. Floor based team building/cohorting, restructure hospitalist role/enhancing ownership), redesigning process flow (e.g. Concurrent multidisciplinary rounds), using appropriate tools of the trade. Integrated Multidisciplinary team will be created for human factor engineering to train health care workers at various levels.
The tools of the trade are: multidisciplinary rounding tool, Hand off tool (between shifts and hospital domains), Bed side Clinical Decision Support devices and Simulators for Procedures and physiologic scenarios. The care processes to be developed are: structured rounds, check lists, care pathways, Inter disciplinary protocols ( eg. Upper Gastrointestinal Bleed) and scoring systems. The analytics to be used are: Departmental morbidity and mortality reviews (with emphasis on root cause analysis models), Hospital reviews for mortalities, near misses, adverse events, sentinel events and never events. Common formats for defining and reporting adverse events will be developed. Intra-institutional blame free real time electronic error reporting systems will be developed with collaboration of software designing experts. National level Guidelines for de-identified database for hospital wise events and glossary of reported medical errors will be formulated.
Objectives
- To develop hospital quality paradigm using patient safety as the central domain at JIPMER
- To formulate the Key Performance Indicators (KPIs) for general adoption for improving
- patient safety in JIPMER
- To develop indigenous and cost-effective technological tools to improve patient safety
- To play a lead role in creating integrated model of Patient safety and quality at regional and national level and develop Health care quality leadership training and patient safety institute
Structure of JIPMER Quality Counicil(JQC)
Founder president/ Chairman
Dr Subhash Chandra Parija, Director, JIPMER
Member secretary and Group Co-ordinator
Dr Muruganandham K, Assistant Professor of Urology, JIPMER
Co-ordination committee
- Dr. Anita Rustagi, DMS, JIPMER
- Dr Gitanjali, Professor of Pharmacology
- Dr Muruganandham K, Assistant professor of Urology
- Ms. Vasantha, Nursing superintendent, JIPMER
- Finance officer, JIPMER
Members of JIPMER Quality Council
(Members in groups 1 to 6 will reassemble to form Groups 7 to 12; each member of JQC will be working in two groups at each time.)
Group 1 | Group 2 |
---|---|
Nosocominal infection | Medication |
Dr Rakhi, Microbiology | Prof. Gitanjali, Pharmacology |
Dr Devi Prasad Mohapatra, Plastic surgery | Dr S. Manikandan, Pharm |
Dr B.V. Sai Chandran, CTVS | Dr Biswajith Dubashi, Medical Oncology |
Dr Murali Poduval, Orthopedics | Dr Vaibhav Wadwekar, Neurology |
Dr Jayaprakash Sahoo, Endocrinology | Dr Ravi Philip Rajkumar, Psychiatary |
Dr Narayanan P, Pediatrics | Dr Rashmi Kumari, Dermatology |
Dr Muruganandham K, Urology | Dr Chanaveerappa Bammigatti, Medicine |
Mrs S. Sushya Tech, Pathology | Dr. Kesavan, Pharmac |
Mr.K. Allimuthu, Tech, Microbiology | Mr Saravanan, Tech, Dialysis |
Komathy.S, Nursing, 46 WD | Daisy.D, Nursing, ICU-32 |
Group 3 | Group 4 |
EMSD | Accreditation |
Dr Nandha Kishore, Surgery | |
Dr M.S. GopalaKrishnan, Neurosurgery | Dr Sarasu Jayaraman, Anatomy |
Dr Satyen Parida, Aanesthesiology | Dr B. Krishnan, Dentistry |
Dr Bibekanand Jindal, Pediatric Surgery | Dr P. Veena, O&G |
Dr Manju, Pulm Medicine | Dr Arvind Ramkumar, Surg Onco |
Dr K. Ramesh Babu, Ophthal | Dr Rakhee Kar, Pathology |
Dr Biju. P, Surgical Gastroenterology | |
Sivaranjani.K, Nursing , EMSD | Ms. Vanitha, Nursing, Uro OT |
Mr. Dinakaran, Nursing, Gastro OT | Mr Sundaramurthy, Tech, Path |
Mr. Senguttuvan, Tech, Path | Muthukumarasamy, MRD |
Mrs V Chitralekha, Social welfare officer | Mr. Venkatraman A,Tech, Biochem |
Group 5 | Group 6 |
Fire safety/ Disaster management | Work place/work force safety |
Dr Shyama Prem, Radiotherapy | Dr Lakshmi. P , Med Gastro |
Dr Dhanpathi.H, Nuclear medicine | Dr Arun Alexander, ENT |
Dr Deepak Bharathi, Radiology | Dr Santhosh Satheesh, Cardiology |
Dr Swaroop, PSM | Dr Sreejith P, Nephrology |
Dr G.S. Gaur, Physiology | Dr K.K. Shaha, Forensic Medicine |
Dr Anita Rustagi, I/C MRD | Dr Dasari Papa, O& G |
Mr K Saravanan, Lecturer, Department of Radiotherapy | Dr Medha. R, Biochem |
Mr Ramkumar(auditorium I/C) | |
Dr Vijayaprabhu, Radiotherapy | |
Mr K Anand, Nursing, Transplant ICU | Mrs. Angelin Mary Sheela, Nursing college |
Mr Rajasekar, Tech, Radiology | Mr Gnansekhar, Tech, Blood bank |
Ms S Gobalakichenin, Tech, Biochem | Ms. Catherine, Nursing, EMSD |
Mr Chinnapparaj, Stores officer | Ms Durgadevi T, Tech, Biochem |
Group 7 | Group 8 |
Never events | Operation room safety |
Dr Narayanan, Pediatrics | Dr Murali Poduval, Ortho |
Dr Veena, O&G | Dr Satyen Parida, Aanesthesiology |
Dr Chanaveerappa Bammigatti, Medicine | Dr Deviprasad, Plastic surgery |
Dr B.V. Sai Chandran, CTVS | Dr Arun, ENT |
Dr Nandha Kishore, Surgery | Dr Rakhi, Microbiology |
Dr M.S. GopalaKrishnan, Neurosurgery | Dr Jindal, Pediatric Surgery |
Dr Medha.R, Biochem | |
Mr Sundaramurthy, Tech, Path | Mr. Dinakaran, Nursing, Gastro OT |
Mr Rajasekar, Tech, Radiology | Ms. Vanitha, Nursing, Uro OT |
Ms. Vanitha, Nursing, Uro OT | Mrs S. Sushya Tech, Pathology |
Group 9 | Group 10 |
SOP/Checklist/Communication | Blood/Injection |
Dr Biju P, Surgical Gastroenterology | Dr Biswajith Dubashi, Med Onco |
Dr Vaibhav Wadwekar, Neurology | |
Dr Lakshmi. C. P, Med Gastro | Dr S. Manikandan, Pharm |
Dr Manju, Pulm Medicine | Dr Sreejith, Nephrology |
Dr Rashmi Kumari, Dermatology | Dr Arvind Ramkumar, Surg Onco |
Dr Shyama Prem, Radiotherapy | Dr Rakhee Kar, Pathology |
Dr Muruganandham K, Urolog | |
Mr K Anand, Nursing, Transplant ICU | Mr Gnansekhar, Tech, Blood bank |
Muthukumarasamy, MRD | Komathy.S, Nursing, 46 WD |
Mrs. Angelin Mary Sheela, Nursing college | Dr. Kesavan, Pharmacy |
Ms Durgadevi T, Tech, Biochem | Ms. Catherine, Nursing, EMSD |
Group 11 | Group 12 |
Sentinel events/Root cause analysis | Radiation safety |
Dr Santhosh Satheesh, Cardiology | Mr K Saravanan, Lecturer, Radiotherapy |
Dr Jayaprakash Sahoo, Endocrinology | Dr Swaroop, PSM |
Dr Sarasu Jayaraman, Anatomy | Dr Dhanpathi.H , Nuc medicine |
Dr Ravi Philip Rajkumar, Psychiatry | Dr B. Krishnan, Dentistry |
Dr K. Ramesh Babu, Ophthal | Dr G.S. Gaur, Physiology |
Dr K.K. Shaha, Forensic Medicine | Dr Anita Rustagi, I/C MRD |
Prof Gitanjali, Pharmacology | Dr Deepak Bharathi, Radiology |
Dr Vijayaprabhu, Radiotherapy | |
Mr. Senguttuvan, Tech, Path | Mr Saravanan, Nursing, Dialysis |
Mr.K. Allimuthu, Tech, Microbiology | Ms S Gobalakichenin, Tech, Biochem |
Sivaranjani.K, Nursing , EMSD | Daisy.D, Nursing, ICU-32 |
Mrs V Chitralekha, Social welfare officer | Mr Chinnapparaj, Stores officer |
Deliverable | ||
---|---|---|
Group | November and December | January |
Group 1 Nosocominal Infection |
|
|
Group 2 Medidcation safety |
Draft template for C-slip circulated to JQC and comments received JIPMER Press contacted and agrees to print books for pilot testing of C-slips C-slip template modified & finalized; logistics of implementation worked out Pharmacy agrees to accept only one prescription with original signature One concept proposal sent to Department of Health Research for funding a project on medication safety |
Pilot testing to start by mid-Jan Start with Medicine, Dermatology, Neurology, Medical oncology, psychiatry Inform the clinical faculty and residents during death meeting and through emails Interns Orientation Programme – sensitize the interns |
Group 3 EMSD |
Triage & Fast Track as a first step towards – Reducing overcrowding – Improving ED Floor management |
Data based assessment of triage Triage as a competency for Interns / CMOs Redesign process for lab investigations |
Group 4 Accreditation |
Reading & Review of Accreditation process | To coordinate ( along with Dr Biju) for Codifying all booklets, checklists etc created at JQC forum. To get the guidelines book from NABH |
Group 5 Fire Safety/Disaster Management |
JIPMER Fire Safety Preparedness Committee- 12/2011 JIPMER fire safety plan formulated Fire safety officer Fire audit Fire safety orientation programmes -staff/faculty carried out-RACE/PASS 150 volunteers from various departments trained Common SOP has been developed Dedicated phone-6999 installed for fire alert Fire extinguishers-procured PAS-public address system Effective fire alarm system HLL –Final Stages Signs for exits Floor maps/plans CompletedFire drill at RCC and EMS |
Admin block |
Group 6 Workplace/Work force Safety |
|
|
Group 7 Never Events |
Laminated A3 size poster of WHO surgical safety checklist piloted in Neurosurgery and Surgery OTCross match form Blood transfusion designed | To distribute the WHO checklist in more OTs in JIPMERTo work on Prevention of patient falls And mortality due to obstetric cause |
Group 8 Operation theatre safety |
Booklet of “JIPMER Surgical Safety check list” Conducted preliminary safety survey Literature review on DVT and Hypothermia prevention |
JIPMER Specific DVT Guidelines Hypothermia prevention protocol at operation theatre Outlining theatre sterility protocols |
Group 9 SOP/Checklist/Communication |
Designed | |
Group 10 Blood, Injection safety |
|
Circulate POSTERS & BOOKLET among JQC members If Approved to Print and Distribute |
Group 11 Sentinel Events/Root Cause analysis |
Created a model of Root cause analysis at Mortality and Morbidity meeting and piloted at Cardiology |
To create electronic error reporting systemCirculation of JIPMER specific Model of Root cause analysis to all JQC members for input and finally take to all departments |
Group 12 Radiation safety |
Formulated a radiation safety committee and the first meeting of the committee was conducted on 09 Nov 2012. Radiation Survey has been in all diagnostic installations in Radio-diagnosis. Identified that two of the installation was not meeting the basis safety requirement. Necessary steps have been taken to restore safety. In Nuclear Medicine the Annual Status Report on Radiation Safety for the year 2012 has been prepared and submitted to AERB. Thirteen application for availing Personnel Monitoring Badges to staff working in radiation field has been processed and the badges will be provided to them shortly. In Radiotherapy the Annual Status Report on Radiation Safety for the year 2012 is under process and will be submitted to AERB shortly |
Radiation Survey will be performed in the diagnostic unit of urology OT. Dental X ray unit in minor OT is also being used as office and stores and rest room for residents. This puts the office and paramedical staff in risk to exposure to radiation. A radiation survey will be performed and appropriate recommendations will be given. Bone densitometer and gamma irradiator are yet to be installed due to lack of space. |
Contact
Dr Muruganandham K,
Member-secretary and co-ordinator
Assistant Professor of Urology, JIPMER, Puducherry-6
Phone: +91-9952014597