Patient Safety

Hospitals operate in an environment where safety risks are high. Despite best efforts, unintentional accidents
sometimes occur which are called patient safety incidents. These incidents are unintentional and occur due to the
complex hospital environment and human factors. As per World Health Organization, no organization has been
able to totally avoid such incidents. However, organizations whose leadership is committed to safety have set
patient safety as a key strategic priority, and go all out to allocate resources to build safe systems and minimize
risks to patients. As a responsible organization, Max Healthcare’s clinical strategy places patient safety as the
topmost priority. We have an unrelenting focus to design our infrastructure, implement processes, closely monitor
our systems and evaluate our progress.

Patient Safety Policies

In line with our commitment to ensure the highest levels of patient safety, Max Healthcare has rolled out several
patient safety policies. These are an important and effective preventive method for mitigating the risk of adverse
events. The total number of policies in the system exceeds hundred. We have a prioritization matrix based on
severity and frequency of impact, which we use for driving results.
 Severity – Each policy is rated from low (score – 1) to critical (Score – 4) based on the risk of severity of
harm it may cause if not followed.
 Frequency of use – is based on frequency of usage of policy in day to day patient care ranging from high
usage (Score – 3) to low usage (Score – 1).
 The Final Risk Score was calculated by multiplying the severity score with the frequency score.

Frequency Severity Matrix

Potential Severity (Criteria/ Impact – Harm/ Injury to patient)
Frequency of Use
Critical (4) High (3) Moderate (2) Low (1)
High (3) 12 9 6 3
Moderate (2) 8 6 4 2
Low (1) 4 3 2 1
Interpretation for
Prioritization Critical = 12 High = 9 Moderate 6 to 8 Low < 6
(Scores)

“Critical to quality” measurable checkpoints are identified in the Critical policies above. Department specific
checklists are developed for each patient care departments to be evaluated. Thus, an objective way to assess
deployment of safe practices is available. This framework is used for our periodic self assessments across all
hospitals. Interventions are taken based on learning’s.

The graphs below are a sample of the self evaluation scores for some of the critical policies. The effort is to
continuously raise the bar.
 Self Evaluation scores for Identified Critical Policies

Reassessment Assessment

88%
Vulnerable Policy 86%

Admission Policy 95%

77%

Discharge Policy 98%

90%

RRT 83%
57%

Patient Identification 93%

80%

Fall Prevention 82%

76%

Medication Safety 87%

78%

Surgical Safety 92%

80%

Hand Hygiene 89%

80%

Initial Assessment 90%

87%

Overall improvement in Compliance to Critical Policies

95%

90%
90%

85%

80% 79%

75%

70%
Assessment Reassessment

Page 2 of 28
 Hospital wise improvement between two Assessments

Reassessment Assessment

Hospital 8 90%
86%
Hospital 7 97%
76%
Hospital 6 86%
69%
Hospital 5 86%
85%
Hospital 4 83%
64%
Hospital 3 91%
78%
Hospital 2 88%
88%
Hospital 1 95%
86%

Patient Safety Goals

Max Healthcares Patient Safety Goals (PSG) are aimed to improve patient safety practices, clinical outcomes, and
reduce the occurrence of preventable adverse events. These goals have been compiled based on international
recommendations of World Healthcare Organization, Joint Commission, and on internally identified opportunities
for improvement. It is our continuous endeavor to meet and exceed the laid down norms, in keeping with the Max
Medical Excellence model.

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Action Plans of implementation:
Every goal is brought into sharp focus for a period of 2 months simultaneously in each hospital. The activities
undertaken for implementation of each PSG are outlined. Hospitals do a self evaluation, conduct various activities
such as training, CMEs, quiz competitions, campaigns etc, to raise awareness and ensure that the best practices
are shared and deployed. A brief of the activities held during the year are shared below.

PSG 1 - Identify Patients Correctly:

MHC has a Patient Identification Policy as per international standards.
Patient identification is of paramount importance as failure to correctly identify patients can result in a variety of
errors like medication, transfusion, testing errors, wrong patient/procedures, discharge of infants to wrong
families etc causing great harm. Staffs are expected to follow all the steps that are written in the policy when they
are performing patient identification.

An “Internal Baseline Assessment” was carried out in the network using a preformed checklist. This helped to
generate the actual level of performance on ground. Results of the baseline assessment were 75%. Hence a
minimum target of 85% was set for the hospitals. To achieve the set target, awareness and training programs were
launched in all hospitals. Training materials in the form presentations, posters, etc were made available.
Awareness campaigns were carried out consisting of a number of activities like grand rounds chaired by the heads
of the hospital, poster and quiz competitions, daily e-mailers, signature campaigns, walk around by hospital
leaders, skit presentations and awards and recognitions of staff. Post a minimum period of 60 days, a surveillance
audit was conducted and findings were recorded. It was noted that overtime there was significant improvement in
the scores (which reflected better practice of patient identification on ground) when compared with the baseline
assessment.
The compliance to the goal is steadily increasing.

Process to ensure 2 identifiers are used to verify patient

identity during procedures

Surveillance Audit Jun- 15 89%

Internal Baseline Assessment Apr- 15 75%

0% 20% 40% 60% 80% 100%

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PSG 2 - Reduce the Risk of Health Care Associated Infections:
At MHC, we have a continuous focus on maintaining compliance to hand hygiene guidelines & bundle care. An
online HAI Tracking system has been developed in house. Through the online system, triggers are available for
positive cultures in patients on devices. Clinical analysis of triggers and other clinical findings by the treating
Physician and Infection Control Nurse has led to accurate and efficient tracking of HAIs. The HAI at Max Healthcare
are showing a positive downward trend towards reduction.

Page 5 of 28
 % Compliance - Hand Hygiene by doctos & Nurses

Dec/15 79%
Nov/15 79%
Oct/15 79%
Sep/15 77%
Aug/15 78%
Jul/15 76%
Jun/15 79%
May/15 80%
Apr/15 80%

74% 75% 76% 77% 78% 79% 80%

PSG 3 - Ensure Surgical Safety Protocols for each and every patient:
The third Patient Safety Goal focuses on the use of an instantly recognized mark for surgical-site identification and
encourages the involvement of the patient in the marking process. Also, it points out to the use of a Surgical Safety
Checklist to verify preoperatively the correct site, correct procedure, and correct patient and that all documents
and equipment needed are on hand, correct, and functional.

Activities undertaken for PSG 3 were:

A “Surgical Safety Booklet” was released Pan Max.
 Strengthening of Surgical antibiotic prophylaxis protocol implementation
 Distribution of MHC Surgical Safety Handbooks to key clinicians. Soft copy made available to all
 Conduct of Compliance Assessment audits
 Conduct of CME’s & CNE’s
 Standardized department specific Surgical Site Infection reporting forms introduced for all surgical
specialties
 MHC Surgical Safety Film was developed and displayed to all concerned staff

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Page 7 of 28
PSG 4 - Ensure Medication Safety (Concentrated Electrolytes):

PSG 4 focuses on safe medication practices with particular stress on identification, location, labeling, and storage
of high-alert medications. It also lays emphasis on the labeling, use, administration and storage of concentrated
electrolytes
 New protocol on “Concentrated electrolytes” was released. Training was imparted in all units for
implementation of the same
 Mailers for creating awareness were designed and circulated Pan Max
 Quiz and poster competitions were conducted
 Conferences were organized ensuring participation of maximum staff

Page 8 of 28
Page 9 of 28
PSG 5 - Reduce the Risk of Patient Harm Resulting from Falls:

This goal stressed on the implementation for the initial assessment of patients for fall risk and reassessment of
patients when indicated by a change in condition or medications, among others. Measures are to be implemented
to reduce fall risk for those assessed to be at risk.
 New protocols and tools on OPD & Pediatric fall risk assessment were released.
 New tools were introduced
 Training was imparted in all units for implementation of the same.
 Skits and conferences were conducted for creating staff awareness

Page 10 of 28
Page 11 of 28
PSG 6 - Improve Effective Communication:

This by far is also one of the most important goals for ensuring patient safety.
This goal focuses on:
 Critical Test Results: Defining and reporting of the test results within a defined time period.
 Handover communication: Exchanging information, transferring responsibility of care, providing
continuity of care and make timely decisions.
 Verbal Orders: Receiving, reading back, implementing and counterchecking the correctness of the verbal
order
Activities undertaken were:
 Policies reviewed and incorporated in manuals of respective departments.
 Structured handover and transfer forms developed for use Pan Max.
 Widespread trainings and events organized to ensure effective implementation.
 Mailers released Pan Max for creating awareness
 A two day workshop with national faculty was organized on “Communication Skills”. 50 participants
consisting of a mix of doctors, nurses and hospital managers attended the program. This was organized in
collaboration with the “Consortium of Accredited Healthcare Organizations (CAHO)”

Page 12 of 28
Page 13 of 28
New Initiatives

USE OF TECHNOLOGY FOR PATIENT SAFETY

Masimo Patient SafetyNet

About Patient Safety Net: Masimo’s Patient Safety Net is a remote monitoring and clinician notification system
that helps in continuous monitoring of patients. It displays the information at a central station and allows for
alarms and alerts from the bedside devices to be sent directly to clinicians via pagers.

About the Technology: The Patient Safety Net system is built on the patented Signal Extraction Technology (SET®)
which has been proven to provide superior performance during conditions of motion and low perfusion. Clinical
studies have shown that SET® technology reduces False Alarms (Specificity) by 95% and increases True Alarms
(Sensitivity) by 97%.

Alarm Management: One of the major features of Patient Safety Net is its superior alarm management. The
system has an intuitive alarm escalation protocol which ensures that alarms when unacknowledged by the primary
caregiver, automatically gets escalated to secondary and higher levels, thus ensuring foolproof patient care.

Evaluation and pilot at Max: Demonstrations of the technology have been conducted at several Max units. A pilot
has been planned for evaluation of the technology in a 21 bed multidisciplinary ward.

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 Figure: Features of Safetynet System
 Patient monitoring & Nurse/Clinician alarming system
 SpO2, continuous Hb, respiratory rate monitoring

Figure: Advantages of Safteynet System

 Step-down ICU like environment w/o increased staffing

 Reduced ALOS in ICU
 Reduced numbers of RRT
 Reduced ward ICU transfer

Use of Technology for safe patient identification

Max Healthcare is gradually shifting to an IT based infrastructure. A “bar code” around a patient’s wrist has been
introduced to avoid medication errors. The concept of Bar Coded Medication Administration (BCMA) includes

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software that helps to identify correct medications, at the correct time by keeping all the records encoded in bar
codes to be administered by the doctor or nurse only. BCMA ensures it is the right patient getting the right
medication at the right time, the right dose and by the right route. This greatly reduces medication errors and
improves time of delivery. Apart from the barcode readers, it also consists of barcode printer, computer on wheels
(COW). The records are thus be digitally recorded, stored and transferred easily for reference.

Smart Sanitization Technology

Smart technologies employ behavioral design and Information Technology to increase hand hygiene compliance.
Seamlessly integrated into high traffic doors, these technologies can produce dramatic increase in hand
sanitization rates without disrupting normal workflow. Clinical Directorate is looking at several third parties for
implementation of such systems. The chosen technology will be implemented across departments and units, post
a successful pilot evaluation.

Multidisciplinary Care Approach

Multidisciplinary team care (MDT) is a model of care where clinicians from multiple disciples and representatives
from various support teams come together to deliver comprehensive care that addresses as many of the patient's
needs as possible. Apart from day to day healthcare delivery, MDT care can be especially helpful for treatment of
emergency cases such as Trauma, Stroke, Myocardial Infarction etc. and for chronic diseases such as diabetes
which have multiple co-morbidities.

MDT approach can be broadly classified into i) MDT Care Models that include establishing overarching treatment
processes, rounds, discharge processes etc. and ii) Disease specific defined protocols for ex. protocols for
Myocardial Infarction or Stroke.

Multidisciplinary
Team Approach (MDT)

Multidisciplinary Team
Multidisciplinary Team
Care - Disease Specific
Care Model
Protocols

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Multidisciplinary Team Care Model

Advantages of Multidisciplinary Team Care

Many research studies have proven advantages of MDT care in healthcare delivery. MDT care has become an
established care model in many developed countries with most reputed clinics and hospitals instituting MDT
processes and protocols. Clinical Directorate has initiated MDT care model at Max Healthcare and within next two
years our vision is to institute these protocols across all units. MDT care will help us achieve Max Healthcare’s
vision of ‘Sevabhav’ and ‘Excellence’.

 Improved Communication – MDT rounds and protocols improve communication between Clinicians from
multiple disciplines and teams such as nursing, billing, paramedics etc.
 Reduced length of Stay – A comprehensive treatment plan with all stakeholders on board reduces chances of
misdiagnosis, re-treatment, patient transfers, relapse etc. and improves patient outcome and recovery. This
reduces patient’s length of stay in the hospital.
 Improved Safety – With improved communication and pre-decided goals errors in treatment will reduce leading
to better patient safety. Reduced length of stay also reduces number of ventilator days/number of central line
days thereby reducing chances of infections.
 Better patient experience – A comprehensive treatment plan and integrated approach also makes patient care
more smooth and continuous. Processes such as admission, tests, discharges etc. become efficient and timely.
Patients also face lesser transfers between departments.

Major Objectives of Multidisciplinary Care

The objective of MDT care is to ensure that an integrated care is provided to the patient by all the stakeholders
involved such as clinicians from different departments, nursing, paramedics, billing, housekeeping etc. The
integrated care will involve daily care goals, long term care plan, identifying and mitigating safety risks, to plan for
transfers or discharges etc.

To review To
current determine
patient care
status priorities

To establish
To create a daily goals
comprehen
Multiple
sive plan of disciplines
care come together
To plan for
potential
transfer or
To discharge
coordinate
patient To identify
care safety risks

Page 17 of 28
 Figure – Objectives of MDT Care

MDT Rounds

Rounds are an important part of MDT care model. Rounds taken by Clinicians can include various stakeholders and
have specific goals. General rounds or daily rounds can have clinicians representing different departments, nursing
team, housekeeping etc. Teaching rounds are focused on improving learning of junior doctors/post
graduates/nurses etc. in a multidisciplinary environment. Safety rounds are focused on reducing errors, infections,
falls etc. wherein clinicians and nurses evaluate the safety risks of a patient during rounds and ensure risks are
mitigated. Discharge focused rounds will involve the billing team along with the clinical teams. These rounds will
ensure that medical treatment has been completed and patient or family has been made aware of future
requirements and that all the documents etc. are completed on time for a smooth discharge.
Develop and refine your aim Structure of rounds is essential
• Ex - Establishing Intermediate • Select appropriate team members
from multiple disciplines
Medical Care Unit (IMCU)
• Develop Daily care goals –
• Ex - By xyz date conduct daily Discontinue oxygen by 4 pm,
multidisciplinary rounds for >3
mobilize patient to walk 20 feet
days post-operative patients
Ex. Decide frequency and focus
of rounds

Leadership is the key

• Assign roles and responsibilities
• Regular follow ups
• Timeliness (essential due to
involvement of multiple teams)

Engage the Patient and Family

• Orientation of the family to Measurement matters
introduce them to the rounding • No. of days/week of MTD rounds
process • No. of disciplines involved
• Encourage participation of family • %age of patients with documented
• Take their inputs during rounds MTD goals
• LOS, ventilator days, ICU days etc.

Figure - Key Considerations during MDT rounds

MDT Pilot at Max

Clinical Directorate plans to initiate an MDT pilot in 2016 at Max Saket and Max Patparganj. After a thorough
evaluation once the processes and protocols are established MDT model will be rolled out at all MHC’s units.

During the pilot we will consider following patients for MDT care:
• Hospital stay > 10 days
• Patient care involves >= 3 dept
• Outstanding bill > 1 lacs

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Teams that will be involved in the MDT pilot are - Clinicians, ER, Nursing and Paramedics, F & B & Dietetics,
Pharmacy, Front-office & billing and Digicare/Homecare teams.

MDT Protocol for Specific Diseases

Disease specific MDT protocols allow for designing more specific and detailed processes and allow better
assignment of roles and responsibilities. The parameters of success also become more particular to the disease
and treatment, and hence become easier to track and evaluate, for ex. ‘Door to balloon’ time can be a parameter
for Myocardial Infarction (MI) treatment. Two departments where defining these protocols becomes very
important are Neurosciences and Cardiac Sciences. Defined protocols in case of emergencies such as Stroke or
Myocardial Infarction can save lives of patients.

Neurosciences - Stroke Protocol

Stroke is a preventable and treatable disease. Over the past two decades a growing body of evidence has
overturned the traditional perception that stroke is simply a consequence of aging that inevitably results in death
or severe disability. Evidence is accumulating for more effective primary and secondary prevention strategies,
better recognition of people at highest risk, and interventions that are effective soon after the onset of symptoms.
Understanding of the care processes that contribute to a better outcome has improved, and there is now good
evidence to support interventions and care processes in stroke rehabilitation.

International & National guidelines cover interventions in the acute stage of a stroke ('acute stroke') or transient
ischaemic attack (TIA). Most of the evidence considered relates to interventions in the first 48 hours after onset of
symptoms, although some interventions up to 2 weeks are covered. Keeping this in mind, MHC’s Departments of
Neurosciences have come up with a MDT Protocol on Stroke which was rolled out Pan Max. As part of this
initiative, data from all hospitals is collected to track and analyse patient outcomes and effectiveness of the MDT
Stroke Protocol. Stroke data format and data-fields are attached in the appendix.

Cardiac Sciences – Myocardial Infarction (MI) protocol

Rapid patient triage and administration of therapy aimed at reperfusion is an essential component in the care of
patients presenting with acute myocardial infarction. An MDT program in MI should be designed to facilitate rapid
triage and management of patients presenting with acute myocardial infarction. This program can have a major
impact on MI patient care at Max units and will need support and involvement of the nursing, pharmacist,
paramedical & nonclinical along with the physician teams. The program has parameters like defined timelines for
initiation of therapy aimed at reperfusion, conducting ECG, notification to CCU doctor on duty etc.

On similar lines to Stroke Protocol, MHC is committed to roll out a MI protocol at Max Healthcare. We also aim to
define data collection metrics for MI protocol to be able to evaluate the effectiveness of the protocol.

Staff Safety - Immunization Policy for Employees

Page 19 of 28
Immunization policy for employees was rolled out pan Max by the Clinical Directorate. Policy aims to provide
proactive and preventive approach towards health of MHC employees. Immunization policy would include
prescribed vaccinations as per employee’s area and nature of work. The objective is to ensure that the applicable
employees are provided vaccinations in order to provide an infection free environment to patients and co-
workers.

The policy covers all employees and associates of Max Healthcare (Employees, Members on retainership mode,
Visiting Consultants and Outsourced staff). Eligible employees and members are required to get the vaccinations
as prescribed by the policy (see Appendix). Immunization would be done for all, at the time of: i) Completing the
Joining formalities or within a week of joining or ii) Annual Health check-up. Operational responsibility of
immunization of employees shall lie with the Medical Superintendents of the units. Human Resources will be
responsible for the documentation.

Patient Safety Metrics

We have instituted a tracking system, called the ‘quality flash.’ The quality flash is a report that captures all safety
related incidents that have occurred in the previous 24 hours. There is an incident reporting system in place that is
accessible to each and every staff member. Staff are empowered and encouraged to report near misses, and any
safety related accidents in a transparent manner, with an aim to identify learning’s and continuously improve.
MHC results are comparable to the best published rates. Some of these are presented below.

Unplanned Readmissions per 100 discharges

Globally, the emphasis is to reduce readmissions related to the primary cause of illness. Tracking this metric
provides the hospital an opportunity to review in depth the reason for a patient returning to the hospital within 14
days of discharge, in identified specialties. Each readmission is peer reviewed to identify factors that contributed
to the readmission, and then make attempts for system wide improvements. The MHC rate has shown a decline
over the months, and is way below the benchmark levels.

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 Unplanned Readmission per 100 Discharges within 14 Days
2.50% (Jan' 15 to Dec' 15)

1.92%
2.00% 2%

1.64% 1.57%
1.92%
1.42% 1.41% 1.40% 1.38% 1.39%
1.50%
1.31% 1.26% 1.26%
1.24%
1.40%
1.38% 1.33% 1.32% 1.41% 1.30%
1.24%
1.00%
1.02% 1.05%
0.92%
0.75% Cumulative
0.50% Rate
Monthly Rate
Lower is better
Target
0.00%
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Readmission Cumulative Rate Comparison

1.5%
1.4%
1.4%
1.4%
1.3%
1.3%
1.2%
1.2%
1.2%
1.1%
2014 2015

Unplanned return to OT within 7 days

In a few patients, some inherent pre existing problems or the illness per se, make them vulnerable to a
complication such as bleeding or other problems, and they have to be re operated. Rarely, it may indicate
opportunities that patient care could have been planned and improved. Monitoring the indicator closely and
comparing it with other studies provides the reassurance that the surgical outcomes are successful, comparable to
globally published levels.

Page 21 of 28
 Unplanned Return to OT within 7 Days per 100 Surgical Procedures
(Jan' 15 to Dec' 15)
1.20%

1%
1.00%

0.80%
Cumulative Rate Monthly Rate Target
0.60% 0.50%
0.41% 0.40%
0.36%
0.40% 0.32% 0.31%
0.30% 0.31% 0.31% 0.30% 0.29%
0.25%
0.33% 0.33% 0.31% 0.31%
0.20%
0.25% 0.26% 0.30% 0.29% 0.28% 0.26% 0.24% 0.25%
Lower is better
0.00%
Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

Return to OT - Cumulative Rate

0.6%
0.5%
0.5%
0.4%
0.3%
0.3%
0.2%
0.1%
0.0%
2014 2015

Hospital Acquired Infections

Many factors influence whether a patient will get an infection during hospitalization, such as immunity levels,
procedures and invasive techniques that may create routes of infection, and inadequate infection control
practices that may facilitate infections to spread. MHC has developed and implemented the best infrastructure,
processes and training programs to prevent and control hospital acquired infections. There is an ongoing
surveillance of infections and these are tracked and reviewed diligently. Opportunities for improvement are
continuously identified. Regular training programs are held for doctors and nurses. The HAI rates are close to the
developed countries benchmarks.

Page 22 of 28
 Central Line-associated Bloodstream Infection
Rate per 1000 Central Line Days
6
Developing Countries
5 4.9
Benchmark (NHSN)
4

3 MHCRate
1.93 1.83 1.75
2 1.68 MHC Target to be
achieved by Mar 2016
1.25 Developed countries
1
0.9 benchmark (INICC)
0
Jan-Mar'15 Apr-Jun'15 Jul-Sep'15 Oct-Dec'15
Lower is better

Catheter-Associated Urinary Tract Infection

6 Rate per 1000 Catheter Days
5.3 Developing Countries
5 Benchmark (NHSN)
4

3
1.71 MHCRate
2 1.28 1.36
1.54
1.17 MHC Target to be
1
1.2 achieved by Mar 2016
Developed Countries
0
Benchmark (NHSN)

Lower is better

CLABSI Rate per 1000 Central Line Days

6
Developing Countries Benchmark (NHSN)
5 4.9
Page 23 of 28
4

3 MHCRate
1.93 1.83 1.75
 Ventilator Acquired Pneumonia
18 Rate per 1000 Ventilator Days
16.5 Developing Countries
16
Benchmark (NHSN)
14
12
10
MHC Rate
8
6
4 2.57 2.31 MHC Target to be
1.81 1.92
2 2.31 achieved by Mar 2016
1.1
0
Jan-Mar'15 Apr-Jun'15 Jul-Sep'15 Oct-Dec'15 Developed Countries
Lower is better
Benchmark (NHSN)

Compliance to Medical Documentation

Medical documentation is an important input for continuity and safe care. The organization critically examines
each and every patient record for completeness and accuracy. The data is accordingly collated for ensuring that
improvements are actioned. The rate of compliance has shown an improvement steadily.

Compliance to Medical Documentation

Higher is better
95%
Target
95% 95% 94% 95%
94%

93%
92%
92% 91%
91% 91% 91%
91% 91%
Sep-15

YTD
Feb-15

Apr-15

Jul-15
Jun-15

Oct-15

Nov-15
May-15
Jan-15

Dec-15
Mar-15

Aug-15

Page 24 of 28
Patient Falls

Patients are sometimes vulnerable to falling and injuring themselves, on account their illness, age, or medications.
MHC has stringent policies in place for fall risk assessment and prevention of each patient. We use the Morse fall
risk scoring system. The nursing plan of care is accordingly made for each individual patient, to ensure that the risk
of patient falls is minimized. The hospital design and processes ensure that this risk is minimal, such as anti skid
flooring in toilets, grab bars, use of bedside rails, seat belts for patients in wheelchairs, and assistance for
ambulation. There is a patient safety goal which has been implemented to augment our efforts. In case there is a
fall, each incident is reviewed in depth to identify causes and ensure corrective and preventive measures are
instituted. The fall rate is also at low levels.

Patient Fall Rate per 1000 Bed days

Target 0.23
0.25
0.22

0.15
0.1 0.1 0.11

0.09 0.07
0.05
Lower is better
Aug/15
Apr/15

Jun/15

Jul/15

Sep/15

Nov/15
Oct/15
May/15

Dec/15

Hospital Acquired Pressure Ulcers

A pressure ulcer, or commonly called a bedsore, is a known cause of pain, and additional treatment for vulnerable
patients.
Those patients, who are unable to move easily and have reduced circulation or fragile skin, are at risk. Further,
prolonged surgery, impaired mental or bowel and bladder function, use of tubes and equipment, inadequate
nutrition and fluid depletion may add to the risk. Critically-ill patients in ICUs are at highest risk for the
development of new pressure ulcers during their hospital stay. At MHC, we ensure pressures ore prevention care
is in place for all patients. These include daily skin assessment and care, regular repositioning, measure and ensure
calorie intake, glucose control, and use of special mattresses amongst others. Nurses are trained and competent in
these protocols. With all these efforts the HAPU prevalence rate remains at a low level.

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 Hospital Acquired Pressure Ulcer Rate per 1000 bed days

0.39

Target 0.26

0.2
0.17
0.12 0.14 0.15

0.13
0.11
0.06
Lower is better
Apr/15

Jul/15

Aug/15
Jun/15

Sep/15

Oct/15
May/15

Nov/15

Dec/15

Medication Errors

A medication error is an unintended gap in the medication process that leads to, or has the potential to lead to,
harm to the patient. These can happen during prescribing, dispensing or administration of medications. The risks
are compounded by multiple handovers, multiple steps, and sound alike and look alike medications etc. At MHC,
we have developed and instituted several protocols and procedural quality checks at each step of the medication
flow process. Staff training is mandatory. The electronic health record and hospital information system is designed
for inbuilt safety checks. These include bar coding for medication administration, allergy alerts, alerts for drug -
drug interaction and dosages etc. Each Physician has access to drug information, so that he or she can ensure the
correct medication is ordered. High risk medications are double checked. Storage and Labeling is standardized.
Infusion pumps are used to ensure correct dosing calculations and administration. Computerized physician order
entry at majority of our units ensures legible and efficient medication orders. Generic drug prescribing, brand
substitution enables cost effective medication practices. The organization is now introducing electronic
prescription systems in OPDs, in a phased manner to further the safety and efficiency of medication practices.
Prescription and medication audits help us as for self evaluation to measure our progress and improve.
Medication error reporting is encouraged, in the spirit of continuous learning and improvement.

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 Rate of Medication Errors per 1000 bed days
3.5

2.9 2.9
3
2.59

2.5
1.95
2 1.74
1.61
1.4 1.34
1.5

1
0.54
Lower is better
0.5

0
Apr/15 May/15 Jun/15 Jul/15 Aug/15 Sep/15 Oct/15 Nov/15 Dec/15

Phlebitis
Sometimes phlebitis may occur at the site where a peripheral intravenous (IV) line was started, or blood sample
taken.
The surrounding area may be painful or developed a bruise. In rare cases, the same can get infected. It is a
constant endeavor of our staff to minimise pain and discomfort to our patients. Protocols for proper hand wash,
use of gloves and disinfectants, and certifying competency of our nurses in phlebotomy techniques have helped
majority of our patients to have safe and clean procedures. Close tracking of the unintentional phlebitis
complication ensures thorough evaluation and insights.

Phlebitis Rate
Dec/15 0.19
0.49
Oct/15 0.07
0.34
Aug/15 0.37
0.59
Jun/15 0.29
0.2
Apr/15 0.5
9g - Patient Safety Culture Survey

Patient Safety Culture Survey

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As part of our commitment for patient safety, MHC has initiated a pilot patient Safety Culture Survey at one of its
hospitals to gain understanding of views of clinical staff on various issues related to patient safety and to further
identify solutions to improve the same. The tool used was adopted from AHRQ (Agency for Healthcare Research in
Quality) Hospital Patient Safety Culture Survey. Around 50% sample staff was involved in the survey consisting of
nurses, doctors, dieticians, pharmacists, physiotherapists, technicians and administrative personal.
The survey helped the management gain understanding on the staff perspective on transparency, non punitive
working environment, responsiveness and communication, staff confidence and challenges existing in the
workplace and accordingly institute measures to address them. Going forward, the survey will be conducted
annually across all units. The overall result is as below:

% wise breakup of respondents - Patient Safety Culture Survey

in Max DDN

Nurse 44%
Attending Physician 10%
Resident Physician 3%
Dietician 1%
Physiotherapist 2%
Technician 14%
Pharmacist 1%
Administration 24%
Dental 1%
0% 10% 20% 30% 40% 50%

% Staff Confidence in Hospitals Safety Norms

Excellent 21%

Very Good 49%

Acceptable 28%

Poor 1%

Failing 0%

0% 10% 20% 30% 40% 50% 60%

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