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QUALITY MANAGEMENT PROGRAM

With a view to provide a safe and efficient access to healthcare to patients, to ensure clinical and operational quality in all departments of the hospital and achieving complete patient satisfaction, Apollo Hospitals Dhaka has put a strong Quality Management Program in place. Achieving the best international standards of patient care and safety through Joint Commission International (JCI) accreditation in 2008 is the testimony to these efforts.

Quality Indicators

The hospital actively monitors the following quality indicators regularly (apart from many other relevant data):

  • Patient safety data
  • Infection control data.
  • Medication safety data.
  • Emergency response data
  • Outcomes of care and complication rates
  • Report turnaround times
  • Process transaction turnaround times
  • Patient satisfaction data
  • Adverse events data
  • Patient length of stay data
  • Quality of medical records

Internal and External Quality Controls

Our laboratories have both internal and external quality controls in ensuring the diagnostic quality:

  • Our laboratories follow daily QC (Quality Check) on each equipment as part of our Internal Quality Control Check.
  • The samples are also assessed with the same samples sent to accredited labs outside the hospital.
  • Our labs are accredited and certified by Bio-Rad, USA.

Quality Steering Committee

Our Quality Steering Committee is a high powered committee comprising of Senior Medical Staff and Senior Management of the hospital. The committee reviews data and reports regularly, and makes suitable recommendations. This group regularly monitors all quality related data from various departments to ensure they meet the requirements. The committee also monitors and analyzes all Patient Safety and Infection Control data of the hospital to ensure patient and staff safety.

Other Quality Initiatives

The hospital has taken a number of steps to ensure that the best quality of healthcare is delivered to its patients, some of which are:

  • Clinical practice guidelines
  • Regular advisory on best practices
  • Monitoring and implementation of Joint Commission International (JCI) quality and international standards across the hospital
  • Critical incidence analysis
  • Quality Improvement (QI) projects in key areas to enhance quality of care and patient satisfaction

INFECTION CONTROL PROGRAM

In view of its strong commitment towards quality and patient safety, Apollo Hospitals Dhaka has a very effective Infection Control Program in place. There are many practical and effective steps Apollo Hospitals Dhaka has taken to reduce the risk of Hospital Acquired Infections (HAI).

Infection Control Committee

There is a designated multidisciplinary committee to oversee the infection prevention and control program in the hospital. This group regularly reviews data on the hospital infections, helps to identify program priorities, guides activities, supports best practices, and meets Infection Control Standards & Regulations. Dedicated Infection Control Nurse regularly monitors all the hospital areas for the potential spread of infections and advises suitable steps to prevent infections. Microbiologists, the most important members of the hospital’s Infection Control team, regularly monitor all the patient care areas (especially critical patient’s care) through Clinical Microbiology Rounds.

Disinfection & Sterilization

The hospital follows strict disinfection and sterilization processes for equipments and hospital areas. The monitoring of sterilization processes is in line with the best international guidelines and involves both chemical and biological indicators.

Isolation & Barrier Practices

There are dedicated customized isolation rooms for patients with contagious infections in wards, critical care areas, and also in emergency department, for the safety of other patients and hospital staff. The hospital also follows strict visitor control and strict isolation and barrier nursing practices to ensure low infection rates.

Tracking of Infections

The hospital tracks the following infections regularly:

  • Ventilator associated pneumonia
  • Surgical site infection
  • Catheter associated UTI
  • Blood stream infections
  • Methicillin Resistant Staph Aureus (MRSA).

Apart from infection tracking, Apollo Hospitals Dhaka has identified the best practices to control these infections. These infection control practices, like the ventilator bundle and others, are actively being implemented.

Low Infection Rates

Apollo Hospitals Dhaka has very low nosocomial infection rates of 2-4 per 100 admissions against the international rates for similar kind of hospitals at 5-10 infections per 100 admissions. What this means to the patient is:

  • They can feel safe after surgery and invasive procedure at Apollo Hospitals Dhaka.
  • They will have very low chances of any infectious complications.
  • This leads to faster recovery and fewer days in the hospital, resulting in lower cost for the total treatment.

CENTRAL STERILE SUPPLY DEPARTMENT (CSSD)

Central Sterile Supply Department (CSSD) of Apollo Hospitals Dhaka receives and stores, sterilizes and distributes to all departments within the hospital, including wards, out-patient department (OPD) and other special units such as operating theatre (OT), continually striving for excellence in achieving best quality services. The objective of establishing a Central Sterile Supply Department in Apollo Hospitals Dhaka is to make reliably sterilized articles available at the required time and place for any agreed purpose in the hospital as economically as possible, having regard to the need to conserve the time of users (especially doctors and nurses). Major responsibilities of CSSD include processing and sterilization of syringes, rubber goods (catheters, tubing, etc.), surgical instruments, treatment trays and sets, dressings, etc.

CSSD centralizes the sterile processing activities in which reusable medical devices and surgical instruments and equipment are processed and issued for diagnostic and patient care procedures. In addition, the professional expertise employed in CSSD is not only to manage efficiency, economy and patient safety, but also to maintain consistent high standards for sterilization technique and decontamination process quality throughout the hospital.

Main Objectives of CSSD

  • To provide sterilized material from a central department where sterilizing practice is conducted under conditions which are controlled, thereby contributing to a reduction in the incidence of hospital infection
  • To maintain record of effectiveness of cleaning, disinfection and sterilization process
  • To monitor and enforce controls necessary to prevent cross infection according to infection control policy
  • To maintain an inventory of supplies and equipment
  • To stay updated regarding developments in the field in the interest of efficiency, economy, accuracy and provision of better patient care
  • To provide a safe environment for patients and staff

Self-check and Self-monitoring

For self-check and self-monitoring of CSSD, two steam machines and one ETO machine are checked every morning in the following way:

  • Body test paper is inserted inside the autoclave machine and an ETO strip is inserted inside the ETO machine, Chemical indicators inside the paper changes its colour from white to black for the autoclave machine and from light brown to dark brown for the ETO machine, indicating that the running machine is okay to do the sterilization work.
  • Biological attest is performed to measure whether microbiological disinfection is taking place inside the machines properly. A kit containing Bacillus stearothermophilus is kept inside the machines; the machines are run and afterwards, the kit is sent to the lab to identify if the bacteria died or not. After this, the machine is declared fit to run.

Other CSSD Activities

Routine checking and monitoring documents of CSSD are preserved and maintained. Any kind of MRSA (methicillin resistant staphaureus), HBsAg and Hepatitis A, B or C positive items are kept inside chemical (cydex) for 30 minutes, followed by washing, drying, packaging and labeling. All positive instruments are made subject to double autoclave sterilization. CSSD maintains records of inventory and consumption of surgical and non-surgical hospital items, maintenance and performance of steam and ETO machine, malfunction and technical round, carbolization and financial statements. CSSD is carbolized once a month for 6 hours each time. CSSD operates 7 days a week, 24 hours a day. It aims at assuming total responsibility for processing hospital items, thereby assuring that all of these items receive the same degree of cleaning and sterilization. It also contributes to the educational program within the hospital relating to infection control, and develops a cost-effective program by cost analysis of personnel, supplies and equipment.

Click here to view the flowchart of CSSD activities.

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