Quality Manual For ISO 9001 - 2008 - Quality Manual

Quality Manual for ISO 9001:2008 - Quality Manual
1 of 56
http://qc.hopehospitals.in/nabh-standards-gui
Quality Manual
Standards of HCOs
01 PCS AAC: Access, Assessment
and Continuity of Care
Quality Manual for ISO 9001:2008
02 PCS COP: Care Of Patients

03 PCS MOM: Management Of
Medication
HOPE
04 PCS PRE: Patient Rights and

Education
QUALITY
MANUAL
Document No. HOPE/QM

Issue No. 1
Revision No. 0
Effective From: 01.08.2007
05 PCS HIC: Hospital Infection Control

06 OCS CQI: Continuous Quality
Improvement
QUALITY
MANUAL
07 OCS ROM: Responsibilities Of

Management
08 OCS FMS: Facility Management
and Safety
09 OCS HRM: Human Resource
Management
10 OCS IMS: Information Management
System
List of Licenses and Statutory
Obligations
ISO 9001:2000
Quality Manual for ISO 9001:2008

Home
11 ANTIBIOTIC POLICY
12 Adverse Drug Reaction
Recent site activity
Procedures and processes

manual
HOPE MULTISPECIALITYHOSPITAL&
RESEARCH CENTER
3RDFL., GIRISH HEIGHTS, BESIDES
BHARAT TALKIES, KAMPTEE ROAD,
SADAR, NAGPUR.
Procedures and processes manual
NABH self assessment

Self assessment toolkit
Join Our Discussion
Ph. 0712-2556866
Minutes of QC meetings
Training Records
CONTENT SHEET
SECTION
Join the Discussion
0.1
0.2
0.3
0.4
1.0
STANDARD MANUAL FOR

HOPE
FOR A COMPLETE SET CLICK
HERE
2116
2.0
3.0
4.0
4.1
4.2
4.2.1
4.2.2
4.2.3
4.2.4
5.0
QUALITY MANUAL
PAGE NO.
Cover Sheet
Content Sheet
Issue History
Revision History of Issue
Introduction, Scope, Exclusion, Approval and
Distribution
Hospital Profile
Quality Policy & Objectives
Quality Management System
General Requirements
Documentation Requirements
General
Quality Manual
Control of documents
Control of Records
Management Responsibility
1
2-4
5
6
7-9
REV.
NO.
0
0
0
0
0
10
11
12
12-13
13
13
13-14
14
14
15
0
0
0
0
0
0
0
0
0
0
3/23/2016 12:29 AM
2 of 56
days since
Project Due Date
Try these samples
Sample case summary
5.1
5.2
5.3
5.4
5.4.1
5.4.2
5.5
5.5.1
5.5.2
5.5.3
Management Commitment
Customer Focus
Quality Policy
Planning
Quality Objectives
Quality Management System Planning
Responsibility, Authority & Communication
Responsibility and Authority
Management Representative
Internal Communication
15
15
15-16
16
16
17
17
17
17
18
0
0
0
0
0
0
0
0
0
0
Sample patient file
Sample bill
SECTION
5.6
5.6.1
5.6.2
5.6.3
6
6.1
6.2
6.2.1
6.2.2
6.3
6.4
7
7.1
7.2
7.2.1
7.2.2
7.2.3
7.3
7.4
7.4.1
7.4.2
7.4.3
7.5
7.5.1
7.5.2
7.5.3
7.5.4
7.5.5
7.6
SECTION
8.
8.1
8.2
8.2.1
8.2.2
8.2.3
8.2.4
8.3
8.4
8.5
8.5.1
QUALITY MANUAL
Page
No.
Management Review
18
General
18
Review Input
19
Review Output
19
Resource Management
20
Provision of Resources
20
Human Resources
20
General
20
Competence Awareness & Training
20-21
Infrastructure
21
Work Environment
21
Service Realization
22
Planning of Service Realization
22-23
Customer related processes
23
Determination of requirements related to service
23
Review of Requirements related to the Service
23-24
Customer Communication
24
Design & Development
24
Purchasing
25
Purchasing Process
25
Purchasing Information
25
Verification of Purchased Product/Service
26
Production and Service provision
26
Control of Production and Service provision
26
Validation of Process for Production and Service
26
Provision
Identification and Tractability
26-27
Customer Property
27
Preservation of Service
27
Control of Monitoring and Measuring Device
28
QUALITY MANUAL
Measurement, Analysis and Improvement
General
Monitoring and Measurement
Customer Satisfaction
Internal Audit
Monitoring and Measurement of Processes
Monitoring and Measurement of Service
Control of Non-Conforming Service
Analysis of Data
Improvement
Continual Improvement
Page No.
29
29
29
29
29-30
30-31
31
31
31-32
32
32
Rev.
No.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Rev. No.
0
0
0
0
0
0
0
0
0
0
0
3/23/2016 12:29 AM
3 of 56
8.5.2
8.5.3
Annex-A
Annex-B
Annex-C
Corrective Action
Preventive Action
Responsibility and Authority
Hospital Organization Chart
Process Charts
32
33
34-36
37-39
40-52
0
0
0
0
0
ISSUE HISTORY
Issued To
Issue
No.
01.08.2007
PROPRIETOR
01.08.2007
CHIEF
EXECUTIVE
01.08.2007
CHIEF
MANAGER
Date of Issue
Description of Documents Issued

QUALITY
MANUAL,
PROCEDURE, QUALITY
FORMATS
QUALITY
MANUAL,
PROCEDURE, QUALITY
FORMATS
QUALITY
MANUAL,
PROCEDURE, QUALITY
FORMATS
QUALITY
PLAN AND
QUALITY
PLAN AND
QUALITY
PLAN AND
REVISION HISTORY OF ISSUE

Remove
Insert
Date of
Page No.: Page No.
Amendment
& Rev No & Rev No.
Nature of Change
Signature of
copy holder &
Date
INTRODUCTION
This Quality Manual describes the Quality Management System, through chapters 4.0 to
8.0 based on the requirements of ISO 9001:2000 which are complementary to the
3/23/2016 12:29 AM
4 of 56
requirements of the services provided, adopted as a strategic decision, implemented and

practiced byHOPE MULTISPECIALITYHOSPITAL& RESEARCH CENTER.
SCOPE
The Quality Management System covers all aspects and facets of: providing
multispeciality medical care under one roof especially expertise in managing critical
medical emergencies and specialized surgeries.
QUALITY MANAGEMENT SYSTEM
The Quality Management System flows out of the Quality Policy and objectives stated in
this manual, and is customer- focused & aimed at enhancing customer satisfaction and
winning his loyalty. It also meets the regulatory and legal requirements of the service. It
uses the process approach, systematic identification and management of activities /
processes that are employed through, a sequential process of Plan -Do -Check -Act
(PDCA) Cycle.
Plan:
It is to establish the objectives & processes necessary to deliver
results.
Do:
Implement the processes identified.
Check: Monitor & measure processes and service against plan & report results.
Act: Take actions to continually improve process performance.
EXCLUSIONS:
ISO 9001:2000 Requirements EXCLUSION TABLE
Exclusion
Justification
Design and Development Hospital does not perform design and development
(Clause 7.3)
activities. It provides the Services, surgery and
treatments, which are accepted worldwide in
medical circles. Hence the applicability of clause
7.3 is excluded
Validation of Processes for Hospitals Service does not require any process to
Service Provision (Clause be carried out on experimental basis. Hence the
7.5.2)
applicability of clause 7.5.2 is excluded.
APPROVAL
The Management approves this Quality Manual and is committed,
To diligently practice the QMS and thus to serve customers with great &
prompt responsiveness.
To enhance customer satisfaction by meeting their requirements &

expectations besides complying with relevant statutory and legal obligations.
To establish, implement and review the quality policy and its objectives,
with a view to ensuring their continuous suitability through improvements as
necessary.
To make available all necessary resources including providing an

infrastructure of facilities for achieving this purpose.
DISTRIBUTION
This Manual, its copies or extract from it, must not be passed on to any person without
the written permission of the Proprietor of the Hospital. Unnumbered / Uncontrolled
copies may be given to customer / outside agencies purely for information purpose.
UNCONTROLLED copies are not covered under change control but are current at the
time of issue.
Management Representative (MR), appointed by the Proprietor, is responsible for
establishing and maintaining the processes of the Quality Management System, for
3/23/2016 12:29 AM
5 of 56
periodically reporting to the management on the performance of the system and for
promoting awareness of customer requirements through out the Hospital.
The CONTROLLED copies are covered by Change Control and are stamped in red on all
pages. It is the responsibility of CONTROLLED copyholder of this manual to maintain
and incorporate all revision on receipt and keep it up to date.
The controlled copy is given to the following:
Master Copy
(with the Proprietor)
Copy no. 1
(with Chief Executive)
Copy no. 2
(with Chief Manager)
All the staff members of the Hospital are allowed to have access to controlled copy lying
with the Chief Manager.
HOSPITALPROFILE
HOPE MULTISPECIALITY HOSPITAL & RESEARCH CENTER is a MULTISPECIALITY
HOSPITAL established in the year 2005 to render various medical services.
The overall management of the Hospital is looked after under the supervision ofDr. B. K.
Murli, PROPRIETOR. Further the Hospital also employs qualified and highly experienced
people to run its operations. The Hospital has the required infrastructure to render the
services.
The Hospital has been following quality management systems stringently, which is clear
from the fact that it has been meeting the tough quality standards prescribed by its
customers. However now with a view to demonstrate it publicly, it has decided to get it
certified as per ISO 9001:2000 standards so that its working team is motivated to
maintain quality standards regularly thus resulting in better quality services.
1.
This Quality Manual is the apex document that describes the Quality
Management
System
established
and
implemented
by HOPE
MULTISPECIALITYHOSPITAL& RESEARCH CENTERto meet the requirements
of International Standard ISO 9001: 2000 and to consistently provide services that
meet customer and, where applicable, regulatory requirements. Quality
Management System, which is customer focused, aims to enhance customer
satisfaction through the effective application of the system and the processes for its
continual improvement and the assurance of conformity to customer and applicable
regulatory requirements.
2.
This Manual applies to all activities, which contribute to the quality of
services provided by the Hospital.
OUR QUALITY POLICY

We ensure for our patients:
The highest standards of clinical care.
Safe environment.
Medication safety.
Respect for right and privacy.
International injection control standards.
Access to a dedicated well-trained staff.

OUR QUALITY OBJECTIVES
3/23/2016 12:29 AM
6 of 56
The important quality objectives of the Hospital are:
To regularly upgrade the quality of services provided by the Hospital.
To provide satisfactory customer service through continuous

improvements of service Quality.
Achieve, sustain and improve its reputation for excellence in medical

treatment by using modern and effective methods.
Continuously explore the developments in surgery, medicine and

diagnosis and adopt the latest methods and medicines accordingly.
Ensure the availability of adequate resources to sustain and maintain

the quality assurance programme of the Hospital and continually
improveits effectiveness.
4.
QUALITY MANAGEMENT SYSTEM

4.1
General Requirements
The Hospital has developed and implemented a documented Quality Management

System to meet the requirements of ISO 9001:2000 standards. The Quality
Management System is implemented by:
a)
Identifying the processes throughout the Hospital including those for
management activities, provision of resources, service realization and
measurement needed for the QMS.
b)
Determining the sequence and interaction of these processes.
c)
Determining the criteria and methods required to ensure the effective
operation and control of these processes.
d)
Ensuring the availability of resources and information necessary to
support the operation and monitoring of these processes.
e)
Measuring, monitoring and analyzing these processes.
f)
Implementing actions necessary to achieve planned results and
continual improvement of these processes.
The Hospital plans & manages these processes in accordance with QMS. The
system also has a framework for controlling processes, which are outsourced.
Main Service Processes:
Consultation & Diagnostic Process (ODP & IPD)
Operation Process
ICU (Intensive Care Unit), Recovery Room, Special ward, General ward,
NeonatologyProcess
Pharmacy procurement of medicine and sale process
Pathology Process
Physiotherapy Process
Radiology Process
Support Service Processes:
Registration process
Insurance cover Patients
Stores Process
Outsourced Processes:
Meal process
House-keeping process
Reference for Service Processes:
Annexure - C
4.2
Documentation Requirements
3/23/2016 12:29 AM
7 of 56
4.2.1 General
a.
The organization chart and job specifications of the key personnel define
and document the level and responsibilities.
b.
The statement of the organizations Quality Policy & Quality Objectives
provides the basis for QMS.
c.
The Quality Manual, which is established and maintained, details the
scope of the QMS and exclusions with justifications.
d.
The Quality Management System enjoins documented procedures as
required by ISO 9001:2000.
e.
Documented operating process wherever required by the Hospital, such
as Process flow chart and Quality Plans etc.
f.
Quality records as required by standard ISO 9001:2000 (4.2.4) for
effective operation and control of activities/processes.
The procedures describing the logical sequence of activities with
necessary control and responsibility are established, documented,
implemented and maintained.
NOTE:
The documentation including procedures is based on the size
and type of our Hospital, complexity and inter-relation of activities and
competence/skill level of personnel. It can be in any form or type of
mediume.g. hard copy/electronic media.
4.2.2 Quality Manual
This Quality Manual, which is established and maintained, details the scope of the
QMS, exclusions with justifications & documented procedures or reference to them.
It also describes the interaction between the processes of QMS.
4.2.3 Control of Documents
All Documents of the Quality Management System are controlled. A documented
procedure (QP 4.1) is established to cover the following:
a.
To approve documents for adequacy prior to issue.
b.
To review, update and re-approve documents.
c.
To identify the current revision status of documents.
d.
To ensure that relevant version of documents are available at the
points of use.
e.
To ensure legibility, identifiably & irretrievability of the documents.
f.
distribution.
To identify the documents of external origin & control their
g.
To prevent unintended use of obsolete documents and suitably
identify them, if they are retained for any purpose.
Reference:
CONTROL OF DOCUMENTS
4.2.4
QP 4.1
Control of Records
A documented procedure, QP 4.2 is established, for the identification, storage,
retrieval, protection, retention-period and disposition of all quality records. Quality
records are legible, readily identifiable and retrievable.
Records required, as evidence of conformance to requirements and for effective
operation, of Quality Management System are controlled.
Reference:
CONTROL OF RECORDS
QP 4.2
3/23/2016 12:29 AM
8 of 56
5.
5.1
MANAGEMENT RESPONSIBILITY
Management Commitment
Management is committed for the development, implementation and improvement
of the Quality Management System through:
a)
Its Communication to all concerned in the Hospital (through internal
meetings, display on the notice board, internal circulars, internal audit etc.),
the importance of meeting customer as well as regulatory and legal
requirements of the service provided.
b)
Establishing of the Quality Policy.
c)
Establishing of the Quality Objectives.
d)
month).
Conducting management review meetings (at least once in nine
e)
Ensuring the availability of necessary resources, physical and human,
for all activities.
5.2
Customer Focus
The Management ensures that customer requirements are determined and are
fulfilled with the aim of enhancing customer satisfaction. The top management of
the company believes that Organizations depend on their customers and therefore
should understand current and future customer needs, should meet customer
requirements and strive to exceed customer expectations. Customer requirements
are generated through internal meetings, management review meeting, customer
Suggestion / Complaint Form etc.
Reference:
CUSTOMER SUGGESTION / COMPLAINT FORM
5.3
HOPE /F/5/01
Quality Policy
The Quality Policy Statement defines the Hospitals quality policy. Employees are
fully briefed about this policy on joining the Hospital and during planned training.
All employees are responsible to implement the Quality Policy of the Hospital. The
Quality Policy is displayed at prominent places within the Hospital and is controlled.
Management, while defining Quality Policy, considers the following;
a.
Hospital.
It is appropriate to the purpose of the services provided by the
b.
It reflects commitment to meet the requirements, and continually
improve the effectiveness of Quality Management System.
c.
It has a framework for defining and reviewing of Quality Objectives.
d.
It is communicated and understood by all concerned in the Hospital.
e.
suitability.
5.4
It is regularly reviewed (at least once in a year) for continuing
Planning
5.4.1 Quality Objectives

Management has established the Quality Objectives at relevant functional levels
within the Hospital.
These objectives are measurable and consistent with the quality policy, commitment
to continual improvement and also provide for meeting the requirements of the
service.
These objectives are reviewed at least once in a year.
5.4.2 Quality Management System Planning
The Quality Management System is planned to meet the requirement of ISO
3/23/2016 12:29 AM
9 of 56
9001:2000 and also the Quality Objectives defined by the Hospital. The
documented Quality Management System is the result of planning and is in line
with the Quality Objectives that the Management sets. The requirement, which the
system is meant to meet, are:
1.
Determination of the processes needed for the system and application
thereof throughout the Hospital.
2.
Determination of the sequence and interaction of these processes.
3.
Determination of the criteria and method to ensure the effectiveness
of the operation and control of the processes.
4.
Making available the requisite resources, human as well as physical,
to support the operation & maintenance of the processes.
5.
Monitoring, measuring and analyzing the processes.
6.
Initiating actions to achieve planned results and also for continual
improvement of the processes.
The management further ensures that the integrity of the QMS is maintained
wherever and whenever any changes to the system are planned & made.
5.5
Responsibility Authority & Communication
5.5.1 Responsibility And Authority

Responsibility and authority are defined and communicated, to all concerned for
effective quality management. The responsibility and authority of key persons and
organization chart are given inAnnexure A & Annexure B respectively.
5.5.2 Management Representative:
Management appoints Chief Executive of the Hospital as a Management
Representative, who, irrespective of other responsibilities, is responsible and
authorized for following:
a.
To establish, implement and maintain the processes of Quality
Management System.
b.
To report to Management on the performance of the Quality
Management System and also on any need for improvement.
c.
Hospital.
To promote awareness of customer requirements, throughout the
d.
To liaise with external agencies on matters relating to Quality
Management System as deemed necessary.
e.
Maintaining the master list of documents and records of all the forms
and formats.
f.
5.5.3
Control and disposal of obsolete documents in the Hospital
Internal Communication:
Appropriate communication processes regarding Quality Management System & its
effectiveness are established within the Hospital. Management verifies the
effectiveness of such communication(s) and ensures that the same leads and
contributes to effective Quality Management System.
Internal communication is through display of quality policy at appropriate places,
briefing the requirements of QMS during internal meetings, internal memos, face
to face verbal communication, or communication through telephone etc. Proprietor
addresses the staff to build quality culture in the Hospital at regular interval. Use of
these tools will depend on the type of activity.
5.6
Management Review
3/23/2016 12:29 AM
10 of 56
5.6.1 General:
Management reviews the implementation of Quality Management System, at
planned intervals (once in nine months) to ensure its continuing suitability,
adequacy and effectiveness.
The review covers:
1.
Assessing opportunity for improvement.
2.
Evaluation of the need for changes to the QMS.
3.
Hospitals Quality Policy.
4.
Hospitals Quality Objectives.
5.
Customer requirements and expectation.
6.
Resource requirement.
7.
Any other point, which come to the notice of the management.
For this purpose a Management Committee consisting of Proprietor, Chief

Executive and Chief-Manager is appointed. Records of management review are
maintained.
5.6.2 Review Inputs:

The inputs for the management review include the current performance and
opportunities for improvements on the following:
Follow up action from previous reviews.
Result of audit reports.
Customer feedback.
Customer Suggestion / complaint.
Process performance and service conformity.
Resources needed.
Status of Preventive and Corrective Actions.
Planned changes that could affect Quality Management System such

as issues related to Quality Policy and Objectives, Technological up-gradation,
Training needs, Resource profiles etc.
Continued suitability and effectiveness of Quality System.
Recommendation for improvement.
Any other issue.

5.6.3 Review outputs:
The outputs from the management review meeting, include actions relating to:
a.
Improvement of the effectiveness of the Quality Management System
and its processes.
b.
Improvement of service related to the customer requirements.
c.
Resources requirements/needs.
The proceedings of the Management Review Meetings are recorded in the form of
minutes and extracts circulated to concerned functionaries for action.
Reference:
MANAGEMENT REVIEW MEETING RECORDS
6.
6.1
HOPE/F/5/02
RESOURCE MANAGEMENT
Provision Of Resources
The Management determines and provide in a timely manner the resources needed:
a.
To implement, maintain and improve the Quality Management
System and continually improve its effectiveness; and
b.
To enhance customer satisfaction by meeting the customer
3/23/2016 12:29 AM
11 of 56
requirements.
Resources include doctors, infrastructure, medicines, equipment, consumables,
equipments, trained personnel, and process control equipments.
Review of resource requirements is carried out formally during internal meetings,
management reviews meetings, resource requirement form and also when any
change in courses is required. The requirements for resources are informally
monitored continuously to ensure compliance with statutory regulations, needs and
expectations of patients and Industry.
Reference:
RESOURCE REQUIREMENT FORM
6.2
HOPE/F/6/01
Human Resources
6.2.1 General
The management ensures that personnel who are assigned responsibilities under
the Quality Management System are competent and are suitably qualified on the
basis of education, training, skill and/or experience. Competency requirements for
various employees have been spelt out by the Hospital.
Reference:
QUALITY PLAN FOR COMPETENCE CRITERIAFOR EMPLOYEESQPL 6.2
6.2.2 Competence, Awareness and Training:
The Management takes action to:
a.
Lay down competence requisites for personnel performing activities
affecting service quality.
b.
Provide suitable training to satisfy these needs.
c.
Evaluate the effectiveness of the training provided.
d.
Ensure that its employees are aware of the relevance and importance
of their activities and their contribution to achieve quality objectives.
e.
Maintain appropriate
skills/experience & training.
personnel
records
of
education,
Reference:
EMPLOYEE COMPETENCE, EXPERIENCE, COMPETENCE
AND TRAINING RECORD
EMPLOYEETRAINING ATTENDENCE RECORD
6.3
HOPE/F/6/02
HOPE/F/6/03
Infrastructure
The Hospital determines, provides and maintains the requisite infrastructure and
facilities (in internal meetings, management review meetings and through resource
requirement form) for achieving conformity of service including:
a.
Buildings, Workspace and associated Utilities.
b.
Process equipments, hardware and software.
c.
Supporting services, if any.
Reference:
RESOURCE REQUIREMENT FORM
HOPE/F/6/01
HOUSE KEEPING CHECK LIST

HOPE/F/6/04
6.4
Work Environment
The Hospital further identifies and manages the human and physical factors of the
work environment necessary to achieve conformity to service requirements.
7.
SERVICE REALIZATION
3/23/2016 12:29 AM
12 of 56
7.1
Planning Of Service Realization

Service realization is the sequence of processes and sub-processes required for
achieving the service conformity and requirements. Management prepares Process
flow chart, Quality Plans and other associated documents that describe how the
processes of quality management system are applied.
In planning the processes for realization of service, the Hospital determines the
following, as appropriate:
a)
Quality Objectives and requirements related to the characteristics of
the service.
b)
The need to establish processes and documentation and to provide
resources specific to the service.
c)
Verification, validation, monitoring and inspection, specific to the
service and the criteria for its acceptance.
d)
The records evidencing the realization process and that the same
meets and fulfills the requirements of the processes and conformance of the
resulting service.
The Hospital determines service realization processes & acceptance criteria,
through Process flow chart, Quality Plans and other documents for specific service.
To meet the requirements of service planning, following steps are followed:

a)
Adhere to diagnostic/ treatment plan as prepared by the consulting doctor.
b)
Provide skilled doctors and competent para-medical staff. Provide equipment and
maintain in fit and reliable condition equipment required for - diagnosis, treatment,
operation and support services.
c)
Establish procedures and stick to these procedures required for rendering quality
services- from appointment to discharge of patient.
d)
Create and maintain medical records, review records, progress records, diagnosis
records and surgery records.
e)
Identification and verification of patient's progress at appropriate stages during
the course of treatment.
f)
7.2
Prepare and maintain quality records.
Customer Related Processes
7.2.1 Determination of requirement related to the service:

The Hospital determines the customer requirements, which includes the following:
a.
Service requirements including availability and support before,
during and post treatment as specified by the customer.
b.
Requirements necessary for service, if not specified by the customer.
c.
Statutory and Regulatory requirements applicable to the service.
d.
Additional requirements as decided by the management/ specialist /
consultants, related to the service.
The Hospital has determined and implemented effective arrangements for communicating
with customers in relation to:
a) Information pertaining to range of treatment, the facilities, fee structure and
other pertinent details that the patient/ customer may seek.
b) Enquiries and corporate contracts.
c) Patient / customer feedback including suggestions & complaints from patients/
customers.
The Hospital has ensured that all patient contracts are subject to contract review. This
3/23/2016 12:29 AM
13 of 56
includes release of health record information for, patient/ client payment agreements and
third party administrator arrangements.
7.2.2
Review of Requirements related to service:

The Hospital reviews the customer requirements related to service, together with
additional requirements as determined.
This review is conducted prior to the commitment to supply the service to the
customer to ensure:
a.
Service requirements are defined.
b.
Contract requirements differing from those previously expressed are
resolved, if any.
c.
The Hospital has the ability to meet the defined service requirements.
The results of the review and subsequent follow-up actions are recorded in the
customer file.
Where the customer does not provide any documented statement of requirements,
the customer requirements are consociated before acceptance, wherever required.
It is ensured that, wherever service requirements are changed, the relevant
documents are amended and the concerned persons are made aware of the
changed requirements.
Note:
Such awareness is relevant in the case of service information
catalogues, brochures, advertisements etc.
7.2.3
Customer Communication
The Hospital identifies and implements effective arrangements for communicating
with the customer relating to following:
a.
Service information. (Throughinformation catalogues, brochures,
advertisements etc.)
7.3
b.
Enquiries, contracts including amendments.
c.
Customer feedback including Customer complaints.
Design & Development

Hospital does not perform design and development activities. It provides the
Services, surgery and treatments, which are accepted worldwide in medical circles.
Hence the applicability of clause 7.3 is excluded.
7.4
Purchasing
7.4.1 Purchasing Process

The Hospital controls its purchasing processes to ensure that purchased
Product/Services conform to specified purchase requirements. The type and extent
of control applied to the suppliers and purchased Product/Service depends upon
the effect on subsequent Product/Service realization processes or the final results
of the Service.
The Hospital evaluates and selects suppliers/consultant Doctors/service providers
based on their ability to supply Product/Service in accordance with Hospitals
requirement. Criteria for selection, evaluation and periodical re-evaluation of
suppliers are established. The results of evaluations and necessary follow up
actions are recorded and maintained.
Reference:
QUALITY PLAN FOR EVALUATION AND RE-EVALUATION OF
SUPPLIER / SERVICE PROVIDER/CONSULTANTS
QUALITY PLAN FOR PURCHASE
QPL/7.4.1
QPL/7.4
3/23/2016 12:29 AM
14 of 56
7.4.2 Purchasing Information

Purchasing documents contains information describing the Product/Service to be
purchased including, where appropriate, the following:
a.
Requirement for approval of Product/Service, procedures, processes and
equipment.
b. Requirement for qualification of Product/Service.
c. Quality management system requirements.
The Hospital ensures the adequacy of specified purchase requirements contained in
the purchasing documents, prior to their communication to the supplier. The
purchasing order can be verbally, telephonic or through purchase order.
Reference:
QUALITY PLAN FOR PURCHASE
QPL/7.5
7.4.3 Verification of Purchased Product/Service

The Hospital establishes and implements, inspection and other activities necessary
for verification of the purchased Product/Service vis a vis the specified purchase
requirements. Where it is proposed either by the Hospital or its customer, to
perform verification activities at the suppliers premises, the intended verification
arrangements and method of Product/Service release, are clearly specified in the
purchasing information.
7.5
Service Provision
7.5.1 Control of Service Provision

The Hospital plans and controls all operations/ service provision under controlled
conditions including as applicable:
a.
Making available, information that describes the characteristics of the
service.
b.
Availability of work instructions, as necessary.
c.
Using and maintaining suitable support services.
d.
Availability and use of the monitoring and measuring devices, where
applicable.
e.
Implementing of monitoring and measurement activities, where
applicable.
f.
The implementation of release and post-service activities.
7.5.2 Validation of Processes for Service Provision

Hospitals Service does not require any process to be carried out on experimental
basis. Hence the applicability of clause 7.5.2 is excluded.
7.5.3
Identification and Traceability

The Hospital identifies, the service provided by suitable means throughout the
process of service realization.
The Hospital does identify the status of the service with respect to monitoring and
measurement requirements.
The Hospital does control and record the unique identification of the all the patients
to whom the service has been provided.
7.5.4 Customer Property

The Hospital takes care of the customer property like medical documents etc. while
3/23/2016 12:29 AM
15 of 56
it is under its control or is being used by the people working in the Hospital. The
Hospital identifies, verifies, protects and safeguards the property of customer. These
medical documents are kept with the incharge/head of the related department. The
Hospital duly informs the customer if any of the customer property is lost damaged
or is otherwise found to be unsuitable for use.
7.5.5 Preservation of Product / Service
The Hospital does preserve the conformity of the service / product, including
constituent parts, with the customer requirements during internal processing and
till release of patient / delivery. This covers identification, handling, storage and
protection.
The Hospital ensures that medicines, equipment, documents, patient items used in
the Hospital are maintained and delivered in a manner that prevents damage,
deterioration and loss. Instructions have been given to staff for handling, storage,
preservationand timely delivery of services to patients so as to achieve the highest
level of customer satisfaction.
Adequate care is taken during treatment of patients, staff takes appropriate care at
applicable stages of treatment / diagnosis.
The diagnostic records etc. are preserved against damage and deterioration.
The Hospital ensures that the services provided match the treatment plan evolved
during the initial visit of the patient and in the time frame as decided during the
initial consultation. On completion of the treatment, the patient is given detail
record.
7.6
Control Of Monitoring And Measuring Devices

Hospital has determined the Monitoring and Measurement to be undertaken and
Monitoring & Measuring devices to provide evidence of conformity of service
provided.
To ensure valid results, measuring equipments are: (a)

Periodically calibrated or verified against measurement
standards traceable to National or International Standards and Calibration
Records are reviewed/maintained.
(b)
Adjusted or Re-adjusted as necessary.
(c) Identified for the Calibration Status.
(d)
Safeguarded from Adjustments.
(e)
Protected from Damage and Deterioration during Handling,
Maintenance and Storage.
When the results of calibration are found to be unsatisfactory or the instrument
goes out of order, the equipment is immediately discontinued from use and the
service agency is informed. The equipment is putback in use only after the defect is
satisfactorily rectified.
In addition the Hospital assess and record the validity of the previous measuring
results when the equipment is found not to conform to requirements.
When used in the monitoring and measurement of specified requirements, the
ability of computer software to satisfy the intended application is confirmed. This is
undertaken prior to initial use and reconfirmed as necessary.
Reference:
EQUIPMENT CALIBERATION CUM MAINTENANCE
REGISTER
CALIBERATION REPORT
RECORD OF VALIDITY OF THE PREVIOUS
MEASURING RESULT
8.
HOPE/F/7/11
HOPE/F/7/12
HOPE/F/7/13
MEASUREMENT, ANALYSIS & IMPROVEMENT
3/23/2016 12:29 AM
16 of 56
8.1
General
The Hospital does define, plan and implement the monitoring, measurement,
analysis and improvement processes needed:
8.2
1.
To demonstrate conformity of the service.
2.
To ensure conformity of Quality Management System.
3.
To continually improve the effectiveness.
Monitoring And Measurement
8.2.1 Customer Satisfaction:

The Hospital does monitor information relating to customer satisfaction as one of
the measurements of performance of the quality management system. The Hospital
also monitors information relating to customer perception for fulfillment of
customer requirement. The methodologies for obtaining and using this information
are determined.
Reference:
CUSTOMER FEED BACK FORM
HOPE/F/8/01
8.2.2 Internal Audit:

The Hospital conducts periodic planned internal audits (at least once in nine month)
to determine whether the quality management system:
a.
Conforms to planned arrangement of the requirements of the
International Standard and to the Quality Management System established by
the Hospital.
b.
That the internal audit system is effectively implemented and
maintained.
The Hospital plans the audit program taking into consideration, the status and
importance of the processes and areas to be audited, as well as the results of the
previous audits. The audit criteria, scope, frequency and methods are defined.
Selection of auditors is done in a manner, which brings about objectivity and
impartiality of the audit process. In case the audit is conducted departmentally
then it is ensured that no person conducts audit in respect of his own area of
activity.
A documented procedure (QP 8.2.2) specifying the responsibilities and
requirements for planning and conducting audits and for reporting results and
maintaining records are defined in documented procedures.
Management takes timely corrective actions on deficiencies found and eliminates
non-conformities and the causes detected during the audit without undue delay.
Follow up activities includes the verification of the implementation of corrective
actions, and reporting of verification results.
Reference:
QUALITY PLAN FORINTERNAL AUDIT
QP 8.2.2
8.2.3 Monitoring and Measurement of Processes

The Hospital applies suitable methods for monitoring & where applicable
measurement of QMS processes. These methods do demonstrate their ability to
achieve planned results. When planned results are not achieved, appropriate
preventive & corrective action is taken to ensure conformity of the service.
QMS process will be monitored and measured by No. of N.C. from

Internal Audit.
Resource requirement process will be monitored by no. of resource

requirement raised and there compliance status.
Purchase Process will be monitored and measured by supplier / service

provider performance rating and consultant performance rating.
HRD process will be monitored and measured by No. of Training
3/23/2016 12:29 AM
17 of 56
Programs arranged and effectiveness of training.
Service Process will be monitored by the progress of service and result of

the service.
Quality Control process will by monitored and measured by no. of

complaints on Quality.
Monitoring of quality objectives also is one of the ways to monitor process

performance and its effectiveness and other way is to have a formal review of
the process during management review and index the effectiveness based on
a questionnaire (Monitoring and Measurement of QMS Processes).
Reference:
MONITORING AND MEASUREMENT OF QMS PROCESSES
HOPE/F/8/08
8.2.4 Monitoring and Measurement of Service

The Hospital monitors and measures the characteristic of the service, to verify that
requirements for the service are fulfilled. This is carried out at appropriate stage of
the service realization process according to planned arrangement.
Evidence of conformity with the acceptance criteria is documented in the patient
file. Records do indicate the person authorizing for release of service.
Discharge of patient does not proceed until all the planned arrangements have
been satisfactorily completed, unless otherwise approved by the relevant authority
and where applicable by the customer.
8.3
Control Of Non Conforming Service

The Hospital ensures that the service, which does not confirm to the requirements,
is identified and controlled to prevent unintended use, delivery and treatment. The
control and related responsibilities and authorities for dealing with
non-conformance service are defined in a documented procedure (QP 8.3).
Reference:
CONTROL OF NON-CONFORMING SERVICES

8.4
QP 8.3
Analysis of Data
The Hospital collects and analyzes appropriate data to determine the suitability and
effectiveness of the Quality Management System and to evaluate where continual
improvements of the Quality Management System can be made. This includes data
generated as a result of monitoring & measurement and from other relevant
sources. The Hospital analyses this data, to provide information on:
a.
Customer satisfaction.
b.
Conformance to service requirements.
c. Characteristics and trends of processes and service including opportunities

for preventive action.
d.
8.5
Suppliers / Consultants contribution.
Improvements
8.5.1 Continual Improvement

The Hospital plans and manages the processes necessary for the continual
improvement of the effectiveness of Quality Management System and facilitates the
continual improvement of Quality Management System through the use of Quality
Policy, Quality Objectives, Audit results, Analysis of data, Corrective and Preventive
actions and Management Review.
8.5.2 Corrective Action
The Hospital takes actions to eliminate the cause of non-conformity in order to
prevent recurrence. Corrective actions are appropriate to the effect of
non-conformities encountered.
3/23/2016 12:29 AM
18 of 56
The documented procedure (QP 8.5.2) for corrective action defines requirements
for:
a.
Reviewing Non-conformities (including customer complaints).
b.
Determining the causes of non-conformities.
c.
recur.
Evaluating the need for actions to ensure that non-conformities do not
d.
Determining and implementing the action needed.
e.
Recording results of action taken.
f.
Reviewing of corrective action taken.
Reference:
CORRECTIVE / PREVENTIVE ACTIONS
QP 8.5
8.5.3 Preventive Action

The Hospital determines action to eliminate the causes of potential non-conformities
in order to prevent their occurrence. Preventive action(s) taken are appropriate to
the effect of the potential problems.
The documented procedure (QP 8.5.3) for preventive action defines requirements
for:
a.
Determining potential non-conformities and their causes.
b.
Evaluating the need for action, to prevent occurrence of
non-conformities.
c.
Determining and implementing preventive action needed.
d.
Recording results of action taken.
e.
Reviewing of preventive action taken.
Reference:
CORRECTIVE / PREVENTIVE ACTIONS
ANNEXURE-A
RESPONSIBILITY AND AUTHORITY
QP 8.5
PROPRIETOR
All statutory and regulatory requirements related to service
Service planning and Service control
Effective utilization of resources
Over all responsibility for service quality
Evaluation, Selection and Re-evaluation of Consultants
To mobilize and monitor finances
Analysis of QMS data
Overall incharge for continual improvement of QMS
Controlling Non confirmity Services
Taking action for customer Suggestion and complaints
CHIEF EXECUTIVE
Overall responsibility to see whether all the documents are controlled
and records are maintained
To communicate properly the decision of the Management to the all
employees
Planning and Conducting management review meetings
Planning and conducting internal audits
Corporate Empanelment
Overall Pharmacy & store control and authorizing purchase
Pathology & Physiotherapy
3/23/2016 12:29 AM
19 of 56
human
-
Business Development
Patient Outstanding
Evaluation, Selection and Re-evaluation of Suppliers
Mobilize and monitor human-resource requirement
To create and provide environment and facility for development of
resources
Ensure availability of all type of resources and infrastructure
Total responsibility for recruitment and training
Taking corrective & preventive action
CHIEF MANAGER
Developing market and establishing Brand
Customer Communication, Customer Complaints and Customer
Support & Customer Relation
Overall control on outsourced process
To maintain the equipments in working condition
Taking care of calibration process
Ensure timely correction of breakdowns
Ensure effective planning & implementation of preventive maintenance
Maintain safety of employees
Preparing all QMS related data
CMO
-
Billing of Patients
Consultant Co-Ordination
RMO
-
Total responsibility to plan and control the Service

Discharge Summary
Appointments
Consultant Co-Ordination
Leave approval
Marinating consultants log sheet
ACCOUNT OFFICER
Hospital & Pharmacy overall Accounting, Auditing and related legal
compliance
Prepare and distribute Salary
Manage Bank operations
Maintain Management information system (MIS)
FRONT OFFICE EXECUTIVE

Complaints
Telephone Handing
STD/Coin Box
Asst. Patient Relation
Repair & Maintenance
NURSE IN-CHARGE
Sister In charge
Medical Equipment Maintenance
3/23/2016 12:29 AM
20 of 56
WARD ASSISTANT
Assistant House Keeping
Maintaining Of H/R Stock
Repairs & Maintenance Report Sister In charge
PHARMACY ASSISTANT
Party Purchase
Pharmacy Purchase
Maintain minimum stocks, where applicable
Maintain stock record in computer and Maintain physical and ledger
balance
25
SOP FOR DOCTORS
1. INTRODUCTION:
This department assists all the patients for treatment.
2. SCOPE OF THE DEPARTMENT:
3/23/2016 12:29 AM
21 of 56
2.1 Goal
To give the patients immediate and right treatment
2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize the Services
Provided
2.3 Type of customers and age groups of patients served
All types of patients (Pvt,TPA,Corporate)

All types of patients (Below Poverty Line to Higher class)
All age groups (infants to adults)
2.4 Timeliness of services provided

Counseling of the relatives while admission(by CMO 20 min
Billing)
Meeting the patient after admission / transfer(RMO)
15 min
Information to the consultant(RMO)
10 min
Doctors referral(RMO)
30 min
Reporting of the investigation (to consultant)(RMO)
Acc to lab TAT
Complaint or query of patient (RMO) 30 min

Filling pre Auth Form(RMO)
1 hour
Filling Discharge card after intimation(RMO)
30 min
2.5 Extent to which

level of care / service
meets patient needs.
Administering the
deliverance of inpatient
care on time with
accuracy and zero error.
3. STRUCTURE:
3.1 Organization chart
4.2 Job description

Medical Suprintendent
1.
He shall be the head of the medical department, responsible for supervision of the doctors and
making policies for them. He shall hold meetings with the RMO incharge weekly.
2.
He sees the establishment and administers the proper treatment and medicines to the patient by
RMO.
3.
He shall be answerable for all the medico legal cases.
4.
He shall be the head medical records and responsible for making policies for medical records.
5.
He is the authority to the release any information from the medical records (patients file).
6.
Address the medical issues / complaints of the patients and take action.
7.
Communicating with the consultant in case if there is any problem.
8.
He shall examine every patient on admission and make proper entries thereof and take care that
such medicines as he may think proper for their certain and speedy cure be duly administered.
9.
6. He shall see every patient once a day and oftener, if requested. He shall order and be
responsible for the drugs, surgical instruments and books belonging to the asylum and he shall report
the case of every patient fit for discharge to one or more of the Committee of Visitors.
10. At each monthly meeting he shall state the number of patients received and discharged, the
number of deaths, the manner of employment, the weekly cost of maintenance with such matters as
may appear as desirable.
11. He shall be responsible for the management and condition of the establishment of the medical,
surgical and moral treatment of the patients and of all general arrangements within the institute, and in
case of emergency shall have the power of calling on the assistance of any physician or surgeon. He
shall also in all cases of fatal or dangerous accident or other emergency immediately communicate to
the Director.
12. He shall regulate the duties of the Doctors and and prepare from time to time a manual there of for
their guidance.
13. He shall review all the discharge summaries before giving it to the patients.
5.1 Qualification:
3/23/2016 12:29 AM
22 of 56
MS, MD or diploma in any specialized field after

Experience
5 years experience in hospital.
5.2 Key skillsManagerial skills, Leadership.
Knowledge of medico legal systems.
5.3 Staffing model

1 FTE
5.4 Infrastructure
Working area Medical superintendent office.
1 PC, Printer,Telephone line-1
RMO Incharge1.
He shall be the incharge of all RMOs and responsible for supervision of the RMOs.
2.
He will make sure that all the medical policies are adhered by the RMOs.
3.
Helping Director or Medical superintendent in drafting policies and implementing them.
4.
Address RMO inter-personal issues.
5.
He shall lead the team of RMOs and motivate the time to time.
6.
He shall hold meetings with the RMOs weekly Address the medical issues / complaints of the
patients and take action.
7.
He sees the establishment and administers the proper treatment and medicines to the patient by
RMO.
8.
He shall handle all the medico legal issues.
9.
He shall check the entire patients files everyday.
10. Helping RMOs in Providing answer to queries / justification to the TPA regards to any patient.
11. Communicating with the consultant in case if there is any problem.
12. He should take round everyday ,speak to the patient relative and ask for feedback.
13. He shall see every patient once a day and oftener, if requested.
14. At each monthly meeting he shall state the number of patients received and discharged the number
of deaths, DAMA, any mismanagement at our end.
15. He shall be responsible for the management and condition of the establishment of the medical,
surgical treatment of the patients and of all general arrangements within the institute, and in case of
emergency shall have the protocol of calling on the assistance of any physician or surgeon. He shall
also in all cases of fatal or dangerous accident or other emergency immediately communicate to the
medical superintendent.
16. He shall regulate the duties of the Doctors and and prepare from time to time a manual there of for
their guidance.
A. Resident Medical Officer (R.M.O.)
(1) RESIDENT MEDICAL OFFICER is the most responsible member of the staff of the Hospital and is
present all times of the day and night on his shift duty. As such no moment the Hospital can be left
uncovered by R.M.O. Even at the end of his shift, he will not leave the post till the other RMO takes
over.
(2) He should also be responsible for the conduct of other junior staff posted in his department.
(3) Though they are administratively responsible to hospital managers but for their work they are
directly responsible to consultants.
(4) He is responsible for all the patients admitted in his department (Pvt./Semi- Pvt./ICU/ICCU or
Economy wards) towards proper medical care. Though a patient as always admitted being on the
spot under a consultant, but he on the spot, will be responsible for either first-aid if consultant has
not seen the case or for carrying out the orders of that consultant.
(5) He will also he responsible for nursing care being provided by the nursing staff. He will ensure
that all advised tests and procedures are carried out without any delay.
(6) On admission or in emergency he will always carry out necessary examination and history
taking so that case sheet of the patient is completed in all respect. He will ensure that the patients
documents are complete more so in cases of medico legal. He should also make sure that
uncommon abbreviations are not used in the case sheet. He will sign the case sheet with his
comments during all his rounds.
(7) He will also be providing medical aid to admitted cases under a consultant, in time of
emergency, but latter informing the consultant about the action taken. He will also consult the
3/23/2016 12:29 AM
23 of 56
specialists at time of requirements.

(8) He himself should take round of all the patient under his care at least thrice a day and as often
as necessary. He will also accompany the consultants, when they come on round and will ensure
that all his orders are carried out.
(9) He will ensure that proper diet is being to the patient as per his medical condition or as advised
by the consultant.
(10)
Discharge summary of the patient who is going to be discharged is to be prepared by
RMO and should be signed by the consultant and RMO both.
(11)
He will also explain the patient about the precaution and medications to be taken
after discharge.
(12)
He will perform his duties as assign to him by the RMO incharge.
6. PROCESS FLOW
7. INTERDEPARTMENTAL LINKS
8. OUTCOMES
8.1 Quality objectives
Higher patient satisfaction through prompt treatment and accurate documentation.
Develop an empathetic approach towards patient care.
Positively impact discharge-planning process/TPAprocess by reducing the time taken for discharge
8.2 Quality Monitors
8.3 Performance Metrics

No. of pending discharge cards
No of DAMA
No of death due to mismanagement
REVIEWED BY
APPROVED BY
MANAGEMENT REPRESENTATIVE
PROPRIETOR
SIGNATURE
-------------------------------------------------------------------------------------------------------------------------------------
SOP FOR NURSING STAFF

1. INTRODUCTION:
The Nursing department assists all the patients for bedside nursing care,mediaction and administrative
functions in the ward.
.
2.1 Goal
To give the patients comprehensive nursing care which will help the patients in the recovery.
Provided
3/23/2016 12:29 AM
24 of 56
Feedback verbal and written

Patients/ relatives / RMO/consultant


Meeting the patient after admission / transfer
(Checking vitals)
10 min
Doctors referral
30 min
Investigation appointment
30 min
Reporting of the investigation
Acc to lab TAT
Complaint or query of patient
30 min
Forms to get filled (insurance)
1 hour
Discharge process
2 hour
Returns of medicine
15 min
Discharge card (doctor to be called)
30 min
2.5 Extent to which

level of care / service
meets patient needs.
Administering the
deliverance of
inpatient care on time
with accuracy and zero
error.
3. STRUCTURE:
3/23/2016 12:29 AM
25 of 56
4.2 Job describtion

1. Nursing Superintendent / Matron
The Matron will be responsible to the MS for the administrative and technological aspects of
nursing in the hospital. Her charter of duties will include the following:
1)
Administration of nurses, their accommodation and messing, viz. equitable distribution and
economic utilization of nursing staff, maintenance of duty roster, turnout and discipline,
supervision over living conditions, amenities and messing facilities in the Nurse mess and hostel;
leave, temporary duty, training etc.; reports and returns; service record of nurses.
2)
Nursing care of patient in the hospital:
(a)
Supervision of nursing by Sister/Nurses to ensure that the high
Standard is maintained all the time.
(b)
Welfare of patients including recreational facilities.
(c)
Cleanliness of Wards/Departments.
(d)
Accompany the MS on his round.
3)
Such other duties, as may be delegated to her by MS.
2. Nursing Supervisor
Duties of Nursing/Superintendent/Matron/Nursing Supervisor can be clubbed or divided as per
available manpower.
A. General Management:
To ensure
1.
Adequate nursing staff.
2.
Duty roster well planned.
3.
Punctuality of staff working under her.
4.
Nurses in proper uniform.
5.
Visit to all the patients.
6.
Availability of material consumable and non-consumable items.
7.
Availability of life-saving drugs.
8.
Availability and functioning of the saving equipment.
9.
To check and ensure the judicious use of telephone.
10. Eatables are not allowed/used at OT or ICU Nursing Stations.
B. Patient Welfare and Safety:
1. Call be well within easy reach.
2. Patient clean and presentable.
3. Patient appears comfortable, free from pain and tension.
4. Bed neatly made.
5. Patient position is correct.
6. Used bed pans and urinals removed promptly.
7. After meals, the food trays removed promptly.
E. Ward General Appearance:

1. Ward/room cleaned and ventilation satisfactory.
2. Patients bathroom are clean and in order.
3. All wash basins clean.
4. All the beds in line.
5. All bed pans, kidney trays and dustbins clean and dry.
6. All drugs to be checked for expiry date.
7. Injection, medicines trolleys fully equipped, clean and tidy.
8. Nursing station clean and organized.
9. Notice board tidy and outdated notice removed.
10. Medicine containers labeled, legible and clean, cupboard tidy and locked.
11. Oxygen cylinders and suction apparatus are adequate and in working order.
12. Adequate supply of linen, thermometer, syringes, dressing sets and other materials are kept out for
use in the ward in her absence.
3. Ward In-Charge/Sister
She will be responsible to the Matron/Nursing Superintendent for the efficiency of the Nursing
services in her ward/department.
Her duties will be administrative and professional.
A. Administrative duties of her will include the following:
1. Public relations.
2. General sanitation in the Ward/department.
3/23/2016 12:29 AM
26 of 56
3. Attention to prevention of hospital cross-infection.

4. Nursing documentation and reports are required.
5. Allotment of duties to subordinates their disciplines, welfare and supervision.
6. Attention to economy in manpower and materials.
7. Maintenance of stock register/inventories and periodicals checks.
8. Check of custody, expenditure and accounting of dangerous and controlled stores.
B. Professional duties of her will be as follows:
1. Supervision of Patient care as laid-down under duties of staff nurses and other ward staff.
2. Attention to details of arrangements for medical and surgical procedures carries out in
ward/department such as sterilization and observation of asepsis, administration of oxygen,
medicines etc.
3. Supervisions over demands for and utilization of diets.
4. Training of nurses and paramedical personnel.
5. Actual nursing care of patients, if required.
6. Participation in training programs.
4. Staff Nurse
General: A nurse by the very nature of her duties is in closer touch with the patients and therefore is
in a better position to win his confidence. It is the duty of every nurse to uphold the noble traditions of
her profession and dedicate herself to the care of patient in her charge. She should pay particular
attention to her turnout and conduct. While maintaining the dignity and decorum of her profession, she
must at all times be cheerful, kind and courteous and sympathetic towards her patients and their anxious
relatives. These qualities along with professional skill will win her respect and cooperation of her
patients. She must remember as good nursing is as important part of efficient patient care as good
doctoring.
Specific :
1. All staff nurses should be wearing white aprons as well overall supplied from the hospital.
2. All nurses should enter the hospital from the back gate as specified for staff entry.
3. Staff nurses posted in any department (ward, ICU, ICCU, OT etc.) are responsible to the Sister
in-charge of that department for all administrative and clinical work. As far as clinical work is
concerned, they are also responsible to the Resident Doctors on duty and to specialists.
4. The nurses are assisted by the other staff of the ward such as ward boy, ward girl, Housekeeping
staff.
5. She has to perform some administrative duties as well along with her professional duties.
6. Any other duty, administrative or clinical, assigned by her seniors related to nursing.
7. The administrative duties are concerned with efficient and economical ward management and
include activities, which are subsidiary to but cannot be divorced from patient care.
These duties are as follows:
i)
Handing over and taking over charges on change of duty staff.
ii)
Cleanliness of ward, annexes, furniture, linen, equipment and stores.
iii)
Preparation of demands for diet.
iv)
Preparation of dressings, bandages and splints and items required for dealing with
emergencies.
v)
Keeping an inventory of all items under their charge.
vi)
Ensuring the serviceability of all equipment and store on charge and accounting for
them.
vii)
Safe custody and accounting of dangerous and controlled drugs.
viii)
Replacement of expandable stores and obtaining replacement of unserviceable
non-expandable items, in accordance with standing orders.
ix)
Exchange of clean linen and patients clothing for solid ones.
x)
Disinfecting the ward, when required.
xi)
Safe custody and maintenance of medical records of patients.
xii)
Control of visitors and public relation.
1. Her Professional Duties are:
i)
General Nursing Care.
ii)
Technical Nursing Care.
iii)
Training Responsibilities.
General nursing care consist of the care of attention to the patient in the interest of his/her comforts and
general well being of his/her physical health. The activities grouped under this functional heading are
generally speaking common to all patients irrespective of the nature of his/her illness. These duties will
be as follows:
i)
Admission and Discharge of patients.
ii)
Assistance and instruction to the patient and their relatives.
iii)
Personal hygiene of the patient, viz. sponging, care of mouth, eyes, hair and nails.
iv)
4-hourly or more frequent attention to pressure points, as ordered, in the case of
bed ridden patients.
v)
Serving and removing hot water bottles, bedpans and urinals.
vi)
Bed-making.
3/23/2016 12:29 AM
27 of 56
vii)
Feeding of patient incapable of feeding themselves, distribution of diet and
preparation of special items of food.
viii)
Ward rounds with Sister/Doctor.
ix)
Supervision of work of staff placed under her.
Technical nursing care comprises those tasks and activities concerned with the treatment and
management of the particular illness of which the patient is suffering. These duties will be as follows:
i)
Administration medicines and/or injections as ordered and recording the same.
ii)
Assisting or actually caring out technical procedures sterilization preparation of
injections, preparing and serving of enemas, catheterization, fomentation, irrigation,
dressing, oxygen therapy etc. and cleaning up thereafter.
iii)
Preparation for and assistance in carrying out clinical tests, investigations,
including collecting, labeling and dispatching specimens.
iv)
Taking and recording Pulse, Temperature and Respiration.
v)
Rounds with doctors.
vi)
Pre and Pos-operative care.
vii)
Escorting patients to and from departments.
viii)
Technical reports.
Training Responsibilities
cover not only the training of those placed under her control but also attention to
self-improvement. These will be as follows:
i)
Demonstration and guidance to student nurses and domestic staff.
ii)
Assistance in orientation of new staff .
iii)
Participation in training program and other professional activities for the
advancement of knowledge and skill.
iv)
Any other duties related to nursing services.
Main points in nursing duties and responsibilities (Clinical) :
1.
Admission and Discharge of patients.
2.
Preparation of patients file.
3.
Sending the patients file at the reception at the time of discharge.
4.
Getting discharge summery prepared by RMO.
5.
Informing the reception about the room no. of the new admission.
6.
Informing all transfers to the reception.
7.
Assistance and instructions to the patients and their relatives.
8.
Personal hygiene of the patient, viz. sponging, care of mouth, back etc.
9.
Serving and removing hot water bottles, bedpans and urinals.
10.
Feeding of patients who can not eat themselves.
11.
Ward rounds with Nursing Superintendent, M.S. and Consultant if required.
12.
Administration of medicines and /or injections as ordered and recording the same in
case sheet.
13.
Assisting doctors in carrying out certain procedures whenever required.
14.
Assisting or actually carrying out technical procedures, sterilization preparation
of injections, indenting of medicines, giving enemas, oxygen therapy etc.
15.
Collecting samples for investigation whenever required. Getting all tests done,
which the treating doctor ordered.
16.
Taking and recording of vital signs like Pulse, Temperature and Respiration.
17.
Pre and Pos-operative care.
18.
Escorting patients to and from departments. OT, either herself or with the help of
ward boy.
19.
Supervision and housekeeping staff getting patients room cleaned thrice a day.
20.
At each change of over, the outgoing nurse will go with the incoming to each patient
from bed to bed, room to room and thus hand over to the patient.
21.
Any worsening of the condition of the patient must be reported to the
RMO/Consultant in-Charge.
22.
Imparting health education to the patients and relatives.
23.
Staff nurse on duty should be changing of IV fluid bottles and in no circumstances
attendant help should be sought for the same.
24.
While putting cannula to the patient, there should be deep plastic sheet under the
site of arm so as not to strain the bed sheet. This should be strictly followed part should be
properly fixed after confirming its patency.
25.
In obstetric cases special attention should be given in care of breasts and perineum
care, catheterization of female patient, baby care, assisting in breastfeeding.
26.
Please ensure that no torn up linen, i.e bed sheets, pillow covers, draw sheets,
blankets etc. are given to the patient at any cost.
27.
Extra caution to be taken for deluxe/VIP suit room patients.
Tissue Box.
Small Soap.
28.
29.
A fresh towel should be given to the patient at the time of admission.

In case of surgical patient to prepare patient for operation, i.e. shaving, cleaning and
3/23/2016 12:29 AM
28 of 56
dressing etc.
30.
To confirm that pre-op papers are complete and fully documented (consent,
investigation etc.). Proper consent must be taken signature of patient (if major and mentally
sound) and nearest relative must in presence of proper witness.
31.
To confirm that advance for surgery has been paid, before sending the patient for
surgery.
ICU Patients
32.
Taking care of bedsore and bedridden patients (after physicians permission).
33.
Any terminal ill patient should not be left alone.
34.
Strict vitals charting of ICU patients.
35.
Assisting in physiotherapy.
36.
Take care while administering NTG drip, Dopamine drip etc. and should start in
presence of doctor on duty.
37.
ICU should not be misused for sitting purposes by any other staff while on duty.
38.
Assistance in orientation of new nurses.
39.
Any other duty related to nursing services.
40.
Last but not least, to see chargeable procedures and consumable are written in the
patients file in charge sheet.
Some of the chargeable items are:
(a) Blood transfusion.
(b) Enema.
(c) Bowl wash.
(d) Gastric lavage.
(e) All lab tests.
(f) All imaging tests.
(g) Oxygen inhalation
(h) Cut down.
(i) Aspiration
(j) Dressing.
(k) Baby care for new born.
(l) All consultants visits.
(m) Medicines are from ward
(n) ECG, Echo, U.S., TMT, Endoscopy.
but not replaced.
Main Points in Nursing Duties and Responsibilities (Administrative)
1.
Night nurses, if found sleeping either with patient or attendant or security staff will
be terminated immediately.
2.
No junior nurse will give an I.V. injection either in vein or in drip set, special drugs
like Insulin, Potassium chloride and Lariago.
3.
Do not appear for duty without your nametag/Identity Card.
4.
Telephone should not be used for personal chat and staff nurse on duty must check
its misuses, by all means.
5.
Eatable should not be allowed or used at Nursing Stations of ICU/OT complex.
5. Additional responsibilities
Attend the phone calls and enquiries about the ward
Make entries in admissions and discharge book
Coordinate with various departments (Admission counter, Casualty, Wards, OT, Medical Records,
Diagnostics, Linen, Security, Food & Beverages etc.) for facilitating services.
Providing reference information to consultants
Ordering stationary twice a month and weekly orders of materials.
Co oordinating discharge summary to the patients.
Completing the documents in the file before dispatching.
Ensure accurate documentation of treatment related documents
Scheduling tests and invasive procedures/ investigations
Liaison with other support services (Housekeeping, F&B, Maintenance, Waste Management and
others) to ensure delivery of care
Requisition for medicines and other medical supplies
Ensure accurate billing entries and facilitate discharge planning
To meet the patients daily and assist them in their queries.
Check the insurance status of the patients.
To coordinate with different departments and to see the best comfort of the patients during their
stay.
Escalate the feedback to the GRO for proper action to be taken.
Complaints received by the nurses to be recorded, follow up is taken if not resolved, and are
escalated to guest relations executives.
Updating the documents in the file in the proper sequence.
5.1 Qualification:
3/23/2016 12:29 AM
29 of 56
GNM. Multi-lingual preferred.
5.2 Key skillsGood communication skills, mannerism, telephone etiquettes, helping attitude.
Multi-task and to enjoy costumers interaction
Knowledge of customer management techniques to deliver higher satisfaction.
5.3 Staffing model

Total staff- 37
Ward
M
Special ward-1
3
Special ward-2
3
Special ward-3
3
ICU
3
OT ( including nurses 3
and tech)
E
2
2
2
2
2
N
2
2
2
2
2
5.4 Infrastructure
Working area is at the nursing station of the respective ward.
1 PC, Telephone line-1
Documents to be maintained
1. Patient file-charting
2. Nurse record written (TPP I/O).
3. All medications are charted correctly.
4. All other treatments charted correctly
5. Stock Register
6. Investigation reports file
7. IP register- entry of the details to be made in the register on admission, discharge, transfer in or
transfer outg
8. Medication register
9. Intubation register
10. Linen Register- Daily stock taking of linen is to be maintained.
11. Maintenance Log book- the maintenance complaint/issues.
12. Inventory register
13. CT MRI register
14. Blood issue register
15. Communication book
16. Duty book
17. Stationary order book
6. PROCESS FLOW
NO
3/23/2016 12:29 AM
30 of 56
Flowchart: Decision:
Blood
test
YES
NO
3/23/2016 12:29 AM
31 of 56
YES
Text Box: H.R.D
3/23/2016 12:29 AM
32 of 56
8. OUTCOMES
Higher patient satisfaction through efficient nursing and accurate documentation.
Develop an empathetic approach towards patient care.
Positively impact discharge-planning process by reducing the time taken for discharge

Complaint resolution rate of 95%( at ward level)
Turnaround time (getting the room ready after discharge)
Average time taken for discharge per patients

No. of Feedback forms collected from the patients
No. of pending discharge cards
No. of Medication error
No. of bedsore
No of patient fall
-----------------------------------------------------------------------------------------------------------------------------------------SOP FOR FRONT OFFICE
TABLE OF CONTENTS
Guest Relations Department
10
Introduction
Scope of the Department
Structure
Job Descriptions
General Instructions
Stationary / records to be maintained
Process Maps
Interdepartmental Links
Infrastructure
Quality Outcomes
Page No
2
2
3
4
8
9
13
14
15
1. INTRODUCTION:
The Front office department assists for the all OPD processes and avoiding errors.
3/23/2016 12:29 AM
33 of 56

2.1 Goal
To give the patients best service with no grievance. Being the first contact point of patients with the
hospital, the experience should be delightful.
Provided
Feedback verbal and written

Patients/ relatives / consultant

Enquiry
3-5 minutes
Registration
5-7 minutes
Admission
5-10minutes(depending upon bed availability)
OPD billing
5-10 minutes
Doctors appointment
5 minutes
Retrieving file
10 15 minutes (subject to godown files)
2.5 Extent to which level of care / service meets patient needs.

Administering the deliverance of inpatient care on time with accuracy and zero error.
3. STRUCTURE:
3/23/2016 12:29 AM
34 of 56
3.2 Day- to -day activities
Enquiry
Registration
Admission
OPD billing
Doctors appointment
2.1 Job Descriptions

2.3.1.
ENQUIRY
This is generally the first interface of customer interaction, when a prospective customer, patient,
relative, or visitor comes to the hospital for any reason.
This desk may be required to furnish information on
Availability of consultants in various specialties.
Timings of consultants.
(Lists are made available at terminal for information for staff.)
Various diagnostic services available in the hospital and their location.
Information on admitted patients and their ward and bed numbers, etc. Refer
computer system provided for the same.
Information on various programmes, seminars, workshops being conducted in

the hospital. F.O. Executive/ assistants will communicate these through IOCs and
circulars.
Information on procedures involved in admission, O.P.D. consultation, taking

appointments for diagnostic services, etc.
Company tie-ups Marketing department will inform from time to time about
credit facilities offered to various companies.
Duties of front office assistant a)

A pleasant countenance and eagerness to serve the customers are basic requirements
for this counter.
b)
Patience and careful understanding of the customers / visitors requirements.
c)
Clear and comprehensive guidance, in reply to different enquiries.
2.3.2
REGISTRATION
This terminal deals with the registration of the patient. In this process a Registration No. is given to the
patient. The file is created for the patient and it is continued for any a OPD process consultation /
procedure .The registration no. is mandatory for any treatment or investigation in the hospital.
Procedure For Registration
This involves filling up the patients details by the patient / relative. Registration is mandatory for all
patients
Patients particulars like name, age, address, phone no, family physician and consulting
doctors name.
The above data is fed in the system and permanent registration no. is generated. The file is
made and given to the patient.
For company patients the a note is written in file for differentiation.
For Company patients credit facility is provided on presenting company referral letter and
3/23/2016 12:29 AM
35 of 56
the same information is fed in the system.
Other duties-
1.
Ensure registration numbers and other details are accurately written on registration
documents (registration file, registration card etc..).
2.
Help the patients relative in filling up the details of the patient if the relative is illiterate.
3.
Handle registration related queries.
4.
2.3.3 ADMISSION
This terminal deals with the formalities related to admission. Any patient who comes for admission
should be registered with the hospital. If the patient comes back for admission in few days then his
discharge summary is retrieved from the system, (and file if needed)
Procedure For Admission

This involves the admission of the patient by the admission staff based on the information given by
patient/ relative.
The different categories of bed and the tariffs are explained to the relative.
With the help of occupancy chart, if The room of choice/ward is available ,is allotted to the
patient.
Facilities are explained to the patient/relative.
IPD registration is done
A print out of the registration form is taken and signature of the relative is taken.
A consent for treatment is taken,form is filled up by the relatives, in that at least 2 relatives
mobile no. is taken. The declaration is to be signed by the patient or his relative / next of kin with the
full name written clearly on the consent.
Once the Performa is completed, it should be filed in the patients record. The person on duty
at admission counter must sign on the admission form for identification of originator, if the
requirement arises.
The patients relative is then sent to the I.P billing department, with details of admission and
the bed/ room allotted, for payment of deposit.
A call is made to the ward regarding the new admission.
Other Duties-
Patients are often admitted in emergency situation. Ensure that the admission procedures are
quickly completed and the patients record is delivered to the
emergency department as speedily as possible.
Contact various wards from time to time, (2 hourly, from 8 a.m. to 2 p.m.)And keep yourself
updated with the bed situation and expected discharges.
The occupancy chart has to be updated and kept handy.
Responding to enquiries regarding admission is duty of front office staff at this counter.
Correct information expeditiously given, is of paramount importance.
In case of out station enquiries for admission, it is advisable to counter check with wards before
confirming bed availability. This is even more significant when a patient is being transferred under
emergency circumstances.
3/23/2016 12:29 AM
36 of 56
2.3.4 OPD BILLING

This counter handles
1.
Centralized collection of cash (consultation, follow-up, investigation, pharmacy diagnostics and
various procedures i.e. dressing, minor O.T and major O.T.)
2.
Collecting payments by Credit card and Debit card.
3.
Refund if any.
Duties Of Staff
A pleasant countenance and eagerness to serve the customers are basic requirements for this
counter.
General Instructions 1.
2.
In case of any difficulty, inform the administrator.

Every patient should get the receipt against the payment.
3.
On change of shift the information should be meticulously handed over with all-important
messages recorded in writing in log book.
4.
Person handing over charge will be held responsible if any lapse occurs on that account.
2.3.5 DOCTORS APPOINTMENT

This counter handles
1.
The doctors appointment
2.
Calling consultant
3.
Making file
4.
Retrieving files from medical record
5.
Sending file to Doctors chamber
6.
Attending patients and consultants queries
7.
Attending phone calls
8.
Keeping record of the files.
9.
Keeping track of doctors availability.
Duties Of Staff
A pleasant countenance and eagerness to serve the customers are basic requirements for this
counter.

3.General Instructions for all the
1)
No staff except the designated ones are allowed to sit in the reception
area.
2)
All staff will enter from the back gate of the hospital in proper dress code.
3)
Reception staff not eat or drink at the counter.
4)
All receptionists should greet a visitor, even if the visitor seems to be
Agitated should not agitate them.
5)
Every receptionist at the start of his shift will make sure that hospitals
charge schedule is available. computers are working normally and telephones are in working
order. If any equipment is not working, it should always be informed immediately to the
concerned (maintenance) department and the seniors and he will be responsible for getting
repaired.
6)
Outside telephone calls should not be transferred to certain telephone
Extensions, viz ..which are mainly to be used as intercoms.
7)
All the telephonic messages for the Director/MS or the consultant who
was not available at that time should be neatly written and sent through
to their chambers.
8)
Reception staff will make sure that the housekeeping staff has done their
3/23/2016 12:29 AM
37 of 56
job properly in the area overlooking the reception.

9)
A logbook shall be maintained at the reception and receptionist should read it
before starting his shift. He has to take action on certain points.
10)
As soon as a patient is admitted by him (if there is no separate admitting
office, or at nights), he shall immediately inform the concerned ward incharge and the consultant n-charge after completing all formalities of
admission.
11)
If the patient is referred by an outside consultant, the reference slip
details should be entered in a register especially maintained for such record purpose.
12)
The details of a patients bill are only for his consumption and should not
be disclosed to any outsider.
Stationary / records to be maintained

Depending on the job description, following record will be maintained at the reception. One of the
hospital administrators or In-charge reception will ensure that all records are properly maintained.
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
IPD register
OPD register
Cash Book
Pharmacy book
Voucher file
Corporate register
Doctors Tariff
Maintenance Book
Communication / Log Book
Telephone Directory
Occupancy Chart
Medical Certificate Book
Death Certificate Book
OPD feedback forms
3.Processes maps
3.1.
Enquiry process flow
3/23/2016 12:29 AM
38 of 56
Medical Records
Emergency
3.2. Process Flow in OPD
3/23/2016 12:29 AM
39 of 56
Flowchart: Alternate Process: Patient

walk in /Appointment
PATIENT
Flowchart: Alternate Process: Patient sent to ward3.3. Admission Process flow
3/23/2016 12:29 AM
40 of 56
Patient
Flowchart: Process:
Admission counter
Text Box: Diagnostics
3/23/2016 12:29 AM
41 of 56
INFRASTRUCTURE
Enquiry,registration,OPD billing, Admission -1 counter two Telephone

1PC, printer
lines,
7.1 Qualification:
Bachelors degree.
Proficiency with Microsoft Office. Multi-lingual preferred.
7.2 Experience:
0-2 years in customer care
7.3 Knowledge, skills and abilities:
Work requires ability to take initiative, multi-task, communicate well, problem-solve and enjoy
customer interactions.
8. Staffing model
Department
Registration
OPD billing
Admission
Enquiry
E
1
At night single person handles the following duties:
Registration
Admission
OPD billing
Enquiry
OUTCOMES
4.1. Quality Objectives
Enquiry-The queries are answered promptly and accurately
Registration All the registration are done with accuracy.
Admission To accommodate the patients and manage the beds effectively thereby
catering critical and emergency patients.
OPD billing Provides smooth and fast service to the out patients .
3/23/2016 12:29 AM
42 of 56
Doctors appointment Has systematic appointment system, the waiting time of the
patients is minimized.
4.2. Quality Monitors
Enquiry
- completion within stipulated time
Registration - completion within stipulated time and errors
Admission
- completion within stipulated time and errors
OPD billing - completion within stipulated time
Doctors appointment waiting time and file retrieval time from medical records.
Enquiry-Avg time taken- Complains-CRR more than 85%

Registration Avg time taken
Admission Avg time taken
OPD billing Avg time taken
Doctors appointment Avg time taken
--------------------------------------------------------------------------------------------------------------
SOP FOR GUEST RELATIONS DEPARTMENT
TABLE OF CONTENTS
Guest Relations Department
Introduction
Structure
Process Flow
Feedback Mechanism Process Flow
Job Descriptions
Outcomes
Page No
5
5
6
8
9
10
11
12
List of Abbreviations
1.
Admin-Administration
2.
Engg- Engineering
3.
F&B- Food And Beverages
3/23/2016 12:29 AM
43 of 56
4.
FTE.-Full Time Employee
5.
G.R-Guest Relations
6.
GRD-Guest Relations Department
7.
GRO-Guest Relations Officer
8.
HK-House Keeping
9.
HOD-Head Of Department
10. HRD-Human Resource Department

11. OPD-Out Patient Department
12. OT-Operation Theatre
13. PGD-Post Graduation Diploma
13. TAT-Turn Around Time
1. INTRODUCTION:
The guest relations department assists the patients and visitors in making their stay
comfortable in the hospital. Guest Relations Executives handle patients queries, concerns,
complaints in terms services and administrative functions and collect the feedback from the
patients.

2.1 Goal
Quick access to care, good outcomes, meeting the patients needs and avoiding errors.
2.2 Methods Used to Assess the Community and / or Patient Needs in order to customize
the Services Provided
Meeting the in patients on daily basis to facilitate the comfortable stay of the patients.
Easy access for patients to get in touch with guest relations.
Feedback given to the concerned HOD and facilitate the corrective action taken.
The feedback form (inpatient and outpatient) is to capture the patients feedback,
suggestions / comments.
Analysis and presentation of the patient satisfaction results and access the gap in
patients services.
3/23/2016 12:29 AM
44 of 56
All age groups and types of patients.

Meeting the patients within 12 hours of admission.
Acknowledging complaints within 24 hrs of receipt of the initial complaint.
Informing the complainant of the approximate time that it will take to resolve the
complaint.
3. STRUCTURE:

To take daily rounds in all wards, check the patients list.
To coordinate with different departments and to see the best comfort of the patients
during their stay.
Colleting the feedback forms from the patients and their relatives, and escalate the
things to concerned HODs for proper action to be taken.
Maintaining the database for feedback forms.
Complaint management Cell: - G.R. Executives and the maintenance co ordinator are
the members of the cell. Complaints are recorded by them , follow up is taken if not
resolved, and are escalated to the CEO
3/23/2016 12:29 AM
45 of 56
Written complaints received through patients or their relatives are investigated,

counseling (assurance or commitment) is done the same is escalated to higher
authorities for further action.
Out patients department visits should be done , queries regarding billing, and other
queries are attended.
4. PROCESS FLOW
Flowchart: Alternate Process: Co- Ordinate with Different HOD
Flowchart: Alternate
Process: Informed
Higher Authorities
Process: Generate Gross
repot on feedback
Flowchart: Alternate Process: Daily Round

Flowchart: Alternate Process: Inform Higher Authorities Flowchart: Alternate Process: Maintaining Database
for feedback
Flowchart: Alternate Process: Counseling
Flowchart: Alternate Process: Follow up done on Discrepancies ahead
Flowchart: Alternate Process: Written complaints ReceivedFlowchart: Alternate Process: Consultants
Requirements
Guests Relations
Process: HODs /
Depts For further
Action
Flowchart: Alternate Process:

Complaint management Cell
Process:
OPD
Rounded Rectangle:
Feedback / Patient
Satisfaction Survey
Flowchart:
Alternate Process:
Complaints
unresolved
3/23/2016 12:29 AM
46 of 56
Patient Queries
Flowchart: Alternate Process: Complaints Resolved Flowchart: Alternate Process: Refer to
higher AuthoritiesFlowchart: Alternate
Process: Patient Discharge
3/23/2016 12:29 AM
47 of 56
6. FEEDBACK MECHANISM PROCESS FLOW

Text Box: Remarks
7. JOB DESCRIPTIONS
Overall responsibility of patient care areas facilitates patients care and resolves their
concerns/ issues.
Assess each patients concerns/ feedback, take suitable action and ensure satisfaction
of patients and their relatives.
Administer patient feedback forms to outpatients and inpatients, ensure higher
response rate, submit data to central complaint management cell and participate in
analyses.
Coordinate effectively with various departments and their respective HODs to ensure
care delivery to patients.
Additional responsibilities/assignments as per senior managements discretion.
Making the complaints process accessible to guests;
Privacy and open disclosure for patients.
Liaison with other support services (Housekeeping, F&B, Maintenance, Waste
Management) to ensure delivery of care
Facilitate Discharge process.
Facilitate admission process / bed allotment.
Call back or sending E mail/letter to the patients after discharge.
Distribution of get well soon cards.
Continuous service improvement by new quality initiatives/projects.
7.1 Qualification:
Bachelors degree, PGD in Hospital Administration.
Proficiency with Microsoft Office. Multi-lingual preferred.
7.2 Experience:
1-2 years experience in hospital industry
3/23/2016 12:29 AM
48 of 56

Work requires ability to take initiative, multi-task, communicate well, problem-solve
and enjoy customer interactions.
Ability to go out of ones way to help patients and deliver on commitments.
7.4 Staffing model

2 FTE. Morning -Night
Shift timings
7.5
Infrastructure
Working area GR ofice
PC, Printer, telephone lines (internal / external).
Documents to be maintained:
Daily reports on patients feedback
All complaints and related information
Patient Satisfaction Survey forms (inpatients and outpatients)
Register complaints
Register the calls made to the patients
Monthly performance indicators
Monthly Analysis
8. OUTCOMES
Quick access to care
Responding to the patients feedback
Patient satisfaction scores
Timeliness of response
8.3 Performance Indicators
No. Of Feedback collected per month.
No. of complaints received per month.
Complaint Resolution rate (CRR)
CRR = (No. of complaints resolved in a month / no. Of complaints received
In that month) * 100
Complaint Redress Index (CRI)
CRI = (No. of complaints resolved within 5 days / no. of complaints to be
resolved in that Month)
No of calls made
No of E mails sent
----------------------------------------------------------------------------------------------------------------SOP FOR ACCOUNTS
TABLE OF CONTENTS
3/23/2016 12:29 AM
49 of 56
Accounts Department
Introduction
Structure
Day to day activities
Job Descriptions
Outcomes
Page No
1. INTRODUCTION:
This department deals with all accounting ,Budgeting, Cash management and Billing
including safekeeping of hospital cash and books of accounts.
2.1 Goal
Recording of all financial transactions and statements and preparation of reports in a
systematic manner.
2.2 Methods Used to Assess the hospital needs in order to customize the Services Provided.
2.3 Type of ventors/customers and age groups of patients served

All age groups and types of patients.
3/23/2016 12:29 AM
50 of 56

3. STRUCTURE:

Accounts Section Hope Hospital
Type of work
Accounting entries
Salary Entries
Insurance related work
Bank Related Work
Loan Related Work
Provident fund related work
Reconciliation of all bank and loan accounts
Reconciliation of Blood bank, Ct MRI Oxygen ledgers.
Reconciliation of pharmacy parties
Tax related work (PF, PT, TDS, Vat, income tax, etc)
Reporting
Manual Work
Maintenance of Records
Receivable statement
Payables statement
3/23/2016 12:29 AM
51 of 56
Accounting entries
Entries of IPD bills, and fileing of bills.
Entries of Pharmacy bills fileing of Bills, Payment of Various pharmacy Parties
Entries of CT Scan, MRI Scan, Blood Bank Oxygen etc fileing of statement and payment to
parties.
Entries of implant bills fileing of bills and payment to implant parties.
Cross checking of cash book daily.
Bank reconciliation daily.
Handling of creditors parties (CT, Blood, MRI, Oxygen, etc)
Handling consultants for payment and visit fess related work.
Handling of staff for PF, PT, salary, salary certificate, PF withdrawal etc related work.
Handling of Corporate payment issues.
Outstanding statements of corporates.
Daily Admission and discharge register
Correspondence work
Salary Related work
Checking of Attendance of each staff

Calculation of PF PT TDS of each staff
Preparation of salary sheet
Payment of salary Cash as well as cheque
Entries of Salary payment in bank book
Salary calculation of ML Enterprises and Hope trust
Calculation of Contract payment
Salary related staff queries, and rechecking of sheet.
Correspondence work (bank transfer letter)
Deduction of salary advance, staff loan, pharmacy adv, hospital IPD, Staff welfare.
Entries in tally
Overtime calculation
Tax related work
TDS deduction and entries in tally

Payment of tds challan
Return filling of tds
Vat calculation
Vat payment
Handling of income tax survey case
Insurance related work
Coordination with TPA

Preparation of cheques of insurance
Reminders of polices, general insurance, life insurance, equipments, vehicles and other assets.
Bank related work
Bank reconciliation
Loan related work
Arrangement of funds before installment date.
Arrangement of various loan related documents for loan
Follow up for various works to the bank agent (like amortization schedule, account statement,
insurance, etc)
Reconciliation of loan statement in ledger and excel sheet.
3/23/2016 12:29 AM
52 of 56
Provident fund related work
Nomination form
PF withdrawal form
Checking of PF deduction from salary
Attending PF case
Entries in tally
Payment of PF
Manual Work
Maintain consultant register manual

Daily Admission and discharge register
Bank ledger
Other manual work
3/23/2016 12:29 AM
53 of 56
7. JOB DESCRIPTIONS
CMO Billing
1. He has to prepare bills of all discharged patients for that day as per the charge
schedule in the minimum time. The rough bill, prepared by him, may be required to be
checked by seniors ,Director. He will also collect payment of the discharged patients as
per the final bill.
A discharged patient should take minimum time in settling his dues. It helps in
making good public relations.
1. He has to counsel the patients relative for depositing at the time of admission.
2. Time to time updating of IP bill and recovery from patients.
3. The copy of the advance statement should be made everyday.
4. Files of all discharged patients after payment are sent to Medical Records Department
5. All pending payments are informed to Director, through advance statement.
6. Issueing the discharge summary to the patients.
7. Collect the advances from the admitted patients, if required.
B. Senior accountant
1.
He will be responsible for the maintenance of all statutory and otherwise required
books in prescribed format.
2.
Accounts Officer will be responsible for :
(a) Safe custody of all cash cheque-books.
(b) Check number of cheque in the blank cheque-book recently issued by the
bank.
(c) Preserve counter foils of cheque for stipulated time period.(Till assessment
is done)
3.
The cash more than Rsrequired for day-to-day functioning of the hospital,
should be deposited in the bank.
3/23/2016 12:29 AM
54 of 56
4.
Cash safe should be in the personal custody of the Accounts Officer. He will be
responsible for any shortage etc.
5.
Money/valuables deposited by patients for staff custody will be accounted for
separately.
Again accounts officer will be responsible for this.
6.
His duty will include arranging of periodical internal/external audits of amounts
and deal with objections/observations raised by such audit.
7.
He will also be responsible for payment of salary to all staff whether by cheque or
cash by 7th of every month.
For it he will ensure that enough cash is available on the 7 th of each month for the
payment of the staff.
8.
Ledgers and cashbooks will be closed at the end of each month and trail balance
matched. The Trail Balance will be signed by the Accounts Officer and countersigned
by the Director/Administrator.
9.
He will prepare all reports required for budgeting and future expansion of the
hospital.
10. His duties and responsibilities will also include any other work assigned by his
seniors pertaining to his department.
7.1 Qualification-CMO Billing
BAMS or MBBS
Multi-lingual preferred.
Experience
5 years of experience
Qualification-Senior accountant
Bachelors /Masters degree in commerce.
Proficiency with Microsoft Office and Tally
Experience:
5 years experience in hospital industry
Work requires ability to take initiative, multi-task, communicate well, problem-solve
and enjoy customer interactions.
Ability to go out of ones way to help patients and deliver on commitments.
7.4 Staffing model-CMO Billing

2 FTE. Morning Night
Staffing model-Accountant
2 FTE. Morning
Shift-10 -6
3/23/2016 12:29 AM
55 of 56
7.5
Infrastructure
Working area Accounts
2 PC, Printer, telephone lines (internal / external).
Documents to be maintained:
Attendance register
Admission and discharge register
CT and MRI register
Sundry Debtors
Sundry Creditors
IPD bill file.
General file of bills
Bank voucher files
TDS File
PF related files
Insurance file
Loan files
8. OUTCOMES
8.3 Performance Indicators
Showing 9 items
Chapters
Evidence
In Charge
Actions
Sort
Sort
Sort
Sort
Showing 9 items
Subpages (10): 01 PCS AAC: Access, Assessment and Continuity of Care 02 PCS COP: Care Of Patients 03 PCS MOM:
Management Of Medication 04 PCS PRE: Patient Rights and Education 05 PCS HIC: Hospital Infection Control 06 OCS CQI:
Continuous Quality Improvement 07 OCS ROM: Responsibilities Of Management 08 OCS FMS: Facility Management and Safety
09 OCS HRM: Human Resource Management 10 OCS IMS: Information Management System
3/23/2016 12:29 AM
56 of 56
Sign in | Recent Site Activity | Report Abuse | Print Page | Powered By Google Sites
3/23/2016 12:29 AM

Quality Manual For ISO 9001 - 2008 - Quality Manual

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Quality Manual For ISO 9001 - 2008 - Quality Manual

Caricato da

Copyright:

Formati disponibili

Quality Manual for ISO 9001:2008 - Quality Manual