Minutes of Meeting: Monthly Quality Meeting

Agenda:

Discussion on mandatory (ICD)Quality Indicators and Trend analysis

New CQI initiatives from Depts.

Date of Meeting: 17th January 2017

Time: 3:00 PM

Location: Board Room

All mandatory QI being monitored and analyzed were presented in power point presentation to
the Committee members.
NABH 4th Edition New Mandatory Quality Indicators were discussed. Updating of current
formulae and continuity of data analysis and mining were discussed.

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Points of discussion Responsibility Timeline

Quality meeting will be held every 3rd Quality Dept. NA

Tuesday of the month to monitor and
analyse trends in CQI monitoring.

It was suggested to use the quality module All Immediate

system to enter the
New Indicator data on a regular
Incidence basis
of Patient Quality, Nursing, 1st Feb
Identification errors, to data
Prophylactic Antibiotic be started
to be given to Med Admin,
OT Admin From 1st Feb
Quality department as QI, from the OT. Operations

Indicator on Percentage of cases in which

planned surgery is changed intraoperatively
alsoMedical
Bio needs to Management
Waste be monitored and
Rules 2016 Medical Admin Immediate
documented.
with inclusion of Red Bag in segregation
Nursing
colour
Blood code
BanktoIndicator
be implemented fromof
for wastage 1stBlood
Feb Blood Bank Immediate
Superintendent
components should be segregated as units
Training effective immediately
discarded from blood bank storage and Housekeeping
units discarded from areas issued.(Ref
NABH 4 Edition CQI 3f)
th

New Indicator on Return to Emergency Emergency Immediate

within 72 hours with same complaints need
to documented and analysed.

In the QI - Percentage of stock outs Pharmacy Immediate

including Emergency Drugs, Stock Out of
Emergency drugs to be shown separately

ICU quality indicators of last 3 months to ICU Immediate

be given to quality department by the 5 of th

every month

Calendar for Mock Drills of emergency Quality Immediate

codes to be informed to concerned teams
Medical Admin
and conducted

Local Purchase procurement should be Pharmacy From 1st Jan

segregated into one that has been
purchased by local purchase within
formulary and one that has been locally
purchased from outside the
formulary(Reference NABH CQI 4a)

Nurse Patient Ratio to be shown in proper Nursing Immediate

ratio
2 | P asymbol(eg1:1)
ge
Near Misses to be shown in harm score Nursing Immediate
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Head Quality

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