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

  1. To develop hospital quality paradigm using patient safety as the central domain at JIPMER
  2. To formulate the Key Performance Indicators (KPIs) for general adoption for improving
  3. patient safety in JIPMER
  4. To develop indigenous and cost-effective technological tools to improve patient safety
  5. 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

  1. Dr. Anita Rustagi, DMS, JIPMER
  2. Dr Gitanjali, Professor of Pharmacology
  3. Dr Muruganandham K, Assistant professor of Urology
  4. Ms. Vasantha, Nursing superintendent, JIPMER
  5. 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.)

Members of JIPMER Quality Council
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
Activities of JQC ( As on 31st December 2012)
  Deliverable
Group November and December January
Group 1
Nosocominal Infection
  1. Conducted infrastructure survery
  2. Created Pocket Guide for Hand washing
  1. Analysis of infrastructure survery
  2. Printing and circulating the pocket guide for hand wash
  3. To bring out 2nd edition of Rational use of antibiotics at JIPMER
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
  1. Formulated "SOP for management of occupational exposures to body fluids in JIPMER, Puducherry."
  2. Drafted "JIPMER Working Manual For Post Exposure Prophylaxis For Healthcare Providers."
  3. Coordinated a meeting under chairmanship of Addl MS involving all departments concerned with the implementation of the SOP and brought out the final accepted version of the above two documents
  4. Formulated action plan for hepatitis B vaccination of staff nurses of JIPMER
  1. To put up posters regarding post exposure prophylaxis
  2. To implement Hepatitis B vaccination programme for JIPMER staff category wise, starting with nursing staff
  3. Data collection from each department regarding specific occupational hazards in each department
  4. Stress management cell for healthcare providers
  5. To monitor the implementation of SOP for needle-stick injuries
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
  1. Blood Bank – Donor feedback Register Feedback- Refreshments
  2. Donor registration – Donor interview, counselling, screening – Blood donation – Post donation care – Donor refreshment
  3. Education of route of administration( wrong injection)- Poster & Booklet
  4. Disposal of syringes and needles- Poster
 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

Email: patientsafety[dot]jqc[at]gmail[dot]com