Quality Assurance

Aster MIMS has been keeping pace with the latest developments in the technology, thus utilizing the technological advancements for better patient service and for cost reduction. A new system of recording and retrieval for discharge summary dictation by doctors has been installed, whereby multiple doctors can dictate the summaries simultaneously. This nhas reduced the time consumed in releasing the patients from our hospital and also saved the precious time of the doctors, which can be utilized in caring the other patients. Aster MIMS believes that there is no upper limit for quality, charity and affection. The quality assurance’s telephone number is displayed in all prominent places of the hospital and in rooms and wards for the patients to contact us personally to give their appreciation, suggestions, complaints or concerns. It is a 24 hours accessible number. MIMS had won the first NABH accreditation among Multispeciality hospitals in India in 2006 and the first NABL accreditation among hospital laboratories in Northern Kerala in 2012 with untiring efforts by the department of Quality. Aster MIMS has secured the first place among hospitals making substantial and sustained efforts in pollution control in the years 2001, 2007, 2008, 2009, 2010, 2011, 2012, 2013,2014 and 2015 from State Pollution Control Board, Kerala. The hospital look forward to get accredited by Joint Commission International (JCI).

Scope of the Department

  • To act as the nodal office to receive verbal and written complaints from patients and relatives. To take corrective and preventive actions on the complaints.
  • To receive, collate, analyze and report on Customer Feedback: The report to include satisfaction levels using an internally devised scoring system, both absolute and relative. The report will be presented to the Heads of Departments of the hospital.
  • To receive and analyze all incidents which are reported. These reports will be studied in depth, root cause analyzed and reports made to Director-QAD as well as to the concerned HOD. The collated results after segregation into 4 types will be presented to the Hospital Safety Committee and also to the Heads Of Department meeting.
  • To receive reports from the various other committees and to ensure compliance to established protocols: The Hospital Infection Control Committee, Drug Committee, Safety Committee, Medical Records Committee, Blood Transfusion Committee, and the Committee for critical care areas.
  • To receive monthly statistics reports from the DHIM and work out and report the utilization co-efficient.
  • To conduct process and outcome audit in clinical areas,

a. Mortality Audits

b. Infection rates

c. Medication errors

d. Prevention of patient falls

e. Audit on patient identity

f. Audit of diagnostic service like lab, radiology, nuclear medicine etc.

g. Surveillance audits h. Biomedical waste management

  • To conduct along with the DHIM, Mortality Audits and report the outcome to doctors meeting.
  • To conduct process and outcome audit in the non-clinical service areas.

a. Time delay studies

b. HAZMAT/E- waste management

c. Customer satisfaction surveys

To audit cost outcomes and make appropriate reports to management.

a. Hospital wise comparison

b. Year wise comparison

  • To improve clinical Governance by establishing evidence-based clinical practice.
  • Review the existing clinical protocols and devise improvement strategies with consultants.
  • To ensure ethical management in place.
  • To ensure compliance to all statutory and regulatory norms.
  • To conduct adhoc and surprise audits to ensure compliance to all applicable norms.
  • To discuss and suggest areas of strength and concern to the top management as well as to suggest avenues for continuous improvement.

Record of Bio Medical Waste Generated

BIO MEDICAL WASTE & GENERAL WASTE WEIGHT April -2018 to September -2018
Sl No Waste Category Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Total Weight (each Category) Remark
1 Yellow (Infected Non Plastic ) 7474 8134 7460 7870 7396 6900 45234
2 Red ( Infected Plastic Items ) 7122 7468 6947 7442 6965 6236 42180
3 Cyto toxic 154 211 172 227 243 213 1220
4 Metallic waste (Needle, Blade ) 295 318 284 309 325 276 1807
5 Non metallic waste (Bottles,Ampules ) 484 504 452 551 582 505 3078
6 General waste 7924 8014 7473 6986 7029 6476 43902

Monthly Weight of Biomedical & General waste October - 2018
DATE RED YELLOW CYTO TOXIC METAL SHARP METAL SHARP TOTAL WEIGHT General waste
10/1/18 210 240 6 12 17 485 211
10/2/18 219 232 5 10 21 487 216
10/3/18 227 237 6 9 18 497 230
10/4/18 211 231 7 9 16 474 212
10/5/18 218 247 5 10 23 503 220
10/6/18 228 248 8 12 21 517 230
10/7/18 209 230 5 9 18 471 200
10/8/18 225 241 7 10 22 505 215
10/9/18 216 230 5 10 20 481 230
10/10/18 218 235 7 12 22 494 220
10/11/18 228 235 8 10 28 509 226
10/12/18 221 237 6 9 29 502 224
10/13/18 213 237 5 9 20 484 230
10/14/18 209 229 7 13 458 201
10/15/18 219 232 5 10 21 487 245
10/16/18 207 221 6 11 17 462 220
10/17/18 211 232 5 12 19 479 223
10/18/18 208 227 4 6 12 457 202
10/19/18 213 234 7 13 16 483 239
10/20/18 212 235 6 14 19 486 201
10/21/18 209 229 10 14 462 199
10/22/18 210 238 5 14 17 484 230
10/23/18 211 230 8 12 24 485 230
10/24/18 202 234 6 11 22 475 241
10/25/18 217 240 5 10 21 493 244
10/26/18 211 233 5 12 20 481 230
10/27/18 218 227 5 13 22 485 235
10/28/18 209 229 8 7 17 470 230
10/29/18 214 230 6 11 20 483 220
10/30/18 217 231 8 14 24 494 230
10/31/18 218 222 6 13 24 483 220
TOTAL 6658 7233 175 333 617 15016 6904
Total
Bio medical waste 15016
General waste 6904

Monthly Weight of Biomedical & General waste November - 2018
DATE RED YELLOW CYTO TOXIC METAL SHARP METAL SHARP TOTAL WEIGHT General waste
11/1/18 215 243 6 11 18 493 238
11/2/18 216 242 7 10 19 494 242
11/3/18 221 221 4 9 17 499 238
11/4/18 195 244 5 10 15 446 225
11/5/18 216 248 6 10 19 495 230
11/6/18 222 234 5 10 18 503 225
11/7/18 217 240 5 9 19 484 230
11/8/18 230 246 6 10 20 506 220
11/9/18 230 241 7 10 20 513 235
11/10/18 217 234 6 11 19 494 220
11/11/18 211 234 4 10 18 477 200
11/12/18 130 241 5 11 19 506 220
11/13/18 222 246 6 10 21 505 218
11/14/18 227 150 7 12 22 518 221
11/15/18 193 200 8 14 25 400 242
11/16/18 179 202 4 31 43 459 221
11/17/18 183 219 3 8 36 452 228
11/18/18 176 198 10 21 405 202
11/19/18 184 215 4 7 23 433 209
11/20/18 111 223 6 21 36 477 212
11/21/18 238 263 4 12 43 560 217
11/22/18 249 272 8 16 48 593 220
11/23/18 259 276 8 14 45 602 218
11/24/18 208 251 7 12 38 516 220
11/25/18 166 176 6 13 21 382 200
11/26/18 171 223 6 12 30 442 210
11/27/18 181 237 7 14 36 475 209
11/28/18 205 255 8 21 38 527 220
11/29/18 185 224 6 18 37 408 200
11/30/18 156 218 5 16 30 425 200
TOTAL 6013 6916 169 382 814 14294 6590
Total
Bio medical waste 14294
General waste 6590

Facilities

Techniques & Technologies

  • PCR & Gel Documentation Systems
  • HPLC Systems
  • Chemiluminescence - Microparticle Assay
  • Automated bacterial culture and identification systems
  • Capillary & Gel Electrophoresis
  • Photometry – Linear & Nom Linear Chemistries
  • Nephlometry
  • Frozen sections, Renal and Skin biopsies
  • Darkfield microscopy
  • Polarising microscopy
  • Indirect Immunoflurescence
  • Immunohistochemistry and Cytochemistry
  • Automated ESR & Coagulation studies
  • Automated ELISA using IIIrd & IVth generation kit
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Services Offered

  • Round the clock services for Laboratory Investigations and Blood Banking (whole blood and components) for outpatients and inpatients.
  • All kinds of routine as well as major specialized investigations are done in all the divisions.
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Infrastructure

  • All the major specialties like Histopathology, Cytology, Clinical Pathology, Haematology, Microbiology, Biochemistry, Immunology, Virology, Molecular Biology, Transplant Immunology are available for the time.
  • Lab Information System linked to Hospital Information System.
  • Follows strict quality control procedures under ISO, NABH, NABL guidelines.
  • Doctors and Technologists are highly qualified and experienced with exposure in India and abroad.
  • Use state-of-the-art equipments and cutting edge technologies.
  • The leader in the Malabar Region.
  • Almost all the systems are fully Automated.
  • Facility for receiving external samples directly and through satellite labs (in the offing).
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