Quality Department

Continuous quality improvement program is implemented by Quality Control Team. The quality improvement programme is being supported by the Hospital management. FMMCH is committed to provide Quality Services to all the stake holders. FMMCH has different committees to coordinate and monitor the services provided. Continuous quality improvement programmes are monitored by core committee by regular internal quality audits, physical checks, data analysis, random sample checks etc. The quality improvement programme is reviewed every 3 months, opportunities for improvement are identified and updated once in a year. FMMCH has identified key performance indicators to monitor the clinical structures, managerial structures, process and outcomes. Hospital conducts Internal Quality Audit every six months to ensure that all employees are strictly adhering to policies, procedures and work instructions/SOPs related to them.

Quality Policy & Objectives

Father Muller Medical College Hospital strives towards a continual quality improvement programme that supports patient safety, satisfaction and protects the rights of patients and all stakeholders, complying with national standards.

Quality Objectives:

• To develop and maintain a Quality improvement programme that is established to meet the requirements of service and expectations of patients as well as staff.
• Monitoring of all the system, process and outcome parameters through indicator analysis, frequent audits and constant feedbacks.
• To develop a team of dedicated and motivated workforce that would work and promote the Quality Improvement Programme.
• To have constant review mechanisms of policy as well as practices to maintain the continuity in improvement of care.

Activities:

• Planning, coordinating, guiding quality control programs designed to ensure continuous improvement in patient care and health care in conformity with all established standards.
• Set quality standards for the hospital, based on the common medical protocols.
• Initiating and assuring compliance with quality management system relating to National Accreditation Board for Hospital and Health Care Providers. (NABH)
• The department monitors the various department staff in order to ensure continuous control over SOP’s and ensure corrective actions.
• Department is responsible for document control: ensures all documents including medical record, formats, policies and procedures are current and updated as per NABH /Legal requirements.
• Training programs are centralized under one umbrella to ensure timely training and awareness is given to the staff.
• Ensuring that the policy implementation is done appropriately and all the staffs are adhering to the standard operative procedures and protocols in the patient care process.
• Monitoring and analyzing the key performance indicators along with the managerial and clinical indicators. Ensuring that corrective and preventive action is done if required.
• Regular audits are conducted to monitor the compliance to the policies and procedures. Following audits are conducted: Internal audit, facility audit, medical record completion audit, medication management audit etc.
• Regular studies are conducted to improve the process/existing system.

Organogram: