Quality safety

JQC

The apex body which plan, coordinate and implement all Healthcare Quality, Patient, Public & Employee Safety aspects in JIPMER based on its Vision, Mission and Quality and Safety Policy.

QUALITY & SAFETY POLICY OF JIPMER

“JIPMER  commits to the  highest standards in the quality of medical education, research and patient care with the safest  environment and practices, aiming for the wellbeing of all patients, employees, students and members of the public”

For achieving the Quality and Safety Policy, JIPMER will

  1. Treat all patients and public with Dignity and Equality in an Ethical manner
  2. Ensure Safety of all Stakeholders including Patients, Employees, Students and Public.
  3. Provide appropriate resources, including staff, finance and equipment in a timely manner so as to conduct its activities in accordance with all statutory and regulatory requirements
  4. Develop and implement a range of policies and procedures in support of this policy and will ensure their effective communication to all stakeholders
  5. Seek and adopt global best practices in healthcare and proactively nurture innovative and dynamic initiatives from within that will assist in delivering the highest standards of quality and safe patient care in a cost effective manner.
  6. Review and amend the policies and procedures on a continuous basis based on a robust feedback system on processes and perceptions
  7. Ensure that all the employees are aware of the Vision, Mission, Quality & Safety Policy as well as rights and responsibilities of patients and employees.
  8. Train and monitor its employees in the implementation of policies and procedures to be followed for achieving the Quality and Safety standards
  9. Encourage all the employees to be proactive in monitoring, detecting and reporting potential hazards, risks and safety incidents so as to learn from them and prevent harm.

Patient safety goals of JIPMER

The JQC decides on the key goals to be achieved, usually based on WHO/GOI guidelines and also taking into consideration the ground level information from JIPMER - this set of goals will be reviewed annually. The patient safety goals of JIPMER in 2022 are:

Goal 1: Identify patients correctly

Goal 2: Improve effective communication

Goal 3: Improve the safety of high-alert medications

Goal 4: Ensure correct-site, correct-procedure, correct-patient surgery

Goal 5: Reduce the risk of health care-associated infections

Goal 6: Reduce the risk of patient harm resulting from falls

Administration of JQC

Head of JQC: Director

Grants executive & financial approval for implementing Quality & Safety program  across JIPMER

Chairperson: Medical Superintendent

Monitors and implements Quality & Safety  aspects related to Patient Care in JIPMER hospital

Co- Chairs

1.Dean(Academic)

Education, training on Quality & Safety of JIPMER to all students, employees of JIPMER

2.Dean (Research)

Research in JIPMER is carried out ensuring safety of all patients and within the framework of legal provisions.

3.Project Coordinator

Projects as well as  the services provided by Facility Management & Engineering services (eg CPWD, HITES etc) comply with  Quality & Safety policy of JIPMER.

4.Deputy Director (Admin.)

Administrative processes are integrated to facilitate implementation  Quality & Safety policy of JIPMER

5.Officer In Charge Nursing

Implementation of Quality & Safety policy of JIPMER for Nurses

JQC Coordinator

Guides the administrators for operating JQC to ensure the Quality and Safety policy of JIPMER is commensurate with the prevailing rules, regulations of the government and courts. Coordinates the  operations with -groups, committees created and monitored by JQC, Heads of all Departments, Divisions and Sections and QIMOs.

Members of JIPMER Quality Council

Director

Medical Superintendent

Dean ( Academic)

Dean ( Research)

DDA

Heads, Officer in charges and QIMOs of ALL Departments & Sections

Members of ALL JQC Groups

Chairman and Member Secretary of ALL Committees formed & monitored by JQC

EX OFFICIO

Director

Medical Superintendent

Dean ( Academic)

Dean ( Research)

Project Coordinator

Deputy Director Admin

All Heads of Departments

All Officers in Charges

NOMINATED

Coordinator JQC

QIMOs of all Departments

Quality Manager JQC

Quality Cell SNOs

Chairman&Member Secretary of the Committees

JQC Group Members

Quality Cell of JQC  

Quality cell is the executive wing of the JQC, which monitors and operationalize Quality and Safety  Goals of JIPMER in close coordination with the Administration, Committees and Groups.

It has its office on the ground floor of Institute Block, intercom number:6051.

All official tapals and correspondence to JQC should be sent to this office, including the copies of minutes of meetings of all groups and committees and the copies of licenses from all sections and departments. The groups of the JQC can have their meetings in this Office.

The following is the composition of Quality Cell.

 JQC Coordinator is the Officer in Charge of Quality Cell.

Quality Manager                                            1

Quality Cell Senior Nursing Officers         10

LDC                                                                1

MTS                                                                1

Committees - formed and/or are monitored by JQC

Committees are formed when

a.There is a legal requirement to form the same

( Eg: Fire Safety, Disaster Management, Hospital Transfusion, HICC etc)

b.JQC feels that an important aspect of the Quality and Safety program requires a constant actionable operation with legal and executive powers.

( eg:  Signage Committee, CPR Committee, Hospital Audit Committee)

Committees will usually have office and other staff independent of Quality cell.

Each committee will have a Chairman, Member Secretary, Alternate member secretary and Members

The committee will regularly discuss the goals, strategies and plans to implement them and meet at least once in 6 months or as per the legal requirement whichever is earlier.

The committees formed as per the request of JQC

  1. Fire Safety Preparedness Committee
  2. Disaster Management Committee
  3. Hospital Infection Control Committee
  4. CPR Committee
  5. Blood Transfusion Committee
  6. Signage Committee
  7. Hospital Audit Committee
  8. Human Resource Management & Training Committee
  9. Hospital Safety Engineering & Facility Management Committee
  10. Hospital Medical Records & HIS Commitee

Groups of JQC

JQC group will

  1. Have specific goals which are reviewed at least quarterly
  2. Focus on a particular quality & patient safety aspect.
  3. Contain 5 to 10 multidisciplinary members
  4. Will evolve strategies to achieve them based on the overall JQC goals.
  5. Have a Group Leader, Group Coordinator and Members.
  6. Each member will be given specific responsibility
  7. Evaluate and discuss the gaps in implementation of its goals at least once a month
  8. Report the difficulties in achieving its goals to the Quality Cell regularly
  9. Be assisted by the quality cell for administrative implementation.

Following are the groups of JQC

  1. Medication safety group
  2. Laboratory safety group
  3. Emergency services group
  4. Surgical safety group
  5. Workplace workforce safety
  6. Safe transport & fall prevention group
  7. Accreditation group
  8. Mother & child safety group
  9. Intensive care group
  10. Nursing services group
  11. Patient welfare group
  12. Documentation/sop group
  13. Infection control group
  14. Radiation safety group
  15. Blood & injection safety group
  16. Never event reporting & root cause analysis group

Last Updated: 22 Feb 2022