Standard operating procedure for Quality Assurance.pptx

SoP for Quality Assurance

1. Standard Operating Procedures(SOP) for Quality Assurance

2. Definition: Standard Operating Procedures (SOP) The most acceptable/correct/usual way of doing something. Established or prescribed set of actions to be followed routinely in a given situation.

3. 18 Departments and their SoP under National Quality Assurance Standard (NQAS) 1. Accident & Emergency 2. Outdoor department 3. Labour Room 4. Maternity ward 5. Indoor Department 6. Nutritional Rehabilitation Centre 7. Paediatric ward 8. Sick Newborn Care Unit 9 . Intensive Care Unit 10. Operation Theatre 11. Postpartum Unit 12. Blood Bank 13. Laboratory 14. Radiology 15. Pharmacy 16. Auxiliary Services 17. Mortuary 18. General Hospital Administration

4. Every Department has 8 Areas of Concern in NQAS Following are the areas of concern in a health facility A. Service Provision B. Patient Rights C. Inputs D. Support Services E. Clinical Services F. Infection Control G. Quality Management H. Outcome

5. Area of Concern G : Quality Management Area of Concern G : Quality Management deals with SoP The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services . Standard G4 is concerned with availability and adequacy of Standard operating procedures and work instructions with the respective process owners. Display of work instructions and clinical protocols should be observed during the assessment . SoP will be assessed by Observation and Review of Records.

6. 4 Assessment Methods for scoring of departments OBSERVATION ( OB ) STAFF INTERVIEW ( SI ) RECORD REVIEW ( RR ) PATIENT INTERVIEW ( PI )

7. Area of Concern G : Quality Management The facility has established, documented implemented and maintained Standard Operating Procedures for all key processes and support services. Standard G4 is concerned with availability and adequacy of Standard O perating P rocedures and work instructions with the respective process owners. Display of work instructions and clinical protocols should be observed during the assessment .

8. Structure of SoP About the Department: Scope of services Timings Types of patients served :- 2. Organogram 3. Quality Policy 4. Quality Objectives

9. Structure of SoP S. No Activity Responsibility Record   The Pregnant woman is admitted to the hospital either when they arrive in labour or when they are nearing the delivery OPD staff nurse   Nil   Pregnant woman diagnosed for high risk signs such as mal-presentation and indications for elective C-Section surgery are admitted 2-3 days prior to expected date. Antenatal ward staff nurse OPD case paper   Pregnant Woman received in emergency as referred in case is attended by Emergency Medical Officer and is directed to the labour room. Casualty Staff nurse   Emergency case paper Patient Admission

10. Structure of SoP General Information of Department Services Policy Procedure Type of patient Documentation and clinical records of Departments Safety measures Work instruction Plan for special circumstances Protocols / Guidelines Tools and checklist - Reference

11. Example- F low-chart / Algorithm of SoP for Triage of Pregnant Women

12. Way Forward Orientation of concerned service providers about SOPs in DHs, FRUs and PHCs is a task towards Quality Assurance. Distribution of SoP to Departmental Head. Customization, Contextualization & Modification in SoP as per service availability in health facility. Proper documentation of SoP and availability of SoP in listed departments. Periodic monitoring of activities of departments as per set SoP by CS, DS and HM, etc. Display of flex board - flow-chart / Algorithm of SoP in Departments. Adopting QI Processes and “ SoP ” to achieve Quality Assurance.